The C.n-.ll.n Nur.. D8c:ember 1979 55 THE CANADIAN NURSE The offtCial /Oumal of the Canadian Nurses Association published In French and English editions eleverlimes per year 1979 Annual Author, Subject Index Vol. 75, No.'s. 1-11 January-December LEGE'D A -Abstract '\ V - Audio ual E - EdilOnaJ pon - ponrn..it ACCIDD/TS A e"'y present danger {Post. Langford) 4!fa Helping preschool children learn to be safe (Eifert) 260 AOOLESCE'CE Pe"'pective (Wheatley) E. r.; .\OOLESCE'TGIRL5-HEALTH ,\'0 H\:GIE"E The smgle mother: can \o\c help'! (Hlllung-Meyer) 26N AGED The loneliness ofthe elderly (Griffin) 23"1) USH. ArleD< Not an patients need hOllitiplta)s. 2 '1r ALBERT A ASSOCIA TIO' OF REGISTERED 'l RSES. A "'l AL MEETI'G Ncwsbeat: the provinciaJ scene. 9J/-\ .\LBERT A CHILDRE"S HOSPITAL Ja -Januar) Fe - Fcbrua.-y "h - '-larch Ap -Apnl M) - Md) Jc June J/.\ -Juh/August S - September Oc -October N - November D - December Learning aoom the hospitaJ at home (Ferguson. Park. Ward).44Ja ALCOCII.. o.nÏS< Books can help. 52Ja ALCOHOLlS'\1 Closeup on physicians at n,k. ION OccupationaJ hea]th nurses auend akoholism conference. 14D ALEMA' \:. Helen Nursing grand-rounds: femoral a)lograft (Ferguson. Grice. Stuanl320c .\LLA:-O. '\Iargam Nursing: fact and fantasy. 31J/A ALLE'. ""o ra U of -\ hO'ljit VISlllng pTOfe ,or. &Ja A'\IBlL.\TOR\: C.\RE Did you know... the Hea)th Care Cenrfe. 9\1r A'DER!tO'. "loll) Bk_ rev., 5:!Fe ^'DERSO:'o. Mona 8k. rev.. :!Fe ANTISEPSIS Cross infeclion: a new approach to an old problem (Cragg) 40Fe Hands that car<: ar< they sare? (Sklar) 100c APATHY Frankly speaking: apathy in nursingfRyanJ J lJe ASSOCIA nON OF Nl RSES 0 PRJ"CE ED" .\RD ISLA:-OD. A:-O'LAL MEETI'G Newsbeat: me provincIa) scene. I J/A 56 D8c:ember 1979 The C.n-.ll.n Nurse ASS\X'IATIO" ot RE(;I!>TFRED "I RSFS Ot' "E\\H)l DI.A'D ARNN remembe pa'\t-Iook!!. to the future. lID Did you know. . 8N 4.STHMA Childhood asthma: an outpatient approach (0 treatment (Ferguson. Webbl '6Fe A TTITl J)F ot' HE.\L TH P"RSO' EL F-nmkly speaking: apathy in nursing (Ryan) 3lJe A\\ARJ)SA'DPRILES CNA's annual meeting. 1M} CNF recei\le k..ellogggranr. 14Ap Did you know...SI.John Ambulance, "Ap Janel "-enny Knox. recipient of the Helen Gibson Memoridl Schola",hip. 49Fe The Jud) Hill Memorial Scholal'ihip. 49Fe Thirteen nurse!!. recel\.e .1wdrd valued at more than SJO.OOO. 12Uc -B- BAILMENTS Where does the nurse'" respon'\ibility begin and end in Cdrlng for a p.1tient"!t. belongmg"'! ( klar) 14S BA ":'III'G. Judith ^'\si!!otant editor (port) 50c The nurse in thecommumty: infant stimulation. 36N BAl "IGART. Alie. Closeup on nursmg networks. 13J/A BtL4. 'GER. Anne "Iarie Servmg Si'iòter. "iO-\p BESII.\RAII. :\1. Ann. Closeup on coalition for the prevention of handicap 29N Commentary (POSI) E. ID PerOiipective. E. 3Fe Sinner, or !'taints? E. 4Je The impo (hle dream? E. 6Ap BES\\ETHE:RICK, "Iargarot StdITmg a"'gnmenl. I My BIETTE. M. Ga)le Burns fhe effects of'ielected factors on the older .1dulfs managment of treatment for hypertension. 550c RILLL 'G-"It'\:ER. Jo fhe'i.1ngle mother: can we: help ::!6N BOt: ". JaM Bk. rev.. 480c Closeup On fetal aJcohol syndrome. 35N New as i"itant editor (port) SJ/A Perspective. E. 5S BOO" RE\ IE\\ S Adler. DianeC. AACN organization and management of crihc.1l-c.1re facditic"i (Shoemaker) 430c Alhane"ie. Jo'\eph A. Nurses drug reference. 440c AlexdJ1der. Mar} M. Pedlatnc hillitory taking and physical diagnosi!'t for nurses (Brown) 450c Axline. Virginia M. Oibs In search of "ielf. 52Ja Barber. Elsie. The trembling years. SlJa Barry. Jeanie ed Emergency nursing. 420c Blackwell. Marian Willard. Care of the mentally retdrded.41\Oc Bretz. H. Lee. Donny and didbetes, 5!1a Brickhill. Paul. Reach forthe sky, 5lJd Brown. Molly. ed. Reading!'t in gerontology. 52Fe Bullough. Bonnie ed. Expanding horizons for nurse.;. (Bulioughl520c Burrell.Jr.. Zeb L Critical care (Burrell) S2Fe Butler. Beverly. Light a single candle. 52Ja Campbell. Claire. Nursing didgnosi"i and intervention in nu ing practice. 52Mr Canadian Council on Children and Youth. Admittance restricted' the child as a cItizen in Canada. 53D Canadian Standards Association. Effective sterilization in hospÎtaJs by the ethylene oxide process. 53D Canadian Standards Association. Effectivc stenlization in hospitals by the steam process. S3D Chaney. Patricia S. ed. Dealing with death and dying. 4'Oc Chnstopher, Matt. Sink it. Rusl.Y. 2Ja Clark. Ann L. Childbearing: a nursing perspective (Alfonso) S20C Clark. Bellina, Pop-up going to the hospital. HD C lark. Carolyn Chambers. Assertive skills for nursc , 5::!Oc Clarke. Louise. Can't re.1d. can't write. cdn't t.1lk too good eIther. "'::!Ja Dahl. Borghdd. Finding my way. !la O'Ambrosio. Richard. No language but a cr). 5!1a De Angells. Catherine. Pediatric primary care. 450c Olson. Norma. ClinicaJ nursing technique",. 500c Dizenzo. Patricia. Why me? 'lilJa Falk. Ann Man. The ambuldnce. J1D F.mshawe. Elizabeth. Rachel. 53Jd Fhnt. 8etty M. New hope for deprived children. 51Ap fnl"i. 8abbl\. k..risty'o;; courage, 53Ja Fromer. Margot Joan. Communit} health care dnd the nursing process. 8Oc Galton. Lawrence The patienf"i guide to "iurgery. 4:!Oc G.1rdner. Richard. The f.1mily book about minimal brain dy...function.53Ja Garfield. James B. Follow my leader. 53Ja Gn, um. M.1rlene Womanpower and health care (Spengler) 5 Oc Gunther. John. Dea(h he not proud. HJa Gydal. M,. When Oily went to hospital (Damelsonl 3JD Haas. Bdrnara Schuyler. The hospital book. HD Haber. Judith. Comprehens,ive psychiatric nursing let aU 480c Haggard. EliZdbeth. Nobody waved goodbye. 53Jd Halpern. Susan. Rape. helping the victim. 5::!Fe Hoffman. Therese Lemire. Into aging, a simulation game (ReiO 5!1e HolI.:md. Je.1nne M. C .1rdiova"icular nursing: prevention. intervention o:\ßd rehabilitation. 430c Hollowa)'. Nancy Meyer. Nursing and the cntlcally III patient. 430c Hudak.. Cðro1yn. ed. Critical care nursing (Gailo. Lohn S2Je Jessel. Camilla. Paul in hospi(al (Jolly) '3D "illilea. Mdrie. "aren. 53Ja k..lein. Normd. What It', aU about. 53J.1 k..nelsl. Carol Ren. Ment.11 heaJth conceph In medical-surgical nursing: a workbook (Ameo;;) k..ramer. Mdrlene. Path to biculturalism (Schmalenberg) 540c Lasker. Joe. He's my bro(her. S3Ja Lawrence. Mildred. The shining moment. 53Ja Laycock. S.R. Family living and sex education: a guide for pdrent"i and youth IC.1ders. 520c [edch. Penelope. Your bahy & child: from binh to age Iive.450c Leininger. Madeleine. Transcultund nursing: concepts. theories and pr.1ctices. 3:!Mr Lewio;;. Clara H. Nutrition. 500c Litchfteld. Ada. A button in her ear. 53Ja Litchfield. Ada. A cane in her hand. 5JJa MdcCracken. M.1ry. A circle of children. 53Ja M.1 ...ie. Roben.Journey (Md......iel 53Ja '11I1er. Michael H. Current per'\pectlves In nUr",mg SOCid1 issue"i and trends (t-lynnJ 490c Neufeld. John, Lisa. bright and ddrk. 53Ja Neufeld. John. Twink. 53Ja Park. Clara Claiborne. The seige. S3Jd Plall. "in. Hey dummy. S4Ja Rey. H .A. C uriousGeorge goc!'t to the hospital (Rey) JJD Robinson. J. ed. Givmg c.1rdiova,çul.1rdru "i \afely. 440c Robinson. Veronica. David in silence. 34Ja Samuels. Gertrude. Run Shelley run. 54Ja Scipien. Gladys M. Comprehensive pediatric nursing (et al) 440c Shaw. Charles R. When your child needs help. S4Ja Silverman. Peter. Who 'ipeak.s for the children: the plight of the battered child. 450c Simon. Norma. All kinds of families. 54Ja Simon. Norma. Wh) am I different. S4Ja Stein. Sara 80nnett. A hospital story. J3D Stewart. Mark A. Raising a hyperactive child tOlds) S4Ja VaJens. E.G. The other side of the mountain. 54Ja Vitale. Barbara. ed. A probiem-solving approach to nursing çare plans (Laue mer. Nugent) S4My Waite. Helen E. Valiant çompanions. 54J.1 Warner. Carmen Germame ed. Emergency çare. assessment and intervention. 48N Weber. Alfons, Elizaheth gels well. HD Weller. Stella. Easy pregnancy wilh yoga. 54My Welzenbach. J.F. Wendy Well and Billy Beller say .. Hello hospitaJ". Visit the hospital see through machme. Meet the hospital sandm.1n and A"k a "mdl-yun" hospital questions (Cline) J3D West. Paul. Words for a deaf daughter. 54Jol Wisc.1n. Principle .1nd practice of psychiatriL: nur...lng (et all490c Wolde.Lunilld. Thom.1!!. goeo;; to the doctor, 33D Wolff. LlI'-erne. F-undamentah of nu mg IWeltzel. fuer u 00c BOOKS 52Ja. 2Fe. 52Mr. SlAp. S4My. S2Je, 2Oc. 4 N. 5'D BOR"I..\.:'I/IS. Janis Your gUide to clinical laboratory proçedure\ (Shepherd. Hynie) 2 S DOL RQlE. Jean-Gu) Admini"itrauve M.1nageroftheCNA Testing Servicc. 7J/A BRADLEY. Christine HeaJthiest babies pos ible(Wdmyca. Ros") 18N BREAST tEEDlNG Hea1th professlOnd1s le.1rn more dbout late<;jt in mfdnt nutrition. 12N BRETT. Kathleen See MacMillan-8reu. k..athleen BRIANT. :'I/ora Bk. rev.. 5 Oc Bl CH..\. ". Jan. The deve10pment of .1 genatnc a!!.sed amendments to CNA bylaw.. liFe Submits briefto feder.d commr sion. CMr The C8n-.ll.n Nur.. D8c:ember 19711 57 (.A".\D1o\" 'IIl"R'\E:S .\SSOCIATlO'. .\'''l.\L "tEt:TI'G IMy Highlights from the port of the cxccutive director f\.lussallem)] ]10.1) National a sociation holds annual meeting. 12My CA....ADlA... 'lR!>t:SASSOCIATlOIlo. AIloIlol'AL MEt:T1'11G. 1979 RNABC submits election resolution. 8Mr CAIIo.\D1A:\ IIol RSES ASSOCI.\ no". .\RCHJ\.ES Nursmg past and present. I Mr CA'O\D1O\.... 'l K t.S '''!>UCIATlO:\. COS'\"E:'TIO' 1988 Vancouver. here we cornel :!:!D C A'ADIA" l\iLRSES ASSOCIA TIO . LlBRAIU See Library update CA"ADlA.... NlRSESASSOCIATlOIlo. TAS" GROl PON "lRSI'G PRACTICESTA"DARDS . (portl HOe CAIloADlA.... Nl "ES .\"SOCIATIO.... ITSTI"l. SER\ICE CNA Testing Senice (Prime. Parrott) 44M) Examination fees to increase in 1980. ION Jean-Guy Bourque is Administrative Manager. 7J/A Newly appointed members orCNA's Testing Service Nursing Assistants 81ueprint Committee met for the first time. 8Mr C A'ADlA' "'l"R!>ES FOL "DATlO!\o CNF receIVes II.ellogg grant. 14Ap New CNF board of directors. &Ja CA'ADlA.... ...lRSES FOL'IIDATIO....-SCHOLARSHIPS Thlneen nurses recei\'e awards \lalued al mOre than no.ooo. 120e CA"'o\DL'\.." ORTHOPEDIC IIoLRSES ASSOCIATIO" Orthopedic nurses set three-day atlendance record. 12Ap CA'ADlA" SOCIETY OFDlI\LYSIS P"-RFl!>lO"I!>TS . End stage renal disease: 1979 and beyond. 8N CANADlA' l"SIVERSlT\ "'lRSI"G STLDE....TS ASSOCIATlo" See CUNSA CA"CER Canng for the child with cancer. the nurse practitioner (Price) 48D Lifestyle crisis (O'Neil) 12Fe CAPE BRETO" ISLAJIoD-"'II'11I'11G D1SI\STER. 1979 Emergency (Miller) 4bMy CAPLI'II. Alice Bk. rev.. 480e CARDIOLOGY '79 Currents in cardiology attract record crowd. SSJ/A CARDIO\ ASCLLAR DI!>EASE:S WPW syndrome: a case study (Manning/ J4D CARROLL. Po_I. Bk. rev.. S2Je CATHOLIC HEALTH ASSOCIATIOr-; OF CANADA Rev. Everett MacNeil. executive director. 49Fe CA "E. Sleole What a liUIe care can do. 381) CEREBRO'\ ASCVLAR DISORDERS Frank's story (Halliian. HunU 2bMr CERTIflCA T10'l Occupational health nurses establish certification program.61a CHALMERS. KBren CNF schola",hip. 120e CHEMOTHERAPY The IV nurse and the chemotherapy patient: a \'ita) role in emotionaJ support (MacMillan-Brell) 28Je CHJLD Helping preschool chddren learn to be safe (Eifert) 2ID CmLD. EXCEYTIONAL A chance to grow wmgs for the spirit. IJe CHJLD ABUSE: CNJ talks to Lois Dale. PHN (port) 39Ja Be it resol\'ed...The role of the nursing association in the prevention of child abuse (MacLean) 40Ja Finding and helping victims of chdd abuse (Sklar) I Ua A team approach to child abu e (I-nzpatnck) 36Ja A work hop on child &tbuse. fJa CHILD BLHA \ lOR An exploratory study of the beha\'iors of children in pain (Macintosh) A, 47Je CHILD CARl" The National IndIan Brotherhood. ISAp Nurses honor chlldren. 8Mr CHILD HEALTH Did you know...a study conducled by.... 9Mr CHILD HEALTH tEDlTORIAL! The impossible dream' (Besharah) E. bAp CHILDRE""S HOSPITAL DIAGNOSTIC CElio TRE:. "ANCOl \"E:R Early diagnosIs in congemtal heanng loss (OahU 17Ja CHILDRES'S HO"t'ITAL OF E.\".EK'I O,"T ARlO Audiology programs: another \'Iewpomt (Smith. Tataryn. Simser) 2IJa A team approach to child abuse (Fitzpatnck) J6Ja CHOI-LI\O. Ag.... T.H. Bridging the gap between education and service (Logan) 34Mr CLAR!\.. Kathio \.I. New education co-ordinator for the RNAO (port) 50Ap CLO\\. Caroline A regIOnal program for the management of hereditary metabolic disease (Reade) 24N COCHRA'E. W.A. Guest editorial. E. JJa COLLEGE OF NLRSES OF ONTARIO Ontario nUrse oppose possible internship program for studenh.6Mr CO...I...IISSIO!\o 0' INQLlR\ I'IoTO REDL"\DA"CIES 0\1100 LAY-OtT'S IN CA'o\DA'S LABOR FORCE CNA submits brief to federal commIS IOn. 12Mr CO"'I'\IL 'ICABLE: DISEASt:S The problem of immunizalion in Canada (LeFon) Z6Ja CO!\l 1l "ICATION Did you know.... 7Ja CO !\Il NITY HEALTH l RSI'IG The nUi30e m the commumty: mfant stimulation (Banmngl36N CO:\lGRE:SSliS Communications specialists from (he eleven l.. NA pro\lincial/territoriaJ association members melln CNA House (port) 6Mr Critical care '78. 8Ja Did you know.... 7Ja Health happenings. I5Ap I.V. nurses meet. IOJa Measuring up, 8Je NationaJ association holds annual meeting. 12My Newly appointed members cfCNA's Testing Service Nursing Assistants Bluepnnt Comnuuee met for the first time. 8Mr Occupational health centre holds inaugural meeting. 14Ap Onhopedic nurses set three-day attendance record. 12Ap Spotlight on continuing education. &Je Time is nOw. nurses decide for selling up doctoral program.6Ja U ni\'c:rsity of Moncton to host annual CUNSA congress. &Ja A ,,"orkshop on child abuse. 6Ja CO,,"SL '\fER SATISFACTION Patient's ad \locate - a new role for the nurse? (Sklar) J9Je CONTRACEYTION Perspective (Wheatley) E. 4N CORRE:. Gioòle Officer. SOAp COTto Jacqueline Serving Sister. 50Ap CRAGG. Catherine E. Cross infection: a new approach to an old problem. 40Fe CRAIG. Dorothy Marlant The de\'elopment of a nursing audit tool. S70C CRAIG. J.:nnifu SI for you and me (PdgeJ ]bl-e CRAIG. J nnifer L"nn The effect of a self-mstructlon,IC FIBROSIS One bred(h at a time ( ms) 205 -D- DAHL. Marilyn o. Early diajnosis in congenital heanng 10 !Þ. I7Ja o 0\LE:. Lnls CNJ tdlb to LOIs Dale. PHN (port) J9Ja DA" EY. Keitha Bk. rev.. S41Jc DA \ IES. Borbara L}nn f.:\ctor.t in\lolved in a mother's decl lon to eek antenata) genetic coun ehng and have dn amniocentesIs at an advanced materna) age. 5bOc 1)4. \- ..... . folonÐCr Lornlln Officer. SOAp UA\\SO!\o,Joao Spedking out. a national child hedlth policy' 240 DEATH Sharing the experience (Willetb-Schroeder) J90c DEBOI:.R, tiw Sir. I know. 43My DELI\"E:RY OF HEALTH CARE Llfes(yle cnsls (O'Neil) 22Fe Perspective (Besharah) E. 3t-e StaJT,ngas.ignment (Be.wethenck) ItiMy DEN'ISO:\l. Ruth E. Assistant administrator. Holy Cross Hospital in Calgary. 491-< DIABETES INSIPIDlS Coping with diabetes in lpidu!o (Moens) 18Ap D1AGSOSIS. LABORI\TORY Your guide to climcallaboratory procedures (Bormanis, Shepherd. Hyme) 25S DIALYSIS End stage renal dISease: 1979 and beyond. tiN DOBBS, CyntIùa Bk" rev.. 420e DOHERTY. Gillian The patient in pain: handling the guilt feelings. 31Fe DO!>,RO"SKY. J. Understanding the phYSIology ofpdÌnlHedlinl2til-e DULCET, SfelJo Burton The young adult's reported perceptions of the effects of coDgenitaJ heaII disease on his life style. S70e DO\\N'S SYNDROME Diagnosis: down's syndrome (Nixon) 33N DRUG ABI.:SE Closeup on physicians at risk. ION DRUG OVERDOSE Emergency trealment of drug overdose (Erb) 30My DKLl\lHELLER MEDIl...1 SECURllY INSTITUTION. HEALTH CAIU:. CENTRE Did you know ...the Health Care Centre. 9Mr DURNFORD. Pbylil Bk. rev..44Oc DRYSDALE:, A.....n Received theJudy Hill Memorial SCholarship. 491-e 58 December 1979 The cenedlen Nur.. -E- EAGLE. D. Joan Bk_ rev.. 480c ECO"OMICS-Nl RSING Nurses from 64 countries attend ICN meeting in Africa. 120 EDl CATION GRADl ATE MARN appTOvcs emergency nUT'\ing course. IWa Time IS now. nur'\e'\ decide forseumg up docwrdl prog.-am. fJa EULC\rIO'. ...-LRSI"G The effect of a self-instrucrional module on the level of questions posed by nursing instructors during posl-ciinicaJ conference... (Craig) 570c RNABC sets up nursing education and re...earch socle,y. I 'Ap Bridging the gdp between education dnd service (Choi-Lao. Logan) HMr EDlCATIO'l/. Nl"RSI'G. BACCALAlREATE A follow-up study of graduates from the four year B Sc_ program in nursing. University of Alberta (Field) 570c Frankly speaking: nur'\ing and the degree mystique. Pt_1 (Hurd) 36Ap Frankly speaking: nursing dnd the degree mystique. P!.II (Hurd) 36My EDl.C.-\TIO'li. NLRSI"G. CONTI"'lING An assessment of selected continui.ng educdtlon experiences for professional growth and competence of nurses (MacI ntosh) 7Oc Nurses want mOre education programs and paid leave 10 allend. 14Ap Spotlight on continuing education, &Je EDI!l:ATION. ". RSI'G. DIPLO"lA PROGRA'\IS Frank)y speaking: nurCiilng and the degree my")tlque. Pt.1 (Hurd) 36Ap Frankly "ipeaking: nursing and the degree mystique. Pt.1I (Hurd) 36M) EDlCATIO'l/. Nl.RSI..G. GRADlATE-NO'\A SCOTIA Post graduate maternity nursing program: meeting the need in the Atlantic region (Steele) 240C EDlCATIO..... "lRSI'G.STA DARDS E"aluation of Alberta nurCiiing mstructors (Cadman) A. 47Je EDUCATlO:>;AL ME!.SURE'\IÐ,T CNA Te"ing Service (prime. Parrol\} 44M) ELFERT. Helen Bk. rev_. 450c Helping preschool children learn to be safe. ::!6D EMERGENUES Emergency (Miller) 6My Emergency treatment of drug overdose (Erb) 30My EMERGE"CY Nl RSING MARN approves emergency nu.....ing cour;ETT, EDen CNF scholarship, 120c HOLDER. Elizabeth Bk. rev.. 500c HOSPITAL EMERGENCY SER VICE The ro)e of the family in the emergency department (Nicklin) 40Ap HOl RIGAN. Eileen CNF schola",hip. 120c HOI'SE. R...alind A trip to the islandCii. 4::!Mr HO\T, Bonn) Executive director of N BARN, 49Fe Hl.MBER COLLEGE. TORO"TO Critical care '78. tUa Hl NT. Lori Whillingtoo Frank's tory (Hdlligan) ::!6Mr HI RD. Jeanne Maric L. Frankly Ciipeakmg: nursmg dnd the degree mYCiitique. PLI. 36Ap Frankly Ciipeaking: nursing and the degree mystlque_ 1'1.11. 36My H\ NIE. Ivo Your guide to clinical laboratory procedures (Bormanis. Shepherd) 25S H\ PERTENSION Hypenensive disorders in pregndncy (Hanley) 4!J/A The effects of selected factors on the older adult's managment of treatment for hypertension (Biene) 5SOC Hypertension: pediatric hypertension - think about it (LeFonl32Ap Hypertension: questions and answers (McCulley) 24Ap HYPERTENSIO'll-DRl'G THERAPY H ypertenslon: antihypertenslve and how they work. (Haslam) 26Ap HYPERTENSION-'l/lIRSI'IIG Hypertension: management m induCiitry - an expanded role for nurses (Milne. Logan) 21Ap - The cen-.llen Nurse a December 11171 511 -1- -"1- IW\1l 'E TOLERANCE The immune system (Hedlin) 27J/A l"I"Il'IT\: The Immune s\ stem (Hedlin) '!7JI A l"I'Il'IZ'\T10' Did you know...a study conducted by.... 9Mr National advisory committee on Immunization: recommended immunization schedules for infants and children. 29Ja The problem of immunization in Canada (LeFon) ::!6Ja l'D1o\'S "-"0 ES"I"IOS ursing north of sixty (Roberts. Ross) 26My l'U.o\"T The National Indian Brotherhood. 15Ap When baNes cry (Hams) 3::!Fe I'Fo\"T. NE\\BOR" Healthiesl babIes posSIble (Warnyca. Ross. Bradley) 181'1 I'Fo\:>.T'l-TRlTlO' HeaJth professionals learn more about latest In mfant nutrition. I::!N I"F.\"TSTI"RLATlO' PR(){;RA'\I The nurse in the community: infant Stlmulahon (Banning) 361'1 I'FECTIO:>. CO'TROL Infection control practitioners. people in the middle. 14D INPl-T Ja. 4Fe. 4Mr. 7Ap. 8My. 6Je. 56J/A. 9S. 6Oc. 61'1. 6D I:>'TE Sl\E CARE Critical care 078. SJa I"TESSI\E CARE l:>'ITS Nutritional assessment of the ICU patient (\1acDougall) 39M) I'TER"ATlO'AL CO" FERE "CE 0' PRI\L.\R\ CARE The impossible dream? (Besharah) E. 6Ap I' TER'A TIOSAL COl CIL OF:IIl RSES IC,," supports primary heallh care. 7Ja Nurses from 64 countries attend ICN meeting in Africa. lID Nurses honorchddren. 8Mr I"TER'ATlO'AL 'l RSES DA \ Nurses honor children. 8Mr l'IER.....ATlO'AL \:"Eo\R OFTHE CmLD. CA' o\D1A:>' COM"IISSIO' The National Indian Brothert100d. 15Ap I'TER'ATIO'AL \:EAR OF THE CHILD. 1979 CNJ's salute. Ua A chance to grow wings for the spirit. lJe Commentary (Besharah. Post) E. 10 Nurses honor children. 8Mr Guest eØitorial. E (Cochrane, 3Ja .....TER'SHJP. "O'\fEDICAL Ontario nurses oppose possible internship program for students.6Mr -J- JACK. !>usanna It's a bird.lt's a plane, It's supernurse! 34J/A JAC"SO:>.. Cheryl CNF schola",hip. HOc JAC08S0 . Mddrod C. Spoiling and helping Ihe learning disabled child (Gasek) l8Je JOWolSON, F.ye Neonatal jaundice and phototherapy (Tufts) 450 JO'llES. PbyUis Appointed dean of the Faculty of Nursing. Uruverslty of Toronto. 45N -K- MLLOGG rol "DATIO:>'. BATILE CREEl\.. MICHIGA.... CNF receives Kellogg grant. 14Ap Health services division receives Kellogg grant. 8N KELSEY INSTITL 7E Did you know.... 7Ja KID'IIE:\:' DISEASES End stage renal disease: 1979 and beyond. 8N "I'll ASH, Rose G. Experiences and nursmg needç, of spinal cord-lI'uured patients. 7Oc KL\:'E. Sandra That's right.I'ma nune. 35J/A ""'0'\. Janet "enny Recipient of the S 1.000 Helen Gibson Memorial Schola",hip.49Fe "0\\ .o\LCHl..... Bolly Frankly speaking: a challenge in office nursing, 485 -L- LABOR.\TOR\ TESTS \' our guide to clinical laboratory procedures (Ðormani Shepherd. Hynie) 25S LA"G. Ga.1 Bk. rev.. 5:!Fe LA 'GFORD. o\.J. A very present danger (PosU 42Ja LASGLOIS. '\farcolle CNF scholarship. 120c L.\SOR, lIot5y Time out! J60c LE.\DERSHIP Nurses need leadership skills (Spennra(h. Tlive.) J3Je LEADERSHJP DE:\ELOP"IE:"T \\ORKSHOPS Nurses need leade",hip skdls (Spennrath. Tiivel) BJe LEAR'I...G DISORDERS Spoiling and helpIng the learning disabled child (Jacobson.Gasek) l8Je THE LEBO\:ER '\IETHOD What does it mean now? (Grossman) :!8Oc LEEC H. Joan CNF scholarship. 120c LEFORT. Sandra Hypertension: pediatric hypertension - think about it. 32Ap The problem of immunization in Canada. 26Ja LEGISLA TIO:>' Error of jUdgment: is it always negligence? (Sklar) 14Mr Finding and helping victims of child abuse (SkJar) IUa On trial'/SkJar) 8Fe Patient's advocate - a new role for the nurse? (Sklar) 39Je The coffee-break: pmenua] pitfall for nurses (Sklar) ISMy Where does the nurse's responsibility begin and end in caring for a patient's belongings' (Sklar) 14S LEGISLATION. MEDICAL Nurses speak out on legal issues in heaJth. S4J/A LEGlSLATIO,".!'ol RSJ'IIG Sinners or saints? (Besharah) E. 4Je LE VESQl E. Loubo CNA's Task G roup On Nursing Practice Standards (port) !JOc Director of CNA projects, 7J/A L1BRAR\ lPDo\TE S4Ja. S2Fe. S2Mr. S2Ap. SSMy. S3Je. S7J/A. SOS. S8OC. L1'DABlRY. VlrgI.... A. Former CNJ editor. educator dies in Florida. 7N WGAN. Alexander Hypertension. management in industry - an expanded role for nu",es /Milne) 21Ap LOGA'. '\far,Dg S. Bridging the gap between education and service (Choi-Lao) 34Mr LO' EY . Gistio Has been appointed CNA Liaison Officer. 7J/A LO'llG TERM CARE Improved care urged by RNABC. 8Mr WWE. Agatb. Gor1rude Jomed Project HOPE medica} education program In Natal. Braz . SOAp WYER, Mario d.. A_ Officer. SOAp "IACCLISH. Barb.ra Visions. J5Fe "lacDONALD. Joyce Closeup on Nova Scotla's reproductive Care program. 270c I 'I O\COO' 'ELL, Susan A teenage pregnancy epidemic? 22N "IACDOlGALL. \"erio Nutritional assessment of the ICU patient. 39My MACI'TOSH. Allee R... An assessment of selected continuing education experiences for professional growth and competence of nurses. 7Oc "I %CI' TOSH. Judith An exploratory studv of the behavIors of children in pain. A. 47Je \f.\CLE'\'.Je_ Be it resolved...The role of the nursing association in the prevention of child abuse. 40Ja "IACLEOD. Shlrioy New CNF board of directors. 8Ja "IAC\fILLAN-BRETT. Kethl..n The IV nurse and the chemotherapy pahent: a vital role in emotional support. 28Je Mac'JEIL. Re"", E"rrett Executive director of the Catholic Health Association of Canada. 49Fe "I'\LCOLM.IIM Bk. rev.. 490c \fALPRACTICE The coffee-break: potential pitfall for nu",es (Sklar) I5My Error of jUdgment: is it aJways negligence (Sklar) 14Mr Nursmg negligence in the administration of medication... Could it happen to you? (Sklar) S U/A On mal! (SkJar) 8Fe Sinners or saints? (Besharah) E. 4Je MA "TOBA ASSOCIA T10'll OF REGISTERED IIIl RSES \1ARN approves emergency nursing course. IWa Kathleen Scherer joined office, 49Fe \fA "ITOBA ASSOCIA TIO'll OF REGISTERED '11I:RSES. .'\":>'J:AL '\IEETI'iG Newsbeat: the provincial scene. IIJ/A \IA"I'G. Coloon WPW syndrome: a case study J4D MA"SOlR. Penni Bk. rev.. SOOC MATHESON. tM y Commander Sister. OAp \fCBRIDE. Bo.....ley Høinl5 Babies with necrotizing enterocolitis: what to watch for. 410 "IcCL LLE\: . '\fary H ypenension: questions and answers. 24Ap "IcDO"ALD. \ida Commander Sister. OAp McEACHER". M.rgaret Mary Serving Sister. SOAp McKEOGH. Clair. Librarian-Archivist at CNA. 7J/A McKEE\ER. PBtriela Bk. rev _. 450c \fcKENZIE. Ruth H. Analysis of the use of a computer generated staffing schedule On a nursing unit in a general hospital. S OC Mc"lASTER l"NIVERSITY . FACULTY OF HEALTH SCIENCES Occupational heallh program launched. 7Mr MeTA VISH. Maureen The nurse practitioner: an idea whose time has come. 41S MEDICAL RESEARCH COI"NCiL U of A host visIting professor. &Ja . 60 D8c:ember 1979 The cenedlen Nur.. "IEDIC o\TIO' ERRORS NUI"I)mg negligence in the ddmml trdtlon of medlcdlJon... Could it happen to YOu') (Sklar) 31J/A "IENTAL RET ARDA TlO;'; o B. stalT alert IC dmeron\ 30N Our c;,pecial children (Peer) 14Ja METABOLIC DlSEo\SES 4.. regional program for the management of hereditðry metabolic di'iicase (Reade. Clow) 24N METRICS\:STE SI for you and me (Craig. Page) 16Fe MIDWIFER\ Nur'ie Midv.-ifery: are we ml,..inlE the boat? (Powi", 210c "IIGRA"F Did you kno\\ _..4fJe MILLER. Dorolh (;ra) Emergency. 46My MIL "E. Barbara Hyperten'lon: mandßcment in mdu'itry - an expanded role for nUr'iiC\ (Log.in) 21 Ap MOE:-OS. Jannelte Coping with diabetcc;, in'iiipidus. 18Ap MOII.\" " COLLEGE OF APPI lED ARTS A"D TECHNOLOG\: A nurse practitioner in a community college setting (Nelle'i,25Fe O()RE. Janel Bk rev.. :!Oc MOl :>OTSINAI HOSPITAL. TORO:>OTO An experiment in innovative "raffing (Stuart) 4 S Sinners or saints? (Bc'iihdrah) E. 4Je inner.t or -;aints? The legal pCripective Pt I (Skl.u) 14N Sinners or saint'? The legd1 per"ipective. Pt.11 'Sklar) 16D \-U'LLEN. Elaine \-.. Bk rev. "'!Ie Ml.L TIPLE SCLEROSIS Health happening'. ISAp Ml'SSAI LE"I. Helen K. Highllght!!l from the report of the executive director. liMy New CNF bOdrd of direclOr,. KJd Nur,e, "'dnt more educdtlon programs and pdld ledve to dllend. 14Ap -N- SAMES 49f-e. 50Ap. 45N NATIONAL AD\lSORY CO"nIITTEE ON 1\1 1'''I.fATlON Recommended Immunization "ichcdule, for mfdnt, dnd children. 29Ja "ATlO'.\L CONt..'Rt:SCE Ot OPFR.\TlN(; ROOM 'lRSES Cover photo. JS NATIONAL CON FERESCE0" HE.\LTH A'D LAW. OTTA"A.1979 NUhe :"IIpedk out on legal i ,ue in health. 54J/A 'ATlO'l,AL INDIAN BROTHERHOOD Among SO group.. to receive fund'ì.. I Ap 'EGLlGÐ.CE Hands that care: are they .are' (Skldr) IOOc NEI LES. Diana A nur!te practitioner in a community col1ege setting, :!5Fe NEVITT. Jovce Has wnllen a history oflhe nu mg profe "\lon in Newfoundland.45N 'olE" BRl 'l/SWIC" ASSOCIA TIO," OF REGI!>TERED NliRSES Appointment of Bonny Hoyt. executive director and Jacqueline Steward. nursing consultant. 49tc Jacqueline Steward. appointed nursing consultant for nursing practice (pon) 50Ap NEW BRL'l/SWICK ASSOCIATION OF REGISTFRED "l RSE!>. ASNL 0\1. MEFTISG New"\heat: the provlncldl "icene. 14J/A NEWS 6Ja, liFe. IIMr. 12Ap. &Ie. 9J/A. 120e. 7N. lID 'IIIC"L1". "end McKnight The role of the f""mily in the emerlEency depanmenl. 40Ap 'IIICHOL. Celia ThaCs no nur"ie...that'.. my mother! 4 Mr :-OIGHTlNGO" N. Lawrence Nursing: nineteen-eighty-floor. I1Mr "IXO'l/. Linda l, Diagnosis: down's ..yndrome, J1N :-OORTHt'R'II Sl.RSING Nursing nonh of ..i,ty (Robens. Ro s) 26My "ORTH" EST TERRITORIES Nursing nonh of Slxt y (Rohens. RO"isl 6M) M RSE CLINICIAN TEACHERS Nurse"i need leadership ..kills (Spennrath. Tiivel JJJe Nl RSE-PATIENT RELATIONS Life"ityle crisl' (O'Neil) 22Fe O,B, "alTalert(Camerom30N Per pective (Be..harah) E. 3Fe The IV nurse and the chemotherapy patient: a vital role in emotiona1 suppon (MacMillan-Brett) :!8.Ie The patient in pain: handling the guilt feelings (Doheny) JIFe "l RSE-PA TlENT REI A TlONSHIPS Per'pecti"e (Bock) E. S !l.lRSE PRo\CTITlO'ER A nu e practitioner in a commumty college setting (Nelles) 2SFe The nurse practitioner: an idea who...e time has come (McTavish) 41S Nl RSF PRACTlTlO'llERS ASSOCIATION OF 0' T,\,RIO NPAO Executive. 140c " I Lt. M.RSI"G Closeup on nur.tmg nelwurks. IJJ/A Nu..ing fact and fantasy (Allan) 37J/A That's nght.I'm a nu",e ("Iyne) 35J/A Nl RSI"G Al DIT The development of nur ing audit tool (Craig) 570c A meS"iage from the pre ident (faylor) 10M} Sl RSING /EDITORIAL, Perspective (Beshdrah) E. -'Fe Nl RSI'G-IIRI fiSH COLlMBIA Nurses review health needs of B.C. Corrections inmates. 140e 'Ill RSI'IIG-CANADA-STANDARDS CNA's T ð.skGroupon Nur!ting Practice Standards (port) HOe I'ollRSING CARE Bndgmg the gap between education dnd Itervlce (Choi-Lao. Logan) 34Mr It's a bird. if's a plane. if'''i supemurse! (Jack) 34J/A Perspective (Bock) E. 5S Sinners O( saints? The legal perspective Pt.l (Sklar) 14N Sinners or saints? The leg perspective Pt.11 (Sklar) 16D The touch oflove (Cdmolinosl JlllA That's right ('m a nu,-"e (KlyneI3SJ/A "lRSI"G CARE- THODS Staffing assignment (Beswetherick) 18My Nl.RSING CARE-STANDARDS Frankly speaking: nursing and the degree mystique. Pt.l (Hurd) '6Ap I-rankly peaking: nur"iing dnd the degree my...tlque. Pt.ll (Hurd) 'liMy fhe coffee-hreak: potential pitfall for nur"ies (Sklar) ISMy A me..sage from the president (faylor) IOMy Project Ethics: a code for Canadian nurses (Roach) E, 6My NURSING EDCCA TIO See education Nl'RSI!IoG-FRA"CE Here and there: a look at nur mg in France (Gro,sman) '00c Nl RSI"'G ST AFF. HOSPITAL AnalysIs of the U!!le of a computer generated "itafTing schedule on a nursmg unit in a general hO"ipit.tI (McKenzie) sSOe An experiment in innovative staffing (Stuan) 45S Sinners or saints? The legal pe pective Pt.1 ,Skldr) I..N Sinnersorsaints?ThelegaJ perspective PI.II (Sklar) 160 Nl'TRITlOI'o l-aclOr Influencing the con"itructlon ofa nutrition knowled.ge te t for the elderly IThur..ton) 570c Nutntion and the chrome "ichlzophrenic (Pyke) 40N Nutrition counseling. 15Ap Nutritional a<\<õõessment of the ICU patient tMdcDouga:!1) 39My -0- OBSTETRICAl Nl RS"G Clo..eup on Nova Scotla's reproductive care program ( acDondld) !JOe CountdownonO.B nur...e, (tleld) 180c The LeBoyer Method: whatdoe"\ It mean now (Grossman) 280e Perspective (Stainton) E, 50e Post graduate maternity nur"iing program: meeting the need in the Atlantic region (Steele) 240e OBSTETRICS CIO' eup on coalition for the prevenllon of hdndicap ( Beshdrah)29N Healthiest babies pO"i..ible (Warnyca. Ro...s. Bradley) 18N That's no nursc.__thaC4\ my mother! (Nichol>>4S:\-1r OCCl'PATIOSAL HEALTH OccupoilionaJ health centre hold"i inaugural meeting, 14Ap Occupational health program Idunched. 7Mr OCClPATIOi'io\L HEALTH Sl RSIN(; Hypenen"iion: management In Indu try - an expdnded role for nU['ô.e (Milne. Logan) 21Ap Occupational health nurses attend alcoholism conference. 140 Occupational heð.lth nurses establish certification program,6Ja Oft ICE "l RSI'G frdnkly speakmg: a challenge 10 office nU lng IKowalchukl48S OLSIA". Mar .rel T. Bk. rev.. 5lOe O'NEIL. Theresa Lire'\ty1e criM!oo. 22Fe ONTARIO BLUE CRU"" Nutrition counseling. 15Ap O"T.\RIO. \UNISTR\"Ot.COLLEGE4."D l M\-ERSITIES Ontario nur"ies oppose possible intem..hip program ror students.6Mr O'l/TARIO NLRSING HOME ASSOCIA TlOS Nursing home nurose"i work to improve care. I D OOLl p. Pilvi Bk. rev.. 440e ORDER Ot' CA,"ADA Edith May Radley. SOAp ORDER OF ST. JOH,\; A number of nurses were honored. 50Ap ORTHoPEDICS Onhopedic nUr"ie!!l set three-ddY attendance record. 12Ap OUTPOST Nl RSI:>OG A trip to the islands (Hou!ooe) 42Mr -P- PAGE. Gordon C, SI for you and me (Craig\ Illfe PAIN An exploratory study of the behaviors of children in pain (Macl ntosh) A. 47Je ^ holistic approach to nursing the patient in pain (Vaterlaus) 22Je The patient in pain: handling the guilt feelings (Doheny) 31F-e Understandmg the physiology of pain (Hedhn. Dostrov ky) 28Fe PARK. Lillian Learning about the ho pitaJ at home (Ferguson. Wdrd) 44Jd The cenedlen Nuree 3 D8c:ember 1979 61 P/\.RRUTT. Eric G CN -\ festms Service (Pnmc) 44\1\ P.-\S.h.. EJiaDor Grace A study of the effects of clinical inve tlgatlons conducted in the homes of children with mtt,arohc disorde",. 550c PATlE'T .\D\OCAC\: Atutude of registered nurses towards consumer nght and nursing independence (Green) 6Oc P3uent"s advocate - a new role for the nurse'> (Sklar) 19Je PATlE'TS Pallent's advocate - a nev. role tor the nurse (Sklar) 19Je Where does the nurse's respon\ibility begm and end in caring for a patient".. belongìngs (Sklar) 14S PATlE'TCARE: PLA!I;'I"G Nursing care plans: a vital tool (Silvcnhorn) 36Mr PA TIE' TS-EDl C A TlO' Currents in cardiology attract record crowd. 3SJ/A PEDIATRIC 'l RSI"G The nurse in the community: infdnt ..tlmulallon (Bannmg) 36N PEDIATRICS A preschoolers" health circus (Crawford) l4Jd A study of the effects of clinical invclliugations conducted in the homes of children with metabolic disorder.. CPask/ 550c A team approach to child abuse (Fitzpatrick} '6Ja A very present danger (Post. Langford} 41Ja Babies with necrotIZing enterocolitl : what to watch for (McBride, 410 Caring for the child with cancer: the nu e practitioner (Price) RO Childhood asthma: an outpatient dpproach to treatment (Ferguson. Webb) 36Fe Early diagnosis in congenital hearing loss (Dahl) 17Jd Guest editonal. E (Cochrane) 3Ja Hypertension: pediatric hyperten\ion - think about it tLeFort} 32Ap Learning about the hospital at home (Ferguson, Park. Ward) 44Ja Our special children (Peer) 14Ja Neondtal Jaundice and phototherapy (Johnson. Tufts) 450 Preparation oftoddler.. and preschool children for ho pilal procedures (Ritchie. J()[) "Problem children" aren't problems anymore (Hegadoren) 31la Spotting and helping .he learning disabled child (Jacobson.Gasek) l8Je What a liule care can do (Cave' 380 WPW syndrome: a ca e study (Manning) '40 PEER.Brigld Old you know___3 study conducted by.... 9Mr Our special children. J4Ja PERSO'i'EL ST AF"FI!I;G A '0 SCHEDlLL'iG Old you know... Labour Relations Council. 15Ap Staffïng assignment fBeswetherick) 18M)' PERSPECTI\ "E: 3Ja. 3Fe. 3Mr. Mp. 6My. 4Je. 5JIA. 5S. 5Oc. N. 50 PH\:SICIANS Closeup on physicians at nsk. ION PINELLI. Janet May A companson of mother's concerns regarding the care-taking tasks of newborns with congemtal hedrt disease before and after assuming their care. 9D PI'\S. SCHOOL Key to cover photo. 3Mr POETRY Sir. I know (DeBoer) 43M) Visions (MacCuish) 35Fe POST. Shirley A very present danger (Langford) 42Ja Commentary fBesharah. E, 10 POWIS. Julianne N urse-Midwd'ery: are we missing the boat? 21 Ck PREGNA."CY That's no nurse...that's my mother! (Nichol) 45\1r PREGN-\NC\: I" -\J)()I.E:SCE"CE The '\ingle mother: can we help'l CBillung-Meyer. :!fiN A teendge pregnancy epujemlc? (MacDonnell) 1:!N PREG"A"('\: TO"E'II-\S H per1ensl\.e disorde" m pregnanc) (Hdnle}'1 41J/" PRE\ENTI\"E: HE-\LTH SER\ tC"'s Nutrition coun eling. 15Ap PRICE. Barbara J. Caring for the child with cancer: the nurse practitioner, 80 PRIMAR\: HEALTH CARE ICN supports primary health care. 7Ja PRI\IE. Bert CNA Testing Service (Parron} 44 1y CNA - ",hat's it all about? WIA Have you looked at your a....ocidtiOn lately? E, 5J/A PRISO"S-BRITISH COLl'IBIA Nurse.. review health needs of B.C. Corrections inmates. 14Ck PRI\ ILEGEDCOM'\1l "ICATlO'l, Patient's advocate - a new role for the nurse? (Sklar) 39Je PROJECT HOPE IE:D1C -\1 EDl CA TlO' PROGRAM AgathaGenrude Lowe.jomed the project m Ndtal. Braz . 50.-\p PS\:CHI..\TRIC "lRSI"G Behaviour.. of patienh de'icnbed by nurses in medical- urgical area.... in the initiation of psychiatric referrals ([homson) A. 47Je "Problem children" aren't problems anymore (Hegadoren) 11la Time out! (LaSon 360c Pl BUC HF-\LTH:IIl RSI'I,. A trip to the Is'ands{Hou to Loi.Odle. PHN (port) WJa Speaking out: a national child hedlth pohcy ! (Dd\\ \on) 140 Not all patient.. need ho\pltals (Aish) 23Mr PLBUC RELATlO1l;S Communications specialists from the elevenCNA provincial/territoridJ as..ociation member.. met in CNA House (port) />Mr P\ KE. Jennifer Nutrition and the chrome schizophrenic, 40N -Q- Ql AUT\: OF HEALTH CARE Frankly speaking: nursing and the degree mystique. Pt.1 (Hurd) 36Ap Frankly speaking: nursing and the degree mystique. I'Ll! (Hurd) 36My -R- RADLE\:. Edith '\Ia) The Order of Canada. 50Ap RAIN" ILLE. Joyce CNF scholarship. 120c RANKIN. H..th.r Handicap: a parent's perspective. 38N RAl\I....I". Lorna Bk. rev.. 43lJc READE. Terry A regional program for the management of hereditary metabolic disease (Clow) 14N REAUTY SHOCK Whither nu",ing? 3 iliA REFERRAL ANDCONSI LTATION Behaviours of patients de..cribed by nur e in medical-surgical areas In the initiation of psychldtnc referrals IThom\onl A. 47Je REGISTERED :IIl'RSES ASSOCIATION OF BRITISH COLlMBIA Improved care urged by RNABC. 8Mr RNABC submits election resolution. 8Mr Sets up nursing education and research society. HAp REGISTERED NlR!>"E:S ASSOCIATION OF BRITISH COLUMBIA. ANNUAL MEETING New beat: the provincial scene. 9J/A REGIS'CERED 'il RSES ASSOCIA TlO:o. OF BRITISH COil MRI-\. I.ABOl R RELA TlO:-'S cm NCIL Did \IOU know... Labour Relation.. Council. 15Ap REGIS.I ERED Sl RSJo.S ASSOCIA TIO" OF SO" A SCOTI/\. Be it resolved...The role of the nur\mg a SOcldtlon an the prevention of child ahu'\e C MacLean) 40Ja REGISTERED 'l RSES -\sson"no" O..O"T-\RIO I\...uhle M. Clark. education co-ordinator (pon) 50Ap Ontano nurse.. oppo..e pos...ihle Internship program for studentCii.6Mr REGISTERED Nl RSF!> ASSOnA TIO' OF 0' T .\RIO. \NNl. AI IEETI"'L Ne "..beat: the provincial '\Cene. 11J/A . RH;J!>....ERED "l R!>ES "SSOCIA TION OF "0\ A SCOTIA. A':IIl AI 'IEFTI"L New beat: the pro\.inclaI..cene. I-1J/A RFGISTERED:IIl RSES rol 'D.\ TIO' OF B.C. RN .t\BC ,et!i. up nur'\mg education and research soclety.ISAp REHABIUT A nON J-rdnk's !!.tory (HalligcUl, Hunt) 16Mr REICHE. Linda CN. schola",hip. 120c RE!>EARCH 7Je. 55Oc. 90 A compdrison of mother's concerns regarding the care-tdking tasks of newborns with congenital heart di ease before and after a.. uming their care C Pinelli} 90 Andlysis of the use of a computer generated staffmg schedule on d nuro;;ing unit in d general hospital IMc....enzie) 5 Ck An a.....e"'..ment of ..elected continUing education experience.. for profesc;.ional growth dnd competence of nurses (Mdcinto h) 57Ck Attitudes of registered nur\es towards consumer rights and nursing independence (Green) 560c Behaviou of patients described by nur'\es in medical-surgical area.. in the initiation of p'!oychiatric referrals (fhomson) A. 47Je Child abuse progmm: Scarborough Depar1ment of Hedlth (Cunningham) 90 fhe development of a geriatnc a.. e"'mem m..trument for long term Cdre facilities (Buchan) 90 The development of a nursing audit tool (Craig) 4i7Oc Old you know.... 46Je The effect of a ..elf-instructional module on the level of questions posed by nursing in\tructors during post-clinical conferences (Craig) 570c The effect of selected factors on the older adult"s management of treatment for hypertension (Biene) 550c E"dJudlion of Alberta nur\lßg instructor.. (Cadmdn) .t\, 47Je Expenence and nur..mg needs of ..pinal cord-lrUured patienls (Kinash. 7Ck An exploratory study of the behaviors of children in pain (Macintosh) A. 47Je Factors influencing the construction of a nutntlon knowledge test for the tlderly ([hurston) 570c Factors involved in a mother'.. decision to seek antenatal genetic coun..eling and have an ammocente..is at an advanced maternal age (Davie J 560c .t\ follow-up study of gradudte from the four year RSc. program in nursing. Univer\lty of Alberta (Field) 570c RN .t\BC sets up nur..ing educdtion and research society. HAp Spinal-cord irUury: early impact on the patient's significant others (Hart) 57Ck A tudy of the effects of clinical investigations conducted in the homes of children with metaÞolic disorJe", (pask) S50C The young adult's reported perceptions of the effects of congenital heart disease on his life style (Doucet) 570c RIDEOI T. Ehzabeth Bk. rev.. 420c RITCHIE. Judith A_ Preparation of toddlers and preschool children for hospital procedures. 3(1) ROACH. Slmo... Project Ethics: a code for Canadian nur'\es. E. 6My . 82 Oecember 1979 The Canadien Nurse New CNF board of directors. 8Ja ROBERTS, Lence W. Nursing north of sixty (Ross) 26M) ROK, Adam Bk. rev.. 480e ROLE Patienfs advocate - a new role for the nurse? (Sklar) 39Je ROSS. Colin A. N ur"ng north of "Xly ,Roberts) 26My ROSS, Susan Healthie" babies possible (Warnyca. Bradley) 18N ROSSITER. Edna 14th Canadian nurse to receive the Florence Nightingale A ward from the I ntemauonal Red Cro".4SN ROWAT, Kathleen C N F schola", hi p. 120e ROY AL. Joøn Bk. TeV.. 430e ROYAL VICTORIA HOSPITAL. '\IONTREAL Nurses need leade",hip skills (Spennrath. Tiivel) HJe RY AN. Jessica Bk. rev.. S30 Frankly speaking: apathy in nu",ing. 3IJe -S- ST JOIL" AMBVLANCE Did youknow...St.JohnAmbulance.ISAp SA MS. Cheryl Ann One breath at a time. 2 OS SASKATCHEWAN I:IISTITUfEOF ARTS AND SCIENCES Did you know.... 1Ja SASKA TCHEW AN REGISTERED Nl'R E:S ASSOCIATION. ANNUAL MEETING Newsbeat: the provincial scene. IOJ/A SA V ARD. Françoise Officer. SOAp SCHERER. Kathleen Jomed office of the Manitoba Association of Registered N u",es. 49Fe SCHILLL"G. Karin voo Bk. rev.. SlAp Bk. rev.. S3D scmZOPHRENIA Nutrition and the chronic schizophrenic (Pyke) 40N SCRlTBY. Lynn Winner of the Helen McAnhur Canadian Red Cross FellowshIp for graduate study.12Oe SEARLE, Catherine Tetanus: the costly CUre. 181/A !;EX EDUCATION Pe"'pective (Wheatley) E. 4N SHEPHERD, Frances A. Y OUf guide to chmcallaboratory procedures CBonnanis. Hyme) 2SS SHIFT SYSTEMS An experiment in innovative staffing (Stuan) 4SS SILVERTHORN. Alida Nursingcare plans: a vital tool, 36Mr SI'\ION FRASER HEALTH UNIT A preschoole",' health circus (Crawford) 14Ja SIM!;ER. Jndy Audiology programs: another viewpoint (Smith, Tataryn) 2IJa SKLAR. Corinne Error of judgment: is it always negligcnce? 14Mr Finding and helping victims of child abuse. llJa Hands that care: are they safe? lOOc Nursing negligence in the admlmstration of medication... Could it happen to you' SIl/A On trial! 8Fe Patient's advocate - a new role for the nurse? 39Je Sinners orsaints?The legal perspective Pt.I. 14N Sinnersorsaints?ThelegaJ perspective. Pt.II.IID The coffee-break: potemial pitfall for nurses. I5My Where does the nurse's responsibility begin and end in caring fora patient's belongings? 14S r. N SMIl H, Andrie DurleuJI: Audiology programs: another viewpoint (fataryn, Simser) 2IJa SMOKI"G Clo"eup on a generation of non-smokers? 12N SNIDER. Eleanor M. Serving Sister. SOAp SOCIAL ISOLATION The loneliness of the elderly (Griffin) 23 My SOCIETIES. Nl'RSING A catalogue of special interest groups lFitzpatnck) 9Je SPAIN. Doris Bk. rev.. SOOC SPECIALTIES. Nl'RSING A catalogue of special interest groups (Fitzpatnck) 9Je SPENNRATH. Susan Nurses need leade",hip skills ([iivell 33Je SPINAl CORD INJl RIES Experience" and nursing needs of spinal cord-ir\iured patients (Kmashl 570c Spmal cord ir\iury: early impact on the patient." significant othe", (Hart) S10e STAINTON, M. Colleen Pe"'pective. E. 50e STEELE. Rosie Post graduate maternity nursing program: meeting the need in the Atlantic region, 240c STE" ARD. Jacqueline Appoi.nted nursi.ng consultant for nursing practice of N BARN (port) SOAp N u",ing consultant of NBARN. 49Fe STEWART-HES!;EL, Elizabeth Bk. rev., 4SOe Bk. rev.. S20e STRESS Hypertension: management in Industry - an expanded role for nurses (Milne. Logan) 21Ap Hypertension: questions and answers (McCulley) 24Ap STUART. AlllsonJ. An experiment in innovative staffing. 4,SS Nursing grand rounds: femoral allograft (Alemany. Ferguson. Grice) 320e Sl'ICIDE. A TTE1\IPfED Emergency treatment of drug overdose IErb) 30My SUTHERLAND. Debbie Bk. rev.. 48N -T- TASK GROUP ON "Il RSING PRACTICE STANDARDS Canadian Nurses Association (port) 13Ck TATARYN.Karen Audiology programs: another viewpoint (Smith. Simser) 2IJa TAYLOR, Helen D. A message from the president. IOMy TECINOLOGY, MEDICAL Your guide to clinical laboratory procedures (Bormanis, Shepherd. Hynie) 2SS TELLIER-CORMIER, Jeanine Serving Sister. SOAp TETANUS Tetanus: the costly cure (Searle) 181/A The unexpected Case of tetanus (Grove) 26J/A THE WORKSHOP. BEACON HILL. MONTREAL U of A hosts visiting professor, 8Ja THOMPSON. M. Bk. rev., S4My THOMSON. Carole Lee Behaviours of patients described by nurses in medical-surgical areas in the initiation of psychiatric referrals. A. 41Je THVRSTON. Norma E:. Factors influencing the construction of a nutrition knowledge test for the elderly, S10e TIIVEL. Judy Nu",es need leadership .kills (Spennrathl HJe TOO. Louise TRAINING SUPPORT WHO to award health fellowships. 1Mr TRANSPLANT A T10N. ALLOGENIC Nursing grand rounds: femoral allograft (Alemany. Fergu..on, Grice. Stuart) 32Ck TUFTS. Frances Neonatal jaundice and phototherapy (Johnson) 450 -U- l'NITED NATIONS Guest editorial. E (Cochrane) 3Ja L"11\ ERSITY OF ALBERTA Health services division receives Kellogg grant. 8N U of A hosts visiting professor. BJa UNIVERSITY OF MONCTON University of Moncton to host annual CUNSA congress. 8Ja lNIVERSITY OF WESTERN ONTARIO Did you know...astudy conducted by.... 9Mr -V- \ANCOITVER PERINATAL HEALTH PROJECT Healthiest babies possible (Wamyca. Ross. Bradley) 18N VA TERLAUS. Emalou A holistic approach to nursing the patient in pain. 22Je \ICTORIAN ORDER OF NUR!;ES FOR CANADA Caseload: over seventy-five (Gibbon) 20Mr Closeup on the Victorian Order ofNu es for Canada. S4J/A \ IRVS DI!;EA!;ES Health happenings. HAp -W- WALLACE, Pat CNA's Task Group on Nursing Practice Standards (port) HOe Project Director. development of nursing practice standards.1J/A WARD. Vera Learnmgabout the hospital at home (ferguson. Park) 44Ja W ARNYCA. Jennifer Healthies babies possible (Ross. Bradley) 18N WATSON. Ina Bk. rev.. 440e WEBB. Anne Childhood asthma: an outpatient approach to treatment (Ferguson) 36Fe WHEATLEY. Shirley Perspective. E. 4N WHITE. Leslie J. Bk. rev.. S4My WILLETTS-SCHROEDER. Valerie Sharing the experience. 390c WINKLER, Joy CNF sChola",hip. 120e W.K. KELLOGG FOUNDATION Time is now, nurses decide for setting up doctoral program.6Ja WOMEN Women as health care consumers. a change and a challenge. 130 WORKSHOPS See Congresses WORLD HEALTH ORGANIZATION A four-member international nursing team. 8Je The impossible dream? (Besharah) E. 6Ap To award health fellowships. 1MT -X\::Z- YOL AND THE LAW I IJa. 8Fe. 14Mr. I5My. 39Je. SIJ/A. 14S. lOOc, 14N 160 ZANIN. Margaret Bk. rev.. 430c . Helping the retarded child in hospital . A team approach to child abuse . Dealing with the problem of immunization . Learning about the hospital at home . Congenital hearing loss . Preventing childhood accidents . A new role for the psychiatric nurse The Can ian \ Nune r 3 . JANUARY 1979 ... \ \ - - -4 \ , " . JIIVl Ij"ttu ^ V 111 ' 1<\' I' IflH11J I J.jI iJ-Hl' Cf{}" J , \ \V "ROYALE SENSATIONS" A beautiful 1 00% textured Dacron s polyester - so light, so luxurious, so feminine - an elegant addition to your Spring wardrobe. Another exclusive fabric from "The House of White Sister" ...... - -- " I " 'Ie No. 42738 - Skirt suit .es: 3-15 oyale Sensations" : e, Apricot. . . about $44.00 Style No. 42736 - Dress Sizes: 3-15 "Royale Sensations" White, Yellow. . . about $36.00 J ., ... , .. A Division of White Sister Uniform In' t '" Available at leading department stores and spe I ialty shops . cro s Canada . . JT' 3 The -, Canacliðn \ _ t: .,,-'-' - lose e The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number I .. \to I, Guest Editorial 3 You and the law Corinne Sklar 11 md Input 5 A preschoolers' health circus Rosemary Crawford 14 News 6 Early diagnosis in congenital hearing loss Marilyn O. Dahl 17 ;1 Calendar 50 Audiology programs: Andrée Durieux. Karen Tataryn, an another viewpoint Judy Simser 21 I Books 52 The problem of immunization in Canada Sandra LeFort 26 .H "Problem children" "ren't problems anymore Kathy H egadoren 31 Library Update 54 Our special children Brigid Peer 34 A team approach to child abuse Lvnda Fitzpatrick 36 CNJ talks to Lois Dale, PHN Lynda Fitzpatrick 39 Be it resolved.n Jean MacLean 40 A very present danger Shirley Posr,AJ. Langford 42 . Learning about the hospital Fave Ferguson. Lillian Park, at home Vera Ward 44 'R :--. The Canadian Nurse welcomes Indexed in International Nursing . suggestions for articles or unsolicited Index. Cumulative Index to Nursing manuscripts. Authors may submit Literature. Abstracts of Hospital , finished articles or a summary of the Management Studies. Hospital . J ... proposed content. Manuscripts Literature Index, Hospital Abstracts, "" should be typed double-spaced. Send Index Medicus. The Canadian Nurse :e, F- ... ' original and camon. All articles must is available in microform from Xerox I be submitted for the exclusive use of University Microfilms, Ann Amor, The Canadian Nurse. A biographical Michigan. 48106. statement and return address should '\ accompany all manuscripts. Subscription Rates: Canada: one '" 4 year, $10.00: two years, $18.00. Foreign: one year. $12.00; two nof The views expressed in the articles years. $22.00. Single copies: $1.50 This month's cover is a are those of the authors and do not each. Make cheques or money necessarily represent the policies of orders payable to the Canadian celebration in two ways. First the Canadian Nurses Association. Nurses Association. red of all. it introduces an issue that is CNJ's salute to the ISSN 0008-4581 Change of Address: Notice should be International Year of the given in advance. Include previous of Child. Secondly. it is our way Canadian Nurses Association. address as well as new. along with ofweIcoming you to 1979 with 50 The Driveway. Ottawa, Canada, registration number. in a a new cover design in color. K2P IE2. provincial/territorial nurses Photo courtesy of Studio association where applicable. Not Impact in Ottawa, and the "responsible for journals lost in mail smiling children of Les Petits due to errors in address. Bouts de Choux Day Care Postage paid in cash at third class rate Centre in Ottawa, Ontario. Toronto. Ontario. Permit No. 10539. - , Canadian Nurses Association. 1978. .. yesterday. . . today. . . tomorrow Add1son-Wesley is new to nursing publiShing, but its long-standing tradition of pu lishing excellence in other professions is recogniZed internationalJy. DiStJ..DguiShed as a publiShe lJ mathematics and physical/life science textbooks, Addison-Wesley has over twenty Nobel IL,ureates as authors. In 1976 Addison-Wesley formed its Med1caJ/Nurs1.ng Dtv1s1on. The new nursiDg program is committed to bringing to nursing the Addison-Wesley tradition of publiShing e cellence. The liStS of new and forthcoming publications (see below) reflect AddiSon-Wesley's concern With meeting the needs for expanded nursing education in a profession that is rapidly grotnng and changing. As yesterday's pioneers in the health care profession, nurses initiated better h th care practices, establ1shed nursing education programs, and demanded legiSlation that w d insure qualiW in the nursing profession. Tcxiay's nurses are creating new trad.1tions in primary alth care, hæpital adrmniStration, medical legiSlation, community health care, and many exp nding professional areas. 'IbmoITow holds even greater promiSe for the nursmg profession. AddiSon-Wesley's nursing program is dedicated to publiShmg the books that will help tad s educators and tomoITow's nurses fulfill that promISe. oeUJ pub\\ca\\oos AddiBon-Weøley'B llurøiDg ....Awnhurt ion B.eview by SaUy L. l8gerqUlst 464 pp. 12.95 Meðica1 Term1DoJ.ogy: A Text/Workbook by Alice Prendergast 279 pp. 9.60 *Politics of PaID. MA'ft ewnent: by Shtzuko Fagerhaugh and Anselm Strauss 323 pp. 8.95 B.eview Mathematics for Ilurøeø 8D4 Health Profeøs iftftA1R : A Text-Workbook on Solutions &Ild Dosage Ca.lcula.tlons by Lucllle M. Parks 291 pp. 8.25 AgiDg 8D4 Health: Biologic &Ild Soc1a.l Perspecttves by Cary S. Kart" Eileen S. Metress and James F. Metress 339 pp. 13.96 *People in Crisis: Understanding &Ild Helping by Lee Arm Hoff 336 pp. 9.60 A Survey of Human Diseases by David T. Purtllo 453 pp. 16.95 '.rraDøactioDal ADalysis in Health Care by Jean Elder 176 pp. 8.95 Shock Syndrome: Mecha.n18ms &Ild Ma.n1festa.tlons by Martha Thompson (:Module Ser1e8) 60 pp. 3.96 Interperøonallnteraction in llurøiDg: Basic Concepts 111 Nurse-Patient Commun1ca.tlon by Virgil Parsons and Nancy Sanford 144 pp. 8.95 POMB: Appl1ca.tion to Nursing :&cords by Gael illiSSe (:Module Ser1aS) 113 pp. 6.95 Medical Dosage Ca1eu1at1cmø, Second Edition by June Olsen, et al. 120 pp. 3.95 *Book of the Year Award. 1978 Amer1ca.n Journal of Nursing t.hCoro\nQ 10r , C O OOS P .,\ .79 I'wtdAwne-nta18 of IlUIBiDg: Concepts and Procedums by Barbara Koziel' and GlEllora Erb Instructors Gu1dB Ava.1Ia.ble 101Opp. 18.95 Psychiatric llurø1Dg by Hol.1y Skodol Wilson and Carol Ren Kne!sl Instructors Gu1dB Ava.1Ia.ble 760 pp. 17.95 LearniDg Activitieø in Psychiatric Ilurø by Hol.1y Skodol Wilson and Carol Ren KnelSl 160 pp. 6.95 The lI'urøiDg Proceøs: A Huma.rust1c Approach by Elaine lNnne La. Monica 400 pp. "9.60* PSBO: ProIIllse, Perspecttve, &Ild Potent1a.l by John W. Bussman and Sharon V Davidson 290 pr 14.95* Communicable Disease Manual for Primary Health Care Prof888ioDa1a by Cornelius A Kolff and Ramon C. Sanchez 200 R>. 8.96* 1 llurøiDg the Critically m A4u1t by Nancy M. HOlloway 608 pp. 17.95* *tent4ttve price .. Ad.d1Bon-Wesley Med1cal/NurslDg D1v1sion . 2727 Sa.nd. Hill Road . Menlo Park, CA 94025 YY Ad.d1Bon-Wesley (Can.a.da.) Ltd. . 36 Pr1nce Andrew Place. Don Mills, Ontario, Ca.na.da M3C 2TB I Your mquiries are invited. 'Ib be considered for complimentary copies write to address below. Please include school affiliation, course title, enrollment and text now being used. The cen-.llen Nur.. .. Jenuery 11711 3 perspective . . Guest Editorial emotional problems in the Immunization: There is an opportune time for all those preschool child to see that evidence that despite the interested in children to The United Nations has there are many problems yet availability of safe and initiate or expand their identified 1979 as "The Year to be solved. effective vaccines. interest and in turn meet the of the Child". In Canada the In 1977. the Canadian immunization coverage is not special needs of Canada's government has established a Institute of Child Health was adequate. Children still eight million young citizens. Canadiag Commission - 1979 founded to act as an advocate develop serious complications The Canadian Institute of International Year of the on behalf of children. It and handicaps from infectious Child Health looks forward to Child whose many functions functions as an action group to diseases such as measles, a cooperative relationship will include promoting public improve the health and rubella. mumps, with the nursing profession, awareness and encouraging welfare and the quality of life poliomyelitis. diphtheria and and all other professional ideas from and the of Canadian children. from tetanus. In November. the groups who maintain a participation of children in the conception to eighteen years Institute took part in commitment to the health and year's activities and of age. Immunization Action Month well being of Canadian celebrations. It would seem For the coming year. the and has just published a children. appropriate that all In titute has decided to focus National Immunization -W.A. Cochrane, M.D., organizations and professional its efforts on five priority Survey with a number of F.R.C.P. (C) Chairman, groups in Canada examine the areas: recommendations. Board of Directors, Canadian contribution they might make Accident prevention: Nearly Institute of Child Health. for improvement in the Prevention of handicap: Of the 4.000 children and youth general well-being of 330.000 babies born in Canada under 19 years of age suffered EDITOR Canadian children. each year. about :!5.000 will accident or death from ANNE (HANNA) BESHARAH In 1973 a conference on be low birth weight and as accidents in 1974. Among the "Unmet Needs of many as 33.000 will be at risk other measures. the Institute ASSISTANT EDITORS Canadian Children" was held of handicap. It is estimated is promoting the use of car LYNDA FITZPATRICK by the Canadian Pediatric that at least half ofthese seats. fire detectors and life SANDRA LEFORT Society assisted by Ross handicaps could be prevented jackets by asking the federal PRODUCTION ASSIST ANT Laboratories of Montreal. or the risk substantially government to remove sales GITA FELDMAN Representatives of various reduced with improved tax on these items. health caring professions. prenatal and perinatal care. CIRCULATION MANAGER teachers and government That is why the Institute Care of children in hospital: PIERRETIE HOTfE officials reviewed many published a report in August Because many hospitalized outstanding problems existing 1978 entitled. Prnention of children are still being ADVERTISING MANAGER in the Canadian childhood Handicap:A Case for deprived of care that GERRY KAVANAUGH population. Topics that were Improved Prenatal and considers their special needs, CNA EXECUTIVE DIRECTOR discussed included caring for Perinatal Care that described the Institute will be HELEN K. MUSSALLEM the well child. problems of the problems and suggested establishing a Resource adolescents and migrant ways to prevent handicap. Centre with books and films to EDITORIAL ADVISORS youth. special needs oflndian Recently, a coalition of be available on loan. In 1979 MATHILDE BAZINET, !lnd Eskimo children. health related associations the Institute will sponsor, chairman, Health Sciences problems of the handicapped. (includingCMA. CNA, along with nursing groups in Department, Canadore College, the inner city child. CPHA and seven other Ontario and B.C., two North Bay, Ontario. psychosocial problems of groups) was formed to workshops to humanize care DOROTHY MILLER,public children and the organization recognize and support the for children and their families. relarions officer. Registered of child health services. concept of prevention of Child health in the next Nurses Association of Nova Scotia. Reviewing the conference handicap. The two-year decade: There is a great need JERRY MILLER. director of recommendations. it is coalition hopes to promote to examine the changing communication services, evident that while some public. professional and practices in child health and to Registered Nurses Association of changes have come about in government education. plan for the future. Currently, British Columbia. the 5-year interval. the needs develop a standard prenatal the Institute is seeking funds JEAN PASSMORE.ediror. of Canadian children are not record. complete a number of for a two-year study of SRNA news bulletin. Registered yet being met in a number of papers on related subjects Canada's nine children's Nurses Association of areas. We have only to look at such as rubella. RH negative hospitals and six major Saskatchewan. the dramatic increase in sensitization and screening of pediatric teaching centers. PETER SMITH. director of publications. National Gallery of adolescent suicides. teenage newborns. Through mutual It is evident that there is Canada. pregnancies. venereal disease. cooperation. the coalition ml)ch to be done in focusing FLORITA the need for improved hopes to affect priorities. attention on the care and VIALLE-SOUBRANNE, maternal-infant care and the policies and allocation 9f problems of Canadian consultant, professional need for earlier screening for resources for maternal and children. The International inspection division. Order of physical, mental and newborn health services. Year of the Child would seem Nurses of Quebec. . . . '---/ Designer Joe Famolare has inven- ted a shoe that Is meantto keep a smile on your face even if you must spend the entire day on your feet. For comfort, there is nothing else like it. The patented four-wave sole serves as the per- fect mediator be- tween your foot and hard floors or pavement, absorb- ing shocks to the IE . )' 't heel and cushioning the arch as it rolls you forward in a graceful, extended stride. The inner sole of this remarkable creation is anatomically contoured to support the foot and buoy up the spirits. Both inside and out, the .:-}': .. Get There ', .........,. OTOSCOPE SET. One 01 Germany.s hneatlnstruments - .:IIE""':"'. _ ExceptionallllumlnaUon. ... \ power1ul magmfymg lens. 3 ....: '1Ia standard size specula Size C ... Dallene. Included toIIetal carry- . Ing case lined wllh soli ClOth " ,. No 30ii sal.IS each. No 3()gA A. eDove but In plasUc pouch "'.16 N. MEASURlt'IIG TAPE u: t a: c sc; \1- .. return toIIade 01 dur.b e . linen toIIeuures to 78.' on one Side, 200 cm on reverse 14.15 a.ch. 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Salin green lellers 14.11 17.88 IImooth linl!lh uSE A SEPARA TE SHEET OF PAPER IF NECESSARY : PATRICIA BROWN fEAD IO>si i - .............................................................................................................................. .. ...................... 10 J.nuery 11711 The c.n-.ll.n Nur.. news I. V. nurses meet II ' 1 0.' . - , I i ., .... I t I I -;I I "'-, r "1 " ..- t "11 , r; · . I" ". I . ..... I, 0 , \ e .,- o E o ;S l- f.;; " .. . ó: '.. .:.s ." E o Õ s: .Q. '- .0 1:: :I :3 o õ s: .Q. , ,- , The third annual convention of the Canadian Intravenous Nurses Association was an educational experience for those who attended, and the lectures were not the only reason. H ere a group of nurses 'isit one of many interesting exhibits set up by leading manufacturers of intrm'enous supplies. Over 200 delegates met at Toronto's Inn on the Park Hotel for the Third Annual Convention of the Canadian Intravenous Nurses Association (C.I.N .A.) held in November. 1978. The meeting addressed some ofthe concern,> and learning needs of the nurses who attended from all parts of Canada. Trudy De Vries opened the first day ofthe meeting with an account of her experiences starting an I. V. team at HolyCross Hospital in Calgary. Alberta. She emphasized the benefits of forming a team. both for the hospital and for the patients, and underlined the needs for standards to ensure safe I. V. practices. Dr. R.M. Filler. surgeon-in-chief at the Ho'>pital for Sick Children and professor of surgery at the University of Toronto. talked about complications in pediatric intra venous therapy. both peripheral and central, from fluid overload to sepsis. R.L. Ravin. pharmacy director at St. Joseph Mercy Hospital in Ann Arbor. Michigan. discussed safe and effective intravenous therapy. pointing out the importance of ensuring the safe administration of I. V. fluids and medications by making sure . that intravenous administrations are compatible and stable; . that additives are diluted appropriately; . that the rate of administration is appropriate; and . that the risks of septicemia are minimized. He stressed the important role of the pharmacist in ensuring safe and effective therapy and gave nurses and a number of pharmacists who attended the meeting a good deal to think about. C.I.N .A. was founded in 1975 because of a need for communication, increased knowledge and idea exchange between nurses involved in I. V. therapy. The third annual convention provided nurses with an opportunity to meet these needs. share concerns. and visit a number of exhibits pertinent to I. V. therapy. MARN approves emergency nursing course \ . The Board of Directors of the Manitoba Association of Registered Nurses recently gave its approval to a post-graduate course for registered nurses in Emergency Departments. The only one of its kind in Canada. the course is sponsored by the Health Sciences Centre in Winnipeg. The program has been in operation since September 1976, and at that time served five Winnipeg hospitals. However, provincial fiscal restraints have reduced its services to two hospitals - the Health Sciences Centre (General and Children's) and the St. Boniface Hospital. The course is designed to provide the client with safer. more comprehensive nursing care in sudden, unanticipated conditions. Effective communication and expansion oftechnical skills are stressed, in order that both the client and his family receive the highest possible level of care. Registered nurses presently working in the Emergency Department of the two hospitals involved are the only nurses eligible to enrol in the nine-month course. Approximately 47 eight-hour class days are spent in theoretical training on the following topics: cardiology, respirology, neurology, urology, abdomen, pediatrics, obstetrics, gynecology, trauma. life crises and psychiatric emergencies, and disaster nursing. As often as possible, specialists are called in to teach in their area of specialty. I n addition to the theory. at least one day a week is spent in the actual clinical setting of the Emergency Department under the supervision of a qualified teacher. In order to gain insight and experience in a variety of areas, three days are set aside for experience with the Winnipeg Ambulance Service and two three-week rotations are arranged with two Emergency Departments in other hospitals. Because of the support the program has received, there is a plan to expand the course to serve a wider range ofhospitaIs, both urban and rural. If sufficient interest is expressed by Canadian and United States hospitals. and by registered nurses, the coordinators of the program hope to be able to request additional funding from governments and other hospitals to provide improved instruction and care in Emergency Departments. I nquiries about the course can be made to: Barbara Duke, Coordinator, Manitoba Emergency Nursing Course, Dep(lrtment of Nursing, Health Sciences Centre (General), 700 William A 'enue, Winnipeg, Manitoba, R3EOZl. Editor's Note: Immunization Action Month ended on November 3D, but its message that all Canadians need protection from communicable disease will hopefuIly stay with us for 1979. CNJ thanks the Ottawa Carleton Regional Health Unit for pointing out that. in general, adults do not receive immunization for diphtheria (as we stated in our November issue, 1978. p.8). Routinely, diphtheria immunization is given up to the age of 14 years. I ' The cenlldl.n NUrH J."...ry 11711 11 YOU AND THE LAW Finding and helping victims of child abuse Corinne Sklar ., -- L_ ... How can the tragedy of child abuse be prevented? What position does the law take with respect to both the prevention of abuse and rehabilitation of children and their parents? What does the law require of the nurse in the matter of child abuse? Child abuse has been variously defined in the literature. The term "battered child syndrome" was first coined by Dr. H. Kempe in 1962 to describe a clinical condition in young children who have received serious physical abuse usuaIly by parents or other guardians including foster parents. The injuries result from non-accidental occurrences and range from minimal to fatal injury.1 The definition of an abused child has been broadened to include the emotionally or psychologically battered child. While physical abuse can be demonstrated by X-ray film of injuries and by visual evidence of bums, bites, bruising and general malnutrition. emotional abuse is more difficult to demonstrate. Obviously, the latter is also more difficult to recognize so that det ction and diagnosis on the emotionalleve\ are often neglected by professionals. Child abuse can result from outright battery or from neglect. The results may be physical or emotional or both. Neglect may be manifested as failure to thrive from physical or emotional neglect resulting from ignorance, indifference or inadequacy on the part of parents or guardians. In legal terms, the a sed child falls within the statutory definition of "neglected child" or "child in need of protection" Ontario'sChild Welfare Act. R.S.O. 1970. c.64 defines â child in need of protection as foIlows: (/)In this Part. (a) "child" means a boy or girl actually or apparently under sixteen years of age; (b) "child in need of protection" means, (i) a child who is brought. with the consent of the person in whose charge he is. before a judge to be dealt with under this Part. (ii) a child who is deserted by the person in whose charge he is (iii) a child where the person in whose charge he is cannotforanv reason care properly for him, or where that person has died and there is no suitable person to care for the child. (iv) a child who is living in an unfit or improper place. (v) a child found associating with an unfit or improper person. (\'i) Repealed (vii) a child who, with the consent or connivance of the person in whose charge he is, commits any act that renders him liable to a penalty under any Act of the Parliament of Canada or of the Legislature. or under an\-' municipal by-law. (viii) a child whose parent is unable to control him, (ix) a child who, without sllfficient cause, habitually absents himselffrom his home or school, (x) a child where the person in whose charge he is neglects or refuses 10 pro\'ide or obtain proper medical. surgical or other recognized remedial care or treatment necessary for his health or well-heinl? or refuses to permit such care or treatment to be supplied to the child when it is recommended by a legally qualif d medical practitioner, or otherwise fails to protect the child adequately, (xi) a child whose emotional or mental de\'elopment is endangered because of emotional rejection or deprivation of affection by the person in whose charge he is, (xii) a child whose life, health or morals may be endangered by the conduct of the person in whose charge he is; You wiIl note that the definition is very broad and encompasses a wide range of situations. This statutory definition is representative of the definitions found in similar legislation in the other provinces. Canadian law dealing with neglect of and offences against children faIls into two categories, each type enacted with differing intent. The Canadian Criminal Code deals with criminal sanctions for offences against children. The intent of the Code is to prohibit proscribed conduct and to punish wrongdoers for crimes committed against children. The Code is primarily punitive rather than rehabilitative in nature. Thus, sexual mis<.;onduct, criminal negligence, and failure to provide the necessaries of life are all punishable on proof beyond a reasonable doubt. Provincial Child Welfare legislation. on the other hand. is aimed primarily at protecting children from a hostile. non-nurturing environment. Its thrust is not to punish parents or guardians inadequate to the task of child-rearing. but to resolve problems based on the "best interests of the child". In order to do so. the full range of available community agencies and professional services optimaIly should be marshaIled. The 12 J.nUllry 11711 The c.n-.ll.n Nur.. "harshest" punishment under these statutes is removal of the child or children from the parental home either on a temporary or. sometimes. on a pennanent basis. Remedial treatment may be required under supervision oflocal agencies, most often the Children's Aid Society or local equivalent. Detecting the child abuser To combat this growing social problem, early detection and prevention are essential. Nurses have a primary role to play in this area; they must be aware of the typical characteristics of the victim of child abuse who may be brought in to the hospital emergency room, the pediatrician's office, the local clinic, or the school nurse's office. Nurses must listen and observe carefully as they fulfill their duties in routine public health visits. They must have a working knowledge of the general profile of the child abuser and be alert to emotional strains to which these individuals are subjected which trigger abusive behavior. Child abusers are not limited to anyone section of the socio-economic scale. While problems of financial distress, overcrowding, alcoholism, etc. are indeed added stressors, abusive conduct toward children is not limited to those at the lower end of the socio-economic scale. The potential child abuser can be found in all walks of life. Anyone who looks after children has the potential to be a child abuser. While studies have shown that there are factors which tend to recur, it is important to realize that the potential for such behavior toward children exists in all individuals. Yelaja 2 describes three categories of abusive parents: . parents who are wilfully and deliberately abusive and neglectful; . parents ignorant of child-rearing; . parents who are burdened with social problems of poverty, physical and m"ental illness, alcoholism, etc. Heins'3 profile finds that females tend to be more abusive than males. . Fathers tend to abuse older children. . Child abusers generally are young. have children early and tend to have many children. . They tend to be socially isolated and nomadic. to have few friends and to be separated from their extended family. . Many child abusers have been abused themselves as children. . Their partnerships tend to be highly unstable. . Some abusive parents tend to have excessively high expectations of themselves as parents and oftheir children. . They may be hostile and immature. . The spouse or partner is usually passive and tends to abdicate responsibility for the rearing of the children. Sometimes the parents are simply highly authoritarian and punitive in their beliefs and childrearing practices. The profile of the child abuser varies; there is no set formula. All of these characteristics serve as danger signals warning of potentially abusive individuals. It is important to note that not all children in a family are abused. Generally, one child bears the brunt of the hostility of the parent. This may be due to some physical characteristic. some abnormality, the sex of the child, or some personality or behavior trait. Raising children is not a simple task; the frustrations. problems and costs are heavy, the responsibility is enormous. Today's highly mobile. "independent" nuclear family often lacks the emotional supports that a less complex, less detached society of a few years ago provided. Parents in need of support and guidance often do not know where to turn for help. As well, parenting is something "one is expected to know how to do properly". Generally, one is loathe to interfere with the child-rearing practices operative within a family. Nurses have to be aware of their own biases and value systems as well as their general reluctance to intenere. Reporting requirements Generally, provincial legislation requires reporting of ill-treated children to the proper authorities. Some legislation provides penalties for failure to do so. It is important for nurses to familiarize themselves with the provincial statute applicable to them for its definition of children in need of protection and for the requisite reporting requirement. In Ontario, the reporting requirement is as follows: (1) Every person havinR information of the abandonment, desertion, physical ill-treatment or needfor protection of a child shall report the information to a children's aid society or Crown attorney. (2) Subsection 1 applies notwithstanding that the information is confidential or privileged, and no action shall be instituted against the informant unless the giving of the information is done maliciously or without reasonable and probable cause. Note that no statutory penalty follows on failure to report. However, this lack of sanction is now under review in Ontario since it is recognized that the reporting of suspected or clear cases of abuse is essential to ensure the protection of helpless children. The sanction for non-reporting may apply, however, only to such behavior as physical abuse and sexual abuse. The concern of the legislation is the condition of the child (physical, emotional or both) not the conduct of the person which causes the condition. Nova Scotia's new Children's Services Act, S.N .S. 1976 c.8 retains the reporting requirements and establishes a child abuse register. A child who has been found to be in need of protection. or is believed by members of the medical fraternity to be subject to abuse, is to be registered. On the report of a suspected case of child abuse, an agency is required to conduct an investigation and obtain a medical statement to determine whether or not abuse has occurred. Conditions for the removal of a registered name of a child and the transmittal of information outside the province are specified. 5 Each province has differing requirements. General penalties for failure to report are found in the legislation of British Columbia, Manitoba, Newfoundland, Nova Scotia, Quebec, Saskatchewan. Ontario does not yet penalize failure to report. New Brunswick and Prince Edward Island do not require reporting of cases. Protection of the informant The responsibility to report usually carries with it freedom from ci vii action for breach of confidentiality unless the information is given maliciously or without reasonable and probable cause. The identity of the informant is protected from publication to encourage reporting of cases. Thus, a report to the authorities, in good faith. where there is reasonable and probable cause for concern will serve to protect the informant from any subsequent action by the parents or guardians. In England recently the House of Lords upheld the right of the National Society for the Prevention of Cruelty to Children to maintain confidential the name of its infonnant. The Society had been informed that the 0 family's baby girl was maltreated On investigation by the Society and the family's physician. the child was found to be healthy and well-eared-for. However, Mrs. D. suffered from depression and ill-health as a result of this complaint and wanted to sue the informant for defamation. The Court found that it was in the public interest that such names should not be divulged, else valuable sources of information would dry up. Information. tendered in good faith, will be protected at its source. The c.n-.ll.n Nur.. J.nUllry 11711 15 . Speech assessment is actually done by the parent, while the expert otTers guidelines. . Dental examination and brushing methods are performed with the child's head on the parents' lap, and the hygienist teaching procedures to be followed in the home, and with siblings. . Experiential learning is emphasized in everything from mental health to nutrition, with the exception of immunization which is provided for children who will be entering schoo). Although it is the public health nurses who do the hard work of organizing the da} 's activities and carry out the necessary follow-up procedures, the event itself has become ( ...... ./ . , "- .. , .. . -Þ ... .( - .Æ, , ,. -- 'n- . Having}oureyes ctwckedby the orthoptist can befun when you're silling on the lap of PHN cum clown. fan SUllon, during 'ision screening mthe health circus. a true expression of community cooperation in positive and preventative health. Local firemen hang street banners; merchants supply nutritious snacks; volunteer agencies set up colorful displays; and school children paint posters and flags to add to the kaleidoscopic etTect. Altogether about thirty-five groups and agencies participate in this worthwhile etTort to maintain a healthy environment and community. From a small beginning a few years ago in the offices of the local public health t:nit, the circus has now escalated to an event that is eagerly awaited by hundreds of local children and adults each year. ..... Pholostory by Rosemary Crmlford , ò -() "" C , .... r '1r I Unconcerned and unaware of the physiotherapist carefullv obserdng her acti\'ities. a young participant jo)fully jumps from springboard to the mat belol\'. 16 January 11711 The can-.llan Nur.. 1 ..... t ,- 'I 'I - \ , " , " . ',- "\ . \ \' Little sister opens wide to help this preschooler take her polIO vaccine from Jean Sellers. PHN. .. Am I tall enough," is the question in the eyes of the young man hm'ing his height checked by PHN Trudv Phillips at the health circus. Acknowledgement: The author would like to acknowledge the cooperation and assistance offour public health nurses - Pauline Dunn. Beverley Hills. Betty-Anne Rogers and Rachelle Siddall- in the preparation of this article. All except the first of these nurses (who is now a nursing instructor at Douglas College) are employed by the Simon Fraser Health Unit. Rosemary Crawford, author of the photostory, "A preschoolers' health circus", is regional health education consultant with the British Columbia Ministry of Health. S he is a graduate of St. Paul's Hospital in Vancom'er, UnÙ'ersity of British Columbia School of Nursing in Public Health and an undergraduate in Education at Simon Fraser U nÙ'ersity. She has been im'oh'ed in community health education for the pastfour years and recently has specialized in audio-dsual with emphasis on educational media. farly diagnosis in congenital hearing loss "I had now the key to all language , and I was eager to learn to use it. Children who hear acquire language without any pa11icular effort; the words thalfallfrom others' lips they catch on the wing, as it were, delightedly. while the Iinle deaf child must trap them by a slow and often painful process. But whatever the process, the result is wondeiful." Helen Keller , " ...- , JlllrilYll O. Dahl J Children with congenital hearing loss are most often born to hearing parent!> who have no kno'o\ledge ahout congenital deafness.' Since deafness does not seem to interfere with the initial bonding process. the mother often remain" unaware for many months that the infant cannot hear. The baby cries. smiles, babbles. reacts to visual. tactile and kinesthetic stimuli as does any normal baby. The mother reacts to the infant's behavior by increasing her attention to him and social interaction takes place. The mere fact that the infant responds to her, increases the mother's vocalizations. At this stage. there is no clue that the baby is not responding to auditory stimuli. Until the age of six to nine months. the deaf baby often sounds exactly like a normal infant. But. vocalizations will gradually decrease and by the end of the first year, the child ma} be making only the primitive sound. "amah" which many mothers report as ., mama" .! When the baby fails to respond to sounds in a normal way and vocalizations decrease. the parent-child interaction pattern is altered. The suspicion and subsequent diagnosis of deafness may put an added strain on the parent-child relationship. Earl suspicion and detection In most cases. parent!> are the first to "uspect that their child is deaf. The more 'ievere the hearing loss. the earlier the suspicion and the shorter the delay until diagnosis. Findings in a study of the Greater Vancouver area published in 1975-' indicate that on the average. a child was about ten month" old before parents presented their suspicions to their primary care physician and even then there was an average delay of over eight and a half months until the diagnosis '0\ as confirmed. In some cases. parental !>uspicions '0\ ere disregarded as 'overanxiety': in other cases. parents were advised to 'wait awhile'. 18 January 111711 The can-.llan Nur.. Current findings indicate that parents are beginning to suspect deafness in their child earlier - at about eight months - and that children are being referred earlier for evaluation. It would seem that professionals are becoming more aware of the importance of early diagnosis and treatment. Risk factors No statistics are available to indicate the number of infants born with congenital deafness in Canada: estimates range from I: 1000 to 5: 1000:' Unfortunately, there is as yet no simple test to detect deafness in the newborn and routine screening in nurseries must be considered ineffective in detecting hearing loss." Nevertheless. there are identifiable factors that increase an infant's risk of congenital hearing loss. In 1974, the U.S. Joint Committee on Newborn Hearing Screening recommended that "infants at risk for hearing impairment should be identified by means of history and physical examination". 7 As a result ofthis awareness. newborns may be categorized on the basis of risk. The risk factors include: I. family history of hereditary childhood hearing impairment 2. rubella or other non-bacterial intrauterine fetal infection 3. defects of ear, nose and throat 4. birthweight ofless than 1500 grams 5. bilirubin level of greater than 20mg/IOO 011 serum. Using these factors as a possible clue in the detection of hearing loss. it has been estimated that about 60 to 70 per cent of congenitally deaf children can be identified."The committee further recommended that infants falling into this category be referred for in-depth audiological evaluation within two months after discharge from the nursery. Even so, deafness may not be apparent and it is important that periodic evaluations be repeated. Acquisition of language Why is early diagnosis and treatment of congenital hearing loss so important? One of the reasons is that language acquisition is a time-locked function. connected to early infancy .HThe first two years oflife are considered to be a crucial time for language learning that can never be regained once this time has passed. It is also suggested that prelinguistic vocalizations and intonations similar to the parents speech are noted as early as eight months. and are basic to language development. IU A child learns to talk by hearing the constant repetition of words. and ifthe infant has any residual hearing and is diagnosed early, he can benefit from the use of hearing aids and/or amplification devices coupled with other teaching approaches. Communication methods Regardless of the severity of the hearing loss, the key to a child's intellectual, social and psychological development is the establishment of successful communication as early as possible. But how is this to be accomplished? Once a diagnosis of hearing loss is made, the parents must select the method of communication best suited to educating their child. This will probably be one of the most difficult decisions parents of a hearing handicapped child will face since experts themselves are not agreed about the best approach. This conflicting advice from experts can rob parents of support and precipitate a prolonged conflict. " There are two fundamental dPproaches to educating the hearing handicapped: Oral communicarion method: teaches speech training, lip-reading and utilizes hearing aids and/or amplification units but discourages the use of gestures and sign language. The theory is that if the child uses sign language. he will not fully develop his verbal kills. Total communication method: trains children in sign-language, finger spelling. speech and lip-reading, and uses the amplification of residual hearing through hearing aids. The theory is that each child must "learn according to his capabilities - that learning to communicate proceeds from the most primitive to the more complex and sophisticated symbol systems that involve all senso"y modalities- auditory. visual and kinesthetic" .'2 At this early stage, the parent's greatest need is for counseling. While some may experience extreme shock and grief. others may have a more moderate reaction. Parents with normal hearing may have difficulty understanding the implications and limitations of the handicap for their child. It is vital at this stage that they understand what the handicap will mean and that no false reassurance is given to them to minimize their concern. The Vancouver Program In the Vancouver area, a child suspected of having hearing loss is referred to the Children's Hospital Diagnostic Centre. Here. the infant is evaluated and the diagnosis is made. Parents are given counseling and a full explanation of the two educational programs available to them. These are: a) the oral method at the Vancouver Oral Centre and b) the total communication method at the Diagnostic Centre. Parents are advised to visit both programs and to choose one of them for their child. Both programs offer support for the family and training for the child. In choosing. parents must consider which method will help the child achieve optimal growth. It is important that it be their choice because they must feel willing and motivated to participate. Oral communication method Many forces playa part in the decision that parents will make. * They may have high expectations for their child and want him to 'pass' in the normal speaking world. They may be drawn to the purely oral approach because it seems to bypass the handicap and requires less emotional adjustment, since it does not require the learning of sign language. '3 Certainly it is natural for parents to hope that their hearing handicapped child will develop the capacity to communicate with the vast majority of people who hear and speak. The Smiths** are an example of one family who chose the oral method for their hearing handicapped daughter. Marie, aged 24 months, is the only child of Mr. and Mrs. Smith. She has congenital deafness of unknown cause. When Marie was 12 months old. Mrs. Smith suspected that something was wrong with Marie's hearing. While on vacation that year, she noticed that Marie did not react at all to a noisy environment. Through her family doctor and ear specialist, she was referred to Vancouver's Diagnostic Centre. Looking back. Mrs. Smith felt that there was nothing in Marie's behavior to make her suspect deafness. She seemed normal. She slept soundly but would react to the vacuum cleaner. Probably she was reacting to the vibration rather than the noise. She was an "independent baby". preferring not to be cuddled. The parents described their reaction to the diagnosis as "fairly severe". but overall, they felt that they have adjusted well. Mr. Smith felt that he had had a harder time than his wife. A number of factors affected the Smiths in their choice ofthe Oral Centre. Although Marie has a profound loss, she has some residual hearing and so can benefit from hearing aids. At age one year, she WdS babbling and had advanced developmental skills. The parents' wish for Marie was that she be as much a part of the normal world as pos ihle. *In other centers across Canada. such as the Audiology Department al theChildren's Hospital of Eastern Ontario in Ottawd, parents do not choose the type of training for their hearing impaired child. The staff of CHEO's program feel that parents do not have the knowledge and are not emotionally able to handle this decision at the time of detection. Instead. an evaluative therapy program will determine and recommend a suitable method for each child. ** All names are fictitious. The oral program has continuity- infant teaching, preschool. kindergarten. and possible integration into the public school system. Because the program has limited grant money. the parents themselves must carry out continuing fund-raising activities to support the program. The program also includes parent group meetings and bimonthly in-home visits from a teacher. By this Fall. Mrs. Smith and Marie will have a daily 45-minute drive to the Centre for pre-school classes. The program emphasizes specific parent behaviors to treat the child like a normal child and to talk to him as often as possible. As Mrs. Smith said. "Repetition is the name of the game. Emphasis now is not on teaching the child to look at you but to make use of the residual hearing. So when Marie has her hearing aid on. I talk to her from behind. try to encourage her to respond to my voice and she does. " Marie wears her aid in a red corduroy pocket on her chest. with cords running to molds in both ears. It took her only a few days to accept the aid. When the aid is on. she uses words with intonation. But when it is off. she makes only a monotone cry. Cost and maintenance of the aid i another stress. Ear molds must be replaced every six months as Marie grows. In terms of family support. the Smiths are receiving some help from Mr. Smith's sister who lives nearby. She accepts Marie"s handicap and provides emotional support. Mrs. Smith's family, during their occasional visits from another province. express pity for Marie and this creates tension. On the whole, Mrs. Smith feels that they are coping well with Marie's needs. She hesitates to use the word "deaf' and substitutes "handicap" instead. But the Smith's have decided not to have another baby. Because they cannot trace their family tree. and thus cannot make use of genetic counseling. they feel they could not cope with having another deaf child. Total communication method The total communication program at the Diagnostic Centre (the only one of its kind in Canada) has a different approach. The Centre's aim is to provide families with an opportunity for extended participation in the program by providing sign language instruction and parent-child training classes. Parents of deaf infants are also drawn closer together to exchange interests and experiences in child-rearing practices in the home. It allows children in the family (both hearing and deaf) to interact with others in a play setting and introduces the family to deaf adults and professionals who work with the deaf. The c.on-.llen Nur.. As well. a deaf adult visits the family in the home. providing a role model. Besides educating the child. the total communication approach helps to integrate the child into the family unit by involving the entire family in "communicating" . Effect on the famil The presence of a deaf infant does not necessarily have a detrimental effect on family interaction. In some instances, brothers and sisters express worry and concern: but in others. the family members are drawn closer together. Members ofthe extended family may wish to enroll in sign language classes in the community if the child is using the total communication method. The effect of a deaf child on the family will depend on the health ofthe family unit. If problems already exist, coping with the handicap may cause further strain. However, if all members can be involved in a common program, learning new methods of communication and helping one another. family bonds may be strengthened. The case of Nancy Moss" and her extended family gives us an idea of how all members can become involved. Nancy. the youngest of three children, developed deafness at six months of age after she had meningitis. Again. it was her mother. Mrs. Moss, who first suspected that something was wrong when Nancy was in the hospital for treatment. She and her parents were referred to the Diagnostic Centre for evaluation. While both parents experienced severe shock at first, they feel they have adjusted to the diagnosis fairly well. In contrast to the Smiths. Mr. and Mrs. Moss chose the total communication method for Nancy. Said Mrs. Moss. "Well. we thought-she's deaf. We can't change that. Ifwe put her in the oral program she'll be with people she can't hear or talk to. She really won't have any world. If we put her in the other program she'll have people she can communicate with in sign language, and we can learn it with her. At least then she'll have a place in her world." The family has a weekly two-hour drive to the Centre for sign language classes and group sharing. A teacher comes to the house weekly. Mrs. Moss states that Nancy is beginning to use sign language and both parents are able to communicate with her by using speech and sign simultaneously. Nancy's three-year-old brother has not reacted to her hearing loss yet but the six-year-old has questions. Since Nancy will soon be fitted with hearing aids. he asks if she will then be able to hear as they do. Those in the extended family have mixed reactions. Mr. Moss' father Jenuery 1171 111 tended to deny the diagnosis at first by making statements like, "She heard that". Now. he comes into the house and signs to Nancy. "Are you Grandpa's girl". The maternal grandparents are gradually showing more support. 'The schools sent out a questionnaire asking what people would like taught as a second language," said Mrs. Moss. "My mother crossed out all the languages listed and wrote down 'sign language' ." All of the family speak of Nancy as "cute and cuddly". For the future. Nancy's educational needs will probably require a move into the city to be near a suitable school. Mr. Moss will need to find other work. Helping behaviors Parents can be taught behaviors that aid in bonding. encourage the child's development and meet the child's great need for visual stimulation and physical contact. Parents are taught to look at the child when speaking and to use good facial expression. But, at the same time. they should not "overtalk". Some parents develop a pattern of talking "at" their child who will soon weary of this and stop trying to understand." Parents are taught to use speech before gesture or speech and sign simultaneously, depending upon the educational method followed. Behaviors are oriented toward helping the baby to develop a watching habit - to watch people's faces. especially the mouth and eyes. These behaviors must be incorporated into the ordinary, everyday routines. a practice that calls for much repetition until the baby understands the message. Understanding should be rewarded with evidence of pleasure and praise. It has been shown that even though the deaf child does not have verbal skills he can conceptualize and has cognitive skills.'s However, if he is deprived of successful communication with others, his social and academic skills will be affected. The greater the lag until his training is begun, the greater the lag in his academic learning and the greater the potential for the development of emotional problems. Since the handicap is a hidden one, the child may be mislabelled as retarded. uncooperative. dull or inattentive by those who are not aware of his handicap. With early diagnosis and treatment most of these problems can be avoided. Nursing implications Nurses have an important role to play in the detection of congenital hearing loss. For example. the nurse working with newborns can bring the five risk factors to the attention of the family pediatrician. Public health nurses are in an especially good position to detect and follow up on suspected cases. The PHN who sees the parents and baby at health 20 Jenuery 1171 The c.on-.llen Nur.. clinics and during home visits often is the only health Care professional involved with the family until school age. On the first post-natal visit to a new mother. the nurse should take a comprehensive hi tory and review the five factors which identify children at high risk for deafness. Children with a history of anyone of these factors should be placed on a "High Risk Registry" and be followed closely. The PHN can also ask the mother questions such as: . Does the baby react to loud noises? . Does noise awaken him from sleep when he is in a quiet room? . By three months. does the baby turn his head towards sound? When the infant is between six and nine months. the age when hearing loss is usually detected. it is useful to again ask the mother about the baby's hearing- does he. for example. turn his head to a familiar sound such as the sound of her voice or the ring of a telephone? Ifthere is any suspicion of hearing loss. the child should be referred to the services available in the area. This may be the family physician or an audiologist. The PHN'sjob does not end here however. If the diagnosis has not been confirmed. the high risk child should be followed up since deafness may show up later. If the diagnosis has been confirmed. the nurse should check with the parents to be sure they have been referred to a treatment program and if so. which program they have chosen. If the family is involved in a program. the nurse should learn what parent-child behaviors are to be followed so that she can offer support and encouragement. She should be aware of parental stresses during this time - the conflict in choosing an educational program. possible feelings of helplessness. guilt or denial and whether relatives are giving support to the family or not. The nurse will also be able to observe parent's behavior towards their child- are they being attentive to him. cuddling him? Both parents and child are apt to find the 12-month period hetween the ages of one and two years a particularly difficult and frustrating time. as much repetition will be necessary hefore the child understands what is being communicated to him. At this tage. parents can become frustrated and so. in turn. can the child. Joyful. reciprocal communication is not easy in this situation. Gaps also exist in educational programs for the hearing handicapped across Canada. For example. although the total communication program at the Vancouver Diagnostic Centre accepts children up to the age of three. no program for preschoolers from three to five exists owing to a lack of funds. Education is picked up again when the child enter school but valuable time has been lost. 16 In the community. nurses can also support positive health programs and promote public education about hearing loss. There is also a very real need for integration and cooperation between all disciplines to ensure the early diagnosis of hearing loss and continuity of treatment that is vital if the child is to have his rightful place in the family unit and in society. "I want to say to those who are trying to learn to speak and those who are teaching them: be of good cheer. Do not think ofto-day's failures. but of the success that may come to-morrow . You have set yourselves a difficult task. but you will succeed if you persevere; and you will find ajoy in overcoming obstacles - a delight in climbing rugged paths. which you would perhaps never know if you did not sometime slip backward - if the road was always smooth and pleasant. .. The Story of My Life Helen Keller. References I Schlesinger. Hilde. Sound alld sigll: childhood del{fileSS and mental health. by... and Kathryn P. Meadow. Berkley. Ca.. U. ofCal. Pr.. 1973. p.3. 2 Downs. Marion P. Guidelines for hearing screening of the infant. preschool and school-age child. In Detection l fdel'elopmental prohlems ill children. Edited by M. Krajicek and A. Tearney. Baltimore. University Park Pr 1977. p.1I1 ff. 3 Freeman. Roger. Psychosocial prohlems of deaf children and their families: a comparative study. by... et aI.Amer.Alln.Deall:!O:4:391-405. Aug. 1975. 4 MacLean. Dr. CD. Personal communication. March 3.1978. 5 Fisch. L Causes of deafness in children. Nurs. Mirror, 143:19:48. NovA. 1976. 6 Downs. Marion P. Joint statement on neonatal screening for hearing impairment. by... et al. Pediatrics 47:6:1971. 7 American Speech and Hearing Association. American Academy of Ophthalmology and Otoldryngology. and American Academy of Pediatrics. Supplementary statemellt o.{joint committee Oil illjllllt hearillg KreellillX. Asha. 16: 160. 1974. 8 Gerber. Stanford E. High risk registry forcongenitLl1 deafness. In Hearing Ion ill children. Edited hy Burton F. Jaffe. Baltimore University Park Pr.. 1977. p.74. 9 Downs. Marion P. Paper presented. Nm'a Scotia Conference on Earl\' I dent fìcation of Hearing Loss. Halifax. N.S. Sep. 8-11.1974. Proceedings. Basel. Switzerland. S Karger. 1976. p.14. 10 Crystal. David. Linguistic mythology and the first year oflife. An edited ver ion of the 6th Jan son Memorial Lecture. Bri.J.Disord.Commun. 8:29-36. Apr. 1973. II Schlesinger. op cit. 12 Downs. Marion P. Goals and methods of communication.I n Hearing loss in children. Edited by Burton F. Jaffe. University Park Pr.. Baltimore. 1977. p.7:!8. 13 Freeman. Roger. Psychiatric aspects of sensory disorders and intervention. I n Epidemiological approaches in child psychiatry. Edited by P.J. Graham. London. Academic Pr.. 1977. p.:!87. 14 Freeman. Roger. Personal communication. Feb.17. 1978. 15 Vernon. McCay. Relationship of language to the thinking process. Arch.Gell.Psychiatry. Vol. 16. Mar. 1967. 16 MacLean. Dr. CD. Personal communication. Mar. 3. 1978 Acknowledgement:TlllWhS go to Dr. R. Freeman. child p,\'\'chiatrist UBC and Dr. C.D. MacLean, Children's Hospital Diagno.Hic Celltre for their assistance in the preparation of this paper. A further thanh you goes to Elaille Cart\'. UBC faculty adl'isor for the stud\'. '- A ut/wr Marilyn O. Dahl (R.N.) prepared this paper during the third year in the B.SeN. program at the Unil'enit\. of British Columbia. A.I' part ofher stlllf\' on congenital hearillg loss. she I'isited two jámilies in the Vancoul'er area. each with a deajï,!flwt. Marilyn is a graduate l f a three \'ear diploma program, Victoria Ho.lpital, Prince Alhert. Smh.. ami has nursed in Sashatchewall. Ontario and B.C. She is presently .finishing her B .SeN. degree at U.B.C. The Cen-.llen Nur.. Jenuery 1171 21 Audiology programs: another viewpoint A number of centers in Canada like the one in Vancouver, provide diagnostic and treatment services and educational programs for the hearing impaired child and his family. But different centers have varying ideas about the benefits of certain communication approaches. To give you a better idea of how other programs across Canada operate, CNJ contacted the Audiology Department of the Children's Hospital of Eastern Ontario in Ottawa. The focus of their program is a little different from the Vancouver approach. Andree Durieux Smith Karen Tataryn Judy Simser The aims of the Audiology Program at CHEO are the early detection of hearing loss and the early habilitation of auditory, speech and language skills in hearing impaired children. Detection is carried out using behavioral techniques whereby sounds are presented and responses observed. In cases where results are uncertain. electrophysiological procedures are used to record changes in brainstem activity as responses to sound. (Brainstem Electric Response Audiometry). This latter procedure enables the identification of auditory dysfunction even in neonates. Hearing aids are fitted as soon after detection as possible. Prior to this, an interpretive session is held with the parents. the audiologist. the social worker of the audiology team and the aural habilitationist who will be responsible for the parent guidance program. In the interpretive session. many important factors are discussed with the parents. These include test results, the implications of the hearing loss. the recommendation of hearing aids, the description of the parent guidance program at CHEO together with the various methods used in training hearing impaired children. The early detection of heanng loss in children is essential. However, detection without training defeats its own purpose. The incidence of hearing loss requiring amplification is approximately 1 in 1000 and of these. only 2 per cent are totally deaf. Many severely to profoundly hearing impaired children can learn to listen and develop effective verbal communication. The development of auditory skills is possibly one of the most difficult tasks for these children to accomplish. It is also believed that the early years of life are critical for using auditory input to develop speech and language skills. The aural" habilitation program at CHEO, which is available from the moment of detection till the child is of school age. aims at teaching parents to work effectively with their child. It is an individually prescribed program stressing the participation of all individuals involved with the child. Sessions are held on a weekly basis and include home visits. The approach used initially is aural, however the therapy is diagnostic in that the child and his family are continually assessed to ascertain which method is most suitable for the child. If after a certain period of time. a child is not progressing sufficiently with the aural approach, signs are introduced and again the child's progress monitored. If it is determined that the child would benefit from a total communication approach he is referred to another program. A close working liaison is maintained with existing programs in the area and the child continues to be followed audiologically at CHEO Parent groups are held on a regular basis for the parents in the CHEO program. The sessions are educational as well as providing an opportunity for parents to identify common concerns and discuss possible solutions. Regular conferences are held for all children at six month intervals The child's progress, both from the parent and professional point of view. short term and long term goals, and upcoming decisions around the child's future are openly discussed. As a child approaches school age, the possible educational alternatives are discussed with the parents. It is our hope that hearing impaired children will be "integrated" into normal schools with the help of special support services. However, in some cases. it may be more beneficial for the child to begin school in a class for hearing impaired youngsters This does not preclude later integration with hearing children. As in our initial interpretive session with parents. all professionals on our team. voice their opinions about appropriate educational placement. Each child and his family are unique and all relevant factors must be considered in our recommendation. However, It is ultimately a parent's responsibility to arrange the chosen school placement for the child. The ongoing audiological assessment and parallel therapy program are closely interwoven at CHEO. We are constantly evaluating each child's progress and attempting to gear our interventions to the specific needs of each child and his family. At the same time, we acknowledge that it is not an easy task for parents to become "teachers" of their hearing impaired child. We are most supportive of parents' efforts and provide counseling for those who may be experiencing abnormal stress. The aim of the CHEO program is the integration of the hearing Impaired child in a normal environment whenever possible. We hope to facilitate this goal by responding to the total needs of each child and his family. .Aural communication concentrates on developing a child's auditory skills using a unisensory approach. i.e. training a child to listen for and distinguish human speech. Andrée Durieux Smith (Ph.D. in human communication disorders, McGill University) is Chief of Audiology, Children's Hospital of Eastern Ontario. Ottawa. Karen Tataryn, (M. S W University of Toronto) Social Worker. Audiology, CHED. Judy Simser (B. Ed.. McGill University; Dip. Education of the Deaf, Manchester, England) Senior Aural Habi/itationist. Audiology. CHEO 22 Jenuery 1171 The c.on-.llen Nur.. Aperfeet eoJUbiuation. . . you and Mosby texts. Your skills in the classroom and our efIectiye texts can assure your students of the best in education. MEDICAL/SURGICAL A New Book! MEDICAL-SPRGICAL NURSING: Concepts and Clinical Practice. By Wilma.J. Phipps, R.:-.!.. B.S.. A.1\1.. Ph.D.; Barhara C. Long. R.:-.!.. M.S.N.; and Nancv Fugate Woods, R.X. :-1.1\:.. Ph.D. Using both a s'\'stems and conceptual approach, this new text reflects' the mvriad changes in contemporary medical/surgical nursing.111 first two parts discuss such general aspects as socio-cultural perspectives. the nursing process. stress and adaptation, and PO:-1R. Part III focuses on specific medical/surgical problems - each includes an assessment of the in'\'olved system. followed hy a management/intelTention process. Chapters seldom seen in other texts explore ecology and health, health care delivery systems, and an epidemiologic PI roach to health care. Febmary. 1979. Approx. 1.600 pp.. 13., illus. About H27.75. Xew 6th Edition' .\1exander's C.\RE OF THE PATlE:VT IN SURGERY. By MarieJ. Rhodes. R.N., n.S.K; Barbara ,J. l.mendemann. R.X., B.S., :'-1.S.; and Walter F. Ballinger. M.D.; witll 21 contrihutors. Long respected for its accuracy and completeness. ilii!' classic text provides a comprehensive ovef\;ew of safe. efficient OR nursing. More than 2.000 superb illustrations (half new) augment forthright discu!'sions including asepsis, positioning, wound healing. and surgical procedures., June, 1978.904 pp., 2.146 illus.. including 2 in full color. Price. 30.00. A New Bo k! C \lXCER - PathophysioloJ!y. EtioloJ!y. Mana ement: Selected RcadiI1 s. By Louise C. Kmse, R.X, B.S.:-.!.. :-1.A.; ,Jean Reese. R.N.. B.S.X., :-U\.; and Laura Ilart, R.X., B.S.N.. :-1.Ed.. M.A., Ph.D.; with 20 contributors. This collection of articles offers VOlU students the latest infonnation on cancer pre\'ention, detection. treatment, rehabilitation - including the rc!e\'ant psychological aspects. Throughout. discussions emphasize the commonalities of cancer problems. and provide a practical, positi\-e pcrspecti\'e of care. ,January, 1979. Approx. 448 pp.. 35 illus. About t416.7;;. Xew 3rd Edition! THE VITAL SIGNS WITH RELATED CLINICAL MEAsrREMENTS. Bv Bettv McInnes, RX. R.Sc.X..l\l.Sc.(Ed). Use iliis valuabl textt teach yourstudentshow to assess measurements made in the clinical setting. The programmed fonnat arranges factual material in small. logical steps - progressing from basic infonnation to the complex. Two new chapters focus on the he rt. and est and lungfuncyons. Fehmary. 1979. Approx. 144 pp., 3., Illus. About 9.7.,. Xew 2nd Edition! CLINICAL IMPLIC\TIOXS OF L\BOR.\TORYTESTS. BySarkoM. Tilkian.l\I.D.;I\1arv H. Conover. R.X.. B.S.KEd.; and Ara G. Tilkian. M.D.. F.A.é.c. Give your students the infonnation they need to detennine the clinical significance of major labordtof\' tests. The hook begins with a section on routine lab tests. a d proceeds with sections on tests used to didgnose specific diseases. This new edition offers new chapters on rheumatoid and infectious diseases - and boasts the strongest cardiology ':.c ion of any similar cxt. Febmary. 1979. Approx. 272 pp., 4;) Illus. .\bout HO.7;). A Xcw Hook! BASIC PATHOPHYSIOLOGY: A Conceptual Approach. By Maureen E. Groer. R.N., Ph.D.; and Maureen E. ShekJeton. B.S.N.. M.S.N. The authors of this useful new text ha\'e organized the '\'ast field of pathophysiology into major conceptual areas. Included in students' study of disease are cellular de\'iation. hodv defenses. physical and chemical equilibrium, and nutrition 1 balance. Each chapter begins with leaming objectives which can be used to aid the student in self-evaluation. Febmarv, 1979. Approx. 560 pp.. 423 ilIus. About 819.25. . ew 2nd Edition! l'ROLOGIC ENDOSCOPIC PROCEDPRES. B Alicc :-Iorel. R:\.; and Gilbert J. Wise. l\1.D.. F.A.C.S. An memhers of the urologic team will benefit from this unique book. It thoroughly details all important aspects of the sul ieet - specific procedures. facilit\. and equipment requirements, and equipment mainten-ance. Revised and updated. tllis edition includes a new chapter on urodynamic procedures. and new infonnation on instmment cleaning and decontamination. March, 1979. Approx. 224 pp.. 258 iIIus. .\bout 81;;.00. The c.on-.ll'" Nur.. Jenuery 11171 23 Xl.''' 2nd Edition! PI AXXIXG . VD I)IPLE IEX- TTXG XrRSIXG IXTERVENTIOX: Stress and .\daptation Applied to Patient Care. By Dolores F. Saxton. R.N.. B.S.. 1\I.A., Ed.D.; and Patricia A. Ilyland. RX. B.S..:\I.5., ;\I.Ed.. Ed.D. Help your students learn how to measure patients' physiological and psychological adaptation to stress - and use t11is infonnation to plan and implement nursing interwn tion. Part I descrihes theory and Part II shows how to apply t11ese concepts. Case studies are used throughout. ;\Iarch. 1979. Approx. 192 pp.. 47 mus. About 810.75. Xew 4th Edition! :\TRSIXG C\RE IX EYE. E.\R. XOSE, .-\..'XD TIIRo.\T DISORDERS. l3y William II. Saunders. ;\1.0.; ,,'il\iam II. IIan..ner. 13..\..1\1.1).; Carol Fair Keith. R.X.. B.S.X.. ;\1.5.; and Gail Havener. R.X. ll1is new edition will help students increase their understanding of the pathophysiology. sign ificant signs and symptoms. treatmen t. and pre\'ention of EEXT disorders. Discussions emphasi.æ the nurse's growing role in the health caI"(' system. including outpatient. inpatient and homegoing preparation situations. Febmary. 1979. .\pprox. 464 pp., 386 illus. Ahout 20.50. Xc,," Yolume I! CrRREXT PR\CTICE IX XI'RSIXG C\RE OF THE ILL ADl'LT: Issues and Concepts. By ;\Iaureen 0. Kennedy. R.X.. 1\1..\.; and (;ail ;\Iolnar. This contempomry new \'olume examines the e\'eryday prohlems encountered by nurses in the medical-surgical unit. Three sections cover current practices (assessment. serious illness). current concepts (patient-nurse interactions. new tools for nursing). and current issues (nursing diagnosis. primary nursing). Key professional issues and their implications arc discussed t11roughout. and many timely topics arc featured. Febmary. 1979. .\pprox. 320 pp.. 20 illus. About 814.50 (llardcovcr):.\hout 810.75 (Paperback). Xc,," Yolume [! CrRREXT PERSPECTIVES IN REIIABILIT:\TIOX XrRSIXG. Edited bv Rosemarv 1\lurray. ;\I..\.. R.X.; and Jean r. Kijek. 1\1..\.. R.X. Xurse . psychiatrists. physical and occupational therapists. speech pathologists. and other rehabilitation team professionals- all join fi)rces toprm;de your sludents with valuahle insights on all facets of this important topic. Particularly noteworthy chapters deal with cultural implications. biofeedhack. sexual therapy. and rehabilitation nursing in the ICU. ;\Iarch. 1979. .\pprox. 256 pp.. 11 illus. About 814.50 (Hardhaek):.\hout 810.75 (Papcrhaek). .\ Xew Book!APRACTICALM. 'Xr.\L FORPATIEXT TE.\CHIXG. Edited b.... Karen 5. Zander. R.X.. 8.5.X., ;\I.S.;\;.; et ai. This new manua(serves as a model and tool for a svstem of patient leaching and documentation. It presents te ching plans and guidelines foranystage of the educational process. and describes objecti\'C methods for evaluating the patient's understanding. Each patient teaching fonn encompasses a purpose. content outline. learner olliectives and e\'aluation. Special features include a practical punched and peIforated fonnat. and sample handouts for patients and families. Septemher. 1 Y78. 412 pp.. 27 illus. Price. 816.75. MA'IDWAL/ODLD HEALnt NeV.' 3rd Edition! MATERNITY NPRSING. By Constance Lerch. R.N.. RS.(Ed.); and V. Jane Bliss. R.N:. B.S.!'\.. M.S.X. Emphasizing t11e family aspects ofbirtb. t11is comprehensive text provides a broad overview of obstetric and neonatal nursing. Students will benefit from well illustrated. detailed chapters on reproductive anatomy. nonnal and high-risk pregnancy, and alleviation of pain. Timely new material focuseson male and female responses to pregnancy and birth. maternal-infant bonding, and congenital heart defects. 1978. 592 pp.. 269 illus Price, 819.25. 4t11 Edition. IATERXIn' l\lJRSING: A Self Study Guide. By Constance Lerch. R.N.. B.S.(Ed.); and V. Jan Bliss. R.N.. B.S.N.. M.S.X. Stimulate class discussion wit11 this helpful workbook! Beautifully correlated with the chapters in MATERXI1Y l'\URSIXG. it offers students an excellent vehicle for self-testing or group study sessions. Incisive questions probe such topics as: family planning, high-risk pregnancy. and the nonnal put:rpcriulll and ù1e recovery nursery. 1978. 228 pp.. 60 illus. Price, 89.00. A Xew Book! l\TITRSIXG CARE OF INFANTS.AND CHILDREN. By Lucille F. Whaley. R.I'\., M.S. and Donna Wong. R.I'\.. M.N.. PXA-P. A comprehensive. practical approach to pediatric nursing. t11is new book focuses on distributive nursing care. and uses a systems approach from the medical model. The authors examine care of the ill or disabled child, and stress promoting the healt11 of t11e well child. Among t11e highlights. you'\1 find pertinent guidelines for action. . . communication with children and families. . . pertinen t lab data and phannaculogy . . . more than 250 tables and 400 illustrations.. .andanappendixofnonnalvaluesand assessment tools. April. 1979. Approx. 1.400 pp.. 744 illus. \bout 24.00. A ;\Iew Book! CHILDBEARING: Physiology, Experiences, Needs. By Jayne DeClue Wiggins.R.I'\., B.N. 1. This new text will help your students learn how to develop expectant-parent education programs. It views labor as part of the much larger process of childbearing - and deals with the entire pregnancy period. prenatal. the actual birth experience. and postnatal Almost 200 illustrations amplifY the discussions. May, 1979. Approx. 144 pp.. 192 illus. About 89.75. A Xew Book! MEXTAL RETARDATIOX: Xursing Approaches to Care. Edited by Judith Bickley Curry, R.X.. M.S.; and Kathryn Kluss Peppe. R.N., M.S.; with 23 contributors. Stressing a family-centered, humanistic approach. this thought-provoking text explores contemporary concepts in the care of the mentally retarded and their families. Students will read definiti\'e. original articles on: methods for maximum family involvement; developmental assessment; and quality assurance in residential settings. April. 1978. 258 pp.. 45 illus. Price, MIO.75. IVIOSBV TIMES MIRROR 24 Jenuary 1971 The Can-.llen Nur.. Put our exPertise to work in your elassroolU. CRITICAL CARE A Xew Book! MOSBrS 1.-t.'\LTAL OF CRITICAL CARE: Practiccs and Proccdures. Bv Linda Feiwell Abels, R.X.. 1. . Offer your students clear. c ncise instructions on basic critical care techniques witl1 this useful new text. Emphasizing systems assessment. it details mtionales and pnxedures necessary for maintenance ofbody homeostasis. Practical. comprehensi'\'C tables and useful appendices are included - and margin indicators highlight significant material thnHl hout the hook. ;.larch, 1979. .\pprox. 254 pp.. laO illus. .\hnut 12.00. A Xew Book! MOSBrS l\L-t.,\TUAL OF EMERGEXCY CARE: Practiecs and Proccdures, By. Janet Miller Barher, R.X.. I.S.; and Susan A. Budassi. R.N., M.S.X. This hea\ilv illustrated new book offers your students a quick reference t assessment skills and specific techniquestè:)r life supportand stabilimtion of the critically ill or injured. Arranged in a handy outlined fonnat, disucssions stress: signs and symptoms; intenelationships of pathological phenomena; and critical criteria and decision-making. May. 1979. Approx. 455 pp.. 404 illus. .\hnut lü.75. Xew 2nd Edition! E fERGEXCY CARE: Asscssmcnt and Intcn'cntion. EditedbyCannen Gennaine Warner. R.N.. P.II.X.; with 38 contributors. Emphasizing an interdisciplinary approach. !be new edition of this highly acclaimed book shares the insights of authorities in all areas of emergency care. They first describe underlying concepts, then focus on specific types of emergencies. Students will benefit from new chapters on child abuse, sexual assault. and spinal cord injuries. April. 1978. 556 pp., 226 illus. Pricc. 2().:)(). A Xew Book! HANDBOOK OF E)IERGEXCY PHAR..\L\COLOGY. By Janet :'-1. Barber, R.X. 1.s. This practical manual will provide your students witl1 concise. up-to-date infonnation on frequently used emergency drugs. Detailed sections - organized according to drug action - outline generic and tmde namcs. adions. incompatihilities. administrations. adult and pediatric dosages. contraindica- tions. and ad\'Crsc reactions. Ocwbcr. 197H. 150 pp_ Price. R:;O. .\ Xew Book! .\.\CX ORG.\XIZ.\TIOX .\XI> M.\X.\( E IEXT OF CRITIC\L-C\RE F.\C1U fIES. Edited hy Diane C. Adler. R.:\:., ;'1..\.. CCRX; and Xonlla. L Shoemaker, R.x.. BSX.; wilh la contrihutors. This unique new hook is the first to relate OI-gani.tation and management concepts directly to critical care facilities. Contrihutors wcll-known in the field dbcuss how to assess the intensi\'c care unit. plan k)r optimal function. and manage available resources. Con Slant attention is given to individual accountahility and the importance of teamwork in the lCU. .\pril. 1979. .\pprox. 192 pp.. 32 illus. .\bout f415.10. FUNDAMENTALS ;\íew 10tl1 Edition! TEXTBOOK OF XXATOMY A. D PIITSIOLOGY. By Catherine Parker Anthom'. R.I'\.. B.A., :'-1.S.; and Gar .. Arthur Thibodeau. Ph.D. Depend on the leading text in the field for a precise. comprehensive. and up-to-date presentation of human anatom\o. The new 10th edition has heen thoroughly re'\'ised and no ' includes; more than 200 full-color illustrations; new chapters on articulation. the immune system, and the endocrine s'\'stem; and expanded discussions throughout. January. -1979. Approx. 672 pp.. 570 illus.. including 211 in 4-color. 20 in 3-color; and 238 in 2-color. About 21.75. Xew 10th Edition! "-t. ATO)n' .-t. D PIITSIOLOGY L\BORATORY :\L-t.'\"'CAL. B\' Catherine Parker Antl10nv R.X.. B.A.. LS.; and Garv Arthur 111ibodeau. Ph.D. Th companion lab manual to-Antl1Ony's TEXTBOOK has also been ù1Oroughly re\'ised - and is the ideal way to give YOl1\' studcnts firsthand pmctice in applying the scientific method to anatomy and physiolo/.,'Y. Highlights indude: measurable olÜectivcs for each exercise; more emphasis on pathology; and the addition of 20 new experiments! .January. 19ï9. "\pprox. 240 pp.. 169 illus. About 9.75. :\:ew 2nd Edition! THE ;\lJRSIXG PROCESS: A Scientific Approach to Xursing Care. B\' Ann larriner. R.X.. Ph.D. The autl10r has compiled 290ut-;'tandingarticles dealing with each phase of the nursing process - assessment. planning. implcmentation. and e'\'aluation. Each group of readings is prefaced by an insightful introduction and followed by an cxtensive hihliography. .January, 1979. Approx. 288 pp.. 6 illus. .\hnut 12.00. ew 2nd Edition! FUXDA..\IENTALS OF OPERA- TING ROO)I ;\TRSIXG. Bv Shirle'\' M. Brooks. R.X., B.A Written especially for studénts with no operating room experience. this valuable text thoroughly details fundamentals of preoperative. intraoperath'e, and postoperative care. The book is specifically designed to be used by students concunently with their rotation in the operating room. A photo-re\'iew quiz is pro,\oided to aid the student in evaluating proficiency. larch, 19ï9. .-\pprox. 21 G pp.. 2Hl illus. .\hout 1O.2:;. ew 4th Edition! CLIXICAL TRSIXG TECH- 'XIQrES. By !\:"onna Dison. R.X.. B.A.. M.A. Guide your students through basic and advanced techniques in medical-surgical nursing with tl1e help of the new edition of this well-recehoed text. They1lIearn procedures step-by-step from authoritati\.c discussions. augmented hymore than ï03 original line drawings. Principles and purpose are emphasi.ted rather than disease orhody systems. A teacher's guide is included .\pril, 1979. .-\pprox. 432 pp., 703 illus. "\bout 14.:;O. The c.on-.llen Nur.. Jenuery 1871 25 Xcw 14t11 Edition! PIL\R.\L\COLOGY IX :\TRSIXG. By Betty S. Bergersen, R.X.. :'-I.s.. Ed.D.; in consultation with Andres Got11. 1.D. Trust this classic text to pro....ide your students witI1 the infonnation the.... need to ensure rational amI optimal drug thempy. 111e auihor has updated all drug infonnation - and each chapter has been critically rc....iewed by Andres GoÙl. renowned authority on phannacology. Highlights include: expanded cm'eragc on drugs for t11e eldcrly; new infonnation on enzymes and drugs acting on gastrointestinal organs; and all new chapter summaries. January. 1979. Approx. 784 pp.. 100 illus. .\bout 20.:;0. CO D TIT 1ßSING A Xew Book! IXXOYATIOXS IX CO nlrXI1T HEALTH :\LJRSIXG: Health Care Delivery in Shortage Areas. Edited by Anne R. Warner. B \.; with 23 contributors. Offer your students a creative approach to community health nursing. This timely book bridges the gap between the real and ideal by presenting first-person accounts of the challenges inherent in inner city and rural practices. Inno....ati....e solutions to both timeless and new problems are described. pro....iding an effecti....e demonstration of the decision-making process in action. March. 1978. 250pp.. 23 illus. Price, 10.25. Xew Yolume I! CrRREXT pR.\mrE IX GEROX- TOLOGIC\L XrRSIXG. Edited by Adm'! :'-1. Reinhardt, Ph.D.; and :'-lildred D. Quinn. R.X..:'-1.S.; with 19contributors. The politics of care for the aged . sexuality and aging. . . growing old in thc Black community .. thelawand t11e elderly - these arejusta few of the many stimulating topics detailed in this new book of readings. The contributors are all knowledgeable and experienced - and together they offer your students a thorough m'erTiew of the sUQject. :'-Iarch. 19ï9. Approx 304 pp. .\hout 14.:;O (Hardhack): -\bout 1O.7:; (Papcrback). A Xew Book! THE A..'XTHROPOLOGY OF HEALTH. Edited by Eleanor E. Bauwens, R.X.. Ph.D.; with 23 contributors. Help students better understand the dÎ'\'erse beliefs of other cultural groups with this new text. Original papers apply anthropological principles to health care; explore the relationship of medicine to culture, society and health carc; survey changing food habits in \'Rrious cultural groups; and discuss the sociocultural aspects of aging and d'\ing. Case studies illustrate major concepts. September. 19ï8. 228 pp.. illustralcd. Price. 12.7:;. ISSUES ' nm,rns A Xew Book! :\TRSIXG: A World View. B'\' Huda Abu-Saad. Ph.D.. :'-I.X. B.S.X Yourstudentswillenj y-and benefit from - this unique new text. It pro....ides a worldwide historical perspecti....e of nursing. co....ering the growth and de....elopment of the profession in more than 30 countries. Useful tables summarize de....elopments in '\'Rriouscountries for quick comparison. :-larch. 19ï9..\pprox.208pp.,14illus. About I:;,OO. .\ Xcw Book! SPECIAL TECHXIQrES IX .\SSERTIYEXESS TRAIXIXG FOR WOMEX IX THE HEALTH PROFESSIOXS. By Melodie Chene....ert, B.A., I.s. Written with humor and insight into human nature, this text focuses on learning to be asserti....e in order to impro....e patient care. Discussions demonstrate ùle significancc of de....eloping greater self-esteem and stronger leadership roles. Examples of specific situations clarify key concepts. Throughout, the author differentiates between effective asserti....eness and abrasÎ'\'e aggressÎ'\'cness. Xm'ember.1978. Approx. 128 pp.. 13 illus. About 9.7:;. Xew \'olume I! CrRREXT PERSPECTIVES IX :\TRSIXG L\XAGÐIEXT. Edited by Ann :'--Iarriner. RX, Ph.D. Twent\ noted nurse leaders ha\'c contributcd insightful articles focusing on specific infonnation that beginning middle managers need to know. Students will benefit from discussions including use of teams in health scrvÎCcs. planned change. communication. patient education. continuing education. and political dynamics. :-larch. 19ï9. .\pprox. 240 pp.. 8 illus. \bOl1t 14.50 (llardback):.\bout 10.75 (Papcrback). PRA.cnCAL TßSING Xew 3rd Edition! BASIC PEDL-\TRIC XrRSIXG. B'\ Persis ;\Iary Hamilton. R.X.. P.H.X. B.S., ;\I.s. Help you"r students better understand the special needs of their childhood patients. This useful text pinpoints the spccific role of the LP/YX in child care. prm'ides comprehensh'e infonnation on growth and de'\'elopment,examinesdisorders common to children, and offers a holistic \'iew of the child in society. Timely. well-illustrated new discussions explore neonatal care, immunization. and diagnostic tests. February. 1978. 490 pp., 272 illus. Price, 1 a.25. Xew4th Edition! L\TERXAL.-\XDCHILD HEALTH :\TRSIXG. By A Joy Ingalls. R.X, ;\1.s.; and 1. Constance Salerno. R.X.. :-1.s.. S.X.P. Well-written and effectively illustrated. this new edition introduces the LP!\'X student to major challenges in maternal/child health nursing. It successfully combines obstetric and pediatric nursing - so \'our students will know what to do, how to do it, and whv. Thoroughly re'\'ised. this new edition includes more t11an 200 new illustrations - and updated infonnation in all areas. :-la , 19ï9. .\pprox. f)ï2 pp.. f)9: illus .\bout 1 H.OO. IVIDSBV TIMES MIRRDR THE C. V. MOSBY COMPANY, LTD. B6 NORTHLINE ROAD TORONTO, ONTARIO M4B 3E5 Mosby kno s nursing. he pr. blem · f immunizati · n in anad · Sandra LeFort , I \ , \ I ;, ,... r - J . . -. I . , . J J I I , I '"' p - - The Cen-.llan Nur.. Januery 11171 77 Few measures in preventive medicine are of such proven value and as edsy to implement as routine immunization against infectious diseases. J Over the last three decades. widespread acceptance of vaccines has dramatically decreased the incidence of certain communicable disedses such as poliomyelitis and whooping cough. According to the World Health Organization even smallpox. the most devastating disease in history. has been completely eradicated from all countries in the world. But with all this success. there is evidence that immunization may be lagging in Canada and that some vaccine-preventable diseases such as diphtheria. may actually be on the increase. Are you aware. for example. that in Canada in 1975. nine children died from whooping cough. two from diphtheria. seven from measles and two from rubella?" Each year. more than 100 babies are born with serious defects because their mothers had rubella during the first three months of pregnancy. Why is this still happening in a highly developed country such as Canada? Immunization programs have been going on since the 40's. but most parents. and medical per'\onnel for that matter. have forgotten the tragedy ofthe polio epidemic of the 50's. As a result. the recurrent need for immunization for both children and adults does not seem as apparent as it once did. As the 1977 annual report of the Canadian Medical Association's Council on Communit} Health stated: . 'I t is clear that the public is being lulled into a false sense of security because of the absence of epidemics of the usual childhood diseases and is neglecting to have young people receive the recommended immunizations'" Which leads us to another question ... What is the recommended schedule of immunizations'? The debate about "which schedule is best" has been going on for some time between medical authorities at all levels - at the local. provincial and national levels. In 1977. a National Advisory Committee on I mmunizing Agents agreed not on one but three immunization '\chedules for infants and children. The rationale for choosing three schedules was that "no single set of recommendations for the use of these vaccines is optimal for all situations." At that time. the committee believed that there was not enough evidence to support one schedule unreservedly and that all three are equally effective. It sounds good. But. according to a recent editorial in the Canadian Medical Association Journal. there is still a problem. Apparently. the provincial health departments do not necessarily follow the recommended schedules. local public health authorities at times do not follow their own provincial programs and finally. some individual physician.. establish their own preference in immunization schedules. If medical duthorities are openly unsupportive of each other. it is no ..urprise then that the public is in the dark. 'The public is confused regarding what immunization they have had. should have had or require. A sizable segment of the health professions is not much better off. "Adding to the confusion are an increasingly mobile population moving to and from areas with varying immunization record transfer and patients who have no personal record or idea regarding what they or their children have been immunized for - or their current immunization status. ..:t Part of the sol ution. according to the editorial. is the acceptance of a single immunization schedule by all health departments and health professionals. Recently. ajoint committee of the Canadian Hospital Association. the Canadian Medical Association. the Canadian Nurses Association and the Canadian Public Health Association supported ,his idea by proposing that all these agencies should accept as a high priority the establishment and promotion of a basic. single. national immunization schedule and program. CNA's Board of Directors ha.. given its support to the recommendation. At a meeting of the National Advisory Committee on Immunizing Agents held in late October 1978. this recommendation and others from various groups were taken into account and now. a single. immunization schedule has been adopted. (See page 29) Even so. the main problem of keeping Canadian children and adult, protected from communicable diseases remains with us. Media campaigns are trying to keep the subject of immunizatIOn in the public eye. A concerned committee has made November "Immunization Action Month". Its immediate objective is to promote immunization against vaccine-preventable diseases for all children in Canada before the age of school entry. And so. what is your part in all this? By virtue of your role as a nurse. whether in a hospital. public health unit or a doctor's office. you are in contact...... ith a great number of children and parents. Have you taken the time lately to talk about immunization to them. ih importance to their health? Have you encouraged primary immunization of all children. stressed the need to schedule vaccinations and emphasized why booster doses are necessary? The following "Immunization Fact Sheet"" prepared for parents by the Canadian Paediatric Society and the Canadian I nstitute of Child Health may be of some help to you as a nurse in pointing out the whys and ho......s of an immunization program to clients. 21 Jenu8ry 11179 Th. c.on-.llen Nur.. Immunization Fact Sheet 1. A re ÏI!fectious diseases a prohlem in Canada? It is astoni'ihing that while notahle results have heen achieved in the control of whooping cough. measles. ruhella. polio. tetanus. mumps and diphtheria - the major preventable childhood diseases - infectious disease'i are still among the four leading caU'ies of hospitalization of children (with accidents. respiratory problems and congenital anomalies being the other three). Many of the'ie infectious disea'ies could he prevented hy immunization. 2. Do children eI'er die from prel'entahle diseases? Some children 'itill die each year from these diseases and others develop serious complications such as encephalitis. pnl?umonia and hearing loss. One study show'i that ahout one in ten children who have measles develop complications. 3. Where can I Ret m\' child imllll/1/ized? In thi'i country many places are availahle to provide immunization and this varies greatly from province to province. Your child may be immuni7ed in public health departments. community clinics. hospital clinics. and schools or thi'i may he carried out hy family physician'i or pediatricians. 4. Who should I..eep the record? As a parent. you should keep a written record of the vaccines that your child receives and the date of the injection. No one else is going to do this for you. You", ill need this information if your child is taken to emergency for treatment of wounds. for example. In this case. the doctor will need to kno", if the child's tetanus immunization is ddequate. Immunization information is al'io required when your child begins school and if immunization i'i part of the school health program. you will need to know what has already heen given and when. I t is al'io needed if you move to another locality or travel ahroad. Recently. a new immunization health record wa'i prepareu hy the Infectiou'i Di'ieases Service at the HO'ipital for Sick Children. It will he extensively used and distrihuted throughout the province of Ontario as a permanent record for children. (See page 30) 5. W hell should my child hi' Ïlnm/l/liznland fár what diseases? I mmunization should be 'itarted hy two or thl ee months of age and should follow a schedule as recommended by your puhlic health clinic or your doctor. Booster shOb. given at intervals following the primary immunization. are necessary to reinforce the child's immunity. 6. What should I\'e do {we plan to trlll'el outside Canada? Because it may take several weeks. be sure 10 check in good time with your doctor or puhlic health department. Several immunizations may he needed depending on the country you plan to visit. 7.1 s immulli;:.ation a mi/ahle jllr all infe( tious diseases? No. but re'iearch is in progress to provide protection against diseases such as chicken pox. gonorrhea and infectious mononucleo'iis. 8.1 s there a way to protect my child aRainH di.\'ea.\es JÓr It'hieh there i,\' no ,'accine? In some instances. temporar} protection may be given or the disease modified. Check with your pediatrician or local health duthority. 9. What is the risl.. (!{damage to a hahy ({the mother del'elop.\. ruhella during the }ìnt three month, of the {lreR/wncy? Overall. there is approximately a 50 per cent risk (0 the baby. The earlier the maternal infection occurs during pregnancy. the more severe the fetal damage. The most common problems are heart defects. deafness. blindness and mental retardation. A pregnant woman should not receive rubella vaccine. 10. ffmy teena,l!e dauRhter has ne"cr heen immunized'/Ór ruhdlaand la/11uncertain (fshe e"er Iwd the disease. It'hat .\JlOuld she do? 1.\ it too late for her to he immunized? No. it's never too late to immunize against ruhella. A simple hlood test can he done to determine whether vaccination is necessary. 1 I. ffm," child JIlI,\' Jwd polio \'accine h,' needle and I\'e mm'e to a place II'liere polio n/ccille is g;,'en h,'. mouth. is it nece.Hary ami s(dé for the' child to he renlCcillated? Regardless of whether the fir'it immunization was by needle or by mouth. if further dO'ies are needed it i'i perfectly safe to follow the practice of where }ou are living. 12. What should I do (/1 su.\'pect my child hm all ÏI!féctiOlH di,\' e a.\(' ? Keep him at home and contact your physician for further advice. .., References I Routine immuniz,ttion 'ichedules.Call..'11ed.A.,..\..J. 117:6:705. Sep. 17. 1977. :! Canada, Statistics Canada. Registrie'i Section. Health Division. IV ot!lìah/c' Diseases - Vital Statistin ami Disease. 3 Geekie. D.A. Promotion and marketing techniques could helpCanada's disorganiLed immulllzation 'ichedules. Call.Aled.A.u.J. 119: :76()-76:!. Oct. 7. 197K 4 11I/1111l11izat;o/1 Fact S 11('('1. Canadian Pediatric Society. Canadian Institute of Child Health. 1977. The Cen-.llen Nur.. Jenuery 11171 211 NATIONAL ADVISORY COMMITTEE ON IMMUNIZATION RECOMMENDED* IMMUNIZATION SCHEDULES FOR INFANTS AND CHILDREN Immunization carried out as recommended in the following revised schedules will provide good basic protection for most children against the diseases shown. With respect to tetanus and diphtheria, the schedules pertain to use of either fluid or absorbed toxoids. but in view of their superior antigenic properties. the use of absorbed products is to be recommended when such products become available. Both live and inactivated polio vaccines have been used in Canada with equal success in preventing the occurrence of paralytic poljo, and either may be used in the schedules presented below. Tabte 1 Routine Immunization Schedule For Infants And Children 2 months Diphtheria 4 months Diphtheria 6 months Diphtheria 12 months Measles 18 months Diphtheria 4-6 years Diphtheria 11-12 years Rubella I for girls 14-16 years Tetanus and Diphtheria 2 Pertussis Pertussis Pertussis Mumps Pertussis Pertussis Tetanus Tetanus Tetanus Rubella I Tetanus Tetanus Polio Polio Polio Polio Polio Polio Table 2 Immunization Schedule For Children Not Immunized In Early Infancy For children 1 through 6 years of age First visit' Diphtheria Interval after 1 st visit 1 month Measles 2 months Diphtheria 4 months Diphtheria 16 months Diphtheria At 11-12 years of age Rubella I for girls At 14-16 years of age Tetanus and Diphtheria" For children 7 years of age or over First visit' Interval after 1 st visit 1 month 2 months 14 to 16 months At 11 -12 years of age At 14-16 years of age Pertussis Tetanus Polio Mumps Pertussis Pertussis Pertussis Rubella I Tetanus Tetånus Tetanus Polio Polio Polio Polio Tetanus and Diphtheria' Polio Measles Tetanus and Diphtheria" Tetanus and Diphtheria! Rubella I for girls Tetanus and Diphtheria 2 Mumps Rubella I Polio Polio Polio Notes: 1. Rubella vaccine is recommended either a) for all infants over the age of one year or b) for prepubertal girls at about the age of 12 years. At the present time. insufficient data are available as to which is the more effective program for preventing congenital rubella syndrome. 2. Tetanus and Diphtheria Toxoid. a combined preparation for use in persons over six years of age, contains less diphtheria toxoid than preparations given to younger children and is less likely to cause reactions in older persons. If it is not available, other combined preparations of diphtheria and tetanus toxoids (without a pertusis component) may be used in a dose recommended by the manufacturer for the particular age group. 3. Although not desirable. measles. mumps and rubella vaccines may also be given at the first visit if it is considered likely that a child will not return for further immunization. 4. Measles vaccine (live, attenuated) may be given either alone. or in combination with rubella vaccine. mumps vaccine or both. In areas where special epidemiological conditions exist. and particularly where measles occurs frequenlly in the first year of life. measles vaccine may be given as early as five or six months of age; if measles vaccine is given before 12 months of age. it is imperative that a further dose be given at about 12 months of age. as persisting maternal antibody may interfere with an adequate immune response to the earlier dose. 5. Where more than one preparation is given. whether they be single vaccines or commercially prepared combinations of vaccines. a separate injection site should be used for each product. 6. Smallpox vaccination is not recommended. *These recommendations were issued by the National Advisory Committee on October 27, 1978 and have been endorsed by the Canadian Paediatric Society. 30 Jenuery 1117V The C.n-.llen Nur.. The Hospital for Sick Children IMMUNIZATION AND HEALTH RECORD Name of Child Birth Date RECORD OF IMMUNIZATION DPT + Polio Vaccine : rn B DT + Polio Vaccine in B First Dose Date Booster Date Second Dose Booster Third Dose Booster Fourth Dose Booster Dose Measles Vaccine Mumps Vaccine Rubella Vaccine Date Tuberculin Test Date Results Hemaglobin Date Results Urinalysis Vision Test Date Results Hearing Test Illnesses & Operations Date Past Infectious Diseases Date Measles Mumps Chicken Pox Whooping Cough This Record Should Be Retained And Kept Up To Date The Cen-.llen Nuree Jenuery 1117V 31 :: :: : ::-.:.:.:. :/>< .:.:.:.:. :. :.';. .;... 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'::: :::: :::: ::: :::::.:.". -:: :::::::-: :::::: .'<: ... . .. . . .: .:-: :-:. ::::= . : :::: ::-. ::: :::::-:-:-: :: :::::::-: . : ::'. . .... . . . . O . . . . .... :. . . . . . . . . . . . . . ... . . . . . ' . . . .. . . :. . . . : . . .: . . . . . :. . . . .. . .. .. ... .. ...... .... ..... . . . . : ::: ........:. :.:- .... ..:-:- .:. :-:.. .:.>> .-:. :-:. .. ..-:. :-:.: .... . .............. . .. . 0 . . . . . . . . . . . . . . . . . . . ........... ............ . .. . . .. ... . . ... .. .. ....... '.. .. .:.... :: :-:':'.':-:-: ::: :-:.:-:-:..... .':::-:- ::: :-:.. ::: : :-:-:.:-: :: :-::: ::.. .>>. ....... ..... .... ... .. ... :... .. ........ .. . ..... . ... '0.00. ..... .... ....... .'. aren't problems anymore At this hospital, there's a nurse in street clothes that nurses, patients and their families can turn to for help in meeting the emotional needs of the "problem child" on the general pediatric ward. Kathy He[?ll(loren 32 Jenuery 111711 For the past three years our hO'ipital ha'i been the scene of an interesting and. we think. successful. experiment aimed at making sure that. when a child is admitted to our general wards. not just his physical. but also his emotional. needs are looked after. As the "pediatric psychiatric nursing coordinator" - a title suggested by one ofthe staff members - it is my job to provide leadership in dealing with psychiatric patients admitted to general pediatric wards and a,sistance in handling any other behavior management problems encountered throughout ourChildren's Pavilion. In recent years the trend at our hospital. as in many others. has been to admit an increa'iing number of children with psychiatric diagnoses to general pediatric wards. More and more behdvioral problems manife,ted during medical or surgical hospitalÌ7ation are al'io being identified on wards. These children require a consistent therapeutic regime to meet their 'ipecialized needs and. while it is sometime'i easy to identify what a particular child's needs may be. difticultie, frequently ari'ie in providing the neceS'iary nursing hours. Dealing with emotionally distressed children can be very time consuming and 'itaff tend to give priority to providing care for the acute medical and surgicdl conditions. Then too. some nursing staff are uncomfortable about being involved with children admitted for psychiatric help; others are he...tant due to lack of e'l.pcrience or previous unrewarding experiences. It wa'i in response to these concern'i that the administrative staff and child psychiatrist decided to create and till the position of pediatric psychiatric nursing coordinator - a nUf'\e who would help The C.n-.llen Nur.. other nurses to find ways of meeting the emotional needs of their patients. The job description made 'ieveral points clear from the beginning: . The per'ion Wa'i to be employed at the general duty level to prevent the necessity of developing a new nursing category within the hospital. . Hours of work were left tlexible to allow the nurse herself to determine which days she would work and at what time her tour of duty would begin. . This person would be directly responsible to the assistant director and supervisor of pediatrics and indirectly to the head nurses of the pediatric units. When I accepted the position of pediatric psychiatric nursing coordinator late in 1975,1 had already worked for three years in adolescent psychiatry. The administrative staff. who predicted that the succe'iS of the program would hinge on my acceptance by everyone on staff. planned a very special kind of orientation for me. We wanted to make sure that all levels of staff saw me first as a nurse with tmditional competencies and second a'i a nurse who could help with specific p'iychiatric competencies. 1 had to avoid being perceived as a suspicious looking "expert" telling others \\hat to do. With these ol:iectives in mind I began my tour of duty as psychiatric nursing coordinalor in uniform. working general duty on each ward for varying periods. Different wards demanded different involvement. A., most of my work would be with children between 'iix and thirteen years of age. 1 spent a \\eek on these wards. I spent three days on wards with children between the ages of eighteen months and six year'i and two day'i on ward., with infants up to eighteen months. It was more ditlïcult for staff caring for infants to see much use for a psychiatric nurse. except in the area of dealing with parents. This orientation period provided me with an opportunity to appreciate nursing problems at different levels of treatment. to become acclimatized to each unit and to sow seeds of information about how this consultant role might develop. The orientation lasted almost two months. and. as it drew to a close. I found myself eager to begin my actual work. My eagerness. however. was coupled with a twinge of anxiety: as this was a unique position. there had been no previous experience from which performance criteria or expectations could be drawn. At time'i I wondered "What am I really getting into?" All this wa, three years ago and by now I feel more comfortable about being the psychiatric nursing coordinator on pediatrics. I wear streetclothes which seem to have been readily accepted by both staff and patients and. although there have been times of personal alienation when I felt a., if I didn't belong. in general. the demand for p'ychiatric competencies has increased. Most of the time I feel that my days are well 'pent. The work varies: the list of activities I have been involved in is long and includes: · C oordinlltion ( "lI11llspects of the psychiatric trealmem program: physiotherapy. occupational therapy. \chool. parents, etc. . W eeMy coriferences with \'lIrioll. stajJ in\'OII'('(1 with the child psychiarri,ft's patients. This meeting is primarily for planning short and long term treatment goals. school planning and discharge planning. A record is kept of the discus,ion. . N lining care planning: team conferences on a/l of the psychiatrist's patients frequently includmg other specific behavior management problems that have been raised by nursing staff. As a result ofthe'ie conferences. st.mdard nursing care plans on some common psychiatric problems have been developed including h perkinesis and school phobia. A guide for developing behavioral-oriented nursing care plan has been posted. In addition. a charting guide for children with behavior problems has been developed and is in the process of being accepted a., pan of the charting manual. . I nser\'Ìce education: This aspect of consultant work is usuallv done through specific ward ses.,ion but is also an ongoing process in team conferences. A growing collection of re'iource material is available to all interested staff. Staff are also invited to attend the weekly student intern seminars given by the child psychiatrist. . Student nurst' education: Student!. are free to attend team conferences and inservice to gain understanding in this panicular aspect of care in pediatrics. Their interest in helping children\\- ith psychiatric problems is also reflected through requests for guest speakers in their training program. . Liaison wor/.. with parents: Parents meet one evening a week with the psychiatrist and ward staff and often discover that they are not the only ones with "problem children". Parents of babies in the Neonatal Intensive Care Cnit meet twice a week to share their fears and questions with unit staff. the pediatric social worker and myself. This service is unique in that it is abo offered to mothers who have gone home without their babies and wish to share their anxietie before and after baby comes home. . Group therapy: a dailv. two-fold re pon.,ibility in that group therapy is a well e.,tablished form of treatment for children with psychiatric problems. serving to teach communication skills The Cen-.llen Nur.. and to seek out alternate ways to deal with life's stresses. It is also a teaching ground used to instruct staff in various group techniques and group dynamics. The after-group sessions with staff provide more teaching opportunities and a chance to discuss day-by-day developments. . Obsen.ation and .mpen'ision oj a comhined Rym proKram: This is a relatively new program where the pediatric psvchiatrist's patients are grouped with adolescent psychiatric patients once a week for various sport'> activities. Our hope is to use this program to teach better sibling and peer group understanding. . Bi-wee/../yfilm entertainment for preschool and ScllOol-aKe patients: The National Film Board is our present ,>ource of films but other sources for children's films are being looked into. The hospital has agreed to provide some monies for film rentals in the next year. . Teacher-coordinator liai.wn: I\lany of the problems of children with psychiatric disorders stem in part from disastrous school experiences. It becomes the task of the therapeutic team to help each child cope with <,chool stresses. Having a close working relationship with the hospital's special education teacher. keeping her informed of daily de\elopments. has improved communication between ward and clas room staff. . School-community liaison: The psychiatrist. his intern. the in-hospital teacher. m}-selfand. when po'isible. ward staff meet with the involved teacher; and the parents at the community schools. There we discuss what we have learned about a child and his family. giving teachers more background. understanding and help in devising effective long term school plans. Jenuery 1117i 33 The future To me. one of the most challenging aspects of this position is the idea that it is till evolving. I meet regularly with the assistant director of pediatrics who provides guidance and assistance a<; well as feedback on how the job is going. In the future the role of pediatric psychiatric nUßing coordinator can take many directions. One avenue which ha been looked at with an eye to future expansion is t.tJat of parents' groups for patients with common concerns. The'ie groups might discu'is the art of parenting or problems associated with failure to thrive. a'ithma.leukemia or orthopedic conditions. Post-discharge group for parents and children can be valuable in the promotion of well-being and prevention of repeated hO'ipitalizations. Home visiting is also an area ripe for expansion. My involvement in the area of child ahuse is still in a very early stage of development. An ongoing inservice program for nursing staff. involving the hospital's psychologist. i being established with the objective of teaching communication .,kills and basic group techniques. These are only a few of the directions that might be follo\\-ed. The creation of the pediatric psychiatric nursing coordinator is evidence not only of the recognition of the emotional needs of children but of a positive step in the direction of meeting the'ie need... '" A t the time of u'ritinK this paper. author Kath Hegadoren II'lIS the pediatric psychiatric nun-inK coordinator. Children's P(II'i/ion. Royal Alexandra Hospital. Edmonton. Alherta. Privr tv tlris position. she \\ as tire coordinaror of the adolescent psychiatric proRram at the R.A.H. As o.fSeplember 1978. Kathy Iras embar/..ed on a new \'entllre in the neonatal intensÌ\'e care nursery liS a matemal-Ì1(fa/lf liaison nune (Ç)(tJJ (p (Çru (b (Çooruoo Caring for the retarded child in an acute care setting BriKid Peer . A ten-year-old who drools constantly and needs help to feed himself . An adolescent who reacts to strange faces and surroundings by "making strange" like a toddler . A "self-stimulating" four-year-old who shows no sign of hearing or seeing you, who refuses to establish eye contact and snaps his fingers instead of talking. Not all retarded children have behavior problems as severe as those described above. but there can be little doubt that in the eyes of the nurse who assumes responsibility for their care in hospital. looking after these special children presents some very special problems. Estimates place the number of retarded individuab in the population at approximately three per cent. Among those of us who are fortunate enough to be excluded from this category, mental retardation evo"e, a variety of responses. most of them negative. Nurses. on the other hand. are "not supposed" to have negative feelings and so we are apt to be unwilling or unable to express the dismay we may feel when confronted with the prospect of caring for a retarded child in an acute care etting. We are frightened of the temper tantrums of the physically mature adolescent: we don't know how to react to the finger-'mapping youngster who doe n't seem to know we exist. We wonder how we're going to find time to feed the newly admitted ten-year-old who needs half an hour of our undivided attention to finish one meal. Often. the easiest course is to confine these children to their beds, to restrain them if they show signs of resIsting, and to provide them with few toys and little or no stimulating interaction with staff and other patients. We sigh with rehefwhen a parent wishes to room-in with his child and, after treatment or surgery. hurry them back to the home or institution where we feel they rightly belong, Ifwe are honest with ourselves. we admit that we are not comfortable with these special children and. as a result, their stay in hospital becomes a traumatic experience for everyone concerned - nursing staff, parents and the children themselves. Piaget has defined intelligence as the ability to acquire knowledge which facilitates the adaptation of the individual to his environment. I.' I tis obvious that. according to this definition, the ability of the retarded child to accept strange surroundings. painful procedures and changes in routine will be limited. His needs. however. are the same as those of the normal child and he is as sensitive as the normal child to his environment and to tho'\e who care for him. Clearly. what is needed in many of our acute care settings is a new and more positive approach to looking after the hospitalized retarded child. Admission Sometimes. when it i.. known thdt a retarded child is going to be admitted. it is helpful for the staff members involved to sit down together and have an honest discussion about their feelings in canng for a retarded child. At that time. those who really do not feel capable of coping can be identified so that they are not put into the position of having to care for the child. One or two ..tatT members may be chosen or volunteer to be the chief caregivers for this particular patient. Since many of the problems invol ved in caring for the retarded child in hospital arise out of lack of understanding. it is important to learn as much as possible about the child at the time that he is admitted. Make time to talk to the parents who. even though they are undergoing a period of stress, can often provide real insight and constructive suggestions. Find out whether the child likes to be cuddled or stroked. whether he has a favorite to) or ..pecial feeding or sleeping ritual. I f one staff member has been chosen to act as chief caregiver. this nurse should obtain a very thorough history from the parent or person who admits the child. Since the retarded child has difficulty in adapting to new situations. all his routines of daily living should be carefully documented. I n this way. the only changes that will have to be made will be those demanded by the medical regimen and the child will settle more quickly into the unfamiliar setting. Whenever possible. a bed should b chosen for him which is near to the center of activity. This child needs more contact with people than a normal child sincf: he is less able to amuse himself. His companion in the room should. preferably. be mobile. able to help his roommate. and to go for help if it is needed. If the companion's parents complain about his being in the room with a retarded child. an effort should be made to have them accept the situation. If they remain adamant. how about moving the normal child to another room '? He is better able to adapt to new The Cen-.ll8fl Nur.. Jenuery 111711 35 surroundings than hi retarded roommate. Too often we see the retarded child shuffled from room to room as complaints come in. until he ends up around the corner. down the hall. by himself. where no one will be bothered by him. Nursing assessment Next. the nurse should make her own assessment of the child's developmental level. This should then become her guide in planning nur ing interventions. Often. chronological age has little relation to the child's capacity to function. In assessing the retarded child. it is not unusual to find an irregular pattern of development: gross motor skills, for example. may be close to normal while all other areas lag far behind. In preparing a retarded child for surgery or treatments. his developmental level is again the guide. All children are entitled to an explanation of what is to be done to them. Even if you feel you are '"talking to the wall" go ahead and prepare him anyway: his comprehension may far outstrip his expressive ability. You have nothing to lose and everything to gain ifhe is prepared. less anxious and therefore easier to care for. I f one approach does not succeed. try another. Sometimes a few extra minutes spent in gaining the child's confidence before a painful procedure or new experience can spell the difference between cooperation and frustration. Toys. books and playtime experiences also must be geared to developmental level and condition. For some children. the busy. noisy playroom may be too confusing and exciting. leading to seizures. aggressive behavior or withdrawal. In this case. the child can be allowed to play in a quieter place. on a one-to-one basis with an adult. Volunteers or students can gain much satisfaction from this type of experience and the child will certainly benefit. To leave a retarded child by him elf for long periods is to invite non-acceptable self-stimularory behavior such as head banging. rocking. masturbation and finger fluttering. since he is often not able to use toys in an entertaining manner. l'iursing care plan In an acute care setting. when'the child is sick or undergoing surgical treatment. special attention needs to be paid to all his basic needs. I. Fluids: The retarded child often cannot ask for a drink: nor can he obtain one for himself. He probably does not understand the need to drink when he is not thirsty. I t is wise to estimate his daily fluid requirements and keep an intah.e and outpllI chart. even when it would not be necessary for a normal child in similar circumstances. 2. Respiration: These children are often very prone to infection. particularly chest infections. and so pre-and post-operdtive breathing exercises become a priority. Here again pre-operative preparation and practise will pay off in the post-operative period. 3. Skin care: Skin care i another Important area. since many retarded children have dry delicate skin which can easily become irritated by contact with sheets. and hospital gowns. Also these children tend to be passive and. when not feeling well. they will not move about the bed as a normal child will. This makes frequent turning and skin care necessary. Incontinence adds anot.her risk and the diaper area should be kept clean and dry. 4. Oral hygiene: Mouth care can become a hassle. as the child is resistant to intrusive procedures. but it should not be neglected for that reason. I f you approach him as though you expect no trouble you are less likely to run into difficulties! Many children readily accept tooth brushing as part of their daily routine. Others will come to accept it if it is carried out gently. firmly and consistently. Understanding and trust Often the retarded child is unable to express pain or discomfort verbally and it is therefore up to his nurse to recognize his non-verbal cues. Sometimes the caretaker can provide a useful description of behaviors that the child exhibits to express discomfort. Ifno cues have been given the nurse should suspect discomfort in the child who begins to act out or become increasingly active or aggressive when this is not his usual pattern of behavior. The child may also bang. chew or rub the painful part in an attempt to remove the pain. Many parents of retarded children feel rejected by society. disappointed and guilty. They are very sensitive to any suspected criticism or rejection of themselves or their child. Take time to establish a trusting relationship with them. You will need all their help and cooperation in caring for their child. but do not let them feel you are opting out and letting them do your work. Praise them for what they have accomplished. and help them to set reasonable goals for themselves and their child. Accept their complaints if they are justified and do something about them. If there are unjustified complaints. do not just "go off in a huff': try and find out what the real problem is. The nur"e does not have to be all things to all her clients: she should make full use of services offered by the hospital, to help her give total care to the child and his family. Psychologists. social worh.ers. pa"toral services. volunteer, and many others can be called upon for advice and help with many of the problems you will face in caring for such a family. Children are very sensitive to non-verbal communication and the retarded child is no different in this respect. He will sense acceptance or rejection and behave accordingly. Because his social controls may not be well developed. his behavior may be aggressive if he feels rejected. frightened or angry. Limits must be set to his behavior. as with any other child. 'Time-out" in bed or his room may be effective in helping him regain control. but the time should be short: in most cases a few minutes is adequate. Cuddling. rocking or other physical contact may be a much more effective way of consoling a retarded child than the use of words. All successful interventions with a particular child should be incorporated in his care plan. as should recognition of his known dislikes. Remember. the staff must be the one" to adapt since this step is. for the most part. beyond the ability of the child. Our special children are a real nursing challenge! Each one has his own special personality and. when you get to know him. you discover that he can be as sweet and lovable. or contrary and mischievous as all the rest. '" References I Piaget. Jean. The child and reality: problems of genetic ps\'chology. Translated by Arnold Rosin. New York. Grossman. 1973. p.ll- 13. p.128-133. 2 Mussen.PauIH.Child de\'elopment alld personality. 3d ed. New YlJrk. Har.Row, 1969. p.302-306. Brigid Peer, is assistant professor in the Faculty of Nursing. U nÌ\wsity of Western Ontario; affiliate appointmefll with Children's Psychiatric Research Institute. LOlldon. She was pre\'iously coordinator of the Maternal and Child Health Program at Algonquin College (Vanier) School of Nursing in Ottawa; joint appointment with Children's Hospital of Eastern Ontario. Born in England. Brigid trained at St. Thomas's Hospital in London and worked in Cyprus, Sowh Africa alld Kenya before joining the RC AF nursing ser\'Ìce in 1960. She recei,'ed her B .Sc.N in N ursillg A dmi"ÜtratiOllalld Educatioll from the U lIi,'ersity ofOttalt'a a"d her M.Sc.N. in Pedia1ric Nursi"g from the U ni,'ersity ( /Florida in G ailles\'ille. - . " " . \, ) '\' ..... - A leam appraach la child ahuse Lvnda Fit patric/.. Jimmy is ten years old. One evening last summer, he was brought to emergency with large bruises on his arms, legs and buttocks and ahrasions on the left side of his face. In emergency, Jimmy remains quiet and withdrawn, refusing to answer any questions about what has happened to him. It is his mother who answers for him. Jimmy was beaten by his father as a punishment for breaking the zipper on his jacket. Sharon and Debbie are sisters. ages three and four respectively. Their mother calIed the hospital to report that the girls had ingested some medicine while she was napping. The nurse in emergency instructed the mother to bring her daughters to the hospital. Instead of bringing them in immediately. however. she goes out and buys some beer. The girls do not arrive in emergency until some eight hours later. at two in the morning. Their mother has slurred speech and smells of alcohol. Sharon and Debbie tell the nurses in emergency that they drank the medicine because they were "hungry". A young unmarried mother calls the Children's Aid Society. She is upset and crying. She says that she is afraid that she has hurt Bobby. her two-and-a-half-year-old boy - says she grabbed him impatiently and roughly as he was jumping down a flight of stairs. She seems alarmed at her own rough behavior and says that she is afraid that she will hurt her son more. because . 'things aren't going well" for her. The case worker talk.; to her for awhile and tells her to take the child to the hospital In emergency. Bobby is examined. He is a healthy. welI-deveioped. and very active little boy. There are small bruises on his upper arms where his mother grabbed him. The Can-.llan Nur.. Oct_11171 37 Each one of these stories is about a family in crisis. The details may vary, but they add up to troubled families and children at risk. At this point in time, none of the stories is complete: the incident that brought each child to emergency isjust that - an incident. There is a good deal of searching to be done before any of these incidents can be seen in context and plans made to help the families involved. In many urban centers in Canada. the work of searching and of planning is done by a multidisciplinary group. sometimes formaJly known as a child abuse team. One of these operates from Children's Hospital of Eastern Ontario in Ottawa. The child abuse team at Children's Hospital has been in operation for as long as the hospital has existed. since the Fall of 1974. For four years now. the team has been confronted with the kinds of situations already described and others. ranging from neglect to beating, from emotional deprivation to sexual abu'ie. Although Jimmy (example one) may be the only victim of outright abuse. there are reasons for the child abuse team to become involved in each of the hypothetical cases described. The behavior of the children's mother in the second example can be seen as neglectful of their needs. perhaps even dangerous to their health. At the very least. the situation needs to be clarified. Bobby's mom. on the other hand. volunteers that she needs help. and her desperdtion is reason enough for knowledgeable and expert intervention. It is because of a wide variety of such situations that the team at Children's uses a broad operational definition of the term "child abuse". Most of the children who come to the attention of the team do so through the emergency department of the hospital. The team at Children's is a hospital-based team and this is why the major source of referral comes from within the hospital itself. Occasionally the Ottawa Carleton Regional Health Unit or the Children's Aid Society will place a child on the agenda for discussion if they feel: . that multidisciplinary input is needed: or . that coding a child's chart will help to aJert the hospital staff in case of future admissions to the hospital. The children referred to the team may be abused children or children in danger of abuse from those who are re ponsible for their care. They need help and their parents also need help. A team approach The child abuse team at Children's Hospital is organized to help families at risk within the Ottawa-Carleton region. The team is composed of pediatricians. a psychiatrist. sociaJ workers and case workers from the Children's Aid Society. There are also nurses involved, from the hospital's emergency department and from the Ottawa-Carleton Regional Health Unit. Each team member comes to the weekly meetings with as much information as possible about the cases to be discussed. The team members personally involved in an individual case may be limited. but those who are not directly in touch with the family in question may add comments from their own perspective. As each individual situation is discussed. the incident demanding intel vention becomes part of a much larger picture. Many times. that incident is not isolated. and there are charts and records that allow members of the team to see an evolving pattern. A multidisciplinary approach ensures that as much evidence as possible is gathered from aJl quarters. an approach that helps in the often difficult task of planning and decision-making. Since September of 1974. the child abuse team at Children's Hospital has been operating for the purpose of detection and short-term management of child abuse in the Ottawa area. Within the hospital. membe", of the team are committed to finding. treating and protecting the child who is the victim of abuse while investigating the circumstances that surround the incident of abuse. The team aims at a plan to teach and support parents whose care of their children is less than acceptable. whose care may, in fact. endanger their children. Educational efforts are directed towards the prevention of violence or neglect of children wherever possible. and within the hospital. team members attempt to create an awareness of children's rights in small ways. Protecting the children Child abuse may be reported by a neighbor. policeman, public health nurse. teacher or social worker- by any individual. regardless of whether or not he serves in a professional capacity. In fact, Ontario's Child Welfare Act states that any individual who even suspects abuse must report it to the Children's Aid Society. Such reporting is common in emergency department'i like the one at Children's. where abused children are eventually brought for medical treatment. What has happened toJimmy is obvious - there is little doubt that hi'i injuries stem from a thorough beating. His mother is in emergency to give a fairly straightforward account of what has happened to her son. But not all cases of abuse are as dramatic or clear cut and very often parents. afraid of punishment for their actions. take. pains to disguise the "reaJ" story from medical staff. It is therefore important that those who work in emergency be able to detect the sometimes subtle signs that sU(!gest abuse. These signs can be detected through careful and skilled observation of the child. his parents and the interaction between them. At risk Eighteen-month-old JiJI was brought in to the emergency department eight hours after "she fell out of her crib". The child is small for her age, remote and detached from the attentions gi ven to her. Physical examination reveals a large bruise on the left side of her forehead and small bruises on both upper arms; an X-ray shows a fractured skull. An old chart tells that Jill is no stran er to the emergency department - that she was here three months ago after another accident. Jill's mother is in emergency to describe the accident. Her description of what happened changes each time she is asked for information. especially in those details related to the time oìthe incident and exactly where the child fell. Moreover. none of her descriptions would seem a plausible cause for an injury as serious as the one Jill has sutTered. Mrs. M. appears nervous and uncomfortable, and seems to show little concern for her daughter's welfare. At this stage. the evidence is hazy. but there are indications that Jill' s fall i more than it seems. The head nurse in emergency is on the child abuse team; consequently the nurses in that department are well aware of the indicators of a suspicious situation. The nurse caring for Jill notes the behavior of both mother and child and fills out the screening survey used atChildren's Hospital for children who have accidents. She notes that: . Jill has been in emergency before \\-ith bruises: . Jill is below the third percentile on a standard growth chart: . the child is detached and withdrawn: . Mrs. M. has called this accident and the trip to hospital "a nuisance"; . Mrs. M. has explained the situation in a contradictory way - her story changes each time she tells it; . Mrs. M. is impatient and seems detached a'i far as J ill's welfare is concerned: . Mrs. M. waited eight hours before bringing Jill to the hospital. M rs. M. is also in a great hurry to leave the hospital. so the nurse quickly reports her observations to the resident on call and pages the emergency social worker. Jill is admitted to the hospital for observation. a step that is taken in the event of suspicious accidents regardless 31 Jenullry 111711 The Cen-.llen Nur.. of the extent ofthe child's injury so that the situation can be investigated and action taken to protect the child. Before Mrs. M. leaves, a sociaJ worker on staff at Children's Hospital talks to her for a short time to "sound her out". see how she feels about Jill. and establish the beginmngs of a supportive relationship with her. Mrs. M. repeats that she is anxious to leave: she tells the social worker that she doesn't like to leave her other three children with her husband "who doesn't know how to take care of them" . Besides, she confides, she hates hospitals and wishes thatJill wasn't "always getting into trouble". At this stage, Mrs. M. is not confronted with the suspicions of the hospital staff. It is also part of hospital protocol to report suspected cases of abuse such as Jill's to the Children's Aid Society. A case worker from the Children's Aid will normaJly confront parents within 24 hours of the diagnosis of child abuse, but it will be a gentle confrontation. If the parents cooperate and accept help from the Children's Aid Society (as most do). the case will be opened and CAS will monitor development in the family and provide support. If the parents resist, however, or if the gravity of the abuse warrants more drastic measures to protect the child. a court case will follow. * Jill's admission gives doctors. nurses. Children's Aid Society case workers, and social workers valuable time. time they need to take a look at the whole family situation, to document evidence as it comes together and to find out the real story. By the time Jill's case is discussed at a meeting ofthe child abuse team. members of the team have been able to reach out to the M. family and information about the whole situation has grown considerdbly... Why Jill? Jill is the youngest offour children in the M. family and all the children are under the age of six years. While she is in hospital. her mother's visits are few. and *The Children's Aid Society prefers to work with the parents rather than in a climate of adversity. last resort legal measures of the Children's Aid Society are: I order of supervision in which the judge grants the C AS the power to visit the family at their discretion: 2 apprehension which grants CAS the power to remove the child immediately, with or without warrant, to a place of safety: 3 temporary wardship in which the custody of the child usually goes to the CAS who usually place the child in a foster home: 4 crown wardship which involves pennanent removal of parental rights. during these visits, the nurses notice that Mrs. M. is gruff and tense. while Jill remains unresponsive, whiney and fretful. But it takes more than just these observations to find out what is really gomg on. Ray Helfer. a well-known authority on the problem of child abuse. has a great deal to say about its etiology. He writes, "First there is the potential. then a particular child and finaJly the crisis... ". Looking at the M. family and other families in which abuse occurs, a recognizable pattern emerges. First of aJl, there is hardly a case of abuse discussed by the child abuse team that does not uncover a revealing story about the parents' upbringing. So often, the experiences that they have had at the hands of their own parents have been less than satisfactory. It is not uncommon to hear their growing experiences described as "horrendous", involving alcoholism. lack of caring and outright abuse. The M.'s are no exception. Mrs. M. "escaped" from the round offoster homes she grew up in through an early marriage. Too soon, she was also a mother. and lacking effective guidance on how to be a mother, she had little to bring to her children but her own unhappy past experience. The situation on Mr. M.'s side was not any brighter. Given their personalities and experiences, it is little wonder that the M.'s live fairly isolated lives within their community. like too many other families in large urban centers. their exchange outside an insular family existence is limited to that which is absolutely necessary. Mrs. M. admits that there is really no one that she can talk to. especially about "trouble". Within this family, Jill is the special child. In her first contact with Mrs. M. the emergency social worker notes the negative way in which Mrs. M. refers to her daughter - she is a "nuisance": at eighteen months, she is "stubborn" and "always getting into trouble". Further talk with M rs. M. indicates that Jill seemed like trouble from the very beginning. M",. M.'s fourth pregnancy had been both unwanted and difficult; then Jill screamed and cried and fed poorly for months on end - there was little about the baby that was endearing in Mrs. M.'s eyes. In a family offour children. Jill is perceived as different from her other siblings. as "just plain difficult" . What then was the crisis that brought Jill to the hospital? Although the family seems to have few resources for dealing with problems. although Jill is perceived as a "problem" child. there are other critical factors that precipitated Jill's injury. Once Mrs. M. has someone to talk to. it doesn't take long to find them out. Last June, Mr. M. lost his job. For a few months he remained at home where he sat, sullen and depressed and drinking too much. When he found ajob once more, it was working night shift, so it was Mrs. M.'s responsibility to keep everyone quiet while her husband slept in the daytime hours. Nightwork was difficult for Mr. M. and grew intolerable for his family. The strain built up... Picking up the pieces The story about Jill as it was known in emergency has grown. and its details begin to hint at the ways in which the child abuse team can help the M. family. The medical evidence, nurses' observations and reports of contacts made by social workers are presented to those at the Tuesday morning meeting so that efforts can be made to develop a helpful plan of action. In a situation such as this, the members of the team need to consider what specific interventions can help the M. family . Input from theChildren's Aid Society case worker indicates that the M. family is willing to accept her help in dealing with family problems. and so CAS intervention will continue until there is no further need. A volunteer worker is lined up to help Mrs. M. within her home, giving her someone to talk to and relieving the isolation that she feels while her husband is still working night shift. A plan is also made to introduce Mrs. M. to a mother's group to give hera support system and an opportunity to "get out of the house". A doctor's appointment is planned to check out her feelings of chronic fatigue and edginess. The possibility of helping Mr. M. consider a more suitable job and aJcohol counseling is also developed. Through these plans the M. family is being guided to better use of the community resources that can help them in their present situation. Outreach Jill's case is not the 001 y case of abuse to be discussed at the Tuesday morning meeting - there may be from four to ten other cases, and each will tell of parents who need help and children who need protection. And there is a meeting every week. each bringing more families to the attention of the team. Investigation of these cases is time-consuming and the challenge of solving complex problems requires even more energy. skill and time. The work ofthe child abuse team also involves educational efforts aimed at the prevention of child abuse before it occurs. and he early detection of abuse so that patterns of famil y violence can be reversed. The team has participated in a comprehensive inservice education effort within Children's Hospital itself. The Cen-.llen Nur.. Jenuery 111711 311 Members have also taken part in educational programs such as courses at Carleton and Ottawa universities and community college refresher programs. The team has also been instrumental in training 15 volunteers who will visit local classes of students in grades II. 12 and 13 and help young people to become aware of child abuse and what it means. Service clubs provide another forum where members of the team can share what they know about child abuse in order to create a climate of awareness. The problem of child abuse is one of enonnous magnitude and significa'lce. Professional collaboration - that is, bringing together the knowledge. skill!> and perspectives of various involved disciplines enables the team to begin to deal with such a problem. The work of the child abuse team does not end in its effort to pick up the pieces in those situations where abuse and neglect has already begun. 011. Acknowledgement: The author wishes to than" the members of the child abuse team ofC hildren's Hospital of Eastern Ontario for their assistance in the preparation of this article. Special than"-s go 10 Diane Ponee. of the Departmellt ofS ocial S en'ices. CH EO (curremly seconded to the C alladian Commission. International Year of the Child}. and .....ate Dagg, head nurse ofrhe emergency department. Borh are members of the child ahuse team. References I Helfer. Ray M. The etiology of child abuse. I n Symposium on child abuse. New York University Medical Center, New York City, June 15,1971. Pediatrics 51:4 pt 2: 777-779. Apr.. 1973. Bibliography I Canada. Parliament. House of Common!>. Standing Committee on Health . Welfare and Social Affairs. Child abuse and neglect. Ottawa, 1976. 2 Helfer. Ray M. Child abuse and neglect: the family and the community ed by ... and Henry C. Kempe. Cambridge, Mass. Ballinger. 197{j. 3 Hepworth, Philip H. Sen'icesfor abused and battered children. Ottawa, Canadian Council on Social Development, 1975. 4 Josten. LaVohn. Out of hospital care for a pervasive family problem- child abuse M .C.N. A mer. J. Matern. Child Nurse 3:2:111-116. Mar./Apr. 1978. 5 Maravchik. Miriam. The child abusers: the story of one family World I :8:28-32. Oct. 1972. 6 Ontario. Ministry of Community and Social Services You and the abused child. Toronto, 1977. 7 Stainton, M. Colleen. Non-accidental trauma in children. Canad.Nurse 71 :10:26-29, Oct. 1975. 8 Symposium on child abuse New York University Medical Center. New York City. June 15. 1971. Pediatrics 51:4 pt 2. Apr. 1973. CNJ talks to Lois Dale, PUN What are the ways in \\ hich public health nurses can be iß\'olved in the prevention. detection and management of child abuse? CNJ talked to Lois Dale. a public health nurse in the Ottawa Carleton Regional Health Unit and member of Children's Hospital of Eastern Ontario's child abuse team to find out about the public health perspective on child abuse. CNJ:I s there really a role for public health nurses in the prel"ention of child ablue? Løis: Oh yes. there are a number of ways in which we're already involved. I see a large part of our preventive role in our involvement with family planning. After all. planned children are the lea'it likely to be abused children. In our prenatal classes. we are involved with couples. and I think that is e'ipecially helpful- we talk about physical and emotional care of the child and factors that promote early bonding within the family. Our post-natal visits also fall into the category of prevention. At this stage. we can help the mother to deal with any fru!>trations that she may have. For example. ifthe mother is troubled by the child's constant crying. we help her look at what is normal for a baby of his age. to look at why the baby cries so much. and at the physical measures that she can take to help her baby and her'ielf too. We have also established a liaison with the maternity nurses in all the hospitals in the Ottawa-Carleton area. Maternity nurses are in a very good position to see the early signs of poor bonding. If they see a high risk situation, they refer the family to us so that we may visit them soon after di'icharge from the ho!>pital. Our weekly conferences with obstetrical nurses are really paying off- more sophisticated observations are being made all the time as we become more attuned to the indicators of a high risk situation. When we visit a family. we try to be aware of early signs of trouble, to sensitize ourselves to family dynamics and be aware of crises - be they financial. marital. or related to the family's isolation from the rest of the community. Because being a public health nurse means knowing about community resources, we can also refer families to helpful services when we recognize that there are risk factors involved. C J: What do you do if you suspect child abuse? Løis: Once we suspect either neglect or outright abuse. we get involved through the Children's Aid Society, the Child Abuse Team. or both. Everybody on the child abuse team works together to get a really good grasp of the situation. The Children's Aid Society case workers are the key workers once they become involved. Our specific role on the child abuse team is con'iultative. We will also visit families where there is a health concern that requires nursing management. I feel that the public health nurse has a very special role to play in the area of child abuse. First of all. we have to realize that our mandate and expertise lie'i in the area of health care and not welfare services. Ifthere is a "health" reason for our vi!>it, we can be especially helpful.just because of the way in which people perceive "the nurse" C:'oiJ:/s that because you have a nOli-Threatening role? Løis: I think so. Ifl visit a family as a nurse, sometimes just introducing myself as a nurse allows me to be of !>ervice. Nurses are seen as helping. caring people. I feel very strongly that we must protect that image of being a nuturing person, because it opens doors and allows us to use our skills in areas where the door quite literally is most often closed. Very often parents aren't abusing their ch il dren pu rposefull y . . . someti mes children receive poor care because their parent'i don't know how to look after them. or because their situation is very unstable. They need help. A nurse may be a non-threatening figure to them. someone who can be seen as a helping person. C J:That sOllnds li"e a si::.eable job for \'011. Løis: It can be. But another good reason for public health involvement in child abuse is that the public health nurse knows her community and its resources, knows just what is available to a troubled family in her district- be it the friendly minister or a formal outreach service. Sometimes a mother may just need someone to go shopping with her, or to take care of her child for an hour or so. 40 Jenuery 111711 The Cen-.llen Nur.. In some communities, these services are really organized: in others we come to rely on helpful neighbors. There are leadership groups being organized in apartment buildings. There are also services offered within our city like marital counseling. credit counseling or day care services. Ifwe know that the mother or family wants these !>ervices we can help by being aware of the services available and how to get at them. CNJ: So child ahuse is really a community prohlem... Lois: Most definitely a community prohlem. We're trying to help point that out too. We have been involved in public panel discussions - usually with a multidisciplinary team. Within the Public Health U nit we also have a lot offormal and informal discu<;sions about the problem - we all need to know more. In high schools we have programs in which we discuss child abuse. to help students become aware of the nature of the problem. People need to know how to deal with child abuse within their community; they need to know how important it isjust to help someone out in the neighborhood. As nurses, we have duties as citizens too. CNJ:As a public health nurse. how do you see the role of other nurses in relation to child abuse. Lois: Since my involvement with the child abuse team, I've become more aware that there is hardly any area of nursing that doesn't have implications for children. We need to learn to listen to parents in a defined way - be it during prenatal classes, during labour and delivery. or postnatally. in the hospital or in the home. We can watch for early signs of bonding. We can help mothers to care for their young children and help families when children are ill. We can be aware as nurses in an adult hospital that if mom or dad is ill. the children are affected as well. We have the education and abilitie<; to take an important leadership role. We aren't doctors and we aren't social workers. But we have developed. and are still developing our abilities to observe and teach health. Child abu!>e is one area where nurses can play an important role by usil1g these very special skills. 41 .J """ Be it resolved... The role of the nursing association in the prevention of child abuse Jcan MacLean At a time \\hen so many organizations are examining their relevance and effectiveness, is the prevention of child abuse an appropriate concern for a professional nursing association? Should organized nursing, in fact, devote some or an of its scarce resources to the problems of child abuse? One a'isociation that has answered this question in the affirmative is the RNANS. Here's how Nova Scotia nurses are meeting this challenge. The Registered Nurse.. Association of Nova Scotia became formally mvolved with the prohlem of child abuse in May, 1971, At that time. Dr. John Anderson. director of Outpatient Service.. at the Izaa\... Walton "-illam Ho..pital for Children in Halifax. wrote to the pre..ident ofRNANS reque!>ting the cooperation of associ.ltion member.. in providing information fÒr a study on child abuse in Nova Scotia. In 1973. when the report of the ..tudy' was released. nurses as well as other group.. were shocked to learn that many cases of child abu..e. suspected or proven. were not being reported a.. required by law. Indeed, the study indicated that many physician.. and nurse.. were unaware of provincial legislation concerning child abuse that hdd been passed in 1968. Section 19A of the Child Welfare Act reads: (I) "Erery pen-on hlll'Ù1R Î1!flJr/llation I\'hether cOll..fìdelltial or pril'ileged ( rthe ahandonml'llt. desertion. phy,Ücal ill-treatment or need..fÓr protection ofa child shall report the i,!fÓrmation to a Socien' or the Director. (2) No action lies aRaÎ11.\1 a penon 1\'1/0 gil'es Ù!(ormation under suhsection (I) unless the Ril'inR of the i,!fl)mwtion is done maliciOll.\1v or without reasonable and prohahle cause." Getting imohed... The response of our association to the ..tudy findings wa.. ..wift. Wor\.....hops were quickly organized on the theme of "Wednesday's children". InfÖrmation about the Child Welfare Act was communicated to member... At our annual meeting in June. 1973, a re..olution on child abuse was pas..ed unanimously: WHEREAS the result,l' ( rll recent ,\tUl V indicate that most cases ( rchild ahuse ami neglect are not reported. and WH EREAS p1"( re,Hional nunes are in a , trateRic positio/l to detl'ct ('I'idence of such ahu,le and neglect. BE IT RESOL ED 1 HAT thl' memhers ( "the Registered Nunes A HocÎatio/l ofN (}I'a Scotia use el'ery opportunity to worh II'ith other conn'1"Iled Rroups in hl'coming Î1!formed ahout \l'ays to help ami protl'ct children and to help the parents ( r such children. The Cen-.llen Nur.e J.nuery 11171 41 How can 'iuch a re<;olution be translated into meaningful action'> At a time when Yoe hear murmurs of professional self-sed.ing and accusations of depersonalized approaches to nursing care. it has been rewarding to see the response of many nurses in Nova Scotia to this challenge. Such a response demonstrates that the caring function which characterized the early emergence of the nursing profe'i<;ion remains alive and well. There ha<; been no difficulty in recruiting bu<;y nurses to serve on committees and help with projects related to solving the problems of child abuse. Once the Nursing Service Committee (one of three major RNANS standing committees) was well informed about the problems involved. it sponsored y"orkshops. community meeting<; and seminars to increa<;e the awareness of other members. A major aim of the Nursing Service Committee wa<; to help nurses understand their role in observing. identifying and referring children who were suspected of needing protection. The term "child abuse" was taken in it<; broadest possible sense to include neglect and deprivation. both emotional and physical. Although most of the activities were taking place at the branch levels. a good deal of support. including information kit<; for member'i. was made available through RNA House. Through its Nursing Service Committee. the association maintained a close liaison with the professional staff of Family and Child Welfare. Department of Social Services. and a<;sisted in developing a standard report form for hospitals and agencies. In February. 1974. aCentral Child Abuse Registry was established by the Department of Social Services. ew legi'ilation became effective in December. 1976 which stated that reporting cases of child abuse to the Central Registry must be done by a "qualified medical practitioner. registered nurse. or administrator of a hospital or institution". Within RNANS. special interest groups like the Canadian Association of Neurological and Neurosurgical Nurses and Operating Room N ur'ies were including the topic of child abuse in their own educational ses<;ions. By this time. it Yo as becoming increasingly apparent that nur<;es could ta"e a major role in the prel'ention of child abuse. In 1976 a task force wa<; appointed to stud possible approaches to the problem. The Yo or" of the task force. involving nurses y"ith special expertise in the hospital. the community and nursing education. has included articles for the RN AN S Bulletin and an educational display at the as",ociation'<; annual meeting in 1977. In October. 1978. the group organized a Yoor"shop for nurses in key pmitions to prevent child abuse. The goal of the Yoorkshop was to provide opportunities for nur'ie<; to: · under<;tand the importance of their role inprel'enting child abuse . . improve their ability to identify high-ri<;k familie,,> . consider the effectiveness of a team approach in helping high-risk families . identify needs for additional skills. Because the workshop could not accommodate all who wished to attend and the response of the nurses attending wa<; so positive. the workshop is to be repeated in June. 1979. -\ speciaJ chaJlenge l'i it appropriate for our professional a<;sociation to devote precious re<;ources to the problems of child abuse? Perhap,,> a statement from One mil/ion children- the C e/dic report is relevant to this question: .. Weare c01/l'inced that the "-nowledge and insight!> about .wcial problem. . gained through seeing their effects on the Iil'es of the indiriduaÜ andfamilie. with whom they 11'01'''-. place a hem'y responsibility not only on indÏ\'idual professionalJ bllt also upon the association of which they are memhers .It i. not enough to protect and promote the well-heing qf their own memhers. or el'en to protect the public from malpractice. The prq(e.uional associations must alw spea"- out and pro ride leadership to help bring about the social changes that will prel'ent the del'elopment ofmany of the problem. in the first place. Society hm a right to expect this of its prq(essionals.lf they prOl'ide this "-ind of leadership. their status and role in society will remain unchallenged." Nursing has been de<;cribed a<; ..the major caring profession". 3 A<; Yo e struggle to define and exert our independent functions at a time of accelerated change. y"e need to ensure that this caring function which has been traditionally ours is retained and adjusted to meet changing needs. We must also remember that as part of our professional association. we can be very effective in our influence. hoy,.ever difficult it may be to measure that influence. The Registered Nurses A'isociation of Nova Scotia believes that the prevention of child abuse is a special challenge requiring the <;pecial skills of nurses. Our definition of nursing. publi<;hed in 1976. ,>tates that "by collaborating with other members of the health team. nursing contributes to meeting the total needs of individuals/families. .., The hard work and enthusiasm ofRNANS members involved in our child abu,>e program illu'itrates one important y"ay in which we a'i nurses may contribute to meeting these health need". "" References 1 Fra...er. Frederic" :\lurray. Child ahuse in/VOI'a Scotia: a rðearch project ahout battered ami maternally depril'ed children by . . et al. Halifa\. 1973. p.3 . Commission on Emotional and Learning Disorders in Children. One million children. IThe C ELDIC Report for the Commission) published by Leonard Crainford. Toronto. 1970. pp.441-44 . 3 Hall. Catherine. :\1. \\hocontrols the nursing profession'.' Role of the professional association Aust. nurses J. 3: : 9-3 . Aug. 1973. 4 Registered Nurses Association of Nova ScotiaA framewor"-for the practice ( ( nursing in N ol'a Scotia: guideline. and ,Hl",dard. . Halifa\. 1975. 5 Helfer. Ray. Child abu, e and neglect: the family and the communin' edited by... and Henry C "'empe. Cambridge. :\lass. Ballinger. 1976. 6 Hurd. Jeanne Marie. Assessing maternal attachment: first step toward the prevention of child abuseJ.O.G. \. .Vurs. 4:4: 5-30. Jul./Aug. 1975. 7 Martin. Harold P. ed. The abused child: a multidisciplinary approach to del.elopmental issues and treatment. Cambridge. :\1ass. Ballinger. 1976. A uthor Jean :\lacLean i, currently ,Vursing Sen'ice C onwltant ( (the Registered Nurses Association ofNOl'a Scotia. A graduate afVictoria Puhlic Hospital. Fredericton. Sew Bruns ,,'id and McGill L' nil'ersin' (8.N.J Montreal. Québec. Jean has had a ,,'ide range of erperiences innur. ing sen'ice and nursing education. She has also ""(Jr"-ed closely with the "'ursing Sen'ice Committee and Tas"- Force on the Prel'ention o..(Child Ahuse . t , n e How do children hurt themselves and what can nurses _ as individuals and as a profession - do to prevent accidents? if./ ) .l,1' .11 f/ ,Q; Shirlev Post A.J. Lanliford accounted for 37 per cent of the deaths among children in this age group. A total of758.504 hospital days were a direct result of these accidents. Is there something that nurses can do to increase awareness among parents and the general public of these threats to the lives of their children? Can nurses Accident!. are the largest single cause of death and injury among children under the age of 19. In 1974 (the latest year for which complete figures are available) accidents. poisoning and violence l - "\. .' - help to prevent accidents through education? There are indications that they can. Nurses are often the first qualified health person contacted in health care and service settings: the doctor's office. emergency wards. health clinics. and even obstetric wards. All ofthese are The C.n-.llen Nur.. Jenuery 11171 43 teaching opportunities. Each contact with a mother. or a future mother. is an opportunity to inform her of potential hazards and to gain her support and cooperation in eliminating them. thus promoting the well-being of yet another child. But. to be successful in educating others in the means of reducing childhood accidents. it is essential that nurses understand the growth and development of children. know what accidents are common to which age group and the preventive measures required for each age group. By developing basic teaching skills and projecting their own feelings and attitudes toward child safety. nurses can join physicians in initiating an effective change in attitudes and influencing parents to keep their children safe by means of prevention. The young child needs constant supervision and protection. Part of this protection lies in altering a "normal" environment to reduce or eliminate possible hazards. Unfortunately. most people who care for children need to be reminded constantly of this and of the fact that benign items of everyday life. such as electrical outlets and appliances. bathtubs. medicines. cleansing agents. balconies. stairs and cars. can become dangerous enemies in a child's world. Toronto's Hospital for Sick Children. in its 1976 "Causes ofInjury Report" . pinpoints some of the problems. In that year: . 300 children between the ages of one and four were treated at HSC for scalds caused by hot liquids (water. tea. coffee), hot water baths and vaporizers. . 211 children between two months and two years of age suffered pulled arms from being swung or lifted by the arms. . 554 children were treated for pedal cycle i'1iuries; 86 of these youngsters required hospitalization. The increased incidence of accidents occurring while children are participating in sports or recreation warrants much closer observation; we need more accurate data on specific categories of accidents. such as skateboard i'1iuries. burns and head injuries among young children. Historically. legislation such as the Hazardous Products Act has proved beneficial. This act. which controls the accessibility of certain products to children and ensures that packages carry adequate warning to parents of dangerous contents. was passed in 1969 and since 1970 there has been a steady decrease in poisonings among children under four. Under this act. an item can be judged" hazardous" , not to be advertised. sold or brought into this country. Examples include baby rattles that could choke a child. certain stuffed animals and a type of baby bottle propper or holder that permitted the mother to leave a child unattended while feeding and could result in asphyxiation or choking on regurgitated milk. In the case of this last item. the Canadian Nurses Association. prompted by reports from members (especially public health nurses) of possible dangers involved in use of the "propper". was among the groups that pressed for government action to prevent the sale and use of the device in Canada. Under another part of the act the government may impose regulations to reduce the probability of accidents. These regulations may require child-resistant packaging or specific labelling; regulated items include toys. cribs. cots. playpens. pacifiers. rattles. car seats. matches. flammable materials used in clothing and a variety of household items such as turpentine. polishes and oven cleaners. Nurses should be aware of this legislation and make it their duty to report to the Department of Consumer and Corporate Affairs (either as individuals or an organization) any products that appear to constitute a safety hazard to children. One area still requiring legislative action is the protection of children while they are passengers in a moving vehicle. Even though mandatory use of seatbelts has been demonstrated to reduce accidents. only four provinces* (Ontario. Quebec. Saskatchewan. and British Columbia) have passed seatbelt legislation. Even in these four provinces. children under the age of six or weighing less than 50 pounds, are exempt. A recent Montreal study found at least half of all children under ten completely unr strained; a further ten per cent were re:;trained in a manner inappropriate for the çhild's age and stage of development. Studies in Calgary. Vancouver and Toronto have yielded similar results. The Canadian Institute of Child Health is presently asking the federal government to remove the excise tax and the 12 percent manufacturer's tax from children's car seats. fire detectors and life jackets. At the same time. the provincial governments are being asked to remove their sales tax on these items. It is hoped that lower prices on these items will motivate parents to protect their children from the three major causes of death by accident: motor vehicle accidents. fires and drownings. *In Nova Scotia. legislation had been passed but had not yet come into force at time of wriling. Accidents can result in permanent physical and mental impairment: they can cause social disruptions and economic difficulties. A child's injuries bring distress to the entire family. altering lives and lifestyles. I n many instances. a heavy emotional and financial burden is imposed not only on the family but on the community. What can nurses do to prevent accidents? They can make 1979their Year of Child Safety. As individuals. they can increase their own awareness of potential hazards in a child's environment and use every opportunity for health education in their homes. their practice settings. and communities. As a group. they can act as a strong political force in influencing communities to provide safer environments. businesses to produce safer products and governments to enact and enforce regulations that will further safeguard the lives of our children. 41 Shirley Post, co-author ( f' 'A I'ery presenr danRer". is I'ice-president of the Canadian I nstitute ( fChild Health. an orxani;:,ation she helped to set up in July. 1977. She is a former director ofnursinR at the C hildren'. Hospital ofE(utern Omario in Ottawa. Audrey Jean Langford, co-author of "A I'ery present danger", is a graduate of General Hospital in Calgary, Alberta. She is presently working part-time ar the Children's H o. pital of Ea. tern Ontario after a number of years spent in raising her fil'e children. She is also a I'olunteer worker with the Canadian lll. titute of Child H ealch in Ottawa. Bibliography I Canada Safety Council. Accident fatalitie. - Canada. Ottawa. 1975. 2 Canada. Laws. Statutes. etc. Ha;:,ardous products act. RSC 1970 C.H3. 3 Hospital for Sick Children. Causes o.finjury. Toronto. 1976. 4 Canadian Institute of Child Health. A ccidents and accident prel'ent;on: 19 year. and under. Ottawa. 1978. Unpublished. I I , 44 Jenuary 111711 The Cen-.llen Nur.. Learning about the hospital at hOllle Faye F ergu.mn Lillian Par/... and Vera Ward -" ... " .:- -1 \ .. --- '-'= ....,..r-........ .:- ..... . 1 -.. /' \ L - - --.: ; - " .' . . -... - , - . . .. III Pre-admi sion nurse Lillian Park ("ontacts the parent. ( r a child scheduled to be admitted to llOspital. A.nother member of the pre-admission team, nurse Vera Ward. receil'es pre-admission hoo/...ings in her o(fìce. The Cen-.llen Nur.. Jenuery 111711 45 Mark Taylor is six years old and ahout to enter Alberta Children's Hospital to have his tonsils and adenoids removed. Five days prior to his scheduled admission, a nurse who identifies herself as a pre-admission nurse from the hospital. contacts his mother. Since Mrs. Taylor had been given a letter at her doctor's office describing this service, she is expecting this call and is happy to make an appointment to see the nurse. . nursing pediatric history sheet. During the completion of this sheet. the nurse enquires about recent immunizations or possible contacts with communicable disease. She also checks to see whether there is a family history of anaesthetic problems or bleeding tendencies, whether Mark has been on medication recently, and whether he has any physical disability. ... -- - -. assures her that she can stay as long as she wishes: in fact. she may even stay overnight if she wants to. Following completion of the various forms, the pre-admission nurse explains what to expect at the hospital. She describes: . the routine admission hospital tests such as the blood test and blood pressure and temperature . the playroom program ...". , -: - ----" At the time of the home \isit, the pre-admiuiollllurse helps the mother to complete the admiuiolls alld cOllsem forms required b\" the hospital. listening to the ad\entures of "Emily" . as explailled b,' the pre-admissioll Ilurse. is a "Jim" way tojìlld oilt more ahout all impelldillg \'/sit 10 the hospital In fact. Mrs. Taylor has many questions about Mark's hospitalization! They agree that the appointment ..hould be for 4:30 p.m. so that Mark will be home from school when the nurse is there. During her visit, the nurse completes, with Mrs. Taylor, the following documents: . admissions form (name, address, and other similar statistical data). . hospital required consent forms. The nurse also takes this opportunity to ask Mrs. Taylor whether Mark has any particular fedrs that might make his hospitalization more difficult. Mrs. Taylor tells her that Mark tends to "get home sick" when he sleeps away from home and enquires about whether she can stay with Mark at the hospital until he falls asleep the night before surgery. The nurse . the visit by the anesthetist . meals and snacks . the fasting requirements for the morning of surgery . the approximate length of surgery . what to expect post-operatively ("l\lark may vomit after his operation, but this is not abnormal. His throat will be very sore, but it will help if you can encourage him to drink" ). I j I 46 Jenuery 111711 The C.n-.llen Nur.. Mrs. Taylor is also advised as to the time ofMark's admission and what articles to bring to the hospital. The nurse tells her about the various amenities available for her use at the hospital such as the cafeteria and parent lounge. Mrs. Taylor is instructed to give Mark a bath and shampoo the morning of admission and to collect a urine specimen. While she is talking. the nurse gives Mrs. Taylor plenty of opportunity to ask questions or express concerns. She gives Mark a coloring book called "Emily Goes To Hospitar'. After the nurse and Mrs. Taylor have finished talking. the nurse looks at this book with Mark. explaining each picture and going over -JA -;; , , 0-7 f " r " I . " " .-- S- . ,4 _ " \ .. -, II. L..--I - - the experiences of"Emily". a whimsical kitten who goes to hospital to have her tonsils out. Mark can keep the coloring book to show his friends. When he comes to the hospital. he will see Emily in a puppet show and after his surgery he will receive a badge with a picture of Emily and announcing in large letters "I had an operation" . At the end of her visit. the pre-admission nurse leaves a hospital pamphlet with Mr!oo. Taylor on which ..he notes the nurse's name. the date and time of admission. and reminders about the.urine specimen. bath and shampoo. She tells Mrs. Taylor to contact her physician if Mark develops cold symptoms. fever. etc.. prior to the admission. As ..he leaves. the nurse encourages Mrs. Taylor to call ifshe has any further questions. When she says goodbye to Mark and his mother she leaves them with the promise that "I'll see you at the hos pital" . Admission day On the big day. Mark and his mother arrive at the hospital at the agreed upon time. They are met at the reception area by the pre-admission nurse. who takes them to the laboratory. then to the nursing unit. After a brief tour of the unit. introductions to the nurses. taking of blood pressure and temperature readings, Mark is able to go to the playroom. The entire in-hospital admission procedure takes about 15 Admission dav arrhes and the nur. e who l'isited th m in their home Rreets the child and his mother in the reception area o/the ho. pital. At the start of his hospital visit, the child and his mother ta/...e the time to learn ahout the facilities and ser\'ices thc hospital prm'ides. minutes and Mark spends the majority of his first hours m the hospital playing with other children in the spacious. toy-filled playroom. A wa) of coping \\ ith stress Nurses who work with young children undergoing a period of hospitalization are very much aware of how stressful this experience can be. both for the children involved and for their parents. They know that while they are in hospital many children ..how signs of regressive or disturbed behavior. These observations are borne out by research studie.. which indicate that. in addition to these obvious problems. hospitalization has adverse results that may not become obviou.. until after the child returns home. The serious nature of these effecto; has recently been noted in two studies conducted in Britain"" which provided strong evidence that one hospital admission of more than a week's duration or repeated short admissions before the age offive years are associated with behavior disturbances and learning difficulties as late as adolescence. Several authors have provided clues as to the reasons that hospitalization is so stressful to children. One important factor is the idea that the hospital is a totally unfamiliar and unpredictable environment for the child. The need to know and predict one's environment seems to be a universal human trait. In health care settings it is becoming .. IIíIÌl,'''=ii:-ilii li! . ,. ? II . .-.e. .lIii-' ;J; II )1 "1 ,I I , , \. f ., I ., : :::::::: , :.-- ::::: :" , - - - - " I. increasingly evident that the degree of anxiety an individual experiences is a function of the accuracy of his expectations. The old adage of "being afraid of the unknown" certainly holds true. I n other words. an individual. whether child or adult. who knows what to expect in an unfamiliar o;ituation will be hetter able to cope and will not feel helpless. A second factor involved in the anxiety-provo\...ing effects of hospitalization on children is the strong influence of maternal stress on the child. For a mother. the hospitalization of a child is always stressful: her degree of stress will depend on the amount of adequate and accurate information she received about the hospitalization before The Cen-.llen Nur.. Jenuery 11171 U it took place. The more predictable the experience is for her. the better she will be able to cope effectively and. thus. to maximaJly support her child. A study of hospitaJized children conducted in 1968" provided strong evidence that the anxiety level of the mother has an effect on the anxiety level of the child: mothers who received adequate. accurate information about the hospitalization and were encouraged to verbalize fears and ask questions displayed a lower level of anxiety. In addition. the children of these mothers displayed lower anxiety levels. made more rapid recoveries and experienced fewer after-effects of the hospitalization. \ \ - - I .. I period of time before the actual admission to prepare for the experience in accordance with the infonnation they have been given. 2. To eliminate the lenRthy admissiom procedure at the hospital. By completing admissions documents in the home. the in-hospital admission procedure can be shortened con'iiderably. thereby eliminating what was often a hurried and unpleasant first contact with the hospital. 3. To encouraRe mothers to effecti\'ely support their child durinR 11O. pitali::.ation . Through the transmission of accurate information. it was felt that the mother would cope more effectively with the \ .-......----.... --.-- 1 -.' I I' ..' . ...' I" - . ". of Calgary chIldren who are scheduled for elective admission to Alberta Children's Hospital will receive a visit from one of these nurses. Out-of-lOwn admissions are contacted by telephone. Effectheness of Pre-Admission \ isiting Since its introduction four years ago. the pre-admission program has been enthusia'itically received by the mothers whose children were admitted under it. Nurses. too. have been pleased to relinquish the "harried" admissions procedure for which they had originally been responsible. The positive effects of the program on the mothers and children have always been suspected but it is only recently that we were able to document them. In , t ; . ....! . I I . .. -. ,.,. , \ ....... - .-. , -- --::::::-- --- ............ -- -- - A "3rd nurse ta/...e the child's admission hlood pressure, one of the \'eryfew procedures that must be carried out before he is allowed to \'isit the playroom. Objecthes ofthe PA \ P It was recognition of the fact that children and many mothers are not familiar or comfortable with nonnal hospital routines. that caused the nursing department at the AlbertaChildren's Hospital to set up a Pre-Admission Visiting Program in 1974. The initial objectives of the program were as follows: I. To pro\'Ïde the child and his mother with accurate information about the hospital process in em em'ironment that is comfortable to them. We felt that both the mother and child would be most relaxed in their own home and therefore better able to absorb the infonnation. express concerns and ask questions. A'i well. they would have a hospital and feel more willing to assist in her child's care. As well. the pre-admission visit would be a time to assure the mothers that their presence in the hospital is welcomed. 4. To lessen the number of children admittedfor .wrgery which 't'{I. later cancelled because of e>;posure to communicahle disea. e or other iIIne.H. Children who have had such an exposure would be identified during the pre-admission visit. thus their surgery could be cancelled before they ever reached the hospital. Over the past three years. the pre-admission program ha'i striven to meet these objectives. Two registered nurses and a clerical assistant comprise the Pre-Admission Team. The majority order to do this. we undertook a controlled evaluative study' of some of the effects of the program on a group of 8:! children between the ages of three and seven. All the children were coming to hospital for tonsillectomies: one half of them received a pre-admission visit. while the other half were admitted directly to the hospital. All were given exactly the same infonnation by the same admitting nurse: only the location and time were different. Ba'iically. the children all had a very similar hospital expenence. The results of the various measures taken on the children and their mothers indicated that: · Mothers who received a pre-admission visit expressed 41 Jenuery 111711 The Cen-.llen Nur.. considerably more satisfaction with the care and health teaching they and their child received in the hospital. Basically. the pre-admitted mothers were happier and more satisfied about the whole experience than were the hospital admitted mothers. . All the mothers displayed a high level of an xiety on the day of admission. but the mothers who had been pre-admitted showed a greater decrease in anxiety. At a post-operative contact. the pre-admitted mothers displayed a very low level of anxiety. while the hospital-admitted mothers showed a considerably higher level. . The children who had experienced à pre-admission visit reported less fear of J t -.... I -- .'- .. - "-. " >- .- ,,. .< \'- . . . . '" . , '... .\ ___0,=;:--. \ \0- . .'\:. :'"_, hospital-related thmgs than did the hospital-admitted children. This difference in the level of hospital fears was apparent at the time of admission and at the pmt-opeHltive contact (u",ually 7 - 10 days after the ..urgery). . The children who had experienced a pre-admission visit displayed a marked reduction in negative post-hospital behavior as compared to the hospital-admitted children. I n other words. the pre-admitted children showed fewer behaviors indicative of sleep disturbances. eating disturbances. aggression. withdrawal. separation anxiety and general anxiety following their hospital experience. The results of this study have been very satisfying and have supported what many nurses have intuitively felt to be true. One unexpected benefit of the pre-admission program has heen it,; effect on the nurses involved in it. The pre-admission nurses have become increasingly skilled at interviewing and have developed new levels of sensitivity to the concerns and anxieties of the mothers they talk to. In their constant evaluation of the information needs of children. these nurses have observed that they are becoming more sensitive to developmental and learning capabilities of children. The pre-admission nurses never lose sight of the family as a unit. and have become appreciative of familial differences including ethnic and cultural effects. As well. the continual need for In the pla room. wearing her hero hutton awarded followillg completioll o( lahoratory hlood te. t. , is Emi!\'. star ofhoth the color;"g hoo/.. alld a puppet . /ww hlued Oil her Iw. pital adl'ellture, . . -=- open channel.. of communication between parent. child and health care professionals has become an important goal of the program. In short. pre-admission visiting is one way to effectively prepare children and their mothers for hospital admission. I t provides both mother and child with information that may assist them to cope effectively with what otherwise could be a strange and frightening experience. OW References I Douglas. J. W. Early hospital admi",sions and later disturbances of behaviour and learning. Del'. Med.child Neurol. 17:4:456-480. Aug. 1975. 2 Quinton. David. Early hospital admissions and later disturbances of hehaviour: an attempted replication of Douglas' findings by... and Michael Rutter. Del'. M ed.C hild N euro. 18:4:447-459. Aug. 1976. 3 Skipper. James K. Children. stress and hospitalization: a field experiment. by... and RobertC. Leonard.J. Health Soc. Behm'. 9:275-287. Dec. 1968. 4 Ferguson. Barbara Faye. Preparing young childrenfor /wspitali:ation; a comparisoll o(two methods. Calgary. 1978. Thesis' (M.Sc.) -Calgary. Faye FergusonrR.N., HolyCm.u Ho. pital. Calgary; B.Sc.N., The U Ilil'ersity of Alherta. Edmollton; M.Sc., U nil'ersity l rC algaT}') is education coordinator at Alherta C hi/dren's Hospital, Calgary. The study cited in this article was part of her thesis research leadillg to a MaHer's degree in Educatiollal Psychology. Lillian Park (R.N.. Killgston General Ho. pital. Killg. toll, Ontario) i. a Ilurse 011 the pre-admi.uion team at Alherta Childrell's Hospital. Calgary. Prior to hecomillg a pre-adminion Ilurse she wor/..ed lU asÚ tant head Ilursefor a numher ofyear. on the .H1rgicalullit at Alherta Children's Hospital. Vera \'\ard rR .N., Holy Cmu Hospital. C algary) i. a memher l (the pre-adminioll team. She was one of the origillal Ilurses Oil the team alld has been illtimatel\' ;'lI'oll'ed ill the del'elopmellt of the Pre-l;dmission Program. She also performed the admissionsfor all the childrell examined in the study described in this article. , butter is really the villain responsible for various common pathologies. . . , these very illnesses continue to occur frequently despite a dramatic decrease in butter consumption over the past thirty years? . And did you know that. during this same period of time. there has been a marked increase in the consumption of margarine in Canada? COMPARATIVE DAILY CONSUMPTION RATES OF BUTTER AND MARGARINE FROM 1948*-1978** IN GRAMS PER PERSON c ,296 112 I , I, O 18 C I V V 1948 MARGARINE 1978 1948 BUTTER 1978 For more facts about dairy foods. write to: Canadian Dairy Foods Service Bureau. 30 Eglinton Ave. E.. Toronto. Ont. M4P 186 *Statlsbcs Canada ** 1978 estimated consumption I J I When you look at the facts you can see the good in butter. 50 J8nu8ry 111711 The Cen-.llen Nur.. calendar January 1979 Continuing education courses offered at the Faculty of Nursing, University of Toronto: Curriculum refinement and revision -Jan. 25-26. $50. Writing workshop: are you getting your message across? -Jan. 31. $25. Family therapy principles for nurses-Feb. 7. $25. The problem of skin disorders for the adolescent. Feb. 12, $25. Care of the disturbed elderly patient-Feb. 15-16. $50. Nursing process in mental health and psychiatric nursing - Mar. 1-2, $65. The community as client: assessing levels of community health - Mar. 28, $25. Contact: Dorothy Miles. Director. Continuing Education Program, Faculty of Nursing , University of Toronto. 50St. George St., Toronto. Ontario, M5S IAI. Continuing Education Programs offered at the University of Alberta. Edmonton: Del'elopment of political sl..ilIsfor organi:.atiunal change. Jan. 25-26. $45. Anatomy and physiology for nur. es, Feb. 8-Mar. 22 (7 Thurs. evenings). $35. CommunicatÙ'e disorders in children: identification and referral. Feb. 8-9. $40. Writing sWlsfor nurses. Feb. 13-14. $60. Control female inCClntinence, naturally Eschmann Female Incontinence Device naturally and discreetly controls stress incontinence in patients awaiting corrective surgery and over long-term periods. Worn internally. the device controls the opening - naturally - of the bladder neck The device is comfortable. easily inserted and removed by the patient after a simple demonstration. --= Available from leading surgical supply dealers or directly from @ESCH advancing the cause of good health Eschmann Canada Limited Barclay Avenue Toronto, Ontano M8l5S6 (416) 252-2281 Geriatrics symposiumfor health care professionals. Mar. 12-14. Quality assessment of mother-child relationship. Mar. 16-17. $45. Performance appraisal for nurses. Mar. 22-24. Nursing aspects of intrm'enous therapy. Apr. 16. S elf care framework applied to nursing practice. Apr. 19-20 Management of pain. April. Competency analysis profile: application to nursing. Mayor June. Nursing pharmacy workshop. May 25. ECG interpretation. June 25-28. $80. Tests and measurements for nurses. Aug. 13-14, $45. Contact: Millie Pasemko, Faculty of Extension , The University of Alberta, Corbett Hall. Edmonton, Alberta. T6G 2G4. February The Canadian Orthopaedic Nurses Association Second Annual Meeting to be held Feb. 6-9. 1979 at the Hotel Toronto in Toronto. Fee: members - $20 per day. or $50 for 3 days: non-members - $25 per day or $60 for 3 days. Contact: Cheryl McCulloch, R.N., CONA, 43 Wellesley St. E.. Toronto, Ontario. M4Y IHI. Annual Pediatric Seminar- "Rights of Children in Hospital". Sponsored by Calgary Health Agencies and the Chinook Affiliate of the Association for Care of Children in Hospital. To be held on Feb. 8-9. 1979 at Foothills Hospital. Calgary. Fee: $25. Contact: Pat Powers, Seminar Chairperson, 6301 Larl..spur Way, Calgary. Alherta. T 3E 5P9. 48th Annual Meeting of the Royal College of Physicians and Surgeons and the Medical Surgical Exposition to be held February 6-9, 1979 in Montreal, Quebec at the Queen Elizabeth Hotel. Contact: Dr. James H. Graham, Secretary, Royal College of Physicians and Surgeons of Canada , 74 Stanley Ave., Ottawa, KIN IP4. March Primary Cancer Care - The Role ofthe Nurse. A two-day workshop to be held March 22-23. 1979 at the University of Calgary. Contact: Faculty ofC ontinuing Education, University of Calgary. 292024 Al'e. N.W., Calgary, Alberta, T2N IN4. April Post diploma maternity nursing course for registered nurses to be held at the Grace Maternity Hospital. Halifax, N .S. A 12-week course beginning April 2 - June 22 and Sept. 10 - Nov. 30. 1979. Contact: Margaret Power, Director of Nursing Education. Grace Maternitv Hm.pital, Halifax, N.S., B3H IW3. Did you know... The Canadian Lung Association has a Nursing Fellowship of $8.500 for Master's or Post Master's study in the clinical speciality of pulmonary nursing. For further information and application form please write: The Canadian Lung Association, 75 Albert Street, Suite 908, Ottlll\'a, Ontario. KIP 5E7. Application deadline: February 15. 1979. Clinical . I I · m solvers from Saunde s r: ------ ------------- order titles on 3O-day approval, enter order number and auth or: Please Print: I I I I I I I I AU: I I I I I Expiration Dat L _ _ W.B. Saunders Company in Canada: 1 Goldthorne Ave., Toronto. Onleno M8Z 5T9 in England: 1 St. Anne's Rd., Eestbourne. East Sussex BN21 3UN In Auslrella: 9 Wallhem StreeI. Artarmon N.S.W 2984 '\ Drain & Shipley .J The Recovery Room i Two leading experts in the field provide clear, accurate coverage of the recovery room in this valuable new, one-of-a-kind book. Topics include the physiology of anesthesia, the effects of various anesthet+c agents. specific care after all types of operations, and factors that affect recovery from anesthesia in particular patients. By Cecil B. Drain. RN, CRNA. BSN. Univ. of Arizona. Tucson, AZ; and Susan B. Shipley, RN, MSN. Nurse Researcher, Nursing Research Service. Walter Reed Army Medical Center. Washington. DC. Aboul 350 pp. lIIustd. Ready soon. Order 3186-X. Sorensen & Luckmann Basic Nursing: A Psychophysiologic Approach The authors of the popular Medical-Surgical Nursing now offer a comprehensive textbook on basic nursing concepts for the practitioner. Twenty-eight contributing experts provide special coverage of important topics such as biomechanics; nutrition; bowel, bladder, and catheter care; vital signs; respiratory care; the therapeutic nurse-patient relationship; blood administration and much more. Particular attention is paid to the role of stress and adaptation in illness, understanding the existence of the patient, therapy and rehabilitation, the nursing process, and the changing role of the nurse. By Karen Creason Sorensen, RN, BS. MN, Formerly Lecturer in Nursing, Univ. of Washington; Instructor of Nursing, Highline College; Nurse Clinical Specialist, Univ. Hospital and Firland Sanitorium. Seattle. WA; and Joan Luckmann, RN, BS, MA, Formerly Instructor of Nursing. Univ. of Washington, Highline College, Seattle, Oakland City College, and Providence Hospital College of Nursing. Oakland. CA. About 1185 pp.. 435 ill. Ready soon. About $23.00. Order *8496-X. Conn Current Therapy 1979 Current Therapy 1979 will be off press in R!bruary-and this new edition of Conn offers more clinically usable datd than ever before! Completely revised by over 335 leading authorities. it provides Quick access to the most-up-to-date, proven treatment methods available. Here are just a few of the topics: Leish- maniasis. Plague, Toxoplasmosis, Bagassosis, Farmer's Lung and other forms of hypersensitivity. Newer agents in therapy of bacteremia. and much more! Edited by Howard F. Conn, MD. With 14 contributors. About 1000 pp IIlustd. $31.05. Re.wy Feb. 1979. Order *2.64-5. AU: AU: o check enclosod-Seunders pøys poslege f!8tat. We accept Visa and Mastercharge ..., o Visa # 0000000000000 o Master Charge # DODD DODD [ill ODD Interbank DDITJ Krause & Mahan Food, Nutrition and Diet Therapy 6th Edition A strong revision of an already excellenttext, the new 6th edition of Krause & Mahan is even better suited to your students' needs. New material includes stress responses, nutrition and cancer, and the low-birth-weight infant. Assessment of nutritionå problems and the importance of nutrition throughout the life cycle is emphasized. Many new iIIust ations, graphs. and tables highlight and enhance better understanding of all aspects of nutrition. By Marie Y. Krause, BS. MS. RD, Formerly Dietitian In Charge of Nutrition Clinic and Assoc. Director of Education. Dept of Nutrition. NY. Hospital; Therapeulic Dietitian and Instructor in Dieletics, Mount Sinai Hospital. Philadelphia, PA; Therapeulic Dietitian and First Asst. to Instructor in Nutrition. Dept. of Medicine. Univ. of Chicago Clinics; and L. Kathleen Mahan. RD, MS, Lecturer, School of Nutritional Sciences and Textiles, Nutritionist, Child Development and Mental Retardation Center. Univ. of Washington; Consulting Nutrilionist, Seattle, WA. About 935 pp. 295 ill. About $19.55. Ready soon. Order *5513-{). Keane Essentials of Nursing: A Medical Surgical Text 4th Edition This is a compact textbook for students beginning the study of medical-surgical nursing. From the more general concepts related to illness (such as adaptability and immobility and homeostasis) and those related to nursing, it goes on to discuss medical-surgical nursing care problems with emphasis on the nursing process throughout. Student aids include; learning highlights (similar to objectives); vocabulary lists; summary tables; and a student study aid section consisting of learning activities, additional reading, and a study outline. By Claire Brackman Keane, RN, BS. MEd. Formerly Director of Nursing Education and Instructor in Medical-Surgical Nursing, Grady Memorial Hospital School of Nursing, Atlanta. GA. About 600 pp. lIIusld. About $16.10. Ready soon. Order *5313-8. -------- CN 1/79 Full Name I I I I I I I I j J , I Home Phone Number Position and Affiliation (If Applicable) Home Address City State ZIP Signature All prices differ oUls,de U.S and subject to change West Washington square .J Philadelphla,pa.19106 _ _ _ _ _ __ 52 Jenuary 111711 The Can-.llen Nur.. books BOOKS CAN HELP Denise Alcod. The experiences or sensitive observations of others when shared in the literary form can educate, enhance the reader's insight and be therapeutic by offering hope and encouragement. This is an annotated bibliography of books which should help the reader gain a better appreciation of the hardships and realities of living with certain disabilities, both from the personal and family points of view. Although many of the books are written for school age and young adult readers - with the exception of picture books - we as professionals can gain valuable insight into the reality oflife for some of our patients and their families. Also included are some books that deal with the complexity oftoday's social life with its resulting emotional and social problems for the child or adolescent. The books have been chosen because they can lend a helping hand. Denise Alcock is the Director of the Child Life Department. Children's Hospital of Ew,tern Ontario, Ottawa, Ontario. Axline, Virginia M.,DIBS In search 0/ self, Boston, Houghton \liffiin Co., 1964. 186 p. With the hel p of play therapy and Dr. Axline. a severely disturbed and withdrawn child discovers his own potential as an exceptionally gifted person. The book is based on actual recordings of weekly therapy sessions and is an absorbing account ofDibs' struggle for identity. Barber, Elsie, The trembling years, N. Y., Macmillan, 1949,237 p. At the age of 17 when life is full of excitement, Kathy is stricken with paralytic polio. Her relationship with people changes, she rebels against her handicap and feels very sorry for herself The story deals with how Kathy struggles to live with her problem and comes to lead a fulfilling life. Bretz, H. Lee, Donny and diabetes, Vancomer, B.C., Tad Publishin Ltd., 1973, 55 p. A pictorial educational guide for children with diabete!>. Brickhill, Paul, Reach/or the sky, N. Y., Norton, 1954,312 p. The incredible true story of Douglas Bader, who lost both legs in a plane crash yet continued to golf. swim, drive a car and fly a plane. During World War I[ he was taken prisoner and twice escaped. A remarkable story of inventiveness and determination. I l T'"- .... \ .... ! ?-.. ...:'! '.- , I I , . - '. " J disability and the family's struggle as well. Most informative regarding problems. treatment methods, resources and impact of dyslexia on the individual and the community. D' Ambrosio, Richard (M.D.), No language but a cry, Dill Publishing Co. Ltd., 1970,314 p. The true story of a physically and mentally scarred twelve-year-old who had been abused as an infant by her parents. It is a story of her rebirth as a functional human being as a result of the patience and wisdom of remarkable nuns and Dr. D'Ambrosio. Dahl, Borghild, Finding my way, N. Y., Dulton. 1962. 121 p. The autobiography of a determined, independent woman. who though blind. maintains her own apartment. travels, and shares practical ways for blind people to stay in the mainstream of life. Butler, Beverl). Light a single candle, Arch"ay paperhack, 1970,217 p. About a teenager's acceptance of and adjustment to blindness which occurs at 14 due to an unsuccessful glaucoma operation. The fact that the author, Butler. lost her sight at the same age contributes to the novel's sensitivity and authenticity. Christopher, Matt, Sink it, Rusty, Boston, Little, Brown & Co., 1963, 138 p. Rusty uses his handicap as a crutch. With the help of a former basketball player whose career was interrupted by the loss of his left hand, Rusty learns to adjust and make the most of his capabilities. Deals with attitudes toward handicap!>. Clarke, Louise, Can't read, can't write, can't talk too good either,N. Y., Walker & Co., 1973. 2HO p. A mother's personal document revealing her child's struggle with severe language The C..-.llan Nur.. J8nUllry 111711 5.1 Dizenzo, Patricia, Why me' N. Y., Avon Books, 1976, 139 p. Examines the loneliness, fears and hurt of a 15-year-old rape victim. Fanshawe, Elizabeth, Rachel, London, England, The Bodley Head, 1975, 29 p. A picture book which illustmtes how Rachel who is in a wheelchair is able to go to school, help at home and at school, go to Brownies, learn to swim and ride and choose a career. Friis, Babbis, Kristy's courage, N.Y., Harcourt, 1965, 159 p. Seven-year-old Kristy is struck by a car. She has facial scars and her speech is impeded. Upon return to school, children laugh at her and tease her. Her mother is in hospital with a new baby. It is the story of how a 7-year-old deals with these problems and how insensitive people can be to visible handicaps. Gardner, Richard, (M.D.), MBD The family book about minimal brain dysfunction, N. Y., Jason Aronson Inc., 1973, 185 p. A two part guide book: part I for parents and part II for children, dealing with the most common concerns regarding brain dysfunction. For parents the book deals with signs and symptoms, adaptive reactions, social problems and the child's future. The second part. with the help of drawings and clear wording, gives the reader (or child being read to) an explanation of brain dysfunction. help available and most important, a feeling that somebody understands the problem. Garfield, James, B. Follow my kader, N.Y., Scholastic Book Services, 1957, 187p. A firecmcker thrown by a friend causes blindness. With the help of a guide dog. Jimmy learns to become an active social and happy person instead of the hostile and dejected person he was just after his accident. Gunther, John, Death be not proud, N. Y., Harper & Row, 1965, 161 p. A father's memoir of his teenage son's battle with a brain tumor and his son's maturity, courage and good humor in the face of his terminal illness. It is written so that others "may derive some modicum of succor from the unflinching fortitude and detachment with which he rode through his ordeal to the end." Haggard, Elizabeth, Nobody waved goodbye, N. Y., Bantam Pathfinder, 186 p. Peter, 16, annot cope with the discipline of schoolwork or with responsibility. This novel reveals the thought processes and feelings of a rebellious adolescent who creates unhappiness for those who love him as well as for himself. Killilea, Marie, Karen, N.Y., Prentice-Hall, 1952,314 p. Karen. the author's first child, has cerebml palsy. Much shopping takes place before Karen's parents are able to find encouragement and medical help. Obstacle after obstacle is overcome until Karen can walk. talk. read and write. Klein, Norma, What it's all about, Archway Paperback, 1978, 146 p. Life for an eleven-year-old with an adopted Vietnamese orphan for a sister. a stepfather that her mother fights with a lot and finally leaves. a father who has just remarried and whose new wife is pregnant. and a young gmndmother who has just remarried. is complex indeed. The story is a reflection of modern day family instability and its bewildering effect on children. Lasker, Joe, He's my brother, Toronto. George J. McLeod Ltd., 1974,36 p. Through excellent illustrations and a simple story, this book helps young children understand a sibling or friend who has a learning disability. Lawrence, Mildred, The shining moment, N. Y., Harcourt, 1960, 187 p. A car accident facially scars a pretty university student. She drops out of university, moves in with her grandmother, and virtually goes into hiding. Eventually as the scar fades and she finds ajob, she becomes interested in local community projects and a young man. The story emphasizes that intellect, friendship and interesting work are better assets than facial beauty. Litchfield, Ada. A cane in her hand, Toronto, George J. McLeod Ltd., 1977, 30p. A picture book about Valerie who is visually impaired. The story is "intended to create feelings of understanding and acceptance toward visually impaired persons." Litchfield, Ada, A buUon in her ear, Toronto, George J. McLeod Ltd., 1976, 28p. A picture book with a story that helps children understand the problems and abilities of their deaf friends who must wear a hearing aid. Massie, Robert and Suzanne,Journey, N.Y., Warner Books, 1973,462 p. Alternate chapters are written by Robert and Suzanne Massie whose only son has haemophilia. It is a compelling story which deals with the anxieties and the hardships of the first eighteen years of Bobby's life. It is also a factual handbook on haemophilia and a history ofthe progress and non-progress of treatment techniques and facilities. MacCracken, Mary, A circle of children, Philadelphia, J.B. Lippincott Co., 1973, 221 p. . 'This is the story of a teacher with a listening heart who learned how to understand her children's private hells of anger. confusion, hurt and tragic loneliness". (backcover) Neufeld, John, Twink, N. Y., New American Library, 1970, 127 p. Twink has cerebral palsy. The whole family is affected and involved. ''Twink'' portmys the anxiety, fear,joy, set-backs, love and survival ofa family with a member who has cerebral palsy. Neufeld, John, Lisa, bright and lÙlrk, N. Y., New American Library, 1969, 143p. A 16-year-old cannot convince her parents she needs psychiatric help. Her teachers are afmid to interfere. Her three teenage friends offer understanding and amateur therapy until they can obtain professional help for her. Lisa's mother reacts to her hospitalization by hiding from neighbors in shame. Park, Clara Claiborne, The seige, Toronto, Little, Brown & Co., 1967, 280p. A mother's account ofthe family's struggle to teach their autistic child to love and to respond during the first eight years of the child's life. Some ofthe incidents this family encountered show that the helping professionals can be rude, self-important and insensitive people. 54 "'nuery 111711 The Cen-.llen Nur.. Platt, Kin, Hey dummy, N.Y., Dell Publishing, 1971, 171 p. -- A pamfully sensitive novel about Neil. a twelve-year-old. who befriends a thirteen-year-old brain-damaged boy. The novel portrays the cruelty of the peer group. the fears of misinformed adults and the pain such a friendship can bring. The ending is unexpected but very real. Robinson, Veronica, David in silence,Philadelphia, Lippincott, 1966, 126 p. The new boy in the neighborhood is deaf. He laugh<; inappropriately and his words are unintelligible. Sometimes it is very difficult for the other children to accept him but slowly they learn ofDavid'<; fears and his need for acceptance. Samuels, Gertrude, Run Shelley run, N.Y.. New American Librar), 157 p. Shelley is a teenager who has had a lifetime of trouble - an alcoholic mother. a stepfather who tries to rape her. a neighborhood where sex and drugs have to be avoided and a training school which is a prison. Run Shelley run! Sha , Charles R. When your child needs help. l'o. Y., William !\torro and Co., 1972, 309 p. Discusse the major emotional disorders of children. Written by a psychiatrist for parents and teacher!> to enable them to better understand the disturbed child. Simon. orma, All kitrds offamilies, Toronto. George J. \1cLeod Ltd., 1976, 36p. With the help of excellent illu<;tration<; this book enables children to explore in words and picture... what a family is and how familie<; vary in makeup and lifestyles. Simon, Norma, n hy am I different, Toronto, George J. McLeod Ltd., 1977. 31 p. Situation in this picture book help children explore differences in growth. hair color. physical abilities. cultural and religiou<; background<; and family structures. Stewart, Mark A. (M.D., and Sail} \\'endkos Olds, Raising a hyperactive child, 1'i.Y., Harper and Row, 1973, 299 p. The purpose of the book is "to restore parents' confidence in themselves by explaining the nature of the problems presented by hyperactive children and by describing practical ways to deal with them. .. Valens, E.G., The odrer side of the mountain, N. Y., Warner Books, 1966, 301 p. The story of Jill Kinmont who in her last qualifying race before the 1955 Olympic tryout crashed and was left permanently paralyzed from the shoulders down. It is a true story of incredible struggle and victory. \\,'aite, Helen E., Valiant companions, N. Y., Scholastic Book Services, 1964, 279p. A biography of Helen Keller and also to some extent. a biography of Anne , Sullivan who. as Helen's teacher opened the door to a full and rewarding life for the blind. deaf and mute Helen. West, Paul, Words for a deaf daughter, "I.Y., Harper & Ro . 1968. 188p. Paul West is a professional writer and the father of a deaf child who describes how he brings the world to his daughter and has as a result come to know and appreciate the world better. Mandy's presence has become ajoyful celebration of the richness oflife itself. He articulately brings to the reader an awareness of many kinds of communication apart from words and also points out the vacuum between the harassed parent and austere professional. library update Publications recenlly received in the Canadian Nurses Association Library a.ce available on loan - with the exception of items marked R -10 CNA members. schools of nursing. and other institutions. Items marked R include reference and archive material that does nor go out on loan. Theses. also R, are on Reserve and go out on Interlibrary Loan only. Requests for loans. maximum 3 at a rime, should be made on a standard Interlibrary Loan form Or by letter giving author. title and item number in this list. If you wish to purchase a book. contact your local bookstore ór the publisher. Books and Documents I. Bou\'ier, G. Le nursing en neurologie et en neurochirurgie. par...Juliana Pleines et Jacques-CartierGiroux. St-Hyacinthe. P.Q.. Edisem; Paris. Maloine cl978. 313p. 2. Brown, Joan C. Prevention of handicap: a case for improved prenatal and perinatal care. A background paper. Ottawa. Canadian Institute of Child Care. 1978. 57p. 3. Canadian Hospiral Associarion Annual general meeting. 1978. Ottawa. Iv. (various pagings) 4. Conférence infernationale sur les soins de santé primaires, Alma-Ata, URSS 6-11, sept. 1978 Documents. Genève. 1978. 5pts. in \. 5. C onférence sur [' enseignement dans ['administration des services de santé au Canada, Ottawa. 1977 Les besoins à satisfaire; enseignement dans I'administration des services de santé au Canada. Compte rendu d'une conférence parrainée par la fondation W.K. KelIoggde Battle Creek, Mich. Ottawa. ColIege canadien des \ I directeurs de services de santé. 1978. 144p. 6. Dickason, Elizabeth J. L'infirmière et la périnatalité. Édité par...et Martha Olsen Schult Montréal. HRW. cl978. 542p 7. Gougeon, J. L Ïnfirmière en rhumatologie. Paris, Expansion scientifique française. 1978. I39p. 8. International Conference on Primary Health Care, Alma-Ata, USSR. 6-11 Sept. 1978 Non-governmental organizations and primary health care. Halifax. 1978. A Position paper prepared for the International Conference... Sponsored by WHO/UNICEF. Washington. World Health Federation of Public Health Associations. 1978. 93p. 9.-.Papers.Geneva. 1978. 5pts. in I. R 10. I nternational Labour Conference. 63rd Ovol 80 Tablets Ovol]40 Tablets Ovol@ Drops Antiflatulent Simethicone INDICATIONS OVOl is indicated to relieve bloating, flatulence and other symptoms caused by gas retention including aerophagia and infant colic. CONTRAINDlCATlONS None reported. PRECAUTIONS Protect OVOl DROPS from freezing. ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOl 80 TABLETS Simethicone 80 mg OVOl 40 TABLETS Simethicone 40 mg Adults: One chewable tablet between meals as required. OVOl DROPS Simethicone (in a peppermint flavoured base) 40 mg/ml Infants: One-quarter to one-half ml as required. May be added to formula or given directly from dropper. Ð HQRflfR " session, Geneva, 1977 Draft programme and budget 1978-79 and other financial questions. Second item on the agenda: programme and budget pmposals and other financial questions. Geneva. International Labour Office. 1977. 83p. (/ts Report 2) II.-.Provisionalrecmd. Sixth item on the agenda: employment and conditions of work and life of nursing personnel. Geneva. International Labour Office. 1977. 3pts. in I. 12.-.Committee on nursing personnel Pmceedings. Geneva. International Labour Office. 1977. 9pts. in I. 13. International Labour Organization Conditions of work and employment of professional workers. Tripartite meeting.. .Geneva. 1977. Geneva. International LabourOffice. 1977. Hip. 14.-Director-General's programme and budget proposals for 1978-79.Geneva, International Labour Office. 1976. Iv. (various pagings) 15. Kesterton, Wilfred H. The law and Ihe press in Canada. Toronto. McClelland and Stewart in association with the Institute of Canadian Studies. Carleton University. '- cl976. :!4:!p. (fheCarleton Library no. 1(0) 16. MacStrm'ic, Robin E. Determining health needs. Ann Arbor. Health Administration Press. cl978. :!68p. 17. N eh' Democratic Party of Ontario. Health Policy Planning C ommitree Health. not illness: A green paper for Ontario. Toronto. 1978. 74p. 18. Organisation mondiale de la Santé Répertoire mondial des écoles d'agents d'assainissement. 1973. Genève. 1978. 81p. - ., ,. \ . . I. . '. .... \..' . J ' .....' I . L .' "/ þ /' THE LAST THING HE NEEDS IS GAS. \' (\ The Cenedlen Nur.. 19. Primary health care. A joint report by the Director-General of the World Health Organization and the Executive Director of the United Nations Children's Fund. Geneva. World Health Organization; New York. UNICEF. 1978. 49p. 20. Public Services International Report. 1973-1976. Feltham, Middlesex, 1977. Iv. (various pagings) 21. Smith, Janet Saskatchewan registered nurses' perceptions of quality of care. A study undertaken by Dept. of Social and Preventive Medicine. Univ. of Saskatchewan...under contract with Saskatchewan Registered Nurses' Association. Regina. Reprinted with a foreword and summary by Sask. Registered Nurses' Assoc. and with permission of the Dept....Saskatoon. 1978. 133p. 22. Les soins de santé primaires. Rapport conjoint du Directeur général de "Organisation mondiale de la Santé et du directeur exécutif du Fonds des Nations Unies pour I'enfance. Genève, Organisation mondiale de la Santé; New Y mk. UNICEF. 1978. 54p. 23. Teaching and evaluating the affective domain in nursing programs. Editor Dorothy E. Reilly. Thorofare. N.J., Charles B. Slack. cl978. 76p. 24. Vanier Institute of the Family The new life. Ottawa, 1977. 51p. :!5.-.Varieties offamily lifestyles: a selected annotated bibliography. phase I. Ottawa. 197? 98p. :!6. World Health Or1!anization World directory of schools for auxiliary sanitarians. 1973. Geneva. 1978.8Ip. (fiD eP'" K!!!!!!i '" .,,-= 'I', , . .. When a patient can't move around, gas can be a problem, and a painful one at that. So for pa- tients who are immobile following surgery or for post-cholecystectomy patients. give them extra strength OVOL 80, the chewable antifiatulent tablets that work fast to relieve trapped gas and bloating. , Jenuery 11171 55 Pamphlets 27. A ssociation des infirmières et infirmiers du Canada La direction des relations de travail de I'A.l.I.C. et vous. Ottawa, cl978. brochure. 28. Canadian Labour Congress By-Laws governing chartered local unions. Rev. Ottawa, 1975. 31p. 29.-.Constitution. Rev. Ottawa. 1976. 47p. 30. Canadian NursesAssociation You and yourCNA Labour Relations Department. Ottawa. cl978. pam. 31. Congrès du Travail du Canada Statuts Édition revisée. Ottawa. 1976. 50p. . 32. L'lnstitut Vanier de lafamille Déclaralion sur les styles contemporains de vie familiale. Ottawa. 1977. Iv. (pagination multiple) 33. Levêque, 8. Comment faire pour que notre enfant soit vite propre la nuit. par...et C. Dilain. Paris. Expansion scientifique française. c1978. 24p. 34. McMurray, David Current economic and industrial relations indicators. Kingston. Ont..lndustrial Relations Centre. Queen's University, 1978. 38p. 35. Munro, John A statement by....Minister of Labour to the sixty-third session of the International Labour Conference. Geneva. Switzerland. Monday. June 13, 1977. 15p. 36. National League for Nursing. Division of Baccalaureate and Higher Degree Programs Doctoral programs in nursing. 1978-79. NewYof'k. 1978. (NLN pub.no. 15-448) 5p. R 37. Queen's U niversiry.1 ndusfrial Relations Centre Collective bargaining and white collar Ovol" 80 r rGas Clrector to commence work February I, 1979. Applicant with Public Health experience required. This is a super- visory position and applicant should be knowledge- able in that field. Salary negotiable based on qualifi- cations and experience. Apply to: Director. Big Country Health Unit. Box 279. Hanna, Alberta. TOJ IPO. British Columbia Rqlltered and Graduete Nunes required for new 41-bed acute care hospital. 200 miles north of Vancouver. 60 miles from Kamloops. Limited furnished accommodation available. Apply: Director of Nursing. Ashcroft & District General Hospital, Ashcroft. British Columbia. VOl< IAO. Challenge and opportunity await the nurse prepared to accept a position In a 1000bed accredited acute care hospital in a booming northern city. We will help the beginning practitioners to expand their knowledge and skills. Write to: Nursing Director. Dawson Creek and District Hospital, 1l100-l3th St.. Dawson Creek. British Columbia. VIG 3W8. British Columbia Gnera1 DuI, N_ for modem 41-bed accredited hospital located on the Alaska HiPway. Salary and penonnel policies in accordance with the RNABC. Temporary accommodation available in residence. Apply: DireClor << Nursin.. Fan Nelson General Hospital, P.O. Boll 60. Fan Nelson. British Colum- bia, VOC tRO. Generlll Duty Registered er Graduate Nu....,. - needed for 2.5-bed acute care hospital in North Central B.c. Salary and working condition according to the RNABC CotltraCl. Apply: Director. Stuart Lake Hospital. Fort St. James. British Columbia. VOJ IPO or call collect (604) 996-8201/996-730.5 . Experienced Nunes (eligible for B.C. Registration) required for full-time positions in our modern 300-bed Extended Care Hospital located just thirty minutes from downtown Vancouver. Salary and benefits according 10 RNABC contract. Applicants may telephone .52.5-0911 to alTange for an interview. or wrile giving full particulars 10: Personnel Direc- tor, Queen's Park Hospital. 31.5 McBride Blvd., New Weslminster. British Columbia. V3L .5E8. Eaperiftced Nllww. (B.C. Keaistered) required for upansion to 463 bed acute. teachina, reaional referTaI hospitllliocated in Fraser Vlllley, 20 minutes by freeway from Vancouver, and within easy access of various recreationlll facililies. Euellent orienta- tion and continuina education proarammes. Salary: S 1184.00-S 1399.00 per month (1977 rates). There is an immediate need tn coronary care. intensive care, operatina rooms and hemodilllysis because 0( increased services. OIher clinical areas include medicine. sUl'lery. obsletrics, pediatrics. emeraency and rehabililation. Apply to: Personnel, Royal Columbian Hospital. New Westminster. British Columbia. VJL JW7. General Duty Nurses (eligible for B.C. registration) required for 12.5-bed hospital in the South Okanagan. RNABC contract in effecl. Reply in writing to: Director of Nursing. South Okanagan General Hospital. Box 760. Oliver, British Columbia. VOH ITO. Experlencrd ICU/CCU and Operatl", Room General Duty Nunes required for full-time and summer relief in a 230-bed accredited hospital in the Okanagan Valley. Must be eligible for B.C. registration. Salary $1,30.5 to SI..542 per month, with differential for special clinical preparation of not less than 6 months. Apply to: Director of Nursing. Penticton Regional Hospilal, PenticlOn. British Columbia. V2A 3G6. Registered Nunes - Required immediately for a 340-bed accredited hospital in the central interior of B.C. Registered Nurses interested in nursing posi- tions at Ihe Prince George Regional Hospital are invited to make inquiries to: Director of Personnel Services, Prince George Regional Hospital. 2000- l.5th Avenue. Prince George. British Columbia V2M IS2. Wanted Immediately. R.N.'. Generlll Duty. Perma- nent full-time and part-time. Apply to: R. Billerlich, Nursing Director, Queen Charlotle Islands General Hospital, Box 9. Queen Charlotle City. British Columbia. VIJf ISO. Phone: (604) .5.59-4411, Local 2.5. British Columbia Faculty - New Position (I) in 2-year post-basic baccalaureate program in Victoria. B.c.. Canada. Generalist in focus. clinical experience is provided in gerontology in community and supportive exlended care units. and in community nursing. Highly-qualified and motivated studenls in a dynamic academic environment stimulate teaching creativilY which. with research, is strongly endorsed. Master's degree. teaching and recent clinical experience in geronlology/med.-surg./reha- bilitation preferred. Salaries and fringe benefits competitive: an equal opportunity employer for qualified persons. Appointment effeclive July I. 1979. Contact: Dr. Isabel MacRae. DireClor, School of Nursing. University of Victoria. P.O. Box 1700, Victoria, B.C.. Canada. V8W 2Y2. Telephone (Area Code 604) 477-6911 - Local 4814. Nova Scotia Teaching Posh Ion Available: Nurse clinician with master's preparation to teach in the Bachelor of Science In Nursing program in the area of children and/or adult nursing. Program enrolment: 100. Salary commensurate with preparation and experi- ence. Write to: Chairperson, Department of Nurs- ing. St. Francis Xavier University. Antigonish. Nova Scolia. B2G ICO. Quebec Cemp Nurses required for childrens summer camp in beautiful Quebec Laurentians. Mid-June to end of August. Resident M.D. Contact: Mr. Herb Finkel- berg. Director of Camp B'nai B'rith. .51.51 Cote SI. Catherine Rd., Suite 203. Montreal. Quebec. H3W IM6, or lelephone (.514) 73.5-3669. Nurses for Children's Summer Camps In Quebec. Our member camps are located in the Laurentian Moun- tains and Eastern Townships. within 100 mile radius of Montreal. All camps are accrediled members of the Quebec Camping Association. Apply to: Quebec Camping Association. 2233 Belgrave Avenue, Montreal. Quebec. H4A 2L9. or phone 489-1.541. United States RN'S-CalifornlL Registered nurses interested in a career in California working in skilled nursing facilities. Salary is comparable to Canadian wages. Moving expenses provided. No California examina- tions are required. Write: M. Cameron. 12.54 Prin- cess Street. ApI. 17. Kingslon. Ontario, K 7M 3C9 or telephone (613 1.544-0 170-Evenings or weekends. Nursing Opportunity - Mississippi Baptist Medical Center, a ma,jor 600-bed hospital. has immediate positions available for experienced RNs and recent nursing school graduates in a variety of specialilies and medical/surgical areas. Competitive salaries. liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (population 300,(00). MBMC is the state's largest and most modern privately operated hospital. For further information write: Mrs. Johnnye Weber, Nurse Recruiter, 122.5 North State Street. Jackson. Mississippi 39201; or call collect 601/968-.513.5. The Cen-.llen Nur.. .. Januery 11171 511 United States United States RNII- Aa Exdtlaa Career Awaits You In Las Vqas. Join Valley Hospital and realize your nursing potential while e oying the unique lifestyle of sunny Las Vegas. Valley Hospital is a progressive, fully-accredited 277-bed facility nNed for providing higfl quality personalized medical care. We offer an excellent salary and benefit package. For more information, write or call collect: Kalene Ryan, Nurse Recruiter. CN-I, Valley Hospital. 620 Shadow Lane. Las Vegas. Nevada 89106, (702) 385-3011. Nanes - RNII - Immediate Openin,lI in California-Florida-Texas-Mississippi - if you are experienced or a recent Graduate Nurse we can offer you positions with excellent salaries of up to 51300 per month plus all benefits. Not only are there nO fees to you whatsoever for placing you, but we also provide complete Visa and Licensure assistance at also no cost to you. Write immediately for our application even if there are other areas of the U.S. thaI you are interested in. We will call you upon receipt of your application in order to alTange for hoSpital interviews. You can call us collect if you Brf an RN who is licensed by examination in Canada or a recent graduate from any Canadian School ct Nursifli. Windsor Nurse Placement Service. P.O. Box 1133, Great Neck. New York 11023. (516-487- 2818). "Our 20th YearofWorJd Wide Service" The Best Location la the Nation - The world- renowned Cleveland Clinic Hospital is a progres- sive, 1020-bed acute care teaching facility committed to excellence in patient care. Staff Nurse positions are currently available in several of our 61CU's and 30 departmentalized med/ surg and specialty divi- sions. Starting salary range is 513.286 to 515,236, plus premium shift and unit differential. progressive employee benefits program and a comprehensive 7 week orientation. We will sponsor the appropriate employment visa for qualified applicants. For funher information contact: Direclor - Nurse Re- cruitment, The Cleveland Clinic Foundation. 9500 Euclid Avenue, Cleveland, Ohio, 44106 (4 hours drive from Buffalo. N.Y.); or call collect 216-444- 5865. NuninB Opponunities - ProJVessive SOO-bed Medi- cal Center in West Texas city of Abilene with population nearly 100.000 is Iookifli for aew ,ndulllft and experienced R.N.'s for positions in O.B.. Pedialrics. SurBery. E.Jt... ICU. CCU. plus surJicai and medical floors. Good compelitive salary and Benerous benefils are provided. Contact: Per- sonnel Office. Hendrick Medical Center. 19th and Hickory. Abilene. Texas. 79601. A....13. ., MEDICAL RE'CRUITERS OF AMERICA INC. MRA recruIts Regls.ered Nurses and recen, Gradua.es tor hosp"al pOSItions In many U S clloes We provide comple'e Work V,sa and Sta.e licensure .ntormaloon ARLINGTON. Tit. 76011 6" Ryan Plaza Dr SUlle 531 (811) 461-1451 CHICAGO. ILL 60607 500 So RaCine 51 SUile 3.2 13121942."46 FT. LAUDERDALE. FL. 33309 800 N W 62nd 51 SUite 510 (305) 172.3680 FOUNTAIN VALLEY. CA. 92708 17400 BrOOkhurst SUile 213 1714) 964.2471 PHOENIIt. AZ. 85015 5225 N 19th A.ve. SUlle 212 (602) 249-1608 TAMPA. FL. 33607 1211 N Wesishore Bivd. SUI1e 205 18131872.0202 ALL FEES EMPLOYER PAID lfh GENERAL ST AFF NURSES Operating Room We require general staff nurses for Ihe Operating Room of Calgary's largest general hospital. The successful applicants must be eligible for registration in Albena and have experience and or a post graduate course in Operating Room technique. The salary range is 51123-51341 per monlh plus educational allowances and shift premiums. There is a comprehensive employee benefit program included. Please apply with resume of qualifications and experience to: Director 01 Personnel CALGARY GENERAL HOSPITAL 1141 Centre Avenue East Calgary, Alberta T2E lOA Unit Co-ordinator Reponing to the Assistant Executive Director. the incumbent will be responsible for managing: a) Spedal Care unit (4 beds) b) Emergency Department c) O.R.. Recovery. N.F.A. area'of an accredited 100 bed. acute Care hospital in Nonhern !vIanitoba. These units normally operate wilh a lotal staff of20-25 people. We require a nurse who is eligible for registration with M.A.R.N. as an active practising member. A nurse who has 3-5 years clinical experience in a critical area and who has graduated from a recognized program in I.C. U. as desired. A BSc. degree in nursing would be a definite asset. The candidate should also be an instructor in C.P.R. or be willing to obtain same and be willing to co-ordinate and participate in clinical teaching in the critical care area. This position offers an excellent range of benefits. including free denlal plan. accident and health insurance. four weeks annual vacation. group life insurance and nonhern allowance. The initial salary will be in excess of 5 16.000 per year. Interested parties are asked to submit a complete resume in confidence to: R.L.lrvlne Direc10r 01 Personnel Thompson General Hospital Tlaompson Drive South Thompson. Manitoba R8N OC8 Canadian Nunes - Our 350+ bed full service community hospital in a city of 70.000 in the piney woods and lakes of beautiful East Texas wishes to extend an invitat,C'n to you to practice nursing in a progressive hospital while you and your family enjoy the good life atmosphere of smaller city living. Our special visa sponsorship and licensure program may be what you have been seeking. We plan a trip to several cities in Canada to interview and hire soon so don't delay your response. For more information. please write or call Jack Russell. 611 Ryan Plaza Drive. Suite 537. Arlington. Texas. 76011. (817) 461-14S1. CeDe to Tn.. - Baptist Hospital of Southeast Texas is a 400-bed growth oriented ol'Janization lookifli for a few Bood R.N.'II. We feel that we can offer you the challenge and opportunity to develop and continue your professional jp"owth. We are located in Beaumont, a city of 150,000 with a small town atmosphere but the convenience of the IlU}Ie city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist Hospital has a progress salary plan plus a liberal fringe package. We will provide your immig- ration paperwork cost plus aiñare to relocale. For additional intonnation. contact: Personnel Ad- ministration, Baptist Hospital of Southeast Texas. Inc.. P.O. Drawer 1591. Beaumont. Texas m04. Aa amrmlllive adIoa employer. Excltemeat: Come and join us for year around excitement on the border. by the sea. an unbeatable combination. Enjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed. acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opponunities. We have immediate openings in all areas. Excellent salary and fringe benefils. We invite you to share the challenge ahead. A"istance with travel expenses. Write or call eoUect: Joe R. Lacher. RN. Director of Nurses. Valley Community Hospi- tal, P.O. Box 4695. Brownsville. Texas 78521; I (512) 831-9611. Primary Cbildren's Medical Center in Utah has A Place lor You. RN's - interested in new born intensive care-We want you! We've opened our new 22-bed intensive care center and have positions available. RN's for Medical. Surgical. Semi- Intensive Care Units and Nursery. Primary Chil- dren's Medical is located in a beautiful residential seclion of Salt Lake City. only minutes from recreational and skiing areas in the Rockies. Excellent benefits package include tuition reim- bursement. Temporary housing Can also be ar- ranged. For personal interview write or call collect now: Beverlee Aaron. RN. Nurse Recruiter, 320 121h Ave.. Sal. Lake City. Utah 84103. Phone 1-801-328-9061. Ext. 3S1. E.O.E. M/F. Switzerland Wintenhur Can.on (n5 bed) hospital near Zlirieh needs Operating Room Nurses for the surgery clinic. Required for immediate or future openings. We offer pleasant workifli conditions. equitable hours of work and leisure. Salary and benefi.. in accordance with the regulations of the Canton of Zürich. Five-day week. accommodation available. cafe'ena. Apply in writing to: Sekretariat Pflegedienst. Kan- tonsspital Win.enhur. CH-1I401 Wintenhur. Swit- zerland. Miscellaneous Africa - Overland Expeditions. London/Nairobi 13 wks. London/Johannesburg 16 wks. "'enya Safaris - 2 and 3 wk. itineraries. Europe - Camping and hotel tours from 16 days to 9 wks. duration. For brochures contact: Hemisphere Tours. 562 Eglinton Ave. E.. Toronto. Ontario. M4P IB9. í 10 J.nuery 11171 The C8n-.ll.n Nur.. Wish ere 4:. .. C' - ...... ...... ._t'. ..- ..>t. T - . . ,.;ro. -.' .${ ,-' ( . ,0 "." - , - . . -..... .. .. . .. .. .in Canada's Health Service Medical Services Branch of the Department of National Health and Welfare employs some 900 nurses and the demand grows every day. Take the North for example. Community Health Nursing is the major role of the nurse in bringing health services to Canada's Indian and Eskimo peoples. If you have the qualifications and can carry more than the nonnalload of responsibility. " why not find out more? Hospital Nurses are needed too in some areas and again the North has a continuing demand. Then there is Occupational Health Nursing which in- cludes counselling and some treatment to federal public servants. You could work in one or all of these areas in the course of your career, and it is possible to advance to senior positions. In addition, there are educational opportunities such as in-service training and some financial support for educational leave. For further infonnation on any, or all. of these career opporttmities, please contact the Medical Services office nearest you or write to; ø........, I Medical Services Branch I Department of National Health and Welfare Ottawa. Ontario K1A OL3 I Name I I Address I I City Provo I I . . Heallh and Welfare Sanfe el B'en-elre socIal I Canada Canada .........., Associate Director - Nursing Service To be responsible for a number of clinical areas within Nursing Service of a 1000 bed active treatment hospital. Qualifications: Master's Degree in Nursing preferred, with at least three years of top nursing management experience. Skills in day-to-day departmental operations including staffing. Experience with various nursing care modalities highly desirable. Apply with curriculum vitae to: Director of Personnel Services Royal Alexandra Hospital 10240 Kingsway A venue Edmonton, Alberta T5H 3V9 Advertising Rates For All Classified Advertising $15.00 for 6 lines or less $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies of the hospitals and agencies advertising in the Journal. For authentic information, prospective applicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse 50 The Driveway Ottawa, Ontario KlPIE2 . The Can-.llen NUrH Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Registered Nurse in search of a change and a challenge - look into nursing opportunities at Vancouver General Hospital. B.C.'s m or medical centre on Canada's unconventional West Coast. Staffing expansion has resulted in many new nursing positions at all levels. including: General Duty ($1231-1455.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the opportunity you've been looking for. For those with an interest in specialization. challenges await in many areas such as: Neonatology Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn Unit Inservice Educatiun Coronary Care Unit Hyperalimentation Program Renal Dialysis & Transplantation Paediatrics If you are a Nurse considering a move please submit resume to: Mrs. J. MIIC:Phail Employee Relations Vancouver General Hospital 855 West 12th Avenue Vancouver, B.C. V5Z IM9 Perinatal Nursing Specialist For Neonatal Nursery Are you looking for a challenging opportunity where you can use your clinical expertise. educational and managerial skills? Are you interested in being a leader in the development of our Neonatal Program working closely with nursing, medical and paramedical personnel? Would you like to be involved in the planning of a 60 bed SpecIal Care Nursery in a new Pediatrics/Obstetric hospital complex and the development of a Family Centre Perinatal Care Program? lfyou are. you might be the person we are lookmg for. This IS a newly created position in which you will help us develop our current Tertiary Program and plan for its move into the new facilities. Future plans also involve the development of Regional Program and Perinatal Care. Salary negotiable, commensurate with experience. Excellent benefits. Preparatiou Desired: A minimum of at least three years of Neonatal Intensive Care Nursing and alleasllwo years experience and preparation as aN urse Educator. Previous experience in administration desirable but not essential. A Baccalaureate or Master's Degree reqUIred. Qualified applicants please send your curriculum vitae and names of three referees to: Mrs. J. MIIC:Phall Empioyee Relations Vancouver General Hospital 855 West 12th Avenlle Vancouver, B.C. \5Z IM9 Januery I tl7I 111 The Province of British Columbia Community Nurses Applications are invited from qualified persons to form an EligibiJity List (valid for six months) of community nurses from which vacancies occurring at various locations in British Columbia will be filled. Duties wiJl include providing general public nursing. counselling and crisis intervention services in the area concerned: to liaise with health professionals and others providing care. and encourage appropriate use of available facilities. Qualifications - University degree in nursing. including public health training. or equivalent combination of educalion and experience: preferably some general nursing experience. including some in directly related duties: registered. or able to obtain registration. in the RegisteR:d Nurses Associat,ion of British Columbia: use own car, or government. on mileage basis. Salary - $16.322 - $19.296 Quote Competition 78:2619-38 Closing Location - Victoria Closing Date - immediately POSlhooS are open to bOlh men and women ObtalO and return applicatIons at addres< below unle,s nlherwlse Indicated Province of British Columbia Public Service Commission 544 Michigan Street. Vlclona. Be V8V 1 S3 a ; I I . I I ' . .. Q - - .- - C'" Nurses Applications are invited for appointment on a permanent or short term basis to the nursing staff of the Cottage Hospi- tal" Burgeo and Harbour Breton, Newfoundland. Salary and bonus in accordance with Nurses Collective Agreement. Living-in accommodations available at reasonable rates. also laundry services provided. Public service benefits apply with annual and sick leave with pay. provincial statutory holidays and contributory pension plan. Applications should be addressed to: Director of Nursing Cottage HospitaJs Dh ision Department of Health Confederation Building St. John's. Ne\\foundland AIC 5T7 112 Januery 1179 UNITED STATES OPPORTUNITIES FOR REGISTERED NURSES A V AILABLE NOW ARIZONA CALIFORNIA TEXAS WE PLACE AND HELP YOU WITH: STATE BOARD REGISffiATION YOUR WORK VISA TEMPORARY HOUSING - ETC. A CANADIAN COUNSELLING SERVICE Phone: (416) 449-5883 OR WRITE TO: RECRl'ITING REGISTERED NURSES INC. 1200 LA WHENCE A VENUE EAST. Sl;ITE 301, DON MILLS, ONTARIO M3A ICI IN FLORIDA OHIO NO FEE IS CHARGED TO APPLICANTS. @ Foothills Hospital Calgary, Alberta The Department of Nursing and the Department of Pediatrics. Neonatology. are offering a five month clinical and academic programme for Graduate Nurses: Advanced Course in Neonatal Nursing Applications are being accepted for clas- ses enrolIing each March and September. Participation in the programme is limited to eight. For further Information pt_ write to: Mr. B. Wrlghl Coordinator of Eduutional Srrvlc:rs FoolhlUs Hospital t40 l9SI. N.W. Calgary. Alberta T2N 2T9 Director of Nursing and Home Care Services Poshion A senior management position in Communily Health Nursing and Home Care Services. Location Mount View Heallh Unit - includes the M.D. of Rocky View. County of Mountain View and I.D. #8. Duties Responsible for planning. organizing. co-ordinating. directing and evaluating all nursing and co-ordinated Home Care programs. QualIDcations Minimum qualifications - a Bachelor of Science in Nursing and demonstrated administrative skills. This nurse should have a minimum of 5 years experience in a supervisory capacity. Salary Negotiable and dependent on qualifications and experience_ Appllcallons Send resume to Medical Officer of Health. Mounl View Health Unit #101. 5421 II th Street N. E. Calgary. Albena T2E 6M4. The Can-.llen Nur.. Clinical Nurse Specialist - Psychiatry required for Medicine Hat & District Hospital Applications are invited for the position of Clinical Nurse Specialist - Psychiatry. for a 247 bed aclive trealmenl and 100 bed extended care hospital located in southeastern Albena. Accountable to the Assistant Execulive Director - Patient Services. Responsible for continuing development of psychiatric program. Master'sDegree preferred Will consider Baccalaureate Degree with minimum three years' clinical expenence in psychiatric nursing. Salary - negotiable. Submit ResumeTo: Mrs. Shirley NeWlon Nursing Director - Slamng Medicine Hat lit District Hospital 666 FIfth Sireet. Soulh West Medicine Hat. Alberta TIA 4H6 Director School of Nursing Reponing direclly to the Executive Director. assumes Ihe responsibility for Ihe organization and administration of ongoing accrediled diploma nursing programs. Quallftutlollll: Appropriate Master's Degree preferred, but applicants possessing a Baccalaureate in Nursing will be considered. Previous experience in the adminislration of an accrediled nursing education program a necessily Please forward. in confidence. a complele resume of experience and qualificalions. including expected salary to: Mr. T.I. Bartman Executive Dlrect(,r Misericordia General Hospllal 99 Cornish A venue Winnipeg. Manitoba RJC tAl High Risk Obstetrics and Neonatal Intensive Care Nurses McMaster University Medical Centre is a progressive teaching hospital with a multi-disciplinary team approach to patient care. M&,jor specialties include Obstetrical Intensive Care and Neonatal Intensive Care unils. When openings occur in these areas for Registered Nurses. we require experienced staff. Inquiries are welcomed at any time from mature. responsible individuals who wish to work in a stimulating environment on a 12 hour shift system. Preliminary interviews can be arranged for out of lown nurses with current Ontario registration if written requests are accompanied by detailed resumes. Please apply to: Ms. Nora Prosser Personnel Interviewer McMaster Unive.-si1y Medical Centre 1200 Main St. W. Hamlhon. Ontario L8S 4.19 Assistant Nursing Dira:tor - Operating Room required for Medicine Hat & District Hospital Applications are invited for the position of Assistant NursingDirector for a six room O.R. suite and six bed Recovery Room. The hospital is a 247 bed active trealmenl and 100 bed exlended care facility located in southeastern Albena. A new facility is presently being planned. Baccalaureate Degree preferred. Post-Graduale course with minimum of three years' experience will be considered. Salary - negotiable. Submit Resume To: Mrs. Shirley NeWlon Nursing Director - Stamng Medicine Hal lit Dlslrict Hospital 666 flfth Sireet. Soulh West Medicine Hal, Alberta TtA 4H6 The Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston Hotel Dieu Hospital Kingston requires Director of Nursing Applications are invited for the position of Director of Nursing in a fully accredited 219 bed general teaching hospital. Reponing to the Administrator. the Director of Nursing will be responsible for managing the Nursing Depanment and maintaining an excellent standard of nursing care in a leaching environment. This vacancy is due to the promotion of the present incumbent. Extensive experie..ce administering a complete nursing program. a B.Sc.N. degree and eligibility for Ontario registration are minimal requirements. Preference will be given to applicants possessing a Master's degree in nursing or administration. Please forward your resume to: Sister K. KHvII Hotel Dleu Hospital Kingston, Ontann K 7L 3H6 Applications are invited for Faculty Positions in the following areas Medical-Surgical Nursing Parent-Child Nursing Qualifications: Preference will be given to advanced preparation in the clinical specialties Salary and Rank: Commensurate with education and ex- perience Applications Deadline: February 15. 1979 Fot" further information contact: Miss Kathleen King Dean Faculty of Nursing llniversity of Toronto 50 St. George Street Toronto. Ontario '\15S fA f The Central Registry of Graduate Nurses 411 Eglinton Avenue East Suite 500 Toronto, Ontario M4P IM7 A non-profit organization welcomes candidates for membership in this prestigious group of nurses specializing in general and private duty nursing in hospitals and homes. Telephone for appoimment 483-4306 Registered Nurses Louisiana (two locations) California (close to Los Angeles) Active care accrediled hospitals each have a requirement for four Canadian RN's experienced in crilical care. As the hospilals are only interesled in persons becoming registered aliens of the USA. these positions would be of inlerest to the married RN whose spouse could not obtain a work permit under the regulalion covering the H-1 temporary permit. Candidates must, under Louisiana and California licens- ing, have written AN's in Canada and received marks of 350 in all five discip- lines 10 obtain license by reciprocity. Apply in confidence to W. P. Dow & Associates lid., (a Canadian company), 361 Tenlh Street W.. Owen Sound. Ontario N4K 3A4 (519) 376-6809. Nurses.. . Are you interested in rural extension nursing? There are openings for you in Africa. Or would you like to teach in nursing colleges in Africa, Papua New Guinea or Latin America? Qualifications: B.Sc.N. or R.N. with Public Health or broad general nursing experience. Inquiries are welcome at: CUSO Health-D Program 151 Slater Street Ottawa, Ontario K1P 5H5 as an alternative. . . _ . . CUSO Th. Cen-.llen Nur.. Jenuery 111711 13 ...I - ,. . , - - . ,. - ..___ .....L - -.. ....".,.. _J , J..,. -- ,.. -' . .' .' . .' .' . ... ", -, . " . I.;., .. . ., . , :. ui", .i. Un,., ....... qar ....::.. :..:. I : .-. .... --. ---- --. ---: -. ---. ..- . .-- -- --. --. ;-_. ....-i ...' . . . JL ___ . It... :- . . ,-- ,--: ::=, 1--: ,--, ! 'III!: " ., ". '111i II , . - \ :;;, '. .. .. , . ..... . f 5 I .: w. Jr.""" . ' 'à . ..... .,. ., . , . . . , . - . , .,..... '" . '" . " ,. -J _t .......,. - _ ,_ ,.."I .. --.I" t - 'l!," " .... '"J /oIõIII:... !;;, ""' - ___ .Þ ",. I' _ Ii .... .." --1--< - II . I . - ...-.1...", "- \\-- l +- . 11 ,,"' .... ',' ' , . . . - _ _ '1 _ ': , "1 I"IJI =_ .. - f. You the Nurse. Hermann the Place. Houston the City. ... Imagine This. The kind of nursing you've always wanted to do. Nursing the way it should be.. .planning and implementing patient care in a primary nursing framework that lets you exercise optimum freedom to carry out your professional goals. You've Got The Talent It Takes. Hermann Hospital has im- mediate openings, especially for those of you with specialty train- ing in surgical areas. We'll assist you financially with your reloca- tion expenses. You'll find the salary program for RNs is more than competitive and we offer a comprehensive benefits package which includes three weeks vacation, nine paid holidays, tuition and rent assistance, fully paid hospitalization, and more. It's an offer you can't refuse! Put Yourself In Our Place. We're in the heart of Houston, where the excitment of the arts, outdoors, and nightlife abound in the en- vironment of the city of the future. Compare Houston's cost of liv- ing with other major cities-it's considerably lower, and the state of Texas doesn't have a state income tax. All things considered, Hermann Hospital and Houston are where you've always really wanted to work and live, so now do something about it. Pnmary Teaching Hospital lor the University 01 Texas Medical School at Houston g HERMANN HOSPITAL HOUSTON'S LIFE _.. . FLIGHT HOSPITAL '-:,- , :I An equal opportunity employer, mIl-handicapped Please contact us for more information about our ex- cellent salaries and com- plete benefits package. Ms. Beverly Preble, Nurse Recruiter, (713) 797-3000. AU: Nurse Recruiter 1203 Ross Sterling Avenue Texas Medical Center Houston, Texas 77030 Name Address City State Zip Phone Specific Area of Interest (Circle) RN LVN Student Nurse &4 Jenuary 1179 The Cen..sJen Nur.. Nursing Consultant, Occupational Health: $19,400- $22,100 The MINISTR Y OF LABOUR, occupational health branch. seeks energetic individuals to: provide consultant services in occupational healln nursing to Ontario industries. employees. health and safety personnel. educators. professional and lay groups and government agencies to ensure quality care for employees at their place of work; assist in developing standards and criteria through interviews. research and surveys. Locations: Sudbury (LB 208/78). Hamilton (LB 209178) and London (LB 210/78). Qualifications: registration as a nurse in Ontario: recognized cenificate in occupational health nursing or public health nursing. preferably with a B.Sc. in nursing: at least three years experience in the field of occupalional health and nursing with some supervisory experience: good communication and interpersonal skills: abilily to work independently: willingness to travel. Please submit application or resume by January 26. 1979. indicating area of preference and quoting appropriale file number. to: Personnel Branch, Ministry or Labour, 400 Unlverslly Avenue, 2nd Floor. Toronto. Ontario. M7A IT7 '["his position Is open eejUlllly to men and women. Ontario Ontario Public Service Moving, being married? Be sure to notify us in advance. Attach label from your last issue or copy address and code number from it here New (Name)/Address Street City Prov./State Postal Code IZip Please complete appropriate category o I hold active membership in provincial nurses' assoc. reg. no./perm. cert./lic. no. o I am a personal subscriber Mail to: The Canadian Nurse, 50 The Driveway, Ottawa, Ontario K2P I E2 Index to Advertisers January 1979 Addison-Wesley (Canada) Limited Canadian Dairy Foods Service Bureau The Canadian Nurse's Cap Reg'd Career Dress (A division of White Sister Uniform Inc.) The Central Registry of Graduate Nurses Equity Medical Supply Company Eschmann Canada Limited Famolare, Inc. Health Care Services U pjohn Limited Frank W. Horner Limited Mont Sutton 2 49 13 Cover 2 63 9 50 4 56 54,55 9 TheC.V. Mosby Company Limited NursingJob Fair Pentagone Laboratories Limited W. B. Saunders Company Canada Limited 22,23,24,25 7 57 51 Wellcome Medical Division! Burroughs Wellcome Limited Westwood Pharmaceuticals Cover 4 CoverJ Adt'ertising Manager Gerry Kavanaugh The Canadian Nurse 50The Driveway Ottawa. Ontario K2P 1 E2 Telephone: (613) 237-2\33 Advertising Representatives Richard P. Wilson :!l9 East Lancaster Avenue ArdmOl;e, Penna. 19003. Telephone: (215) 649-1497 Jean Malboeuf 601. Côte Vertu St-Laurent. Québec H4L lX8 Téléphone: (514) 748-6561 Gordon Tiffiri 190 Main Street Unionville. Ontario UR 2G9 Telephone: (416) 297-2030 Member of Canadian Circulations Audit Board Inc. mEE1 Before you try the Alpha Keri *jKeri * Lotion Moisture System on your patients, try it on yourself. Experience for yourself the soothing. moisturizing qualities of Alpha Keri. Bath Oil or Keri' Lotion. Simply place two capfuls of Alpha Keri in your evening bath. and feel the difference the emollient oil makes to your skin. Alpha Keri cleanses without the need for harsh drying soaps. In the morning. massage super-rich Keri Lotion into hands. legs. and problem dry areas. Your skin will feel softer. suppler. more resilient. and initating itching will be relieved for hours. The same benefits apply to your patients. of course. Alpha Keri and Keri Lotion are indicated for all dry. pruritic skin conditions and may help prevent skin breakdown and the possible fonnation of decubitus ulcers. And bed bathlOg's never been simpler. Just add Alpha Ken to water and gently wash the patient. Soaping and rinsing are unnecessary. so you save time and steps. Actions speak louder than words, and we'd like Alpha Keri and Keri Lotion to speak for themselves. In a special offer to the profession only, a 56 ml size of each will be sent to any nurse who sends her name and address, and 25(; to: The Moisture System, P.O. Box 1538, Belleville, Ont. K8N 5J2 J "r.. A In UN< WESTWOOD PHARMACEUTICALS BELLE\.' LLIE ONTA"'O KeN SEI I "- 'I . "\.- --- l I , Ii 'n ., )t Ie an . J \hlh.t - J ,-- )to ri Ai'E o Nature gives it. " Zincofax* keeps it that wa After every bath, every diaper change and in between, soothing Zincofax protects baby's nature-smooth skin. Protects against chafing and diaper rash, against irritation and soap-and-water overdry. But Zincofax isn't just for delicate baby skin. It's for you and your entire family-to soothe, smooth and moisturize hands, legs and bodies all over. \Vhat's more, Zincof.n.. is economical, even more important now with a new baby at home. ,- , " -.. ,f' .\ \. " \ - "' \ 4"- .... , Zinë'ofa l FOR BABV'S SIC,II keeps a family's smooth skin smooth ---- ..-- .. 5111 ...---- . a '..,} - ø ....Zincofa)( FO ø . Contains Anhydrous Lanolin and 15% Zinc Oxide. Available in 10 and 50 g tubes and 115 g and 450 gji\cs. I Wellcome Medical Divisio Burroughs Wellcome ltd. laSalle. Qué. . Helping mothers when babies cry . How to make sense of the metric muddle . Understanding the physiology of pain . Preventing cross infection on a pediatric ward . Nurse practitioner in a community college setting The Canadian Nune FEBRUARY 1979 r .< } ), ' , 4>- " , . \,' . ... . - , yet both contain the same number of molecules i.e. 6.025!.1 molecules. Does it matter? Yes. because medicine is usually concerned with the concentration of substances in physiological fiuids. The relation!> between these 'iub'itances are more obvious when measured on the basis of their relative number. For example. consider the following laboratory results: Cholesterol Urea S.1. llnit 12.16 m mol/I 6.46 m mol/l Present 250 mg/IOO ml 73 mg/IOO ml Unit Looking at the results expressed in mass units (milligrams per 100 millilitres>. you would think that there is over three times a much cholesterol as urea. The molar units (millimoles per litre) however. show that there are twice as many active particles (molecules) of urea as cholesterol. Drug dO'iages expressed-Ïn moles rather than weight became more logical. At present. there is confusion when a doctor orders 10 mg of morphine. Does he want 10 mg of morphine sulphate, which contain only 8 mg morphine. or 10 mg of active morphine? Using Slone mole of morphine, or morphine sulphate, contains the same quantity of morphine. Potency between harhiturates ordered by mass do es Cdn only be compared after consultation with the memory or the drug manual. Molar doses. however. allow a direct comparison of potency because we are dealing with the relative number of molecules. As Canada "goes metric", nurses can expect to meet the SI units in their 1 metre þ f'. · J .,' -- \, .' L . ) '""" 't decimetre 1 1õõ metre centimetre 1 1õõõ metre millimetre I . SUBMULTIPLES Or reduced to sub-multiples often T able two Some Derived 51 Units Physical Quantity Name of SI Unit Symbol Definition of SI Unit Volume Cubic metre - m 3 Force Newton N kg m S-2 = Jm- I Pressure Pascal Pa kg m-' S-2 = Nm- 2 Work Joule J kg m 2 S-2 = Nm Power Watt W kg m 2 S-3 = Js- 1 Surface tension Pascal metre - Pa m = Nm-' = kgs- 2 Periodic frequency Hertz Hz S-1 Elementary entities mav be atoms. ions, electrons or anv other identical particles - e\'en marbles. even marblese l : \ . . p. . - 025 X 10 23 :i J.w- m8rbl -'" '- : .. ; e.. '< - --- - --- -- op'- -- o , ... ... -- - '" ., -- :;K Th. Can-.llen Nurae F.....u.ry 1 '71 21 . . . or grains of sand "--.... 6.025 10 23 1 grains one mole " ... "r . ) . I .' 6.025!' identical grains of sand may be described as one mole of sand Table three 81 Prefixes Fraction SI Prefix Symbol 10. 2 tera T 10 9 giga G 10 6 mega M 10 3 kilo k 102 hecto h 10 deca da 10- 1 deci d 10- 2 centl c 10- 3 milli m 10-<; micro p. 10- 9 nano n 1O-t! pico P 10-1 femto f 10- 18 atto a A mole of cholesterol weighs 386 grams and a mole of urea weighs 60 grams. Very different weights yet both contain the same number of molecules . . 1 mole UREA 1 mole CHOLESTEROL m !t . ..... . . . . ......... '" .... ..... .. ... . . . . . ...... . .. . , ... ... ..!Þ...... · ..... ; ....... 386 ..... ..:.. ..... >. .. ..... 'f!....... ........, . ..........." .. .......... . ........ . ... e r ..!àY - different weights -same number of molecules practice. The major changes will be the introduction of the pascal as the unit of pressure and the mole as the unit of amount of substance. The short history of our customary units of measurements should have convinced you ofthe need to adopt a more logical system. Although it is natural to feel initially clumsy in our attempts to master the SI units. the effort to do o should be repaid by the increased understanding of the relationships between pressures. now expressed in a variety of units, and between the relative concentrations of substances in physiological fluids. Epilogue When I showed a draft of this article to Jane and Maria to find out what they thought. Jane sighed. "I still don't like the idea. It might seem logical to you, but I'll never remember all that." "At least the children are growing up with it." said Maria. "but I"m too old to grasp all those tens to the minus some number prefixes." Which only goes to show that no one likes changes! But they are coming! 'iii Bibliography Black. Gerald J. Thinking metricfor Canadians, Toronto. Doubleday, 1975. Hill. D. W. The application ofSI units to anaesthesia,B r.J.A naesth. 41:1053-1057, Dec. 1969. Karnauchow, P.N. Experience with SI units in biochemistry, by... and L Suvanto. Canad.Med.Ass.J. 114:6:533-535. Mar.20, 1976. Qulton. John L Systems of measurement: their development and use in medicine.Canad.Anaesth.Soc.J. 23:4:345-356, Jul. 1976. Padmore. G .R. SI units in relation to anaesthesia. A review of the present position. by... andJ.F. Nunn. Br.J.Anaesth. 46:236-243. Mar. 1974. Jennifer Craig is a graduate of the GeneralInfirmary at Leeds, Englandand obtained her B.S.N. from the V nh'ersity of British Columhia in /976. She is currently a graduate student in the Faculty of Education at the V nil'ersitv of British Columbia. Gordon Page, Ed.D. is the Director, Division of Educational Support & Del'elopment in the Health Sciences, V.B.C. Both authors were im'olred ill the production of a slide-tape show ".r.,Jediametric s". The artist was Bruce Stewart. Photographs of his originals are included with this article and are used with the permission of the Department of Biomedical Communications. V.B.C. Copies of the slide-tape show are obtainable from this department. 22 Febru.ry 1171 The Cen.dl.n NUrH 'st . . criSIS , Theresa O'Neil Three months have elapsed since the pathology report came back following the surgery I underwent to excise a molefrom my right knee. The verdict: malignant melanoma, class Ill. What follows is an attempt to give you some idea of what it's like to be "on the other side of the fence" - a family practice nurse one day, a patient suffering from what could be a life-threatening illness the next. It is based on a diary I started at the suggestion ofafriend, a staff doctor who thought this might be. a way for me to let off steam and relieve some of the tension during the ordeal ahead. My diary begins afew days after I received the news of the pathology report. Some of my comments and impressions are not flattering. I trust that these remarks will not be construed as being directed against anyone hospital or against individual staff members but will be understood to focus on the health care system in general. I believe that, as health care professionals, we have a tendency to get caught up in our desire to keep the system operating smoothly; when this happens it is easy to forget about the needs of the individual patient. I hope that, as you read about my experiences, you will see what I mean. , " \ '- , , . . The Cenedlen Nu... F....ry 1171 23 I finally found the courage to seek medical advice about the mole on my right knee following a holiday visit to the South. The mole had been there for two years but lately had shown signs of changing in size and texture. I am not sure now whether my reluctance to have it looked at was caused more by fear of the actual surgical procedure or by the possibility of a positive pathology report ...1 think the latter. A few days after the mole was removed my suspicion was confirmed with a positive report. I t is interesting how one reacts in a crisis. The report that I had been half expecting was now a reality and yet I refused to believe it. What a strange feeling: I felt numb all over, like a zombie but my mind was racing. "My God, I am going to die! I will not let them take my leg - whenever I go. it is going with me." And then the denial. "I am not going to die. I'm too healthy. " I remember the doctor who had a mole like mine removed a couple of years ago. He is doing fine. just like I will. But. I also remember the young seminarian who had one on his finger- a young, healthy guy, dead two years later. "Oh God, please don't let me die!" Telling my family was difficult. The two people I expected to be overcome by the news were my husband and my mother but, instead, they became my strongest supporters. I did not realize how much my husband meant to me until I was faced with a life-threatening illness or how much I needed him and appreciated the fact that he was there. The following morning I saw the plastic surgeon who assured me that the picture was not as black as I had thought My chances of a complete recovery were good. I was booked for a wide excision and skin graft - something I did not question. Just get it over with so I could be a whole person again. The weekend was long and full of anxieties. The thought of spending the next few weeks undergoing scans, X-rays, blood work and surgery was pretty frightening. This was one road I had to walk alone. I seemed to swing from high to low. I suddenly realized that I had not shed a tear since receiving the bad news. I was experiencing fear and anxiety but I had to admit that I was also enjoying the attention I was getting. That sounds morbid, doesn't it? I began to wonder why I was saving my money for a future that might never happen: the concern of providing for my senior years was suddenly lifted from my shoulders, rather a pleasant feeling. I found the role change very difficult. I became judgmental of all health care workers: some were good, others were not. Before the liver scan, the doctor in charge of nuclear medicine talked with me. His first request: "Tell me what you know about your problem." This seemed to me to be a very sensible approach: a doctor who makes sure that his patients are knowledgeable must care about what happens to them. Liver scan negative. One more check mark on the wall. While being scanned, I listened to the staff talking about their personal lives - parties, the budget, vacations. etc. I wanted to scream "Hey guys, get on with it-I've got a malignant melanoma." The next hurdle was the Gallium scan. "Iff get negative on this, I am home free ... I think!" Then there was a misunderstanding: I was booked for a lung scan instead of a full Gallium scan. I refused to leave until I got my full scan. Following the scan, I was ushered into another doctor's office. His message was clear: "Just because the scan was negative does not mean that things are all right: secondaries could appear any time. " On a scale of one to ten. he rated only one in my books. Was I becoming over sensitive? My family doctor gave me the same message but with a lot of reassurance and support. I appreciated his sensitivity and honesty. One doctor appeared tuned in to the technical procedure of the scan, while the other was aware of his patient's anxiety and need for reassurance. Both scans and chest X-ray were negative. Just the surgery to face. A few days prior to my surgery, my hus band and I were invited to a party. Everyone at the gathering had heard of my illness. They seemed disappointed when I assured them that things were looking very positive. Did I imagine this, or is it a quirk of human nature to always look for a little excitement to relieve the monotony of everyday life? I don't know. In hospital I entered hospital on a sunny and unseasonably warm April day. The nurse who admitted me took a detailed history using questions recited from an admission sheet. An hour later the whole procedure was repeated by the resident in plastic surgery. The big day arrived and after receiving Communion, I made my way to the Chapel. How easy it is to pray. and how near we feel to our Maker when the chips are down. I hope I will have as many prayers of thanksgiving when this IS over. The O.R. supervisor was very supportive and stayed with me until I was asleep. By mid-afternoon I was back in my room with a painful knee and hip (donor site). Now I began to find out what "routine nursing care" is all about. How different it is to be on the other side ofthe fence. An hour after my return, my "full fluids" supper tray arrived. Although I protested vehemently, I was urged to consume the contents of the tray so that the [. V. could be discontinued. The chicken soup did not taste any better coming up than going down. The I. V. was discontinued the next day. At 10.00 p.m. I had my Demerol and my vital signs and dressings were checked q4h for 48 hours but, somehow, I found the human element missing. Routine postoperative nursing care was carried out with unfailing accuracy; but good nursing care, where the needs of the patient rather than the doctor are met, seemed to be missing. Postop patients are wakened and checked at 2.00 a.m. and again at 4.30 a.m. (6.00 a.m. is too late to get charts done and report ready). It is unfortunate that the comfort of the patient cannot be allowed to interfere with hospital routine; 4.30 a.m. is an unreasonable hour to wake postoperative or any patients, for that 24 Febru.ry 11171 The C.n.dlen Nur.. matter. starting their day with vital signs, bed pans. medications. ice water. and blazing lights. I was reprimanded for changing my mind about the need for pain medication the first postoperative night: I did not let it happen again. Medical and nursing staff advised me that it was important to keep the donor site (left hip and buttock) dry to prevent infection but they did not tell me how thi" should be done. On the second day. I was the one who suggested to the nursing staff that a pillow at my back would keep my weight off the donor site. a simple nursing procedure thaI the} had overlooked. Today our profession is tuned to producing a more sophisticated style of nurse. We use Standard Care Plans and Problem Oriented Records - both important tools in implementing good nursing care - but do we sometimes neglect our patients because we are too busy implementing these tools to find out what their needs really are? I hope that the nursing profession is on the right track but I must admit that sometimes I am concerned. When I was a patient it wa" difficult for me to discard my role as a nurse. I was experiencing intense physical and emotional trauma: my knee had been mutilated during the course of treatment for a life-threatening disease. Nevertheless. the only problem the student nurses' clinical supervisor chose to deal with was constipation. That nurse and her students missed an invaluable nursing education experience. My next hurdle was the pathology report following surgery. Again, the report was negative. Everyone was oveljoyed but instead of uttering a prayer of thanksgiving. my initial reaction was "My knee wa mutilated for nothing." I could not help wondering if the surgery had really been nece sary. Should I hdve gambled and lived with the initial mole removal? What would my chances of urvival have been? Who decides how radical an excision to make. and why? What percentage of reports come back positive following surgery? How are these positive reports brolo..en down into classes (1.2,3.4.5)?The questions I should have asked preoperatively were suddenly now going through my mind. Had the operation really been neces ary? Was I being ungrateful? I had so many questions and yet I found it difficult to voice them because I did not want to hurt the people who had been kind to me. A nurse clinician brought me back to reality. She made me realize that I was looking at things from a selfish point of view. I have a husband. four lovely children. and a mother who would not want me to gamble with my life. I o\\ed it to them as well as myself to take no chances on allowing the malignancy to spread. Going home On the tenth day. I was discharged from hospital, complete with leg splint and crutches. A week later I was aI/owed a tub bath - a treat that proved to he a very humbling experience. Standing naked in front of my husband with m} imperfect body, waiting for him to help me in and out of the bath. I realized how completely dependent I had become. This dependency has drawn us closer together and now we feel that we have both experienced real emotional growth over the past three months. Over the next month I gradually shed my splint, the dressing, the tensor bandage and elastic stoclo..ing. A new me emerged. At first the graft was rather tight. making climbing stairs difficult and painful for me. but through perseverence and determination I have mastered that obstacle. Small car are still a problem but that too is being overcome. Dre"s styles are longer now so dressing is no problem. I have been wearing slack" rather than shorts and I have bought a new bathing suit that I plan to wear on vacation. I have accepted my body the way it is. If people are "hocked at the sight of my knee, I realize that the problem is theirs and not mine. On thinking it o\er The past three months have given me a whole new perspective on life. I have become more aWdre of my own mortality, of the significance of each day. of the love offamily and friends. I discovered too that a temporary role reversal can be a positive experience. enabling us as health profes"ionals to understand the fears. frustrations and anxieties of our patients and their families during a crisis situation. I have come to realize, also, that a crisis like this can lead to emotional growth and can strengthen the bonds among family members. As nurses. we must put the needs of our patients at the top of our list of priorities. We must make sure that. in our zeal to develop and implement educational tools and to keep the system running smoothly. we do not lose sight of the patient. .., Author Theresa O' eil recei,'ed her R.l\'. from St. Mar...'s Hospital, Montreal and a B.Sc.N.from St. Thomas UnÌl'er.rity. N.B. She jpent the first fell' years fol/oll'ing graduation in Oh.rtetrical Nurs;,,!!. After raising afwnily, she became illterested in Family Practice Nursing llnd has spent the last ten years a,r Head Nurse in St. JÇJ,reph's Hospital Family Medical Centre, London, Ontario. Theresa is a clinical lecturer with the Department of Family Medicine, U ni"ersit\. of Western Ontario and has spent part of her time coordinating an In,ren-ice Education Programme for Family Practice Nurses wor!..ing within tlU' Department ofF amil\' Medicine. .. Th. C....-.lI.... NUrH Februery 11171 25 41 nurse practition r in a community college setting The Health Clinic at Mohawk College of Applied Arts and Technology in Hamilton, Ontario is many things to many people. For some, it is a first aid station for injuries, accidents and burns; for others, it functions as a community health center with a part-time physician; and for still others, it provides a listening ear and a place to seek advice and information on health-related matters. AU in all, it is a great place for a nurse practitioner to work. . - ..... I '""'II .... . ... \ . L' <.. J\1 " . ... e .... I I \. -\ . Diana Nelles . . We hm'e a man 111 the boo!.. store in diabetic comu. we thin!.. - please come down. " "C ome quickl\'. a student is hm'ing a com'ulsion and I think he dislocated his shoulder when he fell. .. "C un I come in for the morning-after pill?" These are just a few of the situations I encounter in the course of my work as a nurse practitioner in a community college health clinic. As you can imagine. the health clinic, serving a population of 5.000 students and staff is a busy, active place. Not only does it serve as a primary first aid station in cases of injuries and accidents, but also functions as a community health center with a part-time phy!.ician on staff. Because of the variety of services I am called upon to provide. I have an excellent opportunity to use my skills as a nurse practitioner to their fullest potential. At time!. this includes the role of first aid attendant, occupational health nurse. health counselor, classroom teacher and drug information giver. I am able to dispense drugs. prescribe treatment and perhaps. most important of all. to teach health education at a primary level. Health teaching, preventive medicine, health counseling and drug information are a very important part of my role. ... -- , .. The NP-Physician Team At our clinic, the family physician is present three mornings a week. Generally, I do the initial assessment of all patients who come to the clinic unless an appointment has been arranged previously to see the doctor. This is a good opportunity for me to explain my role to clients and to emphasize that it is not always necessary for them to see a physician for minor complaints. In this kind of arrangement. the nurse practitioner and the physician must work as a team in order to give the best care possible to the patient. Because the nurse is functioning in an expanded role, the physician mu!.t trust the nurse's judgment and the nurse must know her own limitations and when to seek advice. 2e February 1171 The Cen.dlen NUrH The nurse must be confident that the decision she makes in assessing a patient is the right one. Open, honest communication between nurse and physician ensures good patient care and minimizes legal problems that might develop. The following examples show the nurse practitioner-physician team in action. . A number of young female students come to the clinic to have a well-female examination. I initiate and complete a history including social and family history, past illnesses and allergies. Blood pressure, weight and urinalysis are followed by a pelvic exam, pap smear and vaginal culture. A demonstration of a breast examination and a discussion on birth control is also included. Ifthe . For the protection of both the patient and the nurse, the doctor must be present for allergy injections. Even though the nurse gives the serum, the physician must be in the vicinity. In the past, we have experienced two serious reactions, and medical treatment was immediately available. . The treatment of first degree bums, removal of sutures, syringing of cerumen from ears (after examination by the doctor) and treatment of abrasions and lacerations are all taken care of by the nurse, the physician being notified in case of infection or abnormalities. . As a team, we have also given lectures to classes in the college on subjects such as birth control. communicable diseases in children and "recognizing the sick child". . \ Although some clients may have had ba<;ic sex education in school. many of them have a poor knowledge ofthe reproductive system and birth control. Some clients have never had the opportunity to discuss this topic with a medical person . Young women, in particular, often reluctant to visit their family doctor because he is a "friend of the family". seem more at ease discussing birth control in the accepting atmosphere of the clinic. Maria, a 22-year-old student, is a good example. She was waiting at the health clinic one morning when it first opened and was obviously distraught and very agitated. After I brought her into the office and she calmed down, we talked about what was troubling her. She was convinced that she had become pregnant the - ;-... :, ...... - f L .-.:::--. , >. I I-.! I ... -4 , \- I ,.. .> ---Þ - - "." . I J--, J I ..... '-, o patient wants some form of contraceptive, this is discussed, as well as any problems or concerns the patient may have in this regard. This kind of assessment and teaching forms a large part of the nurse practitioner's role. If the patient wishes to take the birth control pill, she is seen by the physician. The patient can drop in any time later to discuss any problems regarding the birth control method she has chosen. . Pre-employment physicals and immigration physicals are done by the nurse practitioner. This frees the doctor's time for more serious medical problems. However, if! suspect an abnormality or if! am concerned about any aspect of the examination, the physician is notified. The Clients Because the clinic is conveniently located on campus, it is well utilized b} staff and students alike. On the average, 40-50 patients a day come to the clinic with the physician seeing about .-:!O patients each morning she is in. The majority ofvisih are made by students who range in age from 17-25 years. Many of them do not make appointments, but drop in to discuss particular problems they are having. Students in this age group often have concerns about: . birth control . urethritis . venereal disease . obesity . acne . sexual problems. previous night. However, as we discussed the situation, she reported that she did not have intercourse with penetration and there was no ejaculation. Maria came from a strict I talian family and had been very protected. I reassured her about her concerns but she refused to believe that she wasn't pregnant. I saw Maria in the clinic every morning for two weeks after this incident and discovered how uninformed she was about all areas of sexuality and her own anatomy. During that year, health teaching and counseling gave Maria a more healthy and realistic attitude towards her own sexuality and gave her enough confidence to break through some of the restrictive bonds at home. The Cen-.llan Nurae Februery 1171 71 Often. younger girls seek guidance in a group. rather than act alone - a great chance for health teaching "en masse" . Students from out oftown use the clinic as their "family doctor" and often come to the health center for minor ailments. But those with chronic illness. such as hypertension. epilepsy and renal disease also drop in to talk over the problems they may be having with medication and their side effects. If these patients have their own family doctor. I always refer them back to their physician for follow up. Foreign students are another group who are often anxious about their health and who may be homesick. In many instances. they have no knowledge ofthe resources available to them. As a nurse. , I I Because the clinic is so convenient. staff members who might not otherwise find the time to go to their family doctor. drop in to the clinic. A good example of this is Miss D., a 42-year-old faculty member who visited the clinic because she had detected a lump in her breast. She had seldom visited a doctor since she had always been in excellent health and she was reluctant to do so even now. When I examined her. I could feel a hard mass approximately 3 cm in diameter under her left breast. We talked over the implications of this finding and she agreed to go to a surgeon. Subsequently. she had a left mastectomy. That was eight years ago. Today, she is functioning well, is still teaching and continues to come to the clinic for .. J Conclusion Case studies like these show that a nurse practitioner in a community college health service can provide primary health care to a large student and staff population. In a collegial relationship with a physician, the nurse can use her skills and judgment to assess patient problems and to initiate treatment in the shortest time possible. Health care costs are reduced, and good preventive and follow-up care in the form of counseling and teaching is stressed." ... . J '" r-... ,. \C' :J. ' .:: t, \t . \ . . , - "" \ .,) I am able to provide them with some support and guidance in many aspects of day to day living. The Ontario Health Insurance Plan covers all visits to the doctor in the clinic and students without OHIP are treated free of charge. There is no charge for visits to the nurse. Of course. staff also utilize the services of the health clinic. For example. in the role of an occupational health nurse. I am responsible for attending to employees who sustain injuries on the job. for maintaining accurate health records and initiating workman compensation claims. Employees with drug and alcohol problems and/or those whose absenteeism has become a problem, are interviewed and counseled with subsequent programs initiated. periodic checkups. The convenience of the clinic for clients was evident on another occasion. Two days before Christmas. two female employees, aged 22 and 24. came to the clinic and expressed concern that a co-worker had German measles. Both women had missed a period and suspected that they were pregnant. They were unable to contact their doctor and the college physician was also away. I completed pregnancy tests on both women, and both were positive. The patients were sent to the lab for a rubella titre and fortunately had levels higher than I :8. The tests were completed along with results in less than a day. and a worried Christmas was avoided. Eight months later, they delivered normal. healthy babies. Diana :\Telles (R.N., Hamilton General Hospital; Diploma in Primary Care Nursing, McMaster Vnil'ersitvj is the Supervisor of Health Services at the Fennel/Campus, Mohawk College of AppliedArts and Technology. Diana has worked at the College for the past ten years and prior to this time worked in an emergency department and in a physician's office. 2e February 111711 The Cen-.llan Nur.. Understanding the physiology of Anne H edlin Dr. J. Dostrovs/"y Wherever you work, you encounter patients with pain. These patients expect you, as a nurse, to relieve their pain. Knowing about the physiological and. emotional components involved can give you a better understanding of patients' reactions to pain and how you can help. Virtually everyone has experienced pain of varying intensity and duration but no one has yet been able to provide an explanation for the phenomenon of the pain sensation. Many puzzling questions can be raised about the mechanisms involved in the experience of pain. For instance. why is it that a severely injured person does not necessarily experience pain? How is it possible for Indian fakirs to walk on red hot coals or lie on a bed of nails without evidence of discomfort? Why is the needle prick of an injection absolutely dreaded by some but accepted calmly by others? How can there be pain when no evidence of physical injury can be located? Why does the leg-amputee complain of pain in the amputated limb? The failure to discover satisfactory answers to these and other questions is not because of a lack of interest. Not only is "pain" the subject of intensive, world-wide research, but medical and nursing personnel devote much time and effort to alleviating pain resulting from disease, accidents and surgery. Although answers cannot be provided for all questions about pain. certain facts are recognized. Pain stimuli In order to experience a sensation- whether it be visual, auditory, heat, cold or pain - impulses must be generated by a specific stimulus and then transmitted along a specific pathway to a particular area of the central nervous system. For example, impulses that cause a painful sensation arise from stimuli which have the potential to produce tissue damage. ([he exception to this rule is found in some abnormaJ or pathologicaJ states in which pain can result without evidence of noxious or tissue damaging stimuli). These painful stimuli activate specialized nerve endings which respond only or primarily to these stimuli. Other nerve terminals found in the same tissues are activated by non-painful stimuli such as hair movement, vibration or cold. The nerve fibers that transmit the pain signals to the brain are of small diameter and have conduction rates of about 0.5 to about 30 metre/second. They can be divided into two groups, the A b fiber group and the C fiber group. The A B group, composed of nerve fibers .Myelin - the fatlike substance forming a sheath around certain nerve fibers. which are myelinated.. conduct impulses more rapidly than do those of the unmyelinated (' fiber group. This fact may contribute to a dual pain sensation in many instances. i.e. an initiaJ sharp, pricking. well-localized sensation followed by a more prolonged. well-localized, burning type of pain. The latter. which is generally more unpleasant, is mediated by the C fibers. Transmission of pain impulses Pain fibers travel together with other sensory fibers in the peripheral nerves such as the sciatic nerve and enter the spinal cord via the dorsaJ roots (or the trigeminal nerve for pain impulses from the face). As illustrated in figure one, these fibers terminate in the superficial dorsal (posterior) region of the spinal cord. Here, they excite neurons whose axons cross to the opposite side of the spinal cord and travel up to the thalamus by way of the anterolatera.l regions of the spinal cord in the spinothalamic tract. Pain impulses go primarily to the midline region of the thalamus. However. it is not known whether pain is perceived by activation of specific thalamic pain neurons or whether it is relayed to the sensory cortex where all other senses are perceived. Some fibers originating in the spinal cord enter a dense network of interconnected nerve fibers in the brain stem, caJled the reticular formation. It is believed that this region also plays an important role in The Cen-.llen NUrH F-..ery 11171 21 MIDBRAIN Nucleus ot Tnge,mna. Spln.1 Tract MEDULLA Reticular Fonn.'tOn Figure one Pathways for impulses from peripheral sel1sory neurons and the trigeminal nerve (V cranial nerve). Synapses occur in the substantia gelatinosa of he spinal cord and in the thalamus. Collaterals connect these ascending neurons with the midbrain reticular formation. the sensation of pain. But pain is not simply a sensation, it is an unpleasant sensation. This fact imparts a distinctly different quality to pain and distinguishes it from other sensations such as hearing. touch and smell. As indicated by Melzack in The Puzzle of Pain. it "motivates or drives the organism into activity aimed at stopping the pain as quickly as possible. To consider only the sensory features of pain and ignore its motivational-affective propenies, is to look at only part of the problem" . I The thalamus and cortex are the main structures involved in pain and other sensations. Other brain regions are also involved, in what can be classified as the motivationaJ-affective dimension Figure two Olfactory Bulb A diagram including the limbic system and related structures which make an important contribution to the motivational-affective dimension of pain. A-amygdala. M-mammilIary body, S-septum, TN-thalamic nucleus. - of pain and are believed to include both the brain stem reticular formation and the limbic system. Exactly how pain influences these regions is not clear. The reticular formation, which receives input from ascending pain pathways, has connections to most brain regions including the structures ofthe limbic system (figure two). The limbic structures, together with the hypothalamus. are believed to mediate emotional behavior. Evidence of this has been demonstrated by frontal lobotomy. Severing the connections of these structures with the frontal cortex can produce relieffrom pain but at the expense of profound changes in emotional behavior characterized by a marked reduction of emotional responsiveness. Experimental stimulation of amygdala. hippocampus and hypothalamus. has been shown to induce behavior which is otherwise associated with painful stimuli. Thus. behavior in response to or in anticipation of noxious stimuli is believed to be mediated by the limbic system and such structures as the hypothalamus, thalamus and midbrain reticular formation. The type and extent of cerebra! cortex involvement in the experience of pain is unknown. Certainly impulses do reach the cerebral cortex but no specific area of cortex can be identified as a "pain center". Perhaps the cortical contribution is one of cognitive activity. Factors such as the influence of an individual's cultural background. attitude to unpleasant experiences. emotional stamina, tendency to be influenced by suggestions etc. could be fed back from the cortical regions to the thalamus, limbic system or brain stem and could modify the experience. This could account for much of the individual variation in response. On the other hand, the cortex may be involved in localization of pain rather than in mediating the motivational-affective dimension of pain. Each area of sensory cortex receives impulses from a specific cutaneous region and therefore the origin of the impulse can be identified. In addition to the modulation.. which may occur in the brain, it is known that pain transmission to the brain can be influenced in the spinal cord. The gate-control theory proposed by Melzack and Wall (\965) suggests that the dorsal horn cells act like a gate which can regulate the transmission of impulses to higher centers in the central nervous system. Whether the gate is open to alIow pain impulses through or closed to inhibit impulse transmission depends on (a) the relative amounts of input from the uModulation - alteration of response. 30 F.bruary 1171 The C.n-.ll.... Nurae large non-pain transmitting fibers (e.g. touch) and the small pain fibers and (b) on inhibitory impulses descending from the higher centers. Higher centers which may be involved include the midbrain reticular formation and the cortex, especially the frontal cortex. Through memories of painful experiences, emotions and preoccupation with other activities, these centers may exert considerable control over the central transmission cells of the spinal cord. A modification of Melzack and Wall's schematic diagram of the gate-control mechanisms is presented in figure three. Opiate receptors For many years treatment of pain has relied heavily on analgesic preparations, the most effective agents being morphine and morphine derivatives. In the past few years, there has been great excitement in the field of pain research following the discovery that the brain possesses specific receptors for morphine and moreover that the brain produces its own morphine-like compound. The receptors. known d" opiate receptors, exist in high concentrations in certain regions of the brain and spinal cord in a distribution that suggests a close relationship with Morphine-like compounds called enkephalins have been isolated from brain tissue. Relatively high levels of these substances are found in the frontal cerebral cortex, medial thalamus, hypothalamus, amygdala and periaqueductal grey matter. In addition to the enkephalins. other endogenous morphine-like compounds, endorphins, have been isolated from the pituitary gland. The endorphins are fragments of the pituitary hormone, B-lipotropin. Both enkephalins and endorphins exert an analgesic effect. It is proposed that they act as neurotransmitters (chemical substances which mediate impulse transmission at synapses) in pathways concerned with pain modulation. This inhibition may be effected through binding to opiate receptors. Electrical Stimulation Recent experiments have shown that electrical stimulation of the periaqueductal grey matter can produce analgesia. This technique is now being used in a number of hospitals around the world to treat severe chronic pain. which cannot be treated by conventional methods. Stimulation of the brain stem activates some of the pathways that Descending Inhibitory Pathways To Thalamus ---< excitatory synapse -of Inhibitory synapse ...... inhibitory mterneuron Hgure three A modification of Melzack and Wall's schematic diagram ofthe gate control mechanism. Stimulation of touch fibers and impulses from higher centers can inhibit central transmission cells and therefore prevent (close the gate to) central conduction of impulses by pain fibers. the pain pathways. In the brain. the areas of high concentration are: the amygdala, thalamus and hypothalamus (structures concerned with the motivational-affective dimension of pain) and the periaqueductal grey matter of the brain stem. In the spinal cord and trigeminal nucleus. the area of high concentration is the substantia gelatinosa. It is believed that morphine produces analgesia by acting on the opiate receptors found in these areas. morphine activates. The brain stem neurons, which have axons extending down to the spinal cord dorsal horn can intercept and block the transmission of pain impulses from spinal cord to the thalamus. Further investigation of the anatomy and physiology of these endogenous pain inhibitory pathways could lead to the identification of better methods of activating the body's own analgesics and thus could provide more efficient treatment of pain. Nursing implications A wareness of the fact that there are several dimensions to pain is especially important for nurses. The absence of a physical basis for pain does not eliminate the possibility of an experience of pain; motivational-affective dimension through emotions, e.g. anxiety and fear, can aggravate and enhance the painful experience. Psychological needs of the individual such as a need for attention can also contribute to the presence of pain. Attitudes toward pain vary greatly and may be influenced by ethnic background. Some believe that complaining of pain is an admission of weakness while others do not hesitate to display their suffering. Maximum use should be made of the inhibitory influence of higher centers. For example, procedures which can divert the patient's attention from the painful stimulus such as back rubs, conversation etc. can be used as a supplement to pain relieving measures. The scope ofapplication of the growing knowledge of pain is enormous and. for nurses. an area that they cannot afford to ignore." Anne M. Redlin (8.S c.N., University of Saskatchewan; M.Sc., Uni 'ersity of SasJ...atchewan; Ph.D., Physiology, University of Toronto) is a research associate in the department of physiology and a lecturer in the faculty of nursing at University ofT oronto. She has had experience in general duty nursing, public health nursing and nursing education. A nne has published numerous articles, on blood coagulation and bloodfibrinolysis, her main area of research. Dr. J. Dostrovsky(M.Sc., University College, London, England; Ph.D., V niversity ofT oronto) is an assistant professor in the physiology department at the U nh'ersity ofT oronto. His main area of research is the . neurophysiological basis of pain. References I Melzack. Ronald. The puzzle of pain: re 'olution in theory and treatment. New York, Basic, 1973, p.93. Bibliography Fields, H. L. Brainstem control of spinal pain-transmission neurons. by... and A.I. Basbaum.lnAnnual review of physiology. Vol. 40. Edited by Ernest Knobil et al. Palo Alto. Ca, Annual Review. 1978. p.217-248. Melzack, Ronald. Pain mechanisms: a new theory, by... and P.O. Wall. Science 150:971-979, 1965. Snyder, Soloman H. Opiate receptors and internal opiates. Sci.Amer. 236:3:44-56. Mar. 1977. ., The patient in pain: handling the guilt feelings Gillian Doherty Nursing a person suffering chronic or prolonged pain is a draining experience often associated with feelings of guilt. Learning how to handle these guilt feelings in a way which is not harmful to the patient or to herself is one of the hardest tasks a nurse has to face. A nurse's training emphasizes her duty to relieve suffering. Therefore it is not '\urprising that few situations cause a nurse to feel more of a failure than caring for a per,>on whose pain she cannot alleviate. Being unable to relieve pain is frustrating and, as psychological research has demonstrated, frustration often turns to anger at the object or person perceived as responsible, The anger reaction towards the individual whose pain will not go away usuall} causes the nurse to feel guilty. I f the failure-fru'itration-anger-guilt sequence is repeated several times in connection with one particular patient. then the nurse begins to associate that individual with unpleasant feelings. In order to not have to face the di5comfort that this patient evokes in her the nurse may begin to avoid him. This avoidance often originates subconsciously as an attempt to screen out unpleasant reality. in this case failure to alleviate pain and the associated guilt feelings. As long as the nurse does not see the patient she can believe he is no longer suffering. However avoidance rna} not be successful and may actually increase the nurse's feeling of guilt when she realizes what she is doing. How can the nurse constructively handle the feelings that are aroused in her when she cares for an individual whose pain she cannot alleviate? The first requirement is that she face the fact that in some cases it is not possible to totally relieve suffering. Therefore the patient's continuing pain does not automatically mean that the nurse has failed. Prolonged pain does, however, signal a need for the nurse to accept responsibility for assisting the person to cope with it and this requires some understanding of pain's psychological effect. Ho\\< people react to pain For the victim, prolonged pain is a demoralizing experience which thrusts the individual into the role of dependent - a person who cannot take care of his own needs. When this happens the patient's frustration with the situation may show itself as anger directed towards the nurse. Prolonged pain is abo a frightening experience. As the pain continues it wears the person down until he begins to feel that he is in the power of an alien force which he cannot control. If others avoid him in his pain he feels betrayed and abandoned to his fate. Unfortunately the behavior of an individual in pain tends to encourage people to avoid him. Characteristically, as pain continues. the person becomes increasingly preoccupied with his suffering and less responsive to others. It is important to remember that the individual in this situation still needs the comfort of having people spend time with him even though he probably does ot indicate that this is the case. Spending time with a patient does not mean that the nurse has to attempt to engage him in light chatter. To do so when he is in pain is to act a5 if he i5 merely out of sorts and suggests lack of sensitivity to the individual's experience. This kind of behavior may even be interpreted by the patient as denial of his pain; to deny a person's perception of the reality he is experiencing is to rob him of his self-respect. If the nurse wants to assist the patient to retain his dignity in the face of pain, she must verbally acknowledge the existence of the pain and the patient's right to feel frustrated"and angry that his suffering cannot be alleviated. In this way, the nurse indicates respect for and empathy with the individual. but this is not sufficient if the nurse then rushes away. Non-verbal communication is also essential to convey real understanding. This can take the form of turning the person's pillow or some other physical action, but it does not have to. In fact more support may be provided by simply sitting quietly with the patient. If the nurse is not engaged in giving physical care it is more obvious to the individual that she is taking time to face his pain with him and that he is not alone. Therefore. the next time you cannot totally reheve a patient's pain, try not to allow yourself to feel guilty but, instead, take the positive step of recognizing the comfort that can be provided simply by your presence. .., Gillian Dohert} , author of' The patient in paÎ1l: handling the guilt feelings". is a !:raduate of Royal Victoria Hospital in Montreal. After working as a general duty nurse she returned to unil'ersit\' to obtain a Ph.D. in clinical psychology. The information she shares in this article is based on her experience obtained while nursing two family members through terminal cancer at home. "One of these people," she writes. "through his ability to talk openly about what was happening to him. helped me to realize the comfort that can be prol'ided to a patient in prolonged pain by the sheer presence of another person." eQ babies cry Janet Harris It's almost eleven o'clock. The television news will be on soon but Joanne is too tired to watch it. Her day started a little before six this morning when two-week old David's persistent cries wakened her while it was still dark. After he was fed there was breakfast to fix, dishes to wash, a load of diapers to wash, dry and fold. Before that job was done there was another feeding and then David needed a bath. Time to make formula or there'll be no two o'clock bottle. After that a little nap while David sleeps (the bed isn't made yet anyway). Something quick and easy for supper because from five until seven is David's "fussy" time. Why does he always cry when I want to talk? Does he cry more than most babies or does it just seem like it? More than he should? Maybe there's something wrong. Is there something I should know about looking after him? Maybe he's trying to tell me something. Now he's had his ten o'clock feed and he still won't settle down. What' II I do? He can't be hungry, can he? I'm so tired, so mad, I cou Id cry. And she does. Does Joanne's tory sound familiar? Maybe it reminds you of the first few weeks you spent getting to know your firstborn. Or maybe you're a public health nurse and you've 'ieen a lot of mothers like Joanne ... mothers who are frustrated, confused, upset and. yes, probably, tearful because their "mothering" skills seem completely inadequate in the face of the challenge presented by the small crying stranger in their home. Infant cQing "... discharge day arrives. A fragile and unfamiliar bundle is placed in the mother's trembling arms and the 'family', united at last, tries to assimilate the new intruder into their midst.'" Of all the problems faced by families adjusting to a new baby, infant crying is probably the most common. The majority of studies examine infant crying from the point of view of the infant rather than the mother. We know, for instance, that: . over a ::!4-hour period the newborn will have an average of eight crying episodes 2 . most of these episodes occur between si;.. p.m. and midnight" . four distinct and unique crying patterns 4 have been recorded: - the birth cry (not replicated after birth) - the pain cry (usually elicited by painful stimuli o;uch as a heel prick) - the pleasure cry (not usually heard until three months of age) - the hunger cry (a basic rhythmic cry). Infant crying is considered an important signalling behavior which increases the mother's proximity to the child and releases maternal caretaking activities."The mother's motor response Th. Cen-.llen Nur.. Februery 1117i 33 to crying has been studied by several investigators,"" one of whom found that infants whose mothers responded immediately to their cries tended to cry less at the end of a year than infants whose cries did not elicit such a prompt maternal response." Another investigator furnished fertile speculation about the mother's emotional response to crying when she suggested that the vulnerable state of the mother in the postpartum period may cause her to perceive crying as a sign of failure or rejection." Furthermore. persistent infant crying has been linked to later child abuse when the mother interprets the crying as a criticism of her efforts and evidence of her own inadequacy. This is the opposite of the self-esteem enhancing behavior wanted from the child. As a public health nurse visiting new mothers during the initial adjustment period at home, I noticed that some mothers seemed particularly discouraged and perplexed by their newborn's crying. I sensed that in these cases the mother's self-confidence and relationship with her baby were in some jeopal dy and so I decided to investigate what crying means to the new mother and how nurses can assist her in coping with this rather conspicuous behavior. I wanted to contribute to the data base on neomaternal adjustment and specifically to draw attention to the nurse's unique opportunity to promote optimal maternal-infant relations during this period. NEW MOTHERS' INFANT CRYING GUIDE Crying has been described as an important "signalling" behavior because it usually brings the parent to the infant. There is no magic cure for crying but there are a number of simple and sometimes obvious things that may not occur to a tired and harassed parent. HUNGER is the most common cause of crying. The stomach contracts and causes the same kind of "hunger pains" that a hungry adult feels. If the baby is crying but ate well an hour earlier, you can assume that his stomach is not yet empty. If the baby was fed two or three hours earlier and you are breast feeding, he may be hungry as breast milk is more quickly digested than formula and in the early weeks, your baby will need frequent feedings. If you are not breast feeding, go over in your mind how much he took during the last feeding and how long the feeding took. If he took less than usual or the feeding process was not a lengthy one. he may be hungry. If you're in doubt, it's a good idea to try some other measures first. TEMPERA TURE of the room, either too hot or too cold, can cause the baby to cry. A good rule of thumb is to put the number of layers of clothing on the baby that you would be comfortable in and then add a layer, e.g. a blanket or shawl. THIRST Often we don't think of the baby's need for water. An ounce of sterilized water in a bottle satisfies his thirst and at the same time, satisfies the need to suck. THE NEED TO SUCK is naturally strong in infancy. Sucking reduces tension and soothes the baby. Experts believe the pacifier soothes the baby and prepares him for sleep by lowering the activity level. Often a restless. agitated baby will settle down when a pacifier is offered. As he reaches three to four months of age. his need to suck will be reduced and mothers can gradually decrease the use of the pacifier. DISCOMFORT Is something hurting the baby? Is he in an uncomfortable position? Are the diapers dry and comfortable? Are the baby's clothes pinching or rubbing? GAS PAINS These are very uncomfortable and may cause crying. Make sure the baby doesn't take his milk too quickly and that he burps well before being put down. Holding him against your body and stroking his back will help relieve the discomfort. Walking about the room as you do this may provide relief. If stomach discomfort continues. you may wish to consult the doctor to make sure he isn't being overfed. Depending on your baby's size and age, his stomach will not hold excessive quantities of milk and crying may result from feeling too full. THE NEED TO BE HELD Sometimes just picking the baby up and holding him will cause the crying to cease. Because of this some people believe that picking a baby up will teach him that crying "pays off". It is important to remember that the first few weeks outside the uterus are insecure ones for the newborn infant. Being held against the mother's body provides a sense of security for the baby at a time when the development of trust between mother and infant is important. BOREDOM Sometimes a simple change of position can relieve boredom. Interesting sights and sounds will distract a baby if he is close enough to see and hear. Babies can't see very well out of the corner of their eyes and have to turn their heads to see something beside them. Even very young babies can see color and motion. Sights and sounds your baby might enjoy are: Sights Sounds . Mobiles · Bright colors especially red . Parent's face . Pictures' . Mirror . Rattle . Toys . Music . Metronome" . Clock . Parent's voice . Rattle, bell . Vacuum cleaner OVERSTIMULATION Sometimes the baby cries because he needs rest or sleep. Pick the baby up, pat his back, try rocking him to sleep Then place the baby face down in the crib (this position reduces the activity level). stroke the baby's back. reduce unnecessary noise and lights, talk gently and soothingly and then quietly leave the room and do not return if possible. .Infants prefer interesting colorful shapes to grey blobs "At 60 beats per minute, which resembles the mother's heart rate. , 34 Febru.ry 1117i The C8n-.l18n Nur.. The study What are the new mother's thoughts, feelings and actions in response to her infant's crying one month after delivery? I assumed that: . crying elicits a maternal response . mothers can report these responses, and . infant crying plays a role in maternal-infant interaction. In order to carry out my investigation. I interviewed a sample of 35 mothers. Two interviews took place with each of them - the first in hospital between one and three days after delivery and the second at home about four weeks later. The target population was primIparous mothers delivering at a large urban general hospital who . were between the ages of ] 8 and 35 . could speak and understand English . had no obstetrical or neonatal com plications. Thus. a homogeneous sample with no apparent high risk characteristics was assured. To protect against encroachment on the mother's privacy, potential subjects were first approached by a staff nurse who requested written permission for the investigator to approach. Two refused. I then approached the mothers personally to explain the purpose of the investigation and to obtain written consent to participate in the study. An interview schedule was developed to obtain the desired data both in hospital and at home. This instrument was approved for content validity and pretested on five mothers who met the sample selection criteria. The sample size (35 mothers), sample setting (two obstetrical units in one hospital) and the sampling technique (convenience sampling) did not permit generalization of the findings. Findings Approximately two thirds of the mothers reported that their infants' crying had been a major concern to them in the preceding four weeks. There was a significant relationship between mothers who reported high crying frequencies and mothers who reported major concern ahout their infant's crying. The effect of early and extended postpartum contact between mother and infant on the mother's responses to her infant's crying'" could not be analyzed since nearly all the mothers in the sample were in contact with their infants for less than an hour following delivery. Of significance to nurses working with mothers in the perinatal period is the finding that the majority of mothers were not prepared for the amount the infant would cry, or, for how the crying would make them feel. They all indicated that the infant's crying hdd a powenul effect on their feelings that ranged from irritation to frustration to anger (see Table I). Some mothers said they felt guilty about their responses. It is conceivable that these feelings introduced dissonance for these mothers in a society that perpetuates an idyllic picture of motherhood and condemns unloving treatment of children. Table 1 REPORTED FEELINGS EVOKED BY INFANT CRYING Feelings reported Number of Maternal Reports Frustrated 12 Bothered 5 Nervous 5 Sorry 3 Upset 3 Helpless 3 Wonder what's wrong 3 Irritable 3 Guilty about feelings 3 Heart-broken 2 Hostile 1 Violent 1 Mildly angry 1 Exasperated 1 Underconfident 1 Hurt at first, now indifferent 1 Uptight at first, now resigned 1 Afraid 1 Worried 1 Anxious 1 Concerned 1 Don't know what to do 1 Unloving, unattached 1 Terrible 1 Like killing her 1 Needed 1 Resentlul 1 Confused 1 Fed up 1 Tearlul 1 This study leads me to believe that nurses can assist the new mother by helping her prenatally to develop a realistic picture of infant behavior in general and infant crying in particular so that she is better prepared for the postnatal period. The public health nurse should make the baby's crying pattern an essential component of every postpartum assessment. Whenever major concern about the crying or high crying frequencies are assessed, the nurse can assist the mother to interpret the meaning of the crying and detennine the appropriate intervention (See page 33). Many mothers in the study revealed uncertainty about spoiling the baby by responding to every cry. While some mothers found it difficult to stay away for long when the crying persisted, ("Letting her cry is bad for both of us," declared one mother) other mothers believed it was best to stay away since going to the baby reinforced manipulative crying habits. The study suggests that mothers need help in arriving at an approach they feel comfortable with and that the approach will vary among mothers. The mothers' need for reassurance was evident in the questions they asked following the interviews, for example. "What am 1 doing wrong?", "Do other mothers feel this way?" and "Do bottle-fed babies cry this much?" (No significant differences were found between maternal responses and method of infant feeding used by the mother). Five mothers in the study were in frank despair about the baby's crying. These mothers had consulted their physicians and were given prescriptions for pediatric antispasmodic sedatives. All expressed ambivalence about the use of the drug and all but one mother had discontinued it. When asked what she did when the baby's crying persisted, one mother replied, "I cry. "It is possible that this kind of response or that of sedating the baby may not be necessary if mothers are better prepared for what to expect and given more assistance geared towards increasing their knowledge and confidence as welI as strengthening their relationship with the baby during this critical adjustment period. 4r Author, Janet B. Harris, (M.Sc.N.) has worked in public health nursing, prenatal education, outpost nursing and in nursing education. She wrote, .. When babies cry..... as part of the requirements of a Master of Science degree at the U nÎl'ersity ofT oronto. She became involved in health care research while completing studies at U ofT. References ] Enkin, Murray W. Fami]y-centered maternity care. Canad. Fam. Phvs. 19:4:45, Apr. 1973. 2 Rebelsky, F. Crying in infancy. by ... and R. Black.J. Genet. Psychol. ]21:52, Sep. 1972. 3 Bernal. J. Crying during the first ten days oflife and maternal responses. Del'.Med. Child Neurol. 14:363.Jun. 1972. 4 Wasz-Hoeckert, O. The infam cry. A spectographic and auditory analysis, by... et al. Philadelphia. Lippincott. ]968. pA-7. 5 Bowlby, John. Attachment and loss. Vol. 1-3. New York. Basic, ]969. 6 Bell, S.M. Infant crying and maternal responsiveness, by... and M.D. Ainsworth. Child Del'. 43:1]7]-1]90,Dec. ]972. 7 Bernal, op.cit. p. 362-372. 8 Bell, op.cit. p. 1181. 9 Rubin, Reva. Maternal touch. Nurs. Outlook 11:11:831. Nov. 1963. 10 Klaus. M.H. Maternal-infant bonding: the impact of early separation or/oss onfamily development. by... J.H. Kennell. St. Louis, Mosby. 1976. p.53-57. VISIONS I'd like to see a streptococcus hemolyticus on afibrillating circle of atelectasis I'd like to watch a neurogenic polysaccharide Fall off a pile of anaerobic ripe formaldehyde. Or hear the confrontation in a bronchial psychosis Of a visceral injection and parietal osmosis. Oh, wouldn't it be something tofeel the plantar flexion After ketoacidosis and a happy resurrection! Can youfi/l up your cholesterol and by means ofsublimation Balance parenteral nutrition and sensory deprivation? Of all the things I've studied.l think glucose palpitations Are the ultimate in peristaltic articulations. P.S. Who says it's as simple as mandibular kyphosis When your gluteus maximus has osteoporosis? . . -- " : arbara 'Ill< MacCuish, author of" Visions", " an R is verse. alonR \\'ith "Bahi . (C'ì"J I ment o( tire ter, British It}, "as written 3e Febru.ry 11179 The Cen.dl.n Nur.. [hildhood Asthma an outpatient approach to treatment The word "asthma" is derived from a Greek word meaning "panting". Simply stated, asthma is a serious but usually reversible inability to breathe well, and is characterized by wheezing, shortness of breath, tightness in the chest, coughing and sudden choking. The inability to breathe results from a narrowing of the bronchi caused either by muscle spasm, the swelling of tissue, excessive secretions and dried mucous plugs or a combination of all three.:.! The effects of asthma can differ markedly from one individual to another. Some patients have mild uncomplicated asthma that produces symptoms only occasionally (e.g. pollen related asthma), whereas others can have severe life- threatening attacks. In severe asthma, normal amounts of oxygen and carbon dioxide are not maintained in the blood and tissues. 3 The acute attack is the most distressing to the asthmatic patient and can progress to "status asthmaticus" a stage in which the patient deteriorates in spite of adequate treatment. As with other complex conditions, there is no one factor that seems to be the cause of asthmatic attacks. Rather, attacks are usually triggered by some initiating event, factor or combination of factors such as infection. allergies or psychological stress. The building block model is one way of conceptualizing multiple causation in the onset of an asthmatic attack. The Interaction of the infective, allergic and psychological factors can be compared to piling blocks one on top of the other until finally one more block upsets the whole pile. The upset pile is the result of a cumulative effect. Similarly. in an asthmatic attack. a number of factors collect and interact until a certain threshold is reached. When the threshold is exceeded, an asthmatic attack is precipitated. There are two basic forms of asthma which have been described by Rackemann 4 as "extrinsic" and "intrinsic". . Extrinsic asthma is usually allergy induced. Allergic substances (allergens such as dust, lint, pollen) that are foreign to the body combine with specific antibodies within the body to create an allergic reaction. Allergens can be inhaled, ingested or simply enter the body through the skin or mucous membranes. The allergic reaction most often takes the form of allergic rhinitis, hives, eczema or asthma. . Intrinsic asthma identifies asthma whose origin is internal and is usually found in persons who are not allergic to specific substances. Intrinsic asthma is often secondary to chronic respiratory infections. The frequency and severity of attacks are greatly influenced by precipitating factors such as anxiety, stress, temperature and barometric changes, fatigue and endocrine changes. Roy G . Ferguson Anne Wehb The time is three in the morning. On a quiet residential street, the Brown home is in total darkness. All seems still until Susie suddenly awakens struggling to get some aIr. "OM I'm cho/..ing. / can't breathe- my chest feels so tight! What can I do? I feel so scared andfriRhtened and - it's so dark in my bedroom!! I wonder what / should do? / know-I'll call Mommy and she can help me! But- / wonder if she'll be angry with me for waking her up? / know she's tired, because she told me that last night. She's been up with me n'ery night this week and / feel so bad, bill gosh! I just can't get any air. Oh- Mommy, I can't breathe-." These are some of the feelings of a 7-year-old child who is having an asthmatic attack. Waking up in the middle of the night like this isn't unusual for her- she's been having attacks like this since she was two years old. But it always brings with it that awful fear of not being able to breathe. Susie's mother. Mrs. Brown. has come to expect these middle of the night incidents but not without apprehension and some frustration. "/ t is always a shoe/.. to be awakened olll of a deep sleep by Susie's wheezing and labored breathing. Usually, / lie still for only a moment until I realize what is happening and can hear Susie's panicky \'oice calling, 'Mommy,1 can't breathe.' As / jump out of bed and maÁe my way to her room. I often thin/.. of the number of frightening, sleepless nights that / as a parelll ha\'e spent since Susie developed asthmatic symptomsfh'e years ago. It seems like an eternity - one of fatigue, frustration, antiety and at times, hopelessness. / really need some answers to those nagging questions in my mind - when to gh'e my little girl her medications, how long to wait before I whis/.. her off to emergency to hG\'e her symptoms of distress relie\'ed, how to get more understanding and support from my husband, John. Just to be able to sit down and talk with some other parent with an asthmatic child, could be such a help and a support." Th. C8n-.llen NUrH Februery 117i 37 From the standpoint of everyone concerned - the child, the family and hospital personnel - there are man} reasons for attempting to treat childhood asthma on an outpatient basis. At the Alberta Children's Hospital in Calgary, a treatment program that teaches both parents and children how to cope with and control asthma has been oþerating successfully now for five years. -- -----= . , (1 .. 0 , --:) \ 'Þ ( "' .... -- , '" Susie and her parents are not very different from many other families who live with asthma. Because asthma is a chronic condition, it must be dealt with each day - and that is never an easy road. Reliable statistics on asthma in Canada are difficult to find but. in the United States. asthma has been described as the number one cause of school absence due to chronic illness in children under the age of 17 years. The financial burden this presents to parents has also been examined. In Southern California. it was found that in selected families. the management of asthma accounted for from two to thirty percent of the family income.' Considering these points. it is clear that families like the Browns need help to better handle the problems asthma presents to them. One way is by early intervention programs that involve the whole family. The Asthma Program at the Alberta Children's Hospital in Calgary is such a program. The program The Asthma Program at ACH has been in operation in its present form since 1973. It represents a composite of ideas that developed through reviewing the recent literature on the subject and by studying other asthma treatment programs here and abroad. At present there are some 350 families involved in the program. Certainl}. this does not represent all the children with asthma In the Calgary area but rather only the small number of children who do not respond to regular treatment. In general. the families who are referred to the A thma Progrdm tend to be complex cases that involve a multiplicity offactor . In con'iidering this point further. it helps to conceptualize illness as response to disease. The response of children to asthma is influenced by many individual factors such as learning, past experience and anxiety and various environmental factors such as culture. society, economics and the health care system. (See figure one). The children for whom the program is intended are the ones whose illness is more complex because ofa multitude of individual and environmental factors that playa part in their response to the disease. In view of these complexities, our A'ithma Program was developed on an interdisciplinary model (See figure two). The expertise that is provided by many disciplines is the only way to fully meet the total care that these children and families need. Whenever possible the team view the asthmatic child within the context of the whole family. The primary focus of the program is prevention by teaching the child and parents coping skills and mechdnisms which enable them to effectively control and manage the asthma. In providing familie with accurate information about the di ease and teaching them effective management skills. the team attempts to lower anxiety related to asthma and increa'ie confidence in their ability to cope. Through this process, the child and parents assume more responsibility and become more independent. 311 Februery 1117i Th. C8n-.llan Nur.. Medicine ---chemotherapeutic prevention and intervention procedures -allergic reaction desensitization procedures -treatment ofbacteriaJ or viral infections relating to asthmatic distress Nursing -instruction in allergy producing substances -supervision of inpatient hospitalizations -examination of home environment including taking cultures of molds from various parts of the house -follow-up contact Individual Factors (learning, past experiences, anxiety, self-concept. etc.) Figure one Response Environmental Factors (culture, society, family, economics, health care system, etc.) Assessment Families referred to the program are initially a!>sessed by the asthma team in a scheduled clinic. Following the various disciplinary assessments, the team meets to pool their information and design a program specifically suited to the individual needs of the family. The seven disciplines on the team are not all necessarily directly involved in the treatment program. Rather, different combinations of therapeutic input are established for each family depending on their particular needs. The family is integrally involved in designing the treatment program. At specified times each family is reviewed in the asthma clinic to establish the efficacy of the treatment program and to make any modifications which seem necessary. Treatment Generally, the family is treated on an outpatient basis. The following are some of the treatment functions provided by each of the team members. Physiotherapy -diaphragmatic breathing -postural drainage -postural and breathing exercises -formal exercise -inhalation therapy Psychology -anxiety reduction through biofeedback, behavior therapy or hypnotherapy -management of disruptive behaviors occurring during asthmatic distress -facilitate psychological adjustment to asthma through individual. group and family therapy Physiotherapy Figure two Recreation/C hild Life -increase activity level through development of recreational skills -facilitate physical development through recreational activities -facilitate social development through recreational activities Social Ser 'ice -encourage parents to allow age-related independence in child ---correct maladaptive family communication and interaction patterns -encourage family to support child's involvement in peer activities Dietetics -nutritional counseling Special activities designed specifically for the treatment of the asthmatic child and his family are also available. Swimming, for example, is a regular ongoing activity vital to the asthma program. Asthmatic children and their families are invited to participate in weekly swim sessions that serve to increase the child's physical capacity and confidence plus providing an enjoyable recreational activity for everyone. Similarly. progressive-resistant exercise classes have been held on an intermittent basis. Again the intention is to increase the child's physical capacity while at the same time providing a safe environment where he can learn just where his physical limits lie. It is necessary for the child to know these limits in order to implement some of the prevention measures (e.g. diaphragmatic breathing, relaxation training) before this threshold is passed. In the last year the Asthma Program has operated a summer camp for asthmatic children. Data collected at the first camp was very encouraging in demonstrating the utility of a camp as a therapeutic extension of the regular asthma program. Th. C8n-.llen Nur.. Februery 11179 311 Education One of the most important functions of our program is information and education. It has been our experience that parents of asthmatic children do not have accurate information about the disease. In many cases. the anxiety felt by children. families and the general public towards asthma is a fear of the unknown. Reliable information about the disease and its treatment is the key to overcoming misconceptions about asthma. We have noted that health professionals also have a lack of knowledge in this area. Many of them do not have recent information on a thma and relatively few of them spent much time on the subject during their clinical training. As part of our program to provide information about asthma to the public and health professionals, we have focused on a number of areas: . Parent group The parent group consists offour evening sessions attended by approximately 16 parents of asthmatic children. The sessions focus on the physiological. social. medical. nutritional and psychological aspects of asthma. Members of the team present information to the parents. Later they have an opportunity to talk over the material. problem-solve and ask questions. The groups run continuously throughout the year and 21 group have been completed to the present time. . W or/..sllOps in rural areas The asthma team does an average of two workshops per year in rural areas. Generally. there are separate session for parents and for health professionals. In some of the areas the workshops have been the stimulus for establishing a local asthma treatment team so that families in these areas can receive treatment in their own community. . Wor/..slwps in urban areas Workshops have been developed by the asthma team for a variety of health professionals such as psychologists, physiotherapists. and nurses in Calgary. Presentations have also been made to groups such as the Alberta Lung Association and to schools in the area. The team is beginning to develop an in5tructional unit to be included in the medical school curriculum at the University of Calgary. . Educurional resources As a guide for parents in the asthma program. the team has developed a manual and a film called A Child-A ClwllenRe. The manual is given to the parent'i as they enter the program and is intended to be used as a reference for specific information on asthma. The film i shown during parent group and various other workshops as an educational aid. Research With so much energy being expended in running the Asthma Program there ha.. not been much time available for research. So far, only one major re'iearch project which examined the effect of the parent groups on the participants has been completed. The results of the data analysis indicated that involvement in the parent group significantly increa'ied levels of knowledge related to asthma. Similarly. self-report and psychophysiological levels of anxiety related to asthma were reduced through involvement in the parent group. A second project was more of an overall program evaluation. Data wa collected on all of the families involved in the Asthma Program between 1973 and 1975. The results, showing a 40 percent reduction in inpatient admissions, indicated that families were managing the asthma more effectively at home. Although systematic data is not yet available. the number of inpatient admissions for 1976 and 1977 have been reduced even further. Cost comparisons From a clinical point of view there are many reasons for attempting to treat asthma on an outpatient basis whenever possible. But, there are also some economic factors to consider. For the period of July I. 1976toJune30, 1977. we tabulated all outpatient treatment costs for eleven typical patients in the asthma program. This sample consisted of three mild. four moderate and four severe asthmatics. Computerized records for each 'ielected family were reviewed and the total amount of contact by each team member was recorded. The average cost of outpatient treatment per child (including overhead costs) in that year was $395.84. At an average per diem cost of$n7.00 this would allow only 2.9 days of inpatient hospital care. Compare this to the inpatient record of one of the children in the sample: Year Days hospitalized Cost 1975 77 $10.549.00 1976 33 4.521.00 1977 35 4.795.00 It is interesting to note that in this particular family there were considerable psychological factors complicating the asthma. Concentrated outpatient work (costing $393.64) wa'i done in early 1977 with the family. The number of hospitalized days for the remaining ix months of the year following this intervention was only eight. It will be interesting to see if this reduction in hospitalization is maintained in 1978. Summary Asthma is a condition that involves a large number of children. I n fact. the prevalence of asthma in recent years appears to be increasing. The asthmatic process is a complex one usually involving all members of the family. In view of the mult:plicity offactors and complexity usually involved with asthma the resources "of an interdisciplinary team are often required. The Asthma Program at the AlbertaChildren's Hospital in Calgary ha developed this sort oftreatment model and has found that, over time, significantly le s inpatient treatment is neces5ary for the 350 families involved in the program. In addition to being considerably less costly. an outpatient focus to the management of dsthma allows for more activity in the area of prevention.'" . Ro} Ferguson receil'ed his Ph.D. in clinical child psycllOloRyfrom the U /li\'ersity of Alherta. He is director oj the Department of PsycholoRY at the Alherta Children's H (). pital in CalRary and has been a team memher ( f the Asthma ProR1"U1I/ since /973. Anne Webb receil'ed her R.N. diploll/a .Ii'om the St. Boniface General Hospital S cllOol ofN ursinR in M anitoha. She 11(1.\" been the nurs;'lR II/emher of the asthma team at the Alberta Children's H ospiwl since /973 and has enjoyed adaptinK the 11111 sinR role to an integrated model of olttpatient health care. References I Asthma, Denver. Colorado, National AsthmaCentre. 2 Ibid. 3 Ibid. 4 Rackemann. F.M. A working classification of asthma. Amer. J. Med. 3:601.1947. - a new approach to an old problem \ , .. Catherine E. Cragg Recognize Susie Sepsis? Of course that isn't you in the picture above. YOU know better. But is she someone you know? And how many errors can you spot in Susie's technique? Cross infection is a problem that is common to all hospitals; it was a key factor in making hospitals unsafe for both patients and attendants in the early 1900' s and. in spite of antibiotic therapy and sophisticated surveillance progrdms. it is still around today. ï .. . , .. . Susie Sepsis' demonstrating incorrect technique. One of the groups that is most susceptible to nosocomial (hospital acquired) infections includes the patients on the pediatric ward of a general hospital or in a children's hospital. Infants who are in hospital for more than a few days run a high risk of acquiring infection: they have few immunities, are already debilitated by disease and may be exposed to new microorganisms. ) , - At The Hospital for Sick Children in Toronto. routine ',nfant-technique" requires gowning and handwashing by every pero;on in contact with the patient. Nevertheless. the spread of gastroenteritis is frequently a problem on infants' wards, especially during the winter. At the first sign that a child has diarrhea he is transferred to the isolation ward and his former roommates are placed on "enteric precautions", but in most instances the disease spreads to other patients and electron microscopy reveal!. the same viral agent in all. Despite clearly defined procedures of aseptic technique, orientation classes. and frequent reminders. cutting comers on technique may become usual practice rather than the guilt-producing exception. Breaks in routine are hard to trace. at least partly because of the delay caused by the incubation period. When cross infection occurs it is all too easy to find a scapegoat: doctors usually blame nurses; nursing staff blame doctors, cleaning staff, or visitors, and resent being expected to police the activities of others. The lapses that caused the problem are forgotten in the resulting suspicion and hard feelings. In spite of this tendency to "share the blame". there can be little doubt that the nurses' role is central in ensuring maintenance of good aseptic technique on a ward. Nurses know the correct procedures, are always on the ward. and have the most frequent and direct contact with patients. They are responsible for teaching visitors the technique and for protecting their patients by reinforcing its use by other staff. Also, they must bear the brunt of carrying out isolation measures if infection occurs. Our imestigation As educators, our attention was focused on the question of whether or not an education program for nurses could reduce the rate of cross infection on a pediatric ward. To examine this question, we developed an education program that we introduced on two different wards. On the first of these, implementation aroused little interest and resulted in only small improvement. On the second, where staff had requested the program and were prepared to work on the problems. the improvement was noticeable. We believe that the different results reflect different degrees of commitment on the part of ward nursing staffs. Our project grew out of a communication course assignment. Another student and I decided to plan a program to persuade people to do something the}' know is correct but are failing to do. OUI choice of subject was the maintenance of good aseptic technique among nurses on an infants' ward. My colleague. a non-nurse. relied on me for technical and procedural information. We also consulted other members ofthe class and infection control (IC) nurses working in the hospital. Th. C.n-.llen Nur.. We sought to identify the nurses' problems in infection control and demonstrate that improvement is possible. Also. we wanted to show nurses the positive consequences of correct behavior: good technique rarely brings reward - rather. it is the occurrence of infection that stimulates reaction (criticism. and punishment by isolation duty and extra cleaning). Criteria for judging success would be: decreases in the numbers of positive virology stool reports. transfers to the isolation ward. and rooms in isolation. In outlining the program we found that writing each point on an index card and posting this on the wall helped us to keep track of the factors we wanted to consider. to categorize information and to recognize gaps. Table one is a summary of the final organization of our wall of cards. "ard One The two IC nurses and I suggested the project to the head nurse of an infant's ward where nosocomial gastroenteritis often occurs. She agreed that something needed to be done about the nurses' technique and the cross infection rate. We felt that knowledge of correct technique was probably adequate but that staff were cutting comers. All four of us worked together to plan a one-hour "brainstorming" session to identify problems. suggest changes. reinforce technique, and encourage staff to monitor their own technique. The session was repeated a often as needed to include a majority of the nursing staff. The program objectives were posted beforehand in the meeting room. After a brief introduction we asked the nurses about ward factors that contributed to cross infection and possible solutions. In each group they expressed frustration about the many factors contributing to the problem (e.g.. large numbers of visitors. inconvenient location of supplies) and made some practical suggestions for improvement. Many problems were beyond their direct control (e.g.. screening patients on admission does not identify all who already have diarrhea). Topics discussed included a nurse's right to isolate a patient and aspects of correct technique. The ward nurses were interested in the session hut were not willing to assume responsibility for further action nor to monitor one another's technique. They seemed to assume that we (the planners) or someone else would follow through their suggestions: "What are the\' going to do about it?" The nurses agreed that an informative brochure for parents would be valuable. but none was willing to write it. F_u.ry 1811 41 The criteria we were measuring decreased only minimally and we could provide little positive feedback. We concluded that our program had had little effect on nursing behavior or the cross infection rate. We felt there were several reasons for this failure. At some sessions. the 'outsiders' (2 IC nurses. my fellow student. and I) outnumbered the ward participants. Also, this ward was encountering other difficulties - a newly appointed head nurse. shortage of nursing staff. and several seriously ill patients - which probably diffused the impact of the project. Ward T\\,o While we were experiencing this discouragement. a team leader from another ward with a poor record of infection control asked the assistant IC nurse for help. This time. the assistant IC nurse and I felt that we should be the only outsiders involved and that the ward nurses should assume more responsibility. The head nurse and two team leaders joined us in planning. We examined the ward nurses' needs. Did all of them know and understand the technique?The team leaders thought that some did not: they had often noticed errors and heard differences of opinion about what was correct. They wanted the assistant IC nurse and I to discuss the diseases they were encountering and explain correct methods for preventing spread of infection among infants. We agreed to do this. In addition. we wanted the nurses to identify problems and suggest solution,> and to plan for follow-through. For all this. three one-hour se sions seemed appropriate, repeated six or seven times to reach the more than 40 nurses on staff. These bi-\\'eekly sessions took the place ofroutine ward conferences on those days until all staff had participated. The head nurse arranged the staff schedule. and the team leaders made posters, booked a large room with a sink. provided supplies. and ensured that staff members attended. We made pecific plans for sessions one and two. For the firs!. to avoid the stigma of 'the handwashing class' and make the refresher on technique interesting, we decided to advertise and run it as a "fun" session. The second session was to resemble the presentation on the first ward. For each group, the assistant IC nurse and I were coordinators and at least one of the interested team leaders attended. 42 Febru."Y 1871 The C.n-.ll.n Nur.. Table 1 PLANNING A PROGRAM TO REDUCE CROSS INFECTION OBJECTIVES 1. To reduce cross infection on an infants' ward. 2. To decrease . positive stool reports from virology; . transfers to isolation ward; . rooms in Isolation on ward 3. To ensure relevant changes in behavior and environment, Immediately and continuing. WHA T WE KNOW Characteristics of ward nursing staff -40+ RNs and RNAs, all female; experienced and new -perform aseptic technique to some extent now --care for infants and older children; are assigned 4-6 patients per nurse per shift -ward nurses are supervised by head nurse and team leaders -work alone in patients' rooms much of the time Resources . Infection control nurses . Nursing education department . Communication -personal contact with staff -dally ward conferences -videotapes, slides, audiotape cassettes -print (posters, pamphlets, etc.) . Statistics on cross infection . Consultation with and reports from virology and bacteriology departments . Ward-staffs knowledge and ideas Negative Factors . Lack of positive consequences for correct behavior . Complexity of desired behavior: physical inconvenience; routine, drudgery . Other demands on nurses' time . Other people Involved. medical, paramedical, and housekeeping staff, ViSitorS, etc. . Negative connotations of technique -policeman/lawbreaker relationship -handwashlng = "My patien(is dirty" or "I am dirty" WHAT WE NEED Factors to be identified . Amount of staff Interest/commitment to improvement . Staff's present level of knowledge/conformity with technique . Present breaks in technique . Environmental factors contributing to cross infection . Amount of high-status support: nursing department, infection control committee, medIcal staff, administration First Session As staff came in they were given numbers for door prizes (for example, one week without an isolation assignment. or two weeks with no patients with Rotavirus). A team leader introduced the session, and the assistant IC nurse and I briefly outlined the objectives of the program. We Aims . Set realistic criteria · Involve all levels of ward staff · Focus on behavior · Consider environmental factors . Reinforce affective elements · Eliminate or reduce negative factors · Ensure feedback/recommendation for correct behavior GOALS AND METHODS Behavioral Goals . Increased frequency of handwashing · Improved disposal of contaminated articles Methods: 1. Immediate commendation for correct behavior. 2. Rewards for correct behavior (group and individual). 3. Checks on technique (frequenlly, then at longer intervals). 4. Peer monitoring of technique. 5. Staff meetings --involvement in problem identification --involvement in decisions --identification of ways to improve/streamline technique -nurses to choose their own rewards Cognitive Goals . Improved knowledge of correct behavior . Increased knowledge of sequence and pattern of behavior Methods: 1. Increase awareness of technique. 2. Review and demonstrate correct technique. 3. Demonstrations by instructed staff. 4. Periodic follow-up. Affective Goal . Reinforce that technique is: important necessary to protect patients a professional responsibility Methods: 1. Involve others: high-status nurses. medical staff. parents. 2. Cross infection scores; compare with last month and last year. 3. Persuasive messages (e.g., "Caring is clean hands"). Reduction in Negative Factors . Emphasize correct behavior and absence of infection rather than breaks In technique and occurrence of cross infection . Reduce inconvenience wherever feasible . Encourage team work Methods: 1. Rate correct behavior. 2. Post monthly scores for cross infection. 3. Reward Improvement in behavior and achievement of set criteria. 4. Discuss negative aspects with staff. 5. Involve others: medical, paramedical, and housekeeping staff; nursing administrators; parents. 6. Persuasive messages. The room was set up with two infants' units with dolls as patients. I told the nurses there was going to be a demonstration of technique and that they should record everything the nurse did right .or wrong. Naturally, they expected yet another demonstration of correct technique - but then the assistant IC nurse appeared as "Susie Sepsis", presented a slide-tape (provided by the Chief of Virology) on viral gastroenteritis, the ward's major cross infection problem. -> The Cenden Nune . -- ...: Februery 1871 43 wearing a long blonde wig, rings, watch and necklace, brown stockings, and dirty white shoes. Susie's technique included numerous mistakes: 'pinky-dip' handwashes,linen dropped on the floor, movement from patient to patient without changing her gown or washing her hands, and, finally, a dirty diaper pitched across the room, missing the laundry hamper. From 30 to 40 errors were included in each five-minute skit. Invariably, the first mistake, and sometimes also the second, was greeted with a gasp. Then giggles broke out. Comments began.: 'That's me;" "I can't write this fast." Laughter and applause greeted the end of the demonstrations. Comparisons oflists of errors gave us a chance to clarify differences, establish nonns, and explain what was wrong with some practices. Next, we demonstrated correct technique, with the group instructing me in what to do next. When we reached the point where I was supposed to fold the gown to hang it, I was embarrassed to find that I did not know how to do this on the ward's small hooks since I was used to larger ones. However, none of the ward staff did, either. Finally, one of the team leaders demonstrated an easy way fiGURE 1 /' to fold and hang the gown correctly. As even the "experts" had been ignorant. everyone felt comfortable getting up and practicing and helping one another. When repeating the session for other groups, we described what had happened the first time and encouraged everyone to practice hanging gowns correctly. Next we distributed a line drawing of a two-bed room (Figure one) and asked each participant to color-code the areas in the room she considered (a) clean (b) generally contaminated or contaminated by pathogens from (c) Patient A or (d) patient B. There were differences of opinion among the nurses about contaminated areas, and we had an opportunity to discuss reasons for certain conventions and to standardize practice. In preparation for the next session, nurses were asked to note factors contributing to breaks in technique. We ended by picking the number for that day's door prize. Second Session Each group started with blank pieces of newsprint paper. We asked the nurses to "brainstonn" about the problems for WINDOW _UNO WINDOW about half an hour. and then they worked on solutions. No solution was considered too crazy or too expensive, but most were practical and possible. With later groups, at the end of their session we commented on problems and suggestions that were similar to those mentioned by others. Almost all the participants appeared interested in the sessions and contributed to the identification of problems. After all the nurses had attended the second session, we assigned the list of problems among the following categories: . cleaning . nursing technique . supplies · knowledge and application of technique by other than nurses . facilities on the ward or in the patients' rooms . factors beyond the control of the ward's nursing staff. In many-instances the nurses acted immediately on suggestions. For example, when they noticed that it was difficult to keep small amounts of diluted chlorine bleach for cleaning items such as scales. stethoscopes in isolated rooms, someone suggested using spray 02 .. SU " 0001 PATIENT. PATIENT ) HANDLE o Clean o Conta.inatecl for Patient A OConta.lnGteci far patient."" o Conta_il\Qteci for all patient. "" in the roo. Representation of a two-bed infants' room. The nurses colored the areas they considered clean and contaminated, and indicated their color-coding in the boxes (lower right corner offigure). 44 Februery 1971 FIGUR E 1 35 30 25 20 Th. C.n..sl.n Nur.. OCT. / /A--; : -___A  '''' STARTED ........ , I " t .... I I " .... '" I I " "'r:. A..., I I ' ...----Â-_ ... I I ,,' -- ' 'Â" 15 10 5 A 1976-77  1977-78 VIROLOGY SPECIMENS -SENT --- POSITIVE RES UL TS Virology resultsforOctober-ApriI1976-77 and 1977-78 among patients in the second ward./ n addition to the reduction in positÌ\'e results, durin/( 1977-78 the number of positil'es per individual pathogen decreased mar/..edly. confirming decrease in cross infection. hottles from home cleaning products; the next day, they brought in spray bottles. Some solutions created new problems. In one room, diaper-weighing scales and formulas were kept on the same shelf. The formulas were moved immediately but a week later this "clean" area was reported to be inconveniently located and the room was rearranged. By no,"" we had statistics of rates of infection during the project. On Ward Two all the indicators had risen dramatically in the six wed..s before the program began (mid-January, 1978). Immediately after it started. they began to fall. ending up lower than at the same time the previous year (Figure two). In addition. per diem nurses who had gone to the ward for orientation said they had never 'ieen staff carrying out technique so well, and team leaders reported seeing more gown... hung correctly amI hedfing staff COI rect technique and teach pal ents more ClJIIsistently. Third Session We began planning the third session when the second was almost completed. Now we were faced with a problem- we were a hard act to follow! We feared that our success might be short-lived and that cross infection would mount again as soon as the project ended. We had to ensure that interest and enthusiasm were maintained. Some suggestions from the first two sessions required further work. Discussion focused on "Where do we go from here?" After explaining and discussing the graphs of results, we distributed typed copies of the lists of problems and approaches. We suggested the formation of committees to divide the work and continue the project. and asked for volunteers. The first group of nurses hecame anxious: for them, the word "committee" had man} negative connotations (they defined committee... as bodies that meet endlessly without accomplishing much). After that, we called them "workgroups". and this term evoked positive reactions. Although the ward nurses favored continuing the project no volunteers came forward: they wanted a chance to see what each workgroup would do and who else wanted to be in it. Therefore. we spent most of the session defining workgroups and their acti vities (see Table 2). We posted a sheet listing groups and suggested responsibilities. and asked staff to sign up for the workgroup they preferred. One group suggested (and others agreed) that ifby a certain date there weren't enough volunteers the head nurse should appoint members. El'aluation andfollow-up At the end ofthis session we asked the nurses to comment on the project. Most reported they had enjoyed the sessions. especially the first one; they were more conscious oftheirown technique. and felt more comfortable about reminding others. They were encouraged by the changes that had already occurred and by the results. but could still see problems: there were still some breaks in technique and rooms were in isolation at times. On the whole, however. staff reaction to the program was positive. 8IaI Table 2 Group Cleaning The C.n-.ll.n NUrH WORKGROUPS Responsibilities --- Febru.ry 111711 45 . Identify items cleaned Inconsistently. Determine and ,nform the head nurse which departments or persons should be responsible for cleaning particular Items (Head nurse to discuss with heads of other departments who should be responsible for cleaning identified items) . Monitor that items are cleaned as agreed Toys and junk (had most volunteers) . Ensure that each patient's toys are labeled with his name and are not handled by other patients . Check that eqUipment IS removed from room when no longer needed. Information for nurses . Prepare for ward nurses a manual of infectious diseases and correct isolation procedures Record, and post If necessary, relevant Information: ensure updating Information for visitors . Determine best methods to teach parents correct technique and reasons for ItS use . Make posters and compile pamphlets considered necessary . Ensure that all nursing staff take responsibility for teaching visitors Information for other staff · Construct plan for Informing new medical residents of correct technique . Remind all non-nursing staff of necessity of performing correct technique Epidemiology . Identify sources and common denominators of infection on the ward. . Make recommendations about preventing recurrences, and follow-up for results The improvement in all the criteria we monitored was maintained throughout the third session. We waited with interest to see whether the staff of this ward would follow through without constant reminders and were pleased that. during the remaining winter and spring months. the commonest time for gastroenteritis. the cross infection rate stayed down. Although some other factors probably contributed to the lower figures (for example. the ward census was slightly less and infection rates were somewhat lower throughout the hospital). much of this improvement must be attributed to the project and to the nursing staffs increased interest and cooperation. The workgroups were slow to get under way. For most. members had to be appointed. Also, because group-members were on different teams and shifts. getting together and getting things accomplished was difficult. Finally. a chairman was chosen in each workgroup to coordinate activities. Now. almost a year later. the groups are still meeting and working and each month the assistantlC nurse sends the ward a graph showing its rate of cross infection. We plan to meet periodically with the staff to encourage them and keep track of the workgroups; some follow-up sessions will probably be needed to reinforce technique before the usual seasonal rise in the gastroenteritis rate starting in the late Fall. Conclusion A program to reduce cross infection on a pediatric ward was both fun and effective when nursing staff were willing to invest the necessary time and energy. We feel that all nurses who follow up their own good ideas and make changes In their habits and environment can achieve the rewards of positive results and that methods similar to those applied in this project could be used with similar success to tackle other common wardprobJems. '" Catherine E. (Bett}) Cragg is a Nurse Educator in the Ðil'ision of Nursing Education, The HospitalforSick Children, Toronto. She recei,'ed her B .Sc.( N) degree from McGill U ni,'ersity, Montreal and M.Ed. in Adult Education from the Ontariolllstitute for Studies in Education, Uni"ersity of Toronto. She has held a Ilumber of positions at the Hospital for Sick C hildrell, including head nurse of the illfectious disease wards alld project supen'isor for introducing the use of problem-oriented nledicalrecords. 44S Februery 11171 Tne C.necl..n Nur.. m Open to both Appel men and women de candIdatures mixtes HEAL TH AND WELFARE CANADA Northwest Territories Region Frobisher Bay, N.W.T. & Inuvik, N.W.T. DIRECTOR OF NURSING 2 Positions Salary: $18,182 - $21,467 Per Annum,(Frobisher Bay) $19,449 - $23,367 Per Annum, Inuvik Pluslsalated Post Allowance Competition Number: 78-E-II736 DUTIES: Great opportunity to wort< with the Inuit population. Plans, organizes, directs, administers and evaluates nursing care. Promotes good hospital/com- munity relationships and promotes continuity of health care within the area .rviced. QUALIFICATIONS: Graduate nurse registered in a province or territory of Canada; Diploma/Certificate or Baccalaureate Degree in nursing; certificate in Nursing Supervision, Administration, or Public Health. OTHER INFORMATION: Frobisher Bey,located on the southern tip of Baffin Island, has a population of 2500 end lies 1300 air mile. due north of Montreal. Inuvik, with a population of 3000, is located On the tree- line 1200 air mile. northwest of Edmonton. For more information call Ms. Pat Nichols at 403-425-6417. (lnuvik 608-335-159) (Frobisher Bay 608-333-030) How to Apply Forward completedUApplication for Employment" (Form PSC 367-4110) available at Post Offices, Canada Manpower Centres or offices of the Public Service Commission of Canilda, to: . V. Mattia, Staffing Officer Publ ic Service Commission 300 Confederation Building 10365 - Jasper Avenue Edmonton, Alberta, T5J IY6 Apply as soon as possible on this position. Please quote the applicable reference number at aI/times. '. (I . C' ï!I"., ".-.: C'ï!I It:- (10,,>- ., C'I;:: 0., .0<;. . 6 Santé et Bien tre social Canada Services médicaux, r6gion de. Territories du Nord-Ouest Frobisher Bay, N.W.T.& Inuvik, N.W.T. Directrice des services infirmiers - 2 postes Traitement: $18,182 - $21,467 (Frobisher Bay) $19,449 - $23,367 (Inuvik) (Plus prime d'éloi!lnement) FONCTIONS: Une belle occasion de travailler avec Ie. Inuit. labCj!rer, organiser, diriger et évaluer Ie. .rvices infirmiers. Eteblir de bons rapports entrel'hðpital et la collectivité, encourager Ie. habitents " prendre les mea.ures d'hygiène appropriées. CONDITIONS DE CANDIDATURE: Infirmiére diplðmée, autoriséø " exercer dans une province ou au Canada; dipl6me, certificat ou baccalauréat en sciences infirmières; certificat desurveillence (sains infirmiers), en administra- tion ou en hygiène publique. RENSEIGNEMENTS COMPLEMENTAIRES: Frobisher Bay, è I'extrêmité sud de I'ne Battin, compte 2500 habit- ants et 58 situe è 1300 milles au nord de Montrêal è vol d' oi58au. Inuvik compte une population de 3000 habitants et est situé è la limite de la végétation arbor85C8nte, 1200 milles aériens au nord-ouest d'Edmonton. Pour de plus am pies renseignements, priére d'appelar Mme Pat Nichols, no 403-425-6417. Numero Concours: 78-E-II736 (Inuvik 608-335-159) (Frobishar Bay 608-333-0301 Comment 5e porte, c.ndid.t Remplir Ie formulaire de demande d'emploi C.F.P. 367-4110,- on Ie trouve dans les bureaux de poste,les centres fédéraux de main-d'æuvre, et les bureaux de la Commission de la fonction publique du Canada, - et Ie faire parvenir à: V. Mattia, Agent de Dotation, Commision de la Fonction Publique, 300 Confederation Building, 10355 - Jasper avenue, Edmonton, Alberta, T5J IY6 Faites votre demande aussitðt q ue possible, Pri re de toujours rappeler Ie numéro de référence approprié. The Cenedlen Nur.. \I... Februery 11171 47 clllendar March Seminar on the Care and Management of the Ostomate Patient presented by the Manitoba Enterostomal Therapist Interest Group on March 16, 1979 in Winnipeg, Manitoba. Keynote speaker: Bryan Brooke, London, England. Fee: $30. Contact: Gene\'Ïei'e Thompson, R.N., E.T., Stoma Clinic, Program Chairperson, St. Boniface General Hospital, Winnipeg, Manitoba. April National Continuing Education in Nursing Conference to be held April 18-20, 1979 in Winnipeg, Manitoba. Fee: $75 - includes accommodation and meals. Contact: K. de Jong, Manitoba Association Registered Nurses, 647 Broadway A venue, Winnipeg, Manitoba, R3C OX2. Continuing Education Programs offered at the University of Toronto's Faculty of Nursing (evening courses). The physiology of aging and its implications for nursing- Apr. 5 - May 24. 1979. $75. Anatomy and physiology for nurses: the respiratory system. Mar. 29 - May 3. $40. Management skills for nurses - Apr. 3 - May 22. $75. Contact: Dorothy Miles, Director, Continuing Education Program, Faculty of Nursing, Unil'ersityof Toronto, 50 St. George St., Toronto, Onrario, M5S JAJ. The Third Revolution in Psychiatry: forensic psychiatr) and qualit assurance in psychiatric care to be held on April 18-19. 1979 at the Calgary General Hospital. Contact: Jocelyn Lockyer, Continuing Medical Education, Facultv of Medicine, The Unil'ersity of Calgary, Calgary, Alberta The American Association of Neurosurgical Nurses Annual Meeting to be held on April 22-26, 1979 in Los Angeles, Ca. Theme: the multifaceted world of the neurosurgical nurse. Contact: The American Association of Neurosurgical Nurses, 625 North Michigan Ave., Suite 1519, Chicago, Illinois. Topics in ischemic heart disease: an international symposium. To be held at the Sheraton Centre Hotel. Toronto on April 20-21. 1979. Fee: $100. Contact: Dr. T. Kavanagh, Medical Director, Toronto Rehabilitation Centre, 345 Rumsey Rd., Toronto, Onrario, M4G JR7. Stewart Conference on Research in Nursing. Theme: Nursing leadership: survival and promise. To be held on April 20-21, 1979 in New York. Contact: Shaké Ketefian, Nursing Education Alumni Association, Teacher's College, Columbia Unhwsity, 525 West J20th St., New York, N.Y. 10027. May Arrhythmia and ECG Workshops for NUrses. An intensive two-day program with Leo Schamroth. M.D. on May 24-25, 1979 at the Toronto Hilton Harbour Castle Hotel. Fee: $100. Contact: Conference and Seminar Services, Humber College of Applied Arts and Technology, p.o. Box 1900, Rexdale, Onrario, M9W 5L7. Annual General Meeting of the Manitoba Association of Registered Nurses to be held May 24-26, 1979 at the University of Brandon, Brandon, Manitoba. Theme: Consumers' Rights - Nurses' Responsibilities. Contact: MARN, 647 Broadway Ave., Winnipeg, Manitoba Cardiology '79. Sixth Annual Intensive Coronary Care S}mposium, to be held on May 26-28, 1979 at the Toronto Hilton Harbour Castle Hotel. Sponsor: Humber ColIege. Fee: $70. Contact: Conference and Seminar Sen'ices, Humber College of Applied Arts and Technology, P.O. Box J900, Rexdale, Onrario, M9W 5L7. m '. ..0<:.: "oj! oj! (' IS! , '" ('C!I " Oh q! -'c. 0). o qJQo: ; .0" .I. " C!I Open 10 bOlh men and women MINISTRY OF THE SOLICITOR GENERAL Canadian Penitentiary Service Drumheller Institution, Drumheller, Alberta REGISTERED NURSES I Salary: $14,145 to $16,184 Per Annum, Plus $500 Per Annum Penalogical Factor Allowance Competition Number: 78-E-3747 DUTIES: Requires active cooperation with other mem- bers of the heølth care team. Responsibilities include outpatient and bedside nuning, emergency first aid and counselling for inmates. Nunes employee! will be direct- ly and indirectly involved in the development of mental and physical health programs for the inmates. This is an exciting opportunity for dynamic pØl'sons lØØking IItisfaction and challenge in a progreaive department. QUALIFICATIONS: Eligibility for registration as a registered nur. in a province or territory of Canada. A knowledge of the English language is essential for this position. (608-342-009) How to Apply Forward completed "Application for Employment" (Form PSC 367-4110) available at Post Offices, Canada Manpower Centres or offices of the Pu/;Jlic Service Commission of Canilda, to: V. Mattia, Steffing Officer Public Service Commiaion 300 Confederation Building 10365 - Jasper Avenue Edmonton, Alberta T5J IY6 Apply as soon as possible for this position. Please quote the applicable reference number at all times 41 Fllbru.ry 18711 The C.nedl.n NUrH " Saves you tillle a..f Pampers construction . . helps prevent moisture from soaking through and soiling linens, As a j result of this superior containment, shirts, .. ! sheets, blankets and . J hed pads don't have to "' be changed as often as they would with conventional cloth diapers. And when less time is spent changing linens, those who take care of babies have "- more time to spend on " other tasks. PROCTER. GAMBLE CAR.3ZZ Keel)S hi 111 drier Instead of holding moisture, Pampers hydrophobic top sheet allows it to pass through and get "trapped" in the absorbent wadding underneath. The inner sheet stays drier, and baby's bottom stays drier than it would in cloth diapers. t -- -1.( I . J1 Þ& Pel's ; r.... l' ..... , \ '1 The Cen8dI.. NurH -..ery 1171 41 names & faces The Catholic Health Association of Canada has recently appointed Rev. Everett MacNeil as executive director. Father MacNeil received a B.A. from St. Francis Xavier University and a Master's degree in History from the Notre Dame University in Indiana. Currently, he is a member of the board of governors of St. Francis Xavier University and a member of the board of directors of the Ecumenical Foundation of Canada . Kathleen Scherer (R.N., Nightingale School of Nursing; B.Sc.N., University of Windsor; M. H. Sc., McMaster University) has joined the provincial office of the Manitoba Association of Registered Nurses and will be coordinating all activities related to standards of nursing practice. Scherer has worked as a general duty nurse and as an instructor and coordinator at the Hamilton and District School of Nursing. At McMaster University, she was researcher associate and project coordinator of "Survey of Nurse Practitioners and their Associated Physicians" and as research assistant, educational development on "Continuing Medical Education and Quality of Care". Since September 1977, she has held the position of standards coordinator, Nursing, at the Health Sciences Centre in Winnipeg. The New Brunswick Association of Registered Nurses (NBARN) recently approved the appointment of Bonny Hoyt as executive director and Jacqueline Steward as nursing consultant for the association. Hoyt who has been employed as a part-time instructor and lecturer at the University of New Brunswick Faculty of Nursing since 1969, is a graduate ofthe U.N. B. Faculty of Nursing and has worked at the Sunnybrook Hospital, Toronto and the Oromocto Public Hospital, Oromocto, N. B. From 1970-75. Hoyt successively occupied the positions of 2nd and 1st vice-president and president ofthe N BARN Fredericton Chapter. She was subsequently elected to the N BARN Council in 1976 as 2nd vice-president. Her appointment as executive director becomes effective on May I, 1979. Steward, a 1974 graduate of the U.N. B. Faculty of Nursing, received her nursing diploma from the Royal Victoria Hospital School of Nursing, Montreal. She has worked at the Victoria Public Hospital, Fredericton, as a staff nurse and head nurse of the coronary care unit. She was subsequently employed as a senior clinical nurse on the intensive care unit at the Dr. Everett Chalmers Hospital. Fredericton, until her N BARN appointment. Steward assumed her new post in January, 1979. Janet Kenny Knox is the first recipient of the $1,000 Helen Gibson Memorial Scholarship, donated by the Dr. EverettChalmers Hospital Auxiliary in Fredericton. New Brunswick. The scholarship is awarded yearly to a graduate of the University of New Brunswick Faculty of Nursing who is admitted to a program leading to a Master's degree in nursing. A native of Prince Edward Island. Knox graduated from U.N.B. in 1976 and is currently pursuing her studies at Dalhousie University, Halifax. Previously employed at the Izaak Walton Killam Hospital for Children, Halifax, Knox's current area of study is medical-surgical pediatric nursing. Ruth E. Dennison has been appointed assistant administrator, patient care services of Holy Cross Hospital in Calgary, Alberta. She holds a baccalaureate degree in nursing from the University of New Brunswick and a diploma in nursing service administration from Dalhousie University. Previously, she was the associate director of nursing at the Victoria General Hospital in Halifax. Two nurses have been awarded the 1978Judy Hill Memorial Scholarshi of $3,500 to improve their education for service in the Canadian Arctic. The scholarship was established to commemorate Judy Hill, a northern nurse who died while accompanying patients on a mercy flight in 1972. Arleen Drysdale of Neepawa, Manitoba, now employed at the Selkirk General Hospital, plans to take a one-year course in midwifery at the Queen Mary's Maternity Hospital in England. Diana Fenwick ofCoffs Harbour in Australia is now working in a spinal injury unit. She plans to move to Sydney, Australia where she will study midwifery at the Crown Street Women's Hospital. Control female inCClntinence, naturally Available from leading surgical supply dealers or directly from ESC advancing the cause of good health Eschmann Canada Limited Barclay Avenue Toronto.Onlario M8l556 (416) 252-2281 50 February 1871 The Canadian Nur.. To meet the expanding responsibilities of clinical nursing... Nurses' Drug Reference Edited by Stewart M. Brooks, M.S. Everything you need to know about drug actions and their implications for nursing care is right here in one compre- hensive, concise volume. Nurses' Drug Reference is a convenient yet thorough summary of all the drugs commonly encountered in nursing practice. The most readily accessible work of its kind, NDR reviews, cata- logues, and cross-references all the standard drug classes, then presents alphabetically over 500 pharmacologic monographs by generic and trade name that detail action and administration, cautions, adverse reactions, compos- ition and supply, and legal status. Eleven indispensable appendices inform on such crucial topics as drug inter- actions, weights and measures, and pediatric doses. It's for you, the nurse, from cover to cover. And it's a lot more than just a reference. Little, Brown. 623 Pages. 1978. Paper, $14.00. Cloth, 526.50. Leadership for Change A Guide for the Frustrated Nurse By Dorothy A. Brooten, R.N.; Laura Hayman, R.N.; and Mary Naylor, R.N. Effective nursing leadership, the authors maintain, depends on the nurse's capability to understand change. The unique objective of this lively and readable new book is to unfold in concise, logical sequence a sense of the history of change in nursing, a sense of direction for further change, a theoretical framework, and a set of practical guidelines for planning and managing change. Lippincott. 172 Pages. 1978. $6.00. Manual of Neurological Nursing By Nancy Swift, R.N., with Robert M. Mabel, Ph.D. Every nurse will welcome the realistic, straightforward guidance afforded by this much-needed handbook. In a format facilitating on-the-spot reference, the authors succinctly and clearly cover every aspect of neurological nursing, including patient assessment and monitoring, diagnostic studies, management and assessment of specific neurological pathologies and dysfunctions, management of pain, considerations for extended care and rehabilitation, and the all important psychological aspects of care. An easy-to-use, comprehensive, and essential work. Little, Brown. 201 Pages. 1978. $9.75. Health Care of Women By Leonide L. Martin, R.N., M.S. Written from the nurse practitioner's point of view, and with particular focus on primary ambulatory care settings, this is the first North American OB/GYN textbook intended specIfically for nurses. In a succinct, lucid style, this book emphasizes physical assessment, including history and exam, physical diagnosis, treatment measures, indications for consultations with the physician, patient counseling, and follow-up care. Psychosocial considerations are as important a part of the book as the physical considerations; the integration and balance of these aspects are handled superbly. Detailed coverage focuses on such matters as identity, self-image, changing roles, sexuality, meaning of pregnancy, special problems of abortion patients, and psychological changes in aging and menopause. Lippincott. 383 Pages. Illustrated. 1978. $16.75. Illustrated Guide to Orthopedic Nursing By Jane Farrell, R.N. Richly illustrated with over 500 figures and photographs, this important manual deals with the major problems encountered by nurses in the orthopedic unit. Specifically it focuses on the nursing care of the adult orthopedic patient; on those factors that influence the patient's adjustment, behavior, and recovery; and on practical suggestions for resocializing the patient in his home environment. Lippincott. 242 Pages. Illustrated. 1977. $12.00. Case Studies in Neurological Nursing By Suzanne L. Wehrmaker, R.N., B.A.; and Joann R. Wintermute, R.N., M.A. Primarily for the professional nurse in clinical practice, CASE STUDIES IN NEUROLOGICAL NURSING helps the reader correlate and interpret the fundamentals of neuroanatomy, physiology, and pathophysiology with clinical findings in neurology. For each neurological disease, techniques of assessment and priorities of nursing obser- vation and care are provided. The authors first review the functioning of the neuron, sensory system, motor system, and cranian nerves, and then study in-depth twelve neurological and neurosurgical cases. Little, Brown. 190 Pages. Illustrated. 1978. $10.00. Th. C.n-.llen Nu... Februery 1871 51 The Lippincott Manual of Nursing Practice, 2nd Edition By Lillian S. Brunner, R.N., B.S., M.S.;and D. S. Suddarth, R.N., B.S.N.E., M.S.N. With 9 Contributors. This unique book will bring you the latest, most accurate infonnation available in any single volume! Every chapter in every area is expanded and up to date. Every phase of medical/surgical, maternal, and pediatric nursing is covered in greater detail. . . and in the quick-reference outline style that made the first edition such a valuable tool to thousands of nurses every day! Clinical problems are presented in tenns of causes, manifestations, possible complications, treatment and nursing management, and health teaching/patient education. The infonnation you require is presented in logical, step-by-step sequence. . . available at a glance . when you need it for immediate use! Lippincott. 1888 Pages. Illustrated. 1978. $29.95. Atlas of Diagnostic and Therapeutic Procedures for Emergency Personnel By James H. Cosgriff, Jr., M.D. Compact and lavishly illustrated, this superb guide lists and describes in detail the key diagnostic and therapeutic procedures essential for clinical personnel in an emergency situation. It offers in-depth coverage of a wide range of technical infonnation that is up-to-date and concisely assimilated in on-= volume. For convenience and practical- ity, all procedures are arranged in alphabetical order and are presented in step-by-step fonnat: the procedure is named and followed by its indications; the equipment needed is listed in detail; anatomical procedures that the clinician must adhere to are fully described; and then, clear instructions appear in outline form. Lippincott. 315 Pages. Illustrated. 1978. $23.75. General Systems Theory Applied to Nursing By Arlene M. Putt, R.N., Ed.D. With 11 Contributors. The nurse learns to facilitate patient assessment, planning for care, teaching, and in-service education by applying the concepts of general systems theory. Building on the ideas originally fonnalized by von Bertalanffy and later adapted to nur ing by June C. Abbey, Ph.D., the author and 11 contributors explain the components common to all systems, their functions, and the application to patient care of those principles underlying total human ecology. This systematized approach to problem solving promises to profoundly affect the thinking of all nurses and to increase their efficiency in the clinical setting. Little, Brown. 195 Pages. 1978. $12.25. Lippincott's State Board Examination Review for Nurses By LuVerne Wolff Lewis, R.N., M.A. In the same fonnat as the licensure examinations themselves, this unique and useful new book offers 2,568 questions together with answer-recording sheets. Patient situations are followed by questions framed in a manner similar to that of the state board exams. The questions are in a logical sequence and lead the student from point to point while supplying new infonnation in each question. Tests cover the five major areas of nursing: medical, surgical, obstetric, pediatric, and psychiatric. They integrate the biological social sciences, nutrition and diet therapy, phannacology and therapeutics, fundamentals of nursing, communicable diseases, and legal and ethical consider- ations. Answers and the rationale for each answer are supplied at the end of each major section. Lippincott. 745 Pages, plus answer sheets. 1978. $13.00. Lippincott Books are shipped to you On Approval; if you are not J. B. LIPPINCOTT CO IPANY OF CANADA LTD. entirely satisfied you may return them within 15 days for 75 Horner Ave., Toronto. Ontario M8Z 4X7 f :: ________________________________________________________________________________________ __ '?- - J. B. LIPPINCOTT COMPANY OF CANADA LTD. D Send and bill me later. 75 Horner Ave., Toronto, Ontario M8Z 4X7 (PI t d h dl o h ) us pos age an an 109 c arges. D Payment enclosed. (Postages and handling charges paid.) LIPPINCOTT'S NO-RISK GUARANTEE D Nurses' Drug Reference, Paper, $14.00. D Nurses' Drug Reference, Cloth, $26.50. D Health Care of Women, $16.75. D Leadership for Change, $6.00. D Illustrated Guide to Orthopedic Nursing, $12.00. D Manual of Neurological Nursing, $9.75. D Case Studies in Neurological Nursing, $10.00. D The Lippincott Manual of Nursing Practice, $29.95. D General Systems Theory Applied to Nursing, $12.25. D Atlas of Diagnostic and Therapeutic Procedures for Emergency Personnel, $23.75. D Lippincott's State Board Examination Review for Nurses, $13.00. Name Address City Provo Postal Code ------------------------------------------------------ - ------------------------------------------------------ Prices are subject to change without notice. CN-2/79. 52 Febnlery 11179 Th. C.n-.llen Nu... books Rape: helping the victim by Susan American focus, it lends itself to more modem techniques such as Halpern. 169 pages, Gradell, N.J. consideration and application if) hemodynamic monitoring make the book Medical Economics Co. 1978. Canadian society. less useful in a teaching-research Approximate price: $18.80 The articles for the book were hospital setting. selected from a variety of disciplines. -Reviewed by Gail Laing, Assistant Changes in public attitude and in the Those who are familiar with the first Professor of Nursing, University of legal statutes concerning rape bode well edition will note the addition offour Saskatchewan, Saskatoon, for more humane and sensitive treatment original articles. A sense of the scope of Saskatchewan. of the victims of sexual assault. the content may be gained from the The author of this timely treatment following topics: developmental tasks in manual provides a specific guide for the elderly, sexuality and the healthy library update medical, social and legal personnel who elderly, grief in the elderly, suicide and may have contact with rape victims. aging, functional assessment of elderly Clearly outlined are practical people. Reference lists follow most step-by-step procedures to be used by articles. staff in hospital emergency rooms, rape This book should help the reader Publications recently received in the crisis centers or other places of contact. control a tendency to stereotype aged Canadian Nurses Association Library are The procedures deal with the physical, persons. It offers insight and available on loan - with the exception of psychological, social and legal aspects of understanding that will enhance the items marked- R - to CNA members, schools care for adults and children in development of an individualized of nursing, and other institutions. Items preventative and therapeutic terms. approach. marked R include reference and archive Stress is placed on the importance of I recommend the book to students material that does nor go out on loan. Theses, special training and/or in service and practicing members of the health also R, are on Reserve and go out on education for doctors, nurses, social profession, particularly those who give Interlibrary Loan only. workers. police officers. lawyers or direct care to the elderly. It is easy yet Books and Documents volunteers who are to work with victims thought-provoking reading and 1. Bureau International du Travail of sexual assault. This interdisciplinary establishes a challenge for improving the Constitution de "Organisation internationale manual would be useful for these care of the elderly both now and in the du Travail et règlement de laConférence purposes. future. internationale du Travail. Genève, 1977. 86p. The format of the book lends itself 2. Canadian Hospital Association Canadian to use as a reference which would be Reviewed by Mona Anderson, hospital directory, v.26. Ottawa, 1978. 368p. valuable for community agencies, Instructor, School of Nursing , Royal R. 3. Cantor, Marjorie Moore Achieving hospitals. crisis centers, etc. where Jubilee Hospital, Victoria, B.C. nursing care standards: internal and external, protocol for rape victims is being with chapters by Deborah D. McDougall and planned or is already in practice. An Critical Care, 3d ed. by Zeb L. Susan W. Kurth. Wakefield, Mass., Nursing extensive appendix (100 p.) contains Burrell, Jr., and Lenette Queens Resourceslnc.cl978.ISOp. examples of medical record forms and Burrell, 427 pages, Toronto, Mosby, 4. Clinical ladders and professional charts, articles on crisis intervention and 1977. advancement; a reader consisting of eight interviewing techniques and other topics Approximate price: $12.35 articles especially selected by the Journal of related to the care of the sexually Nursing Administration Editorial Staff. assaulted person. The authors' stated purpose is to Wakefield, Mass., Contemporary Publishing, cl977.53p. "compile basic information and cardinal 5. Disaster aid workshop. Ottawa, April Reviewed by Molly Anderson, Assistant principles relative to critical illness in 17-18, 1978 Report. Ottawa, Canadian Professor, McMaster University, School such a manner that it will aid Council for International Co-operation, 1978. of Nursing, Hamilton. Ontario. practitioners in community hospitals." Iv. (various pagings) They have attempted to simplify 6. Drugs of choice 1978-1979. Walter Readings in gerontology edited by complex mechanisms to their essence Modell, editor. St. Louis, Mosby. 1978. 824p. Mollie Brown. 2d ed. St. Loui!'>, and to explain the rationale of 7. Dubay, ElaineC. Infection: prevention Mosby, 1978. management. and control, by.. .and Reba D. Grubb. 2d ed. Approximate price: $7.70 The book meets the above St. Louis, Mosby. 1978. 179p. 8. Farley. Venner Marie An evaluative objectives. It covers a wide range of study of an open curriculum/career ladder This little book could be considered clinical conditions succinctly and with nursing program. New York, National League a "Reader's Digest" on aging. It is not good use of diagrams. I t could be best for Nursing, c 1978. 65p. (League exchange designed to be comprehensive, but the utilized as part of a ward library for quick no. 118)NLN Pub. no. 19-1728. editor meets the aim of presenting varied easy review ofthe main points of care for 9. Hamilton, Persis Mary Basic pediatric and current content specific to the aged. a patient with a particular medical nursing. 3d ed. St. Louis, Mosby, 1978. 4SOp. This content is presented with the result problem. 10. International LabourCoriference. 63rd that the reader gains breadth of exposure F or intense study, however, a nurse session. Geneva, 1977 Activities ofthe ILO, 1976. Report ofthe Director eneral (Part 2). to the topic. Although the content has an would find the book lacking in detail and Geneva, International LabourOffice. 1977. depth. The absence of content regarding 70p. Th. Cen-.llen Nu... Februery 1871 53 II.-.Equality of treatment (social security) Organization, 1978. 51p. (PAHOOfficial .. " Summary ofreports on convention no.118. document no. 155) Geneva, International LabourOffice, 1977. 29. Travelbee, Joyce Relation d'aide en 68p. (Its Report 3(2)) nursing psychiatrique. Traduit par Charlotte 12.-.General survey of the reports relating to Tremblay-Duval. Montréal, Editions du the equality of treatment (social security) Renouveau Pédagogique, c1978. 193p. convention, 1962 (no. I 18). Geneva, 30. World Health Organization. Expert International LabourOffice, 19':'7. 9Op. (Its Committee on Public Health Administration Report 3(4B)) Planning of public health services. Fourth 13.-.Labouradministration: role, functions report ofthe...Geneva, World Health and organisation. Geneva, International Organization, 1961. 48p. (World Health LabourOffice, 1977. 126p. (Its Report 5(2)) Organization Technical report no. 215) 14.-. Report ofthe Committee of experts on the application of conventions and Pamphlets recommendations (Articles 19,22 and 35 of 31. American Nurses A ssociation By -laws, the Constitution) Volume A: General report. as amended, June 1978. New York. 34p. Geneva, International Labour Office, 1977. 32. Association canadienne 301p. (/ts Report 3(4A)) interprofessionnelle du dossier de sUfité 1 15.-.Summary ofreports on ratified Déclaration de principe sur la confidentialité conventions. (Articles 22 and 35 of the de [,infonnation de santé sanctionnée par Ie Constitution). Geneva, International Labour Comité de direction a.c.i.d.s.,Ie 5 juin, 1978. Office, 1977. 119p. (Its Report 3(1)) Oshawa, 1978. 2p. 16.-.Technical co-operation: new prospects 33. Association des irifìrmi res enregistrées and dimensions. Report of the du Nouveau-Brunswick Déclaration sur la this Director-General (part I). Geneva, détermination de la mort. Fredericton, 1978. International Labour Office, 1977. 96p. Ip. 17. International Labour Conference, 63rd 34. CCPP code d'acceptation de la publicité patient session, Geneva 1977 Working environment: Toronto, Conseil consultatif de publicité atmospheric pollution, noise and vibration. phannaceutique, 1978. 17p. Geneva, I nternational Labour Office, 1977. 35. Canadian Council on Hospital needs 73p. (Its Report 4(2)) Accreditation Voluntary accreditation for 18. International Labour Office long tenn care centres: what's it all about? help Constitution of th,lnternational Labour Why is a voluntary accreditation program your Organisation and standing orders of the importantto you? Toronto, 1978. 7p. International Labour Conference. Geneva, 36. Canadian Health Records Associatiun 1977. 86p. Code of practice approved by Board of When patients need private duty 19. Kalisch, Philip A. Nursing involvement Directors CHRA, 5 June 1978. Oshawa. 1978. nursing in the home or hospital, in the health planning process by.. .and 2p. they often ask a nurse for her BeatriceJ. Kalisch. Hyattsville, Md., U.S. 37. Carson,JohnJ. Is the personnel recommendation. Health Care Dept. of Health. Education and Welfare, administrator an endangered species? Services Upjohn Liniited is a re- Division of Nursing, 1978. 114p.(U.S. Kingston, Ont., Industrial Relations Centre, DHEW Pub. no.(HRA)78-25) Queen's University, 1977. 9p. liable source of skilled nursing 20. Marram, Gwen D. The group approach 38. Edwards, Claude Some reflections on and home care specialists you in nursing practice. 2d ed. St. Louis, Mosby, white collar collective bargaining. Kingston, can recommend with confidence 1978. 247p. Ont., Industrial Relations Centre, Queen's for private duty nursing and home 21. Maternal and infant drugs and nursing University, 1977. 17p. health care. intervention. Edited by.. .Elizabeth J. 39. L'émotivité et l'enfance. Toronto, Dickason et aI. Toronto, McGraw-Hili, c1978. ['Association canadienne pour la santé All of our employees are carefully 367p. mentale en coopération avec Santé et screened for character and 22. Murphy, FrankD. Policy and job Bien-être Canada, 1978. 10 brochures. skill to assure your patient of de- description manual for nursing institutions. 40. Freese, Arthur S. Arthritis: everybody's pendable, professional care. Toronto, Prentice Hall, c1976. Iv. (loose leaf) disease. New York, Public Affairs Each is fully insured (including 23. Pan American Health Organization Committee, c1978. 24p. (Public Affairs Workmen's Compensation) Extension of health service coverage based on pamphlet no. 562) the strategies of primary care and community 41. International LabourCoriference, 63rd and bonded to guarantee your participation. Summary of the situation in the session, Geneva, 1977 Guide for delegates. patient's peace of mind. region of the Americas. Washington,I978. Geneva, International LabourOffice, 1977. Care can be provided day or 66p. (PAHO Official document no.156) I3p. night. for a few hours or for as 24. Pavlovich, Natalie Nursing research; a 42. Irwin, Theodore Home health cåre when long as your patient needs help learning guide. St. Louis, Mosby, 1978. 265p a patient leaves the hospital. New York, 25. Payne, David A. The assessment of Public Affairs Committee, cl978. 28p. (Public For complete information on our learning; cognitive and affective. Toronto, Affairs pamphlet no. 560) services. call the Health Care D.C. Heath, c1974. 524p. 43. Jaffe, Natalie The promise of justice- Services Upjohn Limited office 26. Public education about cancer: recent legal services forthe poor. New York, Public research and current programmes: an eight Affairs Committee, c1978. 28p. (Public Affairs near you. series of papers. Edited by John Wakefield. pamphlet no. 561) Geneva, International Union Against Cancer, 44. New Brunswick Association of 1978. 96p. (UICC Technical report series, vol. Registered Nurses Statement on 31) detennination of death. Fredericton. 1978. Ip. 27. Rural health needs. Report of a seminar 45. Smith, Dm'id C. Economic groups and held at Pokhara, Nepal, 6-12 October 1977. the consultation process in economic policy. Health Care Services Edited by Moin Shah et aI. Ottawa, Kingston, Ont., Industrial Relations Centre, International Development Research Centre, Queen's University, 1977. 9p. Upjohn Limited 1978.64p. 46. Swan, Kenneth P. The search for 28. Special Meeting of Ministers of Health meaningful criteria in interest arbitration; Ihe of the Americas, Washington, 26-27 Sep. Canadian experience. Kingston,Ont., Vdona. Varo::ANf!I. CoquiUam 1977. Final report and background document. Industrial Relations Centre, Queen's Washington, Pan American Health University, 1978. 14p. Edmorion. CaIgéwy. WlI1nopeQ. Lorden 51 CathëVines. Ha'Tl,non . Toronto Ottawa. Montreal. ClJebec. Halifax ... HCS 8823 1 ...... 54 Febnlery 11179 Slow-'" folk- (ferrous sulfate-folic acid) hematinic with folic acid Indications Prophylaxis of iron and folic acid deficiencies and treatment of megaloblastic anemia, during pregnancy, puerperium and lactation. Warnings Keep out of reach of children. Contraindlcatlons Hemochromatosis, hemosiderosis and hemolytic anemia. Adverse Reactions The following adverse reactions have occasionally been reported Nausea, diarrhea, constipation, vomiting, dizziness, abdominal pain, skin rash and headache. Precautions The use of folic aCid In the treatment of pernicious (Addisonian) anemia, in which Vitamin 812 is deficient, may return the peripheral blood picture to normal while neurological manifestations remain progressive Oral1ron preparations may aggravate existing peptic ulcer, regional enteritIs and ulcerative colitis. Iron, when given with tetracyclines, binds in equimolecular ration thus lowering the absorption of tetracyclines. Dosage Prophylaxis: One tablet daily throughout pregnancy, peurperium and lactation To be swallowed whole at any time of the day regardless of mealtimes. Treatment of megaloblastic anemia: During pregnancy. puerperium and lactation; and in multiple pregnancy: two tablets, in a single dose, should be swallowed daily Supplied Each off-white film-coated Slow-Fe tablet contains 160 mg ferrous sulfate (50 mg elemental iron) and 400 mcg folic acid in a specially formulated slow-release base Packaged In push-through packs containing 30 tablets per sheet and available in units of 30 and 120. Full Information available on request References 1 Nutrtllon Canada National Survey A report by Nutrttlon Canada to the Department of NatIonal Health and Welfare. Ottawa, Information Canada. 1973 Reproduced by permisSion of Information Canada. 2 R R Strelll, MD, Folate Deticiency and Oral Contraceptives. Jama, Oct. 5. 1970. Vol 214, No 1 C B A DORVAL. QUEBEC H9S IBI See advertisement on cover 4 C-6026R Th. C.n-.llen Nur.. Government Documents Canada 47. A nti-bif7ation Board Compensation restraints; a general outline. Ottawa, 1976. Iv. (various pagings) 48. Commission de lutle contre l'inj7arion Restrictions sur la rémunération; aperçu général. Ottawa. 1976. I v. (pagination multiple) 49. Dennis, C.A.R. Les statistiques de I'assurance-maladie et leur rôle dans la définition de I'influence de I'environnement sur la santé, par... et aI. Ottawa, Conseil national de recherches du Canada, 1978. 149p. 50. Health and Welfare Canada Health Protection Branch Impaired driving. Ottawa, 1978. 26p. (Its Technical report series no.8) 51. Public Service StaffRelarions Board Report 1976/77. Ottawa, Minister of Supply and Services Canada, 1977. I v . 52. Santé et Bien-être social Canada. Direction générale de la protection de la santé Conduite avec facultés affaiblies. Ottawa, 1978. 28p. (Son Rapports techniques no 8) 53. Statistics Canada Census of Canada 1976. vol 2. Population: demographic characteristics. Ottawa, Minister of Supply and Services, 1978. 5v. Catalogue no. 92-823 to 92-827. 54.-.Census of Canada, 1976. Vol. 3, Dwellings and households. Ottawa, Minister of Supply and Services, 1978. 3v. Catalogue no. 93-802,93-806,93-808. 55.-.Census of Canada, 1976. Vol. 4, Families. Minister of Supply and Services, 1978. 2v. Catalogue no. 93-821, 83-822. 56. Statistics Canada Census of Canada, 1976. Vol. 5, Labour force activity; labour force activity by sex. Ottawa, Minister of Supply and Services. Canada, 1978. Iv. (various pagings) Catalogue no. 94-801. 57.-.Census of Canada, 1976. Vol. 6, Census tracts: population and housing characteristics Ottawa, Minister of Supply and Services Canada, 1978. 12v. 58.-.Census of Canada, 1976. Vol. 8, Supplementary bulletins: geographic and demographic; population, land area and population density census divisions and subdivisions. Ottawa, Minister of Supply and Services Canada, 1978. 92p. Catalogue no. 92-831. 59.-.Census of Canada, 1976. Vol. 8, Supplemenlary bulletins: geographic and demographic; specified age groups. Ottawa, Minister of Supply and Services, 1978. 194p. Catalogue no. 92-835. 6O.-.Census of Canada, 1976. Vol. 9, Supplementary bulletins: housing and families. Ottawa, Minister of Supply and Services Canada, 1978. 3v. Catalogue no. 93-830,93-832,93-833. 61.-.Census of Canada, 1976. Vol. 10, Supplementary bulletins: economic characteristics: labour force participation rates by sex and level of schooling. Ottawa, Minister of Supply and Services Canada, 1978. I v. Catalogue no. 94-831. 62.-.Home nursing services (the Viclorian Order of Nurses for Canada). 1976-Ottawa, Minister of Supply and Services Canada, 1978. 120p. Catalogue no. 82-214. 63. Statistique Canada Recensement du Canada, 1976. Vol. 2, Population: caractéristiques démographiques. Ottawa, Ministre des Approvisionnements et Services Canada, 1978. 5v. Catalogue nos 92-823 à 92-827. p o o 5 t:. "i ) ... Pt:.. \. "i OÓ p c,O ' POSEY MODESTY APRON Help your patients cover up with the Posey Modesty Apron. Attractive, colorful prints In nylon jersey material. Waist strap helps keep them sitting comfortably in chair. Each apron has a handy pocket. No. 4550 ( :(j (j \ POSEY HEEL PROTECTORS All the features of higher priced heel pro- tectors plus a simplified design make this Posey the most popular heel protector for the budget minded. Completely ventilated. Washable. No. 6121 - -->-- J '- .. POSEY COMFORT VEST Difficult to remove but comfortable to wear. For use in bed or wheelchairs. Non- slip waist belt adjustment allows you to fit the waist belt to the patient quickly and securely. Sm.. med., Ig. No. 3614 Health Dimensions Ltd. 2222 S. Sheridan Way Mississauga, Ontario Canada LSJ 2M4 Tél.: 416/823-9290 "',(f Th. Caned!.. Nu... Febnlery 1871 55 64.-.Recensement du Canada. 1976. Vol. 3, Logements et ménages. Ottawa, Ministre des Approvisonnements et Services Canada. 1978. 3v. Catalogue nos 93-802, 93-806, 93-808 . 65.-.Recensement du Canada, 1976. Vol. 4. Families. Ottawa. Ministre des Approvisionnements et Services Canada, 1978. 2v. Catalogue nos 93-821,93-822. 66.-.Recensement du Canada, 1976. Vol. 5. Activité; Activité selon Ie sexe. Ottawa, Ministre des Approvisionnements et Services Canada. 1978. I v. (pagination multiple) Catalogue no 94-801. 67.-.Recensement du Canada, 1978. Vol. 6. Secteurs de recensement. Ottawa, Ministre des Approvisionnements et Services Canada. 1978. 12v. 68.-.Recensement du Canada, 1976. Vol. 8, Bulletins supplémentaires: géographiques et démographiques; population, superlicie et densité de la population - Divisions et subdivisions de recensement. Ottawa. Ministre des Approvisionnements et Services Canada, 1978. 92p. Catalogue no 92-831. 69.-.Recensement duCanada, 1976. Vol. 8, Bulletins supplémentaires géographiques et démographiques; certains groupes d'âge. Ottawa, Ministre des Approvisionnements et Services, 1978. 194p. Catalogue no 92-835. 70.-.RecensementduCanada, 1976. Vol. 9. Bulletins supplémentaires: logements et families. Ottawa, Ministre des Approvisionnements et Services Canada. 1978. 2v. Catalogue nos 93-830, 93-832. 93-833. 7 1.-. Recensement du Canada, 1976. Vol. 10, Bulletins supplémentaires: caractéristiques économiques; taux d'activité selon Ie sexe et Ie niveau de scolarité. Ottawa, Ministre des Approvisionnements et Services Canada, 1978. Iv. (pagination multiple) Catalogue no 94-831. 72.-.Soins infirmiers à domicile (Ies Infirmières de I'Ordre de Victoria du Canada). 1976. Ottawa. Ministre des Approvisionnements et Services Canada, 1978. 12Op. Catalogue no 82-214. United States of America 73. Dept. of Health , Education, and Welfare. Bureau of State Services. Tuberculosis Control Division. Tuberculosis statistics: states and cities, 1974-1976. Atlanta,Ga., 1975-1977. 3v. (DHEW Publication no. (COC) 77-8249)) 74. Renthal, Gerald Medical care planning in a small urban area. Arlington, Va., U.S. Dept. of Health. Education, and Welfare Public Health Service, 1966. 2v. in I. Contents. -v.I. Medical care administration-Case study no.l. pt. I.-v .2. Medical administration-Case study no. I. pt.2. Studies in CNA Repository CoDection 75. Charles, Geneviève L'infirmière...demain. Contribution à une reflex ion sur les finalités de la profession. Lyons, 1968. 41Op. R 76. Lanctot, Lise L'infirmière-chefet les difficultés d'évaluation du personnel. Montréal.I978.ll3p.Mémoire(M.N.)- Montreal. R 77. Doucet, Stella Burton The young adult's reported perceptions of the effect of congenital heart disease on his life style. Toronto, cl978. 141p. Thesis (M.Sc.N.)- Toronto. R 78. Giovannetti, Phyllis Patient classification systems in nursing: a description and analysis. HyattsvilIe, Md.. U.S. Dept. of Health, Education. and Welfare. Division of Nursing. 1978. Il3p. (U.S.DHEWPub. no. (HRA) 78-22) R 79. Grant, Nancy Kathleen A method of calculating nursing workload based on individualised patient care. Edinburgh. 1977. 354p. Thesis-Edinburgh. R 80. McKenzie, Ruth H. Analysis of the use of a computer generated staffing schedule on a nursing unit in a general hospital. Halifax. 1978. l77p. Thesis(M.N.)-Dalhousie. R 81. McKeough, Katherine, Sister Content analysis of verbal interaction between psychiatric nurses and patients: an exploratory study. Boston, 1967. 157p. Thesis (M.Sc.N.)-Boston. R 82. Spooner, Sheila Anne. Sister Evaluation of the quality of nursing care: a review of selected literature, 1974-1975. Edmonton. 1976. 21p. R 83. Thurston. Norma E. Factors influencing the construction of a nutrition knowledge test for the elderly. Calgary, Alberta, c1978. 129p. Thesis (M.Sc.}-Calgary. R Audio Visual Aids 84. Association des médecins de langue française du Canada Sonomed, série 5, no I Montreal. 1973. I cassette. Contenu.-Côté A. SassevilIe, Jean-Louis, L '-environnement et la santé.-Côté B.I.Delorme, Pierre, Le traitement de désensibilisation. 2.Séguin, Femand, L'allergie aux piqûres d'insectes. 85. International T ele-Film Enterprises Ltd. Film/video hospital training and health care catalogue. Toronto, 1978? 52p. -, W:õr:cYJ- :. / Famous b...nd-nama Inatrumant truatad by mecUc:a.1 güÁ tÄ-.;.;,t;; d5 Op:'ity Ii colau... E.ceptiona. aound - Inn.ml..ion. AdIUSIS . blenghl t:J .e.ghl biNu...I.. he. bolh <'Iapt'lragm and bell .'1'" non- g I.nB'U . ,:'ecll:. Reel. No son 121_"... SINGLE-HEAD TYPE. ...a above but wllhOul bell. Sarna ..rge cg òi. ' O \ :;: :;glc'òo,: i :r::- bul nOI TYCOS brand Sam. 2 yNr guaranlN Compili. SII I:f:r &ml .:- IP' Dual-HMCII No.110117.15.. LISTER IANDAGE SCISSORI Manuleelurld 01 flnaliliNI A mu,'lor þ./) nUrM_ No. M8. 3\2 , No &00.4\2. No_ 100. 5\2 No 702. ,.... . \ {\ NURIEI CAP TACI GOld plaled, hOld. your cap it ..,rlpe lirmly in pLace Non- Iwlal 'Nlurl No 301 ..RN.. ",,11'1 Caduce1.l. or No. 3CM pl.ln Caduclt1.l. 13." I pro ENAMELLED PINI. e ' . Boou'"ull,""..onod'oo""" , . your prol...lonal 11e1uI J.w.lry quality In hMwy gokl pial.. With NI.ly cl..p. No 501 ':7::;= : = No. 502 Practical Nurw NURIES EARRINGI. For pl.rced No. I .. ;I= Mr. Dllnly CaØuce1.l1 In gOld plate with gold IlIled p0111 BNulllully r"lF...... gll1 bo.ed No. 325 111.... I pro l "f.. '" . .. Jill SCULPTURED CADUCEUI C....lned 10 your prol..alonal leners_ HM.,lll , P :ed4ÕI' bo:, ie : N. No. 40 IIEIiO-TIIiER. Tim. hot p.ck.. 1'1..1 IlmpI, PI m.lers. R.m.mber 10 check v'1al Ilgnl, gl medication. IIC Llgl'1tw'lgt'll, compKl (1 \2.. dla). Mil 10 Þuu 5 10 eo min K.y ring S",'III. made 111." each. r . -1 -ií'- - ; ....' , .. No 308A AI abor. but In plU11c pouch ".15 N. - o\ò- ")f. -. 'C;. . -1......10 OTOSCOPE lET. On. 01 GennanY.llllne.. In.INm.nll. E.ceplionalillumlnllion. pow.rful magnllYlng Iinl. 3 '1andard IIZI lpecull Size C : ::; II ::: o - No_ 308 ".15 MCtt. ........... çg . g.. AM .I?! . ..I. .. . M T STYLES - SIX DIFFERENT COLOURS... :.:'::::: TO OADEA NAIIE PINI ................. ......................................................... .... . FILL IN LETTERIHG ...... SEND TO: EOUITY MEDICAL SUPPLY CO PLEASE . I::g: : ; ..".. lIUne _ _ _ __ ____________ _ _ ______________ 2ndllne POBOX 72&-S, BROCKVILLE, ONT Kev 5ve PfUNTI : !!!r IIERCURY TYPE The ul1lmal. In eecuracy. Foldl In10 lighl bu1 rugged malal c.... HNvy dutr V.lcro cull and ,nllliion ayll.m. 151_" Neb. ---==--:..:.. , .fi DElUXE PocKET SAVER , , . No mo'nnno"no Ink Ilalnl or lrarecl edges 3 comper1m.n11 lor penl. &C'lsora. IIC . plus c....ng. pock.land k.y Ch.,n Whl11 e.1I PII.1ah,Øe. No 505 11." each. , IIEASURING TAPE In Itrong plalllC c... \ Puo" bullon '0' .,,"o - . ... return Mad. 01 durabT. . linen M...ura. 10 78.. , on one llde, 200 em on rewarM. SA 15 Nctl ------------------------ Øl su...10 encIos. your nlm..nd eddrwal. : TY ' All fllfNI HA E BACKGAOUND 2 PINS C.:IJour SAr:ETY P'N8ACI( COLOUR LETTERS PRICES 1 PIN (lam. Nm.1 Ouant Item orllize Pnce Amount : SaUD 'LEXIGLA.....Moldld Irom solkl PII.lgl.. 11011'1'" [j bleell , IIn. [ 13.21 IUI : Smoolhly rounded edge. and comers l.lters deeply o. Cbiue lellerl .ngraY'lld and IIlIed wlll'1laqu.r colour 01 your choice. Pearl C '00 2 Itne [ ....1. .... C grMn I."ers : : : ': : g I : hb =Pnl:IU rWhll._ Black 1 Iin. [ 12.1' 013.72 coniraliing colour core B.velled eøgN malch Block :::::::::,.L l.n.re . 'ellers Salin IIn'lh E_callen1 VSllue al1hll prk:e. Blu. I Whll. 2I1n.. r 13.13 _ 15_12 1.lIer. ONTARIO RESIDENTS ADD 7% TAX : IIETAL FRAIIED...Slmllar 10 abo'f'I bul mounled In I 1 line ADD 50e HANDLING CHARGE : polilhed mll.I'ram. "'111'1 rounded edge. and l Old ",hI1e- 0 BLacIl IlIlIrs [ 12" 14." IF LESS THAN 110. cornerl. EngraY'lld InNn e.n be changed or C 511...... ê ::k 0 White 2 hn.1 C.O D. ORDER DD 12.00 : repleeld. Our Iman.lland n.....1 dellgn I.nerl ... """ NO COD. ORDERS FOR NAME-PINS TOTAL ENCLOSED SaUD IIETALmE.1rem.ly Ilrong and durabll bul M.O L. CHEOUE CASH : IIghl""lght. Len.rl dMply engraY'lld lor absolu1e o Gokl bieek 111n. 13._ .... perm.n.ncaandlllled with rour cholca oliaqu.' biue 111I.ra AS<< A!IOUT 00111 Of.NEIIIIOUS OUA...TlTY DlSCOu...TS FOIII! colour Corners end edg.1 Imoolhlr rounded Salin o SIIWM' '00 2 Iin.1 14.11 017._ CLASS OIFTS. OIlllOUP PUIIIICHASES, FuND 1IIIA1S1NQ (TC : smoolh IInlll'1 ._n I.ner. . USE A SEPAFlATE SHEET OF PAPEFlIF NECESSAFlY . .- L.\' I '. ................... ....... ................ ..................................... .............. ..............................: :g:l n :.Ependlbl. 10 . I year guaranlN 01 accuracy 10 . 3 m.m_ No .10p..pln 10 hide .rror.. Handlom.ZI caII =:.= :I NURSEI PENLIGHT. Powerful beam lor e.amlnatlon 01 Ihroat. IIC Durabl. Ilalnl'II-IIHI case wllh poCilII CliP Mad. In U.S A No 28 16.11 completl wl1h bllI.rtle_ Economy model "'111'1 Chromed bras. call No 2V 12... NUASES WHITE CAP CliPI. Med. In C.neda lor C.nedlan nune. Slro';g I1NI bobby plnl ",lth nylon r;2. 3 :n:æ: ' Sl 01 15, 2"" aize 11.eo I ClIO NURI S 4 COLOUR PEN lor rKOrdtnQ I.mperalure, blood prellure. .Ic. On.hand operallon lelee11 rid, bleek, blue or gra.n No 32 12.21 Mdt. NOTE: WE SERVICE AND STOCK SPARE PARTS FOR ALL ITEMS. CAP ITRIPEI Sell-.dh.I' Irpe, remowabll and r.uaabll No 522 RED. No S20 BLACK, No 521 BLUE. No 523 GREY All 15\2.. &..: ::.rld ('4'1. 12 Ilrlpe. per e.rd. - 58 Februery 1871 Th. Can-.llen NUrH Classified Advertisements Alberta The Big Country Health Unit requires a Director to commence work February I. 1979. Applicant with Public Health experience required. This is a super- visory position and applicant should be knowledge- able in that field. Salary negotiable ba.ed on qualifi- cations and experience. Apply to: Director. Big Country Health Unit. Box 279. Hanna. Alberta, TOJ IPO. Operating Room Supervisor is required for a 185-bed active and auxiliary hospital complex located in a city 40 miles south of Edmonton. Responsibility is to supervise and direct that department in the perfor- mance of day to day duties as well as other administrative duties necessary for the operation of that department. Must have an Alberta registration (or be eligible for) and recognized P.G. in O.R. techniques and management. Salary is to commen- surate with experience, qualifications and in accor- dance with the AARN Contract. Please contact: Miss A.M. Morrison. Director of Nursing. Wetaski- win Hospital District No. 81. 5505-50 Avenue. Wetaskiwin. Alberta, T9A OT4. British Columbia Challenge and opportunity await the nurse prepared to accept a posilion in a lOO-bed accredited acute care hospital in a booming northern city. We will help the beginning practitioners to expand their knowledge and skills. Write to: Nursing Director. Dawson Creek and Djstrict Hospital, 1I100-\3th St., Dawson Creek. British Columbia. VIG 3W8. Advertising rates For All Classified Advertising $15.00 for 6 lines or less $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies of the hospitals and agencies advertising in the Journal. For authentic information, prospective applicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse SO The Driveway . Ottawa. Ontario K2P IE2 British Columbia oeral Duty (R.C. Registered) Nurses required for expansion to 422 acute care accredited hospital located 6 miles from downtown Vancouver and within easy access to various recreational facililies.. Excellent orientation and ongoing inservice prog- ramme. Salary 51,231.00-51,455.00 monthly. Clini- cal areas include coronary care. intensive care, emergency, operating room, P.A.R.R., medical/sur- gical, pediatrics. obstetrics, orthopedics and activa- tion units. Positions are also available for general duty nurses in our modern extended care unit. Apply to: Co-ordinator-Nursing, Dept. of Employee Resources, Burnaby General Hospital, 3935 Kincaid Street, Burnaby, British Columbia. V5G 2X6. Ge.n1 Duty N_ for modem "I-bed accredited hospital located on the Alaska Hialiway. Salary and penonnet policies in accordance with the RNABe. Temporary accommodation available in residence. Apply: Direclor cl Nursin., Fort Nelson General Hospital, P.O. Box 60, Fort Nelson, British Colum- bia, VOC tRO. oeral Duty Rqlstered Nu.... - required for 13O-bed accredited hospital. Previous experience desirable. Staff residence available. Salary as per RNABC contract with northern allowance. For further information please contact: Director of Nursing. Kitimat General Hospital, 899 Lahakas Boulevard North. Kitimat, British Columbia, V8C IE7. Experienced Nurses (ehgible for B.C Registration) required for full-time positions in our modem 300-bed Extended Care Hospital located just thirty minutes from downtown Vancouver. Salary and benefits according to RNABC contract. Applicants may telephone 525-0911 to arrange for an interview. or write giving full particulars to: Personnel Direc- tor. Queen's Park Hospital, 315 McBride Blvd.. New Westminster, British Columbia, V3L 5EII. Experienced Nurses (B.C. Registered) required for a newly expanded 463-bed acute. teaching. regional referral hospital located in the Fraser Valley. 20 minutes by freeway from Vancouver. and within easy access of various recreational facilities. Excel- lent orientation and continuing education program- mes. Salary-1979 rates-51305.00-51542.00 per month. Clinical areas include: Operating Room, Re- covery Room. Intensive Care. Coronary Care. Neonatal Intensive Care. Hemodialysis. Acute Medicine. Surgery. Pediatrics. Rehabolitation and Emergency. Apply to: Employment Manager. Royal Columbian Hospital. 330 E. Columbia St., New Westminster. British Columbia. V3L 3W7. oeral Duty Nurses (eligible for B.C registration) required for 125-bed hospital in the South Okanagan. RNABe contract in effect. Reply in writing to: Director of Nursing. South Okanagan General Hospital, Box 760. Oliver. British Columbia, VOH ITO. Experienced tCU/CCU and Operating Room neral Duty Nurses required for full-time and summer relief in a nO-bed accredited hospital in the Okanagan Valley. Musl be eligible for B.C registration. Salary 51.305 to 51.542 per month, with differential for special clinical preparation of not less than 6 months. Apply to: Director of Nursing. Penticton Regional Hospital. Penticton. British Columbia. V2A 3G6. Shift Supervisor with previous experience required for a 1000bed fully accrediled hospital in North Eastern B.C Must be eligible for B.C registration. N.U.A. course preferred. Apply: Director of Personnel, Fort St. John General Hospital. Fort St. John. British Columbia, VIJ IV3. British Columbia neral Duty Registered Nurses reqUIred for a fully accredited lOO-bed hospital. Apply: Director of Personnel, Fort St. John General Hospital. Fort St. John, British Columbia, VIJ IV3. Registered Nurses - Required immediately for a 340-bed accredited hospital in the central interior of B.C. Registered Nurses interested in nursing posi- tions at the Prince George Regional Hospital are invited to make inquiries to: Director of Personnel Services, Prince George Regional Hospital. 2000- 15th Avenue, Prince George, British Columbia V2M IS2. Applications are invited for teaching positions in undergraduate and graduate programs. Master's or higher degree and experience in clinical field required. Positions open in July, 1979. Candidates must be eligible for registration in B.C. Send resume to: Dr. Marilyn Willman, Director, School of Nursing. University of British Columbia, 2075 Wesbrook Place, Vancouver, British Columbia, Canada, V6f IW5. Experienced Nurse, eligible for British Columbia registralion. required for full time posilion to take charge of Health Care Department in IIO-bed Polish tntermediate Care Facility. Knowledge of both the Polish and the English language necessary. Experi- ence and post graduate courses in Gerontology preferred. Salary and benefits as recommended by the Regislered Nurses Association of B.C Please telephone the Administrator (604)438-2474 for an interview or send resume to: 3150 Rosemont Drive, Vancouver, British Columbia, V5S 2C9. Manitoba Applications. including resume and names of re- ferees are invited for faculty with professional compe- tence in Community and Mental Health Nursing. Re- storative Nursing. Ameliorative Nursing and Preven- tive Nursing (foc... on maternal and child). These full-time positions will commence September I, 1979. Candidates should have at least a completed Master's degree with teaching experience and a pub- lication record. Salary and rank are commensurate with qualifications. Apply to: Dr. Helen P. Glass. Director. School of Nursing. University of Man- itoba. Winnipeg, Maniloba, R3T 2N2. Ontario Applications now being accepted by the Onlario Society for Crippled Children for Registered Nurses, Graduate Nurses and Registered Nursing Assistants for their resident summer camps located near Col- lingwood. Port Colborne. Perth. Kirkland Lake and London. 9 weeks-late June to late August 1979. Various positions available-supervisory. assistant supervisory and general cabin responsibilities. Con- tact: Camping and Recreation Department. 350 Rumsey Road, Toronto. Ontario. M4G IR8 (416) 425-6220. Ext. 242. Quebec Camp Nurses required for childrens summer camp in beautiful Quebec Laurentians. Mid-June to end of August. Resident M.D. Contact: Mr. Herb Finkel- berg, Director of Camp B'nai B'rith. 5151 Cote St. Catherine Rd.. Suite 203, Montreal. Quebec. H3W IM6, or telephone (514) 735-3669. Nurses for Choldren's Summer Camps In Quebec. Our member camps are located in the Laurentian Moun- tains and Eastern Townships, within 100 mile radius of Montreal. All camps are accredited members of the Quebec Camping Association. Apply to: Quebec Camping Association. 2233 Belgrave Avenue. Montreal. Quebec. H4A 21.9. or phone 489-1541. Saskatchewan University of Saskatchewan College of Nursing, with 335 undergraduate students, invites applications ror term or rrgular appoIntments to fill anticipated vacancies in an integrated, conceptually-based baccalaureate nursing program. Preference will be given to applicants with advanced preparation in clinical specialties. The successful applicant will be responsible for leam teaching theory and clinical supervision of students. Salary will be commensurate with Qualifications and experience. Effective date of appoinlment will be August, 1979 with closing date for receipt of applications May 31, 1979. Further information may be received from: Hester J. Kernen. Professor and Dean, College of Nursing, University of Saskatchewan. Saskatoon. Saskatchewan. S7N OWO. United States Nones - RNI - Immediate Openings in Califomia-Florida-Texas-Mississippi - if you are experienced or a recent Graduate Nurse we can offer you positions with exceUent salaries cl up to S1300 per month plus aU benefits. Not only are there no fees to you whatsoever for p1acilll you, but we also provide complete V isa and Licensure assistance at also no cost to you. Write immediately for our application even if there are other areas of the U.S. that you are interested in. We will caU you upon receipt of your application in order to IUTlUl&e for hospttal interviews. You can call us collect if you art an RN who is licensed by examination in Canada or a recent Jraduate from any Canadian School '* Nursina. Windsor Nurse Placemenl Service, P.O. Box 1133. Great Neck, New York 11023. (5t6-487- 2818). "Our 20th Year of World Wide Service" Th. Can-.llen Nur.. United States Nurslnl Opportunity - Mississippi Baptist Medical Center. a mlijor 600-bed hospital, has immediate posilions available for experienced RNs and recent nursing school graduates in a variety of specialities and medical/surgical areas. Competilive salaries. liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (populalion 300.(00), MBMC is the state's largest and most modem privately operated hospital. For further information write: Mrs. Johnnye Weber. Nurse Recruiter. 1225 North State Street, Jackson, Mississippi 39201: or call collect 601/968-5135. The Best Loatlon In the Netlon - The world- renowned Cleveland Clinic Hospital is a progres- sive, 1020-bed acute care teaching facility committed to excellence in eatient care. Staff Nurse positions are currently available in several of our 61CU's and 30 departmentalized med/surg and specially divi. sions. Starting salary range is S 13 .286 to S 15.236, plus premium shift and unit differential. progressive employee benefits program and a comprehensive 7 week orientation. We will sponsor the appropriate employment visa for Qualified applicants. For further information contact: Director - Nurse Re- cruitment. The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio, 44106 (4 hours drive from Buffalo. N.Y.); or call collect 216-444- 5865. C_e to Taal - Baptist Hospital of Southeast Texas is a 400-bed growth oriented oraanization lookilll for a few Jood R.N.'I. We feel that we can offer you the chaUenge and opportunity to develop and continue your professional JI'Owth. We are located in Beaumont, a city of 150,000 with a smaU town atmosphere but the convenience of the larac city. We're 30 minutes from the Gulf of Mexico and surrounded. by beautiful Irees and inland lakes. Baptist Hospital has a progress salary plan plus a liberal frillie packaae. We will provide your immiJ- ration paperwork cost plus airfare to relocate. For additional wonnation, contact: Penonnel Ad- ministration, Baptist Hospital of Southeast Texas, Inc., P.O. Drawer 1591, Beaumont. Texas m04. An alllrmatlft adlon employu_ FebnIery 11171 57 United States OR Assistant Supervisors-Expanding hospital in the Harbor City area, located 20 miles south of Los Angeles near the beach, has full-time day and even- ing positions available. Minimum of four years operating room experience with leadership background. Prefer B.S. degree. Excellent salary and benefits. Please send resume to: Kaiser- Permanenter Medical Cenler. Employee Relations, 1100 W. Pacific Coast Hwy.. Harbor City, Califor- nia. 90710 (213) 325-5111. ext. 1376. Australia Fernlty P...ltlons available in under-graduate instruc- tion in: Medical-Surgical Nursing. Community Health Nursing and Psychiatric Nursing. Dynamic program conducted in col\iunction with a University Hospital. Salary---commensurate with Qualifications and experience. Senior Lecturer AS20.361-21,808. Lecturer ASI5,179-19,939. Preference: Master's degree, teaching and clinical experience. The In. stitue has allowance schemes covering re-Iocation expenses, immediate superannuation, insurance cover and assistance with accommodation. Closing date for applications: 3 weeks after publication of this advertisement. Appointees are expected to lake up duties early in 1979. Curriculum vitae and transcripts of tertiary work to: Lydia Hebestreit. R.N. Head. Department of Nursing, Preston Insti- tute of Technology, Bundoora 3083 (Melbourne) Australia. Miscellaneous Africa - Overland Expeditions. London/Nairobi 13 wks. London/Johannesburg 16 wks. Kenya Safaris - 2 and 3 wk. itineraries. Europe - Camping and hotel tours from 16 days to 9 wks. duration. For brochures contact: Hemisphere Tours. 562 EgJinton Ave. E., Toronto, Ontario. M4P IB9. Saskatchewan Careers Saskatchewan Careers Senior I'ursinl Co-ordinator Saskatchewan Social Services, Home Care Branch, Regina, requires a Senior Nursing Co-ordinator to establish and integrate standards of care and eligibility for services pertaimng to nursing. home making. meals and minor home repairs which will be delivered by district home care boards. The duties will include assessment of care needs and development and delivery of training courses for home care staff. Applicants should have a Bachelor of Science in Nursing. and preferably a Master's degree with advanced training in public health. community or rehabilitative medicine: be eligible for Registration with the Saskatchewan Nurses Association and possess several years experience with a home care delivery or related program. Salary: S20.616 - S25.284 (public Health Nurse 4) S21,48O- S26.364 (with M.Sc.N.) Competilion: 604144-8-782 Closing: As soon as possible Forward application forms and/or resumes to the Saskatchewan Public Service Commission. Please quote position, department, and competition number on all applications and/or inquiries. . 1111\\ Saskatchewan Public Service Commission 1820 Albert Street Regina, Canada S4P 3V7 (306) 525-8355 Registered :-'urses (R.!\/. or Graduates) Saskatchewan Social Services. Valley View Centre. Moose Jaw. invites applications from Registered Nurses. Valley View Centre is the largest institution for the mentally handIcapped in the Province of Saskalchewan. The City of Moose Jaw. wilh a population of 38.000. is situated on the Trans-Canada Highway 45 miles west of Regina. the provincial capital. Applicants must have graduated from an approved school of Diploma Nursing and will be required to register as a Regislered Nurse in the Province of Saskatchewan. Salary: S 12.420 - SI4.400 (Graduate Nurse) SI3.944 - S16.164 (Nurse I) Competition number: 604111-8-681- Nurse I 604090-8-68I-Graduate Nurse Closing date: As soon as possible Forward application forms and/or resumes to the Saskatchewan Public Service Commission. Please quote position, department, and competition number on all applications and/or inquiries. . 1111\\ Saskatchewan Public Service Commission 1820 Albert Street Regina, Canada S4P 3V7 (306) 525-8355 - 51 Febnlery 1871 Career Opportunities In Mental Health Nursing Education Required for a proposed Post-Basic Course in Mental Health Nursing for Registered Nurses to begin in September, 1979. Program Coordinator Eligible for registration as a nurse in New Brunswick; Master's Degree in Nursing Education, Mental Heallh Nursing or related field: alleast three years recent experience in Mental Health Nursing: available preferably May 1st. Function: to participate in curriculum design, coordinate, teach and evaluate the educational program. Instructor Eligible for registration as a nurse in New Brunswick: prefer a Master's Degree in Nursing Education, Mental Health Nursing or related field; at least three years recent experience in mental health nursing; available preferably June 1st. Function: to assist the program coordinalor. Direct inquiries to: Acting Executive Director New Brunswick Association of Registered Nurses 231 Saunders Street Fredericton, N.S. E3B IN6 Deadline: March 15, 1979 The C.nlldIen Nu... Clinical Specialist - Psychiatric Nursing (Nurse 3, Nursing Educalion) 517,350- 521,500 Applications are invited for the position of Clinical Specialist - Psychialric Nursing for a 500 bed active treatment psychiatric hospital. The Position - The Clinical Specialist will be required to function as a role model consultant and as an expert praclitioner by providing leadership to nursing staff in planning patient care. Qualifications: Must possess a current certificate of competency in the Province of Ontario and a Master's Degree in Nursing is required. Please send resume 10: The Stamng Omcer St. Thomas Psychiatric H...plta! St. Thomas, Ontario N5P 3V9 Want to know how to get a job at UCLA MedicarCenter? I'll be touring the United States and Canada during the next few months and I want to hear from RNs and L VNs who are interested in m'aking a career change in either Clinical Nursing or Nursing Administration. Call to discuss your future with UCLA and to schedule a job interview in your local area. I will try to visit many towns that are usually ignored by other Recruiters, so it is imperative that you contact me as early as possible. uclA Medical Center Call Collect: (213) 825-8141 Mr. Tony Weatherford, R.N. Nurse Recruiter UCLA Medical Center 10911 Weyburn Avenue Los Angeles, CA 90024 Ao Eo""' 0"'0""0'" Em"""" M' í Registered Nurses Louisiana (New Orleans & Lake Charles) California (close to Los Angeles) Georaia (best area of Atlanta) Acllve care accredited hospitals each have a requirement for Canadian RN's experienced in critical care. As the hospitals are only interested in persons becoming registered aliens of the USA. these positions would be of interest to the married RN whose spouse could not obtain a work permit under Ihe regulation covering the H-1 temporary per- mit. Candidates must have wriUen RN's in Canada and received marks of 350 in all five disciplines to obtain license by reciprocity, Apply in confidence to W. P. Dow & Associ- ates Ltd. (a Canadian company), SUite 309, 365 Evans Avenue, Toronto, Ontario MaZ 1K2 (416)259-6052. Port Saunders Hospital Port Saunders, Newfoundland Requires two Registered Nurses commencing April 1979 through to September 1979. Applicants must be registered or eligible for registration with the ARNN. Salary scale: $11,448.00-$13,955.00. Please forward application, curriculum vitae and references to: Mrs. Madge Pike Director of Nursing Port Saunders Hospital Port Saunders, Newfoundland AOK 4HO Assistant Supervisor (Intensive Care Unit) The successful applicant will be directly involved in the teaching program and assisting in administrative duties. Clinical and teaching experience is essential. B.sc.N. preferred. Salary commensurate with qualifications and experience. Send resume to: Personnel Department Henderson General Hospital 711 Concession Street Hamilton. Ontario LSV IC3 The Central Registry of Graduate Nurses 411 Eglinton Avenue East Suite 500 Toronto, Ontario M4P 1M7 A non-profit organization welcomes candidales for membership in this prestigious group of nurses specializing in general and private duty nursing in hospitals and homes. Telephone for appointment 483-4306 Switzerland Winterthur Canton (725 bed) hospital near Zürich needs Operating Room Nunes for the surgery clinic. Required for immediate or future openings. We offer pleasant working conditions. equitable hours of work and leisure. Salary and benefits in accordance with the regulations of the Canton of Zürich. Five-day week. accommodation available, cafeteria. Apply in writing to: Sekretariat Pílegedienst, Kan- tonsspital Winterthur. CH-8401 Winterthur. Swit- zerland. Th. Cen-.llen Nu... UNITED STATES OPPORTUNITIES FOR REGISTERED NURSES A V AILABLE NOW IN ARIZONA FLORIDA CALlFOR"IIA OIDO TEXAS WE PLACE AND HELP YOU WITH: STAT.E BOARD REGISTRATION YOUR WOR"- VISA TEMPORARY HOUSING - ETC A CANADIAN COUNSELLING SERVICE PhOM: (416) 449-5883 OR WRITE TO: RECRUITING REGISTERED NURSES INC. 1200 LA WRENCE A VENUE EAST, SUITE 301, DON MILLS, ONTARIO MJA ICI NO FEE IS CHARGED TO APPLICANTS United States Nursina Opponunities - Proaresaive SOO-bed Medi- cal Center in West Texas city of AbiJene with population nearly 100,000 is JookiJijl for ._ ........... and experienced R.N.'s for positions in O.B.. Pediatrics, Suraery. E.R., ICU, CCU, plus surJical and medical floors. Good competitive salary and .enerous benefits are provided. Contact: Per- sonnel Ollice, Hendrick Medical Center, 19th and Hickory. Abilene, Texas, 79601. Director of Nursing Practice The Director will be responsible for the planning. organization and direction of nursing activities in an accredited 555 bed active treatment teaching hospital. The incumbent will assume responsibility for the Nursing Quality Assurance Program. Candidates must possess a baccalaureate degree in Nursing. preferably with a Masters degree in the field of Nursing. Health Care Administration, or Business Administration. Should have considerable Nursing Practice experience, with demonstrated competence in a senior level Nursing Management position. Interested applicants may submit a comprehensive resume, including career objectives and salary expectations to: Director of Personnel Sen ices Misericordia Hospital 16940 - 87 Avenue Edmonton, Alberta T5R 4H5 Februery 1871 511 . A V L1. " MEDICAL RECRUITERS OF AMERICA INC. MRA recruIts RegIstered Nurses and recenl Graduates for hospital posilions on many U.S CIties We provide complete Work Visa and State Licensure information ARLINGTON, TX. 76011 611 Ryan Plaza Dr . SUite 531 (817) 461-1451 CHICAGO. ILL. 60607 500 So Racine 5. . SUite 312 (312) 942-1146 FT. LAUDERDALE. FL. 33309 800 N W 62nd St ,.Su,te 510 (3051 712-3680 FOUNTAIN VALLEY. CA. 92708 11400 Brookhurst. SUite 213 (714) 964-2471 PHOENIX. AZ 85015 5225 N 19th Ave. SUite 212 (602) 24 1608 TAMPA. FL. 33607 1211 N Westshore Blvd. SUite 205 (813) 872-0202 ALL FEES EMPLOYER PAID Exdte.-nt: Come and join us for year around excitement on the border. by the sea. an unbeatable combination. Enjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed. acute care hospital offers the eJlperi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. EJlcelient salary and fringe benefits. We invite you to share the challenge ahead. Assistance with travel eJlpenses. Write or call coUect: Joe R. Lacher, RN. Director of Nurses. Valley Community Hospi- tal, P.O. BOJl 4695. Brownsville. TeJlas 78521; I (512) 831-9611. THE DEPARTMENT OF NURSING LONG ISLAND JEWISH-HILLSIDE MEDICAL CENTER NEW HYDE PARK, NEW YORK is sponsoring QUO VADIS-NURSING? The First International Nursing Seminar MARCH 12 - 22,1979 In Israel Seminar Topics: The Changing Scene in Hospital Nursing in the U.S.A. -- Health Care System in England and the Role of Nursing -- A Practical Approach to Nursing Process -- Nursing in West Africa -- Nurse/Physician Joint Practice -- The Russian Felcher and the Chinese Barefoot Doctor -- Health Care Delivery in Iran This Deluxe 10-day Seminar Tour is approved for CE credit by the American Nurses Association. Seminars will be held in 5-star hotels Ibreakfast, dinner & tours included) in Jerusalem, Haifa, & Tel Aviv. Extension tours to Rome or Athens available. Tax Deductible) Registration Fee $125.00 All inclusive sample tour price from lIIew York - $1,100.00- Add on fares from home city to New York available All fares subject to revision. Faculty include: Rachel Rotkovitch, R.N., Program Chairman Allan L. Abramson, M.D., New York Beverly Bonaparte, R.N., New York Miriam Hirschfeld, R.N.. Israel Linda E. Jessup, R.N.. Maryland Robert K. Match, M.D.. New York Rheba deTornyay, R.N., Washington -NOTE: Tour rates are available for participants traveling to the seminar from outside the U.S.A. For.lnfo m tion: Ann J. Boehme, Clinical Campus, Long Island Jewlsh.Hlllside Medical Center, New Hyde Park. N.Y. 11042 12121 470-2114 110 Februery 1879 The Child Psychiatry Service Allan Memorial Institute and the Post-graduate Board Royal Victoria Hospital, McGill University Present A Two Day Symposium pril6 & 7,1979 Anorexia Nervosa & Obesity: Recent Developments Guest Speakers Hilde Bruch, M.D., Professor Emeritus of Psychiatry. Baylor College of Medicine Texas Medical Center, Houston, Texas Arthur Crisp, M.D., Professor, Department of Psych iatry, St. George's Hospital Medical School, University of London, London. England Paul Garfinkel, M.D., Associate Professor. Department of Psychiatry. University of Toronto , Toronto, Ontario The format will include morning lectures and panels with small group workshops in the afternoon. Meeting Place: Hotel Loews LaCité. Salle Beauchemin 3625 A venue du Parc, Montreal, Quehec, Canada Fees: Before March 5,1979- $100.00 {Physicians) - $75.00 (Allied Health Professionals) After March 5,1979- $125.00 (Phy icians) - $100.00 (Allied Health Professionals) (Registration fees must be paid in Canadian dollars and it includes 2 lunches and coffee breaks) Miss Denise Crépin, Post-Graduate Board, Royal Victoria Hospital, 687 Pine A\enue West, Montreal, Quebec H3A IAI 'lame Addre"s City State ljp OM.n. (specify discipline) o Allied Health Professionals (specify) o Please send me a hotel registration card (make cheque payable to: Post-Graduate Board, Royal ViClorid Hospital) Th. Can-.llen Nur.. University of British Columbia M.Sc. (Health Services Planning) Program A program leading to M.Sc. (Health Services Planning) is offered for three groups of candidates: planners/administrators. planners/researchers, and medical health officers. This program is designed especially for candidates who have been working in the health services or as managers and, whilst other candidates are eligible, preference will be given 10 those with experience as the instructors will assume that some basiç knowledge exists. Candidates must be graduales in health, social or life sciences or commerce. It is anticipated that candidates will find appointments at relatively senior planning and administrative levels of Canadian health services, in health care research or international health care planning and adminislration. For details write: Faculty o'Graduate Studies University of British Columbia 2075 Wesbrook Mall Vancouver, B.C. V6T IW5 Registered Nurses Medicine Surgery We are cordially inviting applications from registered nurses for the areas of general medicine and surgery. These are permanent, full-time, rotating shift positions. Candidates must be eligible for active Alberta registration. Previous experience in your area of preference would be an asset. Interested candidates are asked to suhmit a comprehensive resume to: Personnel Department Misericordia Hospital 16940- 87 Avenue Edmonton, Alberta T5R 4H5 Co-ordinator of Public Health Nursing Services A challenging senior position responsible to the Medical Health Officer co-ordinating all public health nursing activities in Labrador and northern Newfoundland served by The International Grenfell Association. Position is based in SI. Anthony, Ntld., and involves considerable travel by aircraft. Duties involve the planning, admimstering and evaluatmg of public health nursing activities in co-ordination with the other members oflhe health team. Qualifications: Master or Bachelor Degree in nursing with major emphaSIs on public health and administration. Experience in various supervisory positions in public health nursing. Salary: 518.478.00 - 523.583.00 per annum. Vehicle provided for land operations and plane provided for travel to coastal areas. Accommodation provided at a reasonable rate. Travel paid for minimum of one year service. Apply: Mr. Scott Smith Personnel Director International Grenfell Association St. Anthony, Newfoundland AOK 4S0 Foothills Hospital, Calgary, AI berta Advanced Neurological- Neurosurgical Nursing for Graduate Nurses A five month clinical and academic program offered by The Department of Nursing SeIVice and The Division of Neurosurgery (Department of Surgery) Beginning: March, September Limited to 8 participants Applications now being accepted For further Information, please write to: Co-ordinator of in-service Education Foothills Hospital 140319 St. N. W. Calgary, Alberta T2N 21'9 Guelph General Hospital (Fully Accredited - 220 Beds) Requires the SeIVices of An Assistant Head Nurse for New Born Nursery The Obstetrical facilities are new and modem providing for approximately 1500 deliveries annually. Primarily work will be on Day Shift; a B.Se.N. degree, Administrative and Nursery clinical experience necessary Applications should be addressed to: Personnel Officer Guelph General Hospital 115 Delhi Street Guelph, Ontario 'lIE 4J4 O.R. Supervisor Required immediately by an active 100 bed acute care and 40 bed extended care hospital. Must be eligible for B.C. Registration. Post graduate training and experience necessary. Salary $1,477.00 to $1 ,740.00 per month (1978 rates). Apply in writing 10: The Director of Nursing G.R. Baker Memorial Hospital 543 Front Street Quesnel, B.C. V2J 2K7 (604) 992-2181 February 11171 81 The Cen-.llan Nur.. Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Registered Nurse in search of a change and a challenge - look into nursing opportunities at Vancouver General Hospital, B.C.'s ml\Îor medical centre on Canada's unconventional West Coast. Staffing expansion has resulted in many new nursing positions at all levels, including: General Duty ($1231-1455.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the opportunity you've been looking for. For !hose with an inlerest in specialization. challenges await in many areas such as: Neonatology Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn Unit Paediatrics Inservice Education Coronary Care Unit Hyperalimentation Program Renal Dialysis & Transplantation If you are a Nurse considering a mOve please subnut resume to: Mrs. J. MacPhail Employee Relations VanCCHlver General Hospital 855 West 12th Avenue Vancouver. B.C. V5Z IM9 ( OPPæTUNITY A It:rJra Nurse/Psychiatric Nurse Graduates from approved Schools of Nursing and with eligibility for registration with the appropriate Professional Associations in Alberta, are invited to apply for Psychiatric Nurse I and Nurse I positions at the Michener Centre in Red Deer. Alberta. Michener Centre provides residential care and training for approximately 1,700 developmentally handicapped residents. Nurses will participate in life skills programming for the residents in addition to providing general duty nursing responsibilities. Salary $12,804- $15.060 (Currently Under Review) Competition no. 9184-18 This competition will remain open until a suitable candidate has been selected. Apply To: Personnel Administrator The Michener Centre Box 5002 Red Deer, Alberta T4N 5HI Phone: 403-343-5610 --- ,...,. \ .: r , 0 l . 1 4 . . '"'" I : i ' r1 ìi :1 ".\ J 4\ " . - fV -. JJr"-- ]I t .. "They encour e responsibili And that makes me want to do a better job:' As a nurse at Saillt Joseph, you are involved. You are encouraged to fully express your ideas. To take advantage of your education and experi- ence. In both team and primary nursing, you are part of a progressive system of medical care that focuses on the patient 'U our fOI future as a person. To learn all J about Saillt Joseph Hospital, at SaintJoc>anI, . salaries, liberal benefits and ital I more - send the coupon. .I \'PVORTH TEXAS :.}\lg: -----------------------------------------. Gay Cole, Nurse Recruiter Saint Joseph Hospital 1401 South Main Street Fort Worth, Texas 76104 U.S.A. Phone: 817/336-9371 CN-2-79 Name Address City Phone State RND Zip Student 0 L________________________________________. - 12 Februery 11171 School of Nursing requires: Program Co-ordinator - July 9, 1979 Teachers - April 1 and August I, 1979 Inquiries are invited for these facullY positions in a hospital based two-year diploma nursing program which uses an individualized learning-teaching approach. Eligible forM.A.R.N. registration. Bachelor's Degree in Nursing and a minimum of one year's clinical practice experience required for teacher positions. Master's Degree in Nursing with appropriate experience in program planning, curriculum development and teaching preferred for program co-ordinator position. Apply sending resume to: Shirley J. Paine Director of Nursing EducatIOn School of Nursing Brandon General Hospital ISO McTavish Ave. E. Brandon, Manitoba. R7A 2B3 The Cen-.llan Nur.. Community Health Nurse A Community Nurse is required to assist in the developing of a combined primary care and community health program for the t ndian people of North Battleford and the surrounding reserves. The program is being developed and run by th community and staff and will employ a team approach with an emphasis on health promotion and education. Candidate should possess a B.Sc. (Nursing) and some experience or special training in Public Health. Community Health or primary care. Applicants must be sensitive to community and individual needs and be willing to develop new approaches to delivery of health care services. Write or phone in confidence to: Ron Albert, Executive Director Battleford's Indian Health Centre Inc. P.O. Box 250 North Battleford, Saskatchewan S9A 2YI Memorial University of Newfoundland School of Nursing Positions are available for the 1979-80 academic year in . Medical-Surgical Nursing . Psychiatric Nursing . Community-Health Nursing . Maternal-Child Nursing . Primary Care Nursing . And also for a Pediatric Nurse Practitioner Master's Degree in clinical specialty and teaching experience is required. Salary commensurate with educational preparation and experience. Send curriculum vitae and names of three referees to: Miss Margaret D. McLean Professor and Director, School of Nursing Memorial University of Newfoundland St. John's, Newfoundland AIC 587 Canada Before accepting any .... position in the U.S.A. PLEASE CALL US COLLECT We Can Otter You: A) Selection of hospitals throughout the U_S.A. B) ExtenSive information regarding Hospita Area. Cost of Living. etc. C) Complete Licensure and Visa Service Our Services to you are at absolutely no tee to you. WINDSOR NURSE PLACEMENT SERVICE P.o. Box 1133 Great Neck, N.Y. (516) 487-2818 .... Our 20th Year of World Wide Service ...III Royal Australian Nursing Federation (Victorian Branch) Research Officer Community Nursing Practice Applications are invited from interested nurses to undenake a study of community nursing practice in Victoria, Australia. The projec.t will cover areas such as professional role definition throughout the range of practice settings: educational preparation required for practice: terms and conditions of employment: and career opportunities. Research qualifications and experience essential. Research grant available. Further information may be obtained from:- (Miss) ShirJey M. Maddocks Secretary RANF (Vie. Branch) 314 St. Kilda Road Melbourne, Vie. 3004 Australia Vancouver, B.C. Shaughnessy Hospital Our active 1100 bed teaching hospital has immediate openings for BC eligible registered nurses in intensive care related areas and on medical and surgical wards. For further information apply to: Employee Relations Department Shaughnessy Hospital 4500 Oak Street Vancouver, B.C. V6H 3NI (604) 876-6767 - ,it. -ute · " RN ' ., ",""".' S · · · ." l Help Preserve .. the "Life" "Life Flight" - r = --4 . - l : ;-..., OJ" I . r.... t .. .. .. , .. ., - While our Life Flight helicopters are impressive pieces of medical care equipment, the indispensible part of our program is our staff. Without skilled and dedicated patient care experts, our specialty programs would never get off the ground. If you're a nurse with training in a particular area, especially surgical nursing, why not take off on a new career opportunity based on the Primary Nursing framework-each patient has one nurse who directs, plans and implements patient care with the physician. And for nurses without special training, or for recent nursing graduates looking for a flying start, Her- mann Hospital will provide additional training with full pay while you learn. For further information and details about our com- prehensive benefits package, please complete and mail the coupon below. Or call Ms. Beverly Preble. Nurse Recruiter, (713) 797-3000. The Cen-.llen Nur.. .. . \ -r- '-'lie t\1g\1 - "'- . , .. ." o I N <<{. \ ..M.\\\ u ie J urr -, - . ......... .. ...,*4 t, , - , .,.... "0- I '" f..J _' Þ - \ .. . , NAG -,.4 . In Name Address City State Phone Specific Area of Interest (Circle) RN LVN Student Nurse All: Nurse Recruiter -1203 Ross Sterling Texas Medical Center - Houston, Texas 11030 Zip Febru.ry 11171 13 \p' , , / . I. .... , I r -'t ../ Itt. ::,.. .. '\;. It I' \ 1'fI Promary TeachIng HospItal lor the Umvers y 01 Texas Medical S OOI at Houston s HERMANN HOSPITAL HOUSTON'S LIfE . FLIGHT HOSPITAl An equal opportunIty employer " I. handIcapped - 14 Februery 11171 The Cen-.ll.n Nu... ep .. . .. . . .."".. "\ .. ; 'II . Iii l\ 1-, \ - 4 I ".' .::.i!.- f If! I .:-J"'!.. ;;- - --r4i · - . ,"- ..þ can go a long way , ., to the Canadian North in fact! Canada's Indian and Eskimo peoples in the North need your help. Particularly if you are a Community Health Nurse (with public health preparation) who can carry more than the usual burden of responsi- bility. Hospital Nurses are needed too... there are never enough to go around. And challenge isn't all you'll get either- because there are educational opportunities such as in- service training and some financial support for educational studies. For further information on Nursing opportunities in Canada's Northern Health Service, please write to: ø........, I Medical Services Branch I Department of National Health and Welfare Ottawa, Ontario K1A OL3 I Name. I I Address I I City . Provo I I .. Health and Welfare Sanlé eI Blen-êlre social I Canada Canada ,........., Index to Advertisers February 1979 Abbott Laboratories Cover 3 Ayerst Laboratories 7 The Canadian Nurse's Cap Reg'd 4 The Central Registry of Graduates Nurses 59 CI BA Pharmaceuticals 54. Cover 4 The Clinic Shoemakers 2 Equity Medical Supply Company 55 Eschmann Canada Limited 49 Health Care Services Upjohn Limited 53 Hollister Limited 10 J. B. Lippincott Co. of Canada Limited 50,51 Long Island Jewish Hillside Medical Center 59 The C. V. Mosby Company LimiIed 12. 13, 14, 15 Posey Company 54 Procter & Gamble 48 W. B. Saunders Company Canada Limited 5 White Sister Uniform Inc. Cover 2 Adl'ertising Manager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa, Ontario K2P I E2 Telephone: (613) 237-2133 Advertising Repre.fentallves Richard P. Wilson 219 East Lancaster Avenue Ardmore, Penna. 19003 Telephone: (215) 649-1497 Jean Malboeuf 60 I, Côte Vertu St-Laurent. Québec H4L IX8 Téléphone: (514) 748-6561 Gordon Tiffin 190 Main Street Unionville, Ontario L3R 2G9 Telephone: (416) 297-2030 Member of Canadian Circulations Audit Board Inc. 1m.:] BUTTER FLY * the ".,ged ill usion set of choice " . I I . L I eJð .RD. T.M. .... - ...\ - l' '" \ .. \ ,. ,. 'a ... ,. '\ , ,.., , ... .. Ii .. ... ... .. - .. .. 1t1l'" 4 A different appearance- A common need Both may benefit from Slow- folk" Prophylactic iron and folic acid supplementation recently, a number of physicians have queried the during pregnancy is now an accepted practice effect of oral contraceptives on serum folate levels among Canadian physicians. It has also been in women. Dr. Streiff reports: "This complication established, through the publication in 1974 of (of oral contraceptive. therapy), however, may be Nutrition Canada!, that many Canadian women recognized more frequently in the future... Folate may not be obtaining the necessary nutritional deficiency associated with oral administration of requirements from their diets. For instance, 76.1 % contraceptives does not necessarily require of adult women (20-39) had inadequate or less than discontinuance of the drug regimen but folic acid adequate intake of iron and 67.9% were at high or therapy is definitely indicated."2 moderate risk of low serum folate levels. More CIBA Dorval, Quebec woe: 1 R1 J:'nr .....;_f'....._ ,...;...inD inrnr"' tinn f/i:"" n Ð" 4i:d DO r: ') 7" .,. t ".. '= .. ." L. OUi OF Lj:RARY . Home care, a Canadian study plus a report from England . Tips on updating your nursing care plan format . Road to recovery, a first person account by a CV A patient and his nurse . Offshore islands beckon nurses i The Can. Nune BIBLIOTHEQUE SCIENCES INFIRMIERES Ia . MARCH 1979 L SCLf&OL Of I t;1 H' Iv " '1974 r R r\ Ii I I. 0 I J G ø q ^ H 0: J> I r A L FO ,DtD I\ OHN H STRATl,OqO HOSP ,- t:,{ ,r - -S-o . . û' :3 - ..., ... 7. -,;.-_ c.. '4lìFA'f.. 't, ..... .- . .- .... J , JÞ " . ., - H 0 :: . ..... I t ,e r - () - , ). ... . -"\ "' =- ... , "'" - ,.... . . . ....::- ....- .- -; . - 1' . I . . t ,... --- ...... ,. . ' ." ,.:} . -. s . ,"' . .... '" . '1"::'1 "'r,otFl. ,.\t> .:.. - - ' . rt .. , < ;t.. . '- "'- \'t-o" " . >I -9" '" ,.. " '" . ..+ -' - - ., "'I (j p ' . "':r: ... ....... IT 'J -- '...... r. .', ""'- At . : ..J' . 1.11 .r'i! ;" ...- <( ... '+0 \ :::. \ , - \5.q --. . ...... , '1õ. Ol GF !> <:. " " SN9 \11)/ - - OI V1\JJ 11'1\1110 " 1\J3 ÎJ Sll1 Ih::iS ill r 1:/ S S I J W V ,., V 11) :U 7fT V'T 4 6L 1 OT r n 7 r - , \ \ \ ,\ r ) \ -/ ". ------- DESIGNER'S CHOICI Another quality name frol1 "The House of White Sister' desilfner's A L. I CIIOICe A. Style No. 42234 - Dress. Sizes: 3-15. "Royale Liner - 100% textured DACROW polyester warp knit. White, Yellow. . . about $30.( B. Style No. 42272 - Pant suit. Sizes: 5-15. "Royale Liner - 100% textured DACRON' polyester warp knit. White, Pink. . . about $36.( Available at leading department stores and specialty shops across Canad The Canadian Nurse March 1979 The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number 3 Input 4 You and the law Corinne Sklar 14 News 6 Nursing: nineteen-eighty-floor Lawrence N ightingown 17 Books 52 Case load: over seventy-five Mary Gibbon 20 Library Update 52 Not all patients need hospitals Arlene A ish 23 Frank's story Frank Halligan. Lori Whittington Hunt 26 Bridging the gap between AgnesT. H. Choi-Lao. , education and service Marion S. Logan 34 Nursing care plans: a vital tool Alida Sih'erthorn 36 . A trip to the islands Rosalind House 42 That's no nurse! That's my mother! Celia Nichol 45 CNA Financial Statements and Auditors' Report 49 of .... @ , '1 + -::" - ......... . , -:- ril 0 ... -- ...... CJ . i . . Nursing past and present is on di play in the CNA Archives. An important part ofthis display are the nursing school pins donated to your professional association over the years. The pins on this March cover were added to the collection, which now numbers close to 100 pins, during the past year. Nurses wishing to have their school represented should contact the Librarian. CNA House. COVER PHOTO: AI Patrick Photography Ltd.. Ottawa. The Canadian Nurse welcomes suggestions for articles or unsolicited manuscripts. Authors may submit finished articles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and carbon. All articles must be submitted for the exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. The views expressed in the articles are those of the authors and do not necessarily represent the policies of the Canadian Nurses Association. ISSN 0008-4581 Canadian Nurses Association, 50 The Dnveway, Ottawa, Canada, K2P IE2. Indexed in International Nursing Index, Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microfonn from Xerox University Microfilms, Ann Arbor, Michigan 48106. Subscription Rates: Canada: one year. $10,00: two years, $18.00. Foreign: one year. $12.00; two years. $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not 'responsible for journals lost in mail due [0 errors in address. Postage paid in cash at third class rate Toronto, Ontario. Pennit No. 10539. Canadian Nurses Association, 1978. Z ..rch 111711 Th. C....dl.n Nur.. CAN I HE:LP IT IF I DE:AUTIFUL? , . \ <\ 'J ... "0 '.... . . .. . . . .. . . . ... . . .." . ..'111'..... . . . - - . . . . THE CLINIC Yes, I'm proud to be one of your newest Clinic patterns-you'll love my carefree lool"i! ßest of all I'll bring you the same fit and comfort you've learned to expect from Clinic, America's Number One Shoe for Young Women in White! '"'-'\l1lI__"0 ua PA' Of', . MAD( . US" SHOE PM ÌI\,VJhai,@ " SOME STYLES ALSO AVAILABLE IN COLORS. ., SOME STYLES 3%-12 AAAA-EE, ABOUT 33 00 to 48.00 For a complimentary pair of white shoelaces, folder showing all the smart Clinic styles, and list of stores selling them, write: THE CLINIC SHOEMAKERS · Dept. CN-3,7912 BonhommeAve. . St. Louis. Mo. 63105 The Can-.ll.n Nur.. "'rch 11179 3 perspective (] o 0 8 80 15 @ 0@@ @ø 8e @@C0 I\.e} to cover photo: /. Brcmdon General HfJspital Training School for Nurses, Brandon. Man.. 19:!0. 2. StrtltfòrdGeneral H ospiral Stratford,Ont. 3. SailllJohnGeneral Public H ospiwl, St. John. N. 8.. 1888-1930. 4. Jlac/.. Trtlining School, 19:!4. St. Catharines General and Murine Hospital, St. Catharines,Ont. 5. Rusumund Memorial Hospital, Almonte,Ont., 19:!:!-:!6. 6. Mack Training Schuol, 1950. St. CutharinesGeneral and M lrine Hospital, St. Catharines,Ont. 7. Holv Cross Hospital, Calgary, Alberta. 8. Hópital St. Vincent de Paul, Sherbrooke, Qué., 1930. 9. SUSki/toon City Hospital, S cllOOI of Nursing, Saskatoon, Sask., 1936. /0. RoyalColumbian Hospital, New Westminster, B.C., 1923. / /. Victoria General Hospital, Halifax, N.S., 1974. /2. Phillips' Training School of the Homeopathic Hospital ufMontreal, Montreal, Qué., 1894-1951. /3. C harlolle Eleanor Englehart Hospiral, Petrolia, Ont., 1911-1935. /4. Queen Elizabeth Hospital of the Montreal School of Nursing, Montreal. Qué., 1951-1972. /5. Phillips School of Nursing. Nichols Hospital, Peterborough, Ont., 1939. /6. Hótel-Dieu de Gaspé. Gaspé, Qué.. 1950. /7. OtlawaCidc Hospital, Ottawa, Ont., 1929. /8. Misericordia Hospital, Winnipeg, Man., 1925.. /9. Pro 'idence Hospital, MooseJaw, Sask.. 1920-1970. 20. Onrario Hospital Trtlining School, 1935. 2/. NeepawaGeneral Hospital, Neepawa, Man., 1942. n. St. Boniface Hospital. Winnipeg, Man., 1934. 23. York RegionalSchuol of Nursing. Toronto, Ont., 1%7-1973. 24. Saint John General Hospital. St.John. N.B., 1930-1958. 25. G reat War Memorial Hospital, Perth, Ont.. 1929. 26. Saskatoon Citv Hospital SchoulofNursing, Saskatoon, Sask., 1918. 27. Memorial Hospiral, St. Thomas,Ont., 1931. 28. JohnH. Stratford Hospital Training Schoolfor Nurses, Brantford,Ont., 1900-1910. 29. JohnH. Stratford Hospital Training School for Nurses, Brantford,Ont., 1888-1900. 30. BrantfordGeneral Hospital, Brantford,Ont., 1912-1974 l Question: What disease is relatively simple to control. requires a low cost regimen and relatively little medical supervision but nevertheless continues to rank among the top killers in this country? Answer: If you recognized high blood pressure as the culprit, you'll want to read more about this chronic, serious disease in next month's Canadian Nurse. The April issue will feature a nursing update on a variety of aspects of high blood pressure, including a report on an Ontario study which found that nurses working in the business or industrial community do have a definite role to play in helping patients control this disease. Related features include a report on an Ontario Task Force on Blood Pressure Screening Programs, a review of current drug therapy and a look at the part that exercise and diet have to play in controlling hypertension. Don't forget, April is Hypertension Month across the country. In this issue: Noted nursel researcher Mary Gibbon reports on the results of a study she directed in Southern Ontario on the ways that community health nurses can be most effective in the care that they are able to offer the growing number of senior citizens whom they visit regularly in their homes. Mary Gibbon is director of the Hamilton-Dundas Branch of the V ictorian Order of Nurses and her report begins on page 20. EDITOR ANNE BESHARAH ASSISTANT EDITORS LYNDA FlTZPAllUCK SANDRA LEFORT . PRODUCTION ASSISTANT GITA FELDMAN CIRCULATION MANAGER PIERRETIE HOTIE ADVERTISING MANAGER GERRY KAVANAUGH CNA EXECUTIVE DIRECTOR HELEN K MUSSALLEM GRAPHIC DESIGN ACARTGRAPHICS EDITORIAL ADVISORS MATHILDE BAZINET. chairman, Health ScIences Depanment. Canadore College, Nonh Bay, Ontario. OOROTHY MILLER,publlc r /ations offic r, Registered Nurses Associalion of Nova Scotia. JERRY MILLER,dir ctorof communication s rvic s , Registered Nurses Assoctation 0( British Columbia. JEAN PASSMORE.f'dilOr. SRNA news bulletin, Registered Nurses Association of Saskatchewan. PETER SM ITH. dir ctor of publications, National Gallery of Canada. FLORIT A VIALLE-SOUBRANNE, consultant. professional inspection division Order of Nurses of Quebec. - 4 M.rch 1171 The Cen-.ll.n Nur.. input The Canadian Nurse invites your letters. All correspondence is subject to editing and must be signed. although the author's name may' be withheld on request. Solving our health inefficiently and not working demonstrate their capable of performing. In this problems hard enough to meet the responsibility to the patient. respect our press release has Helen Taylor, president demand for services which The intrusion of a "third met with success. of the Canadian Nurses obviously exists. An party" scheme is hardly an -Helen Taylor, president. Association, has stated that over-extended emergency argument; physicians, Canadian Nurses doctors should be on salary. department is a hospital patients, and insurance Association. She has also advocated the administrative problem, and companies have enjoyed Still going strong use of community clinics to the presence of a nearby compatible relationships in Last summer, The help cluttered hospital community clinic is not going North America for many Canadian Nurse reported in emergency wards, and I to solve that problem. years. Still, it was that very the News section that understand that she is 3. The nurse practitioner is a concern about high cost, low McMaster's Educational advocating wider use of nurse valuable member of the health efficiency, and inequity of Program for Nurses in practitioners. care team but many nurses care that has provoked Primary Care (Nurse Let us take these topics politicians to assume greater one by one: with whom I have spoken control in the direction and Practitioner Program) was have indicated reluctance to delivery of our health being discontinued. 1. Placing doctors on salary. work in isolation. After all. I am pleased to report to The physician-patient they will be practicing services. you that the Ontario Ministry relationship is a subtle one medicine and if things go While it is not being of Colleges and Universities, and involving a "third party" wrong they are liable to be suggested that physicians' with the support of the intrudes on a closed and very sued for negligence. In our offices and group practices Ministry of Health, has agreed special two-party system as society nurses working in the cease to exist, the need is to make funds available to has been pointed out by Dr. primary care field appear to be apparent for alternative support the program for facilities where good health Walter C. MacKenzie, Dean most comfortable working in practices can be learned by another year. Emeritus of the Faculty of close association with a The concept of the Medicine at the University of physician. There is a our citizens and illness be program continues to be Alberta and past president of tremendous amount of good either prevented or detected strongly supported by the the Royal College of work that the registered nurse early. The nurse has an Faculty of Health Sciences, especially important function Physicians and Surgeons of in such a setting can do if the in such settings. Expensive McMaster University. Canada. Doctors on salary are practitioner is prepared to medical services are -DorothyJ. Kergin. R.N., responsible primarily to those delegate work to his nurse. I frequently not required and Ph .D., Associate Dean of who employ them. I assume would have thought that Health Sciences (Nursing), that Helen Taylor is Helen Taylor should be the physician is valued greater McMaster University, where his skills are more suggesting that the state be the spending her efforts in appropriately utilized. When Hamilton, Ontario. employer. How naive. when persuading doctors to health and medical Clarification all the evidence shows that delegate, delegate, delegate, diagnosticltreatment centers The College of Nurses of state-run enterprises pay little rather than advocating that are sufficiently available, Ontario gives encouragement attention to cost effectiveness nurses set up shop on their hospital emergency to its registrants to apply the so that high costs combine own. with low efficiency. The I doubt very much departments will likewise be College's "Standards of AuditorGeneral's report is whether the views stated in more effectively used for the Nursing Practice for further evidence of this. the interview express the purposes they were Registered Nurses and established. Registered Nursing 2. In most communities there feelings and sentiments of the The November 1978 Assistants" in everyday are medical professional great majority of the members press release, which elicited practice. The College does not buildings in which physicians, of her association. Dr. A.G. Dawrant's have specialty registers fór assisted by their nursing staff, -Dr. A.G. Dawrant, comments endeavored to those who enter special fields provide service. Usually there president. Canadian interpret nursing to the of nursing, such as are X-ray and laboratory A ssoâlltionfor Independence Canadian public. Nurses work occupational health nursing. facilities. I s Helen Taylor in Medicine. in a multiplicity of settings but A news item in the suggesting that these The president responds: it was not suggested that January issue ofCNJ stated professional buildings be It is difficult to believe nurses hang out their personal that the plans of the Ontario phased out and replaced by that a salaried physician could shingles. This has never been Occupational Health Nurses "community clinics?" The not obtain the same advocated by the Canadian Association (for certification) emergency department of the confidence and trust of his Nurses Association. have received the support of local hospital is an appropriate patient as one who provides It has been most the College of Nurses of place to give first line care on a fee-for-service basis. gratifying to also receive Ontario. I would like to clarify treatment during the evening An increasing number of reports from the public that the College does not have and night and any emergency physicians in this country are indicating their interest and the power to officially endorse rooms which are cluttered are salaried and they, like nurses, new appreciation of the or support certification probably being run have every opportunity to functions that nurses are programs. The Can-.llen Nur.. llerch 1171 II t!I(I Ii! . The staff may give encouragement to colleagues in their development of a plan to upgrade the nursing practice of a group of registrants but this should not be construed as official support. --.loanc. Macdonald, Reg.N., director, College of Nurses of Ontario. Oops! In the November 1978 issue ofThe Canadian Nurse. a report was printed in the "News" section on the Ontario organization of emergency nurses and a recent interdisciplinary meeting attended by them. The article states that Ontario has the only organized group of emergency nurses in Canada. Actually. this is not r t!AE"OSTA FORCEPS (Kell,) Id..' lor clamp,ng 011 tubing. file Oozens 0' uNa Shunl... at..l. loelung t)'þe, 5 \II long P 20 s"a,ght ... Ii PA22 cu,-.,eø SA at .o1IIIIIIIIIii NOTE. ,..... write your lull neme end 1Idd..... "'IIIIIIIIII!I In lbe "'a'V'tI. an accurate statement. The province of B.C. has an active. well-organized group of emergency nurses affiliated with the RNABC Our chapter hosted a well-attended seminar in October 1978 forthe three disciplines of emergency health care. It also featured a basic CPR certification workshop. Our organization may not boast the longevity of the ENAO. but we have been a recognized. organized group for the past three years. -K.L. Murray, R.N., Kamloops Chapter, E.N.G. of B.C. Editor's note: Our apologies for the editorial oversight. CNJ would be pleased to hear from other emergency nursing groups across the country. MERCURY TYPE. The ulhme.e In eccur.ac)' Folc:!a InlO hgl'll but rugged mer.., c... HN"Y duly Velcro cull and .",tlatlon .yatem 151 " eedI. - . : :: I n :' nøaÞI. '0 .. yNr guaranl_ 01 accuracy 10 . 3 m m No alop-þln to hiDe 8"or. Handaome z,ppereeJ caø to hi your pocket 121 H compte... UASES PENLIGHT. Po*ertul beam 'oreumlneuon 01 ttuoal .IC Durable staml..s-sleel case wlln pocket Clip "".ade In USA NO 28 S5 H comple'. with bi!.ter1... Economy model wi.tI ctlromeø bras. C&M t.Jo 29 12 ". NURSES WHITE CAP CLIPS. Mede In Canaøe tor Cenad..n nurse. Slro S,NI bobby pIns WIU'I nylon r;2 M a sl 01 15. 2 aiD ".00 I CMd NURSES 4 COLOUR PEN lor recOrdlnv ,emþeretunt. bloo of educational institutions to prepare a competent basic nurse and the expectations of employers to hire a more experienced nurse. It is further compounded by the rapidly changing health care delivery system. "It is well known that the Ministry of Health is attempting to de-institutionalize health care. " RN AO president Bajnok comments. "On the other hand the Ministry of Colleges and Universities appears to want nurses to be educated with more emphasis in the care of the acutely ill." A Review of the Two-Year Diploma Nursing Program in Colleges oj Applied Arts lmdTecllflology in Ontario. a study commissioned by the Ministry of Colleges and Universities and prepared by ARA Officer. AARN; Marie LammeI'. Communications Officer, SRNA; Jean Cummings, Business Manager and Public Relations. MARN; Carole Elliott , Communications Officer, RNAO; Jean-Claude Patenaude, Director ofl nformation. The Order of Nurses of Quebec; George Bergeron, Liaison Officer. N BA RN: Dorothy Gray Miller, Puhlic Relations Officer. RNANS; Laurie Fraser. Executive Secretary, ANPEI; Phyllis Barrett, ExecutÎl'e Secretary, ARNN; and Rusty Stewart. Public Relations Officer. NWTRNA. Consultants. was released in June 1978. Since then. nursing groups and other groups across the province have submitted responses to the Ministry of Colleges and Universities so that the decisions made about diploma nursing education would reflect input from professional health care workers. The study was commissioned in order to determine the effectiveness of the new two-year graduate. It found that the educational objectives are to produce a graduate who can function as a competent beginning practitioner and meets standards set by the College of Nurse . The employer's dissatisfaction is based on hi<; perception ofthe graduate's ability to meet individual employment setting expectations. "Both RNAO andCNO have stated clearly in their responses to the study that programs could be strengthened by internal program changes in order to solve this dilemma," CNO president Evans observes. "For example, a re-organization to lengthen the pre-graduate clinical experience is a possibility. "We at RNAO and CNO have purposely avoided suggestions that there be an internship for students in diploma nursing programs," the two presidents observed. "A provincially imposed internship will not solve the dilemma but will raise many questions, such as: What would be the major objectives of such an internship? Who will organize such a component in nursing education? Will students be placed under thejurisdiction of the employer or the educational institution? Will such a change really have the desired effect on the new graduate's ability to function? And, indeed. how will such an effect be measured? How will the resultant overcrowding in the clinical settings be handled?" ''The College of Nurses registers only those graduates Tile Canacl..n Nur.. who are competent to practice," according to President Evans. "Every nursing student must undergo a minimum of 1200 hours of supervised clinical nursing experience during the basic program. No valid data has surfaced to prove that additional vocational training is warranted," she continued. The two nursing spokesmen are also concerned about the financial implications of an internship. They ask: What salary would a nurse intern receive? What would the yearly influx of 3,000 nurse interns do to the tight employment situation in our hospitals? "Both RNAO and CNO question that the leadership and supervisory skills identified as weaknesses in the study would be enhanced by an add-on internship. To implement additional vocational training would not be cost effective. Until all the questions we have raised are answered, we strongly oppose a top-gap measure. We believe that strengthening the two-year diploma program- without a vocational training add-on - is the answer. .. Occupational health prograrnlaunched McMaster's Faculty of Health Sciences is launching a diploma program on occupational health and safety in February, 1979. One of the first of its kind in Canada, it will be open to doctors, nurses, industrial hygienists, safety engineers and ergonomists. Working in an interdisciplinary program these health professionals will continue their normal employment in the occupational health field while developing a rigorous and analytical approach to the solution of the problems in the work place. Faculty will be drawn from McMaster University. the University of Toronto, industry and government and includes a number of well-known experts in the field. Students must possess a university degree or the equivalent and be employed in an industrial setting. Much of the funding is being provided by the Ontario Ministry of Labour through Wintario Funds. WHO to award health fellowships The World Health Organization is once more inviting applications from Canadian citizens engaged in a professional capacity in operational or educational aspects of health care. The fellowships have a total value of close to $40,000 and are to be used to provide the winners with short (two to three months) programs of study abroad. Applicants will be rated and chosen by a selection committee on the basis of their education and experience. the field of activity they propose to study and the intended use of the knowledge they gain during their fellowship. Final acceptance will be the responsibility of WHO. Persons who are ineligible for the awards include workers in pure research, undergraduate and graduate students and applicants more than 55 years of age. Requests for information should be directed to: International Health Sen'ices, Brooke Cluxton Building, Tunney's Pasture, Ottawa, Canada, KIA OK9. llerch 11711 7 u 1foUister ostomy pouches --- --- - - - - - - - -- - -- - - - - - - --- --- ...-.. - -- - ------- - ---- --- - --- --- --.... - -- - --- --- --- - --- --- ------- - ---- -..-..- ----- --- --- -- .. - -- -- - - - -- - -- -- - - - -- -------- -- ...... --- - -- - - ===== ==== -- ----- --- -- -- - - ... - .-........... \' \ , ...- \1 kcropll'ous adhesive oÍÍe extra touch of tenderness Fo simpler, more comfortable care for your ostomy patients, Hollister ofters stoma pouches with non-occlusive adhesive-the same type of microporous adhesive you use for taping sensitive skin. It lets skin "breathe" through the adhesive, helping prevent irritating "eat and moisture buildup. A built-in skin barrier-the Karaya Seal Ring-protects against irritation from stomal discharge. Karaya Seal Stoma Pouches with microporous adhesive mean fewer skin problems - and that means less demand on nursing resources. Drainable and closed pouches available: Write today for more information. ; Hol srER Prouu " u. HO L.uTER INCC":IPORAT D l TRILJTED I C.....ADA BV ..,0 EP I 'ti' -)N UME \ F) V. LLC WD T "1 P . llerch 1171 The Cen-.llen Nur.. news .-....--,;. , -' =--=--=--:w::- 1'111 , _-z- -' ---- ----- - , - ---- r .< 'C . --- :!i!- T . .... ,l -. -- - ,-- \ I - -=- ì ..' ....- Q. . " 0 . , 't; ... " cñ \ 0 - ';'). '" - - " . 1:: " :3 0 õ \. .c c.. Newly appointed members of CNA 's Testing Service Nursing Assistants Blueprint Committee met for the first time at CNA House in January, 1979. The purpose of the five-day meeting was to develop an outline of the content to be used on the future examination. Above. Chairman Verna Sylvestre leads the memhers of the committee in discussion. Committee members include Joan Kennedy, Francis Johnson, Marie Pittaway, Janet Gray, Freida Marfell, Verna Steffierand Judith Pemberton. RNABC submits election resolution The Registered Nurses Association of British Columbia has responded to the call for resolutions published in the December issue of The Canadian Nurse and L'infirmière canadienne for presentation to the annual meeting of the Canadian Nurses Association on March 29th. The notice called on individual members and association members ofCNA to submit resolutions to CNA by February 1st, 1979. Although no resolutions submitted by individual or association members after that date can be presented to the annual meeting. voting delegates may submit motions pertaining to the business of the annual meeting during the course of that meeting. The RNASC resolution, which will be considered by CNA directors before presentation to the voting delegates, is as follows: WHEREAS. one of the most important responsibilities of CNA delegates is the election of the Board of Directors; and WHEREAS, any given biennium may be the first for many delegates. who may be unfamiliar with the election process and the candidates; and WHEREAS. the candidates for office. in accepting the challenges associated with running for election deserve an opportunity to present their platforms; RESOLVED. that the CNA Board of Directors make provision in all future biennium agendas for each candidate to address the delegates prior to the voting session. Improved care urged by RNABC Government regulations should be changed to assure better care for residents of personal and intermediate care facilities, according to a brief submitted in late December to B.C. health minister Bob McClelland by the Registered Nurses' Association of B.C. RNABe seeks revisions of regulations under the Community Care Facilities Licensing Act. part of the government's LongTerm Care Program. The nurses recommendations would mean more professional supervision of care, improvements in criteria for care. and administration of medications by trained personnel. Specifically. the association proposes: . that staff in intermediate care facilities be supervised by persons with "documentary evidence of professional (health care) training acceptable to a registering body or professional association of British Columbia". Presently. unlicensed health workers can supervise staff who provide care. and there is no check on their qualifications by bodies like RNABC or the College of Physicians & Surgeons of B.C. . that existing staff-to-resident ratios be adjusted according to the complexity of care actually required. Presently. the regulations specify minimal amounts of time spent with each resident of a facility, regardless of the severity of his or her health problem. . that residents' medications be administered by someone "trained to perform this function". Presently. any staff member may administer medications. Besides revisions of the regulations. the nurses' association recommends: · that designs for future personal and intermediate care facilities take into account the needs of disabled persons using wheelchairs and other appliances. . that any government studies of the Long Term Care Program include evaluations of staffing criteria. . that registered nurses and other health professionals involved in the LongTerm Care Program be invited to participate in government studies of the program. The RNABC brief reflects input from registered nurses throughout B.C. The committee preparing the submission also consulted LaviniaCrane. B.C. director of public health nursing. and Pat Bertles. nursing consultant to the government's Community Care Facilities Licensing Board. Without committing himself to specifics, the health minister told RNABC representatives that new regulations expected in 1979 would reflect the recommendations in the brief. Nurses honor children May 12th. International Nurses Day. is the day chosen by the International Council of Nurses to honor the children of the world in this Year of the Child, 1979. Nurses around the world are being asked by the ICN to demonstrate their support for the International Year of the Child on the anniversary of the birth of Florence Nightingale. ICN president Olive Anstey comments: "Nurses make a major contribution to child care in all countries: they are in a frontline position The Cen-.ll.n Nur.. "'rch 11179 II I to identify the unmet needs of CNA is an active member Did you know... Did you know... children in their communities. of the Canadian Institute of The Health Care Centre at the A study conducted by a "At the national level. Child Health Coalition for the Drumheller Medium Security University of Western Ontario nurses' associations are Prevention of Handicap and is Institution became the first professor of nursing indicates working with other bodies in promoting IYC through its health care centre in the that redhaired children fall ill developing programs designed eleven provincial/territorial Correctional Service of more often. more seriously to improve services for member associations, each of Canada to be awarded and for longer periods of time children. whom have formulated their accreditation status. On than other children. Professor "At the international own support program for the December 7. 1978. Brigid Peer based her findings level. ICN is collaborating year. Fernande Harrison. one of two on a comparison of the health with other organizations to Both The Canadian Canadian Nurses Association histories of 30 redheaded ensure worldwide cooperation Nurse journal and Representatives on the children and 30 children with in improving the quality of life L'infinnière canadienne Canadian Council on Hospital other colors of hair. of children everywhere. .. kicked off IYC celebrations Accreditation. presented a She warns mothers of The Canadian Nurses with special issues featuring a Certificate of Accreditation to children with red hair that Association participated in the nursing approach to health Mr. Stan Baird. Senior Health they should be sure that these establishment of the Canadian care for children in hospitals Care Officer for the children are imm.unized and Commission on the and in the community. Other Drumheller Institution. The that they should take illness International Year ofthe articles focusing on the special Centre functions primarily as among these children Child. It supported the use of health care needs of children an outpatient ambulatory care seriously since they are more UNICEF greeting cards and will appear in the journals unit. likely to develop plans to feature IYC in its throughout 1979. complications as a result of annu:tl meeting program in illness. March 1979. A CNA national forum on nursing education :\m'ember 13. 14.]5 ]979 IN OTTAWA Theme: The nature of nursing education Participants at the Forum will discuss and probe issues and problems related to nursing education and the practice of nursing - here's a chance to exchange ideas with national authorities and leading practitioners... PROGRAM FOCUS - What is "basic" nursing education? - Diploma or Degree? . NURSING MODEL. CURRICULUM. NURSING SPECIALIZATION. ACCREDITATION OPEN TO ALL REGISTERED NURSES TO A MAXIMUM PARTICIPATION OF 300 REGISTRATION: CNA MEMBERS- $]00 NON-MEMBERS - $]75 ð Complete program details and registration tear out in coming issues or from your provincial association REGISTER EARLY Be one of the 300... Canadian Nurses Association 50 The Driveway Ottawa. Ontario K2P IE2 Tel(613)237-2133 10 llerch 11179 The Cen-.llen Nur.. FUNDAMENTALS New 10th Edition TEXTBOOK OF' ANATOMY AND PHYSiOlOGY. Sharing the insights of a new co-author, this classIc IS better than everllt retains the features which have made It the leader In this field and offers many additional nlghhghts Coverage of the endocnne, reproductive, un nary and cardiovascular systems IS expanded - reflecting an Increased emphasIs on physiology Completely new units examine the cardiovascular system. plus defense and adaptation A timely new chapter on articulations and a conCise review of chemIstry also enhance thiS edition By Cathenne Parker Anthony, R N , B A., M S and Gary Arthur Thibodeau, Ph D January, 1979 744 pp, 570 Illus Including 211 In full cdor PrIce, $21.75. New 10th Edition ANATOMY AND PHYSiOlOGY LABOIlÁTORY MANUAL. Reflecting current trends In anatomy and phYSiology, this manual corresponds with the TEXTBOOK OF ANATOMY AND PHYSIOLOGY You'" find new exercises In hematology, the latest information on reproduction and urinalysis, and new appendix matenals By Cathenne Parker Anthony, R N, B A, M Sand Gary Arthur Thibodeau, Ph D January, 1979 270 pp, 1691lfus PrIce, $9.75. New 2nd Edition Pl.ÀHHIHG AND IMPLEMENTING NURSING INTIRVENTlON: Stress and Adaptation Applied to Patient Care. Offer your students a cogent lOOk at how stress and adaptation affect humans with this well-organized text Part I analyzes the concepts of stress and adaptation, along With their roles In the human life cycle Part II uses case hlstones to demonstrate how to apply that theory. For better student understanding, this edition features rewntten definitions of stress and adaptation By Dolores F Saxton, R N , B S, M A , Ed D and PatnCla A Hyland, R.N., B S., M S, M Ed , Ed D. Marcr 1979 Approx 192 pp, 47 Illus About $10.75. New 2nd Edition COMMUNICATIONS AND RELATIONSHIPS IN NURSING. The ablhty to communicate well with patients and staff members IS paramount In nursing. ThIs Innovative text offers students helpful gUidehnes for all aspects of effective commUnication - essential charactenstlcs, self-awareness, appropnate language, and poor hstenlng nablts - then apphes these to specific situations Sixteen" communications interactions" help students practice and reInforce the pnnClples discussed. By Maureen J O'Bnen, R N , M S Apnl, 197B 260 pp., 28111us. Price, $10.75. A New Book NURSING: A World View. Nurture your students' pride In their profession with thiS long-awaited textllt provides a worldwide, histoncal perspective of nursing, encompassing the growth and development of the profession in over 30 countnes on 6 continents Following a comprehensive look at nursing, the author discusses and compares nursing In vanous countnes - Including history, education and present state of the art. Finally, you and your students will take a fasCinating look at the future of nurSing By Huda Abu-Saad, Ph D., M N., B S N March, 1979 Approx 208 pp., 14111us About $15.00. New 3rd Edition THE VITAL SIGNS WITH RELATID CLINICAL MEASUREMENTS. This Invaluable workbook provides scientific concepts essential to the understanding and assessment of vital signs Its programmed format presents manipulative skills In a practical manner that eases their Immediate transfer from classroom to the patient's bedside All aspects of measurements of body temperature and cardiac actIVIty are carefully examined. Two new chapters stress nursing assessment skills By Betty Mcinnes, R N, B SeN., M.Sc.(Ed.). February, 1979 Approx 144 pp., 35111us About $9,75. , T' for a sound nursing education! MOSBY TEXTS. Here's proof... MEDICAL/SURGICAL A New Book CANCER: PATHOPHYS- IOLOGY, ETIOLOGY, MANAGEMENT: Selected Readings. A multidisCiplinary approach, thiS exceptional text explores all facets of the cancer process - prevention, detection, treatment, rehablhtation and psychological aspects Throughout, discussions stress the commonahties of cancer assoCiated problems and provide a practical, positive approach SpeCial attention IS given to patient problems when a cure IS not probable By Louise C Kruse, R.N., B S N , M A., et al January, 1979. Approx 448 pp., 35 Illus About $16.75. New 2nd Edition CLINICAL IMPLICA- TIONS OF' LABOIlÁTORY TESTS. A good understanding of laboratory test results is essential for any nurse - and this conCise text can help USing a step-by-step approach, It emphasizes the physlologlcallmphcatlons, variations and Interrelations of laboratory values Intltial chapters examine the routine multisystem screening panel. Subsequent chapters discuss evaluative and speCific tests for suspected disease entities. Valuable new chapters study Infectious and rheumatoid diseases By Sarko M Tllkian, MD., et al February, 1979 Approx 272 pp, 45 ,lIus About $10.75. New Volume I. CURRENT PIlÁCTlCE IN NURSING CARE OF THE ILL ADULT: Issues and Concepts. Students Will be more capable of unravehng the complexities of modern nurslrg practice with the help of this outstanding text Twenty-five original articles . discuss key professional Issues analyze their Imphcatlons and present clinical guidehnes for assessing or Intervening in speCific nursing situations Alcohol Withdrawal, bioenergetics and patient-nurse interaction are Just a few of the tOpICS examined By Maureen Shawn Kennedy, R N., B S.N., M A. and Gall Molnar Pfeifer, R N , M A Mf!ý, 1979 Approx 320 pp , 15111us. Atout $14.50 (C), $10.75 (P). I ..... A. ....= CM:eIIB IIIøNI ::: ;;r Parent-child nursing NYCHOlOOAL ASPECTS I C. ...r....".... ._,. """'-41.' ",-!'Co ,.. '11""'" ,".." 11 I.' .......!'Ioh.... ....... ....I.......... .... ...1 ""........ ..=' .,.' .'- ' , . " . , ...' . ., ,,,, The Cen-.llen Nurae M.rch 11179 11 A New Book MEDICAL-SURGICAL NURSI....G: Concepts and Clinical Practice. USing both a systems and a conceptual approach. this new text reflects the mynad changes In contemporary medical/surgical nursing The first two parts focus on general aspects Part III explores speCific medical/surgical problems - each discuSSion Includes an assessment of the IrNolved system followed by a managemer o Intervention process Students Will be particularly Interested .In a unique chapter on ecology and health By Wilma J PhippS, RN, B S., AM, Ph D, etal February 1979 Approx 1,600 pp 735111us About $27.75. 2nd Edition INFECTION: Prevention and Control. Introduce your students to Infeclon prevention and control With this updated, logically organized text It prOVIdes a comprehensive O\Iervlew of various aspects of epidemiology and the mechanisms of spread and control of Infection, along with the role of the Infection control coordinator New chapters explore personnel health seMce programs poliCies and procedures for prevention and control, categones of Isolation, i!nd the reporting system By Elaine C Dubay, R N, B S and Reba Douglass Grubb, B S . WlttJ 9 contributors 1978 198 pp., 48 ".us Price, $10.25. A New Book THE NURSE AI>ID RADIOTHERAPY: A Manual for Daily Care. Wnttef'to help nurses better understand - and meet - t>Je challenging needs of cancer patients, s comprehen Ive book provides a po .ve approach ) radiotherapy Begll"\'llng chapters explore >')e role, effects and delivery of radiation treatments, subsequent chapter focus on ps rhOSOCial ImpliCations and developing sc.Jnd nursing care plan" D,scuss 'Jns of poter 11 problems and sol on )ffer a ur =1ue opportUnity to take a creative look at orx:c oglC nursing By Irene M Leahy, B A , R '" et al December, 1978 182 pp 4911 Price, $12.00. FI\THERING T1ONS AND RELATIONSHIps IN NURSING "...."I.. ,..... u, ....,..,....- _ullf.I ':"- ".. ;"Itl Nutrition In the conUnunlt ::.: ... .,:.., _ I ....."...Î..._. .. --,... -+- 'r 4'.. 1r New Volume I CURRENT PERSPECTIVES IN REHABILITATION NURSI....G, Rehabilitation IS a fundamental, yet cruCial part of nursing practice Turn to this outstanding volume to help students better understand thelf role on the rehabilitation team Timely onglnal articles discuss rehabilitation In the ICU, cultural Implications of rehabilitation, biofeedback as a nursing therapy, the Influence of the paranormal, making the world accessible and other Important subjects This IS one text your students will want to read ' Edited by Rosemary Murrèty, M A ,R.N and Jean C Kljek, M A , R N March 1979 Approx 256 pp, 11111us. About $14.50 (C), $10.75 (p). MATERNAL/CHILD New 2nd Edltlor PARENT-CHILD ....URSING: Psychosocial Aspects. Reorganized and expanded, this InCISive text centers on how to alleviate psychologic and social stress factors that can - and often do - Interfere With optimal family growth Students will benefit from forttmght discussions of child abuse, battered wives, rape and Incest By Gladys B Lipkin, R N, M S Apnl, 1978 260 pp 43 Illus Price, $10.25. New 2nd Edition CHilD HEALTH MAINTINA....CE: Concepts in Family- Centered Care. USing both a problem-solving and a conceptual frameworl<. this Important text explores all facets of holistic pedlatnc nursing This IIf':VV editIon reflects contemporary developments In diagnoSIs and quality assurance; emphasizes critical Skills, and pinpOints the child's unique needs as gO\lemed by developmental stages and state of healtl' A detòl d new s tlon on the Integration and asse rT)ent of competenCies .s espeCially valuat"e By Peggy L Chinn, R N . Ph D March. 1979 Approx B96 pp, 377 illus About $24.00. New 2nd EditIon CHILD HEALTH MAINTENANCE: A Guide to Clinical Aucssmcnt. This learning gUide proVides an excellent presentation of gUIdelines for nursing assessmer o of the child-I' story, physical, behavioral and soCIal development The gUIde IS designed to stimulate further learn"13 and expenence I-"he area d health assessme,,' New chapters corresJ: ld with the revl' ns In CHILD HEALTH MAINTENANCE Concepts In Family-Centered Care hO\lllever, the gUide IS complete enough to stand alone By Peggy L Chinn, R N , Ph D and Cynthia J Leitch, R N , Ph D Marcl', 1979 Approx 176 pp, 24111us About $9.75. ,.. New Volume II CURRENT PRACTICE IN OBSTETRIC AND GYNECOLOGIC NURSING. Manifesting a dual concern for Increased phYSIological/psychosocial knowledge and ItS resulting nursing care Implications, thiS noteworthy text examines significant Issues In modern ob/gyn nursing Well-known authorities share their expertise With obstetric hemorrhage, failure to thnve, diabetic pregnancies, fetal breathing and other VItal subjects A particularly timely artIcle on human sexuality and the family IrNestlgates sexual role typing. Edited by Lee Kester.McNall, RN., M N and Janet Trask Galeener, R N, M S, WIth 22 contributors Apnl, 1978 252 pp., 20 Illus Price, $14.00 (C), $10.25 (P). FA THERI....G: Participation In Labor and Birth. What do your students think about fathers In the delivery room? This humanistic text can help them develop an empathy with the father and understand his reactions The authors first discuss the paternal role in labor and delivery and describe the physloan's feelings. They then Include aàual,nteMew5 With fathers, offenng students a fascinating look at a very Important member of the birth team By Celeste R Phillips, R N, M S and Joseph T Anzalone, MD 1978. 164 pp, 73 III us Price, $10.25. 2nd Edition. REVIEW OF PEDIA TIUC ....URSING. Turn to this contemporary text for a challenging review of pediatric nurSing prinCiples and techniques. Using a helpful question/answer format, It probes students' understanding of such key tOPiCS as psychological aspects, high-risk Infants, and chronic or açute Illnesses Noteworthy new features Include. a chapter on family dysfunction, an Informative section on the role of nutntlon. and expanded information on bonding, growth/development, and drug Wlthdrð\Nalm the neonate By Florence Bright Roberts, R N, M N 1978. 22B pp Price, $10.75. COMMUNITY HEALTH/ GERIATRICS New Volume I CURRENT PERSPECTIVES IN GERONTOLOGICAL NURSING. Questions on gerontology? Students Will find accurate answers In this ðuthorltatlve volume USing a multidisciplinary approach, ,t surveys all dimensions of thiS field - phYSIologICal, cultural, psychological, pharmacological and more Thought -provoking chapters on aging In Black, Chicano, Amencan Indian and Anglo cultures are excellent for stimulating class discussIons Edited by Adina M Reinhardt, Ph D and Mildred D QUinn, R N, M S ; With 19 contnbutors March, 1979 Approx 304 pp, 1 III us About $14.50 (C), $10.75 (P). A New Book NUTRITION IN THE COMMUNITY: The Art of Delivering Services. By Reva T Frankel M S Ed D. R D and Arllta Yanochlk Owen, MAR D September 1978 412 PP. 49 illus Price, $15.10. IVIOSBV TIMES MIRROR 12 llerch 11179 ....- this patient needs your help When patients need private duty nursing in the home or hospital, they often ask a nurse for her recommendation. Health Care Services Upjohn Limited is a re- liable source of skilled nursing and home care specialists you can recommend with confidence for private duty nursing and home health care. All of our employees are carefully screened for character and skill to assure your patient of de- pendable, professional care Each is fully insured (including Workmen's Compensation) and bonded to guarantee your patient's peace of mind. Care can be provided day or night, for a few hours or for as long as your patient needs help. For complete information on our services, call the Health Care Services Upjohn Limited office near you. Health Care Services Upjohn Limited Viclona e VancxJlNer e Coquitlam Edmonton e Calgay e Wnnpeg . Lordon Sl. Cathannes . HaT1I on . T oronD Ottawa e Montreal e 0Jebec . Halifax HCS811231 The Cen-.llen Nur.. CNA submits brief to federal commission The following are highlights excerpted from a submission prepared by the Canadian Nurses Association on behalf of Canadian nurses and tabled with the Commission on Inquiry into RedUl1dancies and Lay-offs in Canada's Labor Force. CNA 's director oflabor relations. Glenna Rowsell, and the association's director of professional services, Rose Imai. met in Ottawa with representatives of the commission early this Winter to present their submission. The commission has now completed its hearings and is scheduled to release its report this month. Background . The promotion of social and economic welfare of nurses is one of the objects of the Canadian Nurses Association. This object has been met in many ways over the years and most recently, through the establishment of a Labour Relations Service for the purpose of collecting information. analyzing data and conducting labor education programs. . The nursing profession remains predominantly female. For example, in 1976, of 141 .059 registered nurses employed in nursing, only 0.02 per cent were males. This presents ramifications unique to nursing. together with the fact that the service requires 24 hour coverage, 7 days a week. Given the traditional female roles of wife and mother. and the increasing number of single parents, staffing becomes an extremely sensitive and important aspect in employee-employer relationships. Where financial restraints result in cutbacks of staff but not a reduction in services. the pressures on the remaining staff could jeopardize patient care. This has become such a concern that both professional nurses associatioru; and collective bargaining groups. recognizing the need for data. have adopted means to record and report situations where staff shortages have led to or are leading to unsafe nursing care of patients, in their professional opinion. Observations . Practices related to lay-offs do not necessarily arise from redundancy. At this time, the major cause of the lay-offs of nursing personnel in institutions and agencies arise from budgetary restraints. . Nurses who are not covered by collective agreements generally are bereft of job protection and must rely on the good faith of the employer to give them the consideration due to "good employees" . Nurses who are covered by a collective agreement, may not. in effect, be better protected but they do have recourse through the collective bargaining mechanisms to have their case heard. A cursory review of the existing collective bargaining agreements demonstrates the lack of job security in relation to lay-off. · The employer. represented by the senior executive. in nursing administration or. in the overall administration of the institution. often is caught by the squeeze from above and below. And regardless of the squeeze. the service must be provided to an ever increasingly articulate clientele whose expectations continue to rise. In this particular type of situation, middle management-and some senior staff-may be equalIy vulnerable to lay-off as the staff nurse. Head nurses, supervisors, coordinators ... may find themselves being declared redundant as their positions disappear in the organization. · Overriding the mutual and respective obligations of employer and employee, is the obligation to the community for an essential service. To ensure the provision of the service. joint decision-making by the employer and employee is crucial and concomitant to that. is the need for prior infonnation by the employee. (continued on page 48) Bachelor of Administration (Health Services) Degree Program (Spring-Summer term starting April 1979) Applications are now accepted for the program combining independent study wilh tutorials on weekends in Toronto, as well as for the compelency based, external degree internship option offered for students at a distance. Credits toward advanced standing are given for managenal experience and prior education including B.Sc.N., R.N. and H.O.M. Cenifi- cate. The School is a member of the Association of University Programs in Health Administration and is supponed by the Kellogg Foundation grant. For information and application forms, please write to: Canadian School of Management S-415, OISE Building 151 Bloor St., West Toronto,Onbno M5SIV5 110 ...,j Todays nursing professionals turn to Saunders. Drain & Shipley -The Recovery Room Two leading experts in the field provide clear. accurate coverage of the recovery room in this valuable new, one-ot-a-kmd book Topics include the physiology of anesthesia, the effects of various anesthetic agents. specific care after all types of operations, and factors that affect recovery from anesthesia in particular patients. By Cecil B. Drain, Major, Army Nurse Corps, RN. CRNA. BSN, Unlv of Arizona. Tucson, AZ; and Susan B. Shipley, RN, MSN. Nurse Researcher. Nursing Research Service. Walter Reed Army Medical Center. Washington. DC. About 590 pp.. 165 III Ready soon Order "f3186-X. Sorensen & Luckmann - Basic Nursing: A Psychophysiologic Approach They've done it again! The authors of the popular Medical- Surgical Nursing now offer a comprehensive textbook on basic nursing concepts for the practitioner. Twenty eight contnbutlng experts provide special coverage of important topics such as biomechanics; nutrition; bowel, bladder. and catheter care; vital signs; respiratory care; the therapeutic nurse-patient relation- ship; blood administration and much more. Particular attention is paid to the role of stress and adaptation in illness, under- standing the eXistence of the patient, therapy and rehabilitation, the nursing process, and the changing role of the nurse. You'll' find special features like many new and original illustrations, important information boxed off in each chapter, key points highlighted with arrows, an overvièw and study guide preceed- ing each chapter. and a two-color format for easy reading. By Karen Creason Sorensen, RN. BS. MN Formerly Lecturer in Nursing. Univ of Washington, Instructor of Nursing. Highlme College; Nurse Clinical Specialisl. Univ Hospital and Firland Sani- torium, Seattle. WA; and Joan Luckmann, RN, BS. MA. Formerly Instruclor of Nursing. Univ of Washington. Highline College. Seattle, Oakland Cily COllege and Providence Hospital COllege of Nursing. Oakland. CA About 1285 pp.. 435 ill Ready soon About $2000 Order #8498-X. Dienhart -Basic Human Anatomy and Physiology 3rd Edition The ideal way to refresh your knowledge of anatomy and physiology, this new edition has been carefully revised with special attention to the chapter on the nervous system You'll find expanded coverage of cytology and histology, and expanded glossary, and outstanding new illustrations. By Charlotte M. Dienhart, PhD. Asst. Prof. of Anatomy and Assoc. Prof of Allied Health Professions. School of Medicine Emory Univ.. Atlanta. GA About 350 pp., 170 ill (16 color Plates) Soft cover Ready soon Order #3082 . LaFleur & Starr - Unit aerking in Health Care Facilities This important new book provides a complete learning resource from terminology of anatomy and physiology and communicati ng with personnel to transcrition and making orders. It combines theory and practice in a step-by-step explanation of duties. Behavioral objectives. reproductions of actual forms, review sections and tear-out work sheets are included. By Myrna LaFleur, RN. BEd. Instructor. Unit Clerk Program, Maricopa Technical Communily College, Phoenix. AZ; and Winifred K. Starr, RN. MEd. Director. Unil Clerk Program, Maricopa Technical Community College. Phoenix. AZ. About 765 pp., 1 50 ill Ready soon Order #5594-7. Tllkian & Conover - Understanding Heart Sounds and Murmurs Here's an exciting new. inexpensive package that provides a basic familiarity with normal heart sounds and allows recognition of life-threatening disorders manifested by abnormal sounds. Clear and concise, it's the first package of its kind available to nursing professionals. Order now! Package includes: C-60 cassette plus soft cover book. By Ara G. Tilkian, MD. FACC. Asst Clinical Prof. of Medicine (Cardiology). UCLA School of Medicine. Assoc DireclorofCardiology. Holy Cross Hospital and Valley Presbyterian Hospital, San Fernando Valley. CA. and Mary Bourdreau Conover, Arrythmia Workshops, West Hills Hospilal and West Park Hospital, Conoga Park. CA; and Faculty. National Critical Care Inslitule. Orange. CA. Package. Order #8878-0. Book only. About 145 pp. lIIustd Soft cover. Ready soon. Order #8889-1. Keane -Essentials of Nursing: A Medical-Surgical Text 4th Edition This is a compact textbook for students beginning the study of medical-surgical nursing. From the more general concepts related to illness (such as adaptability and immobility and homeostasis) and those related to nursing, it goes on to discuss medical-surgical nursing care problems with emphasis on the nursing process throughout Student aids Include: learning highlights (similar to objectives): vocabulary lists; summary tables; and a student study aid section consisting of learning activities. additional reading, and a study outline. By Claire Brackman Keane, RN. BS. MEd. Aboul 720 pp.. 125 III Ready soon Order #5313-8. To order titles on 3()-day approval. enter order number and author: ---------------------------- Please Pnnt. CN 3/79 NSG 3/79 AJN 3/79 AN 3/79 I I I I AU: AU: AU: o check enclosed- Saunders PIIYS pOstage fIIII!!I!IIII We accept Visa and Mastercharge o Visa # DO r- l rJflr' flnr o Master Charge # II l == J I Expiration Date Interbank #: , Full Name I Home Phone Number PosItion and AffilIation (II Applicable) Home Address J City Signature State ZIP All prices differ outside U S and subject to change W.B. Saunders Company West Washington Square Philadelphia, Pa. 19105 on Canada: 1 Goldthorne Ave Toronlo. Onlarlo M8Z 5T9 14 Merch 11171 Th. C.nedl.n Nur.. YOU AND THE LAW ...... J _ .... Error of judgment: is it always negligence? Corinne Sklar In discussing negligence and the standard of care required of nurses, I have often referred to the principle that liability does not attach to an error of judgment. Recently, a nurse asked what was meant by an "error of judgment" . This column will focus on the meaning of this phrase and illustrate its application in several cases. In general terms,judgment refers to an opinion. estimate or conclusion. It also refers to the power or ability tojudge well or with good sense. In any given situation, once a conclusion or judgment is made, then one makes a decision based on that conclusion with respect to the behavioral response deemed appropriate. For example, Johnnie cuts his forehead: mother decides to stop the bleeding by applying pressure to the site. Once the bleeding stops, she decides to take him to the hospital for stitches because she observes that the cut is wide and looks deep. This decision is based upon her judgment derived from her observations and her knowledge of the current situation and her general knowledge with respect to such injuries. Nursing decisions and conduct are similarly based on the nurse's knowledge of the circumstances or facts surrounding a given situation and the nurse's special knowledge as a professional nurse. I t is the application of this body of special knowledge, as well as general knowledge, to the situation the nurse faces which is involved in the exercise of the nurse's judgment: the result will be a nursing decision about the course of action to be followed. The decision may be to take some specific action, for example, to call the physician or re-position the patient, or to take no action at all, for example, to continue to observe the patient. When no harm befalls a patient, then the nursing care which was given (resulting from nursing decisions based on nursing judgments) is not subject to legal scrutiny. Although nursing care may result directly from a physician's decision (based on the physician's medical judgment), errors pfjudgment by physicians are not the focus here; the applicable principles are similar, however, and the medical negligence cases cited below are illustrative. It is important to remember that before he can charge someone with negligence, the plaintiff must have sustained injury resultiñi in damage or loss which would not otherwise f have occured. If the patient suffers no injury or harm, then there is no loss on which to frame an action in negligence for compensation. It is possible, therefore.for a nurse to practice at a level substandard to the nursing profession's requirements and yet to escape involvement in a legal action. As long as a patient suffers no harm, the nurse can avoid legal liability to such a patient, although that nurse may well be answerable to the professional disciplinary body for professional shortcomings or misconduct. Measuring care The standard of care to which nurses are generally held is that of a reasonably prudent nurse of like traininf? and experience. This means that a legal assessment of the quality of care delivered to a patient will measure that quality according to the reasonably prudent nurse yardstick. A nurse may deliver a higher quality of care but to deliver care which falls below thIs objective standard is deemed negligence. The nurse is expected to deliver care based on her utilization of the knowledge and skills of her profession. This means that, as the profession's body of knowledge expands and develops, the nurse must keep abreast of generally accepted professional knowledge, principles and practicè. A reasonably prudent nurse is not likely, therefore, to consider obsolete practices appropriate. Similarly, untested innovations, novel practices not widely accepted by the profession-at-Iarge, may not be considered part ofthe profession's general body of knowledgeJThe standard of care required is flexible and non-static. It is therefore imperative tñat nurses continue to update their knowledge and skills to keep abreast of the profession's development.; The lack of knowledge that today a Court sympathetièally determines to be "understandable ignorance" might be deemed negligence if applied to a similar practitioner five years from now. However, the standard of care applicable is that standard of care appropriate at the time the injury occurred, and not the standard of care applicable at the time the case actually comes to trial (see You and the law, February 1979). Application ofthe principles of a bod y of knowledge further involves an asseS'iment ofthe alternatives available and the consequences attendant upon them. Specific nursing care may be given automatically in response to a specific set of symptoms. The underlying process involves the nur!.e's recognition that a certain set of symptoms requires a specific nursing action. The nurse should know of the alternative courses of action available and their attendant consequences after she has learned that there is a specific professionally acceptable response to this set of symptoms. Th. Cenedlen Nur.. llerdl 11171 15 NURSING JOB GUIDE Ihhe acts incorrectly. or fails to act. either because she fails to recognize the patient's difficulty or because she does not know what to do when faced with the symptoms. then her nursing decision and action/inaction would be the result of faulty exercise of judgment based on a lack of knowledge. Because this conduct would fall below the standard of care of a reasonably prudent nurse, the faulty judgment here would amount to negligence and liability would attach. The professional and the patient In examining conduct which is alleged to have been negligent. a Court considers all of the facts and circumstances of the case. The conduct is measured by the objective standard of the reasonably prudent practitioner. This is established by hearing evidence of what the standard or accepted practice is in like circumstances. The Court examines the risk of harm such conduct presented to the patient since exposing a patient to an unreasonable risk of hann may constitute a breach of professional standards. Consideration of such risks involves weighing the degree of risk and the relative benefit to the patient. Thus. if the course of action that is selected is of high risk but was the one considered potentially most beneficial to the patient, and if this action did not significantly deviate from generally accepted professional practice. then resultant harm to the patient may not be deemed to have been caused by professional negligence. In delivering health care. professionals do not guarantee the success of all the care given. Despite heroic measures, the patient may die. The professional person presents him/herself to the patient as possessing and using that reasonable degree oflearning and skill ordinarily possessed by practitioners oflike training and experience (objective standard) . It is the duty of the professional to exercise his/her skill, knowledge and judgment commensurate with that exercised by his professional peers'. This was the finding of the Supreme Court of Canada in Wilson 'Swanson. In that case. a surgeon perfonned a major resection when the growth found in a patient's stomach was considered by the pathologist to be probably malignant on quick section. The surgeon decided to complete the resection rather than postpone the surgery to await further testing. The growth was later detennined to have been benign. The patient sued. The trial judge found that there had been no negligence and dismissed the complaint. However, the British Columbia Court of Appeal disagreed and held that negligence was proved. The Supreme Court of Canada upheld the finding of the trial judge and ruled that the surgeon had exercised his knowledge and skills in accordance with accepted surgical practice: the decision to complete the operation was not founded on a faulty basis of knowledge. The following quotation is taken from the judgment of Mr. Justice Rand in that case: A n error injuclWllent has long been distinguished from an lIct of unsÂilfulness or carelessneH or due to lad of !..nowledge. Although wIÙ'ersally-accepted procedures must be obserl'ed, thev furnish little or no assistance in resolving such a predicament as faced the surgeon here. In such a situation a decision must be made witham dela)' based on limited known and un!..nownfactors; and the honest and intelligent exercise ofjudgment has long been recognized as satisfying the profe.uional obligation. He went on to say that: He is not to be judged by the result, nor IS he to be held liable for an error ofjudgment. 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Cen.dl.n Nur.. failure to apply the proper remedy upon a correct determination of existing physical conditions, or it may precede that and result from afailure properly to iriform himself of these conditions .If the latter, then it mJist appear that he had reasonable opportunitvfor examination and that the true physical conditions were so apparent that they could hm'e been ascertained by the exercise of the required degree of care find skill. For, if a determination of these physical facts resolves itself into a question of judgment merely, he cannot be held liable for his error 2 . ProfessionaJ judgment A finding of no liability for an error in judgment was the result in a recent Ontario case 3 . A psychiatrist and a psychologist had been treating a patient with a long history of mental illness. The patient was a chronic schizophrenic who also suffered from depression. The patient had purchased a gun and, on being alerted to this, the psychologist saw the patient and then consulted with the psychiatrist. The decision of both professionals was that the patient did not manifest sufficient suicidal intent to warrant hospitalization: this decision was based on a complete assessment of the patient who surrendered the weapon to the p ychologist. The next day the patient purchased another gun and, shortly afterwards, killed himself. His wife sued both the psychologist and the psychiatrist. The trial judge found that the professionals had exercised the reasonable skill and care required of them: tht>y had considered all of the relevant factors in arriving at their diagnosis or judgment. Having done so, there was no negligence in their care. A psychiatrist or psychologist who makes a diagnostic mistake or error in judgment does not incur liability whatever the hann if the standard of reasonable care and skill is met. As with physicians, nurses are not liable for an error of judgment. In the Ontario case of Elverson \. Doctors Hospitals et al. ,5the patient. in her eighth month of pregnancy, arrived at the hospital by ambulance. She was accompanied by her husband. Her condition was poor; she was in severe pain; her abdomen was rigid: no fetal heartbeat could be heard. The patient was quickly settled in bed and the defendant nurse began the administration of oxygen for her patient. After a brief period, the patient began to hemorrhage. The defendant nurse decided to elevate the foot of the patient's bed. She left the room briefly, returning with the blocks and another nurse. Both nurses attempted to lift the bed to insert the blocks. This proved difficult, however, and the patient's husband voluntarily assisted with the lifting of the foot of the bed so that the blocks might be properly placed. Unfortunately, while assisting the nurses. he aggravated a pre-existing back condition. The husband sued the hospital and the nurse for damages resulting from this injury. He argued that the nurse was negligent in failing to summon dn orderly to assist in lifting the bed. The Ontario Court of Appeal agreed with the trial judge who had di missed the action. The Court held that the nurse had not made an error through negligence. It was. in their view, an error of judgment for which no liability attached. The elevation of one end of a hospital bed through the placement of blocks was found to be a regular occurrence in a hospital and not one which !>hould have been solely limited to an orderly's assistance. The only "mistake" made by the nurse was an error in assessing the relative strength of the nurses to lift the bed and the patient. Such an error did not amount to negligence in law. The Court went on to find that even if the nurse had been negligent, she still would not have been liable for the injury since the injury to the husband was not reasonably foreseeable as resulting from the completion ofa routine task. Assessing negligence From the foregoing it can be seen that nursing practice in accordance with professional standards will generally protect a nurse from a finding of negligence. As long as the nursing care that is given is in accordance with the objective standard t exemplified by the reasonably prudent nurse, such care will confonn to legal requirements. It should be noted, however, that mere conformity with generally accepted practice will be no defence to an assertion of negligence if that generally accepted practice is in itselffound to be below the legally required standard; for example. blind adherence to a hospital policy will not be a defence where that hospital's policy fails to adequately and reasonably safeguard its patients. In such an instance both the hospital and the nurse might be held responsible. Each case turns on its own facts. If, in theElverson case, the patient had weighed 300 lbs. or if the nurse had rejected the proffered assistance of an orderly, the outcome might have been different. The situation would have been different too if there had been nothing urgent about raising the bed or if the nurse had asked the husband to help her. Each of these variables would alter the assessment of the course of action that would have been taken by the reasonably prudent nurse, the principle yardstick by which the defendant nurse's action i!> measured. There is a factor which was not discussed in the judgment and which in other circumstances might have some relevance: from earliest student days, nurses are taught about proper body mechanics and are cautioned about the hazards of back strain or injury in moving patients and equipment. Such knowledge would be considered part of that body of special knowledge which the reasonably prudent nurse would have. Therefore. it is conceivable that where a nurse invited the assistance of a non-hospital employee (i.e. visitor or patient) in moving or lifting something, any back injury accruing to that person as a result ofthis assistance might be considered to have been reasonably foreseeable to that nurse in the view ofa Court. Again, such a finding and any attendant liability, would depend on all the relevant facts of the case. The finding of no liability for an error ofjudgment will be liI..ely if the nurse utili;:es the special "nowledge that she has I (and ought to hm'e) as a professional nurse. I f she does so with proper forethought as to the alternatives and their attendant consequences, then the fact that her decision as to the choice of alternative is ultimately shown to have been incorrect will not necessarily result in a finding of negligence. Nurses do not have to be right all the time: they are not required to be perfect. The professional exercise of judgment is the key to the nurse's protection from legalliahility. to References 1 Wilson V. Swanson [1956], S.CR. 804. 2 Ibid. p. 812. 3 Haine.5 \'. Bellissimo (1978). 180.R. Cd) 177 (H.CJ.). 4 Ibid. p. 191. 5 Elverson \. Doctors Hospital et al. (1975).4 O.R. (2d) 748 (CA.) -. "You and the law" is a regular column that appears each month in The Canadian Nurse and L'infirmière canadienne. Author Corinne L. Sklar is a nurse and recent graduate of the University ofT oronto Faculty of Law and is currently artic/ing with aT oronto law firm. ." , J- Whether this play is thought to be sarcastic, satirical, caricaturistic, or unintelligible will largely depend upon the perceptions of the individual reader. It is intended only to be a gentle reminder of the caring role of the nurse (from a patient's viewpoint) and a warning of the possible shape of things to come. RBI NINETEEN-EIGHTY - FLOOR - - :3 4 5 dlo Ô 11 Merch 11171 The Cen-.llen Nur.. TIME: SCENE: Sometime in the near future A client monitoring unit on an assessment ward of a large general hospital. Madge is seated in a swivel chair facing a large console covered with switches. buttons and meters, somewhat similar in appearance to the flight deck of ajumbo jet. At eye level there are five television screens, each displaying a patient in bed. Surrounding each screen is a series of monitors which are continuously recording a variety of physiological patient activities. The monitoring unit is linked to each patient by an intercom system. Madge is studying the monitors for bed number two. The patient in this bed is immobile; most of the monitor tracings are flat or approaching zero. Madge is expertly pressing buttons and flicking switches. MADGE: Muttering to herself. Let me see now, patient unresponsive to all stimuli. check; flat EKG. check; all vital signs absent, check; permission for autopsy. check; life-support systems disconnected. check; nursing care plan closed. check; yes, that seems to be about it. With the flick of a sll'itch, the motorized bed moves silently off the screen. Shortly thereafter, another bed glides into place, occupied by Mr. Jones. He is a small, elderly man whu is obviously ill and apparently in some discomfort. He moans gently. MADGE: Switching on the intercom to bed number two. Good morning Mr. Jones. my name is Madge Brown and I am your primary nurse-monitor. According to your initial computer diagnosis you have a bladder tumor which we are going to investigate for you. I understand that you are experiencing discomfort at this time and I am here to help you. Mr. Jones groans quietly. MADGE: Now Mr. Jones, the discomfort you are aware of is perfectly normal and controllable. Perhaps you would like to help yourself by opening that little drawer to your right, marked 'analgesic'. Inside the drawer you will find a pill and a paper cup of water. With some difficulty, Mr. Jones complies. That's right; now swallow the pill with a little water and very soon the discomfort will subside. Mr. Jones again complies and sinks back in his pillows lVith another, luuder groan. MADGE: Perhaps you are concerned about your family while you are hospitalized. You are wondering how they will manage with no income and the possibility oflarge hospital bills to come. We have arranged for the social counselor to visit your wife and make the necessary interim adjustments. You can rest assured that they will be cared for during your stay here. MR. JONES: Forcefully.OhGod! MADGE: I perceive you are a religious man. Mr. Jones. You will find great solace in prayer while you are here. I will arrange for the chaplain to visit you if you wish. The Cen8dlen Nur.. Mereh 1171 111 MR. JONES: MADGE: GERTRUDE: MADGE: GERTRUDE: MADGE: GERTRUDE: MADGE: GERTRUDE: MADGE: Desperately. Nurse, help me? What you are really saying is that you still have some unresolved anxieties. This is perfectly normal. this being your first hospitalization. Perhaps if we commence your environmental orientation you will feel less threatened. Your preplanned diet will arrive promptly at 0800 hrs, 1230 hrs, and 1700 hrs, with a light snack before bedtime. If you place your dentures in the little drawer on your left, marked 'dentures', they will be washed and hygienized automatically. A disposable bedpan can be found in the cupboard by your right hand. When you have finished. _ Madge's counseling is interrupted by a very loud groan from Mr. Jones. and the arrival of Gertrude in the monitoring unit. Hi Madge. how's it going? Not too well. Gert; number two died on schedule but I'm having a problem with his replacement. r. Jones. You mean the bladder tumor? I thought from the computer care plan that he would be fairly straightforward. How far have you got? Let me see now. Presses button and a printed sheet is fed out of the console. Madge reads from the sheet. Introduction; patient-controlled analgesia; social service awareness: pastoral care alert. I have started orientation but I'm still in the early facilitative phase. Hov. 's yourT.U .S. ratings? Scanning the printout. Only about 2.5 so far: I don't think he understands empathy. Maybe we should try some confrontation for awhile. A t this moment. the screen reveals Mr. Goodheart approaching Mr. Jones. Madge. really! Do you allow those technicians near your patients without constant monitoring? He's only a baccalaureate graduate and has no practical T.U.S. experience. Mr. Goodheart li/ts the sheet covering Mr. Jones. Mr. Goodheart, what are you doing with that patient? MR. GOODHEART: Pardon me nurse, but shouldn't v.e be unc1amping this catheter? The patient appears to be very distended. The curtain falls. THE END La\\re.nce ightingownis the pen name ofa nursing officer in a large B.C. hospital. Prior to his present administrative appointment. Mr. Nighting0l1:n held various ward level, supervisory and clinical teaching positions in a number of hospitals in England and Canada. Of "Nursing: nineteen-eight y-floor" , the author writes: "I would hate to be labelled antiscientific or old-fashioned; indeed 1 welcome much that is innovative in our profession . Yet the uncomfortable feeling persists that we are tending to overlook more and more our basic function. that of caring; we seem to be getting further andfurther away from our patients. "I am highlv suspicious of jargon. words such as Primary Care. Nursing Care Planning, Therapeutic Use of Self, Quality Assurance and the like. Whether these supposed imlO\'ations hm'e actually resulted in better care from the-client point of view is. 1 would submit, a moot point. Certainly, they hm'e resulted in more and more nurses spending less time with their patients." Setting realistic goals for nursing the elderly is not easy. When the medical prognosis is poor, it helps to know that "feeling better" is not just a matter of reversing the physical changes that accompany the aging process. Case load: over seventy-five Mary Gibbon By the year 2001, an estimated thirteen per cent of all Canadians will be over the age of 65. Many of these will be in the group designated. for obvious reasons, as the "frail elderly". These over-75's now make up the fastest growing part of our population. They are also, by virtue of the fact that they are the greatest users of the health services, a group that nurses are going to encounter more and more frequently over the next two decades. f' , .. In an effort to find out how visiting nurses. whose caseloads usually include many chronically ill patients, can give this segment of our population more effective care. the Hamilton-Dundas Branch ofthe Victorian Order of Nurses in Hamilton, Ontario organized and conducted a study involving more than 200 frail elderly in that community. A total of 29 VON nurses took part in the project which was supported by a National HealthGrant from Health and Welfare Canada and carried out over a three year period. The findings are significant in terms of helping nurses to define and achieve what is actually a positive relationship with these patients and also in terms of helping the health system to cope with what threatens to become a major problem in the near future. \ , .. I, _,II / '- The subjects A total of201 patients. all of whom were over the age of65. were admitted to the study. Almost three-quarters of them (70 per cent) were more than 75 years of age. The typical patient in the study was female (77 per cent), widowed (60 per cent) and lived alone (40 per cent). When one considers that all these patients had chronic illness severe enough to require physical nursing care. it is easy to see the emerging need for more support services in the community, such as friendly visitors. homemakers. meals-on-wheels. etc. The complexity of geriatric medicine is reflected in the fact that doctors had diagnosed each of these patients as suffering from an average of 3.2 illnesses. Further, only 15 percent of those for whom the physicians provided a prognosis were expected to improve in three months. When we add to this the The Caned Ie" Nur.. Mereh 1171 21 fact that 40 per cent of the subjects had poor or limited vision, another 27 per cent had poor or limited hearing and remember that in this study mobility problems increase significantly with aging. it becomes clear that the setting of realistic nursing goals for this kind of patient is never easy and must be done with great care. The study The object of the study was an examination of the relationship between nurse/patient characteristics and the quality of life of our aged patients. In designing the study, we took into account our conviction that a great deal of what the nurse does is often intangible but, nevertheless, has an overalI effect on the patient's quality oflife. After a review of gerontological literature, we decided to measure three areas where nursing could be expected to make a difference. . A ctil'itie s of daily iil'ing (AD L) was an obvious choice. One ofthe main emphases in gerontological nursing is rehabilitation - to help the aged remain as independent as possible for as long as possible. The patients were asked about their ability both in personal care and household tasks. . Social contacts. the second area, was felt to be of particular importance to community nursing. When the elderly have mobility problems and/or sensory deterioration, the ability to get out ofthe house for additional stimulation is often affected. making the person in danger of social isolation with its attendant complications. Of ten, lack of sufficient social stimulation can result in depression which may be mistaken for pseudodementia. The visiting nurse is therefore expected to look into the patient's social support system to note changes in it and to help the patient obtain social suppon when indicated. Social contacts were measured by actually counting the number of people with whom the patient came in contact. . Morale was the third area to be measured. Morale is especially important in the elderly because of its close association with ilIness and also because illness in the elderly often occurs in conjunction with other losses such as the loss offriends and those involved in the normal changes of aging. The elderly in our sample had low morale scores in comparison with results obtained in studies conducted in Winnipeg ' . 2 and Chicago"'. a finding that did not surprise us since our sample consisted entirely of elderly persons who were ill. while the subjects in other studies included both well and ill elderly. These three areas do not, of course, exhaust the number of areas affecting either the quality of life of the elderly or those where nursing might be expected to make a difference. But they are crucial ones. The design of the study was longitudinal: our subjects were patients 65 years of age or older, admitted for visiting nursing service with a diagnosis of chronic ilIness. Each subject was interviewed three times over a 10 to 12-week period. Initial measurements were taken within 24 hours of admission. Interviews tested for the three areas described above and were conducted by a team of trained interviewers from McMaster University. Observations Our findings were, for the most part, encouraging, particularly in the field of morale where the greatest degree of positive change occurred. Our morale scale contained several subscales: . mood tone . zest for life . depression · attitude towards one's own aging, and . lonely dissatisfaction. Four subscales - depression. zest for life, lonely dissatisfaction and attitude towards one's own aging- showed the most positive change. These findings tend to support clinical observations of the nurse/patient relationship of the elderly patient at home. indicating that the arrival of the nurse usually results in a marked brightening ofthe patient's mood. All nurses receive orientation in normal aging and a positive approach to aged patients and we expect this to be retlected in the care given. Nevertheless. it is somewhat surprising, therefore, that the scale "attitude toward one's own aging" was one of the areas of greatest positive change. Perhaps the change in this scale is related to reliefthat some of the negative myths with which the aged have been living are not true. We were surprised also to discover that nearly half (47 per cent) of the patients demonstrated a reduced ability to perform activities of daily living over the period of the study. Of course, our goal with the frail elderly is often conservative to try to maintain stability both of physical condition and of psychological well-being but, even so, the 47 per cent decline was disappointing. In this connection. it should be noted that one fifth of all patients were receiving visits from either physio or occupational therapists. The decline could retlect either inadequate use of rehabilitation techniques (unlikely in light of the rate of physio/OT referrals) or irreversible physical changes. In either case. we feel that it is an observation that is very significant to those who plan or deliver health care to the frail elderly in the future. North Americans have traditionally emphasized rehabilitation nursing for the elderly, probably as a result of our society's negative expectations concerning old age. We seem reluctant to come to terms with the fact that frailty does occur in many people in later years. More realistically, perhaps, British literature does in fact speak in terms of "comfon" care for those with irreversible changes. We realize that the decision as to whether these physical changes are irreversible or not is, in each case, an individual clinical one. but the study has made us more aware of the fact that there is a point in time when rehabilitation, while giving the professional a sense of "doing" something, can only result in increased frustration fort he patient. In these cases, the professional might be better employed in providing good emotional support as the patient learns to cope with increasing dependency. Because Nonh Americans place strong cultural emphasIs on independence, not only the patient. but also the professional may find it hard to accept dependency: both are apt to find the situation frustrating. This observation is borne out by the results we obtained from measuring nurse characteristics during the study. As part of our project. participating nurses like those who took part in an earlier study of community nurses (Highriter. 1969): completed the California Psychological Inventory . Nurses in both studies who demonstrated a high degree of dominance had significant positive results in improving the Activities of Daily Living (ADL) score of their patients. To our chagrin, however, these same nurses had significant negative results in the area of raising patient morale. Several other attributes that we like to feel describe the well-prepared nurse, including sociability, social presence, self acceptance, also proved important. Patients of nurses who were high in these attributes also el'idenced significant negatÍ\'e morale changes. We have discussed this finding at some length with the nurses involved, who feel that perhaps one reason for this disturbing result is the immense social distance between a well-educated. relatively affluent. energetic nurse and a frail. poorly educated patient whose energy supply is low. Such a patient may, indeed, view her situation very differently from the way in which her nurse sees it. This patient probably does not have the energy to refuse to do what the dominant. confident nurse asks of her: therefore she complies but. in doing so, she becomes unhappy, since her priorities differ from those of the nurse. 22 Merch 1878 The CaNdia" Nur.. Looking at these results. we are sharply reminded that the setting of nursing goals must always be ajoint effort between nurse and patient. Like the rest ofthe nursing profession, we had felt that we were in falòt checking the patient's perception. But. for the frail elderly whose situation is so different from ours, a special effort needs to be made before we can properly determine the patient's perspective. Like Highriter, we failed to find any significant relationship between nurse preparation and outcome. The nurses in our study had varying preparation: R.N.. diploma in public health. B.Sc.N. Four nurses were prepared as nurse practitioners. However, since there were only 29 nurses in the study. there were not enough in each preparation group to show valid relationships. There were also the confounding variables of age and experience which crossed preparation lines. The relationship of service to outcome is less confusing. Correlations of lowered morale and the number of nurses who visited each patient is significant. This is further verified by the observation that. when these visits were made by just one nurse, a positive change in morale was found. This would seem to point out the need for administration to ensure continuity of care for individual patients. It is especially difficult to maintain stability of care for very ill patients who may require visits once or twice daily. We know that elderly patients do have difficulty in adapting to too many changes. Nurses are usually introduced at a time of health crisis when the additional stress of adapting to changing staff is less easily coped with. It is important. therefore, that the stability of staffing pattern be maintained as much as possible. For each patient admitted to the study. the physician was asked for a prognosis as to whether the patient would improve. remain stable or decline in general health status within the three month period. Wefmind that patients who were expected to decline had the highest percentage of improvement in all three outcome measures: ADL, social contacts and morale; those who were expected to remain stable showed the second highest rate of improvement. It would appear that, even when very little can be done to change the disease process per se, nurses can and do have a measurable effect on the quality ofIife of the patient. Even though the overall disease process may not in fact be changed (and this was not measured during our study). there are stilI areas that are responsive and capable of change in which nursing care can make a difference. Our findings indicate that care in the community is one of the factors that can bring about an improvement in the quality ofIife of patients whose general health status is not expected to improve. There are, in other words, other ways of helping a patient besides effecting a change in disease status. As more highly educated. better nourished cohorts reach advanced age. the situation may change but, for the present. the results of this study help to underline the issues that are particularly relevent to caring for the frail elderly. Interpretation ofthe results must be made with the knowledge that the findings apply only to the kind of patient group on which they are based: the visiting nurse caseload of ill. elderly patients in the community. It is among this group. however. that the contribution of the nursing profession is particularly and peculiarly significant. .. .- & . '\1 . I' ...... Il , u References I Havens, B. Social relationships and degree of isolation of elderly Manitobam by... and E. Thompson. Presented at the 10th International Congress of Gerontology. Jerusalem, 1975. 2 Aging in Manitoba; a study of the needs of the elderly and resources available to meet needs. Winnipeg, Manitoba Dept. of Health. Social Development Division of Research Planning and Program Development. 1971-74. 3 Cumming. E.Growing old, by... and W. Henry. New York, Basic Books, 1961. 4 Highriter, Marion. Nurse characteristics and patient progress Nurs.Res. 18:6:484-501. Nov./Dec. 1969. The author of "Caseload: over seventy-five", Mary Gibbon, is director of the H ami/ton-Dundas Branch of the Victorian Order of Nurses. Two years ago, she was named Woman of the Year for the City of Hamilton by the Status of Women committee for "purring more than 100 per cent effort into her job and touching the lives of thousands of people each year. " Mary Gibbon has had a variety of experiences in nursing. She spent her first five years in outpost nursing in northern Ontario, and then began working as a staff nurse with the VON in Hami/ron. She has also acted as regional supervisor in the H unrsville area, and started a home care program in the rural areas around Guelph. Her most recent interest has been in the field of geriatrics. Mary spent last summer conductin!? seminars across Canada on care for the chronically ill, and says that one of her main goals is to help younger people see the elderly as human beings. Mary has also found the time to write two books, olle about her experiences as an outpost nurse, and one about the history ofHami/ton mountain. OFFICIAL NOTICE Canadian Nurses Foundation In accordance with By-law Section 36. notice is given of an annual general meeting to be held on Friday, 11 May 1979 commencing at 2:30 p.m. at CNA House in Ottawa. The purpose of the meeting is to receive and consider the income and expenditure account. balance sheet, and annual reports. All members of the Canadian Nurses Foundation are eligible to attend and participate in the annual general meeting. Helen K. Mussallem Secretary-Treasurer Canadian Nurses Foundation The Caned'... Nuraa March 1871 23 ,'J c The I rth A erican emp I : . .. on mode I I 1.1- .ke institut I I . I e care of the elderly a I d Q I I nically s depersonalizing and unsatisfying for man patients.: ilies. In Britain, the National Health Se'r . ce Pr' . I . S care for these " .ents in the securitÿ-an I co rt of their own homes through a district nursing vi ot all patien s eed hospita s " ..f' .... a" a.- - ... \ ( -- "" Arlene A ish If you walk into any general hospital. it will be evident from even casual observation that many chronically ill and elderly patients are occupying beds- not because they are acutely ill- but because there is a problem in arranging an appropriate place for them to go. In North America. the alternatives for these patients include nursing homes or chronic care institutions. It is the lucky few who are able to be maintained at home. In large part. this is due to the trend in the last few decades to improve acute care services. unfortunately at the expense of home care services. However. this trend is changing. As health care costs spiral, it is no longer feasible to maintain the elderly and handicapped in expensive institurions, especially when at least some of them could be at home receiving support services. Perhaps we are also beginning to recognize that people "do" better in an atmosphere that is familiar to them and where they can have some form of independence, individuality and family support. The British experience It was with this in mind that I recently went to England to learn more about how home care operates there. While on a sabbatical leave from university. I spent eight months working as a district nurse in south west London. The district nursing service provides care in the home twenty-four hours a day. seven days a week through a separate day and night staff. The type of care given by the district nursing service is similar to that provided by the Victorian Order of Nurses in Canada or the Visiting Nurses Association in the United States but the intensity of the service is greater. thus enabling severely disabled patients to stay at home rather than in costly institutions. In my district, for example. Mrs. Smith. who has severe multiple sclerosis. is paralyzed from the neck down and still lives al home. When her husband had a heart attack and was no longer able 10 lift her, the district nurse made five visits a day to the Smith home. An early morning visit was made by the night nurse to change incontinent pads and give skin care; the day nurse made three visits - in the morning to dress Mrs. Smith and get her out of bed. again at noon. and then late afternoon to place heron the commode; and the night nurse returned to put her to bed. This kind of help enables the Smith's to live together in their own home. The team District nurses sometimes work in geographically defined areas but in London's south west district. most are attached to doctor's offices or "surgeries". The surgery where I obtained my experience consisted of a group practice of four physicians with two district nurses and two health visitors attached to the practice. This team of eight met daily at the surgery to discuss patient problems. It IS important to note the difference between the health visitor and the district nurse. The health visitor is a nurse with post basic training in health counseling and preventative measures and functions much like a North American public health nurse. She is involved in the preservation of mental. physical and emotional health. early detection, providing support in periods of stress and health teaching. She does not. however. actively engage in technical nursing procedures. Although priority is usually given to child health, the health visitor who is attached to a group practice devotes a lot of time to the elderly and deals with their environmental. social and emotional problems. 24 M...ch 1811 The C.n-.ll.n Nur.. o. f 01 I ... , , ".... 110 ''!o iI ..:" . r 1{" ... .- l' . ...,..... . The district nurses in a group attachment deal predominantly with the elderly population. The kind of care given by the nurse ranges from physical care such as bathing the patient to emotional support for the depressed individual. When the elderly person lives with a spouse or with children, much of the nurse's attention is directed towards helping the family as a whole to deal with health problem'i. If possible. the nurse teaches a family member how to give phY'iical care, and the family member is reimbursed with an attendance allowance if he/she would otherwise have been earning money outside the home. The elderly For the many elderly people who are entirely on their own. the district nurse is a frequent visitor. When mental or physical health breaks down, solitude becomes a problem. Forgetfulness, ranging from mild to incapacitating. can interfere with the elderly person's ability to cope alone. Furthermore. the elderly are 'iubjectto many chronic diseases such as arthritis or cardiovascular problems which may interfere with self-care. A minor fall can produce a broken wrist which makes managing alone impo'isible. The role of the nurse in the care of the elderly at home covers many areas. The supervision of medications is an important responsibility. For some - ,- " .- .." . . >" .I. P. .. .,.. Jt \- "M . ..... .. .. ......- ""l t -,- -;* .\ ".' --- :at-- J ... - patients. a weekly or monthly visit \Jy the nurse to ensure that prescriptions do not run out will suffice. Others will need aids (such as having the daily doses of medication in marked egg cartons) to remind them to take their medication. Constipation is a common problem. solved initially by enemas and in the long run by teaching the patient about diet and mild laxatives. Another nursing procedure done frequently in the home is ear syringing to remove wax and improve hearing. One of the most challenging areas of working closely with the elderly is the recognition of risk factors that occur in everyday life. Winter presents its special problems. The danger of hypothermia is very real for many of these elderly people. Although most homes have the potential for adequate heat. many elderly British patients. brought up to suffer the cold with forebearance. seem reluctant to turn on the gas or electric heater. While the rising cost offuel is a factor that influences some patients. others are simply too forgetful to turn the heat on or forget how to work the heater. One 90-year-old patient. for example. per'ii'ited in trying to light her electric fire with matches. On the other hand. because of the tendency to sit close to the fire. burns are also a risk. Fire from pots left to boil dry on the stove or gas fumes from stoves that are turned on but not lit are other potential hazards. Many problems experienced by the , j'r ":0-,. .. i1 í .. ....... . elderly overlap the roles of health visitor and district nurse and the division of responsibility will in large part depend on the particular working relationship between individuals. In general. if the district nurse is seeing the patient on a regular basis for a physical problem. she will deal with the other social or emotional problems as well. by making appropriate referrals to Meals on Wheels, Home Help, or voluntary visitors. If there are no physical nursing needs. the health visitor may follow the patient and call in the di'itrict nurse as needed. Because of the chronicity of their problems. the elderly place great demands on the physician's time. Continuous health supervision is needed and many times when the patient calls the surgery about a problem. a visit by the district nurse will save the doctor a house call. However. doctors do make frequent house calls in England. When both doctor and nu rse see the patient in his own environment. there is an increased tendency to view problems in a similar way and therefore to communicate more effectively. The attachment of district nurses and health visitors to group medical practices also facilitates communication among members of the health care team. enabling them to give a better standard of care and to do so with less interdisciplinary friction and more mutual respect. The C.nedlen Nur.. .rch 111711 25 " - \ , .... . ''\ .... .....:.... \ ,.' - . Í _i., . L. I. >.. .. """"",--' ._ <.-;; "'. . 'I Chronic illness District nurses and health vIsitors are also very involved in assessing the needs of young and elderly patients with chronic illness. Some of the most common conditions requiring home nursing are multiple sclerosis. rheumatoid arthritis. diabetes. anemia and cardiovascular disease. Many patients with these problems need basic physical care and help with activities of daily living such as washing. dressing and assistdnce out of bed, While making routine daily. weekly or monthly visits. the nurse has an excellent opportunity to continually reasses s the needs of her patient and to be on the lookout for any new problems. Besides the usual assessmenttool'i such as thermometer and blood pressure cuff, technique.. of physical examination and intervie\\oing must be used to gain a clear picture of the patient's problems which can then be shared with the physician. Other nursing procedures frequently done in the home include injections. dressings to chronic wounds and the collection of blood and urine samples for diagnostic purposes. Psychiatric problems. especially depression and alcoholism. are commonly seen by the district nurse. Usually she comes to know these patients because of their need for help with a physical problem. Since she is already providing physical care which the patient recognizes as helpful. she is able to establish rapport and offer . ... - , ... I!'"' - ..... .... \ - '" tI \ ...:. " t' '\ " - _. -" Photos b)' Bob ACclaro. courtesy of the VlclOnan Order of Nurses for Canada. Ottawa &. emotional support. When intensive counseling is needed. the nurse may refer the patient to a community psychiatric nurse or to a social worker. Surgical patients present a variety of nursing needs. Some. such as colostomy patients. may need teaching and emotional support rather than actual physical care. Other patients with post-operative complications may need daily dressings on a long term basis. Recently. district nurses have been given the responsibility of removing sutures from patients who would otherwise have to be sent back to the hospital casualty department for this procedure. ferminall) ill patients More families in England choose to care for their dying relative at home than do families in Canada. This care places great physical and emotional demands on the family and it is unlikely they could cope as well withoUlthe support ofthe district nursing service. The nurse mdY make suggestions about the environment such as moving the patient downstairs. She can provide aides such as ripple beds and sheepskins. The family is taught how to give physical care and encoumged to participate during the nurse's visit. Towards the end of the illness. nursing visits may be made three or four times daily by day and night nursing staff. Perhaps her. work with the terminally ill, while not a large part of the case load. best illustrates the total role of the district nurse in providing a high standard of nursing care in the home. II involves basic physical care. emotional support. teaching of the patient and family. and \\oorking closely with the patient's physician. '" Conclusion A district nursing service such as the one in south west London enables patients to stay at home within a familiar environment and to live their lives as best they can. As North America looks towards improving home care services for its citizens, we might do well to examine Britain's experience in this important area of health care. For the piat lIille v'ears. author Arlene Aish has beell a teacher at Queell's U nÙ'enity. ^ illgston. Ontario. Prior to this appoilltment. he tauKht at the Unil'ersi(\ ofNeu Brun.vu'ic". Frederictoll alld at the Ullil'ersity of TorOIllU. NunillK practice illdudes tl\'O yean as a public health lIurse for the city oj Torollto. a year ofslllff duty at the V allcoul'erG etleral Hospital and temporary dun' in Seattle alld San FrallcÙ"("(J. Arlelle reeeil'ed a B.SeN. at the Unil'enity ofBriti h Columhia. a lv/aster's ofN un ill/( at the U nil'ersity of Washillxtull alld a poM-master's vear wa.\ ta"ell or the Ullil'ersity of Calijornia. San Frill/cisco Medical Cellter. o \ IQ) << ) In May of 1972. I suffered a massive stroke that left me unable to move or speak. But although I was bereft of muscular mobilit) from my head to my toes, I retained my senses of hearing and sight and most important of all, my mental faculties were not impaired in the slightest. I could comprehend everything that was said and going on around me, but I was physically unable to respond. At the time. the doctors told me that the first eight days would be a "wait and see" period, that the extent of the damage done was as yet unknown. Strangely enough. I didn't feel remotely apprehensive. It never crossed my mind that I might die during this period. Instead. I was somewhat impatient for the eighth day to arrive so that my recovery could begin. an attitude I probably owe to my religious convictions. On the eighth day, the doctor let me know that I had made it - I was over the hill. In the same breath he cautioned me that the road to recovery would be a long one, that he would be pleased even ifl improved at the rate of "an inch a day". A few days later, a group of doctors gave me a thorough examination, each attending to the area of his specialty. Moments after they had all left. one doctor returned. patted me on the chest. and said, "Frank. we'll make a new man of you". I have often wished that I could meet this man again so that I could express in words how grateful I was for his thoughtfulness. . felt that' was right on course, that nothing could obstruct me. An inch a da} It wasn't long before I began to develop leg cramps. I was turned regularly from my left side, to my right and back again, but only the prone position afforded me any relief. In the beginning, I was a'so allowed injections which eased these pains for a few hours. Many weeks later, when I could withstand physiotherapy, my legs gradually ceased to bother me. . also had pain in my left arm and shoulder, an area that was to remain sensitive for the next three years. Initially I was treated with hot packs which relieved the sharpness of the pain; the rest dispersed very gradually as the result of therapy. The Can-.llan Nil... March 1171 27 In time, my mouth, which initially seemed to be locked closed. began to open slightly. Small amounts of pureed foods had to be forced into me. but my mouth still had to be pried open wide enough to insert a spoon. ) managed to swallow by force of gravity only; the muscles concerned were still not working. After each feeding bits of food would cling to the insides of my mouth and) began to appreciate much more the discomfiture implied in the phrase "jungle mouth" A few of the nurses neither spoke to me nor glanced my way. ) suppose that they assumed that I Was in a severe comatose state and that it would be an exercise in futility to attempt any kind of communication with me. Most of the nurses would smile and carryon a one-way conversation, telling me what they were going to do for me at a particular time. Their actions filled me with a sense ofbelonging-) was part of society once more, however slightly. My visitors too had various attitudes towards me. My wife, her brother and some of my relatives and friends never spoke down to me: they always talked to me as though I was recovering from a routine procedure, like an operation. They kept me up-to-date and made sure that I knew what was going on in day-to-day matters. There were other visitors, though, who wore sombre looks, gently patted my hands (while gazing at the wall), whispered a few words of sympathy, and shortly after. departed. ) must confess that at these times I fervently wished) had the power to shout out furiously-"What do you think this is, a W AKET' ) suppose they meant well. There came a time when) was able to emit a few groans and pronounce, in a very inarticulate way, of course. a number of words. At first my vocabulary was lImited to such words as-Yes, No, Nurse and a few others. Just before my transfer from the I.CU., one ofthe nurses made up a set of cards for me on which were printed the words most commonly associated with my needs, words like Yes, No. Pain, Legs. C ü"m fort able . These cards enabled the nurses to communicate with me by pointing to a word, so that) could signify, by a slight movement of my head, what it was I needed. ) felt) was progressing. When) was transferred to a general floor. it came as a surprise to me that the nurses felt the mOVe was somewhat premature. ) felt disillusioned. ) recall another incident that took place at about the same time. I was being fed my usual meal of pureed foods. By this time. ) was capable of rolling my eyes from side to side. Since my tray was in close proximity. I kept eyeing the ice cream andjello in great anticipation. Just when I was ready, the tray was suddenly and unexpectedly removed. I felt like a child must feel when someone steals a popsicle right out of his mouth. ) mention this incident only to point out how much harm a little thoughtlessness can cause - hO\II important the little things really are. It was only one incident. but I remember it well. The road to recO\ ery Towards the latter part of June 1972. I was transferred to a neighboring hospital for a more intense rehabilitation program. My speech continued to improve. But my body from the hips up remained quite flaccid. so that) was unable to sit erect and required a restrainer and built-in wooden tray which fitted onto my wheelchair to help me sit up. I still had no real muscle power - my muscles were not as stiff as they had been. but they were decidedly flabby. I had quite a daily routine - physiotherapy twice a day - once in the morning and once in the afternoon. and morning therapy was followed by occupational therapy. Around two-thirty in the afternoon. I had speech therapy. then my day ended in the workshop. Gradually. I regained strength. The staff felt that I was ready to start dressing" and shaving myself as well as transferring and maneuvering my wheelchair. The entire process was very slow, requiring my endurance and a great deal of patience from the staff. The most trying task for me was dressing myself - I was still in a flaccid condition. My left shoulder remained painful and my neck tended to flop downwards. As my right arm was not fully developed. my electric shaver felt very heavy. Transferring and wheelchair dexterity were equally arduous. In time.) managed. ) developed my speech muscles through conversations between the therapist and myself. ) recall that after my first weekend pass. I could hardly talk. The therapist told me that) had probably been trying too hard to speak above the noise of other conversations. I was advised to avoid speaking above other noise and to concentrate my efforts on one-to-one conversation. I attempted writing exercises, but for awhile. found it difficult to write in a straight line. In the meantime, typing strengthened mv index finger. For a long time I had to be fed by someone else. When for the first time. ) shakily raised a spoonful of food to my mouth. it was a welcome sign of progress. I t is also a memory especially dear to me because) managed to accomplish it on my wedding anniversary. In all things. visitors would offer their assistance. which I had to refuse for my own sake. At times the staff would gently discourage others from offering their aid. I remember one evening as I returned from my dinner, a nurse stopped me to say how much she would like me to encourage a few patients who refused to make any effort towards improvement. My initial reaction was one of shock - I had always taken for granted the fact that everyone was striving to get better. Then I was angry - how could people allow themselves to remain in a state of mere existence? There was no place for them in rehabilitation if that was their frame of mind. When I analyzed the situation more calmly. I concluded that I would not serve any purpose if) confronted these individuals. and) began to realize that there were a number of variables which) would never know that had caused such an attitude. They might have lost incentive to maintain the struggle because of other problems. marital. financial or family worries. As far as my own incentive was concerned: much earlier in my illness) had developed as my motto a couple of lines from one of Robert Browning's poems: A man's reach should exceed his grasp. Or what's a heaven for? Going home I was discharged about mid-January of 1973. At home there were still more obstacles to overcome. I made my way around the house with a shoe horn brace for several weeks until I developed foot drop. necessitating a return trip to the hospital. ) was fitted for a metal brace. an approach that also turned out to be unsuccessful. Thoughts turned to finding the best way for me to get outside during the clement weather. Two people from the occupational therapy department visited our house to advise us on the most suitable place to install a hydraulic lift. 28 U.rch 1878 I am pleased to say that over the past few years, my condition has continued to improve, slowly but surely. I have had periodic setbacks - deep vein thrombosis, pulmonary congestion and angina. Now I have begun to negotiate a few sidelong steps, crouched over a quad cane and supported by the therapist. My left leg is a problem; it will slide to the right and move backwards. but as yet refuses to move forwards. We are confident though that this problem will eventually be overcome. The attitudes of others towards me have made a tremendous difference. During my long rehabilitation period, neighbors would often stop by for a chat. When we went outside. there were those who would steel themselves to gaze away from me. Others glanced my way covertly, through the corners of their eyes. To those who looked me fully in the face, half smiling, I always made a point of waving and saying "hi'", to break down the barrier between us. It is the children though. who make me feel most at ease -I have had so many interesting conversations with them as they lean on their bicycles. As for those who have worked with me for all these years to help me overcome my limitations. I would like to paraphrase a line from the book of Daniel. "Blessed are you who teach how to rehabilitate. for you shall shine as stars for all eternity. ., A Nursing Perspective There are three primary causes for cerebral vascular accidents: cerebral thrombosis. cerebral embolism and cerebral hemorrhage. It is my opinion that this is where generalizations should end, for the results of these insults on the human body are as variable as the individuals who suffer strokes. The degree of recovery for any individual will depend on many factors - the severity and location of the lesion. the physical health of the patient, his age, his will, and the help and encouragement he receives from others. This is why Frank's story is important - it helps us to remember that the patient who has a stroke is a unique individual who needs to be cared for as an individual. The C..,-.lI.n Nur.. Frank's admission Frank Halligan. a 52-year-old school teacher. was admitted to hospital with sudden onset nausea and vomiting and a left-sided weakness or hemiparesis. He also had a right facial weakness and slurred speech. Within 24 hours, Frank had lapsed into unconsciousness and a couple of days later, his clinical picture had become more involved. His left-sided hemiparesis had become a flaccid paralysis or plegia and he had also developed a right-sided hemiparesis. This progression of presenting pathology is often referred to as a stroke in evolution. A number of diagnostic procedures were used to find out the cause and extent ofFrank's C.V.A.: . Lumbar puncture - revealed clear cerebrospinal fluid. ruling out the possibility of cerebral hemorrhage. . EEG and brain scan - both normal . Neurological examination- revealed bilaterally positive Babinski reflexes and a fine horizontal nystagmus to the right. The Babinski reflex is elicited by tactile stimulation of the sole of the foot. Dorsiflexion of the great toe and fanning of the smaller ones occur in the presence of damage to the upper motor neuron pathways. Nystagmus is an involuntary rhythmic oscillation of the eyeball that indicates brainstem involvement. . Testing of the cranial nerves- revealed palsies of the facial and glossopharyngeal nerves. nerves seven and nine. Frank's facial weakness and dry mouth was due to trauma to the facial nerve. Some sensory fibers for taste are also located in the facial nerve which has its cell bodies in the pons and medulla. Frank's ninth cranial nerve was also affected. This resulted in decreased taste in the posterior portion of the tongue. The motor deficits - decreased gag reflex and dysphagia (difficulty in swallowing) presented problems for him as well. . Motor examination of the extremities - revealed slight movement in the right limbs and no voluntary motion in the left limbs. . Sensory examination - showed marked hypesthesia (decreased sensation) to pin prick to the right face and upper extremities. . Orientation to time, person and place was intact. Frank could respond by nodding to questions we asked. Frank could also answer complex mathematical problems: he had no problem-solving difficulties. Frank's past history was relevant- he had had a myocardial infarction twenty years earlier. Neoplasm was ruled out because of the sudden onset of the presenting symptoms. A cerebral embolus was possible, but because of the probability of cerebral atherosclerosis, the diagnosis of pontine artery thrombosis with subsequent quadraparesis and cranial nerve deficits was established. The involvement of the ninth cranial nerve. the glossopharyngeal, was due to cerebral edema in the area of the medulla. Pontine artery thrombosis affects the medulla because of the proximity of the pons and medulla. Cerebral edema following thrombosis of the pontine artery has profound effects on the medulla as well. Acute care The first few days following a stroke are critical. The most important function of the nurse at this stage lies in keeping the patient alive. If he is unconscious, measures that are routine for every unconscious patient, i.e. maintaining a patent airway. nursing the patient in a semi-prone position and suctioning will be necessary. In addition, the acute phase necessitates continual nursing assessment of the patient. The nurse needs to be aware of . changes in the patient's level of consciousness; does the patient change in his response to stimulation; does he resist a change in position? . the neurological vital signs of the patient; these need to be monitored at least every four hours; . the patient's fluid balance; monitor intake and output every 24 hours; . stiffness or flaccidity of the patient's neck; . presence or absence of voluntary or involuntary movements ofthe patient's extremities. Following aC.V.A., edema and necrosis will cause an increase in intracranial pressure. Function will be impaired in those parts of the body normally supplied by the affected vessel. Spinal shock. exhibited by flaccid paralysis and the absence of spinal cörd reflexes is evident during this period of increased intracranial pressure and edema. A state of flaccid paralysis may persist for one to two weeks, after which time, the skeletal muscles have a tendency to become spastic. The C...-.llen Nur.. "'rch 1 871 21 At this time, the patient may not have bladder or anal sphincter control. When the patient is unconscious. an indwelling catheter is used to drain urine, but as soon as the patient's condition stabilizes. the catheter should be removed. Prolonged use of an indwelling catheter can cause bladder atrophy resulting in a low threshold and decrease urethral sphincter muscle tone. Once the catheter is removed, it is important to make sure that the bladder does not become overdistended. as overdistention may cause dangerous stretching ofthe neural receptors in the bladder wall. A bladder routine should be established as soon as possible. Failure to establish a routine may contribute to the necessity of prolonged bladder management. Similarly. a bowel routine must be established as soon as possible. Stool softeners. high fiber foods and possibly natural laxatives may need to be used for satisfactory control of bowel problems. The patient's immobility may complicate an already complex situation. Skin breakdown is one grave consequence of immobility and a positioning schedule must be followed religiously to prevent this problem. Another side effect of immobility is muscle spasm: Frank's leg cramps were alleviated once mobility was resumed. Feeding the patient will be a concern if. as in Frank's case, the patient's gag reflex is diminished or absent. A suction should be kept at the bedside in case of aspiration. Thick fluids such as melted ice cream, thick soups and puddings are generally swallowed more easily than other foods. Suctioning and feeding should always be followed by mouth care, to prevent what Frank calls "jungle mouth". In time. mouth care will become the patient's responsibility. Because meals are generally something the patient looks forward to. it is important to set aside time so that neither the patient nor the nurse will be rushed. Mealtime is a good time to establish a rapport with the patient. This brings me to one of tbe most important areas for nurses to consider when they work with stroke patients - communicatiOJ1. It is often a difficult task to communicate with someone who can speak, but the consequences of a C. V .A. are often such that the patient's speaking ability is impaired. Aphasia can be frustrating for the nurse, the patient and his family. , .. or"" :"\ , , ,,- - i' ..4 . ["! I ;, . OIl ' . ! .. -:.l! ? () Frank's problem was not aphasia but dysarthria. which is an inability to speak because of muscle damage. Trauma of the facial nerve is the underlying pathology. But although Frank was unable to answer us, his comprehension was not impaired at all. Forthis reason flash cards, pictures and body movements could be used to facilitate communication between the nurses and Frank. The use of these devices was explained to Frank's family so that they could take advantage of them. Pain may be a problem, as it certainly was in Frank's case. The use of analgesics must be considered carefully. because both psychological and physiological dependence can occur. I am not suggesting that medication should not be used, only that alternatives such as hot packs or a vibrator be considered as well as medication, for often the pain is not short-lived but rather a problem that will exist for some time. Hot packs were helpful in the treatment ofFrank's shoulder pain. Heat treatment is often used to induce analgesia. especially when pain is caused by muscle spasm. Heat causes an increase in peripheral blood flow, allowing larger quantities of oxygen and nutrients to the painful area and relieving pain. Position changes dlso afford a degree of pain relief as well as offsetting the possibility of decubitus ulcer formation. In addition the effects of the patient's anxiety on degree of pain should be considered: pain is a multidimensional phenomenon, and sometimes the cause is not as it appears. The needs of the patient's family must not be overlooked because family involvement means so much to the recovery of the patient. I f time is taken at the beginning to explain to the family exactly what is going on. the time ahead will be easier for everyone involved. An explanation of what is involved in the recovery process may prevent avoidance or rejection of the patient by his friends and family. Once the critical phase of the patient's illness has passed, efforts must be channeled towards the rehabilitation of the patient. As Frank has pointed out so well. rehabilitation can be a lengthy process, demanding the patience, hard work and support of everyone involved. The rehabilitation period marks a time when everyone must come to terms with what is going on: for the patient and his family. it may mean a greatly altered lifestyle. 30 Merch 1171 The C.nedl.n Nur.. Beginnings Much has been said about the team approach in nursing. In any rehabilitation effort, a team approach is absolutely essential. The disciplines involved in rehabilitation are physiotherapy, occupational therapy, speech therapy, nursing, social work, and medicine. Communication between all these departments is vital if the patient is to receive maximum benefits from the program. In rehabilitation, the nursing care plan is not only helpful- it is a prerequisite for the consistency required to help the patient improve. I stress consistency because any change in routine for a rehabilitation patient can be detrimental. Take for example a patient who requires a great deal of encouragement to perform at his optimum level. As Frank pointed out, not all patients are motivated to the same degree. If the physiotherapy department is successful in helping a patient to perform a given task at a certain level and fails to pass this information along to the nursing department. the nurses may assist the patient where he no longer needs assistance to the patient's ultimate harm. For the patient who needs encouragement to walk, keeping him in a wheelchair through ignorance or misunderstanding is detrimental to his progress. Family involvement in rehabilitation is also very important. The aim of rehabilitation is to return the patient to as normal a lifestyle as possible, and often this means returning to his home environment. If the family's involvement is encouraged from the beginning. family members will show less apprehension and wiII usually be more willing to accept the patient's return home. Family support is often the biggest incentive to getting better. I t is up to members of the health team to establish when and how much family involvement should be encouraged. Premature involvement could be hazardous. For example. if a patient is not yet transferring well from bed to wheelchair with staff members, it would be foolish to insist that the patient's wife take an active role - it would only frighten her and make her apprehensive on future occasions. On the other hand, assisting her to learn her role when her husband is also ready can increase her self-confidence and give her a feeling of satisfaction. . The nurse's role in rehabilitation The prime concern of the nurse in the area of rehabilitation lies in helping the patient learn activities of daily living- eating, dressing, hygiene and bowel and bladder control. Management of medications, with the eventual aim of self-administration is also a nursing responsibility. Psychological support, helping the patient accept his present situation while planning realistically for the future. is a part of daily interaction between nurse and patient. A daily routine needs to be worked out between all disciplines and the patient. The patient must know what is expected of him at all times. It is helpful to post this routine at the patient's bedside to tell everyone what the patient is expected to do, and what he needs to be assisted to do. Such a routine may read as follows: Activity - up with walker alone 7 am -am care with minimal assist 8 am - Physiotherapy 9 am - Breakfast in the dining room 9:30 -Activity Class 10:45 - Speech Therapy 11 am -Rest Period 12:30 - Lunch-Dining Room 1 pm -Activity Class 1:30 - Physiotherapy 2 pm -Rest Period 3:30 -Occupational Therapy 5 pm -Dinner-Dining Room 6 pm -Activity Class I have already mentioned that bowel and bladder routines should be established early in the course of treatment. Rehabilitation seeks to develop this routine further. Any bladder routine begins with a determination of the cause of incontinence. I s it due to physiological problems such as a urinary tract infection? Or is it due to psychological factors such as mental confusion? Once the cause has been established, the patient's drinking and voiding patterns should be noted. The nurse should note the time and amount of fluid intake as well as voiding or incontinence. A fluid intake of 2000 cc per day promotes optimum body functioning. Large amounts of cranberry and apple juice produce an acidic urine and are beneficial as a prophylactic measure against bacterial infection. The patient should be taken to the bathroom after the consumption of 250 cc and every two hours initially until a routine is established. Once this routine is found to be satisfactory, strict adherence is necessary. The voiding process becomes an automatic behavior and bladder control is acquired. I n the initial bladder training stages, men can use external drainage devices so that rest is not disturbed. Once daytime continence has been established. incontinence at night can be decreased dramatically. Encourage the family to take a part in this routine by asking their assistance in recording and encouraging fluid intake. The Can-.llen Nur.. March 1171 31 Bowel training involves the same principles - assess the cause of incontinence or constipation. and then establish a routine. Family assistance can be especially helpful in this area. because family members can provide essential information regarding the patient's previous habits. Initially, discontinue all laxatives and enemas and establish the routine outlined by the patient or family. Ensure adequate fluid intake and high fiber content in the patient's diet. If this approach is not successful, a mild suppository. stool softener or bulk increasing laxative can be given to help establish a new routine. Frank mentioned the importance of letting the patient do whatever he can do for himself. Sometimes it is difficult to discourage well-meaning visitors from assisting the patient. but it must be done. The patient will have difficulty learning to do things for himself. but the only way that he can learn is through repetition. Obviously the problems of dressing. daily hygiene and eating will provide a different challenge for each patient. Depending on the degree of the patient's disability. dressing will take time and a good deal of practice. and will be the source offrustration at the beginning. The patient will be taught to dress the affected limb first (and undress it last), with the assistance ofthe strong limb wherever necessary. There are many helpful aids available. including for example the elastic shoelaces and long handle shoehorns. An occupational therapist can be very helpful in this area. Bath time is important because it accomplishes increased stimulation and circulation for the patient. gives the patient a chance to develop motor skills. and the nurse a chance to assess' improvement or change in function. Very often stroke patients with hemianopsia - or blindness in half the visual field - will have a distorted proprioception, and bathing encourages the patient to accept changes in his body. Eating can be a trying experience for the patient. In hemianopsia. the patient will only be able to see half his tray. It will take time for the patient to be able to coordinate his movements. and it is important to support him and praise his progress so that he will not become discouraged. If. as in Frank's case the problem is dysarthria. then chewing and swallowing may be a slow process. Again it is important to stress independence, as eventually the movement will speed up and independence will be achieved. This independence is symbolic of control of one's situation. which is vital in the rehabilitative process. Cerebral vascular accidents are usually the result of a pre-existing medical condition: the two most common being hypertension and diabetes, both diseases affecting the blood vessels. A common post-stroke complication, and one that Frank experienced, is deep-vein thrombosis, occurring primarily due to immobility and vessel changes. Thrombosis occurs in about 80 per cent of all C. V .A. patients. The use of elastic stockings and early mobilization and exercise aid in the prevention of deep vein thrombosis. Pain in the calf. inflammation. and swelling are the symptoms that the nurse should know about. Patients who have had strokes are often placed on anticoagulant therapy. Nurses should be aware that it is important to avoid giving the patient ASA containing drugs and intramuscular injections. Close monitoring ofthe patient's prothrombin time and partial thromboplastin time is essential. Conclusion These are some of the areas we as nurses must consider in dealing with patients who have suffered strokes. The details add up to a picture of firm and consistent support to help these patients enjoy as much independence as possible. In our teaching, we must be very conscious of the purpose of the routines established. never losing sight of the fact that from the acute stage on. the patient must take daily steps towards his own rehabilitation. Rehabilitation encompasses a wide spectrum of considerations. Patients like Frank have to deal with physical trauma and accept certain limitations, limitations such as they have never encountered before. Their lives are altered. a whole lifestyle ended. As nurses. we are called upon to use all the insight and understanding we can muster if we are to be successful in helping patients like Frank to help themselves. That is why understanding what happened to Frank - from his point of view - is so important. 40 Bibliography 1 Anthony, Catherine Parker. Textbook of anatomy and physiology. 9th ed. St. Louis, Mosby,1975. 2 Horoch, Rose Marie. Elements of rehabilitation in nursing: an introduction. St. Louis, Mosby, 1976. 3 Brunner, Lillian Sholtis. The Lippincott manual of nursing practice. Toronto, Lippincott, 1974. 4 -. Textbook of medical surgical nursing. 3d ed. By... and Doris Smith Suddarth. Toronto. Lippincott, 1975. 5 Bladder and bowel retraining. Rehabilitation Program St. Joseph's Hospital, Hamilton, Ontario. Lori Whittington Hunt, (R ..V.) is a graduate of the Mohawk College Schuol of Nursing. She is currently working in the Rehabilitation Vnit of St. Joseph's Hospital in Hamilton. Frank Halligan taught in the elementary separate school system in both Ontario and Quebec for se 'eral years. concentrating his efforts in the areas of athletics. literature and music. A few years before his illness. Frank was a teacher librarian in an open concept system and was attending Brock Vni 'ersity to obtain a Library Science Degree. 32 M8rch 1878 The C.n-.llen Nur.. Current, luccinct, reliable ... ILLUSTRATED GUIDE TO ORTHOPEDIC NCRSI:\'G By Jane Farrell, R.N. Richly illustrated with over 500 figures and photographs, this important manual deals with the major problems encountered by nur- ses in the orthopedic unit. Specifically it focuses on the nursing care of the adult ortho- pedic patient; on those factors that influence the patient's adjustment, behavior, and recov- ery; and on practical suggestions for resocia- liÚng the patient in his home environment. Lippincott. 242 Pages. 550 Illustrations. 1977. $12.50. LIPPINCOTT'S STATE BOARD EXAI\II:\'ATION REVIEW FOR NURSES By Lu Verne Wolff Lewis, R.N., AI.A. With 6 Contributors and 4 Reviewers. Uniquely designed to incorporate sound teach- ing methods with an accurate reflection of the structure and approach of actual state board examinations, this new review book appears in tÌ1e same format as the licensure examina- tions themselves. It offers 2,568 questions (together with answer-recording sheets just like those in the examinations) that are also in the same ratio as will be found in the exa- mination. Five tests cover five major areas of nursing: medical, surgical, obstetric, pediatric and psy- chiatric. They integrate the basic natural and social sciences, nutrition and diet therapy, pharmacology and therapeutics, fundamentals of nursing, communicable diseases, and legal and ethical considerations. All answers and the rationale for each answer appear at the end of each of the five major sections. Lippincott. 745 Pages plus Answer Sheets. Illustrated. 1978. $13.75. NURSES' DRUG REFERENCE Edited by Stewart M. Brooks, .''v1.S. All nurses will welcome this fingertip guide to drugs, organized specifically with their needs in mind. It lists alphabetically over 500 generic drugs and describes-in an easy-to- consult format-each drug's action and use, dosage and administration, cautions, adverse reactions, composition and supply, and legal status. A glossary of drug classifications affords extensive cross-referencing for quick referral to hard-to-find information. Impec- cably organized and absolutely reliable, XDR will serve as the standard reference for any health practitioner who dispenses drugs regularly. Little, Brown. 500 Pages. 1978. $14.25 (Paper). $27.00. (Cloth). Nt.:"RSING RESEARCH: Principles and Iethods By Denise Polit, B.A., AI.Ed., Ph.D.; and Bernadette P. Hungla. R..\'., B.S.N., JI.S.,V., M..!. This new h:xt clearly and logically presents the essentials of research methudology with specific regard to nursing. Fundamental re- search concepts are supported throughout with practical explanations and numerous examples. Lippincott. 500 Pages. 1978. $19.50. HEALTH CARE 0 F WO IEN By Leunide L. ,Hartin, R.,V., ,\l.S., Written from the nurse practitioner's point of \"iew, and with particular focus on ambulatory care, this is the first combined OB-GYI'\ North American textbook intended specifica- lly for nurses. In a succinct, lucid style, it emphasizes physical assessment, including his- tory and exam; physicdl diagnosis; treatment measures; indications for consultation with the physician; patient counseling; and follow- up care. Psychosocial considerations are as important a pdrt of the book as the physical; the integra- tion dnd balance of these aspects are handled superbly. Detailed coverage focuses on such matters as identity, self-image, changing roles, sexuality, meaning of pregndncy, special prob- lems of abortion patients, dnd psychological changes in aging and menopause. Lippincott. 500 Pages. Illustrated. 1978. 516.75. J. ß. Lippincott Company of Canada Ltd. 75 Horn(Zr Au(Z., Toronto, Ontario mal4H7 The Cen.dlen Nuree Merch 111711 33 MANUAL OF NEL'ROLOGICAL Nt'RSING By Nancy Swzft, R.N., with Robert M. Mabel, Ph.D. Every nurse will welcome the realistic, straightforward guidance afforded by this much-needed handbook. In a format facili- tating on-the-spot reference, the authors succinctly and dearly cover every aspect of neurological nursing, including patient ass- essment and monitoring, diagnostic studies, management and assessment of specific neu- rological pathologies and dysfunctions, ma- nagement of pain, considerations for exten- ded care and rehabilitation, and the all im- portant psychological aspects of care. Little, Brown. 201 Pages. 1978. $9.25. GENERAL SYSTEMS THEORY APPLIED TO NCRSI G Bv A.rlene M. Putt, R.N., Ed.D. With 11 Contributing Authors The nurse learns to facilitate patient assess- ment, planning for care, teaching, and in- service education by applying the concepts of general systems theory. Building on the ideas originally formalized by vun Benalanffy and later adapted to nursing by June C. Abbey, PhD., the duthor dnd 11 contributors explain the components common to all systems, their functions, and the applicdtion to patient care of those principles underlying total human ecolugy. Little, Brown. 240 Pages. 1978. $11.75. THE LIPPINCOTT IANUAL OF NURSIl\'G PRACTICE, 2nd Edition By Lillian Sholtis Brunner, R.N., B.S., At.S.N.) and Doris Smith Suddarth, R.N., B.S.l'''/.E., ,U.S.N. This monumental Second Edition of a mod- em classic-the most comprehensive single- volume reference on nursing practice ever published-incurporates massive revision and updating to offer the latest and most accu- rate information available. \\'hat this means is more detailed, substantive. and complete coverage of every phase of medical/surgical, maternity, and pediatric nursing! Lippincott. 1868 Pages. Illustrated. 1978. $29.95. Il\'TERPRETATIO OF DIAGNOSTIC TESTS: A Handbook Synopsis of Laboratory Iedicine, 3rd Edition By Jacques Wallach, M.D. Extensively revised for its newest edition, this book continues to be a practical aid in the proper selection and interpretation of virtu- all y all clinical laboratory tests. For the first time, extensive pediatric material is included. It provides rCddily accessible and reliable data for maximum efficiency in making an early diagnosis, determining the stage and activity of the disease, detecting its recurrence, and medsuring the effects of therapy. Little, Brown. 600 Pages. 1978. S 11.50. Uppincott - - - - - -j .- i; cõi:i I-; - ' - ;. - -à i;. - .i-ö -; - :r -r - : ,- ;':-r: t: - :;i:- ;; - ; - - - - - - - - -.. Please send me the following book(s) 'on approval:' o Nurses' Drug Reference, Paper, $14.25. D Nurses' Drug Reference, Cloth, $27.00. D Illustrated Guide to Orthopedic Nursing, $12.50. o Nursing Research, $19.50. o Lippincott's State Board Examination Review for Nurses, $13.75. o Health Care of Women, $16.75. o Manual of Neurologic Nursing, $9.25. D General Systems Theory ApVlied to Nursing, $11.75. o The Lippincott Manual of Nursing Practice, $29.95. o Interpretation of Diagnostic Tests, $11.50. Lippincott's No-Risk Guarantee Buoks are shipped to yuu On Approval; if you are not entirel} satisfied you ma} return them within 15 days for full credit. D Send and bill me later. (Plus pustage and handling charges.) D Payment enclosed. (Postage and handling charges paid.) o Visa No. Exp. Date _ D Masten:harge No. Exp. Date_ Signature i\;ame Address CIty Postal Cude Prov Prices subject to Lhange without notice. ----------------------------------------------------------------------------------------------------------------- CN379 34 M.rch 1979 The Cen-.ll.n Nur.. oa between edUcatio \\\e f) i> 't\ ''<< .I11 9 i\ c\ \" - \ ::::: r VJ' þ æ III \ \\\1 "'\ 1 1 (1''''-- =::: fI 1111/11' \,\ éI/Jd 8 J- Þ/ AgnesT.H. Choi-Lao Marion S. Logan The differing value systems of the "work world" and the "school world" can become a source of great concern to a new graduate nurse. Much nursing literature, in particular Marlene Kramer's Reality Shock, has described how the service-oriented values of the hospital and community agency can often be in direct conflict to the knowledge-idea-oriented atmosphere of educational institutions. No matter where we work, all of us have experienced the very real feeling that nursing education and nursing service are two separate entities running along parallel tracks even though better patient care is their common goal. Although this phenomenon of separation is well known and numerous efforts have been made by nurses to correct the situation, the division remains a reality. To facilitate greater exchange between nursing education at the university level and nursing service in the hospital and community, the nursing faculty at the University of Ottawa has tried a number of tactics - among them reciprocal membership on standing committees, joint appointments on the faculty and in the service sector etc. We also felt that it was most important to help nursing students develop some ideas about the scope of nursing service. As a beginning step to help bridge the gap between service and education, a strategy was developed that utilizes the inservice department of hospitals and community agencies. Since quality inservice is one ofthe multi-faceted functions of nursing service, it was hoped that students would achieve a better understanding of one aspect of the nurse's work world. Second year nursing students were chosen to participate in this educational experience. By this time. they had developed a comprehension of basic nursing concepts and had begun studies in first level medical-surgical nursing. We felt that greater exposure to the work world early in their nursing education would be meaningful for them. The Cen.dl.n Nur.. M.rch 111711 35 The strategy Students were required to attend one inservice session offered by either the hospitals or health agencies in our community. The faculty was responsible for reviewing the agencies likely to sponsor presentations in the coming year. Then. students surveyed the suggested agencies and obtained further information about future inservice programs. This information was posted on a bulletin board at the university to increase everyone's awareness of coming events and to facilitate students' selection process. Both students and teachers assumed responsibility for updating the bulletin board. The students were to select a presentation which was applicable to the content oftheir nursing course and was of interest to them. Once an inservice presentation had been selected, the student was asked to discuss the chosen topic with a group discussion leader to assure its relevancy to the theoretical content. A brief evaluation was to be submitted by the student to the group discussion leader within one week of attending presentation. The evaluation included the following points: . title of presentation . place of presentation . persons presenting inservice session . summary of information gained from presentation . impression of presentation - valuable or not valuable and why? The inservice programs Student!. attended a wide vdriety of in service programs. The scope of presentations consisted of specialized subjects. such as malignant hyperthermia and more common health problems such as obesity. They ranged in orientation from moral and controversial issues of rape to pragmatic discussions on how parents can care for their asthmatic children at home. Methods of presentation included lecture, panel discussion. debates and audio cassette. Sessions were held in a variety of settings. such as hospitals, college and university campuses. libraries, church halls and other community agencies. Students noted the roles of the speakers, their academic and professional backgrounds, and their relationship to the health care team. Since many of the sessions were jointly sponsored by members of various health disciplines. students observed first hand how human and material resources can be utilized in an interdisciplinary approach. The description ofthe audience revealed information on attendance, composition and size of audience. Nurse<;. physicians, other health care professionals, policemen. social workers. parents and lay people all had participated in these in...ervice sessions. Information sharing A sharing session was held when all students of a given discussion group had completed their inservice assignment. The students were able to talk about their own experience and to learn about the experiences of others. During the discussion, factors that influenced the effectiveness of the inservice presentation such as physical plan. size and background ofthe audience. methods of presentation and content were emphasized. Practical considerations such as time, finance and personnel were also assessed. Additional efforts were made to compare the education for the student nurse with the continuing education needs ofthe graduate nurse. Students readily identified the responsibility of the graduate as a self-directed learner and the importance of continuous learning. They also acknowledged and expressed appreciation ofthe role of nursing service in providing continued education for nurses, patients and their families and in promoting quality care. This sharing of information proved to be very helpful. Students felt that they had learned from the experiences of others and were eager to apply what they had learned in the clinical setting. This was particularly evident when swdents readily shared gained information about home care for asthmatic children with parents in both the hospital setting and on home visits. Summary It was clear from the evaluations and discussions that students increased their: . depth of knowledge in topics chosen . awareness of community service . awareness of variety and number of inservice presentations offered in the community . awareness ofthe variety of methods of delivery . awareness of membership on the health care team . awareness of importance of continuing education. The assignment had been a positive experience for all concerned. Service agencies welcomed the participation of these young students who are to be their future nurses. The students. in turn, increased their understanding of nursing service. According to Kramer. the first step in bridging the gap between education and service is for the students to develop an awareness and appreciation of the work value system. This awareness of the difference between the two value systems is only the first step in this process. It is hoped that through more planned activities similar to this assignment. a better understanding between nur<;ing education and nursing service will be developed. 41 Bibliography I Kramer, Marlene. Reality shock: why nurses leave nursing. St. Louis, Mosby, 1974. 2 Kramer, Marlene, Path co biculturalism, by... and Claudia Schmalenberg, Wakefield, Ma., Contemporary Publishing. 1977. " . Agnes T.H. Choi-Laois an assistant Professor of nursing, Faculty of Health Science. University of Ottawa. She obtained her B .Sc.N.Ed. degree from the Unil'ersity of Ottawa and her M.Sc.N. degree from the University of Western Ontario. She has been the coordinator of Year II Medical-Surgical Nursingfor the pastfour years and is currently active in research and clinical teaching. Marion S, Logan, assistant professor, School of Nursing , Faculty of Health Science, Unil'ersity of Ottawa obtained herB.Sc.P.H.N. and M.Ed.jrom the Univenity of Ottawa. Past work experience includes staff nurse, public health nurse, and nurse educator (diploma and bachelor level). Specific areas of interest are parent-child and community nursing. 38 Mere" 1979 The C.nedl.n Nur.. Nursin care plans: a , Does your nursing Kardex show the total plan of care your patient requires or is it simply a list of current doctor's orders? Nursing care plans have sparked controversy within our profession for years. Whatever your situation, nursing care plans are only as good as the information written on them. Their value depends upon your input. Alida Sil,'erthnrn l'iursing care plans should ensure effective communication between nurses and other health care personnel. I. We all know how important it is to keep the doctor's orders up-to-date on the Kardex. Why then do we, as nurses, so often let each nurse work out her own plan of action at the time of assignment? If consistent nursing care is the goal. then nurses from shift to shift should have access to the information they need to provide this care. For example, if a patient is afraid of being turned on a circOlectric bed and one nurse handles the fear successfully, then a note made on the care plan of both the problem and its solution will save both the nurse and patient stress and time. 2. A plan can help coordinate care for individual patients. For instance, suppose a physiotherapist has told your patient with burned hands to exercise his fingers every two hours. If you have read this in the care plan then you can praise the patient for following through on the therapist's advice. or else question why he is neglecting his therapy. 3. If new machinery requires particular safety precautions, or if a new or unfamiliar drug is ordered, pertinent information regarding either in the car:e plan would save time and guard against unnecessary complications. 4. As the inpatient service draws to an end. the care plan can be used to show the nurse what the patient needs to be taught. how the individual should be approached, and what arrangements need to be made before actual discharge 5. The care plan can also prove useful as a guide to the points of assessment and care which should be incorporated into the patient's chart. Because patient problems are part of the care plan and can be grouped according to basic human needs, and because the significant aspects of assessment and care for each particular problem are mcluded, the organization of data can be achieved by describing all points under one need before going on to the next. 6. There are other reasons care plans need to be written. Although complete care has always been a goal for nurses, patients have come to expect more for the rising cost of health care, more attention, more individual care. In the case of some hospitals. nursing departments are required to show a care plan indicating the patients' individual needs are being assessed and acted upon accordingly. The resistance One of the main reasons we resist writing care plans is the time written work takes away from practical nursing in a busy clinical setting. If we look at this more closely we find it isn't really the writing that takes the time (we find time to transcribe doctors' orders). it's the mental effort it takes to arrive at an individualized plan. Before a plan can be written, we must assess and analyze the patient's situation thoroughly. We have to determine what problems are being presented and what nursing approach is to be used. The C....dlen NUrH M.rch 11711 37 The format for nursing care plans has been around for many years. There is a place for history, objectives or goals, problems, nursing care and for the doctor's treatment. The doctor's orders can be completed most quickly because the thinking and planning has been done for us. We simply copy that which has been written on the order sheet to the nursing care planr There can be no denying doctor's orders are very important but what has happened to the nursing component of the care? A mental plan is made by each nurse every time she works with a new patient but we don't write our actions down to aid another nurse in formulating her plan for the same patient. We have to ask ourselves if this is really a timesaving measure. Nurses may also resist writing care plans because they see no real purpose in writing all this information down. "We do all the nursing anyway so there is no need to write it all out. " I suggest this statement is open to question and those who make it must analyze their care very closely to see ifit is true. Resistance to care plans may come in relation to writing nursing objectives - some nurses find it difficult to choose the words that best describe their goals of care. There can be resistance to detailed care plans simply because they mean change. A more involved assessment technique needs to be tried if you are to understand how the data can be used and how to base judgements on collected facts. not personal assumptions. Recent graduates may find it frustrating when trying to implement the educational concept of a care plan into a service setting. It must be understood, there is a difference in purpose between the two kinds of care plans. The educational tool is structured to teach the student about patient diagnosis, health problems. nursing actions and rationale. The care delivery tool acts to communicate relevant data. rapidly and efficiently, to other team members. Formulating a care plan Collecting data Assessment is basic to the whole process of planning care. Not only must the information be as complete as possible, it must be factual and free from personal impressions or assumptions. If, while assessing a patient, you "feel" there is a problem but cannot support it factually, state it in such a way that it shows it's only a "hunch", then look for more information to explain, support or rule out what you have described. Several factors can influence the information that an individual nurse collects and how it is interpreted. Depending upon these factors, interpretation of the same event varies from person to person. These factors include the nurse's own: . ability to observe in a systematic, purposeful manner . physical and mental state and needs . cultural and philosophical background . experiences in relation to the present situation · motivational level or other interests . knowledge of the situation. Organizing Data Data will be more thorough and complete if it is collected in a systematic manner and organized into categories. Select a system which suits you best and use it for every assessment you do. Your guide should contain enough detail under each heading to adequately assess the need or system. A guide for systematic assessment on admission of the patient might be similar to the Nursing Data Base below: I -- - -- , =t- - .. - " ...., = t """I (.... . L-. " NURSL"IG DATA BASE A. Reason for admission B. Duration of this problem: length? affects on lifestyle? C. Other illnesses and/or previous experience with hospitalization: reason? problems? D. Observations of the patient's condition: Respiratory system (cough? sputum? dyspnea?) Circulalory system (edema? pulse? temperature? bruises? bleeding? inflammation?) Nervous system (level of consciousness? orientation? senses? headaches?) Motor ability (activity? endurance? range of motion? paralysis?) Nutritional status (appetite? nausea? digestion? diet?) Elimination (diarrhea? constipation?) Skin and body tissue (integrity?i mation? color? turgor? lesions? discharges?) Rest and comfort (pain? insomnia?) E. Mental/Emotional Status: mood? anxiety? expectations? feelings about illness? language? cooperative? F. Allergies: food? drugs? type of reaction? G. Medication: type? dosage? last dose? reason taken? H. Prosthesis: hearing aid? glasses or contacts? cane? false eye? pacemaker? I. Health Practices: breast self-exam? physical exam? Pap smear? smoking? practices related to Ihe patients conditions. i.e. diabetic urine testing. weight control? J. Lifest}le: family? housing? occupation? recreation? financial status? religious practice? education? ethnic background? All subject areas should be assessed thoroughly on the admission Nursing Data Base not only to point out obvious problems but also to detect underlying or hidden problem areas. How much detail you go into in each area depends upon the patient's presenting problem. Let us take. for example, an elderly patient with arthritis who is unable to cope with all of the activities of daily living. In this case you need descriptive data regarding the patient's housing accommodation (steps, conveniences) and available resources (family, income. community housing or lodges). Once the information is colIected, whether it be from the Nursing Data Base interview or on a continual basis, it should be scrutinized to ensure that it is factual. 31 Merch 111711 The Can-.llan Nur.. The words "seems" or "appears" should not exist on the assessment urness they are supported by reasons. Describe what you see. Some nurses say they are not aHowed to write a nursing diagnosis so the problem is often described or charted as if they aren't really sure of what they are observing. For example, "the patient's wound appear,s to be infected." A definite and factual statement would read "the patient's wound is inflammed. firm, tender and has purulent drainage through two 4 X 4 gauze. " Avoid words like 'good' or 'normal'; they are not very descriptive and could be interpreted in several ways. Instead, try to select adjectives which clarify your meaning. Rather than saying "the patient's respirations are normal". describe exactly what you see and hear. "Full expansion of chest. quiet respirations. rate 18 per minute." The writing Once the data has been collected. either on admission or on a continual basis, it is time to draw from your own knowledge and experience and anal1ze the information. What are your goals for the care ofthis patient. what are the physical and psychological needs which you must deal with? Are there problems? Why? Which aspects are in need of clarification and what nursing action is required? The care plan is written once these questions are answered. The type or size of your organization will. to some extent, determine the format of your care plan. But format aside. each plan should include: patient history. nursing goals, patient needs and problems and nursing actions. . The plan must be structured in terms of patient needs and problems to help nurses systematically improve problem analysis, general organization of care, reporting and recording. To begin with you might consider the highly o;tructured format on page 40. An early problem with terminology arises when you try to state your thoughts or goals on patient problems, so write in pencil and start with simple words which can be revised as the work progresses. Everyone on the team who has contact with the patient should be involved in the process. The creative energy and original thought which goes into the task can serve as a challenge rather than an obstacle. The completely written care plan will save time. Trained staff will be able to select their own assignments from the plan rather than wait to be assigned. Each nurse will also be free of the routine "get acquainted" sessions the patient hears so often, and be able to begin the current assessment directly from the written plan. Care plans can make the team conference a time to erase resolved problems, discuss new ones, and suggest possible approaches. At the very least the conference or report will be more organized and complete with the discussion centering around the patients' problems as they have been pointed out on the care plan. - .. '\L J . -" - . , . . Ie.. '- , - , ' -..... Guide to charting The format on which nurses notes are documented has changed from nurses note sheets, to problem-oriented charting, to common progress notes, to flow sheets. Whatever the name, these pages are only as good as the information the nurse writes. The purpose of nurses noteo; is to communicate information about the patient's progress. A way to ensure the completeness of your notes is to use as a guide the patient's problems as outlined on the care plan and write assessment notes to describe each area. Write what your senses tell you - what you see, what you hear. what you smell. and what you feel. If your notes are ever questioned or challenged you can defend them because you wrote what you observed, not what you assumed. Blanket statements like "good night". "feeling better", "settled to ward" do not really explain anything to another nurse. By writing "good night" do you mean that the patient did not arouse each time you made qlh night rounds? Difficulties in selecting words for emotional assessment often results in a note which says "good". Again, think about what you observed. Did your patient talk with you easily? What did you talk about? Was there eye contact? What was your patient's facial expression? Did your patient cooperate with his therapy? A more descriptive statement than "in good spirits" or "cheerful" would be "readily converses on topics associated with his illness, smiles easily". This is a clear statement unclouded by one person's interpretation. The care plan is also the guide to recording responses to treatments and medications. The extent to which procedures must be documented varies with different institutions. If you are legally required to account for all procedures a form can be designed stating each procedure (bed bath. mouth care, back care, etc.) and the nurse can check each area as the action is completed. It is important to remember that the use of a checkmark to indicate that a bed bath was done or mouth care given doesn't indicate anything in terms of patient assessment. In order to indicate assessment or response to a procedure, some kind of mark such as a star (*) could be placed by the procedure to indicate that more is written about this action on the nurses notes page. If the bed bath is checked off and starred, the notes will add "reddened area over coccyx. patient positioned on sides only and changed q2h." The Cen.dlen NUrH 118rch 1171 31 The notes I have illustrated are for on-going data and are found on a nurses flow sheet. This information is intended for all health care personnel to read. The ame information should not have to be rewritten on any other form for the convenience of some other professional to read. The problems are stated. the assessment is written, and those nursing actions are stated which are legally required to be on a medical record. When common progress notes are made, some health personnel object to other health care professional writing on "their" sheet. This problem needs to be worked through. but the important point is that you must record your observations and actions to legally protect yourself from negligence. regardless of what form is preferred or used. Some nurses are not writmg on the e sheets because they feel their notes are not significant enough or that they cannot express what they want to say in an inte\1igent manner. The care plan should help overcome this difficulty. Follow the patient's problems on the plan and write what you observed and/or did about it. This is important information and it is vital if you ever find yourself involved in a court case. Again, the form for charting is only a good as the written notes. A tick mark to indicate something about a problem is meaningless. Watch for what your knowledge and common sense tells you and record the data that needs to be communicated and audited. .. Bibliography Marriner. A. The nursing process. a scientific approach to nursing care. St. Louis, Mosby 1915. Lewis, L. Planning patient care, 2d ed.lowa, Brown Co., 1976. Documenting patient care responsibility, edited by Jean Robinson. Hor,>ham, Pa., Intermed Communications. 1978. (Nursing 78 Skillbook Series) Alida Silverthorn, the author of . 'Nursing care plans: a l'ital tool". is the director of surgical nursing at the University Hospital in Saskatoon. She wrote this article while teaching medical-surgical and intensive care nursing at the University of Saskatchewan. Alida has worked as a medical-surgical nurse-teacher with Project HOPE in Brazil and as head nurse of a medical unit at Foothills Hospital in Calgary. She received her B.S.N,from the University of Saskatchewan. Presenting Problem - developed a cold which didn't Diagnosis pneumonia improve - became congested. rheumatoid arthritis short of breath and weak - right arm feels numb and weak Operation - pain and stiffness in knees more severe Consultations Intravenous therapy Allergies none Date Medication Dosage Frequency Time Route Remarks Revision started date July 31 Ampicillin" 500 mg q6h 06-12-14-22 p.o. watch for Aug. 3 diarrhea PRN's July 31 Darvon-N" Caps II q3-4h pm p.o. for arthritic pain date diagnostic procedures date date specimens date ordered completed ordered sent July 31 chest X-ray July 31 July 31 sputum for C&S July 31 31 ECG 31 31 urinalysis 31 Hemat 7 (WBC) SMA 12 31 31 STAT blood culture 31 "Registered trade marK. 40 M.rch 111711 The Cenedl.n Nur.. ------------------- NURSING HISTORY age 79 birth date Aug. 2, 1899 addressograph occupation retired schoolteacher religion United Church, attends regularly, member of U.C. ladies group, contributes to sewing projects. housing: lives in small house by self, has steps to basement and outside -=-- both have railing, she states "some difficulty" in getting up and down. No relatives in the community. next of kin. economic: manages adequately on government pension. neural: glasses for shortsightedness - develops a headache without them on. Hears moderate voice tones. comfort: rheumatoid arthritis son - Mr. S. Moore in knees (10 yrs). Experiences pain and inflammation during weather changes. Doesn't take medications except occasional ASA, but applies a heating pad. nutrition: cooks for self and buys own Anycity 285-2094 groceries, maintains steady weight, poor fitting dentures. Drinks lots of juices to prevent constipation. respiratory: non-smoker, gets "colds" frequently. long-term objectives - to rehabilitate to independence of activities of daily living - to determine capability to live alone NURSING CARE PLAN short term goals to promote improved ventilation and diffusion to relieve arthritic pain in knees and promote comfort NEED PROBLEM NURSING ACTION NEED PROBLEM NURSING ACTION - shortness of breath - semi-fowlers position and - difficulty chewing diet regular, dental soft due to (I) lower change sides (0 back q2h due to poor fitting fluids 3000 cc/day intake - deep breathe q 1 h - recoro I respiration lobe consolidation, resp. rate q4H . - 0 _ at 41 nutrition dentures poor appetite and output, likes fruit juices, copious secretions due to copious thick observe caloric intake and cough wl(h humidity' - chest secretions and coughing phYSIO qld especially (I) side diet for special tests - potential problem of B.P. q4h tachycardia and circulation shock due to hypoxemia T.P. q4h elimination -elevated temp. due to pneumonia - shortsightedness -leave glasses within - dry skin due to high basin q.d., add 1/2 cap and develops headache easy reach temp. and dehydration, Alpha Keri ** oil neural without glasses on integument foul taste in mouth due - mouth care a.c. meals to secretions and pm. - endurance low due activity *bedrest with BRP - worried about leaving Aug. 1 (days) check with to dyspnea - help to BR and stay her house empty and Mrs. B. (pres. of no one to check church group) to inquire mobility stiffness in knees with pt *physiotherapy for psychosocial for assistance due to arthritis hot packs qd in a.m. - weakness (rt) - assist with anything arm and numb involving hot safety sensation due to? temp. or heavy object. comfort offer Darvon q3h. *means "ordered by Doctor" - pain in knees (R.A.) NAME DOCTOR ADM ROOM DATE Moore. Mrs. Bernice Black July 31/77 624 --------------------- The C.n.dlen Nuree 118rch 1979 41 -------------------- Nurses notes July 31 Aug. 1 1200 - 1530- 2330 - 1530 2330 0730 problem shallow expansion, productive O! at 41 with humidity started at Breathing easier. Decreased cough, rusty colored thick sputum 1600 hrs. Breathing deeper, amount of sputum, still greenish dyspnea & secretions 2-3 times /hr. Chest pain when sputum copious. greenish and coughing. Any exertion causes thinner, less dyspnea, able to walk dyspnea. Dr. R. notified at 1500 to bathroom hrs. weakness R arm R arm feels numb from elbow and includes hand poor appetite took fluids only for lunch. states fluid intake improved. Ate some too tired to eat. fruit for supper. pain in knees constant pain, slight relief with no change. Darvon X 2 with slight less discomfort. Darvon X 1 with Darvon and heat. relief. relief from pain. Son was notified of pts. admission worried about her empty house anxiety - he cannot visit for at least 2 and that she won't be able to live days. Talking constantly about her alone anymore. illness. Worried expression. slept in semi-fowlers position insomnia Awake approx. 5 times with coughing. ...- "r ' .f . ..oc " 4. ..: " "- . I..\- _ I ' - Jt ' iiir" ""f-''' \ t, ;!'1)! 0 .. ,-.. - . .. . '& to .. .. .. .. ... ... <' ... " .,i . ". . -; . . \. .- " .... " -.- \ '"' "- . -- ..,. "- .. .. .. ... ..-. , . .... ", I II.". ..::-. .' ..;. --y, ,# ---- - , . þ , . . , .. . ",) .-,;: 00 , . I- . ,,t1. ' 0.' ," >#!" 0 -f 0 ....;:-- ., '. ..."'" ' .... - I. .... ;..,. .. f . "" . I .. ,." ,.. .. . .' 0 þ - .. .I:' ..... . "'" . .... ...... -_. , "..4 -... 1 f - "'-t' . _4 ,. , , 0 .. " , ," , j ... . .. --. II .. \' 'J .. ...,. ""'* ... .. '-4. .... .. .. " ... .... . .' .. ,. ... .,- ..1 ..,. . . =' . 1- ': . .: . J- ... - ..- .1 . .. . ::....J42 , . , .. . :., ..,. '. .. - - The Cenedlen Nur.e ....ch 1179 43 For most of us, getting to and from work means driving through the rush hour traffic in our car, hopping on a bus or ducking into the nearest subway station. But nurses work in some pretty remote areas of Canada and, for some of them, getting there is half the fun. .J. - -- t " "" ....,. -'" Rosalind House It's early Spring. The Sydney P. Young, a 40-foot Longliner, lies waiting at the dock in the open water at Beachside on the northeast coast of Newfoundland. Beachside is 20 miles "up the bay" from where I work at the outpost nursing station in Springdale.ln our harbor, the water is still frozen so the trip across Green Bay to the islands where our clinics are scheduled for today will begin with a half hour drive along the narrow coastal highway to reach the waiting boat. At the dock, the other public health nurse from Springdale and myself are joined by a doctor, the nurse who works with him and the owner of the boat, Pearce Young. son of Sydney P. Our destination is the closer of two small land masses, Long Island and Little Bay Islands. located about 20 miles farther upGreen Bay from Beachside. Both islands have populations of about 200 people. Their relative isolation is broken mainly by the government-subsidized ferry that makes the trip from the mainland once a day. Various privately owned small craft are also available to transport anyone- usually members of the RCMP, fisheries officers. doctors or public health nurses - who needs to visit the islands when the ferry is not available. Helicopters and twin engine planes also provide a link with the mainland when the weather is good but. for the most part. the islands exist in relative isolation. As a public health nurse working out of Springdale. which is the major service center for some ten or eleven communities bordering Green Bay and nearby Notre Dame Bay, I have made the trip to the islands many times. We visit the islands at least once a month to carry out the school health program (health promotion, immunization, vision and hearing screening, etc.) and also to help staff the regular Child Health Clinics (immunization, development screening and counseling). During our trips to the islands we also include as many "home visits" in our program as possible. - ---- ::;-i:r-...... A doctor from Springdale usually visits the communities once a week depending, of course, upon weather conditions. The trip to the islands offers a wide variety of experiences as the seasons change. Sometimes we sight a couple of whales, or maybe a school of porpoises. Sometimes we see the boats with fishermen out jigging for cod. The work that we do on the islands certainly cannot be overlooked but, for me. it is the trip there and back and the anticipation of these trips that provides much ofthe challenge and excitement in my job. Today, the morning mist is rising very slowly and there is a severe chill in the air. Ice pans float menacingly everywhere. But it is the icebergs we have to watch for. As we move further out the bay we notice several sealing boats in the sea around us. The water is quite smooth (due to the slob ice). We are all peering anxiously through the window to catch sight of a seal. Suddenly there are dozens of bobbing heads to starboard. Approximately 40 seals are swimming less than 50 feet from the side of the boat. An incredible sight! 44 Merch 111711 The C.n-.ll.n Nur.. I. . ... - I T"1 , - '1 . J.. &I" r;:::: .. .... " -. //Í l. / 11 1 , I 1t Farther out a huge iceberg comes into view... worth another picture! By 10:00 a.m. we are docking at Long Island. A taxi (the only one) meets us and we are off to the one-story frame building where we will hold our Child Health Clinic. At noon we go back to the boat for the best meal of the week! And then, it is on to Little Bay Islands- another three quarters of an hour sail. Going into Little Bay Islands is like sailing right into a picture. It has a perfectly protected harbor and the community just snuggles down around the shoreline. We walk up to our clinic (the community hall). The doctor takes one room in which to see his patients who are waiting, while I show a film downstairs to the grades 7, 8 and 9 students who have come over from the school. The other P.H. Nurse holds a Child Health Clinic upstairs. At 4:00 p.m. we pack up and head back to the boat. The crab canning factory has sent down a case of crabmeat, so we open up a tin on our way back. I take a turn at the helm. The boat nearly makes a 360 0 turn, so Mr. Young resumes his position at the wheel. Two hours later we are back at Beachside. It is hard to portray the excitement of it all, the feel of the salt air and great satisfaction felt at the end of the day. But believe me when I say that to be a Public Health Nurse in Springdale, Green Bay, Newfoundland, is a wonderful experience.. . But what is it like to live on one of these islands? Are the inhabitants of Long Island and Little Bay Islands any less healthy than mainlanders because of their relative isolation? What is the long term effect of our intervention going to be on the health status of these islanders? CertainJy, their isolation, in the sense that people who are living on the islands rarely leave and very few people come to settle there, gives the islanders an advantage "health wise" over mainlanders: exposure to infectious diseases, epidemics. etc. is minimal. Similarly, however, lack of exposure to any type of health education program has left the islanders far behind most mainlanders in their understanding of the importance of adequate diet, physical fitness, etc. Limited access to dental care and medical services has resulted in serious disability for many people. It is not uncommon, for example, to see a youngster of twelve or fourteen with quite a few of his permanent teeth missing. Nor to see an elderly man with cataracts who has never had his vision checked. But what happens when we bring these services to the islands? Are we conditioning the islanders to the belief that their physical and mental health status is a reflection of the extent of the intervention of health professionals? Are we encouraging them to believe that illness is more important than good health? Many of the 20 or 30 patients the doctor sees each week in the clinics attend more from habit than any other reason. Their "complaints" are largely the result oflifestyle - hypertension, aging, "colds". Are we unintentionally promoting treatment as opposed to pre 'ention? Is the pressure on health professionals to look after their clients, rather than to encourage them to look after themselves. Are the islands, if this is the case, really any different from anywhere else? When I visit the islands I see people who are, for the most part, hard working and happy. They are also friendly and receptive. I hope that by teaching them about the benefits of breastfeeding as opposed to bottle feeding, by discouraging the consumption of "junk food" in the schools, by counseling, screening and immunizing, I can help them to realize the positive aspects of health. .. Rosalind House (RN, BN) graduated from Memorial University in St. John's, Newfoundland, in May 1975. Since then she has worked as a Public Health Nurse at various locations in that province, including Springdale, where this story was set and in C ornerbrook . Rosalind comments: "I am no longer working in the Green Bay area but, looking back at my time there, 1 can quite honestly say it was a memorable experience ... a happy and productive time for me." . . V e The Cen-.llen Nur.. llerch 1871 45 That's - no f- e.e . ., nurse... \ that's --- "ë. ::; \ :r " I .::J - my - 3 " > - 0 mother! >, - .- " r :I 8 0 Õ .c D.. Celia N ichn/ In keeping with the trend today, my pregnancy was totally planned and absolutely wanted; like so many others today. it also occurred at the worst possible time. "Who ME? Pregnant? N ?.. ow. We had been told in nursing school that this was how all new mother'i felt during the first trimester of pregnancy. Privately, I had considered such emotions ridiculous in this age of planned parenthood and had sworn neverto find myself in that predicament. And yet. here I was pregnant and just starting a new job. How embarrassing! Why couldn't the baby have come last year so I wouldn't have left my old job? Or why couldn't I have been offered this ne", position before I became pregnant, so I wouldn't be pregnant? Ah. well. I should have been prepared for this. After all. I as a Public Health Nurse. wa!in't I and didn't I have experience in counseling pregnant women. laboring women and new mothers? I understood how to cope with all the problems. imagined or real. ofthe childbearing woman. Right? Wrong, as I found out. To begin with. there was my pregnancy. Being an individual who prided herself on health and physical fitness. in fact. a person who preached healthful living to anyone who would listen, I had always pictured myself as the glowing, blooming type of expectant mother. It was therefore more than a little disillusioning to find myself nauseous and miserable in the first three months of pregnancy. It was downright embarrassing to confess to continued digestive upsets right up to my ninth month: particularly when I was always the type who could eat anything, anytime - always in healthful moderation of course. I spent much of my pregnancy looking wan and pale. The only advantage of this continued indigestion which the doctor rea'isuringly told me could be gallbladder. was that I only had a modest ",eight gain. This. I optimistically reasoned. would speed the return to my maidenly figure. Another thing that irritated me in mid-pregnancy was the reddish-purplish streaks that began to appear on my abdomen. At first I thought that in my vain attempt to conceal my advancing state of pregnancy I had crinkled my skin by wearing my clothes too tightly. M} husband. Hal. whom I was trying to educate into expectant fatherhood. enlightened me. "Aren't those stretch marks?'" he asked studiously, recalling his reading. He added knowingly that 'they' usually appear about now. Even he was no comfort. however. when I began to experience alarmingly persistent right-sided abdominal pain. "It's my appendix". I diagnosed with my usually unerring professional judgement and proceded to worry about the effect'i of surgery on the baby and whether I had accumulated enough sick leave. After twenty-four long hours of this "discomfort of pregnancy" I called the doctor. expecting to be summoned posthaste to the hO'ipital. Much to my surprise he assured me that this was a perfectly normal occurrence in pregnancy and that it was associated with the stretching of the round ligament Now why wasn't that taught in nursing school? As is usually the case, the nine months of my pregnancy eventually drew to an end and Hal and I eagerly awaited the big event. "Of course first babies are often late." I cautioned Hal. "We could go two weeks over the due date." Bearing this in mind and determined not to think of the event uppermost in our thoughts we went out to a party on the due date. We came home at midnight and collapsed mto bed. A few hours later. on one of my regular trips to the bathroom. I was vaguely aware that my pajamas were wet. In fact. 'iO was my bed. Being only 'iemiconscious I thought nothing of this phenomenon until the next morning when I awoke to a menstrual-like backache and found myself even damper. "Could this be it?" I wondered but dismissed the thought. After all. this would be exactly on <}chedule and my baby was bound to be two week'i late. Hal didn't agree with me though and shortly after breakfast whisked me away to the hospital. 48 Merch 11171 The Cen-.llen Nur.. Once in the Case Room I was determined to play dumb. No one would accuse me of being a difficult nurse/patient. In fact, no one would accuse me of being a nurse! I explained In layman terms that my membranes had ruptured and that I had some show, pointing out that' 'my bag of waters had broken and that I had a pink discharge." "Oh that often happens at the end of pregnancy:' the nurse laughed condescendingly. "But we'll examine you to find out if anything is happening." I hadn't expected anyone to doubt my word, nor did I expect the results of the examination to be inconclusive: perhaps the membranes had ruptured. Meanwhile I could walk the halls and see if my uterus would contract. "My back does ache..." I began. but stopped. I was the patient and didn't know. So we paced the halls, my husband and I, accompanied by the husbands of all my laboring sisters. Forward and back, all day long, interrupted only by meals and occasional checks with the nurses, who reassuringly said we'd probably be going home soon, that is unless I had begun to have contractions. "I did have some intermittently regular back pains and..." Just keep walking, was the answer. Finally, eight hours later the moment of decision was upon us: a medical examination. Hal and I held our breaths. "Yes, the membranes have definitely ruptured:' said my wonderful doctor. 'The cervix is two centimetres dilated and... the rectum is full of stool! Hasn't she had an enema?" One enema later I began regular rapid labor. A pitocin* drip was ordered to "stimulate" my contractions. As I waited for the nurse to start my I. V.. I gradually realized I was again becoming quite damp. 'This is ridiculous," I reasoned. "I know that the membranes have ruptured and all the fluid is gone." Looking around I noticed that the stopcock of the I. V. tubing had been left open allowing the needle, not yet affixed to me to drain fluid into my bed. At first I was determined not to interfere and waited patiently. as a good patient should, for my nurse to return, but as I grew wetter and wetter I found it harder to resist the urge to turn that little knob. Fortunately I was saved by my husband, who noticed the flood in my bed. "Isn't that tubing leaking?" he asked, watching the stream as fascinated as any small boy. I indicated the offending stopcock and added virtuously "I don't want to interfere with the nurse'sjob:' "Oh, for heaven's sake:' he gasped. "You don't have to be a nurse to do that; anyone can." The flood ceased. *Pitocin is a tradename of Parke Davis. Finally, with enema over and I. V. functioning correctly I prepared myself to embark on that marvellous experience called "Natural Childbirth". Now we could put to the test all the breathing and relaxation techniques we had practised for so long. For, as I had told Hal. analgesics used during labor could depress the baby and an epidural. although a wonderful pain relief, could prolong labor and might possibly necessitate the use offorceps at delivery. As the effects of the pitocin became apparent, however. and my contractions became longer, stronger and very close together, I rapidly reassessed my feelings towards childbirth without anesthesia and decided that I was chicken after aiL The epidural did provide a welcome relief[ had to admit, but I reminded Hal that it would probably slow my labor down. Within the hour, however, I was feeling rectal pressure and voiced some annoyance over this discomfort, expecting the anesthetic to block all such sensations. "Doesn't that mean you're nearing transition?" Hal asked diagnostically. It would be nice if he were correct but "that's rather unlikely," I retorted although I did permit him to report my symptom to the staff. Hal's diagnosis was soon verified by a vaginal examination which showed my cervix to be eight centimetres dilated. Another hour later I was permitted to begin bearing down and shortly afterwards I was moved into the delivery room. I had practised endlessly at home for the delivery. I had putfed, panted and pushed daily, much to Hal's amusement but now all my efforts were put to the test. To my delight I felt in perfect control during the delivery and although very tired, watched the entire proceeding with great excitement. My only negative feelings were induced by my watching the young intern's catheterization technique, which I felt was guaranteed to give me a urinary tract infection. After I was properly draped and prepped. Hal was allowed into the room. He entered red faced. muttering under his breath and looking quite frantic. 'They wouldn't let me in," he almost sobbed. "Everyone kept going in and out and ignoring me. I thought they had forgotten who I was. Did I miss it?" At that moment another contraction began and he was reassured that some action still remained. We all worked together for another half hour, and then. miracle of miracles, our daughter was born. Words can't describe the euphoria Hal and I felt after Christie's birth; we were both so high. so full of this new shared joy. It was a memory to be stored in life's chest of special moments. Nevertheless. hospital life must keep moving and soon we left the case room for the post partum floor. I couldn't understand why it was so quiet until Hal pointed out that it was 2:30 a.m. It seemed incredible that 16 hours had passed since we had arrived at the hospital. After Hal had left. the nurse came in and carried out the post delivery routine including detailed instructions on maternity care, visiting hours, photographers, televisions, telephones etc., none of which I remembered a second later despite my good intentions. 'Try and sleep," she advised. "Your baby win be here at 5:30 a.m. for her first feeding. ,. Obediently I closed my eyes, but was too elated for sleep. Something else was wrong. Systematically. I checked my body out and came to the conclusion that I needed to void - at least I thought so. Normal sensation was only now returning to my legs and I wasn't positive. Eventually I rang for the nurse who supplied me with a bedpan and left me in privacy. At this point. panic struck as I began to recall tales of post partum voiding problems, catheters and other ghastly phenomena. Of course, as a nurse I knew all the techniques to encourage voiding in recalcitrant patients but, infamy of infamies, I could not go! Not only that, I was so uncomfortable that I could no longer bear to sit on the bedpan. Funny, I had never "read of this particular post partum problem in nursing texts. Perversely though, my body told me quite plaintively: I must void. When the nurse came back I asked her if[ could use the bathroom. "Oh. I don't think so:' she said. "You're only just back from the case room." However, I must have looked desperate because she weakened and assisted me to the toilet. I was amazed how weak and sore I actually felt once on my feet. But. oh bliss. I voided and voided and voided: eight hundred cc's... Once again in bed I lay back exhausted, trying to sleep. And then that horrible sensation began again. I needed to void. Why? Where was all this urine coming from? Was I diuresing already? After another arduous trip to the bathroom, where I again voided a vast amount, I finally settled down for some much needed sleep. But not for long. "Here's your baby," said a cheery voice. handing me a screaming little pink bundle. The day had begun. Thus began a continual round of activity that lasted throughout my four-day hospitalization. I devoted myself to not being a nurse/patient. At the same time I tried to be the perfect patient, just in case someone did know I was a nurse and thought I should know what to do. A very tricky balance! The C.n-.llen Nur.. II8rch 111711 47 Things got off to a poor start, though, when I suddenly became weak while showering and had to have someone help me back to bed. I huddled under the covers for a few minutes and then looked at the clock, realizing with horror that I was five minutes late for the compulsory Sitz bath lecture. By the time I hobbled down the hall, I had missed most of the directions so the nurse patiently repeated her instructions just for me. That really made me feel guilty since I already knew how to use the Sitz anyway. On my way back to my room, I was met by a young RNA who glared angrily at me. "Where have you been," she asked, sounding like a mother scolding a naughty child. "I have your baby here and you're always supposed to be in your room when the babies come out. " She thrust my daughter at me. I began to explain about the Sitz demonstration but decided to remain quiet, as all good patients should. "Now, do you need any help?" she asked. "No, no I'm fine," I replied even though I had no idea how I was going to get into bed, crank it up and get Christie positioned to nurse. The first was so painful and the latter. so new. But I didn't want to cause any more trouble. Naturally I was very embarrassed when the same nurse returned a few moments later and found me standing exactly where she had left me. She helped me into a comfortable position, cranked up the bed and said cheerfully, "Feeding time is over in five minutes." Then she departed leaving me trying to wake up my sleeping daughter. Meals that first day were another problem. My appetite. like that of many post partum women. was gigantic and yet obviously that ofthe individual who had ordered my meals was tiny. My breakfast consisted of a piece of toast and coffee. Lunch was fish, cake and lemonade. Not only my appetite, but my nutrition-conscious conscience was offended. And I was embarrassed to keep asking for oddments from other meal trays. Humbly. I swallowed the urge to voice disapproval of this poor example of post partum nutrition.and took to sneaking past the nursing station for frequent snacks. Things went better on the second day. The large, well-balanced meals were those I had ordered myself; I managed all my own post part urn care without help and was in my room when the babies were brought out. I also attended the compulsory bath demonstration and so was prepared to start rooming-in on the following day. I had been told to collect Christie from the nursery at 9 a. m., an hour which seemed quite reasonable. In actual practice. however, I found it a mad rush to fight my way into the shower, have breakfast, line up for a Sitz bath, do my exercises and toast myself under the Baker lamp - all before 9 o'clock. When I arrived in the nursery the nurse nodded significantly at the clock and gave me the baby, her bassinette, a mound of clean laundry and several pages of instructions. Despite this ominous beginning rooming-in was fun. Christie was most cooperative, waking only for feeds and sometimes not even these. This was fortunate since it provided me with the time I needed to carry out my post partum routine. I always swore I'd find time for a rest but somehow there never was room in the day for that. My main difficulty with rooming-in was completing the numerous forms that accompanied Christie's departure from the nursery. I fully intended to record the appropriate data on these charts, voidings, bowel movements and minutes of breast feeding etc., but somehow something happened to distract me and I would forget. Coupled with this was the problem of test weighing the baby before and after feeds. Since the La Leche League propaganda that by now I could recite almost verbatim poohpoohed the need for this procedure, I think my subconscious induced me to forget to do this on purpose. Thus, in the evening I would approach the nursery in great trepidation: head low, dirty linen bag filled and daily forms blank. The first time this happened. the nurse listened tolerantly to my apologies and asked me to guess how many times Christie had carried out each specified activity. The next evening. the same nurse smiled a little grimly, took forms and baby from me and marched into the bowels of the nursery as if she no longer trusted me with my little one. Fortunately I went home the next morning, otherwise I might not have been permitted to room-in for another formless day! During my last two days in hospital I had four student nurses assigned to me which made me wonder if I was demonstrating myselfto be a poor mother. Conversely, I did want to provide the students with a good learning experience so I spent a lot oftime thinking up questions to ask them. Actually, all my questions probably accomplished was to succeed in having me labelled as eccentric. Why else would a young mother ask - what are cord clamps made of, when all the other new mothers were asking things like - how do I look after the baby's cord before it falls off? Possibly the students thought I was suffering from a post partum psycho'iis. Now that certainly would be a good learning experience. Suddenly, almost without warning. homecoming day had arrived. I was terrified of taking this dependent little creature home, where there would be no helpful staff to refer my questions to. I had felt so confident in hospital, but now ... At least, at home I wouldn't have to pretend anymore. My husband knew I was a nurse. And he realized how well I'd prepared him for our childbirth experience and trusted my judgement. At least. that's what I thought. "How often should we feed her at night?" , he casually asked the nurse who was helping us dress her. I blushed and busied myself trying to tie a bootie on a tiny wriggling foot. "I'd ask my wife. she's a nurse you know," Hal said. "but I need to prepare myselffor this and so far she's given me a lot of misleading information." I was mortified. "We've given your wife lots of pamphlets on infant feeding that should help you with your questions," came the helpful reply. "After all, when a nurse works in an operating room for ten years she often loses touch with things like infant care. You'll have to help her learn about them." Operating room? Ten years? Hal and I looked at each other. Obviously this was a case of mistaken identity, but it seemed pointless at this point to disillusion her about my actual professional background. Oh well, even if we were totally ignorant of all that was to follow, at least Hal and I would be equals as we started out on the great adventure of parenthood. .., .. .. , Celia ichol(B.Sc.N.. Ottawa University) has worked in the Nephrology and Urology Clinic at the Children's Hospital of Eastern Ontario. Ottawa and as a public health nurse with the Ottawa Carleton Regional Health Unit and in the Orthopedic Outpatient Department of Children's Hospital. She has also acted as a part-time instructor at Algonquin College, Ottawa in a "pediatric update" program. Following the birth of her baby (May 1978). she began part-time work teaching prenatal classes for the Health Unit. Celia comments: "/ am enjoving this present experience very much and find that my own recent pregnancy experience helps me empathize much more with the prospecti\'e parents." Celia is als(l the author of .. Legg-Perthes Disease' '(June 1976) and "Congenital dislocated hip" (Jul\' 1977). 48 Merch 1878 The Cenedlen Nur.. CNA submits brief (continued from page 12) Recommendations . Since the nursing service provided for the general public is part of the health care system which is funded by tax monies, there must be greater coordination of the allocation offunds to institutions. In this respect, regionalization of health services would be a prerequisite. The provincial governments would not. under these circum'itances. study an institution's proposed budget. but would assess the proposed budgets of all the institutions and agencies in a given region, not only in terms of avoiding duplication of capital expenditures but also for rationali7Îng manpower allocation. . Where changes imply potential redundancy of positions. employers should assume responsibility for seeking assistance to prepare their employees for the change. This could be carried out with the cooperation of unions and with the assistance of professional organizations, educational institutions. government services, to name a few. . Employers should take the following actions where a lay-off is Ovol Drops relieve infant colic. I , /" rPAABI ccpp 1 15m! Ovol Drops contain simethicone, an effective, gentle antiflatulent that goes to work fast to relieve the pain, bloating and discomfort of infant colic. Gentle pepper- mint flavoured Ovol Drops. So mother and baby can get a little rest. (6)Hp n R Oval ffi){) " fast actJng relief of Infant colic I .Ie Shhh. Ovol Drops. Aløo available In tablet fOITn for adulUl unavoidable: -provide reasons for the lay-off: (This should be a mandatory requirement.) -provide advance information whenever possible to minimize adverse effects; --consult the union, if one is involved. at the earliest stage; -inform employees of action already taken on their behalf to assist them: -give special consideration to long service employees; -provide management employees who are not covered by a collective bargaining agreement or legislation. with safeguards against redundancies and lay-offs. . Employees who have been laid off should be given first priority in rehiring and their reappointment should be without loss of seniority or a probationary period. If the reappointment is to a lower position, she should be placed on the same step of the lower position as she held on the higher position. . The Canadian Nurses Association supports the need to develop a code of good practice with respect to redundancies and lay-offs, and would suggest the inclusion of the measures suggested in this statement. Ovol 80 Tablets Ovol@40 Tablets Ovol@ Drops Antiflatulent Simethicone INDICATIONS OVOL is indicated to relieve bloating, flatulence and other symptoms caused by gas retention including aerophagia and infant colic. CONTRAINDICATIONS None reported. PRECAUTIONS Protect OVOL DROPS from freezing. ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOL 80 TABLETS Simethicone 80 mg OVOL 40 TABLETS Simethicone 40 mg Adults: One chewable tablet between meals as required. OVOL DROPS Simethicone (in a peppermint flavoured base) 40 mg/ml Infants: One-quarter to one-half ml as required. May be added to formula or given directly from dropper. Ð HQ nfR The Cen-.llen NUrH Mere .11171 411 Canadian Nurses Association FINANCIAL STATEMENTS AND AUDITORS' REPORT Year ended December 31, 1978 Canadian Nurses Association Balance Sheet December 3 , 1978 Assets 1977 1978 Current Assets Cash in bank Short term deposits-plus accrued interest Accounts receivable Membership fees receivable Prepaid expenses $ 145,266 $ 115,073 292,545 170.234 \,26.147 37,028 2,844 2,694 22.186 18,690 588.988 343,719 Sundry Assets Marketable securities - at cost (quoted value $25.560: 1977 $16.261) Loans to member nurses plus accrued Interest Fixed Assets -note 1 C.N.A. land C.N.A. building Less Accumulated depreciation Furniture and fixtures at nominal value Liabilities and Surplus 148,225 637,343 785.568 393,103 392,465 1 8,044 13,522 21,566 392,466 $1,003,020 6,044 13.420 19,464 148,225 637,343 785.568 361,236 424,332 1 424,333 $ 787,516 Current Liabilities Accounts payable and accrued liabilities Deferred revenue Grants for Special Projects -unexpended portlon- Note 2 C.N.A. House Expansion Fund - note 3 Surplus Approved on behalf of the Board: Helen D. Taylor, President Dr. Helen K. Mussallem, Executive Director (See accompanying notes) $ 53,893 36,400 90.293 3.416 50,000 859,311 $1,003.020 $ 34,903 35,600 70.503 48.421 668,592 $787,516 50 "'rch 111711 The Cen-.llen Nur.. Canadian Nurses Association Statement of Income and Surplus Year ended December 31, 1978 1978 1977 Revenue Membership fees $1,711,153 $1,224,735 Subscriptions 55,243 53,435 Advertising 292,911 317,537 Investment income 46,341 31,390 Sundry income 4,753 4.649 Examination fees 547,214 628,067 2.657,615 2.259,813 Expenditures Salaries 1,132,468 1,098,926 Printing and publications 361,659 351,647 Design and graphics 20,076 31,770 Postage on journal 175,767 162,486 Computer service 101,343 102,434 Committee travel 62,154 89,776 Commission on advertising sales 35,237 43,599 Affiliation fees - I.C.N. 154,949 106,053 - Canadian Council on Hospital Accreditation 14,000 14,000 Professional services - consultants 10,645 14,555 - translation 12,292 12,308 Travel- non-committee 18,297 26,337 Office expense 62,188 72,390 Books and periodicals 14,297 14.962 Legal and audit 9,327 8,206 Building expense 136,912 131,029 Sundry 5,275 6,132 Furniture and fixtures 3,549 12.370 Property improvements 19,517 1,200 Depreciation - C.N.A. House 31.867 31,867 Insurance 4,633 2,358 General meeting - 3,255 Contingency for special projects 5,168 14,900 Item writing 31.735 58.615 , 2,423,355 2,411,175 Non-operating expense: 1978 Biennial Convention (6,459) - 2,416,896 2,411,175 Surplus (deficit) for year 240,719 (151,362) Allocation to C.N.A. House Expansion Fund 50,000 - 190,719 (151.362) Surplus at beginning of year 668,592 819,954 Surplus at end of year $ 859,311 $ 668,592 (See accompanying notes) The C.necllan NUrH Merch 117. 51 Auditors' Report To the members of Canadian Nurses Association Canadian Nurses Association Notes to Financial Statements December 31, 1978 We have examined the balance sheet of Canadian Nurses Association as at December 31, 1978 and the statement of income and surplus for the year then ended. Our examination was made in accordance with generally accepted auditing standards, and accordingly included such tests and other procedures as we considered necessary in the circumstances. In our opinion these financial statements present fairly the financial position of the Association as at December 31, 1978 and the results of its operations for the year then ended in accordance with generally accepted accounting principles applied on a basis consistent with that of the preceding year. Geo. A. Welch & Company, Chartered Accountants Ottawa, Ontario. January 19, 1979 1. Fixed Assets It IS the policy of the Association to expense purchases of furniture and fixtures in the year of the purchase. The CNA House is being depreciated over 20 years at the rate of 5 per cent per annum 2. The Association receives grants from various government agencies for special projects. The unex- pended portion at December 31, 1978 of $3,416 is made up of Unexpended portion December 31,1977 $48.421 add: Grant received in year 90,021 deduct: Unused portion of grants returned Expenditures in year 138,442 4. Retirement Income Plan Effective January 1, 1975 changes were made to the Association's retirement plan resulting in addi- tional benefits for past service. Actuaries have estimated that an annual amount of $38.500 for the nexl11 years will be required to fund the past service benefits. 5. Lease of Equipment During the year the Association entered into an agreement to lease computer equipment. The lease provides for monthly pay- ments of $2,311 until October 1984 al which time the Association has the right to purchase the equipment for $12,761. 6. Comparative Figures Comparative figures for 1977 have been restated, where necessary, 10 conform with the presentation adopted for 1978. 40.929 94,097 135,026 Unexpended portion, December 31,1978 $ 3,416 3. CNA House Expansion Fund In January 1978. the directors of the Association established a fund for the future expansion of CNA House and allocated an initial amount of $50.000 to the fund. 52 M.rch 111711 The C.n-.lI.n Nur.. books Transcultural nursing: concepts, theories and practices by Madeleine Leininger. Toronto, Wiley, 1978. Approximate price $17.50 Transcultural nursing is emerging as a legitimate and viable subfield in nursing. Madeleine Leininger's timely book, Transcultural nursing: concepts, theories and practices, has given crucial theoretical foundation and direction to this emerging field. The author professes that the purpose of the book is "to provide for undergraduate and beginning graduate nursing students a substantive, comprehensive and scholarly book on the new subfield of transcultural nursing" and that claim, in my opinion, has been achieved substantially by the various articles presented in the book. The text is organized in four sections. The first section presents five different articles. all of them authored by Leininger herself. The articles deal with the history of trans cultural nursing, provide some fundamental definitions and concepts relevant to the study of the transcultural nursing phenomena, give some guidelines in conducting culturalogical assessment in nursing, and describe the ethnoscience research approach and its usefulness in eliciting beliefs. values and perceptions of the cultural group under study. The second section consists of six articles. The major theme in all of these articles is the concept of culture and the significance of applying the cultural concept in nursing in providing holistic, humanistic care to clients. The last chapter in this section deals with the cultural significance offood and man's eating patterns. Several universal and non-universal functions offood have been presented in the article which would give some direction and guidance to nurses in giving nutritional advice to clients. The third section presents several field studies in nursing, both in the United States and other parts of the world. These systematic and comprehensive studies provide the nurse with rich descriptive and theoretical data about several cultural groups. Although none of these groups are specificallY Canadian, the models used and the concepts and theories emerging from these studies would be of value to health professionals working in Canadian settings. The last article in this section "Nursing care of the elderly with a transcultural focus," written by Leininger, presents some "major theses to improve the care of the elderly." Since we have some 80 different cultural groups in Canada and in most of these groups the elderly are the least assimilated to the Canadian mainstream of life, a cultural focus in the care of the elderly seems most appropriate. The last section provides useful ideas, concepts, theories and models to nurse educators who are interested in incorporating cultural and transcultural concepts into their undergraduate as well as graduate nursing curriculum. The course outlines and the extensive , bibliography given at the end of this section would be especially helpful for transcultural nurse educators in organizing and developing transcultural courses. In my opinion the book is the first of this kind - comprehensive, substantive and scientific - published to-date on transcultural nursing. Re 'iewed by Theresa George, R.N., M.S.. Assistar.t Professor, School of Nursing, Unh'ersity of Manitoba , Winnipeg, Manitoba. Nursing diagnosis and intervention in nursing practice by Claire Campbell. New York, John Wiley and Sons, 1978. Approximate price: $2/.95 Nursing diagnosis and intervention in nursing practice is a comprehensive work. It has met the author's goal as a practical source from which to prepare patient care plans. Its organization is compatible with the P.O.M.R. system. Nursing diagnosis ... would be a valuable book to have in your personal or hospital library for use as a reference to confirm or elaborate on your nursing diagnosis. It should be emphasized that the text is intended as a quick reference only, and that other basic supplemental texts must be used for rpore complete information. Strong points are that nursing diagnosis is emphasized and a rationale for each nursing action is included. My only criticism of the book is that it is difficult to use. It would seem that a more logical arrangement of subject matter would be to follow the section on nursing action with an evaluation. In a work as comprehensive as this, thumb indexing would have greatly facilitated the speed with which the reader could locate specific content. It would also have been helpful to follow through one specific problem to demonstrate the book's use. Nursing diagnosis and intervention in nursing practice is appropriate for use by any nurse, graduate or student, who is actively involved in providing patient care. It would be equally helpful in in-patient, community or ambulatory care settings. Reviewed by Jean E. Fry, R.N., M.Sc.N., Burlington, Ontario. library update Books and Documents I. Ambulatory care evaluation: a primer for quality review by Marie E. Michnich . . . et aI.: principal investigator Paul R. Torrens. Los Angeles, Ambulatory Care Evaluation Project, School of Public Health, Univ. of California,cI976.9Sp. 2. American NursesAssociation. Statistics Department Report of the survey of salaries of registered nurse faculty in nursing educational programs. Kansas City, Mo., 1976, c1977. S7p. 3. Anthony, Catherine Parker Manuel d'anatomie et de physiologie. 9. ed. par . . . etJean-Guy Pepin. Toronto, Mosby, 1978.617p. 4. Bauwens. Eleanor E. The anthropology of health. Toronto, Mosby, 1978. 218p. S. Bennett, Addison C. Improving management performance in health care institutions; a total systems approach. Chicago, American Hospital Associatil;m, c1978. 243p. 6. Black, Errol Health care in Manitoba, 1978, by . . . Joy Cooper and Guy Landry. Winnipeg,CUPE, 1978. 119p. 7. Blake P J. Applied immunological concepts by . . . and Rosanne C. Perez. New York, Appleton-Century-Crofts, cl978. IS9p. 8. The British health care system, prepared by Economic Models Limited of London for American Medical Association. Chicago,lU.. American Medical Association, 1976. 161 p. 9. Canadian Health Education Society Directory of training facilities in health education. Répenoire des ressources en formation dans Ie domaine de I'éducation pour la santé. Ottawa, 1977. 7Op. R 10. Canadian occupational safety and health law, 1978. Toronto, Corpus. IIv (loose leaf) R II. Canadian V n on of Public Employees. Research Department Survey of wages and working conditions in New Brunswick municipal agreements. Ottawa, 1976. Iv. (various pagings) 12. Carner, Donald Charles Management, physicians and directors. Long Beach, Calif. ExecutivesCo., 1976. l04p. 13. Conférence Internationale sur les Tendances en Relations Industrielles et en Relations du Travail, Montréal, Québec, mai 24-28, 1976. Procès-verbaux. Rédigé par Frances Bairstow et Sally Bochner. Montreal, Industrial Relations Centre, McGill University. 584p. 14. Conference on Education for Health Services Administration in Canada, Ottawa 1977. Unmet needs; education for health services administration in Canada. Proceedings of a conference sponsored by the W. K. Kellogg Foundation of Battle Creek Mich. Ottawa, Canadian College of Health Service Executives, 1978. 124p. 15. Conover, Mary H. Cardiac arrhythmias; exercises in pattern interpretation. 2d ed. St. Louis, Mosby, 1978. 267p. 16. Corporation professionnelle des midecins du Quibec Les fonctions du médecin omnipraticien. Québec, c 1977. 48p. 17. Critical requirements for safe effective nursing practice by Angeline Jacobs, et al. Kansas City, Mo. American Nurses' Association Council of State Boards of Nursing,cI978.54p. 18. Curriculum development and its implementation through a conceptual framework. New York. National League for Nursing. 1978. 64p. (NLN pub. no. 23-1723) 19. Davies, Hywel Understanding cardiology by . . . and William P. Nelson. Toronto Butterwonhs, c1978. 424p. 20. Dunn, Olive Jean Basic statistics; a primerforthe biomedical sciences. 2d ed. TorontoWiley,1977.218p. 21. Emergency nursing edited by Jeanie Barry. foronto, McGraw-Hili. cl978. 491p. 22. Ewing, David W. Writing for results in business, government and the professions. Toronto. Wiley, 1974. 466p. 23. Feuo, Phyllis Health planning and professional standards review organizations: two selected annotated bibliography sic by . . . and Shirley Kressel. San Francisco, University of California, 1976. 51p. 24. Fortier. Üan-Claude Urologie. 2. éd. Momréal. Renouveau Pédagogique, cl970.78p. 25. Hardy, Margaret E. Role theory; perspectives for health professionals by . . . and Mary E. Conway. New York, Appleton.{:entury.{:rofts, c1978. 354p. 26. Health implications of nuclear power production. Repon on a Working Group , Brussels, 1-5, Dec. 1975. Copenhagen, World Health Organization, Regional Office for Europe, 1978. cl977. 73p. (WHO Regional publications. European series no. 3) 27. International Conference on Trends in Induslrial and Labour Relations, Montreal, Quebec, May 24-28,1976. Proceedings. Edited by Frances Bairstow and Sally Bochner. Montreal, Industrial Relations The CeNldlen Nur.. Centre, McGill University, 1977. 584p. 28. National League for Nursing Consumerism and health care. New York, c1978. 58p. (NLN Pub. no. 52-1727) 29. -. Council of Baccalaureate and Higher Degree Programs Curriculum process for developing or revising baccalaureate nursing programs. New York, cl978. 65p. (NLN Pub. no. 15-17(0) 30. -. Decision making within the academic environment. New York, cl978. 63p. (NLN Pub. no. 15-1719) 31. -. Program evaluation. New York. c1978. 71p. (NLN Pub. no. 15-1738) 32. -. Division of Research State-approved schools of nursing- L.P.N./L.V.N.: meeting minimum requirements set by law and board rules in the various jurisdictions. 1978. 87p. (NLN Pub. no. 19-1730) 33. Obstetric, gynecologic and neonatal nursing functions and standards. Chicago, Nurses Assoc. of the American College of Obstetricians and Gynecologists. 1974. 61p. Neonatal intensive care. Supplement, 1978. 9p. 34. Organisation mondiale de la Santi Activité de rOMS en 1976/77. Rappon annuel du directeur général à I' Assemblée mondiale de la Santé et aux Nations Unies. Genève, 1978. 267p. (Ses Actes officiels no 243) 35. -. Neisseria gO'1orrhoeae et les infections gonococcique. Rappon d'un groupe scientifique.Genève, 1978. 159p. (Sa Série de Rappons technique no 616) 36. Pan American Health Organization Final repon of the 25th meeting of the Directing Council , Pan American Health Organization and the 29th meeting of the Regional Committee at the World Health Organization, Washington, D.C. 27 Sept.-6 Oct. 1977 WashIngton, World Health Organization. 1978. 97p. Ilts Official document no. 152) 37. Perspectives of curriculum evaluation by Ralph W. Tyler, Roben M. Gagné and Michael Scriven. Chicago. Rand McNally, cl967. 102p. (Rand McNally education series) 38. Poulton. Karen R. Evaluation on community nursing service of Wandswonh and East Menon teaching district; research repon. London. Grosvener Wing, St. George's Hospital, 1977. 77p. 39. Précis de pharmacologie. 2. éd. par Joanne Bourgeois et al. Montréal, Renouveau Pédagogique, c1977. 4I3p. 40. Primary care. Edited by Cynthia J. Leitch. et aI. Philadelphia, F.A. Davis, cl978. 589p. 4t. Professional Corporation of Phvsicians of Quebec The functions of the general practitioner. Québec, c1977. 48p. 42. Quinet, Filix Collective bargaining in the Canadian comext with references to collective bargaining in the Public Service of Canada. Don Mills, Onto CCH Canadian Limited, 197-. 1 V. (various pagings) 43. -.Négociations collectives dans Ie contexte canadien avec reférences à la négociation collective au sein de la Fonction publique du Canada. Don Mills, Ont. CCH Canadienne Limitée, 197-. Iv.(pagination multiple) 44. Reedy, Barry L. The new health practitioners in America; a comparative study. London, King Edward's Hospital Fund for London. c1978. 79p. 45. Registered Nurse's Association of British Columbia Quality assurance manual. _ch1171 53 Vancouver, 1977. l06p. 46. Soins infirmiers en maternité par Sharon R. Reeder et aI . . . Montréal, Renouveau Pédagogique, cl976. 559p. 47. Système d'information médico-sociale: 'étude des cas, par Jean Rochon et aI. Chicoutimi,Qué..Gaëtan Morin. 1977. 102p. 48. Taurelle, R. L'infirmière en obstétrique. Paris, Expansion scientifique française, cl978. 182p. 49 Victorian Order of Nurses for Canada Repon, 1977. Ottawa, 1978. 81p. 50. -.Repon, statistical supplement, 1977. Ottawa, 1978. 46p. 51. White, Rosemary Social change and the development of the nursing profession. A study f the Poor Law nursing service 1848-1948. London, Henry Kimpton, c1978. 243p. Pamphlets 52. American College of Nurse-Midwives. Research and Statistics Committee Nurse-midwifery in the United States 1976-1977. Washington, cl978. 43p. 53. American Nurses' As.wciation. CommISsion on Nursing Senices Roles, responsibilities and qualifications for nurse administrators. Kansas City, Mo., c 1978. 16p. 54. L 'Association des irifirmières enregistrées du Nou\'eau-Brunswick Deuxième sou mission sur les services d'hygiène mentale présentée au Sous.{:omité du Conseil Consultatif des Services de Santé du Nouveau-Brunswick sur les Services d'hygiène mentale. Frédéricton. fev. 1978. 8p. 55. Canadian Institute of Child Helath Prevention ofhdndicap: a case for improved prenatal and perinatal care. Strategies for action. Ottawa, 1978. 8p. 56. Canadian Medical Association The Canadian Medical Association and abonion. Ottawa, 1978. 4p. 57. Corporation professionnelle des médecins du Quibec. C omiti ad hoc. La gériatrie. Rapport du Comité ad hoc presenté auComité administratif de laCorporation . . . Montréal. 1978. 24p. 58. DartnellCorp. What a supervisor should know aboul getting a full day' work out of his people. Chicago. c 1978. 24p. 59. Dickman. I n'ing R. Where older people live: living arrangemems for the elderly, by . . . and Miriam Dickman. New York, Public Affairs Committee. cl978. 28p. (Public Affairs pamphlet no. 556) 60. The French health care system, prepared by Economic Models Limiled of London for the American Medical Association. Chicago, III.. American Medical Association, 1976. 45p. 61. I nrernational Labour Conference. 63rd session. Genem. /977 Summary of information relating to the submission to the competent authorities of conventions and recommendations adopted by the International Labour Conference. (Article 19 of the Constitution) Third item on the agenda: information and reports on the application of conventions and recommendations Geneva. International Labour Office, 1977. 15p. (/ts Repon3(3)) 62. / son. Terence G. The dimen ion of industrial disease. KingslOn,Ont. Industnal Relations Centre, Queen's University, 1978. 24p. (Queen's University. Industrial Relations Centre. Research and Current Issues serie no. 35) 54 .....ch 111711 63. Koestler, Frances A. Jobs for handicapped persons a new era in civil rights. New York, Public Affairs Committee, c1978. 28p. (Public affairs pamphlet no. 557) 64. Librarian's guide to the new copyright law. Chicago, American Library Assoc., 1976. lOp. 65. Lynch, Eleanor A. Evaluation: principles and processes. New York, National League for Nursing, cl978. 32p. (NLN Pub. no. 23-1721) 66. National League for Nursing The A.D. graduate: excellence in practice - fantasy or reality? New York, cl978. 26p. (NLN Pub. no. 23-1737) 67. -.The AD graduate: from student to employee. New York. cl978. 26p. (NLN Pub. The Cen-.ll.n Nur.. no. 23-1734) 68. -.A.D. graduates: can they fit your system's needs? New York, cl978. 4Op. (NLN Pub. no. 23-1736) 69. -.Home health agencies and community nursing services accredited by NLN/APHA, 1977. New York, 1977. 6p. (NLN Pub. no. 21-1645) 70. -.One step beyond: shock Or reality? New York, c1978. 26p. (NLN Pub. no. 52-1724) 71. -.Dh'ision of Baccalaureate and Higher Degree Programs Masters education; route to opportunities in modem nursing. New York, 1978-79. 25p. (NLN Pub. no. 15-1312) R. 72. National League for Nursing. Division of Diploma Programs Criteria for the rete ast The first and last word in all-purpose elastic mesh bandage. ..- ........... !:".:;r Quality and Choice . Comfortable, easy to use, and allergy-free. Widest possible choice of 9 different sizes (0 to 8) and 4 different lengths (3m, 5m, 25m, and SOm). Highly Economical Prices Retelast pricing isn't just competitive, it's flexible, and can easily be tailored to the needs of every hospital. Technical training . Training and group demonstrations by our representatives . Full-colour demonstration folders and posters . Audio-vÌsual projector available for training progra>nmes . Continuous research and development in cooperation with hospital nursing staff For full details and training supplies, contact your Nordic representative or write directly to us. @ru@)O@ PHARMACEUTICUES LT E PHARMACEUTICALS LTD 2775 Bovet st., Laval. Quebec Tel: (514) 331-9220 Telex: 05-27208 evaluation of diploma programs in nursing. 5th ed. New York, c1978. 22p. (NLN Pub. no. 16-1370) 73. -.Education for nursing the diploma way-I978/79. New York, 1978. 29p. (NLN Pub. no. 16-1314) R. 74. -.Role and competencies of graduates of diploma programs in nursing. New York, cl978. 3p. (NLN Pub. no. 16-1735) 75. New Brunswick Association of Registered Nurses Reaction to RepoI1 of the Task Force on New Brunswick Health Care. Submitted to Department of Health. Fredericton, 1978. 19p. 76. Ogg, Elizabeth PaI1ners in coping: groups for self and mutual help. New York, Public Affairs Committee, c1978. 28p. (Public affairs pamphlet no. 559) 77. Ontario Occupational Health Nurses Association Guidelines for the occupational health nurse in Ontario. Toronto, 1977. 14p. 78. Organisation mondiale de la Santi. Bureau rigional de I'Europe Le rôle des services infirmiers dans les soins aux personnes ågées; rappOI1 sur la réunion d'un groupe de travail, Berlin (ouest) 29 nov.-3 déc. 1976. Copenhague, 1978. 27p. 79. Primary nursing: a reader consisting of eight articles especially selected by the Journal of Nursing Administration Editorial Staff. Wakefield, Mass., Contemporary Publishing, c1977. 44p. 80. Waters. Verle H. Distinguishing characteristics of associate degree education for nursing. New York. National League for Nursing, c1978. 9p. (NLN Pub. no. 23-1722) Government Documents Alberta 81. Alberta. Dept. of Advanced Education and Manpower T ask Force on Nursing Education Summary of responses to repoI1. Edmonton, 1978. 50p. Canada 82. Bibliothèque nationale du C unada Thèses au Canada: guide sur les sources documentaires relatives aux thèses complétées ou en cours de rédaction, compIlé par Susan (Jacques) Bruchet et Gwynneth Evans. Ottawa, Ministre des Approvisionnements et Services Canada, 1978. 25p. R 83. Human Rights Commission Human rights kit. Ottawa, 1978.6 pts. in I. 84. Commission canadienne des droits de la personne Documentation. Ottawa, 1978. En 6 parties. 85. Commission des relations de tral'ail dans lafonction publique Rapport 1976/77. Ottawa, Ministre des Approvisionnements et Services Canada, 1977. Iv. 86. Health and Welfare Canada. Social Service Programs Branch Social Services legislation kit. Ottawa, 1978. 6 pts. in 1. Contents.-The proposed social services financing act.-Summary of the principal components of the social services financing bilJ.-Questions and answers; the federal legislalion on financing social services-1978-Bill C-55, 1st reading.-News release 1978-72..(:ommuniqué 1978-72. 87. LabourCanada. Collecti,'e BargaininR Division. Labour Data Review, wage developments resulting from major collective bargaining settlements (construction industry excluded) (incorporating 1976 revision) 1977. Ottawa. Minister of Supply and Services Canada, 1978. Iv. 88. Santé et Bien-être social Canada. Direction génerale des programmes de se,,'ice social Jeu de documents sur la législation fédérale sur les services sociaux. Otlawa, 1978. En 6 parties. Projet de loi sur Ie financement des services sociaux.-Sommaire des principaux éléments du projet de loi sur Ie financement des services sociaux.-Questions et reponses; la législation fédérale sur Ie financement des services sociaux-I978.-Bill C-55, lère lecture.-Communiqué 1978-72.-News release 1978-72. 89. TramilCanada. Di\'ision de la négociation collecti\'e. Donnie s sur/e rramil Revue, évolution des salaires dans Ie cadre des grandes conventions collectives (excluant I'industrie de la construction) (incorporant la révision de 1976) 1977. Ottawa, Ministre des Approvisionnements et Services Canada, 1978. Iv. 90. National Librarv of Canada Theses in Canada: a guide to sources of information about theses completed or in preparation, compiled by Susan (Jacques) Bruchet and Gwynneth Evans. Otlawa, Minister of Supply and Services Canada, 1978. 25p. R. 91. Statistics Canada Report of notifiable diseases, 1963-1972.0tlawa, 1965-1973. IOv. in I. Catalogue no. 82-201. 92. -.Vital statistics. Otlawa, 1978. 2v. Contents.-v.I.Births 1975-76: Catalogue no. 84-204.-v.3 Deaths 1976. Catalogue no. 84-206. New Brunswick 93. Task Fora on New Brunswick Health Care Report. Fredericton, 1978. 69p. Chairman: S. Cassidy. 94. Comité d'ttude sur le. soins de Santé Rapport. Frédéricton. 1978. 69p. Président:'S. Cassidy. Ontario 95. Ministry Labour. Research Branch Sickleave plans and weekly sickness and accident indemnity insurance plans in Ontario collective agreements. Toronto, 1977. 14p. (BaÍ'gaining information series no. 26) Studies in CNA Repository CoUection 96. Craig, Dorothv The development of a nursing audit tool. Toronto, c1978. 140p. Thesis(M.Sc.N.)- Toronto. R. 97. Darling, Grace C. Behavioursof autistic-schizophrenic children that influenced mothers to seek help. Toronto. c1975. 76p. Thesis(M.Sc.N.)- Toronto. R. 98. Laliberté, Marie Thirèse Elfets d'un nursing basé systématiquement sur les fonctions expressive et instrumentale sur les réactions à la douleur des opérés. Montreal. 1977.313 p. Mémoire (M.N.)- Montréal. R 99. Macintosh, Alice Ross An assessment of selected continuing educalion experiences for professional growth and competence of nurses. Fredericton, 1978. 56p. Thesis (M.Ed.) - New Brunswick. R. 100. Moore, Jannice Evaluation of the quality of nursing care: a beginning review of the literature. Edmonton, 1975. 43p. R. 101. Payer, Thérèse. Soeur Organisation et rôle de cliniques de diagnostic au sem de I'hôpital général. Montréal. 1964. 92p. Thèse (M.A.H.) - Montréal. R Audio Visual Aids 102. Association des Médecins de Langue française du Canada Sonomed. série 5, no 2. Montréal, 1973. I cassetle. Sommaine. Côte A.!. Murray ,Gilles. Principes généraux de I'antibiothérapie. 2. Séguin. Femand, L'elfet biologique des ions négdtifs de I'air.-Côte B. Marchand, Claude. Les médicaments à valeur discutable. Th. C.Nldlen Nur.. "'rch 111711 55 - - .. ". . .. ... ....... .." u .. . ...... - .. k .- .... . :. ---- __I ___- -:: ---: -_I ---. =-. ,,-:. __e ,- J I .-- .-- .-- '--, 1---. ---- . . . e .J . OJ . . -<od R.N. '.. We feel thaI we can offer you the challenge and opportunity to develop and continue your professional II'Owth. We are located åt Beaumont, II city 01' 150.000 with II smaIl town atmosphere but the convenience 01' the laI'Ie city. We're 30 minutes from the Gulf oI'Muico and surrounded by beautiful trees and inland lakes. Bllptist Hospital has a prOiress sillary plan plus II liberal fri."e packaae. We will provide your immil" ration P :r rwork cost plus airfare to relocate. For addition information, COllIact: Personnel Ad- ministration, Baptist Hospilal 01' Southeast Tuas. Inc., P.O. Drawer 1591. Beaumont, Tuas m04. A. .mna.ttYe.... _pIoyn-. Switzerland Hospital of Canton Zürich at Winterthur (725 bed hospital near Zürich) needs Operating Room Nurses for the surgery clinic. Required for immediate or future openings. We offer pleasant working condi- tions. equitable hours of work and leisure. Salary and benefits in accordance with the regulations of the Canton of Zürich. Five-day week. accommoda- tion available. cafeteria. Apply in writing to: Sekretariat Pflegedienst. Kantonsspital Winterthur. CH-8401. Winterthur. Switzerland. Miscellaneous Africa - Overland Expeditions. LondonlNairobi 13 wk!. London/Johannesburg 16 wks. Kellya Safaris - 2 and 3 wk. itineraries. Europe - Camping and hotel tours from 16 days to 9 wks. duratIOn. For brochures contact: Hemisphere Tours, 562 Eglinton Ave. E., Toronto, Ontario, M4P IB9. Interested In Electrolysis Career? Must be an R.N. Successful practice available. Instructions. Write or call: Margot Rivard. R.N.. 1396 St. Catherine Street West. Suite 221. Montreal. Quebec. H3G 1P9. Telephone: (5141861-1952. Bermuda Hospitals Board Applications are invited for the position of Operating Room Supervisor in our 320 bed general hospital. which is accredited with the Canadian Council on Hospital Accreditation. The appointee would be responsible for the management and supervision of a busy Operat- ing Room and Recovery Room suite. undertak- ing some 6000 operations per year. Applicants should be Registered Nurses. who have a minimum offive years Operating Room experience. two years of which were in a management role. Bachelor's degree desirable. Demonstrated ability in management of per- sonnel and coordination of medical staff activities required. Experience and ability in budget preparation and cost control systems would be an advantage. I nterested applicants should apply in confi- dence. submitting resume and statement of desired salary to: Director of ursing King Edward VII Memoriat Hospital P.O. Box 1023 Hamilton 5. Bermuda 56 lIerch 111711 Nursing Instructors Required If you ar : . Imdgmatl"e. creative dnd mtere..ted in pro- fe"lonal fulfillment . looking for a chdllenge in nursing educ.uion . 'dtj..fied \\-lIh nothing ..hurt of eu-ellence . student enlered . intere!'lled in edrning d good '\alary If you ha e: . a 1 t!\oler'. or Baccalaure.ue Degree In NUT'lng . dion.a) pracllce experti..e If )OU set'k a nursing program Ihal: . promutes both perervices to Canada's Indian and Eskimo peoples. If you have the qualifications and can carry more than the nonnalload of responsibility... why not find out more? Hospital Nurses are needed too in some areas and again the North has a continuing demand. Then there is Occupational Health Nursing v"hich in- cludes counselIing and some treatment to federal public servants. You could work in one or all of these areas in the course of your career. and it is possible to advance to senior positions. In addition. there are educational opportunities such as in-service training and some financial support for educational leave. For further infonnation on any. or all. of these career opportunities. please contact the Medical Services office nearest you or write to: ........, Medical Services Branch I Department of National Health and Welfare Ottawa. Ontario K1A OL3 I I I I I I Name I Address I City I . . Health and Welfare Sante et Bien-élre socIal Canada Canada ,........ Prov "" "erch 117i The Cen-.llan Nur.. Clinical Nurse Specialist Psychiatry As an active member of an interdisciplinary psychosocial programme. the incumbent will act as a nursing consul- tant on psychosocial aspects of patient care in a variety of clinical settings with particular emphasis in out-patient and in-patient psychiatry. Candidates must be registered in the Province of Ontario and must have current clinical experience in psychiatry as well as experience in teaching. While preference will be given to those with a Master's Degree in Nursing. those with a baccalaureate degree are also invited to apply. Please send your resume in confidence to: :\-lr. R. E. Capstick Manager, Emplo} ment and StafT Relations Mc!\'laster Universit} Medical Centre t200 ain St. W. Hamilton, Ontario L8S 4J9 Assistant Editor The Canadian urse. a monthly journal published by the Canadian Nurse,,' Association. needs an Assistant Editor. Requirements: R.N. and member of provincial nurses association: bachelor's degree in nursing, journalism. general science, or arts: recent clinical experience: experience and/or interest in writing and editing; and willingness to travel Location: Ottawa Qualified applicants are invited to send their complete resume to: The Editor The Canadian Nurse 50 The Driveway Ottawa, Ontario K2P tE2 Index to Ad vertisers March 1979 Canadian Dairy Foods Service Bureau The Canadian Nurse's Cap Reg'd Canadian School of Management The Clinic Shoemakers Designer's Choice Equity Medical Supply Company Health Care Services U pjohn Limited Hollister Limited Frank W. Horner Limited J .B. Lippincott Company of Canada Limited TheC.V. Mosby Company Limited Nordic Pharmaceuticals Limited Nursing Job Guide W. B. Saunders Company Canada Limited Schering Canada Inc. Cover 3 15 12 2 Cover 2 5 12 7 48 32,33 10,11 54 15 13 Cover 4 Ad\'ertising Manager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa. Ontario K2P I E2 Telephone: (613) 237-2133 Ad\'erti. ing Representatives Jean Malboeuf 60 I , Côte Vertu St-Laurent, Quebec H4L IX8 Téléphone: (514) 748-6561 Gordon Tiffin 190 Main Street Unionville, Ontario L3R 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster Avenue Ardmore, Penna. 19003 Telephone: (215) 649-1497 Member of Canadian Circulations Audit Board Inc. m!EI no relationship has been established between dietary intake and heart disease in the normal healthy adult* . . . so many Canadians pass up the natural good taste of butter? *The 20-year Framingham Study, conducted by the U.S. National Heart, Lung and Blood Institute, shows no significant relationship between dietary variables and CHD. The more conservative position taken by the A.MA. advocates dietary manipulation only for persons with specific lipid profIles. When you look at the facts you can see the good in butter. Canadian Dairy Foods Service Bureau , .' .. I C\ .. When friends or patients ask your advice concerning relief of cold symptoms consider the advan- tages offered by the CORICIDIN family of cold products. The various CORICIDIN*preparations I are formulated to provide effec- tive relief of specific groups of symptoms that generally I accompany colds. Regular CORICIDIN (antihistamine, analgesic, caffeine com- pound) is intended for use at the first sign of a cold ! I where congestion is not a problem or when decon- G gestants are cQntraindi- cated. CORICIDIN 'D' is formulated for use when S Et pronounced. For your younger patients CORICIDIN , is available as CORICIDIN Pediatric MEDILETS* anjj CORICIDIN 'D' MEDILETS, both chewable tablets. and pleasant tasting CORICIDIN Pediatric Drops for infents or very young children. Free Booklet Offer We've attempted to answer many questions about colds, their causes, effects and relief in an informative booklet entitled "How to Nurse a Cold". It's yours. free of charge, if you'll simply fill in and mail the coupon on this page. Iflill HOW / I I I ( I I I r I I TO NURSE! I I I I I I I I. I I , I I I /1 /1 OU'I ,I I 'I Mail to: Schering Canada Inc. 3535 Trans Canada Pointe Claire, Quebec H9R 184 Please send me my free copy of your booklet "How to Nurse a Cold", Additional copies only available upon written request. Name: (Please print) Address' City: Postal Code . Reg. TM Provo . Hypertension - sorting out the facts . Antihypertensives and how they work . Pediatric hypertension - think about it . Are nurses victims of the degree mystique? . Family involvement in emergency care The Canadia N ----- ---- - - -\--\[QL...... U . se B\:::'UC 'Nf\HM\ERES ' \ rl j ENCES \\ /J .." "ì l"/(" f"' APRIL 1979 I I t..J N1)! 01 VTt-,jD VM'V 110- IN3 nlnJ SlVI HS 13SSIMON VMVI1J O ^ I n [6 3l0 LS3 nl ')öZ THE "NO UNIFO in beautiful Dacron. pol E sively ours, of course - , , J - ., I - A) Style No. 2742 - Skirt suit Sizes: 6-16 "Royale Shantung" 80% textured Dacron' polye 20% cotton White, Peppermint. . about $40.00 " B) Style No. 2749 - Skirt suit '-I> . G-i6 -Hoyale Sensation:' 100% textured Dacror,'" poly White. Yellow. . about . 4f) . --- A. - B. , , , , _.. A Div on of White Sister Uniform c . . Available at leading epartment store and specialty shops across I anad'a. Nature gives it. Zincofax* keeps it that wa o I' After every bath, every diaper change and in between, soothing Zincofax protects baby's nature-smooth skin. Protects against chafing and diaper rash, against irritation and soap-and-water overdry But Zincofax isn't just for de1ica te ba by skin. It's for you and your entire family-to soothe, smooth and moisturize hands, legs and bodies all over. \Vhat's more, Zincofax is economical, even more important now with a new baby at home. \. . \ '" '-- , ... ..\ '\ - .... . .. -\ t " Zinë'ofa ' OR BABY 5 sltlll _ 50 I "Q - Zinc,fa)( , FORS S keeps a family's smooth skin smooth Contains Anhydrous Lanolin and 15% Zinc Oxide. Available in 10 and 50 g tubes and 115 g and 450 gjars. I Wellcome Medical Division Burroughs Wellcome Ltd. laSalle. Qué. -Trade Mart W-8005 CONTINUE YOUR STUDIES WHILE YOU WORK, WITH THESE OPPORTUNITIES FOR SENIOR HEAL TH SERVICE EXECUTIVES: I I I I , . I I I I . . I . ea services . . . a miDIs ra Ion As admission criteria, degree requirements, and courses vary at each educational institu- tion, interested executives should write directly to the following: Professor J. Nicholson Department of Administrative Studies Atkinson College. York University 4700 Keele Street Downsvlew. Ontario. M3J 2R7 Professor Frank Silversides College of Commerce University of Saskatchewan Saskatoon, Saskatchewan. S7N OWO Dr. G. Blam Directeur Department d' Administration de la santé Université de Montréal C.P. 6128 Montréal, Québec General information is available from: Canadian College of Health Service Executives 410 Laurier Avenue West. Suite 805 Ottawa. Ontario. K1 R 7T3 The Canadian Nurse April 1979 The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number4 Input 7 Coping with diabetes insipidus Jannette Moens 18 HYPERTENSION Hypenension management Barbara Milne. Here's How 10 in industry Alexander Logan 21 News 12 Questions and answers Mary McCulley 24 Antihypenensives and Calendar 16 how they work Pam Has/am 26 Pediatric hypenen sion- - Names 50 think about it Sandra LeFort 32 FRANKLY SPEAKING Nursing and the Books 51 degree mystique Jeanne Marie L. Hurd 36 The role of the t\un ily Library Update 52 in the emergency depanment Wendy McKnight Nicklin 40 The Canadian Nurse welcomes suggestions for anicles or unsolicited manuscripts. Authors may submit finished anicles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and camon. All anicles must be submitted for the exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. A healthy child, a sure future is the theme for World Health Day - April 7th - this year and on our cover this month. a nurse who is working towards that objective. Photo counesy of Health and Welfare Canada. The views expressed in the anicles are those of the authors and do not necessarily represent the policies of the Canadian Nurses Association. ISSN 0008-4581 Canadian Nurses Association, 50 The Dnveway , Ottawa, Canada, K2PIE2. Indexed in International Nursing Index, Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microform from Xerox University Microfilms, Ann Amor, Michigan 48106. Subscription Rates: Canada: one year, $10.00; two years, $18.00. Foreign: one year, $12.00; two years, $:!2.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not responsible for journals lost in mail due to errors in address. Postage paid in cash at third class rate Toronto, Ontario. Permit No. 10539. Canadian Nurses Association, 1978. .. . , '" " '- 1 . 2 \.\I.cþ. . '-..... "" ) " - . " '- I ' \ '\ ... . k '" + ----- -0;; - íÕ-3"\ \ \. 'l. :!" -:"" . ..;:::-- - - - - 2i -\ . \. 'l. Cþ.1 '- " ., -- - 9' - -, . .. ,,- ,- - -- -'.. ,. , (. . .. .. - Professionals prefer to use precision instruments. That's understandable. A neurosurgeon can't spend time worrying about whether his or her equipment will adequately handle the precise function of a brain probe. He has to know that his instruments will perform without fail so that he can concentrate on technique. Precision instruments are equally important in the area of LV. catheters. When as a professional, you use a B-D I. V. CA TH, you are using a fine, delicate instrument with greater flexibility than most catheters on the market. With the trend to shorter length and smaller gauge catheters that can still deliver maximum flow rates, the B-D I. V. CA TH easily rises to the top of the class. These advantages allow you to concentrate on your technique to a greater degree, resulting in in- creased patient comfort and confidence in the therapist. [6.Q] ,. Start Kit . .. 6708 .....--....... - -= II;':. ........ ::::-::...--:... ... ----.::. ....... --- - ... leg ,. Start Kft OG1 1 4 c - [ê.QJ I.\( Start Kit _.?2 G 1 Si-Jgte Use --::::----- -- -- -- ... ............... l1li: .. .. -.. -- -.... ....._ --.... -...... .---. ......- ..... Use .... ---...... .:. . ;..::.:: :::::-- ... -,,::::.-- ""--- -=---==-- --.. 6706 -... 6705 =- . . ...... . ....-:: ......-.. .... ....-.. . .........--. . .:::;::-- .. -.::::.-- --. -- --- - CTDrf..DfCI( --- ..:.- .. .. - '- , 1 ... ., .... . ;I f . .. .,.. '# -01 .. .. 00 I \ J , l .. ö I - ....& '-. .. 11 - ... .... , -- ""- " MIll .. : . .-: IL...-- . swab -- ... .. __0.- . --- Our precision Catheter has been incorporated into this Professionall Start Kite I We know that in emergency (or just every day) situations, you don't have time to go searching for all the components to start I.V. therapy. That's the reason for the popularity and success of the B-D I.V. Start Kit. All the components for a safe aseptic I.V. start are at your fingertips. . . exactly when you need them. Each component is guaranteed sterile while package integrity is maintained. Affording maxi- mum patient protection, the B-D I. V. Start Kit is ideal for use in isolation wards and burn units. It is designed for single-patient use only. All B-D I. V. CA THS in Start Kits are the same preci- sion instruments as those sold individually. We make them that way so you can concentrate on technique with the ultimate comfort and safety of your patient in mind. The B-D I.V. Start Kit contains all of these essentials: 1 B-D I.v. CA TH 1 - tourniquet 1 - roll 3/4" x 24" tape 3 - 2" x 2" gauze pads 1 - isopropyl alcohol swab - 70% 1 - povidone - iodine prep swab 1 - adhesive bandage 1 - povidone - iodine ointment BECTON J1ICK1NSON Becton Dickinson Canada, Hospital/Medical Products, 2464 South Sheridan Way, Mississauga, Ontario, L5J 2M8 6 April 1979 The Cenedlen Nurse perspective The impossible dream? , ' '- , I World Health Day is observed around the globe on the seventh of April each year, a date chosen to coincide with the anniversary ofthe creation of the World Health Organization. In 1979,31 years after the WHO constitution came into force, the theme is the well-being of the child; the slogan is: "A healthy child, a sure future". The director general of WHO describes April 7, 1979 as "an occasion to rouse the social conscience to the plight of millions of the world's children." He points out that by the turn of the century, one third ofthe world's population will consist of children born between now and the year 2000 and reminds us that the first few years of life are crucial in laying the foundation of good health and improving the quality of life for these children. As things stand now, most of these children (more than 80 per cent of them) will spend these first crucial years - providing that they survive the hazardous perinatal period - battling against tremendous odds. These are the children for whom malnutrition, infection, poor housing, lack of safe water and sanitation, and inadequate health care are the accepted norm. The family health division of WHO comments: . 'Health cannot be achieved where poverty and misery abound, where food and safe water are scarce, where housinf? is inadequate, and where public and community services are lacking orrudimentary./n such conditions,faced by two thirds of the world's people, ill health and premature death are the rule of the day. Most sel'erely affected bv such environmental risk factors are the childbearing women and the children themsell'es. Because of their speciall'llinerability, they pay a hem'y price in terms of death, morbidity, retarded growth and disability." WHO cites some depressing statistics to back up their claim, for example: . one baby out of 12 born around the world this year will die before its first birthday. . the infant mortality rate in developing countries is generally from 10 to 20 times that of developed countries - as high as 200 per 1000 live births in some countries. . in developing countries, maternal mortality ranks among the main causes of death in women between the ages of 15 and 45; forty per cent of all deliveries fall in high risk categories. In the face of these statistics, the commitment of the nations of the world - at the thirtieth World Health Assembly and, more recently, at the International Conference on Primary Care in Alma-Ata- to the goal of "health for all by the year 2000" must be regarded as somewhat utopian, if not actually unrealistic. Unless drastic measures are taken to stamp out poverty, hunger and ignorance around the world, the survivors of to day's adverse environmental conditions will all too soon give birth to another unhealthy generation. Children in our affluent societies are not without their share of problems too. WHO reminds us, for example, that about four per cent of the:! I million Low Birth Weight (small for date) babies born annually around the world are born to mothers in dneloped countries. LBW is the single most important factor determining survival chances ofthe child. Its frequency is closely related to the nutritional status ofthe mother and, in developed countries, the frequency is higher among mothers who smoke during pregnancy. Canadian nurses are aware of other problems adversely affecting the health of the children they care for. Not all children in this country start off life with the same advantages. Some of them are the victims of poverty and ignorance too. Some are handicapped from birth. Some are physically or emotionally abused. Some are neglected. Some are not immunized against the common diseases of childhood. There is no room for complacency in contemplation of the task ahead. Nor can nurses opt out of this task. Whether they are practicing in Canada or abroad, it is the essential elements of health for a11- antenatal, natal and postnatal care, including family planning; infant and childhood care. including nutritIOnal support; prevention and control of locally endemic diseases: immunization against infectious diseases; water, housing and sanitation that permit cleanliness and safe consumption: education and information on health problems - that are at the core of that practice. Health for all by the year 2000 will never be more than a catchy slogan unless we start now to make sure that all of our children the world over ARE healthy... in every sense of the word. Nurses can't do it alone but, on the other hand, without nurses it almost certainly can't be done. -M.A.B. EDITOR ANNE BESHARAH ASSISTANT EDITORS LYNDA FITZPA llUCK SANDRA LEFORT PRODUCTION ASSIST ANT GITA FElDMAN CIRCULATION MANAGER PI ERRElTE HOlTE ADVERTISING MANAGER GERRY KAVANAUGH CNA EXECUTIVE DIRECTOR HELEN K. MUSSALLEM GRAPHIC DESIGN ACARTGRAPHICS EDITORIAL ADVISORS MATHILDE BAZINET, chairman, Health Sciences Department, Canadore Colleae. North Bay, Ontario. DOROTHY MI LLER, public relations officer. Registered Nurses Associallon of Nova Scotia. JERRY MILLER. director of communication services, Registered Nurses Association of British Columbia. JEAN PASSMORE. editor, SRNA news bulletin, Registered Nurses Associalion of Saskatchewan. PETER SMITH. director of publications. National Gallery of Canada. FLORIT A VIALLE-SOUBRANNE, consultant, professional inspection division. Order of Nurses ofQ'lebec. input "..-- ) "\ -- q'J 4 ... t::- :: --- C_ < ..... :" . I -- \' , \ Between friends ...It is refreshing to see our nursing organizations become involved in providing leadership in. and practical assistance for. community health issues and problems ("Be it resolved: the role of the nursing association in the prevention of child abuse" . January 1979). The Colorado Nurses Association has had a drastic decrease in membership in the past two years. We are looking for reasons for this as wen as solutions to this problem. Our membership task force is interested in looking at other nursing organizations to see what kinds of programs they are providing for the community and their membership and how their organizations are faring in this time of decreased professional interest. -Judith M. Paez. R.N., Colorado Nurses Association. Dem'er. Colo. fly gals Air stewardesses hired between 1938 and 1958 were required to be nurses and. for this reason. they may wen be readers of The Canadian Nurse. We would be most appreciative of any help you may be able to give us in attempting to track down these "old fly gals" so that we can proceed with plans for a reunion we are planning to hold in Toronto in May. Anyone interested should contact: Gretchen Marsh (Aird). 8 Skye Place. Guelph. Ontario, N IG IM6. -Gretchen Marsh. Guelph. Ontario. Curiouser and curiouser One ofthe pictures on page 45 of the January issue ofCNJ depicts a stuffed toy by the name of "Curious George". 1 thought you might be interested in knowing that the lettering on George"s chest has been done with a lead-based paint. A concerned parent who suspected this might be the case brought herGeorge to our hospital for X-ray. Sure enough. the lettering was radio-opaque on the X-ray film. I feel this is a potential hazard for the many children who own a . 'Curious George" . -Brenda Price. RN. CFB North Bay. Cornell Heights. Ontario. Editor's note: The manufacturer of' 'C urious George" mluntarily recalled all of these stuffed toys in mid-/978. Refunds .....ere offered to customers and a new toy that does not contain any radio opaque dyes is now on the market. Critical care nurses A group of concerned Registered Nurses in the Region of Niagara are in the process of organizing a Southern Ontario Critical Care Nurses Association in affiliation with R.N .A.O. Anticipated target groups include Intensive Care, Coronary Care. and Recovery Room Nurses. Proposed basic objectives are: · continuing education · professional accountability · promotion of nursing research . development of resource centre. Please direct your comments. suggestions, and enquiries to: Kileen O 'enden B.Sc.N.. Reg. N.. Staff Education Courdinator, Purt ColburneGeneral Hospital. 260SugarloafSt.. Port Colborne. Ontario, UK 2N7 1 Sphygmomanometer Aneroid sphygmomanometer with an adult armlet and a velcro closing (three year warranty) blue or grey colour Stethoscope Single or double head stethoscope (Littman type) silver, red, blue, green, gold and grey colour. Dressing scissors Stainless steel dressing scissors (Lister type) . To obtain our apparatus, please sene your cheque or money order to: A.B.C. Medical Instruments Inc. 2200 Le Corbusier Blvd. suite 100. Chomedey. Laval H7S 2C9 Tel.: (514) 687-4050 Price list: Grey Sphygmomanometer Slue Sphygmomanometer Single head stethoscope Double head stethoscope Dressing scissors 29.30 33.70 6.60 9.75 3.50 do not forget to include the Provincial sales tax For the C.O.D. orders. All orders under $20.00 add $1.35 All C.O.D. orders over $20.00 add $2.25 All our A.S.C. diagnostic apparatus are madE of first quality materials and carry an uncon- ditional warranty against all fabrication defaults . weight-conscious patients often give up the good taste of butter for a less palatable spread in the belief they are cutting calories. . . , they are not aware that margarine has exactly the same caloric density as butter? MARGARINE kca1: 36 kilocalories per 5 grams BUTTER kca1: 36 Butter, consumed in moderation, is an appropriate food for patients on reducing diets. When you look at the facts you can see the good in butter. DaIry Bureau of Canada. input Nutrition for nurses ...especially enjoyed the details Dr. Schaeffer's article on nutritional advantages of the traditional native diet (October, 1978). I would be most interested in seeing more articles on nutrition - with emphasis on the nurse's role in re-educating first herself and second the community on the importance of reducing refined and processed and other "junk foods" in the diet. Thank you for your stimulating articles. -Rosemary Paige Plummer, R.N., TelegraphCreek,B.C. ANF Scholar Word has recently been received that Dr. Muriel Uprichard has been named an American Nurses Foundation Scholar in recognition of her contribution to research in nursing. Friends in nursing will be genuinely pleased that Dr. The Cenadlen Nur.. Uprichard's ability to develop and promote a high standard of nursing education ha<; been recognized in thìs manner. Dr. U prichard was Director, School of Nursing, University of British Columbia from 1912 to 1977. -Margaret MacLachlan. Life Member, New Brunswick Association of Registered Nurses. One more revolution ...1 must point out that Avogadro's Number ("SI for you and me", February 1979) is incorrectly quoted as 6.0252 3 which, in scientific notation, is 8.690 X 10". The correct number is actually 6.025 X IOl.l. I hope that neither number is representative of the turns A vogadro has made in his grave. -BrianJ. Shaheen, R.T. (CSLT)B.Sc., Halifax, N.S. Editor's note: Webster's Third I nternational Dictionary begs to differ and cites A \'ogadro' s number as 6.023 X 10 23 . UWO Scholarship The Senate Scholarship Committee of the Faculty of Nursing of the University of Western Ontario has approved an award in memory of Donna Cairns Wright, a recent graduate of the faculty of nursing of that university. Donna gr.iduated from the Diploma Program in Nursing at St. Joseph's School of Nursing, Hotel Dieu Hospital in Kingston and following graduation practiced as a general staff nurse at the Hotel Dieu Hospital and at St. Mary's Hospital in that area. Following her general staff nurse experience. she enrolled in the BN program offered by Dalhousie University in 1973. She enrolled in the BScN Program for Registered Nurses offered by the University of Western Ontario in September. 1974. At the time of her death, she was a staff member of the Department of Nursing, University Hospital, London. The student must demonstrate the attributes of Aprl11979 9 caring, excelle:lce and commitment to nursing. The value of the award is up to $450. Further information regó.rding the award can be obtained from the Faculty of Nursing; donations to the endowment fund can be forwarded to the University of Western Ontario. -Edna L. Oudot, associate professor. coordinator. BScN program, Faculty of Nursing, U nÏl'ersity of Western Ontario, London, Ontario. Northern news A thousand cheers for Vah rie Walker. R.N. at Black Lake (Input, January). I used to live and work on that reserve long before Valerie came, and all she said is true. People who have never lived and worked up North have no right to criticize Northern nurses as they don't know what they have to put up with. -Dorothea LeCain, R.N., Saskatoon, Sask. SPHYGMOMANOMETERS ÕT:JJ- :S / . n" . .t m:)' medlCI' A- & Pu.h bullon lor aprin . r.1urn M.dll 01 durab . IIn.n M...ure. to 7e. on on. .'de 200 em on , raverse .....5-.ct\. I' NOTE: WE SERVICE AND STOCK SPARE PARTI FOR ALl. ITEMS CAP STRIPES S.II-.dh.sl.... type r.mOyabl. and r.uaeble No 522 RED No 520 BLACK No 521 BLUE. No. 523 GREY AU 15 '. Le; : . <<'oC.) 12 .Iripes per carø .s- ENAMELLED PINS. V a......tdully de"çn.ø to 8how _ your pror.sslonal .t.tue J.w.lry Qualily In 1'I.. y gold . .... pl.I.. With sal.ly elallp. jØ, No 50' 7. = "' ;= ::: No 502 Pllc:llcel NUll. NliRSES EARRINOS. For pierced No. 503 Nun.'. Ald. ..rs Dalnly CadUC....1I In gold plat. All ... 5. ..ch. with gold ruled poete. Beauillully i ã'V gl" box" No 325. I1Utl.,. . l SCUL'TUREOCAOUCEU. . " l ed to your prol.nlonal '.Uers H..w ll )' , P ed..o!' bA1i' .. =h N. No 4..1 MEMO-TIllER Time 1"101 p.Cks, hNt lamp.. pat1l. m.'.r. Rem.mber 10 ge; :: :'I : I :'IC:I '': ... to buu 5 to 60 mln Key ring Sw'..- .. ..L -\: made '13 a ..ell. . ..-., : r OTOSCO'UET On. 01 Germany's hne.' In.truments - . -" po e t :: :: 7: I:.n:i ''': ," .tandard .Ize specul. Siz. C . OIU.II..lncluded M.tal c:arry- . ,ng cas.I'ned wllh .011 c:IOlh " ... No 308 M8 85..ch. No 308A Ae abow. bulln pla.tlc pouc:h 151..5... . NOTE: ENGRAVED NAME-PINS IN {I SMART STYLES - SIX DIFFERENT COLOURS... :.::i:.t::: . ;; ; ;; ;".E.;I ; " ...................................................................... ..................... ;; .T ; .E.åu ;'; ;c'";L. ; ;p . .... .;L.E:" ;... : ::g: : f 1allln. _ _ _ __ ____________ __ ______________ 2ftcIUN_ _ _ _ ____ __ _____ ______ _ __ :.O.uB::07 .: :r I t:dd=:. V8 PRINT! PLEAIE PRINT TYPE : }:;''; fNA::CI( IA ND LETTER' PRICES 1 PIN cSa :I m.) Cuanl Item ; Pric. Amount: NURSES PENlIOHT..Pow.rlul beam lor examination 01 Ihroat .IC Duraþl. .1.lnla'.-III..1 caee wlll'I pod::el clip Mad. In USA No. 28 a... complete willi belt .s. Econom)' mod.' wlll'l c....romed bra.. ç... No 2Q .2.... NURSES WHITE CAP CLIPS Mede In Canada lor Canedi..n nur... Stro 51..1 bobby pins wilh nylon r 2 3M a 5) 01 '5. 2"" .lz.11.ool cerd NURS S 4 COLOUR PEN lOf recordinG I.mp.ralura. blood pr'ssur.. elc. Dne..hlind opera,lon Mleclt bleck, þlu. Or green No 32 12 21 ..Ch. SOLID PLEXIGLASS.hMolded Irom eOIt' PI..lgl.. : ': I I :q ot : : Mother 01 P..r' :, :A t; h ;fn, iII contralltmg colour cor. B.v.lled -'lg.S malch letta,. Satin finl.h EJlc.ll.nl walua.t Il'Ile prlc. PA WN - t Whit. - C Blac :::k _ Whit. "'" [.... ....111 r 11.11 121' 11.72 131:1 M.32 ONTARIO RESIDENTS ADD 7% TAX ADD 50c HANDLI G CHARGE .2" ...... IF LESS THAN $10 COD ORDER ADO $2 ()() 13.11 .. .. NO COO ORDERS FOR NAME.PINS TOTAL ENCLOSED "0 CHECUE CASH .... 16.11 ASI( A_OUT 001': OfNEI':OUS OUANTITY orscOUNTS FOR 14.71 17." CLASS GIFTS, OfiOUP PUACHASfS, FUNP IIAISINO ETC r bl.ck '>-blue C ... - g.... t line I.ner. 2 line 'eUers , IIn. I.tt.... 2lme. 'ell.r. MtTAl FRAIIEÐ...S'mll.r to .bow.but mounted in polt.hed m.tellram. wlll'l rounded edg.. and corn.r. EngraYed In..11 c.n be ch..nged or r.plac.d Our .man.s, and n..t..t d..lgn WhO. 1 IIn. I.u.r. 211n.. leU.r. SOL'Ð IIETAL...E.tr.m.l .'rong .nd durable bUI : = gnh:. ;: I . r. :; : : :: . colour Corn.r. .nd edg.. .moothly rounded Salin smooth 11"..1"1 C Silyer black rblu. ... grMn Ilin. 'eU.r. 2 lin.. I.n.r. .......... ............... ................... ........... .... ........ ....... .............. ............... ......... ...... ......... ....... ......... ...... USE A SePARATe S....EET OF PAPEFI. IF" NECESSAFI.... 10 Aprt11979 Th. C.nedlen Nur.. Here's How Every nurse has practical ideas gathered from his or her experience on how to make life a little easier for nurses and for.patients. Here's How is a column for you and your ideas. If you have an original and practical suggestion that you think might help other nurses to improve any aspect of patient care, why not share it with other nurses? We'll send you $10. for any suggestion published. Let's hear from you. Write: The Canadian Nurse, 50 The Driveway. Ottawa. Ontario, K2P IE2. Put on a happy face! At theChildren's Hospital of Eastern Ontario in Ottawa the I. V. team tries to take the "sting" out of blood-taking by putting "happy face" bandages on the site of the puncture. The nurses on the team use their spare minutes to draw the faces on both the round and long bandages in red or blue ink. The child is given a choice of color and is thereby immediately distracted from the unpleasantness ofthe blood-taking experience. -Carole Fraser, R.N.,I.V. Team, Children's Hospital of Eastern Ontario, Ottawa, Ontario. Emergency Pockets For easy intubation during an emergency. we have the laundry make up a cloth with pockets of various sizes. We label each pocket with the name of the object to be placed inside. The cloth rolls up conveniently and fits in the arrest cart. During a respiratory emergency, it can be unrolled quickly and placed at the patient's head. and the doctor can find his equipment quickly and easily. -Patricia MacFarlane, HeadNurse, Coronary Care Unit, Ottawa Civic Hospital. Postop constipation For patients who are constipated postoperatively and on a full liquid diet, here's a solution that really works. Give the patient a glass of prune juice followed by tea or coffee every morning. Your patient will have good results without medication. - Marie B. Turcotte, S an Francisco, California. Nipple, Medicine Dropper, or Spoon The following describes a procedure used at the Sainte-Justine Hospital in Montreal for children with uncorrected cleft lip and/or palate. The use of an ordinary, moderately soft. rubber nipple is recommended for feeding. It is sometimes necessary to pierce the nipple by making two well-defined cuts in the shape of a cross ( + ) at the level of the opening to facilitate sucking and swallowing. It should be noted that children with cleft lip and palate learn to drink in spite of their problem, that, not knowing anything else, they adapt normally to the situation. Cleft lip is corrected at the age of three months. When the child returns home, we advise that medicine dropper or spoon be used for feeding for about one month. No nipple of any kind may be used during this period. Parents receive an information booklet as a guide for home care before an<.! after the operation. Further information may be obtained from the Sainte-Justine Hospital cleft palate clinic, Montreal. -Hélène Delorme, Instructor, Nursing Care, Hôpital Sainte-Justine, Montréal, Québec. Emergency Teaching In the emergency department where I work, we use printed sheets on various subjects - for example, cast care, suture care, crutch walking etc. - as a supplement to our patient teaching. So often, the patient in emergency is under a great deal of stress in a busy environment. and may only remember a small portion of what the nurse explains to him. The instruction sheet offers the patient a tangible reference when he is discharged from the department. -Maureen Morrice, R.N., Winnipeg, Manitoba. A uthor Corinne Sklar is on holidays. You and the Law will return in May. 5 anty) * Collagenase ointment Description: Collagenase IS an enzymatic debndlng agent derived from the fermentation 01 C1ostnOlum hlstolytlcum " possesses the unique ability to digest native collagen as well as denatured collagen Action: Smce collagen accounts for 75 c 'O of the dry weight of skin tissue. the ability of Collagenase to digest collagen In the physIOlogical pH range and temperature makes It particu- larly effective In the removal of detritus Collagenase thus contributes toward the formation of granulation tissue and subsequent epithelization of dermal ulcers and severely burned areas Indications: Santyl Ointment IS indicated for debndlng dermal ulcers and severely burned areas Contraindication.: Application IS contraindicated In patients who have shown local or systemic hypersensitivity to Collagenase Precautlona: The enzyme's optimal pH range IS 7 t08 Lower pH conditions have a definite adverse effect on the enzyme s acllvlty. and appropriate precautions should be taken The enzymatic activity IS also adversely affected by deter- gents and hexachlorophene and heavy metal Ions such as mercury and sliver which are used In some antiseptics When It IS suspected such matenals have been used. the site should be carefully cleansed by repeated washings with normal saline before Santyl Ointment IS applied Soaks containing metal Ions or aCidic solutions such as Burow s solution should be avoided because of the metal Ion and low pH Cleansing matenals such as hydrogen peroxide or Dakin s solution do not Interfere with the actIVIty of the enzyme Deblhtated patients should be closely monitored for systemic bactenal infectIOns because of the theoretical pos- Sibility that debndlng enzymes may Increase the nsk of bacteremia The Ointment should be confined to the area of the lesion In order to avoid the nsk of Irritation or maceration of normal skin A slight E:rythema has been noted occasionally In the sur- rounding tissue particularly when the enzyme ointment was not confined to the lesion ThiS can be readily controlled by protecting the healthy skm with a matenal such as lassar s paste '" Smce the enzyme IS a protein. senSitization may develop with prolonged use although none has been observed to date Adverse Reaction.: Adverse reactions to Collagenase have not been noted when used as directed Do....ge I: Administration: Santyl Ointment should b..! applied once dally (or once every other day In the case of outpatients) In the following manner (1) Pnorto application the lesions should be gently cleansed with a gauze pad saturated In normal saline. buffer (pH 70- 7 5) or hydrogen peroxide to remove any film and digested matenal (2) Whenever Infection IS present. as eVidenced by positive cultures. pus inflammation or odor. It IS desirable to use an appropriate topical antibacterial agent Neomycln- Bacitracin-Polymyxin B (Neosponn) has been foundcompat- Ible with Santyl Ointment This antlbloltc should be applied to the lesion In powder form or solution prior to the apphcatlon of Santyl ointment Should the infection not respond. therapy with Santyl ointment should be discontinued until remiSSion of the Infechon. (3) Santyl Ointment should be applied (using a wooden or plastic tongue depressor or spatula) directly to deep wounds. or. when dealing with shallow wounds. to a stenle gauze pad which IS then applied to the wound The wound IS covered with sten'e gauze pad and secured with clear tape or Kling bandage (4) Crosshatching thIck eschar wIth a #10 blade " helpful It IS also desirable to remove as much loosened detntus as can be done readily with forceps and SCissors (5) All excess ointment should be removed e ch time dressing IS changed T (6) Use of the Ointment should be terminated when sufficient debndement of necrotiC tissue has taken place. Overdose: Action of the enzyme may be stopped. should this be desired. by the appllcalton of Burow S solution U S P (pH 3 6-4 4) to the leSIon How Supplied: Available In 25 gram Jar of sterile Ointment Product monograph available on request. Store at room temperature -Reg T M of Knoll Pharmaceutical Co ø Pentagone LABORA -IR S lTO V....Gr.....1 eu.to.c clears the way for healing dermal ulcers and burns Experts describe the unique ability of Santyl In dermal ulcers: "Among the proteolytic enzymes,only collagenase is able to digest the helical structure of un- denatured collagen fibres. These fibres are involved in the retention of necrotic wound debris." (Varma, Bugatch & German, Surgery. Feb. 1973) In burns: "In a typical patient, after five days of treatment with collagenase ointment, second-degree burns of the lower extremities were completely healed and re- epithelization from the cutaneous layers of deep second- degree burns had started on the hands. After fifteen days of collagenase treatment, third-degree burn areas were completely cleared of eschar." - W. E. Zimmefmann, Mod. Med. (U.S.A.), Apr. 1970 Santyl clears the way for healing: "By clearing the ulcer base of necrotic, pyogenic material, healthy granulations are able to appear and subsequent epithelization ofthe ulcer can occur. I think the significant aspect of topical collagenase is its ability to rapidly debride the ulcer base so that in the meantime other causative factors can be determined, compensated and treated." (M. Murray Nierman. "Cutis", Oct. 1976) e Pentagone Santyl* * :; c: Send for free 12 page brochure Fully illustrated in colour, this brochure describes more fully how clinical trials have impressed physicians: in 140 debilitated male patients ". . . debridement of necrotic tissue and subsequent granulation and epithelization can be attained in decubitus ulcers that were previously considered refractory. . ." (Helga Vetra, Derrick Whittaker. Geriatrics, Aug 1975) Clip coupon or entire ad and attach to your letterhead Discover how Santyl may help improve healing processes in your patients, including gangrene, diabetic ulcers and venous ulcers. r--------------------. Santy) ointment . Please send me free 12 page Santyl brochure fully illustrated in colour. Name (please pnnt) Address Postal Code SIgnature Mail to. Penlagone Laboratories Ltd., 1000. Roche Boulevard, Vaudreuil. Québec, J7V 6B3 L____________________ M........ I PMAC) I PAAB I 12 April 19711 The C.nadlen Nur.. news Orthopedic nurses set three-day attendance record Close to 600 nurses and allied health professionals met in Toronto in early February to attend the second Annual Conference of the Canadian Orthopedic Nurses Association. For three days, the nurses. who came from all across Canada - from British Columbia to Newfoundland- heard an impressive list of speakers discuss the most recent advances in orthopedic surgery, medicine and nursing care. A platform of more than 20 speakers, described by one participant as the "Who's Who" of orthopedic surgery in Canada, discussed a wide variety of topics including: . hand and wrist surgery . management of open fractures . bone tumors . thrombo-embolic complications . routes of infection in the OR . Dwyer and Harrington instrumentation . Wagner resurfacing procedure of the hip joint . new techniques in radiology . the future and bioengineering. Physicians speaking to the group related their areas of expertise to nursing, emphasizmg points of particular importance to nursing Cé\re. The nurses who addressed the audience included: Susan Gilmore, staff nurse in the pediatric unit, Princess Margaret Hospital, Toronto, who talked about the nurse's response to cancer; Ann Campbell, Inservice Education Supervisor at the Ontario Crippled Children's Centre, Toronto, who presented a lively film about the role of the nurse in pediatric rehabilitation: Sandra Matthews, currently on the faculty of George Brown College in Toronto, who updated and reviewed the anatomy and physiology of bone: and Phyllis Jones of the Faculty of NUT sing, University of Toronto who discussed a research project on nursing diagnosis. Also enthusiastically received by the audience was a discussion on the nurse and the law by Alan J. Lenczner, a practicing lawyer with the College of Nurses of Ontario. The meeting provided many opportunities for the audience to ask questions following each address: Time was also allowed for nurses to study the over 20 exhibitors' booths displaying the latest in orthopedic equipment and other related products. CONA Injust five years, the Canadian Orthopedic Nurses Association has grown from a small interest group into a national association with 478 members and five charter chapters located in Montreal, Ottawa, Toronto, Peterborough and Hamilton. And it's still growing. The emphasis of the Association is on establishing a vehicle for continuing education in order to promote the highest standards of practice in orthopedic nursing. The annual meeting is one avenue for keeping nurses informed about the most recent developments in orthopedic nursing. Norma Haire, CONA president and head nurse in the OR at the Orthopedic and Arthritic Hospital in Toronto, states, "the Association is doing things that will be of value to nurses working in the field." Members of the board of directors of the Canadian Orthopedic Nurses Association are: (back, left to right), Heather Reuber, chairperson of continuing education, St. Michael's Hospital, Toronto; Valerie Dubrovskis, S unnybrook Medical Centre; Joan (}Sborne,secretary, Orthopedic and Arthritic Hospital. Toronto; Laurel Wallace, vice-president, Toronto General Hospital; Barbara Burnett, chairperson Within the past year, CONA has established a continuing education committee dedicated to providing nurses with a library of clinical resource material to help solve orthopedic problems they may be experiencing in their center. A library of teaching aids such as films, slides etc. will soon be available to nurses and hospitals as learning tools. To keep members informed of advances in the field and to give members a voice, the association has a new officialjournal- the CONAjournal- to be published four times a year. In addition, continuing education meetings are held by chapters approximately 10 times a year. f _ . " ê .. ë o i: E o .c I- ... - c c .i) o .. '" e '" J: o " 15 8 o õ .c 0.. of bylaws committee, Orthopedic and Arthritic Hospital. Toronto; Marion Marshall, chairperson in charge of membership; (front, left to right) Rosanna Norden, treasurer, Toronto General Hospital; Norma Haire, president, Orthopedic and Arthritic Hospital. Toronto; Kathryn Hancock, Toronto General Hospital. Toronto; Cberyl McCulloch, editor of CONAjournal, St. Michael's Hospital, Toronto. Two members of the association were honored at the conference as Orthopedic Nurses of the Year. The awards, sponsored by Dillon manufacturing, went to Joan Jones, St. Joseph's Hospital in Peterborough and to Janice McAdam, Royal Victoria Hospital in Montreal, both of whom were instrumental in the development of chapters in their area. Membership in CONA is open to all nursing personnel and other health professionals interested in the field of orthopedics. Anyone interested in becoming a member or in organizing a local chapter can contact: The Canadian Orthopedic Nurses Association, 43 Wellesley St. East, Toronto. Ontario. .--.- - : · · CELET BY ANY OTHER E.. . I NOT AN II -A-: i I BRACELET . . . .- )0- lilt . , . ,/ t /1 J _trer thplus comfort r I ---., - smooth vInyl polyester.folm I · -BAf\D - I " f H 'LLISTEF 14 AprI11979 The C....dl.n Nur.. news Occupational health centre told the Commission of Dr. Mussallem said that holds inaugural meeting Inquiry on Educational Leave the very nature of the and Productivity in a brief profession and the continuing presented in early February. need for nurses to keep "Industrial accidents in the collaboration of industry, Executive director, abreast of new and changing Canada total almost 4,000 a business,labor and the Helen K. Mussallem, said that knowledge demands that the day and range from abrasions provincial and territorial the association places great Canadian Nurses Association to amputations," says J .H. governments. " emphasis on the promotion of strongly support the need for Currie, chairman of the The Centre has the education programs required systems of paid leave for Council of Governors, objective of promoting the to achieve high standards of educational purposes. Canadian Centre for physical and mental practice and the promotion of CNF receives Occupational Health and weIl-being of Canadians at high quality nursing care for Safety. He adds that 40 to 45 work by providing a national the people of Canada. Kellogg grant per cent of work-connected focus for information and data "There are problems accidents are serious enough coIlection on all matters within the present practices of The Canadian Nurses to require time off and affecting health and safety paid or unpaid educational Foundation is among eight anything that gives rise to a in the workplace. leave: changes and Canadian associations in the claim for compensation Boudreau said that the improvements are needed in areas of health and education suggests that there is Centre will have the the continuing education awarded grants by the W.K. something wrong in the responsibility of exposing an programs already in existence KeIlogg Foundation of Battle workplace. unhealthy or unsafe work and there is need for more and Creek, Michigan, for lectures The inaugural meeting of environment and it will varied systems," she or other presentations dealing the Governors of the Centre, encourage federal, provincial commented. with critical problems in an autonomous corporation and territorial jurisdictions to Dr: Mussallem said that it modem society. reporting to Parliament use appropriate suasions and has become increasingly Titled the W.K. KeIlogg through Labour Minister sanctions for the difficult for nurses, Foundation 50th Anniversary Martin O'ConneIl, was held in establishment of high particularly general duty Lectureships, the Ottawa in February. A grant standards of occupational nurses, to receive paid or presentations will be made at of $385,000 was voted by safety and hygiene. unpaid leave of absence. The the associations' annual Parliament to launch the A representative on the majority of nurses work at the conferences or other Centre; the location and Employers' Associations bedside and are on rotating important sessions during president will be announced section of the Council of shifts. 1979 and 1980. later this Spring (Ottawa, Governors is Margaret R. The CN A believes that all AIl of the lectures will Winnipeg or Toronto have Charters, Assistant nurses should have the consider contemporary ways been proposed). Administrator, Nursing and opportunity of participating in of applying existing The chairman said that Patient Care Services, programs of continuing knowledge to current or more man days are lost to Hamilton Genenil Hospital, education and it recognizes emerging problems - a theme Canadian industry because of Hamilton, Ontario. Huguette the need for developing reflected in the KeIlogg accidents than through strikes LabeIle, Assistant Deputy systems of leave for Foundation's half century of and lockouts. He estimated Minister, Corporate Policy, educational purposes which support for pilot projects that the cost to industry is $1 Department of Indian Affairs will meet the requirements of which focus on the application biIlion a year. and Northern Development nurses. of knowledge to the problems Emile Boudreau, member and a former president of the Eight specific of people. of the Council and Canadian urses Association, recommendations with Other Canadian representing workers' is among federal respect to public policy or associations which will organizations, said that representatives on the policies that might be adopted receive lectureship grants Canada is the 29th or 30th Council. by labor and management as (valued at $2,500 each) country to establish aCentre. may seem appropriate, were include the Association of He sees this as an advantage Nurses want more presented to the Commission. Canadian Community in that Canada can benefit education programs Recommendations made Colleges, Association of from the experience of other by the association include Canadian Medical Schools, countries. "We have a long and paid leave to attend asking employers to budget to Association of U ni versities way to go to catch up. An Act provide for paid educational and CoIleges of Canada, of Parliament isn't enough: a The prime purpose of leave; educational programs Canadian Hospital Centre like this is not created educational leave for that consider the needs of Association, Canadian by law, rather the people of continuing education is to nurses and reintroduction by Medical Association, Canada must want it and its assist the nurse in improving Labour Canada of financial Canadian Public Health findings must be made care and service to clients, assistance programs to post Association, and the available to the community. representatives of the secondary colleges and International Council on The Centre is the product of Canadian Nurses Association institutions. Adult Education. The C.ned... Nur.. AprIIII71 15 news RNABC sets up nursing education and research society The Registered Nurses Association of British Columbia is establishing a non-profit society whose prime objective wiJl be to promote nursing education and research in that province. To be known as the Registered Nurses Foundation of BC, the new society should be operational bý mid-1979, according to RNABC executive director, Marilyn Cannack who notes that the major reason for starting the RNF is to create a channel for more private funding of nursing education and research. RNF will administer the association's education loan program as well as operation of a new RNABC funding program for development of clinically oriented post-basic continuing education. New funding for these ventures amounts to $200.000 for 1979 and the foundation will also receive all repayments of education loans made previously by the association. Health happenings Distemper virus is considered to be a "prime candidate" for causing multiple sclerosis according to a New Jersey neurosurgeon. Dr. StuartD. Cook told the audience attending the recent February meeting of the Royal College of Physicians and Surgeons of Canada that studies done in the Orkney and Shetland I slands off northern Scotland suggest that close human contact with dogs increases the rate ofM S in a population. Distemper virus (CDV) is closely linked to measles virus; researchers have long theorized that measles virus may cause MS by lying low for a number of years before damaging the central nervous system. Dr. Cook suggests that CDV or some similar virus may also commonly infect man with MS as a rare complication. Nutrition coumeling by a qualified registered professional dietition is now included in the extended health benefits available through Ontario Blue Cross. Eligible subscribers will now be able upon referral of a medical doctor to obtain individual counsel that will pennit them to adjust their daily food intake to meet their personal health requirements. The move. according to the president of the Ontario Dietetic Association, is a milestone in preventive health care. "We belIeve provision of nutrition counseling services will be an important factor in lowering escalating costs of provincial health care services.. .too many acute care hospital beds are occupied by patients with nutritonally related diseases." The National Indian Brotherhood is among 50 groups to receive funds from the Canadian Commission for the International Year of the Child in the first stage of its S 1 million grant program. The Brotherhood will undertake a $4000 fact-finding study to establish areas of need in Indian infant and child care. Funds for the program are being made available through Health and Welfare Canada. Of the 400 patients who get meningitis in Canada each year. 25 per cent of them die of the disease. The reason for the high mortality rate lies in the speed of bacterial attack (death can occur in 48 hours). But soon, meningitis may be a scourge of the past thanks to Dr. Harry Jennings and Dr. Paul Kenny of Health and Welfare Canada. They have fonnulated a broad-spectrum vaccine which protects laboratory animals from all strains of Neisseria meningitidis. Testing on humans has already begun. Did you know... The St. John Ambulance has been able to assist 39 volunteers so far this year through nursing bursaries totalling $19,600. The majority of these bursary recipients are St. John Ambulance Cadets and Crusaders who have been motivated to enter nursing through their volunteer work with St. John Ambulance. Did you know... The Labour Relations Council of the RNABC has authorized the employment of a consultant on a fee-for-service basis to help with the preparation of staff rotations. Under the provincial hospital agreement, the Labour Relations Division is to assist in developing rotations when employers and nurses disagree on staff scheduling. In a related development. the RNABC Executive Committee has approved a step-by-step set of guidelines to preparing 8-hour rotations. These will be published in conjunction with guidelines for 12-hour rotations. which are being written. Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE. QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth, and more information, please clip this coupon and mail today. Name ...................................................... (bIadt .....) Addresa ................................................... City ................................... .Polltal Code ....... Your gl'1lduatlon school .. . . . . . . . . . . . . . . . . . . . . . . . . . . . _ _ . . _ . 16 Aprtl111711 The Cenedlen Nur.. calendar May Operating Room Nurses of Greater Toronto Eleventh Conference. To be held on April30-May 2. 1979 at the Skyline Hotel in Toronto. O.R. and R.R. nurses welcome. Contact: Doris Calvery, Convener, Publicity Commillee, 644 Sheppard A 'e. East, Apt. 325, Willowdale, Ontario, M2K 1C1. Alberta Association of Registered Nurses AnnuaJ Meeting. To be held on May 8-11'- 1979 at the CaJgary Inn, Calgary. Alberta. Contact: AARN, 10256 -112 St., Edmonton, Alberta, T5K 1 M6. Registered Nurses Association of Ontario AnnuaJ Meeting to be held at the Royal York Hotel in Toronto on May 3-5. 1979. Contact:RNAO, 33 Price St., Toronto, Ontario, Registered Nurses Association of British Columbia AnnuaJ Meeting to be held on May 9-11. 1979 in Harrison Hot Springs. B.C. Contact: RNABC, 2130 West 12thA 'e., VancOlH'er, B.C., V6K 2N3. Saskatchewan Association of Registered Nurses AnnuaJ Meeting to be held on May 9-11. 1979 atthe Hotel Saskatchewan in Regina. Theme: Children - our resource and our challenge. Contact:SRNA,2066 Retallack St., Regina, Sask. SECOND NATIONAL CONFERENCE ON HEALTH AND THE LAW organized by the CANADIAN HOSPITAL ASSOCIA nON IN CO-SPONSORSIßP WITH THE: CANADIAN BAR ASSOCIATION CANADIAN LAW REFORM COMMISSION CANADIAN MEDICAL ASSOCIATION CANADIAN NURSES ASSOCIATION CANADIAN PU BLiC HEALTH ASSOCIATION To provide most up to date information. background material and guidelines to governments. the health care industry and professions with a view to legislative and administrative decision making. Consent to treatment (concerning 3rd pørties) Medicine vs the state Communicable diseases. immunization Human organs and blood donations Death and dyinR OTT A W A, MAY 2-4, 1979 For further information write to: SECOND NATIONAL CONFERENCE ON HEALTH AND THE LAW Canadian Hospital Association, 410 Laurier Avenue West, Ottawa, Ontario K I R 7f6 Telephone: (613) 238-8005 InternationaJ Association for Enterstomal Therapy - 11th AnnuaJ Conference to be held on May 8-10. 1979 at the Hotel Vancouver. B.C. This education program focuses on inflammatory bowel disease. Contact: Marie Burroughs. R.N., E.T., 3650Edgemont Blvd., North Vancom'er, B.C., V7R 2P7. MaternaJ and perinatal care 1979. To be held at Mount Sinai Hospital. Toronto on May 18-19. 1979. Fee: $80. Contact: S. Roblin, M.D., Co-director, Obstetrical Anaesthesia, Mount Sinai Hospital, 600 U nh'ersity A 'e., Toronto. Manitoba Association of Registered Nurses 64th Annual Meeting to be held May 24-26. 1979 at the University of Brandon. Brandon, Man. Theme: Consumer's rights- nurses' responsibilities. Contact: MARN, 647 BroadwavAve., Winnipeg, Manitoba,R3C OX2. The 1979 NationaJ ProvinciaJ Education Conference of the Canadian Institute of Public Health Inspectors to be held on May 27 to June I. 1979 at the Banff Centre, Banff. Alberta. A short course on epidemiology will be given. Public health and occupational health nurses invited. Contact: Kenn Blom, Conference Chairman, Box 1000, Coaldale, Alberta. June Canadian Association of Neurological NeurosurgicaJ Nurses AnnuaJ Meeting to be held on June 13-15. 1979atthe Chateau Halifax. Halifax, N.S. Contact: Juliana Pleines, 1005 - 3601 Sainte Famille, Montreal, P.Q., H2X 2L6. Canadian Public HeaJth Association's 1979 AnnuaJ Meeting to be held in Winnipeg. Manitoba on June 18-22, 1979. Theme: Public Health in Canada 1909-1979. Those interested in presenting papers at the meeting are asked to submit an abstract before January 31. 1979. Contact: Canadian Public Health Association, 1335 Carling A 'e., Suite 210, Ollawa, Ontario, K IZ 8N8. 1979 InternationaJ Childbirth Education Association Canadian Conference. "Rights of parents and children exploring alternatives". To be held on June 28-30, 1979 at the Harbor Castle Hilton in Toronto. Contact: Childbirth Education Association, 33 Price St., Toronto, Ontario, M4W 1Z2. , Association for the Care of Children in Hospital 14th AnnuaJ Conference. "Caring for children in the health world". To be held in Los Angeles, C al. in June 4-7. 1979. Contact: 1979 ACCH Conference Office, Wright Institute Los Angeles, 1100 South Robertson Bh'd., Los Angeles, Cal., 90035. 70th Annual Meeting of the Registered Nurses Association of Nova Scotia to be held June 6-8, 1979 in Bridgewater, N .S. Theme: The nursing profession -Its influence on health in Nova Scotia. Contact:RNANS, 6035 Coburg Rd., Halifax, N.S.. B3H IY8. The Canadian Dietetic Association "Conference 79" to be held at the Metro Centre, HaJifax, Nova Scotia on June 24-28,1979. Contact: Elizabeth Lambie, Associate Professor, Faculty of Health Professions, Dalhousie University, Halifax, N.S. (continued on pøge 481 SPECIAL GROUP DISCOUNT OFFER FOR THE CANADIAN NURSE READERS r ___ i i i I 11111 I \ TïTITITI TIlll ïlllTI ; i i i if i \ Ii 11111111111111111 lit g :I III " /1" /I' . · 5: e. . ;r . · ,. , . a. . .. · :;: lit - - " - . ø I .",. 10 .' .... . . You and your family are invited to sample the most readable, most understandable encyclopaedia ever created. THE new ENCYCLOPAEDIA BRITANNICA You've heard about - - read about - - perhaps even seen the revolutionary new Britannica 3, more than a new encyclopaedia, a complete home learning center you and your family can use. NOW AVAILABLE TO YOU AT A SPECIAL GROUP DISCOUNT. We invite you to fill in and mail the postage-paid reply card opposite and you'll receive a FREE full-colour Preview Booklet that completely describes Britannica 3 and the advantages it offers the entire family. You will also receive complete details on the Special Group Discount, available on convenient terms. BRITA ICA 31 NO\\ EASIER TO USE.. .EASIER TO READ.. .EASIER TO UNDERSTA D. The complete 30 volume work has been completely rewritten so even a child can read and learn from it. To make it easier to use, Britannica 3 is divided into 3 parts: ........ .. .,.... .........rI:"'n rJ;' .t. n . nJ;" K'\õO\\LEDGElN DEPTH Business Reply Mail No Postage Stamp Necessary if mailed in Canada Postage will be paid by SPECIAL GROUP OFFER POST OFFICE BOX 501 STATION Fr TORONTO, ONTARIO M4 y 9Z9 \... )ÞI Ot:TLlNE OF KNOWLEDGE A one volume outline of all man's knowledge and your guide to the use of the all-new Britannica 3. I it easier to "look things up" to learn a Instant Research Service - specialized tain this magnificent reference set al a POSTAGE PAID REPLY CARD FOR . Suite 1100, Toronto, Ontario M4W 3J I . " 8 o õ .c 0.. I I . l'ara' dial!no i /\ diagno...i'i of diahete... in...ipldu'i ma} he made in \ie\, ofth patient''i ...ymptom... :,nd a large urine volume \\;ith a "'peÓfic gravity helo\\; 1.0 I 0 and osmolarity less than that of plasma. But 'iuch a diagnosis demands indefinite replacement therapy and 'ihould not he made without c- Va...opre"in i... given. after \\ hich the patient \\;ith diahete... in...ipidu... \\ ill . .. I 511 I re...pond \\ ith ,llllar\..cd antidiurcric clTect. rhen. \\ hen the \ a...opre......in ha... returned the \,ater le\eI to normal. the patient i... given an infu...ion ofh\ pertonic ...:lIine ...olution. The patient \\ ith diahete'i in...ipidl.... \\ ill sho\\ no change in output. \\ herea... the patient with p...ychogenic pol}dip...ia (or the normal individual) \\ ill ...hlm a pronounced antidiuretic effect. I-'\ce......ive drin\..ing i... prohihited during this te...t. hecau'ie it \\;ould cau...e dilution of ...:lIine in the ...y...tem. rhe...e three procedure... help the physici,tn differentiate het\\;een diahetes in'iipidu'i and other conditions and al'io help to pinpoint the cause of diahete... in'iipidu'i - whether it originates from a di'iturhance in the hypothalamu'i. in the o'imoregulators. or in the renallllhuies themselves. It wa'i a major event for Tara to he hrought many miles away from a protected home to a 'itrange large hO'ipital. The tests she had to undergo may have heen for her henefit. hut they were. nevertheless. a traumatic expenence. During the water deprivation tests. all fluids were withheld and all taps carefully guarded. Tara saw these measures as a war waged upon her little soul. Her nur'ie tried to divert her attention and to provide some relief by moistening her mouth. She also watched carefully for vasomotor collapse and recognized that Tara hecame clinically dehydrated in no time. Her temperature went up to 38 0 C , she was nauseated and flushed. had severe headaches. and after the test. the scales revealed that she had lost about five per cent of her hody weight. What the test also revealed, however. was that Tara was able to concentrate urine to 1.027. which is quite high for a patient with diabetes insipidus. This indicated that Tara was able to produce enough ADH to see her through a short term situation if necessary. but that it would put a considerable strain on her system. After the test came the moment of release; Tara was allowed all the water she could drink. And drink she did. while her nurses smiled and 'ihared in her relief. But when fluids had to be withheld again. Tara became extremely upset and hostile, crying "you're doing that on purpoo;e" - to tease her. she thought. Many patient (child-size) explanations were necessary. I Life was happy for Tara. As the sixth child in a close-knit family of nine, she had all the love and companionship a little girl could want. But when she woke up one May morning, there was a lot to dampen her spirits. For one thing, it was raining outside, and to make matters worse, her bed was wet, and it wasn't the roof that was leaking either. The incident was shrugged off. After all, the salt cod the family had enjoyed for dinner the night before had made everyone thirsty, and a five-year-old's accident was nothing to get upset about. But although no one knew it at the time, life had taken a different twist for little Tara - she was beginning to show the symptoms of diabetes insipidus. 20 April 1979 The Cenedlen Nurse Tara responded to the tests in the classic manner of the patient with diabetes insipidus. but showed some evidence of ADH activity. small though it was. An intravenous pyelogram showed a pos"ihle ahnormality of her urinary tract. But although her skull X-ray was negative. Tara's diabetes insipidus was eventually established as central. Her EEG results were abnormal. consistent with a midline functional disturbance. Two years before the onset of her symptoms, Tara had fallen from her bicycle, landing hard enough to fracture her clavicle and knock out two teeth. The doctors weighed the possibility that this accident was the cause of the disturbance, that it could have caused a basal skull fracture. They felt, however, that the symptoms would have begun sooner if this accident had been the cause. A pneumo- encephalogram may have provided further clues, but the doctors were reluctant to put Tara through an ordeal they felt wasn't necessary at the time. It was decided to treat Tara with Pitressin tannate in oil injections, then re-evaluate her at a later date. Treatment Treatment of diabetes insipidus involves either the correction of the underlying cause or maintenance of the patient's flUid halance through medication. Pitressin tannate in oil is the replacement injection of choice þecause it has prolonged hormonal action; it is usually effective for 24 to 72 hours (in contrast with plain Pitressin. which only lasts for three to four hours). Nasal insufflations or sprays are also available and are more easily administered. hut have a tendency to produce chronic rhinopharyngitis or even stomach upsets due to swallowed powder. Pitressin tannate must he administered properly to be efTective. Examination of a vial of Pitressin tannate shows the active particles settled to the bottom; for this reason. it is most important to shake the vial thoroughly. Warming the vial before use can he helpful. Because Pitressin is in an oily hase. the patient "hould lie quietly for a few minutes after admini"tration and be watched for any oozing. The drug can also cause occasional vasopressin resi"tance. usually due to development of an allergy to the hormone or to the oily medium. but also caused hy low serum potassium and high calcium level" which inhibit the action of ADH. Chlorthiazide has also heen u..ed to increase water absorption but is usually not totally effective for central diabete" insipidus - the patient often requires some replacement therapy, as well as potassium supplements to compensate for the potassium loss caused by the medication. Hypoglycemics are sometimes used for patients whose tests reveal that they are capable of releasing ..mall amounts of ADH. These drugs increase the effectiveness of the residual hormone. They also have side effects. such as gastrointestinal disturbances. weakness, headache. tinnitus and alcohol intolerance. Tara became known as "the pincushion" in the doctor's office. Twice weekly, she sat waiting impatiently for her injection. Now a year older, she was quite accustomed to the previously dreaded needle. She turned very pale after her injection because of the vasoconstricting action of P'tressin. But if anyone other than family members asked what was wrong, she made a point of evading the issue. It was nobody's business that she required a needle so that she wouldn't have to void so much! A t home. it was a different story. The effectiveness of Pit res sin is diminished under any kind of stress. especially after emotional outbursts. If Tara had a squab hie with one of her sisters. all she had to do was make a fuss. The argument had to be settled then and there. and Tara got her way. because if she cried too hard. her needle "wouldn't work" . And it didn't always work anyway. Any carelessness in administration of the injection - for example. if the vial wasn't shaken properly - caused Tara "hamefully wet nights and time lost from "chool. There weren't many who took kindly to Tara's advice to "shake it better" . Tara al"o had to learn to cope with her symptoms when they returned a day or two before her next injection was due. At first, it was hard for her. She had special permission at school to go to the bathroom without asking. and that caused difficult questions. It didn't help much when a group of boys in her class decided to hold her back one day when the teacher wasn't around - Tara cried to see a puddle growing at her feet. Unlike other cla'osmates. "he couldn't "pend the night with one of her friends. Her sense of ..hame was accentuated hy the fact that her parent" insi..ted that no one know of her condition; thi.. made it even harder for Tara herself to accept. G rowing up But as she grew older. her sense of humor took over and she viewed most inconveniences from the light side. an attitude that helped when she took her fir"t trip to Furope. Tara and her sister 'otayed at the home of relatives who were not only light sleepers but who also had their bedroom adjacent to the bathroom. No problem - Tara found a big old garbage can that she faithfully spirited to her room each evening. Her "ister got used to waking up in the middle of the night to a loud drumming on the bottom of the pail. In the morning Tara would empty her pail before anyone was up. She didn't want to chance meeting anyone as she crept stealthily through the house with a large bucket of gently sloshing urine. Tara's most uncomfortable session, however, came when she was admitted to hospital for knee surgery. Because of the stress of the operation, her Pitressin injection had no effect and she wasn't able to fend for herself. The nurses looking after her had to be patient and understanding of what it means to have diabetes insipidus. Later on, Tara began to develop a resistance to the injection. It proved to be a blessing in disguise; her doctor finally decided to switch her from the injection to an oral hypoglycemic agent. This change had such good results for Tara that today she is virtually symptomless and leads a completely normal life. So when she returned to Furope to work there for a year, she didn't need her garbage pail. Tara displayed none of the side effects that accompany hypoglycemic drugs except for one - intolerance to alcohol. At first she was unaware of it. but she caught on quickly; even a small glass of wine caused her face to turn bright red. In fact. after tasting a few drops that spilled on her fingers at the restaurant where she worked. the boss asked her how many drinks she had had herself. She cautiously peered into a mirror and there she was, glowing like a neon sign to the tips of her ears. All foreign languages left her at the sight. But that is a small price to pay for regained normalcy. And twenty-five-year-old Tara is once again leading a happy and normal life . .., Bibliography I Berger"en. Betty S. PlllIrmacoloRY innursinR. by... and AndresGoth. nth ed. St. Louis. Moshy. 1976. 2 Chaffee. Fllen E. Basic physioloRV and anatom.\'. hy ... and Esther 1\1. Grei..heimer. )d ed. Toronto. Lippincott. 1974. ) Harrison. Tinsley Randolph ed. Principle.l. (!f intertlal medicine. edited by ... et al. 7th ed. New York. ML-Graw-Hill. 1974. 4 Shafer. Kathleen Newton. M edical-surRicalnursinR. by ... et al. 6th ed. St. Louis. Moshy. 1975. .Pitressin is a registered trade mark of Parke. Davis and Co. Jannette Moens author ofC opinR with diabetes insipidus. Rraduated from Galt School ofNursinR in LethbridRe. Alberta. She spent her working days in a small hospital and later a clinic which pro 'ided her with a \'ariety of nursinR experiences. Hypertension: management in industry - an expanded role for nurses Barbara Milne Alexander LORan Hypertension . screening programs have enjoyed considerable popularity in recent years but detection alone is simply not enough to ensure good blood pressure control. Individuals with high blood pressure must be thoroughly evaluated, treated and followed up to ensure compliance and control. Authors Barbara Milne and Dr. Alexander Logan found that nurses working in business and industry have a big part to play in helping patients manage blood pressure problems. Uncontrolled hypertension is recognized as one of the major causes of death and disability in North Amenca. Surveys have revealed that approximately five to 'iix per cent of the population has hypertension, defined as a diastolic blood preS'iure of9O mm Hg or greater after two successive screenings. I The present system of health care may be effective in dealing with most acute medical problems, but it has not been successful in getting more than 30 per cent of the total hypertensive population under good blood pressure control. e In spite of the availability of effective antihypertensive therapy. poor blood preS'iure control continues to be a significant community health problem. Blood pressure screening programs have enjoyed con'iiderable popularity in recent years, but detection alone is not enough to ensure good blood pressure control. It must be followed up by evaluation, treatment and patient compliance. The gap between detection and good blood pressure control is a large one and the reasons for such a gap are understandable. A patient may be detected by a screening program, but fail to seek further medical evaluation. When medication is prescribed, patients are often reluctant to take it because of the asymptomatic nature of hypertension in its early stages. Furthermore. therapy is sometimes accompanied by unpleasant side effects; the patient may actually feel worse after initiating treatment. Add to these deterrents the inconvenience of physician appointments. the cost of medication and the need for life-long treatment and follow-up and the motivation to continue therapy rapidly dissipates. What type of program. then. would ensure an emphasis on blood pressure control within the community? Nurses have long proven effective in major clinical responsibilities, both in specialty areas in hospitals and in the community. Therefore. an expanded role for nun,es to provide long-term care to hypertensive patients under physician supervision in an ambulatory setting would appear to be a reasonable alternative. To demonstrate this idea. we decided to study the role of the nurse in the detection, evaluation and long-term management of hypertension in the business community. The program The objectives of the trial were to detect untreated hypertension in the business community, to link it to an evaluation and treatment program and to compare health care delivery from two sources: . a specially trained nurse at the work site; and . employees' family physicians within the community. The comparison was to be made in terms of clinical effectiveness and medication compliance. Two nurses were chosen to provide patient care at the worksite. One had extensive experience in cardiovascular 22 April 1979 Th. C.nedlen Nur.. nursing in an acute care setting, the other had practiced puhlic health nur ing in the community. Both nurse were accustomed to making independent nur'iing decision.. and had received pecial training in physical a'i..e..sment and hi'itory taking. During the period from Octoher 1975 to July 1976. approximately 22.000 employees from 41 different business 'iettings in Metro Toronto were screened hy trained blood pressure technicians. A variety of businesses were represented, including hoth white and blue collar workers (e.g.. those from hanh, government offices and factories). Those individuab who showed an elevated hlood pressure after two screenings and who met our admission criteria were invited to participate in the program with the approval of their family doctor. Blood pre'isure entrance criteria were: . a diastolic hlood pre....ure of 95 mm Hg: or . a diastolic blood pressure of91 - 94 mm Hg plus a systolic blood pressure of 141 mm Hg. A total of 457 individuals elected to participate in the program and their tlow through the various stages of the project is shown in Figure one. In order to exclude individuals with potentially curahle forms of hypertension, all members of the study population received an investigative work-up for hypertension where they worked. The work-up was done by the two nurses and included measurement of hemoglohin. WBC. serum pota'i..ium. serum creatinine and urinalysis. In addition. blood 'iugars, 'ierum cholesterol and 'ierum uric acid were measured to assess concomitant risk factors, and an FCG wa'i done to detect target organ damage. The results of the initial a'i'ie'isment were sent to each patient's family physician. At this point the study population was randomly allocated into either the community (physician-treated) or the worksite (nurse-treated) group. All participants in the community group were asked to see their family physician at least once. Follow-up appointments for the worksite group were arranged by the nurses who were suhsequently responsible for their care. The nurses, hased at Mount Sinai Hospital. visited each work'iite once or twice a month for one year. Their respon'iihilities included: . complete history using a pretested highly structured questionnaire and physical examination of all work'iite group participants. This was reviewed by the supervising physician. . initiation and adjustment of medication according to a Stepped Care Protocol developed for the study (Figure two). . weekly conferences to review patients' charts held at the hospital with the supervising physician. . measurement of blood pressure, pulse and weight at each patient encounter. . management of the side effects of medication. . ..upervision of drug-induced FLOW DIAGRAM FOR SELECTION OF STUDY POPULATION Figure one Business Community Metropolitan Toronto Primary Screening Suspected Hypertensives Secondary Screening Hypertensive Evaluation Not Hypertensive Ineligible Hypertensives biochemical changes (e.g. hypokalemia, hyperuricemia). . patient education about hypertension and the treatment regimen. . counseling in lifestyle modification for concomitant risk factors (i.e. "moking. obesity. dietary habits). . supportive counseling for tho'ie patients who responded to their diagnosis with hostility, denial. anxiety. or depression. After six months in the program. participants in both groups were interviewed hy a trained observer at the worksite who took a blood pressure measurement. determined whether the patients were on medication. and assessed medication compliance hy direct questioning. Those individuals who stated that they were taking their medications received a home visit to confirm their compliance by pill counting. Those taking less than RO per cent of their medications were considered to be non-compliant. In spite of our fears that patients would view this procedure as an invasion of privacy, most accepted the home visit and realized that a compliance check was a necessary part of research. Meeting the goal For our study, goal pressure was defined as a reduction in diastolic hlood pressure to less than 90 mm Hg in those with an initial diastolic pressure greater than 95 mm Hg or a reduction in diastolic blood pressure of at least six mm Hg in those with an initial diastolic pressure of95 mm Hg or less. What did our results show? At six months, significantly more patients were at goal blood pressure in the nurse-treated group. Similarly, the overall mean reduction in diastolic blood Figure two STEPPED CARE PROTOCOL step one THIAZIDE DIURETIC step two (if needed) PROPRANOLOL/METHYLDOPA step three (if needed) HYDRALAZINE pressure was significantly greater in the ,-"orksite group. Although mo"t patients in both groups were considered to have a blood pre sure problem, patienh in the nurse-treated group were more likely to be placed on drug therapy than patients in the physician-treated group. Physicians were much more likely to u!>e non-drug therapy !>uch as weight reduction. salt re!>triction. cessation of cigarette smoking. exercise, and/or reduction in life !>tIe "es a!> the sole mode of treatment. In addition, compliance ,-"ith antihyperten"ive therapy was significdntly better in the nur!>e-tredted group. Thus the difference in clinical effectl\-eness in the two groups ma} have been due to better compliance with medication. Another possible explanation for the difference was that more nurse-treated patients were on medication. However. when only those on drug therapv in the two group!> '-"ere compared. the nUlse-treated group continued to ha\-e significantly more patients at goal blood pressure. Comparison of the drop-out rates in the two groups will be made at the end of the program. Discussion Crucial elements in effective blood pressure control programs are keeping patients in treatment and ensuring adequate compliance with antihypertensive medications. Under usual treatment conditions over 50 per cent of hypertensive patient!> drop out of therapy entirely within a year of starting it. 'Ofthose who remain under medical care, about 40 per cent fail to take enough medication to achieve therapeutic benefits. .Thus high treatment drop-out and low compliance with medication erode most of the benefits of care. Attemph to overcome the problems are encouraging. Many investigators have reported the use of allied heaJth personnel to help physicians control hypertension and reduce patient drop-out from therapy. For example. Wilber was able to keep significantly more patients in treatment and improve blood pressure control in a ruraJ setting by the use of home follow-up by the Public Health Nurse. s More recently. Alderman reported on his successful experience of using a health team guided by a physician to detect and treat hypertension at the worksite. 60ther programs include using nurses in special hypertension clinics in both urban and rural settings 7.8 and on mobile units." In each instance more patients were kept under care and there was improved blood pressure control. Our study. in addition to providing convenient care at the worksite, is also The Cened... H...... evaluating the use of specific behavioral techniques to improve compliance. Those patients whose blood pressure was not under control and who were found to be non-compliant at the six-month evaluation were started on compliance intervention manouvers which included: · Linking pill-taking to "ignificant events or routines during the day. · Use of a home brood pressure cuff for daily blood pressure monitoring as instructed by the nurse. · Recording of daily blood pres"ure readings and pill inge tion on special charts. · Increase in the frequency of visits to the nurse for blood pres!>ure monitoring. .a, .1 II If 4 - I Conclusions The concept of managing hypertension at the worksite would appear to have a number of advantages: · It automatically links case-finding with follow-up care. · There is a minimum of waiting time and loss of employee time from work. · The time of visits is less severely regulated, allowing more time to communicate with patients about their concerns. · Patients can be kept under close supervision -those who miss appointments are promptly followed up. · The "stepped care" approach provides for logistical increases in medication that a nurse can initiate without m<\Ïor medical decision-making. In conclusion, the preliminary results of our study suggest that specially trained nurses under physician supervision are clinically more effective in terms of achieving good blood pressure control and improving compliance with medication. ... AprIl tl7t 23 "'2 References *1 Hypertension Detection and Follow-up Program Cooperative Group. The hyperten ion detection and follow-up program. Prel'.Med. 5:207-215.1976. *2 National Heart, Lung, and Blood Institute. National high hlood pres.Wlre education program info. memo. Bethesda, Md., May 197R (No. 13). 3 Caldwell, J.R. The dropout problem in antihypertensive treatment A pilot study of social and emotional factors influencing a patient's abihty to follow antihypertensive treatment. by... et aLl. Chronic Dis. 22:579-592, Feb. 1970. 4 McKenney, J.M. The effect of clinical pharmacy services on patient with essential hypertension, by . . et al. Circulation 48: 1104-1111, Nov. 1973. 5 Wilber, J.A. Reducing elevated blood pressure. Experience found in a community, by... andJ.S. Barrow. Minn.Med. 52:1303-1306. Aug. 1969. 6 Alderman, M.H. Detection and treatment of hypertension at the worksite, by... and E.E. Schoenbaum. N.Eng.J.Med. 293:2:65-6H. JuLIO. 1975. *7 Hames. C. Hypertension intervention in a bi-racial rural community, by _ . .et al. Circulation 52: Suppl. 2: 193. 1975. 8 Stamler, R. Adherence and blood-pressure response to hypertension treatment. by . . .et al. Circulation 52: Suppl. 2:95. 1975. 9 Runyan. John W. The Memphis chronic disease program. Comparisons in outcome and the nurse's extended role.l.A.M.A. 231:3:264,Jan. 20.1975. *Not verified by CNA Library Barbara Milne, R.N. B.Sc.N.. graduated from the University ofT oronto School of Nursing and has spent most ofher career in public health nursing. She is currently employed as a nurse practitioner in the Hypertensi&n Detection and Treatment Programme at Mount Sinai Hospital in Toronto, Ontario. Dr. Alexander Logan, (Unil'ersity of Toronto) is a nephrologist at Mount Sinai Hospital as well as medical director of (he Hypertensiun Detection and Treatment Programme. Acknowledgements: Wendy Campbell. Christine Achber, Prudence Kupka. Hypertension: questions and answers -- Mary McCulley Hypertension and its control pose a worldwide health problem. Until two years ago, when several national and provincial health bodies - public, voluntary and scientific - sponsored the formation and operation of a number of hypertension task forces and study committees, I answers to many basic questions regarding the disease had yet to be answered. Recognizing that any recommendations made in answer to these questions could result in lifelong hypertensive treatment for a million or more Canadians, these bodies felt a grave responsibility not to advocate any intervention, however well-intentioned or plausible, unless it had been proven effective in rigorous trials. It is not surprising that these bodies, which shared overlapping terms of reference, some common membership and common data sources, asked many of the same questions and, in the end, produced identical sets of recommendations. What follows are some of the questions that these committees asked about hypertension; the answers are based on recommendations cited in the Hypertension Task Force Report of the Ontario Council of Health. 2 I. Does the treatment of hypertension do more good than harm? In the case of malignant hypenension (diastolic pre sure in excess of 130 mm Hg and papilledema). treatment does indeed do more good than harm. Left untreated, all malignant hypertensives die usually within a year of detection. Iftreated, a majority are alive one year later. With less severe hypenension, I andomized trials show that hypenensive patients randomly a,>signed to receive active drugs suffered two/thirds fewer "hypenensive" complications (first stroke, hean failure, retinal or renal deterioration) than did control hypenensive patients who received inen placebos. Re ults were less clear for the" atherosclerotic complications" such as MI. In general. the Hypenension Task f'orce of the Ontario Council of Health concluded that: . Antihypenensive drug therapy should be initiated among all adults whose fifth phase diastolic blood pressures are consistently at or above 105 mm Hg. This finding must be evident on two or more separate examinations by a clinician two weeks or more apan. . Therapy should be initiated in adults (over 18) with lower diastolic BP (90-104 mm Hg) when evidence oftarget organ damage is present. Target organ damage includes one or more of the following: hypenensive retinal damage. renal damage, dyspnea of cardiac origin on ordinary activity, angina pectoris. prior myocardial infarction, left ventricular hypertrophy on ECG, cardiac enlargement on chest X-ray. prior stroke or transient ischemic attack. 2. How much uncontrolled hypertension exisls? Data provided by the Nutrition Canada Survey. an epidemiologic survey of Newfoundland communities and community screening programs conducted in Edmonton. Albena and Hamilton, Ontario show that a substantial ponion of hypenension (averages for all ages in these surveys range from 7-14 per cent) goes undetected. untreated or uncontrolled. Although one-third to one-half of those individuals found to be hypenensive on a first examination will reven to normal pressures on a repeat examination. these and other data led the ta k forces to conclude that large numbers of Canadians have hypertension which. unless brought under control. will continue to add to an already enormous burden of unnecessary disability and death. 3.ls C011ll1/unity screening ofl'alue;n the detection of hypertemion? In an effort to apply the law of "mas action" to the hypenension problem. many groups have suggested that hypenension detection be carrièd out at every opportunity: in the shopping plaza, dentist's office. pharmacy, emergency room. and so on. However. in their recommendations. the task force either rejected or substantially restricted these approaches. A review of the shopping center screening programs revealed that, even when extremely well organized and staffed and continued for as long as SIX months, they scanned less than one tenth of the local adult population. and of those screened. the me!> ofh}perten,ion remain ob,cure. there i no doubt about the con!>equences - they are alarming. The ri..." of coronary disea e in Pdtients \\-ith diastolic pressures of 105 mm Hg and higher i!> four times that of the normal population. The shearing !>tresses from increa!>ed intravascular pressure can result in damage to the arterial wall that will, in turn. accelerate the deposition of lipids and calcium salt . The vascular lumen narrows and the intimal lining roughens. cau!>ing thrombu!> formation. If this proce"s occurs in the brain. it leads to cerebrova cular thrombosis or hemorrhage. Ifit takes place in the heart, coronary thrombosis and myocardial infarction will re!>ult. And in the renal vesseb. the atherosclerotic process may predispose the patient to renal ischemid and failure. The consequences of hypertension are reflected in the relationship between diastolic pres!>ures and mortality rate!>. When the diastolic pre!>!>ure ranges from 95 to 104 mm Hg. the mortality rate is 60 per cent higher than that of the normal population. The m<ûor impact occurs, however, when dia tolic pressures exceed 105 mm Hg. At this level. the mortality rate is three times greater than normal. All causes of hypertension, whether essential or resulting from an identifiable lesion. can be classified as either beni!:n or mt/ligna",. The blood pressure of a patient with benign hyperten ion will elevate slowly and progressively over a period of }ears. Complications develop somewhat insidiously. In a small percentage ofthe!>e patients. the hypertension becomes malignant or rapidlv progressing. Characteristic vascular changes in the retina of the eye appear early in this pha!>e of the disease. and kidnev function often become!> rapidlv impaired. Patients with malignant hvpertension have a very limited life expectancy. usually succumbing \\-ithin a few months. but occa.,ionally !>urVI\ ing one or two years. Ho\\ is h) pertension treated'! Since patients with essential hyperten"ion exhibit no identifiable cause for their disease. therapy has been largelv directed to\\-ards reduction of blood pressure by various means. Treatment is usually considered for patient!> oi any age with diastolic pre!>sures consistently greater than 95 mmHg. The physician has several options in planning a treatment program for his patient. He must take into consideration the patient's weight and salt mtake. A \\-eight reducing low sodium diet may be prescribed. Other factors. such a!> cigarette smoking. stres!>es in the patient'!> lifestyle and exerci!>e pattern!>. must also be considered. And if the patient's arterial pressure remains consistently high. the physician will resort to a drug treatment program. There i no doubt that drug treatment lowers blood pres ure and prolong!> life. The problem with this type of therapy lies in the fact that many patients fail to adhere to their treatment program. Why? The disease. for many, is asymptomatic. The patient. who feels well. may have a great deal of difficulty understanding that he has a problem. And the drug!> he i!> told to take have unpleasant and even dangerous side effects. He may actually feel worse on medication. But failure to continue taking this medication will result in a rapid return of arterial blood pressure to his previous hypertensive level. Accurate blood pressure measurement The range of a patient' s blood pre ,ure. as well as the factor!> atfecting that pre...!>ure. underlie the importance of taking successive readings. It is common to obtain an ele\oated reading in ten e and hyperactive patienh. particularly at the early stages of a ph} sical examination. Subsequent readmgs \\-ill often be substantially lower than the initial reading. A more accurate reading would probably be obtained in an environment familiar to the patient, such as hi., own home. For the most accurate re.,ulh. vou should kno\\- when to take your patient's blood pressure, and ho\\- to eliminate technical errors that might give }ou a falsely elevated reading. First of all. your patIent should be in a !>table relaxed position for at least five minute . Ideally, he should not have eaten or exerci...ed within the last half hour. J....eep the patient's arm at heart le\oel ""hen you take his BP. and make ure that the cuff is wide enough - it hould be at least O per cent greater thdn the diameter of the extremit} that you are lI!>ing to measure hi., pressure. If the cuff is too narrow. it will only compress the deep arterie., when the cuff pre !>ure greatly exceeds arterial pressure. If you apply the cuff too loosely. It becomes rounded before exerting pressure on the ti.,sues. resulting in a fabelv high reading. And if you deflate the cuff too .,Iowly. the venou., congestion in the extremity will give you a falsely high readi'lg. And finally, if you are using a mercurv sphygmomanometer, make sure the mercury column i at e}e level. Ifit i higher than eye level. you may again obtain a falsely high reading. Table one COMMON ANTIHYPERTENSIVE DRUGS GENERIC NAME TRADE NAME DOSAGE RANGE COMMON SIDE EFFECTS THIAZIDE DIURETICS CHLOROTHIAZIDE Dluril 0.5 G 10 1 G p.O. dally.n single or divided Side effecls common 10 Ihls group of doses. Dosage Increased or decreased drugs Include. Hydrodlunl according 10 Ihe blood pressure erum eleclrolyle disturbances. HYDROCHLOROTHIAZIDE EsKlnx 50 - 100 mg p o. dally as single or dIvIded dizziness. fatigue. G.!. disturbances Hydrozlde dose. Dosage Increased or decreased hyperuricemia. hyperglycemia. Hydro-Aquil according to blood pressure hypotension. blood dyscraslas Use with Neo-Codema caution with women 01 childbearing age since thiazldes cross the placental BENZTHIAZIDE Benzthiazlde Initially 50 - 100 mgp.o. dally In divided barner Exna doses alter breakfast and IUrlch Adjust maintenance dose 10 minimum effective level BENDROFLUMETHIAZIDE Naturelin 5 - 20mg p 0 daily. POTENT DIURETICS FUROSEMIDE Lasix 20 - 40 mg p.o. for 1000Iation of therapy Orthostatic hypotension when used with F uroside and maintenance. II this dosage range other anllhypertensives. Electrolyte Norosemide does not produce satisfactory results depletion (dIzzIness. fatIgue. lethargy. other antihypertensives musl be added muscle cramp ) dermatitis. dehydration. ETHACRYNIC ACID Edecrln 40 mg p.o b I.d. adjusted to blood Electrolyte depletIOn. vertigo tinnitus and pressure. deafness. gaslrointestlnal ellects(nausea. vomiting. diarrhea) 21 April 1879 The C.nedlen Nur.. Understanding antihypertensive drugs Where do you fit into the picture? As a nurse. you are panly responsible for helping the patient adjust to his treatment program. I n order to teach him how to cope with the medications he must take. you must have a working knowledge of the common antihypenensives. This mean knowing how the drugs work and what side effects to expect from them. Although there are many antihypenensive drugs available. the way in which they act allows them to be divided into three major classes: . diuretics: . drugs that inhibit the activity ofthe sympathetic nervous system: and . drugs that act directly on vascular smooth muscle. Diuretics Unless specifically contraindicated. diuretics are the first line of defence in controlling mild to moderate essential hypenension. The patient treated initially with only a diuretic may have a diastolic pressure of over 110 mm Hg, but will show few or no secondary changes in the brain, retina or kidney. For many patients in this group, an oral diuretic may be the only drug required to control hypenension. The thiazides are the most popular diuretic, a popularity enjoyed because they are safe and effective. What do they do? Thiazides block the reabsorption of electrolytes and water by the renal tubules. resulting in a decreased extracellular fluid volume and consequently a decreased blood pressure. It is felt that an additional hypotensive effect occurs because these drugs dilate vascular smooth muscle. When the patient begins taking a thiazide diuretic, his blood pressure falls initially because of a decrease in blood vol ume. Even when his blood volume returns to its pretreatment levels, however. his blood pressure remains lower. A doctor generally stans the patient on a small dosage ofthe drug. then slowly increases the dosage to a level which controls the patient's blood pressure with a minimum of side effects. Some of the side effects that you may see in patients on thiazides are hypokalemia. dizziness, gastroenteritis and an increase in blood urea nitrogen levels. Hypokalemia impairs efficient functioning of both skeletal and gastrointestinal smooth muscle. You should begin to suspect its presence when the patient complains of weakness, a 'feeling of fullness' . and constipation. Often the patient's doctor will prescribe an oraJ potassium supplement to offset such complications, but if the patient is not receiving supplements, he should be advised to include potassium rich foods in hIs diet - trUits such as oranges, bananas and apricots, and juices like orange or tomatojuice. Under cenain circumstances. the doctor may choose to use a more potent diuretic than those in the thiazide group. Two preparations used are furosemide (Lasix*) and ethacrynic acid CEdecrin*). These drugs inhibit cellular activity both in the ascending loop of Henle and elsewhere in the nephron. The result is that they prevent the kidney from reclaiming large amounts of water and electrolytes and thus cause a powerful diuresis. Because these diuretics seem to increase renal blood flow, they may he used if the patient with hypenension has an associated renal disease. The long term effects of potent diuretics have yet to be fully studied. It is essential that you as a nurse make cenain that the patient knows why he is taking diuretics. and how the drugs act on his disease. You should also determine whether or not the patient has been told when to take his diuretics. Often a patient is told to take his medication once or twice a day. But he should not take diuretics at bedtime: the last dose of the day should be taken in the late afternoon. Dosage ranges and side effects of both the thiazides and potent diuretics are summarized in Table one. If diuretics do not bring the patient's blood pressure within a satisfactory range, the physician may add a drug that inhibits sympathetic nervous system activity. To understand exactly what this group of drugs does, it is necessary for you to familiarize yourself with the structure and function of the sympathetic nervous system. How s)mpathetic inhibitors work Nerve fibers can be divided into two categories, depending upon whether the organs they deal with are under the control of the will or not. That ponion of the nervous system which is autonomous or functionally independent is called the autonomic nervous system. There are two divisions of the autonomic nervous system, sympathetic and parasympathetic. It is the sympathetic nervous system that activates our "fight or flight" response. Under sympathetic stimulation, the hean rate accelerates, the bronchi dilate and pans of the peripheral vascular system v asocons trict. All autonomic motor nerves descend from the central nervous system in two stages. The first set of fibers extends from the central nervous system to a collection of nerve cell bodies called ganglia located outside the spinal cord. The ganglia act as relay stations. From them a second set of fibers are sent out, and these fibers lead to the target organs. In sympathetic fibérs, the chemical norepmephrine conducts impulses from the nerve ending to the target organ. In addition, sympathetic target organs have at least two different receptor sites that can accept norepinephrine: the alpha receptors and the beta receptors. The ways in which body organs or structures respond to sympathetic impulses depend upon the type of receptor heing stimulated. For example, the heart, which has only beta receptors. responds to the release of norepinephrine by increasing in rate and vigor of contraction, whereas cutaneous vessels, which have alpha receptors, respond by vasoconstricting. Antihypenensive drugs that depress the activity of the sympathetic nervous system act in different ways. For instance, some drugs successfuly reduce blood pressure by intenering with the formation of norepinephrine. Others depress sympathetic centers located within the central nervous system. There are even drugs that block both sympathetic and parasympathetic systems at the autonomic ganglia. And there are more specific drugs that will block either the alpha or beta receptor sites, preventing norepinephrine from making contact with these receptors. Propranolol One drug with antihypertensive propenies that is frequently prescribed is propranolol (Inderal*). Propranolol is a sympathetic beta blocker that is used along with other drugs to treat almost every degree ofhypenension. This drug is panicularly compatible with thiazide diuretics. The full mechanism of the antihypenensive effect of propranolol is still not established. It is known that because it blocks beta receptors in the heart, both hean rate and muscle contractility diminish, lowering cardiac output. For this reason, the drug must be used with caution in diabetics. since it masks the tachycardia and tremors that indicate possible insulin-induced hypoglycemia. The chief advantage of propranolol is that it has few side effects. Unlike other antihypenensives such as methyldopa and reserpine, it causes vinually no postural hypotension. Some patients, however, have reported lethargy, fatigue and gastrointestinal irritation. The drug may also cause a severe bradycardia, and so must be given with care to patients who have pre-existing myocardial disease. as it could precipitate congestive heart failure. The maximum decrease in the patient's blood pressure may not occur until he has been on propranolol for SIX to eight weeks. Point this out to the patient and encourage him to keep up his visits to the doctor until optimum control has been established. The Cen-.llen Nur.. Aprtl1878 211 Methyldopa Another drug that \\-orks \\-ell for Pdtients \\- ith moderate hypenension is methyldopa (Aldomet*).It is believed that methyldopa inteIfere with the formation of norepinephrine. thereby depre sing sympathetic transmission in the peripheral nerves. Methyldopa is mo t often u ed in cOJ1Ïunction with a diuretic. since its antihypertensive action is variable when it is used alone. In addition to causing anerial dilation. methyldopa causes venodilation. Blood pools in the enlarged veins. resulting in some reduction in cerebral and coronary blood flow. This effect is accentuated when the patient is in the standing position. and may cause him to have episodes of dizziness and fainting. The patient is more likely to experience po tural hypotension with methyldopa than with some of the other antihypenensive drugs. He should be cautioned to change his position slowly and to repon any incidence of dizziness or fainting to his physician. Many patients experience drowsiness when they begin to take methyldopa. but it usually di.,appears after the first few days of treatment. Other adverse effects that the Pdtient may suffer are dryness of the mouth. nasal stuffiness. gastrointestinal upsets. fever, reversible jaundice, impotence and depression. The patient should be encouraged to tell his doctor about these symptoms; the physician then has the option of recalculating the dosage of methyldopa or using different drugs entirely. Clonidine Clonidine (Catapres*) is one of the newer antihypenensive drugs that acts on the central nervous system to inhibit sympathetic activity. The antihypenensive potency of clonidine is comparable to that of methyldopa. And like methyldopa. clonidine is used in combination with other drugs to treat mild to moderate hypenension. If your patient is being treated with clonidine. he should be advised ne\'er to skip or discontinue the prescribed dosage. for the consequences could be very serious. If the drug is stopped abruptly. restlessness. insomnia. nausea, sweating and chills sometimes occur. In addition, the patient's blood pressure may overshoot to higher than pretreatment levels. It is felt that this reaction is triggered by a sudden release of norepinephrine-like chemicals. Consequently, it is most imponant that clonidine dosage is withdrawn graduaJly. Like other antihypenensives, clonidine produces some side effects. The patient may complain of drowsiness of a more severe and persistent nature than that caused by methyldopa. Constipation. dry mouth. dizzmess. impotence and fluid retention may also be problems. Patients with a known history of depression should be supervised if they are being treated with clonidine. Reserpine Reserpine (Serpasil*) is yet another compound that the physician may choose to give (with an oral diuretic) when management of mild to moderate hypenenslOn has proven to be ineffective with other drugs. This drug achieves its antihypenensive effect by depleting the storage sites of norepinephrine-like chemicals in the brain. and by preventing the release of norepinephrine at the sympathetic target organs. It also ha., a tranquilizing effect on the central nervous system, an effect that benefit'> hypenensive individuals who are tense and anxious. Reserpine. however. has a high incidence of undesirable side effects, and for this reason is often used by the physician as a last reson to control hypenension. Because severe mental depres ion can result with the use of this drug. the patient's family should be alened to the early warning signs of depression such as lassitude. early morning insomnia and loss of appetite. Like methyldopa. reserpine may also induce drowsiness. The patient should be advised to be cautious about driving or carrying out other tasks that require concentration. Other adverse effects of reserpine include gastric hyperacidity. nausea, vomiting. bradycardia. angina-like symptoms, impotence and a parkinsonian rigidity. Many patients on reserpine complain ofnasaJ stuffiness and dryness of the mouth. These effects are more annoying than serious, but if the patient finds them troublesome. he should be encouraged to draw them to his doctor's attention. Guanethidine Guanethidine (lsmelin*) is a poweIful antihypenensive drug which acts chiefly by inhibiting the release of norepinephrine at the junction between the sympathetic nerve and its target organ. It is one of the agents used in the management of severe hypenension, but it may be prescribed for patients with mild to moderate hypenension whose disease is not adequately controlled by other drugs. One of the worst side effects of guanethidine is posturaJ hypotension. The patient must be cautioned to avoid sudden rising. panicularly early in the morning. Postural hypotension will be aggravated by prolonged standing, alcohol ingestion, hot weather, and heavy work. If the patient feels dizzy or faint, he should stop what he is doing and rest, preferably in a sitting or lying position. Patients on guanethIdine may also experience severe diarrhea after meals. fluid retention, fatigue. loss of sexual potency and bradycardia. To keep the required dosage down to minimum levels. guanethidine may be given in conjunction \\-ith an oral diuretic and a sympathetic inhibitor such as propranolol or methyldopa. Drugs acting directl on \ually tries the patient on one drug at d time. evaluating the effectiveness of each drug or combination. The thiazide diuretics are usually the first drugs used. and often they are sufficient to control the patient's blood pressure satisfactoril y. If his blood pressure does not respond to an oral diuretic after a few weeks, a second drug such as propranolol or even methyldopa may be added. And if the patient fails to respond to gradually increased levels of these drugs. he will be placed on a third agent, usually hydralazine. By adding drug!'> one at a time, minimal dosages can be calculated, and side effects.observed. This approach is known as a Stepped Care Protocol and is illustrated in Table three. A suitable treatment program for an individual patient is best established by a dialogue between that patient and his doctor. For optimum success, the patient must be encouraged to bring any annoying side effects or adverse reactions to his doctor's attention. For many patients, drug treatment brings blood pressure under control quickly and effectively. And it will stay in control as long as the individual follows his therapeutic program. Let's get back to Danny and see how he got along with his antihypenensive therapy. Danny's blood pressure was initially brought under control with a thiazide diuretic and propranolol. His symptoms - severe headaches and diLziness - abated. and he felt fine. But six months after staning therapy, Danny moved to take up a new job in a different city. Because he felt well. he did not bother to refill his prescriptions when his medication ran out. And so, a year later, when an oral surgeon took his blood pressure before a dental extraction, Danny's blood pressure was IH5/120. Naturally, he was surprised: aside from a few headaches, he had been feeling fine. He wondered where he had gone wrong. Nursing implications The key to keeping patients like Dann} on medication is education. And no matter what antihypenensive drug the patient is taking, there are several poinb that we as nurses can emphasize concerning drug therapy: . The patient should take the drug as prescribed. He must be told ne\'er to alter the dosage or skip a dose. . The patient should be encouraged to discuss the use of any non-prescription drugs with his doctor or pharmacist. . He should be encouraged to adhere to his diet and should not drink alcohol without first checking with his doctor. . I f the patient is under the care of The C.ned... ........ Table three AN EXAMPLE OF A STEPPED CARE PROTOCOL Add or substitute: Guanethidine Add: Hydralazine Step 4 Alternatives: Prazosin Q) 1ií :::J w Add: Propranolol Step 3 Alternatives: Q) Methyldopa 1ií :::J Clonidine w Step 2 Q) 1ií :::J w Thiazides Step 1 other doctors. he !>hould be told to inform them that he is taking antihypertensive drugs. especially if an anesthetic or surgery is contemplated. . The patient needs to know that he should report to hIs doctor any symptoms that appear after he start!> taking antihypertensives. If your patient is taking methyldopa, reserpine, hydralazine, prazosin or guanethidine, he may experience some postural hypotension. Tell him that he should stand up slowly from a lying position to prevent dizziness. and to avoid standing for long periods of time. Methyldopa, reserpine and clonidine may produce drowsiness, a feeling that will disappear in time. But caution your patient to proceed with care if he must peIform tasks that require mentaJ alenness. If your patient knows about his drugs, chances are that he wiJl stay on drug therapy . You can help him comply by encouraging him to put up with minor .,ide effects such as dry mouth and nasal stuffiness, effects that are more unpleasant than serious. If he is taught to take his blood pressure at home, he may be able to relate adherence to his treatment program with effective control of his blood pressure. And if he is taking several doses of medication each day, and has difficulty remembering what to take when, encourage him to associate piJl-taking with the significant events of each day, such as meals or bedtime. There is no doubt that effective control of blood pressure and recognition ofcomplications will enable your patient to live a longer and more satisfying life. I f education is one of the keys to improved medication compliance, your teaching can go a long way in helping an individual live successfully with his hypertension. .. a II II .. -.. L Bibliography 1 Asperheim. Mary Kaye. The pharmacologic basis of patiem care, by ... and Laurel A. Eisenhauer. 3d ed. Philadelphia. Saunders, 1977. 2 Benditt, Earl P. The origin of atherosclerosis. Sci. Amer. 236:2:74 passim, Feb. 1977. AprIl 1171 31 3 Berne. Roben M. Cardiol'Uscular physiolo!(y. by . _. and Mathew N. Levy. 3d ed. St. Louis. Mosby, 1977. 4 Assessing I'italfunctions accurately. (Nursing Skill book Series) edited by P.S. Chaney. Horsham Pa., Intermed Communication.,. 1977. 5 Gilles. Dee Ann. Patient assessmell1and managemem by the nurse practitioner, by... and Irene B. Alyn. Philadelphia. Saunders. 1976. 6 Kosman. Mary Ellen. Evaluation of a new antihypenen!>ive agent: prazosin hydrochloride (Minipress). JAMA 238:2: 157-159. Jul.l I. 1977. 7 Mcintosh, Henry D. Hypenension - a potent risk factor, by . _ et al. H ea rt Lun/? 7: I: 137-140. Jan./Feb. 1978. 8 Drug. of choice /978-/979. Walter Modell. editor. St. Louis. Mosby. 1978. 9 Page.I.H. Arterial hypenension in retrospect Circ.Res. 34: 133-14:!, Feb. 1974. lOG il'ing cardiOl'ascular drugs safel\', eN ursing Skillbook Series) edited by J. Robinson. Horsham Pa.,lntermed Communications, 1917. II Compendium of pJwrmaceuticllls and specialties. edited by Gerald N. Rotenberg. 13th ed. Toronto. Canadian Pharmaceutical Association. 197H. I:! Rushmer. Roben F. Cardiol'llsculardynamics 4th ed. Toronto. Saunders, 1976. 13 Schroeder, John Speer. Techniques in bedside hemodynamic monitoring, by... and Elaine Kiess Daily. St. Louis. Mosby, 1976. 14 Repon of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure: A Cooperative Study.JAMA , 237:3::!55-:!6I.Jan.17.1977. *Registered trade mark. . Pam Haslam, (R.N.. Toromo Western Hospital, Toronto. Omario, B.N.Sc. Queen's Unil'ersity, Kingston, Ontario. W.S., Boston College, Boston, Massachusetts) author of "Amihypertensil'es and how they wort.... is a former instructor of coronary care nursing at Algonquin Colle!(e in Ottawa. Pam is a co-author of a textbook on interpretation of the electrocardiogram and has had articles published by Nursing Clinics of North America and the Canadian Council ofCardiOl'ascular Nurses. , - - Hypertension: Pediatric hypertension think about it 1. What is the incidence of hypertension in children and adolescents? Statistics on pediatric hypertension are difficult to compile. In the United States, investigators believe that as many as one million children and adolescents are affected - approximately 2 per cent of the school-aged population. I Canadian estimates range from less than 1 per cent to just over 2 per cent of the child and adolescent population. 2 Considering that the incidence of hypertension in the adult population is about 15 per cent, is it worthwhile checking for pediatric hypertension when the incidence is so small? Emphatically, yes. Some studies suggest that children destined to have essential hypertension may have higher blood pressures than their peers at a very early stage of life. If these children can be picked up early, then intervention by dietary modification, relaxation training, exercise and other non-pharmacological methods can be started. Early treatment of hypertension can dramatically reduce the incidence of complications that will occur in later life. In the case of secondary hypertension in youngsters or adolescents, the cause of the elevated blood pressure can be found and treated. 3. What are the causes of pediatric hypertension? In about 80 per cent of prepubertal children, hypertension is secondary to renal disease such as chronic pyelonephritis, glomerulonephritis, congenital malformations and renovascular lesions. Other associated conditions include coarctation of the aorta, obesity, endocrine dysfunctions and the use of drugs such as glucocorticosteroids, amphetamines and oral contraceptives (in the adolescent). In general, only after all secondary disorders have been ruled out. can the diagnosis of essential or primary hypertension be made. 4. At what age Should a child have his blood pressure checked? Most authorities suggest that a child should have a blood pressure check starting at three years of age and annually thereafter. However, because elevated blood pressures are being found with increasing frequency in youngsters, some physicians are recommending checking it as early as two years of age. 5. How do you take a youngster's blood pressure? As you can imagine. this isn't the easiest thing to do with a squirming, non-cooperative child. Try to keep the youngster as calm and relaxed as possible. If he is old enough to understand, explain what you are doing. If the baby cries, or if a young child is very restless and fitful, wait until he settles down. It is important for the child to be as quiet and relaxed as possible for an accurate reading. If the child does not seem to be calming down, let it go until the next visit. · Take readings with the child either supine or sitting with the heart at arm level. . Make a note of the position and use the same position for subsequent readings. A change in position can make a significant difference. · Cuff size is extremely important Make sure the cuff covers about two-thirds the length of the upper arm. A cuff that is too narrow produces a false high reading; if too wide, a false low reading. So instead of automatically reaching for the infant or child-size cuff, be guided by the actual size of the child. · Remember that sometimes, it is difficult to measure a young child's BP accurately. Errors can be generated in Korotkoff sounds by heavy pressures on the stethoscope held in the anti-cubital space. 6. What is considered high blood pressure in a child? When dealing with children, remember that they do not have the same baseline blood pressure as adults. Blood pressure rises with age and it is not until adolescence that a child's blood pressure approaches that of an adult. Besides this, a child's BP is very labile. If the pressure is higher than 120/75 mm Hg in a child age 3-9 years, or above 130/80 mm Hg in a child ten years or older, take two additional readings five or ten minutes apart. If the blood pressure is still elevated, the child may be anxious (check for increased pulse, sweating, dilation of pupils) or it may be indicative of true hypertension. If you suspect hypertension, the child should have three follow- p readings at different times to confirm that the blood pressure is elevated. 7. How is high blood pressure treated in children? Children or adolescents with continued, mildly elevated hypertension may only need to make a change in their lifestyle - changes in such activities as diet. exercise. smoking and oral contraceptive use. For those with more severe hypertension, medication may be necessary. Hypertensive medication is used Tile ee.-.n NUrN Aprtlll71 33 only wnen the supine diastoliC pressure is persistently over 90 mm Hg and where there are other known risk factors - suCh as a strong family history of hypertension. obesity, high cholesterol, etc. A pediatrician who is a specialist in the area of hypertension should be consulted before any child is put on hypertensive medication. Drugs must be given with a great deal of caution since there have not yet been sufficient studies of the long term effects of these drugs on children. . Three groups of drugs are used: 1. Diuretics such as chlorothiazide are often used initially. This group is the cornerstone of all hypertensive therapy. If a child is taking diuretics, both the parents and child must be aware of the need for an increase in potassium (bananas, dried apricots, tomatoes, oranges). Oral potassium supplements may be needed as well. 2. Drugs that affect the adrenergic nervous system (such as methyldopa) are used if a diuretic alone is ineffective. These drugs may cause fatigue and lethargy, but the symptoms generally disappear with continued use. Children on this group of drugs must be watched carefully. 3. A vasodilator may be added to the regimen if neither of the above are successful in maintaining a normal or near normal blood pressure. Again, a child on one of these drugs must be carefully monitored. In the case of secondary hypertension, treatment of the underlying cause usually results in a return to a normal blood pressure. B. Is diet an important factor in children with hypertension? For about 50 per cent of children with mildly elevated pressure, obesity is a factor in hypertension. A reducing diet for these children is tremendously important. Salt intake must also be reduced. For teenagers, this can be very difficult, so emphasize cutting down salt rather than cutting out. The child's mother needs to be aware of the importance of a reduced salt and decreased caloric intake for her child, so this will necessitate some change in how she cooks. 9. Can hypertensive children benefit from exercise? Of course. Some children are extremely active, and they can be encouraged to continue in their activities. Others are much more lethargic and will need to be started on a regular, progressive exercise program. Walking, jogging, cycling, calisthenics and swimming are all beneficial to the cardiovascular system. Many teenagers need a lot of positive feedback about how they are doing - from physicians, nurses and their parents. These children should be seen at least every three months for monitoring and for encouragement. 10. Have any studies been done on pediatric hypertension in Canada? At least three studies have been done since 1975. ..I.' One study of a high school population in Edmonton" indicated that approximately 2.2 per cent (350) of 15.594 students had hypertensive readings when taken at school. The parents of the hypertensive adolescents were advised by letter to have a further evaluation by a physician. Six months after the initial reading. only 67.2 per cent of the hypertensive group had visited a physician. Of these, 19 cases of hypertension were confirmed by the physician. Why so few? The report suggests that physicians did not use pediatric cuffs when they should have (a cuff that is too wide gives a false low reading). Another possibility is that readings were only taken on one occasion. It is suggested that three separate readings at different times be taken before recommending a physician visit. 11. What can nurses do about pediatric hypertension? School nurses are in an ideal position to screen for pediatric hypertension. Talk to your health unit or medical officer of health and plan what can be done in your area. If you are a nurse in a doctor's office. you have all kinds of opportunity. Does the physician have pediatric and adult size cuffs? Are they both in easy reach? Does the physician need a reminder to monitor blood pressure in children? If he/she is too busy, make it your responsibility to check the blood pressure of children and adolescents who come to the office. If you are a nurse practitioner with your own caseload. it's in your hands. And all nurses who are in contact with children and their parents can do some counseling about obesity, diet and exercise. o.A fourth group of drugs may abo be pre crjbed. They are the anti-renin drugs such as propranolol. This group inteneres with the release of renin which activates angiotensin. a very potent vasoconstrictor. It is especially useful in tho e situation where high levels of circulating renin are present in hypertensive patients. ... References 1 Buckley. Kathleen. Why hypertensive teenagers accept our treatment program. RN 40:5:49, May 1977. 2 Hart, Paul L. Blood pressure in a sample of Canadian school children, by... et al. Canad.Fam.Phys. 24:1 :64 passim Jan. 1978. 3 Biron, Pierre. Blood pressure values in 116 French-Canadian children. by... et al. Canad.Med.Ass.J. 114:5:432, Mar. 6, 1976. 4 Silverberg. Donald S. Screening for hypertension in a high school population, by... et al. Canad.Med.Ass.J. 113:2:103-108, Jul. 26.1975. 5 Ibid. Bibliography 1 Gellis, Sydney S. Current pediatric therapy, by... and Benjamin M. Kagan, Toronto, Saunders. 1968. p.390-392. 2 Loggie, Jennifer M.H. Add HBP to your list of childhood ills, by... et al. Patient Care 12:20:16-24, Nov. 30.1978. 3 McLain, Larry G. Therapy of acute severe hypertension in children. JAMA 239:8:755-757. Feb. 20. 1978. 4 Vogel, Martha A. Hypertension in children. Pediat.Nurs. 3:6:37-39. Nov.lDec. 1977. Acknowledgment: Thanks go to Bonnie Maloney, R.N., Sandy Hill Health Centre and to Norman Wolfish, MD., Children's Hospital of Eastern Ontario in Ottawa, Ontario for their help in the preparation of this article. ... , ." .:; >. .c e.. f!! '" " ] "- ... " ";: ñ 0.. :< - o >. " t: " 8 o 0.. . . t , ... 34 April 19711 The Cenedlen Nur.. Today's texts for Tomorrow's nurses Fundamentals FUNDAMENTALS OF NURSING, 6th Edition By Lu Verne Wolff, R.N., M.A.; Marlene H. Weitzel, R.N., Ph.D.; and Elinor V. Fuerst, R.N., M.A. l\lassively revised, reorganized, and updated with much new material and artwork, the 6th edition of this leading text is heavily patient-oriented and emphasizes the role of the family. It is well-suited for conceptual curricula. Nursing is viewed as a process in which the nurse works with patients instead of doing for them without explanation. Lippincott. Abt. 725 Pages. March, 1979. Abt. $16.50. NURSES' HANDBOOK OF FLUID BALANCE, 3rd Ed ition By Norma Milligan lHetheny, B.S.N., M.S.N., Ph.D.; and W. D. Snively, Jr., M.D., /i.A.C.P. The purpose of the book is to clearly and concisely present the fundamental physiology involved in body fluid distur- bances, employing a systematic yet simple approach to classification and diagnosis. Lippincott. Abt. 400 Pages. March, 1979. Abt. $14.50. A GUIDE TO PHYSICAL EXAMINATION, 2nd Edition By Barbara Bates, M.D. Several entirely new chapters on interviewing and history- taking- together with a wealth of expanded and updated material-mark the second edition of this comprehensive guide to physical assessment for beginning health practi- tioners. Detailed yet succinct, the Second Edition serves as an excellent working reference for interviewing and examination; fOT assessment of health status; and for differentiation among abnonnal findings. Lippincott. Abt. 425 Pages. March. 1979. Abt. $25.00. COMMUNICATION FOR HEALTH PROF ESSIONALS By Voncile M. Smith, Ph.D.; and Thelma A. Bass, M.A. This timely book identifies and describes problem situa- tions stemming from communication breakdowns that commonly affect health care personnel. Lippincott. Abt. 200 Pages. March, 1979. Abt. $9.00. ... Pharmacology PHARMACOLOGY AND DRUG THERAPY IN NURSING, 2nd Edition By Mortun J. Rodman, B.S., Ph.D.; and Dorothy W. Smith, R.N., AI.A., Ed.D. The second edition has been so exhaustively revised that it is virtually a new textbook, yet it retains the lucid and read- able style, and the comprehensive coverage, that put the first edition in a class by itself. In addition to massively revising the contents of all chapters carried from the first edition, the authors have added several entirely new chapters and have expanded some first edition chapters into complete sections. Lippincott. Abt. 9UU Pages. April, 1979. Abt. $18.00. NURSING PHARMACOLOGY: A SYSTEMS APPROACH TO DRUG THERAPY AND NURSING PRACTICE By Alvin K. Swonger. Ph.D. With the increasing responsibilities placed on today's nurse and the growing complexity of drug information, there exists an urgent need for a comprehensive, logically organized pharmacology text written specifically for the student nurse. NCRSING PHARMACOLOGY meets this challenge head-on. Little, Brown. 329 Pages. Illustrated. 1978. $12.00. MATHEMATICS FOR HEALTH PRACTITIONERS: Basic Concepts and Clinical Applications By Lawrence Verner, B.A., Ph.D. The text is organized in three parts. Part One, "The Build- ing Blocks," deals with the basic mathematics concepts of fractions and decimals. Part Two, "Tools of the Trade," is devoted to the metric system, the apothecaries system, and conversion between these systems. It develops a simple approach to conversion called the "equation method," which is the key to all of the medical applications. The method is easy to understand and involves no memorization of proportions or formulas. Part Three, "Medical Applica- tions," discusses dosages and solutions, including oral dosage, parenteral dosage, preparation of solutions, and pediatric dosage. Lippincott. 165 Pages. Dec. 1978. $7.50. Th. Cenedlen Nur.. April 197V 35 Maternal-Child Health MATERNITY NURSING, 13th Edition By Sharon R. Reeder. R.N.. Ph.D.; Luigi Mastroianni, Jr., \I.D., F.A.C.S., F..I.CO.G.; I.eonide L. .\lartin, R.'v', M.S.: and Elise Fit::patrick, R.N.. .\1..1. This comprehensi\e edition of an outstanding text reflects the most recent advances in knowledge and changes in famil} life styles. It integrates nursing assessment of both physical and emotional facturs, applies evaluation and diagnostic skills, and provides thorough coverage of current concepts in maternity nursing. Lippincott. 706 Pages. 1976. $20.00. NURSING CARE OF CHilDREN, 9th Edition By Eugenia H. Waechter, R.N., Ph.D.; Florence G. Blake, R.N., .\I.A.; and Jane P. Lipp, M.D. Completely revised and expanded, this edition is without peer as an in-depth studv of pediatric nursing. rhe text is organiLed by age groups, from infancv to adolescence, with emphasis on ph}sical and psvchosocial growth, develop- ment, and health care planning for each age. lajoT revi- sions reflect increased nursing responsibilities in assessment and management of the well child, children at risk, and the ill child. Lippincott. 834 Pages. 1976. $21.00. NURSING CARE OF THE GROWING FAMilY: A Child Health Text By A Pillitteri, R.N., B.S.N., .\I.S.N., P.'v'A. In this exceptional textbook for child health and pediatric nursing courses, prospective nurses will find the infor- mation they need to become competent and compassionate child health nurses. Clearly and engagingly-written, this text is unique in its emphasis on the social and psycholo- gical components of normal growth and development, the important role of the family in child health care, and the child health nurse's rapidly growing responsibilities, partic- ularly in planning and implementing programs of well child care. Little, Brown. 834 Pages. Illustrated. 1977. $22.25. NURSING CARE OF THE GROWING FAMilY: A Maternal-Newborn Text By A. Pillitteri, R.N., B.S.N., M.S.N., P.N.A. This comprehensive text meets head-on the needs of the nursing student - and the practicing nurse - for a lucid, completely up-to-date source of infonnation and prac- tical guidance in one of the most rapidly changing fields of nursing today, maternal and child care. It gives careful consideration to the psychological and emotional aspects of expectant motherhood and fatherhood, and equally important, emphasizes the nurse's expanding role in as essing, delivering, monitoring, and overseeing the health care of the expectant mother and newborn infant. Little, Brown. 445 Pagt:s. Illustrated. 1977. $19.75. Medical-Surgical TEXTBOOK OF MEDICAL-SURGICAL NURSING, 3rd Edition By Lillian Sholtis Brunner, R.^'., B.S., Jl. S.; and Dorzs Smith Suddarth, R.N., B.S.N.E., .\I.S..V. Outstanding in its depth of scientific content and in the practicality of its application, this leading text has been heavil} revised and updated, with much new material. Throughout the text the pathophysiologic basis of disease is discussed as well as the psychosocial aspects of nursing care. Kursing management in various clinical situations is frequently outlined in tabular form. To further aid the student, the authors have added a content guide at the beginning of each chapter; detailed bibliographies, and an appealing two-color format that highlights the chapter openings, special table titles, and many illustrations. Lippincott. 1,156 Pages. I1Iustrated. 1975. $27.25. Review LIPPINCOTT'S STATE BOARD EXAMINATION REVIEW FOR NURSES By Lu Verne Wolff Lewis, R.N.. .\1...1. With 6 Contributors and 4 Reviewers. Uniquely designed to incorporate sound teaching methods with an accurate reflection of the structure and approach of actual state board examinations, this new review book will delight students and teachers alike. It appears in the same fonnat as the licensure examinations themselves, and offers 2,568 questions (together with answer-recording sheets just like those in the examinations) that are also in the same ratio as will be found in the examination. Five tests cover five major areas of nursing: medical, surgical, obstetric, pediatric and psychiatric. They integrate the basic natural and social sciences, nutrition and diet therapy, phannacology and therapeutics, fundamentals of nursing, communicable diseases, and legal and ethical considerations. All answers and the rationale for each answer appear at the end of each of the five major sections. Lippincott. 745 page plus answer sheets. I1Iustrated. 1978. $13.75. Lippincott J. B. LIPPI COTT COMPANY OF CANADA LTD. Serving the Health Professions in Canada Since 1897 75 Horner }he., 1oronto. Ontario !\t8L 4X7 Prices subject to change without notice. - '" Frankly speaking Nursing and the degree mystique ...... A university degree for every nurse may be a worthwhile goal in view oftoday's emphasis on higher education. But what happens when the professional elite proceeds t6 penalize the silent majority of nurses - those who do not yet possess university degrees - and all in the name of quality care? In part one of a two part article, author Jeanne lvlarie Hurd takes a long hard look at the degree mystique and the disruptive influence it may have on nursing as a whole. Jeanne Marie L. Hurd We have all seen the adverti"ement many times in popular magazines. What it shows is a svelte, sophisticated and ultra-modern woman holding a cigarette which is obviously intended to exemplify the same characteristics. The caption, "You've come a long way, baby", epitomizes the distance modern woman has travelled to achieve relative equality in today's society. It is left to the reader to determine whether the cigarette in her hand has helped her achieve this equality, or whether her achievement in itself has earned her the right to smoke. But the distinction is of small consequence. What is important is the cigarette's impact as a status symbol. which is, of course, exactly what the advertisement intends. Nursing too ha come a long way, especially in the past few decades. The preface to a classic history of nursing written over thirty years ago comments that "the nurse is a mirror in which is reflected the position of women throughout the ages". I And considerable progress can be traced both in women's rights and in the nursing profession since these words were written. The question I am asking, however, is this: has modern nursing, in the process of change, acquired a new status symbol that shares some significant characteristics with the cigarette just described? Professional status symbols The nurse's cap, once the cherished symbol ofa proud profession, has long ince been shelved by many of those entitled to wear it. The school pin has likewise been eclipsed by a new professional status symbol, one that cannot be worn, but must instead be displayed on a wall. The new symbol is of course, the university nursing degree, which nursing's modern avant garde is striving to make an essential requirement for the professional nurse. The aim of this well-established movement, which is to improve the product through higher quality education and thus to upgrade the profession, is a sincere and laudable one. And the movement's ultimate objective - a university degree for every nurse - is quite understandable in view oftoday's emphasis on the importance of the degree as an admission ticket to the professions. That nurses are able to pursue a university education in nursing is of particular significance to the profession, because, unlike medicine, nursing's roots are outside of the academic system. How then, could a symbol as worthy as a university degree be compared to the cigarette in the advertisement? Even the most dedicated smoker will admit that the cigarette is the vehicle of an expensive and dangerous addiction, causing among other things, bad breath, stained fingers, a hacking cough, serious illness and even death. Th. Cenlldlen Nur.. April 197V 37 Although it is obvious that the analogy cannot be pushed too far. there are. I think. significant similarities between the cigarette and the nursing degree as status symbols. The mystique surrounding the degree itself has begun to take on characteristics that are by no means free of pollution. If this mystique continues to develop unchecked, with less and less relationship to the real meaning of a university education. the consequences for nursing itself as well as for the public may be at best serious, at worst disastrous. The degree mystique What is the degree mystique? And what is its effect on those who come under its spell? A university education may be variously viewed as a privilege. an opportunity. a challenge. or a necessity. But however it is perceived at the outset. only the unusual student fails to realize by the time he has graduated that the knowledge he has acquired is infinistesimal in proportion to what he does not know. Any serious and responsible student will recognize, at least to some degree, the limitations of his achievement. Few feel equipped to stand on the summits of their respective disciplinary mountains. nor would their faculty advisors dream of encouraging them to do so. Most are happy to have climbed a few foothills. In other words. the university graduate's most important achievement may be the acquisition of a sense of humility. Now let us look at what university nursing is currently telling the baccalaureate nursing student. "Because you have chosen the best pathway to nursing - that is, a university program - when you pass the qualifying examination, you will be aprofessional nurse. whereas your colleagues who pass the same examination from a hospital or community college base wiJl be merely technical nurses." This distinction is explained in tenns of the greater breadth. depth and scope of the baccalaureate student's education. On the surface. it may sound both reasonable and logical. But such a stance has other implications which result in judgments being made - not between two types of educational programs, but supposedly between two types of students. To those influenced by the degree mystique. a student who selects a university program is . of higher calibre than one who selects a community college or hospital program: . more highly motivated; and . more intelligent. Other circumstances that may affect the student's choice - financial, geographic. cultural, personal - are seldom considered. Once the choice is made. it is obvious to those mesmerized by the nursing degree that the baccalaureate student is exposed to an education so superior to the others that her mind, abilities, clinical skills and judgment expand much faster accordingly. Regardless of individual differences, unique personal qualities, or varying balances of strengths and weaknesses, the university graduate is frequently considered better than - not merely, according to the current euphemism - "different from" the hospital or community college graduate. Fortunately. the stuff that a nurse is made of usually detennines to a large extent how she will perfonn, regardless of her educational affiliation. I am fortunate to know a number of superb nurses. some of whom happen to hold one or more degrees, while the others have diplomas and certificates instead. I find it ironic that. should a diploma nurse decide to work for a nursing degree, she is almost always treated as a second class citÎzen in the university environment - a phenomenon reflecting a variety of "you can't get there from here" syndrome. The implication is that because she made the wrong choice to begin with, she is now "too rigid" to be able to function at the true baccalaureate level. As part ofthe "lost tribe" she never quite attains the priesthood, even if she eventually achieves a Ph.D. It is still a truism however. that the diploma nurse, especially the hospital-trained diploma nurse. often has a decided advantage over the degree nurse immediately following graduation, in tenns of perfonnance ability and resulting ego strength. Employers generally rate her highest on initial ability to function, presumably because of her greater familiarity with nursing's -clinical skill . Spinning straw into gold Now the baccalaureate nurse is caught between two opposing forces. On the one hand. her employers ask for at least a modicum of initial clinical and administrative skills. Her university instructor insistS, however, that because of her superior cognitive skills, she should not have to practice, or in some instances, even learn, many of nursing's traditional and potentially obsolescent procedures. The university graduate is thus placed under unreasonable pressures to perfonn. These pressures are partly due to clinical imperatives that cannot wait for her to acquire the necessary experience. But they are also due to the attitude of her school, which like the miller in the story of Rumplestiltskin (who insisted that his daughter could spin straw into gold), has assured the baccalaureate nurse that she is equipped to function at a beginning level in all areas, whether she can or not. Particularly ironic is the strident insistence of many university nursing schools that their graduates are now equipped to do primary care nursing. Such a claim is based on the inclusion in the curriculum of a prescribed amount of theory, with small - ----- 38 April 1979 Th. Canadian Nurse opportunity for practice. It is frequently implied and often stated outright that these new graduates are more legitimately equipped to handle primary care than are qualified and experienced nurse practitioners whose intensive clinical training ha followed a diploma rather than a degree progmm. I t would be interesting to see what would happen if. for instance, medicine were. to follow university nursing's present example. To do so, it would have to cut out clinical clerks hips and internships, substituting for both a few hours a week of carefully protected clinical practice under the supervision of physicians who carry no patient care responsibilities. Then, on the stl'dent's graduation from medical school, he could immediately be turned loose on the public as a qualified beginning level general practitioner. EtiolollV ofa mystique How has the degree mystique managed to become so all-pervasive in recent years? Is nursing going through a developmental stage - its adolescence perhaps - in which its search for identity is reflected in exaggerated claims? Or is the enchantment with our new status symbol due to the fact that it holds out the hope ofreal equality in the professIonal world? Perhaps a look at the process of planned change would help us understand what is happening as nursing education transfers from a hospital to a university base. Edgar Schein. an organizational psychologist at the Massachusetts Institute of Technology has developed a planned change model which he applies to educational systems. In his book Professional education: some new directions. 2 he describes a three stage process necessary for successful change. the stages of unfreezing. changing. and refreezing. His thesis is that before change can take place, motivation to change must be induced through a proper balance of I) forces that arouse discomfort. tension and threat and 2) forces that create sufficient psychological safety to make motivation to change possible. For change to occur then. individuals and/or systems must be made to question traditional beliefs, attitudes and values or behavior patterns to the point that they reach a state of "guilt-anxiety" through comparison of actual with ideal states. Once this happens. enough unfreezing has taken place for change to occur. after which refreezing must be begun through a process of stabilization and integration of the new attitudes, values etc. into the rest of the system. What does this have to do with nursing? I would suggest that nursing education is following this model very closely in effecting the ideological transfer from hospital to university. In the long run. this important change will. no doubt. be successful, and in the twenty-first century. it may well be common practice for a high school graduate with nursing ambitions to go to university for her education. My purpose is not to argue against the need for change or the benefits that may accrue from it, but to recognize the increasingly evident problems accompanying the unfrt;ezing stage of the change process - that stage in which Schein's disconforming forces induce sufficient guilt-anxiety to produce change. The deliberate induction of guilt-anxiety within a population targeted for change obviously requires a certain amount of ruthlessness. To some degree, ruthlessness appears to be a necessary factor in the change process. But what happens when .the ruthlessness required to motivate change is unchecked, and like the genie in the bottle, begins to dominate the process it is intended to serve? In nursing education. unchecked ruthlessness can not only destroy the much needed unity of society's largest group of health professionals. but more subtly. in its massive upheaval of the status quo, it can submerge the original objectives of the change process so that they are lost. The process itself becomes all important. I would suggest that the dynamics of the current movement to relocate nursing education within the university reflect both a high level of unchecked ruthlessness, which in itself contains a significant potential for backlash, and a goal which is increasingly perceived in terms of its form rather than its substance. It is the unÎl'ersity degree that is becoming important. rather than what it represents - a unÎl'ersity education. No doubt, these dynamics have developed as a re ult of largely unconscious forces. I believe, however, that we must recognize the dynamics for what they are. and take decisive steps now to mitigate the problems they are causing. This is the only way to ensure a successful relocation of nursing education. The professional/technical split Nursing has always prided itself on being a helping profession. It would appear however from the behavior of the degreed elite towards the non-degreed majority of nurses that charity in nursing does not begin at home. As one wag has put it "some people get worse by degrees" - and unfortunately there are too many degree nurses who put themselves into this category when they use their achievement, consciously or unconsciously, to devalue their colleagues whose preparation has been different from theirs. Th. Cenedlen Nur.. April 197V 39 More and more. nurses are being evaluated not on the basis of their respective abilities and achievement. but in terms of their possession of either a diploma or degree. While the general rule of thumb seems to be that, all things being equal. the degree nurse should be given job preference. what in fact usually happens is that.\.whether or not "things are equal". the degree nurse gets thejol\ The persistent use of the terms technical and profe'isional is another attempt at differentiation which unfortunately has derogatory overtones. The degree nurse is professional. the diploma nurse only technical. even though the same functions are frequently expected of both. Such an attitude is indeed ironic in view of recent statistics indicating that roughly 90 per cent of all nurses in Canada currently hold diplomas rather than degrees."This same 90 per cent is of course eligible for membership in nursing's national and provincial professional nursing associations. And this important group obviously carries approximately 90 per cent of the associations' costs. Yet influential spokesmen within the remaining 10 per cent continuously press for recognition of the degree nurse alone as the true professional. What would happen to other disciplines' professional associations if 10 per cent of their memberships were to attempt to demote the other 90 per cent to non-professional status? In the United States, the split between the two groups is widening dangerously. RN Magazine centlY conducted a poll to discove how nurses feel about an Americ Nurses Association resolution designating 1985 as the point at which a bachelor's degree wiJI be required for entry into professional practic . Of the ten thousand nurses who responded to RN's poll, the overwhelming majority (72.7 per cent) opposed the proposed professional/technical split.' And the bare statistics were buttressed by the published comments of the poll's respondents, revealing an even more appalling division within nursing over this issue. Mystique in motion I f a profession as a whole is to have a constructive impact on society. it must enjoy a positive self-image. The current attempt to treat the future of nursing (an era when university preparation will be the norm) as if it were already here merely fans the flames of internal frustration and discontent. Furthermore, it fails to recognize the important achievements of today's nursing majority which has worked just as diligently and well via the diploma route as will tomorrow's nurses in the university setting. It is one thing for a minority to raise a standard and lead a discipline toward a worthwhile goal. It is quite another thing for this minority to raise the standard and then. without allowance for lead time, proceed to penalize the remainder of the discipline for not having already reached the goal toward \\0 hich the few are supposedly leading it. What the nursing elite is doing to the rank and file of registered nursing is. in my view, both demoralizing to nurses themselves and subtly antithetical to optimal patient care. The public deserves to be served by a profession that is psychologically whole. not torn apart by internal attempts to de-professionalize its own majority. Nursing might be currently described as "its own worst enemy". May we as a profession recognize this before it is too late. ... References I Robinson. Victor. White caps, the story of nursing, Philadelphia, Lippincott, 1946. 2 Schein,EdgarHenry. Professional education; some new directions, by... with the assistance of Diane W. Kommers. New York, McGraw-Hili, 1972. 3 Canada. Statistics Canada. Nursing in Canada: ('anadian nursing statistics, 1977. Ottawa, Information Canada, 1978. Table 2. p.21. 4 Lee, Anthony. No! Seven out of ten nurses oppose the professional/technical split. RN 42: I :83-93, Jan. 1979. Jeanne Marie Hurd(B.A., Ohio Wesleyan Uni\'ersity; M.A., Columbia Unh'ersitv; M.N., Yale Universitv) has taught nursing in both Canadian and American unÌ\'ersit;e.{. Prior to mewing to Ottawa, she was a senior program consultant with Manitoba's Department of Health and Social De\'elopment. She is currently engaged in writing, teaching and consulting (the latter in the area of maternal and child health). T The role of the family in the emergency department Do family members waiting in an emergency department want to be kept informed of the patient's progress? Would they like to see the patient at the bedside? Could these relatives take a more active role in emergency? Do they want to be more involved in the patient's care? Author, Wendy McKnight Nicklin takes a look at these questions and comes up with some suggestions for nurses who work in an ER. Wendv McKnif!ht Nick/in , \ . .. '- J ".. .... ,.... po. , - "t . . ...... , , The Cenedlen Nurse Aprl11979 41 . 'I tOO/... my friend up to the hMpital yesterday. He had had .{tomach pains and plloned me for ad\';ce abolll what he should do to Ret rid ( fthem.1 felt that lie should go to the emergency room, so 1 dro\'e him O\'er. Do you /...now. 1 waited for three hours and not onre did anyhody tell me whllt was lIappening.1 was worried. Not only that but 1 missed supper and a dentist's appoi"'ment. There's got to be a better way." Sound familiar? Compare it to the story of:\frs. F. She brought her husband to emergency after he had experienced his first bout of renal colic. Mrs. F. states: "They are wonderful at that hospital. The nurse kept me informed of what wa<; happening and I was even allowed to see George. I was sure relieved to know that he was promptly given a drug to lessen the pain. The doctor spoke with me later when we were about to leave' and explained everything. Wejust hope the pain doesn't return. ,. From these two incidents. it appears that the degree of satisfaction experienced by a friend or relative during an emergency room visit depends largely on the nature of the contact he has with the patient and the health care personnel in that hospital. Whether the visit is anxiety-provoking or anxiety-relieving would appear to be influenced by whether or not he feels involved in or informed of the patient's care and progress. How does the friend or relative acquire this information? How much and what kind of information does he need? How can we best assist the family while a patient is being treated in the emergency department? Present role ofthe family in acute illness It is clear that the family plays an 'important role in the pre-hospital phase of a patient's illness. Individuals who become ill usually experiment with a treatment such as aspirin that they can take at home to relieve their symptoms. If the remedy is ineffective and their condition persists or worsens, a relative or friend is often called upon for advice. This "consultant" may suggest another remedy and. failing that, may suggest that the patient contact his doctor or proceed to the nearest emergency department. The decision to go to emergency is seldÇ)m made by the patient alone. Following this interaction, the relative u<;ually drives or accompanies the patient to the hospital. Once at the emergency department however. the role of this "helper" is minimized and the hospital takes over meeting the patient's needs. This may be a welcome relief for many family members who are only too willing to relinquish the responsibility of caring for a sick relative to tmined personnel. But if the patient's condition does not require hospitalization and he is discharged. the family is once more in a position of responsibility. Too often. relatives leave an emergency department without having had an opportunity to speak with a nurse or doctor about the patient's condition or treatment regime. But it is the relative who may initiate some form of treatment and offer reassurance to the patient if his symptoms reappear. or if. for example. the prescribed antihiotics do not immediately reduce the patient'<; fever. It is evident that relatives and close friends of the patient playa large part in the patient's welfare both pre and post hospital visit. Bearing this in mind. is there potential for a more active role for relatives in the emergency room? Can these relatives serve to increase their 0\\ n satisfaction with the patient's care? Do they want to be more involved in the care? The potential role of relathes I. Historian Family members can prove to be a source ofvaluable information about the patient. But this will only be discovered if the relative is permitted at.the patient's bedside or if nurses and physicians take the time to talk to relatives. The patient may not be able to provide a complete medical history or information about his present illness because of his physical condition and his anxiety level. Relatives might be able to fill in the details. As well. they may have observations to share about the patient's health or illness. observations that the patient may have forgotten or consider insignificant. The case ofMr. and Mrs. A. serves to illustrate how helpful a relative can be: Mr. A., a 54-year-old married executÌ\'e, was brought to the emergency room by a co-worker at !3oo hours. He had de\'eloped numbness in his left arm. a symptom which made the doctors suspect a cardiac condition. H owe\'er, an ECG and blood tests did not support their diagnosis. His past history did not put him at 'high risk 'for cardiac disease. By 17oo hours, the doctors were still pu;:z/ed and hesitant to discharge Mr. A. until the diagnosis could be made. At that point, his w{fe was permitted at his bedside and chatted with her hushand. After an hour, DoctorT. returned and told Mr. and Mr.L A. that "in all honesty 1 am really stumped". Then Dr. T. said, "Are you sure you'\'e ne\'er had a diJC prohlem with your neck in tile past?" .'vir. A. emphatically replied, . '/'\'e nner had that at a:l. 1 told you that hefore. " Mrs. A. interrupted her husband and said, "Bill Joe, don't you rememher. 15 \'ean ago, when you fell down the stairs and had to wear a nec/... collarfor se\'eral weeks?" Mn. A. was the indh'idual who found the missing piece of the pu;:z/e. 2. Supporti\'e role The significant supportive role which the family can fulfil for the patient i<; well documented. Brouse attributes this to the fact "that the family is concerned and acknowledges that the patient is in trouble. '" I n a discus<;ion of cri'iis theory. Robi'ichon considers the family as the most outstanding force in the individual's environment. 'The presence ofa <;upportive relallve at the patient's bed<;ide can reduce the patient's anxiety level and this might ultimately enhance the effectiveness of the treatment regime. e.g. the more relaxed the patient. the more effective the analgesic. 3. Aide to nurse.{ A relative at the bedside may be able to assist in meeting some of the patient's basic needs, thus leaving the nurses free for other patient assessments. For instance. while the nurse is caring for other patients. this relative may assist the patient in ohtaining his Kleenex. eye glasses or perhaps making a phone call for him if desired. Further. if the patient's symptoms worsen or change (e.g. he becomes nauseated or lightheaded) the relative may prove to be most helpful if he in turn reports this change to the nurse. It appears that the family could be more involved in patient care - an involvement that could benefit the patient, family and the staff. The degree of involvement could vary from simply being kept informed of the patient's condition by the staff to being permitted to be with the patient for periods of time. In either case, relatives will increase their awareness of what is going on- through di<;cussions with the nurse or doctor. by discussions with the patient. or by making direct observations of the patient and his surroundings when at the bedside. However. does the family want to be more involved? Do they want to be kept informed of the patient's progre<;<; and/or to see the patient? Or. are these false assumptions? 42 April 197V The Cenedlen Nurse The needs of the fami!} in the emergency room Recently, 1 conducted a study into the needs of the family in emergency room waiting areas. The sample consisted of 60 relatives, 30 from each of two emergency department waiting rooms. These relatives were approached about participation in the study one hour after their arrival with a patient at the hospital. 1 contacted those who agreed to participate by telephone the following day and asked them to respond to a question naire. The results indicated that all waiting relatives want [0 receive information about the patient's progress. It was interesting to note as well that 51 of these relatives (85 per cent) wanted some degree of personal contact with the patient during the emergency room visits - to be at the bedside even for just a few minutes. A significant finding, however, was that even though all relatives wanted to be kept informed, only 27 (45 per cent) of them initiated action to obtain information about the patient. For these relatives, certain factors seemed to transform this 'want' for information into a 'need'. Perhaps by understanding the factors that influence relatives to actively request information, we might better understand our role in conveying information about the patient and the importance of involving the relatives as much as possible. On the other side of the coin, if conveying information serves no useful purpose except ensuring that individuals are satisfied, then is it worth our time and energy? Factors influencing the need for information The study results indicated that a relative's first encounter with an emergency department results in a greater need for information than on subsequent visits. The first exposure to an emergency room setting serves as a learning experience for the relative, so that subsequent waits in emergency, regardless of who the patient is, do not seem to elicit as great a need for information as that first visit. During this initial visit, the uncertainties associated with how the emergency department operates and what to expect may be anxiety-provoking, resultÍng in a "need" to obtain mformation to decrease the degree of unknown. During future visits, this same relative may still desire information. However, he is now famiJiar with the overall routine and process of delivering emergency care so that his need for information is slightly less than during the first visit. The following case illustrates this finding: :.-......... 111 I I , t . .. .. , .. .-4 \. , '4 . ,...,. ........ÞI "" \ .. . '. 3"- ... ""'- .w .. , -t " Mrs. R. brought her 45-year-old husband to the hospital. He was pale, diaphoretic and complaining of a 'pressure 'feeling in his chest. He was immediately ta!..en into the treatment area. After registering her husband, Mrs. R. waited quietly in the emergency department waiting room. She remained standing for the next hour but did not once seek information about her spouse. After an hour and a half, a nurse informed her that Mr. R. would be transferred to the Coronary Care Unit momentarily. The following day, J contacted Mrs. R. in order to ascertain her feelings about the visit. She explained that she did not askfor information because, "/','e been through this before. My husband had a heart attack a year ago and J know what is likely happening. They'll tell me when they can." Mrs. R. had wanted information during the "is it yet her familiarity with the environment permitted her to cope with the unmet need. .... The more acute the patient's condition, the greater the need for information. In other words, the relative accompanying the patient sutlering from an asthmatic attack is more likely to need information than the relative accompanying the patient with a bad cold. Relatives who accompany patients with a condition of a vague nature such as abdominal pain also tended to seek out information about the patient's progress. Conditions like thi., often necessitate a wait of two or three hours and usually require a number of diagnostic tests before a differential diagnosis can be made. Perhaps the nonspecific nature ofthe symptom is anxiety-provoking for relatives and consequently the need for information is high in order to lessen the associated degree of anxiety. A third factor influencing the need for informatior: was the environment in which the family must wait. The study revealed that a waiting room which meets the basic needs of the users (i.e. easily accessible and visible washrooms, vending machines and telephones) tended to reduce their anxiety level and thus their need for information. This kind of environment seemed to lessen the uneasiness associated with the emergency visit, thereby enhancing their ability to cope with the experience. Within this setting, the visible presence of a nurse who could give them information also seemed reassuring. In contrast to this, another emergency department where washrooms, vending machines and telephones were difficult to find, the registration process confusing and clerks the chief source of information, proved to be anxiety-provoking for relatives. This second setting seemed to increase the relatives' need to obtain information about the patient. /' Although three separate factors - past experience, the nature of the patient's condition, and the environment - appear to have influenced the family's level of anxiety and the need for information, in ssence it is the interrelation of all these factors that determined the coping abiJity of relatives and friends. / The results of the study indicate that a relative's need for information increases in direct proportion to his level of anxiety. This anxiety is related to the degree of 'unknown' inherent in the situation. Thus, attempting to obtain information (to feel involved in the situation by being aware of what is happening) either verbally from a nurse or doctor or by making observations at the patient's bedside is a strategy used by relatives to lower their anxiety level. The Cønedløn Nurse , April 111711 43 What does all thie; mean? I t has been shown that the family hae; a potential role to play in the patient's care. It is also evident that most relatives want to be more involved in the care - at least, to be kept informed. Receiving information. no matter how little, will likely serve to decrease the level of anxiety experienced by relatives. As previously stated. since the relatives will possibly be caring for the patient after discharge, the more they understand about the patient's condition and the prescribed treatment regime. the better they will be able to ae;sist the patient during the recovery phase. It has been noted that relatives or close friends can be "just as re<;pon<;ible for the patient's not following doctor's orders or not returning for further treatment ac; are the cessation of symptoms and the patient's personal opinions about proper treatment..'" As nurses working in the emergency department, how can we help to develop a role for the family based on their need for involvement? Some suggestions Not all individuals who are waiting for patients in an emergency department desire the same type or amount of information. Some relatives may be satisfied with a brief explanation of the \ patient's condition: others may want an in-depth explanation of the treatment regime. while still others may want no explanation at all. They may just want to be at the patient's bedside. Therefore. in ' attempting to develop a role for the family in emergency care, it is important to assess each case individually and not to stereotype the needs of all relatives. Consider the case of M rs. B. She accompanied her 72-year-old husband to hospital in the ambulance. He I\'as in respiratory distress due to Chronic Obstructil'e Lunl? Disease and had I'Üited the emergency department and clinics many times before. On arrival to hospital. Mrs. B. sat quietly outside of the treatme11f area and after half an hour, a nurse in the area informed her of her husband's condition. During the c01!l'ersation Mrs. B. explained her husband's illness history to the nurse. At that poi11f the nurse asJ..ed her if she wished to see her husband or not. Her reply was' 'N 0, thank vou. I will go and wait in the waiting area. We have been through this many times before and my presence does not allow him to relax. As long as you tell me what is happenin!? and that he J..nol\'s I am here, I'll be C011fe11f in the waiting room." This woman J..new better than the staff what her husband's reactions to her presence might be. Thus the first step in conveying / information to the family i<; to briefly a<;sess their need for involvement. What do the\' want to know? Find out if they understand what ha<; been explained to them and note how they interpret the situation. You may be surprised to hear the various erroneous interpretations given to a supposedly simple explanation. Attempt to meet the relative's expressed need for information. This need not be a time-consuming interaction - quality of explanation. not quantit} is the essential ingredient. If the patient's treatment regime and condition permit. ask the relative whether or not he wishes to see the patient. In Mrs. B.'s case, she did not want to <;ee her husband. Conversely. ask the patient if he desires the encounter. Ifboth parties want to see each other. then the ensuing encounter will likely be therapeutic and lessen anxiety. The supportive ability of the relative should also be assessed. The hysterical wife will be of little support to her sick husband. However. the rational and calm individual may be of definite value in assisting the patient to cope with his illness. Before the patient is discharged. it is essential that the emergency room <;taff involve the relatives in discharge teaching. As mentioned earlier, relatives need to obtain information about the patienCs condition and his treatment in order to help him at home. When Mrs. S.. a waiting relative. was asked why she thought the family should be involved in the treatment process. she replied. 'The ramily must understand. We have to care for the patient after he leaves the hospital. His illness affects our whole family'" It is interesting to note that during discharge teaching, the relatives often ask important questions about the treatment or <;upply information about conditions at home that ER staff might not have previously considered. When giving explanations to the family and patient, try to be simple and concise. Anxiety interferes with an individuars ability to understand and remember details, so the simpler the explanation the better. Following discharge teaching. ask the relative and/or patient to repeat what has just been explained to them. By using this technique. you can partially assess their comprehension of the discharge instructions. Typed handout sheets with instructions are useful. providing that time is taken to ensure that the information is understood. These sheets should not be used as an excuse for decreasing the teaching time required: they are only helpful if the information is explained at the patient's level of understanding. Conclusion In conclusion. if our goal i" to improve the quality of patient care and if we believe that the family can play an important role In patient care. then the responsibility falls on the nur<;es caring for these patient<; and families to begin involving the relatives to a greater degree in the care being delivered. Conveying information is not a time consuming proce...s. As this becomes an integral part of our care. it will become as important and as automatic to u,; as taking vital signs. In consideration of the family's role in illne<;... - pre-hospital. potentially during the hospital visit. and post-hospital- it behooves us to deepen our understanding of and involvement with these significant indi"iduals. 40 References I Brose. Carolyn. Theories offamily cri<;is.1 n Family amI health care, edited by Debra P. Hymovich and Martha Underwood Barnard. Toronto. McGraw-Hili. 1973. p. gO. 2 Robischon. P. The challenge of crisi<; theory for nursing. In Family centred community nursing: 1I socio-cultural frameworJ.., edited by Adina Reinhardt and Mildred D. Quinn. St. Louis, Mosby, 1973. p. 46. 3 Freidson, Eliot. Patient ,'iews of medical practice. NY: Ru<;sel Sage Foundation. 1961. p.147. Bibliograph} McKnight, Wendy. A descriptil'e study of the information seeJ..ing behm'iour of relatil'es in emergency room n'aitin!? areas. Montreal. 1978. Research Paper (M.Sc. (App.)) - McGill. Author, Wend} Mcknight Nicklin !?raduated from the Ottawa Ci\'Ïc Hospital School of Nursing in /970 and from McGill Unil'ersity in Montreal with a B.N. degree in 1972. After I\'orking as a staff nurse in the emerl?ency department of the Ottal\'a Civic Hospital for a "ear, she became im'olved with nursing education both at Algonquin C ol/e!?e in Ottawa and at Queen's UnÍl'ersit\, in Kin!?ston. The article, "The role of the family in the emergency department" is based on a research paper she completed for a M.Sc. (A) degree from McGill in 1976. Curre11fly, Wendy is worJ..in!? as a clinical specialist in the emer!?ency departme11f of the Ottawa Cil'Íc Hospital. .a , Team up with Mosby to make sure your students get the most current ànd authoritative nursing texts. A New Book FUNDAMENTALS OF NURSING PRACTICE: Concepts, Roles, and Functions Two widely respected nursing authors collaborate to provide a unique introduction to nursing fundamentals. Emphasizing holistic care, their book: . defmes nursmg's place in the health care delivery system . offers an overview of the nursing proces , . provides separate chapters explOring the dlHerent r- I - nurses, such as LOmmUniCator, planner. prote tor omforter healer teacher, rehabilitator, and coordmator-collaborat')r, . exammes Issues and trends relevant to the futur of n Jr . presents essential concepts and shows how thE apl- holistic nursmg care . mtegrates legal aspects wherever appropriate By Fay LOUIse Bower. R N.. D.N.Sc.. F.A.A.N. and E'm Olivia BevIs, R N , M.A.. F.A A.N ; with 8 contributors January, 1979 614 pages, 391 illustrations. Price, $16.95. ., 6'" . New 14th Edition Fundamentals of nursing practice (O'\,lIPI'!;>.R(XI'1 1\1'\,1'11 '" II PHARMACOLOGY IN NURSING Ik,""UI. ANI> IIL"I The latest edition of this classic will help you gUide your students in providmg rational and optimal drug therapy. Clear and complete discussions focus on basIc mechanisms of drug action, indications, contraindications, toxicity, side effects. and safe therapeutic dosage range. Highltghfs in this new edition include: . expanded mformation on administration of drugs to t L - elderly; . chapter summaries that review key concepts in the discussions . new material on enzymes and drugs acting on gastromtpstinal organs. By Belly S. Bergersen. R.N., Ed.D. January, 1979. Approx. 784 pages. 100 illustrations About $20.50. '" A r.'4> , q; · ",..& rO -._ _ Oe-ÿ ..:- ..... ......- .. - . -... .,.. . _ -4Þ .__ . .- ...... :- . .. .... . -..- .#' .f:' 3rd Edition NUTRITION AND DIET THERAPY Since publication of the first edition. this text has been a leader in its field. This current edition continues - and exceeds -that tradition of excellence. It focuses on the role of nutrition in public health. in the basic health care specialties. and in the clinical management of disease - all in the context of human needs. Students will be particularly mterested in these new items: · authoritative sections on behavioral approaches to weight control and utilizing the problem-oriented medical record: · expanded information on minerals in the body, with emphasis on zinc; · new and revised tables, including the latest RDA. By Sue Rodwell Williams, M.P H., M.R.Ed., Ph.D. 1977.741 pages, 134 illustrations. Price, $20.50. New 2nd Edition CLINICAL IMPLICATIONS OF LABORATORY TESTS When students ask questions on the significance of laboratory test results. offer them this concise resource. Using an effective. step-by-step approach, it first examines the routine multisystem screening panels - routine unnalysis and hematology screening and sequential multiple analyzer tests. Subsequent chapters focus on evaluative and specific tests of suspected disease entities. Throughout, the authors emphasize physiological implications, variations, and interrelationships of laboratory values. New features: · offers handy sections on patient preparation, instruction. and aftercare; · replaces the chapter on serodiagnostic tests with two new chapters on rheumatoid and infectious diseases; · provides an extensively revised chapter on gastroenterology; · reflects the latest research m the table of normal values. By Sarko M. Tilkian, M.D.. Mary Boudreau Conover, R.N., B.S.N.Ed.: and Ara G. Tilkian. M.D., F.A.C.C. January. 1979. 334 pages, 45 illustrations. Price, $10.75. <:$ <::::> d ø .t' A New Book MEDICAL-SURGICAL NURSING: Concepts and Clinical Practice Uniting the benefits of both a conceptual and a systems approach, this new text will be the best choice for your studentsl The authors have organized information in a way to make It easily accessible and have emphasized total patient care throughout. A few key features of this important text are: · a systems approach within a conceptual framework - meaning your students will be able to locate important information quickly and better understand how specific medical details relate to total patient care; · a beginning section on "Perspectives for Nursmg Practice" offers a useful look at many issues your students will face; · a vital section on stress and adaptation; · a nursing process format is used in each clinical section- where the authors first present a chapter on general assessment of the involved bOdy system, then discuss specific management techniques in a separate chapter By Wilma J. Phipps. R.N., Ph.D.; Barbara C. Long. R.N., M.S.N.; and Nancy Fugate Woods, R.N., Ph.D. February, 1979 Approx. 1,600 pages, 735 illustrations. About $27.75. Q.c / - / -. $ QQ /' . ' f ' \ L - t\.. ' \ \.. "" \ ...... 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HEALTH ASSESSMENT Written by nurses for nurses, this well-illustrated guide provides practical methods for obtaining a complete history and performing a thorough physical examination. Students will especially benefit from discussions which: . detail beneficial techniques for appraising client function; . examine nutritional assessment, sleep-activity patterns, and the use of clinical laboratory skills. By Lois Malasanos, R.N, Ph.D.; Violet Barkauskas. R.N.,C.N.M., M.P.H.; Munel Moss, R.N., M.A.; and Kathryn Stoltenberg-Allen, R.N., M.S.N. 1977.538 pages, 769 illustrations. Price, $26.00. A New Book NURSING CARE OF INFANTS AND CHILDREN Using a systems approach, this new book provides a comprehensive. practical look at pediatric nursing. The authors not only examine care of the ill or disabled child, but also stress promoting the health of the well child. Among the highlights you'll find: . pertinent guidelines for action, . a distributive nursing care approach; . lab data and pharmacology information; . emphasis on and guidelines for communicating with children and their families; . an appendix of normal values and assessment tools. By Lucille F. Whaley, R.N.. M.S. and Donna L. Wong, R.N., M.N., P.N.P. April, 1979 Approx. 1,408 pages, 746 illustrations About $24.00. Team up with Mosby. Basic pathopbysiology A CONCEPT JAl AI Groer and 8ft CD C> r MATERNITY CARE: The Nurse and The Family Both contemporary and humanistic in approach. this important volume can help the student function more effectively as a maternity nurse in today's changing society. Following the chronologie order of childbirth. it discusses the biopsychosociaJ aspects of human sexuality, then proceeds to family planning, pregnancy, interferences with normal pregnancy, labor and its complications, the post-partum period, and both normal and high-risk infants. Throughout. the authors: . integrate diagnostic, therapeutic. and educatIOnal objectives; . present intervention plans; . combine clinical and psychosocial aspects. Timely discussions explore such key topics as genetics. legal factors, fathering, and P.D.M.R. By Margaret Duncan Jensen. R.N., M.S.; Ralph C. Bensen, M.D.; and Irene M. Bobak, R.N., M.S.; with 2 contributors. 1977. 784 pages, 684 illustrations. Price, $24.00. ",. w 2nd E:.dltlcn CHILD HEALTH MAINTENANCE: Concepts in Family-Centered Care Students will benefit from the integrat _n t.f at.... approach. a problem-solving framework. and a stron1.,rr on the holistic person of the child, in this new E" jihon , fan exciting text. It reflects contemporary advances in dlagno_ .> _fJd quality assurance as It examines such tOpiCS as problems of single parent families, care of the terminally ill child, high risk infants. nursing assessment, and specific health problems. This new edition also offers: e a definitive section on competencies - physical, learning. social, and inner; e major sections on health promotion and prevention of illness; e revised discussions of the family unit; e an expanded chapter on high risk infants - including cardiopulmonary disorders, mfection, and GI disturbances; e thought-provokmg discussions of Juvenile and adolescent rape victims. By Peggy L. Chmn, R.N., Ph D March,1979 Approx 896 pages, 377 illustrations. About $24.00. New 2nd Edition CHILD HEALTH MAINTENANCE: A Guide to Clinical Assessment This concise text serves as both a student-oriented learning guide for comprehensive health assessment and as a source of information for effective pediatric care The authors present a wealth of information on developmental differences observed from birth through adolescence - indicating possible deviations and their health care implications. This edition also incorporates these valuable new insights: e an authoritative chapter on assessment of learning, thought. social. and inner competencies; e a detailer! chapter on norms and standards for nursing assessment and intervention providmg nOrmal growth/development charts. recommended schedules for Immunization and laboratory procedures; e a new chapter on assessment tools and case audit gUides- suggesting guidelines for family. mfant. child. and play assessment By Peggy L. Chinn, R.N., Ph.D. and Cynthia J. Leitch, R.N., Ph.D. March. 1979 Approx. 176 pages. 24 illustrations. About $9.75. ". \.. .,> " " 5 ...f1%? , Child healÖ1 malrrtenance . , . . , A New Book PRINCIPLES AND PRACTICE OF PSYCHIATRIC NURSING Using a nursing-oriented conceptual approach to psychiatric nursing. this text describes man's adaptation to illness. and identifies nursing diagnoses and specific nursing interventions. · Part I is organized according to specific nursing diagnoses- anxiety, disruption in the communication process, and grief, for example; · Part" exammes various therapeutic modalities presenlly in use; · throughout, the authors stress nursing interventions and the application of the nursing process. By Gail Wiscarz Stuart, R.N., M.S., C.N.: and Sandra J. Sundeen. R.N.. M.S.: with 15 contributors. May. 1979 Approx 736 pages. 24 illustrations. About $20.50. A New Book COMMUNITY HEALTH CARE AND THE NURSING PROCESS Help your students stay mformed of the exciting new changes in community health nursmg with this comprehensive text. Its timely discussions provide a holistic view of human development by stressing three basic concepts: the health- illness continuum: humankind as an open system that always relates to and interacts with its environment; and the effects of various situations, health problems. and stressors on the health and development of the individual, family. and community. Student-oriented features include: · an eclectic approach to community nursmg; · up-to-date discussions - both m concept and content · fascinating case studies to develop the thinking process and stimulate the ability to make creative Judgments; · the insights of noted contributors. By Margot Joan Fromer, B.S., M.A.: with 7 contributors. January, 1979 484 pages, 110 illustrations Price. $18.00. IVIDSBV TIMES MIRRDR THE C. V. MOSBY COMPANY, LTO. 86 NORTHLINE ROAO TORONTO. ONTARIO M48 3E5 A90430 43 Aprl/1979 (continued from page 16) Ad\ances in research and ser\ices for children \\ith special needs. An international conference to be held at the University of British Columbia, Vancouver, B.C. on June 18-19, 1979. Conract: Dr. Geraldine Schwllrt . Conference C o-ordifllltor. ChiÌdren'sHospital,l50 West 59th AI'e., VlInco/ll'er. B.C., V5X IXl. Annual Meeting of the Canadian Lung Association. Canadian Thoracic Society and the Canadian Nurses Respiratory Society to be held at the Sheraton Centre Hotel. Toronto. Ontario on June 25-27,1979. Contact: Huhert Drouin, Executil'e Secretary, ClInlldian Lung A.uodation. 75 Alhert St., Suite 90B, Ottall'a. Ontario. KIP 5E7. Canadian Physiotherapy Association Congress '79 to be held in Victoria. B.C. on June 12-16,1979. Contact: c.P.A. Congress '79,30 Beach Dr., Victoria, B.C., VBS 2L2. The Canedlen Nurae New Brunswick Association of Registered Nurses Annual Meeting to be held on June 5-7, 1979 in Moncton, N.S. Contact:NBARN,231 Saunders St., Fredericton, N.B., E3B IN6. Association of Nurses of Prince Edward Island Annual Meeting to be held May 30 in Charlottetown. Contact: ANPEI. 41 Palmers Llme, Charlottetoll'fl, P.E./.. CIA 5V7. August Chautaugua '79. Continuing education symposium to be held in Vail. Colorado. August 4-11. 1979. Contact: Colorado Nunes Association, 5453 Ellst EI'lIns Place, Delll'er, Co. l?Ol22. September Atlantic Operating Room Nurses Conference to be held at the Confederation Centre in Charlottetown, P.E.I. on Sept. 24-26, 1979. Contact: When a person is get- ting on in years, constipa- tion may become a problem, The bowel needs a little gentle encouragement. Why not recommend a laxative that works slowly, gently and effectively. That's the Metamucil way. IEJ1 D æJÆJTIf L" ':^ê. 1 Metamucil is made ) from (gluten-free) grain, fv'{) ( I providing fiber that '1.... produces soft, fully formed stools to promote regular bowel function. Metamucil powderislowinsodium r;, I and may be preferred for r r . the treatment of constipa- I v tion in geriatric and ........ cardiac patients. Available as a powder (low m 2 \ ( \ sodium) and a lemon-lime flavoured . ",-' \ ) "...., Instant Mix (low in calones). C Why not give your patients our helpful booklet about constlpatlOn? . Metalnuåf ii\ _ II ., PAAB ccpp - -,- . . Marilyn Driscoll. R.N., Charlottetown Hospital, Charlottetown, P.E./. Ontario Assembly of Emergency Care 2nd Annual Meeting to be held at the Skyline Hotel in Toronto on Sept. 23-26, 1979. Contact: R.H.L.Ga//il'er, M.D., Department of Emergency Medicine, St. Joseph's Hospital, 30 The Queell.nmy, Toronto, Ontario, M6R IB5. 10th International Conference on Health Education to be held in London, England on Sept. 2-7,1979. Theme: Health education in action - achievements and priorities. Contact: The Conference Centre, 43 Sf. Charles St., Ma)iair, London, WIX 7PB, England. October Association of Registered Nurses of Newfoundland Annual Meeting to be held on Oct. 1-3. 1979. Contact: ARNN,67 LeMarchant Rd.. St. John's, Newfoundland. AIC 6AI. Second National Symposium of the Canadian Infection Control Association. To be held in Toronto on October 18-20, 1979. Original papers are invited for presenration. Contact: Elaine Magder, 586 Merton St., Toronto, Omario, M4S IB3. Ontario Public Health Association 30th Annual Meeting to be held at the Constellation Hotel. Toronto on Oct. 14-17,1979.Contact: Kae Sutherland, Office Secretary, OPHA, 7Carlis Place, PorrCredit, Ontario, L5G lAB. Did you know... Nurses' selfstudy programs covering a variety of topics are available for both individuals and groups. Contact: Continuing Education, Faculty of Eaension, The Unil'ersity of Alherta, Corbett Hall, Edmonton, Alberta, T6G 2G4. v .' { The laxative most recommended by Physicians. ONE-STOP SHOPPING for most of your antiseptic needs '-' ""- - I.::;;;;. I';/! ---........ . J - '11/ - - I, --- ---- '" . - --- 'i.. I ,,I -- I , e .- I , 1/1 \ In 11-. .II . ' ,í/ -. tþØ\\It"" -, ..... .... j, . ""- "t "- . \ , I:Þ. ..... ' .. L ::"- r eanser : cleaning solution :hlorhexidine gluconate b-up and general hand J ( ) J :; w V) 0::: ::> Z Z 4: Q 4: Z 4: U V) 0::: W Q 4: w 0::: ate 20% Solution d-spectrum antiseptic Jerative patient 3ral disinfectant use. . antiseptic line lives up to a .ality which is backed by ;e. More and more Canadian T their prime source of mation. If you would like to f these products, contact your Implete and retum this coupon. AYERST LABORATORIES [ - . . ision of Ayerst, McKenna & Harrison limited A Quol t hos tu t Montreal, Canada '7 '-Þ I I I no SUI>> I e ["M"cl _ *Reg'd ilBITANE and SAVlON made on Canada by arrangement with IMPERIAL CHEMICAL NDUSTRIES LIMITED \ SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetië equipment. ,-------------- TO AYERST LABORATORIES I 1025 Laurentian Blvd., Montreal, Quebec. H4R 1J6 I I -= Hibitane" Gluconate I 20% Solution I NAME I ADDRESS I NO I CITY I would like to receive information on: - Hibitane* Skin Cleanser r Savlon * Hospital Concentrate Sonacide* (PLEASE PRINT) STREET 48 April 1979 (continued from page 161 Ad'\ances in research and senices for children "ith special needs. An international conference to be held at the University of British Columbia, Vancouver. B.C. on June 18-19, 1979. Contact: Dr. Geraldine Schll'art , Conference Co-ordinator, Children'sHo pital, 250 West 59th A \'e., 1/1lI1Coul'er, B.C., V5X IX2. Annual Meeting of the Canadian Lung Association, Canadian Thoracic Society and the Canadian Nurses Respiratory Societ) to be held at the Sheraton Centre Hotel, Toronto. Ontario on June 25-27.1979. lontact:Huhert Drouin. Executil'e Secretary, Canadian Lung A ssoC'Ïation, 75 Alhert St., Suite 908, Ottm\'([, Ontario, KIP 5E7. Canadian Physiotherapy Association Congress '79 to be held in Victoria, B.C. on June 12-16,1979. Contact: c.P.A. Congress '79,30 Beach Dr., Victoria, B.C., 1/8S 2L2. The Cenedlen Nurs. New Brunswick Association of Registered Nurses Annual Meeting to be held on June 5-7. 1979 in Moncton, N.S. Contact: NBARN, 231 Saunders St.. Fredericton, N.B., E3B IN6. Association of Nurses of Prince Edward Island Annual Meeting to be held May 30 in Charlottetown. Contact: AN PEl. 41 Palmers Lane, Charlottetoll'n, P.E.I., CIA 51/7. August Chautaugua '79. Continuing education symposium to be held in Vail. Colorado. August 4-11, 1979. Contact: Colorado Nurses Association. 5453 Ea. t EI'tl1l.l" Place, Delll'er, Co. 80222. September Atlantic Operating Room Nurses Conference to be held at the Confederation Centre in Charlottetown, P.E.1. on Sept. 24-26, 1979. Contact: When a person is get- ting on in years, constIpa- tion may become a problem. The bowel needs a little gentle encouragement. Why not recommend a laxative that works slowly, gently and effectively. That's the Metamucil way. 'íjì , -- \ .. - ,- PAAB CC PP --=====- . . Marilyn Driscoll, R.N., Charlottetoll'n Hospital, C Iwrlottetoll'n, P.E.I. Ontario Assembly of Emergency Care 2nd Annual Meeting to be held at the Skyline Hotel in Toronto on Sept. 23-26, 1979. Contact: R.H.L.Gallil'er, M.D., Department of Emergency Medicine, Sr. Joseph's Hospital, 30 The Queensway, Toronto, Ontario, M6R IB5. 10th International Conference on Health Education to be held in London, England on Sept. 2-7,1979. Theme: Health education in action - achievements and priorities. Contact: The Conference Ce1!tre, 43 St. Charles St., Ma:\,fair, London, WI X 7PB, England. October Association of Registered Nurses of Newfoundland Annual Meetin to be held on Oct. 1-3, 1979. Contact: ARNN, 67 LeMarchant Rd., Metamucil is made from (gluten-free) grain, providing fiber that produces soft, fully formed stools to promote regular bowel function. Metamucil St. John's, Newfoundland, AIC 6A1. Second National Symposium of the Canadian Infection Control Association. To be held in Toronto on October 18-20, 1979. Original papers are invited for presentation. lontact:Elaine Magder, 5R6 Merton St., Toronto, Ontario, M4S IB3. Ontario Public Health Association 30th Annual Meeting to be held at the Constellation Hotel, Toronto onOct.14-17,1979.Contact: Kae Sutherland, Office Secretary, OPHA, 7Carlis Place, Port Credit, Ontario, DG IA8. Did you know... urses. self study programs covering a variety oftopics are available for both individuals and groups. Contact: C o1!tinuing Education, Faculty of Eaension, The Unil'ersitv of Alherta, Corbett Hall, Edmo1!ton, Alherta, T6G 2G4. ;;:tJ m )> o m ;0 V1 1I () ""t )> n Z r )> ): 0 r )> C Z ï ï ". Z ;t C ï ;0 C V1 m Available as a powder (low in 2 \ ( sodium) and a lemon-lime fl . avoured . \ Instant Mix (low in calories). C Why not give your patients our helpful booklet about constipation? . Metaln1 The laxative most recommended by Physicians. ONE-STOP SHOPPING for most of your antiseptic needs . - ,;t ,-- I" t- ... I -'" .._;; " .......--!J!!. J -" ' J, j Jil . I - -._ , 1 " --.. r I {Iy , II , . . . ../. -- - - -. '-..... I -""'--... /} " . I I l' ( ..11 . ' ..... eftldr,. .......... """...- . !r , - HIBITANE* Skin Cleanser a sudsing, antiseptic cleaning solution containing 4% w/v chlorhexidine gluconate for preoperative scrub-up and general hand washing. HIBITANE* Gluconate 20% Solution :l multipurpose, broad-spectrum antiseptic ::;öncentrate for preoperative patient preparation, and general disinfectant use. =ach product in the AYERST antiseptic line lives up to a Nell-earned reputation for quality which is backed by I\YERSrS technical expertise. More and more Canadian ,ospitals are making A YERST their prime source of mtiseptic products and information. If you would like to mow more about any or all of these products, contact your WERST representative or complete and return this coupon. AYERST LABORATORIES ,sion of Ayerst, McKenna & Harrison limiled A . Quoli t hos t t Montreal, Canada '7 no SUI>> I U e .....AC) . R ' d _. eg ilBITANE and SAVLON made ,n Canada by arrangement with IMPERIAL CHEMICAL NDUSTRIE LI I ED 4W 4 4, f4 \, ..... " .., . ... .. " :;I..:; ......f """.... t I SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetië equipment. ,-------------- TO AYERST LABORATORIES I 1025 Laurentian Blvd.. Montreal, Quebec. H4R 1J6 I I 0 Hibitane" Gluconate I 20% Solution I NAME I ADDRESS I NO I CITY I would like to receive information on: -= Hibitane* Skin Cleanser r Savlon * Hospital Concentrate Sonacide" - ( PLEA SE PR INT) STREET 50 April 1979 The C.n-.llen Nur.. names & faces Kathie M. Clark was recently appointed as the new education co-ordinator for the Registered Nurses Association of Ontario. She will be responsible for associations and agencies, and developing briefs and statements in response to issues relating to nursing education. Clark graduated with her BScN from the University of Toronto and worked at the Clarke Institute of Psychiatry in Toronto as an assistant head nurse and clinical instructor. In 1968 she moved to British Columbia where she worked in a variety of teaching and clinical settings at the University of British Columbia. She then completed her Master's degree in adult education at UBC focusing on self directed learning and nurses'leveis of participation in continuing education. planning RNAO workshops and conferences, co-ordinating continuing education courses with allied CNA NATIONAL FORUM ON NURSING EDUCATION 13, 14, 15 November 1979 SKYUNE HOTEL- OTTAWA Theme: The nature of nursing education Focus: What is basic nursing education? Diploma or degree? ð . . Nursing model and the Curriculum . Nursing specialization . Accreditation OPEN TO ALL REGISTERED NURSES - MAXIMUM OF 300 . . . CNA Members -$100 Non-Members - $175 Complete program details and registration fonn in coming issue or write The Canadian Nurses Association, 50 The Driveway, Ottawa, Ont. K2P IE2. Tel. (613) 237-2133. PLAN AHEAD AND REGISTER EARLY Edith May Radley, a Manitoba nurse who has spent most of the last 30 years providing health care to the Umbundu people of central Angola in Africa, will be among 64 Canadians to be invested with this country's highest distinction, The Order of Canada, at a ceremony this Spring. A graduate of Dauphin General Hospital, Radley also attended the University of Manitoba in Winnipeg and Seneca College in Toronto. A number of nurses were honored by being invested in the Order of St. John in late 1978. They include: In the Grade of Commander Sister Margaret Mary Matheson, Stellarton, N.S. Vida McDonald, North Battleford, Sask. In the Grade of Officer Gisèle Corre. Montréal, Que. Florence Lorraine Davies, Ottawa, Onto Marie des Anges Loyer, Ottawa, Ont. Françoise Savard, Montréal, Que. In the Gr-dde of Serving Sister Anne Marie Bélanger, OMM, CD, Ottawa, Ont. Jacqueline Côté, St-Bruno, Que. Patricia Lynn Gibson, Miami, Man. Audrey May Goodchild, Victoria, B.C. Margaret Mary McEachern, Edmonton, Alta. Eleanor M. Snider, Fonthill, Onto Jeanine Tellier-Cormier, Trois Rivières, Que. Patricia M. Harris, Orillia, Onto The order of St. John is an ancient order of chivalry and the investiture of nurses is reserved for those who have served in the brigade as nursing officers for a period of time on a voluntary basis. Agatha Gertrude Lowe, a native of Barbados, West Indies, and a long-time resident of Hamilton, Ontario, has recently joined the Project HOPE medical education program in Natal, BraziL She will conduct a training program in community health nursing. Lowe received her nursing degrees from the University of Western Ontario and the University of Toronto. She also holds a master's in health education from The Pennsylvania State University. Prior to joining Project HOPE, Lowe was assistant professor of nursing at McMaster University in Hamilton. She will serve with HOPE in Brazil for - approximately two years. '" Jacqueline Steward has been appointed nursing consultant for nursing practice - with the 7000 member New Brunswick Association of Registered Nurses. Steward, who is a graduate of the Royal Victoria Hospital School of Nursing, Montreal and the University of New Brunswick (BN) will act in a consultative and advisory capacity to nurses employed in the provincial health care delivery system. Beforejoining the N BARN staff, Steward was head nurse in the special care unit of the Doctor Everett Chalmers Hospital, Fredericton. The C.nedl.n Nur.. April 111711 51 books New hope for deprived children. by Betty M. Flint. 200 pages. Toronto, University of Toronto Press, 1978. Approximate price-$/2.50. Although basicaJly a report on the conception, planning. implementation and outcome of a longitudinal study of a group of severely deprived children, this book conveys more than that. It speaks of dedication to a belief that each human being has worth and potential for development. and that professionals have the knowledge, understanding and personal resources to provide and facilitate the nurturing environment from which severely deprived, institutionaJized infants can gain the strength to master developmental tasks and become contributing members of society; in this lies the message of hope for deprived children. This book is of interest to a wide range of professionaJs, including nurses, who work with children and families and/or have a concern about their growth and development. The study design and its therapeutic programmes are sufficiently described and documented to aJlow researchers in the field of child development to assess the validity of the theoreticaJ framework and the variety of measurements used in documenting developmental progress. The Security Theory as developed by Dr. W.E. Blatz and his colleagues at the Institute of Child Study in Toronto was selected and consistently applied throughout the phases of the study; this theory provides a central theme in the publication. Those who work with children are usually familiar with the security concept and can derive meaning and encouragement from a theory which can be applied in simple behaviouraI terms. The book is easy and interesting to read. In spite of a strong focus on research method and findings (often illustrated with tables and graphs) the human element. conveyed in case descriptions and behavioural records, keeps the children and their destiny close to the reader's heart. The organization of content is somewhat confusing. Chapter headings do not appear to follow a logical sequence (which is either research oriented or developmentally derived). Yet to report an extens.ive, complex study with considerable clarity and some attention to detail within 200 pages is quite an accomplishment. It's encouraging to note that recognition is given to the person who played a significant and instrumental role throughout the length of the study. A full chapter is devoted to the role of the child care worker, yet the reader is acutely aware throughout the book that the success - the actuaJ hope for deprived children -lies with people like Mary Kilgour, who through their sensitivity in human relations and their willingness to offer themselves can apply their knowledge and professional expertise to the fullest. A similar message is apparent in the postlude where the author summarizes the research project and its implications for current child care practices. Here again, the significance and value of "care-takers" of children is emphasized: the author pleads for proper preparation and recognition of aJl who care for children, people who mold character and influence development towards healthy outcomes. Much can be learned from this book about the effects of institutional care on young children, about efforts in therapeutic intervention which can relieve serious developmental deficiencies and. about the significance of knowledge coupled with personalized. individualized care to give new hope to deprived children. .r- Re,'iewed by Karin ,'on Schilling, Associate Professor, School of Nursing, McMaster University, Hamilton. Ontario. THE APOTHECARY SERVICE 260 Redwood Ave. at Main St. Winnipeg, Manitoba (204) 582-5437 HOSPITAL & NURSING HOME CONSULTANTS in the MONITORED DOSAGE SYSTEMS. f I - CA LL or WRITE us for relief to the drug related problems of your institution. SAFETY and SECURITY with SA VNGS THE APOTHECARY SERVICE B division of SHOPPERS DRUG MART "SAFETY WITH SAVINGS" A DOSe t- .. . .. j . .. . . i . 1 . JL - 52 April 1979 Th. C.nedlen Nur.. " this patient needs your help When patients need private duty nursing in the home or hospital, they often ask a nurse for her recommendation. Health Care Services Upjohn Limited is a re- liable source of skilled nursing and home care specialists you can recommend with confidence for private duty nursing and home health care. All of our employees are carefully screened for character and skill to assure your patient of de- pendable, professional care. Each is fully insured (including Workmen's Compensation) and bonded to guarantee your patient's peace of mind. Care can be provided day or night, for a few hours or for as long as your patient needs help. For complete information on our services, call the Health Care Services Upjohn Limited office near you. Health Care Services Upjohn Limited VlCtona e VafYXANf!/: e rIIam EånonIon e CalQéIY e Wimpeg e London 51 Calhænes. HM1IIIon e T oronlo Ottawa e Montreal e 0Jebec e Halifax l HCSIIII23. , ""'II library update Publications recently received in the Canadian Nurses Association Library are available on loan - with the exception of items marked.R- to CNA members, schools of nursing, and other institutions. Items marked R include reference and archive material that does not go out on loan. Theses, also R, are on Reserve and go out on Interlibrary Loan only. Requests for loans, maximum 3 at a time, should be made on a standard Interlibrary Loan form or by letter giving author, title and item number in this list. lfyou wish to purchase a book, contact your local boohtore ór the publisher. NOTE: Readers are reminded that they should check first with the li rary of their provincial nurses association, university or college, to determine whether they may obtain the publication(s) they require from this source. Books and Documents I. Alexander. Edyth L. Nursing administration in the hospital health care system. 2d ed. Saint Louis, Mosby, 1978, 289p. 2. Anderson, Norma J. Pediatric nursing; a self-study guide. 3d ed. Toronto, Mosby, 1978. 221p. 3. Association of Universities and Colleges of Canada A Canadian directory to foundations and granting agencies. 4th ed. Edited by Allan Arlett. Ottawa, cl978. Iv. (various pagings) R 4. Benchimol, A. Noninvasive techniques in cardiology for the nurse and technician. Toronto, Wiley, c1978. 316p. 5. Birminf(ham, Jacqueline Joseph The problem-oriented record; a self-learning module. Toronto, McGraw-Hili, cl978. 161p. 6. Chatenay, Henri Paul Echoes of silence. The chronicles ofW.G. Mainprize, M.D., 1911-1974, 75th anniversary edition. First Baptist Church and town of Midale. Sask. 1903-1978. Midale, Sask., Printed by Alberta Handicapped Forum Ltd., cl978. 127p. R 7. The collective agreement and its administration. A revision of Chapter 7 and the 2d ed. of Labour relations law. Revised by Bernard Adell. Kingston, Ont., Industrial Relations Centre, Queen's University, 1978. 186p. 8. Commonwealth Caribbean Regional Nursing Body Annual General Meeting. Sixth, Kingston. St. Vincent. 15-19Aug. 1978. Report. Iv. (various pagings) R 9. Dunkel, Patty L. CUJ:Ticulum for educators in health care institutions. Summary of the proceedings of a conference held on Jan. 6-7, 1977. Chicago, Hospital Research and Educational Trust, cl978. 85p. 10. Feldman, Silvia Choices in childbirth. New York. Grosset and Dunlap, cl978. 267p. II. Gordon, Richard The private life of Florence Nightingale. London. Heinemann, cI978.233p. 12. Griffith, John R. Measuring hospital pelformance. Chicago Blue Cross Association, 1978. 86p. 13. H amonet, C I Abrégé de rééducation fonctionnelle et de réadaptation par. . . et J.N. Heuleu. 2. ed. revue et corrigée. Paris, Masson, 1978. 242p. 14. Inlernational Conference on Primary Health Care. AlmaAta. USSR. 6-12 Sept. 1978 Primary health care. Report of the. jointly sponsored by the World Health Organization and the United Nations Children's Fund. 79p. 15. International Labour Conference, 63rd session, Geneva. 1977 Working environment: atmospheric pollution, noise and vibration. Fourth item on the agenda. Geneva, International LabourOffice, 1977. 61p. (Its Report 4 (I)) 16. Jungers. Paul The essentials in hemodialysis, by. . .andJohannaZinf(raff, Nguyen K. Man and Tilman Drueke. Boston, MartinusNÿhoff,1978.102p. 17. Kohnke, Mary F. The case for consultation in nursing; designs for professional practice. Toronto, Wiley, c 1978. 185p. 18. McKeown, Thomas The role of medicine; dream, mirage or nemesis? London, The Nuffield Provincial Hospitals Trust, 1976. 18Op. 19. National League for Nursing Protct every child; childhood immunization community action kit. New York, 1978. 95p. (NLN Pub. no. 52-1717) 20. Nursing: levels of health intervention. Edited by Ann Wolbert Burgess. Toronto, Prentice-Hall, cl978. 809p. 21. Obstetric, gynecologic and neonatal nursing functions and standards. Chicago, Nurses Assoc. of the American College of Obstetricians and Gynecologists, 1974. 61p. 22. Pan American Health Organization Extension of health service coverage based on the strategies of primary care and community participation. Summary of the situation in the region of the Americas. Washington, 1978. 66p. (P AHO Official document no. 156) 23. Primary care. Edited by Cynthia J. Leitch et aI. Philadelphia, EA. Davis, cl978. 589p. 24. Putt. Arlene M. General systems theory applied to nursing. Boston. Little Brown. c1978. 195p. 25. Roberts, Phyllis Adams Regional blocks for nurse anesthetists; a technical manual. Springfield, III. Charles C. Thomas, c1978. HIp. 26. Sloan, FrankA. Equalizing access to nursing services: the geographic dimension; health manpower references. Hyattsville, Md. U. S. Dept. of Health Education and Welfare, 1978. 252p. (U.S. DHEW Pub. no. (HRA) 78-5 \) ....,j Luckmann I . ensen Sorensen TEXTBOOK 0 f Luckmann t MED1CAL - SURGICAL BASIC NURSING URSING I AI'!. cI>CJp'1\.JOIogIC 2nd Edition . They've done it . I again. Sorensen & Luckmann BASIC NURSING: A PSYCHOPHYSIOLOGIC APPROACH and coming soon- Luckmann & Sorensen TEXTBOOK OF MEDICAL-SURGICAL NURSING 2nd edition Sorensen and luckmann now offer BASIC NURSING, a comprehensive textbook/refer- ence based on the concepts of stress, adaptation, and homeostasis. You'll find expert coverage of the nursing process, physical examination, legal concepts, basic and advanced clinical considera- tions, and important nursing techniques that are spelled out step by step with accompanying scientific rationales. Helpful study guides preceding each chapter, objectives, vocabulary aids, many original draw- ings, and an easy-to-read, two-color format add to a long list of valuable features. Ideal as a textbook for students or a reference for practitioners, BASIC NURSING in combina- tion with the forthcoming revision of TEXTBOOK OF MEDICAL-SURGICAL NURSING is a must for every nurse's library. By Karen Creason Sorensen, RN, BS, MN, Formerly Lecturer in Nursing, Univ. of Washington; Instructor of Nursing, Highline College; Nurse Clinical Specialist. Univ. Hospital and Firland Sanitorium, Seattle, WA; and Joan Luckmann, RN, BS, MA, Formerly Instructor of Nursing, Univ. of Washington, Highline College, Seattle, Oakland City College and Providence Hospital College of Nursing, Oakland College, CA About 1285 pp. 435 ill. Just ready. About $25.00 (Canada $30.00). Order #8498-X. -............- I NSG 4/78 CN 478 Please send on 3D-day approval: I I ] Sorensen & Luckmann I I BASIC NURSING: A PsychopsysiologicApproach #8498-X. I I o check enclosed-Saunders peya postage I I e::;trnÖ[rC Ö[} n . I : DM"""Owge' DG:IJQ]]crn : I Expiration Date Interbank # DrlCIJ I Please PrInt. I I I Full Name I I I I Position and AffIliatIon (If Appllcabte) Home Phone Number I I Home Address I ZIP I I I I I . I City . State . SIgnature All prices dIffer outsIde U S and subject to change. . I W.B. saunders Company .westWashington Square Philadelphia, Pa. 19105 In Canada: 1 Goldthorne Ave.. Toronto, Ontario M8Z ST9 In England: 1 SI Anne's Rd., Easlboume. East Sussex BN21 3UN In Auslralia: 9 Waltham Slreel. Artarmon N.S.W 2964 54 April 111711 Th. C.n.dlen Nur.. \o\ QoQ ,,"i Os ..( QO 0 ..( \)fJ\ f:j Q' -4 , - POSEY SOFT BElT Comfortably prevents patients from slid- ing In wheelchairs or geriatric chairs. Soh polyurethane cushion Is so soft your pa- tient will hardly know It's there. Wash- able. Sm., med., Ig. No. 4125 , , \ -- \ \ I , POSEY FOOTGUARD Helps prevent footdrop or rotatIon while allowing foot movement Rigid plastic shell with soft liner supports the foot and keeps the weight of bedding off of the foot "T' Bar stabihzes foot. No. 6412 ,.. .,.- " í POSEY PATIENT RESTRAINER Get the added plus of shoulder loops and straps. Comfortable. vest criss-crosses In front or rear and waist belt lies to bed spring frame. Excellent In wheelchairs too. Sm.. med., Ig. No. 3111 ",1 Health Dimensions Ltd. 2222 S. Sheridan Way Mississauga, Ontario Canada L5J 2M4 Phone: 416/823-9290 27. T ask Force on Concerns of Physically Disabled Women Toward intimacy: family planning and sexuality concerns of physically disabled women. 2d ed. New York, Human Sciences Press, c1978. 63p. 28. Taylor, MalcolmG. Health insurance and Canadian public policy; the seven decisions that created the Canadian health insurance system. published forThe Institute of Public Administration of Canada. Montreal. McGill-Queen's University Press, c1978. 473p. 29. Weller, Stella Easy pregnancy with yoga. Vancouver. Fforbez EntelJ'rises, c1978. 187p. 30. World Health Organization International classification of procedures in medicine. World Health Organization, Geneva, 1978. Iv. Pamphlets 31. American Nurses' Association Accreditation of continuing education in nursing: the site visit process. Kansas City. Mo., c1978. 23p. 32. Canadian Medical Association Guide for physicians in detennining fitness to drive a motor vehicle. revised December 1977. Ottawa, 1978. 41p. 33. Criterion measures of nursing care quality, August 1978. Hyattsville, Md.. National Center for Health Services Research. 28p. (NCI-:(SR Research summary series) (U.S. DHEW publication no. (PHS) 78-3187) 34. Manitoba A ssociation of Registered Nurses Standards for the approval of diploma schools of nursing in Manitoba. Winnipeg. 1956. 6v. R Government Documents 35. Agence canadienne de développement international Rappon. 1977/78. Ottawa. 1978. 48p. 36. Canada Institute for Scientific and Technical Information Scientific and technical societies of Canada. Ottawa National Research Council of Canada. 1978. I3lp. R 37. Canadian Government Specifications Board: Role and operations. Ottawa. 1976. 24p. 38. Canadian International Development Agency Review, 1977/78. Ottawa, 1978. 48p. 39. C01iférence nationale sur la condition physique des employés, Ottawa, 2,3 et4 déc. 1974 Recommandations. Ottawa, Santé et Bien-être social. 1975. 9p. 40. Conseil privé. Comité spécial d'examen de la gestion du personnel et du principe du mérite. La gestion du personnel et Ie principe du mérite; un document de travail. Ottawa. Ministre des Approvisionnements et Services Canada. 1978. 412p. 41. Health and Welfare Canada Canada health manpower inventory. 1977. Ottawa, 1978. 254p. 42. InstitutCanadien de ['information scientique et technique Sociétés scientifiques et techniques du Canada. Ottawa. Conseil national de recherches Canada, 1978. I3lp. R 43. Labour Canada, Collective Bargaining Division. Labour Data Branch Calendar of expiring collective agreements. 1979. Ottawa. Minister of Supply and Services Canada. 1978. I J3p. 44. -. Legislative Research Human rights in Canada, 1978. Ottawa. Minister of Supply and Services Canada. 1978. 93p. 45. L 'Office des normes au gouvernement canadien: son rôle et ses activités. Ottawa. 1976. 24p. 46. Privy Council. Special Committee on the Review of Personnel Management and the Merit Principle Personnel management and the merit principle; a working paper. Ottawa. Supply and Services Canada. 1978. 384p. 47. Santé et Bien-être Social Canada Répenoire de la main-d'oeuvre sanitaire au Canada, 1978. Ottawa. 1977. 254p. 48. Statistics Canada Census of Canada. 1976. Vol. 2 Population: demographic characteristics; five-year age groups. Ottawa. Minister of Supply and Services Canada 1978. Iv. (various pagings) Catalogue no. 92-823 Studies in CNA Repository CoUection 49. Anderson, Joan The effects of the patient's diagnosis on professionals and students in a psychiatric setting: a labeling perspective. 50. Registered Psychiatric Nurses Association of British Columbia. Committee on Nursing Education and Practice. Repon on minimal level of competencies expected of the graduate psychiatric nurse. Burnaby. B.c.. 1978. 98p. R 51. Thille, Mary, Sister Follow-up study of graduates of the Saint Boniface School of Nursing. St. Boniface, Manitoba. 1931-1955. SI. Louis. Mo.. 1957. 118p. Thesis (M.Sc. N.E.)-St. Louis. Untversity. R Audio Visual Aids 52. A ssociation des Médecins de Langue française du Canada Sonomed, série 5. no 4. Montréal.1973. I cassette.Contenu.-Côté A.L Emanuel. Elliott. L'environnement et les maladies mentales. 2. Chicoine. Luc. L'emploi des antibiotiques en prophylaxie.- Côté B. Weber, Michel. Bronchiolites. laryngites épiglottites. 53. -. Sonomed. série 5. no 3. Montréal. 1973. 1 cassette. Contenu. -Côté A.L Myre, Maurice. L'embolie pulmonaire. I re panie: physiopathologie. 2. Seguin. Fernand. Le fléau de lamalaria. -Côté B.Grégoire, Jacques. Les lentilles cornéennes. 54. Mecque, Ie marché des moyens d'éducation par Ie cinéma et I'audiovisuel au Québec. Répertoire '78. Montréal, vac offset. 1978. Iv. (sans pagination) Bachelor of Administration (Health Services) Degree Program Applications are now accepted for the program combinirIJI independenl study with tutorials on weekends in Toronto, as well as for the competency based, external degree internship option offered for students at a distance. Credits toward advanced standirIJI are given for managerial experience and prior education includirIJI B.Sc.N., R.N. and H.O.M. Certifi- cate. The School is a member of the Association of University Programs in Health Administration and is supported by the Kellogg Foundation grant. For infonnation and application fonns, please write to: CIIIIUlIIII Scboot of Mllllaaemeal S-425. OISE BuUdIaa 151 Bloor St., West Toronto, Oatario MSS JV5 The Cen-.llan Nur.. Aprllll171 55 Classified Advertisements Alberta Retl*red Nunes required for acute care general hospital, expandinø from n beds to 300 beds. Clinical areas include: medicine. surgery, obstetrics, paediatrics, psychiatry. activation and rehabilita- tion. operating room. emergency and intensive and coronary care unit. Must be eligible for Alberta registration. Personnel policies and salary in accor- danee with AARN contract. Apply to: Personnel Administration. Fort McMurray Regional Hospital, 7 - Hospital Street, Fort McMurray, Alberta, 1'9H IP2. Registered :'\Iurses required immçdiately in a 68-bed active Ireatment hospital located in Northeastern Alberta. Accommodation is available in Nurses' Residence. Salary and benefils in accordance with the negotiated provincial agreement. Apply in writing to: Director of Nursing. Lac La Biche General Hospital. Box 507, Lac La Biche. Alberta. TOA 2CO. British Columbia Gneral Duty (R.C. RexIstered) NUne8 required for expansion to 422 acute care accredited hospital located 6 miles from downtown Vancouver and within easy access to various recreational facilities. Eltcellent orientation and ongoing inservice prog- ramme. Salary SI,231.00---SI.455.00 monthly. Clini- cal areas include coronary care, intensive care, emergency, operating room. P.A.R.R., medical/sur- gical. pediatrics, obstelrics, orthopedics and activa- tion units. Positions are also available for lftIeral duty DUI'RS in our modem extended care unit. Apply to: Co-ordinator-Nursing. Dept. of Employee Resources. Burnaby General Hospital, 3935 Kincaid Street. Burnaby. British Columbia, V5G 2X6. Challenge itnd opportunity aWait the nurse prepared to accept a position in a 1000bed accredited acute care hospital in a booming northern city. We will help the beginning practitioners to expand Iheir knowledge and skills. Write to: Nursing Director, Dawson Creek and District Hospital. 1l100-l3th St., Dawson Creek. British Columbia, VIG 3W8. GeDeral Oaty NIIIWI for modem 41-bed accredited hospital located on the Alaska Highway. Salary and personnel policies in accordance with the RNABC. Temporary accommodation available in residence. Apply: Director of Nursing, Fon Nelson General Hospital, P.O. Box 60, Fort Nelson, British Colum- bia, VOC IRO. Gnenl Oldy RepIemI N...- - required for l3G-bed accredited hOlpital. Previous nperience desirable Staff residence available. Salary as per RNABC contract with northern allowance. For further information please contaCl: Director c:A Nursin&. Kitimat General Hospital, 899 Lahaku Boulevard North, Kitimat, Brittsh Columbia, VSC IE7. Nurse PractItioner required immediately for well equipped, one doctor, government sponsored. community health dinic at Madeira Park. B.C. Anractive rural coastal area. Hours 9-5 Mon. through Fri. with sharing of weekday evening stand by dulies. Salary: S16.332.. 4 weeks annual holiday. car allowance. Apply to: Secretary. Pender Harbour and District Health Centre Society. P.O. Box 308. Madeira Park. British Columbia. YON 2HO. Tel.: (604) 883-2764. Ellperlenced Nunes (eligible for B.C. Registration) required for full-time positions in our modem 300-bed Extended Care Hospital located just thirty minutes from downtown Vancouver. Salary and benefits according to RNABC contract. Applicants may telephone 525-0911 to arrange for an interview, or write giving full particulars to: Personnel Direc- tor, Queen's Park Hospital, 315 McBride Blvd., New Westminster. British Columbia. V3L 5E8. British Columbia Experienced I'unes (B.C. Registered) required for a newly expanded 463-bed acute. teaching. regional referral hospital located in the Fraser Valley. 20 minutes by freeway from Vancouver. and within easy aCCess of various recreational facilities. Excel- lent orientation and continuing education program- mes. Salary-I979 rates-SI305.00---SI542.00 per month. Clinical areas include: Operating Room. Re- covery Room. tntensive Care. Coronary Care. Neonatal IntensIve Care. Hemodialysis. Acute Medicine. Surgery, Pediatrics. Rehabilitation and Emergency. Apply to: Employment Manager. Royal Columbian Hospital. 330 E. Columbia SI.. New Westminster. British Columbia. V3L 3W7. Experknced ICU/CCU and Operallna Room General Duty Nurses required for full-time and summer relief in a 23G-bed accredited hospital in the Okanagan Valley. Must be eligible for B.C registration. Salary SI,305 to SI.542 per month. with differential for special clinical preparation of not less than 6 months. Apply to: Director of Nursing, Penticton Regional Hospital, Penticton. British Columbia. V2A 3G6. Director of Nurslna - Applications are invited for the position of Director of Nursing in a 150 bed accredited general hospital located on central Van- couver Island. The Position - The Director of Nursing is a member of the hospital's senior management team, and as such is involved in the development and implementation of all aspects of hospital policy. The successful candidate will be hired with a view towards an evolving Direclor of Patient Care concept. This vacancy is being created by the retirement of the currenl Direclor of Nursing. The Penon - Applicants should possess suitable academic preparation; have an established record at a senior administrative level with a strong clinical background; and be eligible for R.N .A.B.C. registra- tion. Please send confidential resume indicatina Qualifications, experience. date available, and salary eltpected to: Administrator. West Coast General Hospital, PortAlberni. B.C. V9Y 4S1. Genual Duty RN's or Graduate Nurses for 54-bed Extended Care Vnitlocated six miles from Dawson Creek. Residence accommodation available. Salary and personnel policies according to RNABC. Apply: Director of Nursing. Pouce Coupe Community Hospital. Box 98. Pouce Coupe. British Columbia or call collect (604) 786-5791. Ellperlnced GeDerai Duty Nunes required for 12G-bed hospital. Basic salary S1305 00 - SI542.00 per month. Policies in accordance with RNABC Contract. Residence accommodation available. Apply in writing to: Director of Nursing, Powell River General Hospital, 5871 Arbutus Avenue, Powell River, British Columbia, V8A 4S3. ReJlstered Nunes - Required immediately for a 340-bed accredited hospital in the central interior of B.C. Registered Nurses interested in nursing posi- tions at the Prince George Regional Hospital are invited to make inquiries to: Director of Personnel Services. Prince George Regional Hospital. 2000- 15th A venue, Prince George. British Columbia V2M IS2. R red N...... required immediately for perma- nent full time positions at I G-bed hospital in B.C. Salary at 1978 RNABC rate plus northern living allowance. Recognition of advanced or primary care education. One year experience preferred. Apply: Director of Nursing, Stewart General Hospital, Box 8, Stewart, British Columbia. VOT IWO. Telephone: (604) 636-2221 Collect. GeDeral Duty Nu.... required for an active, IOJ-bed hospital. Positions available for experienced R.N.'s and recent Graduates in a variety of areas. RNABC tontract in effeCl. Accommodation available. Apply to: Director of Nursing, Mills Memorial Hospital, 4720 Haugland Avenue, Terrace, British Colum- bia VSG 2W7. . British Columbia St. Paul's Hospital invites applications from R.C. Rqiltered Nunes for full and part time positions in all areas of the hospital. St. Paul's is an acute referral teaching hospital located in downtown Vancouver. 1979 R.N. rates S1305.00 - SI542.00. Generous fringe benefits. Apply to: St. Paul's Hospital, Personnel Department. 1081 Burrard Street. Van- couver, British Columbia. V6Z IY6. Rq\ltered Nunes, casual and full-time. required for 227-bed general hospital with progressive policies, located approltimately 35 miles south of V ancouver. near the V nited States Border. Demonstrated competence in surgical, medical, obstetrics. I.C.V. or E.C.V. functions required. Apply: Personnel Officer, Peace Arch District Hospital, 15521 Russell Avenue. White Rock, British Columbia, V4B 2R4. New Brunswick Faculty members required with teaching and clinical experience for an mtegrated undergraduate program. (1/ Community Health Instructor to work Yo ith team who teach in the third year. (:!) Co-ordinator of Pedietrics. for students in .econd and third years. \taster's degree desired. baccalaureate e.sential. Salary based on Qualifications and experience. Apply to: I. Leckie. Dean. Faculty of Nur'Ing. Uni\ersity of f'iew Brunswick. Fredericton. N.:w Brun."ick E3B A3. Northwest Territories The Stanton Yellowknife Hospital. a 72-bed accre- dited, acute care hospital requires registered nurses to work in medical, surgical. pedIatric. obstetncaJ or operating room areas. ExceUent orientation and in service education. Some furnished accommoda- tion available. Apply: Assistant Admimstrator- Nursing, Stanton Yellowknife Hospital. Box 10. Yellowknâe. N.W.T.. XIA 2NI. Ontario Childrens summer camps in scenic areas of Northern Ontario require Camp Nunes for July and August. Each has resident M.D. Contact: Harold B. Nashman. Camp Services Co-op, 825 Eglinton Avenue West, Suite 211, Toronto. Ontano, M5N IE7. Phone: (416)789-2181. Co-ed camp ages 14 A 15, Northern Ontario - RN for 6 wks., attractive salary. pnvate room A board. approx. 70 campers, June 25 10 Aug. 14. Write/phone: Camp Solelim, 588 Melrose Ave.. Toronto. Ontario, M5M 2A6 (416) 781-5156 or 635-5410. Quebec RqIotered Nune required immediately in Co-ed Boarding School in country. Applicant must live in and share duties with another resident nurse. Apartment with maid service provided. Excellent working conditions. Liberal holidays. Applications statin, Qualifications and experience 10: Comptrol- ler. Blshop's College School, Lennonille, Quebec, JIM IZS. Saskatchewan R.N.'s and R.P.N.'s (eligible for Saskatchewan registration) required for 340 fully accredited ex- tended care hospital. For further information. contact: Personnel Department. Souns Valley Ex- lended Care Hospital. Box 2001. Weyburn. Sas- katchewan S4H 2L7. - 58 Aprllll171 The C.nedlen Nur.. --- Saskatchewan Regiltered Nunes needed for IO-bed Outpost Hospi- UII in native community 400 miles north of Saska- toon. Contact: Director of Nursing, St. Martin's HospiUII, La Loche, Saskatchewan, SOM IGO. United States Cllllfomla - Sometimes you have to go a long way to find home. But. The White Memorial Medical Center in Los Angeles, California, makes it all worthwhile. The White is a 377-bed acule care teachirIJI medical center with an open invitation to dedicated RN's. We'll challerlJle your mind and offer you Ihe opportunity to develop and conlinue your professional growth. We will pay your one-way transportation, offer free: meals and 10dgirIJI for one month in our ultra-modem nursirIJI residence and provide your work visa. Call collect or write: Ken Hoover, Assislant Personnel Director, 1720 Brook- lyn Avenue, Los Angeles, California 90033; (213) 269-9131, ext. 1680. Critical Care Nurses - EI Camino Hospital, a 464-bed acute care facility has excellent oppor- tunities for full-time or part-time or Per Diem nurses on 3-11 PM or 11-7 AM stufts in the following areas: ICV - new l6-bed med-surg (includes adult open heart patients). CCU - 12-bed new unit equipped with H.P. arrythmia detection monitors offering patient teaching program and nursing research. TCV (Transitional Care Vnit) - 25-bed unit equIpped wilh telemetry for 12 patients. Offers unique cardio-vascular nurse/client teaching program. ER - new spacious area providirIJI a complete range of basic emergency service to 3000 patients per month. The RN staff is certified in Advanced Cardiac Life Support. All these units offer the latest in innovative staff development, patient teaching programs, edu- cational opportunities and a time-saving Com- puterized MedIcal InformatIon Srstem. Salary $1363. (Staff II Step II) shift differenllal $.55/hr. 3-11 and $.75/hr. 11-7. For information, call Patti Aalgaard. RN, Coordinator, Nurse Recruitment at (415) 968-8111. Ext. 44543 or write EI Camino Hospital. 2500 Grant Road. Mountain View. California 94042. An Equal Opportunity EmployerMIFIH. Florida Nunl.. OpportWlltIa - MRA is recruitirIJI Registered Nurses and recent Graduates for hospilal positions in cities such as Tampa, St. Petersburg, and Sarasota on the West Coast; Miami, Ft. Lauderdale and West Palm Beach on the East Coast. If you are considerirIJI a move to sunny Florida, . contact our Nurse Recruiter for assistance in selecting the right hospiUII and city for you. We will provide complete Work Visa and State Licensure infonnation and offer relocation hints. There is no placement fee to you. Write or call MedkaI ReeraltenofAmerlca,IDC.(ForWestCoast) 1211 N. Westshore Blvd., Suite 205, Tampa, FI. 33607 (813) 872-0202; (For East Coast) 800 N.W. 62nd St., Suite 510, Ft. Lauderdale, Fl. 33309 (305) 772-3680. RN's - Boise, Idaho - How would you like a rewardirIJI career in an environment which offers you immediate access to uncongested recreation areas with rivers, lakes and mountains? Do you erijoy tennis, golf, racketball, campirIJI, hiking. skiirIJI and horseback ridirIJI? Sound excitirIJI? It is. And there are many opportunities for satisfying work at one of Idaho's largest and most progressive medical complexes. St. Alphonsus, located in Boise, is a 229-bed facility offering "you positions in orthopedics, ophthalmology, dialysis, menUil health, neurosurgery and trauma medicine. Excellent salary, generous benefits and job security. StartirIJI salary adjusted for experience; benefits include travel assistance, shift rotation, and free: parking. Write or call collect: Employment Supervisor, Penonnel Office, St. Alphonsus Hospital, 1055 North Curtis Road, Boise, Idaho 83704, (208) 376-3613. EOE. Nun", Opportllllltia III New OrIaIaI, LoaUIua - MRA tS recruitirIJI Registered Nunes and recent Graduates for severalleneral and teachina hospitals in the exciti", New Orleans area. OpenirlJls in many specialties and most Canadian Registered Nunes can qualify for licensure endonement in Louisiana. Contact our Nurse Recruiter for infonnation about the hospiUlls and their relocation and tuition assistance plans. We will provide complete Work Visa and State Licensure infonnation. There is no placement fee to you. Write or call MedIal! RKraJten of A_rica, Dc., 800 N. W. 62nd Street, Suite 510, Ft. Lauderdale, Fl. JJJ09. (J05) 772.3680. United States Nursing Opportunity - Mississippi Baplist Medical Center, a mllior 600-bed hospital, has immediate positions available for experienced RNs and recent nursirIJI school graduates in a variety of specialilies and medical/surgical areas. Competitive salaries. liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (population 300.(00), MBMC is the state's largest and most modem privately operated hospital. For further information write: Mrs. Johnnye Weber, Nurse Recruiter, 1225 North State Street, Jackson, Mississippi 39201; or call collect 601/968-5135. Nurses - RNs - Immediate Openings in Califomia-Florida-Texas-Mississippi - if you are experienced or a recent Graduate Nurse we Can offer you positions with excellent salaries of up to $1300 per month plus all benefits. Not only are there no fees to you whatsoever for placirIJI you, but we also provide complete Visa and Li6:ensure assistance at also no cost to you. Write immediately for our application even if there are other areas of the V.S. Ihat you are interested in. We will call you upon receipt of your application in order to arrarlJle for hospital interviews. You can call us collect if you are an RN who is licensed by examination in Canada or a recent graduate from any Canadian Scbool of NursirIJI. Windsor Nurse Placement Service, P.O. Box 1133, Great Neck, New York, 11023. (516 - 487-2818). "Our 20th Year of World Wide Service" TM Bert LocatIon In tbe Nadon - The world- renowned Cleveland Clinic Hospital is a progres- sive, I02O-bed acute care teachirIJI facility committed to excellence in eatient care. Staff Nurse positions are currently available in several of our 6 ICV' sand 30 departmentalized med/surg and specialty divi- sions. StartirIJI salary range is $13,286 to $15,236, plus premium shift and unit differential, progressive employee benefits program and a comprehensive 7 week orientation. We will sponsor the appropriate employment visa for qualified applicants. For further information contact: Director - Nurse Re- cruitment, The Cleveland Clinic Foundalion, 9500 Euclid Avenue, Cleveland, Ohio, 44106 (4 hours drive from Buffalo, N.Y.); or call collect 216-444- 58M. Canadian Nunes - Our 350+ bed full service community hospital in a city of 70,000 in the piney woods and lakes of beautiful East Texas wishes 10 extend an invitation to you to practice nursing in a progressive hospiUII while you and your family erijoy the good life atmosphere of smaller city living. Our special visa sponsorship and licensure program may be what you have been seeking. We plan a trip to several cities in Canada to interview and hire soon so don't delay your response. For more infonnation, please write or call Jack Russell, 611 Ryan Plaza Drive, Suite 537, ArlirlJlton, Texas. 76011. (817) 461-1451. The Eyes of Teus beckon RN's and new grads to practice their profession in one ,of the most prosperous areas of the U.S. We represent all size hospiUlls in virtually every Texas and Southwest V.S. city. Excellent salaries and paid relocation expenses are just two of many super benefits offered. We will visit many Canadian cities in March and April to interview and hire. So we may know of your interest won't you contact us today? Ms. Kennedy, P.O. Box 5844, Arlington, Texas, 76011 (214) 647-0077 or Ms. Candace, P.O. Box 14745, Austin, Texas, 76011 (512) 459-0077. C_ to Tnu - Baptist HospiUII of Southeast Texas is a 400-bed growth oriented organization lookirIJI for a few IIOOd R.N.'s. We feel that we can offer you the chalTerlJle and opportunity to develop and continue your professional growth. We are located in Beaumont, a city of 150,000 with a small town atmosphere but the convenience of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist HospiUII has a progress salary plan plus. a liberal frin&e package. We will provide your immIg- ration paperwork cost plus airfare to relocate. For additional infonnaIion, contact: Personnel Ad- ministration, Baptist HospiUII c:A Southeast Texas, Inc., P.O. Drawer 1591, Beaumont, Texas 77704. An alftnllllllft...... employer. McMaster University Educational Program For Nurses In Primary Care McMasler University School ofNur - ing in conjunclion with the School of Medicine. offers a program for regis- tered nurses employed in primary care eltings who are wIlling 10 assume a redefined role in the primary health Cdre delivery team. Requirements Current Canadian Re- gistration. Sponsor hip from a medi- cal co-practitioner. A( least one year of work experience. preferably in primary care. For further information write to: Mona Callin, Director Educational Program for Nurses in Primary Care Faculty of Health Sciences McMaster University Hamilton. Ontario L8S 4J9 Port Saunders Hospital Port Saunders, Newfoundland Requires two Registered Nurses commencing April 1979 through to September 1979. Applicants must be registered or eligible for registration with the ARNN. Salary scale: $11,448.00-$13,955.00. Please forward application, curriculum vitae and references to: Mrs. Madge Pike Director of Nursing Port Saunders Hospital Port Saunders, Newfoundland AOK 4HO Laurentian Ualvenhy Sc:boo1 of Nunlal Sudbury,Ont. Applications are invited for Faculty Positions In The Following Areas Psychiatric, malernal child and community nursirIJI, NursirIJI Research QuaIIlkIII...: Preference will be given to applicants with master's and/or docloral preparation in the areas noted, and to applicants nuent in French and EnaIish. Salary and rank commensurate with education and experience. For information contacl: Wndy Gerhard DIrector Sc:boo1 of Nun". Laure.d. Ualftnlty SudlMary, o.tarIo P3E lC' The Cenedlen Nur.. - ----.. Aprll1879 57 .... AV " MEDICAL RECRUITERS OF AMERICA INC. MRA recrUlls Registered Nurses and recent Graduates for hospital positions in many U.S. cities. We provide complete Work Visa and State licensure information ARLINGTON. TX. 76011 P.O Box 5844 (214) 647-0077 AUSTIN, TX. 78761 P.O Box 14745 (512) 459-3235 CHICAGO, ILL. 60607 500 So. Racine St.. SUite 312 (312) 942-1146 FT. LAUDERDALE, FL. 33309 800 N W 62nd St . SUite 510 (305) 772-3680 TAMPA, FL. 33607 1211 N Westshore Blvd.. Suite 205 (813) 872-0202 ALL FEES EMPLOYER PA/D The International Grenfell Association requires Regional Nurses on perma- nent or short-term basis for nursing stations as well as hospitals. Salary in accordance with nurses collective agreement. Accommodation, fringe benefits, group life insurance. Travel paid for minimum of one- year service. Apply to: Mr. Scott Smith Personnel Director International Grenfell Association St. Anthony, NOd. AOK 4S0 University of Victoria School of Nursing Applications are invited for the position of Director, School of Nursins, University of Victoria. The School of Nursins presently has one baccalaureate (BSN) program for Registered Nurses. Planning for undergraduate (basic) and graduate programs is in progress. The School of Nursing is part of the Faculty of Human and Social Development which also includes the Schools of Social Work, Child Care, and Public Administration. Experience in administration in the university settins as well as appropriate professional Qualificalions and experience are required. Preference will be given to candidates with a doctoral delVcc. Appointment level and salary will be commensurate with Qualifications and experience. Applications with C.V. and three referees should be sent to: De.. of* Fwulty of Hum_ a_ Soda! DeY U"ftnlty of VIdorI8 P.O. Box 1'711 VldorIa, R.C. VIW 1Y1 United States RNs - AD Excltl"ll Career Awaits You 10 Sunny Las Vex..! Join Valley Hospital, a 28 bed, fully- accredited hospital and increase your nursing skills while enjoying the unique lifestyle of Las Vegas. Contact: Kalene Ryan, Nurse Recruiter. Dept. C-4, Valley Hospital, 620 Shadow Lane, Las Vegas, Nevada, 89106, (702) 38.5-3011. Excitement: Come and join us for year around excitement on the border. by the sea, an unbeatable combination. Er\ioy the sandy beaches of So. Padre tsland or the unique cultures of Old Mexico. Our new 117-bed, acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. Excellent salary and frinse benefits. We invite you to share the challenge ahead. Assistance with travel expenses. Write or call collect: Joe R. Lacher. RN, Director of Nurses. Valley Community Hospi- tal, P.O. Box 469.5. Brownsville. Texas 78.521: I (.512) 831-9611. Nunes - RN. - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa fonns and provide assistance with licensure at no cost to you. Write for a free job market survey. Marilyn Blaker, Medex, .580.5 Richmond, Houston, Texas 770.57. All fees employer paid. ReJløtered Nunes, Uceued Voclltlo.... Nu.... aDd Nunes Aida needed to work at the Kerrville State Hospital in Kerrville, Texas. Kerrville is approx. 6.5 miles north of San Antonio in West Central Teltas. It is a noted recreational area, with the Guadalupe River, many camps and open areas for hiking. Benefits include forty hour work week, sick leave. paid vacation, holidays, good retirement benefits and free group insurance. Starting salary for Registered Nurses is 51,141.00, for Licensed Voca- tional Nurses 5768.00 and for Aides 5.5.52.00 (per month). Nurses and L. V. N.'s are required to have a current Texas license and Aides are required to .be high school graduates. We are an Equal Opportunity Employer. Apply to: Box 1468, Kerrville, Texas 78028. Come to Coastal Tell.. - We are located in a resort, retirement and farming community one mile from the Gulf of Mexico. We are a small friendly hospital in a small friendly community just two hours from Houston. We offer you a rounded career develop- ment program: medical, sU'1lical, OB, nursery and emergency room. We are fully accredited. Rapid advancement to Head Nurse startins at 513,000 plus shift differential, call pay and liberal fringe benefits. New nicely furnished tWD-bedroom apartments are reserved for ' ou. Share one with a Canadian RN companion 0 your choosins, if you like, for 51.50 each includins gas and water. We will pay immigra- tion, licensins and relocation transportation ex- pense. Openinss are limited-four at this writing. Contact: Personnel Department, Wagner General Hospital, Box 8.59, Palacios, Texas 7746.5; or call Athlyn Raasch, .512-972-2.511 collect. Switzerland Hospital of Canton Zürich at Winterthur (72.5 bed hospital near Zürich) needs Operati"ll Room Nurses for the surgery clinic. Required for immediate or future openings. We offer pleasant w,!rking condi- tions. equitable hours of work and leISure. Salary and benefits in accordance with the regulations of the Canton of Zürich. Five-day week. accommoda- tion available. cafeteria. Apply in writing to: Sekretariat PIlegedienst. Kal'tonsspital Winterthur. CH-840I. Winterthur, Switzerland. Miscellaneous Africa - Overland Eltpeditions. LandonJNairobi Ü wkl. London/Johannesburg 16 wks. KeIIya Safari. - 2 and 3 wk. itineraries. Eorope - Campins and hotel tours from 16 days to 9 wkl. duration. For brochures contact: Hemisphere Tours, .562 ElI1inton Ave. E., Toronto, Ontario, M4P 189. Interested 10 Electrolysis Career? Must be an R.N. Successful practice available. Instructions. Write or calJ: Margot Rivard. R.N.. 1396 St. Catherine Street West. Suite 221, Montreal. Quebec, H3G 1P9. Telephone: (.514) 861-19.52. r'" Before accepting any position in the U.S.A. PLEASE CALL US COLLECT We Can Offer You: A) Selection of hospitals Ihroughout the U S.A. B) ExtenSive information regarding Hospital-- Area. Cost of Living, etc. C) Complele licensure and Visa Service Our Services to you are at absolutely no fee to you. WINDSOR NURSE PLACEMENT SERVICE P.O. Box 1133 Great Neck. N.Y. (516) 487-2818 Our 20th Year of World Wide Service .... Foothills Hospital, Calgary, AI berta Advanced N eurological- Neurosurgical Nursing for Graduate Nurses A five month clinical and academic program offered by The Department of Nursing Service and The Division of Neurosurgery (Department of Surgery) Beainn....: MJlrch, September Limited to 8 participants Applications now being accepted For further Information, pleue write to: Co-ordinator of In-service Education Foothill. Hospital 140329St. N.W. Calpry, Alberta T2N 2T9 UNITED STATES OPPORTUNITIES FOR REGISTERED NURSES A V AILABLE NOW IN ARIZONA CALIFORNIA TEXAS WE PLACE AND HELP YOU WITH: STATE BOARD REGtS"ffiATION YOUR WORK VISA TEMPORARY HOUSING - ETC A CANADIAN COUNSELLING SERVICE Phone: (416) 449-.58\13 OR WRITE TO: RECRUITING REGISTERED NURSFS INC. 1100 LAWRENCE A VENUE EAST. SUITE 301, DON MILLS, ONTARIO M3A ICI FLORIDA OHIO NO FEE IS CHARGED TO APPLICANTS 58 "prlll!!7!! The Canedlen Nur.. University of British Columbia Government of Canada Teaching Positions HEALTH CARE OFFICERS Applications are invited for teaching positions in undergraduate and graduate programs. Master's or higher degree and experience in clinical field required. Positions open in July, 1979. Candidates must be eligible for registration in B.C. Send resume to: Dr. Marilyn Willman Director, School of Nursing University of British Columbia 2075 Wesbrook Place Vancouver, British Columbia Canada V6T lW5 Psychiatric Nursing Co-Ordinator (Assistant Director of Nursing level position) for 80 - 100 beds of Psychiatry in a 450 bed accredited General Hospital. Qualifications: Registered Nurse with Baccalaureate Degree and current clinical experience in psychiatric nursing. Experience in nursing administration also neces- sary. Salary and benefits commensurate with qualifica- tions. Write, giving qualifications and experience to: Catherine E. Smith Executive Director of Nursing Owen Sound General & Marine Hospital 12016th Ave. West Owen Sound, Ontario N4K SH3 Canadian Penitentiary Service Various Locations - Lower Mainland- including Fraser Valley This competition is open to both men and women who are residents of the province of British Columbia. Salary: $16,347 - $18,974 per annum Plus Penological Factor Allowance Clearance Number: 709-004-004 Duties: The successful candidates will assist the medical staff in examination and treatment, provide direct nursing care to inmates and counsel staff and inmates on matters of health and hygiene. Qualifications: Applicants must be eligible for registration as a registered nurse in a province or territory of Canada and have several years experience in implementing nursing practices and techniques. Willingness to work in an institutional environment on a shift rotating basis is also required. Knowledge of English is essential. Send your application form and/or resumé, quoting Reference Number 79-V-CPS-2 before April 30, 1979 to: C. Pinhey Regional Staffing Officer Public Service Commission P.O. 11120, Royal Centre 500 - 1055 West Georgia Street Vancouver, B.C. V6E 3L4 Th. Canedlen Nur.. April 1979 59 ATTENTION: NURSES, PSYCHIATRIC NURSES, REGISTERED NURSES AND RECENT NURSING GRADUATES If you are a graduate nurse or obout to graduate from an approved school of nursing thinl about starting your coreer at The Alberta Hospital. Edmonton. This is a progressive psychiatric treatment facility which presently has positions avail- able for general duty and psychiatric nurses to work on a rotating basis. In addition to an excellent starting salary. the opportunity exists to expand your psychiatric nursing qualifications through on-the-job experience. Management programs are offered periodically to those interested in professional advance- ment. An Accredited Hospital A facility of Alberta Social Services and Community Health. the Alberta Hospital is a dynamic regional centre with three (3) year accreditation status. Exceptional Benefits The Alberta Hospital offers a pleasant nurses residence with attractive staff facilities. You'll enjoy twelve (12) paid holidays. three (3) weeks annual vacation (rising to 4 weeks after 10 yeors) and a very attractive employee benefit package. Fringe ßenefits include uniforms. laundry and free porking. Job Satisfaction Since staff are encouraged to use their own initiative as part of a concerned inter-disciplinary team. morale is high and nurses enjoy a pleasing sense of job satisfaction. If you re serious about your nursing coreer and want to advance here is the ideal place to pursue your goo Is. Immediate vacancies now exist for graduate nurses and Head Nurses. Relocation ossistance is offered to applicants at senior levels. Qualifications Graduation from an approved school of nursing Must be eligible for registration with the respective professional Alberta Associations Salary $13.608.00 to $15,996.00. Starting salary within this range will depend on qualifiCations and ex- perience. NOTE: Salary scale does not reflect additional increments for forensic work and shift differential Apply To: PERSONNEL ADMINISmATOR. ALßERTA HOSPITAL. ßOX 307. DMONTON, ALßERTA T5J 2J7. Quating Competition No. 9184-3 This competition will remain open until suitable candidates have been selected. All:øra 60 April 1979 The Cenedlen Nur.. Applications are invited for Public Health Nursing Supervisor ()ualifications: Bachelor of Science in nursing. leadership ability. a minimum of three years' experience in a generalized Public Health program. Po"ition available: May 5. 1979. Application with curriculum vitae should be ",ubmitted to: Mr. R. Dick Personnel Officer Waterloo Regional Health Unit 8th Floor, Marsland Centre 20 Erb Street West Waterloo, Ontario N2J 4G7 Registered Nurses 1200 bed hospital adjacent to University of Alberta campus offers employment in medicine, surgery, pediatrics, obstetrics, psychiatry, rehabilitation and extended care including: . Intensive care . Coronary observation unit . Cardiovascular surgery . Bums and plastics . Neonatal intensive care . Renal dialysis . Neuro-surgery Planned Orientation and In-Service Education programs. Post Graduate clinical courses in Cardiovascular- I ntensive Care Nursing and Operating Room Technique and Management. Apply to: Recruitment Officer - Nursing University of Alberta Hospital 8440 - tl2th Street Edmonton, Alberta T6G 287 Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Regislered Nune in search of a change and a challenge- look into nursing opportunities at Vancouver General Hospital, B.C.'s lru\Ïor medical cenlre on Canada's unconventional West Coast. StaffirIJI expansion has resulted in many new nursing positions at all levels, includirIJI: General Duty ($1231-1455.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the oppl'rtunity you've been 100kirIJI for. For those with an interest in specializaIion, challenges await in many areas such as: Neonatology Nursing Inservice Education Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn Unit Coronary Care Unit Hyperalimentation Program Renal Dialysis & Transplantation Paediatrics If you are a Nurse considering a move please submit resume to: Mn. J. MacPbaII Employee Relations Vancouver General Hospital 855 West 12tb Avenue Vancouver, H.C. V5Z IM9 [l]@ University of Alberta Hospital Edmonton, Alberta o The Cenedlen Nur.. '.. \ .s 4 , ".1 ;:z I , JJ! I "'l..- - .-...r4i i r -. . . III \t-\ '\ \ "' .. can go a long way , . . to the Canadian North in fact! Canada's Indian and Eskimo peoples in the North need your help. Particularly if you are a Community Health Nurse (with public health preparation) who can carry more than the usual burden of responsi- bility. Hospital Nurses are needed too... there are never enough to go around. And challenge isn't all you'll get either - because there are educational opportunities such as in- service training and some financial support for educational studies. For further information on Nursing opportunities in Canada's Northern Health Service, please write to: ø........, I Medical Services Branch I Department of National Health and Welfa,. Ottawa, Ontario K1A OL3 I Name I I Address.. I I City Provo I I .+ Health and Wella", Sanlé el Blen-.lre lIoclal I Canada Canada ,........ Aprl1187i 111 m '. '\ C' i:' "i... "'''$ ;(:- C' o i:' O'. o .o . $ Open to both men and women HEALTH CARE OFFICER (508-326-006) Salary: $15.117to$16.986 Aef. No: 79.PSC/SOL.().A2 ICNI Solicitor General Canada. Correctional Service of Caneda Prince Albert. Saskatchewan Duties Requires active co-operation with other members of the health care team. Responsibilities include out-patient and bedside nursing. emergency first aid and counselling for in- mates. Nurses employed will be directly and indirectly in- volved in the development of mental and physical health programs for the inmates. This is an exciting opport,mity for dynamic persons seeking satisfaction and challenge in a progressive department. Oualificlltlons Eligibility for registration as a registered nurse in a province or territory of Canada. Knowledge of English is essential. For further information contact, K. S1nclair at (2041 ..949-2463. Winnipeg. How to Apply Send your application form and/or résumé to: K. Sinclair. Staffing Officer PubUc Service Commission of Canada 500 Credit Foncier Building. 286 Smith Street Winnipeg. Manitoba A3C OK6 Please quote the applicable relerence number at all times. ...... 62 April 1878 Th. Cenedlen Nurs. University of Western Ontario Faculty of Nursing Faculty positIon available July I, 1979, or by arrangement. Rank open. Master's degree or doctorate required. Teaching and research In various areas of nursing. Salary in accordance with the University of Western Ontario policies. This appointment is subject to funds being avail- able. Applications should be forwarded to: Dr. 8everlee Cox, Dean Faculty of Nursing Health Sciences Centre The University of Western Ontario London, Ontario N6A 5Cl Director of Nursing Service Required for Wetaskiwin General Hospital Applications for the above position are invited on or before June 1, 1979. The Wetaskiwin General Hospital is a 135 bed active treatment hospital and is located in a small city just 35 miles south of Edmonton. The facility is part of a complex which operates a 50 bed auxiliary hospital and a 50 bed nursing home. The successful applicant should ideally have ex- perience in the administration of a nursing program and possess a B.Sc.N. Degree, but, equivalent combination of formal education and experience will be accepted. Position will open on retirement of present incum- bent. Address all inquiries in writing together with a complete resume to: P.O. Langelle Administrator Wetaskiwin Hospital District 5505 - 50 Avenue Wetaskiwin, Alberta T9A OT4 General Duty Nurses The Royal Alexandra Hospital, 970 Bed teaching hospital requires: General Duty R.N.'s for temporary vacation relief posttlons in most clinical areas. Positions vary in duration between 9 weeks and 20 weeks, depending on clinical area. Employment date -July 2, 1979. Applicants must be eligible for Alberta registration with A.A.R.N. Please direct inquiries to: Mrs. R. Tercier Director of Nursing Personnel - Administration Royal Alexandra Hospital 10240 - Kingsway Avenue Edmonton, Alberta T5H 3V9 Registered Nurses Come to work in scenic Corner Brook for the summer months. Summer-relief registered nurses are needed for this 250-bed regional general hospital with detached 60-bed Special Care Unit serving the West Coast of Newfoundland. The area offers many facilities for summer activities and sports including swimming, sailing, camping, and hiking. One-way Air-fare to Corner Brook will be paid. Salary scale: Presently under negotiation; $11,448.00 - 13,955.00 per annum. Service credits recognized. Residence accommodation available. Apply: Director of Personnel Western Memorial Regional Hospital P.O. Box 2005 Corner Brook, Newfoundland A2H 6J7 Telephone: (709)634-5101 Ext. 367. The Cenedlen Nur.. April 1979 83 Southern California Nursing: Three Who Made The Change " It was a big step to move from Southwestern Ontario to an entirely new job and surroundings in California. but everyone on the staff at S1. FrancIs made me feel very welcome. They're all so warm and friendly - I really feel like an integral part of their team. "S1. Francis is more than I ever expected. but for me Labor and Delivery is the most exciting. Along with my helpful coworkers, the advanced monitoring equipment. and delivery room techniques. I've found my unit a great place to advance my knowledge. '" am proud to be a part of S1. Francis Medical Center. Irs a great place to work _.. come and see for yourself." Shirley Allin, RN . . . ... \ "I'm from Prince Edward Island, Canada, and have been employed by S1. Francis Medical Center for one year now _ I spent four months trying to obtain my visa to Southern California - S1. Francis obtained it for me in one week. "S1. Francis is located within a short distance from the beach and mountains. offering you a wide choice of social recreation. "I am really enjoying my nursmg experience with S1. Francis and have found the staff especially friendly and helpful " Patricia MacLeod, RN , " I came to S1. Francis from Calgary. Alberta Canada The atmos- phere at St Francis is warm and personal and the people never hesitate to make me feel at home. "S1. Francis provides many channels for growth. The staff IS always available for help. "The knowledge and experience I am gaining through living and working in a different country are limitless. I have met many new people and seen many new places thanks to St Francis." Colleen McPhail, RN II I \ ................................... : S1. Francis Medical Center is located just outside of Los Angeles, in the city of Lynwood Facilities . . embrace a complete range of medical-surgical services, including open-heart surgery, intensive and . coronary care, definitive observation, acute and renal dialysis, neurostroke, inpatient psychiatry, in/ out . . patient rehabIlitation, intensive newborn care, diagnostic and therapeutic radiology including cobalt and . . ultrasound. and a 24-hour Emergency Department. The 524-bed hospital has a nursing staff of . approximately 700. . Make the change to a hospital that lets you be what you want to be. Write us for more information or . . call Brent Nielsen. RN, Nurse Recruiter, collect at (213) 603-6083. . . 0 Please send me a brochure about SL Francis Medical Center. . · Name St Francis · : : ress Slale Z;p H r: . Phone (-) RN 0 Student 0 Lynwood California 90262 . . Area of interest An equal opportunity employer CN 4-79 . ................................... 114 April 1878 Th. Cenedlen Nurs. Uncoln Institute of Health Sciences School of Nursing Lecturer: Post Registration Courses The Lincoln Institute's School of Nursing invites applications from suitably qualified and experienced nurses for the above position. The position will involve teaching post registration nursing students undertaking degree and diploma courses, which include major components of advanced nursing practice. Qualifications: Comparatively recent expenence of study in an area of clinical nursing or in nursing research, and experience in nursing education. A formal qualification in teaching and a degree in a discipline relevant to nursing practice would be an advantage. The Lincoln Institute of Health Sciences is a tertiary education institution fully funded by the Commonwealth Government. It offers degree or diploma courses in a number of the health sciences. The total student population in 1979 will be approxi- mately 1500. Some 250 of these will be undertaking nursing programmes. Salary range: Lecturer II $A 15,786-$A 18,050; Lecturer I $AI8.474-$A20,736. The position is for a fixed term appointment of three to five years, or a continuing appointment would be considered. For an overseas appointment, his/her fare would be met, and there would be an allowance for baggage expenses; as well, the Institute would contribute towards fares and baggage costs for dependents. Applications in writing, including full curriculum vitae together with the names of three professional referees, should be addressed to Assistant Registrar, Lincoln Institute of Health Sciences, 625 Swanston Street, Carlton, Victoria 3053 Australia. Advertising Rates For All Classified Advertising $15.00 for 6 lines or less $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies of the hospitals and agencies advertising in the Journal. For authentic infonnation, prospective applicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse 50 The Driveway Ottawa, Ontario KlPIE2 . Index to Advertisers April 1979 Cover 4 Abbott Laboratories A.B.C. MedIcal Instruments Inc. The Apothecary Service (A Division of Shoppers Drug Mart) Ayerst Laboratories Becton Dickinson, Canada Canadian College of Health Service Executives 7 51 49 4,5 2 8 15 54 Canadian Dairy Foods Service Bureau The Canadian Nurse's Cap Reg'd Canadian School of Management Career Dress (A Division of White Sister Uniform Inc.) Encyclopaedia Britannica Publications Limited Equity Medical Supply Company Health Care Services U pjohn Limited Hollister Limited J. B. Lippincott Company of Canada Limited TheC.V. Mosby Company Limited Pentagone Laboratories Limited Cover 2 17 9 52 13 34,35 44,45,46,47 10,11 54 Posey Company W.B. Saunders Company Canada Limited 53 48 G .0. Searle & Company Canada Limited Simpsons-Sears Limited Wellcome Medical Division (Burroughs Wellcome Limited) Cover 3 Advertising Manager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa, Ontario K2P I E2 Telephone: (613) 237-2133 Advertising Representatives Jean Malboeuf 601, Côte Vertu St-Laurent. Québec H4L IX8 Téléphone: (514)748-6561 Gordon Tiffin 190 Main Street Unionville, Ontario UR 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster Avenue Ardmore, Penna. 19003 Telephone: (215)649-1497 Member or Canadian Circulations Audit Board Inc. Iæ1:J , - - " " .... - .. . , ,\(1. 1ø\ , atØ iJ.-øe . You." a",,'ec;ate the fine fit and easy upkeep of our smart uniforms. Both are in a Dacron" polyester warp knit, Zelcon -treated to 'breathe' mOre like a natural fabric, and to release soil easily when machine-washed. Comfort- able 'action back' lets you move freely. 8 to 18. Shirt dress with 2 patch pockets, detachable belt. White. 31 R 002 302 A. $25 2-pc. pant set has button- front top with 2 pockets. Pull-on pants. Mint Green, White. 31 R 002 393 B. $30 .Reg'd Can. T.M. II I Ii i I Sears , Simpsons-Sears Limited, These and other uniform fashions can be found in our Sears retail stores, and our 1979 Spnng and Summer catalogue I:-- BUTTERFLY * the winged infusion set of choice I J L ,. ::1 M;'-' c:J 'RO T.M . Caring for the suicidal patient . Nutrition and the ICU patient The Canacl Nune . Northern nurses speak out . Cape Breton mining disaster - how nurses helped . Annual meeting highlights BIBlIOTHEQUE SCIENCES INFIRMIERES M AY A I 9 l O {9' . I : RARY MAY 1979 ""'" - - - - ç ..' :: - - - - - '" - ""- .... , . .. 'I '" t ... , . -.,.- I .. '\. ...- .... - . . . "'\ ",,\ .. .; ,"i..- ...... : ..... till ..:! . -J..' . {..;- ...- ;' ... ... .... c- -. " .. ..., \ .. ...- .. \ .. . ""'- .. " ..... ...... .. . r;t-ì Nl>1 II . -- Ii 1 ..'....., ..' " .. . . . II I I! ,I ,I JH!Vl"'r:J VM\lllJ ^ V gIl \JIS, 1'1 V V l l J 1 AJIS ^I n C;f.f.L9.l0ÇL..>3 &l71 11::1 . ,. p Siste , 1 .. I r IJ , I JJ \ Style No. 42373 - Pant suit Sizes: 3-15 "Impact Plus 100% textured Dacron" polyest with ZelconiR> finish White, Peppermint. . . about $3 e No. 2330 - Dress )izes: 8-18 i'lmpact Plu .. 100% textured Dacron" polyester lVith Zelcon" finish Nhite, Pink, . . about $32.00 ... .-. A · - . u nU , a swer .0_ Iii - na ura . res "ZELCO Q" - e. e'd n w'. all exclusive '" I .act -Ius' 0,0. t ur-d I . C . po -. t - r a.. kni . omf tab e to wear and so e. . c. - fa . The Canadian Nurse May 1979 The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number 5 Input You and the law Calendar 8 COVER STORY CNA's 1979 annual meeting STAFFING ASSIGNMENT A review of past and current systems of nursing care delivery The loneliness of the elderly 10 Margaret Beswetherick 18 Amy E. Griffin 23 Lance W. Roberts Colin A . Ross 26 Heather L. Erb 30 Jeanne Marie L. Hurd 36 Valerie MacDougall 39 Lise DeBoer 43 44 Books Library Update 15 51 54 Nursing north of Sixty Emergency treatment of drug overdose 55 FRANKLY SPEAKING Nursing and the degree mystique Nutritional assessment of the ICU patient Sir, I know CNA Testing Service EMERGENCY A special report on the Cape Breton mining disaster and the nurses involved Dorothy Gray Miller 46 ;( , I .. t .- .... r ... I The Rt. Hon. Edward Schreyer was an honored guest at CNA's annual meeting this year. Two nurses who have special reason 10 remember the occasion are Dr. Moyra Allen. (far right) professor of nursing and director of research at MdJiII University in Montreal, and Huguette Labelle. (second from left) assistant deputy minister. Corporate Policy. Department of Indian and Northern Affairs, Ottawa, recipients of the 1979 CNA awards to outstanding nurses. C O\'('r photo and com'ention co"erage bv AI Patrick Photography Ltd. The Canadian Nurse welcomes suggestions for articles or unsolicited manuscripts. Authors may submit finished articles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and carbon. All articles must be submitted for the exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. The views expressed in the articles are those of the authors and do not necessarily represent the policies of the Canadian Nurses Association. ISSN 0008-4581 Canadian Nurses Association, 50 The Driveway, Ottawa, Canada, laP IE2. Indexed in International Nursing Index, Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microfonn from Xerox University Microfilms, Ann Arbor, Michigan 48106. Subscription Rates: Canada: one year, $10.00; two years, $18.00. Foreign: one year, $12.00; two years, $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not "responsible for journals lost in mail due to errors in address. Postage paid in cash at third class rate Toronto, Ontario. Pennit No. 10539. Canadian Nurses Association, 1978. Team up with Mosby to make sure your students get the most current and authoritative nursing texts. A New Book FUNDAMENTALS OF NURSING PRACTICE: Concepts, Roles, and Functions ( Two widely respected nursing authors collaborate to provide a unique introduction to nursing fundamentals_ Emphasizing holistic care, their book. . I on the h alth c..tre de (f>ry_ e , ... -. J P oce!' e 'onng the dlf1 lanne r J:- _ __ _ (m 11 >rter coord na'or-coP'lbora,or . L ,nt nas relr vant t e fL. Ire f nlJrring . n ow how _pply to ., 6 . New 14th Edition Fundamentals of nursing practice . J W aporopn By Fay Louise Bower, R.N_. D.N.Sc., F.A.A.N. and Em Olivia Bevis, R.N., MA, FAA N.; with 8 contributors January. 1979 614 pages, 391 illustrations Price. $16 95. c. ""'\"l t "1'" roC.)1 t..... '\F'.1111 'l 11\ . ... PHARMACOLOGY IN NURSING Ih"'\IKA'I1.)Ht".-. The latest edition of this classic will help you guide your students in providmg rational and optimal drug therapy_ Clear and complete discussions focus on basic mechanisms of drug action, indications. contraindications, toxicity, side effects, and safe therapeutic dosage range_ Highlights in this new edition include: . In adrr allan f drug ""'" þ """'\ , ,.. . ... ""'$ O _.. _ O&'y #..-- ..... --......- - .. - - -.-. .,..... · .- eã.. · . . . .. ...<" .... .::+" ..,. $ ,.. "t' "'Ii e hBlJt' d .'1at review key ('')n- pt., m the . r, NIT' 'nlymf>S and d,..!" ar " on 'lastromt"'stmal - 1ars By Betty S Bergersen R.N., Ed D. January, 1979 Approx. 784 pages. 100 illustrations. About $20.50. 3rd Edition NUTRITION AND DIET THERAPY Since publication of the first edition, this text has been a leader in its field. This current edition continues - and exceeds -that tradition of excellence. It focuses on the role of nutrition in public health. in the basic health care specialties. and in the clinical management of disease - all in the context of human needs. Students will be particularly interested in these new items: · authontative secllons on behavioral approaches to weight control and ulolizmg the problem-onented medical record; · expanded mformatlon on mmerals m the body with emphasl on zinc; · new and revised tables mcluding the latest RDA By Sue Rodwell Williams. M.P.H., M.R.Ed.. Ph.D. 1977. 741 pages, 134 illustrations. Price. $20.50. New 2nd Edition CLINICAL IMPLICATIONS OF LABORATORY TESTS When students ask questions on the significance of laboratory test results, offer them this concise resource. Using an effective. step-by-step approach, it first examines the routine multisystem screening panels - routine urinalysis and hematology screening and sequential multiple analyzer tests. Subsequent chapters focus on evaluative and specific tests of suspected disease entities. Throughout, the authors emphasize physiological implications. variations, and interrelationships of laboratory values. New features: · offers handy sections on patient preparation. mstructlon, and aftercare; · replaces the chapter on serodiagnostiC tests with two new chapters on rheumatoid and mfectlous diseases. · provides an extensively revised chapter on gastroenterology. · reflects the latest research in the table of normal values By Sarko M. Tilkian. M.D.; Mary Boudreau Conover, R.N.. B.S.N.Ed.: and Ara G. Tilkian, M.D., F.A.C.C. January, 1979.334 pages, 45 illustrations. Price. $10.75. q' ''/0 , . . <:::::; <::> A New Book MEDICAL-SURGICAL NURSING: Concepts and Clinical Practice Uniting the benefits of both a conceptual and a systems approach. this new text will be the best choice for your studentsl The authors have organized information in a way to make it easily accessible and have emphasized total patient care throughout. A few key features of this important text are. · a -ý-'-ms approach wlthm a conceptual framework - - meanrng your s _dents will be able to locate Important Information qUickly aõ1d better undrrstand how specIfic medical details relate tr total patl nt care · a begmnrng set Ion on "PerspectlvPs for Nur!..ng Practice offers a useful look at many issues your students will face, · a vital section or strE'-, and adaptation · , nurs ng process format .> u ..:d m E..lch clinical section - where the authors first present a chapter on general assessment of the involved body system. then dlf- -- specific management trchr qucs m a separate chapter By Wilma J. Phipps. R.N.. Ph.D.: Barbara C. Long. R.N.. M.S.N.; and Nancy Fugate Woods. R.N., Ph.D. February. 1979. Approx. 1,600 pages, 735 illustrations. About $27.75. . "" _# .$ - - + '"' . #" .f / , '. \ \ ........, .\ \ ,," \'" IIt,_ ..""""" ....... ". \t "'... " t \ ..... "h ". -- .. 'S IVIOSBV TIMES MI O A New Book BASIC PATHOPHYSIOLOGY: A Conceptual Approach The authors of this useful new text have organized the vast field of pathophysiology into major conceptual areas. Your students will study various disease entities as they relate to such concepts as cellular deviation, body defenses. physical and chemical equilibrium, nutritional balance, reproductive and endocrine integrity, and structural and motor integrity Specific noteworthy discussions investigate: . immunopathology: . aging as a genetic process: . atherosclerosIs: . diabetes and obesity; . immune viral organisms of human cancer. Each chapter begins with learning objectives which can be used to aid the student in self-evaluation. By Maureen E. Groër, R.N.. Ph.D. and Maureen E. Shekleton. R.N.. M.S.N. February, 1979. Approx 560 pages, 423 illustrations. About $19.25. HEALTH ASSESSMENT Written by nurses for nurses, this well-illustrated guide provides practical methods for obtaining a complete history and performing a thorough physical examination. Students will especially benefit from discussions which: . detail beneficial techniques for appraising client function . examine nutritional assessment. sleep-activity patterns and the use of climcallaboratory skills By Lois Malasanos, R.N, Ph.D.; Violet Barkauskas, R.N.,C.N.M., M.P.H.; Muriel Moss, R.N., M.A.: and Kathryn Stoltenberg-Allen, R.N., M.S.N. 1977.538 pages, 769 Illustrations. Price, $26.00. A New Book NURSING CARE OF INFANTS AND CHILDREN Using a systems approach, this new book provides a comprehensive, practical look at pediatric nursing. The authors not only examine care of the ill or disabled child, but also stress promoting the health of the well child. Among the highlights you'll find: . pertinent guidelines for action, . a distnbutlve nursmg care approach: . lab data and pharmacology mformatlon; . emphasis on and gUidelines for communicating with children and their families, . an appendix of normal values and assessment tools. By Lucille F. Whaley, R.N., M.S. and Donna L. Wong, R.N., M.N., P.N.P. April. 1979. Approx. 1,408 pages, 746 illustrations About $24.00 Team up with Mosby. Basic pathophysiology A CONCEPTUAl AP Groer and Shakl . éS . MATERNITY CARE: The Nurse and The Family Both contemporary and humanistic in approach, this important volume can help the student function more effectively as a maternity nurse in today's changing society. Following the chronologic order of childbirth, it discusses the biopsychosocial aspects of human sexuality, then proceeds to family planning, pregnancy, interferences with normal pregnancy, labor and its complications, the post-partum period, and both normal and high-risk infants. Throughout, the authors: . integrate diagnostic. therapeutic, and educational objectives, . present intervention plans: . combine clinical and psychosocial aspects Timely discussions explore such key topics as genetics, legal factors, fathering, and P.O.M.R. By Margaret Duncan Jensen. R.N.. M.S.; Ralph C. Bensen, M.D.; and Irene M. Bobak, R.N., M.S.: with 2 contributors. 1977. 784 pages, 684 illustrations. Price, $24.00. New 2nd Edition CHILD HEALTH MAINTENANCE: Concepts in Family-Centered Care Students will benefit from the integration of a conceptual approach, a problem-solving framework. and a strong emph<-_ _ on the holistic person of the c ild, in this new edition of an exciting text. It reflects contemporary advances in diagnosIs and quality assurance as It examines such topics as problems of single parent families, care of the terminally ill child. high risk infants, nursing assessment, and specific health problems This new edition also offers: · a defmitive section on competencies - physical. learnmg social. and Inner. · major seclions on health promotion and prevention of illness. · revised discussions of the family unit; · an expanded chapter on high rrsk Infants - mcluding cardiopulmonary disorders infection, and GI disturbances. · thought-provoking diScussions of Juvenile and adolescent rape victims. By Peggy L. Chinn, R.N., Ph.D. March, 1979. Approx. 896 pages. 377 illustrations. About $24.00. New 2nd Edition CHILD HEALTH MAINTENANCE: A Guide to Clinical Assessment This concise text serves as both a student-oriented learning guide for comprehensive health assessment and as a source of information for effective pediatric care. The authors present a wealth of information on developmental differences observed from birth through adolescence - indicatmg possible deviations and their health care implications. This edition also incorporates these valuable new insights: · an authorrtatlve chapter on assessment of learnmg. thought, social, and mnercompetencles; · a detailed chapter on norms and standards for nursmg assessment and mtervention providmg normal growth development charts recommended schedules for immunization and laboratory procedures · a new chapter on assessment tools and case audit gUldes- suggesting gUidelines for family. infant. child. and play assessment. By Peggy L. Chinn. R.N.. Ph.D. and Cynthia J. Leitch, R.N., Ph.D. March, 1979. Approx. 176 pages, 24 illustrations. About $9.75 Child healö1 maintenance \ i' -. ..... L ø-. ....... A New Book PRINCIPLES AND PRACTICE OF PSYCHIATRIC NURSING Using a nursing-oriented conceptual approach to psychiatric nursing. this text describes man's adaptation to illness. and identifies nursing diagnoses and specific nursing interventions. · Part lis organized according to specific nursmg diagnoses _ anxiety. disruption in the communication plocess. and grref. for example; · Part II examines varrous therapeutic modalities presenlly m use; · throughout the authors stress nursing interventions and the application of the nursing process By Gail Wiscarz Stuart. R.N., M.S., C.N.: and Sandra J. Sundeen, R.N.. M.S ; with 15 contributors. May 1979. Approx 736 pages. 24 Illustrations About $20 50. A New Book COMMUNITY HEALTH CARE AND THE NURSING PROCESS Help your students stay informed of the exciting new changes in community health nursing with this comprehensive text. Its timely discussions provide a holistic view of human development by stressing three basic concepts. the health- illness continuum; humankind as an open system that always relates to and interacts with its environment: and the effects of various situations, health problems, and stressors on the health and development of the individual. family, and community. Student-oriented features inc:ude: · an eclectic approach to communrty nursmg · up-to-date discussions - both in concept and content; · fascmatmg case studies to develop the thmking process and stimulate the ability to make creative Judgments · the insights of noted contrrbutors By Margot Joan Fromer. B.S., M.A.; with 7 contributors. January. 1979. 484 pages. 110 illustrations. Price. $18.00. IVI OS BV TIMES MIRRDR THE C. V. MOSBY COMPANY, LTD. 86 NORTHLINE ROAD TORONTO, ONTARIO M48 3E5 A90535 . May 11171 The Canadl.n NUrH perspective Project Ethics: a code for Canadian nurses In October 1978, acting on a resolution proposed and accepted by CNA membership, directors of this association agreed to proceed with development of a Canadian Code of Ethics for nurses. Since then, directors have approved the appointment of Sister Simone Roach, CSM, Ph.D., chairman of the nursing department of St. Francis Xavier University in Antigonish, N.S. as director of Project Ethics. - , . Sister Simone Roach Nurses have always been concerned about ethics - the rules and principles which guide the practice of nursing. The scope and applicability of these rules and principles have varied, just as the practice of nursing itself has varied during successive periods of its history. A Code of Ethics reflects an ethos; that is, it emanates from the specific characteristics and values of a particular group or society. But it also says something to that group, for a code is built upon more enduring principles than constantly changing rules or judgements. Ethics provide standards based on fundamental moral principles. Today, as people in every culture and discipline question the moral basis of their respective structures, activities, and patterns of behavior, the nursing profession is seeking to articulate, with renewed clarity, the fundamental principles which provide support for, and give direction to. its specific mandate. Concern about ethical issues in health care, mounting in Canada over the past number of years, was expressed by the nurses of Canada at their last biennial meeting. That we are now committing ourselves to the development of a Code of Ethics is a further expression of this concern. The task of developing a Canadian Code of Ethics is a complex undertaking; it represents a challenge to nurses across the country. As project director, I solicit your input. As a suggestion, you might like to identify: . the principles which you believe ought to be the basis for a Canadian Code of Ethics . general content areas which ought to be considered . areas of ethical conflict which you are presentl y experiencing . the kind of help you would hope to derive from having our own code. Please address your communications to: Project Ethics Canadian Nurses Association 50 The Driveway Ottawa, Canada K2P IE2 herein This month, Dorothy Gray Miller, public relations officer with the Nova Scotia Nurses Association, shares with us the exciting and untold story of the part that nurses played in the February mining disaster in that province when 12 miners were trapped by an underground explosion. In aCNJ exclusive feature report, beginning on page 47, she tells us about the nurses who went down into the pit, waited at the Mine's nursing station and helped to care for the six survivors in hospital outpatient departments and bum units. It all goes to show something that we've suspected for some time: nurses in this country are taking on some pretty challenging and unusuaIjobs these days. They're moving out of our hospitals, into the community - into outpost clinics, northern nursing stations, offices, schools and factories. They're bringing health to the people where those people live and work and learn. We'd like to share more of these stories with you. If your job presents this kind of challenge, or if you know of a nurse whose work demands a special caring quality, why not let us know. Next month, Thomas Edison and Albert Einstein are recognized the world over for their contributions to human knowledge and the advancement of scientific understanding. What is less well known is the fact that both Edison and Einstein were "learning-disabled" children, later diagnosed as being dyslexic. Difficulty in learning to read or write (dyslexia) is one of many perceptual motor processing deficits which can turn children into under-achievers. Next month, a professor of speech pathology and a nurse who is herself the mother of a learning disabled cbild discuss how nurses can work with parents, teachers, psychologists, and other professionals to recognize and obtain help for children with learning disabilities. EDITOR ANNE BESHARAH ASSISTANT EDITORS LYNDA FITZPATRICK SANDRA LEFORT PRODUCTION ASSISTANT GIT A FELDMAN CIRCULATION MANAGER PJERREITE HarrE ADVERTISING MANAGER GERRY KA V ANAVGH CNA EXECUTIVE DIRECTOR HELEN K. MUSSALLEM GRAPIßC DESIGN ACARTGRAPHICS EDITORIAL ADVISORS MATHILDEBAZINEf, chairman, Health Sciences Department, Canadore College, North Bay, Ontario. DOROTHY MI LLER, public relations officer, Registered Nurses Association of Nova Scotia. JERRY MILLER, director of communication services, Registered Nurses Association of British Columbia. JEAN PASSMORE,editor, SRNA news bulletin, Registered Nurses Association of Saskatchewan. PEfER SMITH,directorof publications, National Gallery of Canada. FLORIT A VIALLE-SOUBRANNE, consultant, professional inspection division. Order of Nurses of Quebec. arpen yo ù r c lI nIcal expertIse with these Saunders books. Ariz. Moncrief & Pruitt Burns: A Team Approach This up-to-date manual provides comprehensive coverage of thermal injury and its complications. Organized chronologically according to treatment, the book details everything from the pathophysiologic consequences of thermal injury to rehabilita- tion, to reconstruction. Special emphasis is plaæd on: organ and systemic response to thermal injury; early care-first aid, trans- portation, emergency room and outpatient care; local wound care including wound excision techniques: definitive grafting procedures; burn treatment for specific critical areas; and much more By the Late Curtis P. Artz, MD. FACS. John A. Moncrief. MD. and Basil A. Pruitt. Jr.. MD FACS. 583 pp. 402 ill. $40.80 Feb 1979 Order #1418-3. Tilkian & Conover Understanding Heart Sounds and Murmurs Here's an exciting new, inexpensive package that provides a basic familiarity with normal heart sounds and allows recognition of life-threatening disorders manifested by abnormal sounds. Clear and concise. it's the first package of its kind available to nursing professionals. Order now! Package includes C-60 cassette plus soft cover book. By Ara G. Tilkian, MD. FACC. and Mary Boudreau Conover. RN. BSN, Ed. Package: Order ff8878-0. Book only: about 120 pp. Illustd. Soft cover. Aboul $21.60. Ready soon. Order ff8869-1. tv1ar1ow Textbook of Pediatric Nursing 5th Edition Because pediatric nursing has come a long way, so has Marlow. The fifth edition of this highly respected work maintains a tradition of detailed coverage of child care, while offering detailed information on everything from necrotizing enterocolitis to genital herpes to child care in the emergency room. By Dorothy R. Marlow. RN. EdD. 949 pp. 382 ill. (plus 4 color plates). $21.55. August 1977. Order .,,6099-1. Klaus & Fanaroff Care of the High Risk Neonate 2nd Edition Patterned after the highly successful first edition, this new rigorously revised and updated second edition further bridges the gap between the physiologic principles and clinical man- agement in neonatology. Popular features, such as critical comments on controversial points, case material, and Question- answer exercises that apply and amplify information from each chapter, have been retained. By Marshall H. Klaus. MD and Avory A. Fanaroff, MB (RAND). MRCPE About 415 pp Illustd Ready 500n. Order fi5478-9. Reece Reece-Chamberlain Manual of Emergency Pediatrics 2nd Edition Indispensable as a Quick source of pertinent life-saving and pain-lessening information, this new edition has been revised to include many additional contributors. more detail. and to emphasize actual emergency situations. Completely reorgan- ized, it alphabetically lists problems in five sections: true emergencies, neonatal emergencies, presenting complaints in emergency room pediatrics, specific diagnostic entities, and procedures and therapeutics. Ediled by Robert M. Reece, MD. With 37 contnbutors. 721 pp. lIIustd. Soft cover. Spiral bInding $19.15. July 1978. Order "'7498-4. I .. 'j-' - ....... "\ , ..... , '\ Smith. Bierman. & Robinson The Biologic Ages of Man From Conception through Old Age 2nd Edition The biggest change in this exællent revIsion IS the inclusIon of psychological data by Nancy Robinson. a nationally known authority on mental retardation. Other significant additions include sections on young adulthood and middle life, and new material on death and dying, including legal and e.thical implications. Edited by David W. Smith, MD; Edwin L. Bierman, MD; and Nancy M. Robinson, PhD. 279 pp. 146 ill. Soft cover. $11. 95. Nov. 1978. Order fi8409-2. Drain & Shipley The Recovery Room Two leading experts in the field provide clear, accurate coverage of the recovery room in this valuable new, one-of-a-kind book Topics include the physiology of anesthesia, the effects of various anesthetic agents. specific care after all types of opera- tions, and factors that affect recovery from anesthesia in particular patients. By Cecil B. Drain, RN, CRNA. BSN and Susan B. Shipley. RN MSN. 608 pp., 167 ill. $20.35. Ready 500n. Order fi3186-X. r-............-w I To order the following titles on 3D-day approval enter Order # and Author: CN 5/79 I I I Dcheckenclosed-Saunderspøysposlage I We accept Visa and Mastercharge. I I 0 Visatt DODD ODD ODD r .J I I 0 Master Charge # DODD DOC] []l ]Q I I Expiration Date I nterbank:lt ocr]] I I Please Print: I I Full Name I I I I Position and AffIliation (If Applicable) Home Phone Number I I Home Address I I City State ZIP I I Signature I I All prices differ outside U S. and subJect to change I I W.B. Saunders Company I . West Washington Square Philadelphia, Pa. 19105 . in Canada: 1 Goldthorne Ave., Toronto, Ontøno M8Z 5T9 in England: 1 Sf. Anne's Rd.. Eastbourne. East Sussex BN21 3UN in Australia: 9 Waltham Street. Artørmon N.S.W 2964 I Moly 111711 The Cenedlen NUrH input The Canadian Nurse invites your letters. All correspondence is subject to editing and must be signed, although the author's name may' be withheld on request. Back to basics interestingly interpreted in Summary Nursing is caring "Who took the nurse out terms of human energy, "Hands on" care is indeed an Three cheers for you (M. of nursing?'., our editor, frequently being labeled as essential component of Anne Besharah) and Theresa turned patient asks. Despite bioenergetics. While it nursing. The uniqueness of O'Neil for having the courage all of our professional efforts remains "a little understood nursing quite conceivably to tell it like it is! "...don't ask to achieve and excel, many of enigma of a signally human results from the fact that me to help you define nursing us are uncomfortably aware interaction,' eastern cultures nursing directs a continuously practice as it relates to patient that something is indeed interpret the basis for this interacting biopsychosocial care." (February 1979) I missing. interaction to be a state of art and science at assisting the couldn't agree more. In attempting to answer matter called prana, a vitality holistic, complex, You can take all your her question, one readily or vigor of which the healthy biopsychosocial being in models and theories and identifies one major change individual has an maintaining homeostasis in all definitions and it means that has occurred over the overabundance which can be realms. No other helping absolutely nothing if that years. Much of the traditional transferred to another person profession interacts with the caring factor isn't there. I too "hands on" physical care of if one has the intent to do SO.2 recipient of care in the same have been on the receiving the patient has been delegated Therapeutic touch is complex fashion. end of that care and I could to someone lower in the differentiated from the simple Failure to capitalize on tell you a few stories but they hierarchy. touch required in routine every opportunity to provide make me ashamed to say I'm a "Even an aide can readily nursing procedures in and enhance nursing through nurse. The good stories are learn to give a backrub or Krieger's research into the the use of "hands on" care few and far between. What is wash a patient's hands and impact of therapeutic touch on detracts from all efforts to wrong with a practice face!", we say. "Why pay a mean hemoglobin values. 3 provide biopsychosocial discipline that makes "good" baccalaureate nurse to do However. one might deduce nursing care and ultimately nurses want to leave the something a diploma nurse from her findings that varying results in the provision of bedside? can do? Or a diploma nurse, to amounts of caring touch inferior nursing care. Recently the wife of one do something that a nursing occurring in the process of Continued failure of the of my patients called me at assistant can do? Or a nursing providing "routine" nursing profession to recognize the home because she was upset assistant, to do something that care would have a positive significance of simple "hands about something happening a student nurse or aide can correlation to the therapeutic on" care may severely impede with her husband. She hadn't do?" is a question every nurse effects observed in the our progress toward the been able to get what she administrator must answer in recipients of such "hands on" recognition we seek as needed from the ward nurses these days of economic care. professionals. and her daughter had said: constraints. If we believe that man is a Our editor has every right . 'Call Leslie, if anyone can "How can one allocate so holistic, complex to ask "Who took the nurse help you, she can. " Words much time to basic physical biopsychosocial being, we out of nursing?" We must can't express how I felt when care when there is so much would have to conclude that take this question seriously she told me this a few days more indepth knowledge to be there are probably and examine carefully the later...1 hadn't been there learned?" is a question every psychological and social direction in which our when she needed me. nurse educator must ask when components also involved in profession is moving. The I want to say to you and structuring curriculae into the therapeutic laying on of preceding theoretical many others that there are program timetables. hands, and that these. explanation of the importance nurses who care. We get very "What are the patient's components are probably of the most basic component tired trying to compensate for priority needs and which of interacting simultaneously. of nursing perhaps provides all those who don't, and we these can be met by care All this assumes, of the sOphisticated sanction we can't be everywhere for delegated to the nursing course, that the nurse does seem to require to advance everybody all the time. assistant, the student, or the have psychological and social without losing sight of our -Leslie Key, Reg.N., aide?" is a question every energies, as well as physical purpose. London,Ont. practising nurse must ask. energies, in overabundance to -Carole L. McWilliam, Caught up in our efforts transfer. This would be chairman, School of Nursing, Let us hope that to develop professional evidenced by that caring Fanshawe College, concerned nurses do not deny sophistication, we appear to attitude we all so highly value Woodstock,Ont. the evidence...Are nurses so have lost sight of the very in a nurse. In the absence of References busy attempting to upgrade essence of our art. The this caring, it is believed that I Krieger, Dolores. their profession that they have therapeutic comforting effects the nurse would not achieve "Therapeutic Touch: The forgotten what nursing is? of simple "hands on" care are this transfer of energies in the Imprimatur of Nursing". It appears that this may perhaps so much a part of our performance of physical American Journal of Nursing, be the case and before long, if practice that we have become nursing care. Vo1.75, No.5, May 1975, we are not alert, the Marcies all but indifferent to them. p.784. of this world will have taken Therapeutic touch by the 2 Ibid., pp.785-6. our place. They appear to be laying-on of hands is also 3 Ibid., P.786. the ones effective in The Cenecllen Nu... "'y11179 . responding to the patients' needs, which we so blithely discuss but rarely nowadays seem to do anything about. h would be nice to think that the writer's experience was an isolated incident but in our heart of hearts we know this is not so. The patient is the only reason for the existence of a health service. Perhaps we should be looking at what they want from a nurse, rather than at what we think they should want. -MarionJ. Boyd, Edmonton, Alia. I certainly hope that your generalization is not the rule. I don't consider myself a super nurse but I do take a very active interest in all of\ 3ÑG eE. ÑGE. Ct-\ aspects of my patients' care. I see nurses all the time who also show an honest interest in the well-being of their patients. I do not deny that because of the degree of specialization occurring in hospitals today, coupled with the RN to patient ratio. a nurse is hard pressed to keep on top and involved in all aspects of her patients' care. I find a round in the morning to introduce myself and tell the patient what to expect during the day helps to relieve the frustration of being shuffled from department to department. Then, sometime later in the day, I make another round to see how the day has been and how they felt they did in their activities. This afternoon round only takes minutes per patient but it is worth a lot and helps to show my patients that I trul y care. I work a twelve-hour routine which allows me extra time to devote to my patients. I used to go home frustrated and mad; everything was so rushed that I didn't have time to stop and listen or even hold someone's hand. I empathize with RN's that still work a 73/4 hour day: it's really tough to be good under today's condition. Were your nurses truly uncaring? Or did they leave emotional needs until they had a spare moment - a moment which never came because of their workload? -Dianne SuI/ivan, Nanaimo, B.C. The last chapter I feel it may be of interest to you and perhaps many readers ofthe article hMy fight for life" (November, 1978) to know that Linda Walker was admitted to the Sherbrooke Hospital for the final time in January and died on January 15th. Bob, her faithful friend and his mother were with her at the time of her death. Linda had pre-arranged that her body should go for medical research, which it did, but several of the hospital taff attended her memorial service which she had helpeJ to plan and it was a very meaningful and comforting service. -Lily Suggitt, Sherbrooke, Quebec. - - o J I .. . , i - ' :I _ K TI" r-ç f.} J , '==-- . :..õi.....-1"\;z'.. . r Wti _ _ ,,, It - ',' 4' ' i;\\- < .'1':-. '. ) .- .' '.' 1:1'" . . j....'J . r-:- 'r.- _OJ , .".I" .' ..... - '. 't I \.. \ .. ..,. ,.' " . .:' ', , 'i'::' .'t", ....-::: . -- --..-.-, INTRALIPID@ RENAMED @ . NUTRALIPID :. , f 4J; '. EFFECTIVE APRIL 1, 1979 ../0 t . ) .), J , ;1 NUTRALIPID 8 -10% Soybean oil emulsion -formulated to supply energy and essential fatty acid In Intravenous nutrition Pharmacia p :J44 C ('. , t .. / ...-- 1'" -=-f- /'" . " "í '" _,,:,;. The nurse, still alone with all five post-op patient... went to carry out the order. After domg so, she al!.o took a telephone call before returning to the plaintiff. Mrs. Laidlaw. I' "'y 1179 The Clin.dl.n NUrH ... . _æ\1 f 0 @ . 1",e \de nt - etiO n aga lns reates t prote nd incidentS. . se a \ pre"ents 0' C"P- . 1a m pe r pro 11'\0"a\ trete"'Ing unaut",ori!ed in9 pre"ents Sent irritation po\yester-,,\m Sheath ",e\PS pre" .' 9 \h "'1''1\ . ontalnln S,,",oo e"a\uatiOn Kit,. c el1'\e r ge nc 'i' d tor a tree d \t pedia tnC , e\ets. se n ot our aU, d wide brae sal1'\p\es b\ood an 11'\0t",er/ bab 'i' . , .....rr.þ: ndepe ndon ' ' 'iouea., t",e 01'\'1 nal1'\e I .'r)\ùg ER . ois606 "'"' or orated, \"Iicag o , II\I Hollister \ C fl iC go "'\Ieflue:.... lIister Lirfllte , M2J p8 . E.aSt., da b'i f' ofltarlO 2.. diflcaflB '.'.\\OINda\e. S"ESE,,"EO. Distribute ers Road. ".1 PO". EO .LL,,'GI'I 322 COfl SUrfl 'S E" ,,.co" "',Gt'\1 19'19 t'\OLL rnP"ir. On her return. the nurse observed that Mrs. Laidlaw was not breathing and put through a calI for assistance to another anesthetist. At about the same time another patient was brought to the recovery room and another physician was summoned. The absent nurse returned about this time. The function of the recovery room is to provide highly specialized care to patients immediately post-op. The trial judge described the necessity for frequent and careful observation of patients still under the influence of the anesthetic: "Respiratory arrest is not an uncommon occurrence in the PAR room (post-anesthesia recovery) and. therefore. the personnel in this room must be watchful and alert at all times in order to protect patients in this labile and vulnerable stage. The nurses in this room are there for the purpose of promptly recognizing any respiratory problem. cardiovascular problem or hemorrhaging. They are expected to take corrective action and/or to summon help promptly. "4 In the judge's view. the recovery room is the most important room in a hospital precisely because of the potential dangers to the patient during the post-anesthetic period. "This kno....n hazard curries with it in my opinion a high degree of duty owed by the hospital to the patient. As the dangers or risks are ever-present there should be no relaxing of vigilance if one Ü to comply with the standard of care required in this room." 5 The trial judge based this conclusion on the evidence ofthe witnesses and. in particular. on the evidence of the physicians. He further found that in order to meet the standard of care required in a recovery room. there should be always a minimum of two registered nurses present with a staff/patient ratio of one registered nurse for every three patients. Here the hospital had assigned the appropriate number of registered nurses to duty in the recovery room. The negligence occurred when appropriate substitutional relief was not obtained so that the nurses on duty could absent themselves from the unit. The trial judge found the charge nurse negligent in I) failing to provide the required observation for the patient. 2) permitting the other nurse to leave for coffee at a time when other patients were expected or ought to have been expected from the OR. Relief assistance should have been arranged. From her knowledge of the surgery organized for that morning, the nurse was negligent in failing to make adequate arrangements for patient care. "These items constitute in my 'iew more than mere errors injudgment.1 am mindful that the standard demanded by law is not that of perfection; but an anesthetized person is entitled to expect a high degree of performance, diligence and ob.5ervation on the part of the nurses in the PAR room because of the great risk of an obstruction or other trouble developing." 6 The other nurse was found negligent in leaving the recovery room without considering the needs of the patients therein and the further anticipated arrivals from the OR. The hospital was found liable for the negligence of its nurse employees. In this case. the trial judge concluded that the "necessity for watchfulness had given way to carelessness."7 A lackadaisical attitude had developed with respect to coffee-breaks. This should have been i:orrected by the hospital through its nursing supervisor. Decision: negligence The decision in the Laidlaw case was referred to in Krujelis et al. v Esdale et al. sHere. a ten-year-old boy suffered irreversible brain damage post-operatively while in the recovery room. He died shortly thereafter. The inaljudgt found that there had been no negligence on the part of th.' surgeons or anesthetists. The patient had been admitted for su.-gical correction of over-prominent ears. When he left the OR he was in "excelIent condition" . The C.n-.ll.n "ur.. "ey 11178 17 The patient arrived in the recovery room at about 9:45 a.m. when his vital signs were recorded and entered. His condition was found to be satisfactory. Six other patients were already in the recovery room at the time of his arrival. At approximately 10: 13 a.m.. one of the nurses returning from coffee-break went to examine the child. The patient was cyanotic. She found no vital signs. The patient had suffered a respiratory obstruction followed by cardiac arrest. His condition had been unobserved. The damage was done. Five nurses were on duty that morning. Three of these nurses had gone for coffee before the arrival of this patient and they had returned at about 10: \3. after his cardiac arrest. Two nurses were present in the recovery room during this time. The trial judge found that the injury to the patient resulted from inadequate observation of his condition by the nursing staff. This inadequacy was the direct result of the absence of three of the nursing staff for coffee during the busiest time of day for the recovery room. The hospital was found liable for the negligence of its nursing staff in the course of their regular duties. Standard of care Nurses owe to their patients a duty to safeguard their health and well-being. The standard of care required applies not only to the actual physical care delivered to the patient but also to proper observation of the patient's condition. Adequate observation requires adequate numbers of competent staff to properly fulfill this duty. That is not to say that nurses are to be denied meal and coffee-breaks. What is required of the professional nurse is discharge of the responsibility of ensuring that. in one's absence, patient safety and well-being are properly safeguarded. As these cases illustrate, failure to do so may amount to a breach of duty and may result in a finding of negligence and liability where harm befalls a patient. [tI(Q)ææIHJ(Q)IJ]]) 1? t j G-ó/ ) U When your patient has hemorrhoids, constipation should be avoided. The bowel may need a little gentle prompting to begin functioning normally again, and that's where Metamucil can help. Why not recommend a laxative .,jj\ at works slowl)\ , gently and _ effectively. Thafs . . the Metamucil ! _ _ -=:::-. way. I::::: I "-1' I 1- -===- m ...I References I (\%9), 2 D.L.R. (3d) 533 (B.C.C.A.) 2 (1969), to D.L.R. (3d) 539 (S.c.c.) 3 (1969) 8 D. L.R. (3d) 730 (B.C.S.C.) 4 Ibid., 737. 5 Ibid., 737. 6 Ibid., 738. 7 Ibid.. 739. 8 (1971). :!5 D.L.R. Od) 557 (B.C.S.c.) Legislative update Readers are reminded that legislation - both prOl'incial and federal- is continually changing: existing acts are amended or repealed. others are newly enacted. Because of the lapse of time bet....een research and publication of each"Y ou and the la...... column, legislati 'e enactments which come into force during these weeks cannot be included in the pertinent column. The allthor welcomes informationfrom readers who become aware of changes in their prOl'inciallegislation so that this information can be passed along in subsequent columns ./n this ....ay. the profession can assist in keeping its members up-to-date on changes in legislation that affect nursing !..nowledge and practice. A case in point is a communication from George Bergeron. communications officer. New Brunswick Association of Registered Nurses. concerning the "You and the law" column dealing with child abuse (January, /979). George informs us that a recent amendment to the New Brunswick Child WelfarJ Act now ma!..es the reporting of child abuse mandatory in that prOl'ince. "You and the law" Is a regular column that appears each month in The Canadian Nurse and L'lnfirmlère canadienne. Author Corinne L. Sklar Is a nurse and recent graduate of the University of Toronto Faculty of Law and Is currently artlcllng with a Toronto law firm. Metamucil is made from (gluten-free) grain, providing fiber that produces soft, fully formed stools to promote regular bowel function. Available as a powder (low in sodium) and a lemon-lime flavoured Instant MIx (low in calones). Why not give your patients our helpful booklet about constipation? @ Met , The laxative most recommended by Physicians. \ :areview of past and current systems of nursing care delivery " -,,1 ..... "" "- \.- , ).. "A system for delivery of services must incorporate methods that provide to patients and staff members the security of a structured, purposeful day's responsibility. Without this, the average nurse expresses afeeling of powerlessness. She feels she is unable to provide salisfactory nursing care. ,,* The ideal system of delivering nursing care is one that satisfies both the nurse and the patient. It is a goal that every nursing service administrator pursues - with more or less success depending upon her skill in matching up the heeds of the people concerned with the resources at her disposal. It is a goal that administrators everywhere have struggled with for close to half a century. Today, rising costs and higher rates of consumption of health care services are forcing directors of nursing to make even more strenuous efforts towards productivity, efficienc y and economy. In attempting to predict the direction that the resulting changes will take, it is both interesting and enlightening to take a look at the major trends of the past 50 years. In the beginning, the choices made by nurse managers were intuitive; their decisions were based on their own experience and on a social order founded on a rigid class system and a military type of discipline. But as time passed and behavioral and social theorists began to have an impact on the work setting, nurse managers quickly assimilated this new knowledge into the practice of nursing. Nowhere was this assimilation more evident than in the changing patterns of staff assignment. *Faye G. Abdellah. "New directions in patient-centered nursing", pAl. Margaret B eswetherick In the quest for an ideal staffing model, beginning with the functional method of the early thirties, right up to the present day concept of primary nursing, some half dozen patterns have been employed or modified to fit a myriad of work settings. The process has been a metamorphic one, moving from functional nursing, in which the nurse was viewed as having limited talents and abilities, through team nursing. in which the work group and the group process maximized individual personnel talents, up to and including primary nursing where the focus is on the individuality of the patient and the professional attributes of the nurse. Other models such as group assignment, patient assignment, case assignment, progressive care and unit assignment are part ofthis metamorphic process and also deserve consideration. Each staffing pattern was developed around a set of basic premises and beliefs about patients, nurses and nursing and it is these governing premises which make each model or method of assignment unique. The value of historical review is derived from objectively ascertaining whether there are enduring characteristics which might assist today's nurse manager in arriving at a solution to this most fundamental, difficult and ongoing administrative challenge. Functional assignment Functional or efficiency method of assignment was based on the work of F.W. Taylor, father of scientific management. I His management concepts were first made public in 1910 in an effort to bring "rationality" and "efficiency" to the workplace. 2Taylor's theory of management was based on the premise that managers were people who are capable ofthinking and planning; the worker was viewed as a person needing close supervision and constant direction. Because ofthis all activities and tasks were rigidly controlled by management: rules and regulations were highly structured; activities were task oriented; workers were matched to jobs; workers were viewed as working best alone or in small groups and managers were considered experts with specific zones of influence. Table one 1900 Major Periods of Influence for Nine Staffing Modalities from 1910 to 1978. 1910 1920 1930 1940 1950 1960 1970 1980 - .. Intuitive Functional Group I I I - I Patient Progressive Friesen Team Primary Unit Period of Influence None Rigid and simplistic as this approach to management may seem, it influenced nursing for three decades in the guise of functional nursing. During this period the "charge" nurse was the supreme authority on her ward. Rigid sets of rules, regulations and procedures were strictly adhered to. The focus was on tasks and duties. The charge nurse was responsible for the assignment of bed making, baths, temperatures, dressings and similar tasks. These tasks were assigned in accordance with status and level of competency of the individual nurse. Probationary student nurses were generally assigned housekeeping duties, morning washes and bed making. Intermediate students cared for the patients' physical and hygenic needs; they were responsible for duties such as bed baths and simple treatments like hot fomentations. Senior students and graduate nurses were assigned the more complex and demanding tasks of medications and dressings. The charge nurse practiced close supervision and made all decisions related to the care of the patients on her ward. All of the nurses reported directly to the charge nurse when their work was finished; she would inspect their work and then assign additional tasks. Nurses were allowed limited leeway in carrying out their duties and routines. Perusal of the procedure books used at this time reveals minutely detailed Minor instructions for each task, beginning typically with" ... wash your hands and pull the curtains. " Finally, the charge nurse functioned as the communications center within and outside her unit, reporting to and receiving instructions from the physician. As time went on, there was a growing realization among administrators that the patient might be better cared for if he were looked after by a single nurse rather than by many nurses. The outcome of this change in thinking was a gradual move towards group nursing assignment. Group, patient and case assignment methods.. The late forties were characterized by growing concern about "continuity of care" - a concern intensified by the gradual change from the twelve-hour day to the eight-hour day. This concern resulted in a move toward group nursing assignment. an approach that was still task-oriented and continued to embody a functional approach, but was based on the premise that a single nurse could **A review of the literature can lead to confusion when attempting to differentiate between group. patient and case assignment staffing methods. For the purpose of this article, the author has made an arbitrary differentiation in an attempt to highlight the subtle changes in the beliefs governing staffing modalities. Major provide a better level of care to a small (four to six) group of patients when she herself carried out all the treatments, medications and basic care. The head nurse remained supreme in that she established the grouping of patients and the level of care to be provided. Again the graduate nurse and the senior student were assigned the most difficult care. Ward or unit routines were still an important part of the assignment. Nurses continued to report to the head nurse who wrote the "day report" and continued to communicate with the doctors. .#' - iø>{ J ff ? t L _ Ã;7 J1 \ 'feJ c: I The patient assignment method, as indicated by its name, was based on the selection and assignment of patients in accordance with the severity of their illness and the presenting signs and symptoms. Under this system, an attempt was made to optimize the nurses' skills and talents so as to fully benefit the patient. De-emphasizing task orientation brought about a corresponding change in 20 "ey 111711 The CIIn-.ll.n Nur.. attitude towards the nurse who was seen to possess intellectual as well as manual skilIs and was therefore capable of providing a knowledgeable level of care. With this change in focus there was a move away from rigid time schedules and routines; the nurse was made responsible for her own recording and reporting and she began to communicate directly with the physician. The case assignment method took staffing patterns a step further in the metamorphic process. The basic components were the same as those in patient assignment, but in order to provide real continuity of patient care the nurse was assigned a case load, that is, she was assigned a number of patients for the duration of their hospital stay. When a patient was discharged and another admitted, the nurse assumed care for the newly admitted patient. Using this approach, patient flow was seen as the key to patient assignment. Random selection, however, also meant that an experienced nursing staff with well rounded skills and abilities had to be available if the patients'lot were to improve. Nursing in transition At about this time, nursing was confronted with the realities of World War II. Nursesjoined the armed forces and acute staffing shortages were experienced throughout the country. As these shortages worsened and student nurses could no longer fill the void, the problem was solved by the introduction of a new category of worker - the "nursing assistant". The nursing assistant was regarded as having limited skilIs and was to function at the task level in much the same way that, under the functional method of assignment. the probationary or intermediate student had performed. Her work was assigned and supervised by nursing. This change might have gone unnoticed except for the fact that the nursing assistant was only one of a growing number of workers, including clinical dieticians, physiotherapists, respiratory therapists, social workers and a variety of technicians , who were becoming directly involved in patient care. Because of this proliferation of workers directly involved in patient care and services, the coordinating function of the nursing profession took on new meamng. Following World War II there was an outflow of research dealing with individual and group behavior; individual differences and needs; motivation and leadership. Toward the mid 1950's and the early 1960's, these studies made an impact on nursing. There was a move from a task orientation towards a human needs orientation. It was at this time Abraham Maslow's "hierarchy of needs" ordered individual needs and provided a model for rational discussion. 3 I t was also at this time that the National League for Nursing Sub-committee on Records ordered patient needs in the form of' 'twenty-one nursing problems" .. Crystalizing insights caused a surging movement towards "total" or "comprehensive" patient care. These terms implied meeting all of the patients' needs- physical, emotional, spiritual, socio-economic and rehabilitative needs. L iN itJl 11ft! {D(;. '4.0' ,,',-- It> The nurse was not only responsible for providing care, but greater stress was placed on her planning, coordinating and teaching functions. There was a similar surge to achieve "individualized" or "patient-centered" care. This approach included the concept of comprehensive care but again went one step further in that care was to be provided on a personal level. The patient was considered as a member of a family and a community. It was essential then that both the patient and his family be included in the planning for his care and discharge. Community services were seen as an extension of care facilities and were to be used to the fullest. Progressive patient care A combination of three factors resulted in the search for more innovative approaches to the provision of care: I. A rapid escalation of knowledge in the medical and technical field culminated in a sharp increase in the demand for personnel equipped with this special knowledge and skills. 2. A parallel increase in the demand for complex equipment. especially life support and monitoring equipment, occurred. 3. I ncreased concern for patient safety prompted the establishment of post-anesthetic recovery rooms and, a little later, intensive care units. Costs for both equipment and personnel began to spiral and it became apparent that changes were necessary. One answer to the growing problem was the development in the late fifties of progressive patient care. According to this approach, total hospital services are organized around patient needs; "special" nursing units to which patients are assigned in accordance to degree or severity of ilIness are established with the object of having the" ...right patient in the right bed with the right service at the right time".5 Staff is assigned in accordance with abilities and skills in a specialty area. These areas are designated according to the severity of illness: intensive care, intermediate care, self care, long-term care, home care and outpatient care. 6The patient is then moved from one level of care to another as his condition changes. Assessment criteria, standards and policies must govern patient admission to each level of care. In point offact success is clearly dependent on a patent patient flow from one level of care to another. Progressive patient care met with opposition on the grounds that the patient was denied continuity of care. If the nurse was to be successful she had to be versatile in that she cared for patients in all age groups and with all disease entities. TfJis method of assignment also served to highlight the high cost of providing professional services particularly in the intensive care area . As a result non-nursing functions were graduaIly reassigned to appropriate departments - housekeeping, dietary, pharmacy and stores departments. Ward clerks took over many of the mundane administrative tasks but for the most part the head nurse retained major administrative functions. In many settings this pattern continues to the present day but there was a breakthrough in the early 1960's when the "unit manager" , in partnership with the head nurse, took full charge of administration of the non-nursing duties on the nursing unit. Progressive patient care addressed the problem of matching patient needs to the physical plant, resources and personnel but it was the Friesen Concept of hospital design that was to be instrumental in providing a unique approach to this match. There remained the problem of assigning staff in each specialty area: old patterns were employed but there was a growing interest in the team approach. The Friesen Concept of nursing Toward the end ofthe 1940's and early 1950's an architect, Gordon A. Friesen, concerned himself with the effect of hospital design on the professional practice of nursing. He envisioned the patients' bedside as the end point of the supply and communication system. In this way total hospital services could respond immediately to nurse requirements based on individual patient needs. He also saw the professional nurse as the key provider of care. With this in mind he designed a patient care unit that allowed the nurse to spend the major portion of her time with her patients. Supply technicians are responsible for maintaining adequate standard of supplies at each patient unit. Administrative communications clerks are responsible for" ...traffic control, non-nursing communications and non-patient related physician interaction..... 7 One author describes the changes involved in this concept in the following way: "Two aspects of the Friesen Plan have particular implications for nursing. One is the replacement of Central Supply by a highly systematized Supply, Processing and Distribution Service, popularly known as the SPD, that is intended to carry the maximum responsibility possible for the functions indicated by its name. The other is the replacement of the traditional nursing station by a secretarial office, and the construction of an area in each patient room where the requisite supplies and equipment can be provided and removedfrom the corridor by SPD, where the patient record and a telephone are at hand, and where the nurse does her charting. Thus a nursing team concentrates its attention on that portion of the floor assigned to it. "8 The team nursing approach is an integral part of the Friesen Concept and the physical layout reflects this. The nursing unit is "zoned" into 20 bed units. Each unit is assigned to a team and contains a Team Conference Center which serves as a meeting place for team conferences and for physician-nurse discussion. 9 For the nurses who work in them, the total freedom from non-nursing responsibilities that is part of the plan provides an opportunity to experience. for the first time. the full scope and true impact of nursing practice. Team nursing The year 1951 serves as a bench mark in the nursing literature devoted to team nursing. It was in that year Viola Brendenberg's book Nursing Research: Experimental Srudies With the Nursing Team was published. to Since then, numerous authors have addressed themselves to the virtues and problems inherent in team nursing. The CIIn-.llen NUrH In team nursing the central focus is on the work group or team which is made up of both professional and non-professional nursing personnel. It is believed that each member of this team makes a valuable contribution towards patient care and this is particularly so when work arrangements and patient assignments are coordinated by the team itself. A sound understanding of group dynamics and individual behavior is essential. This includes an awareness of group norms, rules of conduct, goals, identity, cohesiveness and especially leadership. ,f; 00 u I F--,, (}( ) f1f- ( {, 1f;1 11 7 "r] ì r1 vi J tI. ']tj The team leader must possess the ability to lead patient-centered conferences and must be able to plan for patient care. The team leader must also be skilled in quickly assessing patients' needs and implementing the necessary nursing measures. The leader is responsible for coordination of team efforts and she is also responsible for evaluation ofteam performance. Because of the expectations surrounding the leadership role. and because of a constant patient flow, expert leadership and stable staffing patterns are crucial elements if team nursing is to flourish. Yet in many instances, stafTturnover and rotating shift coverage dIctate the need for a rotating leadership. When this happens the essential "esprit de corp" and smooth group functioning are mitigated; under these circumstances team nursing is minimally successful. Unit assignment The mid-sixties saw a renewed search for a more efficient match between patient needs and nursing services. For the most part nurse/patient ratios were arrived at intuitively. based on past experience but this type of approach did not accommodate the peaks and valleys of patient care demands. In order to control costs and provide a satisfactory standard of care, an answer to this problem was required. One suggestion was a return to categorization of care similar to that established in the progressive care approach. characterized this time by an attempt to link these categories to a time-based index. The search moved in two directions: employment of computers as an aid to efficient planning and decentralization of wards into' 'units of care". Attempts to computerize care "'y 1171 21 planning have met with limited success, mostly because of the numerous and changing variables presented by each individual patient and by fluctuations in the staffing component caused by high rates of turnover. The second approach is embodied in the unit assignment method of staffing, according to which a unit consists of the number of patients that can be cared for effectively by a registered nurse. provided she has adequate back-up services. The focus is on patient needs and requisite care. Units are categorized as: intensive care; above-average care; average care; and minimal care. Unit size depends on patient classification and patients are moved from one classification area to another as their condition changes. A work load index tool is employed to determine numerically the number of stafTneeded. Each unit has a standardized portable supply and communication station. lI This allows for expansion or decrease in relation to unit size. The unit assignment concept is based on efficiency and economy, that is a fair day's work for a fair day's pay. This method seeks to achieve equity in the distribution of work loads. a search that is complemented by adequate back-up services in the area of supplies and administration. A strong point in its favor is the flexibility and optimum utilization of nursing personnel permitted under the unit assignment method. Primary nursing Recently, a changing social climate has succeeded in re-ordering a number of basic premises within nursing; key factors are the changes in nursing education. the place of women in society, and a clearer definition of nursing as a practice and as a profession. These changes. coupled with others that have occurred over the past forty years. have resulted in a changing belief system. The outcome is highlighted in the primary nursing method of assignment, first introduced in 1968 on a trial basis on a 24-bed medical unit at the University of Minnesota Hospitals in Minneapolis, Minnesota. Primary nursing resembles the case method of assignment but the crucial difference is its focus on the nurse as a professional practitioner and provider of care. As it was originally conceived. primary nursing called for a registered nurse (later changed to an RN with baccalaureate preparation) to assume responsibility and accountability for the care of two or three patients over a 24-hour period throughout their hospital stay. The result is highly individualized care provided by one nurse and the 22 U.Y 111711 Th. C.n-.ll.n "ur.. establishment of the basis for a one-to-one nurse/client relationship. The primary nurse is responsible for all facets ofthe nursing process: . assessment of patient needs . development of a care plan focusing on patient-centered goals . implementation of nursing interventions . supervision of other workers who assist in the care . evaluation of nursing actions based on achievement of patient -centered goals. The primary nurse assumes responsibility and accountability for the outcome of care and nursing actions and must therefore be free to act independently in areas designated as nursing prerogatives. Primary nursing can flourish only where the organization is prepared to accept the nurse as a full-fledged professional capable of self-direction and self-discipline. This requires a change in the hospital philosophy, structure and process to accommodate the basic elements of primary nursing. Organizational policies must reflect this acceptance by enhancing the autonomy of the nursing staff. Personnel policies governing hours of duty and time scheduling must be flexible. Staff evaluation procedures must focus on job performance as it relates to patient care. Self evaluation, continuing education and collegial sharing must be planned and carried out. This requires budgetary provision for study leaves and an interchange of experience with other professionals. Charting and report procedures must reflect the key steps in the nursing process. Patient histories, patient care plans and goals. patient orders, and patient care and intervention notes must become essential components of the patients' chart. Many observers today are convinced that primary nursing is the key to maximum development of a professionally based nursing assignment. Conclusion There is no doubt that the search for economical and efficient methods of providing care will continue for many years to come. Added knowledge and more sophisticated methods of dealing with that knowledge will continue to reshape belief systems that govern nursing practice. In view of this fact, it is essential that our commitment to anyone particular approach or modality remain tentative and that, as a profession, we maintain a flexible attitude towards the development of new and improved methods of providing satisfactory nursing care. References 1 Taylor, Fredrick W. Scientific management, comprising shop management, the principles of scientific management and testimony before the Special House Committee, 3 Vols. New York, Greenwood, 1947. 2 Kanter, Rosabeth Moss, Men and women of the corporation New York, Basic, 1977. p.20-23. 3 Maslow. Abraham H. Motivation and personality New York, Har-Row, 1954. p.97. 4 Abdellah. Faye. Patient-centered approach to nursing, by... et al. New York. Macmillan, 1960. 5 Haldeman, Jack. Elements of progressive patient care In Progressil'e patient care: an anthology, edited by Lewis E. Weeks and John R. Griffith. Ann Arbor, Mi., Health Admin. Pr., 1964.p.1. 6 Ibid. p.2-3. 7 CHI Systems Inc. The Friesen no-nursing station concept: its effects on nurse staffing Ann Arbor, Mi., 1970. pA-5. 8 Brown, Esther Lucille, "Nursing reconsidered - a study of change" Pt. 1, the professional role of the nurse. Philadelphia, Lippincott, 1970. p.M. 9 Op cit. p.lO. 10 Brendenberg, Viola Constance, Nursing service research: experimental studies with the nursing service team. Toronto, Lippincott. 1951. 11 Sjoberg, Kay B. Unit assignment: a patient-centered system. Nurs.Clin. NorthAm. 6:2:340-34 I. Jun. 1971. Bibliography 1 Abdellah. Faye, Patient-centered approach to nursing, by... et al. New York, Macmillan. 1960. 2 Symposium on toward the professional practice of nursing. Nurs. Clin. North Am. 6:2:271-362. Jun. 1971. 3 Brendenberg, Viola Constance, NursinR service research: experimental swdies with the nursing service team. Toronto, Lippincott, 1951. 4 Ciske, K.L. Primary nursing: an organization that promotes professional practice.J.NursAdmin.4:28-31, Jan./Feb. 1974. 5 CHI Systems Inc. The Friesen no-nursing station concept: its effects on nurse staffing Ann Arbor, Mi., 1970. 6 Haldeman, Jack, Elements of progressive patient care In Progressive patient care: an anthology, edited by Lewis E. Weeks and John R. Griffith. Ann Arbor, Mi., Health Admin. Pr., 1964. p.I-B. 7 Hall, Lydia E. A center for nursing. Nurs.outlook 11: 11 :805-806, Nov. 1963. 8 Kanter, Rosabeth Moss, Men and women of the corporation. New York, Basic, 1971. 9 Maslow, Abraham H. Motivation and personality. New York, Har-Row, 1954. 10 Taylor, Fredrick W. Scientific management, comprising shop managemènt, the principles of scientific management and testimony before the Special House Committee, 3 V ols. New York, Greenwood, 1947. Margaret A. Beswetherick, the author of .. StaffinR assignment", is associate professor (Nursing Administration) at the University of Alberta, a position she assumed after a term as nursing adl'isor to the Registered Nurses Association of Nova Scotia. She is the author of several reports published by the RNANS and has contributed to the Newsletter of the Alberta Association of Registered Nurses and to the Canadian Nurse. A graduate of Vancouver General Hospital School of Nursing, Beswetherick received her Diploma in Clinical Supen'isionfrom the University of British Columbia and her Bachelor of Nursing and Master of Science (Applied) from McGill Unil.ersity. ..ç .... The C.n-.ll.n Nu... 118)' 111711 23 The loneliness of ee er Amy E. Griffin The realit of the other person is not in "hat he reveals to you, but in what he cannot reveal to you. Therefore if ou would understand him, listen not to what he says, but rather to what he does not say. Kahlil Gibran ., .. \'1 " I r J"ø-""'.Þ>- 0 You and I know that to be alone is not necessarily to be lonely; as individuals we vary greatly in the amount of solitude that we seek or can tolerate. In much the same way, being with others does not always preclude or overcome loneline!>:>. "Togetherness" can be a source of isolation. especially if you feel alienated by your own personal circumstances from the people around you. Must the circumstances that surround the aging process always culminate in loneliness? I think of the old people I know who live alone, isolated by their growing physical infirmity, by the loss of friends and family through death or other circumstances. I think of the elderly who are "alone" in the midst of friends, family or care givers because they are hard-of-hearing or slow of speech and these people, after a few perfunctory remarks, either inadvertently or deliberately exclude them from their conversation. I think of all the factors that can precipitate this kind of loneliness and I wonder what we can do to prevent it. I think first of Sarah, a spinster with an atypical track record in this migratory age. Sarah has lived 8:! of her 87 years in the same house. has never worked outside her home. nor lived with anyone other than her family. Her parents died :!O years ago, her sister 10 years ago. Since that time she has lived alone. Her house, on the outskirts of the city, is something of a landmark, nearby houses having disappeared along with her close neighbors. She has considered leaving her home but says, "I'd be a stranger in an apartment complex, I'd know no one and I hesitate to make new friends." Still the old house. with its narrow steep stairs presents a problem. For one thing, it has only cold water and even that must be hand-pumped to the second floor. So the kitchen, with its sofa for a bed, really constitutes "home" and the bathroom upstairs is quite inaccessible to her, ." "', ,. .. Æ ç"" "'l '" , { "'Y . 1! '. '..y' oA . Jf: . ., .;;. t }- of , ., .. þ ? .-4 . 'I}., ". f' . . ." " ", \ ' ,. .' . ;. ..1 ). . 1 o . o O_' especially since she suffered a fractured hip and the onset of congestive heart failure about a year ago. Her regular visitors comprise a distant cousin and his wife who come in once or twice a month, a couple from her chutch who try to see that she attends sabbath service, a friend in a nearby nursing home who telephones every morning at the same time and one of my colleagues who provides voluntary personal support and health monitoring. Compared with many older people that seems like quite a few interested folks, doesn't it? But most days and nights are interminably long and the hours of actual human contact are few. Sarah talks now and then of leaving the home that she has lived in for a lifetime to go to B.C. and live with a cousin. Or she mentions having an unknown "someone" come to live with her. Both of these arrangements, for one reason or another, seem prohibitive and undesirable to her. My colleague finds her alert but very indecisive. Her hands could be busy with crafts but she has no way to obtain the materials she needs and no one to provide her with instructions. Last winter, in the town where we live those of us who are ambulatory and motorized were completely snowbound three times. When this happened, radio announcers commented on the perils of "cabin fever" with its various consequences, including violence. Sarah, by contrast, was never out of her home from November to April. Winter comes every year and for Sarah the prospects never seem inviting. What to do? ,.. ... ... 24 ".Y 18711 The Cen-.llen Nur.. r- ft ft And what about George who is 20 years younger than Sarah, divorced but with several grown-up sons and daughters. This could be good, were it not for their alcoholism and rather frequent, if brief, jail confinements. One daughter could perhaps be described as "half-way reliable" but his childrens' visits in the acute care hospital are haphazard at best and often seem prompted by the hope of a hand-out. either to replenish their liquid stores or to extricate them from their current predicament. It is really little wonder that George complains if they visit and complains if they don't. George has chronic emphysema which has necessitated several hospital admissions for artificial pneumothorax. He seems unable to accept the chronicity and progression of his disease, becomes hysterical if anyone near him smokes, is discontented with his doctors. It takes little provocation for him to lash out in bitterness and anger at anyone and everyone - and the social distance between him and others imperceptibly lengthens. Unable at this point to get up in a chair. he is facing likely transfer to a chronic hospital rather than a return to his bachelor apartment in a senior citizens' complex. I wonder! How much has George created his own circumstances? How much have they created him? How do we help him change either? Now let me briefly introduce you to John, aCarmdian Indian who has been in a nursing home for the last four years. Circumstances preceding his head injury and double leg amputation in a collision with a train are unclear. People who try to communicate with John now recognize that they will have to persist many times if he is to remember from one time to another - even that his roommate is not his brother Jim. f.:I" 0 Interestingly enough. if his nurse takes the time to show him, for example, how to make flowers out of Kleenex@ to decorate a parade float, he takes great delight in producing masses of them. Indeed, John does reach out. When other people's visitors are around, he is right at the door in his wheelchair to greet them - and they respond to his happy disposition with remembrances such as birthday gifts etc. But John misses his own culture and his own people. He sees his common-law wife from the reserve 100 miles away perhaps three times a year, his two children never and the other folks back home just seem to have forgotten. Nursing home personnel have good intentions but little time and somehow volunteers haven't provided the answer for John or others. Their early enthusiasm often peters out in a few weeks and the potential pool of volunteers in this small town just doesn't suffice. I wish I could have offered helpful suggestions to the young ambitious director of the nursing home who talked to me recently about John. Meanwhile, I guess he'll just have to borrow his friends from others and hope their interest in him persists. Have I selected from all the elderly people in our community only those with particularly unfortunate circumstances or inept coping mechanisms? Have I presented only exaggerated examples? What really is the norm in the human condition? Certainly it is true that fortune seems to smile more kindly on some than on others and there are intrinsic as well as extrinsic factors which govern anyone individual's circumstances and their reaction to them. But many elderly people live in perplexing milieus that present complex problems requiring adjustments both in themselves and their surroundings. These people need varying degrees of help, at different times if they are to achieve either short or long term solutions to their problems. o. O. O. ,'0 Sarah, George and John are all part of the puzzle of the elderly - in their own homes, in nursing homes or in hospitals - people who face a continuing illness, handicap or gradual deterioration in their general health. But what of the countless old people who are thrust abruptly into briefer episodes of markedly changed circumstances, stripped of their usual social contacts yet surrounded by a throng of strangers with whom they must interact? On two occasions last year I sat with my sister during the hours preceding a cataract operation and then accompanied her to the operating room. On her second visit to the hospital, Anna shared her room with an 80-year-old lady. This dear soul was scheduled to undergo the same operation as my sister at four o'clock that afternoon. Unfortunately, her only relative within easy commuting distance was a daughter with two school-aged children. School was in progress so she waited alone, some eight hours of arduous waiting. She could not read to pass the time; she could not even tell the time of day. I conversed with her as much as I could and sensed her fear and uncertainty over her impending surgery. It wrung my heart when, more than once, she said to me "Your sister is lucky to have you." My heart went out. as well, to two particular patients I nursed on a terminal care unit last summer. Betsy was literally "a little Chinese doll". In all my years of nursing I have seen no more pathetic person: extending carcinoma of the vulva is not nice. Betsy was a Second World War bride from Hong Kong whose husband had died, leaving her with one son and one daughter. When I met Betsy her daughter had just returned to England where she no\\ lives. Betsy was quiet and subdued in her grief at her daughter's departure. We noticed that On his rather infrequent visits. her son rarely went close to her bed and never touched her. He almost seemed afraid that his mother's cancer might be "catching" . The C.n-.ll.n Nur.. M8y 111711 25 ø f!ItH In spite of these problems, it was really rather wonderful to see the serenity that came over Betsy when someone took the time to hold her hand, to feed her gently. to place her rosary between her fingers or to play the Chinese music thoughtfully provided by the music therapist. I never heard Betsy's voice but her eyes were eloquent. I know her days were numbered but I was thankful that the kind folks there would never let her walk alone in the final steps of life's journey. On that ward, Betsy's quietness was offset by Bill's explosiveness. Concomitant with caring for him I had a whole new course in blasphemy. Violent outbursts alternated with periods of total withdrawal when Bill disappeared under the bedclothes and effectively shut the door on everyone. I noticed that these "hide and seek" episodes often coincided with the happy times of the patient opposite him. Russell's wife arrived daily as regular as clockwork. sometimes accompanied by his son or daughter, his grandchildren or his favorite dog. It \\-asn't always easy to be nice to Bill: perhaps he epitomizes what unthinking professionals have come to call "the difficult patient" _ I wonder! Putting myself in Bill's shoes. I wonder how I would behave - a chronic "bouty" alcoholic who knows my spreading cancerous neck lesions are close to my carotid artery and could invade it at any time? How would I respond to the spasmodic visits of a son whom I had not been close to for a long time? How would I feel. day after day. with no other visitors. no former buddies to talk about better times? What would I do in these cramped quarters, coping with a hospital routine. even a "liberal" one, when all I've ever wanted was to be a free spirit and "do it my way". Well, this episode. however difficult, was relatively brief for Bill. It ended shortly after I arrived on the unit and. ifloneliness was his final lot, was he unique? I find myself hoping that St. Peter understood the sublime hidden behind Bill's blasphemy, that he had a few good tales to swap with him and that perhaps he even offered Bill a nip of his favorite brandy - Bill's, that is! What does all this mean? What are people like Sarah. George, John, Betsy and Bill telling us? Many things, but perhaps mostly they are pleading with us to look beyond what they do, to hear more than they say. to really take in their human condition and not "pass by on the other side". When a friend says to me, as she often does, "I guess I can stand a lot of my own company". does she mean that she prefers to be alone? Is she "whistling to keep her courage up"? Or does she insist that she is self-sufficient because there is likely to be no one there most of the time anyway? Is there a link between loneliness and physical. mental or emotional illness which may trigger its onset or confound its curative or rehabilitative aspects? I f I encounter submissiveness. withdrawal. depression. hostility. irritability, loquaciousness. silence. stoicism, anger or a host of other manifestations. what do I think? Isn't all behavior centered in the individual who portrays it and in his human condition? Isn,'t loneliness one of those factors which finds its expression in many divergent ways and which, if we really want to help the elderly as we say we do, we discount at our peril? Have you seen loneliness lately in your friends or your family. in your co-workers or your neighbors, in those whom you serve. or even yourself'? Hov. do you and they cope? And is there a better way? Acknowledgement: This article is based on a presentation by the author to the Canadian Association on Gerontology in Edmonton, Alta., in October. 1978. Photo by Canadidn Govcrnment Photo Centre Amy E. Griffin, the au thor of' '7 he loneliness of the elderly", is professor of nursing administration in the Faculty of Nursing of the Uni\'ersit\' of Western Ontario. Formerly director of research in the School of Nursing , she has also sen'ed as coordinator of graduate programs at UWO and was until recently assistant dean (academic). A graduate of Hamilton General Hospital School of Nursing , she receh'ed her B.A. and Certificate in Nursing Educationfrom the Unh'ersity of 70ronto before continuing on to Jt ayne State University where she recei\'ed her Waster of Science in Nursing and to Columbia U ni\'ersity where she was awarded her doctorate in education. During the Second World War Dr. Griffin ser\'ed in Europe with the Royal Canadian Army WedicalCorps. Since then she has accepted short-term assiR/lfnents for the World Health OrRanization to India and the Philippines where she assisted in curriculum de\'elopment of nursinR programs in these countries. Dr. Griffin is actÌ\'e in the Canadian Association ofUnÏ\'ersity Schools of 'V ursinR, the Canadian Nurses Association and the Registered Nurses Association of Ontario. ze M.y 111711 The C.n.dl.n Nur.. ,. \. .i 0 " "" " ixty , " I Lance W. Roberts , I , . Colin A. Ross ; Have you ever thought ..... of packing it all in, getting on a plane and flying off into the sunset to start a new life as a nurse on Canada's last frontier - north of the 60th Parallel? If you have, and even if you haven't, you may want to read what nurses working in the Northwest Territories have to say about the rewards and frustrations .. of practicing north of ... -. Sixty. - - \ , --- (U . CI - The Can8dlan Nu... May 11171 27 Is northern nursing more challenging than practicing in the south? Are northern doctors as good or better than southern ones? Why do some nurses leave after a few months while others stay for years? The information that follows was obtained by the authors during a preliminary investigation into the perceptions of northern medical needs by nurses working in the Northwest Territories. Fifteen nurses responded to a questionnaire we sent out to 44 nurses working in the I nuvik Zone. Although the results are not statistically significant because of the small size of our sample, some of the comments that we received are interesting. L The setting Inuvik was built in the 1950's on a location known as E3 in the MacKenzie Delta. The site was chosen by engineering consultants, and although gravel, water, docking facilities and building sites are plentiful, moving to Inuvik meant a disruption for the native peoples. From Inuvik you can see the Richardson Mountains to the west beyond Aklavik; it is in these mountains that the natives hunt caribou. Unfortunately a native living in Inuvik cannot travel easily to the mountains for a caribou hunt. Nor is the hunting and fishing good in the region surrounding Inuvik. Since Inuvik was built in order to replace Aklavik as the area administrative center. and since many native people have moved to Inuvik, the choice of site has helped to sever native connections with the land. By northern standards I nuvik (population 4(00) offers big city lights and fast living: not surprisingly the native people of Inuvik have problems with alcohol and unemployment. \ I , f , .4t \ i '- , 'I .r ,. . t , . " 4. , , ,"0 - .. We saw something of Inuvik's alcohol problem in the answers to our questionnaire. The ten Inuvik nurses estimated, on average, that 65 per cent of the patients they see have alcohol-caused or alcohol-related complaints. Nurses in the smaller settlements. though, estimated that only 15 per cent of their patients present problems directly related to alcohol. The social breakdown experienced in the North is most acute in Inuvik and it is our experience that I nuvik is a less pleasant place in which to live than the smaller settlements. This opinion was confirmed in an indirect way by the nurses: the ten I nuvik nurses have spent an average of 6.6 years in the Northwest Territories while the nurses in the smaller communities. on the other hand, have spent an average of 15.2 years in the North. It seems that a real commitment to the North is more likely to occur in a smaller community, something that a southern nurse thinking of a move North might bear in mind. What sort of person moves North. then stays for 15 years? Although we don't know enough to provide a definitive answer to this question, our results do supply some facts about northern nurses. I n both I nuvik and the other settlements, more than half (60 per cent) of the respondents were single: most of these nurses were between the ages of 25 and 35 years. none were over 55 and none under 20. All but two have their RN's: they received their training in every region of Canada, with Alberta and Ontario most heavily represented. Only two nurses received their training outside Canada. What does this mean for the nurse thinking of a move North? Simply that age. marital status, and present place of residence in themselves appear to have little influence on the decision to go North, or on the length of stay and a nurse thinking about transferring to the I nuvik Region need not worry about being too young, too old, married, single, or living too far away for he or she is likely to find colleagues with similar backgrounds there. , " Work and colleagues We also asked the nurses whether. overall, they found northern nursing more challenging and rewarding than nursing in the South. Eighty per cent of the nurses in the smaller settlements said yes: the remainder stated that it is hard to compare the two. The Inuvik nurses were more divided in their opinion: about two thirds said that northern nursing is more challenging. while the remaining third were split three ways between responding that "northern and southern nursing are about the same", "working in the South is preferable", ze M.y 111711 The Cen-.ll.n Nu... - and "it is difficult to compare the two nursing environments". This suggests that the southerner who moves North will be unlikely to find her work dull. especially if she moves to a nursing station outside Inuvik. Also. it seems likely that nurses leave the North after a relatively short period, not because they dislike their work. but for other reasons. I n small northern communities there are usually two or three nurses but no resident doctor. The medical facility is a nursing station. not a hospital. Doctors from Inuvik do visit the smaller communities on a regular basis. however. and phone consultations are common. Under these conditions we wondered whether the nurses in the settlements perceived northern medical needs differently from their colleagues in Inuvik. Table one shows the responses of the 15 nurses to a question about what medical areas they would like more money spent on in their community. We asked them to rank five funding areas 1".....:....... 1 .....'" +...... ...... ............o.r+ .....:rt.....;..,,\ 0"10"''''''' f'n.lln . - -- ,. \ I - - 'iI --- , , ........ " Table one: Average ranked responses of nurses to the question, "Please indicate which of the following areas you would like to see more money spent on in your community. "* Area deserving funding public health education treatment of alcoholism training outpost nurses medical equipment and facilities more doctors' visits Nurses in Inuvik 1.9 2.4 2.9 3.2 4.5 Nurses outside Inuvik 1.8 2.4 2.8 3.6 4.4 *Ranked on a five point scale with 'I' as the highest priority. The Can8dlan Nur.. May 111711 211 that the needs in Inuvik, as perceived by nurses, are very similar to those in the smaller settlements. We were not surprised to find that funding for treatment of alcoholism received the second highest priority since the Inuvik nurses estimated that 65 per cent of their patients arrive at the hospital for reasons directly related to alcohol. Clearly the fact that public health education was given the highest priority is related to both the concern with alcoholism and the general northern need for the greater practice of preventive medicine by a more informed public. Greater training of outpost nurses and the need for more medical equipment and facilities were ranked as of moderate, but not of pressing, importance. Finally it is interesting to note that the nurses rated more doctors' visits as of lowest priority. This ranking probably reflects the relative independence enjoyed by nurses practicing in the North. We also asked the nurses to list in order of priority five areas in which they v.ould like to receive extra training. There was no trend at all in their replies to this question: it appears that the responses reflected the nurses' areas of personal interest more than they indicated deficiencies in present northern medical needs. Training in public health and nurse practitioner courses were, however, mentioned more often, and with higher priority, than the other areas. The general feeling was that a broad training with emphasis on a fev. areas of particular interest would "fit the bill". Such training is readily available to southerners contemplating a career in northern medicine. I n a remote settlement one hears a great deal of smalltown gossip, much of it malicious. Nurses and doctors are the subject of a great deal of this gossip and a southerner who moves into northern nursing will soon learn that in Fort Norman, or Fort Good Hope, she is the nurse 24 hours a day. This can make northern nursing difficult. During our time in the North we heard much gossip about medical matters. General practitioners in the Inuvik Region have on more than one occasion been referred to as "horse doctors". We wondered what the nurses in the region thought of northern doctors. and asked a number of questions to find out. We discovered that these nurses considered northern doctors as good or better than southern ones. Asked to compare the level of competence among northern GPs with that of southern doctors. 80 per cent of the nurses stated that the two are equal. and the other ::!O per cent claimed that northern GPs are superior to southern general practitioners. When we asked, "How adequately do you feel that doctors are trained for northern service?", almost 75 per cent of the nurses stated that general practitioners are adequately trained for northern practice. When we asked, "Hov. necessary is it that doctors receive special training for northern service?" , 60 per cent replied "somewhat necessary", 27 per cent replied "very necessary", and 13 per cent did not answer. Taken together, these findings suggest that northern nurses are quite satisfied with the standards of general practice in the North. In one of our open-ended questions we asked, "In what ways do you think nurses have trouble adjusting to northern conditions?" Here are some of the replies: . I hm'e more respolUibility, insufficient staff . most nurses come from big hospitals and are used.to one brand of medicine: in the North they han' to work in all areas . accepting cultural differences, i.e. complacencv of many nati"es re tal..inf! prescribed medications, keeping appointments, etc. . do not understand cultural d(f/erences and attitudes toward health; some hm'e trouble with climactic and em'ironmental differences . I found no trouble adjusting other than worl..;ng in a new em'ironment but this was no different from changing jobs in the south . , \ . social life is somewhat restricted, the terrain is rugged - suitable only to those who enjoy the outdoors . the way the children are neglected - and when they get sick - the parents seem unable to follow simple instructions to help their children get well . er:pected to handle ICV cases without adequate training . isolation from urban cent r, lacl.. of recreational facilities -unable to go off on weekends, etc. These comments provide a mea'iure of insight into why some nurses leave after a few months, while others stay 20 years. As one northern nurse pointed out: "those with a feeling for the bush. the river, the ptarmigan, the power and beauty of the northern landscape will have more reason to stay in the north." Adjusting to the differences, however, is often not an easy task. Another nurse said to us: "I don't think they (nurses) have trouble adjusting:' they don't try to adjust, instead they bring their personal problems with them. They are here to escape. They are only here for the kicks - just up for a short period for the experience. Only one nurse in 20 is really interested." That's a radical statement, and it tells us a lot about the problem of white transiency in the North. The North is the last Canadian frontier but even now disruptive development activity, caused by the South's insatiable demand for oil and mineral resources, is rapidly changing the social and physical landscape. Since nur es hold central positions in most northern communities, they must deal with the physical and mental consequences of industrial expansion. It follows that the future of northern nursing is likely to be filled with new experiences and challenges. As researchers who have lived in the North, we think that life north of Sixty, especially in the health professions, can be very rewarding and we hope that this brief sketch of northern nursing will be of int rest to southern nurses considering a move to the Northwest Territories. "Nursing North ofSixt ... was co-authored by Lance W. Roberts, Ph.D., a professor with the Department of Sociology of the Vni,'ersitv of Jfanitoba, and Colin A. Ross, a medical student attending the V nh'ersitv of Alberta. PholOS coune y Health and Welfare Canada ( \ IE I \\? ',. ergency treatment of drug overdose . t h ,/ hil1>;r" . )'J, .r rr ! 1/ " ,1 .'\!1{ I '\ I ' --.( , :: ,. . ----- The individual who takes an overdose of drugs needs expert physical and psychological care in the Emergency department. Author Heather Erb bikes a look at treatment measures, psychological assessment and steps that the emergency nurse can take to ensure that the suicidal patient receives the best care possible. '. .. ,'- ,:;. :;. " " . í.. .'. . " ". #,.: .". ., ,. ,. ,. ,. - ....., .:;.. .:: '. " .' ,,:": / ."" ./. ':.- . ...;. .:. . :... \.. :.: . ".." t 7 ' . , -.' . ;;;, .... "' --;..,,- To most people, drug overdose means attempted suicide. Assumptions. however. can be misleading: overdose may be suicidal or it may be accidental in nature. Often individuals are not aware of drug interactions and so they combine the wrong medications or they take more than the recommended number of pills. thinking that "if one works. two will work better". The result may be accidental overdose. Children are particularly susceptible to accidental overdose or poisoning: they may ingest medications or household products out of curiosity. totally. oblivious of the consequences. The nurse working in emergency will no doubt deal with both deliberate and accidental overdose. Although treatment measures are similar for both. teaching, support and patient education follow different routes entirely. depending upon the circumstances. Let's take a closer look at suicidal overdose with both medical and psychological considerations in mind. I t is very important for emergency nurses to know how to help those who are suicidal. whether the patient has already attempted suicide or shows the potential to do so. We are very often the patient's first contact with health professionals and so our task is a large one. We must provide basic life support; we must recognize the signs of the patient's distress and give him immediate psychological support; andjust as important, we must take definite steps to ensure that the patient does not leave the emergenc department without first Deliberate or accidental? When a patient is admitted to the emergency department following an overdose of drugs, we must do all that we can to find out the circumstances surrounding the event. Many of those who attempt suicide leave a note or try to make contact with someone - their's is a cry for help. and they may perceive that a suicide attempt is the only way to get that help. There are others who are discovered strictly by chance; a relative or friend returns to the individual's home quite unexpectedly to discover the victim unconscious. Even in these circumstances, it cannot be assumed that the patient did not intend or want to be discovered. Keep an open mind: the patient may have been unable to reach the phone in time. Patients with an altered mental health status often possess medications that can be used in overdose. Such an overdose may not be an attempted suicide however - it may result from the patient's confusion or lack of orientation to his surroundings. Never jump to the conclusion that an individual presenting with signs of an overdose is attempting to end his own life. Patients have been admitted to emergency with an assumed overdose that turned out to be another illness entirely. I t is important that you as a nurse make every attempt to verify the cause of the patient's signs and symptoms. Jumping to conclusions can have a negative effect on the patient's ultimate health. 4 Heather L. Erb 1 - There are certain valuable clues which can alert you to both the causes of an attempted suicide and to the potential for such an attempt. Being aware of these clues enables you as an emergency nurse to make appropriate referrals so the patient can receive further help. fhe following individuals may require help: . the individual who has recently suffered a loss through the death of a relative or a close friend: . the adolescent who is having parental problems, peer problems or boyfriend/girlfriend problems: . the individual who innocently asks "1 wonder how many of these pills it would take to do someone in?" . the individual who shows signs of depression: . a person who is living alone: . one who demonstrates overt hostility; . one who complains of poor appetite and sleep habits; . the individual who is preoccupied; . one who expresses helplessness. unworthiness or worthlessness: . one who expresses direct or suggestive expressions of self harm. Take a look at what is happening in the patient's life. For some people. losing ajob or moving to a new house causes unresolvable problems. If the individual cannot resolve conflicts or feels his burden is too great. he may consider suicide for any number of circumstantial reasons. I n emergency, we can be alert to all these factors to find out ifthe patient requires further help. """ Treatment of drug overdose 1 Induced emesis Syrup of Ipecac IS the drug most commonly used to induce vomiting. It should only be used if: e the patient is awake: e the patient has not taken an antiemetic or drugs with antiemetic properties: e coma and lethargy are unlikely to occur. Ipecac acts on the medulla (chemoreceptor trigger zone) and thus ItS effects will not be seen for 20 to 25 minutes. The drug should be repeated only once as protracted vomiting may occur if the patient IS given too much. Fluid should be given after the patient takes Ipecac. In our emergency department. we hnd that warm water and orange or apple JUice work well with the Ipecac (we give about two eight ounce glasses of flUid). Dosage range: age 9 months to two years - 15 ml age 2 years to 10 years - 20 ml age 10 years and older - 30 ml' 2 Gastric lavage Gastric lavage is the treatment used for patients who are comatose or may become comatose Endotracheal intubation IS recommended to prevent aspiration. A gastric lavage tube is passed through the mouth and Into the stomach. then Irrigation with water or saline is done until the returns are clear. Lavage is done in order to remove the Ingested drug. After lavage. activated charcoal,s often passed through the tube and Into the stomach. 3 Adsorbing agents Activated charcoal IS the most common adsorbant used. Charcoal attracts most drugs to itself. with the exception of cyanide. I: is supplied ,n 500 ml plastic bottles containing 50 grams of charcoal - 400 ml of water is added to the charcoal' The patient may drink the charcoal. but It is most commonly given through the gastnc lavage tube. If the patient has already received an emetic. make sure that it has worked before giving charcoal. as charcoal will bind to the emetic as well 4 Purgatives Purgatives are also given in the emergency room In order to speed the elimination of the drug through the Intestines The most commonly used purgatives are castor oil (30 to 60 ml) and sodium sulphate (30 to 60 ml of a 50 per cent solution).' If you give a purgative In emergency. be sure to chart it so that the nurses recelv,ng the patient on a ward will be aware that they should watch for results. 5 Antidotes Antidotes are used to reverse or diminish the effect of the drugs Ingested An antidote IS useful In specific cases only. The following IS a list of toxic agents and their antidotes. Toxic Agent Opiates (NarcotiCS) Insulin Cholinesterase Inhibitors Methanol Iron Atropine" or scopolamine Warfann Arsenic or mercury Lead Cyanide Carbon monoxide Antidote Narcan " Glucose Atropine' and pralldoxlme Ethanol Sodium ferrocyanide and deferoxamlne mesylate Cholinesterase inhibitors (physostigmine) Vitamin K Dimercaprol (BAL). Ethylenediamine tetra-acetic aCid (EDTA) Nitrites and sodium thiosulfate Oxygen or hyperbanc oxygen 6 Increased fluid intake The more fluid the patient takes In the more he will excrete. hastening the speed with which the ingested drug 'eaves the body. Contralndlcallons to forced flUid therapy Include renal insufficiency. pulmonary edema and cardiac insufficiency 7 Dialysis Dialysis is a last resort measure In the treatment of drug overdose - it is used in very severe cases. when all else has failed This procedure is not carned out In our emergency department. but when Indicated. IS performed by expenenced renal personnel. \.. Drugs commonly used in overdose The following drugs are commonly used in an overdose or attempted suicide. Treatment varies according to the condition of the patient - obviously I a patient who walks into emergency talking coherently and breathing well does not require intubation. Knowledge about the drugs used most commonly in overdose is important because it enables you to watch for and anticipate what may happen to the patient. Complications or other illnesses that the patient has will necessitate changes in the course of treatment. Basic life support is always the first priority. The CPS is a good reference for the toxic doses of each drug. It is also important to be aware of the poison control center in your area. I n cases where it is impossible to determine what the patient has ingested, treatment is given according to the presenting symptoms of the patient. (/) Drugs W 222's , ASPIRINGÞ, ANACINGÞ, BUFFERIN , DRISTANGÞ ...I > o ::i c( (/) Therapeutic uses analgesic. antipyretic, anti-inflammatory Therapeutic dose 0.6 g every three to four hours (adult) Fatal dose 0.4 g to 0.5 g/kg body weight Absorption and excretion rapidly absorbed from stomach and duodenum. Rapid excretion from kidneys - this explains large and frequent therapeutic doses Effects of overdose acid-base disturbance kidneys excrete increased amounts of potassium, sodium bicarbonate and retain chloride (trying to compensate) hypokalemia hypothrombinemia hyperthermia gastroenteritis tinnitus sweating spontaneous bleeding twitching dehydration flushed face uremia inconstant pulse initial rise, then fall in blood pressure depression convulsions pulmonary edema death from respiratory failure Diagnostic tests e artenal blood gases e blood salicylate levels: take one specimen on admission. and another in two hours. If the second one is higher, it shows that the drug is still being absorbed - repeat again in two hours. If the second level taken is lower, drug absorption is on the decline. e blood urea nitrogen - if the urinary output is not adequate e electrolytes - to pick up hypokalemia e vital signs - at least every hour e urinalysis - mayor may not give true reading of glycosuria or ketonuria Treatment e emetic jf conscious, cooperative and not in danger of coma e gastric lavage if unconscious, confused; follow with activated charcoal e intravenous therapy to correct acid-base imbalance, electrolyte imbalance e sponge baths to reduce fever e whole blood or platelet transfusion if hemorrhage occurs . dialysis for extremely toxic levels of salicylates if renal insufficiency or failure is present Comments Depending on the severity of the overdose, an emetic may be all that is needed in treatment. If the patient fails to respond to the emetic more active treatment is called for. Aspirin is commonly found in most households, readily available for ingestion in a suicide attempt. Many people feel that aspirin is harmless and may overdose (not wishing to die). unaware of its potential. However, serious illness and death can result from salicylate overdose. Aspirin is sometimes taken in conjunction with other medications; do not overlook the effects of aspirin just because the other drugs seem more lethal. Z Drugs W :J: Q. o Z - :æ c( to- W o c( TYLENOL GÞ Therapeutic uses analgesic, antipyretic, commonly used in place of salicylates, no anti-inflammatory effect Therapeutic dosage 325 to 650 mg four times daily Lethal dose can be fatal in doses from 10 to 15 g Absorption and excretion absorbed rapidly from the GI tract rapidly metabolized in the liver, small per cent excreted unchanged in the urine Effects of overdose nausea vomiting upper abdominal pain drowsiness progressing to coma due to hepatic necrosis death Diagnostic tests e liver enzymes - will show gross elevation . bilirubin level- will be elevated e prothrombin time - prolonged . blood sugar - will show hyperglycemia or hypoglycemia Treatment e Ipecac-induced emesis . activated charcoal . dialysis e Mucomyst'" (experimental) Comments Acetaminophen causes severe liver damage - if the liver receives more of this drug than it can handle, the drug binds itself to the liver macromolecules and kills the cells. The result is hepatic damage. Treatment is similar to that of other drug overdoses with the exception of using Mucomyst. which is being used experimentally to prevent liver damage. Mucomyst is administered orally or by intravenous' -It inactivates the by-products of acetàminophen and thus prevents liver damage Drugs AMYT AL I!'). SECONALI!'). NEMBUTALI!'). LUMINALI!'), PHENOBARBITALI!') - II Therapeutic uses used for insomnia. calming and sedation. convulsions. anesthesia. pre-operative medication. and for obstetrical and psychiatnc purposes Therapeutic dosage varies with the drug used. II is Important to find out which drug the patient ingested. Minimum lethal dose short acting barbiturates (Nembutal and Seconal) 3.5 mg 11 00 ml blood level: long acting barbiturates (Luminal and Phenobarbital) 8.0 mg/1 00 ml blood level or approximately 15to 20 times the therapeutic dose Absorption and excretion short acting barbiturates are absorbed and excreted rapidly. while long acting barbiturates are slowly absorbed and excreted and may have a cumulative effect. If the barbiturate is a sodium salt. it is more rapidly absorbed than the free acids in barbiturates. Barbiturates undergo some change in the liver and may be excreted partly unchanged and partly altered The more slowly the drug is altered. the more slowly it is excreted. Effects of overdose Mild effects: drowsiness mental confusion headache Severe effects: hyporeflexia shallow. slow respirations delirium circulatory collapse cold clammy skin pulmonary eclema dilated. non-reacting pupils stupor decreased blood pressure rapid. weak pulse coma and then death Diagnostic tests . arterial blood gases . blood levels of the drug taken on admission and later to determine if the level is increasing or decreasing. If it is increasing. blood tests will have to be repeated until results reach therapeutic levels. . electrolytes . urine for toxic screen Treatment . emetic to induce vomiting. ob&erve until patient alert . oropharyngeal airway if the patient is unconscious and gastric lavage is not being done . endotracheal tube should be inserted if gastric lavage is to be done or if respiratory failure is imminent or apparent. Gastric lavage is followed by acti\lated charcoal. . intravenous therapy -take care not to overload the Circulatory system as pulmonary edema is a danger with barbiturate overdose. In case of shock. an IV line should be available to maintain blood pressure with plasma or extra fluids. . catheterize patient to monitor urinary output . vital signs. mental status. skin color, lung bases. reflexes and sensations at regular intervals (at least every one to four hours depending on patient's status) . dialysis may be necessary in severe cases Comments Barbiturates are frequently used for psychiatric purposes. Thus they provide patients under psychiatric care with a means to attempt suicide. Very often. patients drink alcohol prior to taking barbiturates. and the combination of alcohol and barbiturates is deadly. Alcohol potentiates the effect of barbiturates en W N ::i 5 . Drugs VALlUM , LlBRIUMI!'). SERAXI!'). ATARAXI!') Therapeutic uses used to allay moderate anxiety states and relieve muscle tension associated with psychomotor agitation c( I- o z - Therapeutic and lethal dose depends upon the drug used Effects of overdose similar to the barbiturates in their effects on the body. Alcohol also potentiates the effects of these drugs en W N ::i Drugs PHENERGAN(!!), STELAZINEI!'), STEMETIL I!') o z c( Therapeutic use antipsychotic Therapeutic and lethal dose depends upon the drug used o Effects of overdose see minor tranquilizers myocardial depression with EKG changes severe hypotension due to central nervous system effect, direct myocardial depression and vasodilation seizures may occur as phenothiazines lower the seizure threshold extrapyramidal effects Treatment . see barbiturates . cardiac monitor with life support drugs and equipment available . control seizures cautiously with phenobarbital . treat extrapyramidal effects with Cogentin or Benadryl'!t en I- Z c( en en w Q. W c i= z c( o ::i > o æ I- Drugs ELAVILI!'). TOFRANILI!'), AVENTYLI!') Therapeutic uses potent antidepressants, mild sedatives Therapeutic and lethal dose varies according to the drug used Effects of overdose anticholinergic. atropine-like. antihistamine. and antiadrenalin actions arrhythmias dry mouth thirst dilated pupils agitation delirium coma decreased respirations Treatment . induce emesis if patient alert . intubation before gastric lavage or if there are respiratory difficulties. Gastnc lavage followed by activated charcoal . intravenous therapy - so a route is established if necessary . cardiac monitoring along with vital signs . physostigmine may be of some use en w z i Drugs BENZEDRINE , DEXEDRINEI!') METHEDRINEI!') I- Therapeutic uses W mild depressive states (non psychotic) ::J: depress appetite in the treatment of obesity Q. narcolepsy Therapeutic and lethsl dose depends on drug used. refer to CPS Excretion excreted in acidic urine. will be reabsorbed in alkaline urine Effects of overdose stimulation of the central nervous system visual. tactile. auditory hallucinations mood elevation tachycardia dyspnea chest pain hypertension arrhythmias dilated pupils blurred vision respiratory failure Diagnostic tests . blood and urine for toxic screens . urinalysis to determine pH . EKG . any other tests applicable to the particular situation Treatment . induce vomiting if patient alert . gastric lavage if patient unconscious. followed by activated charcoal . purgatives are useful . monitoring vital signs with a close eye for respiratory depression . cardiac monitor for arrhythmias . intravenous therapy -to have a route established in case arrhythmias occur and drugs must be administered . atlemptto acidify the urine to shorten effect of druq 34 ".Y 111711 The Cen.dl.n Nur.. A threat of suicide should never be taken lightly. Most people who communicate in some way that they intend to kill themselves make an attempt to do so. This holds true for children and adolescents as well; suicide in these groups is on the upswing. "The common protestation that the patient is too cowardly to harm himself means nothing in practice as bravery and cowardice have little relevance to suicidal behavior." t Many patients express regret soon after the suicide attempt - they may apologize for being foolish and promise that it will not happen again. The temptation in emergency may be to discharge these individuals without psychiatric assessment and follow-up. but it is highly unlikely that they have resolved any of their problems; each patient needs follow-up. The following is a guide to help you assess the suicidal patient, whether he has already attempted suicide or shows the potential to do so. Assessment guide When you assess a suicidal patient, your attitude and the manner in which you approach the patient are most important. The patient does not need your reproach. judgment or condescending behavior. It is important in following this guide to show genuine interest in the patient's welfare and not just curiosity. Find out: Vital statistics: the patient's name, age, address, phone number. marital status, significant others (family. boyfriend, girlfriend etc.) If the patient has alread} attempted suicide the following information is relevant: Wethod: overdose of drugs. gun. rope; what did the patient use to attempt suicide? Location: was the patient alone or with someone? Did he attempt to reach someone by phone? Time of day: was there apt to be anyone around at the time? Intention: what did the patient hope to accomplish? Did he expect to die? If the nature of his act was manipulative. has his expectation been met? A ttiwde: is the patient angry. sad. resentful. depressed. etc.? Social circumstances: what triggered this attempt - family situation, friend. job, etc. ? Past history: has the patient been treated for a psychiatric problem? Has he (or a family member) made an earlier suicide attempt? Other patients may indicate a potential for attempting suicide, although they have not yet made a direct attempt. Often an individual presents in emergency with the simple admission that he wants to take his own life; he may state that he is depressed or agitated; or he may be brought in by a worried relative or friend. In assessing the patient with suicidal potential. the following approach is helpful: . show interest in what is happening to the patient, but talk generally with him and get to know him before asking specific questions about suicide; . find out about the patient's current social circumstances. attitude. and past history (as above); . find out what is making the patient feel the way he is feeling. or what he thinks is the cause of his feelings; . don't be afraid to ask the patient if he has thought of taking his own life. Your question will give him the opportunity to express his feelings. Note his verbal and non-verbal response to your question. If his answer is yes. find out if he has plans about how he would do it; . ask the patient if his feelings about suicide are related to something that has happened or is happening - his wife. job, money, etc.; . ask the patient about his alcohol and drug consumption. Once you have gathered the information that answers these questions you will be able to assess the patient's emotional status, discuss your findings with the physician and determine an appropriate course of action. It must be remembered that this is only a guide- certain issues will naturally be discus!.ed that are pertinent to the patient or situation he is presenting. If you feel that you need help with the patient or his problem, consult with the doctor. Many suicidal patients need psychiatric care; although there is no time in emergency for therapy. there is room for assessment and referral for further care. Remember that before the suicidal patient is discharged from emergency, something positive must have happened: something must have changed for him. Otherwise, you will be seeing him again. And the next time may be too late. Recognizing your biases If we as nurses are to have a positive effect on the suicidal patient. we must provide emotional support. But before anyone of us can intervene effectively with the patient who has taken or may take an overdose. we must take steps to identify and come to terms with our own feelings.about suicide. As members of the "helping profession". many of us find it difficult to understand why we are treating an individual who is trying to end his own life. when so many other . people must struggle in order to live. We may find ourselves looking at those who attempt suicide as worthless individuals who are simply wasting time, time we could be spending with those who want desperately to live. These kinds offeelings are projected onto the patient, evident both in our speech and in our actions. Undoubtedl} they affect the care that we give. And the person who deliberately takes an overdose of drugs often has a low self-esteem to begin with: if we add to his feelings of unworthiness, we are hardly helping him. At one time. attempted suicide was against the law and had to be reported to the police as an offence. Perhaps the roots of our attitude problem lie here. While we provide support to the woman who has lost her husband. we justify holding back from the individual who has attempted to take his own life. I feel that it is about time we examined the way we react to those who attempt suicide and improved the quality of care we offer them. Nurses are not alone in their negative attitudes towards those who overdose; physicians also have a great deal to learn. We must work together as a team to change attitudes. There is no doubt that basic life support is a priority when the patient is first admitted, but once he is stable, we can all begin to help him psychologically, instead of merely checking his vital signs every hour, offering minimal human contact. It is one thing to give lip-service to the idea of psychological support and altogether another to give it. But remember that any individual who is admitted to emergency after an attempted overdose is vulnerable. and his visit to emergency is the time to help him recognize his need for further help. Almost every suicide attempt can be associated with a specific incident in an individual's life. Although this fact may not be evident in the emergency department. the patient needs to deal with it in interviews and therapy that can be arranged by those who meet him in emergency. Obstacles to care Attitude is far from the only obstacle to quality care of the suicidal patient. We must spend time to discover other barriers to thorough treatment with the aim of instituting a better system of care. The Cen-.ll... Nur.. ".Y 1871 36 One of the obvious obstacles is related to staffing limitations in the emergency department. Emergency rooms are servicing an ever increasing numher of patients today with no compensation in the number of staff members needed to deal effectively with this patient load. How is it humanly possible to spend all the time necessary to help the patient who has attempted suicide because his problems are too much for him to handle? Perhaps we should consider organizing volunteers, trained in crisis intervention. to fill that need. Volunteers would have the time to sit and talk with patients, free from the burden of responsibilities that doctors and nurses carry. They could also help pass the time with patients who are awaiting admission or test results. Secondly. there are definite knowledge needs for those who care for suicidal patients. Hospitals should be providing inservice programs for staff members who deal with these patients. For example. certain drugs are used to overdose more than others within a given geographical area - your hospital can be aware ofthe drugs most commonly used in its area as well as antidotes used in treatment. Public education is also important; information posters in outpatient and emergency departments are helpful. On the posters. include a li t of agencies where further help can be found. Physicians within the community should be encouraged to question why they persist in giving certain drugs, for example. antidepressants. They need to consider preventive medicine - tallo..ing to the patient to find out why he is depressed, and what can be done to change the patient's situation, rather than merely giving out medication. Follow-up is another neglected area in the treatment of overdose patients. Too often, the patient is simply patched up and discharged. with no concrete effort made to provide follow-up care. Studies show that once a person has attempted suicide, chances are that he will try again. "This fact underlies the necessity for follow-up care. Many emergency departments discharge an overdose patient with a note in his pocket for an appointment with a Mental Health Clinic. But how many of these patients actually keep that initial appointment or return for subsequent appointments? Those who overdose often use their own prescription drugs. Follow-up could be ensured if the patient's family doctor were notified by phone or mail that his patient was seen in the emergency department following an overdose, and strongly underlining the need for follow-up. With some support in the community. the patient may not feel the need to attempt suicide again. Unless we as nurses take time to talk to the patient. he may not feel encouraged to seek help available to him in the community. If you have little time to spend with him. and he is to be discharged from emergency after treatment, arrange with someone in the social services department to visit him in his home. All of these attempts to arrange follow-up have the potential to set the patient in the right direction. Not all patients who overdose are admitted to the hospital. nor are they evaluated by a psychiatrist. With good physical and psychological support and careful attention to the details offollow-up care. nurses in emergency can playa part in ensuring that the suicidal patient receives the help he so desperately needs. References I Bridges, P.K.Psvchiatric emergencies: diagnosis and management. Springfield. III.. Thomas. 1971. p.88. 2 Perlin. Seymour. A Iwndhoo/..for the study of suicide. Toronto, Oxford University Press. 1975. p.154. 3 Cosgriff. James H. The practice of emergency nursing. by... and Diann Laden Anderson. Toronto, Lippincott. 1975. p.158. 4 Dreisbach. Robert H. Handhoo/.. of poisoning: diagnosis and treatment. 8th ed. Los Altos. Ca.. Lange, 1974. p.16. 5 Cosgriff. op. cit. p.160. 6 Ibid.. p.161. *7 Reversing Acetdminophen OD. EmerKency Medicine. Feb. 1978. p.109. 8 Cosgriff. op. cit. p.163. *References not verified in CNA Library Bibliograph I Bellack. Leopold. EmerKency psychotherapv and brief psycJlOlogy. by ... and Leonard Small. New York. Grune. 1965. 2 Bergersen, Betty. Pharmacology innur. ing. 12th ed. St. Louis, Mosby. 1973. 3 Bridges. P.K. Psychiatric emergencies: diagnosis and management. Springfield. III.. Thomas, 1971. 4 Cosgriff. James H. The practice of emergency nursing, by... and Diann Laden Anderson. Toronto. Lippincott. 1975. 5 Dreisbach. Robert H. Handhoo/.. of poisoning: diagnosis and treatment. 8th ed. Los Altos. Ca., Lange. 1974. 6 Geolot, Denise. The emergency nurse practitioner. Nurse Pract. 3:3: 12.28, May/Jun. 1978 7 Glick. Robert A. Psychiatric emergencies. edited by... et al. New York,Grune, 1976. *8 Graber. Richard F. Treating the acute overdose victim. Patient Care, Jan. 15. 1977, p.76-103. 9 Macey. Anne M. Preventing hepatotoxicity in acetaminophen overdose. A mer. J. Nul's. 79:2:301-303. Feb. 1979. 10 Mennear, John H. The poisoning emergency. Amer.J. Nul's. 77:5:842-844, May 1977. II Perlin. Seymour. A handhoo/..for the study of suicide. Toronto. Oxford University Press. 1975. 12 Prentice. Glen. Evaluating suicide potential. Nurse Pract. 2:5:30-31, May/Jun. 1977. 13 Rosenbauer, Audrey. Suicide prevention and the emergency room nurse. Heart Lung 7: I: 101-104. Jan./Feb. 1978. 14 Suicidology: contemporary del'elopments, edited by Edwin S. Schneidman. New York,Grune. 1976. 15 Stevens, Barbara C. Preventing fatal overdose. Nul's. Mirror. 145:24:47-48, Dec.15. 1977. 16 Sumner, Frances. A nurse for suicide patients, by... and Theresa A. Gwozdz. Amer.J.Nurs. 76: II: 1792-93. Nov.1976. 17 Yowell. Sharon. Working with drug abuse patients in the ER. by ... and Carolyn Brose.Amer.J.Nurs. 77: I :82-85, Jan. 1977. Others * I Tricyclic overdose: the lab can help. Emergency Medicine. Mar. 1978- p.144.146. *2 Verge of death. Emergency Medicine. Mar. 1978. p.39. 44-45. *3 Poisons. C urrent Medical ÐiaKnosis and Treatment. 1976. p.928-956. *References not verified byCNA Library Heather L. Erb, author of Emergency treatment of drug ol'erdose is a graduate l fthe Saint John School of Nursing, Saint John. New BmnswicÂ. Following graduation. she worked for two years in the emergency department at the Saint John General Hospital. Currentlv enrolled in McMa. ter U nÎl'ersir.;' s Educational Program for Nurses in Primary Care. Heather is receÎl'inK clinical experience in emergency at Saint John's Hospital. Frankly speaking Nursing and the degree mystique Nursing now has a place on the university campus, but has it reall)" freed itself from the shackles of its hospital past? In part two of Nursing and the Degree Mystique, author Jeanne Marie Hurd looks at what nursing otTers to those who are seeking a university education. Jeanne Marie Hurd There is an urgent need in nursing today for expanded minds to keep pace with the profession's expanding role. Now that the university school of nursing appears to symbolize nursing's relative equality with the other health professions, it is usually assumed that the nursing degree represents the ultimate opportunity for academic and professional mind expansion in nursing. But does it really? Or is the parochialism inherited from the profession's hospital-dominated past insidiously choking out both the intellectual curiosity and the freedom of thought essential to the attainment of a real university education. Parochialism. or narrowness of vision, can cripple a developing profession to a dangerous extent. Its symptoms are highly visible in contemporary university nursing education. with both practical and historical reasons contributing to the etiology of these symptoms. To begin with the practical, it is obvious that university nursing is currently faced with a very real dilemma - it must combine both basic university preparation and professional education within the increasingly limited confines of an undergraduate program. Nursing's medical counterpart has escaped this dilemma by placing its professional education at the graduate level. thus permitting medical students to be regular university students during their undergraduate days. In recent years, moreover. medical schools have increasingly encouraged their aspirants to major in something other than "pre-med" at the baccalaureate level. Recognizing that professionaJ education is by definition highly specialized. they base their recommendations on the premise that a medical student must gain exposure to the liberal arts and sciences if he is to achieve a well-rounded university education. And such exposure is possible onJy before his professional education begins. Nursing does not have the luxury of this type of separation. The university school usually makes a valiant attempt at offering both liberal and professional education within the scope of one degree. but the pattern of the past fe\\- years shows professional content steadily encroaching on the liberal arts. From a nursing viewpoint, the reasons for this encroachment are quite logical. First. there is increasing pressure on university schools of nursing from employers who complain that baccRlaureate graduates lack basic clinical competence. presumably . because of their abbreviated clinical experience. Naturally. since nursing faculties are anxious to turn out "superior products". an increasing proportion of student time is thus devoted to nursing courses. Furthermore, hecause the nurse's role is rapidly expanding in today's world. it is incumbent on faculty to incorporate a growing number of new concepts and skills into basic nursing preparation. And it must be remembered that a university nurse is expected to be qualified as a beginning level practitioner in all areas the day she graduates. It is small wonder that many university schools of nursing. which but a few years back were not beginning nursing courses until the student's third university year. are now introducing professional content at the first vear level. The Cenedlen NUrN II., 1171 37 While such programming undoubtedly enriches the student's professional preparation, it also cuts back significantly on the liberal arts portion of the curriculum. Supposedly, providing adequate opportunity for exposure to the liberal arts was a major reason for moving nursing education to the university in the first place. Without such an intent, the move was hardly justifiable, as the clinical facilities are certainly much hetter in the hospital. Defenders of the trend toward an increasing percentage of professional content will no doubt point to the sizable proportion of physical and social sciences woven into the nursing curriculum. The crux of the matter, however, is that the student's curriculum is increasingly programmedfor her in terms of what the faculty feels is appropriate. While most universities now include a given number of elective courses as part of their requirements, electives are not a priority in university nursing. More important, the-philosophy behind the availability of elective courses - that is. the encouragement of the student to pursue truth wherever it may lead him - is certainly not a university nursing priority, especially when the student's concept of truth and what she would like to learn conflicts with the faculty's preconceptions. And the fact that most nursing students accept this state of affairs without question attests to the success of the programming from the standpoint of protecting and promoting professional content. The 'liightingale s ndrome While the practical reasons for nursing's retreat into itself are readily identifiable, there is a deeper reason for the parochialism that often dominates the university nursing scene today. This reason relates directly to the profession's history. Until recent times, nursing was content to accept a basically subservient role, seeing itself as a facilitator of the decisions of others and giving little thought to the generation of ideas, theories and concepts of its own. But while passive and subservient vis-à-vis other professions. nursing began to compensate by becoming rigid and authoritarian in its dealings with its own members. This phenomenon gained high visibility in the era of Florence Nightingale, whose amazing ability and forceful personality teamed up with the British military system to establish the framework for modem nursing. ", 2 I would suggest that this rigid, authoritarian and hierarchical framework is by no means past history. It has simply moved from the hospital to the university campus as nursing has changed its base of operations. Instead of presenting as an overt characteristic of nursing's management structure, however, it exists now beneath the surface - and is thus doubly dangerous. Most university nurse educators are probably unaware of its existence, having convinced themselves that nursing has liberated itself from its past and now operates flexibly, with a scholar's approach to disciplinary content. But has the leopard really changed its spots? A large percentage of today's nurse educators and nursing school administrators were themselves "trained" in diploma programs and then went on to acquire university degrees. These nurses are often the first to criticize hospital-based programs for training rather than educating nurses, yet the very characteristics they deplore in diploma programs have become part of the unspoken modus operandi of many university schools. Graduates of these schools continue to perpetuate the system under the illusion that it is completely free of the "training school" approach. There are understandable and very human reasons for this development. The phenomenon might be likened clinically to the battered child syndrome in which children who have been battered become battering parents in turn - and so the cycle repeats itself endlessly unless skilled intervention occurs to break it. Nurses trained under auspices affected by the "Nightingale syndrome" (which few modem nursing schools completely escape) unconsciously become its victims and just as unconsciously perpetuate it in the next generation of nurses. Without both recognition of the problem and conscious intervention, there is no end to it in sight. The circle game There is a commonly accepted premise in modem professional practice that carefully protects nursing's absolute right to perpetuate its own internal cycle without any threat of interference. I refer to the concept of peer review. It is fascinating to note that university nursing schools perceive their peers in terms of other university schools of nursing - not in terms of other schools, faculties and departments on their own campuses. Peer review for each school then, must not only come from outside its own university, but from another university nursing school. This means that most university administrators have little idea of how their own nursing schools operate, functioning largely as passive bystanders and granting pro forma approval when the accreditation reports prepared by other nursing experts are presented. The idea of inviting criticism from outside nursing is unthinkable: after all, only nurses are qualified to comment on nursing. Each university school of nursing is evaluated and recommended for accreditation by experts from other schools whose philosophies and operational styles are similar to its own. It is not surprising, then, that there is little basic criticism forthcoming. Nor could such a practice be expected to review nursing as it relates and compares to the other disciplines with which it shares the university campus. In a world of increasing interdependence, nursing seems to prefer to maintain its isolation within the university as if afraid of competition with or contamination from sources outside itself. Let me cite one example to illustrate the type of results to be expected from peer review, narrowly defined. The entire third year class of a certain university nursing school, completely frustrated by the use of programmed learning and independent study to the virtual exclusion of all other teaching methods, decided to express its concerns in what the students had been taught to believe was a professional manner. Following numerous unsuccessful individual and small group attempts to gain a hearing for their concerns, they prepared a brief which respectfully requested a more balanced mix of 38 May 111711 The Cenadlan Nur.. teaching techniques. The brief was phrased in decidedly positive terms: the students had made every attempt not to appear critical. They requested direct contact with and input from their faculty who they felt had the wisdom and experience to provide them with the guidance they felt they needed. Although the brief was presented to the faculty by the entire class, it was greeted with a mixture of hostility and ridicule by the instructors, while the school's administrator chose not to attend the meeting. As one student sadly remarked afterwards, "They listened, but they didn't hear us." Some time later, at a regional student nurses' conference, the school's student association officers shared their disillusionment over what had happened with officials from the national accrediting organization. "We are urged by our faculty to become change agents," they lamented, "but if we try to follow their advice, we're promptly beaten down." The officials strongly urged the students to take their case to the headquarters of the national accrediting body, which the students did in spite of their keen awareness of the possibility of reprisal. Since their school was preparing for an accreditation visit by two prominent professors of nursing from other universities, the students were advised by headquarters' officials to discuss their grievances with the visiting accreditors. This was done at a <;pecial meeting requested by the students. Before leaving the campus, the accreditors presented their preliminary report at a meeting including nursing faculty and administrators, the dean of health sciences and the university's vice-president for academic affairs. A glowing account of the academic health of the school was presented, with special kudos for the programmed learning and independent study program. Finally, a special commentary on student participation in the accreditation visit \\-as included. The accreditors had concluded that, because the students had been so vocal, clear and incisive in outlining their concerns anti criticism, it was obvious that the school was in the habit of promoting free and open expression on the part of its student body. Naturally, no change was recommended. The faculty was of course delighted with a report that so neatly reversed the facts. The university administrators were assured that all was well within their school of nursing. And the students? Having survived their first major bout with the Nightingale syndrome, they had learned a fundamental lesson in the theory and practice of nursing. Perhaps the lesson can best be summarized like this: it is both futile and self-destructive to question the ideas or authority of those above one in the nursing hierarchy, no matter how rational the argument or how just the cause. A need for vision Important as its implications ilre for nursing's future, the transition from hospital to university cannot be expected to confer on nursing immediate academic maturity. Such maturity wiII come only after a long period of growth - growth that must be enriched by a cross-fertilization of ideas resulting from active involvement with the other disciplines on the university campus. To assume immediate academic equality with those disciplines whose university traditions are much longer merely serves to cloud realistic self-awareness. And to expect to maintain this assumed equality in relative isolation from all other disciplines is both fatuous nd dangerous. Furthermore, the abiding presence of the rigid authoritarianism on which modern nursing is based must be fully recognized if the profession is to free itself of the shackles of the past. University nursing ignores the need to rid itself of this spectre at its own peril. Unfortunately, the power it has gained with its new status can be, and has been. used to demand conformity from its students and from the profession at large - in the best tradition of the Nightingale syndrome. Short-term objectives can perhaps be reached this way, but the long-term goal of making nursing a highly respected, truly academic profession will most certainly be short-circuited if power and authoritarianism are treated as synonyms. The expanded minds needed to guide nursing's future can develop best in an atmosphere of freedom to think, to question existing va1ues, and to debate ideas with other disciplines. Such an atmosphere should be the environment of a university education. Without the nurturance of such an environment, a profession may exist on a university campus but fail to be a part of it. The need for the mind expansion so necessary today is often most apparent among those who have had the maximum rather than the minimum exposure to modern nursing educational methods. In itself this may be the most telling criticism of contemporary higher education in nursing. The pharisaism frequently visible in the powerful group emerging from university nursing stands in stark contrast to the collective career decisions being made by an increasing number of today's bright diploma nurses. Seeking the intellectual fulfillment promised them at the university, they are discovering that they cannot find it within nursing. As these nurses continue to swell the ranks of social work, psychology, medicine, education and many other disciplines, is it not time for nursing to reassess its future in terms of what is happening to its present? References 1 Woodham-Smith, Cecil, Florence Nighting'ale, New York, McGraw-Hili, 1951. 2 Bollough, Vern L. The emergence ofmodern nursing, by . . . and Bonnie Bollough. Toronto, Macmillan, 1969. Jeanne Marie Hurd (B.A., Ohio Wesleyan University; M.A., Columbia University; M.N., Yale University) has taught nursing in both Canadian and American universities. Prior to moving to Ottawa, she was a senior program consultant with Manitoba's Department of Health and Social Development. She is currently engaged in writing, teaching and consulting (the latter in the area of maternal and child health). .,. Nutritional assessment of the ICU patient My first encounter with Sam Dunn took place the day before he was scheduled for aorto-coronary bypass surgery and a mitral valve replacement. Sam was in his mid-50's and he struck me as a friendly, warm man. handsomely graying, robust and healthy. although somewhat overweight. As a second-year nursing student. I was assigned to look after Sam in the post-operative period. I knew, of course, that his appearance would change considerably after his surgery, but I wasn't prepared for the change I saw in the recovery room. Four days after surgery. he was stilI semi-comatose, pale and weak. Sam had a long and gruelling recovery period. He spent four weeks in the intensive care unit as a result of the complications that developed. Afterwards, he spent four additional weeks in rehabilitation. I nursed Sam for the first three weeks he was in ICU. At the beginning of the second week his appearance was almost that of an old man - he was thin. weak and lethargic; he had lost 24 pounds. Because of the many complications Sam had developed. including internal bleeding, cerebral anoxia. pulmonary edema and arrhythmias, he required a great deal of expert nursing care. But as I went through the daily routines, the area that was virtually neglected. as is often the case for ICU patients, was a Valerie MacDougall nutritional assessment. With all the other life-threatening problems, nutrition was low on the priority list. Sam was so weak and thin. however. that I decided to evaluate his current nutritional status and needs in this area. Nutritional status My first step in the assessment was to take a 24-hour record of Sam's average intake' (see table one, two and three) and his average energy expenditure (see table four). Then, I examined his nutritional needs and devised a plan of care in order to help him gradually regain his strength and his pre-operative nutritional status. A second goal was to increase his knowledge of his nutritional needs, knowledge that would affect his dietary choices in the future. Sam's dietary intake According to Canada's Food Guide, a person should select foods from each of four food groups each day. The recommended daily intake for adults is: · milk and milk products - 2 servings · meat and alternate - 2 servings · bread and cereals - 3-5 servings · fruits and vegetables - 4-5 servmgs. In comparing Sam's darly intake to Canada's Food Guide, it was obvious that he was deficient in many {lreas. He ate only one serving from the milk and milk products group. instead of the recommended two. He had one and one half servings from the meat group; and he was certainly not receiving enough of his caloric and nutrient intake from the bread and cereal group. He was eating only one and a half servings instead of 3-5. Only in the fruit and vegetable group was Sam eating according to the recommended dietary intake. Intervention It was obvious that Sam needed encouragement and teaching to enable him to regain a sufficient daily nutrient intake and prevent further weight loss. By the thirteenth post-op day, his mental alertness had increased and he was much more aware of what was happening around him. I found out from Sam that he wasn't pleased with his meals at all. so each day we went over the menu and I helped him choose foods that would be both nutritious and pleasing to him. I reported his likes and dislikes to the dietary staff so that they would be alerted to his preferences. Then I made his trays as attractive as possible to increase his appetite. and gave him only small. frequent meals at first since he complained that the sight of a full tray made him nauseous. At each mealtime, I encouraged him to eat more and talked to him about which foods were rich in the nutrients he needed (see table three). I spoke to him about how the nutrients would work in his body to gradually improve his nutritional and health status. - 40 "'y 111711 The Cenedlen Nur.. Nutritional Needs Calories The body needs energy to perform all life-sustaining functions. When we eat, our bodies convert the ingested foodstuffs into energy - whether these foodstuff be carbohydrates,fats or protein. In looking at Sam's caloric intake, it was clear that he was receiving an inadequate number of calories for the energy he was expending in: a) daily activities such as washing. eating etc. b) coping with pulmonary edema and pneumonia, both of which lead to an increase in the basal metabolic rate and therefore an increase in caloric needs. 2 On his 13th post-operative day, Sam had loss of muscle tone, muscle mass, a weight loss of 24 pounds and he was experiencing weakness and fatigue - all indicative of a caloric deficit. Protein Man must have an adequate source of protein in order to grow and maintain the body's integrity. Protein forms the bulk of muscle and tissue and is constantly heing utilized to maintain hodv cells, tissues and fluids. Of the 22 amino acids that make up protein, eight or nine of them are considered essential because they cannot be synthesized bv the body. They must be present in the diet. Sam had experienced the normal catabolic response to surgery with a loss of protein in the form of lean body mass and loss of body fat. Post-operatively, he was semi-comatose and had an endotracheal tube. Forthe first week. he was NPO and received 5 per cent dextrose in water intravenously. He was also in negative nitrogen balance with a low serum protein of 5.9g/dl on the 9th post-op day. A negative nitrogen balance occurs in the presence of inadequate protein and caloric intake, increased utilization of protein and nitrogen loss in the catabolic response to surgery. 3.4 To correct this situation, Sam was given Amigen, a protein hydrolysate that supplied him with the proteins he needed to: . rebuild his body tissues . regulate his body processes . form antibodies to fight infection . build hemoglobin. The Amigen. plus the protein in his food, raised his serum protein levels to 7.8g/dl, well within normal limits. Carbohydrates Carbohydrates are the most important sources of energy for the body. Because thev are very easily digested, they have a protein sparing effect, all effect that allows protein to be usedfor growth and repair rather than for energy. Carbohydrates are also necessary for the utilization offats. As Sam's appetite slowly increased, and with an awareness of why he needed certain foods. he began to choose high carbohydrate foods such as breads, potatoes. fruits and vegetables - all of which provided him with calories and energy. Fats Fats are aform of stored energy in man. They serve multiple functions including helping with the absorption offat soluble vitamins A, D, E and K; for protecting parts of the body; andfor supplying essential fatty acid. to the body. 5 With increasing nutritional knowledge, Sam began to choose foods more wisely and to receive more of his energy needs from fats and carbohydrates. Foods containing fat are whole milk. butter. meat, whole milk cheese, nuts and salad dressings. In Sam's case, fats greatly contributed to his total caloric intake. They also served to prevent protein catabolism and further weight loss. Calcium Calcium is necessary for the formation of bone and teeth, for the maintenance of a normal heart beat, healthy nerve function and good muscle tone. I t also aids in normal blood c1ottillg. 6 Because Sam had undergone aorto-coronary bypass surgery, a good supply of calcium was necessary to aid in the healing of his sternum. Foods which contain ample amounts of calcium are cheese, whole milk, and milk products such as custard and ice cream. Knowing that prolonged bed rest and a high calcium intake could put Sam at risk for calculi, I encouraged mobilization as early as he could tolerate it. Iron /ron is vitalfor the formation of hemoglobin ill red blood cells alld ill the functioning of certain enzyme systems. Table one 24-hour dietary intake on 13th post-op day Table two Medications on 13th post-op day Breakfast - 11 2 cup grapefruit Juice 1/2 cup puffed rice 7 ounces whole milk 112 slice white toast 1f 2 tsp. butler 1f 2 tsp. jam Lunch - 1f4 cup cream of tomato soup 2tbsp.peas 1 ounce hamburger 2 tbsp. tomato sauce 80 cc. black tea 11 2 cup strawberry jello Supper - 4 leaves lettuce in vinegar 3 ounces broiled chicken 1f2 small boiled potato 1/4 cup green beans 112 diet pear 1 cup coffee 20 cc cream Snack - 1 cup gingerale 10% KCL. 20 cc p.o. Tid provides: 23.4 mg of potassium chloride 2. 5% Amigen in D5W with 10 mEq KCL, 1200 cc/24 hours provides: protein - 60 9 - 240 calories sodium - 0.97 9 potassium - 1.089 9 calcium - 0.120 9 3. D5W, 1200 cc/24 hours provides: 240 calories potassium chloride - 0.47 9 4. Thiamine 100 mg 1M bid provides: 200 mg of thiamine The Cen-.llan Nur.. May 11171 .1 Table three" Constituents of daily intake calones protein (g) CHO (g) fat (g) calcium (mg) iron (mg) Vitamin A (IU) Vitamin C (mg) thiamine (mg) riboflavin (mg) niacin (mg) sodium (mg) potassium (mg) phosphorus (mg) magnesium (mg) folacin (mEq) "ThIS Includes nulTlen\8lrom both dlelary and medoca on sources ..For a moderately acllve 154 pound man. Total nutrient intake of Sam Dunn' 1303 107 162.5 28.5 512 5.35 2975 82 200.2 0.808 12.12 610.8 2047.4 847.3 71 105.16 Canadian recommended nutrient Intake" 2300 56 50-60% caloric intake 1S 30% caloric intake ,. 800 10 5500 30 1.4 1.7 18 800 300 200 Since Sam had lost blood post-operatively and consequently had low hemoglobin and hematocrit levels. he needed encouragement to eat foods such as liver. red meats and green vegetables. In addition, I knew that a source of Vitamin C taken close to meals would increase the iron absorption. so fruit juices were offered to him near mealtime. 7 II itamin A Vitamin A is essential to healthy skin and membranes and is necessaryfor t'ision in dim light. 8 Sam's intake of Vitamin A was a little less than the recommended daily levels. However. since Vitamin A is stored in the body, he had sufficient supply to meet his immediate needs. Foods with moderate amounts of Vitamin A such as dark leafy vegetables, yellow fruits. liver and whole milk cheeses helped to maintain his body stores. ViÚlmin C One of the main functions oft'itamin C is the formation of collagen, a protein substance that cements cells together. It is important for maintaining the integrit..... of blood vessel walls. promoting IHJund healing and helping tissue formation. Y Although Sam was receiving more Vitamin C than is recommended. any excess was excreted in the urine since it is a water-soluble vitamin. It is found predominantly in fruits and vegetables. especially citrus fruits. strawberries. cantaloupe and raw leafy vegetables. It is also found in milk and in meats Riboflavin, thiDmine and niacin These vitamins are involt'ed in energv metabolism. Riboflavin helps in the maintenance of good appetite and normal digestion, healthy skin and eyes, and functions to maintain the nervous system. Thiamine, which may also promote appetite, is inl'Olved in the normal functioning of the nen'ous S'l.'stem and has an action in the metabolism of carbohydrates. Niacin also helps to maintain the normal function oftheGI tract and ne/1.'OUS system. 10 Foods rich in these vitamins are milk and milk products (except butter), liver. fish. green vegetables. cereals. legumes. and nuts. In addition to these foods. Sam was receiving a thiamine supplement which is thought to act as an appetite stimulant. Sodium Sodium acts to regulate the water balance within the body, helps to maintain acid-base balance, transmits nerve impulses and relaxes muscles. It is also neededfor glucose absorption and for the transport of other nutrients across cell membranes. II Sam was on a restricted one gram sodium diet to help reduce his pulmonary edema and thus the workload on his healing heart tissue. Since sodium holds water within the body. restricting sodium intake is an attempt to decrease fluid retention. A week post-operatively, his plasma level was 161 mEq/L (the normal range falls between 137-148mEq/L *). Sam told me that he was aware of why his sodium was restricted since he had been on a no-added salt diet before his surgery. I checked his tray before he ate to make sure there was no salt present and also to check what foods he was served. As well, his fluid intake was restricted to 1800 cc/day to control blood volume, therefore to lessen the workload on the heart and also to lessen his pulmonary edema. Potassium Adequate levels of potassium are necessaryfor normal heart muscle actÎ\'ity. Potassium reduces the conduction velocity in the heart and shortens the refractory period. It also reduces the heart's automaticity. H.....pokalemia can lead to heartbeat irregularities as well as muscle ...'ea"ness, pain, drowsiness, dizziness and confusion. Hyper"alemia can lead to intrat'entricular heart bloc". 12 Sam had been receiving potassium supplements since his operation to promote heart muscle activity. He also needed K'" supplements to replace the potassium loss in the urine. a loss that resulted from taking a diuretic. His potassium level was 4.1 mEq/L. which was within the normal range of 3.75-5.5 mEq/L *. Foods rich in potassium include bananas, citrus fruits. meat. fish. potatoes and milk. *Normallevels at Royal Victoria Ho pital. Montreal. 42 May 111711 The Canadian Nur.. Phosphorus This mineral facilitates the absorption and transport of nutrients , regulates the release of energy and is necessary for bone formation. In eating foods such as meats, fish. poultry. eggs. nuts, milk and cheese. Sam was receiving adequate amounts of phosphorous to meet his needs, especially to aid in bone formation of the sternum. Magnesium Magnesium is a constituent of bone and is necessary for the metabolism of calcium and phosphorus. It also helps in the regulation of muscles and nerves and acts as an enzyme in energy producing systems. Sam needed adequate levels of magnesium to help in the repair of his sternum. Food sources are cocoa, nuts, whole grains. spinach. liver and clams. Folic acid Fdic acid is necessary for the formation of red blood cells in the bone marrow. By increasing the level ofRBC's,folic acid or folacin helps to promote good cellular nutrition, respiration, growth and healing. 13 Sam received folic acid in foods such as asparagus. bananas. liver and spinach. Other ideas In formulating Sam's nutritional assessment. I talked to the senior dietician at the hospital. Together we came up with some suggestions that could be useful in promoting a more adequate dietary intake in patients like Sam. For example: . add one third cup skim milk powder per 8 ounces of milk; the patient can receive up to twice the nutrients in the same amount of fluid. . high protein milkshakes with fruits blended in (such as bananas and strawberries) can increase potassium, Vitamin A and folic acid intake. . eggnogs are an excellent source of Vitamin A, calcium, protein. . blend yogurt with fruit, or ice cream with fruit or custards to give the patient an increased carbohydrate intake along with niacin. thiamine, riboflavin, calcium. protein etc. . make meal trays as attractive as possible. Take an active interest in your patient's eating habits - encourage. motivate and explain. . communicate with the dietician and dietetic staff concerning the patient's likes. dislikes. progress. dietary problems. etc. In talking with the dietician. I realized how valuable she or he can be to the nursing staff and to the patient. If we are concerned about the nutritional status of our patients, we can make the problem known to the dietician and together an assessment and a plan can be implemented. At home In Sam's case, a good dietary intake and an increased knowledge of nutrition proved to be extremely helpful to his recovery. and to his nutritional status after discharge . Two and a half months after his discharge. I spoke with Sam. His appetite had improved gradually and his weight had increased from his post-operative weight of 157 pounds to 168 pounds. His daily nutrient intake corresponded with the recommendations ofCanada's Food Guide for a moderately active adult. He told me that he had improved his eating habits, that it helped to know which foods were good for him. Gradually. he had been building up his activity level by walking, working in the garden and painting. He said he felt "great". References I Both Canada's FoodGuide and the Canadian Recommended Daily Nutrient Intake were used in the nutritional assessment. The Daily Nutrient Intake. which sets standards for feeding groups of healthy individuals, was used to illustrate how one individual's dietary intake is affected by his health status and to show how nurses may intervene to promote good nutrition and health. 2 Luckmann, Joan. Medical-surgical nur. ing: a psychophysiologic approach by ... and Karen C. Sorenson, Philadelphia, Saunders, 1974. p.953. 3 Bistriam. Bruce R. Protein status of general surgical patients. JA MA, 230:6:858-860, Nov. II. 1974. Table four 17 Energy expenditure in 24 hours on 13th post-op day Time Activity Duration Energy Total/24 hours (min) (kcal/min) (kcal) Mornmg sleeping 480 1.0 480 (12PM-8AM) ate breakfast 15 3.0 45 up in chair 90 1.5 135 washed and shaved 30 3.5 105 lying at ease 55 1.4 77 slept 60 1.0 60 Afternoon ate lunch 15 3.0 45 lying at ease 95 1.4 133 slept 210 1.0 210 Evening ate supper 15 3.0 45 lying at ease 95 1.4 133 slept 300 1.0 300 1768 kcal 4 O'k..et:fe. S.J.D. Catabolic loss of body nitrogen in response to surgery. Lancet by... et aI. 7888: 1035-1037, Nov. 2,1974. 5 Canada. Health and Welfare Canada. Health Protection Branch. Educational Services Division. Selected nutrition teaching aids. 1976. p.ll. 6 Ibid. p. 13. 7 Ibid. 8 Ibid, p.11. 9 Ibid, p.12. 10 Ibid. II Luckmann, op. cit. p.638-640. 12 Ibid, p.23:!-234. 13 Robinson. Corinne H . Normal and therapeutic nutrition by... and Marilyn R. Lawier. 15 ed. Toronto, MacMillan, 1977. p.187-188. 14 Canada. Health and Welfare Canada. Health Protection Branch. Educational Services Division, op. cit. 15 Williams. Susan R. Nutrition and diet therapy, St. Louis. Mosby. 1977. p.I:!. 16 Ibid, p.30. I7 Canada. Health and Welfare Canada. Health Protection Branch. Educational Services Division, op. cit. Valerie \lacDougall is currently a third year student in the B.Sc.N. prof(ram at McGill University. She wrote, "Nutritional assessment of the ICU patient" u'hile in her second year. Valerie u'rites, "I would like to express my sincere thanks to two special people:first of all, to Susan Zuijdwijk, formerlecturer in nursing at McG ill University who encouraf(ed me to try to publish this paper and 10 Ka) Watson, dietician in Dietetic Education at the Royal Victoria Hospital in Montreal, who helped me to ralidate the material in this paper. " .. - - The Cen-.ll.n NUrH "'y 1171 43 SIR, I KNOW Can you see me? Do you know that I'm here? Wake up, sir. Here's your breakfast. Wake up. You're 92 today. It's your birthday. Do you know? Can you hear? Ready for your breakfast? Do you know I'm here? Here's your porridge. Come on, sir Open up It's your porridge. Close your mouth, sir. It's dribbling down your chin. Oh, sir! Do you know what's going on? Oh! I hope not. How degrading It is to be fed and bathed. Do you want to go on the bed pan? Oh, I see. You couldn't help it. Yes, I know, it's okay. Oh, sir, please don't cry. Don't you see I understand I've been told what's going on. And I know you know what's going on. You're not cute or sweet. You're a MAN. And sir, remember I know it. Lise DeBoer About the author - Lise DeBoer is a first year student in the two-year associate degree program at Douglas College. Surrey, B C. She wrote "Sir, I Know" after completing her first clinical rotation in Extended Care and her introductory experience in caring for geriatric patients. [DR' sting Servile The Canadian Nurses Association Testing Service is now in the fmal stages of development of a comprehensive examination for nurse registration/licensure: the exam will be introduced for use in 1980 and is the result of many years of hard work by a large group of dedicated nurses across Canada. The event will mark the end of the present five-part examination and in fact, Canada is likely to become the first country in the world to use a comprehensive examination for nurse registration on a national basis. It is also noteworthy that for the first time, a national registration examination is being developed in English and in French. The comprehensive examination is being developed around examples of a number of nursing situations commonly found in practice. Each situation will result in between 20 and 40 test items that will focus on the basic and important nursing concepts one would expect the beginning practitioner to know and understand. The examination will be general in nature and test items will be intermingled rather than grouped by clinical subject areas. CNA's public relations officer Bert Prime, interviewed the director of CNA TS, Dr. Eric Parrott, for the Canadian Nurse. Dr. Parrott commented: "CNA TS touches every nurse when he or she writes the exams and every working day thereafter since the exam is one measure of a candidate's eligibility to become a professional nurse. " Dr. Parrott talked about the significance of the comprehensive examination and what it means to the future of the nursing profession. , BP: Where does the content knowledge comefrom? Dr. Parrott: It comes from the representatives of the eleven jurisdictions, who are involved in all phases oftest construction through membership in blueprint committees, objectives committees, item-writing groups and jurisdictional appraisal committees. \ BP: What is the composition of the various committees involved in the phases of creating a blueprint and in item writing? Dr. Parrott: Committee involvement comes from all parts of Canada totalling approximately 200, all of whom are nurses. English committees work on the BP: What is it exactly that the CNA TestinR Sen'ice does? Dr. Parrott: I t develops and administers a series of examinations that measure knowledge and theory necessary for basic nursing practice. It supplies the expertise needed to produce statistically sound tests that measure mental traits, abilities and processes. Questions most frequently asked about the Canadian Nurses Association Testing Service Q. How many candidates are tested at the different times of the year? A. Candidates write the RN examination at three times during the year: January, June and August. The numbers tested at each administration varies. They also vary a little from year to year - in the last two or three years they have been decreasing. Approximately 8,500 to 10,000 candidates write during the year. Most RN candidates write in August- approximately 5,000 to 5,500. Another 2,000 to 2,500 write in January and about 1,500 to 2,000 in June. Q. Are most of them in Ontario? A. Yes - approximately 50 per cent of the candidates are from Ontario. Q. What is the passlfail ratio? A. The failing rate seems to be affected by a number of factors. It may vary a little from year to year, and may also vary from one writing to the next or from region to region. It's difficult to give a meaningful overall figure. CNA TS believes the failing rates are at least comparable to those in other professions. Q. What kind of recourse do the student nurses have if they feel a mistake has been made? A. She or he has the right to appeal to the provincial jurisdiction and request that the examination score be rechecked. The provincial jurisdiction will then refer the request to CNATS. Particular attention is paid to ensuring that there are no errors in computing scores. Since it costs the candidate money to have the score checked, and since great care is given to ensuring the accuracy of scores in the first place, candidates are not encouraged to spend their money needlessly on such a request. If, however, the candidate feels he or she wc>uld be more satisfied with a reread, this will be done. Q. Is there a time frame for appealing? Is it strict? Why? Why not? A. Yes, a candidate must appeal within a year of writing the examination. This is fairly strict because it is not possible to store all failing records indefinitely. It also puts responsibility on the candidate to take action within a reasonable time. Candidates know the limitations. They must make up their mind within the specified time if it is felt that an appeal is justified. If there were no time limit, it would be very difficult to decide how long records should be kept and a system would have to be introduced that might be expensive and that might impose an additional financial burden on candidates. The Cenedlen NurH ..." 1171 45 English examinations and French committees work on the French examinations. The English and French examinations are developed from the same blueprint and the same nursing situations: they test the same content areas even though the test items may differ. BP: What is a blueprint? Dr. Parrott: As it says in the blueprint for the comprehensive examination, a blueprint is both a guide and a prescription for those who", ill be using it. As a guide. it otTers a flexible framework within which the examination can be developed. As a prescription, the blueprint determines the components of the examination and specifies how they are to be used. It then describes the basic elements of the nursing situations around which the examination will be structured. The technique used to classify the cognitive abilities required ofthe candidates is described and the. relationships among the various components are combined to form a single document - the blueprint for the , ,. ,,' i ..J4.J" .. -' , - . .... examination. The basic elements of the blueprint are those variables relating to man which must be considered in all nursing situations. These elements are growth and development. lifestyle patterns and unanticipated events. Nursing competencies needed to provide adequate anticipatory and therapeutic care are identified: assessment, planning. implementation and evaluation and professional responsibilities that are legal. ethical, collaborative or administrative in nature. BP: What is the definition of the comprehensi,'e examination? Dr. Parrott: The Committee on Testing Service has developed the following definition: "A comprehensive examination tests candidates" cognitive abilities by requiring them to demonstrate the integration of the elements of knowledge basic to a discipline in solving problems presented in a: series of situations." You can see from this definition that a comprehensive examination is viewed as one that will be global in nature...It will test the candidate's ability to solve nursing problems and require the integration and application of knowledge and abilities derived from nursing and other related disciplines. We believe that an examination of this type supports the philosophy that basic nursing programs preparing candidates at the beginning level of practice are general in nature. This type of exam will focus on the nursing process and allow for a more reasonable "weighting"" of examination content. 1 ... J'I - .. - .... r . --:J- . .. - -1"" . . fi .. I t ,. .. --- ... , \ t: t -4> j. - '4,"" - , ---- .. the disease process. whereas the focus should be on a "nursing model"' and on health rather than on illness. To make the registration/licensure examination more relevant for nursing, it was decided to develop the com- prehensive examination. Nursing education in Canada has experienced and undergone considerable change in recent years. Diploma programs in which most RN's are prepared at the basic level. have in many cases been shortened from three to two years. They have moved out of the hospital settings into community colleges. institutes of applied arts and technology. or independent schools. In addition. curricula are being integrated and emphasis is being placed on health promotion rather than on curing disease. BP: Who will u'rite the comprehensi,'e examination? Dr. Parrott: The comprehensive examination will be written by candidates who have successfully completed a basic nursing program in Canada and wish to enter the nursing profession. It will also be written by 1 - ... - ,---- candidates who have obtained their basic nursing education in a foreign country and are requesting registration/licensure in Canada in accordance with the requirements of a registering/licensing . . body. . - , , BP: Why is it necessary to hm'e a comprehensi,'e etamination? Dr. Parrott: The present examination used in Canada on a national basis is divided into clinical areas: medical. surgical. obstetric. children's and psychiatric nursing. This division of content is not considered appropriate today for a qualifying examination for candidates being prepared to enter nursing at a level of general practice. It puts too much emphasis on what is thought of as a "medical model" and on BP: What are the implications of this comprehensh'e examination for future candidates entering the profession? Dr. Parrott: We believe the comprehensive examination will be a better measure of a candidate's nursing knowledge than the present examination It is designed to be closer to the realities the nursing practitioner will experience when she enters the profession. A major function ofthe CNA Testing Service is to find better ways to measure a candidate's potential to enter practice and we believe the comprehensive examination is a step in that direction.'" ... ''''.. .. ,- "s ..... r J . 4 - .. . - - : .r \ '.I,: w(; '} . . -.' \ , , - ( I , I en z ". õI J: .' , '" .:i I Q SO ... '" -.; 'ë ... " . :S 2 E >> .so o Õ so ... A special feature report on the part that nurses played in a mining disaster that made headlines across the country last February. Dorothy Gray Miller It is four-thirty on a misty Saturday morning in February, in Glace Bay, Nova Scotia. Suddenly the phone rings in the one-storey building about 100 yards from the entrance to No. 26 colIiery. a coal mine that goes down 760 meters and extends eight kilometers under the sea. Carol Sheriff, the nurse on duty in the mine's nursing station, answers and is told by the pit dispatcher to calI the underground manager to the pit immediately. He offers no explanation. Ten minute!> later he calls again to ask that the Devco Manager be notified ([he Cape Breton Development Company is the crown corporation which operates the mines). Smoke is coming from 12 South, but communication with that area seems to have broken down. The Cenedlen Nu... ..." 11171 47 The next call comes within a fe\\- minutes. It is one of the underground emergency technicians from the first aid station who says that there has been an explosion at 12 South. that possibly seventeen men have been injured and she must get all medical help possible. He thinks this may be a "capacity disaster" involving 15 or more casualties. Carol goes into action. She phones the Devco director of health services. Dr. Albert Prossin, who declares a "capacity disaster". Now Carol knows exactly what to do. She calls nursing supervisor Brenda Penny and the number two staff nurse on her list. This starts a chain reaction: each person in turn calls another with the statement: "Capacity disaster declared at No. 26. You are required for duty. Answer yes or no." Next Carol calIs the doctor nearest the colIiery. Dr. J. B. Tompkins, and alerts the two Glace Bay hospitals. the Community and the General. and the ambulance services. Carol knows that she has at least an hour before casualties start to arrive at the nursing station. since 12 South, the scene ofthe accident. is the furthest "wall" in. Medical personnel may take as long as 45 minutes to get to the site of the disaster: it will be difficult getting stretchers through and then there is the long way back. She starts moving furniture to set up for receiving casualties. As yet she is not sure what kind of injuries to expect. One of the station nurses. \fyrtle CampbelI. who lives close by. arrives. She immedIately gets into her pit clothes. and checks to see that she has all equipment in her emergency bag which when fully packed weighs 25 pounds. She also checks the portable ventilator. Dr. Tompkins. accompanied by Father Robert Floyd. Who has been calIed by management. checks in and they both go directly to the pit. The two remaining station nurses, Rita Butts and Annunciata Rogez. also arrive. Although they all want to go down into the pit. only Myrtle wilI go. The others wilI help Carol ready the station. These nurses are "pit wise". They travel the pit at least once a month and go down whenever their help is needed by the underground emergency technicians who man the first aid station at the pit bottom. Carol has made three trips down earlier on her shift. just for minor injuries. Dr. Prossin and Dr. M. R. Rajani arrive and get into their pit clothes. With Myrtle. they go down to the pit bottom. The nursing supervisor has arrived and is now calIing in extra nurses: 12 nurses report in between five and six o'clock. The phone rings again. It is one of the underground emergency technicians on the direct line from the first aid station to the nursing station. He says that they should expect at least six bum cases. The rest are probably dead. The station set-up now features a bum area. a cardiac and respiratory area. a fractures and minor injuries area and a holding area. A nearby repair shop has been designated as a temporary morgue. A call comes in from the pit bottom where Myrtle and the two doctors have set up for triage in an open area. There is some light here and Mvrtle has found benches to use for the emergency equipment. dressings. etc. There is further information. Dr. Tompkins is at the mine face atl2 South. He will be sending the casualties by stretcher to the triage team at pit bottom. As each man is treated the nursing station will be advised of the extent of injuries. the treatment given and the deployment. An ambulance and one or two nurses are to stand by to convey each man to hospital. The station contacts the outpatient departments at both hospitals. relays the information and then assigns ambulances and nurses to the pit head to accompany each man coming up. In alI. six badly burned men are brought to the surface and taken to the Community hospital five minutes away. An emergency plan is also in effect at the General but there are no more victims: the rest are dead. Now that the living have been attended to. the task of bringing up the dead begins. The nurses at the station will help to identify and tag the bodies. Transportation to the Community Hospital temporary morgue is arranged. Suddenly it is all over. Six and a half hours have elapsed, and it is II a.m. The nurses gather at the station to drink innumerable cups of coffee and relive it all. They come to the full realization of what has happened here on this February morning. They know all these men - they have relatives, friends and neighbors at No. 26. Most of them have fathers. brothers, uncles who have been mmers. They worry about miners like the one who appeared at the mine head checking each injured man as he came up and then each body. "One of my young fellows was down there, .. he says by way of explanation. But he cannot find his son, aged 23. The nurses know that as occupational health nurses. they will have to deal with the aftermath of this tragedy - to listen to the miners who will come to the nurses to talk out their fears. to get help in dealing with deep depression. Glace Ba} Communit} Hospital An hour after the first word ofthe tragedy has filtered to the surface, the staff at the outpatients department of Glace Bay Community Hospital are at work preparing to receive the casualties. From the seaward windows of the hospital an observer can spot No. 26 colliery. By the time director of nursing Betty Dowe arrives from her nearby home. night supervisor Florrie Paruch has mobilized the resources ofthis 140-bed hospital and alerted the OPD. Betty starts calling in the OR and ICU nurses and all her supervisors and head nurses. She also calls the hospital's in-service director, Peggy Bonner. chairman of the disaster committee. When Peggy arrives. they meet with the chief of medical staff. Dr. John :\er ity Hamilton, Ontario L8S 4.19 Vernon Jubilee Hospital, a 258-bed acute and extended care hospital in the Sunny Okanagan requires immediately a Head Nurse - Psychiatric Unit Previous clinical and administra- tive experience required. Post graduate courses, administrative education, or BSN preferred. Must be eligible for B.c. regist- ration. To commence immediately. Personnel policies in accordance with RNABC contract. Apply sending complete resume to: Director of Personnel Vernon Jubilee Hospital Vernon, British Columbia VlT 5L2 Advertising rates For All Classified Advertising $15.00 for 6 lines or less $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies of the hospitals and agencies advertising in the Journal. For authentiC information, prospective pplicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse SO The Driveway Ottawa, Ontario K2P tE2 .. United States RN's - Bolle, ldabo - How would you like a rewarding career in an environment which offers you immediate access to uncongested recreation areas with rivers, lakes and mountains? Do you eqjoy tennis. golf. racke1ball, camping. hiking. skiing and horseback riding? Sound exciting? It is. And there are many opportunities for satisfying work at one of Idaho's largest and most progressive medical complexes. St. Alphonsus. located in Boise. is a 229-bed facility offering you positions in orthopedics. ophthalmology. dialysis. mental health. neurosurgery and trauma medicine. Excellent salary, generous benefits and job security. Starting salary adjusted for experience; benefits include travel assistance, shift rotation. and free parking. Write or call collect: Employmenl Supervisor. Personnel Office. St. Alphonsus Hospital. 1055 North Curtis Road. Boise. tdaho 83704, (208) 376-3613. EOE. Nunlng Opportunity - Mississippi Baptist Medical Center, a ml\ior 6O(}.bed hospital. has immediale positions available for experienced RNs and recent nursing school graduates in a variety of specialities and medical/surgical areas. Competitive salaries. liberal benefits. Visa. licensure and relocation assistance provided. Located in 'iississippi's capilal cily of Jackson (population 300.(00). MBMC is the state's largest and most modern privately operated hospital. For further information write: Mrs. Johnnye Weber. Nurse Recruiter. 1:!25 North State Street. Jackson. Mississippi 39201; or call collect 601/968- 5135. Tbe Best Loc:.lion in the '.tion - The world- renowned Cleveland Clinic Hospital is a progres- sive. 1020-bed acute care teaching facility commiued 10 excellence in patient care. Staff Nurse positions are currently available in several of our 6ICU's and 30 departmentalized med/surg and specialty divi- sions. Starting salary range is 513.286 to 515.236. plus premium shift and unit differential. progressive employee benefits program and a comprehensive 7 week orientation. We will sponsor the appropriate employment visa for qualified applicants. For further information contact: Director - Nurse Re- cruitment. The Cleveland Clinic Foundation. 9500 Euclid Avenue. Cleveland, Ohio. 44106 (4 hours drive from Buffalo. N.Y.); or call collect 216-444- 5865. C....dlan Nunes - Our 350+ bed full service community hospital in a city of 70.000 in Ihe piney woods and lakes of beautiful East Texas wishes to extend an invitation to you to practice nursing in a progressive hospital while you and your family enjoy the good life atmosphere of smaller city living. Our special visa sponsorship and licensure program may be what you have been seeking. We plan a lrip to several cities in Canada to inlerview and hire soon so don'l delay your response. For more infonnation. please wrile or call Jack Russell, 611 Ryan Plaza Drive. Suite 537, Arlinglon. Texas. 76011. (817) 461-1451. The Eyes or Tex.. beckon RN's and new grads to practice Iheir profession in one of the most prosperous areas of the U.S. We represent all size hospitals in virtually every Texas and Southwest U.S. city. Excellent salaries and paid relocation expenses are just two of many super benefits offered. We will visit many Canadian cities in March and April to interview and hire. So we may know of your interest won't you contact us today? Ms. Kennedy. P.O. Box 5844, Arlington. Texas. 76011 (214) 647-0077 or Ms. Candace. P.O. Box 14745, Austin. Texas, 76011 (512) 459-0077. Come to Tn.. - Baptist Hospital of Southeast Texas is a 400-bed growth orienled organization looking for a few good R.N.'s. We feel that we can offer you the challenge and opportunity to develop and continue your professional growth. We are located in Beaumont. a city of 150.000 with a small town atmosphere bUI the convenience of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist Hospital has a progress salary plan plus a liberal fringe package. We will provide your immig- ration paperwork cost plus aiñare to relocate. For additional infonñation, contact: Personnel Ad- ministration. Baptist Hospital of Southeast Texas, Inc.. P.O. Drawer 1591, Beaumont, Texas 77704. An .mnnlllive action employer. The C.n-.ll.n Nur.. Before accepting any position in the U.S.A. PLEASE CALL US COLLECT We Can Offer You: A) Selection 01 hospitals throughout the USA. B) ExtenSive information regarding Hospita Area. Cost 01 living. etc. C) Complete Licensure and Visa Service Our Services to you are at absolutely no fee to you. WINDSOR NURSE PLACEMENT SERVICE P.O. Box 1133 Great Neck, N.Y. (516) 487-2818 Our 20th Year of World Wide Service ..... Nurses Required For Fogo Island HospItal Salar) : As per experience in accordance with Union Agreement. Applications in writing should be addressed to: Personnel Director James Paton Memorial HospitaJ 125 Trans Canada High"a) Gander. Ne"foundland Al\lP7 U ITED STATES OPPORTt::\ITIES FOR REGISTERED NURSES AVAILABLE NOW I' ARIZO'A CALlFOR'I-\ TEXAS \\E PL>\CE AND HELP YOU WITH ATE BOARDREGtSffiATION \OLJR WOR"- VISA TE PORARY HOUSING - ETC A C >\NADIAN COL SELLING SERVICE PhoM: (416) 449-58R3 OR WRITE TO: kECRllll'liG REGISTERED Nl'RSES "c. 1200 L-\ \\'kE'liCE -\\"E:'\ol E EAST. SUTE JOI, 00' ILLS, ONTARIO \f3A ICI FLORID-\ OHIO NO FEE IS CHARGED TO APPLICANTS ..., 1171 51 United States N..... - RNs - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa fonns and provide assistance wilh licensure at no cost to you. Write for a free job market survey. Marilyn Blaker, Medn. 5805 Richmond, Houston, Texas 77057. AU fees employer paid. Exdtemrnl: Come and join us for year around excitement on the border, by the sea. an unbeatable combinalion. El\Îoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed. acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. Excellent salary and fringe benefits. We invite you to share the challenge ahead. Assistance with travel expenses. Write or ClOD coDed: Joe R. Lacher. RN. Director of Nurses. Valley CommunilY Hospi- tal. P.O. Box 4695. Brownsville. Texas 78521; I (512)831-9611. red N...... Uce Vocatloaal Nu... and N..... AIdes needed to work at the Kerrville State Hospital in Kemille, Texas. Kemille is approx. 65 miles north of San Antonio in West Central Texas. It is a noted recreational area, with the Guadalupe River. many camps and open areas for hiking. Benefits include forty hour work week. sick leave, paid vacation, holidays, good retirement benefits and free group insurance. Starting salary for Registered Nurses is 51.141.00, for Licensed Voca- tional Nurses 5768.00 and for Aides 5552.00 (per month). Nurses and L.V.N.'s are required to have a current Texas license and Aides are required to be high school graduates. We are an Equal Opportunity Employer. Apply to: Box 1468, Kemille. Texas 78028. Come to COMIai Tens - We are located in a resort, retirement and farming community one mile from the Gu! f of Mexico. We are a small friendly hospital m a small friendly community just two hours from Houston. We offer you a rounded career develop- ment program: medical, suraical, OB, nursery and emergency room. We are fuUy accrediled. Rapid advancement to Head Nurse starting at 513,000 plus shift differential, call pay and liberal fringe benefits. New nicely furnished two-bedroom apartments are reserved for you. Share one with a Canadian RN companion of your choosing. if you like, for 5150 each including gas and water. We will pay immigra- tion. licensing and relocation transportation ex- pense. Openings are limited-four at this writing. Contact: Personnel Department, Wagner General Hospital. Box 859. Palacios, Texas 77465: or call Athlyn Raasch, 0-512-972-2511 collect. Switzerland Hospilal of Canton Zürich at Winterthur (725 bed hospital near Zurich) needs Openting Room Nurses for the surgery clinic. Required for immediate or future openings. We offer pleasant working condi- tions. equitable hours of work and leisure Salary and benefits in accordance with the regulations of the Canton of Zürich. Five-day week. accommoda- tion available. cafeteria. Apply in writing to: Sekretarial Pflegedienst. Kantonsspital Winterthur. CH-8401. Winterthur. Switzerland. Miscellaneous AI'riaI-Overland Expedilions. London/Nairobi 13 wks. London/Johannesburg 16 wks. Kenya Safans - 2 and 3 wk. itineraries. Europe - Camping and hotel tours from 16 days to 9 wks. duration. For brochures contact: Hemisphere Tours, 562 Eglinton Ave. E., Toronto, Ontario. M4P I B9. Cherokee Lodge, Lake Rosse.u, near Pori Sandfteld. A small friendly lodge. catering to adults who want a quiet relaxing holiday. Open May 24 10 Thanksgiv- ing. Good deepwater swimming, boating and walk- ing. Golfing. dancing, riding a short drive away. Rales and folders on request. Write or phone: The Turleys, (705) 765-3601, R.R. 2, Port Carling, Ontario. POB IJO. 80 Mer 111711 Required Associate Director of Nursing - Patient Care Duties: Responsible for setting the slandards for quality of care in the Department of Nursing, and see that these slandards are implemented and evaluated on an on-going basis. Quallllcatlons: Graduation from a recognized school of nursing. Clinical background experience, preferably in diversified fields, at a managemenl or instruc- lor's level. Post-graduate studies in nursing administra- tion. Baccalaureate degree in nursing preferred but not essential. Or any equivalent combination of experience and training. SalllrySCllJe: $16,760-21,390 Applications in writing should be addressed to: Penonnet Dlrectot James Paton Memorial Hospital Gander, Newfoundtand AIV 1P7 School of Nursing Nursing Instructors required for July 1979 in a 2 year English language Nursing Diploma program. Qualifications: Bachelor of Nursing with experi- ence in teaching and at least one (l) year in a Nursing Service position, courses in Teaching Methods and eligible for registration in New Brunswick. Apply to: Harriett Hayes Director The Miss A.J. MacMasler School of Nursing Postal Station" A" , Box 2636 Moncton, N.B. EIC 8H7 Telephone: 506-854-7330 Diploma in Occupational Health and Safety The Occupational Health Program al McMas- ter University, Hamilton, Ontario, Canada offers two programs each year for this Dip- loma. A full-time program starts in September catering 10 those who wish to complete the course in three months. A part-time program starts in February through to November. and is designed so Ihat sludents may continue their normal employment. Special interest relevant to health and safety problems in particular industries will be encouraged. Physicians. nurses, industrial hygienists and related professionals engaged in industrial settings are invited to apply. A relevant university degree or equivalent is required. For further information please contact: Miss Helen Fulton McMaster Unlvenlty, H.St.C. 1100 Main Street West Hamilton, Ont. Canada L8S 4J9 Tel: 416-525-9140 Ex. 2333 The Cen-.llen Nur.. Registered Nurses Career Development Opportunities in Vancouver If you are a Registered Nurse in search of a change and a chaUenge, look into nursing opportunities at Vancouver General Hospital, B.C. 's major medical centre on Canada's unconventional west coast. Recent changes in both budget and organization have resulted in many new general duty nursing positions. Salary range of: $1,305 - $1,542, plus educational premiums. Recent graduates and experienced professionals alike will find a wide variety of positions available which, together with planned professional and career development programs, could provide the opportunity you've been looking for. For those with an interest in specialization, challenges await in many areas such as: Neonatology Nursing Intensive Care (general and neurosurgical) Inservice Education Cardiothoracic Surgery Coronary Unit Burn Unit Hyperalimentation Program Pediatric Renal Dialysis and Transplantation If you are a Registered Nurse considering a move please send resume to: Mrs. J. MacPhail Vancouver General Hospital 855 W. 12th Avenue Vancouver, B.C. V5Z IM9 Nurses Wanted Jobs: Permanent or temporary (two to four months in hospital or nurs- ing station). Requirements: Member of the Order of Nurses of Quebec Wishful : . excellent knowledge of French . experience: two (2) years . post-graduate in public health . be able to accept isolation P.S. Excellent occasion to see a typical part of the country and be able to appreciate it. Increase your knowledge ofthe French language. To live a unique experience in an isolated region. Facility to visit Newfoundland. For more information, please contact: Notre Dame Hospital Personnel Director Lourdes de Blanc Sablon Co. Duplessis (Québec) GOG 1 WO Telephone: (418) 461-2144, Ext. 219 The Can-.llan Nur.. The University of British Columbia Applications are invited for teaching positions in undergraduate and graduate programs in nursing. Master's or higher degree in nursing required as well as experience in the clinical field. Openings available in all clinical areas including Rehabilita- tion nursing. Candidates must be eligible for registration with the Registered Nurses Association of British Columbia. Competitive salaries and good fringe benefits dependent on qualifications. Send resumes to: Dr. Marilyn Willman Director School of Nursing University of British Columbia 2075 Wesbrook Place Vancouver, British Columbia Canada V6T lW5 Mey 1171 11 Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Registered Nurse in search of a change and a challenge- look inlo nursing opportunities at Vancouver General Hospital, B.C. 's ml\Îor medical centre on Canada's unconveritional West Coast. Staffing expansion has resulted in many new nursing positions at all levels, ancluding: General Duty ($ 1305. - 1542.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the opportunity you've been looking for. For those with an interest in specialization. challenges await in many areas such as: Neonatology Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn Unit Paediatrics Inservice Education Coronary Care l'nit Hyperalimentation Program Renal Dialysis & Transplantation If you are a Nurse considering a move please submit resume to: Mrs. J. M""Phall Employee Rea-lions Vancouver General Hospital 855 West 12th Avenue Vancouver, B.C. V5Z 1\19 International Nursing What A Challenge! The opportunities offered in International nursing are unlimited and include the chance to share your skills and knowledge, the chance to grow personally and professionally and the chance to see the world. The King Faisal Specialist Hospital and Research Centre in Riyadh, the capital city of Saudi Arabia, can offer you all of these things and more. The Hospital, managed by the Hospital Corporation of America group, is a 250-bed referral and specialist medical center staffed with professionals from the United States, Europe and the Middle East. Current R.N. openings include NICU, CVICU, Peds and O.R. Other positions available periodically. Requirements include minimum three years current experience in an acute care hospital. current R.N. license in Canada and fluency in written and verbal English. Salary is excellent with furnished lodging, 30 days paid vacation, bonus pay and leave and other exceptional benefits. Interested. qualified candidates should forward a resume with salary history to: Kathleen Langan, R.N. Senior International Representathe Hospital Corporation International One Park Plaza :'oIashville, TN 37203 l: A HOSPITAL CORPORAnoN II"-=-ii: " 6">'"' '>I. Equal Opportunity Employer 112 ..., 11711 The Canadian Nur.. Director of Nursing Service Required for Wetaskiwin General Hospital Applications for the above position are invited on or before June I, 1979. The Wetaskiwin General Hospital is a 135 bed active treatment hospital and is located in a small city just 35 miles south of Edmonton. The facility is part of a complex which operates a 50 bed auxiliary hospital and a 50 bed nursing home. The successful applicant should ideally have ex- perience in the administration of a nursing program and possess a B.Sc.N. Degree, but, equivalent combination of formal education and experience will be accepted. Position will open on retirement of present incum- bent. Address all inquiries in writing together with a complete resume to: P.D. Langelle Administrator Wetaskiwin Hospital District 5505 - 50 A venue Wetaskiwin, Alberta T9A OT4 General Duty Nurses The Royal Alexandra Hospital, 970 Bed teaching hospital requires: General Duty R.N.'s for temporary vacation relief positIons in most clinical areas. Positions vary in duration between 9 weeks and 20 weeks, depending on clinical area. Employment date -July 2, 1979. Applicants must be eligible for Alberta registration with A.A. R.N. Please direct inquiries to: Mrs. R. Tercier Director of Nursing Personnel- Administration Royal Alexandra Hospital 10240- Kingsway Avenue Edmonton, Alberta T5H 3V9 Nurse Clinician/Operating Room Applications are invited for the above position in the Operating Room of the Vancouver General Hospital, an active teaching and tertiary referral hospital for the province. The Department consists of 30 theatres involved in all surgical discipline. Duties involve providing clinical expertise and leadership in the delivery of care standards in the development of staff in collaboration with the O.R. instructor and head nurses. Applicants must be registered nurses, preferably with a B.S.N. degree, and Post Graduate Course in Operating Room Techniques or equivalent. Salary $1,500 - $1,772. Benefits according to R.N.A.B.C contract. Please submit resume to: Mrs. J. MacPhail Employee Relations Vancouver General Hospital 855 W. 12th Avenue Vancouver, B.C. V5Z IM9 The Abbie J. Lane Memorial Hospital, Halifax requires a Director of Nursing Applications are invited for the position of Director of Nursing in a fully accredited psychiatric teaching hospital with 90 in-patient beds, 50 day treatmenl places and a large outpatient service. Reporting to the Administralor, Ihe Director of Nursing will be responsible for managing the Department of Nursing and maintaining a high standard of nursing care in a teaching environment. This position will be available in June, 1979. II is expected that the applicant will have a degree at the Master"s level, psychiatric nursing experience, and be eligible for registration with the R.N.A.N.S. The applicant should be able to demonstrate skill in administra- tion. and exhibit a potential to guide a progressive department in new directions. Please forward your resume to: Mr. Stephen Jenner Administrator Abbie J. Lane Memorial Hospital 5909 Jubilee Road Halifax, Nova Scotia B3H 2E2 The Cenedlan NUrM Ryerson Poly technical Institute Nursing Department Presently Offers a General Post-Diploma Intensive Care Program Running Twice Consecutively From September - December & January - April A 15-week course. beginning in Sept. '79 & Jan. 'SO aimed at producing general staff nurses qualified to work in medical, surgical or general intensive care areas. Emphasis is placed on pathotht:rapeutics and as- sessment skills and an integrated clinical experience. Clinical experience offers ample opportunity for immediate application of new knowledge and testing of hypotheses. For further infonnation. contact Admissions Office. Ryerson Poly technical Institute. 50 Gould Street. Toronto, M5B lES. or telephone Nursing Depart- ment. (416) 595-5191. Registered urses I OO heJ ho...pital aJjal.:enr to Univer'\itv of -\Iherta I.:ampu... offer... empkn ment in meJil.:ine. ",urger . peJiatril.:.... oh...tetric.... p"' chiatr . rehahilitation anJ e\tenJeJ care induJing: .Inren...i\el.:are . C oronar oh...ervation unit . CarJiova'\ollar ...urger . Burn... anJ pla...til.:'" · ..... eonatal inten...i\ e I.:are . Renal Jial ...i... . '\,euro-...urgen Planned ()nenlallon and I n-"\cn i\:e FduGItion program.... p,,,, (,raduate dinical cour....:... in (.ardlO\ ,!'cular- Inten...j\c Care "'ur...ing ami Opcla'ing Room r e\:hnique .tnd \tanagemenl. \ppl to: Recruitment Officer - 'ur...inJ: l nÌ\er...it ot -\I rta Ho'pital X II- 112th treet Edmonton. -\I rta [M;2ß7 118y 1171 83 . UNIVERSITY OF WINDSOR SCHOOL OF NURSING The University of Windsor, School of Nursing invites applications for one (1) year term appointments for the 1979-80 academic year. Qualifications: Master's Degree in Community Health Nursing Work experience in community health nursing Teaching experience Current Ontario Certificate of Competence or eligibility for same Send curriculum vitae and names and addresses of three references to: A. Temple Director School of Nursing University of Windsor Windsor, Ontario, N9B 3P4 [2]@ University of Alberta Hospital Edmonton. Alberta ') Wish ere .JI , @. -:,,' -- ,....; '" "ct f <-I : .. .in Canada's Health Service Medical Services Branch of the Department of National Health and Welfare employs some 900 nurses and the demand gro\\ s every day. Take the North for example. Community Health Nursing is the major role of the nurse in bringing health services to Canada's Indian and Eskimo peoples. If you have the qualifications and can carry more than the normal load of responsibility... why not find out more? Hospital Nurses are needed too in some areas and again the North has a continuing demand. Then there is Occupational Health Nursing \\hich in- cludes counselling and some treatment to federal public servants. You could work in one or all of these areas in the course of your career, and it is possible to advance to senior positions. In addition, there are educational opportunities such as in-service training and some financial support for educational leave. For further information on an), or all. of these career opportunities, plea'ie contact the Medical Service!> office nearest you or write to: ........, I Medical Services Branch I Department of National Health and Welfare Ottawa. Ontario K1A OL3 I Name I I Address I I City Prov I I . . Health and Welfare Sante et Bien-élre social I Canada Canada . Index to Advertisers May 1979 Canadian Dairy Foods Service Bureau The Canadian Nurse's Cap Reg'd Canadian Pharmaceutical A sociation Cover 4 48 14 Canadian School of Management 55 Equity Medical Supply Company 49 Health Care Services Upjohn Limited 55 Hollister Limited 16 J.B. Lippincott Company of Canada Limited 52,53 The C.V. Mosby Company, Limited 2,3,4,5 Nordic Pharmaceutical Limited 56 Pharmacia (Canada) Limited 9 Public Service Canada 51 W.B. Saunders Company Canada Limited 7 G.D. Searle & Company Canada Limited 17 Smith & Nephew Inc Cover 3 Stiefel Laboratories (Canada) Limited 14 White Sister Uniform Inc Cover 2 Advertising Manager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa, Ontario K2P I E2 Telephone: (613) 237-2133 Advertisinf: Representatives Jean Malboeuf 601. Côte Vertu St-Laurent. Québec H4L IX8 Téléphone: (514) 748-6561 Gordon Tiffin 190 Main Street UnionviIle, Ontario UR 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster Avenue Ardmore, Penna. 19003 Telephone: (215) 649-1497 Member of Canadian Circulations Audit Board Inc. IæE I ,1.1. Why c dressings several times a day when once a week is plenty1 This is an Op-site dressing for non-infected ulcers. When it goes on, it stays on... for a whole week. Because Op-site is an adhesive, transparent dressing that breathes and sweats with the skin. So you can keep your eye on the entire healing process without the interruptions of frequent dressing changes. Op-site is easy on the patient too. It's neat, not bulky. Patients can take regular baths or showers without discomfort because Op-site is water-proof. Op-site is also bacteria-proof, protecting the ulcer from contamination. Because Once a week is plenty, Op-site means fewer dressing changes. And that's less work and more time for you. -------------------- I Op -Sit e '"J Forf';lrtherinforma ion,! ut I I I Op-slte ulcer dressmg, fill In the ultimate wound dressing and mail this coupon. I I I : Name I I I I Address I I I I City Prov._Code I I Mail to' Ej ----. SmIth f, Nephew Inc. 2100.52ndAvenue I . : Stlf Medical Division Lachine. Qué., Canada I I '.. -.: H8T2Y5 -------- ----------- butter is really the villain responsible for various common pathologies. . . , these very illnesses continue to occur frequently despite a dramatic decrease in butter consumption over the past thirty years? . And did you know that, during this same period ",(time. there has been a marked increase in the consumption of margarine in Canada? COMPARATIVE DAILY CONSUMPTION RATES OF BUTTER AND MARGARINE FROM 1948*-1978** IN GRAMS PER PERSON I '\ 000 180 I V V 1948 MARGARINE 1978 1948 BUTTER 1978 For more facts about dairy foods, write to: Canadian Dairy Foods Service Bureau. 30 Eglinton Ave. E.. Toronto, Ont. M4P IB6 L_ '\ 296 =:J 112 I When you look at the facts you can see the good in butter. *Statistics Canada ** 1978 estimated consumption . Are you a nursing leader? . A guide to special Interest groups . When your patient says It hurts . The nurse and the learning disabled child . The IV nurse and the chemotherapy patient - a special relationship The Can- Nurse c 00 BI8L10-:- !:,'" : SC"[NC S I.-u IR...IERES ;; o 1 (3. . I .. I NOT TAKE ll!JRARY JUNE 1979 s L)j V./!.U Av J dIl l:t lt OPl l]}>J\ll I V \lll' I 1 \J3 n=, ", I: =3 "'V ll l::fJJlHl C;ff.Q9 7 IÇ;L 1 ----.- - 1 Style No. 42728 - Dress Sizes: 3-15 "Royale Shantung" 80% textured Dacron ll polyester, 20% cotton White, Pink. . . about $35.00 I' . " A Division of White Sister Uniform Inc, DRESS UP F' · S P RI NG in beautiful Dacron';;: polye ter and cotton blend. Exclusively our of course .. - " ., tyle No. 1 - Dress izes: 6-1 . 'Royale Si otta" 0% textu 0% cotton hite. k... about $3- Available at leading department stores and specialty shops across anada \\ \ \ .-: ... CNA NATIONAL FORUM ON NURSING EDUCATION 13,14,15 NOVEMBER 1979 SKYLINE HOTEL OTfAWA ð ç:;:' OF THEME: THE NATURE NURSING EDUCATION ð ç:;:' PROGRAM: KEYNOTE SPEAKER: ALICE J. BAUMGART, DEAN, FACULTY OF NURSING, QUEEN'S UNIVERSITY REACIlON PANEL: Jocelyn Hezekiah, Cécile Lambert, Dorothy Kergin, Ann Hilton SESSIONS: Nursing Model Evelyn Adam Basic Nursing Service Mary Cruise, Lucille Parent Marie White, Ginette Rodger Reality Shock Heather Smith Margaret Edmonds Pat Stanojevic Specialization Madeleine Blais Nursing Skills/Competencies Margaret Steed Accreditation Myrtle Crawford SPEAKERS AND PARTICIPANTS WILL DISCUSS WHAT IS BASIC IN NURSING EDUCATION AND PRACTICE IN SESSIONS AND OPEN DISCUSSIONS - ALL NURSES CAN GEf INVOL VFD . . . OPEN TO ALL REGISTERED NURSES TO A MAXIMUM OF 300. NOTE: CNA has reserved a block of rooms at the Skyline Hotel, 101 Lyon Street, Ottawa, KIR 5T9, at a special convention rate of $4 1.00 single and $47.00 double occupancy. Please make your reservations directly with the Skyline indicating you are participating at the Canadian Nurses Association National Forum on Nursing Education and request the convention rate quoted above. Name .......................................... Address _ _ _ . . . _ .. _ _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postal Code . ...................................... Telephone (Business) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rome ......... . . _ . _ _ . . . . . Place of Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CNA Member 0 0 (Ontario nurses who belong to RNAO are members ofCNA) Yes No (Province of 1979 Registration) (Registration number) FEE: CNA Member- $100.00 0 Non-<::NAMember-$17.5.00 0 Check which applies Cheque payable to: Canadian Nurses Association, 50 The DrIveway, Ottawa, Ontario. K2P lE2 T ephone:(613)237-2133 Cancellations pennitted until November I $2.5.00 processmg fee deducted. c5ì1 ica's number shoe , for ]6ung women in white! THE LINI SHOE pk Ìll.IIJ'nMi. \ . . \. ' . . - . .... , . .. . ....... ..., .. ... I . .... ." . .. . . . . ......... SOME STYLES ALSO AVAILABLE IN COLORS. . . SOME STYLES 3%-12 AAAA-E, 30.00t053.00 For a complimentary pair of white shoelaces, folder showing all the smart Clinic styles, and list of stores selling them, write: THE CLINIC SHOEMAKERS. Dept. CN-6, 7912 BonhommeAve. . St. Louis. Mo. 63105 The Canadian Nurse June 1979 The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number 6 Input 6 A catalogue of special interest groups Lynda Fitzpatrick 9 News 8 Spotting and helping the MiidredC. Jacobson learning disabled child George Gasek 18 You and the law 39 A holistic approach to nursing the patient in pain Emalou Vaterlaus 22 Research 47 The IV nurse and the chemotherapy patient: a vital role in emotional support Kathleen MacMillan-Brett 28 Books 52 FRANKLY SPEAKING Apathy in nursing Jessica Ryan 31 Library Update 53 Nurses need leadership skills Susan Spennrath Judy Tiivel 33 . The Canadian Nurse welcomes suggestions for articles or unsolicited manuscripts. Authors may submit finished articles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and carbon. All articles must be submitted forthe exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. A chance to grow wings for the spirit is how IYC officials describe this month's promotion of the special needs of those children who are "the same but different". Exceptional children are bound to find the going rough but they deserve a real childhood. To achieve this, they need special care and attention. As nurses we can make sure that they get it. Cover photo: National Film Board of Canada. The views expressed in the articles are those of the authors and do not necessarily represent the policies of the Canadian Nurses Association. ISSN 0008-4581 Canadian Nurses Association, SO The Driveway, Ottawa, Canada, K2P IE2. Indexed in International Nursing Index, Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microfonn from Xerox University Microfilms, Ann Arbor, Michigan 48106. Subscription Rates: Canada: one year, $10.00; two years, $18.00. Foreign: one year, $12.00; two years, $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not responsible for journals lost in mail due to errors in address. Postage paid in cash at third class rate Toronto, Ontario. Pennit No. 10539. Canadian Nurses Association, 1978. 4 June 1979 The Cen.dl.n Nur.. perspective Sinners or saints? The gavel has descended. The Ontario Division Court has upheld the ruling of a three-man arbitration board that found in favor of the employer, Mount Sinai Hospital in Toronto, and against three ICU nurses employed by that hospital. The nurses in question refused to accept a work assignment because they felt their existing workload made it unsafe for them to 'care for another patient. They were subsequently disciplined for insubordination and, failing satisfactory resolution of the grievance procedure, the matter proceeded to arbitration. The situation on the night of February 27, 1976 was one that many nurses will recognize - six ICU nurses charged with the responsibility of caring for eight seriously ill patients, five of whom were on ventilators and required one-to-one nursing. Two of the six were relief nurses. For one of them this was her first shift in ICU; for the other it was her first time in this unit. The night was "the busiest ever" and the workload was such that nobody took time out for lunch or coffee breaks during the shift which lasted 12 hours and 4U minutes. I nformed of the imminent arrival of another patient from Emergency, One of the six nurses responded that "no nurse feels capable of accepting the responsibility of another ventilator patient". It was their subsequent failure to "accept a report and patient from the nurse who had transferred a critically ill patient from the Emergency Department" as well as to provide any significant assistance to the doctors caring for this patient which became the basis for disciplinary action against three of the nurses. The arbitration board found the hospital had "just cause" for the discipline imposed on the grievors. The courts have upheld this ruling and, for now, that is where the matter rests. Whether or not another ruling is forthcoming, I believe it is incumbent On nurses everywhere to give careful consideration to some of the questions raised during the arbitration hearing. These are issues which are fundamental to the direction offuture growth and autonomy within our profession. For example: . Can nurses, if they feel the circumstances warrant it, challenge the propriety of a work assignment? Can they refuse to carry out an assignment and then raise the legitimacy of that order as a defence against the charge of insubordination? . Are the recognized exceptions to the "obey and grieve" rule (i.e. where recourse to the grievance procedure will not adequately protect his/her interests) too narrow to afford adequate protection to the nurse? to the patient? . What effect does the introduction of patient interests have on the application ofrecognized principles of arbitration? . Can a hospital setting be compared to an industrial plant? Where relationships are of a professional character, as in a hospital, is it desirable to accord greater respect to the employee's judgment (as to the wisdom or necessity of a work instruction) before instituting disciplinary action for insubordination? Where do professional judgment, responsibility and accountability - all of the current buzz words - fit into the scheme of administrative authority? The right to direct the work force and to make work assignments has always been a management prerogative. To allow an exception to the "obey and grieve" rule like the disputed claim - i.e. that in being asked to accept yet another patient, to "cope" . the nurses were being required to carry out a task that was either unsafe or iIIegal- would. in the words of the award, "effect a substantial inroad" into this management right. It could also pave the way for future negligence suits against the hospital. As the award notes: "The employer as a hospital is under a statutory obligation to provide care for patients admitted into the hospital. Moreover, the employer may well be liable both originally and vicariously for damage which results to patients while in the institution. That circumstance requires that the employer be put in a position in which it can effectively insist that certain instructions be carried out. If the employer were unable to so insist and were put in the position of having to defer to the superior professional judgment of its employees it would be placed in an intolerable legal position, One in which it could not protect itself from legal liability ." The nurse, it would appear, is caught between the legal consequences of the overriding interests of her employer, and the dictates of her own professional conscience and disciplinary body. In a dilemma like this, according to Principal Nursing Officer Dr. Jo Flaherty who testified on behalf of the three defendents, the choice is obvious: "As professionals they (registered nurses) are accountable for their behaviour rather than accountable to someone in a hierarchy. And, as persons who are accountable for their professional behaviour, they must make judgments about the appropriateness of their nursing actions.Irat any time they believe that an order is questionable those nurses are obliged by the ethical code governing nursing and by the contents of and the regulations under The Health Disciplines Act of Ontario to refuse to carry out questionable orders until they satisfy themselves that the carrying out of the orders would not be in conflict with their professional ethics and with their commitment to excellence in the practice of their profession. .. Nurses at Mount Sinai (1ike those at half a dozen other Ontario hospitals) now have a "professional responsibility" clause written into their collective agreement providing for referral of nursing and workload problems to an impartial panel of outside nurses. The hospital has also increased its full-time staff. But the question posed in his dissenting judgment by arbitrator William Walsh remains: "How does such a predicament arise? How do those in authority allow a situation to arise where experienced ICU nurses, caring for very sick patients earnestly conclude they require help for patients already under their care and cannot attend to still an additional critically ill patient without further endangering those already in their care. Surely if this intolerably wretched circums tance is the result of some failure in management, then the people at the bottom of the ladder, the hardworking professional nurses, should not be made the scapegoats. " There are strong overtOnes in Walsh's observation reminiscent of a warning issued by president Sue Rothwell to members of the Registered Nurses Association of British Columbia last year. "Quality of care in practice settings," she told nurses then, "is the single most important issue facing us today." She described the contentious situation that existed at that time at Vancouver General Hospital as "only the tip of the iceberg" and predicted that "the coming year will bring one crisis after another in nursing care, not just in B.C. but right across the country." Unfortunately. time has proved her right and today, three years after the Mount Sinai incident, no province, no hospital. no nurse charged with providing care can contemplate the future with any degree of equanimity. - M.A.B. herein When Jessica Ryan agreed to write this month's Frankly Speaking, she thought the job would be relatively simple. "After all. I'm one nurse who does have strong feelings about this topic. I get very uptight about inaction and apathy among nurses. "But to say this to all the nurses of Canada sort of scares me. In any case, I'm a nurse - at the bedside and very active in my profession - and this is the way I feel. .. Jessica's opinion column which appears on page 31 of this issue is the first of a series of contributions that EDITOR ANNE BESHARAH ASSISTANT EDITORS LYNDA FITZPATRICK SANDRA LEFORT PRODUCTION ASSISTANT GIT A FELDMAN CIRCULATION MANAGER PIERREITE HarrE ADVERTISING MANAGER GERRY KAVANAUGH CNA EXECUTIVE DIRECTOR HELEN K. MUSSALLEM GRAPIßC DESIGN ACARTGRAPHICS EDITORIAL ADVISORS MATHILDE BAZINET. chairman. Health Sciences Department, Canadore College, North Bay. Ontario. DOROTHY MILLER,public relations officer, Registered Nurses Association of Nova Scotia. JERRY MILLER, director of communication services. Registered Nurses Association of British Columbia. JEAN PASSMORE,editor, SRNA news bulletin. Registered Nurses Association of Saskatchewan. PETER SMITH. director of publications, National Gallery of Canada. FWRlTA VIALLE-SOUBRANNE. consulrant. professional inspection division. Order of Nurses of Quebec. CNA members-at-large wtll be making to the Frankly Speaking page. Next Fall Margaret McCrady, member-at-large for nursing education, will give her views on some of the concerns that currently face nursing educators in this country. The past ten years have seen a dramatic growth of special interest groups in nursing - from local groups that meet the needs of small numbers of interested nurses. to national and international organizations that serve a variety of needs of a large body of nurses. across Canada and the world. These groups have a vital role to play in your professional development. Find out about what they have to offer to you on page 9. A reminder...this year as in 1978 theJuly and August issues of your journal are to be combined and will appear in a single edition that will go into the mails J ul y 31 st. Watch for our special feature presentation in the July/August issue - A Report from the Provinces - on what's going On across the country in the organized nursing profession. CNJ staff and special reporter Bert Prime. CNA public relations officer, will visit eight provinces and report to you on the concerns and issues brought by membership to their annual meetings this Spring. TIlE A Y\A PEGO\ \ PEELI'G af{' Efff'clÏ\:e "The Anna Pegova Peeling'is renowned for ifs effecfiveness on rejuvenescence, acne, and other related skin problems. It is fhe only infernafionally recognized peeling and is presenfly being marketed throughout Europe. In France, in 1965, thi s product won the Gold Cup from le Comité du Bon Goût Françai s. France Clavet, R.N. (Hôtel Dieu - Chicoutimi, affiliafe of laval University) has the exclusive rights for this formula in Canoda. Studio Clovet Inc., nho has been serving Canadians for yeors in Montreal, is currently recruiting nurses interested in increasing their income by becoming owners of a studio. Studio Clovet Inc. hos qualified professionals who are ready to train you to become specialists in this field. If you have approximotely 7 years nursing experience and wish fo discover new horizons, please con fact : Studio Clavet Inc. 14 U Saint - Hubert Montreal Quebec. H2L 3Y9 Tel,: 1-:H-I. 8-1 -3046 We are a member of the Better Business Bureou. Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE. NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth. and more information. please clip this coupon and mail today. Name ...................................................... (blodl: len_I Address ........................................ ........... City ................................... .Poatal Code ....... Your graduation achool ..".......,.....................". I June 111711 The Canadian Nur.. input A nurse Is a nurse Is a... The interdependent Down with apathy year internship of pure clinical Some comments 0\1 the functions are carried out as Three cheers for Jeanne experience (not unpaid) letter from Dr. A.G. Dawrant, the Qurse works with patients Hurd. I have long felt that the before being licensed as president of the Canadian and other health care workers apathy of the 90 per cent of registered nurses? Association for Independence in the planning and the members of ()ur oanAnderson, R.N., B.N. in Medicine (Input, March)... implementation of health care associations will be our (retired), Vananda, B.C. Dr. Dawrant does not for patients. downfall. Unless we want to seem to understand the The dependent functions be classified as technical Recipes anyone? function ofthe primary care involve the carrying out of nurses, now is the time to The Charlottetown nurse in the health care instructions from other health register our protests. Chapter of the Association of system. Primary care nurses care workers, including Perhaps degree nurses Nurses ofP.E.1. has recently have been involved in health physicians, and the carrying should fonn their own published a cookbook care in Canada since the days out of the policies and association if they are so containing recipes ofIsland of Jeanne Mance. Some of practices ofthe agency in obviously dissatisfied with the nurses. The proceeds will be them refer to themselves as which the nurse is employed. R.N. associations. After all, used for the education of nurse practitioners. Many A t no time is a nurse free as Jeanne points out, we do nurses and to help furnish the members of our profession, to carry out orders, policies or pay the m<\Ïority ofthe costs, Association office. The however, believe that any procedures unthinkingly. and I feel very strongly about cookbook costs $3.50 and is nurse who practices is a Canadian nurses are bound by this blatant attempt to available from: Rosemary practitioner and they law, by professional "declass" the diploma nurse. Herbert, 29 Birch Hill Dr., therefore prefer the tenn standards and by the ethics of Let your associations Sherwood, P.E.l. Our chapter "primary care nurse". the nursing profession to know how you feel! is still small, but growing, and Relatively few primary question orders, directions, -Kathie Lillyman, R.N., we are quite excited about this care nurses work in complete policies and practices about Winnipeg, Man. project. isolation. Even primary care which they have doubt. -Rosemary Herbert, nurses practicing in Careful study of Helen Practice makes perfect Sherwood, P.E.l. underpopulated parts of our Taylor's comments reveals I wish to express my deep country, who are physically that she and the association of appreciation to author Jeanne An idea that works isolated from other health care which she is president have Marie Hurd (April, 1979) for As a nursing student workers, usually have the never recommended that her presentation of a problem whose interest revolves opportunity for contact by nurses "set up shop on their that has caused anxiety to around preventive health care phone and/or radio as well as own" as Dr. Dawrant many in the nursing and health education of the occasional visits from other suggests. As a member of the profession. Even as a young pediatric client, I would like to health care workers. Canadian Nurses Association, student, I was utterly appalled congratulate the Simon Fraser Dr. Dawrant needs to be I would be disturbed indeed if at the common practise of Health Unit on their ingenious reminded that primary care my president urged physicians university nursing programs, idea of the health circus. nurses practice nursing and to delegate to nurses rather Le. to graduate students with I agree that being healthy are accountable for their than work with nurses as an extremely limited clinical begins with teaching and that professional nursing practice. equal members of the health experience to serve the public teaching is retained when it If they are negligent in this care team. as licensed R.N.s while they becomes an enjoyable activity practice they can be charged Physicians have no right were still inept at the for the child and his parents. under the statutes governing to delegate the practice of necessary nursing technique. What better way to relate to the practice of nursing. medicine to members of Many of us have made the pediatric client as he I disagree with Dr. another profession that is the same comparison Hurd becomes the center of health Dawrant that there is a governed by separate statutes makes, that the medical screening procedures and the tremendous amount of good and that is accountable to its profession with its taxing educational process than that work that the registered nurse own statutory body for its academic program also of a health circus! in such a setting could do "if practice. I wonder if, in his provides an equally taxing -Rae helle Sapp, East the practitioner is prepared to efforts to promote clinical program which Tennessee State University, delegate work to his nurse". independence in medicine, involves peIfonnance in the Johnson City, U.S.A. Nursing practice involves Dr. Dawrant recognizes the clinical area during the independent, interdependent need for independence for academic program and for at Correction: the fly gals and dependent functions. The other professions in their own least one year post graduate. reunion for formerT .c.A. independent functions involve practice and I urge him to So most physicians do at least stewardesses (April Input) decision-making by nurses infonn himself better about 2 years internship and some as will take place a year from regarding nursing the purpose, functions and many as 5 years at great now, in May 1980, rather than interventions. Sound nursing scope of the nursing economic risk. Is it asking too this year. decisions are based on profession in this country. much of the university nursing observations by the nurse, -M. Josephine Flaherty, program to specify at least one application of theory and Principal Nursing Officer, (continued on page 48) practical experience. Health and Welfare Canada. What's New? TEXTBOOK OF HUMAN SEXUALITY FOR NURSES By Robert C. Kolodny, M.D.; William H. Masters, M.D.; Virginia E. Johnson; and Mae A. Biggs, R.N., M.S. While nurses fully realize that sexual health is an important com- ponent of the overall well-being of their patients, the effeas of health problems on sexuality are less apparent. To explain the biologic and psychosocial impacts on sexuality of a variety of medical and surgical conditions, the authors of TEXTBOOK OF HUMAN SEXUALITY FOR NURSES draw on 25 years of clinical experience and research from the Masters & Johnson Institute. From its opening chapter, Sexuality as a Clinical Science for Nurses, to its closing pages of questions and answers, this text effectively incorporates human sexuality into nursing practice at a level that can be understood by both practicing and student nurses. Little, Brown. 450 Pages. Illustrated. 1979. Paper, $15.00. Cloth, $21.00. GERONTOLOGICAL NURSING By Charlotte Kopelke Eliopoulos, R.N., B.S., M.S. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. Specific coverage is given to measures designed to promote good respiration, elimination, and activity to compensate for age-related changes interfering with these functions. CommQn diseases of each body system and their unique features in the aged are discussed in detail. Harper & Row. 384 Pages. Illustrated. 1979. $15.00. A GUIDE TO PHYSICAL EXAMINATION, 2nd Edition By Barbara Bates, M.D. New chapters on interviewing and history-taking, and much expanded and updated content mark the new edition of this outstanding guide to physical assessment for health practi- tioners. Detailed and concise, it's an excellent on-the-job reference for interviewing and examination; for assessment of health status; and for differential diagnosis among abnormal findings. There are now more examples of abnormalities, more information on the cardiac chapter, a new section on the stuporous or comatose patient and revised chapter on the pediatric examination. Lippincott. Abt. 425 Pages. 1979. $25.00. NURSES' HANDBOOK OF FLUID BALANCE, 3rd Edition By Norman Milligan Metheny, B.S.N., M.S.N., Ph.D.; and W.O. Snively, Jr., M.D., F.A.C.P. Almost totally rewritten and revised, with a wealth of new material, this edition is twenty percent larger than the previous one! It presents basic knowledge of body fluid balance distur- bances, with emphasis on practical application. New material and major revisions include: new knowledge of homeostasis; a summary of the latest information on nutrition; an expanded section on real-life case histories; greatly increased emphasis on acid-base disturbances; and greater coverage of elemental diets, tube feedings, diuretics, and adrenocortical steroids. Lippincott. Abt. 400 Pages. 1979. Abt. $15.00. NURSING MANAGEMENT FOR PATIENT CARE, 2nd Edition By Marjorie Beyers, R.N., Ph.D.; and Carole Phillips, R.N., M.S. In this second edition, the authors live up to the impeccable reputation established by NURSING MANAGEMENT FOR PA TlENT CARE. Important new features include reports on recent theories of management, a deeper explanation of the nurse manager's relationship with staff members, an enlarged chapter on the plan of care, and timely discussions of the expanding role of the nurse manager, including her function in health-care organizations other than hospitals and in disputes with unionized employees. little, Brown. 292 Pages. Illustrated. 1979. $10.75. COMMUNICATION FOR HEALTH PROFESSIONALS By Voncile M. Smith, Ph.D.; and Thelma A. Bass, M.A. This timely book identifies and describes problem situations stemming from communication breakdowns that commonly affect health care personnel. It relates the importance of communication to the maintenance of public confidence in health care institutions and personnel, and explains skills necessary to communicate effectively with patients and clients, co-professionals, supervisors, and subordinates. Lippincott. Abt. 200 Pages. 1979. Abt. $8.50. Lippincott J. B. LIPPINCOTT COMPANY OF CANADA LTD. Serving the Health Professions in Canada Since 1897 75 Horner Ave., Toronto, Ontario M8Z 4X7 LIPPINCOTT'S NO-RISK GUARANTEE Books are shipped to you On Approval; if you are not entirely satisfied you may return them within 15 days for full credit. re ; : ------- o KOLODNY: Textbook of Human Sexuality for Nurses, Paper, $15.00. o KOLODNY: Cloth, $21.00. o ELIOPOULOS: Gerontologicll Nursing, $15.00. o BATES: A Guide to Physical Examination, 2nd Ed., $25.00 o METHENY: Nurses' Handbook of Fluid Balance, 3rd Ed., $15.00. o BEYERS: Nursing Management for Patient Care, 2nd Ed., Abt. $15.00. o SMITH: Communication for Health Professionals, Abt. $8.50. o Payment enclosed (postage & handling paid) o Bill me (plus postage & handling) Name Addres5 City Postal Code Provo Prices subject to change without notice. CN6/79 - 8 June 111711 The Cenedlen Nur.. news Spotlight on continuing education More and more, continuing education is recognized as a necessity for the safe and competent practice of nursing; but there are stiII many unknowns. How do we, for example, identify the real educational needs of nurses? Do we want to see continuing education become a mandatory requirement for relicensure?Oo we have any proof of the effectiveness of programs currently being offered? Do they improve the quality of care provided? Are they cost effective? These are only a few of the many questions addressed at the first National Continuing Education in Nursing Conference held in Winnipeg, Manitoba on April 18-20, 1979. The meeting, supported by the Manitoba Association of Registered Nurses, attracted over 70 nurses from all ten provinces and the North West Territories. They came together to discuss concerns and problems and to share their ideas and expertise about continuing education in their own locales. The participants came from a wide variety of work setti ngs: . inservice education departments in hospitals . continuing education in community colleges and universities . professional associations . federal and provincial governments . nurses in service settings, ego directors of nursing, staff nurses, community health nurses. After three days oflively discussion, the group unanimously agreed on a three-fold plan of action: I. to hold a second National Conference on Continuing Education for Nurses in Vancouver in conjunction with the Canadian Nurses Association biennial meeting inJune 1980; 2. to submit a resolution to the CNA indicating the need for a position paper on continuing education for registered nurses in Canada; 3. to improve communication about continuing education for nurses by various means available, ego "talking up" CE to colleagues; sensitizing provincial nursing associations about the concern for quality continuing education programs; utilizing the provincial association bulletins and The Canadian Nurse journal to inform nurses ofCE issues and programs. Four speakers provided the impetus for many animated and provocative group discussions. The first speaker, Margaret Steed, associate professor and director of continuing education in nursing at the University of Alberta looked at the issue of program evaluation. Although she acknowledged the current popularity of continuing education for nurses, she asked the audience to consider whether the information being taught in many CE programs is "useful" to nurses. She posed the question: "Do nurses use the information to improve their nursing practice and the quality of nursing service?" Steed suggested that continuing education in nursing must provide proof of its effectiveness in order to (continued on page 46) ...........'".""'""..- h j, L'\ I\lH 'IÀJ J J )I . I: I . I !It . 'tt!.! !.I' I í 4Þ ..' " I , , I \ .,I - J i;;:. , - - A four-member international nursing team visited CNA House in late February as part of a cross Canada tour to promote the theme "Towards the Year 2000", a theme derived from the World Health Organization resolution "Health for all in the year 2000". Pictured during their Ottawa visit are (left to right): Syringa Marshall-Burnett of the Faculty of Nursing, University of We t Indies o - Measuring Up: Nancy Williamson (right) of the Northwest Territories, shown above with fitness examiner, Carol Lindsay. was one of 24 nurses from across Canada who took part in a one-week fitness and lifestyle workshop at Geneva Park, Ontario, in February. The workshop, sponsored by the Fitness and Amateur Sport Branch of Health and Welfare Canada, was designed to give participants - all of whom were chosen by their provincial or territorial ....- ;H UlJ./ J I ) .. 'r I I, 'j , ,: - "ut! .. I;J f: . \. " Jamaica; Dr. Nita Barrow, Director, Christian Medical Commission, World Council of Churches, Geneva, Switzerland; Dr. Aleya El-Bindari Hamad, Program Leader, Primary Health Care, World Health Organization, Geneva; and Verna Huffman Splane, honorary lecturer at the University of British Columbia and a vice-president of the International Council of Nurses. /. " , þ ÿ i - r ': t professional ussociation - basic information on fitness and to acquaint them with programs they might use in their agency. The workshop was the last in a series of three funded. planned and staffed by Health and Welfare Canada. The first. for nurse educators, was coordinated by the Canadian Nurses Association. The two remaining workshops, coordinated by the Victorian Order of Nurses, were designed for occupational and community health nurses. A catalogue of special interest groups Lynda Fitzpatrick How do nurses keep up with what is going on? There's inservice education, grand rounds and, o in awhile, a lecture from a visiting doctor. Sometimes an article from a nursing journal gets pinned on the bulletin board, or the clinical nurse specialist brings in a new idea or two. But do you ever wonder if nurses in other units, hospitals or even o her parts of the country are doing things differently? Perhaps you've been told that your unit is unique, but do you know why? There are exciting ways to keep up with rapid changes in nursing practice, to share your ideas about nursing care, and to develop your contribution to.the nursing profession- through special interest groups in nursing. If you have attended meetings in a specialty area. then you already know what it means to get a broad view of what is going on in your specialty - what you take back to your unit is a new way of looking at things, new life and purpose. These are the special interest groups - international, national, provincial and local - available for your professional development. Whether you are an orthopedic nurse. a nurse interested in pursuing research, or the member ofan LV. team, they have much to offer. Find out about them. They have a vital role to play in your professional practice. ..-' 10 June 111711 NATIONAL ASSOCIATIONS CANADIAN ASSOCIATION OF NEUROLOGICAL AND NEUROSURGICAL NURSES If your area of special interest is the field of neurological and neurosurgical nursing, then this may be the group for you. Founded by Jessie Young in 1969, its objectives are: . to promote the highest standards of practise in the field; . to foster continuing professional education of members; . to establish methods of sharing this knowledge; and . to establish lines of communication between nursIng and other disciplines practising in the field of neurological sciences. The association offers a stimulating annual meeting held in conjunction with the Canadian Congress of Neurological Sciences. Councillors are elected at the annual meeting to represent each province; together these counciUors form the association's board of directors. The association is affiliated with the Canadian Nurses Association and the Canadian Congress of Neurological Sciences. President: Pauline Weldon 27 Lawson A venue Dartmouth, Nova Scotia B2W 1Z2 CANADIAN ASSOCIATION OF PRACTICAL AND NURSING ASSISTANTS In May of 1972, a meeting of provincial associations was held in Thunder Bay, Ontario, to form a national association of nursing assistants. CAPNA is made up of all nursing assistants who belong to their provincial associations across Canada.. The group was formed because of a need for improved health care for Canadians and the recognition that training programs should be the same in all provmces. CAPNA holds annual meetings in conjunction with the annual meetina of the host province. The group's primary concern is education, including post-graduate training for registered nursing assistants. Sec:retary-treasurer: Joan Hayman R.R.4 St. Stephen, New Brun wick E3L 2Y2 President: Inez M. Smith The C.n.dlan Nur.. CANADIAN ASSOCIATION OF UNIVERSITY SCHOOLS OF NURSING CAUSN exists to provide an organized national body to promote the advancement of nursing education in universities The association dates back to 1942, when eight university schools of nursing met to form a provisional council to determine standards for university schools of nursing and to support the development offuture schools. Since 1942, 15 additional schools of nursing have been establi5hed and are members ofCAUSN, so that the association now represents 23 university schools. r Membership in CAUSN is by institution only; the association is supported by fees from constituent universities. Fees remain within the four regions (Atlantic, Quebec, Ontario and Western Regions) to support regional activities. The objectives of the organization are: . to develop criteria for ulllversity education in nursing; . to promote research in nursing; . to promote the interchange of nursing knowledge among members; . to represent the views ofthe association to educational, professional and other appropriate bodies; and . to promote understanding by the public that university education in nursing contnbutes to the development of health services in Canada. CAUSN is the official accrediting agency for university nursing programs in Canada. It holds two national meetings a year. The association assisted in the planning and presentation of the recent Kellogg-sponsored Conference on Doctoral Preparation for Nurses in Canada and offers assistance of a consultative nature. The group is affiliated with the Association of Universities and Colleges of Canada (AUCC) and thus has a national forum for discussion of issues in higher education. President: Dr. Dorothy J. Kergin McMaster University Hamilton, Ontario L8S 4J9 Executive Sec:retary: Kathy Lauzon 216 Avenue des Fondateurs Aylmer, Québec J9J 1M3 CANADIAN COUNCIL OF CARDIOVASCULAR NURSES Cardiovascular nursIng has come a long way, along with recent advances in coronary medicine and cardiac surgery. If you are interested in any aspect of cardiovascular nursing, be it continuing education, research, or idea exchange, this association holds a number of benefits for you. The association began in April of 1973 with some 200 members, the culmination of a series of meetings of interested nurses which began at the Canadian Heart Foundation's Annual Meeting in Calgary in 1966. In March of this year, the association's membership stood at 1.085. In Canada, members pay a $10 fee ($15 as of September I, 1979). Among the benefits of membership are: . the oppol1unity to attend the annual meeting and scientific sessions of the Canadian Heart Foundation, Canadian Council of Cardiovascular Nurses and Canadian Cardiovascular Society; . receiving the quarterly Bulletin, written and published by the CCCN, containing educational articles, news happenings and courses offered across Canada; . eligibility to attend seminars and workshops at the provincial level; . a voice in the election of national and provincial representatives; . free subscriptions to three official journals of the American Heart Association - Modern concepts of cardio 'ascular disease. Cardiovascular nursing and Current concepts of cerebrovascular disease: . a nursing research fellowship for nurses seeking advanced preparation at the masters or doctoral level; . reduced fees for Council-sponsored programs. Write: Canadian Council of Cardiovascular Nurses c/o Canadian Heart Foundation Suite 1200 I Nicholas Street Ottawa, Ontario KIN 7B7 Chairman: Glenys Whelan 3 Marigold Place St. John's, Newfoundland AlA HI CANADIAN INTRAVENOUS NURSES ASSOCIATION There is so much to know about intravenous therapy - from how to set up an I.V. team in a small hospital to safe administration of intravenous medication. CINA was founded in 1975 with the aim of promoting higher standards of intravenous therapy through communication, idea exchange and continuing education. The association is concerned with setting up flexible standards for intravenous care, and with working together with other nurses, pharmaci5ts and drug companies, to give the best I.V. care possible. Association membership: 425. CINA has a lively annual meeting; all presentations pertain to the many aspects of I. V . therapy and approximately 25 exhibitors attend, adding further dimension to the educational nature of the meeting. Fees for active members: $17. Members receive the Americanjournal oflY. therapy every two month,>, as well as a bimonthly new'iletter which is a vehicle for communication, advice and problem sharing. Due to the many requests received for standards and -guidelines in I. V . therapy, the association acts, with limitations, as a resource center. CINA has chapters in Windsor, London and Toronto, with Ottawa and Hamilton under consideration. Write: CINA 4433 Sheppard Avenue East Suite 200 Agincourt, Ontario MISIV3 President: Barbara Hill Toronto East General Hospital 825 Coxwell Avenue Toronto, Ontario M4C 3E7 CANADIAN NURSES FOUNDATION The Canadian Nurses Foundation (CNF) is the only Canadian foundation that deals exclusively in supporting nursing scholars. Since 1962, close to 200 nurses have benefited fromCNF scholarships These nurses in turn have contributed a great deal to nursing as leaders on university faculties, as administrators, researchers ånd clinical nurse specialists. . r I CNF solicits and holds funds to provide scholarships for nurses undertaking graduate studies in nursing and to provide grants in aid of nursing research. The Foundation has an elected voluntary board of directors chosen every two years from among its membership. Since 1967, the Foundation's entire source of revenue has been from nurses through individual membership or personal donations or bequests or from provincial nurses associations. As of November of 1978, the Foundation had a total of 404 members. Fees: regular membership 510; sustaining $50; patrons $500 and $100 annual fee Applicants for an award must be a member of their provincial nurses association and have gained acceptance into graduate school. They must identify the practice area in which they wish to study and have definite career goals. Write: Canadian Nurses Foundation SO The Driveway Ottawa, Ontario K2P IE2 President: LouiseTod Sec:retary-treasurer: Dr. Helen K. Mussallem CANADIAN NURSES RESPIRATORY SOCIETY If you are a nurse involved in the prevention, treatment or rehabilitation of respiratory disease, the Canadian Nurses Respiratory Society has a great deal to offer you. This group is a section of the Canadian Lung Association and is affilialed with the Canadian Nurses Association as a special interest group. Membership is open to nurses who have been registered in Canada who are enjaged in or interested in alleviating the problems associated with respiratory disease. Membership, August, 1978: 160 members. Payment of an annual membership fee provides members with two official publications of the Canadian Lung Association - the quarterly Bulletin and the bimonthly The C.nedlen Nur.. Canadian Lung Association Newsletter. Among the group's objectives: . to contribute to the promotion of health of Canadians; . to funher the objectives of the Canadian Lung Association within the scope of the nursing profession and in conjunction with other related professional organizations; . to encourage members of the nursing profession to keep up with advances in the prevention, treatment and rehabilitation of respiratory diseases; . to act in an advisory capacity to nursing and allied professional groups on matters pertinent to respiratory care; . to encourage nurses to engage in research related to respiratory health and disease (research grants and funding available). Write: Nurses Section Canadian Lung Association 75 Albert St. Suite 908 Ottawa,Ontano KIP 5E7 President: HeatherDiane Stewart Instructor Nursing Program George Brown College Toronto Western Hospital Campus 399 Bathurst St. Toronto, Ontario MST :!S8 CANADIAN ORTHOPEDIC NURSES ASSOCIATION In just five years, this group has grown from a small interest group into a national association with 525 members and five charter chapters (Montreal, Ottawa, Toronto, Peterborough and Hamilton). The group exists to provide a vehicle for continuing education in orthopedics in order to promote the highest standards of practice in orthopedic nursing. And although relatively young, it has done a great deal to meet this objective. The first volume ofthe CONAjournal. the association's ofl'lcialjournal, was published in December 1978, and will continue to be published four times a year. Within the past year, CONA has established a continuing education committee dedicated to providing nurses with a library of clinical resource material to help solve orthopedic problems. CONA also has an annual conference and monthly chapter meetings of an educational nature. Fee $10. Membership is open to all nursing personnel and other health professionals interested in the field of orthopedics. Interested? Write: The Canadian Orthopedic Nu rses Association 43 Wellesley Street East Toronto, Ontario M4YIHI President: Norma Haire CANADIAN UNIVERSITY NURSING STUDENTS ASSOCIATION University nursing students across Canada can share their interests through CUNSA. the only association that briftgs student nurses from east and west together. The association aims . to provide a communication link between Canadian university students; . to act as the official voice of university nurs students; . to provide a medium through which students can express their opinions on issues in nursing; . to encourage participation in professional and liberal education; . to provide liaison with other organizations concerned with nursing; . to assist in and/or initiate nursing research. CUNSA has over 5000 members from 22 universities. Students registered in a program of basic nursinl or post basic studies at aCanadian university become members by joining the nursing student association of their own university. Membership fees are paid by member universities. The fee is $1.00 a year per student So that the university pays a fee according to student enrollment. CUN SA is divided into four regions: Atlantic, Quebec, June 1171 11 Ontario and Western regions. Each has a regional chairperson and research representative. Annual meetings provide members with time for sharing ideas, concerns and information CUNSA is aßUiated with CAl'SN. National chairperson: Cindy Telfer Lakehead University Residence Thunder Bay, Ontario P7B 5EI NATIONAL COMMITTEE OF CANADIAN NURSE MIDWIVES This group has a loose structure and is composed of representatives from three nurse-midwife associations: Atlantic, Ontario and Western. Formation of a national association of nurse midwives is still under discussion. September of 1978 saw four Canadian nurse-midwives representing Canada at the International Congress of Midwives. Concerns of the group include education for nurse-midwives, recognition of the nurse-midwife role, humanizing hospital births and home births. ChairlDlIn: Patricia Hayes Faculty of Nursing University of Alberta Edmonton, Alberta TfG 2G3 NATIONAL CONFERENCE OF OPERATING ROOM NURSES This group is the newest ofCNA's atTtJiates. On a national level, its structure is still a loose one, as each province is relatively autonomous. Operating room nursing groups are active in every Canadian province. Every second year the national group meets in the host province. The National Conference of Ope rating Room Nurses is chiefly concerned with continuing education forO.R nurses with high standards of care in theO.R., and with increased opportunities for communication betweenO.R. nurses. National Chairman: Jean Mitchell 12 June 11179 President Operating Room Nurses of ional nurses. social and economic welfare ofnurse!t, advancement of knowledge techniques and competence within the profession, and promotion of understanding, unity and good professional citozenship among its members. Nuning Administration (Manitoba) Chairman: Minnie Janzen Box 207 Blumenort. Manitoba R3E (JT2 Occupational Health Nurses (Manitoba) Dorothy Creek 923 Dugas St. Winnipeg, Manitoba R2J OZ9 Personal Care Homes Interest Group Middlechurch Home of Winnipeg Balderstone Rd. Middlechurch, Manitoba President: Beryl Wales PhiUipplne Nur!ie'i Association, Manitoba Winnipeg Municipal Hospital Nurses Residence 3d Floor, Modey Ave. East Winnipeg, Manitoba President: Victoria Nicholas Registered Psychiatric Nurses Association of Manitoba 871 Notre Dame Avenue Winnipeg. Manitoba R3E OM4 Executive Director: Mrs. A.Osted RespiratolJ' Interest Group, Winnipeg, Manitoba Contact: Margaret Thomas. Chairman Physiotherapist Canadian Arthritis and Rheumatism Society 825 Sherbrook St. Winnipeg, Manitoba R3G2L3 Winnipeg Association of Critical Care Nurses (W ACN) President: Ruth Seimsky Grace General Hospital Intensive Care Unit 300 Booth Dr. Winnipeg, Manitoba R3J 3M7 ONTARIO Association of Nursing Directon and Supervisors of Official Health Agencies (ANDSOOHA) President: J. Keslick 176 Valley Road Willowdale. Ontario M2L IG4 Association of Nuning Executives, Metropolitan Toronto Chairman: C. McGregor Central Hospital 333 Sherbourne Street Toronto. Ontario M5A 2S5 Clinical Nurse Specialist Interest Group (RNAO Affiliate) Chairman: Judith C. Britnell 38 Strathgowan Ave. Toronto, Ontario M4N IB9 Community Mental Health Nurses Association of Ontario (RNAO Affiliate) President: Vi Spooner 235 Baseline Road East London, Ontario N6C 2N6 or c/o London Psychiatric Hospital London, Ontario N6A 4HI Emergency Nurses Association of Ontario (RNAO Affiliate) President: Sandra L. Easton Contact: Mary Arntfield Business Secretary 36-1764 Rathburn Rd Mississauga, Ontario L4W 2N8 Registered Nurses -\s..ociation of British Columbia :! 130 We..t I :!th A venue. V,lßcouver. B.C Vf>", :!N3 Execlitil'e Director - Mdrilyn Carmack Memht>nhip - IfI.f>9'\ AI rtÐ Association of Registered Nurses 1O:!56 - 112th Street. Edmonton, Alta.. TS'" IM6 Execlitil'e Secreltlry - Yvonne Chapman Membership - 13.6f>1 skatchewan Registered Nurses Association 2066 Retallack Street Regina. Sa..k.. S4T :!K:! Execlitil'e DireOor - Barbara Ellemers Membership - 7,373 As!>OCialion of "I/urses of Prmce Edward Island 41 Palmer; Line. Ch"rlolletown. P.E.I CIA SY7 ExeclIti\'e Set retllr\'-ReJ(iltmr - Laurie Fra er .'I,lembership -967 Registered "I/urses A,sociation of Ontario 33 Price Street. Toronto. Ontario. M4W In Ereclitil'e Director- Maureen Powers Wembership - 14.00:! Northwest Territories Registered Nurses Association Box 2757, Yellowknife, N.W.T.,XOE IHO Execlltil'e Director-Rej!istrar - Mary Lou Pilling Membership-219 CANADIAN NURSES ASSOCIATION The spokesman at the national and international level for professional nursing in Canada, CNA is a federation of eleven member associations and is financially supported by membership fees collected by these associations. As members of their provincial/territorial association, nurses are entitled to the following services from CNA: LIBRARY Canada's only national nursing library now contains more than 12,000 books and documents and close to 500 periodicals. Also housed in the library are the nursing archives and national repository collection of nursing research studies. INFORMATION The Canadian Nurse and L'i'lfirmière canadienne boast a combined circulation of more than 137,000 and are distributed in approximately 100 countries of the world. LABOR RELATIONS Data collection and analysis, information and education programs and research activities are carried out by this unit ofCNA staff. bringing together information provided by professional associations, collective bargaining conference members. federal and provincial labor departments, national unions and other sources. NATIONAL TESTING SERVICE Machine-scored objective-type examination. in English and French are prepared and processed for registering and licensing authorities for both nurses and nursing assistants wishing to enter the profession. LIAISON CNA maintains liaison with most departments of the federal government as well as more than 100 Ottawa-based health-related agencies and organizations. A member of the International Council of Nurses, CNA represents the nurses of Canada at the international level and communicates with other international organizations active in the health field I Registered Nurses AssocIation of Nova Scotia 6035 Coburg Road Halifax. N.S., B3H IY8 Executil'e Secretary -Joan Mills Membership -6,518 "IIew Brunswick Association of Registered Nurses 231 Saunders Slreet, Fredericton, N.B., E3B IN6 Executil'e Secretary - Mari!yn Brewer Membership -4,871 !\-lanitoba Association of Registered Nurse!> 647 Bro,ldway Avenue. Winnipeg. Mdn.. R3C OX:! Ereclitit'e Director- M. LouiseTod Membenhip -7.f>93 Ordre des inlirmières et inlirmiers du Québec 4:!00 Dorchesler ouest. bd. Monlreal, Quebec. H37 IV4 E-.:ecutil'e Director lInd Secretan' of the Order- Nicole Du Mouchel Membership - 45,782 Association of Registered Nurses of Newfoundland 67 LeMarchant Road, St. John's, Nfld., A IC 6A I Executive Secretary - Phyllis Barrett Membership -3,715 18 June 111711 Gerontological Nuninl A_ociation or Ontario P.O. Box 368 Postal StatIon K Toronto, Ontario M4P 1G7 President: Barbara Jensen Ontario Association of Registered Nursing Assistants 112 Merton Streei 3rd Floor Toronto,Ontwño M4SIAI President: Mrs. M. McDavid Ontario Community Mental Health Nunes Association President: Lynda Hessey 2 Farnham A venue, Apt.69 Toronto, Ontario M4V IH4 Ontario HospltaJ Association, Nursing Administration Section Chairman: Jean Pain Director Nursing Service Brantford General Hospital 200 TerTaCe Hill Street Brantford,Ontwño N3R IG9 Ontario Lulll Association, Nunes Section President: Jean BuIler Sr. Nurse Epidemiologist Borough of East York Health Unit 550 Mortimer Ave. Toronto, Ontario 4J 2H2 Ontario Nurse Midwives Association (RNAO Affiliate) President: May Toth 9 Richmond St. Hamilton, Ontario LSP 4J3 Ontario Occupational Health Nunes Association President: Grace BlackweIl Contact: Sylvia Matchett 3209 Rymal Rd. Mississauga, Ontario L4Y 388 Operating Room Nurses or Greater Toronto President: Jean Mitchell North York General Hospital 4001 Leslie Street Willowdale, Ontario M2K lEI The Cenadlan Nur.. HamUton Area Intenst Group or Orthopedic Nunes Asøodation President: Irene Cummings Hamilton, Ontario Contact: The Canadian Orthopedic Nurses Association 43 Wellesley Street East Toronto,Ontwño M4Y 1H I HospltaJ Health Nurses Group, Southwest Ontario Chairman: Gwen Carville clo Our Lady of Mercy Hospital 100 Sunnyside Ave. .Toronto, Ontario M6R 2N8 Lakehead Operating Room Nurses Association (LORNA) Contact: Valerie Laakkonen O.R. Nurse General Hospital of Port Arthur Thunder Bay, Ontano P7A 4X6 Metro Toronto In-Service Educators Association Secretary: N. Geddes Ontario Crippled Children's Centre 350 Ramsey Road Toronto, Ontario M4G IR8 Northern Ontario Operating Room Nunes Contact: Mrs. Perry O.R. Supervisor Kirkland &District Hospital 145 Government Road E. Kirkland Lake, Ontano P2N IR2 Northwestern Ontario Occupational Health Nurses Association Contact: Monica McComber Confederation College P.O. Box 398 Station F Thunder Bay, Ontario P7C4WI Nurse Practitioner Association of Ontario (RNAO Affiliate) President: Suzanne Finnie Membership Chairman: Jenny Rypma 10 First Ave. Burford, Ontario NOEIAO Nunes for We Contact: Marilyn Marcotte clo Obstetrics Unit St. Joseph's Hospital London,Ontwño N6A 4V2 Nursing Administrators Intenst Group, Ontario (NAIG) Contact: Dorothy Wylie Vice-President, Nursing Toronto General Hospital 101 CoIlege Street Toronto, Ontario MSG IL7 Psychiabic Nunes Asøodation of Ontario P.O. Box 2103 Station B Scarborough, Ontario MIN 2E5 Executi"e Director: M. Oke Psychiatric Nllrsing Interest Group, Ontario 2350 Dundas St. W. Apt. 2703 Toronto, Ontario M6P 4BI Chairman: Anne Harris PubUc Health Nunes Interest Group (RNAO AffI1iate) Secretary: Diane Bean 304-11 Oriole Parkway Toronto, Ontario M5P 1G9 Registered Nunes In Private Practice (RNAO Interest Group) Chairman: Leonida Hudson 509-810 Edgeworth Ave. Ottawa, Ontario K2B 5LS Toronto Area Interest Group or the Orthopaedic Nurses Association 40 Holmwood Ave. Apt. 102 Toronto, Ontario M4Y 2K2 President: Heather Reuber, O.R. St. Michael's Hospital Toronto. Ontario Secretary: Miss J. Osborne Toronto Area Nursing Education Administrator Group (RNAO A ffI1iate) Chairman: Susan Reimer clo Sheridan School of Nursing 2186 Hurontario St. Mississauga, Ontario LSB IM9 QUEBEC Association des inftrmlères Uceodees pour øervlce prlvé en nursing, Le réglstre VIIIe-Marie Inc. de... IIH8 est, rue Sherbrooke Montréal, Québec H2K I B3 Prisidente, Lucille Hétu Association des infirmlères et Inftrmlers en santé du travaU du Québec Inc. Présidente: Germaine G. Painchaud Case Postale 218 Succursale Outremont Montréal, Québec H2V 4M8 Association des infirmières-sages-femmes du Québec Présidente: Madame F.G. Cooper 526-39th Ave. Lachine, Québec HST 2EI Comlté des sages-femmes c.P. 121 Succursale St. Martin Montreal, Québec H7V 3P4 Corporation professionneUe des inftrmières et inftrmiers auxUiares du Québec/Professional Corporation of Nursing Assistants of Quebec 1980 ouest, rue Sherbrooke Suite 920 Montreal, Québec H3H IE8 Présidente: Mme C. O'Rourke Infirmlères hatlennes de Montréal Contact: Lucille Charles or Ghislaine Télémaque 2204, Chemin Oka Deux-Montagnes, Québec J7R IN7 Oncology Nursing SocIety, Montreal Area President: Jennie E. MacDonald Oncology Day Centre Royal Victoria Hospital 687 Pine Ave. W. Montreal, Quebec H3A IA I Operatmg Room Nurses Group or Quebec/Le groupe des inftrmières des salles d'opération du ébec ContaCl: Mrs. J. Veronneau Montreal General Hospital Operating Room 1650 Cedar Ave. Montreal, Quebec H3G IA4 (continued on page 50) ,'f' , Why change dressings several times a day when once a week is plenty! This is an Op-site dressing for non-infected ulcers. When it goes on, it stays on... for a whole week. Because Op-site is an adhesive, transparent dressing that breathes and sweats with the skin. So you can keep your eye on the entire healing process without the interruptions of frequent dressing changes. Op-site is easy on the patient too. It's neat, not bulky. Patients can take regular baths or showers without discomfort because Op-site is water-proof. Op-site is also bacteria-proof, protecting the ulcer from contamination. Because once a week is plenty. Op-site means fewer dressing changes. And that's less work and more time for you. -------------------- I O p -Site!íì) For fl!rther infonna!ion ix?ut I I I Op-slte ulcer dressing, fdlln I the ultimate wound dressing and mail this coupon, I I Name I I I Hospital Affiliatio n I I I Address I I City Prov._Cod e I I Mail to. [8] '--", Sm'th&Nephewlnc 2100.52ndAvenue I . : S II' Mediclill Division Lachine. Qu . CZ!lnllda I I .'. .' HaT 2Y5 -------------------- 18 June 1979 The Ce...dlen Nur.. Spotting and helping the learning disabled child We are all different. We are all the same Mildred C . Jacobson George Gasek Margaret S. is a public health nurse with a regional health unit in one of our large Canadian cities. Five mornings a week she works out ofthe nurse's office of one of the elementary schools in "her" area of the city. On this particular Tuesday morning her first appointment is with one of the 21 first-graders at the largest of these schools. Ronnie's teacher is concerned because he can't seem to keep up with the other children in his class. She complains that he daydreams, he acts younger than the other children in the class and now, after almost a year in grade one, he still can't read even simple words and when he tries to print he gets the letters all mixed up. From talking to his parents, Margaret knows that they are worried and puzzled, too. Until he started school last Fall, Ronnie seemed peñectly normal, brighter, even, than his two older sisters. Now, obviously upset and frustrated by his inability to learq like the other children in his class, Ronnie is becoming more and more withdrawn, preoccupied and sullen. Margaret is puzzled too. She knows that Ronnie's general health is good. His hearing is satisfactory. He eats well and gets adequate rest. Why then can't he "catch on" like the other children . I his class? If Ronnie is lucky, Margaret will remember hearing or reading about the learning disabled child. She will recall that between 10 and 15 per cent of all children are thought to sutTer some form of learning disability. She will kno\\- too that, although the range of disabilities is wide, the end result for many of these children is the same - failure to realize their cademic potential. Margaret will realize that the kind of assessment which will help Ronnie to conquer his learning problems can only be carried out by a team that includes psychologists, remedial teachers, and his parents as well as health professionals. Ronnie is going to need all the help he can get, not just for the next few months, but probably into his adolescence. Reading, spelling and arithmetic are going to present a major challenge to him. Literacy sometimes takes years for these children to achieve and many continue to read slowly and laboriously even as adults. Most of all, though, Ronnie is going to need support, understanding and encouragement from his parents, his classmates and school officials so that he can make the most of whatever potential he has to become a well-adjusted and self-confident person. The Cen.dlen Nur.. June111711 19 Not so long ago. underachievers like Ronnie were given short shrift in our educational system. They were labelled "dull" or "lacking academic potential" or some similar term and relegated. usually. to the back of the classroom. Today. although there is still much to be discovered about learning disabilities - how they occur and how to deal with the problems that result - educators and psychologists have begun to find some of the answers to helping these children overcome their handicap. What is a learning disabled child? In looking at this question it may help, first of an. to determine what he is NOT He is not. for example. retarded, emotionally disturbed. lazy. unmotivated or stupid. Nor is he necessarily poorly coordinated or hyperactive. The term learning disabled is applied to a child who is average or above average in general intellectual abilities but who presents with specific learning and behavioral disabilities. One Canadian author describes it this way: " ...a permanent difficulty in perception. conception or motor expression, both with verbal and non-verbal material. which inteneres with normal academic learning. Children with these types of handicaps usually cannot profit very much from normal teaching methods, and the permanence of their disability suggests an existing physiological abnormality that impairs normal neurological function. Neurological damage or dysfunction can be identified in about half of underachievers. ..t Researchers still cannot agree on what causes these on-going disorders in the child's brain or central nervous system The United States Department of Health Education and Welfare comments: "These aberrations may arise from genetic variations. biochemical irregularities. perinatal brain insults, or other illnesses or injurie.i sustained during the years which are critical for the development and maturation of the central nervous system, or from unknown causes. "2 Among the physiological or organic factors that have been implicated in learning disabilities are: brain damage or dysfunction, genetic defects. endocrine gland dysfunction. malnutrition. lead poisoning. radiation stress, sensory defects. maternal drug consumption. smoking and drinking. 3 For the nurse who is concerned about spotting the child with a learning disability, identifying his problem and helping to involve him in some type of remedial program. the nine clinical syndromes described below may provide the clue she needs to recognize a learning disabled child: I. Visual disability: These children typically have reading problems because they are unable to discriminate between similar looking letters and numbers, for example. p, b, d. 9. Similar difficulties occur with geometric shape discrimination. Thus, they will be unable to differentiate between squares. rectangles, triangles, etc. Many of these children also have problems with visual memory; that is. remembering visually presented information. " j \ õ õ If "E .. o '" É Ii: ] , . '" Z >. . J> o Õ .c n. 2. A uditory disability: These children frequently misunderstand what is said to them because they cannot discriminate between similar sounding speech sounds, for example. p and b. t and d. Consequently, they may hear the word buy as pie or two as do. There is also a problem with auditory memory for many of these children that results in an inability to correctly remember a series of things said to them. 3. Eye/hand incoordination: These children an seen as being somewhat clumsy. They spill thing" easily, have difficulty catching a ball, are unable to write or color within the lines, cannot copy words or pictures from a chalkboard onto a piece of paper. 4. Spatial disorientation: These children cannot discriminate between right and left, up and down, under and over, around and through. etc. Because they are unsure of their spatial relationship to other objects, they tend to bump into things and trip over objects. 5. Temporal disorientation: These children have a poor concept of time. They do not know the relationship between seconds, minutes and hours or days, weeks, months and years. They have difficulty injudging the duration of activities. 6. Hyperactivity: These are the children who seem to be in perpetual motion. They are fidgety. restless. distractable and inattentive. They have short attention spans and talk constantly. Much of their behavior is impulsive and leads to antisocial acts such as hitting and stealing. 7. Speech and language disabilities: These children may have difficulty in formulating the message they want to express or they may express their ideas very ungrammatically and immaturely. On the other hand. they may have a great deal of difficulty in making sense out of what is being said to them. In addition to such language problems, these children may also have speech problems where they misarticulate sounds to the point of being totally unintelligible. 8. Perseveration: These children have a great deal of difficulty in shifting or moving from one activity to another. Because of this they are often seen as being hypoactive and generally slow moving. 9. General motor incoordination: These children are very clumsy in both fine and gross motor ability. They have difficulty in running, skipping, hopping, block building, walking straight lines, etc. - 20 June1171 The Cened.n ...... Living with their handicap In addition to these specific disabilities, learning disabled children often develop a number of secondary emotional problems. Because they know they are different from other.children, that they cannot learn as fast as their peers, these children become convinced that they are stupid and inadequate. They lose their self-confidence and self-esteem. This is further compounded by the teasing they must often put up with. They become frustrated and anxious about their social and academic inabilities and, consequently, get no feeling of accomplishment. Eventually, many are so demoralized that they develop delinquent tendencies and a distrust of adults, even those closest to them. The children themselves are not the only ones adversely affected by their disabilities. Very often their parents are also victimized by their children's learning disabilities. Because learning disabilities are frequently not recognized for what they are, the parents are accused of being ineffectual, poor disciplinarians, and uncaring. When they seek help and understanding for their children's "peculiar" behaviors, they are labeled aggressive, overanxious and neurotic. When, on the other hand, a diagnosis of learning disability has been made, the parents are often regarded as being unrealistic in their expectations for u their children. Many parents feel guilty and wonder where they went wrong in their child rearing; often this guilt is reinforced by relatives and professionals. Because professionals cannot agree about these childrens' problems, the parents frequently find themselves in the frustrating position of receiving different and even contradictory information and advice from them. Cause and effect Although the exact cause of learning disabilities is not known for certain, it is generally assumed that these disabilities are associated with a functional deviation of the central nervous system. The fact that almost all the synonyms for learning disability in common use today (minimal brain dysfunction or damage, neurological, perceptual or educational handicap. for example) are neurologic labels is certainly indicative of this assumption. Actually, in most cases of learning disabilities, no neurologic i'!iury or damage can be found. Rather, this assumption is based on the observation that these learning deficits are very similar to those seen in children who do, in fact, have known brain damage. h has also been suggested that learning disabilities may be related to nutritional deficits. Malnutrition in mothers prior to and during pregnancy has been shown to affect the learning abilities of their children. 4 We are what we eat, as one observer has noted, and the learning ability and behavior of children certainly reflects the quality of their diet. Good nutrition, however, is more than just three meals a day and several investigators have found mineral and vitamin deficiencies (manganese, iron, zinc, sodium, potassium, vitamin C) in the diets of many learning disabled children. 5 Moreover, when these deficiencies were corrected, many of these children showed improvement in their learning and behavior. " C, / .. "" c .. .c -'.'ä .. J: ... o i:;' .. t: " o u o Õ .c n. --... The community health nurse is the logical person to act as the uniting force on such a team: . she has easy access to the child, his family and school; . she knows what community resources are available; . she is able to communicate effectively with physicians and to effectively relay information between physicians, parents and teachers. In addition to her potential role as a team leader, the nurse can make specific contributions in the areas of prevention and management of learning disabilities. Prevention: Within this area the nurse can provide: . counseling to teenagers, especially girls, regarding proper nutrition; . pre-natal counseling regarding proper nutrition; . a follow-up program to children born at high-risk including, children born to rubella-exposed mothers; prolonged labor babies; instrument-delivered babies; children born to mothers who had serious health problems during pregnancy; children born into families with histories of learning disabilities. etc. Management: Within this area. the nurse can: . evaluate the health and developmental history of children who seem to be having learning and behavioral problems; . screen such children for possible visual, auditory, perceptual, motor, speech and language and nutritional problems; . refer children who fail these screening tests to other agencies or professionals for more in-depth testing; . monitor a child who is on drugs; for example, Ritalin@ for hyperactivity. and report to parents, teachers, and physicians about the effectiveness ofthe drug on his learning and behavior; . counsel the learning disabled child about his problems and reinforce the notion that he is not stupid or lazy; . counsel the child's parents about his problem and allay any unnecessary fears they may be having about him; . educate the public about learning disabilities - what they are and are not and what can be done to prevent and manage them. Certain learning disabilities like dyslexia (the inability to read) are thought to be genetically derived. For example, parents commonly report that they know of other family members with learning disabilities similar to those of their children who had difficulty in learning to read or spell. Prevention and management (diagnosis. remediation and counseling) of learning disabilities require a comprehensive program involving a number of disciplines and including, for example, medicine, education, social services, speech pathology, occupational therapy, psychology. Unfortunately, most services to these children and their families are fragmented, with overlapping in some areas and gaps in others. What is needed is a consolidation of professional services with a team approach to caring for these children. TIle c....... NurM ......1 Z1 A plan of action The year 1979 has been declared the International Year of the Child. It is a year in which governments. organizations and individuals are being given the opportunity to focus on the various needs of children and to develop programs to adequately deal with these needs. Learning disabled children, like their more fortunate peers. have the right to be helped to reach their maximum potential so that they can look forward to adulthood with confidence and optimism. Nurses can and should see 10 it that they get this chance. .. Mildred C. Jacobson,B.N., R.N., is the mother of three children. A graduate of Jewish General Hospital in Montreal and Dalhousie U nh'ersity, she is now completing a Master of Science degree in speech pathology at Dalhousie University. George Gasek, Ph.D., is assistant professor of speech pathology at Dalhousie University. He is a graduate of the University of Denver (B.A.) and received his Master of Arts and Doctor of Philosophy degrees in speech pathology from the University of Washington. References. I Gaddes. W.H. Learning disabilities: the searchfor causes. Montréal. Québec. Association for Children with Learning Disabilities, 1978. p.3. 2 U.S. Dept. of Health. Education and Welfare. Terminology and identification./ n Pearson. Hugh. Physical is fundamental. p.l. 3 Gaddes, op.cit. p.4-7. 4 Are learning disabilities really hidden medical disorders. The Post. Dec. 1975. p.2. 5 Ibid. *References not verified in CNA Library TO PARENTS who bear the ultimate responsibility for making decisions: TO PROFESSIONALS who try to help the parents make those decisions, sometimes with conflicting advice, and TO FRIENDS, RELATIVES AND NEIGHBOURS who want to help but do not always know how: REMEMBER Not everything is curable. Sometimes the best thing we can do about a disability that proves to be permanent is to prevent it from becoming the most important influence on the child's or the family's life. Love your child, and because you love him, help him understand about limits and self-discipline. Help him develop skills for meeting the demands of the world he lives in. Help him enrich his life with appreciation of the beautiful and interesting things around him. Help him maintain his curiosity about how things work. Help him develop an interest in people. Help him learn how to find friends and keep them. Help him feel secure about his own worth and about the warmth and support of his family. Help him live as normal a life as possible. Enjoy the positive things about him and he will, too. Reproduced with the permission of the Canadian Association for Children with learning Disabilities, "The Earliest Years", by Elizabeth S. Freidus. The Gateway School of New York. FOR FURTHER INFORMATION The Canadian Association for Children with learning Disabilities Kildare House 323 Chapel Street Ottawa, Ontario K1N 7Z2 Provincial associations Alberta A.C.L.D. 201,10180 - 108 Street Edmonton, Alberta TSJ 113 British Columbia A.C.L.D. 14673-108Ave. Surrey, B.C. V3R 1V9 Manitoba A.C.L.D. Room 5 - 1070 Clifton St. Winnipeg, Manitoba R3E 2T7 New Brunswick A.C.L.D. P.O. Box 1363 Postal Station A Fredericton, N.B. E3B 5E3 Nova Scotia A.C.L.D. P.O. Box 604 Halifax, N.S. B3J 2R7 Ontario A.C.L.D. 60 St. Clair Avenue E. Suite 202 Toronto, Ontario M4T 1N5 Prince Edward Island A.C.L.D. P.O. Box 1081 Charlottetown, P.E.I. C1A 7M4 Quebec A.C.L.D. 4820 Van Horne Ave. Suite 8 Montréal, Québec H3W 1J3 Saskatchewan A.C.L.D. Room 308, College Bldg. University of Sask. College and Scarth Regina, Sask. S7N OW9 Yukon A.C.L.D. P.O. Box 4884 Whitehorse, Yukon Y1A 4N6 22 June 1979 The Cen.dlen Nur.. A holistic approach to nursing the patient in pain Emalou Vaterlaus . 0 \; " , ) , \ ,..... '- " j , ,.. \ " " 0' N .c Õ Õ .c c.. ] o = .5 ü: õI c .2 1ií Z >. .C> o Õ .c c.. How do you feel about patients who continually ask for pain medication? Do you suspect that you are being used, that these patients are tat-..ing advantage of you? Do you sometimes, in your own mind or aloud, dismiss certain patients as complainers or malingerers? Are there patients that you feel don't deserve or need the pain relief that has been prescribed? I .. Take Mrs. Shale, for instance. S is 46, one of Dr. Mac's patients, admitted four days ago for treatment of chronic 'ow- back pain. This morning, after she refused her bath, you saw her walking in the hall with her husband and heard her' laughing on the phone. Mrs. Shale's requests for pain medication occur with lockwork regularity - every three hours almost to the minute- but you'rê beginning to think she's putting you on. YOI don't think she hurts that much: she just likes the attention she gets when she complains. She's always being admitted for this problem. You wonder why she doesn 'tjust go home and stay there! . , .. j '\ - y .....- ..... ---- ....'" .,. "' . You are the head nurse on this ward. When Mrs. Shale's light comes on and she asks for something for pain, what is your reaction? Do you offer some excuse and make her wait? Do you go into her room and try to evaluate her pain? Or, do . you take the medication she requests to her promptly? If your feelings in a situation like this are decidedly negative, you are not alone. I felt like that, too, until I came to terms with the fact that judgment has no place in the treatment of pain. There are no good or bad values attached to pain. Pain is a personal, The Cen.cllen Nur.. June 19711 23 private sensation of hurt. It is whatever the person who is experiencing that pain says it is. It makes no difference what the nurse believes about the pain a patient describes or about the patient himself. The important thing is to recognize, when a patient complains of pain, that pain does exist for him at that time. And this is where effective and conscientious nursing care must begin- with logical analysis and knowledgeable interventions leading to control and management. What is pain? Pain is perceived by the sensory part of the nervous system and arises from harmful or destructive stimulation of any organ of the body. Although pain appears to originate at the site of this stimulation, the sensation is registered and interpreted in the brain. Pain impulses are carried by either A or C nerve fibers to the spinal cord, up the spinothalamic tract. to the thalamus. From the thalamus, these impulses are relayed to the cortex or master computer where the sensations are integrated and interpreted with the result that the person perceives pain. Pain impulses travelling this route can, however. be blocked or intercepted before they reach the thalamus by activating what is known as the gate control mechanism. When this gate is "open". unpleasant stimuli relayed by the thin, unmyelinated C fibers activate the motor mechanism made up of aU the brain areas that contribute to overt behavioral response. But when activity takes place in the thicker, myelinated A fibers. which have a lower threshold and respond to touch or light pressure, negative feedback occurs along the way. This blocks transmission of the pain impulses and, in effect, closes the gate to all neural traffic. The pain inhibitory pathways which are activated by the gate control mechanism thus permit raising of the pain threshold. Types of pain In attempting to control and relieve pain. the nurse may come to recognize three types or varieties: acute, chronic and progressi ve. . Acute (or superficial) pain may last for minutes, hours or days but is always temporary in nature. The cause may be traced to trauma such as an external injury Oaceration) or an internal injury (MI). Mr. Alvarez, for example. a patient who has just undergone surgical repair of a hernia, is probably experiencing acute pain. This type of pain serves as a warning. It mayor may not be accompanied by anxiety. Tissue damage is usually present. A reaction from the sympathetic nervous system causes an increase in the blood pressure. pulse and respiratory rate. The patient can usually describe with relative accuracy the sensation involved and the location of this pain. . Chronic pain, on the other hand, may last for months, years or until the patient dies. The illness which causes this pain is not life-threatening and the pain is not constant nor progressive but the patient is not able to predict when a flare-up will OCcur or a remission begin. Betty S., a 37-year-old rheumatoid arthritis patient, has suffered chronic pain off am' on since this incurable disease began to affect the connective tissues of her joints ten years ago. Permanent relief from the discomfort and impaired mobility that she suffers is not possible, so Betty concentrates on controlling the symptoms of pain and inflammation - particularly the pain. Chronic pain such as that experienced by Betty S. or by Mrs. Shale no longer serves a useful function as a warning sign to the patient and his physician. This type of pain is often accompanied by depression. Tissue damage is not always present. Usually, there is no noticeable increase in vital signs because this type of pain wears out the sensory nervous system. Many chronic pain patients have difficulty in describing their pain; they may refer to it as being "like a nightmare" . The patient with chronic pain does not control that pain but rather the pain controls that person's life. . Progressive (or terminal) pain is constant, persisting until the death of that patient. It occurs in conjunction with a life-threatening illness and can shorten life. Although the intensity of this pain may vary, and nursing measures may result in relief or reduction, it cannot be "cured". This pain may warn of changes but is not generally useful. Patients with progressive pain often show symptoms of anxiety or depression or both. Tissue damage mayor may not be actively present and, again, the pain is difficult to describe and not easily delineated. Approximately half of all cancer patients suffer progressive pain during the last stages of their illness. Reactions to pain Although the perception of pain is a phenomenon of the senses, reaction to it is physiologic. Studies have shown that the pain threshold - the point at which an individual begins to perceive pain- is relatively uniform for almost everyone. Tolerance levels, however, are strongly influenced by psychic factors and vary greatly from one person to another. Apprehension and attitude, including anxiety and depression, can make an individual more susceptible to pain. Culture and race also have a bearing on pain tolerance levels. Only the person who is experiencing that pain can actually "feel" it. Nurses and others who are involved in caring for someone who says that he is in pain, must rely on the patient to help them find the answers to questions they have about the intensity and cause of that pain. In your assessment, it is important to try to determine some ofthe psychological and social components that determine individual reaction to pain. In a hospital setting, it is often the cleaning lady who gets to hear the details of a patient's description of the pain that he is experiencing. Next in line for listening are friends and the hospital chaplain. Where are we when we are needed? Patients with chronic pain, like Mrs. Shale with her "bad back", present a real challenge to successful interaction. Many of them have developed ways of camouflaging the pain that they have. They are accustomed to managing their own medication. Previous hospitalizations and nursing care may have conditioned them to "fear the worst" . Chronic pain is debilitating. It weakens the person who experiences it and it can also destroy the relationships between members of a family. Mrs. Shale's teenaged daughter, for example. planned a slumber party for her birthday. When the day came, she had to cancel it because her mother was in such pain. Mr. Shale, too, made arrangements a month in advance to take his vacation, but was unable to leave town on that date because Mrs. Shale couldn't stand the long drive. She had pain; fear and anxiety made that pain worse. Can you imagine the quality of the relationship that exists between Mrs. Shale, her husband and daughter? 5 es t talk about How many of these facts about butter, margarine and fat do your patients know? act . Just 6% of the . recommended daily caloric intake is contributed by butter. Many health professionals mistakenly believe that butter is a major contributor to the over-consumption of fat by Canadians which is considerably higher than the 35% of total caloric intake recommended by Health & Welfare Canada. In point of fact, Canadians eat more margarine than butter as well as many other fat-contributing foods such as meat, fish, poultry, eggs, cereal products, salad oil and cooking oil. act . The correlation be- . tween the consump- tion of hydrogenated ve , etable oils and the incidence 0 colon and breast cancers has been widely publicized. Results of a research study conducted by a team of scientists headed by Dr. Mark Keeney of the University of Maryland, and published in the summer of 1978, produced compelling evidence of a possible link between the con- sumption of hydrogenated vegetable oils and the incidence of colon and breast cancers. act . The hy rogenation of . marganne changes the molecular structure of vegetable oils. Hydrogenation is the process which solidifies liquid vegetable oils into margarine, making it "spreadable", and giving it longer shelf life in the store. This process changes the chemical composition of the vegetable oils. . . and it also "saturates" fats which, for what it is worth, were originally polyunsaturated. act . Cholesterol is an . essential substance, naturally present in the human system... and is a problem only to patients with specitic lipid prof'des. Such unsatisfactory conditions cannot be significantly changed by dietary manipulation. act . Butter has exactly . the same number of calories as margarine. Weight-conscious patients, in the belief that they are cutting calories, often give up the good taste of butter for a less palatable spread. . . an unnecessary sacrifice. act . Canadians, on a per . capita basis, consume just haIfan ounce of butter per day. This is just a fraction of the amount generally believed by many health professionals to be the per capita consumption of butter by Canadians. When you look at the facts, you can see the good in butter. DAJRY BUREAU OF CANADA act . Approximately 3% of . butter is linoleic acid - the ingredient which many scientists believe to be the moderating, beneticial factor in the diet-heart relationship. The idealleve1 of linoleic acid in fats intended for human consumption is not yet agreed upon. act . Data exists which . show a definite correlation, in certain cultures, between the high level of animal fat consumption and the low incidence of CHD. The Masai and Innuit cultures indicate just such a correlation. Interestingly, so, too, does the Irish whose butter consumption, though markedly greater than their lrish- American counterparts, have a much lower incidence of CHD. SOURCES: Mary C. Enig, Robert J Munn and Mark Keeney_ DIetary fat and cancer Irends-a critique FederatIon Proceedmgs 37.2215-2220.1978 Mann. C.V. and Spoerry. A Studies of a surfactant and cholesteremia in the Masal.Amer.J Oin_ NutL 27464,1974 Gershon Hepner. Richard Fried, Sachea, 5t Jeor. Lydia Fusetli, and Robert Monn HypocholesteroJe:nic etfeCl of yogurt and milk Am_ J CIin. NUIr., 32019-24, 1979 Dairy Farmers of Canada Dairy Facts and FIgures at a Glance 1978 2e June 1979 The C.n.dlen Nur.. If Mrs. Shale requests a pain pill and you get to her room and she's asleep, what do you do? It's a standing joke with the public that patients are awakened for sleeping pills. Chronic pain patients suffer fatigue and do not sleep well. Nevertheless, fatigue and pain are vicious circles: wake her up and give her her medication. Do not allow the pain to peak because when it does peak it may' take the next two or three doses of medication to bring the pain back down to the level it was at when the medication was first requested. Save your patient added hours of suffering. Like most chronic pain patients, Mrs. Shale has learned to modify her behavior. She has gotten rid of her facial grimace; she no longer rubs the part that hurts; her nail beds don't turn white anymore; her blood pressure and pulse don't even go up. She exhibits no physical evidence of pain. It took her two years and a great deal of practice to accomplish this feat. When Mrs. Shale says, "I am in pain", what would you like her to do to prove it? Don't wait for her to show you. Medicate her! Believe her! Go into herroom. Take the time to sit down and talk to her. Make a verbal contract, telling her what you will do for her. She may test you, but then she'll know that you are someone who cares and will help her make it. If, on the other hand, you do not want to become involved with the patient, do not allow her to ventilate her feelings, bringing all the pain to the surface. Counteracting and controlling pain When a patient complains of pain do you instinctively check first to see when the last shot was administered and how soon, within the limits of prescribed medication, that patient can have another shot? If you do, you may be neglecting some of the nursing comfort measures that have a direct bearing on the psychosocial welfare of your patient. Minimizing pain through nurse/patient interaction can be, in some situations, as hel pful as offering relief through medication. . Disassociation encourages the patient to detach himself from the perception of pain by concentrating on other sensations. A patient who is having a tube inserted, for example. can be encouraged to concentrate on the feeling of pressure rather than the pain involved. In OB.labor proceeds more smoothly when the mother-to-be concentrates on pushing rather than pain. Children undergoing allergy tests can be encouraged to concentrate on the sensation of coldness and the itchy feeling rather than pain. It helps a patient whose dressing is being changed to concentrate on the sensations of cold or warmth that are involved rather than pain. · Distraction or diversion can take the patient's mind off pain and turn it to another occupation. Some of the activities which can distract a patient whose pain is not too intense include: -reading -watching television -needlework, knitting. etc. -talking on the phone with a friend. When it seems appropriate, talk with your patient about his family. Encourage a husband or wife to bring in pictures that the patient can put in an album, talk about and show off to other patients, staff and friends. Ifit is available, a metronome can distract a patient during a myelogram - watching and counting offer a welcome diversion. Often it is the patient's need for distraction that makes him want you to remain in his room. Human contact, or "presence" can be an effective defence against pain, even if that person is not actively taking steps to relieve the pain. . Reassurance and encouragement can also have a noticeable effect on pain tolerance levels. Surgical floors. especially between the hours of noon and four p.m., tend to be extremely busy places but effective pre-op teaching pays dividends in terms of better nurse/patient relations the following day. Patients who know what to expect - the comparatively short duration of incisional pain. for example - are reassured by that knowledge and therefore less demanding. They require less medication and often are able to leave hospital earlier. Patients can als be taught to recognize sensations such as pulling, stretching or burning and to distinguish these from pain. A cholecystectomy patient. for example, is reassured by being told that his incision will not "pop open" even though it feels that way. Remember that inco"ect information. ignorance and fear work together to lower pain tolerance. . Relaxation exercises can be used profitably to induce a state of tranquillity in the patient. Yoga, biofeedback and hypnosis are among the techniques currently employed to reduce muscle tension and anxiety, thereby making the patient less aware of the sensation of pain. Nurses can improvise on these techniques to achieve similar results. You can, for example, adopt a step-by-step approach to relaxation that will teach the patient to tense and relax the various parts of the body (fingers, hand, wrist, lower arm. upper arm), one at a time until his entire body is involved. Your goal should be to train the patient to relax his muscles at will. Teach the patient to relax before the pain becomes too severe. Have him assume a comfortable position, preferably lying down, before beginning. Earphones that allow him to listen to tape recorded music are often an aid to relaxation, as are movies. Encourage him to imagine a restful setting and a sensation such as floating. Deep breathing is also an aid to relaxation. For best results, teaching should be carried out pre-operatively ather than post-op. Nursing interventions Of all the modes of pain relief available, including drugs, surgery, electrical stimulation, counseling, etc.. some of the simplest and best are still the ones that every nurse recognizes as basic to her practice. These include: . non-judgmental listening . skillful body positioning . splinting an incision when a patient coughs or turns . supplying rational explanations for practices and procedures . taking steps to ward offanticipated pain so that the patient does not need to fear loss of control . educating the patient in how to use his medication effectively. how to achieve pain control, how to recognize side effects and who to call if he needs someone . pacing medication to minimize the pain involved in ambulation . and. last but not least, the comfort measures involved in good nursing care: a clean bed, smooth sheets, a back rub with a smile. Remember. keeping a patient comfortable is a skill that you develop over years of practice; share your experience with younger nurses. TIM Cenadlen Nur.. Pain management The more you know about a patient, the more successful you will be in helping him to control and manage his pain. Priorities differ. Maybe aU Mrs. Shale wants is to be able to get up in the morning, prepare a nice big breakfast for her daughter and husband, and then see them off with a good start on the day. If so, sit down with her and re-schedule her medication and activity plan so that she allows for a rest period after they leave the house. Maybe Mrs. Shalejust wants to keep up a good appearance in front of her friends and relatives. Schedule her pain medication before visiting hours: help her to fix her hair and dress in something attractive. Continuing sexual relations with her husband may also be one of Mrs. Shale's priorities. If so, you can help her by suggesting a position that will allow maximum comfort. When a chronic pain patient is admitted to your care, find out that patient's particular pain pattern - what medication he takes at home and how often. Enquire also about the other measures he uses to provide relief - heat, cold, massage, pressure, movement, lying still, distraction, etc. What makes his pain tolerable? WhiJ,t increases his pain? Does pain affect hIs ability to sleep? What words and phrases does the patient use to describe his pain? Pain should be recorded in order to help diagnosis. It helps also to determine causative factors in relation to pain- incision pain from trauma to the tissues or gas pain with return of bowel functions, etc. Find out the reaction component (what meaning the pain has to the patient) and have the patient identify the pain by comparing it to something else to help you assess and evaluate it better. When a surgical patient requests pain medication post-op be sure to find out where the pain is. Know the location and intensity. This will help you to avoid situations such as the one in which a post-op woman was medicated for pain that the nurse assumed was caused by her surgery. Not long after, the doctor made rounds only to find the patient was having an MI. Always as!.. and then document it. I have learned the value of walking rounds: IV's are on time and patients are medicated prior to the change of shift rather than having to wait until after report. Walking rounds increase the rapport between patient and nurse and keep the patient informed about his progress. Other interventions Transcutaneous electrical stimulation is another method of pain management currently being used in certain cases. Success depends on many variables, one of the most important of which is the skill of nursing staff in teaching the patient to care for and understand these implants. Medication is, of course, the intervention which comes to mind first. Measuring the efficacy and comparing cost and safety factors of the various analgesic drugs is made more complicated by the subjective nature of pain itself. Comparisons are further complicated by the realization that as many as one third of all patients complaining of pain will respond favorably to administration of a placebo. . Am ng the most commonly prescribed analgesics are: acetyl salicylic acid (ASA), acetaminophen, codeine, propoxyphene, pentazocine, morphine and meperidine (pethidine or Demerol ). When administering any of these drugs, nurses should check to see for themselves the effectiveness of the dosage and method of administration route. They should also be aware of and watch for possible side effects. In acute pain, an analgesic in combination with an antianxiety drug may prove most effective. In chronic pain, the analgesic and antianxiety drugs may be combined with an antidepressant for optimum relief. Terminally ill patients may receive orally administered opiates (Brompton's Cocktail). This mixture usually consists of morphine, cocaine, alcohol, chloroform water and a flavoring syrup and may be administered routinely or PRN. Advantages include keeping the patient alert and well-oriented so that he maintains a good relationship with his family right up until death occurs. A little knowledge, a little understanding Eventually Mrs. Shale will go home from the hospital, only to return later to ask for further help in controlling her pain. Don't you be the nurse who says, "Oh, not.her again," or "Please send her to another floor, we get her all the time!" Maybe during this hospitalization you can help her find other methods to help control her pain. If you do, you will be the light in her life that she's been waiting for. . Be someone who takes the time to help her attain enough control to be able to pursue certain activities at home. She's not making such a bad job of living! Most of the time she fools a lot of people into thinking she doesn't hurt and it's only when the pain is unbearable that she comes to the hosl.'tal. When she smiles and says, "I a pain. Can I have something?" B'i.:,,'e her. I do! Won't you? .. June 1979 27 About the autbor:Emalou Vaterlaus attended Carroll College in Helena, Montana and graduated from St. Vincent's School of Nursing in Bi/lings, Montana. Now living in Williston, North Dakota, and working at the Craven-H agun Clinic, her areas of nursing experience include medical, surgical,lCU and emergency room department nursing. She is a state and national registered emergency medical technician-ambulance (EMT) and a past president of Upper Missouri District No. 8 Nurses Association. Acknowledgment:The author would like to gratefully acknowledge the assistance of two of her colleagues -J oA nn Eland, RN, BSN. MA, and Marion Johnson, RN, BSN, M SN, - in the preparation of this article. - The role of the intravenous nurse in the emotional support of the chemotherapy patient cannot be overrated. It may, in fact, be crucial to the holistic management of the patient and his disease. By synthesizing the ideas and observations of co-workers and current literature on emotional support, author Kathleen MacMillan-Brett provides IV therapists with a new focus on their role in chemotherapy. The IV nurse and the chemotherapy patient: Nursing's primary concern is always for the patient and his needs. In the case of chemotherapy patients, a host of emotional complexities are at play. Sooner or later, these patients must deal with body image changes, the presence of pain, the spectre of death and a number of other very real concerns in their lives. All members of the health team who interact with these patients have a part to play in helping them to cope with their feelings but sometimes IV nurses - who are also members of the health team - overlook the opportunities that arise for providing emotional support. Their contacts with these patients are frequent - starting IV's, starting blood transfusions, administering antibiotics, IV drugs and, in some hospitals, giving chemotherapeutic agents - and the chances are many. As an IV therapist, I feel that there are three factors that can help us to maximize our role in providing emotional support to this group of patients: . we must have a good working knowledge of chemotherapeutic agents . we must have a close working relationship with both nursing and medical staff and . we must be able to understand and accept individuals. Chemotherapy The IV nurse must know, first of all, what chemotherapy is, what it hopes to accomplish for each patient, how the agent works and what its side effects are. When a patient in our hospital is about to begin a chemotherapy treatment, the IV nurse starts an intravenous infusion with 5 per cent dextrose solution. She does not, however, inject the antineoplastic drug; this is done by the doctor in most cases or by the staff nurse in the case of 5FU (5 Fluorouracilll\)) which is mixed in solution. Kathleen MacMillan-Brett I \ \ a vital role in emotional support At our hospital, IV therapists are also involved in an outpatient chemotherapy unit which handles approximately 30 patients per week. These patients are probably the largest, single group that we deal with on a regular basis and this kind of contact means that we can get to know the ones who return regularly for treatment. The chemotherapy unit is essentially a well-patient clinic. The atmosphere is relaxed - IV's are often started with patients lying down but once the IV is running well, they can sit in a chair to chat with a friend over a cup of coffee until the doctor arrives. Close bonds are formed among these patients and they often have a deep understanding for one another's experiences. Our IV therapists try to insert the IV needle as painJessly as possible. A local anesthetic of I per cent Lidocainell\) is injected intracutaneously and 20 g catheters are used for all cases except when a blood transfusion is to be given. We also take care to pick sites that will produce the fewest complications. All these measures provide comfort for the patient and a caring attitude tends to increase trust between the patient and the IV nurse. This trust is particularly important in establishing a relationship with a patient who has over-used veins, a patient who has come to be frightened of the whole procedure. Just as we try to get to know each patient as a person, we feel it is important for them to know each of us as a person. We always introduce ourselves by both first and last names. This gives the patient an opportunity to establish a first-name relationship with the nurse if he wants to.lfhe requires a more formal structure and uses last names, that is fine too. He is letting us know what form of address makes him most comfortable. The c....... NIne .....1171 21 In the outpatient unit, we constantly help to interpret the patient's particular reaction to the chemotherapy and to provide an ear for his distress from adverse reactions. These are particularly hard for the patient to accept especially if he has felt relatively well before beginning the chemotherapeutic regime. The nurse's attitude to the treatment is of vital importance if she is to support the patient in this situation. Working relationships At our hospital, we see the IV nurse's role as closely approximating that of a patient ombudsman, both because of our unique relationship to the nursing and medical staff and because of our continuing relationship with the patient. IV nurses see the patient in the initial post-op period, for his initial chemotherapy in the hospital and later in the outpatient chemotherapy unit. This enables us to function as an interpreter between the patient and his doctor, filling the patient in about his treatment. We have the opportunity to get to know our patients and their families and to communicate our insights and observations to the staff on the floor. It is my feeling that IV nurses are in a unique position to relate to the patient because we are not involved in an invasion of privacy to the same degree as the nurse who gives physical care. In addition, since the procedure is a technical one, once the skill is mastered, the nurse is free to interact with the patient on a personal basis. I n other words, the procedure is separate from our relationship with the patient. We also operate as liaison personnel, carrying information back and forth between the chemotherapy unit and the floor: between staff and patients. If one of the patients in the outpatient unit has been hospitalized, the others want to know how he or she is doing; if there are no objections, we relate the information as best we can. Sometimes. the news is not good but we feel that being as honest as possible under the circumstances is important if we wish to maintain a trusting relationship with them. Understanding individuals This is the most exacting of the three functions that I see for the IV therapist. As human beings. we must all face the fact that we have cultural biases. The strong negative feelings that we may have about some patients' attitudes towards their illness are based on our own bias about what is appropriate or acceptable. If we can keep that thought foremost in our minds then we can accept the fact that these people are experiencing illness according to their own illness practices. in the framework of their own cultural system. Any attempt that we might make to have them conform to our ideas of "how one is ill" will only add stress to our relationship with that particular patient. And stress is the last thing the patient needs. There are times however when we know that we are not getting along with a patient on a personal level. In this case, it is in the patient's best interest for us to recognize the situation and bring it to the attention of other members of the IV team. Another nurse may have much more success with this patient and may, in fact, be able to build a trusting relationship with him. The patient will likely cooperate if he likes and trusts the nurse who must start his IV. In the end, it will mean fewer frustrations on all sides. Part of understanding an individual is learning about him through communication. by encouraging him to talk and express his feelings. In a nurse/patient interaction, one of the most effective ways of promoting open communication is by the use of open-ended statements and questions. This non-directed technique does not influence the patient's response - he is able to express in his own way his ideas and feelings. For example: Situation 1 A) Patient: I'm getting so manv treatments but I don't seem to be feeling better. Nurse: You haven't beenfeelini( too well, Jim? Can you tell me more about it? B) Patient: /' m getting so many treatments, but I don't seem to be feeling any better. Nurse: That's too bad, but the treatments are important. Situation 2 A) Patient: Oh, not another IV. I'm so tired ofbeini( poked and prodded. N urse: You seem to be on edge today, Mrs. Smith. Is there something troubling you? B) Patient: Oh, not another IV. /' m so tired of being poked and prodded. Nurse: Sorry, Mrs. Smith, but your doctor ordered the IV. Interaction A, in both situations I and 2, consists of the nurse inviting the patient to share more of his feelings and ideas with her. Interaction B. on the other hand, demonstrates answers by the nurse that do just the opposite. Remember too that talking with relatives provides a valuable opportunity for information sharing and a chance to find out more about the patient from those who know him or her well. The ability to maintain control of a situation is very important for some people and we try to accommodate this need. I remember one man, with his own business, who really let us know of his need for comrol. He always had to make a last-minute trip to the bathroom, change his gown or finish his coffee before he would let us start his IV. Occasionally he would ask us to return after lunch. We started to consult with him early in the morning about when he would like his treatment and where he wanted the cannula placed. We learned to tolerate the other delays when we realized that to him. his behavior was a way of maintaining control in a very difficult situation. Our relationship with him blossomed over the seven years he was our patient. We have found also that it is usually beneficial to let patients decide about possible IV sites, and whether or not they would like armboards. Generally, chemotherapy patients guard their IVs very carefully and know what is most comfortable for them. Patients also participate in decision-making by deciding the time for their IV to be started and the time when they feel able to have their infusions discontinued. Emotional support We all know that as nurses we are supposed to provide patients with emotional support. It is at the bottom of every article on every aspect of nursing care. But it is only lately that the term is being defined, explained and outlined. Empathy is not innate: it is a learned response which we acquire by listening. 30 June 1979 The C.nedl.n Nur.. Our brains, like computers, must have intake before they can give any valuable output. Emotional support does not require that you have all the answers; it does require that you listen. Remember how important it is to use open-ended conversation techniques and to ask questions. Just being there.allows the patient the opportunÌty to discuss his fears. This can be just as important as visible physical care. There are times when it is more important to sit beside a patient and talk than it is to answer the beeper immediately. In other words, holding a crying patient is just as necessary as starting an infusion. Being an effective nurse means involvement. We can sit down with a patient and his family over a cup of coffee; in some circumstances, small gifts such as a flower from the garden can mean a great deal to a patient who fears losing his identity to his disease. Extending a relationship outside the hospital is one way of being involved for some nurses. One patient that I remember well was determined to live to see her only son get married. Three weeks before the wedding she became very ill with a fungal pneumonia and, when she expressed fear of missing the ceremony, I offered to take her if her doctor consented. We went and it gave me a great deal of satisfaction to see her so happy. Three days later she died. Another technique that is helpful in dealing with patients is to ask them if there is anything else that you can do for them. Little things such as positioning a pillow, pouring a glass of water, or pinning the call bell in place, take only a second but they say a lot about caring. What about the IV therapist and non-verbal communication? Such things as facial expression, posture and pupillary reaction can reveal a great deal about the true feelings of an individual. The IV nurse is in a unique position to communicate through touch. We deal with hands and can therefore establish contact which is friendly, normal and comfortable. Holding hands is acceptable social contact. When preparing to insert an IV, grasp the hand firmly, use a gentle touch and avoid giving unnecessary discomfort. The patient's reaction to an IV is often negative. At these times it is helpful for us to remember that we often see the patient when he is at his lowest ebb, when he has been ill all day, unable to tolerate fluids, or requires a blood transfusion or antibiotics. Or, he may have had to take a day off work to come in for treatment. The tears of frustration and anger or the outright rage that sometimes greet the IV nurse can be a rare opportunity to establish a trusting relationship. Comments like, "Did it help to get it all out" or "It seems you are feeling pretty upset today" go a long way towards showing acceptance and stimulating trust. Then you can sit down with a patient, touch his shoulder or hold his hand. It has been my experience that patients will communicate their feelings to the IV nurse if she is open. A patient may have a long-standing relationship with a particular IV nurse from the chemo unit, or he may simply recognize that s he is not a member of the floor staff. Sometimes a patient feels more free to discuss personality conflicts with staff or other patients or just to express his feeling that the staff doesn't know or care about him to nurses he considers "neutral". Armed with these bits of information, the IV nurse may be able to help by acting as a go-between with the staff. Conclusion Looking at the role that the IV nurse plays in emotional support, it is evident that a registered nurse is the most appropriate professional to fulfil the three functions outlined. I n this era of budget constraints, the suggestion is sometimes made that IV nurses be replaced by technicians. I couldn't disagree more. I feel that the IV nurse has a vital role to play precisely because she is a nurse first and a technician second. Communication skills are the key. As a nurse, the IV therapist is in a special position to offer emotional support, particularly to patients with whom she can establish a trusting relationship. Fulfilling this function only adds to the satisfaction that this branch of nursing brings. .. Bibliography I Collins, Mattie. Communication in health care. 51. Louis, Mosby, 1977. *2 Davis, Judy. Administration of chemotherapy - the IV therapists responsibilities. Amer. J.lntrm'enous Therapy. by... and Candise I. Pillow, 4:4,July, 1977, p.15. 3 Rinear, Eileen E. Helping the survivors of expected death. Nurs. 75. 5:3:60-65, Mar. 1975. *Not verified byCNA library. Author Kathleen MacMillan-Brett presented' 'The IV nurse and the chemotherapy patient: a vital role for emotional support" to a group of intravenous nurses at a chapter meeting of the Canadian Intravenous Nurses Association in Toronto. She is a 1970 graduate of the Toronto East General and Orthopedic Hospital School of Nursing. Since graduation she has worked in medicine and as an IV nurse. Currently she is working part-time on the IV team at the Scarborough General Hospital, Scarborough. Ontario. She is also afull-time student at the University ofT oromo studying anthropology and biology. Kathleenfeels strongly about the role that the IV nurse can play. She states: "It occurred tome that many people will consider it (my paper) idealistic. and impractical in the face of the heavy and often frenetic schedule of the IV nurse. Although this is true to some extent, we do make it work at Scarborough. and I think it is due to both cooperation and commitment. The commitment factor is important. The girls that I work with are proud to be nurses. and unlike some hospitals. the IV Team at Scarborough is orl(anized under the auspices of the Nursing Department. Because of this I think the commitment to patient care is more obvious than it would be if the team were under the laboratory or pharmacy as it is in some hospitals. The other factor is cooperation. We are a team in the true sense. By this I mean that we help each other when necessary. rather than just seeing that ollr own work is done. This means that if one of those opportunitiesfor communication present themselves, we can ask someone else to take our calls forafew minutes ifit is at all possible. Without this type of staff the ideas which I have presented would be very difficult to put into practice, and I would like to credit my co-workers. and my head nurse, Jean Downer, with some of the ideas, and with the opportunity to practice them." .. . I .. -.", The Cenecllen Nur.. Frankly speaking June 1979 31 Apathy . In . nursing JessIca Ryan These days, you don't have to look very far afield to encounter apathy: it occurs in every walk of life, every possible setting.lfit is true that people can be divided into two groups - the doers and the sayers - then, it is also true that the sayers have finally come to outnumber the doers. Take politics, for example. Everyone criticizes politicians but when it comes time to attend a meeting or convention or to allow their name to stand for office, where are these people? Everyone has disappeared. This makes a mockery of selection or election of the best qualified person to fill a position; it becomes a case of take it or leave it and, often, the best person does not end up in a position because the best person just couldn't be bothered. In a noble profession such as nursing, you might expect that this situation would not occur. Everyone knows that nurses are "selfless", putting the needs - the health and welfare - of others ahead of their own. Within the past 20 years, however, apathy has become the name of the game in nursing just as it is in other groups. Out of tOO "typical" nurses, only about ten can be expected to attend a nurses' union meeting; fewer than that will show up at their provincial association's annual meeting and only about five will bother to attend a regular chapter meeting. Unless they are going to get a day off to make up for it, or unless their way is paid, most nurses don't take advantage of the seminars and workshops that are available to them in their area. On their days off they prefer activities not related to professional development. In other words, unless they can see some tangible reward, most nurses just don't get involved in more than the bare necessities of knowledge and experience they need to do their job. Is this because they really "don't have time" or because they are "just too tired"? If you think that's the answer, consider the number of these same nurses who spend their free Friday evenings or Saturday mornings working at fund-raising events like bake sales, card parties or handicraft sales. There they are in droves, donating their precious time off and the money they earned by nursing to all sorts of worthwhile but nevertheless non-nursing activities and functions. None of these activities, all of which involve hard work, contribute in any way to advancement or enhancement of their chosen career of nursing. Faithful attendance at chapter meetings, on the other hand, keeps a nurse up-to-date about what is happening in nursing today. Attendance at union meetings ensures that she understands the issues involved in her social and economic welfare. And yet, it costs nothing to attend these meetings - no baking, no effort, no membership fee - oftenjust a little time and attention. Perhaps that's where the problem lies: it's too free, it's too easy. All that is required is to listen and to learn. The same thing happens when nurses are required or invited to sit on hospital committees such as nursing records, nursing audit or nursing techniques. They find it difficult to attend and even more difficult to be interested. They do not seem to realize that, at this level, they have a lot to say about influencing nursing in their hospital. Every time a nurse does not appear at a meeting or conference, the administration of that hospital assumes that nursing is not interested. Pretty soon nursing stops being invited and finally administration is dictating to nursing and to nurses on duty. Then nurses complain and become more and more unhappy in their work. It is apathy that does this. Nurses must stand up and be counted. The opinion of the nurse at the bedside is invaluable: these are the nurses who are with the patients: they are caring: they are communicating. In other words, the bedside is where it's at and where it must stay - in the hands ofregistered nurses. This creeping apathy about professional meetings, union meetings, unit meetings, staff meetings and hospital committees must be stopped. It must not only be stopped but it must be reversed from apathy into caring. Nursing must become, once more, more than just ajob. It must become the proud profession that people on the . outside looking in believe it to be. To do this, . nurses must make nursing their first interest, their first love, their first ideal. They must understand what they are voting about before they vote. . nurses must read and know what new things are developing in nursing. . nurses must understand that they belong to one of the largest and most powerful health groups in the country as well as the largest women's organization in Canada. Together nurses can turn the tide of apathy. They can become a cohesive force of interested caring, sharing men and women. The price is simply enthusiastic attention to nursing affairs, participation in professional and union meetings, attendance at educational conferences, reading and continuing to educate oneself either at the bedside or at school. Continuing education is not for the few, it is for the masses, whether it is done on a grand scale or as an individual effort. It must be done. We must continue to grow and to become more aware. Nursing is changing, nurses must change. There are needs that must be met and nurses must be ready to meet these needs. If nurses continue to be apathetic and to let others govern their work life and their professional life, then eventually these others will fill the gap, meet the needs and take over nursing. '" Jessica Ryan, author of this month's Frankly Speaking, was elected member-at-large, nursing practice, at the /978 annual meeting of the Canadian Nurses Association. She is head nurse, pediatrics, at Chaleur General Hospital in Bathurst, New Brunswick. Jessica has been an active member of the New Brunswick Association of Registered N ursesfor several years and is also a member of the board, Bathurst Schoo! of Nursing and president ofT he Atlantic affiliate of the Associationfor the Care of Children in Hospital. At only half the cost of most other products, the new EPICt 100-A Electronic Parenteral Infusion Controller brings innovative simplicity to I. V administration. 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Trademark of The Ðow Chenncal Company t Trademark o' Burron Medical Products. Inc. USA \ -.:[ l' Nurses need leadership skills Susan Spennruth Processionary caterpillarsfeed upon pine needles. They mo 'e among the treesin a long procession, one leading and the othersfollowing - each with his eyes half closed and his head snugly fitted against the rear extremity of his predecessor. Jean Henri Fabre, the French naturalist, tried an experiment with these caterpillars. He enticed them to the rim of a large flowerpot. where he succeeded in getting the first one connected with the last one, thus forming a complete circle which started modng around in a procession that had neither beginning nor end. Fabre expected that after awhile they would catch on to the joke - get tired of their useless march and start off in some new direction. But not so. Through sheer force ofhabit. the living, creeping circle kept mm'ing around the rim of the pot- around and around, keeping the same relentless pace for seven days and seven nights- and would doubtless have continued longer but for exhaustion and starvation. An ample supply offood was close at hand. and plainly visible, but it was outside the range of the circle, so they continued along the beaten path. They were following instinct.. . habit .. . custom .. . tradition. .. precedent...past experience...they mistook activity for accomplishment. They meant well- but they got nowhere. ( , Judy Tiivel If you were asked to describe the qualities a person needs to give the best possible nursing care, what adjectives would you use? Some have said that a good nurse must be "nurturing, caring, tender, compassionate, and able to intuitively relate welI with others and be supportive of their needs" . I There is no doubt that these qualities are essential for good patient care. But are these the characteristics that we find ourselves needing most when we take on nursing leadership roles? As charge nurse on night duty coping with overwork and staff shortages; as team leader on days planning team assignments, coordinating care plans or dealing with physicians who disregard nursing decisions; as head nurse working on staff rotations, staff evaluations, or implementing new concepts on her unit; as nursing director guiding her staff to form a dynamic team or working on detailed ward budgets? Don't we also need to be decisive. objective, creative, rational. persistent, resourceful, courageous and motivating? The answer is obvious: good nursing management requires, even demands, these qualities. The unfortunate thing is that many of us simply are not given the opportunity to develop those characteristics before being placed in a leadership role. - /-, J i:í .. .... J --......... '- \ I , I 34 June 1979 The CeNldlen Nur.. Shaky situation Within a few months of graduation, many new staff nurses find themselves in charge of their units on evenings and nights. These and other leadership duties continue throughout their nursing career. The Royal Victoria Hospital in Montreal, for example, is a busy, acute care hospital in a multicultural and multilingual city. Nursing units are of a highly specialized nature and most new staff are recent graduates of community colleges or university schools of nursing. Nursing staff turnover rates are high, up to 40 per cent annually so the new staff nurse quickly becomes a senior nurse- usually within six months to a year. As Nurse Clinician Teachers (Ncr) at the Royal Victoria, we work closely with the nursing staff - orienting them to the c1inicaJ area, increasing their knowledge of a nursing specialty, evaluating and identifying their learning needs. It has been our observation that there is a great need for staff nurses to develop leadership skills, to be more confident and capable when in charge of a team or a unit and therefore, less apprehensive about their own abilities - in short, better leaders. What to do? Having recognized that leadership is a neglected area in nursing education, we (the NCfs) decided to present a series of Leadership Development Workshops. The first workshop was presented in March 1977 to a group of 32 team leaders and other interested nurses at our hospital. Having tried several methods of presenting leadership and management skills, we decided to use experiential exercises as our method of teaching. Experiential learning has been used with great success in a variety of settings - universities, business and industry. We felt that the time was ripe for hospitals as well to start experimenting with this method, especially in teaching leadership skills. Experiential learning - what is it? In its simplest terms, experiential learning is "learning by doing". The exciting factor in this model of learning is that the responsibility for learning rests with the individual. Participants must be active and assertive and must set their own goals ifIearning is to take place. "Experiential learning is based upon three assumptions: . that you learn best when you are personally involved in the learning experience . that knowledge has to be discovered by yourself ir-it is to mean anything to you and . that committment to learning is highest when you are free to set your own goals and actively pursue them within a given framework. "2 We felt that the workshop approach was best suited to our needs. Objectives The main objective of our workshop was to expose the participants to a series of exercises designed to promote effective leadership. These exercises emphasized: . understanding group dynamics, especially the components of respect, trust and acceptance . recognizing the vital importance of communication and feedback . understanding what it feels like to be a new member of a group - a new staff member on a floor or unit or a relief nurse who encounters new situations all the time . realizing the need for expression of minority or unpopular viewpoints . comparing the results of group decision-making with individual decision-making . recognizing the value of planning as the key to effective leadership. The exercises allowed the participants to take a look at themselves - how they function in a group, how sensitive they are to their own needs and then to the needs of others. Experiential exercises also gave them an opportunity to discuss and evaluate the dynamics of their interaction in a non-threatening and sharing environment. The workshop The first workshop was two days in length and was held in the hospital well away from patient areas. We wanted to make it as informal as possible so the participants and the facilitators (NCfs) came in street clothes, addressed each other by firs t names and had lunch together at an outside restaurant. Because we limited attendance to 32 participants, there was time for each nurse to express herself and to experience both the observer and participant roles. On the first day, the nurses worked in groups of six or seven; on the second day, the members of one group were asked to join an already established group. These "displaced" persons experienced how it feels to be a "new" team member and at the end of the day shared their feelings about this with the group. Prior to attending the workshop, participants had been asked to complete a self-evaluation of their leadership characteristics. These replies remained anonymous and at the end of the session they completed a duplicate form and then compared and measured their change in self awareness over the two days. We also supplied them with several articles and asked them to read these before attending the workshop (See suggested reading list). The exercises. Six experiential learning exercises that covered six aspects ofIeadership were completed during the two-day workshop. Members of each group were given handouts describing the exercise and received further instructions as needed. After each exercise, there was time for group feedback and then short lectures were presented on the theory that had been illustrated by the exercise. .. J Exercise 1 BROKEN SQUARES Purpose: To develop a team approach to problem-solving and to show the difference in results between a cooperative and competitive attitude. I nstructions: Participants are given envelopes containing jumbled pieces of cardboard that when put together form squares. Only parts of the pieces for forming the five squares are in each envelope. The task of the group is to form one square in front of each member. The exercise has two goals: the individual is to form a square in front of himself as fast as possible; and the group goal is to have squares formed in front of every member of the group as fast as possible. A person may give a cardboard piece to another person but no talking or signalling of any kind is allowed. Noone may ask for a cardboard piece. The Cenedlen NUrH June 1117V 35 The groups are not given identical instructions. Some are encouraged to take a competitive attitude while others are given cooperative guidelines. Outcome: It became readily apparent that successful completion of the task was much more rapid when all members of the group were cooperative and placed their team goals above their individual goals. Even if the participants were given competitive instructions rather than cooperative ones, all the nurses without exception became cooperative in order to get the job done quickly. II II . '" o. " .. ,. , ---.,. - '-4- ..0:: .. J Exercise 2 THE DIALYSIS I.ACHINf. Purpose: To study problem solving procedure in groups and to examine the impact of individual's values and attitudes 01' group decision-making. I nstructions: The group is told that they are members of a hospital committee who must select one of five candidates for placement on a hemodialysis program. There is only one vacancy and the group must give its unanimous agreement to the selection of the individual. (The other four candidates are not likely to live if denied access to the machine). The group is given a brief biography, including sociological and psychological data on each candidate. The five patients come from a wide variety of backgrounds and the group must decide their own criteria for selection. They have one hour to make their choices. Outcome: This exercise clearly illustrates the difficulty of objective decision-making when data is of a subjective nature. Discussion was very heated, and because the nurses in each group were from varied backgrounds, each placed different values On sociological, psychological, economic, moral, religious and academic standards. Rarely did two groups come to the same decision for similar reasons. There were interesting consistencies among the nurses in the groups. Without exception. a high value was placed on marital status and number of dependents. If the patient was married and had several young children. the majority of participants felt that these factors should be given priority. They placed very low value on the needs of a single professional woman in her mid-thirties. and patients with "problems" such as suicidal tendencies were almost never chosen. Prejudices and 'labeling' were obviously at work here. Why were nurses, educated in a caring and helping profession, so ready to label and reject people needing psychological and sociological help and understanding? After the exercise was completed. the nurses discussed the importance of recognizing prejudice and the role of prejudice in decision-making - a subject of considerable significance to nurses in their professional life - whether they sit on ethics committees, abortion committees or selection committees - or when they must cope with their attitudes towards patients and colleagues. Exercise 3 SUR VI V AL I!'ol THE WINTER Purpose: To compare individual decision-making with group decision-making. Instructions: Participants are asked to imagine that they are survivors of an airplane crash. They are in a wilderness area, 80 miles from the nearest town, and the last weather report indicated temperatures of _25 0 . Each person is. given a list of 15 items salvaged from the wreckage and asked to rank these items in order of importance to their survival. They are given 10 minutes to complete the task individually and then the group is given one hour to reach a team decision on the importance of the various items. I n the last phase of the exercise, individual and team answers are compared to answers prepared by a wilderness survival instructor. Outcome: In the majority of cases, it was readily apparent that the group scores were better than the individual scores when compared to the expert answers. If an individual had done better, the group discussed why she hadn't been able to convince the others and why they had disregarded her answers. Why didn't they utilize the expertise that was readily available to them? In groups which had done well, every member had participated enthusiastically and shared her knowledge or logical reasoning to the benefit of the group. In studies of the group decision-making process, the overwhelming conclusion is that group decision-making is much better than individual decision-making. The resources of all members are pooled, errors are detected more easily and hlind spots corrected. (I t is always easier for us to see other people's mistakes than it is to see our own). Group discussion stimulates idea.'i that might not otherwise occur to the individual working alone. Finally, there is more security in taking risks in group decision-making than in individual decision-making. 3 Participants discussed these factors and were quick to see the many ways that this theory can be applied in the nursing world - care planning. the team approach to health, staff appointments, changes in ward routines - can all be more innovative and effective when several people pool their ideas. , \ ... Exercise 4 HOLLOW SQUARES Purpose: To focus on the tasks of planning and implementation. Instructions: The goal of this exercise is to arrange 16 pieces of cardboard so as to form a large square with a hole in the middle. Each group is divided into two teams. The first team is given a diagram ofthe finished square; they are not allowed to touch the cardboard pieces. Their task is to plan how to instruct the second group in assembling the square as quickly as possible. The second group waits until the first team plans their strategy and then receives their instructions on how to assemble the square. Once the instructions have been given by the first team. no further communication is permitted between the two groups. The second team goes ahead with the implementation of the plan. 31 June 1171 TIM Canecl"n NurM Outcome: This task brought out many frustrations. The implementers had to wait for an hour while the planners planned; they worried about what the task would be, whether they would be given adequate instruction and whether they would be able to accomplish what was asked of them. They sent notes to the planners which were ignored or answered in a condescending way - "Can't you understand that you're interrupting the very important process of planning?" During the instruction phase, the planners explained their carefully thought-out instructions and, at the signal to start, stood back to watch the implementers carry out the "easy" task offollowing their directions. But it didn't quite work out that way. The implementers didn't find the instructions clear at all- in fact, they were quite confused. Well, perhaps they had better ignore their incomprehensible instructions and put the pieces together by using their own logic and ability. But it wasn't that easy and they ran into trouble. The planners meanwhile, unable to communicate, were chewing their fingernails and pacing up and down. It was painful and frustrating to watch their carefully thought-out plans being misinterpreted or, even worse, ignored. They felt a lot of anger towards the implementers for letting them down and, by the end of the exercise, neither the planners nor implementers had good feelings about each other. What went wrong? The pitfaHs are similar to many "real world" ward level situations. When the hospital- administration hands down a directive that appears stupid, when a procedure is changed in what seems an unrealistic way, when a nursing care plan is made and then promptly ignored by the staff, when a head nurse stays overtime and the stafffeeis that she doesn't really think them capable of using that new piece of equipment - someone has made the same sort of mistakes that were made in the Hollow Squares exercise. Planning can be so interesting and absorbing that planners can forget that implementers become anxious and nervous about their responsibility. Implementers usually develop some feelings of antagonism or hostility towards their planners while they are waiting for their instructions. This antagonism increases if they are given complex instructions in a short amount of time and they are left confused as they take responsibility for finishing a task. 4 The participants learned that time spent planning, and time spent communicating is time well spent. They also learned that the implementers should be invited to observe a planning meeting since the committment to implement a task is usually built through the planning process. They became aware that there is considerable frustration in planning something that others are responsible for carrying out. Through this exercise and the ensuing discussion, the teams developed a deeper understanding of each other's needs, anxieties and capabilities. . . ' 1 ...... .. - --=-- ...... .... ( 1:: Exercise 5 MOON TENTS Purpose: To explore aspects of motivation and its role in leadership. I nstructions: Each participant in the group is given diagramatic instructions on how to make tents out of paper, allowed to practice and then asked to estimate how many she could make in six minutes. All participants are timed and their tents inspected for quality. They are then able to see if their estimate is realistic and their work satisfactory. Next, the group as a whole makes an estimate of the number of tents the group can make and works as a team to reach this goal. No extra marks are given for manufacturing more tents than has been projected. Outcome: After the exercise, the participants were asked why they made the estimates they did. Did they use feedback? Were they aware ofthe estimates of others when setting their Own goals? How did they define the objectives of the game, e.g. beating the rest of the group, competing with their own goals, making a lot of marginal quality products or a few high quality products? In other words, what motivated them? The way individuals perform is affected by what motivates them, and researchers have been able to identify three broad categories of identifiable human motives - the need for affiliation (n-Aft), the need for power (n-Pow) and the need to achieve (n-Ach). Most people are influenced by each of these motives but in different degrees. Obviously, the way that these needs are arranged affects the leadership style of any individual. 5 The high n-Achievement person for example has three characteristics that facilitate her effectiveness in goal achievement and problem solving: 8 l. She strives to define situations in such a way that she has personal responsibility for the outcome of the situation. She does not like to gamble. She wants to be involved. 2. She is good at calculating the realistic risk to be taken in a situation. She takes risks that are challenging but attainable. 3. She seeks feedback on the effects of her actions. She does not like situations where she is not accountable for outcomes. She treats both her failures and successes as learning experiences and as opportunities to improve herself. The discussion that followed this exercise revealed that nurses in charge positions want to know more about motivation and that one of their greatest challenges, and at times frustrations, lies in motivating their staff. This exercise gave them somé insight into their own motivating forces and the forces that motivate others, insight that is necessary for good. effective leadership. "'< .' "." ::-'.'" ... " ç ,"> "' ,.. Exercise 6 THE LEGOX' MAN Purpose: To diagnose the dynamics of an intact group in terms of role-taking, leadership style, developing alternatives, dominance and submission within teams and distribution of the work and resources. TIM CeMdIM..... ......1 17 Instructions: Each team is given a set of 48 Lego Building Blocks that are a variety of sizes and colors. The task is to assemble the pieces into a "man" , identical to a model placed on a central table. The model cannot be handled in any way and the blocks cannot be touched until the team is ready to start assembling them. The team is free to structure their time and resources in any way they find useful. During the planning phase, team members, one at a time, can take a look at the model as often as they wish. They can take all the time they want to prepare. An observer keeps a record of the time spent planning and the time spent in assembling the Lego man. Outcome: Although at first glance this seemed to be an impossible task, the assembly was correctly accomplished by almost every group. Most groups took a long time to plan and a relatively shorter time to actually carry out their goal- the correct assembly of the Lego man. Pfeiffer and Jones" suggest that there are three main types of working groups and that by measuring the time spent planning vs. the time spent assembling or completing a task, it is possible to place most groups into one of these categories (See table one). Table one OJ E ï= O(j .= c c Co. ::c E OJ '" ", < O(j c c c '" ë: ::c ï: I ;; ë: < Fragmented Conflicted Group Type Smooth . In the fragmented group, decisions tend to be made rather quickly without making good alternate plans. Autocratic leadership tends to prevail and openness is not the norm. This group exhibits minimal effort and minimal gain. . The conflicted group is cautious and, while considering alternative plans, is seldom able to move towards concensus. Members tend to use majority vote, usually a desperate move, and there is little committment to the plan or outcome. They exhibit maximal effort and minimal gain. . The smoothly functioning group tends to be trusting, cohesive and exhibits high interaction and sharing. Individuals in this group are committed to the plan and outcome. They are characterized by minimal effort and maximum gain. Most people can identify some committee or ward within their hospital setting that fits into the "fragmented" or "conflicted" grouping. Nurses in the workshop who could identify with these groupings shared common complaints of frustrations, irritations and minimal satisfaction in the completion of the task. Workshop groups enjoyed this particular exercise the most. They had expended tremendous energy in the previous exercises and had learned a lot from their mistakes. For this task, they were able to put into action all that they had gleaned from the workshop. They used their listening skills, communication skills. organization and planning, good division oflabor, utilized all their team members to best advantage and demonstrated individual and group committment to the goals. As health professionals, these skills are invaluable to us to achieve a smoothly functioning group. Hopefully, the added benefit of increased job satisfaction will be accomplished at the same time. ::c E OJ .I' '" < Winding down To end the workshop, the nurses completed a questionnaire about their leadership styles identical to the one they had filled out before the course began, and then compared the two. Evaluations told us that they had developed a great deal of insight into their own leadership styles and were grateful for the feedback from the other participants. Groups exhibited a growth in cohesiveness during the two-day course. Groups which did not do well in the exercises on the first day invariably did better on the second day. Bonds were formed and util ized at a later date. -.. - ... - The role of "observer" was also appreciated. Participants found that by fIJling this role they were able to start developing the analytic and feedback skills that are also necessary for effective leadership. Results The experiential learning experience proved to be tremendously exciting for the nurses involved: they went back to their wards with many innovative ideas. One ward, dissatisfied with its current team system, used the group decision approach to design a totally new approach to team nursing which is now working well. Team leaders are also participating in some interview sessions with job applicants and are giving evaluations. On a more personal level, several nurses felt ready to apply for more senior positions: others decided that they needed further self-development and postponed plans to try for promotion. Because the response from the participants was so favorable, we were asked to repeat the workshop for head nurses and directors of nursing. A third workshop was also offered to nurses from other hospitals in the city with the added bonus of strengthening interhospital ties. - ..... "'-- "'" Another exciting offshoot was an invitation to participate in the orientation period for staff of a newly opened Plastics Unit. Head nurse, staff nurses, orderly, ward secretary and nurse clinician teacher all worked together on some problem-solving and decision-making exercises that enabled them to better understand each other's strengths and weaknesses. They were able to build a strong team in the classroom before the umt opened and before they were all required to work different hours. 38 June 11179 The Cenedlen Nur.. It was the excitement generated by these workshops that prompted us to share these experiences with a larger audience. Our nursing department answered our original question as to whether nurses need to develop the skills of good managers with a resounding "YES". We have demonstrated that nurses are eager to learn organizational skills, that they are willing to come on days off to develop these skilIs. that they were able to readily implement what they had learned and most gratifying to us - we all had fun learning! .., *Complete instructions to the exercises are not given here. They can be found in the following references: I Broken Squares. Johnson, David W. Joining together: group theory and group skills, by... and Frank P. Johnson, Englewood Cliffs, N.J., Prentice-Hall, 1975. 2 Dialysis Machine. Pfeiffer, J. William. The kidney machine: group decision-making. Nineteen seventy-fourannualhandbookforgroup facilitators. ed. by... and John E. Jones, La Jolla, CA, University Associates. 1974. 3 Survival in the Winter Exercise. Johnson, op. cit. 4 Hollow Square. Ibid. 5 Moon Tent. Kolb, David. Organizational psychology: an experimental approach. by... et al. Englewood Cliffs, N.J., Prentice-Hall,1974. 6 Lego Man. Pfeiffer, J. WilIiam. Nineteen sel'enty-two annual handbook for group facilitators, ed. by... and John E.Jones. La Jolla, CA, University Associates, 1972. References I Heide, Wilma Scott. Nursing and women's liberation - a parallel. Amer.J.Nurs. 73:5:824-827, May 1973. 2 Johnson, David W.Joining together: group theory and group skills, by... and Frank P. Johnson. Englewood Cliffs, N.J., Prentice-Hall, 1975. p.7. 3 Ibid., p.75. 4 Ibid., p.35. 5 Kolb, David A. Organizational psychology: an experimental approach, by ... et al. 2d ed. Englewood Cliffs, N.J., Prentice-Hall, 1974. p.67. 6 McClelland, David C. Achieving society. New York. Halsted Press, 1976. 7 Pfeiffer,J. William. Nineteen seventy-two annual handbookfor group facilitators, edited by ... and John E. Jones. La Jolla, CA, University Associates, 1972. p.39. Recommended Reading * I Argyris, Chris. Interpersonal barriers to decision-making. Harv.Bus.Rev. Mar./Apr. 1966, p.84-97. *2 Blake, R. Robert. Reaction to intergroup, by... and Jane Mouton. Manage.Sci. 4: July 1961. 3 Grissum, Marlene. Woman power and health care, by ... and Carol Spengler. Waltham. MA, Little Brown, 1976. *4 Hall,J. Communication revisited. Calif.Manage.Rev. Spring 1973, p.56-57. 5 Hanson, PhillipG. Giving feedback: an interpersonal skilLin Pfeiffer, J. William. Annual handbook for group facilitators, edited by ... and John E.Jones. La Jolla, CA. University Associates, 1975. 6 Harris, Thomas A. I'm O.K.- you're O.K. Boston.G.K. Hall,1974. 7 Henning, Margaret. The managerial woman. by .. .and Anne Jardin. Garden City, N . Y., Doubleday, 1977. *8 Janis, Irving L. Group think. Psychology Today. Nov. 1971. 9 Kolb, David. Organizational psychology: an experimental approach, by ... et al. Englewood Cliffs, N .J . , Prentice-Hall. 1974. *10 Lawrence, Paul R. How to deal with resistance change. Harv.Bus.Rev. May/Jun. 1954. II Likert, Rensis. The nature of highly effective groups. I n Likert, Rensis. New patterns of management. New York, McGraw-Hili. 1961. * 12 McClelland. David C. That urge to achieve. Think magazine. 1966. 13 Y ura, H. Nursing leadership: theory and process. New York, Appleton-Century-Crofts, 1976. *References not verified in CNA Library Photos courtesy oro. Tetreault. Royal Victoria Hospital. Montrea] . Susan Spennrath(R.N., Central Middlesex Hospital, London, Eng.; certified urology nurse; CMBI: certified CPR instructor) is a nurse clinician teacher at the Royal Victoria Hospital in Montreal. Her previous nursing experience includes day and night supervision, urology,lCU, private duty, midwifery, outpatient department, and industrial nursing. Judith C. Tiivel is a teacher in the Staff Development Department at the Toronto General Hospital. She obtained herR.N. from the Royal Victoria Hospital and B.N. degree from McGill University, Montreal. Past work experience includes staff nurse , head nurse, industrial nurse, nurse clinician teacher. Areas of interest include developing programs to assist nurses to increase their skills in leadership, interviewing, and patient teaching. ",; ,.. The Cenedlen NUrH June 1117V 311 YOU AND THE LAW Patient's advocate - a new role for the nurse? The primary goal of almost all persons who are hospitalized is to regain and/or maintain their health. As long as they are sick, patients do not usually assert their rights with the same force as they might in a healthy and independent state. But once embarked on the road to recovery. it is a different story: patients today can no longer be considered passive recipients of health care, accepting whatever comes their way with an uncritical eye. They see themselves as consumer recipients of health care services and. as such. bring the critical attitude of the consumer to bear on their assessment of the nature and quality of care that they receive. As consumers, these patients frequently find that they are dissatisfied with the product that is offered. They express their dissatisfaction through the medium of published stories, articles and interviews and also through the formation of patients' rights associations, the goals of which are to apprise other consumer/patients of their rights and to encourage and assist these individuals in enforcing these rights. ., ----..\ L-- ... .\ Corinne Sklar The need for advocacy Nurses know that many people find the experience of hospitalization both depersonalizing and dehumanizing. Patients frequently complain to them of inadequate communication between the members of the institution staff and the patient and his family. They may consider the quality of care delivered by this staffto have been inadequate or even substandard. Their complaints are not limited to physical ministrations by physicians and nurses; frequently it is the affective or interpersonal component that is the target of their complaint. Patients report that staff behaved rudely, derisively, brusquely or with indifference in dealing with them. Such behavior tends to be accentuated in an environment which requires and oftentimes fosters the physical and emotional dependency of the patient-consumer. Under these circumstances, patients are vulnerable and may be acutely sensitive to the attitudes of the staff and tht: atmosphere in which their care is delivered. 40 June 1919 The Cenedlen Nur.. When patients believe that they have reason to be dissatisfied with the care that is available to them - both in quality and the manner of its delivery - to whom can they turn? Who will enforce their rights on their behalf? It is in this context that the special role of the "patient's rights advocate" has been advanced. This individual, according to one authority, is a person whose primary responsibility it is to assist the patient in learning about, protecting, and asserting his health rights within the health care context. I In the opinion of that authority, such an individual will perform an adversarial function in assisting the patient. The advocate will be concerned with the care of the patient as delivered by the total system: the hospital, the physician, the nurse. Others view the advocate's role more restrictively. In some institutions, a patient representative handles patient complaints but only those of an administrative nature. Grievances concerning the quality of care delivered by medical and nursing staff remain outside the representative's function. Here, only complaints related to patient comfort and convenience are the representative's concern. I n the light of such a sweeping definition of the role of the patient's rights advocate, it is not surprising that many members of the nursing profession have adopted the view that patient advocacy is an integral part of their function. However, before we can decide on whether or not nurses are taking on a new role in accepting this function, we should determine just what these legal rights consist of, either as they are asserted by the patient or by others on his behalf. Patient rights The rights of the individual around which COncern has been focused can be divided into three categories: . considerate care . consent . confidentiality. Looking at these three concerns it becomes obvious that they are united by the common thread of "communication". As stated earlier, there is no legislated list of specific patient rights. There have been, however. pronouncements of expected standards from many bodies. One of the most widely distributed statements is that of the American Hospital Association, published in 1973. 2 While called aBill of Rights, this statement is One of standards or guidelines and is of no legal effect. It does, however, reflect the classes of concern referred to above. In Canada, there is no list of these rights enacted by specific legislation but, as we shall see, our laws do cover the rights asserted. The effectiveness of the legal protection afforded by rights governed by Common law or legislation is considered inadequate because of the difficulties of implementation or enforcement of these rights by patients. The public is protected generally by provincial legislation governing the standards of practice of professionals in order to ensure the delivery of care by duly qualified practItioners. As well, there is legislation in each province with respect to the standards under which hospitals and other similar institutions must operate. Therefore, the general right of the public to receive competent health care is legally safeguarded. The purp05>e and intent of the A.H.A. statement and other similar pronouncements is to bring about more effective patient care and more satisfaction for the patient and those delivering patient carë through observance of the enumerated rights. . Consideration The right to considerate and respectful care is the first right enumerated in the American statement. That such a "right" has to be officially promulgated is a sad commentary on the quality of the relationship that exists between the patient and the helping professions. We cannot legislate tenderness, kindness or respect in their positive form. Instead, the negative aspects of human behavior are enjoined. Thus, it is deemed professional misconduct to abuse a patient verbally or physically. The positive qualities of behavior are promoted in professional codes of ethics such as the I.C.N. Code of Ethics for Nurses, for example, which states: "The need for nursing is universal. Inherent in nursing is respect for life, dignity and rights of man. It is unrestricted by considerations of nationality, race, creed, colour, age, sex, politics or social status". Under the heading 'Nurses and People" the I.C.N. Code continues: "The Nurse's primary responsibility is to those people who require nursing care. The nurse, in providing care, promotes an environment in which the values, customs and spiritual beliefs of the individual are respected." By bringing to their nursing care the essence ofthe Nursing Code of Ethics, nurses will safeguard the right of the patient to respectful and considerate nursing care. . Consent The patient's right to information and participation in the decision-making process is the area of major COncern of patient's rights groups. This concern is also reflected in the A.H.A. Bill in which six of its twelve articles deal with consent, two focusing primarily on consent in the context of the physician-patient relationship. The right to informed consent is most important. Similarly, the right to refuse treatment to the extent permitted by law must also be safeguarded. Where the patient is to be involved in research. experimentation or teaching, the right to sufficient information and the right to refuse to participate must also be safeguarded. The law has always protected the inviolability of the human body from invasion without consent or legal justification. The requisite elements of consent must be present for there to be valid consent in law. 3 While information for consent to major surgical and medical interventions is the responsibility of the physician, nevertheless, consent is an important element in the delivery of nursing care as well. Explanations to the patient of what is happening, or what to expect are appropriate even in the most simple terms. "I am going to change your dressing now" or "This may feel cold or sting a little" - minor communications, but their expression to an individual demonstrate the nurse's delivery of care to a person rather than "just a body". No doubt the lack of information given to patients during the course of their treatment lies behind the impetus for the right to access to medical records. Generally the view is that the chart "belongs" to the physician or institution while the information contained therein "belongs" to the patient. Policies and practices vary with respect to the patient's access to his record (unless of course the record is subpoenaed, i.e. required to be delivered by law). It may well follow that by increasing the quantity and quality of the information a patient receives and by facilitating the patient's participation in his care and treatment the demand for such access might well be decreased (/ tis beyond the scope of this column to discuss the pros and cons of this issue per se). The Cenedlen NUrH . Confidentiality The right ofthe patient to professional confidentiality is unquestioned. Failure to exercise discretion in disclosing confidential information about a patient is considered to be professional misconduct for which disciplinary action by the professional body may result. Further. a breach of confidentiality is in violation of the I.C.N. Code of Ethics: "The nurse holds in confidence personal information and uses judgment in sharing this information". Confidentiality applies to information written in the chart or received orally from or about the patient. 'I t is the duty of the professional nurse to maintain confidentiality and safeguard this responsibility to the patient. The nurse as 8 patient advocate It is my opinion that the responsibility ofthe nurse to protect these rights of patients is not new. Nor does this responsibility constitute a new role and function for nurses. Basic to nursing education is discussion of the needs of patients: identifying. recognizing. anticipating and meeting these needs is an integral part of delivering patient care. Communication and observation are important elements in fulfilling this aspect of nursing care. To extend the role of the nurse as a patient advocate to one of advising and assisting aggrieved patients who wish to take legal or administrative action. as has been suggested by some authors. might well strain the position ofthe nurse. Such a role could also result in conflict between the nurse and her co-workers (i.e. nurses. physicians etc.) or between the nurse and her employer (i.e. the hospital or other institution). It is important that nurses be aware of the rights of patients and of their own responsibility in safeguarding these rights. Such awareness is the first step in effective implementation and enforcement ofp tient rights. Nurses who put into practice the basic and ethical elements of patient care are. in my opinion. already functioning as advocates of the rights of their patients. .., References I Annas, GeorgeJ. The Rights of Hospital Patients. New York. Avon. 1975. p.21O. 2 Ibid.. p.25.and for a discussion of the need for a Canadian Patients' Bill of Rights, see also Rozovsky. L.E. A Canadian patient's bill of rights. Dimem. Health Sen'. 51: 12:8-10. Dec. 1974. 3 Sklar. c.L. legal consent and the nurse. Canad.Nllrse 74:3:34-37, Mar. 1978. 4 Sklar. C. L Unwarranted disclosure. C an ad . N llrse 74:5:6-8. May 1978. "You and the law" Is a regular column that appears each month In The Canadian Nurse and L'lnflrmière canadienne. Author Corinne L. Sklar Is a nurse and recent graduate of the University of Toronto Faculty of Law and Is currently artlcling with a Toronto law firm. -- ... . .... June 111711 4' , . G\}\l,"e @l s 1t\e \dent-A-B ion against ml)l.U ' a 'es t prote gre ,l . and il"cldents. \ pre"ents , C\ip.se a perproo mo"a\ etct\ing 1a"'nautt\ o riz ed r.e. pre"ents str t irritatiOn U ter. n \'" \"ln ln 9 t\e\PS pre"en . po\ye s V'ny\ s"e ath ontainlng s",oot" I e"a\uatiOn.Klt,. c emergency. send 'or a : r adu\t, ped: brace\ets. samp\es 0 b\ood and mothOr/babY. , I\.rr-þ( depend on ,\..Jt=.I OU can tt\e on\Y name Y Q LlO\ÙSTER . is 606 11 o po rated. ..... cag o IIIIno \nc or C"I' . d \1olliS ter C\"Iicago ",,,enueÌ1ollister LirT\lte . M2J 1 P8 211 East in canada by . da\e. ontariO Q istributed fl, oad. \NIIIO rn ers 322 conS u Selecting texts for next semester? Look to Mosby - for many choices in every nursing specialty. Medicall Surgical ".1 I i ORTHOPEDIC I i9 NURSING 1;\ l'iUJROLOGICAL AND NEUROSURGiCAL Nl;RSINC' New 7th Edition. Carini and Owens' NEUROLOGICAL AND " NEUROSURGICAL NURSING. t I ð_' By Barbara ng Conway. R.N., M.S.: \\ . y: WIth 3 contributors. Extensively revised , D 4. " and updated. the new edition of this widely ' \.. 4 adopted text .refI.ects both innovations in the "" {I, " ... Co fiel a.nd nursing s expanded role. It emphasizes tL "'\: holIStic nurs ng ca and the rationales for 'q speCific nursing actions. Three major : · ( sections focus on anatomy and ì ..,. " physiology of the nervous system. disorders \ . \\' of neurologic structures. and care of specific ,\l, r--\ disorders. You'll find important new ' \l chapters. on embryology. functional physiology. '\.1..Ü neurological assessment. sexual integrity. trophic \ f changes. and rehabilitation. July. 1978.656 pp., - 307 iIIus.. with 2 in color. Price. $2050. 2nd Edition. ADULT AND CHILD CARE: A Client Approach to Nursing. By Janet Miller Barter. R.N., M.S.; Lillian Gatlin Stokes. R.N.. M.S.; and Diane McGovern Billings. R.N.. M.S. Focusing on the patient as client. the second edition of this popular text integrates both adult and child care.according to basic human needs (safety and security. activity and rest. sexual role satisfaction. need for oxygen, nutrition. and elimination). The authors present much in-depth information on pathophysiology and discuss all aspects ofnursing care. 1977. 1,050 pp.. 738 iIIus. Price. $24.00. 6th Edition. MEDICAL-SURGICAL NURSING. By Kathleen Newton Shafer. R.N., M.A.: Janet R. Sawyer. R.N.. Ph.D.; Audrey M. McCluskey. R.N., Sc.M.Hyg.: Edna Ufgren Beck, R.N.. M.A.: and Wilma J. Phipps, R.N.. A.M.: with 28 contributors. The 6th edition of this classic text continues to focus on individualized care of the total patient. Throughout. you will find increased emphasis on physiology. pathophysiology. and nursing assessment. Particularly noteworthy chapters discuss cardiac disease. family planning. counseling. ecology and health. neurologic disease. musculoskeletal disorders. and injuries. 1975. 1.048 pp.. 608 illus. Price, $26.00. 9th Edition. ORTHOPEDIC NURSING. By Carroll B. lÄrson. M.D.. F AC.S.: and Marjorie Gould. R.N., M.S. Turn to this classic text for an up-to-date. comprehensive overview of orthopedic fundamentals. It describes - and graphically illustrates - the basic skillsand principles essential for planning and implementing holistic patient care. New student-oriented features include: a definitive chapter on emergency nursing in the orthopedic unit; a detailed section on anatomy and function of joints; and revised material on bone tumors. amputations. and caring for the ærebrovascular patient. 1978.508 pp., 466 iIIus. Price, $18.00. New 2nd Edition. HUMAN SEXUALITY IN HEALTH AND IllNESS. By Nancy Fugate Woods. R.N.. Ph.D.: with 7 contributors. This new 2nd edition again explores all facets of the complex phenomenon of sexuality. Three major units examine the biopsychosocial nature of human sexuality. analyze sexual health and health care, and define clinical aspects of human sexuality. You'll find 4 new chapters: assessment of sexual health; roles for professional nurses in thedeliveryofsexual health care: sexuality. fertility. and infertility; and sexuality and mental health. March. 1979.412 pp.. 11 iIIus. Price, $12.00. PATIENT CARE STANDARDS. By Susan Martin Tucker. R.N.. B.S.N.. P.H.N.; Mary Anne Breeding. R.N.; Mary M. Canobbio. R.N.. B.S.N.: Gloria D. Jacquet. R.N.: Eleanor H. Paquette. R.N.: Marjorie E. Wells. R.N.; and Mary E. Willmann, R.N. This book presents patient care standards to help the student plan, implement. and evaluate nursing care. A clear. concise outline format stresses the observation. management, and teaching required in individual patient situations. Every aspect of effective care is explored: the patient's physical. psychosocial. and emotional needs: medical conditions; surgical interventions; diagnostic procedures: chemotherapeutic agents; and supportive mechanical equipment. 1975.442 pp.. 71 iIIus. Price.518.00. 6th Edition. Alexander's CARE OFTHE PATIENT IN SURGERY. By Marie J. Rhodes, R.N., B.5.N.; Barbara J. Gruendemann. R.N.. M.S.: and Walter F. Ballinger. M.D.: with 21 contributors. long respected for its accuracy and completeness. this classic text provides a comprehensive overview of safe. efficient OR nursing. More than 2.000 supertJ illustrations (half new) augment forthright discussions of asepsis. positioning. wound healing, surgical procedures. and other important subjects. 1978.904 pp.. 2. 146 iIIus., including 2 in full color. Price, 530.00. MOSBV TIMES MIRRDR THE C. V. MOSBY COMPANY. L TO. B6 NORTH LINE ROAO TORONTO. ONTARIO M4B 3E5 Review 9th Edition. MOSBY'S COMPREHENSIVE REVIEW OF NURSING. Edited by Dolores F. Saxton. R.N.. Ed.D.; with Patricia M. Nugent, R.N.. A.A.5.. M.S.; and Phytlis K Pelikan, R.N..A.A.S.. MA. assistant editors; with 1 0 contributing authors. The latest edition of this widely acclaimed volume is clear. concise.andcomplete.ltreviewsall nursing and nursing related areas essential to any inserviæ or refresher program. All content has been field tested for accuracy, reviewed, and updated to answer today's nursing needs. You'll appreciate important matenal on psychosomatic disorders. parent , ,. .\ 197. "j 1 . I. lutl. II' holdl'( 11 Dr. C. Keith Conners Professor of Psychiatry Department of Psychiatry Western Psychiatric Institute and Clinir University of Pittsburgh School of Medicine Dr. Gabrielle C. Weiss Clinical Director Department of Psychiatry Montreal ChiJdren's Hospital For IftCIft information write to: The Secretary 1979THISTLETOWN SYMPOSIUM 51 Panorama Court, Rexdale Toronto, Ontario. M9V 4L8 nurses must be revised. She urged nurse educators to develop mechanisms adaptable to individual nurses and their learning needs. In conclusion, she stressed the need for the development by the CNA of more specific standards on continuing education for nurses in Canada. With the rapid change in health care technology and the abundance of information available. how do nurse educators even begin to identify the learning needs of nurses? This was the question posed by Margaret McCrady, the third speaker on the agenda. Currently the member-at-Iarge for nursing education on the CNA board of directors and also the director of education services at the Health Sciences Centre in Winnipeg, McCrady discussed the identification of learning needs. She mentioned a number of techniques to identify real learning needs from other categories of needs or from perfonnance problems. She encouraged the use of advisory groups. interviews. informal communication, questionnaires. brainstonning sessions, pre and post tests, analysis of management records and reports. and surveys of professional literature to help the nurse educator identify real educational needs of nurses. McCrady warned that it is unrealistic to hope to meet all the learning needs of nurses and that educators must identify learning priorities. The final speaker, Josephine Flaherty, Principal Nursing Officer, Health and Welfare Canada. discussed the problem of record keeping and recognition of continuing education crf'dits. The objective of her talk was to sensitize nurses to the complexity of the issues involved and to pose questions for the audience to consider. For example: Are records ofCE necessary? What infonnation should be kept? Who should keep records: the individual. the employer. the educational institution, the statutory body? When considering the recognition ofCE credits, Flaherty asked, "What are we recognizing?" Are we looking at attendance, sponsorship, content. skills or marks? When a nurse receives CE credits, does this warrant a change in pay, job responsibility. or privilege? Flaherty's message came through loud and c1ear- nursing must carefully think about these issues before making decisions about continuing education for nurses in Canada. Background In the past. a number of attempts have been made to organize a national meeting on continuing education for nurses. It was not until last year, however. at theCNA meeting in Toronto in lune. that 78 concerned nurses met to discuss the issue. From this group, a core planning committee was developed, composed of: Helen Niskala, RPNABC; Kathy Clarke, RNAO; Mary Hammond. U of Alberta; Ruth Burstahler, RNABC; Rita Lussier. OIlQ; Marina Heidman. Humber College, Toronto: and Kay de long. MARN. The audience acknowledged that it was to the credit of the pldnning committee that this first national meeting was a learning experience for all concerned. Did you know... A research project to examine a link between migraine headaches and weather will be conducted jointly by the Atmospheric Environment Service of Environment Canada and The Migraine Foundation. The project will study the so far unproven belief that certain kinds of weather can trigger or worsen migraine attacks which affect at least 20 per cent of the population. '" Th. C....dl.n NUrH Jun. 1979 47 research Resumes are based on studies placed by the authors in the CNA Library Repository Collection of Nursing Studies. Behaviours of Patients behaviors on only a few Evaluation of Alberta use of practices to d irectl y Described by Nurses in occasions, and most often Nursing Instructors. observe the nursing instructor Medical-Surgical Areas in from the families of patients. Edmonton, Alta., 1977. and the possibility of the Initiation of Two-thirds ofthe nurses Thesis (M.Ed.), constructing evaluation Psychiatric Referrals. reported delays in the referral University of Alberta by instruments based upon Toronto, ant., 1976. process. The major reason Lee Ellen Cadman. criteria which were identified Thesis (M.Sc.N .), was that physicians were This study was designed to as important. University of Toronto by often not convinced that the examine the perception of Carole Lee Thomson reported behaviors did in fact nursing instructors in Alberta An Exploratory Study of (H endrikson). exist. Patients were able to regarding I) actual and the Behaviors of Children This study was a descriptive present acceptable behaviors preferred evaluators 2) data in Pain. Montreal, survey of a group of forty to the physicians while nurses gathering practices and 3) Quebec, 1977. Thesis, nurses who were interviewed saw and reported other criteria for assessing the (M.Sc. (Applied) in in medical-surgical areas to behaviors. The nurses said effectiveness oftheir Nursing), McGill detennine what patient that their contacts with teaching. A questionnaire, the University by Judith behaviors had stimulated resource personnel did not Nursing Instructor Evaluation Macintosh. them to request psychiatric delay the consultation process Instrument, was distributed to The purposes of this consultation referrals within to any significant degree. On those teaching nursing in exploratory study were to (I) the past year. It also sought to only one occasion was the diploma or basic validate the pattern of identify the other resource suggested referral mentioned baccalaureate programs. behaviors observed during personnel contacted to to a patient before the request Personal and professional fieldwork with school-aged improve communications with was made. Only rarely did infonnation and the actual and children experiencing pain, patients before consultations physicians observe patient preferred importance of 12 and (2) verify that this pattern were requested. An interview behaviors; usually, they data gathering practices and of behaviors occurs regardless schedule of closed and learned of them through 30 evaluation criteria were of the amount of pain open-ended questions was nurses' notes and progress requested and a statistical experienced. used. notes, Kardex rounds, or analysis was done. A pattern of six behaviors The patients most reports of nursing care Senior administrators and in four phases was observed in frequently identified as conferences. immediate supervisors were fieldwork. These were: requiring psychiatric The m ority of nurses seen by the teacher as the Phase I: crying or sobbing: consultation by the nurses expressed the viewpoint that most important evaluators but Phase 2: (a) calling out to were those who were they should be actively they would prefer that others to relieve the pain, uncooperative in their involved in initiating instructors themselves and (b) describing the sensations responses to nursing care or psychiatric referrals, that they immediate supervisors be felt as painful; treatment or were a physical and the physicians needed to most important. Master's Phase 3: (a) making threat to themselves or others. be more aware of patients' level prepared instructors and suggestions about how care Less frequently identified psychological problems, and those teaching in may be conducted more were patients who did not that they should collaborate baccalaureate programs had comfortably. (b) cautioning directly express their more effectively. The the strongest preference for others to treat the injured area psychological distress or recommendations included: peer evaluation. They also gently; needs. Nurses referred (l) the creation of a direct saw and preferred more PhasE: 4: requesting specific patients for psychiatric nursing referral system to a student involvement in the care and diversional activities consultations from various mental health psychiatric evaluation process than did Thirty-three children, medical-surgical areas. No nursing consultant through other Alberta nursing between five and twelve years predominant medical which nurses in instructors. The instructors old composed the sample. A conditions accompanied the medical-surgical areas could preferred that a broader range five point scale was selected behaviors for which nurses make infonnal requests for of data gathering practices and as a pain estimate for children. initiated consultations. Other help with patients in criteria be utilized in Each child rated his pain on reasons for psychiatric psychological distress; (2) evaluating their teaching this scale for three-five days. referral were the nurses' more regular collaboration effectiveness especially At the same time, the concern about patients' among resource personnel; practices involving the direct investigator observed and diagnoses, and their need to and (3) closer liaison between observation of the teacher; recorded each child's plan for care or discharge. nurses in medical-surgical criteria involving evaluative behavior on a behavioral Nurses contacted resource areas and nurses in and communicative skills observation schedule. While personnel primarily to have. community health when were considered important. no significant trends were them solve patient problems planning for the patient's There is a need for further established, there was a rather than for assistance in readjustment to the assessment of the roles tendency for the children to coping more effectively with community. various personnel might play follow in the pattern of the six patient behaviors. Nurses in Alberta nursing instructor listed behaviors. 'j, sought clarification of patient evaluation, development and 48 June 1979 The Cenedlan Nur.. input (continued from P38e 6) A reply To the nurse who writes that she has worked 25 years with Indian patients in the Wetaskiwin Hospital (February CNJ), I have worked ten years among the people on this reserve which is populated by approximately 4,500 people who are lucky enough to be among the Albertans who have had oil discovered on their land - I repeat, their oil on their land. These native people have been able to build many lovely homes with the royalties from this resource. I have been in virtually every home in my area of the reserve. I could count on the fingers of my hands the poorly cared for or dirty homes. The remainder are clean, tidy and most attractively furnished. Like the farming population a generation ago, vegetables are their priority. You can't eat flowers! The people are, however, beginning to take a real interest in a more attractive yard. It's only lately. that there has been water available to establish nice lawns. You insinuated that Indians would rather live on oil money and welfare than work. Have you talked to any unskilled young people lately who are trying to enter the work market? I think not, or you would have a more realistic view as to the impossible employment situation. A large percentage of the people on the reserve do hold jobs. Indians receiving oil money do not receive welfare. The bands are, in effect, paying their own welfare with oil revenues. Native people have both strong points and faults. Like the rest of us they aren't perfect. They are individual human beings, and deserve respect and consideration. -Beth Mason, Community Health Nurse, Hobbema Reserve, Alberta. A gradual process Ms. Walker\ one-sided letter (Input, January) left a very bad taste in my mouth. Having worked on two reserves for more than four years, I can appreciate her frustrations. But changing attitudes and health practices is a long and difficult process in any community and I think she forgets that she is dealing with people whose culture goes back many years and whose contact with health education is, by comparison, very recent. There is some truth in what she writes but she forgets the positive aspects of working on a reserve and with Indian people. I agree that changes are needed. Perhaps her attitude might be a place to start or perhaps she should consider working elsewhere. -Patricia Foster, RN, BScN, Nursing Station, Big Trout Lake, Ontario. Say it isn't so Surely no public health nurse would advocate a hospital patient being meek, submissive, uninformed and totally accepting of poor and unsympathetic care. I refer to the March article, "That's no nurse...that's my mother!" A good patient should not accept things such as a leaking I. V., an inadequate diet for a nursing mother or criticism for arriving late when the lateness is due to feeling weak. 1 realize the article was written from a human interest point of view. However, the concept of the only good patient being one who questions nothing is one which should have been dropped years ago. A well-informed, involved patient will progress far better and make nursing a more rewarding career. -Kay Cunningham, P.H.N., Guelph, Ontario. g :f. :YmodICOI I \ S ;HY : ; :S g lt Ä .T ;;Ot d5o;r IY t:J h - \ S ?n 5 . : .. I . 0"n o 'c o ' c r B . .nd_ colours Exc.pllon., Bound - h ---.:.:.. i . ',on.ml..lon Adlu.toblo "Oh'-. \111 weigl'll binaural.. h.. both \ diaphragm and bell wllh non- .. chili rlna ChOON Black, Red. \.,. I :' 79 'ï;3 ;: ' SINGLE-HEAD TYPE. Aa abO\le . I I but WI thou I b4111 Same larg. ' 1 '. \"1 8'N ,-r;.'M'OhÓt ;:W;g c :3 :; :0". t ' but nol TYCOS brand Sarna 2 y..r guarAnt... Complele :11 ;I . I :r:80ml II;-a P.. Dual-HNd No. l'O,,7.a5... LISTER BANDAGE SCISSDAS J.4anulaelur 0' IInesl .t..1 A A ; ? nur.. NO egg, 4"'" No 700,5\2" No 702.7'1.. HAEMOSTATIC FORCEPS (KaIIY) 'de., tor cl.mplng 011 lublng, .Ie Dozens of u.... S..lnl.s. .t..I, loeking.ype, 5 " long. 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No mo'..nnoyino ;nk 1 s,aln. or Irayed edge.. 3 compal1ments 'or pena, leisaor.. atc., plua changa pockeland kay chain Whltecalr Plaalahida No.50511.II..c:h. MEASURINQ TA':E In a.rong pl..Ue ca... -. Pulh button ror sprin , relurn Mada o. durab e '\ linen M...urea.o 78'. on one IIlde. 200 cm on " reverIM 14.11$ ..ch NDTE: WE SERVICE AND STOCK SPARE PARTS FDA ALL ITEMS. CAP STRIPES S."-adhealve Iype, f.movabl. and re-u..bl.. No 522 RED, No 520 BLACK. NO. 521 BLUE. No 523 GAEY AII15Y.!" Le; ::_red 11"') 12 slflpe. pef cant 3' ENAMELLED PINS. Beautifully d.algned 10 Show - - your profe..lonal ..alu. Jew.lry quality In heavy gold . ,,; . plale. With ...ety cla.p No !t01 C:C=':7: = =:: No. 502 p,.ctlcel Nu.... NURSES EARRINQS. Fot pIerced No 503 Nun... Ald. ears D.lnly Caducau. In gold plate AIIII.i.each_ with gold ' . Uled po.ts. Beautifully 1\ gilt bO.ed. No. 325. 111.41/ pro n .- +0 l SCULPTUAEDCADUCEUS ed to your prol..Slonal letler.. H..vlly . P åt bo;l ia . =h N, No. 401 "EMD-TIMEA. 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Satin rg,..n lanera ....71 17.M USE A SEPARATE SHEET OF PAPER IF NECE5SAA : . .... ............ .......................... .... ........................... .............. .............................................................. ADD !tOe HANDLING CHARGE IF LESS THAN 110 C 0.0. ORDER ADD 12 00 NO COD ORDERS FOR NAME-PINS TOTAL ENCLOSED M.O L CHEQUE "lCASH 1 line letter. 2 linea len.rs S," 14." 13.11 ONE-STOP SHOPPING for most of your antiseptic needs . .'\ . . \ . - ..;;.. .. "-... - _ . I -... -, I - JI ' -1/ ' _ '1, f .. II . .. - ,1 - --- ..... ..... ..... """-- , . .... ..lll " Ittl II 'I I 'J ..- ..... '" ....... III " iii . - ... y: ...... . ,. " .... , 4W4 ;- 4' .. I...Jo:' .. " .. II HIBITANE* Skin Cleanser a sudsing, antiseptic cleaning solution containing 4% w/v chlorhexidine gluconate for preoperative scrub-up and general hand washing. HIBITANE* Gluconate 20% Solution a multipurpose, broad-spectrum antiseptic cåncentrate for preoperative patient preparation, and general disinfectant use. Each product in the A YERST antiseptic line lives up to a well-eamed reputation for quality which is backed by AYERSrS technical expertise. More and more Canadian hospitals are making A YERST their prime source of antiseptic products and information. If you would like to know more about any or all of these products. contact your A YERST representative or complete and retum this coupon. AYERST LABORATORIES r - ---, . 11vision of Ayerst, McKenna & Harrison Limited Quol I'tøs Montreal, Canada L- l no suu>t,Me I MACI .Reg'd mgrr:fR 1 I 'E N made ,n Canada by arrangemenlw'lh IMPERIAL CHEMICAL \ SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetic equipment. 1-------------- TO AYERST LABORATORIES I 1025 Laurentian Blvd.. Montreal. Quebec. H4R 1J6 I I 0 Hibitane. Gluconate I 20% Solution I NAME I ADDRESS I NO I CITY I would like to receive information on: o Hibitane. Skin Cleanser = Savlon" Hospital Concentrate o Sonacide" IPLEASE PRINT, STREET 50 June 1979 A catalogue of special interest groups (continued from page 16) Orthopedic Nnrses Association, Montreal Chapter Contact: Mrs. J. McAdam 9 West Royal Victoria Hospital 687 Pine Avenue West Montreal, Quebec Société du Timbre de Noel du Quebec, Inc,/Quebec Christmas Seal Society, Inc., Nurses Section Présidente: Liliane Beaudry c/o 264 rue Chénier Québec, Québec GIKIR2 NEW BRUNSWICK Association of New Brunswick Registered Nursing Assistants/ Association des infirmières auxiUares enreglstrees du Nouveau Brunswick 39 Coventry Road Fredericton, N.B. E3B 4P4 New Brunswick InfediQn Control Practitioners Group President: Joline Voye Carleton Memonal Hospital P.O. Box 400 Woodstock, N.B. EOJ 2BO New Brunswick Occupational Health Nursing Group (NBOHNG)/Groupe de Spécialisation du Nursing de la Santé au Nouveau Brunswick (GSNSNB) President: Pamela Innes West Saint John Community Hospital Prince St. West Box 3610 West Saint John, N.B. E2M 4X3 New Brunswick Operating Room Nurses Group (NBORNG )/Groupe d'infirmières des Salles d'opération du Nouveau Brunswick (GlSONB) Contact: Donna Goodin c/o New Brunswick Association of Registered Nurses 231 Saunders Street Fredericton. N .B. E3B IN6 The Cenedlen Nur.. Respiratory Interest Group, Fredericton Onterdisciplinary) Chairperson: Margaret Irwin Physiotherapist Victoria Public Hospital Contact: Alma Leclerc Program Director New Brunswick Tuberculosis & Respiratory Disease Association Box 1345 Fredericton, N.B. E3B5E3 NOVA SCOTIA Ambulatory Care Nurses Interest Group, Nova Scotia Contact. Louise Corbett Dalhousie Family Medicine Centre Dalhousie University Halifax, N.S. B3H 3J5 Atlantic Maternal & Newborn Nurse-Midwives Association Contact: LyndaDavies MacDonald School of Nursing Dalhousie University Halifax, N.S. B3H 3J5 (forN .5. & P.E.L) Contact: Hope Toumishay School of Nursing Memorial University St. John's, N fld. A Ie 5S7 (for Nfld. & Labrador) Directors of Nursing Service, Nova Scotia (RNANS Affiliate) Coordinator: Yvonne Nichols Director of Nursing Western Kings Memorial Hospital P.O. Box 490 Berwick, Nova Scotia BOP I EO Emergency Nurses Association of Nova Scotia PresIdent: Marilyn MacVicar 12A Owen Drive Dartmouth, N. S. B2W 3L9 Evening and Nigbt Supervisory Gronp, Nova Scotla/Gronpe de SurveiUance de Soirée et de nuit, Nouvelle-Ecosse Chairman: Kay McGuire SI. Rita Hospital 409 King's Road Sydney, Nova Scotia BIS IB4 Gerontological Association of Nova Scotia Contact: Jean MacLean c/o RNANS 6035 Coburg Road Halifax, N.S. Bm IY8 Nova Scotia Certified Nursmg Assistants Association 12 Marvin Street Dartmouth, N.S. B2Y 2M I President: Albert Mad ntyre Nova Scotia Operating Room Nnrses PresIdent: Bernice Frances c/oO.R. Plastic Service V ictoria General Hospital Halifax, N.S. B3H 2Y9 Occupational Health Nurses Association of Nova Scotia President: Ann MacMullen Crossley Karastan Willow Street Truro, N .S. B2N 4Z5 Psychiatric Nurses Association of Nova Scotia 4 Christopher Avenue Dartmouth, N.S. B2W 3G3 Secretary: E.I. Shortt PRINCE EDWARD ISLAND Licensed Nursing Assistants Association of Prince Edward Island President: Debra Thistle Contact: Mrs.-J.E.V. Bolger Depl. of Health P.O. Box 1253 Charlottetown, P.E.I CIA 7M8 NEWFOUNDLAND Infection Control Association, Newfoundland President: L. Case c/o General Hospital Health Services Centre Prince Philip Drive St. John's, Nfld. AIB3V6 Newfoundland Nursing Assistant Advi!lOry Committee P.O. Box 8234 St. John's, Nfld. AIB3N4 NORTHWEST TERRITORIES Registered Psychiatric Nurses Association of the Northwest Territories President: Sheila Duff Box 2580 Yellowknife, N.W.T. Acknowledgement Thanks go to the staff of the CNA Library for their assistance in the research of this article and to the national associations and interest groups whose enthusiastic responses helped to paint a clearer picture of what is offered through association membership. Tilkian & Conover Understanding Heart Sounds and Murmurs Here's an exciting new pack- age that provides a basic familiarity with normal heart sounds and allows recogni- tion of life-threatening disorders manifested by abnormal heart sounds. Pack- age includes G-60 cassette plus soft cover book. By Ara G. Tilkian, MD, FACC and Mary Boudreau Conover, RN, BSN, Ed. Packaqe. $16.95 Order #8878-0. Book only. About 120 pp. lIIustd Soft cover $895. Ready soon. Order #8869-1. The 1979 Saunders Winners Circle Drain & Shipley The Recovery Room Two leading experts provide clear, accurate coverage of the recovery room in this exciting new book. Topics include the physiology of anesthesia, the èffects of various anesthetic agents, specific care after all types of operations, and factors that affect recovery from anesthesia in particular patients. By Cecil B. Drain, RN, CRNA. BSN; Major. Army Nurse Corps., and Susan B. Shipley. RN, MSN; MaJor. Army Nurse Corps 608 pp.. 167 ill $1695. March 1979 Order #3186-X. Dienhart Basic Human Anatomy and Physiology 3rd Edition The new third edition of an already popular text has been revised with special attention to the chapter on the nervous system and includes expanded coverage of cytology and histology, an expanded glossary and outstanding new illustrations. By Charlotte M. Dienhart. PhD 311 pp. 171111. $9 95. Soft cover Ready soon. Order #3082-0. Krause & Mahan Food, Nutrition and Diet Therapy 6th Edition Featuring new material on stress responses, nutrition and cancer and the low-birth-weight infant, this strong revision is even better suited to your needs. Many new graphs, illustrations and tables highlight and enhance better understanding of all aspects of nutrition. By Marie V. Krause, BS, MS, RD and L. Kathleen Mahan, RD, MS. 963 pp., 254 ill $18.50. Jan. 1979. Order #5513-0. Bleier Bedside Maternity Nursing 4th Edition This new edition includes new and updated material, a new chapter on economic and social problems of the modern family and current issues in maternity care. By Inge J. Bleier, RN. BS, MS. About 360 pp., 160 ill. Soft cover Ready soon. Order #1743-3. Watson Medical-Surgical Nursing 'and Related Physiology 2nd Edition Thoroughly revised, this new edition includes the latest infor- mation on topics ranging from patient's rights, response to illness and physical assessment to immunologic response, shock and much more The chapters on cardiovascular disease and the nervous system have been extensively revised. An excellent choice for those preferring a smaller medical-surgical text. By Jeannette E. Watson, RN. MScN About 1010 pp 175 ill. About $19.50. Ready soon Order #9136-6. Keane Essentials of Medical-Surgical Nursing You'll find coverage of the general concepts related to illness and nursing as well as medical-surgi 1 nursing care problems in this introductory text. Student aids include: learning highlights; vocabulary lists; summary tables; and a student study aid section consisting of learn- ing activities, additional readings, and a study outline. By Claire B. Keane, RN, BS, MEd. 721 pp., 187 ill. About $19.95. Ready soon. Order #5313-8. -............... . To order on 3D-day approval, . . enter order '# and au thor: CN 6/79 . . I I L I I . . AU AU AU I o check enclo8ed- Saut\den pay. po.lage . We accept VIsa and Mastercharge. -=- I I D Visa # OJDD ODD ODD [[]] I I D Master Charge # moo DODD [ll] ODD I I Expiration Date I nterbank # DDCIJ I I I Full Name , I I I ZIP I . I I I . I I I Posillon and Affiliation (If Applicable) Home Phone Number I Home Address I CIty I . SIgnature All prices differ outsIde U S. and subject to change. I I W.B. Saunders Company . West Washington Square Philadelphia, Pa. 19105 in Canada: 1 Goldthorne Ave., Toronto. Onlario M8Z 5T9 In Englend: 1 SL Anne's Rd., E..lboume, Eesl Sussex BN21 3UN In Austrella: 9 Weltham Slreet, Arlarmon N.S.W 2964 State 52 June 1979 The C.nadl.n NUrM books Into aging, a simulation game by Therese Lemire Hoffman and Susan Dempsey Reif. 90 pages. Thorofare, N.J.. Charles B. Slack, 1978. Approximate price: $12 .50 I nto Aging, a small paperback manual, describes a unique simulation game developed by two nurse educators for the purpose of sensitizing players to the issues cQnfronting those over 65. The manual would be of value to anyone wishing to provide experiential learning about aging to groups oflay persons, skilled personnel or professionals. I feel it has particular value for use with students who are or will be encountering the elderly in their practice but would recommend that the teacher/facilitator already possess a knowledge of the aging process and well-developed group leadership skills. The simulation game outlined in the manual is introduced by a foreward, a preface, an introduction and an overview. Shirley Smoyak, author of the foreward. notes that the game was well-researched in its development; I feel, however, that one weakness throughout the manual is the lack of documentation and supplemental references. The preface is a loose clarification of the premises underlying the game UInto Aging" and describes such factors as the potential harmful effects of inappropriate stereotypes of aging and the value of simulation games for learning. The introduction raises the reader's awareness of key societal issues such as life expectancy and social structure, retirement, physical changes of aging and the need for public education. The overview describes the format ofthe game "Into Aging" and outlines briefly the physical and human resources needed to play the game. The next section of the book is entitled, "Playing the Game"; it is written in extra large print, giving it the appearance of a first grade reader. The required physical layout of the room is diagrammed and the specifics of the game are outlined. Players will pass from an identity table on through stages of independent to dependent living, based on the instructions they receive in selecting life event cards, which are included in the appendix. Also included in the appendix are detailed lists of the materials required at each table. Having played the game through, I found the instructions to be adequate and the cost of the needed materials to be less than $10. The discussion which followed my use ofthe game was lively and meaningful and addressed many of the issues outlined in the section of the book entitled "Debriefing". The 4 game facil- itators had mixed reactions to enacting the prescribed roles since the instructions clearly require them to be stereotyped and powerful in their interactions with game players. While bearing some of the fun associated with the playing of Ugames" , this manual affords educators an opportunity to provide a serious re-evaluation of basic attitudes and practices in the care of the elderly. Indeed, "Into Aging" is a creative contribution to nursing literature. Reviewed by Elaine M. Mullen, R.N., M.S.N., Assistant Professor. Faculty of Nursing, Lakehead University, Thunder Bay, Ontario. Critica) Care Nursing, 2d ed by Carolyn Hudak, BarbaraGallo, and Thelma Lom, New York,J.B. Lippincott, 1977. I have found this an excellent text of core information, useful both to the nurse starting in a critical care setting and to the nurse with critical care experience. Texts dealing with specific areas of critical care (ie. coronary care) would be more useful to a nurse interested in a particular aspect of critical care, but, as a basic text this book is a good choice. This second edition has been revised and updated. based on the premise that role functions will continue to expand "particularly for the critical care nurse practitioner, and will involve the incorporation of more highly technical and intellectual skills to match the increasing responsibilities in the patient care arena" . The text uses current theory and information with an emphasis on technical skills as well as theory. A chapter dealing with the psychosocial aspects of critical illness for the patient, the family, and the nurse includes a useful approach for dealing with sensory input emphasizing planning and" quality of stimuli in the external environment" . Each ml\Ïor body system is dealt with in a separate chapter, preceded by a review of the relevant anatomy and physiology. Frequently encountered problems and "management modalities" or interventions used in the critical care setting are covered in relation to each body system. The sections on assessment are presented clearly and contain much useful information. Sections on arrythmias and hemodynamic pressure monitoring (including the use of pulmonary catheters) cover the theory and the skills involved. In depth coverage of blood gases and acid-base balance meets the need for greater understanding of this area, a need commonly felt by critical care nurses. The neurological assessment covers the important points, emphasizing the importance oflevel of conciousness as the most reliable reflection of neurological status. The "Management modalities" covered are easily understood and include helpful hints the authors have gained from experience. The text covers a range of implementations from positioning the spinal cord iQjured patient to the use and management of cardiac pacemakers, with a well organized, clinically-oriented presentation. Looking to the future, a review of endotracheal intubation is included but coverage of the management of ventilators is limited. The section on C.P.R. continues to recommend the use of precordial thump in a critical care setting. Exercises in the accompanying workbook cover" a range of critical care concepts from anatomy and physiology to the emotional aspects of a critical care environment" . The question methods used encourage application of the material as well as assessment of knowledge. Reviewed by Pamelq Carroll,lnstructor, Royal Jubilee Hospital School of Nursing, Victoria, B.C. library update Books and Doc:uments 1. Bar/cns, J. L. Protecting yourself against crime. New York, Public Affairs Committee, c1978. 28p. (Public Affairs pamphlet no. 564) 2. Bradley, C. F. The Vancouver Perinatal Health Project: a summary report, by . . . et aI. Vancouver, Vancouver Perinatal Health Project, 1978. 42p. 3. Bur au int rnational du Travail Annuaire des statistiques du travail, 1977. Genève, Organisation internationale du Travail, c 1977. 909p. 4. By rs, VirginiaB. L'infirmièreet I'observation. 3. ed. Paris, Maloine, 1978. 128p. 5. Canadian Council on Childr n and Youth Task Forc on th child as a citiz n. R port. Admittance restricted, the child as a citizen in Canada. Ottawa, Canadian Council on children and youth, 1978. l72p. 6. Canadian Nurs s A ssociation Brief to the Commission of Inquiry on Educational Leave and Productivity. Ottawa, 1979. 2Op. R 7. Cournoy r, Mauric Notions élémentaires de pathologie médicale. 2d ed. rév. par Noël Verschelden. Ottawa, Editions du Renouveau pédagogique, c1968. 201p. 8. Cr ason,NancyS. Effects of external funding on instructional components of baccalaureate and higher degree nursing programs. New York. National League for Nursing, c1978. 74p. (League exchange no. 119) (NLN Pub. no. 15-1732) 9. Federer. Marge Nursing is a "human" profession not a "female" profession. Milwaukee, 1976. 23p. 10. International Seminar on Health Education, Hamburg, 1969 Behaviour change through health education: problems of methodology; reports on fundamental Bachelor of Administmtion (Health Services) Degree Progmm Applicalions are now accepled for the program combining independent study ..ith tutorials on weekends in T oroDtO, as well as for the competency based, external depu inlernship option offered for students at a distance. Credits loward advanced standing are given for practical managerial experience and prior education includina B.A., B.Se., B.Se.N., R.N., R.T., H.O.M. Cenificate and University or CoIleøe Courses. The Sehool is a member of Ihe Association of University Prosrams in Health Administralion and is supported by the Kelloa Foundation grant. For information and applicalion forms, please write to: Cuadlaa School of Mauaemeat 8.425, OISE BulJdlq 252 Bloor St., West ToroBto, Ûlltario M5S IV5 The C.nedlen NUrN research in health education, presented at the . . . (communication, media comparison, evaluation) March 1969, Hamburg, Federal Republic ofGennany. 2d ed. Geneva, International journal of health education, cl979,1978.272p. II. Ison, TerenceG. Human disability and personal income. Kingston, Ont. ,Industrial Relations Centre, Queen's University, c1977. 33p. 12. Jones, Dorothy A. Medical-surgical nursing: a conceptual approach by . Claire Ford Dunbar and Mary MarmoU Jirovec. Toronto, McGraw-Hill, cl978. 1418p. 13. Leduc A. Le drainage Iymphatique; Theorie et pratique. Préface du Pr. R. Vanden Driessche. New York, Masson, 1978. SOp. 14. Meyer, DIane Grasp; a patient infonnation and workload management system. Rev. Morganton, N.C.M.C.S., cl978.2I1p. 15. National League for Nursing Concepts and components of effective teaching. New York, cl978. 86p. (NLN Pub. no. 16-1750) 16. -. Dept. of Diploma Programs Charting a course for future action for diploma programs in nursing; papers presented at the 1978 annual meeting of the Council of Diploma Programs, held in New York during April 1978. New York, 1978. 42p. (NLN Pub. no. 16-1741) 17. -.Dept.ofHomeHealthAgenciesand Community Health Services Publicity for your community health 88ency. New York, 1978. 37p. (NLN Pub. no. 21-1748) 18. Practical Manual for patient-teaching, edited by Kara S. Zander et aI. Toronto, Mosby, 1978. 394p. 19. Queen's University. Industrial Relations Centr Cafeteria, deferred and flexible compensation; a bibliography 1970-78. Compiled by the Research Reference Section. Kingston,Ont., 1978. 4p. 20. Queen' s University. I ndustrial Relations Centr Executive and management compensation. Compiled by the Research Reference Section. Kingston,Ont., 1978. 26p. 21. - . Profit sharing; a bibliography 1970-1978. Compiled in the Research Reference Section. Kingston, Ont., 1978. 5p. 22. Registered Nurses' Association of Ontario Community health nursing. Toronto, 1978. I3p. 23. - .Guide to responsibilities and qualifications of nurse educators in universities, colleges and nursing assistant programs. Toronto, 1978. 27p. 24. - . Statement on the role and function of the nurse practitioner. Toronto, 1978. 2Op. 25. Ro mer. Milton I. Health manpower policies under five national health care systems. Insights for the United States from the experience of Australia, Belgium, Canada, Norway and Poland, by . . . and Ruth Roemer, Los Angeles, Ca. School of Public Health, University of California, 1977. Reproduction. Springfield, Va., National Technical Information Service. 229p. 26. Saltman, Jules Immunization-protection against childhood diseases. New York, Public Affairs Committee, cl978. 21p. (Public Affairs pamphlet no. 565) 27. Trainex Corporation Trainex health education catalogue. Garden Grove, Ca.. 1978. Iv. (loose-leaf) June 1179 53 p o S E ) "f p 0 E . \. 'l ð (jO ' \ \ POSEY FINGER CONTRACTION CUSHION Separale fingers WIth this high strength palm grip. 100% texlured polyester filled Wllh synlhellc fur One size fits all hands. Atlracllve blue color No. 6560 POSEY SAFETY BElT A genlle but effecllve reminder to Ihe pallent not to get out of bed Reslrain pallents from thrashing about and poss- Ibly hurting themselves while sleeping Sm, med, Ig No 1322 ... . · f"""""- POSEY MISSION VEST Help prevent slumping forward or sliding down In wheelchairs May be crossed on patient's back or behind the chair for additional support. Ideal for bed use or in wheelchairs No. 3137 Health Dimensions Ltd. 2222 S. Sheridan Way Mississauga, Ontario Canada LSJ 2M4 u Phone: 416/82 9290 54 June 1979 Slow- foIk. (ferrous sulfate-folic aCid) hematinic with folic acid Indications Prophylaxis of iron and folic aCid deficiencies and treatment of megaloblastic anemia, dunng pregnancy, puerpenum and lactation Warnings Keep out of reach of children Contraindlcatlons Hemochromatosis, hemosiderosIs and hemolytic anemia. Adverse Reactions The following adverse reactions have occasionally been reported. Nausea. diarrhea, constipation. vomiting, dizziness. abdominal pain, skin rash and headache. PrecauUons The use of folic acid in the treatment of pernicIous (Addisonian) anemia. in which Vitamin 812 is deficient. may return the penpheral blood picture to normal while neurological manifestations remain progressive Oral1ron preparations may aggravate existing peptic ulcer, regional enteritis and ulcerative colitis Iron, when given with tetracyclines, binds in equimolecular ration thus lowering the absorption of tetracyclines Dosage Prophylaxis: One tablet daily throughout pregnancy, peurperium and lactation. To be swallowed whole at any time of the day regardless of mealtimes. Treatment of megaloblastic anemia During pregnancy, puerperium and lactallon; and in multiple pregnancy. two tablets, In a single dose, should be swallowed daily. Supplied Each off-white film-coated Slow-Fe tablet contains 160 mg ferrous sulfate (50 mg elemental iron) and 400 mcg folic aCid in a specially formulated slow-release base Packaged in push-through packs containing 30 tablets per sheet and available in units of 30 and 120 Full information available on request. Relerences 1 \ Nutntoon Canada Natoonal Survey A reporl by NutritIon Canada to the Department of Nal'onal Health and Welfare. Ottawa, InformatIon Canada, 1973 Reproduced by permIsSIon oflnformaf,on Canada 2 R R Stre,ff. MD Folate DefIcIency and Oral ContraceptIves Jama. Oct 5. 1970, Vol 214 No 1 CIBA DORVAL QUEBEC t<9S IBI See advertisement on cover 4 C 6026R The Cenadlen Nurse Pamphlets 28. American Nurses' Association Certification - assurance of quality. Kansas City, Mo., 1978. pam. 29. -. Self-directed continuing education in nursing. Kansas City, Mo., 1978. 14p. 30. -. Commission on Nursing Education Statement on graduate education in nursing. Kansas City, Mo., 1978. 7p. 3l. -. Division on Maternal and Child Health Nursing Practice Standards of pediatric oncology nursing practice, approved by, . and Association of Pediatric Oncology Nurses. Kansas City, Mo., 1978. 7p. 32. Canadian Council of Cardiovascular Nurses Invitation to membership. Ottawa, 1973. pam. 33. Conseil canadien des injìrmières(iers) en nursing cardim'asculaire Invitation. Ottawa, 1973. pam. 34. National LeagueforNursing Program for accreditation of home health agencies and community nursing services. New York, 1978. pam. (NLN Publication no. 21-1505) 35. -. Division of Measurement Test services for schools of nursing 1978-79. New York, 197?lv. 32p. 36. Ontario Occupational Health Nurses A ssociation Guidelines for the occupational health nurse in Ontario. Mississauga, Ont., 1978. 14p. 37. Vancouver Perinatal Health Project. Vancouver, 1978. IIp. Government Documents Canada 38. Labour Canada. Collective Bargaining I '!formation Centre Collective bargaining information sources. Ottawa, Minister of Supply and Services, 1978. Iv. (various pagings) 39. Santi et Bien-être social Canada. Assurance-hospitalisation et sen'ices diagnostiques Rapport, 1976. Ottawa, 1976-77. 15p. Saskatchewan 40. Committee on Rights in Relation 10 Health Care in Saskatchewan Report. Regina, 1977. 49p. United States of America 41. Dept. of Health. Education. and Welfare. Public Health Service. Di,'ision of Nursing Methods for studying nurse staffing in a patient unit. A manual to aid hospitals in making use of personnel. HyattsviJIe. Md., 1978. 222p. (DHEW Pub. no. (HRA) 78-3) 42. MAST Interagency Executive Group Program manual for MASf programs. Washington, Dept. of Transport, 1978, 1977 2Op. Studies in CNA Repository CoUection 43. Allen, Moyra Framework for the study of nursing practice and outcomes for client/families during the period of participant observation prior to evaludtion. The Workshop - a health resource/L'atelier à votre santé. PointeClaire/Beaconsfield, Montreal, McGill University School of Nursing, 1978. 7p. R 44. Andrews. Heather A. Educational needs of registered nurses: a report commissioned by the Alberta Association of Registered Nurses. Ad Hoc Committee to Study Ways of Promoting Post-Basic Degree Program Studies in Alberta. Edmonton, Alberta Association of Registered Nurses. 1978. l06p.R 45. Biette. M. Gayle Burns The effects of selected factors on the older adult's management of treatment of hypertension. Toronto, 1978. 145p. Thesis (M.Sc.N.)-Toronto. R 46. Cutshall, Patricia Monitoring and maintaining competence of health professionals. Vancouver, c1978. 23Op. Thesis (M.A.)-U.B.C. R 47. Ferguson. Barbara Faye Preparing your children for hospitalization: a comparison of two methods. Calgary, c1978. 89p. Thesis (M. Sc. )-Calgary. R 48. McDowell, Edith M. Report of "Project 65". The Saskatchewan study of the Centralized Teaching Program for Nursing Students and the participating hospitals and schools of nursing. Saskatchewan, Sask., Centralized Teaching Program for Nursing Students, 1966. 117p. R 49. McTavish, Maureen Louise The underutilization of the nurse practitioner. Calgary,Alta.,1976. 48p. R 50. Ponak, Allen M. Registered nurses and collective bargaining: an analysis of job related goals. Madison, Wi., 1977. 197p. Thesis-Wisconsin R 51. Registered Psychiatric Nurses A ssociation of British Columbia. C ommiltee on Nursing Education and Practice Report on a survey of inacti ve membership interest in a refresher course in psychiatric nursing. Burnaby, B.C., 1978. 17p. R 52. -. Task Committee on Forensic Nursing Report on competencies and skills required of nurses working in forensic areas. Burnaby, B.C., cl978. 122p. R ... Challenging Career Opportunity for Registered Nurses in Canada's North A 100 bed acute care hospital in Northern Manitoba which services Thompson and several small communities in the surrounding area has immediate vacancies in Pediatrics, Medicine/Surgery. Obstetrics and Critical Care. This opportunity will appeal to nurses who want to increase their existing skills or develop new skilJs through our comprehensive inservice program. Many of our nurses have become experienced in flight nursing. Candidates must be eligible for provincial registration as active practicing members. We offer an excellent range of benefits, including free dental plan, accident, health and group life insurance. Salary range is $1,078 - $1,340 per month dependent on qualifications and experience plus a remoteness allowance. Apply in writing or phone: Mr. R,L.Irvine Director of Personnel Thompson General Hospital Thompson Manitoba R8N OR8 Phone: (204)677-2381 ,- , The Cenedlen Nur.. June 111711 55 Classified Advertisements Alberta The Drumheller Health Unit requires a Supervbor of N..,.. with experience and quaJifications in Public Health for supervision of a staff of eight district nurses in preventive proarams of community health to a population of 28,000 in an area of 4000 square miles. Main office is located in Drumheller, popula- tion 6,000, 85 miles from Calaary. For information or applicatioo forms please reply, lIivina curriculum vilac to: AJP1es E. O'Neil, M.D., D.P.H.. Medical OfrlCer of Health, Box 1780, Drumheller, Alberta, TOJ OYO. RqIIIend N...... required for acute care lIeneral hospital, expandina from 75 beds to 300 beds. Clinical areas include: medicine, suraery, obstetrics, paediatrics, psychiatry, activation and rehabilita- tion, operatina room, emeraency and intensive and coronary care unit. Must be eliaible for Alberta reaistration. Personnet policies and salary in accor- dance with AARN contract. Apply to: Penonnel Administration, Fort McMurray -Reaional Hospital, 7 - Hospital Street, Fon M urray. Alberta, T9H tP2. Big Country Health Unit reqlllÎres a D1nctor to commence worlc. as soon as ssible. Applicant must be a Rellistered Nurse With some experience in Public Health. This is a supervisory posilion and applicant needs to be knowledaeable in the manage- ment field. 'Salary nellotiable based 00 qualifications and experience. Please apply in writina to: Director, Bill Country Health Unit, Box 279. Hanna, Albena, 1"OJ IPO. R.N. required by 2()"bed acti ve treatmenl hospital. Must have AARN rellistration or be eligible for rellistration. Salary & benefits accordinll to A.H.A.-A.A.R.N. contract. Apply: Director of Nursina, Myrnam Municipal Hospital, Myrnam, Alberta, TOB 3KO. Telephone no.: (403) 366-3870. RqIIIered N...... required for part-time and full- time employment. Must be elillible for registration with AARN. Salary and benefits as per U.N.A. contract. Residence available. Apply in writina to: Director of Nursina, Wainwright Hospital Complex. Wainwright, Alberta, TOB 4PO, or phone (403) 842-3324. British Columbia Ex rleoced General Duty Graduate Nunes required for small hospital located N.E. Vancouver Island. Maternity experience prefened. Personnel polide accordina to RNABC contract. Residence accom- modation available $30 monthly. Apply in writina to: Director of Nursina, St. George's Hospital, Box 223, Alen Bay, BrilishCoIumbia, VON IAO. General Duty (B.C. reaJstered) Dunes required for expansion to 422 acute care accredited hospital located 6 miles from downtown Vancouver and within easy access to various recreational facilities. Excellent orientation and on-going inservice prog- ramme. Salary: $1.305.00-$1.542.00 monthly. Clini- cal areas include coronary care, intensive care, emergency. operatinll room. P.A.R.R., medical/sur- lIical, pediatrics, obstetrics, onhopedics and activa- tion units. Head Nurse position also required for our critical care unit, effective immediately. Candidates must have had at leasl two year's related experience and should have a demonstrable record of manage- rial skill. Apply to: Co-ordinator-Nursinll, Dept. of Employee Resources. Burnaby General Hospital, 3935 Kincaid Street, Burnaby, British Columbia, V5G 2X6. Head None aDd Regbtcred Nunes for a ncwly renovated 8-bed Coronary/Intensive Care Unit. Registration or eligibility for rellislration in B.C required. Experience in Coronary/Intensive Care Nursing preferred. Experience and/or administrative training preferred for the Head Nurse position. Apply to: Director of Nursing, Cowichan District Hospital, Gibbins Road. Duncan. British Columbia, V9L IE5. British Columbia GfteraI o.y N..,.. for modem 41-bed accredited hospital located on the Alaska Highway. Salary and personnel policies in acc:ordance with the RNABC. Temporary accommodation available in residence. Apply: DU"ector of Nunina, Fon Nelson General Hospital, P.O. Box 60, Fort Nelson, British Colum- bia, VOC IRO. General Duty Nunc for modem 35-bed hospital located in southern B.C.'s Boundary Area with excellent recreation facilities. Salary and personnel policies in accordance with RNABC. Comfortable Nurse's home. Apply: Director of Nursina, Bound- ary Hospital, Grand Forks. British Columbia. VOH IHO. Experlcuced Nunn (eliaible for B.C. Registration) required for full-time posilions in our modem 300-bed Extended Care Hospital located just thirty minutes from downtown Vancouver. Salary and benefits according to RNABC c:ontract. Applicants may telephone 525-0911 to arranlle for an interview, or write givina full particulars to: Personnel Direc- tor, Queen's Park Hospital, 315 McBride Blvd., New.Westminster. British Columbia, V3L 5E8. Experienced Nunes (B.C. Regislered) required for a newly expanded 463-bed acute, leachina, reaional referral hospital located in the Fraser Valley, 20 minutes by freeway from Vancouver, and within easy access of various recreational facilities. Excel- lent orientation and c:ontinuinll education proararn- meso Salary-I979 rates-$130H)()-$1542.00 per month. Clinical areas include: Operatina Room, Re- covery Room, tntensive Care, Coronary Care, Neonatal Intensive Care, Hemodialysis, Acute Medicine, Surgery, Pediatncs, Rehabilitation and Emergency. Apply to: Employmem Manqer, Royal Columbian Hospital, 330 E. Columbi SI., New Westminster, Bntish Columbia, V3L 3\\ . AppticatioDs are invited for the position of Director of N........ for a hospital situated in the South Okanagan Valley, havina 45 acute and 75 extended care beds. Applicant II\IIst be eliaible for B.C. rellistration and should possess a combination of sUitable experience and academic prepara ioD, with post graduate dearee preferred. Shall assist the Nursina Administrator in planninll, orpnizina. directina and supervisina nursina services. Send complete resume to: Mrs. D. Bonnett. Nursinll Administrator, South Okanaaan General Hospital, Box 760, Oliver. British Columbia, VOH tTO. Expcrlcuccd GfteraI Daly N...- required for t20-bed hospital. Basic salary 51305.00 - $1542.00 per month. Policies in accordance with RNABC Contract. Residence accommodation available. Apply in writina to: Director of Nursinll, Powell River General Hospital, 5871 Arbutus Avenue, Powell River, British Columbia, V8A 4S3. Rcp.tered N..,.. required immediately for perma- nent full time positions at I()"bed hospital in B.C. Salary at 1978 RNABC rale plus nonhern livinll allowance. ReCQgnition of advanced or primary care education. One year experience preferred. Apply: Director of Nunina, Stewart General Hospital, Box 8, Stewart, British Columbia, VOT tWO. Telephone: (604) 636-2221 Collect. St. Paul's Hospital invites applicallons from B.C. aep.tend N..,.. for full and part time positions in all areas of the hospital. St. Paul's is an acute referral teachina hospital located in downtown Vancouver. 1979 R.N. rates $1305.00 - $1542.00. Generous frinae benefits. Apply to: St. Paul's Hospital, Personnel Department, tOllI Burrard Street, Van- couver, BntishColumbia, V6Z tY6. Manitoba ExpcrieDCed Jlallltered N...- required for a fully accredited 2()()..bed Health Complex Iocatod in Nonhern Manitoba. Must be cliaible for reJÍstration in Manitoba. Salary dependent on experience and education. For further information contact: Mn. Mona Seguin, Personnel Director, The Pas Health Complex Inc., P.O. Box 240, The Pas, Manitoba, R9A I K4. Athletic Camp Nunn required for four one week sessions commendnll AUII. 4, 1979. The camp is situated in the International Peace Gardens and includes instruction in Soccer. Volleyball. Sailina, Basketball, Track & Field, Equestrian. and Gymnas- tics. R.N., L.P.N.. and/or student nurse applica- tions arc invited. Please send resume or contact for further information: A.M. Hunt, Director Health Services, Apt. 1003-690 Kenaston Blvd., Winnipell, Manitoba, R3N IZ3. Tel.: 475-1701. Northwest Territories The Stanton Yellowknife Hospital, a 72-bed accre- dited, acute care hospital requires reJistered nurses to work in medical, surgical, pedlatnc, obstetrical or operatina room areas. Excellent orientation and inservice education. Some furnished accommoda- tion available. Apply: Assistant Administrator- Nursina, Stanton Yellowknife Hospital, Box 10, Yellowknife, N.W.T., XIA 2NI. Ontario RN, GRAD or RNA, 5'6" or over and strona, without dependents. non smoker, for t75 lb. handicapped, retired executive with stroke. Able to transfer patient to wheelchair. Live in 1/2 yr. in Toronto and 1/2 yr. in Miami. Wqes: $200.00 to $250.00 wkly. NET plus $80.00 wkly. bonus on most weeks in Miami. Write: M.D.C., 3532 Eglinton Avenue West, Toronto, Ontario, M6M IV6. Childrens summer camps in scenic areas of Northern Ontario require Camp N...- for July and AUlLust. Each has resident M.D. Contact: Harold B. Nashman, Camp Services Co-op, 825 Eglinton Avenue West, Suite 211, Toronto, Ontario, Mm IE7. Phone: (416) 789-2181. Saskatchewan R.N.'s and R.P.N.'s (eligible for Saskatchewan registration) required for 340 fully accredited cx- tended care hos f ital. For funher information, contact: P.:rsonne Department. Souns Valley Ex- tended Care Hospital, Box 2001, Weyburn, Sas- katchewan S4H 2L7. United States Nurses - RNs - Immediate Openinlls in California-Florida-Texas-Mississippi - if you arc experienced or a recent Graduate Nurse we can offer you positions with excellent salaries of up to $1300 per month plus all benefits. Not only are there no fees to you whatsoever for placina you, but we also provide complete Visa and Licensure assistance at also no cost to , ou. Write immediately for our application even i there are other areas of the U.S. that you are interested in. We will call you upon receipt of your application in order to arranae for hospital interviews. You can call us collect if YDU are an RN who is licensed by cxaminatioD in Canada or a recent llraduate from any Canadian School of Nunina. Windsor Nurse Placement Service, P.O. Box 1133. Great Neck, New York, 11023. (516- 487-2818). "Our 20th Year of World Wide Service" 58 June 18711 United States C.uromla - Sometimes you have to 110 a lona way to fmd home. But, The White Memorial Medical Center in Los Anlleles, California, makes it all worthwhile. The White is a 377-bed acute care teachina medical center with an open invitation to dedicated RN's. We'll challenae your mind and otter you the opportunity to develop and continue your professional growth. We will pay your one-way transportation, offer free meals and lodgina for one month in our ultra-modem nursina residence and provide your work visa. Call collect or write: Ken Hoover, Assistant Personnel Director, 1720 Brook- lyn Avenue, Los Anaeles, California 90033; (213) 269-9131, ext. 1680. FlDrkIa NanIq OpportMItIB - MRA is recruitina Reaistered Nurses and recent Graduates for hospital positions in cities such as Tampa, St. Petersbu..., and Sarasota on the West Cout; Miami, Ft. Lauderdale and West Palm Beach on the East Couto U you are consideri 1 a move to sunny Florida, contaA:t our Nurse ecruiter for assistance in selectina the riabt hospital and city for you. We wtll provide complete Work Visa and State Licensure information and offer relocation hints. There is no placement fee to you. Write or call MedIcal Rec:ndten., rica,IK. (For West Coast) 1211 N. Westshore Blvd., Suite 20 , Tampa, Fl. 33607 (813) 872 202; (For East Cout) 800 N. W. 62nd St., Suite IO, Ft. Lauderdale, Fl. 33309 (30 ) 772-3680. Nurslnll Opportualtlella New Orleua, uJslu. - MRA tS recruitina Reaistered Nurses and recent Graduates for severalleneral and teachina hospitals in the excitina New Orleans area. Openinas in many specialties and most Canadian Reaistered Nurses can qualify for licensure endorsement in Louisiana. Contact our Nurse Recruiter for tuition assistance plans. We will provide complete Work Visa and State Licensure information. There is no placement fee to you. Wrile or call Medical Recruiters or America, IDe., 800 N.W. 62nd St., Suite SIO, Ft. Lauderdale, Fl. 33309. (JOS) 772-3680. Nunlnll Opportualty - Mississippi Baptist Medical Center, a ml\Ïor 600-bed hospital, has immediate positions available for experienced RNs and recent nursina school araduates in a variety of specialities and medical/surgical areas. Competitive salaries, liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (population 300,000), MBMC is the state's largest and most modem privately operated hospital. For further information write: Mrs. Johnnye Weber, Nurse Recruiter, 122S North State Streel, Jackson. Mississippi 39201; or call collect 601/968- S 13 S. Ceaadlan Nunes - Our 3S0+ bed full service community hospital in a city of 70.000 in the piney woods and lakes of beautiful East Texas wishes to extend an invitation to you to practice nursing in a progressive hospital while you and your family enjoy the llood life atmosphere of smaller city livina. Our special visa sponsorship and licensure prollram may be what you have been seekinll. We plan a trip to several cilies in Canada to interview and hire soon so don't delay your response. For more information, please write or call Jack Russell. 6tt Ryan Plaza Drive, Suile S37, Arlinaton. Texas, 76011. (817) 461-14SI. Come 10 T_ - Baptist Hospital of Southeast Texas is a 400-bed growth oriented orllanization lookina for a few 1l00d R.N.'s. We feel that we can offer you the challenae and opportunity to develop and continue your professional growth. We are located in Beaumont, a city of IS0,OOO with a small town atmosphere but the convemence of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist Hospital has a proaress salary plan plus a liberal frinae packqe. We wtll provide your immill- ration paperwork cost plus airfare to relocate. For additional information. contact: Personnel Ad- ministration, Baptist Hospital of Southeasl Texas, Inc., P.O. Drawer IS9t, Beaumont, Texas 77704. An .mrmall.c Kt.... employer. The Cenedlen Nur.. Before accepting any positìon in the U.S.A. PLEASE CALL US COLLECT w. Can Offer You: A) Selection of hospItals throughout the U.S.A. B) ExtenSive information regarding Hospit Area. Cost of living, etc. C) Complete licensure and Visa Service Our Services to you are at absolutely no fee fo you. WINDSOR NURSE PLACEMENT SERVICE P.O. Box 1133 Great Neck, N.Y. (516) 487-2818 Our 20th Year of World Wide Service ... R.N. 's Nursing opportunities are available in the Cardiovascular Unit at the Holy Cross Hospital. Active experience preferred in Medicine. Pediatrics and/or Surgery. Previous experience preferred. Interested applicants must be eligible for Alberta registration. Please apply to: Personnel Department Hospital District #93 940 - 8th A venue S. W. Calgary, Alberta T2P IH8 UNITED STATES OPPORTUNITIES FOR REGISTERED NURSES AVAILABLE NOW FLORIDA OIDO IN ARIZONA CALIFORNIA TEXAS WE PLACE AND HELP YOU WITH: sr T.E BOARD REGISTRATION YOUR WORK VIS^ TEMPORARY HOUStNG . ETC. A CANADIAN COUNSELLING SERVICE Phone: (416) 449-S883 OR WRITE TO: RECRUITING REGISTERED NURSES INC. 1:ZOO LAWRENCE AVENUE EAST, SUITE JOI, DON MILLS, ONTARIO M3A ICI NO FEE IS CHARGED TO APPLICANTS. United States 'nit _,. .f T_ beckon RN's and new IIJ'IUIa to practice their profession in one of the most prosperous areas of the U.S. We represent all size jlospitals in virtually every Texas and Southwest U.S. city. Excellent salaries and paid retocation expenses are just two of many super benefits ottered. We will visit many Canadian cities in March and April to interview and hire. So we may know of your interest won't you contaA:t us today? Ms. Kennedy, P.O. Box 5844, Arlinaton, Texas, 76011 (214) 647-0077 or Ms. Candace, P.O. Box t474S, Austin, Texas, 7601 I (SI2) 4S9-0077. E"dtcpICIII: Come and join us for year around excitement on the border. by the sea, an unbeatable combination. Eqjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed, acute care hospital offers the experi- enced nurse and the newly araduated nurse an array of opportunities. We have immediate operunas in all areas. Excellent salary and frinae benefits. We invite you to share the challenac ahead. Assistance with travel expenses. Write or all coIled: Joe R. Lacher, RN, Dtreclor of Nurses, Valley Community Hospi- tal, P.O. Box 469S, Brownsville, Texas 78S21; t (SI2) 831-9611. N_ - aNs - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa forms and provide assistance with licensure at no cost to you. Write for a free job market survey. Marilyn Blaker, Mcda, S80S Richmond, Houston, Texas 770S7. All fees employer paid. ......nð N_, IJc:eMed Voe...... Nann u4 N_ Aw. needed to work 111 the Kerrville State Hospital in Kerrville, Texas. KerrviIle is approx. 6S mites north of San Antonio in West Celltral Texas. It is a nOled recreational area, with the Guadalupe River, many camps and open areas for hiltina. Benefits include forty hour work week, sick leave, paid vacation, holidays. 1l00d retirement benefits and free group insurance. Startinll salary for Rellistcred Nurses is $t,14I.OO, for Licensed Voca- tional Nurses $768.00 and for Aides $SS2.00 (per month). Nurses and L.V.N.'s are requiTed to have a curn:nt Texas license and Aides are re ired to be high school araduates. We are an Equal portunity Employer. Apply to: Box 1468, Kerrv' Ie, Texas 78028. C_ to c..taI T_ - We are located in . resort, retirement and farmina community one mile from the Gull of Mexico. We arc a small friendly hospital in a small friendly community just two hours from Houston. We otter you a rounded career develop- ment proaram: medic81, su...ical, OB, nursery and eme...ency room. We are fully accredited. Rapid advancement to Hcad Nurse startinll at $13,000 plus shift differential, calt pay and tiberal frinae benefits. New nicely furnished two-bedroom apartments are reserved for , ou. Share one with a Canadian RN companion 0 your chaosina, if you like, for $ISO each includina lias and water. We wtll pay immiara- tion, licensina and relocation transportation ex- pense. Openinas are limited-four at this writina. Contacl: Personnel Department, Waaner General Hospital, Box 8S9, Palacios, Texas 7746S; or call Athlyn Raasch, o-St2-972-2S1 I collect. Miscellaneous Africa -Overland Expeditions. LondonfNairobi I3 wks. London/Johannesburg 16 wks. KellY. Safaris _ 2 and 3 wk. itineraries. Europe - Campina and hotel tours from t6 days to 9 wks. duration. For brochures contact: Hemisphere Tours, S62 Ealinton Ave. E., Toronto,-Ontario, "d4P IB9. Cherokee LocI., L8U u, Dear Port SaacltIcld, A small friendly lodlle, caterina to adults who wan a quiet relaxina holiday. Open May 24 to ThankslltV- ina. Good deepwater sWimmina, boatina and walk- ina. GoUina, dancina. ridina a short drive away. Rates and folders on request. Write or phone: The Turleys, (70S) 76S-360I, R.R. 2, Port Carlina, Ontario. PUB IJO. Interested In EIectroly.s Career? Must be an R.N. Successful practice available. Instructions. Write or call: Margot Rivard, R.N., 1396 St. Catherine Street West. Suite 221, Montreal, Quebec, H3G 1P9. Telephone: (SI4) 861-19S2. School of Nursing Nursing Instructors required for July 1979 in a 2 year English language Nursing Diploma program. Qualifications: Bachelor of Nursing with experi- ence in teaching and at least one (I) year in a Nursing Service position, courses in Teaching Methods and eligible for registration in New Brunswick. Apply to: Harriett Hayes Director 1be Miss A.J. MacMaster School of Nursing Postal Station" A" , Box 2636 Moncton, N.H. EIC 8H7 Telephone: 506-854-7330 Foothills Hospital. Calgary, AI berta Advanced Neurological- Neurosurgical Nursing for Graduate Nurses A five month clinical and academic program offered by The Department of Nursing Service and The Division of Neurosurgery (Department of Surgery) Beginning: March, September Limited to 8 participants Applications now being accepted For further information, please write to: Co-ordinator of In-service Education FoothiUs Hospital 1403 29 St. N. W. Calgary, Alberta T2N 21'9 Grande Prairie Hospital Complex Assistant Directors of Nursing Extended Care Acute Care Two challenging management positions required for our 230 bed Acute Care Hospital, Auxiliary Hospital. and Nursing Home with planning and construction underway for a 457 bed complex to open Spring 1983. Upward mobility within the organization possible. Nursing and management experience required. Bachelor's or Master's Degree in Nursing and/or Administration desirable. Salary based on qualifications. Apply to: Mrs. D. O'BrIen Director of Patient Services 10409 . 98 Street Grande Prairie, Alberta TSV 2E8 or Phone: (403) 532-7711 The Cen-.llen NurH Director of Nursing Applications are invited for the Director of Nursing position for our 330 bed acute care general hospital. The Director will report to the Assistant Executive Director (Patient Services) and will be responsible for planning, organizing, directing and evaluating the activities of the Nursing Department to ensure the highest standards of patient care are provided. The Director will be a member of the senior management com- mittee. The Director of Nursing must possess a Master's Degree or B.Sc. Degree in Nursing and have extensive experience managing a nursing department. Applicants must be registered or eligible for registrat.ion in Saskatchewan. The salary is commensurate with qualifi- cations and experience. Fringe benefils are in accordance with our out of scope policies. Please forward applications to: Personnel Director St. Paul's Hospital Grey Nuns' of Saskatoon 1702 - 20th Street West Saskatoon, Saskatchewan S7M OZ9 Offers R.N. 's An UNUSUAL OPPORTUNITY. A.II.!. Will FURNISH One Way AIRLINE TICKET 10 Telas Ind 5500 Inltlll LIVING EXPENSES on a Loan Basis. AIIlr Onl Var's Slrvlce, TIlls LOin Will be Cancelled MI American Medical Intemational Inc. . HAS 50 HOSPITALS THROUGHOUTTHE u.S. . lIow A.II.!. Is Recnllltøg R.II. '1IDr HDlp1b11 in TII.I. Immldill. Open'.... S.lsry R.ng. 111.000 ID 116,500 per V.... . You can enloy nursing In General MedIcIne. Surgery ICC CCU. Pediatncs and Obstetncs . A M I provIdes an excellent ollentallOn program. ,n-servlce training r------------.. I . I . U.S. Nurse Recruiter I . P.O. Box 17778. losAnAeles. Calif. 90017 I I . W,thoul obhgatlon. please send me more . InformallOn and an Apphcatlon Form I . NAME . AOOR ESS =========== I . DTY____ IT.___ZIP___I TELEPHONE 1_ _1_ _ _ __ _ _ __ I LlCEIISES:___________1 . SPECIALTY:_ _______ -_-I VEAR OIlAOUATEO:_ _ _ ITATE: _ _ __ '-____________rI June 111711 57 MANIT BA Civil Senice Commis!iion This po.ition is open to both mtn and women. Appl) In writing rtftmng to COmpetItion NumberC"'-14t. Imnvchat.ly. As.",islant DirKtor of'ul"\lnK F..ducllhon Tht D SlVI 3S RJl !3SSHIOW VMV110 :fO ^JNrt BZ Çlb99HZO L 3 ":i A Division of White Sister Uniform In 50n Flowing 5klrt Suits in our beautiful new ROY' SPUN-COTTA ....,. ,.- ......... ........ ....... , -"ì ) r J -JJ , '" Style No. 43948 - Skirt Suit Sizes: 3-15 Royale Spun-Cotta Spun Textured Dacron Polyester Knit White, Apricot. about $39.00 Style No. 43945 - Skirt Suit Sizes: 5-15 Royale Spun-Cotta Spun Textured Dacron Polyester Knit White, Yellow . about $38.00 The Canadian Nurse July/August 1979 The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, I'< umber 7 CNA-What's it all about? 6 Tetanus: the costly cure Catherine Searle 18 News 9 The unexpected case of tetanus JeanE. Grove 26 Calendar 16 The immune system Anne Hedlin 28 \ou and the law 51 The touch of love Francine Camolinos 31 It's a bird, it's a plane, Input 56 it's supernurse! Susanna Jack 34 Here's how 57 That's right.I'm a nurse SandraKlyne 35 Library update 57 Nursing: fact and fantasy Margaret Allan 37 Hypenensive disorders in pregnancy Bonnie Hartley 42 ::> ::> The Canadian Nurse welcomes '"' ,4 .' Indexed in International Nursing .D :. .. suggestions for anicles or unsolicited Index, Cumulative Index to Nursing . manuscripts. Authors may submit Literature, Abstracts of Hospital r - finished anicles or a summary of the Management Studies, Hospital .. ..... - proposed content. Manuscripts Literature Index, Hospital Abstracts, .' ....:.., should be typed double-spaced. Send Index Medicus,Canadian Periodical .. . original and carbon. AII anicles must Index. The Canadian Nurse is .. be submitted for the exclusive use of available in microform from Xerox The Canadian N drse. A biographical University Microfilms, Ann Arbor, .. statement and return address should Michigan 48106. accompanyalI manuscripts. Subscription Rates: Canada: one year, $10.00; two years, $18.00. The views expressed in the anicles Foreign: one year, $12.00; two are those of the authors and do not years, $22.00. Single copies: $1.50 COVERPHOTO-CNA House. necessarily represent the policies of each. Make cheques or money ndtional headquaners for the Canadian Nurses Association. orders payable to the Canadian Canada's nursing profession, was Nurses Association. built by the nurses of Canad a for I SSN 0008-4581 Change of Address: Notice should be the nurses of Canada and given in advance. Include previous officialIy opened in 1967 by the Canadian Nurses Association, address as weIl as new, along with then Gove rnor GeneraI. the Rt. 50 The Dnveway, Ottawa, Canada, registration number, in a Hon. Roland Michener. Photo by K2P IE2. provincial/territorial nurses John Evans Photography Ltd., association where applicable. Not Ottawa. responsible for journals lost in mail due to enors in address. eCanadian Nurses Association,1979. c!jlmerica's number 1 shoe for Yðung women in white! THE CLINIC __._.... us....CI'.. .__ SHOE ft k ÏøI,\IJkJi.@ . " . ... .. ;a , CHOOSE FROM MORE THAN 30 PATTERNS .. SOME STYLES ALSO AVAILABLE IN COLORS. _ . SOME STYLES 3Y2-12 AAM-EE For a complimentary pair of white shoelaces, folder showing all the smart Clinic styles, and list of stores selling them, write: THE CLINIC SHOEMAKERS e Dept. CN-S, 7912 Bonhomme Ave. . St. Louis, Mo. 63105 r The Cenedl... NUrN Julyl AUfluet 11171 S perspective HA VE YOU LOOKED AT Without a national and a An association needs EDITOR YOUR ASSOCIATION provincial association there involvement by all its ANNE BESHARAH LATELY? would be no free voice of members in order to make its nursing. It may tackle any programs and services ASSIST ANT EDITORS Recently, I have talked with subject, any issue - it may relevant to the fast changing SHARON ANDREWS JANE BOCK many nurses, not as a patient state anything in which it needs of its members and the SANDRA LEFORT but as a communicator, an believes as an objective. It general public. observer and a friend. I have presents a united front with An association can only PRODUCTION ASSISTANT been privileged to see and considerable clout - if it has be as strong as its membership GITA FELDMAN hear nurses working outside the support of all its makes it collectively. Each CIRCULATION MANAGER of their clinical caring role as membership. member, by virtue of PIERREITE HarrE business professionals, As a recognized social belonging, has a responsibility planning, rejoicing at institution, associations make and a commitment to ADVERTISING MANAGER progress, sometimes damning an important contribution to participate and to speak out. GERRY KAVANAUGH it, but always looking ahead the continuous give and take I can't help feeling that a CNA EXECUTIVE DIRECTOR into the future. The setting for which constitute the political lot of work is being done by HELEN K. MUSSALLEM these observations has been power structure of too few people. I can't help the annual meetings of the contemporary society. They asking some 38,500 nurses if GRAPlßC DESIGN professional associations in provide their members with a they have looked into their ACARTGRAPHICS the provinces. forum which serves the dual provincial and their national EDITORIAL ADVISORS Without a seat mate on purpose of disseminating association lately? MATHILDE BAZINET, one of my return trips, I began ideas and helping to reach a -Bert Prime, CNA Public chairman, Health Sciences to reflect on alii had seen and onsensus on contemporary Relations Officer Department, Canadore College, heard in various parts of Issues. Nonh Bay,Ontario. Canada. My focus was on the An American social DOROTHY MILLER,public association. What is it? What scientist has described the relations officer, Registered does it mean? How valuable is function of the association in herein Nurses Association of Nova Scotia. it? What have I learned? this way: . 'F or most of the JERRY MILLER, director of Studying pages of notes, profound issues of our commu nication services, seeking some answers, I common humanity, associated Registered Nurses Association discovered that the three action is preferable to of British Columbia. annual meetil1gs I had individual action. From the JEAN PASSMORE,editor, attended representated a point of view of the political SRNA news bulletin, Registered collective membership of community, voluntary Nurses Association of almost 40,000. Attendance at associations provide that Saskatchewan . these three meetings added up pluralism of meaning and PETER SMITH, director of to not quite 1.500. purpose on which the - publications, National GalIery I asked myselfifit could community depends for its of Canada. FLORITA be possible that 38,500 vitality of richness. From both VIALLE-SOUBRANNE, registered nurses had to be on these standpoints, voluntary consultant, professional duty, had responsibilities or associations have a vital role inspection division. Order of so few resources that they to play in constituting our This month, CNJ welcomes a Nurses of Quebec. could not attend these annual public life." new member to the journal meetings. Is it apathy or lack Associations must have staff - assistant editor Jane of understanding that keeps the active participation of Bock. Jane is a graduate of the Correction: professionals from attending their members. They need this Toronto General Hospital The editorial in the June issue association meetings? Do we cooperation to define their School of Nursing and has a refers to testimony during as members of professional needs. to establish priorities B.A. in English literature from hearings into "the Mount associations take the time and for meeting these needs and to the University of Toronto. Sinai incident" by Principal effort to find out what is being find the most efficient and Jane's clinical experience is dOne on our behalf? satisfactory way of varied and includes staff Nursing Officer, Health and I"m not going to attempt determining what their nursing in thoracic surgery at Welfare Canada, Josephine to answer all the questions. I requirements are likely to be TGH and the urology service Flaherty. Dr. Flaherty am going to respond to one ... in the future. at the Wellesley Hospital reminds us that she appeared (Toronto); she has as an expert witness rather participated in a drug research than on behalf of any ofthe study as well. She has had contestants and that, on April several articles published and 29th, 1977, she was still Dean, has previous editing Faculty of Nursing, the experience. University of Western Ontario. II Julyl AUfluet 11171 The Cenedlan Nur.. CNA - WHAT'S IT ALL ABOUT? Bert Prime For 71 years, the Canadian Nurses Association, by addressing the concerns and interests of registered nurses has stimulated professional development. This page is simply an overview ofCNA activities and the people involved in these activities: in the next six months we propose to deal in more detail with CNA's priorities. (Watch "Close Up" next month for an interview with Louise Levesque, director ofCNA projects and Pat WalIace, project director, development of nursing practice standards.) The structure of the 23-member CN A board is such that there can be no regional disparity - no lack of representation and/or involvement by members separated by vast distances or by cultural differences. During this 1978-80 biennium, priorities being implemented are: . development of a definition of nursing practice and national standards for nursing practice . convening of a National Forum on Nursing Education . national accreditation program for nursing education programs . development of a Canadian Code of Ethics . completion of a comprehensive examination for use by alIjurisdictions . increased visibility as an association of more than 121 ,000 registered nurses concerned about health care maintenance and services for Canadians. Other areas of immediate concern are: . support for improvement in patient care settings . CN A views on health promotion . colIaborating with CBC to provide educational programs in health maintenance and promotion . income tax deduction for continuing education . home deliveries of newborns . doctoral preparation in nursing . International Year of the Child . proposed model for consent for sterilization. ---- -r L- The executive director and staff provide assistance to the board which has the responsibility and the authority to establish policies, to revise policies in the light of changing circumstances and beliefs and to ensure that these policies are implemented. .. .. - 'f.. 1 - ... . \ ..,....... "-. .. , The national pilot project to evaluate the diploma schools of nursing resulted in a new approach to the education of nurses. CNA took a firm stand against the introduction ofthe physician's assistant and was successful. In recent months, the association has been outspoken regarding funding for health care programs and services; salaries and working conditions of public health nurses; layoff and redundancies; educational leave; continuing education; health delivery systems; health care programs; confidentiality of patient health records; health services for native peoples; continuing education for nurses and involvement of nurses in the political process. There are other issues that have been dealt with either through the national media, the association, publications or directly in briefs to Royal Commissions or in communications with governments at alIlevels. There will be many in the future. , - I - '- .- I , V , , . , . - ..- , - ---.. - - Professional/administrative staff - (left to right) Claire McKeogh, Rose Imai, Gisèle . - - - - t -- - - 4 - < . Testing service -seated (left to right) Lorraine Bourque, Gladys Jones, Eric Parrott, Lise Chevrette; standing Shirley-Ann I 1\1 1 '.. I I / , '. i /11 , --- Library and editorial staff - seated (left to right) Monique Bissonnette, Marie Lalonde, Claire Bigué, Suzanne Joannisse, Loney. Helen Mussallem, Bert Prime, Beryl Darling, Darcie Clarke, Louise Lévesque. L - - I J .1 .. I j " I ,. -. . '-="" .. I Service to members Development of the CN A Testing Service, initiation and support of the Canadian Nurses Foundation and the continued co-sponsorship of the Extension Course in Nursing Unit Administration have figured significantly in the strengthening of professionalism and service. As the national voice for nursing, CNA maintains liaison, affiliation and membership with many departments of the federal and provincial governments and more than 100 health-related organizations or agencies. Liaison involves representation to external committees, conferences, task forces and working Parent, Lynn Forcier, Jean-Guy Bourque, Catherine Renaud, Danielle Legault. Aileen Rooney. ," r I J t. I ."- T. , Sandra LeFort, Candis Done; standing Gita Feldman, Ginette Dessureault, Sharon Andrews, Claudette Gauthier, Jane Bock. I The Canedl., Nurse Jutr' quilt 1171 7 committees, consultation on request, presentation of briefs and submissions to governmental and non-governmental agencies, membership participation in various national and international organizations as well as joint meetings and sharing of information and ideas with related professional associations that have similar interests and concerns about health care in Canada and abroad. C A achie\emenLs CNA has demonstrated leadership over the past decade by grappling with nursing issues such as salaries and working conditions - establishing a labor relations department as a positive program and a continuing service to members. The collection and processing of national data on nurses and nursing education - a first for the health professions - provides assistance in manpower planning. The statistical unit also collects and analyzes national data on collective agreements for all jurisdictions. CNA's executive director meets regularly with her national counterparts in the Canadian Medical Association, Canadian Hospital Association and Canadian Public Health Association as well as with the interprofessional group of 15 chief executi ve officers of health-related national professional associations. She also meets and maintains communication with key elected and senior governmental officials in several federal departments. As a member of the International Council of Nurses, CNA is responsible for representing Canadian nurses at the international level and for communicating with other international organizations active in the health field. ... yo. , I t Support staff - seated (left to right) Shirley Dormuth, Nancy Wallace, Lyne Leduc. Brenda Mallett, Jo-Anne Beauchamp; "L. standing Darlene Houde, Susan Graves, Debbie Cadieux, André Latour, Tina Lobin, Debbie Arnold, Hélène Roy, Brenda Kropp. - , . . - .... . - 1 - .. I, --- -- -:: {I . - i '" I .. The national journals have a combined circulation of 130,000; they feature the activites, interests and developments that affect the professional lives of nurses in Canada, as well as providing a platform for beliefs and opinions. Public relations is a priority - developing a long term program to achieve national visibility for the profession and emphasizing concerns about health care. The CNA library is the only recognized nursing library in Canada providing services in both official languages - it also houses an archives that is of great historical interest and value. In the final analysis, the actions and involvements of CNA has an effect on the individual member - aware of it or not, each CNA member is a participant in the work of the national association. \ Circulation and advertising - (left to right) Susan Vann, Manelle Lafrance, Maureen Ghosh, Pierrette Hotte, Dawn Baker, Gerry Kavanaugh. ew faces at CNA Louise Lé esque is Director of CNA projects. She has a master's degree in nursing from McGill University. and a diploma in social administration and community work from York University (England). Her last position was associate professor, teaching nursing education and community nursing, at the Faculty of Nursing, University of Montreal. She was also involved in research activities. Claire McKeogh is the Librarian-Archivist at CNA' McKeogh obtained her ' Bachelor's degree in library science from McGill University, and went on to acquire her Master's degree in 1971. She is fluently bilingual and has much eXl'erience in library administration. She was with several Montreal libraries and most recently with Algonquin College. Pat Wallace is Project Director, development of nursing practice standards. A native of Fredericton, N .B., Pat is a graduate of the Montreal General Hospital School of Nursing, and has a B.N. from Dalhousie University. She obtained her master's degree in health services administration from the University of Alberta. In addition to her experience teaching nursing administration at the University of Alberta she has been most recently administrative assistant and Director of Nursing Service at the Royal Alexandra Hospital in Edmonton. Jean-Gu) Bourque is Administrative Manager of the CNA Testing Service; he comes toCNA with more than nine years of administrative experience in health services. He has a Bachelor of Commerce degree from Carleton University, Master of Health Administration from Ottawa U ni versity and a diploma in Business Administration from Algonquin College. He was mOst recently executive assistant (nursing) at the Ottawa General Hospital. Gisèle Loney who has been with the Testing Service has been appointed CNA Liaison Officer. She is a diploma graduate from Hôpital St. Luc, Montreal and has a B.A. Administration from the Université de Québec (Hull). Photos by John Evans I , I \ ) \ '( . Developments in Nursing , 'I guarantee that this book will sweep the nation! It is rare in my career that I have seen such a superior book. It is leagues above all other texts in readability, easy flow of writing style, and depth of content. It is appropriate for both two and four-year programs. , , (Teacher in large urban program) I . Used alone or as a companion to Medical-Surgical Nursing, this remarkably detailed volume encom- passes the full range of nursing fundamentals- from global concepts of humanness-to health and ill- ness-to a thorough introduction to basic nursing practice and the more advanced techniques. The broad coverage is enhanc by the use of a unique feature-36 detailed procedures found throughout the text which set up basic guidelines for effective nursing care. Included as well are topics on stress, adaptation, the nursing process, legal and ethical issues, plus important separate chapters on care of children, care of the elderly and care of the grieving and dYing. As a carefully organized, psychophysiologic ap- proach, BASIC NURSING draws students actively into the I arning experience Boxed materials, tabula- tions, chapter overviews and selected vocabulary only begin the long list of study aids in each chapter An Instructor's Manual is available. 1311 pp. 408 ill. $34.80 March 1979. Order *8498-X. A Sorensen & Luckmann BASIC NURSING: A PSYCHOPHYSIOLOGIC APPROACH and coming soon .................... Send on 3D-day approval: CN 8179 . . . . 0 Sorensen & Luckmann: BASIC NURSING . . #8498-X $34.80 . ...., Luckmann & Sorensen: · MEDICAL-SURGICAL NURSING · · #5805-9 · . . : ru : . POSITION & AFFILIATION (IF APPLICABLE) . . . . ADDRESS . . CITY STATE ZIP. . 0 check enclosed 0 bill me Prices differ outside uS . . laendpOS1pald) Q and are subJ&c1 to change . : , !1 , : . 1 Gol(lthorne Avenue. Toronto, Ontario M8Z 5T9. Canada . . PO. Box 207. Philadelphia. PA 19105 . ( St Anne.sRoad. Eastbourne. East Sussex. BN213UN. England I 9 Waltham Street. Artarmon NSW 2064 Australia ................... ..-1- MEDICAL-SURGICAL NURSINO, A PSYCIIOPIIYSIIlOIIC APPIIOACII Luckmann & Sorensen MEDICAL-SURGICAL NURSING: A PSYCHOPHYSIOLOGIC APPROACH. 2nd edition If you hked the first edition. youlllove the second' Updated. revised and expanded. it keeps pace with the needs of today's nurse. All the features you liked in the first edition; clear organization, the instructor's manual, study guides, boxed matenal, and tables, have been retained. There is a rigorously revised section on shock, and entirely new units on psychosocial and physical assessment. emergency and disaster nursing, and dependency on alcohol and other substances are included. Particular attention has been given to the rewriting, updating and expansion of the sections on the renal and liver and male reproductive systems. In addition, the opening chapters emphasize the importance of nursing as an art process and many new illustrations provide a balance with the textual material. By Joan Luckmann, RN, BS, MA, formerly, Instructor of Nursing, Unlv. of Washington, H,ghline College, Seattle; Oakland City College and Providence Hospital College of Nursing, Oakland, CA. and Karen Creason Sorensen, RN, BS. MN, formerly, Lecturer in Nursing, Univ. of Washington, formerly, Instructor of Nursing, Highline College; formerly, Nurse Clinical Specialist. University Hospital and Firland Sanatorium, Seattle. About 1600 pp. Ready soon Order "5806-7. 2111 BITDI The Cenedl.. NurM Julyl AUfluet 1171 . NEWSBEAT: THE PROVINCIAL SCENE BRITISH COLUMBIA and treatment programs for ALBERTA children in B.C.: and a brief presented to the Motor Vehicle Task Force which The "V ear of the Nurse" "How is it that British involved recommendations Columbia has a nursing . aimed at reducing the deaths drew to an end in Alberta as shortage? Where are the and injuries caused by motor almost 1200 members nurses if they are not working vehicle, cycle and pedestrian gathered at the Calgary I nn for in nursing?" Sue Rothwell, '\. accidents. the 62nd annual convention of president of the Registered the Alberta Association of Nurses A!>sociation of British Registered Nurses held May 8 Columbia in her address to the Voting on resolutions through II. annual meeting said that these Several of the resolutions Revolving around the are questions the RNABC Rothwell said that there approved by membership theme "Concerned, Qualified, executive and board have has been a marked change in dealt with various aspects of Prepared to Care" , the tone of raised and ones which need to official attitudes toward nursing education programs as the convention was set by be answered quickly and with nursing and a new willingness they exist and are developing each speaker's emphasis on a unified professional voice. to listen on the part of in the province. As a result of accountability, rights and "It is not simply a question of government officials. She said these resolutions, the RNABC responsibilities. supply and demand. that the government now will: Outgoing president, Registration, which is the seeks advice on policy, the . urge the B.C. Valerie Ayris, spoke on the keystone of professional health act, and proposed government to consider a provincial association's regulation, is also a very changes in health services in province wide, coordinated responsibility to ensure that strong economic lever," she longtenn care to remote areas health education program as a Alberta's nurses are indeed said. of the province. school curriculum qualified and prepared to care. Rothwell noted that in the requirement: The convention's area of professional affairs, Membership growing . urge the Ministry of keynote address was the most outstanding Executive director Marilyn Education and Universities in presented by Dr. Elizabeth association activities recently Cannack reported that the province to investigate the Carnegie, editor emeritus of have been in relation to the RNABC membership has implementation of external Nursing Research and safety to practice increased by close to 40 per B.S.N. programs andlorother president of the American conferences. The initial round cent over the past five years flexible and accessible Academy of Nursing. Dr. of these conferences was - approximately 8 per cent methods of obtaining B.S.N. Carnegie addressed the geared to nurse and hospital annually. She cited as major preparations: concerns of the public as administrators on the areas of concentration of . conduct a feasibility discerned by nurses - the assumption that if they were effort the work being done by study into the provision of desire for the consumer to uninfonned or recalcitrant, two of the association's i nternshi pi residency have quality nursing care implementation of efforts to committees - one established programs for new graduates in given by qualified, competent improve and evaluate nurse to study the future of nurse nursing: a position statement and professional nurses. She perfonnance or patient care midwifery in BC and another to be developed following went on to say earning settings would meet with set up to consider revisions to completion of the study to credentials is vitally important resistance or at least less than the Community Care serve as a basis for the orderly in order to prove our enthusiastic acceptance. Facilities Licensing Act planning of educational competence to the public. "There has been a fair Regulations. programs and employment Other speakers at the amount of concern from Describing RN ABC provisions for new graduates: AARN convention included: members over the fact that the accomplishments during the . collaborate with the Phyllis Kritek, associate initial approach was not past year, Cannack reported Registered Psychiatric Nurses professor, University of directed to general duty on an inquiry into uranium Association of British Wisconsin - Milwaukee, who nurses and I think this mining: a change in the B.C. Columbia and the Licensed asked "Qualified - will you concern is legitimate. I can Building Code to ensure that Practical Nurses Association be?" and Shirley Stinson, answer that the work on all highrise public buildings in the preparation of ajoint professor at the University of reporting nursing problems have elevators of a sufficient statement for public relea e Alberta and president-elect of and perfonnance evaluation size to accommodate a which defines the provisions the Canadian Nurses has proceeded as well as the stretcher: reconsideration of for registration, licensing and Association who traced the development of learning the proposed Family and monitoring of competence of historical development of the resources on care plans. This Child Legislation and altering each of its members and profession and challenged the coupled with the plan for it to ensure the children's which defines the tenn nursing profession of the orderly implementation of rights to good health are "graduate nurse" in orderto future to be actively involved safety to practice will payoff protected; investigation of the clarify the titles and roles for in the health concerns of in the long run." situation of alcohol education consumers. society. ß 10 Julyl Auguet 1171 The Cen-.llen Nu... -- As a tribute to the International Year ofthe Child, well-known personality, Art Linkletter, author of Kids say the darndest things, addressed the conference on Wednesday evening. 'The world's children: their needs and rights" drew laughter and tears from the audience as Linkletter used touching anecdotes to demonstrate the plight of the world's children and the awesome task being attempted during the International Year of the Child. . \ 01 ...., , \ Þ The 1979 "Nurse of the Year" award was presented during the convention to Margaret "Gerry" Seymour, the acting coordinator of nursing at Red Deer College. This annual award is designed to honor and recognize AARN members who participate in community affairs. Referring to Gerry one colleague said, "She is the kind of person a young nurse aspires to be: thoroughly professional yet humorous: knowledgeable but never self-important: practical but warmly human." Two prominent Alberta nurses received honorary AARN life memberships. Honored were Winnifred Shandro, regional supervisor, of the Jasper Place Clinic in Edmonton and acting director of the North Eastern Alberta Health Unit and Claudia Tennant, volunteer worker with the United Nations Development Program in Yemen. The official closing ceremonies saw retiring president Valerie Ayris turn the gavel of the presidency over to president-elect, Jeanette Pick. SASKATCHEWAN "7 I -,...' r '(--1f"' 1:. ' ." '" <> ø" ""\ .. 10 t, fiV' J l !1 :.'" , , ., ß: \ '\\ -. " j r with honesty, openness and communication, we are adding to these people's problems rather than helping them. " Child life workers, according to Kettner, can and do provide an important support team for nursing and play an invaluable role in the hospital setting by serving as non-threatening intermediaries between parents and children. nurses and doctors. Nonsense and commonsense approaches to two important areas of child development - bonding and parenting - were the subject of a two-part presentation by Dr. Kenneth McRae, director of the child development clinic at the Children's Hospital in Winnipeg. He warned nurses that they can look forward to having to deal with larger numbers of children hospitalized for treatment of emotional and social problems as the census of acutely ill children falls and the number of referrals for behavior problems grows. Among the most common of these in his practice are feeding difficulties, aggression. hyperactivity, lying, stealing. and school entry readiness problems. Dr. McRae described a number of "societal realities" as factors contributing to breakdown of the attachment process between children and parents. These included: mothers whose own backgrounds left them without nurturing capabilities, alcohol abuse by family members. the physical separation of parents and babies for health reasons '- "\ -I .'L ..... .f (particularly common among the native population) and the tendency of child care workers and agencies to keep shifting children from one substitute "mother" to another more suitable one. Getting baby ofT to a better start with the latest and best in infant nutrition was the subject of Elaine Scott's presentation. Scott, who is a provincial nutritionist with the Saskatchewan Department of Health, described the results of a recently completed survey on breastfeeding practices among a sample of more than 1000 women in rural Saskatchewan. One in five of these mothers breastfed their babies until they were more than six months old. The four members of a panel discussion on the rights of children - in hospital. in school. and in the community - were: Helen Grimm of the emergency department of Pasqua Hospital in Regina; Eldon Gritzfeld, a Regina lawyer: Terry Russell, psychologist with the Saskatchewan Department of Health and Bea Williams, public health administrator in Rosetown. Agnes Herd, chairperson of the Health Sciences Department of Wascana Institute of Applied Arts and Sciences, served as moderator of the discussion and introduced the participants. Membership concerns SRNA members attending the meeting approved a total of 16 resolutions as well as three changes in the association bylaws. As a result of these amendments nurses in the I .. .:t t New SRNA life members pIctured with CNA president Helen Taylor (far left) and SRNA president Betty Hailstone (farright) are: (from left to right) AgnesGunn, Elizabeth Cullen, Winnifred Evans. Patricia Mfurath, Frances Copeman, Jean Armstrong and Laura Webster. Children - in hospital, at home, in the community, children of all ages, sick or well- were the center of attention at this year's 62nd annual meeting of the Saskatchewan Registered Nurses Association. Close to 400 members attended the meeting which took place May 9, 10, and II at the Hotel Saskatchewan in Regina. The program for the meeting was planned around the theme "Children - our resource, our challenge" and a total of seven speakers. including a pediatrician, the director of a child life program, nutritionist. lawyer, psychologist, public health nurse and staff nurse in a hospital emergency department, contributed their special expertise to nursing's look at the child in society today. A special plea for absolute honesty and more open communication in dealing with both the hospitalized child'and his parents was directed to the nurses in her audience by one of these speakers. the director of the child life program at Winnipeg Children's Centre, Ruth Kettner. She urged nurses to ask themselves "what if! were that patient?" and to remember that "unless we deal with stressful situations as they come along province will pay a slightly higher fee for membership in their provincial association in each of the next two years. Registration fees will be $90 (up from $75) in 1980 and $100 in 1981. The resolutions covered a wide range of subjects. Many were intended to promote the level of health care services available to the general public in Saskatchewan. Among these were resolutions suggesting: . adoption by the proper authorities of more informative labelling of prescription drugs. . creation of public education programs in the symptoms of a heart attack and how to gain entry to the emergency care system; . adoption ofthe universal emergency telephone number (911) to gain access to the emergency medical system; . development of community support programs for individuals receiving cancer treatment and their families; . high priority be given by governments to increa'ied day care facilities. particularly for children undertwo; . strengthening of "the generalized public health nursing service" provided through provincial and municipal go'/ernments as fundamental service to families. A number of resolution!> were concerned with improving educational opportunities for nurses already registered in the province. Of these, one of the most important was a resolution authorizing the SRNA to create a trust fund. to be known as the Saskatchewan Nurses Foundation. to provide financial assistance to association members for continuing education. lVIembers also authorized the association to carry out an investigation into "the current status of continuing education" in the province and the implications for the nursing profession of mandatory versus voluntary continuing education as a requirement for maintaining practicing membership. The Cenedl.n NUrM President's addre'is SRNA president, Betty Hailstone. reporting to membership on action taken on their behalf during the past year. touched on a number of significant accomplishments. ,including completion of an addition to the SRNA headquarters and described some of the long-range plans ofthe association. New membership services include a phone-in consultation service. a multi-media resource center and a special outreach program for nurses employed in northern portions ofthe province. "In the immediate future." Hailstone noted. "the Council has identified quality nursing practice as a high priority and plans to implement a five-year plan for quality assurance in nursing." CNA president Helen Taylor, who brought greetings from the national association. congratulated Saskatchewan nurses on several "firsts" in Canada. including: . nurse practitioners . community health centers . relocation of all nursing education programs in educational institutions rather than hospitals . a higher ratio of baccalaureate to diploma nurses than in other provInces. New Council members Delegates elected the following officers to serve as members-at-Iarge: Doreen Cheetham, North Battleford; Bonnie Rushowick, Ituna; Susan Ward and Phyllis Wise. Regina. Members of the nominating committee are: Cecile Hunt. Melfort; Irene Murphy. North Battleford; Ina Watson, Saskatoon. Life memberships Seven nurses received special recognition from the SRNA for outstanding service to the people of the province. Those cited were: Jean Armstrong and Frances Copeman of Moose Jaw; Elizabeth Cullen. Weyburn; Winnifred Evans. Cabri; Agnes Gunn. Lloydminster; Pat McGrath. Saskatoon; Laura Webster. Unity. MANITOBA In an opening address to the 65th Annual Meeting of the Manitoba Association of Registered Nurses. the Honourable L.c. Sherman, Minister of Health and Community Services in Manitoba. specified government endorsement of a six-month clinical practicum for student nurses as one method of providing job orientation. Following media reports and delegate protests. the Minister communicated that there would be no interference by government in the nursing education system. that the practicum should take the form of paid job-orientation for a period as yet not finally determined but certainly not to exceed six months. He said that any practicum must not be exploitive but must be designed to benefit the nurse-graduate. the health facility and the consumer. Keynote speaker at the annual meeting was June Menzies. head of the National Farm Products Marketing Council. Speaking to the theme. Consumers' Rights- Nurses' Responsibilities. she said that nurses have fought for. and won. professional status in the health care field. "You have won the right to control the education and training of those who have chosen to enter the profession. to !>et standards and to discipline your members. This is an important achievement. but one which brings with it additional responsibilities. not only to yourselves and your fellow health professionals, but to consumers for whom the health care system was developed," she reminded her audience. Menzies, who until recently served as vice chairman of the national Anti-inflation Board. said that nurses can give practical support to consumer rights and that the emergence of "patient power" should not be seen as a threat, but ultimately as a means to improve the health care Julyl Auguet 1171 11 system to meet the needs of those it was designed to serve She noted that nurses can playa major role in informing and educating the consumer on how to stay healthy; where to seek help when ill and what services are available; how to get the full benefits of the health care system. . 'The patient wants to know what diagnosis and treatment of the illness entails and how to care for herself." Menzies believes that the nurse's responsibility concerning patient teaching is also connected to the consumer's right to be respected as the person with the ultimate responsibility for his own care: he must know how to care for himself and he must have guidance. She called on nurses to learn all they can about consumer rights by having this subject included in the curriculum along with related subjects such as law, ethics, sociology and health administration. Nurses at the forefront Professor Jan Storch, Division of Health Services Administration, University of Alberta, said that professional associations must: . seek to educate their membership about human rights and consumer rights in health care; . speak out against violations of these rights; . support their members who "risk" to speak out or to try to change systems to accommodate consumer rights; and . seek to find innovative approaches in health care to assure patient rights. Professor Storch emphasized the potential nurses have to effect change, to gradually change the health care system so that consumers are respected. maintain autonomy or freedom, and maintain their integrity. As "front line" workers, nurses are "experts" in speaking about those actions, policies and situations which enhance or violate patients' rights. Reporting to the membership, President Mollie Willard said that in determining a course of 12 Ju1y/Augu8l1171 action for the past year, ten objectives were established. Commenting on some of these objectives she said that MARN will continue to develop. implement and evaluate broad and specific standards of nursing practice in Manitoba; to seek immediate introduction and passage of the proposed R.N. Act in the legislative assembly and to promote continuing education for registered nurses and the establishment of a masters in nursing program at the University of Manitoba as well as support the concept of a second baccalaureate program in nursing in Manitoba. Among the resorutions approved by the meeting were directions from the - membership that MARN conduct a comprehensive study of the perfonnance expectations of new registered nurse practitioners and that the Board of Directors of CNA study the issues inherent in continuing education for nurses and produce a position paper on continuing education for registered nurses in Canada during the 1980-1982 biennium. ONTARIO The voice of professional nursing in Ontario will operate on a new frequency following restructuring of the Registered Nurses Association of Ontario according to a completely revised set of bylaws. Ratification of the more than 100 association bylaws was a major accomplishment of delegates to the 54th annual meeting and convention of the RNAO at the Royal York Hotel in Toronto. May 3, 4 and 5. It was the first major revision of the RNAO bylaws in 12 years. Chief among the changes is the reduction in size of the board of directors from its fonner 64 members to nineteen voting members. These include the president, president-elect, 12 regional representatives and five members-at-Iarge. The Cen-.ll.n Nur.. I n her report to membership. executive director Maureen Powers commented on the reasons for the restructuring, pointing out that the changes are "intended to facilitate wise decision-making, rapid identification of nursing issues. rapid response to these issues. an increase in regional activity and the vitality and relevance ofRNAO in today's world. .. One proposed bylaw which would have shortened the term of office of the president and president-elect, making it one year instead of the present two years. was defeated. Instead. under the tenns of a resolution passed at the annual meeting, a task force will be set up to study the demands placed on the president and president-elect during their terms of office in the light of the need to find desirable alternatives. Working together Retiring president Irmajean Bajnok, in her address to delegates, referred to "the many problems of a threatening nature that the profession is currently experiencing. .. Among these she included high unemployment. impending changes in the process of certification for competency. diversification of health care requiring changes in the education process. and new demands for accountability from clients. "Given the budgetary restraints. many a nurse is attempting to do the work of three nurses and. on top of that. to explain to the uninfonned patient the rationale for other cost-saving practices in the system. The reality of the system is that until nurses speak with a unified voice and learn the political process, we will not become part of the decision-making pro'cess." Bajnok challenged nun,es to work together to develop a sense of colleagueship within the profession. "If we as nurses can begin to talk to, support, use. advise and challenge each other in a respectful way, we can strengthen the profession and thereby strengthen the contribution we can make." She urged nurses not to resort to professional in-fighting, not to give in to the tendency to "scapegoat" the two-year graduate for all of the weaknesses in the health care system. to offer support to other women working in male-dominated areas. and to resist the "anti-intellectual tendency" in our profession by refusing to "put-down" nurses who have and attempt to use added education. "Somehow," Bajnok said. "we have to convey to each other that as nurses, it is okay to be different, okay to be angry, okay to be good at something. okay to have limitations, okay to need others. and okay to be educated. " Membership concerns Directors of the association met at the conclusion of the annual meeting to begin work immediately on implementing some of the many resolutions approved by membership. As a result. nurses in Ontario can look forward to several new developments. including a meeting of consumer groups and nursing organizations interested in maternity care, with a view to legalization of the practice of midwifery. Work will also begin on a resolution calling for the association to "propose action plans for the education of nurse midwives in Ontario as recommended by the RNAO Working Party on Nurse Midwifery." Two priorities were identified by membership and referred to the national association for action. These were continuing education for nurses and national accreditation of nursing education programs. As a result, RNAO will press CNA for representation on the national association's ad hoc committee on accreditation and urge that high priority be given to work on this project. RNAO will also request the national association to develop a position paper on continuing education for registered nurses in Canada during the next two years. Other resolutions approved during the annual meeting are intended to promote: . sensitizing of the nursing profession to the needs of the elderly . development of strategies for the provision of temporary bed accommodation for vacation relief and/or social emergencies for longtenn patients being cared for at home as an alternative to longterm institutionalized care . better understanding between members of the nursing profession working in various agencies and between nursing and other health-related professions . public education concerning the roles and responsibilities of registered nurses and registered nursing assistants . facilitation of public education programs in parenting . passage of legislation preventing discrimination against disabled persons in the area of employment where the disability is unrelated to ability to perfonn the duties required . implementation of pilot projects demonstrating various models of diploma nursing education programs designed to prepare graduates for current and future practice ' - JÞ;... .... , o. .t " .- t" ,--- Colleagues honored One of the highlights of the meeting was a brief ceremony during which an honorary life membership in RNAO was conferred on Blanche Duncanson, associate professor, Faculty of Nursing, University of Toronto. and Kathleen R. (Kay) Lewis. (above) was made an honorary member of the association. Lewis was fonnerly associate director of The Cen-.llen Nur.. the RNAO employment relations department and is now associate executive director of the Ontario Nurses Association. \ Neft president Incoming president. Jocelyn Hezekiah, commenting on the need for nurses to take an active role in influencing and improving the health care system. encouraged the readiness of nurses to move into community and health promotion work. "The determination of the ministry of health to increase community health facilities and to stem the growth of hospitals wilI open opportunities for more nurses to move into the community. RNAO is encouraged by this direction. It remains for nurses to face the chalIenge." \'- "" " Hezekiah, who has been president-elect since May 1977. is chairman of basic nursing programs at Humber ColIege of Applied Arts and Technology. Toronto. She holds an M.Ed. from the Ontario Institute for Studies in Education and a B. Sc. N. from McGilI University. Montreal. Closeup on Nursing Networks Nurses should be looking beyond individual conscious-raising to the larger issue of reforming the structural constraints imposed by society on their behavior. It is organizations - not people - who must change, according to the dean of Queen's University's School of Nursing in Kingston, Ontario. "Right now nursing services. especially in hospitals. are organized along the classic sexist model of women's place, women's work," Alice Baumgart told delegates to the 54th annual meeting of the Registered Nurses Association of Ontario. "The ways in which nursing services are organized and how these systems can be modified to provide more opportunifies, more power and improved quality of work life needs our urgent attention." Baumgart described social support networks in nursing as "an idea whose time has finally come" and urged nurses 10 overcome their cultural conditioning and learn how 10 help each other to gain access to the persons, information and resources they need to attain their professional aspirations. Nurses, Baumgart says, need to establish a system of informal information channels in order to continue the development of a stronger role in determining the destiny of their profession and in voicing opinions on health care policies. These nursing networks would actually help nurses achieve their professional goals by providing task-oriented assistance, emotional support and. more specifically, information, advice, guidance. contact and protection. That is not to say that nurses have never had networks. Baumgart assured listeners, but in the past the problem has been that the networks that did exist often motivated nurses to work in ways that were actually antithetical 10 both individual and collective professional goals. In other words, she said, nurses tend not to help one another succeed. A good network of information sources need not be seen as a sort of 'good 01' boy' system such as is frequenlly seen in male dominated professions and occupations, because this sort of network is often narrow-minded and exclusive. However, nurses do need to look at this sort of organization and utilize the same principles in order to form a useful professional network. Commemorative plaque CNA president Helen Taylor. who addressed the meeting during the opening ceremonies. thanked RNAO members for their gift of a bronze plaque which has been mounted at the entmnce to CNA House in Ottawa. The plaque commemorates the official opening of the national association headquarters in 1967. Professional deulopment The concluding day of the convention was devoted largely to professional development. A panel discussion on patient teaching was presided over by Dorothy Wylie. vice president. Nur"ing, Toronto General Hospital. Members of the panel were: Patricia Kirkby. head of nursing programs at , . . .'11 "- - , . ",.. - . ., I \t V -,. . July/Auguet 1171 13 Cambrian ColIege of Applied Arts and Technology in Sudbury; Susan Gilmore. a staff nurse in pediatric oncology at Princess Margaret Hospital in Toronto; and Elinor Graham. educational coordinator with the Middlesex -London Health Unit. Five concurrent education sessions were offered. Speakers were: Shirley Post, vice president of the Canadian Institute of Child Health; Mary Bawden, team leader, rheumatic diseases unit. University Hospital in London; Mary ay Harrison. professional nursing consultant; Alice Baumgart. dean. Faculty of Nursing, Queen's University. Kingston; and Janet McChesney. career planning consultant, Toronto. Baumgart stressed that nurses must look realistically at the profession and realize that nursing is still a sort of 'female job ghetto'. "II has become fashionable," she said, "to admonish nurses for not sticking together. for being competitive rather than co-operative, and for thinking of nursing as a job rather than a career." She stressed that this blame placing does no good and nurses would be better to look at how traditional definitions of sex roles and appropriate behavior has made it difficult for nurses to maintain long term associations. For years, she pointed out, women's principal ties were to home and family, and their professional identity was often subordinate to the other important female roles of wife and mother. Another negative effect has been the perceived prejudice of women toward other women: for too long women have felt that professional men were more competent than their female counterparts. Fortunately, some of the worst of these attitudes are beginning 10 disappear, and nurses can now look realistically at how to build informal information and support systems to reinforce professional identity. Baumgart gave examples in her talk on how this was happening in Ontario with the growing number of special interest groups (see CNJ June 79), unionization, and the expansion of opportunities for continuing education. The positive effects of continuing education and special interest groups is easily understood but Baumgart clarified the importance of nursing unions by saying that they were part of a step to develop strong professional organization. Groups like hospital associations have a vested interest (that IS to say, economic) in preventing such strong nursing networks; she said such groups use 'divide and rule' tactics, and often have a 'keep them barefoot, pregnant and down on the farm' attitude. In a summary of her talk. Baumgart noted that success in an occupation or profession is no longer considered deviant behavior' for women, and that consequently the idea of informal social networks for support and information is one whose time has finally come. But, she predicted. the road will be long and difficult and fraught with problems. 14 Julyl Auguet 1871 The Cen-.llen NUrM -- NEW BRUNSWICK that if nurses don't define membership - among the nationally as a member of the standards of practice, then the recommendations approved board of directors of the government would gladly were: Canadian Nurses Association Unless the nursing profession oblige us - to a more . a third public member be and a former president of the can explain what it does, what ominous stage where added to the board of Canadian Nurses Foundation. and how it affects the patient, governments are legislating directors as a consumer of Robichaud, who recently there will continue to be an practice acts. " health care (not a civil retired as director of public erosion of nursing, said Scherer said that at a time servant) and that this person health nursing with the Kathleen Scherer, keynote of escalating health care costs, be named by the Ministry of provincial department of speaker at the 63rd annual when nursing salaries account Health health, was a member of the meeting of the New for such a high percentage of . four nurse members- N BARN Council for ten years Brunswick Association of the health care dollar, we at-large be elected and president from 1971 to Registered Nurses. The must be prepared to justify by N BARN members to serve 1973. meeting was held June 5-7 in these expenditures. on the board for a two-year Moncton. "Cost (>onscious tenn NOVA SCOTIA Scherer is nursing administrators do well to raise . NBARN create a new consultant, standards, the the question: why not hire staff position of administrative Manitoba Association of three registered nursing officer Registered Nurses. She said assistants instead of two . and. in addition to other Responsible participation by that with the advent of other RN's? I four response to that evaluation methods, in two or nurses in extending the health professions and query is simply: well the three years feedback be traditional boundaries of the paraprofessions the role of the quality of care would diminish sought from the public and profession, a stronger voice in registered and baccalaureate - then we can understand consumer groups on nursing exploring and meeting the nurse in health care has why the administrator and the NBARN philosophy health needs of society and become blurred. chooses the RN A . s. If our and objectives, and whether new roles for nursing "Accountability, that is reply is: there would be no NBARN is meeting the needs practitioners within the the acceptance of patient teaching - then we of the people ofN.B. systems and programs they responsibility for our actions had better be prepared to . the possibility of an help to develop, are all part of and inactions. is the major document patient teaching N BARN foundation for the exciting challenges for the impetus in the development of and patient outcomes funding education and future foreseen by the standards. The formalization associated with patient research. president of the Canadian of standards is one method of teaching. For it remains (EarIierthis yearCNA's Nurses Association. demonstrating accountability insufficient to plead need, director of administrative "N urses should lobby as a profession." rather we must demonstrate services. Beryl Darling, was more for social change, for a Scherer said that nurses need, effectiveness and cost asked to make political system based on are under pressure to develop benefits. " recommendations to the human need, not solely on standards from within the committee for the economic need," Helen profession. "In the past, we Fee increase development of administrative Taylor told Nova Scotia performed our functions with NBARN membership changes.) nurses meeting in Bridgewater a degree of certitude. Now we approved a bylaw change that New president early in June to celebrate the have pediatric nurse will allow the annual During the meeting, Anne 70th anni versary of the practitioners, enterostomal membership fee to increase Thorne, director of the Saint founding of the Registered nurse therapists and clinical from $65 to $95 for practising John School of Nursing, was Nurses Association of that nurse specialists. members and $15 from $10 for installed as the 21st president province. "We must learn to "There is a lack of clarity non-practising members of the New Brunswick assist in the planning, within the profession," said effective 1980. A motion for Association. Thorne, who was development and Scherer. "How do we further increase in 1981 was elected by the general implementation of new fonns differentiate between an defeated. membership earlier this year, of care in a changing society expanded role and that of a Among the resolutions will hold office for two years. which encourages client or nurse physician?" carried are that NBARN She replaces Judith Oulton as patient involvement and Scherer said that there is investigate the feasibility of president. where the total demand for a real need for nurses to extension courses leading to a During the meeting, two services will always be greater communicate with each other, Bachelor of Nursing degree nurses, Jean Anderson and than we can satisfy with our to define what it is they do and being offered in the various Appolline Robichaud, both of limited economic and what effect this has upon the health regions of the province Fredericton. were awarded manpower resources." recipients of their care. in accordance with the life memberships in NBARN Taylor's address on "Another pressure languageCs) that meet the in recognition of their present trends and future brought to bear on nurses to needs of the region. outstanding service and directions set the stage for develop standards arises from The professional contributions to nursing in three days of discussion by consumers of health care. association will also look at New Brunswick. A life the RNANS members on the Consumers have verbalized the feasibility of setting up a membership was also awarded theme of 'The nursing that nursing has failed to meet formal post-basic course in earlier this year to Doris profession: its influence on their needs and their intensive care nursing in N.B. Grieve of Fredericton. Only health in Nova Scotia". It also persistent vocalization has 32 nurses have received life paved the way for approval at paid off," she said. memberships in NBARN the conclusion of the meeting "The government exerts Structure and function during the last 60 years. of a motion calling for the pressure upon us to develop A report on the structure and Anderson, who served as association to study ways and standards. We have long since function of the association both executive secretary and means of making individual passed from the inference two years in the making was president of the provincial nurses more politically aware state, where it was implied presented to N BARN association, was also active and active in facilitating change within the health care system. Results of a demonstration project conducted by members of the RNANS Research Committee during the meeting indicated that only about one third of the nurse respondents considered themselves "politically aware" and that even fewer felt prepared to take action to influence health policy. The CNA president reminded her audience that Canada still lacks "a continuing measure of the health or sickness of the population" and that the absence of this "elementary marketing infonnation" makes it difficult to define the overall objectives of education for the various health professionals and to detennine the best balance of facilities and services. She described the role of the professional association as one of responsibility for monitoring trends. accumulating infonnation and making predictions regarding relevant health and social issues. "Nurses' groups." she said. "can establish priorities and initiate local and general programs to best respond to these issues. Nurses need to operate at all levels and echelons of the system. We must be planners. administrators. specialists. generalist practitioners. teachers. evaluators and researchers. " The nurse of the future. according to the CN A president. will need new conceptual maps and a new compass to serve as a guide in unfamiliar territory. She must: . maintain the essential caring role while, at the same time, assuming increased responsibility as a provider of primary care . take increasing responsibility for coordinating care. promoting contimùty of care and intervening in situational and developmental crises . be prepared to grapple constructively with individual, family and community crises The Cllnedien Nu.... . learn new community skills such as consultation, community organization, convening of service networks, monitoring unwholesome networks, collecting and communicating feedback information . understand the significance of suppoI1ive forces within the population (for example. self-help groups such as Alcoholics Anonymous and single parent groups) and learn how to work with them . be prepared to function in a variety of settings, maintaining traditional clinical roles at the bedside and also contimùng to extend life saving and life sustaining functions in highly specialized units. I n order to acquire these new skills and meet the demands of these new roles, nurses will need to work together as members of a professional association, clarifying common goals, avoiding duplication of costly projects and providing each other with mutual SuppoI1 in the interests of providing improved health care to the population. Retrospective re\ie\\ A special feature of the 70th anniversary meeting was the historical exhibit organized by RNANS life member and fonner executi ve secretary. Frances M. Moss. The display commemorated 70 years of nursing history in Nova Scotia -dating from the incorporation of the Graduate Nurses Association of Nova Scotia in 1910 (the first of its kind in Canada) to the present - and included original photos. documents and other memorabilia from every school of nursing which ever existed in the province, as well as other aspects of the association's history. "A look back to see where we are going", was also the theme of three special presentations by representati ves of three RNANS committees: nursing education, nursing service and social and economic welfare, under the direction of Jean Hughes. Geraldine Webber and Winnifred Kettleson. Organizational stud) An interim repOI1 on a review of the organizational - objectives, policies and procedures of the RNANS currently being carried out by a six-member committee appointed in April. ]977, was presented to membership for infonnation and discussion. Preliminary results of an opinion survey on membership awareness and perceptions of the RNANS. conducted by a management consulting finn as part of the larger study. were also reported to members. - . .J - ... Lif s,yl award w;nn r Ma'6ar t Br;" 11 Action on resolution Six resolutions. on subjects ranging from dissemination of voting results to voluntary retirement benefits and penalties, were approved by membership. One resolution - that the RNANS study the issue of mandatory continuing education as a requirement for renewal or registration - was approved by a majority of one vote. Another motion indicating membership support for study at the national level of the issues involved in continuing education and preparation of a position paper on this subject by the Canadian Nurses Association, was also approved. A motion providing financial backing to the extent of$IOOO for the province's student nurses association (one of the few still existing in Canada) was also passed. A report from SNANS infonned members of plans by the students for a camping jamboree and election of a new president, Donna Haverstock, of Halifax Infinnary School of Nursing . JuIy/AIIfIU-' 1171 111 Life Member A fonner member of the faculty and assistant director of the School of Nursing at Dalhousie University in Halifax, Jean Church was selected to receive a life membership in the RNANS on the occasion of the association's 70th anni versary. A fonner president of the provincial association. Church was also a member of the nursing education committee of the Canadian Nurses Association and RNANS representative on the first CNA Testing Service Board. PRINCE EDWARD ISLAND The 58th annual meeting of the Association of Nurses of Prince Edward Island attracted more than 120 nurses to Charlottetown on May 30 to discuss issues and concerns in health care. Keynote speaker, Dr. Marvin Clarke, deputy minister of health for Prince Edward Island spoke to his audience about new directions in health on the island and the new organization of the health department to meet these needs. ]n particular, he stressed that the community and the individual must assume more responsibility for their own health care. The assembly of nurses discussed and voted on a number of resolutions concerning continuing nursing education and new provincial employment regulations among other topics Members also approved a $15 fee increase. bringing the current practising fee (including the premium for professional liability insurance) to $85, effective next year. Five nurses were elected to membership on the AN PEl Council. They are: Juanita MacDonald Lechowick. vice-president; Vernita Gallant and Deborah MacDonald-Connolly. Charlottetown district council members; Shirley Murray Williams, West Prince county district. (continued on page 54) 11 Julyl AUflUIt 1171 The Cenadl.n"urN calendar September Programs in continuing education for nurses to be held at the University of Toronto, Toronto, Ontario: Nursing process in mental health and psychiatric nursing. Sept. 17-18, 1979. $65. Care of the disturbed elderly patient. Sept. 20-21,1979. $50. Stress relieving strategies: nurses in managemenl positions. Sept. 26, 1979. $25. Understanding adolescents. Oct. 3, 1979. $25. Geneticsfornurses. Nov. 28-29, 1979. $25. Evening courses Quality assessment using the nursing audit. Oct. 2-N ov. 6. $75. Cardiac anatomy and physiology for nurses. Oct. 4- Nov. 22,1979. $65. Contact: Dorothy Miles, Director, Continuing Education Programme, FaculfY of Nursing, University of Toronto, 50 St. George St., Toronto, Ontario, M5S /A/. Management of the patient with amyotropic lateral sclerosis (ALS). To be held at the Inn on the Park Hotel, Toronto. on Sept. 20, 1979. Papers on: management of upper and lower limb weakness, bulbar problems, respiratory muscle weakness, nutrition, biofeedback, speech and non-verbal communication. Tuition: $45. Contact: Doreen Konradis, MARY DOE R. N. SUPERVISOR NAME PINSI Shipped 48 Hours from Receipt of Order Attractive first quality name pins for your uniform from the largest name badge company in the world. Name badges are our only business. All badges are unconditionally guaranteed and come with nickel plated jewellers locking pin. Variety of colours to choose from Please check colour combination below: ë adg; u ce B ;;jjed Ëd ge ij ;-L;ïI;;'S- o White C White 0 White o Black 0 Black 0 Black o Blue 0 Blue 0 Blue Name (1st line) (Pl.... prlnl cl.er1y) Tille? (2nd line) PRICE: $2.50: with title $3.25. Extra badges ordered at same time (same name) $1.00. No minimum order. No handling charge. Enclose checue or money order with your order and mail to: (B.C. & Sesk residents, acid sales lex) J TH. I P.O. BOil 58160, Sin. "L", Vancouver, V6P 6CS BADGE -or- MA....... P.O. BOil 3480, Regina, S..k., 54P 3J8 Executive director, ALS Society of Canada, 1 Eccleston Dr., Suite 4/5, Toronto, Ontario, M4A / K/. Third North East Canadian! American Health Conference. To be held on Sept. 26-28, 1979 at St. Andrews, New Brunswick. Theme: Painful choices for tomorrow. Contact: North East Canadian/American Health Conference, Box /4/8, Fredericton, N.B.. E3B 5E3. October Competency-based education, self-learning packages and values clarifications workshops. A three-day workshop with Dorothy del Bueno and Diane Uustal. To be held on Oct. 29-31, 1979 at the Hotel Toronto in Toronto. Contact: Ruby Browne, Nurse Educator, Dept. EO, /2 Lakeside Park, Wakefield, MA,O/880. Continuing nursing education programs presented at the School of Nursing. Dalhousie University, Halifax, N.S.: Workshop on crisis intervention, Fall 1979. Caring for children: a nursing update, Oct. 15-16. 1979. Fee: $45. Occupational health nursing: ritual or reality?, Nov. 1-2, 1979. Fee: $45. Contact: Denise Sommerfeld. Assistant professor, Chairman, Continuing Education, Office of the School of Nursing , Dalhousie University, Halifax, N.S. Operating Room Nurses Group of Quebec 18th Annual Conference. To be held on October 30-N ovember I, 1979 at the Queen Elizabeth Hotel in Montreal. Contact:J. Verronneau, R.N., Operating Room, The Montreal General Hospital,/650CedarAve., Montréal, Québec, H3G /A4. The rehabilitation of the traumatic brain-injured aduit: an international conference. To be held at the Royal York Hotel, October 13-14, 1979. Sponsored by Centennial College, U. ofT.. and Ashby House Rehabilitation Centre Contact: Roy Del Bianco, Co-ordinator, Astonbee Coriference Centre, C entennial College, 65/ Warden Ave., Scarborough, Ontario, M/L 3Z6. Ontario Occupational Health Nurses Association Eighth Annual Conference. To be held at the Holiday Inn Downtown, 89 Chestnut St., Toronto, Ontario on Oct. 22-26, 1979. Contact: Helen Krafchik, Chairman, OOH N A, Warner-Lambert Canada Ltd., 2200 Eglinton Ave. East, Scarborough, Ontario, M/L 2N3. Association of Registered Nurses of Newfoundland Annual Meeting to be held Oct. 1-3. 1979 in Cornerbrook, Newfoundland. Contact: ARNN, 67 LeMarchant Rd., P.O. Box 4/85, St. John's, Newfoundland, A/C 6A/. Respiratory care educational update seminar. To be held on October 25, 1979 at the Royal York Hotel, Toronto in conjunction with the Ontario Thoracic Society Annual Conference. Contact: Eleanor Ross, York-Toronto Region Respiratory Care Society, J4 WilgarRd., Toronto, Ontario, M8X lJ4. A Conference on Pediatric Respiratory Care in the Community. To be held on Oct. 1-2, 1979 in Winnipeg, Manitoba. Contact: The Manitoba Lung Association, 629 M cDermot A ve., Winnipeg, Manitoba, R3A IP6. The Cllnedien NurM .luly/Auguet 1171 17 for professional growth... 1 MANUAL OF PEDIATRIC NURSING CAREPLANS Department "of Nursing, The Hospital for Sick Children, Toronto. The authors cover the entire spectrum of pediatric disorders and present two sets of interrelated care plans: one based on the hospitalized child's age; the other on his or her specific disease. Throughout, the manual emphasizes the parents' Important role in the treatment program and offers specific guidelines for their involvement. little, Brown. 320 Pages. 1979. $13.00. 2 GERONTOLOGICAL NURSING By Charlotte Kopelke Eliopoulos, R.N., B.S., M.S. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. Specific coverage is given to measures designed to promote good respiration, elimination, and activity to compensate for age-related changes interfering with these functions. Common diseases of each body system and their unique features in the aged are discussed in detail. Harper & Row. 384 Pages. Illustrated. 1979. $15.00. 3 NURSES' DRUG REFERENCE Edited by Stewart M. Brooks, M.S. All nurses will welcome this fingertip guide to drugs, organized specifically with their needs in mind. It lists alphabetically over 500 generic drugs and describes-in an easy-to-consult format- each drug's action and use, dosage and administration, cautions, adverse reactions, composition and supply, and legal status. A glossary of drug classifications affords extensive cross-referencing for quick referral to hard.to-find information. Impeccablyorga- nized and absolutely reliable, NDR will serve as the standard ref- erence for any health practitioner who dispenses drugs regularly. little, Brown. 500 Pages. 1978. Paper, $14.25. Cloth, $27.00. 4 THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 2nd Edition By Lillian Sholtis Brunner, R.N., B.S., M.S.N.;and Doris Smith Suddarth, R.N.., B.S.N.E.,"M.S.N. This monumental Second Edition of a modern classic-the most comprehensive single-volume reference on nursing practice ever published-incorporates massive revision and updating to offer the latest and most accurate information available. What this means is more detailed, substantive, and complete coverage of every phase of medical/surgical, maternity, and pediatric nursing! lippincott. 1868 Pages. Illustrated. 1978. $29.95. LIPPINCOTT'S NO-RISK GUARANTEE Books are shipped to you On Approval; if you are not entirely satisfied you may return them within 15 days for full credit. 5 PERSPECTIVES ON ADOLESCENT HEALTH CARE By Ramona Thieme Mercer, R.N., Ph.D. With 12 Contributors. Counseling adolescents on their optimal growth and health requires a wide range of specialized knowledge and skill. Here at last is a text that not only presents the major ideas and issues on this subject; it offers valid, practical suggestions that can be put to use in a variety of clinical settings. Ramona Thieme Mercer together with twelve contributing authorities, develops several major themes in relation to specific perspectives on adolescent health. These themes include the special psychosocial needs of the adolescent, the interrelation. ships of his or her family members, and the effects of larger society on the adolescent's evolving adult identity. lippincott. 420 Pages. May, 1979. $15.50. 6 OPERATING ROOM TECHNIQUES FOR THE SURGICAL TEAM Edited by Lois C. Crooks, R.N., B.S.Ed. The first two chapters deal with aseptic technique and sterili. zation and with the anesthetized patient. The emphasis is on the underlying principles, as shown by the concentration on the four sources of contamination in the chapter on aseptic technique. The remaining ten chapters of OPERATING ROOM TECH. NIQUES FOR THE SURGICAL TEAM are devoted to precise descriptions of anatomy, disease entity, diagnostic measures, surgical techniques, and nursing responsibilities for the most frequently performed surgical procedures. little, Brown. 459 Pages. Illustrated. 1979. $21.00. Lippincott J. B.lIPPINCOTT COMPANY OF CANADA lTD. Servmg the Health Professions in Canada Since 1897 : : :: .O:'O : :X7 _ o_ Please send me for 15 days 'on approval': 2 3 4 6 5 o Payment enclosed (postage & handling paid) o Bill me (plus postage & handling) Name Address City Postal Code Provo Prices subject to change without notice. CN7/79 . \( ",: t .... . ..r , -" ,. :;.. '" -"- : } R>. " -,.. .., :.\ ": '. ;'" _tJ..,,, ' ""-. tI ,- ... 'tI.- t - \ ;;: j , " . ... ... (\ --- 411 4#.:#' , . . -, ,ç,... } - to t .. :.wø" ... :1\ :;;: - oé': #' ....- ... .. etanus: tbe costly cure Catherine Searle r æ ........ .. 4 4 ,of . 't"e r.-. f e) I .. .. we are taught to take care of patients with love and understanding. I know this and yet. after two summers as nurse's aide in a hospital. I wonder whether any ofthe nurses working there had ever learned these basic principles. The nurses caring for chronic patients in the prolonged care section ofthat hospital left me completely disillusioned. They tied patients to their beds because it was a nuisance to have them walking around the halls; they put the call button somewhere the patient couldn't reach; they even closed the door to a patient's room when that patient disturbed everyone by crying too much because he wanted comfort. I . t about ere How many of these facts about butter: margarine and fat do your patients know? act . Just 6% of the .Ii . recommended daily caloric intake is contributed by butter. Many health professionals mistakenly believe that butter is a major contributor to the over-consumption of fat by Canadians which is considerably higher than the 35% of total caloric intake recommended by Health & Welfare Canada. In point of fact, Canadians eat more margarine than butter as well as many other fat-containing foods such as meat, fish, poultry, eggs, cereal products, salad oil and cooking oil. ad . The correlation be- .Ii . tween the consump- tion of hydrogenated ve , etable oils and the incidence 0 colon and breast cancers has been widely publicized. Results of a research study conducted by a team of scientists headed by Dr. Mark Keeney of the University of Maryland, and published in the summer of 1978, produced compelling evidence of a possible link between the con- sumption of hydrogenated vegetable oils and the incidence of colon and breast cancers. 'C aet - Hydrogenation _ changes the molecu- lar structure of vegetable oils. Hydrogenation is the process which solidifies liquid vegetable oils into margarine, making it "spreadable", and giving it longer shelf life in the store. This process changes the chemical composition of the vegetable oils and it also "saturates" fats which, were originally unsaturated. faet - Cholesterol is an _ essential substance, naturally present in the human system...and is a problem only to patients with specific lipid profiles. Such unsatisfactory conditions cannot be significantly changed by dietary manipulation. 'C aet - Butter has exactly _ the same number of calories as margarine. Weight-conscious patients, in the belief that they are cutting calories, often give up the good taste of butter for a less palatable spread. . . an unnecessary sacrifice. 'C aet - Canadians, on a per _ capita basis, consume just haIr an ounce of butter per day. This is just a fraction of the amount generally believed by many health professionals to be the per capita consumption of butter by Canadians. When you look at the facts, you can see the good in butter. DAIRY BURFAU OF CANADA 'C aet - Approximately 2 to _ 3% of butter is linoleic acid - the ingredient which many scientists believe to be the moderating, beneficial fador in the diet-heart relationship. The ideal level of linoleic acid in fats intended for human consumption is not yet agreed upon. 'C aet - Data exists which _ show a definite correlation, in certain cultures, between the high level of animal fat consumption and the low incidence of CHD. The Masai and Innuit cultures indicate just such a correlation. Interestingly, so, too, does the Insh whose butter consumption, though markedly greater than their lrish- American counterparts, have a much lower incidence of CHD. SOURCES: Mary C Enig. Robert 1- Munn and Marl< Keeney DIetary fat and cancer trends - a cnllque FederalJon Proceedings 372215-2220. 1978 Mann. C.V. and 5poeny. A 51udies of a sutfactant and cholesteremia m the Masal. Amer J Om Nutr .27 464.1974. Gershon Hepner. RIchard Fned. Sachea. 51 Jeer Lydia Fusetti and Robert Monn Hypocholesterole'nic effect of yogurt and mill<. l\m 1- Om Nutr.. 32:19-24. 1979 rÆliry Farmer.; of Canada rÆliry Fads and Rgures al a Glance 1978 34 JuIy/Augu.ll17t The Cenecllan N_ began to think twice about becoming an RN. I asked some of these nurses what made them so hard. They answered: "Vou become hardened over the years. It seems to me that. this is impossible for it is through experience that your abilities increase. After years of practice a nurse should be better able to cope with illness, all the while providing more and more comfort to the patient. If she cannot do this, perhaps he should go back to her schoolbooks to see how to treat patients physically and It's a bird, it's a plane, it's supernurse! Susanna Jack "Who took the nurse out of nursing?" is by now a familiar lament. What has become of, if indeed she ever existed, the warm and attentive nurse, the ideal "nursely" nurse, who takes the time to really nurse, nurturing he patients physically and psychologically? Lately, I have started to wonder about this question which has been sounding in my ears since my nursing school days more than 10 years ago. I have begun to say to myself: if something continues to be notably not-there for so long perhaps what is wished for is not possible. Perhaps the questioner must examine her wish instead of constantly reproaching reality as she finds it. The day of the fatherly country doctor who knew all about you and would always come to see you has pas ed.1t may be that the time of the motherly nurse who cared for you with devoted tenderness is gone too and presentday nurses must assess what it is that they now can do appropriately and well. There is no doubt that when ill we all long for mother and father. not as they actually were, maybe, but as we wi<;hed them to be - caring and powerful. emotionally. Or perhaps she should even consider leaving nursing for awhile. Anything rather than further decrease the morale of her patients, even lower, that is, than it already is. As a student nurse I understand that I still have years in front of me to really learn how to cope with patients in every situation But surely love is not learned; it is innate. And I believe that one rule of thumb in caring for patients should be always to ask yourself "How would I feel if I were in his place?" But nurses and doctors are not mother and father although these roles devolve upon them by analogy both in their own and in their patients' fantasies. Nurses have trouble extricating themselves from this situation. The ideology oftheir profession supports the<;e ideals; what is not taken into account is the fact that this ideology was developed in an era when the moral and social climate was quite different and when nursing tasks were much less technologically demanding. There is need for a reexamination in light of the current nursing environment. Nurses are expected to be both caring and technically competent and yet they are persistently obstructed in these aims. The staff nurse usually has a patient assignment of such size that to give basic physical care require the full shift; she has to attend to the demands of many people at once and cannot afford to focus her attention totally on one person for any length of time since other patients under her care cannot safely be forgotten. An individual really in need of special attention to his emotional state often becomes a source offrustration, guilt and, ultimately, anger. Also, it can be hard to feel really competent and autonomous as a nurse. De<;pite all attempts to make nurses feel proud of their unique occupation it is nonetheless apparent that in the eyes of the staff and patients with whom they constantly interact. theirs is a lesser statu warranting less respect than that of the medically better trained doctors. Having le!>s respect from others, it is easy to have less respect for oneself and what one does. I t seems to me that nurses are very much in the position of housewives a few years ago before the wave of feminism made clear the ab urdity of their assumptions. Many women felt that they should be perfect housekeepers, mates, mothers. and career women simultaneously. Similarly, staff nur<;es are encouraged to take on increasingly demanding technical tasks, to be Maybe then we will see what a true nurse IS. Francine Camolinos,SN, has now completed her second year of nursing at Dawson College in M onlreal after working for two years as a nurse's aide. She notes that she has worked in 'arious departments, including the chronic care section,lCU and also emergency. n I' s;; l r " ,\ .., .... ... .... ---. ... / - ... ---- ---- .. nurturing to their patients using great interpersonal skills, and at the same time, to maintain their emotional balance in the emotional hothouse of the busy hospital ward. They are told that if they organize their time properly it is quite possible. I believe strongly that people who are ill need sensitive psychological attention from those caring for them. I have also concluded that this is not available often from nursing staff because of the limits of their training in interpersonal skills and the limits of"their working situation. Their energy is directed to the tasks that have a more obvious priority and to maintaining their own emotional equilibrium. In other cultures it is expected that the family will assume the work of emotional support and to a degree give physical care to the sick person. In our milieu the current atrophy of social supports is actually made worse by hospital regulations until the nurse does seem truly responsible for "total patient care .. The Canadian Nuree Jul)'/AuDU 11171 36 Most nurse'ì I know try hard to look after their patients decently but they are not able to live up to the fanta y of the perfect nurse. Patients have every right to ordinary kindness but it is not realistic to expect the nurse to take over the task belonging to family and friends. Although the literature spurs them on, most nurses' have worked with are not willing to involve themselves deeply with more than a few patients; they don't have that kind of emotional energy. They That's right, I'm a nurse Sandra Klyne I am unlike the advocate of an alternative lifestyle or radical philosophy seeking an understanding or sympathetic ear. My lifestyle is more traditional - I am a nurse. But I am writing in the same spirit as the organic fanner or the "new woman in the boardroom" . I want you to understand. I am troubled by the public - and particularly the feminist - view of the nursing profession. If hatred doesn't exist, certainly there is an air of antipathy and perhaps a little contempt towards nursing and indeed all of the so-called "pink collar" jobs. The women's movement has done much in recent years to point out the inequalities in the workplace between women and men. The stereotyping of both sexes injob orientation has also been discussed. But' believe insufficient attention has been paid to those who have made a conscious choice for the traditional profession and to the social usefulness of women in these occupations. The choice . chose to be a nurse. . was not "steered" into it by well-meaning parents or counsellors who thought I' d find a doctor and settle down. My mother would probably have liked me to be a secretary, if only because she had been one and loved it. My father saw me are willing to do a competent job of implementing the hospital"'i physical support system and to be plea'ìant about it. They are willing to tolerate and work around the sick per on's emotionalup and downs as long as he i not too disruptive of their accompli'ìhing their nursing tasks. Unless the hospital environment changes dra tically. . wonder if demanding more from most nurse i'ì realistic? o a a doctor one moment and as a lawyer the next. But the important point is neither of them imposed their opinion on me. This is nOl to say that I've never wanted to be anything ebe. Like most children' sometimes dreamed of being a dentist. a cowgirl (cowperson?), an entertainer, a teacher or a writer. But I always came back to nursing. . chose nursing for a very corny reason.' wanted to "help out" Assisting people regain or maintain their health fascinated me a'ì much then as it does now. Think, for example, of a mother who has just given birth by Caesarian ection. The morning after surgery she is ill: she is fed by intravenous drip, she has a catheter in her bladder and pain from her incision. She is allowed neither food nor drink. She is feverish and irritable. By the afternoon of the same day. she is sitting up. drinking juice, going to the bathroom. and spending time with her baby. Much of this is due, not to medicine. but to nursing interventions. Nursing is doing things for other people that they would do for them elves if under the circumstances it were possible. This includes everything from the administration of a vaccine, to the maintenance of basic life support. Nursing takes knowledge, skill, compassion and a willingness to keep learning and growing for a'ì long as one practices. A nur e who has not made a Susanna Jack (R.N., Nightingale School of Nursing, Toronto; M.A., counseling, McGill Unil'ersitv) is currently a psychiatric nurse consultant at the Montreal G eneral Hospital. Montreal. Quebec. Prior 10 this appointment. she wor/...ed as a staff nurse and then later as the head nurse of the department of psychiatry at MGH. She has also had experience in medicine, gynecology, ohstetrics and psychiatry. - , , .- deliberate choice in this direction cannot urvive the demands of my profession. Doctors and nurses Many people think of a nurse as a handmaiden -or slave - to the doctor This is. quite simply. not so. Nursing and medicine share a body of knowledge that belongs exclu ively to neither. These subjects include anatomy, physiology. pathology, microbiology and pharmacology. Each profession also has its own body of knowledge. I make no apologies for the fact that' cannot remove somebody's gallbladder. It isn't my job to do so. But I do have skills that physicians and surgeons do not. I clearly remember hearing a lot of bangs. crashes and groans from a patient's room one day not long ago. A well-meaning doctor had tried to mobilize a post-stroke patient for the first time. The tangle of tubes, bottles, bedrails and limbs was ex traordinary. That would not have happened if a nurse had helped the patient. The doctor was to blame for doing something for which he was not trained. Fortunately, no one was hurt. An act such as this by an unskiIled person can bejust as dangerous as surgery performed by an unskilled person. The handmaIden public image of the nurse could be the result of the phrase "doctor's orders". Actually a doctor's order is a medical prescription but the 341 Julyl AUDU 11171 The CenMilen Nu.... words are often understood by those outside nursing to mean a military command barked by a polished higher-up to his cowering underling. A doctor's order is written,just as a prescription would be for a pharmacist if the patient were at home, and carried out by the nurse as it would be by the pharmacist. Except in dire emergency it is illegal for a nurse to act on a verbal prescriptionjust as it is illegal for a doctor to prescribe orally. I wonder - is the doctor-pharmacist relationship considered master-slave? Most of a nurse's day-to-day activites do not require prescription. Prescriptions are needed only for medications and certain invasive procedures or treatments such as the drawing of blood or the introduction of a urethral catheter. For the most part nursing care is given according to the nurse's assessment of the patient's individual needs. The types and methods of hygenic intervention, mobilization, comfort, rehabilitation and health education (to mention onJy a few) are all based upon independent nursing judgements. Even procedures which require prescription are carried out by a nurse because nurses have the knowledge of sterile technique, patient comfort and safety that are outside the realm of the physician. In the average day the nurse can often make more decisions regarding patient care than the doctor. Decision-making The decision-making process in the health care system varies from country to country, province to province and in many places, hospital to hospital. This is because government and private involvement in the health field differs wherever you go. In some jurisdictions there are no private health services at all, in others, none are public. "Public" may imply federal, provincial or municipal control. "Private" may refer to a company-owned general hospital, a small-group clinical practice or one person running a nursing home. But in almost all of these cases more and more nurses are becoming involved in the decision-making process. I will use Quebec as my most familiar example. The boards of public hospitals (public meaning provincial) are made up of elected representatives from all health professions (medical and non-medical), non-professional employees, users (patients) and members of the community. Most hospitals are public and all significant changes in operation must pass these boards. In the day-to-day running of most institutions nurses sit on virtually every committee that plans changes and sets policy, The mandates of committees range from determining the manner of record-keeping to describing methods of procedure: from quality care assurance to the hospital's plan for accommodating disaster victims. The people invol ved on these committees are not only management nurses but regular staff as well. There are two other nursing groups that come to mind in any discussion of decision-making. The first is a small but growing core of nurses employed by all levels of government to act as consultants in health care matters. The second is the professional association which acts, either locally or nationally, as a pressure group on their corresponding level of government. Professional competence Unfortunately there are members of the "medical establishment'" who are incompetent, or contemptuous of their clients, or both. Fortunately I believe they are in the minority. It has been my observation that professionals who are going to heap scorn do so in direct proportion to: - social class of the client (the lower the class, the greater the contempt) -degree of client c1eanJiness (dirty equals worthy of contempt) -apparent intelligence (the lower the perceived intelligence, the higher the professional"s level of contempt) -degree of the client's tendency to ask questions (to "be a bother"). Nurses, lawyers, social service workers, all professions contain a small core of people whose attitude to others leans this way. But th majority of !. - - professionals are decent, hard-working, humane folk who should not have to take the lumps for their less-desirable colleagues. Perhaps they could be more aggressive about participating in weeding out the dead wood but that is another matter. Health care for women The feminist argument that women will be respected consumers of health care services only when more women are doctors is not entirely satisfactory. Improved health care for all people depends not upon the number of womèn in anyone health profession, but upon the quality, availability and variety of services offered to the client. We tend to think of nur es caring for the critically ill at the hospital bedside. But nursing has a great responsibility in keeping the population well and this has to be one of our priorities for the future. In schools the nurse can assess both the physical and social problems that impede learning. For example, the performance of some female students in subjects like math can be influenced by environmental factors. The nurse is also helpful in providing practical information and reassurance in guiding youngsters through the physical and emotional changes of adolescence. I n well-being clinics the nurse can promote awareness of the normal functioning of the body and teach her clients how to maintain that normalcy and detect problems. This would include teaching women breast self-examination and promoting the understanding of the reproductive system, as well as instruction in nutrition, hygiene and other health care basics. The nurse has a role to play in family planning clinics. The use, benefits and risks of the various methods of contraception can be explained by the nurse who can also act as a sounding-board for women who are making family planning decisions. Let us not forget nursing and the new parent. It is a function of the nurse to teach care of the newborn as well as to promote parent/child bonding. In so many health issues - the problems of aging, the non-medical use of drugs, venereal and other contagious diseases - nurses perform vital functions by participating in prevention programs, counseling, referring and supporting their patients. These are special skills that nurses have acquired by looking at themselves as health maintainers as well as providers of care to the sick. This is an image that has been adopted by our educational institutions at both the basic and graduate levels. Education acts to enhance the nurse's ability to deal with these new responsibilities. The CUledlen Nu..e Julyl Auguet 1179 37 Nursing is for both sexes A much as we speak of a male-dominated medical establishment we should remind ourselves that the nursing establishment has been unkind to male practitioners. Until the early seventies men were barred from nursing practice in Quebec. Even where men have been active in nursing for some time, their roles have been stereotyped. They have been steered into psychiatry (where presumably all you need is muscle) and urology (tote those buckets). Society has also been unkind to the male nurse with patients of both sexes often refusing care from a man. Promotion to managerial status has been slow for many men. All of this is changing, partly as a result of human rights legislation, but also due to human enlightenment. Men now work in such diverse areas as neonatology, pediatrics and surgery. More men are pursuing advanced studies in nursing which often leads to promotion. They are becoming more active in professional associations. Most importantly, the notion that a man cannot be gentle, compassionate and supportive is disappearing. Nursing: fact and fantasy Margaret Allan Do you remember why you decided to be a nurse? Do you remember making a promise to yourself as you graduated? "I will take the time to be reassuring and understanding. The patient is my first concern. " Over the years have you lived up to that commitment? Was it, then or now, a realistic goal? Most people, when they think of a nurse, visualize an efficient, yet compassionate. woman in a white uniform and cap. However for many of these people, hospitalization comes as something of a shock: many nurses do not wear white uniforms or caps, some nurses are not An apology? So if you think I "doth protest too much" I regret your interpretation. but not a word of what I have written. To me nursing means providing every individual who seeks my care with all of the skill and compassion I have. Sex does not influence a person's skill. As a professional body largely made up of women we are in a position to promote public health. I am concerned that my profession is all too often passed off with a wink as "pink collar"- somehow degraded and made light of by those who can most benefit from it. Women who have decided to become nurses don't need sympathy -we know our true value. Sandra KI ne, a graduate ofthele....ish General Hospital School of Nursing in Montreal, has had a l'ariety of....orl..ing experience that includes staffnursing in neonatalog...., orthopedics and pril'ate duty. Currently, she is clinical coordinator of ambulatory' . er\'ices at the le....ish General. KI\'ne also holds a B.A. degree from SirGeorge Williams U nh'ersity (no.... C on cordia Uni 'ersitv) in Mof/treal. women and, most significantly, some nurses are not compassionate. Efficient. a term more often applied to robots, may be the only word that really seems to suit. But nur es are not robots with levels of performance standardized at the factory, nor are they white angels floating through hospital corridors and doorways. Nurses are human beings in constant interaction with other human beings. It is unfortunate that the qualities that make nurses human, such as concern and compassion, are the very qualities most susceptible to the pressures of constant interaction. These pressures vary from the anxiety of saving lives to the irritation of changing one bed eight times a shift. Different activities require different emotional responses and each response must vary with every patient. Time and repetition may improve the nurse's efficiency but the capacity for caring is often drained by the numerous demands that are made upon it. To the demands of the patient you have to add the effects of the nurse's co-workers - the doctors and administrators. The net result of all of this? Some of the nurse's personal qualities are strengthened, some are eroded and some get buned under a hard, protective coating of apparent .- .. , . '- - . @/ ) i v . . . a f ... " unconcern. Nursing change the nurse and compa sion is only one of the qualities affected. The changes are gradual but they do not go unnoticed by nurses them elves. A nurse told me that she caught her;elf one night "treating a person like an . it" . I had to shake myself and try to remember that this uncon'icious patient was a normal person like my elfwhojust wasn't alert at that time. ,. Most nurses would nod their head appreciatively at this statement, but the mythic image of the nurse as a perfect white angel persists. Why') Perhaps it is because this flattering picture i so often painted by someone outside the profession that nurses don't want to mar it with truth. Attitudes change The rosy picture of a caring angel i dangled in front of the student nurse throughout training. The reality of regular hospital nursing comes as a rude shock to the idealistic new graduate. As one young graduate said, "I thought that I would always be sweet, reassuring and patient...but some day you're grumpy and the situation is not exactly as I had imagined. ., Another recent graduate said she entered nursing because of a curiosity about the human body but left general duty nursing because "the job of nursing 31 July/Auguet 11171 The Canadian NUf811 --- is tied up in bedpans. It got me down." Both nl,lrses had professional expectations which were not fulfilled on wards. One of them said she was "disillusioned by the whole medical scene. No one cares." In four months she changed the image she had of herself as well as the image she had of nursing. She wonders if in two years she will become like those who "are more interested in coffee breaks and a cigarette than in the patients?" Although this graduate had to alter her own expectations others still expect certain things of her. One nurse said the high standards that others expected caused her to retain and renew her medical knowledge both when she worked and long åfter s he retired. Some expectations do not have such beneficial results. Nurses who trained in hospitals prior to the mid-sixties were expected to fill the traditional role of the cnsp professional at all times. It was the image of the nurse that was important not the relationships that were set up. A natural interaction between human beings was impossible under this expectation of strict professionalism. Those who trained as nurses before the early sixties were also expected to be unquestioning servants to doctors. A research study conducted throughout the I%O's found that "nurses as a group share the common characteristics of submissiveness and dependency."'The nurse's relationship to the doctor Was based on the premise that "he's God almighty and your job is to wait on him."2 Every nurse one researcher interviewed felt that "making a suggestion to a physician was equivalent to insulting and belittling him.' '3 That was 1968. The nurses who have trained since then are more assertive- at least they don't stand at attention when a doctor approaches the desk - but the nurses who trained earlier still feel the subservient effect of their training. Tired legs, aching back Although expectations vary with the times, the one force that remains constant in nursing is the effect of shift work. Most nurses feel that shift work hinders their family and social life, limits their friendships to those also working shifts and exhausts them. Re earchers know that shift work disrupts all body rhythms, but the knowledge of this fact doesn't help the nurse who struggles to stay awake at five in the morning or to go back to sleep at noon. As one nurse said, ") never get enough sleep (when) 'm working) nights. ) 'm not as efficient then, yet that's when)'m really needed because that's when people die." Because they are tired and restricted by shift work, most nurses remember only negative effects but there are positive aspects as well. Shift work allows nurses with small children to work without worrying about babysitters or daycare. Other nurses find the evening and night atmosphere on wards relaxed and more conducive to closer patient relationships. One nurse even reported an enhanced marital relationship due to shift work - her husband began to appreciate her more. Nurses admit there are some advantages to shift work but they would be hard pressed to find anything good to say about the heavy physical work nursing involves. Although some wards are more difficult than others most nurses would agree with the graduate who said, "When I work) only work. I ha ve no time or energy for anything else." The constant walking, running, bending and lifting induces a fatigue that affects the nurse's relationships with her patients, co-workers and family. This exhaustion combined with shift work 1 . . . .. . ...r- n , -'-\\._' - e '" .. '"'.- .Ii.' . I .., - t , J""V'. _ f: 't .... prompted one nurse to say, "N ursing becomes a lifestyle...1 don't see how a person can remain nOnTIal while working full-time. .. The weariness nurses experience can be seen as a short-term result of shift work and heavy labor but there is also a 10ng-tenTI effect. The nurse's field of interest is narrowed. ")'m too tired to even read; I'vejust got enough energy to look after myself' and so the nurse is forced to lead a very circumscribed life. both physically and intellectually. In addition to this, shift work and the attitude of most hospital administrators make it nearly impossible for one to enroll in any kind of class or to sign up for any sports acti vities. Updating The working nurse also faces stagnation within the profession. One recent graduate pointed out, ") 'm not as smart now as when) was a student. .. One of several reasons for this is that, even when the hospital provides classes for nurses, they don't provide the time to attend them. "It's a drag attending in-service education," said one disgusted nurse, "because you sit thinking of all the work you left behind. And if the classes are held on your days off you don't come back because your time off is too precious. " The new graduate also said she felt she wasn't as "smart" because she missed the stimulation of the new and different infonTIation that books and wards had given her in training. Nurses seldom rotate on wards. This means that very few have new learning experiences after their first months on their assigned ward. One author wrote, "Maybe the patients, who eventually do leave the institution, are better off than the employees who may acquire dulled intellects as well as feelings of unimportance from...the routine of their work. "5 Besides mental and physical exhaustion nursing also arouses feelings , . f -- / of anger and frustration. As all nurses emphatically agree their deepest frustration stems from the shortage of staff which administrators seem to ignore or dismiss with the eternal words "budget cutbacks". (Those words ring in our ears while administrators spend money to replace bottles of Airwick with expensive little gadgets that release deodorizer at timed intervals.) The frustration of nurses arises, not from the increased work load produced by staff shortages, but from their inability to provide good nursing care no matter how hard they work. There just isn't enough time. One nurse said that although almost everyone meets this kind of frustration on their job, leaving a column of figures unadded is different than leaving the needs of patients unmet. Not only is a nurse dealing with human beings, she is dealing with human beings whose needs are immediate. Tomorrow might be too late. Racing the clock The frustration of those without the time The Cenedlen "UrN July/Augu 11171 311 to fulfill the needs of their patients has caused many good nurses to leave their profession. One nurse left because she never had enough time to comfort the crying children on the pediatric ward. Another nurse marched down to the Nursing Office and said. "I refuse to be responsible if something goes wrong." The Nursing Office ignored her req uest for help and so. in frustration, she quit. Yet another nurse summed up her frustration with stafTshortages by saying, ". didn't need that kind ofs.... so . quit." There is frustration due to a gap between the patient's needs and the nurse's time. But there is also frustration with doctors who often seem not to care (especially fortheirelderly patients) and with a "system" that insists that ice water be passed out to patients at five-thirty in the morning even if the rattling of carts, buckets and jugs wakes every patient on the ward. Fruitless attempts to change such stupid routines have caused many nurses 10 quit their jobs or stop complaining and join the ranks of those who "take the easy way out. .. Frustration. experienced by all nurses, has also caused some to adopt a hardened approach. Many of the nurses I spoke with felt their changed attitude should more correctly be called "controlled". This control allows these nurses to protect themselves from too much pain. They said it also gave them a certain sense of command of the situation although many added they often paid for their control with emotional stress later. Some nurses admitted they had become at least a little hardened and in order to feel real compassion they had to imagine a loved one in the same situation as their patient. One nurse said, "I used to worry about my patients. now. just think about them." Perhaps this decreased emotional involvement is due as much to emotional exhaustion a it is to physical fatigue, frustration and day-to-day routine. One nurse speculated. "Maybe wejust run out of compassion." Another confessed. "Sometimes I just get tired of complaints all day'" But she went on to add, ". get mad when I catch myself not responding properly." At least some nurses are aware of the hardening process and can say. "I still cry over some deaths. And I'm glad I'm still able to." Getting to know death Although many say that they have "come to terms with death" crying remains one way of coping. Most nurses do not accept the idea of their own eventual death or that of a loved one any easier than they did before they nursed. "Coming to terms with one's own death is not necessarily the result of cumulative experience with death and dying. "6This is illustrated by the nurse who worked on a cancer ward; she faced at least one death a week but said. "I'm still afraid to die." They may still be afraid to die but the majority ofnu....es are more comfortable with the dead ar dying than is the generdl public. The working experience of nurses has forced them 10 think and talk about death. Some nurses have been prompted 10 ponder the metaphysical aspects of their eXistence; one nurse I spoke with said that death made her "realize the living body is more than just a heart and blood" while another spoke of the "presence" of the living body. Although many nurses are stIli depressed by deaths on wards, some find working with the dying intensely . , ì I . , . 1 il . .. -- ., ;: - - ...... .... gratifying. One nurse who had worked on a cancer ward said, "I gained somethmg from the experience. I really, really felt like I was doing something worthwhile." But she went on to say. "There is only satisfaction in working on a ward like that if there is sufficient staff. If there isn't it is the most fru'itrating place in the world." Thi'i woman had worked on another cancer ward which she said was "ugly" because it WdS short-staffed. "You gave all you could in physical care and there was nothing left for emotional care." And so. even a discussion of death is reduced to a recital of frustrations due to staff shortages. That is part of what nursing is all about. Mixed with the grand mysteries of birth and death are all the down-to-earth matters of bedpans. sore feet and frustration. Some nurses do "run out of compassion". One nursing instructor said, "It happens to them. It.s not that they're taught that way" Of course not The overwhelming experience of general duty nursing - the satisfaction, frustration. wonder. orrow.joy and initation - affects the whole being. not just the intellect, of the nurse. Not all change is positive but change itself is an ongoing process and a neceS'iary part of growth."" References I Muhlenkamp. A.F. Characteristics of nurses: an overview ofrecent research published in a nursing research periodical. by... and J.L. Parsons.J. Vocational Beha\'. 2:261-273, JuI. 1972. 2 Stein, Leonard .. The doctor-nurse game. AmerJ.Nurs. 68: 1:101-105, Jan. 1968. 3 Ibid. *4 Luce, Gay Gaer. Bod\' time. Toronto. 1973. p.8. 5 Brandner. Patty. Are nurses unique? Supen'.Nurse 7:1 1:34.37-38. Nov. 1976. 6 Popoff, David. What are your feelings about death and dying? Pt. I. Nursin[< '75 5:8:15-24, Aug. 1975. *7 Intervie\-\s with six individual nurses and one group of nurses, all of whom prefer not 10 be identified. Regina, Nov 1978. *References not verified in CN A Library '\-largaret Allan. the author of "Nursing: fact andfantas\" , !'.'rote this article from research carried out in a general hospital in one of Canada's westem prm'inces. The I J nur. es she spoke !'.'ith ran[ - - - - -. .. - - - - -.. -- ...-. .. --. ...... .. Mosby The Nursing Publishe PJU WNG WOODS NIl -. Nt . OLC;y \. I! --- .,. .. ' -' . r CI ... . n .... <.( ..: . .\. . / . . of ... ::s · HCMIICINs .. - .. .. .. .. .. ... ::s -. .' MObB\' )# f U "0 - :E u '2 . - "3 "'0 A ClItNT A < fa NUltSING aulD. ßOQ1 _L..c:òI MATERNITY CARE Basic . pathophysiology . - Ch... .....I-t'... ...... __InC_ IinIIr a e D - -- -- G . a-. "".", 'UDJ.._ - '.!!l .. ., S .. Community health care and the nursing process -- -- - c.- .:::,......:: -- Fundamentals of nursing practice --- Need we say more? IVIDSBV TIMES MIRROR THE C. V. MOSBY COMPANY. L TO 86 NORTHLINE ROAD TORONTO. ONTARIO M48 3E5 ,0.91)6(2 I- · '_ ;i{ . = 1 : .i i =-- - -: 5:': t -:-- - . pertensive . . I Isor I Irs In Irelnancy Bonnie H orIley Hypertensive disorders in pregnancy remain one of the three leading causes of maternal mortality. The disease appears in five to ten per cent of all pregnancies, and is responsible for a death rate of more than one per cent. * The traditional I term 'toxemia' ís becoming inappropriate in that research has revealed there is no toxin involved, but the word is still used frequently both clinically and in research literature because no more appropriate name has been found. The role of the nurse in both recognizing and monitoring the development of the hypertensive disorders in pregnant women is an important one. Thus, it is necessary to have a good understanding of the basic pathophysiology, medical management, and nursing care of these disorders. This learning package is intended to provide you with such an understanding, and it operates in a very simple fashion. The information content is presented in stages in small sections after which pertinent questions are asked to emphasize the most important points. The answers are provided at the end, followed by a short post test which will check your understanding of the material. 'Canadian statistics report 22 maternal deaths from complications in pregnancy in 1976; 6 of these were from toxemia. The Can-.llen NUrH .JUlr/Augu8t 1171 43 CYCLE 1: Introduction Up to 10 per cent of all pregnant women demonstrate hypertension; of these women, two thirds have chronic hypertension, while the remaining one third develops a form of hypertension, or toxemia, which is peculiar to pregnancy, appearing late in gestation and subsiding after delivery. There are several methods of classifying the hypertensive disorders; one is as follows. .1. Preeclampsia a) mild b) severe 2. Eclampsia .Chronic hypertension Frequently the disorder is considered to be a continuum of mild preeclampsia to severe preeclampsia to eclampsia; approximately 5 per cent of all the patients with preeclampsia actually progress to eclampsia. CYCLE 2: Changes in Hypertensive Disorders of Pregnancy "Toxemia" is often called "the disease of theories" because it seems that everyone who has ever worked with "toxic" women has put forth a suggestion as to its cause. These ideas range from too little protein in the diet to incorrect alignment of the woman's bed with the north pole! However, the exact cause is still unknown. Toxemia is characterized by vasospasm and intravascular coagulopathy. "Recent scientific studies have shown that these generalized changes in the vascular system result in a number of alterations in the uteroplacental bed that may compromise the integrity of the placenta and the fetus. "I Another study notes that women who develop toxemia are apparently more sensitive to the pressor hormones than other women. 2 The cause of the vasospasm is still not completely understood; the results can be depicted as follows: Vasospasms Hypertension ! t , Renal perfusion & , Glomerular filtration /\ /' Damaged blood Hemoconcentration vessel walls Tissue damage Utero-placental blood flow Proteinuria Edema ( , - short arrow, means decreased) The classical triad of manifestations of preclampsia is HYPERTENSION, PROTEINURIA and EDEMA, and may be put into a simple formula. "TOXEMIA" = HYPERTENSION + PROTEINURIA + EDEMA In the hypertensive disorders there IS widespread which provokes This also leads to decreased glomerular and .... JuIy/AugU8t 1971 The Cen.dl.n Nur.. Now that you have mastered the basic physiology you should find the rest relatIvely simple. But don't forget the formula! CYCLE 3: Predisposing Factors "Toxemia" usually occurs suddenly sometime after 24 weeks gestation. It is seen most frequently in primagravidas (especially the very young or those over 30), diabetics, chronic hypertensives, and in women who have co-existing conditions in pregnancy such as hydramnios, multiple fetuses or hydatidaform mole. As for other factors, authorities are in disagreement on the importance of protein deficiency in the diet. However, it is important to note that the incidence of this condition is much higher in the lower socioeconomic groups who are more likely to have a nutritionally deficient diet and less prenatal care. Research has found a tendency for this condition to be familial. One group of researchers has discovered that a high proportion of pregnant women who demonstrate a rise in diastolic blood pressure of at least 20 mmHg when turned from a lateral to supine position subsequently develop preeclampsia. 3 This has been known as the "rollover test" and may be employed as a screening test during antenatal visits. CYCLE 4: Mild Preeclampsia. Manifestations and Treatment The early signs of mild preeclampsia are often so subtle that a woman may be unaware there is anything wrong. The most dependable sign is a rise in blood pressure: an increase of 30 mm or more systolic or 15 mm diastolic over the patient's baseline values is significant. Excessive weight gain - more than 1 kg per week - is another early sign. Proteinuria at this point may be absent or minimal. By the time the patient develops signs that she herself can detect, the disorder is usually advanced. In this early stage, patients are often advised by their physicians to rest in bed most of the day as this promotes diuresis by increasing venous return; a mild sedative may be prescribed. Historically, sodium has been restricted, but more recently authorities recommend a normal sodium intake. 4 The woman is instructed to weigh herself each morning before breakfast, and visits to her physician may be increased to twice a week. Many practitioners even hospitalize the patient; in hospital urine testing for protein is started, and the woman is encouraged to participate in her own care, doing such things as recording her daily weight, testing urine, and selecting her diet. CYCLE 5: Severe Preeclampsia In severe preeclampsia, each of the three manifestations becomes more severe. The blood pressure continues to rise and may reach 160/100. Edema increases and facial and ankle swelling may be noticed. Proteinuria, which indicates the extent of glomerular damage and the possible presence of small renal hemorrhages, may reach 10 grams per litre of urine. What are the predisposing factors in toxemia? What clinical manifestations are presented in mild preeclampsia? (give values where applicable) 1. Hypertension: 2. Edema: 3. Proteinuria: What would you be advising a patient with mild preeclampsia? 1. 2. 3 The C8nedlen Nur.. Julyl Augue11171 45 Signs of increasing Central Nervous System irritability will appear: headaches, dizziness, nervousness, visual disturbances, nausea and vomiting, and exaggeration of reflexes (hyperreflexia). The vasospasm also contributes to the visual disturbances by affecting the retina causing edema, hemorrhage and even detachment. Of special note is the fact that epigast!'ic or right upper quadrant pain (thought to be caused by stretching of the hepatic capsule) is a sign that convulsions are imminent. How do the 3 major manifestations present now? (give values where applicable) 1. Hypertension: 2 Edema: 3. Proteinuria: KEEP GOING! YOU'RE GETTING THERE. CYCLE 6: Management of Severe Preeclampsia The objectives of management at this stage are: .prevention of convulsions .delivery of a viable child .delivery with a minimum of trauma for mother and child .prevention of residual hypertension The patient is now in hospital and placed on bed rest with encouragement to spend as much time as possible lying on her left side. (Research has shown this position increases uterine blood flow.)S Phenobarb has been used as sedation in the past but this is now believed to have an adverse effect on the fetus. 6 A standard nursing care plan will include the following potential problems: What are five sIgns of CNS irritability? What may signal a convulsion? PROBLEM EXPECTED OUTCOME 1. Deteriorating condition due to increasing vasospasm. 1. BP will decrease. 2. Weight will decrease. 3. Urinary output will increase 4. No signs of increasing CNS irritability . 2. Apprehension due to lack of knowledge re her condition and the fetus' . 1. Will indicate understanding of why procedures are done. 2. Can answer simple questions re treatment. 3. Will discuss her anxiety about the baby. 3. Skin breakdown due to edema. 1. No skin breakdown. 4. Boredom due to prolonged hospitalization and inactivity. 1. Actively participates in hobbies and diversional activities NURSING ACTIONS 1. Monitor BP. PR. q4h or as ordered 2. Weight daily a.c. 3. Accurate intake and output. 4. Observe q4h for signs and symptoms of Increasing CNS irritability, i.e. anxiety, headaches, nausea, visual disturbances, epigastric pain. 1. Explain all procedures and nursing measures carefully. 2. Employ empathic reflective communication techniques. 3. Be on alert for verbal cues. 4. Ensure husband is included in explanations so he can help support wife. 1. Ripple mattress or sheepskin. 2. Genlle skin care to pressure areas q4h. 1. Determine patient's interests and involve appropriate services, i.e. library. occupational therapy. 2. Encourage family and friends to visit in moderation, and involve client in sedentary occupation. 3. Visit frequenlly for short penods, i.e. 5 minutes per 1-2 hours. 48 July/Augu8t 1979 The Cen-.llen Nur.. CYCLE 7: Magnesium Sulfate If the preeclamptic patient does not respond to bedrest, antihypertensive and anti-convulsive therapy is begun. Magnesium sulfate is the drug of choice here, acting to block neuromuscular transmission. It is given intravenously as intramuscular administration tends to be very painful. The nurse must be aware that magnesium sulfate is a potent drug and can cause CNS depression. The patient must be monitored closely and observed for decreased rate of respiration, absence of patellar reflex, drowsiness, lethargy, slurring of speech, and anxiety. It is imperative that respirations remain at mo e than 12 a minute, and since this drug is excreted entirely by the kidneys it is crucial that the urine output be monitored - otherwise, the level of magnesium sulfate in the blood may rise to toxic levels. The antidote for this is Calcium Gluconate and should be readily available at all times in the event of sudden CNS depression. Serum magnesium should be checked frequently; values of 4 to 6 mgm/1 00 cc are enough to prevent convulsions in the mother without causing CNS depression in the neonate. PRECAUTIONS FOR WOMEN RECEIVING MAGNESIUM SULFATE 1 . Continuous nursing care 2. Intravenous must be running 3. Foley catheter connected to drainage 4. Give drug only if a. Patellar Reflex present b. Urine output more than 20 ml/hr. c. Respirations more than 12/min. 5. Calcium Gluconate is at the bedside There's a lot in this cycle. isn't there? MagnesIUm Sulfate is an important drug and deserves a great deal of attention. CYCLE 8: Treatment Continued Hydralazine (Apresoline) is used as an antihypertensive agent. Because of the hemoconcentration present in toxemia, it is important that an adequate fluid intake be maintained. As the drug takes effect and vasospasm decreases, there should be a resulting increase in the patient's urinary output. Thiazide diuretics are not recommended to increase diuresis as there is evidence that such drugs reduce uteroplacental perfusion. 7 If severe preeclampsia does not improve after a few days of treatment, termination of the pregnancy is advised. A premature baby has a better chance of survival in an efficient and well-equipped neonatal intensive care unit than in the uterus at this stage of the mother's illness. An oxytocin induction of labor is attempted but if this is not successful, a Caesarean section will be performed. Magnesium sulfate is frequently administered prophylactically throughout labor, as this is the time when convulsions are most likely to occur. In addition, the mother should be carefully observed for signs of abruptio placenta. Even after a safe delivery, nursing care of the hypertensive patient should not slacken. During the first 24 hours postpartum close observation is necessary as eclampsia may develop. Normally, the hypertension may persist for a short time following delivery, but by six weeks postpartum the patient should be normotensive. The baby may be small due to the premature birth or intrauterine growth retardation. What are some of the patient's potential problems at this time? 1. 2. 3. 4. What is the action of Magnesium Sulfate? ______. What are the indications of CNS depression? What nursing precautions should always be followed? 1. 2. 3. 4. 5. What antihypertensive agent is frequently employed? . As vasospasm decreases, what should happen to the urinary output? ConvulSions are likely to occur during_ and the first hours postpartum. The Cenedlen NUrM July/Aulluell117i 41 CYCLE 9: Nursing Care Plan If magnesium sulfate and other drugs were required in the control of severe preeclampsia. the nursing care plan would require somE! adjustments It would include the following: POTENTIAL PROBLEM EXPECTED OUTCOME NURSING ACTIONS 1. Coma & convulsions due to CNS irritability. 1 No coma or convulsions 1. Private room. 2. Restrict visitors. 3. Complete bedrest, side rails up. 4. Talk quietly. 5. Plan care so patient is disturbed as little as possible. 6. Keep noise to a minimum. 7. Draw drapes, keep room lighting dim. B. Take BP, PR, q2h (or as ordered) 9. Observe carefully for signs and symptoms of increasing CNS irritability or impending convulsions, e.g. nausea, hyperreflexia, headache, dizziness, visual disturbances, epigastric pain. 10. Administer drugs as ordered. 11. Monitor or administer magnesium sulfate as ordered. 12. Have 'toxemia tray' in room with emergency equipment: calcium gluconate, needles, syringes, airway. 13. Rolled face cloth or padded tongue depressor at bedside. 14. Oxygen and suction equipment available. 2. Oliguria due to renal shutdown. 1. Urine output will be greater than 720 ml per 24 hours. 1. Encourage rest in lefllateral position. 2. Monitor renal function a) hourly output b) dip-stick test for proteinuria. 3. Report urine output if it drops below 30 ml/hr. 3. Undetected labor due to heavy sedation 1. Signs of progressing labor would be detected early. 1. Check for uterine tightenlngs q2h. 2. Observe for show q2h. 3. Observe for restlessness. 4. Fetal distress due to decreased uteroplacental blood flow 1. Fetal heart rate will remain stable. 1.CheckFHq1h. 2. Monitor the patient (as ordered). 3. Support during fetal monitoring. 4. Save 24 hour urine for estriol. if ordereu. - What are the patient's potential problems at this time? 1 2. 3 4 DON'T QUIT NOW! This is the end of preeclampsia so there isn't much more to go. Just a bit on eclampsia and chronic hypertension... 41 July/Augu8t 1979 The Cen.".n NUrH Eclampsia means a "flash - a shining forth" - a name which denotes sudden onset. In eclampsia, all the manifestations of severe preeclampsia are intensified It is characterized by convulsions and coma, and may result in death for both the mother and the fetus. Treatment is directed at controlling convulsions, stabilizing blood pressure and maintaining renal function. Symptoms can usually be controlled in 4-6 hours using magnesium sulfate and anti-convulsants such as Valium and Dilantin, but care must be taken to keep CNS stimulation to a minimum. The nursing care is the same as for the severe preeclamptic with the addition of protection of the patient against injury during convulsions. When eclampsia occurs during labor, contractions usuaJly increase in force and frequency, thus hastening delivery. With most patients, the prognosis is favorable in that diuresis is usually rapid after delivery. In some cases, however, pulmonary edema, cardiac failure or aspiration pneumonia may result in death. CYCLE 10: Eclampsia What event differentiates severe preeclampsia from eclampsia? . What drug is most frequently employed in the management of eclampsia? Hypertension is often referred to as the "silent killer". Many hypertensive women are unaware of their problem until it is detected at a prenatal visit. Hypertensive disease in pregnancy occurs most frequently in women who are older, multigravid or obese. About 25 per cent of these patients develop superimposed preeclampsia. This is likely to appear earlier than ordinary preeclampsia and in a more severe form. For all women with chronic hypertension there is a major risk of fetal growth retardation. CYCLE 11: Chronic Hypertension Descnbe a "typical" hypertensive gravid patient. What is a frequent fetal complication with this condition? O.K., you've finally reached the end! Check your answers and then how about trymg the post test to determine how much you've learned? ANSWERS CYCLE 2 Vasospasm, hypertension, filtration, edema CYCLE 3 Primagravida, diabetics, chronic hypertensives, hydramnios, multiple fetuses, hydatidiform mole, lower socioeconomic status CYCLE 4 1. Hypertension: systolic 30 mm Hg, diastolic 15 mm Hg above base 2. Edema: weight gain of more than 1 kg per week 3. Proteinuria: absent or minimal 1 . Weigh herself each morning before breakfast 2. Spend most of the day in bed 3. Keep each appointment with her doctor CYCLE 5 1. Hypertension: as high as 160/100 2. Edema: becomes visible in the face and ankles 3. Proteinuria: as high as 10 g/Iitre Headache, dizziness, nausea, visual disturbances, hyperreflexia Pain in epigastrum or right upper quadrant CYCLE 6 Apprehension, skin breakdown, deteriorating condition, boredom CYCLE 7 Blocks neuromuscular transmission Anxiety, drowsiness, lethargy, slurnng of speech, depressed respiration. 1. I.V. running 2. Catheter connected 3. Give drug only if a) patellar reflex present b) respirations are above 12/minute c) urine output is greater than 20 cc/hr. 4. Calcium gluconate at bedside 5. Continuous nursing care CYCLE 8 Hydralazine (Apresoline), increases, labor, 24 hours CYCLE 9 1. Development of coma and convulsions 2. Oliguria 3. Undetected labor 4. Fetal distress CYCLE 10 Convulsions magnesium sulfate CYCLE 11 older, multigravida, obese Intrauterine growth retardation The Cen-.llan Nur.. July/Augu8l1971 49 POST TEST In the 15 multiple choice questions select the best or most complete answer. Sally Kemp, 30 weeks pregnant, h,as just been told by the obstetrician that she has mild preeclampsia. As the office nurse, you remember that 1. Preeclampsia is more likely to occur in 1. young primigravidas 2. diabetiC's 3. placenta previa 4. low socioeconomic groups a.1 b.2,4 c.1,2,3 d.1,2,4 2. Sally might complain about a.nausea b. tight rings c.backache d. constipation 3. You stress to Sally that increased rest is very important, because it a. minimizes the work of the heart b. aids diuresis c. decreases the likelihood of infection d. would make her feel better Sally's condition does not improve, so she Is hospitalized. 4. The changes within the kidney which lead to proteinuria include 1 . increased tubular reabsorption of sodium 2. small hemorrhages within the kidneys 3. concentration of intravascular contents 4. changes within the glomerulus a.1,2 b.2,4 c.1,3,4 d.1,2,3,4 5. As Sally's edema increases, her urinary output will probably a. decrease b. remain constant c. increase slightly d. increase substantially 6. A moderate or high protein diet is ordered for Sally because a. these patients tend to have smaller babies and extra protein increases the baby's birth weight b. babies born to these mothers tend to be premature and extra protein increases their chances of survival c. extra protein helps decrease the sodium content of the diet d. the mother is losing albumin and amino acids from her body Sally's diagnosis Is now severe preeclampsia. 7. Signs of severe preeclampsia might Include 1 . blurred vision 2. irritability 3. diuresis 4. pyrexia a.1,2 b.3,4 c.1,2,3 d.1,2,3,4 8. The primary action of magnesium sulfate Is to a. prevent and control convulsions b. decrease blood pressure c. depress the central nervous system d. alter the urinary output 9. Magnesium sulfate Is eliminated by a.liver b.skin c. gastrointestinal tract d. kidneys 10. The antidote for magnesium sulfate Is calcium a. carbonate b. gluconate c. citrate d. chloride 11. Signs of toxicity from magnesium sulfate Include 1. depressed patellar jerks 2. patient's complaints of anxiety 3. decreased respirations 4. patient's complaint of epigastric pain a.1 b.2,3 c.1,2,3 d.1,2,3,4 12. When giving nursing care to Sally, It Is important to 1. turn her from side to side q1 h 2. allow her as much rest as possible 3. keep accurate intake and output records 4. answer her questions honestly and simply a.1,2 b.3,4 c.2,3,4 d.1,2,3,4 13.ln order to facilitate emergency treatment, the nurse would expect the "toxemia" tray to contain 1. an airway 2. padded tongue blades or rolled facecloth 3. needles, syringes 4. suction catheters a.1 b.2,3 c.1,2,3 d.1,2,3,4 14. The main event which differentiates preeclampsia from eclampsia Is a. proteinuria b. epigastric pain c. convulsions d. hypertension 50 JUIr/Augual1979 The C8nedlen Nur.. POST TEST ANSWERS 15. After an eclamptic patient has delivered, she must be closely watched for the first a. 24 hours b. 48 hours c. week postpartum d. month postpartum 1 (d) 2(b) 3(b) 4(b) 5(a) 6(d) 7(a) 8(a) 9(d) 10(b) 11 (c) 12(c) 13(d) 14(c) 15(a) References 1 Tichy, Anne M. Placental Function and its role in toxemia, by on and D. Chong. MCN Amer. J. Matern. Child Nurs. 4:2, Mar-Apr 1979, p. 84. 2 Pritchard, Williams. Obstetrics. 15th ed. New York, Appleton-Century-Crofts, 1976, p. 553. 3 Ziegel, Ema, Obstetrical Nursing, by... and M. Cranley. 7th ed., New York, Macmillan, 1978, p. 657. 4 Pritchard,op. cit. p. 56. 5 Ziegel,op. cit.. p. 657. 6 Pritchard.op. cit., p. 566. 7 Pritchard,op. cit., p. 565. Bibliography 1 Alfonso, D. Complications arising during pregnancy by ... and D. Danforth. (In Clark. Ann L. Childbearing: a nursing perspective, by... and Dyanne D. Alfonso, Philadelphia, FA Davis and Co., 1976) 2 Butts, P. Magnesium sulfate in the treatment of toxemia. Amer. J. Nurs. 77:8:1294-1298, Aug. 1977. EXPERIENCED RN'S & NEW GRADS "THE PERFECT OPPORTUNITY" Saint Anthony Hospital, located in Columbus, Ohio. This 400-bed acute care facility offers excellent opportunities for furthering your nursing career. No Contracts to Sign Rotating Shifts Air Fare Paid One Month Free Accommodations Plus Exciting Challenges Saint Anthony, a medical-surgical institution, has a complete range of services, including: . Open Heart Surgery . Intensive and Coronary Care . Definitive Observation Unit . Renal Dialysis . Diagnostic and Therapeutic Radiology . 24 Hour Emergency Department Don't wait, call or write immediately. Make the change to an institution that lets you be what you want to be. For further information, call our Nurse Recruiter, Norma Shore, Collect. EXCLUSIVE CANADIAN REPRESENTATIVES RECRUITING REGISTERED NURSES INC. 1200 Lawrence A venue East Suite 301, Don Mills Ontario M3A ICI Telephone: (416) 449-5883 3 Jensen, Margaret.Maternity Care: The nurse and the family, by... et al. St. Louis, Mosby, 1977. 4 Miller, Mary Ann. The childbearing family: a nursing perspective, by n. and Dorothy A. Brooten. Boston, Little, Brown & Co., c1977. 5 Sonstegard, Lois. Pregnancy induced hypertension: prenatal nursing concerns. MCN American J. Matern. Child Nurs. 4:2:90-95, Mar-Apr, 1979. Bonnie Hartley is a graduate of Kingston General Hospital and Queen's University, Kingston, Ontario. She obtained her M.Sc.N. degree from the University of Weste", Ontario. Bonnie has taught obstetrics for a number of years and is currently a co-ordinator of continuing education at Ryerson Polytechnicallnstitute in Toronto. She has written three other articles for The Canadian Nurse, most recently an instructional package on Cortisone (CNJ, February 1978). The author wishes to express appreciation to colleagues E. Collins, G. Donner, and S. Spiegel for their assistance. -;--, "r I I I' I ., I I I I 11111111 IIIIIIII! I U"III l I - .-- The Cenedl.n NUr.. July/AulIUå 1171 51 Nursing negligence in the administration of medication... Could it happen to you? YOU AND THE LAW Corinne Sl..lar Medication errors - the wrong drug, the wrong dosage or concentration. the wrong route or method of administration, the wrong patient or wrong time of administration - CAN happen. What's more. whenever a nurse makes an error in administering medication to a patient. this action constitutes a potential legal hazard. Although to date there have been few Canadian cases arising out of charges of negligence against nurses involved in the administration of medication, the possibility ofIegalliability does exist. As the presiding judge in one of these cases (BuRden v. Harbour View Hospital) pointed out: "Persons who are in charRe of dangerous things under which category, I think. drugs are included, are Il1lder a duty to handle them with such care that harm will not arise to those who depend upon their sl..ill." I / . i\ and harm befalls the patient, both the hospital and the nurse may be held liable for her negligence. The hospital's liability would be founded upon the doctrine of "respondeat superior" ("Iet the master answer") for hospitals are responsible in law for the negligence of their employees in the performance of their duties. The cases that follow illustrate errors in the administration of medication that have resulted in Court actions: consideration of them will serve as a reminder that the possibility of such incidents with their tragic consequences is ever-present. (Many of the cases are American because. as has been pointed out. there are few reported Canadian cases in this area of nursing negligence .) The wrong medication In BURden '. Harbour View Hospital,2the patient as being treated for a dislocated thumb. The physician asked nurse A for Those who administer drugs must, therefore, handle and novocaine. Nurse A asked nurse B to obtain the novocaine. administer them with the greatest of care and attention. To Nurse B handed a bottle to nurse A who handed it to the avoid errors and in order to ensure that the right patient physician. The physician drew the medication into the syringe receives the correct drug in the correct dosage by the correct and injected it into the patient's thumb. Unfortunately, the route as ordered by the physician, adherence to the basic bottle contained adrenalin (as labelled) and the patient died nursing principles of medication administration is necessary. shortly thereafter. Neither nurse checked the label: if either Checking the label three times and confirming the identity of the had, she would ha ve seen that the wrong drug had been patient verbally or by examining the hospitall.D. band, are not procured. The physician did not read the label either. supertluous procedures. The harmful effects of medication The Court held that both nurses were liable for their errors upon patients can develop rapidly and disastrously if the \ respective failures to take care in supplying a dangerous drug. procedures designed to ensure accuracy and due care are The hospital was liable under the doctrine of respondeat neglected. superior, for the nurses were acting during the course of their A nurse's conduct may be found by a Court to amount to employment. Mr. Justice Doull found the physician not negligence if the course of that conduct falls below the standard negligent in failing to examine the label. He reached this of care to be expected in the circumstances. ie. that of the conclusion because the order for the medication was a routine reasonable prudent nurse ofIike training and experience. matter and as there was nothing in all the circumstances to put Nurses are expected to have a working knowledge ofthe"'---- the physician on inquiry thereby necessitating further medications which they administer. their side effects and- observation on his part, he was entitled to rely on the contraindications, regular dosages and routes of administration.- competence of experienced nurses in carrying out his order. Nurses are expected to be able to competently administer Thejudge said that if it is the duty of several persons to medications and to reasonably foresee that harm will result to a guard against danger. one who fails to take precautions cannot patient where there is negligence in the administration of escape by saying that another should have been careful enough medications. to have caught his error. 3 He went on to state that such damage Nurses are expected to utilize their professional was foreseeable: a trained nurse would know that novocaine is knowledge, skill and judgment in administering medication. In to be hypodermically administered. Thus it was impossible for a fact, physicians can rely on the nurse's competence in carrying nurse to be unaware that if adrenalin instead of novocaine were out their order. It is incumbent upon the nurse to question the used, the danger of death would be great. It was the duty of prescribing physician where she has any question or doubt or these nurses to check the label to see that the proper drug had where there appears to be some error in the order. Failure to do been obtained. so might expose the patient to an unreasonable risk of harm. As The physician was absolved ofresponsibility because he well, such an omission might further result in the liability of the routinely would not have checked the label and the court said he hospital or the physician or both. could rely on a trained and experienced nurse to obtain the To voice one's concern and to clarify the order would seem bottle as requested. to be the choice of the reasonable and prudent nurse. Failure to As a nurse, you mayor may not agree with the decision communicate has been considered by the Courts to have been absolving the physician but, on the facts of the case. these unreasonable and negligent in the circumstances. nurses clearly departed from standard. routine nursing practice Where there has been an error or other mishap in the when they failed to check the label on the bottle.' administration of medication as a result of the actions of a nurse . 52 July/Augu8t tll7i The Cenedlen Nur.. Creighton 5 describes two other cases: In the first. a hospital and nurse in the U.S. were held liable for injuries suffered by the patient when the nurse inserted drops of hydrochloric acid in the patient's nose instead of nose drops. In the second, a student nurse failed to read the warning on the ampoule that the drug therein contained was for I.V. use only. She injected the drug I.M. into the patient's buttocks. The patient suffered damage to his leg. Wrong dosage or concentration In a 1940 Canadian case. a nurse administered silver nitrate drops to the eyes of a new-born baby. She did not check the strength of the solution she was administering; the concentration was too high and the baby suffered severe damage to one eye while losing the sight of the other. The hospital was held responsible for the negligence of the nurse. 6 In another case.-the efforts of a well-intentioned nurse resulted in the death of a three-month-old child admitted to hospital with a congenital heart condition. Special arrangements were made at the time of admission that the child's mother would administer the child's daily dose of Lanoxin.@The nurses were to give it only if the physician wrote a specific order. That day, he had written "give 3.0 cc Lanoxin today for one dose only. .. The pediatric unit was very busy that day and the assistant director of nursing. while on her rounds. decided to assist. Noting that this drug had not been given, she proceeded to prepare it. The nurse was unfamiliar with the pediatric elixir of Lanoxin and from her knowledge of injectible Lanoxin. he thought that the dosage was high for a child. There was some discussion with the registered nurse on duty and with a consultant on the case. At no time was the prescribing physician called. The nurse gave the injection. The dosage given was Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE. QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth, and more information, please clip this coupon and mail today. Name . . . . . . . . . . . . . . . . . . . . (blåë:k 'Jëñërå)' . . . . . . . . . . . . . . . . . . . . . . Address City ................................... .Postal Code ....... Your graduation school about five times the strength of the pediatric elixir. The child died. The parents recovered damages from the nurse and physician. Thejudgment read. in part. as follows: "As laudable as her intentions are conceded to have been on the occasion in question, her unfamiliarity with the drug was a contributing factor in the child's death. In this regard. we are of the opinion that she was negligent in attempting to administer a drug with which . he was notfamiliar....Not only was Mrs. Evans unfamiliar with the medicine in question but she also l'iolated what has been shown to be a rule generally practiced by the members of the nursing profession in the community and, which rule we might add, strikes us as being most reasonable and prudent, namely, the practice of calling the prescribing physician when in doubt about an order for medication." Wrong route or method Dramamine@ hypodennically was ordered for an obese patient. The nurse charted its having been so given. The patient. however. suffered severe necrosis of tissue in the area of the injection site and required further surgery and hospitalization. In awarding damages against the hospital. the Court 7 held that on the evidence the injection. though charted as I.M., could not have been thus given. The only conclusion consistent with the injuries was that the Dramamine had been given s.c. (subcutaneously). Only a subcutaneous injection of Dramamine, which is highly irritating to tissues, could have caused such damage. The Court found the nurse negligent because: I. She should have known that Qramamine, a well-known drug. if given by injection must be given I.M. because of its irritating qualities; and 2. The nurse should ha ve foreseen that a longer needle would be required to achieve deep muscle penetration for an I.M. injection to a patient of this girth. Injuries resulting from administration In giving I.M. injections. nurses are taught to carefully detennine the site to avoid hitting the sciatic nerve. There are reported cases where the patient recovered damages for injuries sustained when the sciatic nerve was struck during injection. R In an American case of this nature, the damages awarded were $17.000. The patient was left with a limp that severely hampered his ability to carryon his business. The necessity for showing that the proper procedure was followed is demonstrated in the decision of Cavan l'. Wilcox. ß In that case. the physician ordered an injection of BicillinQl) which the nurse gave in the deltoid muscle. The antibiotic entered the circumflex artery and as a result the patient developed gangrene in part of his hand. The Supreme Court of Canada absolved the nurse of responsibility for this damage. The Court found that the evidence indicated that she had followed accepted nursing procedures and had pulled back on the plunger prior to injecting the Bicillin to ensure that a blood vessel had not been penetrated. Because no blood entered the barrel. the injection was properly given. The Court also found that the nurse was not negligent in her failure to foresee such damage because of the proximity of this artery. Such knowledge was established as not being part of nurses' training and therefore was not part of that body of knowledge to be possessed by the reasonable prudent nurse. There have been some reports of cases where injury resulted from the breaking of the needle during injection. In a case where liability was found 10, a five-and-a-half-year-old child was injured when the needle broke in his ann during a vaccination. The child was upset and jerked his arm upon feeling the prick of the needle. The Court found that the physician had not met the required standard of care because he failed to ensure that the ann was sufficiently immobilized. The TIle Cllned18n NUrN physician knew the child was upset and nervous and should not have proceeded with the vaccination. However, in Vezina v. D.II, the doctor was not found to have been negligent. Here, the needle broke during the administration of a spinal anesthetic prior to surgery. The Court found that the physician had taken all reasonable precautions to prevent such an accident. While the needle was of a fragile type, there was no evidence that it had been twisted, bent, or otherwise misused prior to breaking. Having done all he reasonably was expected to have done, the physician's conduct did not fall below the standard of car required. Mistaken identity Nurses must be certain that the patient receiving the medication or treatment is the person for whom it is ordered. In an American case, a nurse and intern proceeded to administer a blood transfusion over the protests of the patient. The nurse had remarked that the blood had been donated by her daughter; the patient insisted she had no daughter. In fact, the blood had been ordered for another female patient on the same floor. The patient recovered damages for the injuries she sustained as a result of the blood incompatibility. Such an example clearly underscores the responsibility to confinn the patient's identity. Further, it illustrates the necessity of heeding the patient. The patient's protestations in the foregoing example should have put the nurse and physician on inquiry. A simple investigation likely would have clarified the situation and the hann would have been avoided. Nurses should listen to the communications of their patients. From these case illustrations, it is easy to see that errors occurring in the administration of medication can result in legal liability to the nurse and her employer, the hospital. The nurse's adherence to the basic nursing principles of drug administration and handling will serve to safeguard the health and well-being of the patient. It may also serve to protect the nurse and the hospital from either the commencing of a lawsuit or a finding of liability. Safety, generally, is the concern of hospitals and the individuals connected with these hospitals. Safety in the administration of medications, because of their inherently dangerous nature, should be of paramount concern. References I [1947] 2 D.L.R. 338 (N .S.S.c.). p.340. 2 Ibid. 3 Ibid. 4 R. v. Giardine (1939) 71 c.c.c. 295 where the facts were similar to Budgen (supra). 5 Creighton, Helen. Law every nurse should know. 3d ed. Toronto, Saunders, 1975. p.128. 6 Barkerv. Lockhart (1940), 3 D.L.R. 427 (NBCA). 7 Barnes v. St. Francis Hospital and School of Nursing, Inc. 507P. 2d. 288(1973 Kan.) 8 Huberv. Barnaby General Hospital. [1973]D.R.S. 653 (B.C.S.C.) as reported by Picard E. in Liability of doctors and hospitals, p.37!. 9 Cavan v. Wilcox [1975] S.C.R. 663. 10 Cardin v. City of Montreal et al., [1961] S.C.R. 655. II [1961] Que. S.c. 245. '9\ "You and the law" is a regular column that appears each month in The Canadian Nurse and L'irifirmière canadienne. Author Corinne L. Sklar is a nurse and recent graduate of the University ofT oronlO Faculty of Law and is currently arricling with a T oronlO law firm. '\. .. The soft touch for tender tissue. - 100 JL CKS* Pre-Moistened Pads For hemonhoi ds, feminine hygiene, piles and personal itching problems. Culi., -"il'. AIm.,,,, DtN443&46 .A8gIStered trademark of Parke DaVIS & Corroa Parke. D8vIs & Company LId. registered I P'I , Relieve postpartum and postsurgical itching and burning with Tucks. PARKE-DAVIS 54 July/Auguet 111711 TIle Cen-.ll.n Nur.. - news (continued from page 15) Nurses speak out on legal issues in health Nurses, doctors, hospital administrators, lawyers and theologians from all across Canada gathered in Ottawa early in May for the Second National Conference on Health and the Law. Approximately 200 registrants attended the three-day session presented by the Canadian Hospital Association in co-sponsorship with five other agencies including CNA. Speakers at the conference addressed themselves to several of the legal problems that concern health care workers: . consent to treatment (including spouses, children, the mentally ill or retarded patient, and prisoners) . communicable diseases, immunization . human organ and blood donations . death and dying . cessation of treatment, euthanasia and patient suicide. Papers dealing with each subject area were presented by various authorities. These formal proceedings were followed by open forum discussions which allowed participants to voice their specific legal concerns. Nurses who addressed the audience included Peggy Searle, assistant director health care services, Stony Mountain Institution, Manitoba who spoke on the nurse's view of a prisoner's consent to treatment; Huguette Labelle, assistant deputy minister, Corporate Policy, Indian and Northern Affairs who spoke on a spouse's consent to treatment; Lorine Besel, director of nursing, Royal Victoria Hospital, Montreal who spoke of consent to treatment by the mentally iIIj retarded; Marllyn VanBibber, Stanton Yellowknife Hospital, Yellowknife, N.W.T. who spoke about communicable diseases among people living in the Arctic; and Lesley- Degner, associate professor, school of nursing, University of Manitoba who presented a preliminary report from a study she is currently completing on nurses' views concerning cessation of treatment and euthanasia. Several nurses spoke up about their concerns as health care workers who have to deal with the practical application of the law on a day-to-day basis. The director of nursing from one hospital in Regina asked about her legal responsibility if called upon to assign staff to care for a patient with a highly infectious disease. Under these circumstances can hospital employees refuse to treat a patient? In response to this question Dr. Phll Stuart. assistant professor of medical microbiology and assistant professor of medicine at the University of Toronto commented that health care workers have a moral and ethical responsibility to care for all patients. He suggested workers who have already had contact with the infectious patient during diagnosis be assigned continuing care. Lome Rozovsky, barrister and solicitor from Halifax said hospitals have a responsibility to their patients to live up to current standards in health care. "You must warn your employees of the inherent dangers," he said, "and provide them with all possible protection to minimize their danger of contracting the disease. If you assign an employee to a patient and he or she refuses to comply then you must decide if this means they are in breech of their job contract. From there you can fire them or advise them to quit. " Dr. David Roy, director of the center for bioethics at the Clinical Research Institute of Montreal said it is important for us to "say that a doctor is allowed, without incurring penalty, to detennine death through brain death. There are people in Canada who have to risk criminal incrimination every day that they have to go through the decision-making process. " A nurse from Saskatchewan spoke as a health professional who is at the bedside giving care eight hours a day. "The people who are working directly with patients who experience brain death need some support. I need input to help me cope with this situation. I'm making an appeal for someone to come up with something now to help us cope." Closeup on the Victorian Order of Nurses for Canada How does a venerable institution such as the VON, now going into its eighth decade of existence, adapt to societal changes that have taken place since its founding? National director Ada McEwan, in her report to the 81 st annual meeting in Ottawa last Spring, outlined some of the innovative steps being taken by various branches to meet the changing health care needs of the diverse population served by VON nurses. . Last year, for example, one branch established a foot care service for the elderly in that community. A podiatrist provided a short orientation for the two nurses on staff and, in the first month of operation, more than 70 requests for the service were received. . Approximately one third of all branches now provide health counseling services in senior citizen complexes in an effort to help these individuals remain healthy and independent as long as possible. . One branch has developed a specialized visiting program for patients with chronic respiratory problems; the same branch also provides a homemaker/home help program and occupational health service. . Another branch has opened an adult day care center offering an exercise program, craft activities, games and films to selected clients. . Two branches offer daily visiting for at least the first five days after early (soon after delivery) discharge of healthy mothers and newborns. . Eight branches participate in a meals-on-wheels program in their community. . Four branches offer homemaker/home help service to temporarily replace family members caring for relatives in their homes as an alternative to institutional care. Some other interesting statistics on the VON included by the national director in her report: . All but two of the 75 branches continue to have as their main mission the provision of generalized visiting nursing service. . In 1978, a total of 1,503,121 visits were made to 87,924 patients. . Visits in 1978 were up slightly (six per cent) over the preceeding year. . Almost three-quarters (74 per cent) of the 1978 VON visits across Canada were paid for by government sources - ranging from 100 per cent in Manitoba to 21 per cent in Nova Scotia. TIle Cen-.llan NUrN July/Auguet 11171 55 Currents in cardiology attract record crowd !vlore than 400 nurses and 100 physicians attended the 6th annual Cardiology '79 conference sponsored by Humber College in Toronto May 26 and 27. A total of 350 nurses also participated in the two-day pre-conference ECG workshops: the Dean of Humber's Faculty of Health Sciences. Lucille Peszat. was enthusiastic about the attendance saying she felt it was a sign of nurses' increasing interest in continuing education. and their desire to meet with other nurses and share experiences. Rosemary Coombs. assistant director of Nursing Service at the Ottawa Civic Hospital. excited her audience with a presentation on the Civic's cardiac patient teaching program. including a portion of the slide and sound show actually shown to patients. Coombs outlined the development and evaluation of the project. and spoke briefly of some of the problems that had been encountered. On the whole. she said. it was felt the project was a success: patients were showing a better understanding of their illness. SPHYGMOMANOMETERS TYCOS-TAYLOR / STETHOSCOPES Famous brand nama ,natrumenlln.lal.cl Þr m.cltc.al g ':.' -':'T Ë.o, .,O;:II. Þ \ :, olaun EJlc.eplionalaound t:J \ .,.nsm..s.on AdlustaÞlellgtlt-, 'I .e'g"' blnauno'.. "u bo'" . diaphragm and bell Wit" non- t ctlill nna Choose Black, Red. \1' ' -5ci7911;3 esG: \ SINGLE-HEAD TYPE_ Aa above but wlthoul bell Slim. large \ , \ì tg 'MrOhDi .;: gk'òCPE r: , :; :-oowe I but nOI TYCOS bral"ld Sama 2 Y'" guarani.. Compl... SI ;I =I:r: &ml des" P. " Du....HNd No 110117.&5.. LISTER BANDAGE SCISSORS Manulactur.cl 01 hneata'M' It : ;:!)' nUr$a. No egg,4Ya No 700.5Ya" No 702.7'- MERCURY TYPE. TM ultimal. In accuracy FOIc:Ja InlO hgttl but rug m...1 caM HHyy duly V.lcro cull and Intl."on aya.em 1$8.85 MCtI . t =:: I n :' ndllbM. 10 . ,..r gu.ren'.. of accuracy '0 _ , 3 m m No alop-pln '0 hide .,. 8"0fS H.ndsom. ZIP ea_ '0 ti' wour pO .1 121.11 camp"'e. NURSES PENLlQHT. Powerful bNm tore..mlna"on of ,tI'oel. elc Durabl. ...InI......I..1 ease wlttt pock.1 Clop Mad. In USA No 28 IS.II comple'e with bellen... Economy model wlttt cnromed braaa caN No 29 12 II. NURSES WH"E CA' CLIPS. Mede tn Canad. tor CanaGl.n nurses Slror;3 ....1 bobb.y pin. wlltt nylon f;2 3M :Z: a sl ot 15, 2 alze 11.001 rd NURS S 4 COLOUR PEN tor f'KOrdlng ..mp.relure. blood prea.ure. .1C O......tt.nd oper...on selscla red. lack bl.... or green No 32 12 21 Nell METAL FRAIIED...Simll.r 10.bO't'e bioi' moun'.d in poll.hed m.I.1 fr.m. wlltt rounded .dg.. and corn.r. Engraved inS." ca.n be changed or replK4ICI Our aman.sl and nealesl d.algn SOLID METAL...E..rem.ly alrong and dureble but hgttlw.,gnl L...." deeply engr.wed tor .baolu'. perman.nea and IIIled wlttt your ChOice of laQu.r colour Corn.r. end edg.a amOOlhly round.d. Salan amooth hnlSh L SII... Other sessions included presentation!> by Drs. H. Marriott of Flonda and Leo Schamroth of Johannesburg. South Africa. who spoke on arrhythmias and radiological pointers for the nurse. respectively. These two presentations served as an appetizer for more comprehensive workshops held by the doctors in the afternoon. but were very informative. Other afternoon options were: . a workshop on basic 12 lead ECG interpretation given by Marina Heidman. coordinator of the coronary care nursing program at Humber College. . a talk by Louis Wilson, R.N.. of the Lyndhurst Hospital in Toronto on pulmonary function as related to cardiovascular disease. . a discussion of cardiac cellular physiology led by Anita MacDowell. R.N.. coordinator of staff development at Scarborough General Hospital. Also included in the conference materials was a paper on a patient teaching program in Sarnia. Ontario, written by Margaret Zagrodney. ' NURSE. CA' TACS Gold pl.led nolds your c.p V . Siripe hrmly In plac. Non. IWI.' 'N'ure No 301 FIN wl'h Caduceus or No. 304 pl..n C.duc.ua U.'SI pro t. , \ , r OELUXE POCKET SAVER b .I. ro,' ::':;:sln; compa"m.n'a tor pen.. IICla.ors. ate. plua chang. pock.land k.y chain " wnlla eall PI....hld. tt No 50511.e5NCti. IIEASURING TA:E ' In atrong plelilc cu. 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Julyl AIIfI.... 1171 The CaneclI.n Nur.. input The Canadian Nurse invites your letters. All correspondence is subjed to editing and muat be signed, although the author's name 1NIy' be withheld on request. More mystique unfortunate that it is the I must take strong university graduates who have As a graduate of a schools of nursing themselves exception to the view still so much to learn about three-year basic degree which tend to perpetuate this expressed blaming Miss practical nursing skills. program,l read Jeanne Marie by implying that certain Nightingale for the woes of As Jeanne Marie Hurd Hurd's article "Nursing and technical skills are not reaIly modem nursing. At indicates in "Nursing and the the degree mystique" (April) important to learn. Nightingale School, St. degree mystique" (Apr. 1979) with great interest. This schism seems to Thomas's Hospital. we were the nursing profession may When I was in third year I extend to all areas of nursing. subject to discipline, but a weIl be in time of transition found that I was stiIl afraid of It seems that good Ward Sister was looked with its future involving a handling a simple I. V ., even treatment-oriented nurses up to by everyone from higher percentage of degreed after two semesters of don't understand preventive consultant to ward maid, and nurses in our ranks. medical-surgical teaching and health care, and vice versa. almost revered by the patient. Let us hope that part of practice. It took working as a There is a subtle 'putdown' of As students our observations this change will include a nurse's aide over Christmas each other's role and function. were listened to regularly, and renewed commitment to the break to convince me that I Is this split indicative of an our training led us graduaIly ethics of our profession and could. identity crisis in nursing? upwards in responsibility. respect for all our many This may sound like a Perhaps our profession is Miss Nightingale members who adhere to them. very simple and - yes, going through its adolescence: effectively removed Sara Otherwise we will lose the technical- thing to be it is my hope that a firm and Gamp and the gin bottle, and benefit of very valuable skills concerned about, but the united identity will emerge but made nursing respectable. and talents that exist among point is I felt that as a third in the interim it is imperative Her ideal was to educate and the majority of nurses from year nursing student I should that we all, whether degree or train young ladies to care for different educational have been more comfortable diploma graduates, remember the sick - a skiIl never backgrounds. with technical things than I that our basic function is to completely learned by sitting Thank you for expressing actually was. I could provide assistance to the in a classroom. To blame her so well the thoughts of so appreciate Hurd's statement health care consumer. Ifwe now for the worst of mode rn many of us with or without that "it is still a truism that the can do this, we wiIl weather developments is to do her degrees. diploma nurse...often has a the crisis. memory a grave injustice. -Norma-Jane Miller, R.N., decided advantage over the -Muriel Sherring, Wabasca, -Elisabeth Harding, SRN, Community Mental Health degree nurse immediately Alberta. SCM, NipiRon, Onto Worker, Revelstoke, B.C. following graduation in terms Jeanne Marie Hurd's . ..As a non-degreed of performance ability and excellent article (April) has nurse, I am very grateful that Articles such as "Nursing resulting ego strength." received wide approval among within the ranks of our and the degree mystique" One of the biggest many nurses here. Nurses profession we have academics reflect the growing quality and complaints of my nursing must co-operate and promote and degreed nurses who are wealth of ideas that The class was about the lack of avenues of continued able to theorize about nursing Canadian Nurse has to offer actual practice time. Of education for all. practice. At the same time, as today. course, if we were concerned Regardless of the one who has worked in senior Thanks again. enough we could gain preparation base, knowledge nursing administration -Heather Malone, R.N., additional experience during and skills become outdated positions, I am profoundly Vancow'erGeneral Hospital. summer break periods. In too quickly to develop any grateful for the significant Vancouver, B.C. short, we felt that more elitist group based on a contribution that hundreds of practice was important. While once-earned degree rather non-degreed nurses and Clarification the performing of technical than achievement and current licensed practical nurses skiIls may be seen as a simple competence. continue to make to the Despite the fact that I feel task, until these skills are The personal goal of quality of patient care. there is some substance to the weIl-mastered they tend to continuing education is too I agree that a high level of concerns implicit in the seem incomprehensible and often blocked by a feudal education for nurses is to be article: "N ursing rather frightening. system of oppression of those desired, but education is also Nineteen-Eighty-F1oor" that It is interesting too to who choose avenues other found in places other than appeared in The Canadian note that many diploma than university to maintain universities or even colleges. Nurse, (March 1979) I would nurses refer to university . like to take this opportunity to graduates as "Oh, them... .. competence. Current Some of my most respected state that I am not the author information is more readily colleagues have obtained with a tone of condescension acquired through other within the hospital who has chosen to use the pen which may be attributed to the avenues since curriculum environment a level of name Lawrence Nightingown. new degree graduate's lack of revision at the university level education which makes them -Lawrence H. Jones, BScN technical expertise. (but was is a slow process. invaluable to their patients, RN, Assistant Administrator that all?).This appears to be -Marlene Kucey, Assistant their co-workers, their Nursing Services, Trail evidence of the Administrator. Frank Eliason supervisors and perhaps Regional Hospital, Trail, B.C. "professional-technical split" Centre, Saskatoon, Sask. above all, those new Hurd refers to. It is The Cllned18n NUrN JuI)'/Auguet 1171 57 Conlents.-Lener 1064-2-C7, Feb. 14, I97S.-Visit to library United Kinsdom.-Visits to Scandinavian countries. here's how 16. D /ilg . D nis Humanison.les hõpitaux, par.. .et Xavier Leroy. Publié pour I'J nstitut Sardoz d'études en matière de santé et d'économie sociale. Paris, Maloine, 1978. 238p. 17. Doy/ , Timothy C. The impact of health system changes on the nalion's requirements for registered Every nurse has practical ideas gathered from Publications recently received in the Canadian nurses in I98S. by... George E. Cooper and Ronald G. Anderson. Hyattsville, Md., U.S. Dept. of his or her experience on how to make life a Nurses Association Library are available on loan - Health, Education and Welfare, Bureau of Heallh little easier for nurses and for patients. Here's with the exce.ption of items marked R - to CNA Manpower, Division ofNursins, 1978. 71p. (U.S. How is a column for you and your ide{ls. If members, schools of nursins, and other institutions. DHEW Pub. no. HRA 78-9) you have an original and practical suggestion Items marked R include reference and archive 18. Entry into nursing practice. Proceedinss of the material that does not go out on loan. Theses. also R, national conference, Feb. 13-141978, Kansas City, that you think might help other nurses to are on Reserve and go ou( on Interlibrary Loan only. Mo. Kansas City, Mo., American Nurses' improve any aspect of patient care, why not Requests for loans, maximum 3 at a tim . Association, 1978. 163p. share it with other nurses? We'll send you should be made on a standard Interlibrary Loan form 19. Gabri /, Rog r Medical data interpretation for $10. for any suggestion published. Let's hear or by letter giving author, title and item number in MRCP, by.. .and Cynthia M. Gabriel. Toronto, from you. Write: The Canadian Nurse, 50 The this list. Butterwonhs, 1978. 192p. Driveway. Ottawa, Ontario, K2P I E2. If you wish to purchase a book. contact your 20. "God bless you, my dear Miss Nightingale" local bookstore or the publisher. Letters from Emmy Carolina Rappe to Florence NOTE: Readers are reminded tbat they should check Nightingale 1867-1870. Edited by Benil Johansson. Separate egg and add... ftrst wltb tbe Ubnlry or their JII'Ovinclal DUnes Stockholm. Sweden, Almquist and Wiksell ueoclaUon, university or coJleJe, to determlM International, 1977. S7p. We found a 'recipe' that works wonders whether they may obtain the publkatlon(s) they 21. Hospital R s arch and Educational Trust on babies admitted with severe diaper require from tbls øoun:e. Being a nursing aide. 2d ed. Chicago, cl978. 442p. rash. Place the baby on his stomach and BooIu and Documents 22. How to read financial statements: a practical expose the buttocks, leaving his J. Ab/ son, J. OUlput variables and proposed approach to sound decision-makins for Canadian investors. Montreal, Canadian Securities Institute, undershirt on or nightgown rolled up and tables. by.. BN Chinnappa, E. Praught and J.D. cl977.4Op. a receiving blanket across his thighs. Richardson. Ottawa, Dept. of Health and Welfare 2J. I nr rnarional Labour Office Yearbook of Survey, 1978. 146p. Apply unbeaten egg white and dry with 2. - . Variables de production et pro jet de labour statistics, 1977. Geneva International Labour oxygen at least three times a day. The tableaux, par... BN Chinnappa. E. Praught et I.D. Organisation, cl977. 909p egg white provides the skin with prolein Richardson Ottawa Ministère de la Sante nationale 24. Lachanc . R.A. Preparing your income tax et du Bien-ètre social, Enquète santé, 1978. ISOp. returns Canada and the provinces. by... and G.D. necessary for healing. The area should 3. Alb rta Association of R gisr r d Nurs s The Eriks. 1979 edition for 1978 tax returns. Don Mills, remain exposed. clean and dry at all quiet evolution: expanding roles for registered Ont. CCH Canadian Ltd, 1979..328p. times. nurses inAlbena. Edmonton, 1978. Iv. (unpaged) 2S. Laun r, D borah J. Modem personnel forms, -Judy Win"-, R..V., Brookfield, 4 Alternative birthins facilities. Columbus, Ohio, prepared by... Boston. Warren, Gorham and Ross Laboratories, 1978. 8Sp. Lamont, cl976. (various pagings) Bona 'ista Bay. Nfld. S. Am rican Nurs s Association Guidelines for 26. L wis, Clara M. Nutritional considerations for review of nursing care at the local level: emphasis the elderly. Philadelphia, Davis, c 1978. 49p. Hand Ice Packs given to professional standards review organizations Have"you ever needed to apply ice packs and the use of outcome criteria in the review of nursins care. Kansas City, Mo.. American Nurses to reduce swelling and found that none Association. 1978. 12Sp. were available? Well.. found that a 6. Am rican Nurs s' Association ANA manual of To Canadian Nurse disposable, non-sterile glove filled with style. 3d ed. Kansas City. Mo., 1978. 77p. Readers ice and tied tightly at the cuff serves the 7. An exploration ofthe limitations of contraception. Proceedinss of a conference. Ontario purpose. Wrap the glove in a towel or Science Centre. November I97S. Toronto, Onho padding in case of leakage - if the cuff is Phannaceutical, 1975. 64p. tied tightly, there shouldn't be any 8. Anduson. Elizab rh T. The development and There are a few English and problem. implementation of a curriculum model for some French CPS, 12th and 13th community nurse practitioners. Hyattsville, Md., -Charlene Martineau, St. Bruno, U.S. Dept. of Health, Education and Welfare. Public editions, (for reference only) Quebec. Health Service. Division ofNursins, 1977. I 26p. available to Students on a 1st (U.S. DHEW Publication no. (HRA) 77-24). come 1st served basis, at $6.00. Help for Handicapped 9. Bampton. B rsy A. The female reproductive system. rev. ed. Springfield, Va. Reproduced by An invention for the handicapped patient National Technical Information service, 1977. S8p. The Compendium of allows him to feed himself finger foods. 10. B lzile. B rrrand Inflation, indexalion et The arm from wrist to elbow rests inside conflits sociaux, par...etJean Boivin. Gilles Pharmaceuticals and Specialties a box constructed ofIight metal and Laflamme et Jean Sexton. Québec. Presses de is a valuable reference used by !'Universite Laval. I97S. 228p. padded with washable material. which II. Chisholm. David M. Par-Q validation repon: all health professionals. rocks easily on acuned metal base. The the evaluation of a self-administered pre-exercise patient cannot lift his arm unaided, but screenins questionnaire for adults. by. net aI. Send your orders to CPS (Nurse), Ottawa. Health and Welfare Canada, 1978. 14Op. he can raise food to his mouth. 12. Collishaw. N il E. Physical aclivity in Canada, 175 College Street, Toronto, -Jean Smith, R.N.. Regina, Sas"-. July 1978. by... John R. McWhinnie and Anila Ontario M5T IP8, include Salmon. Ottawa, Lons Ranse Planning Branch, cheque or money order for $6.00 Dept. of Health and Welfare, 1978. lOOp. Pruning Pills 13. Th Commonw alrh F oundarion - a fine offer, should you prefer It was a patient who told me about the Commonwealth Caribbean directory of aid agencies: the 14th edition CPS '79. Price most effective way to cut a hard, charities. trusts, foundations and official bodies $28.50. unscored pill- use pruning shears. offerins assistance in Commonwealth countries in the Caribbean region, edited by Norman Tell, and Using the shears insures that the cut will Ronald Macfarlane. London, 1978. 128p. be perfectly smooth and straight. Make 14. C ons il canadi n d I' nfana r d la sure that the shears are clean and if you j un ss . C omiri d' itud sur /' nfant n rant qu want to be more sanitary about the job, citoy n. Rapport. Interdit aux mineurs: la place de !'enfant dans la sociéte canadienne. Ottawa, Conseil place the pill between two layers of canadien de I'enfance et de lajeunesse, 1978. 19Sp. tissues while cutting. IS. Crichton, J. U. WHO Travel Fellowship -Joan E. Travers, R.N., Victoria, B.C. repon. Vancouver, 1975. 3 pts. in I. 51 July/Auguet 1171 o S "'l O "'l ):\. obÇ;'i ÂP (jOr' ) POSEY CINCH LIMB HOLDER Secure patient's limbs instantly without worrying about tightening or loosening. One piece. one strap make this a "cinch" to apply. Semi-disposable. Includes 36" cOMecting strap. No. 2528 - Wrist No. 2529 - Ankle .-. 1) ---.; POSEY SAFETY VEST Help prevent the patient from sliding for- ward or falling out of wheelchairs, or to help prevent falling from hospital beds Lightweight nylon mesh material with tie end straps. Small, medium, large. No. 3311 T . I . POSEY ADJUSTABLE FOOTBOARD The most advanced footboard available. Light metal plate adjusts to any poSition desired. Easy to install; does not bolt to bed. Includes anti-rotation blocks Fits any hospital bed No. 6428 Health Dimensions Ltd. 222 S. Sheridan Way Misslssauga, Ontario Canada L5J 2M4 Phone: 416/823.9290 The Cen-.llan Nur.. 27. Mans II. Jacqui An inventory of innovative work arrangements in Ontario, by..: Ron Wilkinson and Alan Musgrave. Toronto, Onlario Ministry of Labour, Research Branch, 1978. Illp. 28. Nash, Patricia M. Student selection and retention in nursing schools. Hyattsville. Md. U.S. Dept. of Health, Educalion, and Welfare. Public Health Service. Division of Nursing. 1977.7.5p. (U.S. DHEW Publication no. (HRA) 78-.5). 29. N ational L agu for Nursing Generating effective teaching. New York, cl978. 81p. (NLN Pub. no. 16-1749) 30. National R s arch Council. Committ on a Study of National N udsfor Biom dical and B ha.'ioraJ R s arch Pusonn J Personnel needs and training for biomedical and behavioral research. The 1978 repon of the... Washinglon, National Academy of Sciences, 1978. 368p. 31. Now that we've burned our boats...the repon of the People's Commission on Unemployment Newfoundland and Labrador. St. John's, Newfoundland and Labrador Federalion of Labour, 1978. 117p. 32. Organisation mondia/ d la Santi Critères d'évaluation des objectifs éducalionnels dans la formation des personnels de santé. Rappon d'un groupe d'étude de rOMS. Genève, 1977. 48p. 33. Qu vauvilli rs. J. Connaissances de base, soins courants. Protection de la mère et de renfant par.... L. Perlemuter et. P. Conrad-Burat. Paris, Masson. 1977. 148p. 34. St. Jos ph's Hospital Foundation. Palliati>' car workshop. Hamilton, Ontario, March J J, 1978 Press kit. Iv. (various pagings) 3.5. Sod r..trom, L The Canadian health system. London, Croom Helm, c1978. 271p. 36. Sutton. Lor tt V. A repon of a World Health Organization travel fellowship to observe home health services in the United States. Ottawa, Victorian Order of Nurses for Canada, t978. .5Op. 37. Univ rsity of Toronto. Offiu ofR s arch A dminislration Patterns of research, edited by T.C. Clark. Toronto, 1976-1978. 2v. 38. Wamer,AnneR. Credentialingofhealth manpower and the public interest. Repon of conference held January 30-31, 1978 Stouffers's National Center Hotel, Arlington. Va. New York, National Health Council, 1978. 69p. 39. World Health Organization Steroid contraception and the risk of neoplasia. Repon of a WHO Scientific GroUD. Geneva. 1978. .54p. Ots Technical repon series no. 619) Pamphlets 40. Ag nu canadi nn d dév /oppl!ment international Programme en bref de la direclion des ONG pour 1977-1978. Ottawa. 1978. 41p. 41. American Hospital Association Educational programs in the health field. Chicago, 1977. 3.5p. 42. American Hospital Association. Assembly of Ambulatory and Hom Car S rvius A prospectus for a national home care policy prepared by... et aI. Chicago, c1978. .5p. 43. Am rican National Standards Institut American national standard for writing abstracts. New York, 1971. 12p. 44. - . American national standard for bibliographic references. New York, 1977. 92p. 4.5. - . American national standard for the preparation of scientific papers for written or oral presentation. New York, 1972. 16p. 46. - . American national standard guidelines for format and production of scientific and lechnical repons. New York. 1974. 16p. 47. American Nurses' Association Code for nurses with interprellve statements. Kansas City, Mo., 1978.2Op. 48. American Nurses' Association Guidelines for continuing education in developmental disabilities. Kansas City. Mo., 1978. 27p. 49. -. Commission on Nursing S rvices Policy statement on nursing resources. Kansas City, Mo., 1978.I.5p. .50. Boyd. Edmond The government health Care program in Cali, Columbia. Washington, Pan American Health Organization, 1974. 9p. .51. - . Health Services in Cuba. np. 197.5? 19p. .52. Boyd. Edmond The Mexican institute of social security OMSS). Washington, Pan American Health Organization, 1974? lOp. .53. British Columbia Operating Room Nurses' Group Operating room standards; palienl outcomes, nursing process and managemenl responsibilities. A working document. Vancouver, 1978. 24p. .54. Bruu, David L. Effects oftrace concentrations of anesthetic gases on behavioral peñormance of operating room personnel, by.. .and Mary Jane Bach. Cincinnati, Ohio, U.S. Dept. of Health Education and Welfare, Public Health Service, Centre for Disease Control, National Institute for Occupational Safety and Health, Division of Biomedical and Behavioral Science, 1976. 32p. (U.S. DHEW Pub. no. (NIOSH) 76-169) .5.5. Canadian 1 ntemational D v /opm nt Ag ncy NGO program summary, 1977-78. Ottawa, 1978. 41p. .56. Canadian R d Cross Soci ty Annual repon, 1977. Toronto. 38p. .57. L Cons iI intuprof ssionn 1 du Qulb c L'avenir du professionnalisme au Québec; la réponse des 38 corporations profession nelles, membres du CIQ. Montréal. 1978. 23p. .58. Dupuis, R. Travelers to the tropics-guidelines for physicians, by... J. Keystone. J. Losos and A. Meltzer. Ottawa, International Developmenl Research Centre, 1978. 36p. (IDRC Pub. no. 106e) .59. Friend, Judy Basic review for abdominal examination during labour, by.. .and Peggy-Anne Field. Edmonton, University of Albena, Faculty of Nursing, 1977. t4p. 60. G t. Britain. Joint Board of Clinical Nursing Studies Notes on the outline curricula. London, 1978. 16p. 61. Hunt, T.E. Geriatric medicine and gerontology in the United States, Great Britain, Sweden and the Netherlands. Saskatchewan, 197.5. 26p. 62. Hypoficondite t infécondit en Afrique Résumé du rappon d'un se:minaire international sur les facteurs d'hypofécondite et infécondite en Afrique, tenu au centre des conférences de rUniversité d'lbadan, au Nigeria, du 26 au 30 novembre 1973. Ottawa, Centre de recherches pour Ie développement international, c1977. 31p. 63. Manitoba Association ofR gister d N urs s Educational leave and productivity. Position paper. Winnipeg, 1979. l.5p. 64. Mc Whinnie , John R. L'évolution des années potentielles de vie perdues (APVP) Canada et provinces 1969-1976, par...et James C. Cudmore. Otlawa. Planification à long terme (sante:) Ministère de la Sante: nationale et du Bien-être social, 1978. 39p. 6.5. - . Trends in potential years of life lost (PYLL); selected causes. Canada and provinces 1969-1976, by...andJames S. Cudmore. Ottawa, Long Range Heallh Planning Branch. Dept. of Health and Welfare, 1978. 39p. 66. Manitoba Association ofR gist red N urs s Occupational health nursing handbook. Winnipeg, 1978.2Ip. 67. National Health Council Distribution of health personnel, an annotated bibliography, compiled by Ellen Sax and Barbara Unterman. New York, 1976. 33p. 68. National Leagu for Nursing Developing a master's program in nursing. New York. cl978. 37p. (NLN Pub. no. 1.5-1747) 69. National Leagu for Nursing Responsibilities and liabilities of board members in health care agencies. New York. 1978. 26p. (NLN Pub. no. 21-1740) 70. - . Council of Diploma Programs Roles, rights and responsibilities: the educational administrator's 3 Rs. New York, 1978. 41p. (NLN Pub. no. 16-1712) 71. -. Council of Home Health Agenci s and Community Health Servius Community health administration in a cost-containmenl era. Papers presented at the annual meeting Mar. 1-3, 1978, Washington, D.C. New York, 1978. 18p. (N LN Pub. no. 21-1743) 72. -. Effective boardmanship: hiring and evaluating tl1e agency administrator. Three of the papers in the collection were presented at the annual meeting. Mar. 1-3, 1978. Washington, D.C. New York, N.Y.. 1978. 2.5p. (NLN Pub. no. 21-1742) 73. -. Extended hours for /J.ome health services Papers presented at the annual meeting Mar. 1-3. 1978. Washington. D.C. New York, cl978. 18p. (NLN Pub. no. 21-1746) 74. - . A home health agency's approach to marketins. Paper presented at the annual meetins, Mar. 1-3, 1978. Washinston,D.C. New York, 1978. 7p. (NLN Pub. no. 21-1744) 7.5. Nursins administration: a selected annotated bibliography of current periodical literature in nursins administration and management, prepared by graduate sludents in nursing administration at the University of Texas School of Nursing at San Antonio. New York. National League for Nursihg, 1978. 21p. (League Exchange no. 120) (N LN Pub. no. 20- 174.5) 76. Ogg, Elizab th Changins views of homosexuaJity. New York. Public Affairs Committee, c 1978. 28p. (Public Affairs pamphlet no. .563) 77. OntarioCouncilofH alth The planning function of district health councils. Toronto, 1977. 3.5p. 78. On.ario C ouneil ofH al.h Medical record keeping. Toronto, 1978. J8p. 79. On.ario Nurs s' Associa.ion Statement of beliefs and long term goals with proposed time-table for phasing in these goals. Toronlo, Ontano Nurses' Association, 1979. 18p. 80. Organisa.ion mondia/ d la San.i Promotion et developpement de la médecine traditionnelle. Rappon d'une réunion de rOMS. Genève, 1978. 43p. (Sa série de rappons techniques no 622) 81. Palm r, S. Public accountability and peer review in health care delivery in the United Slates and United Kingdom, by...and D.G. Gill. Bethesda. Md., U.S. Dept. of Health, Education, and Welfare Public Health Service, National Institutes of Health.... 1977. 31p. (U.S. DHEW Pub. no. (NIH) 77-1429) 82. R gis' r d Nurs s Associa'ion ofOn/ario Submission to the Royal Commission oflnQuiry into the Confidentiality of Health Records in Ontario. Toronto, 1978. 12p. 83. Saska'ch wan Pnchia.ric Nurs s Associa.ion Handbook. Regina, 1978. 3Op. 84. S minar on uliliza.ion of au;ciliari s and community I ad rs in h allh programs in rural ar as. Maracay, Vl'n zu /a, 18-27 NO\' mlHr. 1974 Final repon. Washington, Pan American Health Organization, Pan American Sanitary Bureau, Regional Office of the World Health Organization, 1978.2Ip. 8.5. Smi.h.E.S.O. Venereal disease programs in Great Britain. West Germany. Denmark and Sweden with implications for Canada. Edmonton, 197.5. 17p. 86. Von Schilling. Karin Studies of child development. Hamilton, 1974. 16p. 87 . World H al.h Organiza'ion The promotion and development of traditional medicine. Repon of a WHO meeting. Geneva, 1978. 41p. (Its Technical repon series no. 622) GovernlMnt Documents British Columbia 88. Brilish Columbia. Commission of Inquiry Concl'rning .hl' Educalion and Training ofPrac'ical Nurs s and R /a. d Hospilal Pusonn 1 Repon. Vancouver. 1977. 16p. Canada 89. Commission d lafonclionpubliqu Canada. Offic dl' la promolion d laf mm Brochures. Ottawa, 1978. 3v. Sommaire: - 1. us conges de maternité dans la fonction publiQue fédérale, 1977. - 2. La garde des enfants: renseignements a I'intention des fonctionnaires, 1978. -3.Le travail å temps paniel dans la fonction publiQue fédérale. 90. Dl'pl. of N alional D f nu . Canada Em rgl'ncy M asurl'S Organizalion Canadian Emergency Measures College Arnprior, Ontario. Ottawa, Dept. of National Defence, 1978? 8p. 91. Emploi llmmigra/ion Canada. Analys I dév /op ml'nl-prof ssions I carriirl's Carrières dans les services de santé. Ottawa, The C8n-.l\en NUrN Looking for more control over your nursing career? Medical Per- sonnel Pool can give it to you. Choice of assignments, flexible hours, staff development programs. But don't think you have to sacrifice for it. MPP offers exceUent insurance coverage, RN consulta- tion, and the freedom to choose your O\AIT) hours. Medical Personnel Pool is an established leader in the provision of qualified, experienced, supple- Approvisionnements et Services, 1978. 24p. 92. Employm n' and Immigra/ion Canada. Occupa/ional and carur analysis and d ,' /opm n/ Careers in health services. Ottawa. Supply and ServicesCanada. 1978. 24p. 93. H al.h and W lfar Canada tntroduction to medical services. Ottawa, 1978?v. (unpaged) 94. HnJllh and W lfar Canada. Hospi.al Insuranc and Diagnoslic S rvic s Repon, 1976. Ottawa. 1976-77. l.5p. 9.5. - . F ami/}' Planning Di.ision Communication in family plannins: a self-teaching manual. Ottawa, 1978. 16p. 96. - . H allh C onsullanls Dir clOral . H allh Programs Branch Review of the literature on home care. Ottawa. 1977. 93p. 97. -. M dical Sl'rvius Branch Repon. 1976. Ottawa.'v. 98. Labour Canada Canada and the international labour code. Ottawa. Supply and Services Canada, 1978. 83p. 99. Labour Canada. Employm n/ R /alions Branch I ndustrial relations research in Canada. 1976-77. Ottawa, Minister of Supply and Services Canada. 1969-1978. 317p. 100. LaM's. S.a/ul s, I'lc. Canadian Centre for Occupational Health and Safety Act, S.c. 1978. Bill C-3.5. Ottawa. Queens Printer, 1978. lOp. 101. Lois, SlCJluU. Ic. Centre canadien d'hygiène et de sécurité au travail. S.R. 1978. Bill C-3.5. Ottawa, Imprimeur de la Reine. 1978. lOp. 102. M inislir d la D f nu naliona/ . Organisation d s mesur s d' urg ncl' du Canada Collège canadien des mesures d'urgence, Arnprior, Ontario. Ottawa, 1978? 8p. 103. PublicS ,,'icI'Canada. Offic of Equal Oppor/uni.il's/or Wom n Pamphlets. Ottawa. 1978. 3v. Contents: -I.Maternity leave in the federal public service, 1977. - 2 Child care information for public servants. 1978. -3.Pan-time work in the federal public service. 104. San/i IBi n-llr social Canada Profit des services médicaux. Ottawa, 1978? Iv. (non paginé) 10.5. - . Division d la planificalion familia/ La communication dans la planification familiale; guide autodidactiQue. Ottawa, 1978. 16p. 106. S cr lary of Slall'. Educalian Suppor. Branch Julyl Aug.... 11711 III e. An International Nursing Service You'll find us lIsted in the u,hlte pages. Guide 10 government of Canada programs of financial aid for Canadian post-secondary students Ottawa. Minister of Supply and Services, c 1978. 16p. 107. Sla/lSlics Canada Consumer price index; revision based on 1974 expenditures; concepts and procedures. Ottawa. 1978. 91p. (Catalogue no. 62-.546) IOS. -. Universities: enrolment and degrees. 1977. Ottawa, 1979. 72p. (Catalogue no. 81-2(4) 109. Stalisliqu Canada L'indice des prix à la consommation; revision fondée sur les dépenses de 1974; concepts et procédes. Ottawa. 1978. 91p. (Catalogue no 62-546) 110. Travail Canada Le Canada etle code international du lravai!. Onawa, Ministre des Approvisionnements et Services Canada. 1978. 92p. III. Travail Canada. Dir c/ion d s rl'la/ions n maliir d' mploi La recherche sur les relations indusl/ielles aU Canada- 1976/77. Ottawa, Minislre des Approvisionnemenls et Services Canada. 1969-1978. 317p. Ontario 112. LaMs. s/alu/ s, I'lc. An act respect ins the occupational health and occupational safety of workers. Bill 70. Toronto, Queen's Printer, 1978. 4Op. Q bK 113. \1inis/ir d s AJ]airl's socialu. Cons iI d s Affair s socia/ s / d lafamill laQu ,tion de la promotion des initiatives volontaires dan, Ie domaine des affaires sociales au Québec. Quebec. 1978. 27p. Saskatchewan 114. D p/. ofH allh Proposal for a national health disciplines education accreditation council. Regina, 1976. .5p. United States or America 11.5. D pl. ofH al/h. Educa/ion. and W lfar . Division of Nursing A directory of expanded role programs for registered nurses. 1979. Hyattsville. Md.. U.S. Dept. of Health, Education and Welfare. 1979. Iv. (DHEW Pub. no. (HRA) 79-10) R eo July/Auguet 111711 The C.nedl.n NUrM 116. - . Public H alth S rvia. C ntu for Dis as Control Sexually transmitted disease (SID) statistical letter. Atlanta, 1978. .56p. 117. D pt. of Health, Education and Welfar A directory of preceptorship programs in the health professions. New York, National HealthCouncil, 1977. 7.5p. (U.S. DHEW Pub. no. (HRA) 77-62) 118. - . Offia of Prof ssional Standards Review Professional standards review organizations, a selected bibliography. Rockville, Md.. 197.5. 101p. 119. V /eransAdministration. D pt. ofM dicin and Surgery Program guide, nursing service. 2d ed. Little Rock, Ark.. VA Hospital, 1972. Iv. (various pagins) Scarborough Depanment of Health. Toronto, Faculty ofNursins, University of Toronto, 1979. 174p. R 122. Greniu. Raymond Etude évaluative d'un programme d'enseignement préopératoire de groupe offen àdeux moments différents. Montréal, 1977. 174p. Mémoire -(M.N.) - Montréal. R 123. Linehan, Marc lIa P. Absenteeism and job satisfaction among nursing staff in a 100 bed hospilal. Halifax. Registered Nurses Association of Nova Scotia, 1978. 64p. Thesis (M.N.) -Dalhousie. R 124. Park r. Nora I. A competency approach to the development of credit examinations for assessing point of entry of diploma graduates into a baccalaureate nursins programme. Toronto. 1978.9p.R 12.5. R gistered Nurses' Association of Ontario Repon of the workins pany on approaches to facilitate Ihe fit of new two year graduates. Toronto, 1978. .5lp. R 126. Toumish y, Laura Hope Punishing the Studies In CNA Repository Collection 120. Cam ron, Cynthia Challenge in implementing a conceptual framework. Strategies to favour or avoid political perspective. Toronto. 1978. l.5p. R 121. Cunningham. Rosella Child abuse program The University of Michigan Hospitals sponsors H.1 working visas for Canadian RNs -.;;: " t' ... .. ....... ,.., ':, r . :r .'0' ' ..... - ""- '- BEDSIDE NURSINCi We feel that a nurse's time should be spent with patients: not carrying messages. transporting patients, or searching for supplies and equipment That is why each decentralized nursing unit is assigned a Unit Management Supervisor to see that non-nursing tasks are camed out by non-nursing personnel. This leaves our nurses free to devote their time and energy to the important task of patient care. We thmk It makes sense If you agree. we would like to tell you more about the career opportunities at U of M Hospitals in Ann Arbor Please call collect (313) 763-3010, or mail coupon below for additionalmformatlon to: Nurse Employment Office University of Michigan Hospitals 3280 HFPB, Box 46 M Ann Arbor, Michigan '48109 OThe o Y ; ----------------------------------------ëÑ879- Name I I I Addr... I I City I l______ _________ _________ ! ______ Stet. Zip pregnant innocents: single pregnancy in St. John's. Newfoundland. St. John's. 1978. l48p. Thesis (M.Sc.)-Memorial R 127. Trimmer, B lIy Lou Impacts of early learning in a bicultural situation. Ann Arbor, Mich., 1973. IIp.R 128. Unil'ersité Laval. Écol d s Sci nas irifirmi r s Les sciences infirmières etles sciences de la santé. Mémoire de l'École des sciences infirmières, Université Laval. Québec, Qui. 1968. 112p. R A udlo VIsual Aids 129. Binh control: methods and principles. Garden Grove,Ca.. Trainex, 1978. I pam. I filmstrip, I audiocaselte. no. Canadian Nurses' Associa/ion. Biennial Com'en/ion. Toron/o, June 25-28.1978 Proceedings and papers. Toronto. Audio Archives of Canada, 1978.9 audiocassettes. Contents.-I.A Challenge to the professional. Donna Wicks, Jocelyn Morin. The emergins conflict of professional and consumer rights. Bernadette Walsh.-2.The everyday realities of ethical concerns. David Roy .-3.Ethical issues in professional development. Abbyan Lynch, Margaret SCOII Wright. Margaret Neylan.-4. Ethics of nursins research. Laurier Lapierre. Moyra Allen, Huguette Labelle, Marie-France Thibaudeau, Beverlee Psychiatric Nursing Post Graduate Program For Registered Nurses This 16 week full-time program combines clinical experience with studies in comparative theories of Personality Development, PredisposinslPrecipitating Factors, Crisis Theories..Nursing Process, Therapeutic Modalities such as Counselling and Group work, Outreach programs, Community psychiatry and Professional Development. Fall program begins September 4, 1979. Winter program begins February 4. 1980. For funher information contact: Department He.d Diploma Nursing Health Scienc:es Di\'ision Durham CoUege P.O. Box J85 Oshawa. Ontario LlH7L7 Cox.-.5.The professional association meels the challenge. Marguerite Schumacher. Sheila Belton.-ti.The frontiers of science and humanity. Roy Bonisteel.-7.Canada health survey. T. Stephens.-8.Current conflict and a look toward the future. M. Josephine Flaheny .-9.President's address. Joan Gilchrist. 131. Decisions. decisions. decisions. Garden Grove. Ca. Trainex. 1978. I pam., I filmstrip, I audiocassette 132. Labe" . HlIgue/l Health: the major link for community development activities. Paper delivered to the 2nd International Congress of the World Federation of Public Health Associations and Ihe 69th annual conference of the Canadian Public Health Association.. .on May.23rd, 1978. Halifax, 1978. I audiocassette. 60 min. 133. Leadership in nursing. Garden Grove, Ca. Trainex. 1978. I pam., I filmstrip, I audiocassette. 134. Mental heallh series. Garden Grove. Ca. I pam.. J filmstrip. I audiocassette. 13.5. The nurse. ethic!!. and the law. Garden Grove. Ca. Trainex, 1978. I pam.. I filmslrip, I audiocassette. 136. The nursing audit. GardenGrove, Ca. Trainex, 1978. I pam.. I filmstrip, I audiocassette. 13 7. The nursing history. Garden Grove, Ca., Trainex. 1978. I pam.. I filmstrip. I audiocassette. 138. Pharmacology. Garden Grove, Ca. Trainex, 1978. I pam., I filmstrip. I audiocassette. The Can-.llan Nur.. Jul)'/Auguet 11711 11 Classified Advertisements Alberta ReaI*red Nunn required for acute are general hospital, expandina from 75 beds to 300 b1õds. Clinical areas include: medicine, surgery, obstetncs, paediatrics, psychiatry, activation and rehabilita- tion, operatins room, emergency and intensive and coronary care unit. Must be eligible for Albena registration. Personnel policies and salary in accor- dance with AARN contract. Apply to: Personnel Administration, Fon McMurray Regional Hospital, 7 - Hospital Street, Fort McMurray, Albena, 1'9H IP2. Big Country Heallh Unit requires a DIrector to commence work as soon as ssible. Applicant must be a Registered Nurse wtth some experience in Public Health. This is a supervisory position and applicant needs to be knowledgeable in the manage- ment field. Salary nego .able based on qualifications and experience. Please .pply in writina to: Director, Big Country Health Unit, Box 279. Hanna, Albena, TOJ tPO. ReaI*red Nunn required fo.r .pan-time d II- time employment. Must be ehglble for registration with AARN. Salary and benefits as per U.N.A. contract. Residence available. Apply in writins to: Director of Nursins, Wainwright Hospital Complex, Wainwright, Albena, TOB 4PO, or phone (403) 842-3324. British Columbia Head None - Pedletrks required for progressive general hospital in Fraser Valley. Eligibility for Registration in B-c. required. Advanced preparation in administrative nursing techniques, including ward management and principles of supervision or its equivalenl. Apply in writing to: Director of Nursins, Matsqui-Sumas-Abbotsford General Hospital, Ab- botsford, British Columbia, V2S 3PI. SUIft Nunes required for the following areas: Psychiatry and Medical. Eligibility for registration in B.C. required. Formal trainins and/or experience preferred. Apply in writing to: Direclor of Nursing, Matsqui-Sumas-Abbotsford General Hospital, Ab- botsford, British Columbia, V2S 3PI. E1Iperienced General Duty Gnduale Nurses required for small hospital located N.E. Vancouver Island. Maternity experience preferred. Personnel policies according to RNABC contract. Residence accom- modation available $30 monthly. Apply in writins to; Director ofNursins. St. George's Hospital. Box 223. Alen Bay, British Columbia, VON IAO. Genenl Duty (B.C. registered) nurses required for expansion to 422 acute care accredited hospital located 6 miles from downtown Vancouver and within easy access to various recreational facililies. Excellent orientation and on-goins inservice prog- ramme. Salary: $1.305.00--$1,542,00 monthly. Clini- cal areas include coronary care, intensive care. emergency. operating room, P.A.R.R.. medical/sur- gical, pediatrics, obstetrics. onhopedics and activa- tion units. Head Nurse position also required for our critical care unit, effective immediately. Candidates must have had at least two year's related experience and should have a demonstrable record of manage- rial skill Apply to: Co-ordinator-Nursing. Dept. of Employee Resources. Burnaby General Hospital. 3935 Kincaid Street, Burnaby. British Columbia. VSG 2X6. E1Iperienced Nunes (eligible for B.C. Registration) required for full-time positions in our modem 300-bed Extended Care Hospital located just thiny minutes from downtown Vancouver. Salary and benefits according to RNABC contract. Applicants may telephone 525-091 I to arrange for an interview. or write giving full paniculars to; Personnel Direc- tor, Queen's Park Hospital. 315 McBride Blvd.. New Westminster. British Columbia, V3L 5E8. British Columbi J Assistant Director or Nunll1J! - Applicants are invited for the position of Assistant Director of Nursing. for a ;225-bed Acute General Hospilal. Saint Mdry's Hospital is fully accredited and olTers Medical. Surgical. Pediatric and Sub-special ser- vices. Qualifications: At least B.Sc.N. with de- monstrated leadership ability. Minimum of S years progressive nursins experience with at least 2 of these years in a Nur.ins Administrative position. Address all enquiries in writing together with complete resume 10; Director of Nursing, Saint Mary's Hospital, 220 Royal Avenue, New Westminster. British Columbia. V3L IH6. Experienced Nunes (B.C. Regislered) required for a newly expanded 463-bed acute, teaching. regional referral hospital located in the Fraser Valley. 20 minutes by freeway from Vancouver. and within easy access of various recreational facilities. Excel- lent orientation and continuing education program- mes. Salary-I979 rates-$130S.00--$1542.00 per month. Clinical areas include: Operating Room, Re- covery Room, tntensive Care. Coronary Care, Neonatal Intensive Care, Hemodialysis, Acute Medicine. Surgery, Pediatrics. Rehabilitation and Emergency. Apply to: Employment Manager. Royal Columbian Hospital, 330 E. Columbia St., New Westminster, British Columbia, V3L 3W7. Head Nurse - r.eoDatal Intensive Care Unit. The Prince George Regional Hospital. a 340-bed acute care and !2-bed extended care hospital. requires a Head Nurse for the Newborn and Neonatallnten- sive Care Unit. Requirements: Demonstrable lead- ership and administrative skills. Clinical preparation and previous experience in care of the critically ill neonate and eligibility for registration with the RNABC. Salary Range: $1500.00 - $1772.00 per month. Interested applicants are inviled to submit applications to the: Director of Personnel Services, Prince George Regional Hospital. 2000 - 15th Avenue, Prince George. British Columbia. V2M IS2. Regløtered Nunn required immediately for perma- nent full time positions at IO-bed hospital in B.C. Salary at 1978 RNABC rate plus nonhern living allowance. Recognition of advanced or primary care education. One year experience preferred. Apply: Director of Nursing, Stewan General Hospital, Box 8, Stewan, British Columbia, VOT IWO. Telephone: (604) 636-2221 Collect. General Duty Nurses reqUIred for an acute general hospital in the tnterior of B.C. Apply in writing to: R. L. Keiver. Assistanl Administrator. Personnel, Trail Regional Hospital. Trail. British Columbia, VIR 4MI. The Cancer Control Agency of British Columbia has openings for experienced oneolo8} nurses in am- bulatory eare and inpatient units. Positions olTe r opponunities for teaching and research responsibil- ity as well as patient care based on a primary nursing concept. Interested applicants should write or phone: Sue Rothwell. Director of Nursing. C.C.A. B.C., 2656 Heather Street, Vancouver, British Columbia, VSZ 3JJ (604) 873-6212. St. Paul's Hospital inviles applications from B.C. Regløtered N..... for full and pan time positions in all areas of the hospital. St. Paul's is an acute referral teachins hospital located in downtown Vancouver. 1979 R.N. rates $1305.00 - $1542.00. Generous fringe benefits. Apply to: St. Paul's HOSpital, Personnel Depanment, 1081 Burrard Street. Van- couver, British Columbia, V6Z IY6. Manitoba Experienced Reaistered NuIWS required for a fully accredited 200-bed Health Complex located in Nonhern Manitoba. Must be eligible for registration in Manitoba. Salary dependent on experience and education. For funher information contact: Mrs. Mona Seguin, Personnel Director, The Pas Health Complex Inc., P.O. Box 240. The Pas, Manitoba, R9A I K4. Northwest Territories The Stanton Yellowknife Hospital, a 72-bed accre- dited, acute care hospital requires registered nurses to work in medical, surgical, pedlatnc, obstetrical or operating room areas. Excellent orientation and in service education. Some furnished accommoda- tion available. Apply: Assistant Adminislrator- Nursins. Stanton Yellowknife Hospital, Box 10, Yellowknife, N.W.T., XIA 2NI. Ontario RN, GRAD or RNA, 5'6" or over and strong, without dependents, non smoker, for 175 lb. handicapped. retired executive with stroke. Able to transfer patient to wheelchair. Live in 1/2 yr. in Toronlo and 1/2 yr. in Miami. Wages: $200.00 to $250.00 wkly. NET plus $80.00 wkly. bonus on most weeks in Miami. Write: M.D.C., 3532 Eglinton Avenue Wesl. Toronto, Ontario, M6M IV6. Saskatchewan R.N.'s and R.P.N.'s (eligible for Saskatchewan registration) required for 340 fully accrediled ex- tended care hospital. For fun her information. contact: Personnel Depanment. Souris Valley Ex- tended Care Hospital. Box 2001. Weyburn. Sas- katchewan S4H 2L7. United States CaUrornia - Sometimes you have to go a long way to find home. But. The White Memorial Medical Center in Los Angeles. California. makes it all wonhwhile. The While is a 377-bed acute care teaching medical center with an open invitalion to dedicated RN's. We'li challenge your mind and offer you the opportunity to develop and continue your professional growth. We will pay your one-way transponalion, offer free meals for one month and all lodging for three months in our nurses residence and provide your work vIsa. Call collect or write: Ken Hoover. Assistant Personnel Director. 1720 Brook- lyn Avenue. Los Angeles. California 90033 (213) 268-5000. ext 1680. Nurse. - RN. - Immediate Openings in California-Florida-Texas-Mississippi - if you are experienced or a recent Graduate Nurse we can offer you positions with excellent salaries of up to $1300 per month plus all benefits. Not only are there no fees to you whatsoever for placins you, but we also provide complete Visa and Licensure assistance at also no cost to you. Write immediately for our application even if there are other areas of the U.S. that you are interested in. We will call you upon receipt of your application in order to artanse for hospital interviews. You can call us collect if you are an RN who is licensed by examination in Canada or a recent graduate from any Canadian School of Nursing. Windsor Nurse Placement Service. P.O. Box 1133, Great Neck, New York, 11023. (516- 487-2818). "Our 20th Year of World Wide Service" 112 July/Auguet 11711 The Can-.llan Nur.. United States United States Replltered Nunes - CI.UfomIa - Rapidly growillj inland port city in the heart of California's Big Valley. 260-bed, fully accredited teaching hospital. Ideal location within 2-3 hours by car of San Francisco, Yosemite, Lake Tahoe, Monterey Penin- sula and historic Mother Lode. Four-season climate with snow-free winlers. Contact: Laurel Murphy, Director of Nursillj, P.O. Box 1020, Stockton, California, 9.5201, (209) 982-t800, Ext. 6016. Amr- maIlve actlon/equlll opportunity employer. R.N.'. - Our Florida Hospitals need you. We will provide the work visa, help you locate a position. find housing. arrange your relocation. No fees. Call or write: MedIcal Rec:rulters of Amerlc:a, 1211 N. Westshore Blvd., Suite 20.5, Tampa, Florida 33607 (813) 872-0202. F10rlda NursIng Opportualt1eø - MRA is recruitillj Reaistered Nurses and recent Graduates for hospital positions in cities such as Tampa, St. Petersburg, and Sarasota on Ihe West Coast; Miami, Ft. Lauderdale and West Palm Beach on the East Coast. If you are considering a move to sunny Florida, contact our Nurse Recruiter for assistance in selecting the right hospital and eity for you. We will provide complete Work Visa and State Licensure information and offer relocation hints. There is no placement fee to you. Write or call Medklll Recruiters of America, Inc. (For West Coast) 1211 N Westshore Blvd., Suile 20.5, Tampa, FI. 33607 (813) 872-0202; (For East Coast) 800 N.W. 62nd St., Suite .510, Ft. Lauderdale, F1. 33309 (30.5) 772-3680. ReJløtered and L1celUed Pradlcal Nuneø needed in Georgia of the U.S.A. Salary negotiable. Applicants please reply to: Personnel Office, Shirley's Conva- lescent Center, P.O. Box 96, Dahlonega, Georgia, 30.533. RN's - Boise, ldabo - How would you like a rewardillj career in an environment which offers you immediate access to uncongested recreation areas with rivers, lakes and mountains? Do you enjoy tennis, golf, racketball, campillj, hiking, skiins and horseback ridins? Sound excitins? It is. And there are many opportunities for satisfying work at one of Idaho's largest and most progressive medical complexes. St. Alphonsus, located in Boise, is a 229-bed facility offering you positions in orthopedics, ophthalmology, dialysis, mental health, neurosurgery and trauma medicine. Excellent salary, generous benefits and job security. Starting salary adjusted for experience; benefits include travel assistance, shift rotation, and free parkillj. Write or call collect: Employment Supervisor, Personnel Office, St. Alphonsus Hospital, 10.5.5 North Curtis Road. Boise, tdaho 83704. (20111 376-3613. EOE. Nursinll OpportunIties In New Orleans, Loulslana- MRA IS recruitins Registered Nurses and recenl Graduates for several general and teaching hospitals in the exciting New Orleans area. Openinss in many speciallies and most Canadian Registered Nurses can Qualify for licensure endorsement in Louisiana. Contact our Nurse Recruiter for tuition assistance plans. We will provide complete Work Visa and State Licensure information. There is no placement fee to you. Write or call Medlclll Rec:rulters of America, Inc., 800 N.W. 62nd St., Suite .510, Ft. Lauderdale, F1. 33309. (30.5) 772-3680. Nursing Opportunity - Mississippi Baptist Medical Center, a major 6()(}.bed hospital, has immediate positions available for experienced RNs and recent nursing school graduates in a variety of specialities and medical/surgical areas. Competitive salaries, liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (population 300,(00), MBMC is the state's largest and most modem privately operated hospital. For further information write: Mrs. Johnnye Weber, Nurse Recruiter, 122.5 North State Street. Jackson. Mississippi 39201; or call collect 601/968-.513.5. r" Before accePti",L any position in the .S.A. PLEAS CALL US COLLECT w. Can Offer You: A) Selection of hospitals Ihroughout the USA B) Extensive information regarding HospitaJ-- Area. Cost of living. etc_ C) Complete licensure and Visa Service Our Services to you are at absolutely no fee to you. WINDSOR NURSE PLACEMENT SERVICE P.o. Box 1133 Great Neck. N.Y. 11023 (516) 487-2818 Our 20th Year of World Wide Service ....,j Grande Prairie General Hospital Assistant Director of Nursing (Acute Care) Position required for a 230 bed hospital complex wilh planning and construction underway for a 4 7 bed complex to open Spnng 1983. located in a city of 20.000. Upwdrd mobility within the organization possible. Nursmg and Management experience required. Experience in critical care nu.-sing an asset. Bachelors or Masters degree in Nursmg and/or administration deSIrable _ Sdlary: $20.000 - $23.000 annually. Apply to. Mrs. D. O'Brien Director of Patient Service t0409 -98th Str t Grande Pralri., Alberta T8V 2E8 Or phone: (4011 32-7711 (Ext. 241 UNITED STATES OPPORTUNITIES FOR REGISTERED NURSES A V AILABLE NOW IN ARIZONA CALIFORNIA TEXAS WE PLAC E AND HELP YOU WITH: STATE BOARD REGISTRATION YOUR WORK VISA TEMPORARY HOUSING - ETC. A CANADIAN COUNSELLING SERVICE PhoM: (416)449-5883 OR WRITE TO: RECRUITING REGISTERED NURSES INC. t200 LA WRENCE A VENUE EAST, SUITE JOI, DON MILLS, ONTARIO M3A ICI FLORIDA OHIO NO FEE IS CHARGED TO APPLICANTS. R.N.'. U.S.A. - Dunhill with 2.50 offices has excitins career opportunities for both recent grads and experienced R.N:s. Locations North, SOulh, East and West. AU fees are paid by the employer. Send your resume to: SOl Empire Buildillj, Edmon- ton, Alberta, T.5J IV9. NursIng P08ltlons AvaIlable: At a replacement facility due to completion in early 1980. Diversified services in a small community selling 6 miles from Ihe Atlantic Ocean where water sports are available all year round. University is within 30 miles where you can further your education in nursing. Contact: Mrs. B.J. Donnally, Director of Nursing, J.A. Dosher Memorial Hospital, Southport. North Carolina 28461. (919) 4.57-6664 Belween the hours of 8:00- 4:30 p.m. Monday thru Friday. Dallas, Houston, Corpus Cbrlstl, etc, etc, elC. The eyes of Texas beckon RN's and new grads to practice their profession in one of the most prosperous areas of the U.S. We represent all size hospitals in virtually every Texas and Southwest U.S. City. Excellent salaries and paid relocation expenses are just two of many super benefits offered. We will visit many Canadian cities soon to interview and hire. So we may know of your interest, won't you contact us today? Call or write: Ms. Kennedy, P.O. Box .5844, Arlinston, Texas 76011. (214) 647-0077. Come to Texu - Baptist Hospital of Southeast Texas is a 400-bed growth oriented organization look ins for a few good R.N.'s. We feel that we can offer you the chalIense and opportunity to develop and continue your professional growth. We are located in Beaumont, a city of 1.50,000 with a small town atmosphere- but the convenience of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist Hospital has a progress salary plan plus a liberal fringe package. We will provide your immig- ration paperwork cost plus airfare to relocate. For additional information, contact: Personnel Ad- ministration, Baptist Hospital of Southeast Texas, Inc., P.O. Drawer 1.591, Beaumont, Texas 77704. AD amrmaIlve adloa employer. Nuneø - RN. - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa forms and provide assistance with licensure at no cost to you. Write for a free job market survey. Marilyn Blaker, Medn, .580.5 Richmond, Houston, Texas 770.57. AU fees employer paid. Excitement: Come and join us for year around excitement on the border, by the sea, an unbeatable combination. Enjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed, acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openinss in all areas. Excellent salary and frillje benefits. We invite you to share the challense ahead. Assistance with travel expenses. Write or call coiled: Joe R. Lacher, RN, Direclor of Nurses, Valley Community Hospi- tal, P.O. Box 469.5. Brownsville. Texas 78.521; I (.512) 831-9611. Miscellaneous Cherokee LodI", Lake Rosseau, near Port Sandßeld. A small friendly lodge, catering to adults who want a Quiet relaxing holiday. Open May 24 to Thanksgiv- ing. Good deepwater swimmins, boatins and walk- ing. Golfing, dancing, ridins a short drive away. Rates and folders on request. Write or phone: The Turleys. (70.5) 76.5-3601, R.R. 2, Port Carling, Ontario. POB IJO. Elec:trolysls - Successful Electroly,,, Practice for Sale. 6 months specialized included. Write or phone: Margot Rivard, 1396 St. Catherine Street West, Suite 221, Montreal, Quebec. HJG IP9. Telephone: (.514) 861-19.52. The Cened.... Nu.... OPPORTUNITIES Associate Director of Nursing Services The Victoria General Hospital, an 800 bed adult teaching hospital associated with Dalhousie University, provides tertiary care in all clinical specialties except pediatrics and obstetrics. Located in Halifax with a wide range of educational. cultural, and recreational opportunities. The Hospital operates its own school of nursing and seven other Allied Health Schools. Responsibilities: Works under the general direction of the Director of Nursing Services. One ofthe prime responsibilities will be for the personnel management aspects of this department of approximately 1200 employees. QualifICations: Education: Baccalaureate degree in nursing required. Masters degree preferred. Experience: Minimum of three years experience in a senior nurse-manager position. Special Knowledge and Abilities: A ware of current concepts of nursing service. education and research. principles of administration and personnel development. Professional Opportunity: The close liaison with Dalhousie School of Nursing provides a ready opportunity to pursue professional interests. Salary and Benefits: 1978 salary to $24.237. - currently under review. Full Civil Service Benefits. Competition is open to both men and women. Please quote Competition Number 78-455. Enquiries should be addressed to: Chairman of the Search Committee for Associate Director of Nursing Senices c/o Executive Director Victoria General Hospital 1278 Tower Road Halifax, Nova Scotia 83H 2Y9 Julyl AUfluat 1171 83 ð invites applications for the position of Canadian Nurses Association Executi ve Director The Executive Director is the chief executive officer of the Association. Applicants must have experience in nursing in Canada and be a member of a professional nurses association. Demonstrated senior administrative capabilities and ability to maintain relationships with governments, allied professionals. international organizations and the public are essential. Successful candidate must be able to work in both official languages. Masters' degree required. doctoral degree preferred. Salary negotiable. Applications should be forwarded in confidence, with complete resume of experience and qualifications, before 21 September 1979 to: Director of Professional Senices Canadian Nurses Association 50 The Driveway Ottawa, Ontario K2P tE2 I rrv 41_ Unit Supervisor Alberta Social Services and Community Health, Eric Cormack Centre. requires an individual for the direction ofa specific 24 bed unit, on a shift rotational basis and be responsible to assist in the perfonnance of general supervisory and administrative duties. Duties include providing direction to unit personnel regarding resident care and programming, assisting staff in the initiation and development of specific programs, to provide for growth and development of each resident. Qualifications: Graduation from recognized School of Nursing (R.N.. R.P.N., M.D.N.). Eligible for registration in A.A.R.N. or other appropriate professional organization. Considerable related nursing experience, some of which should be in a supervisory capacity. Experience in the field of mental retardation would be an asset. Salary $15,372 - $18,840 Competition #9177-4 This competition will remain open until a suitable candidate has been selected. Apply to: Alberta Government Employment Office Sth Floor, :\Ielton Building 10310 Jasper A venue Edmonton, Alberta TSJ 2W4 14 July/Auguat 1171 The Cen-.ll.n Nu.... Wish ere 4;1 .( . , . .... I. -- ... _I ,_r. ,'. ....,. , - l' ç-....... . . . . t'- .),"- ( .,- " "." -. . ...in Canada's Health Service Medical SelVices Branch of the Department of National Health and Welfare employs some 900 nurses and the demand grows every day, Take the North for example. Community Health Nursing is the major role of the nurse in bringing health selVices to Canada's Indian and Eskimo peoples, If you have the qualifications and can carry more than the nonnalload of responsibility. .. why not find out more? Hospital Nurses are needed too in some areas and again the North has a continuing demand. Then there is Occupational Health Nursing which in- cludes counselling and some treatment to federal public selVants. You could work in one or all of these areas in the course of your career. and it is possible to advance to senior positions. In addition. there are educational opportunities such as in-selVice training and some financial support for educational leave. For further infonnation on any. or all. of these career opportunities. please contact the Medical SelVices office nearest you or write to: --------, I Medical Services Branch I Department of National Health and Welfare Ottawa, Ontario K1A OL3 I Name I I Address I I City Provo I I . * Heallh and Welfare Sanle et Bien-ëtre social I Canada Canada ,--------, Manager of Nursing - Operating Room & Manager of Nursing - Recovery Room -Intensive Care Unit Required for Saskatoon City Hospital Under the direction of the Director of Nursing, the Manager of Nursing -Operating Room is accountable for the total operation of a 6 theater operating room in a 376 bed. fully accredited acute care Hospital. Under the direction of the Director of Nursing. the Manager of Nursing - Recovery Room -Intensive Care Unit. is accountable for the total operation of a combined. II bed Recovery Room and 4 bed Intensive Care Unit. Qualifications Registered Nurse with a Baccalaureate Degree or a course in Post Basic Administration. Minimum of 2 years related experience. Proven managerial ability certainly an asset. Salary Commensurate with qualifications and experience. Please send resume of qualifications and experience to: Personnel Services Administrator Saskatoon City Hospital Queen Street & 7th A venue Saskatoon, Saskatchewan S7K OM7 Advertising Rates For All Classified Advertising $15.00 for 6 lines or less $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies of the hospitals and agencies advertising in the Journal. For authentic information, prospective applicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse 50 The Driveway Ottawa, Ontario K2PIE2 . TheCa__ """/AUfluet 1171 III Southern California Nursing: Three Who Made The Change " It was a big step to move from Southwestern Ontario to an entirely new job and surroundings in California, but everyone on the staff at St. Francis made me feel very welcome. They're all so warm and friendly - I really feel like an integral part of their team. "St. Francis is more than I ever expected, but for me Labor and Delivery is the most exciting. Along with my helpful coworkers, the advanced monitoring equipment. and delivery room techniques,l've found my unit a great place to advance my knowledge. "I am proud to be a part of St. Francis Medical Center. It's a great place to work... come and see for yourself." Shirley Allin, RN .., " , . " " It was an experience moving from Ontario, Canada to the Los Angeles area, but the entire. staff of St Francis Medical Center made me feel welcome and right at home. St. Francis is a very good medical center. I work on Definitive Observation which is both challenging and a good place to advance your knowledge. " Mary Jane Grant, RN " I came to St. Francis from Calgary Alberta Canada. The atmos- phere at St. Francis is warm and personal and the people never hesitate to make me feel at home. "St Francis provides many channels for growth The staff is always available for help. "The knowledge and experience I am gaining through living and working in a different country are limitless. I have met many new people and seen many new places thanks to St Francis." Colleen McPhail. RN , \ "''I ................................... = St. Francis Medical Center is located just outside of Los Angeles, in the city of Lynwood. Facilities . . embrace a complete range of medical-surgical services, including open-heart surgery, intensive and . coronary care, definitive observation, acute and renal dialysis, neurostroke, inpatient psychiatry, in/out . . patient rehabilitation, intensive newborn care, diagnostic and therapeutic radiology including cobalt and . . ultrasound, and a 24-hour Emergency Department. The 524-bed hospital has a nursing staff of . approximately 700. . Make the change to a hospital that lets you be what you want to be Write us for more information or . . call Brent Nielsen, RN, Nurse Recruiter, collect at (213) 603-6083. . . 0 Please send me a brochure about St Francis Medical Center. . = Name St. Francis = Address ,.c: Medical C nt · City State Z. e er . . Ip 3630 E. Imperial Highway . . Phone ( - ) RN 0 Student 0 . Lynwood, California 90262 . . Area of interest An equal opportUnity employer . CN-8-19 ................................... ee July/Auguel1878 The Cen.dl.. Nur.. Ryerson Poly technical Institute Nursing Department Presently Offers a General Post- Diploma Intensive Care Program Running Twice Consecutively From September - December & January - April A IS-week course, beginning in Sept. '79 & Jan. '80 aimed at producing general staff nurses qualified to work in medical, surgical or general intensive care areas. Emphasis is placed on pathotherapeutics and as- sessment skills and an integrated clinical experience. Clinical experience offers ample opportunity for immediate application of new knowledge and testing of hypotheses. For further information. contact Admissions Office, Ryerson Poly technical Institute, 50 Gould Street, Toronto. M5B IE8. or telephone Nursing Depart- ment. (416) 595-5191. Registered Nurses 1200 hed ho"pital adjacent to U ni.. er"ity of Alherta campu" offers employment in medicine. "urgery. pediatric", ohstetrics. p"ychiatr . rehahilitation and e'dended care including: . 1 nten"ive care . Coronary ohsenation unit . Cardiovascular surgery . Hums and plastic" . Neonatal intensi\ e Care . Rcnal dialy"is . Neuro-"urgery Planned Orientation and In-Service Education Programs. PostGraduate Clinical Courses In Cardiovascular- Intensive Care Nursing and Operating Room Nursing -\ppl to: Kt'cruitmt'nt Oftkt'r - '\ursin l nÏ\t'rsit of \Iberta Hospital X II- I12th Stret't Edmonton, -\Iberta T6<; 287 Moving, being married? Be sure to notify us in advance. Attach label from your last issue or copy address and code number from it here New (Name)/Address Street Cily Prov./State Postal Code /Zip Please complete appropriate category o I hold active membership in provincial nurses' assoc. reg. no./perm. cert./lic. no. o I am a personal subscriber Mail to: The Canadian Nurse, 50 The Driveway, Ottawa. Ontario K2P fE2 [l]@] University of Alberta Hospital Edmonton. Alberta o Assistant Director (Clinical Nursing) required for a 227 bed general acute and extended care hospital, situated approximately 30 miles from Vancouver in a community of approximately 30,000 people. This position is a leadership opponunity for a highly motivated, innovative nurse to concentrate primarily in the promotion of quality patient care. Liaison with a multi-disciplinary team in development of patient programs is necessary . The applicant requires successful clinical nursing experience at a leadership level and must be eligible for registration in British Columbia. Preference will be given to candidate with a Bachelor of Nursing Degree. Apply: Personnel Officer Peach Arch District Hospital 15521 RusseU Avenue White Rock, B.C. V4B 2R4 (," j I'" , ,I 01 . ',I.. Public Health Nurses The Cened.... NuI'M Julyl AUflUelll71 87 ( OPPORTUNITY Al tærra Psychiatric N urses/ Registered Nurses Offers R.N. 's An UNUSUAL OPPORTUNITY. The Alberta Hospital, Ponoka. an active treatment psychiatric hospital. located 104 kilometres south of Edmonton. has positions available for nurses. A.M.I. Will FURNISH Onl Wly AIRLINE TICKET to Tlla. Ind $500 Inlllil LIVING EXPENSES on I Loan Basi.. Aftlr Onl Yar'. Slrvlcl, TIll. Loan Will ÞI Canclilld MI American Medlcallnlernalionallnc. . HAS 50 HOSPITALS THROUGHOUT THE U.S. Qualifications: Must be a graduate from an approved school of nursing. Related experience would be an asset. Registration in the appropriate nursing association. . lIow A.M.I. II "'endlngR.II. 'lID. HDlplllllln TIIiI. Immlll'lIl tlplnlnp. 51'1" Rlngl 511.100 ID 516.500 plr Vllr. . You can enjoy nursIOg In General Medicine. Surgery. ICC. CCU. Pedlltllcs and ObstelllCS . A M.I. provides an excellent ollenlatlOn program In-service IralOlng Salary: $13,608- $15.996 r------------" I . . U.S. Nurse Recruiter I I P.O. Box 17778, Los Anlleles, C lif. 90017 . I . Wllhoul obligation. please send me more . Inlormallon and an Application Form I I NAME I AOOR ESS ======= === I I ClTY_ --- ST.___ZIP___I TELEPHONE 1_ _I. _ _ _ _ _ _ __ I LlCENSES:___________1 . SPECIALTY:_ _ ____ _ __-I YEAR GIIAOUATEO:_ _ _ STATE: _ _ __ '------------- Competition #9176-8 This competion will remain open until a suitable candidate has been selected. Apply to: Personnel Director Alberta Hospital Box 1000 Ponoka, Alberta TOC 2HO High Risk Obstetrics and Neonatal Intensive Care Nurses McMaster University Medical Centre is a progressive teaching hospital with a multi-disciplinary team approach to patient care. Major specialties include Obstetrical Intensive Care and Neonatal Intensive Care units. When openings occur in these areas for Registered Nurses. we require experienced Staff. Inquiries are welcomed at any time from mature. responsible individuals who wish to work in a stimulating environment on a 12 hour shift system. Preliminary interviews can be arranged for out oftown nurses eligible for Ontario registration if written requests are accompanied by detailed resumes. Occasional openings also occur in other areas. and, all applications will be given careful consideration. The City of Toronto , Department of Public Health. requires Public Health Nurses fluent in two languages. and qualified for a generalized program. 1978 Salary Range $17.338 - $19,494 per annum with attractive fringe benefits. Apply in writing. giving full resume of qualifications and experience to the: Director of Public Health Nursing Department of Public Health 8th Floor, East Tower, City Hall Toronto, Ontario M5H 2N2 Please apply to: Ms. Nora Prosser Personnel Interviewer Chedoke-McMaster Hospital McMaster University Medical Centre Division 1200 Main Street West Hamilton, Ontario LSS 4J9 All positions are open to women and men applicants. ee July/Auguelll71 The Cllnedl.n Nu.... @ Foothills Hospital Calgary, Alberta The Department of Nursing and the Department of Pediatrics, Neonatology, are offering a five month clinical and academic programme for Graduate Nurses: Advanced Course in Neonatal Nursing Applications are being accepted for clas- ses enrolling each March and September. Participation in the programme is limited to eight. For furtber Inform.tlon please write to: Mr. 8. Wright Coonlln.tor of Educ.tlonlll Services Foothills Hospltlll 1403-29 St. N.W. Clllg.ry, Albert. T2N 2T9 Registered Nurses Grande Prairie General Hospital i, presently accepting applica(ion for full-time, part-time, and casual nurses. Present vacancies Me in Fmergency/OPD. Maternity/Surgery. and Fenldle Medical. Anticipated vacancie, in other units. Apply to: I\1rs. A. Janie !'IIursin Office 10409 - 98th Street Grande Prairie, AIt rta T8\' 2EII Or call: (01031 532-7711 (Ext. 2-1' McMaster Universit) Educational Program For Nurses In Primary Care McMdMer Univer_ity School ofNurs- ing in conjunction with the School of Medicine. otTers d progrdm for regis. tered nur'es employed in primary care ,ettings who are willing to assume a redefined role in the primary hedlth care dclivery team. Requirements (urrent Canadian Re- gistralion. Sponsor hip from a medi- cal co-prdctitioner. At least one year of work experience. preferably in primdry care. For further information write to: Mona Callin. Director Educational Program for Nurses in primar) Care "'acuity of Health Sciences McMaster llniversity Hamilton, Ontario I liS 4J9 Shaughnessy Hospital Vancouver, British Columbia Shaughnessy Hospital is a community teaching hospital centrally located in the City of Vancouver, B. c., having approximately 1100 beds and a staff of 1500 employees. Currenl expansion on the Shaughnessy site will include by 1980, a Children and Maternity Hospitals which will total approximately 300 additional beds. Plans for the future also include a 150 bed extended care unit. In its growing role as an active community teaching facility Shaughnessy Hospital requires energetic nursing staff who are committed to the delivery of high quality health care. For further information regarding current Nursing vacancies please contact: JoaJUIe Stagll.no Employee Rel8tlons Depllrtment SlulUghnessy H08plt.1 4500 o.k Street V.nrouver, B. C. Telephone: (604) 876-6767,1oc1I1271 Patient and Nursing Services Consultant Metro-Edmonton Hospital District No. 106 is seeking a Patient and Nursing Services Consultant with several years of experience in nursing administration at a senior level. The duties will involve assuming a mi\Îor role in formulating the direction of clinical and general patient services programming, facility development. staffing and organizational structure. In addition to being a consultant and clinical advisor, the successful candidate will become an integral member ofthe Administrative and Planning team for a new general hospital facility in Edmonton. This is a senior position. The salary is negotiable. Please respond 10: Executive Director Metro-Edmonton Hospital District No. 106 8th Floor, 10009- 108 Street Edmonton, Alberta T5J IK8 International Grenfell 1\ssociation nqUires immediatel) Assistant Director of ursing for dccredited 1M-bed general ho'pital in SI Anthony. Newfoundland DUlle"i 10 mclude asslsling the Director of Nursing with the pldnning. orgamzin(t. direcllng dnd evaluating of the nUf..mg ,erVlce.. of Curti' Memorial Hospital. Accommodation provided at rea'\onable ratc"'. [ravel borne by the d!.soclation on minimum of one year lliicrvicc. Group life health in"iurance and penlliolon plðn otTered. Other fringe bcncfih. .t\ppllcdnt\ mu'l be eligible for registration with ^ "ocidtion of RC(ti"iICred N urse of Newfoundland. Post-ha..ic preparation. bdccaldureatc degree in nur ing or OIhcr dC"ilfdhlc combination of experience and Iraining. Sdlar)' an dccordance wilh Nfld. gO\lernmenl..,cale. Apply to: Mr. Scoll Smith rsonnel Dirrdor International Grenfell Association St. Anthony. Nnd. AO" 4S0 Assistant Director of Nursing Applicants are invited for the position of Assistant Direclor of Nursing. for a 225 bed AcuteGeneral Hospital. Samt Mary's Hospital is fully accredited and offers Medical. Surgical. Pediatric and Sub- pecial services. Qualifications: At least B.Sc.N. with demonstrated leadership ability. Minimum of 5 years progressive nursing experience with at least 2 of these years in a Nursing Administrative position. Address all enquiries in writing together with complete resume to: Director of Nursing Saint Mary's Hospital 220 Royal A venue New Westminster, British Columbia V3L IH6 Registered Nurses 300 bed Accredited general hospital in Vancouver requires full time R.N.s for medical areas and 4 bed I.C.U. Candidates should be eligible for registration with the RNABC. Recent nursing experience preferred. ICU candidates must have previous ICU experience. Starting salary $1305 - $1542 (RNABC contract). Please apply in writing to: Employee Relations Department Mount Saint Joseph Hospital 3080 Prince Edward Street Vancouver, B.C. V5T 3N4 R.N.'s Registered nurses needed dt St. Theresa. Fon Vermilion. Albena. We are looking for nurses who are willing to be challenged with a wide variety of nursing care settings in rural Albena. Three full-time positions are open immediately and another 3 positions after mid-June. Nonhem allowance and subsidized single staff housing are provided. Please submit dpplicdtlOnS 10: \fr. M. Ods Bal: 400 Hil:h Level, Alberta TOH tNO The Cenedlan Nur.. July' Auguet 1171 It Assignments in Abu Dhabi (Middle East). If you're enjoying your nursing career but feel in some way that you're not completely fulfilled, join us in Abu Dhabi (United Arab Emirates) for a uni- que challenge...you'll profit in more ways than onel You'll experience a new cult1.lre, New people. New sights. New sounds. And you'll gain a greater degree of personal growth by caring for a wider range of medical problems and interfacing with people of different nationalities. Whittaker is offering Registered Nurses with 3 years' post-registration experience a once-in-a- lifetime challenge -the challenge of helping patients who really need your help, and seeing direct results from your knowledge and skills. But there's more. There's free furnished housing. An excellent salary of $16,500 (U,S. Dollars). Free medical and life insurance, plus many other benefits. Fulfill your nursing career. If you're the kind of per- son who can contribute your expertise and profit the most from this kind of assignment, please sub- mit your resume to: Ellen Herman Whittaker Corporation Life Sciences Group 10880 Wilshire Blvd., Suite 604, Dept. 400 Los Angeles, CA 90024 Who says nursing has to be duD? l\ " I '" f . c I - " .. J ! , 1 - ,. / J , '- I .. \ . , - "'" I , "" .,.. \ .. , " .. /I) .. t t i. . " " I .. '\. \ t ' 'If '-f..' 4 a::" .. ;,. . " o ., . -- ... , W hittakell Ufe Sciences Group . ": -It 70 July/Auguel1979 The Cenedlen Nur.. Public Health Nursing Supervisor Public Health Nursing Supervisor required by or hefore mid-August by district health unit. Qualifications preferred include Certificate of Competence from College of Nurses of Ontario; Degree in Public Health Nursing and including supervisory and administrati ve ability. proficiency in oral and written communications. and at least five years recent experience in public health nursmg. Salary scale maximum (1979) $20.054.; excellent benefits; 35 hour week; transportation may be supplied by the employer if required. Written applications are requested to: Personnel Officer Kingston. Frontenac and Lennox and Addington Health Unit 22] Portsmouth A venue Kingston, Ontario K7M ]VS Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Regi\tered Nurse in search of a change and a challenge- look into nursing opportunities at Vancouver General Hospital. B.c.'s major medical centre on Cdnddd's unconventional West Coast. Stdffing expansion has resulted in many new nursing positions at all levels. including: General Duty ($1305. - 1542.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions availdble which could provide the opportunity you've been looking for. For thuse with dn interest in specializdtion. chdllenges await in many drea ,",uch a,: Neonatolog)' Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn Unit Inservice Education Coronary Care Unit Hyperalimentation Program Renal Dialysis & Transplantation Paediatrics If you are d Nurse considering a move please submIt resume to: Mrs. J. MacPhail Employee Relations Vancouver General Hospital 855 West 12th Avenue Vancouver. H.C. V5Z IM9 Index to Ad vertisers July/A u gust 1979 The Badge Maker Canadian Dairy Foods Service Bureau The Canadian Nurse' s Cap Reg' d Canadian Pharmaceutical Association Career Dress (A Division of White Sister Uniform Inc.) The Clinic Shoemakers Dow Chemical of Canada Limited Equity Medical Supply Company J. B. Lippincott Company of Canada Limited Medical Personnel Pool TheC.V. Mosby Company Limited Mostly Whites Limited Parke. Davis & Company Limited Posey Company R ecruiting Registered Nurses Inc. W. B. Saunders Company Canada Limited Uniformity - 16 32.33 52 57 Cover 2 4 25 55 17 59 40,41 Cover 4 53 58 50 8 Cover 3 Ad 'ertisillg M{lflager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa. Ontario K2P I E2 Telephone: (613) 237-2133 Ad 'ertisillg Represelltatives Jean Malboeuf 601. Côte Vertu St-Laurent. Québec H4L IX8 Téléphone: (5 1 4}748-fi56 I Gordon Tiffin 190 Main Street U nionville. Ontario UR 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster A venue Ardmore, Penna. 19003 Telephone: (215) 649-1497 Member of Canadian Circulations Audit Board Inc. I3æE] Welcome To w UNIF' R " ITV . Uniformity is simply a uniform store. But by no means is it a simple uniform store. Uniformity is the very first "classy" uniform store, equipped to cater to your budget. If you are a nurse, lab technician, doctor, dentist, medical assistant, or lion tamer, then please come by and look us over. We can be whatever you want us to be, from conservative to avant garde. Square One Mississauga, Ontario 275-6470 Bramalea City Centre Brampton, Ontario 453-8300 Oshawa Centre Shops Up Top 579-1123 Sunnybrook Plaza Bayview&Eglinton 485-1888 Orillia Square Orillia, Ontario (705) 325-9394 545 Sherbourne St. Sherbourne North of Wellesley 968-1808 Upper Canada Place 460 Brant St. Burlington, Ontario o To assist us with our grand opening, just bring this ad and present it at the store nearest to you for a 10% discount on regular priced merchandise. Come see us. WE'RE NEW! WE'RE DIFFERENT! WE'RE UNIFORMITY! IN THE OTTAWA AREA - PROFESSIONALS KNOW THAT ONLY "MOSTLY WHITES L TD" PROVIDES EVERYTHING THEY NEED: STORE NO.1 STORE NO.2 UNIFORMS - HOSIERY - LINGERIE DUTY SHOES - NAME BADGES CAPS And We Only Carry Canada's Finest Names: WHITE SISTER MLLE. GLAMOUR WHITE CROSS DESIGNER'S CHOICE UNIFORMS REGISTERED TWO LOCATIONS TO SERVE YOU BELL MEWS PLAZA 1355 BANK STREET BELLS CORNERS, NEPEAN (COR BANK & RIVERSIDE) (EVENING SHOPPING) OTTAWA 820-1308 523-8988 DROP IN AND SEE US IF YOU CAN, OR DROP US A LINE IF YOU CAN'T! @ . - --.,.'1 I(i 6S e (( , I '.. I · , A__L .>> ' I .. I , . .;. ,I. 'Ë"_ !Ë: Bulk En nombre thrd trot_me c.... dII Ej .. 10539 - - . A guide to clinical lab procedures . A family-oriented clinic for CF patients . A new role for the office nurse? t , , tS7 J78L.b9 5 U IV Ot CTTAk CPISSET S EH I Al CUR d" .: T.Jj..h A or... TAR I e . . The Can Nune SEPTEMBER 1979 - ,u II U - . .""Tr\) b '"' ... -.J I " - ' .....,....... , -,...-. - .tlu\h..LI\.:.....J , C-rv """' 1 ' ' 9 . I ' r :J I. Nu ' .,..... I "',.... L '''' ",.:, ''1-.1 . ....,RY . White - I -1 =l-- · '(","'1 \ I -J ... - ..... Style No 43859 - Pant suit Sizes 5-15 '""Cares e Linen' 100% textur:ed polyester warp knit Wtllt. Robin . . - . . '" . , . } [ ...... Style No 43820 - Dress SIZes" 5-15 "Caresse Linen 1-00% textured polyester warp knit White, Robm - White Sister 1> ,- - '- The Canadian Nune September 1979 2! a.. lU Q> The official journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75. NumberS -- Here show 8 One breath at a time Cheryl Ann Sams 20 Input 9 CLINICAL LABORATORY PROCEDURES: /979 Update 25 You and the law 14 The nurse practitioner: an idea whose time has come \1aureen McTal'ish 41 Calendar 18 An experiment in innovative staffing A lI.son J. S,"art 45 Library update 50 FRANI\.LY SPEAKING A challenge in office nursing Betty Kowalchuk 48 I ... ..- ,.. The Canadian :V urse welcomes suggestions for articles or unsolicited manuscripts. Authors may submit finished articles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and camon. All articles must be submitted for the exclusive use of The Canadian Nurse. A biographical stalement and return address should accompany all manuscripts. \.. Cover photo - Behind the mask. someone who cares. This month CNJ salutes the newest ofCNA 's affiliated member associations - the National Conference of Operating Room Nurses. Our cover photo courtesy of Department of Medical Communications. Ottawa General Hospital. Ottawa. The views expressed in the articles are those of the authors and do not necessanly represent the policies of the Canadian Nurses Association ISSN 0008-4581 Canadian Nurses Association. 50 The Driveway, Ottawa. Canada, K2P IE!. Indexed in International Nursing Index. Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index. Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microform from Xerox University Microfilms, Ann Amor, Michigan 48106. Subscription Rates: Canadd: one year. $10.00: two years, $18.00. Foreign: one year, $I:!.OO; two years, $:!:!.OO. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not responsible for journals lost in mail due to errors in address. CJCanadian Nurses Association,1979. c54merica's number 1 shoe for Yðung women in white! J, - THE CLINI SHOE ft.k Íll.VJhaL ... - . ..4 " '.::- . .' . . . .. .. . "'-. II , .þ .. /' ... .." / .... "- CHOOSE FROM MORE THAN 30 PATTERNS. . . SOME STYLES ALSO AVAILABLE IN COLORS... SOME STYLES 3V2-12 AAM-EE For a complimentary pair of white shoelaces, folder showing all the smart Clinic styles, and list of stores selling them, write: THE CLINIC SHOEMAKERS · Dept.CN-9, 7912 Bonhomme Ave. . St. Louis, Mo. 63105 The Cenedl.. Nur.. September 1171 I perspective .. Let no man imagine he has no with nurses who need to hospital? How does she deteriorate before our eyes, influence. .. elevate their standard of care. peIform as a patient then we shall have to live with Henry George More often than not, we didn't advocate? the consequences of do a thing about it. First, she must recognize diminished respect in the Last April a letter appeared in A few months ago I that the patient is in a very community; if we want to the Sault Ste. MarieStur accompanied a close friend to vulnerable position and that maintain pride in our chosen written by a woman who the emergency ward of a her first responsibility is to work, we must take an active complained about the care her downtown Toronto hospital to him, to see that he gets the role in renewing that pride. small child had received in a collect the belongings of his best possible care. Directly or hospital in that city. She brother who had died of a drug indirectly, this must be done. -Jane Bock, assistant editor mentioned that all the nurses overdose. I knew one of the I nstead of witnessing an on the pediatric ward seemed nurses at the desk; she smiled incident of poor care or unsafe "tired and frustrated" and and asked how I'd been and practice and then discussing it that the unit was "run more when we asked about the informally with other nurses like ajailthan a hospital". She clothes she replied casually, at lunch or coffee, that nurse complained generally about "Oh, he was a DOA - we must take positive action. It the lack of professionalism never strip the DOA's when may be as simple as among the nursing staff and they come in, we just send the approaching the nurse at fault finished by saying, "It is up to bodies to the coroner." I and offering to teach her the EDITOR nurses tOu.do something could see my friend reeling proper way, or directing her to ANNE BESHARAH about it. " from the reference to his dead help, or it may require ASSISTANT EDITORS Not long after, we at CNJ 21-year-old brother as a consultation with her head SHARON ANDREWS received a somewhat similar 'DOA', but the E.R. nur e nurse or supervisor. JANE BOCK letter from a nurse who didn't. For days afterward I "Oh, I can't do that," SANDRA LEFORT complained about the poor thought that I should go back one nurse replied to this nursing care her mother had and tell her how callous she suggestion after describing a PRODUCTION ASSISTANT received in hospital. She had seemed, and how she had harrowing evening working GIT A FEillMAN documented incidents succeeded in upsetting a with an inexperienced nurse reflecting both an appalling bereaved relative, but I didn't. she worried was not CIRCULATION MAfljAGER lack of professional ethic Everyone knows that administering medications PIERREITE HOlTE (nurses discussing their Emergency nurses get correctly; "She wouldn't ADVERTISING MANAGER hangovers in patients' rooms) hardened after awhile, don't listen and I'd feel like I was GERRY KAVANAUGH and an ominous lack of they? tattling. " CNA EXECUTIVE DIRECTOR professional knowledge The fact is that we can "If a nurse feels she can't HELEN K. MUSSALLEM (accounts of near errors in make no excuses for even go to her head nurse," medication administration). these minor flaws in suggested Allison J. Stuart, EDITORIAL ADVISORS This nurse too thought that if professional demeanor. The administrative assistant to the MATHlillE BAZINET, we printed her account nature of the average hospital associate executive director- chairman, Health Sciences perhaps "nurses would do patient is that of the nursing at Mount Sinai Department, Canadore College, something about it". 'uninformed consumer'; he Hospital in Toronto, "she Nonh Bay, Ontario. DOROTHY MILLER. public The fact that nurses can knows absolutely nothing should go to her co-ordinator, relations officer, Registered - and must - "do something about the bulk of hospital or the in service education Nurses Association of Nova about it" is undeniable; but routines, terminology and instructor, or even to the Scotia. writing letters is not the procedures. He relies on us director of nursing." The JERRY MILLER. direclOrof answer. for everything. And ifwe're administration in most communication services, When nurses refuse to reading letters from parents hospitals is "humanistically Registered Nurses Association acknowledge that incidents of who feel their child was oriented" and nursing of British Columbia. incompetence and 'jailed' in hospital, or from administration is receptive to JEAN PASSMORE,editor, below-standard nursing care nurses who feel care given to anyone's problem, SRNA news bulletin, Registered exist, they are like the ostrich their relatives was inadequate, particularly a problem related Nurses Association of Saskatchewan. burying his head in the sand: isn't it time we got worried to patient care. PETER SMITH, director of we know about it, but we about it?The patients are The message is clear: talk publications, National Gallery don't want to see it, and certainly worried and to somebody, DO something of Canada. maybe if we don't talk about frightened. - not just within the halls and FWRITA it, it will all go away. What to do? It is all very rooms of hospitals but VlALLE-SOUBRANNE, Certainly, the number of well to talk about the nurse's wherever your practice takes consultant, professional nurses who are actually role as patient advocate, but you. inspection division. Order of incompetent is a very small what does this actually mean Ifwe nurses are content Nurses of Quebec. minority but we have all, at for the average hospital staff to stand by and watch our one time or another, worked nurse, in or out of the professional standards about How many of these facts about butte margarine and fat do your patients know? act .lust 6% of the . recommended daily caloric intake is contributed by butter. Many health professionals mistakenly believe that butter is a major contributor to the over-consumption of fat by Canadians which is considerably higher than the 35% of total caloric intake recommended by Health & Welfare Canada. In point of fact, Canadians eat more margarine than butter as well as many other fat-containing foods such as meat, fish, poultry, eggs, cereal products, salad oil and cooking oil. act . The correlation be- . tween the consump- tion of hydrogenated ve , etable oils and the incidence 0 colon and breast cancers has been widely publicized. Results of a research study conducted by a team of scientists headed by Dr. Mark Keeney of the University of Maryland, and published in the summer of 1978, produced compelling evidence of a possible link between the con- sumption of hydrogenated vegetable oils and the incidence of colon and breast cancers. 'C aet . Hydrogenation . changes the molecu- lar structure of vegetable oils. Hydrogenation is the process which solidifies liquid vegetable oils into margarine, making it "spreadable", and giving it longer shelf life in the store. This process changes the chemical composition of the vegetable oils and it also "saturates" fats which, were originally unsaturated. aet . Cholesterol is an . essential substance, naturally present in the human system... and is a problem only to patients with specific lipid profiles. Such unsatisfactory conditions cannot be significantly chan d by dietary manipulation. act . Butter has exactly . the same number of calories as margarine. Weight-conscious patients, in the belief that they are cutting calories, often give up the good taste of butter for a less palatable spread. . . an unnecessary sacrifice. act . Canadians, on a per . capita basis, consume just half an ounce of butter per day. This is just a fraction of the amount generally believed by many health professionals to be the per capita consumption of butter by Canadians. When you look at the facts, you can see the good in butter. DAIRY BUREAU OF CANADA 'C aet . Approximately 2 to . 3% of butter is linoleic acid - the ingredient which many scientists believe to be the moderating, beneficial factor in the diet-heart relationship. The ideal level of linoleic acid in fats intended for human consumption is not yet agreed upon. aet . Data exists which . show a definite correlation, in certain cultures, between the high level of animal fat consumption and the low incidence of CHD. The Masai and Innuit cultures indicate just such a correlation. Interestingly, so, too, does the Irish whose butter consumption, though markedly greater than their Irish- American counterparts, have a much lower incidence of CHD. SOURCES: " Mary C Emg. Robert ). Munn and Mark KeenllY OJetary fat and cancer trends - a critique Federation Proceedmgs 372215-2220. 1978 Mann. C.V. and Spoerry. A StudIes of a surfacta..r and cholesteremia in the MasaJ.Amer.] Gin Nutr.27 464.1974 Gershon Hepner. RIchard Fned. Sachea. Sr.]eor Lydia Fusetli. and Robert Monn Hypocholesterok nic dfect of yogurt and mùk o\m ). Gin. Nutr.. 32,19.24. 1979. Déllry Farmers of Canada Dairy Facts and Figures at a Glance 1978 . Seplember 111711 here's how Every nurse has practical ideas gathered from his or her experience on how to make life a little easier for nurses and for patients. Here's How is a column for you and your ideas. If you have an original and practical suggestion that you think might help other nurses to improve any aspect of patient care. why not share it with other nurses? Well send you $10. for any suggestion published. Let's hear from you. Write: The Canadian Nurse, 50 The Driveway, Ottawa, Ontario, K2P IE2. Ovol Drops relieve infant colic. '" , r 'PAABI ccpp The c.on-.llen Nur.. Beautiful walls Our ho pital walls are often bare and drab - to brighten them we di play chool children's art or photograph.. of interesting people - royalty. pioneers, civic leaders, etc. But the best idea so far was to invite local artists to display their oil paintings. with or without price tags. The response has been very good. to the benefit of artists. patients. staff and visitors. Ours is a rehabilitation center and we have a recreational director responsible for the work involved but volunteers very often help. -Jean Smith, R.N., Regina. Sask. ., 1 . L Oval ffiP3 9ÆTfmI:ow. r fS.i Icohc eH::JRnEk Shhh. Ovol Drops. Also.v....bl.mtabl..formfor.dul.. Ovol Drops contain simethicone, an effective, gentle antiflatulent that goes to work fast to relieve the pain, bloating and discomfort of infant colic. Gentle pepper- mint flavoured Ovol Drops. So mother and baby can get a little rest. (ij)HqRnER Easy breast feeding With the advantages of breast feeding becoming widely known (and its popularity increasing) the postpartum and nursery nurse needs to know how to help the new mother with that often bewildering first feeding. Even when the mother has prepared her breasts and nipples during pregnancy. the newborn may have difficulty grasping the nipple. So the baby howls, his mother ten es up, and nursing becomes frustrating if not impossible. This simple trick has helped many obstetrical patients - myself included! The large rubber nipples designed for the premature infant can be held in place over the mother's nipple like a shield (taking care to keep the outside nipple sterile). The infant sucks breast milk through the rubber nipple while his mother holds it in place. The frantic and hungry newborn will relax and so will his mother, facilitating her letdown reflex. Engorgement will be relieved and the sucking action will draw out mothers own nipples. The rubber nipple can soon be removed, leaving the baby to continue to nurse at the breast. -M. Jordan, Halifax. Nova Scotia. OVOI@80mg Tablets OVOI@40mg Tablets Ovol@ Drops Antiflatulent Simethicone INDICATIONS OVOl is indicated to relieve bloating, flatulence and olher symptoms caused by gas retention including aerophagia and infant colic. CONTRAINDICATIONS None reported. PRECAUTIONS Protect OVOl DROPS from freezing ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOl80 mg TABLETS Simethicone 80 mg OVOl 40 mg TABLETS Simethicone 40 mg Adults: One chewable tablet between meals as required. OVOl DROPS Simethicone (in a peppermint flavoured base) 40 mg/ml Infants: One-quarter to one-half ml as required_ May be added to formula or given directly from dropper. A HORnER ..,. Montreal. Cø.-.ada input \n impatient adH)Cate Corinne Sklar's ..)' 011 alld the law" columns are both thought-provoking and informative. I commend CNJ for this eries. I found her June column, however. like a "who done it". mystery: I knew before very many lines the position the author would take - i.e. the typical position of those who write about nursing from a legal point of view. U sing as my reference point the experiences of patient-consumers. concerned nurses and patient representatives. I would like to make the following points: . It is no longer a matter of introducing a role. The question now before us is whether nursing or some other discipline will fill the role (e.g. the United States). . The Society of Patient Representatives (American Hospital Association and Canada) have shown in evaluation of their programs that a Patient Representative system works and to the benefit of all concerned. (Most problems are resolved at first level and thus a breakdown in Patient-Professional communication is avoided.) . This position could be reasonable if patients and nurses functioned in isolation. What of the other members of the Health Care Team? I have received many letters from patients. patient representatives and nurses citing incidents of violation. ignoring and denying ofrights of patients - which involve the care of the patient as delivered by all professionals in the total health care system. Having recently attended an annual provincial nurses association meeting, remembering what nurses are expressing to each other about continuing conflict between nursing peers, their The c.on-.llen Nur.. co-workers and employers and recognizing the limited number of nurses who speak up with the facts. I am faced with two questions: b it reasonable to expect all nun,es to be their patients' advocate when in essence they are still struggling with the difficulties of being their own (nurses) advocate? Where does this leave the helpless desperate health consumers and those nun..es who voice concern" on their behalf? Patient Advocate, a luxury or necessity? Are you kidding? -Arlee D. M(Gee. R.N., B.N., Resollrce Persoll- Patiellts' RiRhts, New Brullswic/.. Associatioll of Re[;:istered Nllrses, Frederictoll. N.B, Unsafe at any speed As a nurse who has "been there" I would like to comment on the June "Perspective" . I commend the nurses involved who in my mind acted appropriately. professionally and most of all safely. How many of us have been asked to "cope", sometimes ordered to "cope" I with an unsafe workload? Is "coping" good enough when we continually hear terms like "quality care" and "medical. nursing legal implications"? I wholeheartedly agree with Dr. Jo Flaherty. I do believe registered nurses are accountable for their behavior and I find it appalling that three I.C.U. nurses were disciplined for recognizing an unsafe situation and responding in a sensible manner. I wonder what the outcome would have been that night, Feb. 27, 1976 at Mount Sinai Hospital had a catastrophe occurred? Would the nurses involved have been disciplined or even sued for not recogni7ing an unsafe workload? Let"s face it. right now, in 1979. nurses are in a "Catch 22" situation. -Mary C. Watsoll. R.N., Stell'art, B.C. Looking back As a writer and researcher of insignia, I found the March 1978 cover illustrating school pins most informative. An organization which looks after the wellbeing of its members and looks to the traditions of the past for inspiration is indeed unique these days. I was able to identify several pins in my collection Sep1ember 111711 II The Canadian Nurse invites your letters. All correspondence is subject to editing and must be signed, although the author s name may be withheld on request. and may include them in a future article. -EirallHarris, Molltreal. Quebec. Information sharing I am about to begin a study into "Humall Semalitv: The Effect of LOlIg-T erm H ospitali::atioll of Premature Babies Oil the Sexllal Relatiollship of the Parellts dllrill[;: that Time" and would dppreciate correspondence from health care professionals whose field is related to this area. -L.D. ClOURh, R.N., B.S.N..20I, 3309 DUllbarSt., Vt/1lcoll\'er. B.C.. V6S 2B9. Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE. QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth, and more information. please clip this coupon and mail today. Name .................................................... (block letIens) Address ................................................... City................................... .Postal Code....... Your graduation school .................................... Team up with Mosby to make sure your students get the most current and authoritative nursing texts. A New Book FUNDAMENTALS OF NURSING PRACTICE: Concepts, Roles, and Functions ( Two widely respected nursing authors collaborate to provide a umque Introduction to nursing fundamentals Emphasizinq holistic care. their book. . ," C" I r .... tl '""' h . IP ., 6 . . . . . New 14th Edition Fundamentals of nursing practice By Fay LOUIse Bower, R N., F.A.A N. and Em Olivia Bevis R.N.. M.A., F.A.A.N.; 8 contributors. January. 1979.614 pages. 391 illustrations. Price, $18 00 ( OM I p.re;. ft(JI. t ^..P.. ... IIO\H PHARMACOLOGY IN NURSING The latest edition of this classIc will help you gUide your students In provIding ratIonal and optimal drug therapy. Clear and complete diScussions focus on basic mechamsms of drug action Indications contraindications, toxicity, side effects. and safe therapeutic dosage range Highlights In this new edition Include. . . ...... A 4\-....+ , ; · _ "''''$ O .. - Oe-..".., ..:- .....- ........ .. - .. .. -.-- -.-. .,.. .- -- - - . . - --: .... .. .. ... . *<" .# .. .;' . .II By Betty S. Bergersen. R.N Ed.D; In consultation with Andres Goth. M.D. January. 1979 792 pages 100 illustrations Price, $21 75. Jrd Editl.Jn NUTRITION AND DIET THERAPY Smce publication of the hrst edltl >n this tØxt t""lS been a leader m its field This current edition contmues - and exceeds -thattradltion of excellence. It focuses on the role of nutrition m pubhc health, in the bastc health care specialties. and i, the clinical management of disease - allm the context of human needs Students will be parllcularly interested in these new Items. . . A <' <::> <::> . By Sue Rodwell Williams. M.P.H. M.R Ed.. Ph.D. 1977 741 pages. 134 illustrations Price, $21 75. New 2nd Edition CLINICAL IMPLICATIONS OF LABORATORY TESTS When students ask questions on the sigmficance of laboratory test results, offer them this concise resource Usmg an effective, step-by-step approach. it first exammes the routine multisystem screening panels - routine urinalysis and hematology screening and sequential muiliple analyzer tests Subsequent chapters focus on evaluative and specific tests of suspected disease entities. Throughout. the authors emphasize physiological implications. variations. and interrelationships of laboratory values New features. . , , A New Book MEDICAL-SURGICAL NURSING: Concepts and Clinical Practice . N Umtmg the benefits of both a conceptual and a systems approach. this new text will be the best choice for your students' The authors have organized information in a way to make It easily accessible and have emphasized total patient care throughout. A few key features of this important text are' . nrr::l /'oJ thlr hl::!o fr CI\ ,.-I", . . By Sarko M. Tllkian. M.D.' Mary Boudreau Conover. R.N . B.S.N.Ed.: and Ara G. Tilkian MD.. F A C.C January. 1979 334 pages. 45 illustrations Price. $12.00. . N . . 11 m- Ir III By Wilma J. Phipps. R.N.; Barbara C. Long. M.S.N.; and Nancy Fugate Woods R.N_ Ph.D. March. 1979. 1,648 pages. 731 illustrations Price. $30 00. ! \ . ,\, " " \ ."'.... , '-\ · ....... , t " ' ...... :: .: w -" S. / <- / '.- C" # / IVIOSBV TIMES MI C A New Book BASIC PATHOPHYSIOLOGY: A Conceptual Approach The authors of this useful new text have organized the vast field of pathophysiology into major conceptual areas Your students will study various disease entities as they relate to such concepts as cellular deviation. body defenses physical and chemical equilibrium. nutntlonal balance. reproductive and endocrine integrity and structural and motor integrity. Specific noteworthy diScuSSions Investigate: . Immunopathology . aging as a genetic process. . atherosclerosIs: . diabetes and obesity . Immune viral orgamsms of human cancer Each chapter begins with learning objectives which can be used to aid the student in self-evaluation. By Maureen E. Groêr. R.N. and Maureen E. Shekleton. R.N. March. 1979 534 pages, 423 illustrations. Price, $1925. HEALTH ASSESSMENT Written by nurses for nurses. this well-illustrated guide provides practical methods for obtaining a complete history and performing a thorough physical examination. Students will especially benefit from discussions which: . detail beneficialtechmques for appraising client function. . examine nu!ntlonal assessment sleep-activity patterns and the use of climcallaboratory skills By Lois Malasanos. R.N. Ph.D.; Violet Barkauskas. R.N..C.N.M.. M.P.H.: Munel Moss. R.N.. M.A.: and Kathryn Stoltenberg-Allen R.N.. M.S.N. 1977 538 pages. 769 illustrations. Price. $26.00 A New Book NURSING CARE OF INFANTS AND CHILDREN Using a systems approach. this new book provides a comprehensive. practical look at pediatnc nursing The authors not only examine care of the ill or disabled child. but also stress promoting the health of the well child Among the highlights you'll find: . pertinent guidelines for action . a distnbutive nursing care approach . lab data and pharmacology information. . emphasIs on and gUidelines for communicating with children and their families: . an appendix of normal values and assessment tools By Lucille F. Whaley. R.N., M.S. and Donna L. Wong. R.N., MN.. P.N.P.: with 5 contributors March, 1979. 1,734 pages. 746 illustrations. Price. $26.50. Team up with Mosby. Basic pathophysiology- A CONCEPTUAL API na Groer and 81M o o C$ MATERNITY CARE: The Nurse and The Family Both contemporary and humanistic in approach. this important volume can help the student function more effectively as a maternity nurse in tOday's changing society. Following the chronologic order of childbirth. it discusses the biopsychosocial aspects of human sexuality. then proceeds to family planning. pregnancy. interferences with normal pregnancy. labor and its complications. the post-partum period. and both normal and high-risk infants. Throughout. the authors. · integrate diagnostic. therapeutic. and educational objectives . present intervention plans. · combine clinical and psychosocial aspects. Timely discussions explore such key topics as genetics. legal factors fathering. and P.O.M.R By Margaret Duncan Jensen. R.N.. M.S.: Ralph C. Bensen. M.D.: and Irene M. Bobak. R.N.. M.S.: with 2 contributors. 1977. 784 pages 684 illustrations. Price. $24.00. CHILD HEALTH MAINTENANCE: Concepts in Family-Centered Care Students will benpfit from the intt>gr.. on c. a r( approach a problem-solvrng framework an1 a f' on the holisllc person of the Child, rn this new edlTlOl an excltrng text It reflects contemporary advances rn dlagnc. , and quality assurance as It examines such topics as problem- - single parent families, care of the terminally III child. high I k infants, nursing assessment. and specIfic health problems Th new edition also offers: . . . . . By Peggy L. Chrnn. R.N.. Ph.D. March. 1979 948 pages, 377 illustrations. Price. $2400 New 2nd Edition CHILD HEALTH MAINTENANCE: A Guide to Clinical Assessment This concise text serves as both a student-oriented learnrng guide for comprehensive health assessment and as a source of information for effective pediatric care. The authors present a wealth of information on developmental differences observed from bIrth through adolescence - indIcating possIble deviations and their health care Implications This edition also incorporates these valuable new insights: · a- 'h'Hltatlve rhapter on as-essment of learnrng. thought I and rnl er (.Jml-etencles · ad, , ed chapter on norms and standards for nursrng -, and rnt"""entlon providrng normal arL wtt Je ment charts recommended schedules for or ".....r zatlon é'nd ..Iboratory procedures. · a nr hdptcr -- M----"l1ent tools and case audit gUldes- .10 una C1Jldelines for famll rnfant child and play Dccrner.. By Peggy L. Chinn, R.N., Ph.D. and Cynthia J. Leitch, R N.. Ph.D. March. 1979 166 pages. 24 illustrations. Price, $9 75. " ",0 " , A' r " , '- ,. " ., Child hea h malrrtenance , . " . . , A New Book PRINCIPLES AND PRACTICE OF PSYCHIATRIC NURSING Using a nursrng-orlented conceptual approach to psychiatric nursing, this text describes man.s adaptation to Illness. and Identifies nursrng diagnoses and specific nursrng mterventions · Part I is organized according to specific nursrng diagnoses - anxiety. disruption rn the Communication process. and grief. for example · Part II examines various therapeutic modalities presently rn use: · throughout the authors stress nursmg rntervenllons and the application of the nursrng process By Gail Wiscarz Stuart. R.N.. M.S., C.S.; and Sandra J. Sundeen, R.N.. M.S.: with 15 contributors. April, 1979.656 pages, 24 illustrations Price. $20.50 A New Book COMMUNITY HEALTH CARE AND THE NURSING PROCESS Help your students stay informed of the exciting new changes in community health nursmg with this comprehensive text. Its timely discussions provide a holistic view of human development by stressrng three basic concepts. the health- Illness continuum. humankmd as an open system that always relates to and interacts with ItS environment. and the effects of various situations, health problems. and stressors on the health and development of the individual family. and community. Student-oriented features Include. · an eclectic approach to community nursmg: · up-to-date diScussions - both m concept and content. · fascinatrng case studies to develop the thinkmg process and stimulate the ability to make creative Judgments: · the insights of noted contributors. By Margot Joan Fromer B.S., M.A.; with 7 contributors January. 1979 484 pages, 110 illustrations Price. $1800 IVIOSBV TIMES MIRRDR THE C. V. MOSBY COMPANY. L TO. 86 NORTHLINE ROAO TORONTO, ONTARIO M4B 3E5 Pnces subject to change A90735 14 Seplember 1871 The Centldl.n Nur.. YOU AND THE LAW Where does the nurse's responsibility begin and end in caring for a patient's belongings? Corinne Sklar Case stud) Fifty-five-year-old Mr. Evans is admined to your floor in late March with a diagnosis of pulmonary emphysema. 0,: admission he wears, in addition to his ordinary st1'f!et clothing, a heavy hooded winter jacket, ski boots and an expensive new watch. Some friends who come to visit bring him a new bathrobe and a pair of slippers. His doughier decides that it would be safer to take his watch home; since tire weather is turning milder, she also removes hisjacket and ski boots and substitutes a lighter raincoat and d1'f!sS shoesforthem. As Mr. Evans' nurse you mayor may not be aware of all these changes. Should you be? What is the legal position ofthe hospital and the nursing staff in the care of the patient's belongings? Is it the nurse's responsibility to catalogue each item of the patient's clothing an"d personal belongings on admission and thereafter to police each itém?The responsibility of a hospital and its staff may seem self-ev1dent when the patient is unconscious or on his way to the O.R. but, typ!cally, the patient is conscious, eventually ambulatory and shanng ward accommodation with others. Each patient is admitted ånd discharged as his condition dictates. The frequency of patie'1\ moves either into, within or out of the hospital may vary fro'JI week to week, from day to day, from shift to shift. The " increased flexibility of visiting hours adds to the number of individuals who have access to patients and their belongings. Is it the responsibility of the nurse to ensure that the nature and quantity of the patient's belongings upon admission remains unchanged throughout the period of hospitalization? Must hospital permission be granted each time the nature and/or quantity of the patient's belongings changes? Statutes and regulations governing public hospitals generally do not specify the care to be accorded the patient's belongings: the aim and purpose of such legislation is to regulate;: hospitals and those delivering care therein to promote and safeguard the health, safety and well-being ofthose seeking care and treatment within. Hospitals are responsible for the treatment, care, supervision and maintenance ofthe patient. Implied within this undertaking is the responsibility to exercise care with respect to the patient's belongings. The hospital carries out its duties toward the patient either directly thro h the hospital corporation, for example by hiring of staff, or through the services of its employees, servants and agents. It is responsible in law for the negligence of its employees, servants or agents acting within the scope of their employment (doctrine of "respondeat superior" or "let the master answer"). The failure of nurses to exercise due care in the care oj patient's belongings might result in personal liability and/or liability to the hospital-.employer. There are two aspects of this problem to consider: · belongings delivered to the staffby the patient or his representative ' . . belongings remaining in the patient's possession. Let us consider the ramifications of each. Staff "control" of patient possessions . patient 1\ gives the admitting nurse his wallet containing credit cards and $90.00, his new watch and his keys, all for safekeeping until his wife arrives. . . patient B is going to the O.R. for neurosurgery; she Ives the nurse her gold earrings, her watch, her engagement nng, her glasses and her dentures. . Timmy's mother asks the nurse to put away his battery-operated game until he has fully recovered from the effects of the anesthetic; since it is his prized possession, he'll want it immediately on waking. In each of the foregoing situations, when the nurse takes the patient's belongings for safekeeping, the legal relationship of bailment has occurred: temporarily, the owner has delivered up possession of his property to the custody and control of another. The person delivering up the goods is called the "bailor" while the person with whom the goods are deposited is called the "bailee". The bailment which occurs in the hospital setting is a "gratuitous" bailment, that is, a bailment for which there is no compensation payable to the bailee. The goods ofthe bailor are to be returned to him either upon his request or in accordance with his instructions at the time the bailment was created. However, in law there are several other categories of bailment. A familiar bailment situation is that which occurs when you. as bailor, deliver your car to a parking lot attendant; the bailee gives you a ticket and then drives away to park your car. A bailment has been created. On your return, you hand over your parking ticket and pay your fee; the bailee delivers your car to you and the bailment is terminated. . In any bailment, the duty of the bailee is to take due care of the bailor's property while under his care and control. The bailee is answerable for any loss or damage to the property o( the bailor while the property is in the hands of the bailee if such , loss or damage results from his neglect or default. If the bailee can show that such loss or damage did not occur as a result of his default or neglect then no liability will result. The onus lies with the bailee because he has the knowledge of what has happened while the goods were in his possession. '. Where the bailment is gratuitous, usually gross neglIgence on the part of the bailee must be proved although in the view of Fleming, the modem approach to such cases would tequire proof of negligence and not gross negligence on the part of the bailee. The standard of care required in the case of bailment is the usual standard required in tort (civil) cases, that is, the common law standard of the reasonable prudent perso . This standard is adjusted to consider the individual-circumstances oLthe case. Note that this is not the usual higher standard required ofthe professional. i.e. the standard of the reasonable prudent nurse. Few such cases involving hospitals and their staff exist in Canadian law. The ones that do are not recent and, in their results, tend to absolve the hospital and staff ofresponsibility. . In a 1905 case , lerÛno v Toronto General Hospital Trustees,. the plaintiff alleged that $160.00 had been taken from him while he was a patient in the hospital. His claim failed. The court found that the evidence of the defendants contradicted the evidence of the plaintiff and indicated that no money was taken from him. During his seven-day hospitalization, the plaintiff never once referred to this money nor asked for it. . In a 1921 case,2 the jury's decision in favor of the plaintiff was overturned by the appellate court thereby absolving the hospital ofIiability. The plaintiff claimed that the $461.00 he had with him when he was admitted to the hospital with severe inj uries as a result of an accident was lost as a result of the hospital's failure to safeguard his money. . The majority of the court held that there was no findmg that anyone connected with the hospital had taken charge of the plaintiff's money, clothes or purse. The Canedlan NUrH However, in dissent, Magee J .A. said: 3 It was said that the plaintiff was treated gratuitously at the hospital; but the trustees receÜ'e large grants of public money for the purposes of the hospital, which must include taf...ing due care of patients brought in, perhaps unconscious or suffering, and unable to taf...e charge of their own property. The hospital trustees cannot of course be held responsible for thefts when prop r care has been taf...en: but even if they are only gratuitous bailees. remonable care should be taken of the patients' property; and, if the stor)' of the plaintiff, whom the jury seemed to ha\'e belie\'ed. were true, there mustha\'e been e\'en gross negligence in a system which did not pro\'ide for due care or in the carrying out of the S\'stem. . In a 1952 case, 4 the patient sued for loss of a ring valued at $1,400. I ntroduced into evidence was a document signed by the patient's wife on his behalf stating that the ring was left at the patient's own risk. However, the case turned on its specific facts rather than the words of the document. The evidence was that the patient wore his ring until one evening when, feeling dizzy and increa ingly ill, he gave the ring to the nurse. The ring was returned to him the next morning and he wore it all that day until evening wherl he was given an injection and fell asleep. At that time. the ring was on his finger: when he awoke, the ring was gone. The court found that no bailment was violated because none had been established. The hospital did not receive the ring for safekeeping. The trial judge found that the patient was in a ward with seven other patienrs and there were a number of possibilities as to what had become of the ring. In fact, the patient had clearly stated that in his view, the safest place for the ring was on his finger. There was no reason for the staff to again remove the ring for safekeeping. Based on these facts, the plaintiffs case was dismissed. - Where the patient delivers up possession of his valuables to the hospital staff, reasonable care must be exercised to safeguard the patient's property in order to fulfill the legal requirements ofthe bailment created. Belongings remaining in the patients' possession The King case supra is an example of a court decision where it was found that the patient had retained possession of the valuable in questionfWlTere the patient retains possession of his belongings, bailmenhs not create(l1However, this does not mean that there is no respon ibilirYon the part of the hospital. .....Thellospital remains responsible whére there is evidence to support a finding that the property was taken charge of by a nurse or other hospital employee. {n giving care to patients, nurses periodically handle the patient's belongings placing them in drawers or lockers provided by the hospital. While doing so, the nurse must ex'=rcise reaspnable care. As stated earlier, the standard of care to which the nurse is held is that of the reasonable and prudent person..- A standard item which patients retain and for which due care by nurses should be exercised is dentures. Dentures should be placed in a transpare_nt container. The container should be clearly and coñspìcuously labelled to avoid loss, damage or misuse. Carelessly placing dentures in tissue or a towel could result in their loss or damage for which the staff and hospital might be found liable. Patients are admitted to hospital with their belongings. It is best to encouràge them to retain a minimum of personal effects in their possession while hospitalized. Families should be encouraged to assume custody of valuables and sums of money on admission so that such items do not remain on the ward. Prior to surgery or where the patient asks that the staff lock up valuables, the usual nursing procedures should be followed. The items placed in custody should be clearly listed on the envelope and the list should be dated and signed by the patient and the nurse. On return of items to the patient, the patient should acknowledge in writing receipt of his valuables; it would be prudent to check off the list of items and date of their return in the presence of the patient. The soft touch for tender tissue 100 T A! e: Pi:: CKS* ao.1 ''1 Pre-Moistened Pads For hemorrhoids, feminine hygiene, piles and personal itching problems. fI.,i.'....tti.'. btri.".t DIN 443646 Aeg.s!ered traaemar1< d Parke DaVIS 8. con-c"ar J Parke DaVIS & Company LId . reglstereá u p' ITa Relieve postpartum and postsurgical itching and burning with Tucks. PARKE-DAVIS 11 September 1171 The C.n-.ll.n Nur.. 'llIE A' A PE{;O\ A PEELI:\G afe Effective "The Anna Pegova Peeling"is renowned for its effectiveness on rejuvenescence, ocne, and ofher related skin problems. It is fhe only internationolly recognized peeling and is presently being morketed throughout Europe. In Fronce, in 1965, this product won the Gold Cup from Le Comité du Bon Goût François. Fronce Clavef, R.N. (Hôtel Dieu - Chicoutimi, affiliate of Laval University) has the exclusive rights for this formula in Conada. Studio Clavet Inc., "ho has been serving Conadians far yeors in Monfreal, is currently recruifing nurses interested In increasing their income by becoming owners of a sfudio. Studio Clovet Inc. hos qualified professionols who are ready to troin you fo become specialists In fhis field. If you have approximotely 7 yeors nursing experience ond wish to discover new horizons, please contacf: Studio Clavet Inc. 1415 Saint - Hubert Montreal Quebec, H2L 31'9 Tel.: 1-514, 845-3046 We ore a member of the Better Business Bureau. SPHYGMOMANOMETERS TYCOS-TAYLOA I STETHOSCOPES \ Famous brand-name Ina.rument trusted by medica' guÁ':. .ÓST';:E olr ds O;' IY colours E.cepllona.aound nan.ml..lon AdJua.ablelight. ? i':? : d' t:J þ j; No 7Q 123_115 N. , SINGLE-HEAD TYPE Aa abovlI . bul wl1hout bell Same large 'l. '"I l!g';:Õ f OhDi .;:W:t8 c : : , :; :O .' but nOI Tyeas brand Same 2 year guarant.. Compla'e SI' ;I :, ';r r:80ml II; P.. Dual-Hatld No I.D 117.15 N. MERCURY TYPE. The uillma.e In accur.cy. Folda Into light but rugged melal ca.e. H.....y duly Velcro cull and Inllallon .ySlem 151.15 Nch. -===--=- , LISTER SANDAOE SCISSORS Manulaclured 01 hneSI alNI A mu.' tor 8YSry nuras. No. 898, 3'h" No. ð8i, 4'h' No. 700, 5'h . No. 102. n . (' H:::::b FORCEPS (K.n,.) Ideal lor clampmg g' z : " ue: . Slalnle.s sla.I, lock:ing Iyp., 5'h . long P420 sHalghl &.4.11 P422 curved 14.11 : :g I:n :e endable 10 . )'Nr guarenl" 01 accuracy to _ , 3 m m No slop-pin 10 hide .... errors Handsome zippered caa. to lit your pockef. 128.98 complet.. NUßSES PENLIGHT. Power1ul beam lorexamlnahon 01 Ihroal. elc Durable stamlesa-sleel case Wllh pockel chp Made In U.S A. No. 28 15.98 complele with Mlle"e.. Economy model wllh chromed bras. ca.. No 29 12.ei. NUßSES WHITE CA' CLIPS. Made In Canada 'or Canadian nuraes Slror;a .Ieel bobby pins with nylon r 2 :r: a sJ 01 15. 2. sin 11.00 / urd I : e:. c n C:n C; :IYo ':f. u . black:, blua or gr..n No 32 12.28 Neh. In transferring patients within the hospital, staff should exercise due care in ensuring that all of the patient's personal effects accompany him. Where the patient is unconscious or unable to assume any responsibility for his personal belongings. the staff should make every effort to see that any valuables are protected. While hospitals are not insurers of the belongings of patients. they are responsible for loss or damage when caused by tfieir negligence. The care that is required is that which would be ordinarily taken in similar circumstances. The want of such care by the hospital staff in the performance of their duties may result in a finding of liability. * References I (l905).50.W.R. p.76 (CoCt). 2 Gumina ". Toronto General Hospital Trustees. (1921), 19 O. W.N. p.547 (CA.) 3 Ibid., p.548. 4 King v. The Sisters of St. Joseph of the Diocese of Hamilton, [1952]O.W.N. p.345. *References not verified in CNA Library .... ..... "You and the law" is a regular column that appears each month in The Canadian Nurse and L'infirmière canadienne. Author Corinne L. Sklar is a nurse and recent graduate of the University ofT oronto Faculty of Law. ... *7 ,.."", " NURSES CAP TACS Gold plaled, hold. your cap ? Slrlpe IIrmly in placa. Non- Iwlat ,..tura. No. 301 RN" . wllh Caducaus or No 304 plain Caducaus 13.115/ pro 3' ENAMELLED PINS. V st..uU'ully d..lgned 10 shOw your prol.salonal alatua. Jewelry qualll,. In "MYy gOld . fI;' pial.. Wllh salely claap. No 501 =':7:: := =::: No 502 Prsctlul Nur.. t-!URSES EAA'UNOS. For pierced No 503 Nu,...'s Akie ears Calnly Caduceua In gold plale AnSl.SII-.ch. wllh gold Iilled poslll ØNulilully .jf!;f g," 00.... No. 325 ""'0' P'. ; ..j31 ffil SCULPTURED CADUCEUS .. l' ed 10 your prole.slonal leners. HNYII)' . p e ot 'H :I I . =h N, No. 401 MEMO-TIMER. Time nOI packs. nNI lamps, psr1l meter. Aemember 10 : : I :: ( d! 'a: : 'If.. ti!i a U :"; II:O . Key rln" Swl... ".* r OTOSCOPE SET. Oneol Germany.elinesllnstrumenl. E_ceptionalilluminalion. power1ul magnllylng lens. 3 , . ''':' \1IÞ , - ;p _ ' _.:' ._, ': :: -:'Ii : :: :1;' No. 3OV. l1li.15 NCti. No 30VA As aboye but In pl..llc pouch 158.15 N. II ð ' 1 f"} DEL y , atalns or 'rlyed edges. 3 companmenla lor pans. ecl..or., etc., plua change pock:et and key chain While call Plaslahlde \. No. 505 11.IS Nch. MEASURING TAPE In alrong pl.sllc caBe Puah bullen lor .prtn , relurn Made 01 durab e . e:"e I u;: c:., 7 re....r.. &.4.115 Nch. - NOTE: WE SERVICE AND STOCK SPARE PARTS FOR ALL ITEMS. CAP STRIPES Sell edh.aiva Iype, r.mowaDle and r.usable No 522 flED, No 520 BLACK, No 521 BLUE, No 523 GREY AII15'1.1:" i.e;: .red (U) 12 slrlpas par card. ENGRAVED NAME-PINS IN 4 SMART STYLES - SIX DIFFERENT COLOURS... :.::i:.'::: :.; ; ;; ;"E.;I ; . .. ... .... ............. ..... ........ .... ....................... ......... .................. ... ;Ê ; .E U .;..; ;;.:L. ;P.L . .....;L.E:..; ... : FILL IN LETTERING POBOX 728-5, BROCKVILLE. ONT KeV V8 PRINT I : I:: : : 1allln. _ _ _ _ _ ____________ _ _ _ _____________ 2nd Iina _ _ _ - - - - - - - -- - - - - - - - -- - -- Øa au,. 10 encloae ,.our name and add,.sa . PLEASE PRINT AU. PINS HAVE BACKGROUND LETTERS PRICES 1 PIN 2 PINS Ouant Item Colour Pnca Amounl : TYPE SAFElY PIN8ACIC COLOUR (Same nama) or.lze SOLID PLEXIGLASS...Molded from solid Plexlgla. Mother black I line 13.21 15.2' : ; -:'iy a u . ot: :g ,. 01 blue 'enars Paarl ,eO 2 line &.4.11 IB.II : green leUers r A .g I g: hb :g:fnl: III , Whlle_ Black lime 12.11 13.72 8'.ck leUers . cot'1trasUng Colour core Bevelled edges match I Blue ""I White 2I1n.. , 13.13 1532 letlers Salin IInlah Excellenl value allhls prlca leUers ONTARIO RESIDENTS ADD 7% TAX : 1- ADD SOc HANDliNG CHARGE : METAL FRAMED...Slmller 10 abOW'e but mounled In 1 line 12.11 &.4.11 IF LESS THAN SID pollahed metallrame wllh rounded edgel! and - Gold 0 whlle- Blsck leners C.O.D ORDER ADD 12 00 : cornera Engraved Ina.n can be changed or u Sliver 0 : k ro Whtte 21mea NO C.O.D. ORDERS FOR NAME.,-PINS replaced. Our aman...and n..'esl d..lgn leUers 13.11 1B.41 TOTAL ENCLOSED MO CHEOUE lCASH : II e g t.il : r : 7v i:v: ru: : I I Gold o black 1 line 13.11 15.11 blue lellers ASk ABOUT OUIII GENEAOUS OUANTITY DISCOUNTS FO,," : permanence and lilled wllh your choice Dllaquer [ SII\'8r ,eO 2 lines ..... 17... CLASS GIFTS. GROUP PUACHASES. FUND IIIAISINO ETC COlour Corner. and edges amoolhly rounded S.Un gr..n lenera : smoolh IInlsh USE A SEPARATE SHEET OF PAPER IF NECESSARY PATRICIA BROWN lEAD ...... - ............................................ ... ...................... .................. ................... ........................... .................. SPECIAL GROUP DISCOUNT OFFER FOR THE CANADIAN NURSE READERS --- i i i TIlT i --- \ ( 1IIIIIIIIIlÏIITffi .r i N IØ c:a. A. 111 111 I II 11111 It .... .. \ CIJ .. f f if iii = 0' :3. :So i i I II t Jr Jrf- :I a, f .. .. · e. .. ;: " '" :;: .. . ' , .=. - " You and your . family are invited to . -- sample the most readable, r ... most understandable " . encyclopaedia ever created. THE NEW BRITANNICA 3... a C0l11plete Honle Learning Centre You've heard about - read about - perhaps even seen the revolutionary New Britannica 3, more than a new encyclopaedia, a complete home learning centre you and your family can use. 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OUTLINE OF KNOWLEDGE A one volume outline of all man's knowledge and your guide to the use of the all-new Britannica 3. With Britannica 3 in your home, children's homework gets done better, faster; parents find it easier to "look things up" to learn more about almost anything. Britannica 3 ownership will also give you access to the Britannica Instant Research Service - specialized reports on virtually any subject you may require. By the terms of this offer you can obtain this magnificent set at a reduced price, a price lower than that available to any individual purchaser. FILL IN AND MAIL THE POSTAGE PAID REPLY CARD FOR A FREE FULL-COLOUR PREVIEW BOOKLET RIGHT NOW. If the reply card is detached, please write to Bntannica Special Group Offer, 2 Bloor Street West, Suite 1100, Toronto, Ontario M4W 3Jl I i "- "J , . \, ' '.ii ''\ ........ ( \, \ , , \. - ,- '(r - ...... .............. 18 Seplember 1171 The c.n-.llen Nurse calendar September Annual General Meeting of the Corporation of Nurses of the Montreal District. To be held at the Sheraton Mont-Royal Hotel, Montreal, Que., at 19:30 hours on Sept. 26, 1979. Contact:C.N.M.D., 666 West Sherbrooke St., Room 1004, Montreal, Que., H3A /E7. Ontario Assembly of Emergency Care 2nd Annual Meeting to be held at the Skyline Hotel. Toronto on Sept. 23-26,1979. Contact: R.H.L. Galliver, M.D., Dept. of Emergency Medicine, St. Joseph's Hospital, 30 The Queensway, Toronto, M6R IB5. October Annual Meeting of the Nurse's Association of the American College of Obstetricians and Gynecologists (District V) to be held October 17-20, 1979 at the Skyline Hotel, Ottawa. (Conjoint meeting with ACOG). Theme: Women as health care consumers, a change and a challenge. Contact: Donna Barrett, 1/71 Ambleside Dr., Apt. 2107, Ottawa, Ontario, K2B 8E/. Dynamics of Critical Care 1979. A two-day seminar on metabolic emergencies and neurological emergencies to be held Oct. 1-2, 1979 at the Holiday Inn, Downtown Toronto. Contact: Toronto fJ,,(ftDl efJ." + 1t ChapterAACN, P.O. Box 37, Postal Station "Z", Toronto, Ontario, M5N 2Z3. Nurse Practitioners Association of Ontario Fall Meeting to be held at the Ramada Inn, Airport Rd., on Oct. 13, 1979. Guest speaker: Dr. Josephine Flaherty. Contact: NPAO, Ruth Nodn'edt, 29 - 1055 ShawnmarrRd., Mississauga, Ont., L5H 3V2. Call for papers for the 1980 Conference of the Association for the Care of Children in Hospitals to be held in Dallas, Texas. Proposals for papers are welcome until Oct. I. 1979 in the following areas: adolescent care, ambulatory care. child life. environment. infant care, parents and families. professional development, research. Mail proposals to: /980 ACCH Conference Office, Children's Medical Center, /935 Amelia, Dallas, Texas, 75235. November CNA National Forum on Nursing Education. To be held Nov.13-15,1979attheSkyline Hotel, Ottawa. Theme: The nature of nursing education. Focus: Degree or diploma? Open to all registered nurses to a maximum of 300. Contact: The Canadian Nurses Association, 50 The Driveway, Ottawa, Ont., K2P /E2. THE LAST THING HE NEEDS IS GAS. When a patient can't move around, gas can be a problem, and a painful one at that. So for pa- tients who are immobile Ù --- -. following surgery or for I Oval ' post-cholecystectomy patients, give them extra I strength OVOL 80 mg, the i chewable antiflatulent ' tablets that work fast to I 51........ relieve trapped gas and bloating. 80 ForGas Centre IesGaz tQ'"Ø 8HQBJ}.fR rPAAil lfE!!J Pro u{ t monoftraph available on request. ] r Your patient may enjoy being pregnant. But she certainly doesn't enjoy the constipation that often goes with it! She'll thank you for recommending a laxative that works slowly, gently and effectively. That's the Metamucil way. . u" I = -= = .I . --=- E ..J OVOI@80mg Tablets OVOI@40mg Tablets Ovol@ Drops Antlflatulent Simethicone INDICATIONS OVOl IS indicated to relieve bloating. flatulence and other symptoms caused by gas retention including aerophagia and infant colic. CONTRAINDICATIONS None reported. PRECAUTIONS Protect OVOl DROPS from freezing. ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOl80 mg TABLETS Simethicone 80 mg OVOl4O mg TABLETS Simethicone 40 mg Adults: One chewable tablel between meals as required. OVOl DROPS Simethicone (in a peppermint flavoured base) 40 mg/ml Infants: OnE -quarter to one-half ml as required. May be added 10 formula or given directly from dropper. e HQB R The c.n-.ll.n Nur.. Metamucil is madp from (gluten-free) grain, providing fiber that produces soft, fully formed stools to promote regular bowel function. Available as a powder (low In sodlUm) and a lemon-lime flavourpd Instant MIX (low In calories). Why not gIve your patients our helpful booklet about constipation? Seplember 1.71 1. MetaJnbcll@ The laxative most recommen cians. Looking for more control over your nursing career? Medical Per- sonnel Pool can give it to you. Choice of assignments, flexible hours, staff development programs. But don't think you have to sacrifice for it. MPP offers excellent insurance coverage, RN consulta- tion, and the freedom to choose your oo..vn hours. Medical Personnel Pool is an established leader in the provision of qualified, experienced, supple- e. mental nursing personnel with over 130 offices coast to coast in Canada and the U.S. We understand your needs. Contact your nearest MPP office today. We'd like to tell you the whole story. An International Nursing Service You'll find us listed in the white pages. 20 Seplember 1878 The c.n-.llen Nur.. CF children need lots of pills, Or they become very ill. Little children, a little child, Deserves to live longer than a little while. Diseases, pain and sorrow, Let's hope for a cure tomorrow. Kevin D. was 15 when he wrote this verse. When he was three, after recurrent bouts of damaging respiratory infection, his parents took him to a doctor who diagnosed cystic fibrosis. Kevin has lived since then "one breath at a time", constantly struggling to keep his lungs free of tenacious life-threatening mucus. Over the years, Kevin has been a frequent visitor to the Hospital for Sick Children in Toronto where he has been treated as both an inpatient and clinic patient. The HSC clinic, one of25 such clinics in Canada, follows a total of 530 CF patients, including between 20 and 30 newly diagnosed patients annually. The program that the nursing staff on the chest ward in this hospital has developed to meet the special needs ofCF children and their families is a multi-disciplinary approach that stresses independence and self-reliance. The disease CF is an inherited generalized disorder which affects the exocrine glands of the body. Non-mucus producing glands affected are the sweat glands which produce secretions abnollTlally high in sodium chloride. The mucus-producing glands altered in CF are found in the lungs, pancreas, liver, nasal sinuses and urogenital tract. In CF the mucus produced by these glands is abnollTlally thick and sticky and collects in the organs.causing them to expand or hypertrophy. Some glands may be more affected than others; some patients with CF may be more seriously ill than others. The lung is the organ most profoundly affected by cystic fibrosis. The cilia do not function properly making it very difficult for the patient to cough up the excess mucus. This condition creates a very good breeding ground for bacteria, usually staph aureus or psëudomonas. The CF child easily develops lung infections which lead to areas of inflammation and bronchiectasis. The damaged areas become scarred and fibrotic, which decreases gaseous exchange and gradually compromises pulmonary function. CF patients develop barrel chests, clubbed fingers, and they tend to exhibit use of accessory muscles in respiration. , e ea a e . t t A family teaching program for children with cystic fibrosis. Cheryl Ann Sams The nasal sinuses too become obstructed with mucus and are prone to the development of nasal polyps. The pancreas is involved in about 85 per cent of cystics. The p'ancreas produces trypsin, lipase, and amylase but in CF the ducts which transport these enzymes become blocked with mucus and do not pellTlit the flow into the intestine to aid in digestion offood. The pancreas as a result becomes atrophied and fibrotic, and the CF patient has great difficulty in digesting fat and proteins. Fat-soluble vitamins are not absorbed well- the patients become thin and malnourished. Similarly, in the liver the biliary ducts can become blocked and the secretion of bile salts, which are a factor in fat and protein digestion, is prevented. In addition, the liver is unable to store the fat soluble vitamins A, E, D, and K. This blockage can lead to tissue destruction and cirrhosis. Unless they are severely affected by the disease most CF patients have some changes at puberty. Females have a . greater incidence of cervical polyps, and some have lowered fertility, but generally they can reproduce normally. There are now six CF mothers in the clinic at the Hospital for Sick Children, and they all have had nOllTlal children; the children, however, are all carriers of the disease. Of male CF patients, 99 per cent are sterile because they are born with incomplete vas deferens, seminal vesicles and epididymis. Cystic fibrosis usually affects Caucasian children, but the underlying cause of the disease's many complic'itions is not known. Occasionally there will be a CF child born to a family of another race, but this is not common. One out of every 3500 births is a CF child; the disease is - inherited as a Mendelian recessive trait, and both the parents of a CF child must carry the CF gene. The carrier rate in the general population is I :20 but in spite of the tremendous amount of research being done in this area, it is still not possible to identify carriers of the disease. Ifboth parents are carriers, there is a 1:4 chance of their producing a CF child. At the present time there is no way to predict in pregnancy whether or not the child will be afflicted. Diagnosis In some instances CF can still be difficult to diagnose. In very early childhood the disease can mimic other conditions- celiac disease, for example, or bronchitis and asthma. Newborns will sometimes present with meconium ileus and rectal prolapse. The child's skin may have a salty taste or he may have recurrent respiratory infections, fail to thrive, or have large foul-smelling floating stools (steatorrhea). Initial screening forCF is usually a sweat chloride test which is considered to be abnormal above 60 mEq/litre. The amount offat being excreted in the stool can be measured and duodenal contents tested for the presence of pancreatic enzymes. Radiological examination for changes in the lungs is yet another indicator. The age at which CF is diagnosed varies: newborns with meconium ileus are usually diagnosed immediately, but some newly-diagnosed patients may be in adolescence. Manifestations The main complications ofCF result from the respiratory problems. Repeated infections cause lung damage, the bronchial obstruction leads to puJmonary hypertension and eventually cor pulmonale. If the heart cannot cope with this extra workload, it may go into right-sided failure. Patients with advanced disease can present with pneumothorax involving a varying percentage of the lung. But there are other manifestations of CF as well: · Patients can exhibit hemoptysis which occurs when the bronchial arteries going through the parts of the lung affected by bronchiectasis become distended and rupture. · When biliary cirrhosis occurs, patients may develop esophageal vances and portal hypertension. . Diabetes can develop in the adolescent and young adult which is usually controlled by insulin. The cause of this is not known. The C.n-.ll.n NUrH September 11179 21 Treatment The management of cystic fibrosis focuses primarily on the prevention of chest infections. ForCF patients to keep their lungs clear they must follow a rigorous daily treatment regime which includes inhalations and physiotherapy. The inhalations contain an antibiotic. a bronchodilator, and tluid which helps to liquefy the mucoid secretions. making them easier to cough up. These inhalations take about twenty minutes to administer three times a day which is followed by vigorous chest physio, aided by a mechanical compressor. The patient must concentrate on the individual lobes of his lungs, spending about ten minutes on each. The CF patients at HSC are on high saturated fat, high protein and high calorie diets. They also take Vitamin E. multivitamins, Vitamin K. saffioweroil, and vitamin B with C fortis as supplements to their meals. Patients with pancreatic involvement must also take cotazymes (pancreatic enzymes), which usually amount to 7 to 10 capsules to be swallowed per meal. I n addition to these medications every CF patient is on antibiotic therapy prophylactically, and if he develops an infection he starts on another. Commonly used antibiotics are cephalexin monohydrate (Ketlexl!Þ or Ceporexl!Þ), clindamycin, ampicillin, trimethoprim -s ul famethoxasole (Septral!Þ, Bactrim ). If the infection becomes serious the child is admitted to hospital and given ticarcillin and tobramycin intravenously. Living with CF The impact of cystic fibrosis is tremendous: how a patient and his family adjusts to the diagnosis physically and emotionally has a profound effect on the course and outcome of the disease. CF still has an uncertain prognosis. Patients are now living longer than ever before and may reach their twenties and thirties, due to antibiotics and physiotherapy. Older patients are pushing back the frontiers: the oldest patient at the HSC clinic is 39. Many factors affect the prognosis in CF: it is important first of all that a child be diagnosed early before permanent damage is done. If there is good compliance with the treatment plan, there is a good chance of preventing any permanent lung damage - many of the complications ofCF are in fact preventable to an extent. It is important for the CF patient to have a good understanding of his disease and a positive attitude; otherwise coping ", J I with the time-consuming daily routine will be extremely difficult. \1any CF children feel isolated and 'different'. as the disease affects every part of their lives. Treatments interfere with after-school play and often children cannot fully participate in strenuous physical activities. Many are self-conscious about taking all their pills in front of their classmates at lunch time. They may frequently be absent from school and can fall behind in their schoolwork: teachers often misunderstand the implications ofCF. Because of the treatments and expense, some CF children have never been away from home or on a vacation. Because CF is an inherited disease. parents are also affected: they have to deal with feelings of guilt and responsibility, and anxiety over the health of their child. A studyt of 30 adolescents and young adults showed that communication was reduced or non-existent in over two-thirds of the CF families. The divorce and separation rate too is above average in number because of the stress involved. The fact that the CF child requires a great deal of attention may create a dependence that is difficult to break and parental- particularly maternal- overprotection may intensify this. It is difficult for the young CF adult to begin functioning completely on his own. Siblings may feel neglected by their parents, jealous and perhaps guilty that they are healthy. Parents may not have any energy or time left over for unaffected children. The stud y 2 also showed that CF children often feel inferior to their peers: most had a poor body image. Typically the adolescents are thin and have a frequent harsh cough, and lack the pubertal changes that make them attractive to the opposite sex. The need to conform is \'ery strong among adolescents and the difference of their lives is very obvious and painful. Rebellion is often a part of personal growth and many CF teens focus their anger on their treatments. They stop doing their physio and refuse to take their pills in front offriends. Some will not tell their friends that they have CF or they will not tell them the whole story. This is also a time when physical activity lessens, particularly in girls, and there is a greater danger of chest infection. Maintaining the treatments in the face of this rebellion places an even greater strain on the parents: they know that failure to follow the regime will impair the adolescent's health. but in any case, emotional relationships will be affected. Education In orderto helpCF patients and their families overcome the physical problems and to develop a positive attitude and healthy self-image. the nursing staff on the CF chest ward at the Hospital for Sick Children developed a special patient teaching program. The focus of the program was to foster independence and self-reliance through increased knowledge of cystic fibrosis and its treatment. The age of patients admitted ranged from 2 years to the early thirties, and most are admitted for treatment of chest infections. staying two to three weeks: all are included in the teaching program. HSC Cystic Fibrosis Clinic Patients, by age under 5 yr - 13% 5 - 10 yr - 22% 10 - 14 yr - 25% 15 - 19 yr - 23% over20 yr - 17% Total - 530 Teaching plan There are many staff members involved in the teaching program: a geneticist, nutritionist. physician. public health nurse and social worker as well as staff nurses on the ward. The teaching team leader organizes the individual plans and ensures that each patient and his family are taught according to the plan that is drawn up for them. At the time of a child's admission, the nursing staff decides which nurse will do the patient's assessment and plan the teaching using a basic plan and fitting it to the child's particular needs. If possible, we try to assign a nurse who has already established some rapport with the child. 22 September 1171 The Canedl.n Nur.. To help us in our assessment we ask the patient and his parents to fill out a questionnaire which is intended to reveal knowledge of the disease, who participates in treatments at home and preparation of medication, and how the disease has affected activities. In addition, we try to determine how well the family is functioning, how independent the child is, what attitudes exist about CF and generally what kind of support the family may need. We base the teaching program on all this information. CASE STUDY: Ann Ann is a I3-year-old girl who was admitted for investigation of repeated respiratory infections, which had previously been diagnosed as complications of asthma. Her sweat chlorides on admission were 96 and 88 mEq/1 and her chest x-ray showed over-inflation and patches of atelectasis. A stool specimen for fecal fat showed that she was excreting more than the normal amount of fat, and her pancreatIc stimulation test showed she was not secreting sufficient enzymes. Ann's diagnosis was cystic fibrosis. As part of our routine, we asked Ann to fill out a knowledge assessment questionnaire to see what she had picked up from otherCF patients on the ward and to determine what her misconceptions were. In analyzing the results we found that Ann had only a superticial knowledge of anatomy and physiology. We made appointments for the parents to attend teaching sessions; while they were relieved to have a firm diagnosis of Ann's condition after all these years, they were very upset about the implications ofCF. Gradually all three were able to deal with their feelings and they were receptive to our teaching as we reviewed our plan with them, and helped to define their goals. We planned both separate and combined sessions for Ann and her parents. Learning Diane was a nurse who had built up a good relationship with Ann and who did most of the teaching. She discussed with Ann the causes ofCF, which parts of her body were affected, and she explained any specific complications that Ann was experiencing. Tools used included posters and a realistic lung model. For younger children we have a play kit which includes medical equipment such as I.V. tubing and auger suction, and a picture explanatory storybook. Many \.1 r " "..I - "- , .\,\ \ l \ .\ '- children like to hook up the tubing to dolls and put masks on them. As Ann was older we asked her to draw a picture of herselfla belling the affected parts of the body. We hoped through this to get some idea of her subjecti ve image of self, and we then reviewed the material with her parents. The next session covered medications; we feel that as soon as a child is able to understand, he should know what medications he is taking and why. Diane taught Ann about her medication, including the indications and the possible side-effects she could experience, using in part a slide-tape presentation. She demonstrated pouring the medication, and then allowed Ann to do this. After Ann was supervised several times and showed she was capable, she routinely prepared and administered them herself. I n another session the physiotherapist from the clinic discussed the rationale of the physio routine and then encouraged Ann and her parents to handle the equipment. Once they had been taught, the parents gave Ann her treatments, and then Ann gave them herself. Once again, as Ann proved herself to be capable, she was responsible for her own treatment. The nutritionist assessed Ann's diet taking into account calories and Ann's personal preferences. She then formulated a diet for Ann to be on at home which was compatible with the family's normal diet and budget allowance. She was able to provide some recipes for use at home. The geneticist discussed the implications ofCF with Ann's parents. For older patients, genetic counseling and birth control information can be given, as well as sperm counts for male patients who wish to know about their fertility. Fortunately, Ann's father had a drug plan through his employer; these group plans normally cover drugs, the mechanical air compressor and the physio tilt board necessary for postural drainage. However, in the absence of such a plan, we can arrange for payment through an Ontario Crippled Children grant. Review day After all the team members had gone through the planned program with Ann and her parents. we arranged a review day to discuss and evaluate progress. The doctor discussed first cystic fibrosis and its prognosis, and the physiotherapist reviewed the all-important therapy with the family to make sure they felt confident. The nutritionist also reviewed her aspect of the management; the public health nurse described follow-up care and identified helpful agencies. The nurse from the ward reviewed once again Ann's medication, and watched the family prepare the medications for her. The social worker had seen the family earlier and encouraged them on review day to talk about their feelings, and she offered her continuing assistance; the geneticist reviewed his counseling regarding genetic implications. Finally, a nurse from the CF clinic introduced the family to the clinic. Review day is held for all newly-diagnosed cystics and for those patients too who are found to need re-teaching. Evaluation We evaluated the effectiveness of our teaching before Ann was discharged by re-administering the questionnaire and checking the differences in her responses from the time of admission and by giving her a short test. We observed Ann and her family doing physio and preparing medications one final time. We stressed the importance of flexibility in planning a treatment schedule that would fit into the family's lifestyle. Ann was particularly concerned about doing her treatments at school, but Diane discussed this with her as well as the issue of telling her friends and taking her pills in their presence. In spite of the apparent organization. there are many factors which interfere with implementation of the teaching plan. Patients who have just been diagnosed need time to adjust before they can learn anything; if they are anxious or depressed, fear death or worry about their status, their concentration is impaired. If parents The Canadian NUrH Sept....t>er 11171 23 have not told a child about his disease. information from hospital staff could be upsetting and even unwelcome. On the other hand. some patients cope by denying their illness entirely and of course they resist any teaching. Those who were diagnosed years ago may not be aware of advances in treatment and think they need no more teaching. We try many different approaches in attempting to break down these barriers. For example. if a patient seems uncomfortable on the ward. the nurse may arrange a session in a more informal atmosphere. Some patients are extremely resistant to organization and may respond better to a casual on-the-spot teaching approach. during the physio routine for example. Parents who are defensive and reluctant to have a child taught may need to work with a social worker first to explore their feelings about having a child with CF_ The teaching focuses on the family when the patient is very young. but ifthe newly-diagnosed cystic is an adolescent. then education is directed at him. In every case the effectiveness of the teaching depends on the confïdence the patient and family has in the staff. Ann and her family adjusted well as they were a close and supportive family who were able to cope well with the diagnosis. However. many CF families are not so easily ma aged: examples of some more difficult cases follow. Case reports . Mike was a 15-year-old boy whose condition had been diagnosed at birth and who was admitted for treatment of a chest infection. His beha vior on the ward in previous admissions had been a problem and an assessment now revealed that his knowledge ofCF was poor. He refused to cooperate for blood samples. was generally rebellious and appeared to have absorbed nothing from the program. Shortly afterwards he went to another ward for minor surgery but requested that he return to the chest service. Reassessment showed he had a greatly increased understanding of his condition: we find that many rebellious patients store up the information we give them and use it when they can cope with it. . Twenty-year-old David's condition had been diagnosed when he was 2. and he was admitted for treatment of hemoptysis. During the teaching we realized he knew nothing of the genetic implications ofCF, nor that he was possibly sterile. He requested a sperm count and learned that he was in fact e -, ,l" aspermatic. By the time he was discharged he had been able to discuss his feelings about this and he appeared to have adjusted. . Alan, a 14-year-old boy who had been diagnosed CF at birth. came in with a chest infection. We learned that he did his treatments only sporadically and appeared to know little about CF. He was very shocked and upset when a fellow patient died - he said he hadn't known anyone could die from CF. When he was discharged he knew much more. possibly because of the extra motivation to learn. The bottom line The teaching program at HSC has facilitated discussion of the patient's and parent's individual problems with the result that they generally benefit from the sharing of these experiences. The program has also provided an opportunity for them to work out guilt feelings and anger. We have found patients who have CF to be very special people: they have to overcome apparently insurmountable odds. Our teaching program comes from the basic belief that with support. encouragement and affection. information and a focus on the positive aspects of/ife. a person with CF can live well. even if it is only one breath at a time. .., References *1 Lefebvre. A. Problems ofcystic fibrosis patients in adapting to adolescence and adulthood. Toronto, University ofToron o. 1974. Dissertation submitted in partial fulfillment of the requi rements for the Diploma in Child Psychiatry. 2 Steinhauer. P.O. Psychological aspects of chronic illness, by ... et al. Pediatr. Clin. North Amer. 21 :4:825-840. Nov. 1974. . Bibliography I Anderson. Charlotte M. Cystic fibrosis o.(the pancreas: manual 0.( diagnosis and treatment, by ... and M.C. Goodchild. Oxford, Blackwell Scientific Publications. 1976. 2 Burnette. B.A. Family adjustment to cystic fibrosis. A mer.J.N urs. 75: II: 1986-1989. Nov. 1975. 3 McCollum. AT. Coping with prolonged health impairment in your child. Boston. Little. Brown, 1975. 4 Fakkem. La Verne. How to help the child with cystic fibrosis. Amer.J.Nurs. 59:9:1269-1271. Sep. 1959. 5 Leonard. C.O. Genetic counseling: a consumers' view. by... et al. New Eng. J. Med. 287:433-439. Aug. 31. 1972. ,/ *U nable to verify references in CN A Library Cheryl Samsis a graduate of the Toronto General Hospital School o.(Nursing and has worked in pediatrics at Scarborough Centenary Hospital and the Hospitalfor Sick Children in Toronto where she is now the teaching team leader on the n'stic fibrosis unit. Tom Burns is the award-winning photographer who took the photos 0.( Cheryl Sams and Diane Hardisn on the CF ward at HSC. Mr. Burns is a cystic himse((and isfollowed through the HSC cystic fibrosis clinic. Why c dressings several times a day when once a week is plenty1 This is an Op-site dressing for non-infected ulcers. When it goes on, it stays on... for a whole week. Because Op-site is an adhesive, transparent dressing that breathes and sweats with the skin. So you can keep your eye on the entire healing process without the interruptions of frequent dressing changes. Op-site is easy on the patient too. It's neat, not bulky. Patients can take regular baths or showers without discomfort because Op-site is water-proof. Op-site is also bacteria-proof, protecting the ulcer from contamination. Because once a week is plenty, Op-site means fewer dressing changes. And that's less work and more time for you. -------------------- I Op - S ite(íi For f';lrther informa!ion a!x?ut I I I Op-slte ulcer dressmg, fill m the ultimate wound dressing and mail this coupon. I I I I I I I I Address I I I I City Prov._Code I I Mail to' [8] '---'" Smith f, Nephew Inc. 2100. 52nd Avenue I . :5...: Medical Division l..ðchine.Oué..Canada I I ". .-' HBT2Y5 -------------------- Your guide to Clinical Laboratory Procedures t- ð a: L5 t- In laboratory medicine, approaches and techniques are changing more rapidly than in any other branch of medicine. The automation of procedures has resulted in a drastic decrease of cost per test, shorter time requirements, increased availability of different kinds oftests, and improved accuracy and especially the precision of the results. The unprecedented explosion in the volume of laboratory tests, which has inevitably followed, changed the whole approach to medicine and has greatly increased its dependence on the laboratory. The impressive improvements in diagnostic accuracy and speed are undeniable but something in the human approach to the patient has been lost - he is frequently subjected to tests that will not alter medical management, tests ordered to confirm results of other tests, and sometimes to a battery of tests that are ordered simply as a matter of policy. It is important, therefore, that the whole medical team, including the nurses, have a better understanding ofthe significance of specific laboratory data for the welfare of the patient. The following condensed information is presented to contribute toward this goal. This is the sixth time that clinical laboratory procedures have appeared in chart form in The Canadian Nurse since the original compilation in 1949. Each time, the information has been updated; again this time, a number of changes, additions and deletions have been made. A complete conversion of the values to SI units was deemed impractical at this time - the system has not been officially implemented in Canada yet and most laboratories do not use it. It is also recognized that th "normal values" differ from laboratory to laboratory due to methodological differences. This problem will not be remedied until national reference methods are developed and accepted. This summary deals with Hematology, Blood Banking, Biochemistry, Function Tests and Microbiology in that order. Obviously, microbiology cannot be reviewed from the point of view of normal values, since the discipline deals with identification of organisms not present in health ratherthan with quantitative measurements of the deviation from normal. The brevity ofthe chapter on microbiology is a reflection of its unique character, not of its clinical importance. 2tI September 1171 The C.n-.ll.n Nur.. ABO - the main blood group system Ac. - acid A.C.D. - anticoagulant used in preserving blood I a cid-citrate-dextrose) ACTIi - adrenocorticotrophic hormone A.F.B. - acid-fast bacillus; a characteristic staining quality of the tubercle bacillus Alk. - alkaline B.S. - blood sugar BSP - bromsulphalein; a liver function test B.T. - bleeding time BUN - blood urea nitrogen C. - centigrade Ca - calcium CI- chlorine C.P.K. -the enzyme creatine phosphokinase Cr - chromium C.S.F. - cerebrospinal fluid Cu - copper C.VJ. - cell volume index dl- deciliter Diff. - differential; used with reference to a smear of blood or C.S.F. to determine the types and percentages of white blood cells present ECG or EKG - electrocardiogram EDTA - an anticoagulant, frequently used in blood samples for hematology EEG - electroencephalogram Eos. - eosinophil; a variety of white blood cell E.S.R. - erythrocyte sedimentation rate F. - Fahrenheit F.B.S. - fasting blood sugar Fe - iron FSH - follicle stimulating hormone ofthe pituitary gland g. - gram G.A. - gastric analysis GC - gonococcus, causative organism of gonorrhea GI- gastrointestinal H & E - hematoxylin and eosin stain; used in the preparation of pathological material for examination Abbreviations and symbols 17HC -17-hydroxycorticoids HCG - human chorionic gonadotrophic hormone, present in pregnancy Ipregnancytest) and malignant tumors of the testes Hg - mercury Hgb. - hemoglobin 5HIAA - 5-hydroxyindoleacetic acid Ht. - hematocrit ICDH - isocitric dehydrogenase, a tissue enzyme Ig - the blood immunoglobulins, such as IgA, IgG, IgM, etc. IU - international unit I.V. - intravenous K- potassium 17KS -17-ketosteroids; urinary hormones from the adrenal cortex and testes L. or I. -liter LDH -lactic dehydrogenase, a tissue enzyme L.E. -lupus erythematosus Lymph. -lymphocyte, a type of white blood cell MCH - mean corpuscular hemoglobin MCHC - mean corpuscular hemoglobin .. concentration MCV - mean corpuscular volume mEq.ll. - milliequivalent per liter mg. - milligram; see Weights mi. - milliter, 1/1000 part of a liter mOsm - milliosmole, 1/1000 part of an osmotically active unit per liter Myelo - myelocyte, the forerunner ofthe granular leukocyte N - nitrogen Na - sodium Neut. - neutrophil. a variety of white blood cell NPN - nonprotein nitrogen O xygen Osm - one osmotically active unit Imolecule or ion) per liter P.A. - pernicious anemia Pap stain - Papanicolaou stain for cancer cells PBI- protein-bound iodine, and estimation used in connection with thyroid function pCO.-partial pressure of carbon dioxide pH - a symbol used to express acidity and alkalinity PI.Ct. - blood platelet count pO ,-partial pressure of oxygen P.S.P. - phenolsulphonaphthalein test, a method for assessing function R.A. - rheumatoid arthritis R.B.C. - red blood cell count Retic - reticulocyte, a young R.B.C. RD - rheumatoid factor, present in blood in rheumatoid arthritis and occasionally in lupus erythematosus, etc. Rh - Rhesus, the Rh factor of blood risa - radio-iodinated serum albumin, a material for measuring plasma volume SGOT - serum glutamic-oxalacetic transaminase SGPT - serum glutamic-pyruvic transaminase S.G. - specific gravity T ,,-an in vitro test for thyroid function IT 3 resin uptake) T.--a test for thyroxine, the thyroid hormone T.PJ. - Treponema pallidum immobilization, a specific test of serum for syphilis TSH - thyroid stimulating hormone ofthe pituitary gland U. - Uflit, a comparative weight measure U.A. - urine analysis Ur.Ac. - uric acid VDRL - flocculation test for syphilis VMA - vanilmandelic acid, a test for adrenal medulla function W.B.C. -white blood cell count Weights - 1 kg kilog. 10 3 g. 1 g gram 1 mg millig. 10- 3 g. 1 ILg microg. 10-1\ g. 1 ng nanog. 10- 9 g. 1 pg picog. 10- 1 . g. W.R. - Wassermann reaction An Acknowledgment: Clinical laboratory procedures first appeared in The Canadian Nurse in 1949; the author of the original summary was Dr. E.M. Watson. The author of the last revision, which appeared in 1974, was Dr. A.H. Neufeld. We are indebted this time to the following for their special expertise: Blood bank: Janis Bormanis, M.D., F.R.C.P.fc), clinical hematologist at the Ottawa Civic Hospital; Hematology: Frances A. Shepherd, M.D., F.R.C.P.fc), the Director of Medical Services at the National Blood Transfusion Service in Toronto. Biochemistry: Ivo Hynie, M.D., Ph. D., F.R.C.P.fc), Director of the Bureau for Medical Biochemistry at the Laboratory Centre for Disease Control in Ottawa; The C.nMII.. Nur.. September 1171 'rT Tests identified by proper names The use of a scientist's name for laboratory tests fortunately is on the way out, along with outmoded tests. However, some persist and those most commonly used follow: Bence-Jones protein -the abnormal protein found in the urine of about 50 per cent of patients with myeloma Bodansky unit-the amount of phosphatase required to liberate 1 mg of phosphorus; test result for alkaline or acid phosphatases (see also Sigma) Coombs - a test used in pregnant women and newborn infants relative to Rh sensitization; also used in hemolytic anemias Duke - a method for determining the bleeding time of a patient Kahn - a test for syphilis King-Armstrong unit - an amount of phosphatase required to liberate 1 mg of phenol; test result for alkaline or acid phosphatases Lange's Colloidal Gold - a test on C.S.F. as an aid in diagnosis Mosenthal- a two-hour specific gravity volume test for evaluating kidney function Papanicolaou - a technique for identifying cancer cells PauJ-Bunnell- a serological test for infectious mononucleosis Rumple-Leede - not a laboratory test, but a method to determine capillary fragility by inflating a blood pressure cuff and counting the petechiae in a circumscribed area of skin Schilling - a radioisotope test for pernicious anemia and malabsorption Sigma - the amount of phosphatase required to liberate 1 mg of phosphorus; test result for alkaline or acid phosphatases (see also Bodanskyl Wassermann - the original test for syphilis Westergren - a technique for performing the R.B.C. sedimentation rate Widal- a serological test for typhoid and paratyphoid fevers Wintrobe - a special tube for determining red cell volume and sedimentation rate Ziehl-Neelsen - a stain for acid-fast bacteria, usually for tubercle bacilli Clinical Microbiology Clinical microbiology is a specialty that includes bacteriology, mycology, parasitology and virology It is most essential that sterile techniques be followed for all specimen collection, containers used and transport to the laboratory; the slightest contaminant may well invalidate the result Parasitology: With increasing travel and temporary residence abroad, just about all human parasitic infections are being seen in Canada. In general. specimens, especially stools, must be delivered to the laboratory in as fresh a state as possible. Examples of medically important parasites are as follows: Protozoa - amoebic dysentery, malaria Platyhelminths -tapeworm. schistosomiasis Nemathelminths - round worms. pinworms Arthropods - scabies, body lice Bacteriology: In the laboratory most specimens are cultured on various types of media. depending on the suspected organisms. The organisms are subsequently identified and subjected to various tests, such as antibiotic sensitivity, etc. It is important that. whenever possible. specimens be procured prior to use of antiseptics or antibiotics. Virology: The presence of virus is established either serologically or by isolation. Virus laboratories are highly specialized centers. Therefore. in most instances, specimens are referred to them for isolation and identification. Usually, special specimen containers are supplied. Mycology: These organisms (fungi) can frequently be identified by microscopic examination. When it is necessary to culture them, they require up to several weeks for growth and identification. Hematological Values Hematological analyses are performed on blood collected in anticoagulant, the usual amount of blood required being 3-7 mi. The anticoagulants used are EDTA for routine hematological analyses and sodium citrate for most tests of coagulation. Other tests may be done on serum. Many of the routine tests in hematology are now done on automated electronic particle counting machines. The determinations listed are by no means a complete representation of all tests done in a hematological laboratory. They do however represent the more common tests that are requested. Normal values listed are generally accepted values but there may be individual variations at different institutions. These variations however are usually minor but of particular relevance to tests of coagulation. The column of clinical significance is very much abridged and only gives some important considerations. Determination Normal Values Clinical Significance Autohemolysis 0.2-2.0% without glucose differential test for certain hemolytic anemias (spherocytic) Bleeding time Duke 1-4 min prolonged when platelets reduced Ivy 1-7 min in number or defective in Template 1-9 1/2 min function Blood film normal morphology of essential in diagnosis of most (smear) RBC's, WBC's platelets hematologic conditions Blood volume 60-90 ml/kg increased in polycythemia vera; (Isotopic decreased in dehydration, shock, determination) hemorrhage Carbon monoxide minute amounts carbon monoxide poisoning or hemoglobin intoxication (car exhaust, smoking) Clot retraction 50-100% at 2 hrs a test of platelet function Clotting time below 15 min (Lee White prolonged in hemophilia, also with method) heparin administration Coagulation Factor VI/I (50.200 percent) classical hemophilia facto rs Factor IX (60-140 percent) Christmas disease other Factors other coagulopathies, hereditary or acquired Differential Total WBC 4,800-10,800 White Cell Count Mature neutrophils increased in many bacterial 40-75%; 2,OOO-7,500/cu mm infections Lymphocytes increased in some viral 20-45%; 1,500-4000 infections; decreased in lymphocytic leukemias Monocytes 2-10"41; 200-800 Eosinophils increased in allergic 1-6% ; 40-400 conditions Basophils 0-1%; 1-100 In children lymphs and monos can be higher Erythrocyte Male: 0-9 mm/hr increased in infectious and Sedimentation Female:0-20 mm/hr inflammatory diseases Rate (Westergren) Fibrinogen 150-400 mg/l00 ml decreased with severe liver disease, (D.I.C.) disseminated intravascular coagulation The Cen-.llen Nur.. September 11171 211 Determination Normal Values Clinical Significance Fibrinogen Split negative reaction at 1/4 increased in fibrinolysis, liver Products dilution (latex fixation) disease,D.I.C. Folate 3- 20 \lgll folate deficiency Folate in R.B.C. 160-640 \lgll as above G-6-PD (glucose- Usually a normal screening test low values in G6PD 6-phosphate deficiency associated with dehydrogenase) quantitative values: hemolysis 120-240 mU/10 9 R.B.C. Hematocrit Male: 40-54% decreased in the anemias; Female: 37-47% increased in polycythemia and hem oconcentration Hemoglobin Adult male: 14-17.5 gl100 ml decreased in the anemias; Adult female: increased in polycythemia and 12-15.5 gl100 ml hemoconcentration Children: (3-6 years) (shock, burns, myocardial infarction) 12-14g/100ml Hemoglobin HgA - about 95% hemoglobinopathies electrophoresis HgA - < 3.5% (sickle cell anemia, HgP -<2% (50 - 90% in the thalassemias, etc.l newborn) HgS sickle cell disease HgC HgC disease Iron See Biochemistry Iron binding capacity See Biochemistry l. E. Preparation none positive in lupus erythematosus Mean corpuscular 27-32Wg increased in macrocytic hemoglobin anaemia (i.e. pernicious anemia; low in hypochromic anemia i.e., iron deficiency) Mean corpuscular 33-38% same as above hemoglobin concentration Mean corpuscular 80-100 cu \1m same as above volume Mono Spot negative screening test for infectious mononucleosis Partial thrombo- 25-37 sec prolonged in hemophilia and plastin time (PTT) other coagulopathies, used in control of heparin therapy Paul-Bunnell negative differential test for (heterophil infectious mononucleosis antibodies) Plasma hemoglobin 0-3 mgll00 ml increased in hemolytic anemia (primarily intravascular) 30 Sept....t>er 1171 The C.nedlen Nu... Determination Normal Values Clinical Significance Plasma volume 40-50 mllkg decreased in hemoconcentration; (Isotopic increased in some with hypertension, determination) and some other clincial conditions Platelet function normal response to useful to detect poor platelet test (aggregation) ADP, Collagen, function, hereditary or drugs Epinephrine Platelets 150,OOO-450,OOO/cu mm decreased in thrombocytopenic purpura and other clinical conditions; increased in some inflammations Prothrombin time 11-15sec mainly used in control of oral anticoagulant therapy; prolonged in liver disease Red blood cell 25.35 mllkg in males decreased in blood loss; volume ( 51 Cr) 20-30 mllkg in females increased in polycythemia vera Red cell fragility increased if hemolysis useful in diagnosing hemolysis (osmotic fragility occurs in over 0.5 percent due to spherocytosis (Le. test) NaC1 hereditary spherocytosis) Red cell survival Half-life: 25-35 days decreased in hemolytic test (with 51 Cr) anemias; a test for life span of the red blood cell Reticulocytes 0.5-1.5% of all red an indication of marrow capability, blood cells decreased in aplastic and other anemias; increased as response to blood loss or hemolysis Schilling test 10"41 and over test for absorption of B 12; (radio cobalt (urinary excretion) can diagnose malabsorption or Vitamin B12) pernicious anemia Sedimentation See Erythrocyte rate Sedimentation Rate Vitamin B12 150-600 pglml decreased in pernicious anemias, malabsorption, malnutrition; increased in chronic leukemia, infectious hepatitis, liver cirrhosis Blood Bank Results Determination Blood Bank Results Clinical Significance ABD Group Antigen on Red Cells Group 0 Group A Group B Group AB Antibody in Serum anti-A & anti-B 45% anti-B 40% anti-A 10% neither 4% determined on every donor and potential blood transfusion recipient anti-A and anti-B cause rapid destruction of transfused red cells that carry the correspondìng antigen which may cause mild hemolytic disease of the newborn, or may cause fatal blood transfusion reaction The C8nlldlen Nur.. September 11171 31 Determination Blood Bank Results Clinical Significance Rh (Rhesus, D) Group Red Cells Rh (0) positive 85% - determined on every donor and Rh (0) negative 15% potential blood transfusion candidate - anti-Rh (0) may be found in the blood of an Rh-negative person following transfusion of Rh- positive blood Dr pregnancy with an Rh-positive fetus - may cause severe hemolytic disease of the newborn - causes destruction of transfused Rh-positive red cells Other Rh (Rhesus) Red cells blood factors Dr C 70"10 - not routinely determined antigens E 30% - these antigens may stimulate c 80% antibodies e 98% - once present, they, like anti-Rh (0), cause the destruction of transfused red cells carrying that antigen - these antibodies are produced less frequently than anti-D Antibody screen: Positive: the patient's serum contains - the crossmatch with some donors search for antibodies antibodies to antigens on red cells will be incompatible in a potential selected to detect most clinically - test is usually done before the recipient's serum significant antibodies crossmatch to allow the lab (other than anti-A Dr to identify the antibody to find anti-B) compatible blood Negative: no antibodies to antigens - expect the crossmatch to be on the screening cells were detected compatible - less possibility of danger if uncross-matched blood is required in an emergency situation Crossmatch WHENEVER POSSIBLE, DONOR IS (Compatibility test) THE SAME ABO AND Rh GROUP AS THE PATIENT Incompatible: the patient's serum - if antibodies are detected in contains antibodies to antigens tests at 37 D C, indicates that on the donor's red cells the red cells would be destroyed if transfused - in general, the more incompatible in vitro, the more rapid the red cell destruction in vivo Compatible: antibodies against - no antibodies detected antigens on the donors red cells in the crossmatch, does not not detected always guarantee n"Drmal survival of red cells - antibodies against antigens not on the donor cells will not be detected - very low levels of antibodies may not be detected by the routine crossmatch technique and may rise at a later date to produce delayed destruction of red cells. - antigens present on donor cells and absent on recipient cells will not be detected, and may result in antibody production at a later date - does not prevent febrile and allergic transfusion reactions 32 September 11171 The Cen-.llen NUrH Determination Blood Bank Results Clinical Significance Direct Coombs' test EDTA BLOOD SAMPLE PREFERRED - caused by antibodies to antigen binding or Direct anti- Positive: patient's red cells on own red cells or on transfused globulin test have detectable globulin (antibody red cells or antigen-antibody complexes or complement! on their surface adhering to red cells - may indicate an immune basis for red cell destruction in vivo Negative: patient's red cells do - any red cell destruction if not have detectable globulin on present is unlikely to be of their surfaces immune origin Cold autoagglutinins WARM (37 0 C) CLOTTED SAMPLE - may occur as an isolated disorder Auto-antibodies Positive: indicates a cold autoagglutinin or may be associated with active mainly in the is present infections such as Mycoplasma cold pneumonia and infectious mono- Whenever a positive result is nucleosis or Iymphoreticular obtained the specificity, titre, disorders and thermal amplitude (highest - if temperature of patient's temperature of antibody reactivity) body or extremities reaches the should be determined temp. of antibody reactivity, the antibodies will cause destruction of red cells in vivo Negative: no significant cold - any red cell destruction, if present, auto-agglutinins were detected is not likely being caused by cold autoagglutinins Biochemistry, Blood, Plasma or Serum Values Most biochemistry tests are routinely carried out on serum. However, some tests require special collection techniques and are performed on plasma or whole blood. New micromethods are not available in all hospitals and the required volume of the specimen has to be verified with the laboratory. Determination Normal Range Note Clinical Significance Acetoacetate 0.3 - 3.0 mg/dl increased in diabetic ketoacidosis, after plus acetone prolonged fast, etc. Aldolase 1.3 - 8.0 mU/ml increased in many conditions including hepatitis, muscular dystrophy, and myocardial infarction Aldosterone 48 29 pg/ml supine, high sodium diet high supine value in primary aldosteronism Ammonia nitrogen 15 - 110 Jlg/dl in heparinized blood, must be delivered on ice increased in severe liver disease, GI bleeding, immediately some inborn errors of metabolism normal range dependent on methodology, check with your laboratory Amylase 40 - 160 U/dl increased in acute pancreatitis, parotitis, abdominal trauma Ascorbic acid 0.4 - 1.5 mg/dl decreased in nutritional deficiency Bicarbonate 22. 30 mEq/1 abnormal in acid-base balance disturbances, GI and renal diseases Bilirubin up to 0.3 mg/dl increased in obstructive jaundice Direct The Cen-.llen NUrH September 11171 33 Determination Normal Range Note Clinical Significance Bilirubin up to 1.2 mg/dl increased in jaundice Total Calcitonin not measurable high in medullary carcinoma of thyroid Calcium 8 - 10.5 mg/dl increased in hyper-parathyroid ism, some 4 - 5.25 mEq/1 forms of cancer and other conditions decreased in hypo-parathyroid ism, rickets, renal disease, intestinal malabsorption Ceruloplasmin 27 - 60 mg/dl range dependent on methodology decreased in Wilson's disease Chloride 95. 105 mEq/1 abnormal in electrolyte imbalance due to GI, renal or metabolic problems Cholesterol 45 - 65 mg/dl higher in female high levels correlated with decreased risk of HDl increased on exercise ischemic heart disease Cholesterol 150 - 250 mg/dl lower in children increased in primary or secondary total hypercholesterolemia high level indicates increased risk of ischemic heart disease Cholinesterase 0.5 - 1.3 pH units decreased in liver disease (Pseudo Decreased or qualitatively abnormal cholinesterase) in some healthy people - high risk in anesthesia Copper 70 . 1401Jg/dl decreased in Wilson's disease Cortisol 5 - 25 1Jg/dl diurnal variation: increased, no diurnal variation in a.m. higher than p.m. Cushing's syndrome or disease Creatine female - CPK isoenzymes useful to determine increased in muscle, myocardium or CNS Phosphokinase 5-35IU/1 the tissue of origin disease (CPK) male- 5-55IU/1 Creatinine 0.6 - 1.4 mg/dl increased in renal disease Gastrin o - 20 'JIg/dl may be increased with duodenal ulcer Glucose 60 - 110 mg/dl less than 160 after meal increased in diabetes. Decreased in different (fasting) types of hypoglycemia Growth hormone less than 5 ng/ml fasting, no stimulation. increased in acromegaly. low value (HGH) significant only after stimulation Immunoglobulins IgG 500 - 1650 mg/dl decreased in immune deficiencies. IgA 60 - 340 mg/dl for children consult detailed Increased in infectious, autoimmune IgM 40 - 160 mg/dl age tables diseases, liver diseases, myeloma, etc. IgD 1 - 6 mg/dl Insulin 4 - 26J1U/ml usually with glucose tolerance (fasting) High in insulin resistant diabetes, insulinoma Iron 60 - 160 \Jg/dl higher in males than females increased in hemolytic anemias, hemochromatosis. Decreased in iron deficiency anemia Iron binding 250 - 410 Jlg/dl increased in iron deficiency anemia, capacity pregnancy. Decreased in hemochromatosis, hemolytic anemia 34 September 11171 The Cen-.ll.n NUrH Determination Normal Range Note Clinical Significance - lactate 0.6 - 2.0 mEq/1 oxalate blood, deliver on ice immediately. increased in lactic acidosis Higher in venous than in arterial blood lactic 60 - 160 U/ml lDH isoenzymes can identify Increased in myocardial infarction, dehydrogenase source of increased lDH pulmonary infarction, liver disease, etc. (lDHI lipase up to 2.0 U/ml I ncreased in acute pancreatitis lipids 450 - 1000 mg/dl increased in some hyperlipidemias. lipid fractions (cholesterol, triglyceridesl more useful for diagnosis lipoproteins normal electrophoretic increasingly replaced by cholesterol, the electrophoretic pattern diagnostic for pattern of chylomicrons, H D l cholesterol and tri-glycerides five types of hyperlipoproteinemia pre-beta, beta and alpha Magnesium 1.3 - 2.1 mEq/1 decreased in some forms of renal disease, after insulin administration, rarely in tetanus; increased in renal failure, metabolic acidosis 5'-N ucleotidase 0.3 - 3.0 units increased in some liver diseases Osmolality 280 - 295 mOsm/kg abnormal in hypo- and hyper-osmolar states p C0 2 35 - 45 mm Hg arterial blood, deliver on ice increased in respiratory acidosis pH 7.31 - 7.45 arterial blood, deliver on ice low in acidemia, high in alkalemia p 0 2 75 - 100 mm Hg arterial blood, breathing normal air. low in respiratory or heart failure. May be 500+ mm Hg if patient Important for monitoring patients on breathing oxygen respirator Phosphatase male- increased in cancer of prostate, in acid up to 0.63 sigma U/lnl non-hemolyzed hemolyzed serum female - fresh or frozen serum up to 0.56 sigma U/ml Phosphatase 3 - 13 King-Armstrong higher in children and adolescents increased in biliary obstruction,liver disease alkaline U/dl bone disease 13 - 40 lUll Phosphorus adult - increased in renal failure inorganic 2.5 - 4.5 mg/dl low in hyperparathyroidism children - up to 6.5 mg/dl Potassium 3.5.5.0 mEq/1 serum must not be hemolyzed increased in renal failure, ketoacidosis, Addison's disease. Decreased in recovery phase from diabetic coma, in alkalosis Prolactin 2 - 15 ng/ml high in galactorrhea due to hypothalamic lesion Protein fractions albumin low in albuminuria,liver disease. albumin 3.5 - 5.0 g/dl Globulin fractions increased in infections, globulin total 2.3 - 3.5 g/dl some forms of cancer, etc. globulin a 1 0.1 - 0.4 a2 0.4 - 1.1 ß 0.6 - 1.2 y 0.5 - 1.5 The C.n-.llen NUrH September 11171 35 Determination Normal Range Note Clinical Significance Protein total 6.0 - 8.4 g/dl increased in dehydration, myeloma. Decreased in renal diseases,liver disease, malnutrition, protein-loosing enteropathy Renin 1.1.! 0.8 ng/ml/hr supine, normal diet important in differential diagnosis of 10.0.:t. 3.7 ng/ml/hr upright, low sodium diet hypertension plus diuretics Sodium 135 - 145 mEq/1 increasl!1 in hyperosmolar coma, some forms of dehydration. Decreased in diarrhea, vomiting, tube drainage, diabetic keto-acidosis, Addison's disease T 3 resin 25 - 40% normal varies considerably increased in hyperthyroidism, nephrotic uptake from laboratory to laboratory syndrome Decreased in hypothyroidism, oral contraceptives. 5.5 - 12.5 g/dl normal range varies from increased in hyperthyroidism, after oral T4 laboratory to laboratory contraceptives. Decreased in hypothyroidism and in states with low TBG e.g., protein loosing enteropathy, nephrotic syndrome. SGOT 10 - 50 U/ml increased in diseases of liver, muscles, and (glutamic - myocardial necrosis oxalacetic transaminase) SGPT 10 - 40 U/ml in liver disease increased more than SGDT (glutamic - pyruvic transaminase) TBG 10 - 25119T 4/dl important to clarify discrepancy between !thyroid binding clinical thyroid status, T 4, and T 3 resin globulin) uptake Testosterone adult male - low value in some forms of male sterility 300 - 11 00 ng/dl adult female - 25 - 90 ng/dl T riglycerides 50 - 150 mg/dl increased in type I, lib, III, IV and V hyperlipoproteinemia, diabetes, nephrotic syndrome, hypothyroidism TSH 0.5 - 3.5 \lU/ml test not sensitive enough to usually high in hypothyroidism distinguish reliably abnormally low value from lower limit of normal range Urea Nitrogen 8 - 25 mg/dl decreased in serious liver disease. Increased (BUN) in renal failure, dehydration, circulatory failure Uric acid 2.5 - 8.0 mg/dl male higher than female, increased in gout,leukemia, renal failure significant racial differences glycogen storage disease type I, lesch-Nyhan disease 36 September 11171 The C.n-.llen NUrH Urine Values Determination Normal Value Specimen Note Clinical Significance Required . Acetone plus negative random diabetic ketoacidosis acetoacetate (Ketone bOdies) Aldosterone 5-201lg/24 hr 24 hr special di t, hyperaldosteronism keep specimen cold Amylase 40-240 Somogyi random pancreatitis, U/hr parotitis, pancreatic trauma Calcium 50-250 mg/24 hr 24 hr hyperparathyroidism, hypercalciuria with kidney stones Catecholamines: Epinephrine up to 20119/24 hr check with the Norepinephrine up to 1001lg/24 hr . 24 hr laboratory for Metanephrines up to 1.3 mg/24 hr preservative; increased in pheochromocytoma Vanillyl- 1.8-9 mg/24 hr avoid interfering mandelic acid medication (VMA) Chlorides 100-250 mEq/1 random or important in studies of fluid and 24 hr electrolyte balance Copper less than 24 hr high in Wilson's disease 1001lg/24 hr Coproporphyrins 50-250 \19/24 hr 24 hr collect with increased in some types of 5 9 of sodium porphyria carbonate Cortisol 20-7511g/24 hr 24 hr keep specimen investigation of adrenal cortex cold Creatine less than 24 hr higher in children, increased in some muscle diseases 100 mg/24 hr in pregnancy Creatinine 15-25 mg/ 24 hr constant under most conditions. 24 hr/Kg of Quantitative measurements in urine body weight frequently expressed per mg of creatinine Follicle men- Stimulating 5-25 IU/24 hr Hormone (FSH) women - 24 hr important in the investigation of midcycle endocrine disturbances 15.60 IU/24 hr Follicular and luteal 5-25 IU/24 hr 17-0H male- range lower for corticoids 8.25 mg/24 hr 24 hr some modern investigation of adrenal cortex female - methodologies, 5-18 mg/24 hr check with your laboratory; for children consult age tables 5-hydroxy indole- acetic acid . 2-9 mg/24 hr 24 hr collect with increased in carcinoid (Serotonin) 10 ml HCI tumors The C8nlldlen NUrH September 11171 37 Determination Normal Value Specimen Note Clinical Significance Required 17-ketD- age male female for smaller investigation of adrenal and steroids (mg/24 hr) children consult testicular functions 10 1-4 1-4 24 hr detailed tables 30 8-26 4.14 70 2-10 1-7 lead less than 24 hr investigation of chronic 120,.g/24 hr lead exposure Osmolality 50-1200 mOsm/kg 24 hr investigation of concentrating ability of the kidneys Phosphorus 500-1500 mg/24 hr 24 hr influenced by diet together with serum phosphate important in Ca and P metabolism investigation Porphobilinogen less than 24 hr important in investigation of 2 mg/24 hr random porphyrias Qualitative test negative Potassium 25-100 mEQ/24 hr 24 hr varies with dietary important in investigation of intake renal function, of adrenal cortex, of water, electrolyte, and acid-base balance Pregnanediol female - 3-10 mg/24 hr 24 hr increased in investigation of ovarian function, male- pregnancy and adrenal tumors 0-1.5 mg/24 hr Protein less than increased in nephritis 150 mg/24 hr 24 hr and nephrosis Sod ium 27-287 mEQ124 hr 24 hr same as potassium Titrable 20-40 mEQ/24 hr renal and acid-base investigation acidity Urea 6-17 g/24 hr 24 hr some metabolic investigations Nitrogen Uric acid 0.4-1.0 mg/24 hr 24 hr useful in investigation of renal stones, metabolic disturbances Urobilinogen 0.2.3.3 mg/24 hr 24 hr preserve with increased in liver diseases and Qualitative: sodium carbonate hemolytic jaundice positive 1:20 random under petroleum eth er Cerebrospinal Fluid Values Test Normal Value Note Clinical Significance Appearance clear and colorless cloudy in meningitis, bloody or yellow in CNS bleeding Bacteriological negative frequently diagnostic in CNS infections examination Cell count 0-5 mononuclear number and type of cells variable with cells per mm 3 the type of infection 35 September 11171 The Cen-.llen NUrH Test Normal Value Note Clinical Significance Chlorides 115-130 mEq/1 20 mEq/1 higher than serum increased in uremia, decreased in tuberculous meningitis Colloidal gold 0000000000 - abnormal in meningitis, syphilis test 0001222111 Glucose 40-85 mgldl 20 mgldlless than serum. Always decreased in bacterial and tuberculous compare with serum value meningitis, abnormal value significant only if compared with blood concentration Pressu re 70-180 mm of H2O not a true laboratory test increased in meningitis, brain edema, 5-15 mm Hg hemorrhage, etc. decreased in dehydration, spinal renal block Protein: albumin about 50% of total increased in meningitis, spinal cord tumor, IgG 5-15% of total etc. total 15-45 mgldl Functional Tests The normal range is not only influenced by the variations between laboratory methodo- logies, but also by modifications of the tests themselves as they are performed in different establishments. The "normal value" below may provide useful information but should be verified locally. Only the more common tests are listed. (Not alphabetically listed.) . . Test Principle Normal Value Clinical Significance . Metabolic al)d . .. Endocril)e a.c.-p.c. blood capacity of endocrine a.c. less than 110 mgldl useful in diagnosis and management of glucose pancreas to react to p.c. less than 160 mgldl diabetes mellitus glucose load Oral Glucose 3 hr GTT . the sum of 0,1,2,3 hrs diagnosis of diabetes mellitus. Useless Tolerance test same as above blood glucose concentration less if diagnosis can be established by a.c.-p.c. (GTT). Usually than 500 mgldl blood glucose 1.75 of glucoselkg 5 hr GTT - blood glucose back of body weight to normal after 2 hrs, does not in reactive hypoglycemia drop of blood drop below 55 mgldl thereafter glucose below 55 mgldl is accompanied by clinical symptoms 48 hr fast secretion of insulin no symptoms of hypoglycemia, in hyperinsulinism (e.g. insulinoma) test (after Dver- should virtually stop glucose stays above 60 mg/dl, has to be terminated due to symptomatic night fast, with decreasing insulin drops hypoglycemia and persistent high plasma monitor insulin, blood sugar insulin level blood glucose . and clinical . symptoms every 2 hr) Lv. insulin evaluation of the blood glucose drops to profound drop in hypopituitarism, sensitivity functional capacity 45-60 mgldl after 1 hr Addison's disease and some other (0.25 U/kg) of anti-insulin conditions. Note: be ready to administer systems Lv. glucose immediately if needed Lv. tolbutamide tolbutamide induces plasma insulin level increased by prolonged hypoglycemia and elevated test release of patient's less than 50 uUlmllafter 30 min. plasma insulin in hyperinsulinism. Note: (I g Lv.), own insulin Blood glucose more than 70% have Lv. glucose ready before starting measure blood of fasting value after 1 hr the test glucose, plasma insulin every 10min. The Cenedlen NUrH September 1171 31 Test Principle Normal Value Clinical Significance radioactive measure of the rate 5-45%, depends on geographical decreased in hypothyroidism, thyroiditis. iodine uptake of thyroid hormone area and diet Increased in hyperthyroidism. Correlation synthesis with clinical findings essential for correct interpretation T 3 suppression T will suppress T 4 drops to subnormal level or suppression absent if thyroid not regulated test T H with resulting to 50% of initial level by pituitary gland, e.g., thyroid adenoma (100 Jig daily for drop in T 4 production 10 days) ACTH stimulation ACTH stimulates urinary 17-DH steroids increased evaluation of endocrine adrenal cortex test synthesis of 3-4 times functional reserve glucocorticDids Metapyrone test inhibition of cortisol urinary 17-0 H steroids doubled evaluation of pituitary - adrenal cortex synthesis leads to functional response. Contraindicated increased ACTH if ACTH stimulation is negative secretion and to increased production of cortisol precursors Dexamethazone dexamethazone will urinary 17-0H steroids decreased to useful especially in differential diagnosis suppression suppress normal ACTH about one-third of pre-suppression of Cushing's syndrome test secretion amount Renal diurnal normal kidneys react night volume smaller than day Sp. gravity almost constant (near 1.010) variation promptly to osmotic volume. Sp. gravity variable in some chronic renal diseases. changes due to normal during daytime by at least activity and diet 9 points (e.g. 1.005-1.015) cycle Concentration testing maximum impaired in chronic pyelonephritis and and dilution ability to concentrate other renal diseases test or dilute urine after over 1.025 less than 1.003 water deprivation or water load Creatinine measures glomerular 90.130 ml/min most sensitive simple test for decreased Clearance filtration glomerular function Renal plasma PAH excreted both useful in differential diagnosis of flow by glomular filtration 500-700 ml/min renal diseases and tubular secretion Tubular e.g., excretion of 77 mg/min of PAH useful in differential diagnosis of functions PAH or reabsorption 380 mg/min of glucose renal diseases of glucose Reabsorption the relative amount of decreased, e.g., in hyperparathyroidism of phosphorus phosphorus reabsorbed from over 80% glomerular filtrate Gastrointestinal D-Xylose xylose is absorbed more than 5 g excreted in urine urine excretion diminished in malabsorption absorption test by normal intestine in 5 hrs (first establish normal renal function) (25 g p.o) and partially serum level over 25 mg/dl excreted by urine after 1 hr Vitamin A absorption of fat. vitamin A level in serum doubled useful in investigation of malabsorption absorption test soluble material in 3 hr syndrome (200,000 units in oil) 40 September 11171 The C.n-.llen NUrH Test Principle Normal Value Clinical Significance Schilling test See Hematology Gastric juice: volume fasting 30-70 ml/hr useful in differential diagnosis of nocturnal 600-700 ml stomach diseases 24 hr 2-31 Acidity: pH 1.5-2.0 acid output basal male 1-4 mEq/1 useful in differential diagnosis of female 0.5-3 mEq/1 stomach diseases Acid output after stimulation male 15-30 mEq/hr maximum by histamine s.c., female 10-22 mEq/hr preceded by Phenergan or Histalog Fecal fat more than 93% of less than 7g/day of fat in stool investigation of malabsorption (3 days fat should be absorbed 50 g/day died Bromsulphalein in healthy subject less than 7% retention after 45 m in liver function test Lv. excreted almost entirely by liver Secretin Lv. secretin over 1.8 ml/kg of body wtlhr decreased in diseases of exocrine test increases volume and bicarbonate concentration pancreas of pancreatic juice over 80 mEq/1 Pulmonary FEV 1 forced expiratory depends on age, height and weight decreased in restrictive lung diseases volume in 1 second 3.71 for middle-aged average man average man MMEF mean maximal about 3_5 I/sec for middle-aged decreased in restrictive lung diseases 25- 75% expiratory flow man and obstructive airway disease over the middle half of FEV Blood gases pH 7.31 - 7.45 high pH - alkalemia PC02 pH and pC02measured ---------------------------- - __Lo_ p_"!.::.!! 'l.'!'La_ -- r-r-- - _ _ _ ____. "respiratory component 0 acid-base directly, all other values 35-45 mm Hg balance. Increased in respiratory acidosis, (including buffer base decreased in respiratory alkalosis. In and actual bicarbonate metabolic acid-base disturbances the pC02 not listed here) arecalcul- change is secondary to changes in bicarbonate ated from the two above (decreased in metabolic acidosis, increased in alkalosis). standard theoretical value "metabolic component" of acid-base bicarbonate of bicarbonate con- balance. Increased in metabolic alkalosis, ( HC0 3) centration if blood 22-28 mEq/1 decreased in metabolic acidosis. Secondary was equilibrated changes of standard bicarbonate in chronic at pC02 = 40 mm Hg respiratory acid-base disturbances follow the same direction as the pC02 abnormality base excess calculated value, indicates deviation -3 - +3mEq/l a measure of "metabolic component" of buffer base above from normal p 0 2 See Chemistry Sweat test various methods of Na+ below 80 mEq/1 concentrations of Na and Cl increase in inducing sweating Cl- below 60 mEq/1 cystic fibrosis followed by electrolyte determination in sweat The Can-.llen Nurae September 1171 41 The history of the nurse practitioner moument as an acknowledged force in this countQ' can be traced to the end of the last decade. (Its histoQ as an accepted but largel ' unrecognized feature of the Canadian health care scene goes back much further than that - to the days when nurses like Jeanne Mance set up her cottage hospital in what was to become Montreal and the Gre ' Nuns began \'isiting the sick in homes in the Quebec City area some 300 'ears ago.) Thenurse practitioner: an idea whose time has come Maureen McTavish In the 1960's expectations concerning the possibility of formalizing the role of the nurse practitioner ran high. Many members but b ' no means all of the nursing profession felt that nursing wàs read ' to accept a more independent and autonomous function in the health care hierarchy. And the issue is still a controversial one today. Author Maureen McTa\'ish has giwn some thought to the issues that surround the question and come up "ith some ideas on how nursing can regain the impetus it once had in this direction. NURSING ..... .M.. .HE \5 NUR.SE IÐ "Primary health care is essential health care made universally accessible to indi\'iduals and families in the community bv means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part hoth of the country's health system of which it is the nucleus and of the o\'erall social and economic de\'elopment of the community.'" This is the definition that delegates to the International Conference on Primary Care, meeting in AlmaAta, Russia in September 1978, decided upon. Reading it, you may wonder just how relevant such a statement is when applied to developed countries like Canada. After all, we can afford a very high standard of health in this country and we have an abundance of physicians in urban areas at the moment. So why settle for something as esoteric as "primary health care" when we can go to the hospital or the doctor's office? But take another look. Our views on i1Iness and health are changing. We are beginning to see that we have created a health care system that is staggeringly expensive but is, nonetheless, incapable of expanding fast enough to meet the burgeoning health care needs of the community that supports it. Prevention is beginning to be recognized as the onJy workable approach to this dilemma. As our approach changes, as it must in the light of this reality, what are the alternati ves? One of them of course is the division of responsibilities for meeting primary health care needs along new lines - acceptance by the public and by the health professions of a more autonomous role for nursing in new practice patterns and settings. One group of nurses with a special interest in achieving greater independence in their practice is the group known as "nurse practitioners". \. \JIJJ.'_'^ """.. . 42 Sepllllllber 1871 The Can-.llen Nurae What's happening? In Canada. the idea of an expanded role for nurses seems to be losing ground. Despite the hue and cry from both inside and out of the health professions about the inefficiency of the health delivery system and the need for more services for more people. the nurse practitioner continues to be underutilized. Is it because we in Canada believe that there is no place for such a health professional? If so. perhaps we should examine the question more closely. The increasing need for community health services. more emphasis on preventive measures. more patient teaching, more responsibility for health in the hands of individuals - if we believe that these are part of the direction that health care should be headed towards, then are nurses preparing for it? It is these needs that the nurse in primary health care or the nurse practitioner seems to be gearing herself to meet. In the early 70's, the Burlington Experience 2 demonstrated the safety and efficiency of the nurse practitioner in providing primary health care. But not much has been done since. The issue is an extremely complex one. involving both practical and theoretical considerations. Abstract or "theoretical" obstacles to utilization of the nurse practitioner include: . conflicting philosophies as to what a nurse practitioner ought to be and ought to do: . lack ofreal definition as to the role of the nurse practitioner; . discord within the nursing profession itself as to whether this is the route nursing should follow; . professional territoriality; and . the whole complex process of change itself. Along with these abstract considerations. there are also some very practical reasons why the nurse practitioner has continued to be underutilized. These barriers include: . the method of remuneration; . the licensing of nurse practitioners; . level of preparation; and . lack of awareness and acceptance on the part of physicians, administrators and consumers about what the role of the NP is or should be. The outlook is not totally bleak, however. The social climate today supports efforts to break free of longstanding stereotypes to a degree not experienced by any other generation. It is a time that is encouraging a re-examination of traditional roles. that invites flexible and innovative planning and action. 3 Nursing's choice Two questions require a decision by the nursing profession as a whole: . Is this the way for nursing to go in the future? . Is this to be the goal for all nursing education and the pattern for all nursing practice: or. are these practitioners to remain a select and small group within the profession? If there is to be any truly informed judgment as to whether the nurse practitioner role is an appropriate one, then nursing research must provide answers. For too long. members of other disciplines have charted nursing's future course. 5 Through research. nurses must examine the validity of the practitioner role for nursing and at the same time, take into account society's need for increased quality and quantity of care and consider nursing's share in the responsibility for ensuring that these needs are met. This is not to say that nursing research has completely ignored the nurse's role in primary health care. The Burlington studies are a prime example of research carried out by members of a variety of health disciplines including nursing. But when the Boudreau report 6 was released in 1972. one of the principle recommendations it contained was to the effect that numerous studies across the country would be necessary to properly investigate the question. So far, the nurses' role in primary health care has been the subject offormal study in onJy two provinces - Newfoundland and Ontario. Another research project. this one in Quebec, was begun three years ago by McGill University School of Nursing in Montreal. A community health clinic. staffed by nurse practitioners with physicians acting on a referral basis onJy, was set up in a middle class suburb. The project is an experiment to see if focusing on nursing care and preventive health. with particular attention to the family, is a distinct service that nurse practitioners can bring to the community. Even this project. however. is in jeopardy. It has not received additional funding from the federal government for the coming year and so will be closing its doors sometime this summer. It is particularly unfortunate because the clinic will have been in operation for just under three years- not really long enough to evaluate its effect on the health of the community it serves. Defining the role Perhaps one of the major problems. so far. is that the role of the nurse practitioner has been inadequately defined. It is up to nursing to define the role of the nurse practitioner more exactly, by developing specific lists of functions with specific objectives for each function. In my opinion. this is the first step in gaining acceptance by both consumers and physicians. These groups must know what they can expect from the nurse practitioner. In addition. the legalities involved in expanding the nursing role must be fully appreciated. One of the best existing models that demonstrates the kind of work that must be done to define the role of the nurse practitioner is found in Clinically Trained Nurse programs (CTNs). established at several Canadian universities to educate nurses working in isolated outposts in the early 1970's. The medical and nursing educators associated with the CTN programs became increasingly aware that the role of this new professional in the health field had no clear definition. They decided that without specific criteria the competencies of the CTN graduates were very difficult to evaluate. Consequently, the educators responsible for the CfN programs decided to define the role of the competent clinically trained nurse in a clear. rigorous and thorough way. For example. for each erN skill that was described. certain criteria had to be met: . the skill. when performed, could be observed by another nurse. physician. etc. . the description had to specify when and where the clinically trained nurse could be expected to adequately perform the skill. The Can-.llen Nurae September 1871 43 Deciding on "hat's important I n developing a program such as the CTN program, a research committee had first of all to decide on the objectives of the program - what were necessary skills?The literature 7 . b . 9 indicates that if three out offour experts agree on the desirability of an objective, then the objective can be considered as having content validity. Because the role of this health professional was a contentious issue however. further criteria were developed. A validating panel was set up composed of nurses, physicians. content specialists (eg. obstetricians for obstetrics) and university faculty. The only skills that were considered absolutely necessary for aCTN were those that were labelled as "necessary" by 75 per cent of each group on the panel. "'The objectives also state very clearly how independent the (TN may be in her practice. They indicate if she is to treat the patient by herself; . to consult with a physician (including the time constraints) . to refer to a physician (including the time constraints) . to evacuate the patient (including the time constraints and treatment dunng evacuation). This bank of objectives is part of the research being sponsored by Medical Services Branch of Health and Welfare Canada. Interestingly. several research programs have been conducted at the University of Alberta's CTN program which indicate that nurses without the CTN program do not possess necessary specified skills even when they are trained at the baccalaureate level. have had e"perience in northern nursing stations. or have had midwifery training. II The CTN program is just one model for a nurse practitioner. Other specific models need to be developed for each kind of nurse practitioner. While the CTN program is geared to nurses who will be in isolated areas with minimal access to a physician. nurse practitioners in other settings will function very differently. e.g. as co-practitioners in a doctor's office, a'i health professionals attached to a public health unit, perhaps in some cases as a physician's assistant. These different roles require definitions that specify exactly what functions and responsibilitit;'> these practitioners have. Once these functions are established. the content ofthe curriculum for nurse practitioners needs to be analyzed in order to establish whether the training is appropriate to their level of functioning. .2 For example. the programs may need more of a practice orientation than an academic orientation. Other programs may need to modify their approach to make students more responsible for their own learning. 13 Increased responsibilit) for patient assessment It is obvious that there is a need for all nurses to assume more responsibility for total patient assessment. Beginning practitioners need more skill in complete health and nursing history taking and in behavioral and physical assessment skills than they have learned in traditional programs. 14 Needs which have been identified are: I . a faculty which is more prepared in the current clinical practice of professional nursing; . a clearer statement of the scope of the complete behavioral and physical assessment process as it applies to nursing; . a plan for the inclusion of all or portions of that process into the curriculum in order to prepare graduates who can practice nursing at the level currently accepted as professional. Progress in this area has already been made. University schools of nursing have incorporated the teaching of additional assessment skills into their baccalaureate programs and many are revising their curriculums in order to reflect a broadened concept of nursing. Diploma schools of nursing have enlarged the scope of their curricula so that graduates will be able to move out of their traditional roles and into the community. However. some schools seem to have done this to a greater degree than others and collaborative effort needs to be made to standardize programs across the country and arrive at standards which are uniform to all nursing graduates. The problem ofreahty shock is still with us. As yet there is still little effort being put into building a support system which could facilitate the students' transition to the work setting. In many cases the biases. priorities and role images of the educators are academic or disciplined-focused rather than utilization-focused. 16 It is the responsibility of nursing educators to build the role of the educator as a link to the delivery system. 17 Greater utilization Once the role of the nurse practitioner is clearly defined. the functions specifically stated. the activities objectively evaluated, the educational preparation analyzed. then and only then can some of the practical barriers and resistance to the utilization of the nurse practitioner be removed. How will this happen? Only through nursing research of varied approaches and in various locations that demonstrate the vital and desirable contribution that nurse practitioners can make to primary health care. Adequate funding will only be obtained when nursing can approach governments, health departments. community health centers and general practitioners with precise facts and data validating both the economic rewards and the quality of care gained by utilization of the nurse practitioner. Of course. in order to conduct such research projects. funding is necessary. Therefore. the interest and impetus that was behind the nurse practitioner concept in the early 1970's will have to be revived. This means not only exerting political pressure on governmental structures but also gaining public support. This may be difficult to do because nursing has never done a very good job of "selling itself' to the consumer. Somehow. the idea that our services are a commodity to be bought by the public has been repugnant to the profession as a whole. But this is in fact the situation that nursing - among other health professions - is finding itself in. Ifwe feel that nurses in primary care have a vital and desirable service to offer then we must also convince the community of this. if we are to be allowed to provide this service. Polish the image I feel that nursing has in recent years alienated itselffrom the general public partially through putting increasing emphasis on remuneration and financial benefits. This is not to say that adequate financial rewards for nursing services are less than important. But the problem it seems to me is that the public is still unaware of exactly what nursing does for them. what it has to offer. They have to know why we're worth more. The nursing profession must direct itself to becoming more tuned into the public and tuning the public into them - its members must increase contact through public education and the media in order to gain acceptance and support for the expanded role of the nurse. Licensing and accreditation including removal of some of the legal restrictions on nurse practitioners can only be commenced once the functions and expectations of the role are more clearly defined. How can someone be licensed for something if it isn't clear what that "something" is. 44 SepI","ber 1879 The Can-.llen Nurae Research and more research The resol ution of these problems - financing and licensing - will be the greatest contributors to acceptance of nurse practitioners and thus to their utilization. But research must come first. Although not all barriers contributing to the underutilization can be laid directly at nursing's door, it seems to be that nursing itself has been the biggest obstacle in gaining utilization of the nurse practitioner. If the issue of the u nderutilization of these health professionals is ever to be resolved, then nursing must pull itself out of its lethargy and apply the problem-solving process, beginning with research. It is time to collect sufficient data on a number of unresolved issues. for instance: . the name to be used to refer to nurses working in each expanded role in the primary care setting (nurse practitioner or otherwise); . the conflicting philosophies and discord within the profession itself as to what a nurse practitioner is, does, or should be; . professional territoriality and its influences on expansion of roles; . the traditional image of the nurse and its contribution to resistance to change; . the effective identification and utilization of the process of change itself; . licensure of the nurse practitioner and examination of the legal aspects of expanded role nursing with the view of protecting individuals engaged in this form of practice; . minimum education requirements for primary care nursing, mechanisms to ensure the quality of the educational programs and mechanisms to ensure the quality of graduates ofthese programs; . funding and guidelines for the social and economic welfare of nurses working in expanded roles; . lack of awareness on the part of physicians, administrators and consumers. It has been too easy in the past to blame the physician, the consumer, the government or the system when, in fact, responsibility for resolution of these problems rests squarely on "nursing shoulders"! The nurse practitioner is an idea whose time has come. And with it, I believe our time has come, as nurses, to not only improve the quality of health care in Canada but to open up a challenging and rewarding field for our profession. Let's not miss our opportunity! 'iii References I Primary Health Care. Ajoint report by the director general of the World Health Organization and the executive director of the United Nations Children's Fund. WHO, Geneva, 1978. p.2. 2 Sackett, D.L. The Burlington randomized trial of the nurse practitioner: health outcomes of patients. Annals of Int. Med. 80:137-142, 1974. 3 Musgrave, Corrine. The nurse with something extra may soon be phased out in Ontario. T orontoGlobe and Mail. Sept.2, 1976. 4 Lewis, Edith P. Editorial: nurse practitioner the way to go? Nurs.outlook. 23:3:147, Mar. 1975. 5 Ibid. 6 Canada. Dept. of National Health and Welfare. Committee on Nurse Practitioners. Report. 1972. 7 Bloom, B.S. Handbook on formative and summative evaluation of student learning, by... et al. Toronto, McGraw-Hili, 1971. 8 Hayes, Patricia. Competency criteria for nurse-midwifery, a methodological study. Edmonton, 1974. Thesis (M.H.S.A.). 1973. 9 Hazlett, C. B. Evaluation on formative and summative evaluation of student learning. by... et al. Toronto, Canad.Med.Ass.J. 108:1282-1287, passim, May 19, 1973. 10 Hazlett, op. cit. p.703. II Ibid., p.708. 12 Herzog, Eric L. The underutilization of nurse practitioners in ambulatory care. Nurse Pract. 2:1:26-29, Sep/Oct. 1976. 13 Manthey, Marie. Primary nursing, by... et al.Nurs. Forum. 9:1:64-83, 1970. 14 15 16 17 Ibid. Ibid. Herzog, op. cit. p.28. Ibid., p.28. Maureen McTavish (B .N., University of Calgary) is presently working as a staff nurse in obstetrics at the Prince Rupert Regional Hospital in British Columbia. She states, "From the beginning of my nursing education I have been drawn to the concept of the nurse practitioner. In my final year at the University of Calgary in 1977, I had an opportunity to research and write a rather extensive paper entitled The underutilization of th{ nurse practitioner. I found it to be a very complex issue." The present article, The nurse practitioner: an idea whose time has come, is a condensed 'ersion of the longer paper. - - ), \J NURSING 1M E \S NURsE f OUT 1 Th. Cen-.llen Nur.. ;. f1 Within a nursing department the is'iue of staffing evokes universal interest, but from different points of view. The nursing administrator focuses on adequate coverage to provide cost-effective quality patient care while meeting contractual obligations. The staffnurse's focus is on the time schedule which best allows for her private as well as nursing life: specifically. the number of weekends off, split days off, evening and night shifts, etc. We decided to work at creating a time schedule that would reflect everybody's needs. The trial was conducted on the newly-created 34-bed inpatient Rehabilitation Unit which was staffed by 12 R.N. 's and 5 R.N .A. 's. Our experience with rehabilitation nursing in an acute care setting was limited, and we recognized that we could not automatically assume that what worked for other inpatient units would work here as well. We had to be creative and flexible in responding to this nursing unit's particular needs. Our timing was good: the unit had been functioning for only eight months which Was long enough for the initial settling in to have taken place, but recent enough that the staff was comfortahle in trying out new ideas. Objectives Before creating a new staffing pattern we discussed the specific goals we hoped to achieve. These needs, as expressed during our initial planning sessions, included the following: . to concentrate coverage at those times of the day when the most nursing intervention was required; SepI_1871 45 In these times of result-oriented planning, a group of nurses at Mount Sinai Hospital in Toronto discovered that the process of working out a problem can sometimes be as useful as the solution itself. Here is what these nurses learned when they experimented with a new method of stamn . . to provide learning opportunities for increasing nursing knowledge of the rehabilitation process; . to increase involvement of those working evening shifts in day activities. and to provide a smooth transition from day to evening coverage; and . to meet the staffs requests for fewer shift changes, more weekends off duty, extended shifts - and extended time off. To meet all these very worthwhile objectives was a definite challenge to our ingenuity. After much discussion we decided to utilize both eight and twelve hour shifts in the one staff rotation. This would provide us with the flexibility needed to achieve the diverse goals we had set for ourselves. (See figure one) Planning The use of the twelve hour shift is well-documented but we planned to use it in a slightly different way. Our twelve hour shift would be predominately an evening shift. This would allow for increased contact between day and evening staff, a greater number of staff during two of the three mealtimes, increased numbers available for afternoon educational and rehabilitation therapy sessions, and increased time for nursing conferences. We also used longer periods of shift work than was normal practice in our hospital. The nursing staff were to be on twelve hour day and evening shifts for blocks offour weeks. This measure was meant to meet the staffs request for fewer shift changes. However, the concept was in violation of our collective agreement with the Ontario Nurses Association, which did not allow for more than two weeks of shift work .. without a period of days. The staff petitioned their association for permission to use this new approach and permission was granted. The proposal in its final form was presented to the Registered Nurses whose response was, on the whole, favorable. It fulfilled many of their requests and they understood that the new schedule could provide for more effective patient care and staff education. It was agreed that the new schedule would be tested for a three-month period and then be evaluated by all concerned. Working it out The transition to the new schedule and adaptation to the extended shift was rapid. probably due to the staffs enthusiasm for change. However, as time passed it became apparent that the new schedule was not meeting the goals we had projected for it. We attempted to examine the problems as they arose and resolve them as best we could. One of the major problems - and one that was not specific to this unit - was that the registered nursing assistants could not, according to their union contract, work the extended shift. This meant that there were in fact two parallel systems working at the same time: the traditional eight hour shifts and corresponding reporting times, and the twelve hour shifts and their reporting times. Consequently. the nurses felt they were spending much of their time receiving or giving reports. The rhythm of neither the eight nor the twelve hour shift established itself satisfactorily. A problem that is always difficult to overcome when instituting change is that The Can-.llen Nur.. FIGURE ONE 4-WEEK TIME SCHEDULE (schedule rotates downward) Dates Su MTu WTh F Sa Su MTu WTh F Sa Su M Tu WTh F Sa Su MTu WTh F Sa R.N. n n n x x n n n n n n n x x x n n n x n n n n n n @x x R.N. d x @)d d d x x d d x x d d d d d d n x x x x d d d d d R.N. d x x E E E x x x x x E E E e x x E E E x x x x x E E E R.N. x d d@) x d d d d x d d d x x x d d d d d d x d d d d x R.N. x E E E x x e E E E x x x x x E E E x x e E E E x x x x R.N. s d d n n x x x x d d d d d d x d d d d x x d x d d R.N. E E e x x x x x E E E x x E E E e x x x x x E x x E R.N. e e x x d d d d x d d d d x x d d@) x d d d d x x d n n R.N. x x x x E E E e x x E E E x x x x x E E E e x x E E E x R.N. x D D D x x D D D e x x x x x D D D x x D D D e x x x x R.N. x x D D D d x x x x x D N N n x x D D D x x x x x D D D R.N. D x x d D D x x x x x D D D D x x d D D x x x x x D D D 4S September 1179 Name Permanent night shift 12 R.N.'s Code: N 12 hour night (1930-0745) n 8 hour night (2330-0745) D 12 hour day (0730-1945) d 8 hour day .(0730-1545) E 12 hour evening (1130-2345) e 8 hour evening (1530-2345) s statutory holiday o possible position for statutory holiday x day off of tradition: expectations develop as a result of what has been experienced in the past. In this situation. the expectations of both patients and staff had to be considered. A patient on a Rehabilitation U nit has usually had an extensive period in hospital prior to his arrival and has developed expectations as to how his day will progress. He has come to know that patients always have their baths first thing in the morning, followed by having their beds made. Nurses seem to know that too, regardless of what their common sense may tell them! The discomfort that is caused by not meeting these expectations, by nót following the traditional pattern, is intensified by the expectations of those around us. Accordingly, it was difficult to change times for baths and other routine aspects of patient care to correspond with the periods of increased staff. The new staffing pattern also posed difficulties for Þoth the internal staffing of the unit and the external staffing of the hospital in toto. If a nurse working the twelve hour evening shift is going to be absent, how can you replace her when this shift is not being used anywhere else? If you have a shortage in the morning which can be alleviated by the twelve hour evening shift's arrival, do you choose to overstafffor the rest of the shift, or ask a nurse to change nursing units in the middle of the day? These questions were never satisfactorily resol ved, and our goal of making effective use of human resources was not met. I n practise, the nurses did not find they were using the afternoon overlap effectively. They became involved with their patients and found it difficult to extricate themselves for conferences, rehabilitation therapy sessions and the like. This is not a new problem in nursing, but it remains a thorny one all the same! Looking back The three month trial was completed and the schedule was re-assessed. It was the feeling of both the unit nursing staff and nursing management that the schedule had not achieved the specified goals. As neither group was satisfied with the results it was an easy matter to revert to the traditional eight hour shifts and from that position to determine how the Rehabilitation Unit's goals could be better met. Although the exercise had proved to be a failure in a general sense, there were certain benefits derived from the attempt. The unit staff were pleased that the nursing administration had responded to their concerns and had been willing to try innovative ways to meet their needs. The staff also felt very much involved in the change process and at no time were there complaints that "N ursing Office" had arbitrarily inflicted the new system on them. It also reinforced for us, as managers, the idea that what seems to work on paper does not necessarily work in practice! Our experience and even our mistakes helped us to accept the fact that failures can oCCUI whenever new approaches are tried out, but the admission offailure need not be negative. Our efforts may also be of use and encouragement to others who are interested in trying innovative staffing methods to solve the diverse and difficult problems with which we are constantly being confronted. 'iii The author wishes to express her appreciation to Mrs. M. Kerr, Head Nurse. Mount Sinai Hospital, who was instrumental in the development of this project. Mrs. E.M. Rice, associate executive director-nursing. also provided valuable advice. AUison J. Stuart. R.N., B.S c.N., D.H.A . was the surgical coordinator at Mount Sinai Hospital, Toronto, when she wrote this article. She is currently the executive assistant to the associate executive director - nursing at the same hospital. Tilkian & Conover Understanding Heart Sounds and Murmurs The 1979 Saunders Winners Circle Watson Medical-Surgical Nursing and Related Physiology 2nd Edition Thoroughly revised, this new edition includes the latest in- formation on topics ranging from patient's rights, response to illness and physical assess- ment -to immunologic response, shock and much more. The chapters on cardiovascular disease and the nervous system have been extensively revised. An excellent choice for those preferring a smaller medical-surgical text. By Jeannette E. Watson, RN. MScN, Prof. Emeritus. Faculty of Nursing. Univ. of Toronto. Toronto. Can Abou11045 pp., 175 ill. About 523.40. Ready soon Order *9136-6. Here's an exciting new pack- age that provides a basic familiarity with normal heart sounds and allows recogni- tion of life-threatening disorders manifested by abnormal heart sounds. Pack- age includes C-60 cassette pi us soft cover book. By Ara G. Tilklan, MD. FACC, Asst. Clinical Prof. of Medicine (Cardiology). Univ. of Cali- fornia School of Medicine, Los Angeles; and Mary Boudreau Conover, RN. BSN, Ed.. Inslructor of Critical Care Nursing and Advanced Arrythmia Workshops. West Hills Hospital and West Park Hospital. Canoga Park. CA Book only: 122 pp. IIlustd. Soft cover. 510.75. April 1979. Order *8869-1. Package: 520.35. Order *8878-0. Dienhart Basic Human Anatomy and Physiology 3rd Edition The new third edition of an already popular text has been revised with special attention to the chapter on the nervous system and includes expanded coverage of cytology and histology, an expanded glossary and out- standing new illustrations. By Chartotte M. Dienhart, PhD, Asst Prof. of Anatomy and Assoc. Prof. of Allied Health Professions. Emory Univ. School of Medicine. Krause & Mahan Atlanta. GA. 311 pp.. 171 ill. 511.40. Soft cover. April 1979. Order Food, Nutrition and Diet Therapy *3082-0. 6th Edition Drain & Shipley Featuring new material on stress responses, nutrition The Recovery Room and cancer, and the low-birth-weight infant, this strong Two leading experts provide clear, accurate coverage of revision is even better suited to your needs. Many new the recovery room in this exciting new book. Topics graphs, illustrations and tables highlight the text and include the physiology of anesthesia, the effects of enhance better understanding of all aspects of nutrition. various anesthetic agents, specific care after all types By Marie V. Krause, BS. MS. RD. Formerly, Dietitian in Charge of of operations, and factors that affect recovery from Nutrition Clinic. N.Y. Hospital; and L Kathleen Mahan, RD. MS, anesthesia in particular patients. Lecturer. School of Nutritional Sciences and Textiles. Univ. of By Cecil B. Drain, RN. CRNA. BSN. Major. Army Nurse Corps., Univ. Washington. Seattle. 963 pp.. 254 ill. 522.20. Jan 1979. Order of Arizona. Tucson; and Susan B. Shipley, RN. MSN, Major, Army *5513-0. Nurse Corps., Nurse Researcher. Walter Reed Army Medical Center, Washington. DC. 608 pp.. 167 ill 520.35 March 1979. Order *3186-X. -------------------------------- I Toordertilieson3O-daY8DDrOvai Please Print" CN 9/79 enter order number a nd author I I I I I I Expiration Date Interbank # DODD I L__ Keane Essentials of Medical-Surgical Nursing You'll find coverage of the general concepts related to illness and nursing as well as medical-surgical nursing care problems in this introductory text. Student aids include: learning highlights; vocabulary lists; summary tables; and a student study aid section consisting of learning activities, additional readings, and a study outline. By Claire B. Keane, RN. BS. MEd, Formerly, Dlreclor of NUr1>lng Education and Instructor in Medical-Surgical Nursing. Grady Memorial Hospital. School of Nursing. Atlanta. GA 721 pp.. 187 ill. 520.35. April 1979. Order *5313-8. Bleier Bedside Maternity Nursing 4th Edition This new edition includes new and updated material, a new chapter on economic and social problems of the modern family, and current issues in maternity care. By Inge J. Bleier, RN. BS, MS. Asst. Prof. Maternity Nursing. DePaul UniV. 362 pp.. 160 ill. 510.75. May 1979. Order *1743-3. I I I I I I I P.O. Box 207, Philadelphia, PA 19105 I 1 Goldthorne Avenue Toronto Ontario MBl 5T9. Canada .J T Sf Anne S Road. Easfbourne. East Sussex BN21 3UN. England. _ _ _ 9 Waltham Street Artarmon NSW 2064 Australia Position and Aff,lIatoon (if Applicable) I Home Phone Number I I I I Full Name AU AU AU o check enclosed-Seunders pays postage We accept Visa and Mastercharge -=- 'WiI1! o Visa # DODD ODD ODD DOu o Master Charge # DODD DODD [DO ODD Home Address City State ZIP Signature All prices differ ouTside U Sand subjecl to cha,'ge Frankly speaking A Challenge in Office Nursing Betty Kowalchuk If there is any group of nurses in the profession who appears to the public as a 'handmaiden to the doctor', it has to be the office nurse. Her peers look upon her as having a 'cushy' job, with little responsibility, and her medical employers do not tend to encourage her initiative. Betty Kowalchuk believes the office nurse is as interested in quality patient care as any other nurse. and she sees a new and expanded role for her: the nurse co-ordinator. -, r - I .. ,t ,. \ Kowalchuk: (getling angf}'JLook, you don't just tell me that my daughter is a diabetic and then act vague. There's urine testing, diets, more blood sugars and so forth. I'm a nurse. I do know a little bit. What comes next?! - - - ... - rl '2 " J: Ö " > " -; o '"' " 1: " 8 o l c.. . - r- Pause , Receptionist: Just a minute. please. J 1 I, FÙ'e minutes later. Doctor: Yes, Mrs Kowalchuk, Sheila's blood sugar is 265, she's definitely diabetic. She's only 17, so she should start on insulin right away. Kowalchuk: What about a trial diet? She's not a small child. My 17-year-old daughter had had a number of unusual symptoms over the past few weeks: constant thirst, numerous trips to the bathroom, and others. I decided to !o.end her to our family doctor to have a routine blood sugar test done. The day after her visit, I called the physician's office a"king for the results, and this is what ensued: Doctor: How long has she had her full growth? Kowalchuk: About two years. Doctor: Okay, I thmk we can try diet for awhile. (Pau.çe) I hate 10 admit this, but I looked up her record for January (Sheila had had cy.uitis then) and there was a trace of sugar in the urine. I'm afraid I over- looked it because I wasn't looking for sugar, just a sign of infection. I'm sorry about that; as soon as I saw the white cell count I didn't look further or think it necessary 10 see her personally. Kowalchuk: I'm calling about Sheila's blood sugar. Receptionist: Just a moment. please. Sneral minutes ofhemg On Hold later Yes her blood sugar was high. Dr. .....- says that Sheila is definitely diabetic and will nt'ed treatment. Another slight pause and then. as if talking to himself LONG Sf LENCE Kowalchuk: Well, what comes next? I really should interview every patient; the chance of overlooking anything would be much less. Receptionist: Well, I guess he'll want 10 see her. The point of repeating that whole telephone conversation is not to blame my family physician: he is far from stupid but he is just too busy to remember everything, all the time. The point is that I feel there is a place in family medical care, in doctors' offices or clinics or whatever, for a new type of The Cen-.llen Nurae September 1171 41 nurse - the nurse co-ordinator. I see an urgent need for specially trained RN's in these areas, nurses who would coordinate a patient's problem from start to finish, keeping track of his progress from family doctor to specialist or lab and back again, and following up after treatment or surgery. Aside from speeding up matters, the obvious advantage to this type of service would be the alleviation of patient anxiety. Every nurse has a few horror stories to tell about patient mismanagement - missed diagnoses, treks from specialist to specialist, and the long anxious waits for lab results. I sat down to supper one evening in the hospital cafeteria with an ICU nurse who described her own trial and error experience in trying to discover the cause of constant rectal bleeding. She could not understand how her problem could be so easily dismissed time after time, with no suggestion (If follow-up. She said she finally gave up, and tried to live with the problem for a few months until the problem got still worse, and she went to another doctor and then another surgeon. Finally the diagnosis of a rectal fistula was made and the recommendation of immediate surgery, but by then she was so confused and upset that she refused. She would decide in her own time, she said. Now, I'm sure this nurse wouldn"t have chosen to ignore a serious health problem for months: it was only that nobody showed any interest. My own harrowing experience of ten months duration began with a complaint of severe pain in one toe of my foot and ended by my finally getting a diagnosis of periostitis and having the toe partially amputated. Along the way, I was passed from specialist to specialist, received recommendations to try chiropractic, acupuncture, biofeedback, and once even the suggestion that perhaps a psychiatrist could help. I see here in all these personal experiences, in all the stories I hear, a real need for a special kind of nurse who can step in and coordinate the communication between doctor and patient; someone who can prevent the traumatic and frustrating medical merry-go-round ride that so many people find themselves on. What would the nurse coordinator do? First of all, let me point out that she should in no way be confused with the nurse practitioner, who has often to diagnose and treat on her own. The nurse coordinator would function strictly as a liaison, taking the responsibility of directing pertinent information to the doctor, and of explaining same to the patient. This person would have to be interested, sympathetic, knowledgeable, efficient and responsible. Working in a family pmctice office, for a pediatrician, or in a clinic, her job would be to follow up on those patients who have not been immediately diagnosed. She can relieve a patient's anxiety by keeping him up-to-date on his test results, and making sure he keeps his appointments with specialists, labomtory and radiological facilities. Patients who have had treatment also require some sort of follow-up. A phone call just to say "How are you, how are things coming along?" can be the stage at which possible future problems are recognized, as well as giving the patient that much needed 'somebody cares' feeling. Is this a 'pie-in-the-sky' idea? Am I naive in thinking that medical practitioners could be sold on the idea of expanding the role of the office nurse? There are some advantages for the physician such as improved coordination of patient care, and generally a better grip on the responsibility of a heavy patient load, but is that enough? Will the busy family doctor who hardly knows which end is up after a long day admit he needs help? Not a half-trained receptionist, but a nurse who is interested in communication and patient care? When I told my family doctor that I had eventually had to have surgery he simply said, "Well. it doesn't matter how the problem was diagnosed; as long as it was eventually straightened out, that's all that matters." I don't agree. I think something can be done to eliminate the frustration, confusion and omissions that occur, and I think nurses are the key. The office nurse should be more than a typist and telephone answering service. I think she can be a person of extreme value. Is this a real solution? Is there anyone in a position to do anything about it? Is the nurse coordinator a practicable idea? Nursing education tries to focus on the practical application of nursing skills but I don't think there is a course anywhere on Office Nursing. Perhaps it's time there was. .. Betty Kowalchuk is a graduate of the Brantford General Hospital. and has a diploma from the Margaret Hague Maternity Hospital. N.J. She was head nurse in the Case Room at Toronto East General Hospital prior to hadng her own family; she works now at TEGH as a general duty relief nurse. 110 September 1879 The Can-.llan Nur.. library update NOTE: Readers are reminded that they should check first ..ith the library of their provincial nurses association, university or coUege, to determine whether they may obtain the puhlkatlon(s) they require from this source. Publications recently received in the Canadian Nurses Association Library are available on loan - with the exec pI ion of items marked R - to CNA members, schools of nursing. and other institulions. r; - Items marked R include reference and archive material that does not go out on loan. Theses, also R, are on Reserve and I!O out on Interlibrary Loan only. Requests for loans, maximum 3 at a time, should be made on a standard I nterlibrary Loan form or by letter giving aulhor. title and item number in this list. If you wish to purchase a book, contact your local bookstore or the publisher. ït either a case of acute laryngitis or an obscene caU.." deq S!giOBe It's more than good-tasting, it's good medicine. Antibacterial, antifungal lozenges \GlI G/axo Laboratories v A GLAXO CANADA LIMITED COMPANY .U1"'t"!:.'I "\lt"'ut UH', "ko( '-"to "\1\1 ,D Product monograph available on request. Books and Doc:umenu I. American Nurses' Association. Council of Nurse Researchers. Information package. Kansas City, Mo. 1978. 9 parts in Iv. Contents. - I. ANA By-laws to June 1978. - 2. Human righls guidelines for nurses in clinical and other research. -3. The ANA and research in nursing, reprint from Nursing Researchers. - 4. Nursing Administration Quarterly v.2 no.4, summer 1978. - S. Research in nursing. - 6. Preparntion of nurses for participation in research. - 7. Priorities for research in nursing. - 8. List of Executive Committee. - 9. Members of Commission on nursing research. 2. Anderson, Peggy Nurse. N.Y.. SI. Martin's Press, cl978. 311p. 3. Association des Hôpitaux de la Province de Québec. La révision de la loi sur les services de santé et les services sociaux (L.Q. 1971, c.48) et sujets connexes. Montréal, 1978. 82p. 4. Baldwin. Linda Mobile intensive care; a problem-oriented approach, by...and Ruth Pierce. Toronto, Mosby, 1978. 329p. S. Bazowski. Peter Report on VancouverGenernl Hospilal. Vancouver, 1978. Iv. looseleaf 6. Bergerson, Belly S. Pharmacology in nursing, by...andAndresGolh. 14th cd. St. Louis, Mosby, 1979. 779p. 7. Berry, Edna Cornelia Introduction to opernting room technique, by...and Mary Louise Kohn. Sth ed. Toronto, McGraw-Hili, cl978. SS8p. 8. Brown, Jack Harold Upton The health care dilemma; problems of technology in health care delivery. New York, Human Sciences Press, cl978. 183p. 9. Butnarescu. Glenda Fregia Perinatal nursing. Toronto, Wiley, 1978. 296p. 10. Cancer nursing; medical. Edited by Robert Tiffany. Boston. Faber and Faber, c1978. I9Op. I I. Childbearing: a nursing perspective. by Ann L. Clark and Dyanne D. Alfonso. 2d cd. Philadelphia. Davis, cl979. IOS2p. 12. Chinn. Peggy L. 1941- Child health maintenance; concepts in family-centered care. 2d cd. Toronto, Mosby, 1979. 934p. 13. -. Child health maintenance; a guide 10 clinical assessment. by...andCynlhiaJ. Leitch. 2ded. Toronto, Mosby, 1979. IS7p. 14. Comment lire les états financiers; un guide pratique pour les investisseurs. Montréal, L'institut canadien des valeurs mobilières, cl977. 43p. IS. Commonwealth Nurses Federation. Background papers. Meeting of Commonwealth National Nurses Association, Imperial Hotel, Tokyo, 29 May 1977, London. Iv. (various pagings) 16. Comprehensive pediatric nursing, by Gladys M. Scipien...et aI. 2d ed. Toronto, McGraw-Hili, c1979. l092p. 17. Distributive nursing prnctice: a syslems approach to community health. Edited by Joanne E. Hall and Barbara R. Weaver. Toronto. Lippincott. c 1977. S36p. 18. Elder. Jean Transactional analysis in health care. Don Mills, Ont., Addison- Wesley, c 1978. 17Sp. /9. Emergency first aid: safelY oriented. 1st Canadian cd. Ottawa, St. John Ambulance, The Priory of Canada of Ihe Mosl Venernble Order ofthe Hospital of St. John of Jerusalem, cl977. 136p. 20. Freeman, HowardEdgar. 1929- ed. Handbook of medical sociology, by...et aJ. 3d cd. Englewood Cliffs, N.J., Prentice-Hall, cl979. S16p. 21. Future directions in health care: a new public policy. Edited by Rick J. Carlson and Robert Cunningham. Cambridge, Mass.. Lippincott. cl978. 239p. 22. Gout: a clinical comprehensive. Research Triangle Pack, North Carolina, Burroughs Wellcome, cl971. 91p. 23. Groer, Maureen E. Basic pathophysiology; a conceptual approach, by.. .and Maureen E. Shekleton. Toronto, Mosby, 1979. S24p. 24. Holloway, Nancy Meyer. 1947- Nursing the critically ill adult. Don Mills, Ontario, Addison-Wesley, cl979. S98p. The c.n-.llen Nur.e Seplember 1171 51 Keep up with the NEW and the NOW in Nursing Update your clinical skills with these new books 1 New! OPERATING ROOM TECHNIQUES FOR THE SURGICAL TEAM. A comprehensive reference for practicing operating room nurses, this book is designed to present overviews of the major surgical procedures, including relevant anatomy, indica- tions for each procedure, and the related nursing obligations. By L. c. Crooks, R.N. Little, Brown. 459 Pages. Illustrated. 1979. Paper, 115.00. Cloth, $21.00. 2 New! PERSPECTIVES ON ADOLESCENT HEALTH CARE. Here at last is a text that not only presents the major ideas and issues on this subject; it provides many clinical examples and offers valid suggestions that can be put to use in a variety of clinical settings. By R. T. Mercer, R.N., Ph.D. Lippincott. 420 Pages. 1979. $15.50. 3 New! NURSES' HANDBOOK OF FLUID BALANCE, 3rd Edition. It presents basic knowledge of body fluid balance distur- bances, with emphases on practical applicah"on. By N. M. Metheny, B.S.N., M.S.N., Ph.D.; & W. D. Snively, Jr., M.D., F.A.C.P. Lippincott. 406 Pages. 1979. 115.00. 4 New! MANUAL OF PEDIATRIC NURSING CAREPLANS. This handy spiralbound manual will help nurses in all areas of prac- tice to provide total care for the sick child as a member of the family. The Hospital of Sick Children. Little, Brown. 347 Pages. Illustrated. 1979. $15.00. 5 New! PHARMACOLOGY AND DRUG THERAPY IN NURSING, 2nd Edition. In addition to the inclusion of several new chapters, every chapter in the first edition has been extensively revised; some have been expanded into complete sections! By M.J. Rodman, B.S., Ph.D.; & D. W. Smith, R.N., M.A., Ed.D. Lippincott. 1085 Pages. 1979. 126.00. 6 New! GERONTOLOGICAL NURSING. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. By C. K. Eliopoulos, R.N., B.S., M.S. Harper & Row. 384 Pages. 1979. 115.00. 7 New! PRIMARY CARE ASSESSMENT AND MANAGE- MENT SKILLS FOR NURSES: A Self-Assessment Manual. This unique manual provides a self-evaluation in physical assessment, medical management of diseases, health counseling, and coordina- tion of community resources for health promotion. By M. Frank- Stromborg, R.N., Ed.D., N.P.; & P. M. Stromborg, M.D. Lippincott. Abt. 500 Pages. 1979. Abt. $20.00. 8 New! HIGH-RISK PARENTING: Nursing Assessment and Strategies for the Family at Risk. High-Risk Parenting has a two- fold purpose: to identify family difficulties resulting from situa- tions that place a child or a parent at risk; and to suggest nursing strategies for preventing and reducing these family problems. By S. Ii. Johnson, R_N., M.N. With 24 Contributors. Lippincott. 424 Pages. 1979. $17.75. 9 New! CARDIAC REHABILITATION: A Comprehensive Nursing Approach. It covers the realm of cardiac rehabilitation in its enh"rety-from hospital admission to hospital stay, and from out-patient follow-up through life-long health maintenance. By P. M. Comoss, R.N., C.C.R.N.; E. A. S. Burke, R.N., C.C.R.N.; & S. H. Swails, R.N. Lippincott. Abt. 250 Pages. 1979. Abt.116.00. 10 New! A GUIDE TO PHYSICAL EXAMINATION, 2nd Edition. New chapters on interviewing and history-taking, and much expanded and updated content mark the new edition of this outstanding guide to physical assessment for health practi- tioners. By B. Bates, M.D. Lippincott. 440 Pages. Illustrated. 1979. $27.00. 11 MATHEMATICS FOR HEALTH PRACTITIONERS: Basic Concepts and Clinical Applications. Through a simple ap- proach to conversion called "the equation method", this important new text helps dispel the "math anxiety" that most students experi- ence when having to deal with numbers. By L. Verner, Ph.D. Lippincott. 165 Pa.\:es. 1978. $7.50. 12 New! TEXTBOOK OF HUMAN SEXUALITY FOR NURSES. From its opening chapter to its closing pages of questions and answers, this text effectively incorporates human sexuality into nursing practice at a level that can be understood by both practicing and student nurses. By R. C. Kolodny, M.D., et al. Little, Brown. 450 Pages. Illustrated. 1979. Paper, $15.00. Cloth, $21.00. 13 New! NURSING MANAGEMENT FOR PATIENT CARE, 2nd Edition. Important new features include reports on recent theories of management, a deeper explanation of the nurse mana- ger's relationship with staff members, and discussions of the expan- ding role of the nurse manager. By M. Beyers, R.N., Ph.D.; & C. Phillips, R.N., M.S. Little, Brown. 292 Pages. llIustrated. 1979. Paper, $10.75. Cloth, $15.50. 14 New! COMMUNICATION FOR HEALTH PROFESSIONALS. This timely book identifies and describes problem situations stemming from communication breakdowns that commonly affect health care personnel. By V. M. Smith, Ph.D.; & T. A. Bass, M.A. Lippincott. 238 Pages. 1979. $7.50. 15 THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 2nd Edition. This monumental second edition of a modern classic incorporates massive revision and updating to offer the latest and most accurate information available. By L. S. Brunner, R.N., B.S., M.S.N.; & D. S. Suddarth, R.N., B.S.N.E., M.S.N. With 9 Contri- butors. Lippincott. 1888 Pages. Illustrated. 1978. $29.95. 16 New! CLINICAL GERIATRICS, 2nd Edition. New chapters in the Second Edition include discussions of the aging kidney, the lung, the female reproductive tract, and the oral cavity; also sexual functioning and noninvasive diagnostic technology. By 1. Rossman, M.D., Ph.D. With 43 Contributors. Lippincott. 704 Pages. mustrated. 1979. 145.00. 17 NURSES' DRUG REFERENCE. Finally, a fingertip guide to drugs organized with the nurse's needs in mind. More than 500 drugs, listed alphabetically, are described in a consistent, easy-to- consult format that includes the drug's action and use, dosage and administration, cautions, adverse reactions, composition and supply and legal status. Edited by S. M. Brooks, M.S. Little, Brown. 625 Pages. 1978. $14.50. LIPPINCOTT'S NO-RISK GUARANTEE Books are shipped to you On Approval; if you are not entirely satisfied you may return them within 15 days for full credit. --------------------- J. B. LIPPINCOTT COMPANY OF CANADA LTD. 75 Homer Ave., Toronto, Ontario M8Z 4X7 o Bill me (Plus postage and handling) o Payment enclosed (Postage and handling paid) Please send me on 15-day approval the book(s) whose number(s) I have circled below. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Name Address City Postal Code Prices subject to change without notice. 1____ ____ ____ _____ c:!!.9/7 !!.-J Provo 112 September 1171 The c.n-.llen Nur.. 2 . Kinsbourne, Maral Children's learning and attention problems, by...and PaulaJ. Caplan. Boston, Little, Brown, c1979. 300p. 26. Kneisl. Carol Ren, 1938- Mental health concepts in medical-surgical nursing; a workbook, by...and Sue Ann Ames. 2d ed. Toronto. Mosby. 1979. 163p. 27. Kozier, Barbara Blackwood Fundamentals of nursing; concepls and procedures, by...andGlenora Lea Erb. Don Mills, Ont., Addison-Wesley, 1979. 98Op. 28. Kubler-Ross. Elisabeth To live until we say good-bye. Englewood Cliffs. N.J.. Prentice-Hall, c1978. 16Op. 29. McGraw-Hili handbook of clinical nursing. Edited by Margaret E. Armstrong ...et al. Toronto, McGraw-Hili, c1979. 1474p. 30. McGrory, Arlene A well model approach 10 care of the dying client. Toronto, McGraw-Hili, c1978. 18Op. 31. Moir, Donald D.. Pain relief in labour; a handbook for midwives. 3d ed. New York. Churchill Livingstone, 1978. 122p. 32. Morris, Dwight A. Health care administration; a guide to information sources. by...and Lynne Darby Morris. Michigan.Gale Research. c1978. 264p. R 33. Nursing care in eye, ear, nose and throat disorders, by William H. Saunders et...al. 4th ed. Toronto, Mosby, 1979. 2Op. 34. O'Brien, Mary T. Total care ofthe stroke patient. by...and PhyllisJ. Pallett. Boston. Little, Brown.cI978.379p. rete ast The first and last word in all-purpose elastic mesh bandage. .ø= r- t/ ':::::' 1' ;;,.. .:::. Quality and Choice . Comfortable, easy to use, and allergy-free. Widest possible choice of 9 different sizes (0 to 8) and 4 different lengths (3m, 5m, 25m, and 50m). : .. . .. _. r . " --... ..... Highly Economical Prices Retelast pricing isn't just competitive, it's flexible, and can easily be tailored to the needs of every hospital. "'#I'W- .. - . -<''fr ..... Technical training . Training and group demonstrations by our representatives . Full-colour demonstration folders and posters . Audio-visual projector available for training prograYJ1mes . Continuous research and development in cooperation with hospital nursing staff For full details and training supplies, contact your Nordic representative or write directly to us. (]J (f:J@[;J@)O@ LABORATORIES INC 217 Bovel St . P 0 Bo. 403 Chomedey Laval P Q H7S 2A4 3 . OSlrea, Enrique M. The careofthe drug dependent pregnant woman and her infant, by...et al. Lansina. Mich., Michiaan Department of Public Health, 1978. 83p. 36. Phipps, WilmaJ. ed. Medical-surgical nursina: concepts and clinical practice, by...et al. Toronto, Mosby. 1979. 1634p. 37. Polit, DeniseF. Nursing research: principles and methods. by...and Bemadelle P. Hungler. Toronlo, Lippincott, cl978. 663p. 38. RegisteredNurses Association of British Columbia. Labour Relations Division. Staff representatives manual. Vancouver, 1978. Iv. (loose-leaf) 39. Secourisme: orienté vers la sécurité - urgence -1. éd. canadienne. Ottawa, L'ambulance St-Jean, cl977. 14Op. 40. Sorensen, Karen Creason Basic nursing: a psychophysiologic approach. by.. .and Joan Luckmann. Toronto, Saunders, 1979. 13llp. 41. Stevens, BarbaraJ. Nursing theory: analysis, application, evaluation. Boston, Little, Brown, c1979.28Op. 42. Tilkian, Sarko M. Clinical implications of laboratory tests, by ...and Mary H. Conover. 2d ed. St. Louis, Mosby, 1979. 319p. 43. Tubesing, Donald A. Wholistic health; a whole-person approach to primary health care. New York. Human Sciences Press, c1979. 232p. 44. Wilson, Holly Skodol Psychiatric nursing, by...andCarol Ren Kneisl. Don Mills, Addison-Wesley. c1979. 8 5p. 4 . Women in stress; a nursing perspective. Edited by Diane K. Kjervik and Ida M. Martinson. New York. Appleton-Century-Crofts, cl979. 342p. Pamphlets 46. Alberta Association of Registered Nurses. Recommended role. Qualifications and terms and conditions of employment for the occupational health nurse in Alberta. Edmonton, 1979. 14p. 47. Association of Universities and Colleges of Canada and Association of Canadian Community Colleges. Health Sciences Accreditation Task Force. Report ofthe joint working groups on co-ordination of accreditation of health science educational programs. Otlawa. Health and Welfare Canada, 1976, Bp. 48. Canadian Nurses Association Submission to the Commission on Inquiry into Redundancies and Lay-offs in Canada's Labour Force. Otlawa, 1978. IIp. 49. National League for Nursing Nursing administration present and future. New York, 1978. 29p. (NLN Pub. no. 20-1739) O. Registered Nurses Association of British Columbia Statement on the province of British Columbia lonalerm care program. Vancouver, 1978. lOp. 51. Styles, Margretta M. Proposal for a study of credentialing in nursing. submitted to the American Nurses Association, Nov. I, IQ7 . Revised Dec. 7. 197 , Delroil, Mich., Wayne State University, College ofN ursing, Center for Health Research, 197 . 31p. Government Documents Canada 2. Santi et Bien-2tre social Canada Direction génerale du perfectionnement des programmes. Direction des services médicaux. Recueil de données sur la santé. Ottawa. 1978. 76p. 53. Secrhariat d' Érat. Direction ginirale de /' aide à I'iducation Guide des programmes d'aide financière du gouvemement du Canada destinés aux étudiants canadiens de niveau postsecondaire. Ottawa, Ministre des Approvisionnements et Services, c1978. 16p. 4. Statistics Canada Methodology of the Canadian labour force survey 1976. Ottawa, 1977. 139p. 5. -. Health Division Utilization of health care services in Canada; Irends in utilization of newborn and obstetric services: implications for future demand. Ottawa. HeallhDivision, Statistics Canada. 1978. 88p. ONE-STOP SHOPPING for most of your antiseptic needs - ._r-t-- 'it.. -.... ,---- .-. -., f "-___ ---- ....... - 11.1 -- - l' -- -- ---- --- . ---- -.... - , - ---- 'II . . --. 1", ,,-= I --. -- I - ----....' I .- ... --=--- " f '- \ I ..11 .1 ' f i 11 I I , . ., '....... , H -í 'J" --.,: ""w " , ) HIBITANE* Skin Cleanser a sudsing, antiseptic cleaning solution containing 4% w/v chlorhexidine gluconate for preoperative scrub-up and general hand washing. HIBITANE* Gluconate 20% Solution a l}1ultipurpose, broad-spectrum antiseptic cåncentrate for preoperative patient preparation, and general disinfectant use. Each product in the AYERST antiseptic line lives up to a well-earned reputation for quality which is backed by A YERST'S technical expertise. More and more Canadian hospitals are making A YERST their prime source of antiseptic products and information. If you would like to know more about any or all of these products. contact your AYERST representative or complete and return this coupon. AYERST LABORATORIES - - jivision of Ayerst, McKenna & Harrison Limited A\lØrC.t Quali tut S . Montreal, Canada '!' no SUD>h e '''MAC) . R ' d ___.. eg HIBITANE and SAVLON made In Canada by arrangement with IMPERIAL CHEMICAL INDUSTRIES LIMITED , . SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetic equipment. ,-------------- TO AYERST LABORATORIES I 1025 Laurentian Blvd., Montreal. Quebec, H4R 1J6 I I ,- Hibitane. Gluconate I 20% Solution I NAME I ADDRESS I NO I CITY I would like to receive information on: _ Hibitane" Skin Cleanser D Savlon. Hospital Concentrate D Sonacide* (PLEASE PRINT) STREEl 54 Seplember 1171 The Cen-.llen Nur.. British Columbia Classified Advertisements Alberta University of Alberta Hospital and Faculty of Nursing, U niversily of Alberta, requires a clinically current nurse 10 develop and inslruct in a program to prepare nea-natal nurse c1inicans. The primary appointment will be al University of Alberta Hospital and will involve clinical and classroom inslruction at the post baccalaureale level. The individual must therefore be eligible for appoinlment to the Faculty of Nursing. Qualifications: Master's Degree preferred; candidates with baccalaureate degree and relevant combination of experience and other education will be considered. Musl be eligible for A.A.R.N. Registration. The University of Alberta is an Equal Opportunily Employer. Salary determined on basis of qualifications and experi- ence. Apply to: Dr. A.E. Zelmer. Dean. Faculty of Nursing. The University of Alberta, 3rd Floor - Clinical Sciences Bldg.. Edmonton, Alberta, T6G 2G3. ltepstered Nunes required for part-time and full- time employment Must be eligible for registralion with AARN. Salary and benefits as per U.N.A. contracl. Residence available. Apply in writing to: Direclor of Nursing. Wainwrighl Hospital Complex, Wainwright, Alberta, TOB 4PO, or phone (403) 842-3324. British Columbia Experienced General Duty Graduete Nurses required for small hospital located N.E. Vancouver tsland. Maternily experience preferred. Personnel policies according 10 RNABC contract. Residence accom- modation available S30 monthly. Apply in writing to: Director of Nursing. St. George's Hospital. Box 223, Alert Bay, British Columbia, VON IAO. Registered and Graduate Nurses required for new 41-bed acute care hospital, 200 miles north of Vancouver, 60 miles from Kamloops. Limited furnished accommodation available. Apply: Director of Nursing. Ashcroft & Districl General Hospilal, Ashcroft. British Columbia, VOK IAO. Generat Duty (B.C. registered) nunes required for expansion to 422 acute care accredited hospital located 6 miles from downtown Vancouver and within easy access to various recreational facilities. Excellent orientation and on-going in service prog- ramme. Salary: SI,305,OO-SI,542,OO monthly. Clini- cal areas include coronary care. intensive care, emergency, operating room, P.A.R.R., medical/sur- gical. pediatrics, obsletrics, orthopedics and activa- lion units. Head Nurse posilion also required for our critical care unit, effective immediately. Candidates must have had at least two year's related experience and should have a demonstrable record of manage- rial skill. Apply to: Co-ordinator-Nursing. Dept. of Employee Resources, Burnaby General Hospital, 3935 Kincaid Streel, Burnaby, British Columbia, VSG 2X6. Shift Supervisor wilh previous experience required for a 1000bed fully accredited hospital. Must be eligible for B.C. registralion. N.U.A. course prefer- red. Apply to: Director of Personnel, Fort St. John General Hospital, Fort St. John, British Columbia, VIJ IY3. Generel Duty Nurse for modern 35-bed hospital localed in soulhern B.C. 's Boundary Area with excellenl recreation facilities. Salary and personnel policies in accordance with RNABC. Comfortable Nurse's home. Apply: Direclor of Nursing, Bound- ary Hospital, Grand Forks, Brilish Columbia, VOH IHO. Generel Duty Rexiltered Nurse, preferably with one year experience, including Obstelrics. Salary, be- nefits as per RNABC contraCI. Starts August 27. Small hospital in scenic West Kootenays - skiing, fishing. golfing, boating, hiking, swimming. Apply: Siocan Community Hospital, Box 129, New Denver, British Columbia, VOO ISO. British Columbia Carlboo Collexe invites applications for Instructors with clinical experience in medical-surgical, and psychiatric nursing. Master's degree is preferred, but will consider B.S.N. with at least 2 year's teaching experience. Salary range is SI5,801 to S28,131 per annum, presenlly under review. Place- menl will be based on qualifications and experience. There are presenlly two positions available, com- mencing as soon as possible. Please submit resume, complele with letters of reference, prior to Sep- tember 20. 1979 to: Personnel & tndustrial Relations Manager. Cariboo College, Box 3010, Kamloops, British Columbia. V2C 5N3. Experienc:ed Nurses (eligible for B.C. Registration) required for full-time posilions in our modern 300-bed Extended Care Hospital located jusl thirty minutes from downtown Vancouver. Salary and benefits according to RNABC conlract. Applicanls may telephone 525-0911 to arrange for an interview. or write giving full particulars to: Personnel Direc- tor, Queen's Park Hospital. 315 McBride Blvd., New Westminsler. British Columbia, V3L 5E8. Experienced Nunes (B.C. Regislered) required for a newly expanded 463-bed acute, teaching. regional referral hospital localed in the Fraser Valley. 20 minutes by freeway from Vancouver. and within easy access of various recreational facilities. Excel- lent orientation and continuing education program- mes. Salary-1979 rales-$1305.00-$1542.00 per month. Clinical areas include: Operating Room, Re- covery Room. Intensive Care, Coronary Care, Neonatal Intensive Care. Hemodialysis, Acute Medicine, Surgery, Pediatrics, Rehabilitation and Emergency. Apply to: Employment Manager, Royal Columbian Hospital. 330 E_ Columbia St., New Westminster, British Columbia, V3L 3W7. Applications are invited for the-position of Director of Nunlng wltb admlnlslretIve qualifications. Applic- ants must have Iheir B.C. registration and should have post graduate degree in nursing administration wilh several years of practical experience al the supervisory level. This position will encompass the administration of a 7 bed hospital on Vancouver Island. It will necessitate the supervision of the nursing and support staff, purchasing and financial reconciliation at month end. An invaluable oppor- tunity to gain experience in all facets of hospital administration. The hospital is situated in a rapidly expanding area of Northern Vancouver Island. This position is available immedialely. Salary negotiable. Please reply in writing to: Mrs. K. L. Watson, Chairman, Port Alice Hospital Board, Box 100, Port Alice, British Columbia, VON 2NO. RexJslered Nurses required immediately for a 340- bed accredited hospital in the Central Interior of B.C. Registered Nurses interested in nursing posi- tions at the Prince George Regional Hospital are invited 10 make inquiries to: Direclor of Personnel Services, Prince George Regional Hospital, 2000- 15th Avenue, Prince George, British Columbia. V2M IS2. Reailtered N...... required immediately for perma- nent full time positions at to-bed hospital in B.C. Salary at 1978 RNABC rate plus northern living aIlowance. Recognition of advanced or primary care education. One year experience preferred. Apply: Director of Nursing, Stewart General Hospital, Box 8, Stewart, British Columbia. VOT IWO. Telephone: (604) 636-2221 Collect. Two geoerel duty a...... for 21-bed acute care hospital on Vancouver Island's beautiful Pacific Coast near Pacific Rim National Marine Park. Friendly atmosphere. Salaries in accordance with RNABC agreements. Apply: Direclor of Nursing, Tofino General Hospital, Box 190, Tofino, Brilish Columbia, VOR 2Z0. (604) 725-3212. St. Paul's Hospital invites applications from B.C. ReJlltered NUIWI for full and part time posilions in all areas of the hospital. St. Paul's is an acute referral teaching hospital located in downtown Vancouver. 1979 R.N. rates SI305.00 - SI542.00. Generous fringe benefits. Apply to: St. Paul's Hospital, Personnel Department, 1081 Burrard Street, Van- couver. British Columbia, V6Z. IY6. Manitoba Experienced Jte&lstered Nunes required for a fuIly accredited 200-bed Health Complex located in Northern Manitoba. Must be eligible for registration in Manitoba. Salary dependent on experience and education. For further information contact: Mrs. Mona Seguin, Personnel Director, The Pas Heallh Complex Inc., P.O. Box 240. The Pas, Manitoba. R9A I K4. Northwest Territories The Stanton Yellowknife Hospital. a 72-bed accre- diled. acule care hospital requires regiSlered nurses to work in medical. surgical, pedtalric, obstetrical or operating room areas. Excellent orientation and inservice education. Some furnished accommoda- tion available. Apply: Assistant Administrator- Nursing, Stanton Yellowknife Hospital, Box 10, Yellowknife, N.W.T., XIA 2NI. Ontario Neurosurgkal stan' nune. Ontario registration, re- quired for rull time position in I,OOO-bed teaching hospilal affiliated with the University of Toronto. Includes neurosurgical intensive care area and spinal cord if1.iury unit. Preference given to applicants wilh recenl related experience. Salary and benefils according to ONA contract. Applicants may send resumes to: Sunnybrook Medical Cenlre, Personnel Department, 2075 Bayview Avenue, Toronto, On- tario, M4N 3M5 or phone (416) 486-3612. RN. GRAD or RNA. 5'6" or over and strong, without dependents, non smoker, for t75 lb. handicapped, retired execulive with stroke. Able to transfer patient to wheelchair. Live in 1/2 yr. in Toronto and 1/2 yr. in Miami. Wages: $200.00 to S250.00 wkly. NET plus $80.00 wkly. bonus on mosl weeks in Miami. Write: M.D.C.. 3532 EgJinlon Avenue West, Toronto, Ontario, M6M IV6. Saskatchewan R.N.'s and R.P.N.'s (eligible for Saskalchewan registration) required for 340 fully accredited ex- tended care hospital. For further information, contact: Personnel Department, Souris Valley Ex- tended Care Hospital, Box 2001. Weyburn, Sas- katchewan S4H 2L7. Two Rexiltered NUIWI required by 27-bed hospital localed 90 miles East of Regina, Saskatchewan on Highway No. 48. Salary as per S.H.A.-S.U.N. 1978-1979 contract agreement. Please send resume to: Mrs. Loretta Ferch, Director of Nursing, Kipling Memorial Union Hospital, Box 420, Kipling, Sas- katchewan SOCJ 2S0 or phone: 736-2553, Extension 2. United States CellfomJa - Sometimes you have to go a long way to find home. But, The White Memorial Medical Center in Los Angeles, California, makes it all worthwhile. The White is a 377-bed acute care teaching medical center with an open invitation 10 dedicaled RN's. We'll challenge your mind and offer you the opportunity to develop and continue your professional growlh. We will pay your one-way transportation. offer free meals for one month and all lodging for three months in our nurses residence and provide your work visa. Call collect or write: Ken Hoover, Assistant Personnel Director, 1720 Brook- lyn Avenue, Los Angeles, California 90033 (213) 268-5000, ext. 1680. The c.nedlen Nur.. Seplember 1171 55 United States United States Rqlslered Nunes: Several openings for e!'perienced nurses (including tCU/CCU) in a full servIce I 50-bed hospital. Fifteen minutes to the beach & 2 hours to the mountains of Southern Calif. Located on the southern rim of the L.A. basin. Bay Harbor Hospital is rated for outstanding patient care and innovative nursing programs. We will provide the necessary assistance for a working visa. Write: Sally Madden. Nurse Recruiter. Bay Hamor Hospital, 1437 W. Lomita Boulevard. Harbor City, California, 90710. California - Rqbtered Nunes and Ne.. Graduates. St. Vincent Medical Center is a 386-bed. modern facility with positions in the following areas: Med/Surg, Oncology, Nephrology. ICU, CCU, Cardiology. Cardiac Surgical unit, Renal Dialysis, Otology, Operating Room. We provide training for all areas. temporary housing and assistance with visa and licensure. To obtain further information write to: Mary J. Wylde, 2131 West Third Street. Los Anseles. California 90057 or call collect to (213) 484-7221. Reptered Nunes - Callfornla - Rapidly growing inland port city in the heart of California's Big Valley. 260-bed, fully accredited teaching hospilal. Ideal location within 2-3 hours by car of San Francisco, Yosemite, Lake Tahoe, Monterey Penin- sula and historic Mother Lode. Four-season climate with snow-free winters. Conlact: Laurel Murphy, Director of Nursins. P.O. Box 1020, Stockton, California, 95201, (209) 982-1800. Ext. 6016. Amr- maUve adloD/equai opportwalty employer. Florida NunlDa Opportunities - MRA is recruitins Reaistered Nurses and recent Graduates for hospital positions in cities such as Tampa, St. Petersburg, and Sarasota on the West Coast: Miami, Ft. Lauderdale and West Palm Beach on the East Coast. If you are considerins a move to sunny Florida, contact our Nurse Recruiter for assistance in selectins the right hospital and city for-you. We will provide complete Work Visa and State Licensure infonnation and offer relocation hints. There is no placement fee to you. Write or call MrdkaI ltecrultrnof America, Inc:. (For West Coast) t211 N. Westshore Blvd., Suite 20S, Tampa, FI. 33607 (813) 87H)202; (For East Coast) 8OON.W. 62nd St., Suite StO, Ft. Lauderdale, Fl. 33309 (3OS) 772-3680. Nunln, Opportunities In New Orleans, Loul8ll1.Da- MRA tS recruitina Registered Nurses and recent Graduates for several general and teaching hospitals in the exciting New Orleans area. Openinss in many specialties and most Canadian Registered Nurses can qualify for licensure endorsement in Louisiana. Contact our Nurse Recruiter for tuition assistance plans. We will provide complete Work Vis'! and State Licensure infonnation. There is no placement fee to you. Write or call Medical Rrc:ru1len of America, lac., 800 N.W. 62nd St., Suite 510. Ft. Lauderdale, FI. 33309. (305) 772-3680. Nar.1 - RNs - Immediate Openings in Califomia-Florida-Texas-Mississippi - if you are experienced or II. recent Graduate Nurse we can offer you positions with excellent salaries of up to $1300 per month plus all benefits. Not only are there no fees to you whatsoever for placìna you, but we also provide complete Visa and Licensure assislance at also no cost to , ou. Write immediately for our application even i there are other areas of the U.S. tbat you are interested in. We will call you upon receipt of your application in order to arrange for hospital interviews. Y 011 can call us collect if you are an RN who is licensed by examination in Canada or II. recent graduate from any Canadian School of Nursins. Windsor Nurse Placement Service, P.O. Box 1133, Great Neck, New York, 11023. (516 - 487-2818). "Our 20th Year of World Wide Service" Dallas, Houston, Corpus Christl, etc, elc, elc. The eyes of Texas beckon RN's and new grads to practice their profession in one of the most prosperous areas of the U.S. We represent all size hospitals in virtually every Texas and Southwest U.S. City. Excellent salaries and paid relocation expenses are just two of many super benefits offered. We will visit many Canadian cities soon to interview and hire. So we may know of your interest, won't you contact us today? Call or write: Ms. Kennedy, P.O. Box 5844, Arlington, Texas 76011. (214) 647-0077. Before accePti'l.l any ""II position in the .S.A. PLEASE CALL US COLLECT We Can Otter You: A) Selection of hospitals throughout the U S.A B) Extensive information regarding Hospita Area. Cost of Living. elc C) Complete Licensure and Visa Service Our Services to you are at absolutely no tee to you. WINDSOR NURSE PLACEMENT SERVICE P.o. Box 1133 Great Neck. N.v.11023 (516) 487-2818 "'- Our 20th Year 01 World Wide Service United States Nursing Opportunity - Mississippi Baptist Medical Center, a mllior 600-bed hospital. has immediate positions available for experienced RNs and recent nursing school graduates in a variety of specialities and medical/surgical areas. Competitive salaries, liberal benefits. Visa, licensure and relocation assistance provided. Located in Mississippi's capital city of Jackson (population 300,(00), MBMC is the state's largesl and most modern privately operated hospital. For further information write: Mrs. Johnnye Weber, Nurse Recruiter, 1225 North State Street. Jackson. Mississippi 39201; or call collect 601/968-5135. /" ""\ Offers ReNe's Ë A An UNUSUAL OPPORTUNITY. AVI A.M.I. Will FURNISH Onl Wly AIRLINE TICKET to Tlxas Ind $500 Inlt"l LIVING EXPENSES on a loan Basis. Attlr Onl Vllr'. Service. TIll. loin Will ÞI Canclllid "'MI American Medicallnternalionallnc. . !lAS5O HOSPITALS THROUGHOUT THE U.s. r . lIow A...I. II RlavlUng 11.11.'11. HOIplllilin TIIII. I IlIImldllt. Op.nl.....I.llry Rlngl $11.000 to $16,500 plr Yur.1 . You can enJOY nurSing In General Medicine. Surgery. ICC. CCU. Pedialrics and Obstetllcs . A M 1_ provllles an excellent ollentallon program in-service Irainlng_ r------------" I , , U.S. Nurse Recruiter , , P.O. Boll 1777e, los AnSeles, Calif. 90017 , I . Without oDllgatlon please send me more , Intormatlon and an Application Form I IIIAME_________ ___ I ADDRESS___________I , ClTY_ ___ ST.___lIP___1 TELEPHONE 1_ _) _ __ _ _ _ _ __ I LlCENSES:___________, , SPECIALTY:_ _ ______ -_-I YEAR GRADUATED: _ _ _ STATE: _ __ "'------------ R.N.'s U.S.A. - Dunhtll with 250 offices has excitins career opportunities for both recent grads and experienced R.N.'s. Locations North, South, East and West. All fees are paid by the employer. Send your resume to: 801 Empire Building, Edmon- ton, Alberta. TSJ IV9. Nurses - RNs - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa fonns and provide assistance with licensure at no cost to you. Write for a free job market survey Or call collect (713) 789-1550. Marilyn Blaker, Medu, 5805 Richmond. Houston, Texas 77057. All fees employer paid. Come 10 TUII5 - Baptist Hospital of Southeast Texas is a 400-bed growth oriented organization looking for a few good R.N.'s. We feel that we can offer you the challenge and opportunity to develop and continue your professional growth. We are located in Beaumont, a city of 150,000 with a small town atmosphere but the convenience of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. Baptist Hospital has a progress salary plan plus a liberal frinse packaae. We will provide your immig- ration paperwork cost plus aiñare to relocate. For additional infonnation, contact: Personnel Ad- ministration, Baptist Hospital of Soulheast Tellas, Inc., P.O. Drawer 1591, Beaumont, Texas 77704. An amrmatlw adloa aaployer_ Ellc:ltemrnt: Come and join us for year around excitement on the border, by the sea, an unbeatable combination. Eqjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new J17-bed, acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. Excellent salary and fringe benefits. We invite you to share the challenge ahead Assistance with travel expenses. Write Or call collect: Joe R. Lacher, RN, Director of Nurses, Valley Community Hospi- tal. P.O. Box 4695, Brownsville. Texas 78521; I (512) 831-9611. Project HOPE is in the process of recruitmg Nune Educ:alOn in the following specialities and countries: Midwife and O.R. Nurses in Egypt, ICU and O.R. Nurses in Morocco, Family Nurse Practitioners in Jamaica, and Ph.D. Nurse Educators in Brazil. Excellent benefits, travel paid and salary negotiable. Send resume to: Joan Harmon, Project HOPE, Millwood, Virginia 22646, U.S.A. Equal Opportun- it y Employer. Australia Faculty POIItIo.. - Available in under-graduate instruction in: Medical-Surgical Nursing and Com- munity Health Nursins. Dynamic program con- ducted in coqjunction with a University Hospital. Salary - commensurate with qualifications and experience. Senior Lecturer AS2I,I80-$24,687. Lecturer A$15,786-$20,736. Preference: Masters Degree, Teachins and Clinical Experience. The Senior I..eclurer will be responsible for course co-ordination and curriculum development. An extensive teachins background is essential. The Institute has allowance schemes covering re-Iocation expenses, immediate superannuation, insurance cover and assistance with accommodation. Closins date for applications: 3 weeks after publication of this advertisement. Appointees are expected to take up duties in November, 1979. Curriculum vitae and transcripts of tertiary work to: Miss Lydia Hebes- treit, R.N. Head, Department of Nursing, Preston Institute of Technology, Plenty Road, Bundoora, 3083 (Melbourne) Australia. Miscellaneous Electrolysis - Successful Electrolysis Practice for Sale. 6 months specialized included. Write or phone: Margot Rivard, .1396 St. Catherine Streel West, Suite 221, Montreal. Quebec, HJG IP9. Telephone: (514) 861-1952. 51 Seplember 111711 The Can-.llen Nur.. RN's and GRADS Looking for the perfect position? If you describe it in a letter, we'll let you know when we see it. or one that comes close. Possibly it is in one of our client hospitals, like St. Mary's in Nevada, The Medical Center in Texas. Piedmont in Georgia. or in a hospital in anyone of a dozen different states and provinces. Our client hospitals pay us to help you look. and that's a nice arrangement for you and for us. Wood, Watson Professional Search Suite 207, 1962 Y onge Street Toronto, Ontario M4S IZ4 (416) 482-2238 Special Scholarships The International Association for Enterostomal Therapy wishes to announce the fonnation of new scholarships to be awarded to registered nurses interested in working in this specialty field and in improving quality care for the Ostomy patient. Presently, there are twelve E. T. training programs in the U.S. Scholarships are to be awarded to applicants who have met the requirements for admission to an E. T. program. Application deadline is December I, 1979. For further information write: International Association for Enterostomal Therapy, Inc. Central Office 2506 Gross Point Road Evanston, Illinois 60201 50th Anniversary Celebration Seton General Hospital in Jasper National Park invites all ex nursing staff to attend their 50th Anniversary Celebrations May 5th to lith. 1980 Inclusive. A Gala Banquet and Ball atJasper Park Lodge. May 10th. Come and renew old acquaintances and make some new ones! F or further infonnation contact: Mrs. Donna Lane, R.N. Box 1063 Jasper, Alberta TOE IEO Head Nurse Head Nurse for 24-bed coronary and post-coronary care unit, in a 650-bed fully accredited hospital. North Vancouver. B.C. Candidates will have Baccalaureate in Nursing or Advanced Preparation in Administration. Clinical expertise in coronary care. Previous Head Nurse experience preferred. At least 4-5 years successful graduate experience. Salary : As perR.N.A.B.C. Agreement- $1500.00-$1772.00 per month. Please send resume to: Lions Gate Hospital Personnel Department 230 East 13th Street North Vancouver, British Columbia V7L 2L7 Department of NursinJl:, Grace Materni\) Hospital. Halif.... seeks Head Nurse For Special Neonatal Care (Tnit ChallcnglnKJobopponumty In nconatèl.l nur,mgml-anadd-" large...t obstclncal hO!ior11al (SOOO deh \<'cnC'-'/ycar; 1000 admi......ons to Special "oeonalal Care l!mt/).cdr, M or ob"lrlncal and neonatalleachm, ho'\pltal (or Dalh('lU<;;lc LJmvcr...ty èl.nd the central oMlclneal rcfcrral UnIl for Nova Scolla. Pnncc Edward bland and pam, ofNcw Brun'iiwlck Rcspon'iilblc 10 Ihe Chnlcal Co-ordmalor for organlzallon and admlnlSlrallon or clmlcal nu....mgcare glvcn loaculcl)' III and convalc'iiclng ncwtx>rn mfanh E!l.ccllcnl opponuml)' 10 perfect pre!>cnt programmcs and 10 dcvclop ncw programme!!. .umed al Impro\-'lng and cXlendmg thc scope or neonalal nursm, Salary aC(:ordmg 10 Nova Scolla Nu es' Umon Coniraci PO"1 avallablc Immedlalely Thc candldale!> musl havc S )"cars' c'pencncc m nconalal nur m, and musl be eh,lbk for regl'loiraiion Iß Nova Scolla Manaaemcnt expenencc dnd skill!>. broad knowledge or pennalal hcalth concepl!> and graduallon rrom a po!>1 diploma nconalal nunlnlcou c dC!>lrablc Apply m wnlmg 10 Miss \tar..ret. FURuson. R....... DU"< are also 8v.;ulablc for Icncral dUly nur'iiCS m 1M nconalal Unit Fishermen's Memorial Hospital reqUIres One (1) (O.R., 0.8.S., O.P.D.) Supervisor PG in OR rëquired: Past Administrative Experience & OBS experience desirable Please address all inquiries to: Director of Nursing Fishermen's Memorial Hospital Lunenburg, Nova Scotia BOJ 2CO McMaster University Educational Program For Nurses In Primary Care McMaster University School ofNurs- ing in conjunction with the School of Medicine. ofFers a program for regis- tered nurses employed in primary care settings who are willing to assume a redefined role in the primdry hedlth care delivery team. Requirements Current Canadian Re- gistration. Sponsorship from a medi- cal co-practitioner. At least one year of work experience. preferahly in pn mary care. For further information write to: '\'Inna Callin. Director Educational Program for "Iurses in Primar} Care Faculty of Health Sciences lc laster llniversity Hamilton. Ontario L8S 4J9 Nursing Co-ordinator Applications for the position of Medical-Surgical Co-ordinator are being accepted for mid-September by this 300 bed fully accredited hospital. Experience in supervision with a Bachelor of Nursing Degree preferred. Temporary accommodation available. Please reply sending a complete resume to: Director of Personnel Stratford General Hospital Stratford. Ontario N5A 2Y6 Foothills Hospital, Calgary, AI berta Advanced N eurological- Neurosurgical Nursing for Graduate Nurses A five month clinical and academic program offered by The Department of Nursing Service and The Division of Neurosurgery (Department of Surgery) Beginning: March, September Limited to 8 participants Applications now being accepted For further information, please write to: Co-ordinator of In-service Education Foothills Hospital 1403 29 St. N. W. Calgary, Alberta T2N 2T9 The C.nedlen Nur.. Bermuda Hospitals Board R.N.'s- Victoria, B.C. Applications dre invited for the position of Operating Room Supervisor in our 3!O bed general hospital. which is accredited ",ith the Canadian Council on Hospital Accreditation. On the West Coast you can enjoy a unique Canadian climdte and a challenging nursing career at a progressive 422-bed acute care hospital. The appointee would be responsible for the mandgement and supervision of a busy Operat- ing Room and Recovery Room suite. undertak- ing some 6000 operations per year. An active Operating Room and a referral Intensive-Care Nursery are seeking experienced nurses to join their team. Applicams should be Registered Nurses. who have a minimum of five years Operatins Room experience. two years of which were in a management role. Bachelor's degree desirable. Demonstrated ability in management of per- sonnel and coordination of medical staff activities required. Experience and ability in budget preparation and cost control systems would bean advantage Applications are also invited from nurses with an interest in Cardio/Pulmonary, Urology, and General Medical/Surgical nursing. Extended shift schedules available. Applicants must be H.C. registered or eligible for registration in H.C. tmerested applicants should apply in confi- dence. submiuing resume and statement of desired salary to: Apply in writing indicating experience and area of interest to: Director of Nursing King Edward" II Memorial Hospital P.O. Box 1023 Hamilton 5, Bumuda \t. J. Duncan (Ms.) Personnel nager Victoria General Hospital 841 Fairfield Road Victoria, British Columbia V8\ 386 EXPERIENCED RN'S & NEW GRADS HTHE PERFECT OPPORTL ITY" Saint Anthony Hospital, located in Columbus, Ohio. This 400-bed acute care facility offers excellent opportunities for furthering your nursing career. No Contracts to Sign Rotating Shifts Air Fare Paid One Month Free Accommodations Plus Exciting Challenges Saint Anthony, a medical-surgical institution, has a complete range of services. including: . Open Heart Surgery . Intensive and Coronary Care . Definitive Observation Unit . Renal Dialysis · Diagnostic and Therapeutic Radiology · 24 Hour Emergency Department Don't wait, call or write immediatel . Make the change to an institution that lets you be what you want to be. For further information, call our Nurse Recruiter, Norma Shore, Collect. EXCLt:SIVE (' ANADIAN REPRESE T A TlVES RECRUITL G REGISTERED NURSES INC. . '111111 IIIIII U'..I. 1200 Lawrence Avenue East Suite 301, Don Mills Ontario M3A ICI Telephone: (416) 449-5883 . September 1171 57 University of Saskatchewan ," 11 "' .s... Dean of Nursing ._ " ., - .;- . ( In' Applications dnd nominations are invited for the position of Dean of Nursing with the appointment to be made effective July I, 1980. The College of Nursing currently has a complement of 28 full-time faculty including the Dean and an Assistant Dean. 1978/79 enrollment in the four-year baccalaureate program was 350 full-time students. Applicants must have appropriate academic and professional qualifications and the necessary leadership and management skills to direct effectively this important segment of the University's Health Sciences program. Nominations and applications with complete resumes will be accepted until 15 December. 1979 and should be addressed to: Dr. R.W. Begg, President Unhersit) of Saskatchewan Saskatoon, Sask. S7N OWO ,-. r I I I I I I . --'--"j -,.. ,- I;) 58 September 1171 The c.n-.ll8n Nur.. Registered Nurses The Perfect Opportunity Could Be Right Around The Corner How can you be certain that the opportunity you see to-day is the best one for you? The truth is, you can't. without the guidance of job-market professionals who know the nursing business as well as the placement business. That's why. before you sign on Ihat dotted line to-day, you should check wilh Recruiting Registered Nurses Inc. We're the Canadian Medical Placement Specialists throughout the United States. We know where the bests jobs are. how much they pay, and where you'll fit in. R.R.N. can give you more than just ajob- we can help you build a satisfying career. R.R.N. has immediate positions available in: California- Texas-Florida-Ohio Don't wait!!!! Call or write immediately for further infonnation. Recruiting Registered Nurses Inc. 1200 Lawrence Avenue East, Suite 301 Don Mills tM3A lCI) Ontario Telephone: (416) 449-S883 "No Fee To Applicants" REGISTER NOW ð CNA NATIONAL FORUM ON NURSING EDUCATION 13, 14, 15 November 1979 SKYLINE HOTEL - OTT A W A Theme: The nature of nursing education Focus: What is basic nursing education? Diploma or degree? . Nursing model and the Curriculum . Nursing specialization . Accreditation OPEN TO ALL REGISTERED NURSES - MAXIMUM OF 300... CNA Members - $100 Non-Members-$175 Complete program details and registration form in June issue or write The Canadian Nurses Association, 50 The Driveway, Ottawa, Onto K2P lE2. Tel. (613) 237-2133. I OPPORTUNITY .J._ Assistant Director of Nursing Rosehaven is an accredited extended care facility accommodating approximately 300 geriatric residents and is located 60 miles southeasl of Edmonton in the city of Camrose. Reporting to the Director of Nursing, the successful applicant will be responsible for assisting in policy fonnation, planning, organizing, implementing and evaluating all aspects of resident care. This position will become vacant during June. Qualifications: Nurse applicant must be eligible for registration in Alberta. B.Sc. in Nursing preferred. They should have progressive nursing experience in which leadership and other administrative skills have been demonstrated. Salary up to $20.604. Competition #9186-6 This competition will remain open until a suitable candidate has been selected. Apply to: o\lberta Government Employment Office Sth floor. Melton Building 10310 Jasper Avenue Edmonton, Alberta TSJ 2W 4 ...4 Ad vertising Rates For All Classified Advertising $15.00 for 6 lines orIess $2.50 for each additional line Rates for display advertisements on request. Closing date for copy and cancellation is 8 weeks prior to 1st day of publication month. The Canadian Nurses Association does not review the personnel policies ofthe hospitals and agencies advertising in the Journal. For authentic infonnation, prospective applicants should apply to the Registered Nurses' Association of the Province in which they are interested in working. Address correspondence to: The Canadian Nurse 50 The Driveway Ottawa, Ontario KlPIE2 . The c.nedlan Nur.. Nursing Opportunities in Vancouver Vancou\'er General Hospital If you arc: a Regis(ered Nurse in search of a change and a challenge - look into nursing opponunities at Vancouver General Hospital. B.C:s nuijor medical centre on Canada's unconventional West Coast. Staffing expansion has resulted in many new nursing positions at all levels, including: General Duty ($1305. - 1542.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the opponunity you've been looking for. For those with an interest in specialization. challenges await in many areas such as: Neonatology Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Burn L'nit Paediatrics Inservice Education Coronary Care Unit H} peralimentation Program Renal Dialysis & Transplantation If you are a Nurse considering a move please submit resume to: Mrs. J. MacPhail Employee Relations Vancouver Genenl Hospillll 8SS West 12th Avenue Vanc:ouver, B.C. VSZ 1\19 DALHOl'SIE l"'IIVERSIT\ HALIFAX. . s. C.....ADA Ær Director of the School of ursing Applications are invited for the position of Director of the School of Nursing. Dalhousie University. The appointment should be taken up by July 1st, 1980. The School of Nursing is pan of the Faculty of Health Professions. which also includes the Schools of Pharmdcy. Physiotherapy. Physical Education. and Humdn Communication Disorders. Olher Faculties within the University relating to health care are Dentistr) and Medicine. There are four programmes within the School of Nursing: namely the Basic B.N. degree. the Post-R.N. degree. a regional M.N degree. and the Diploma in Outpost and Public Health Nursing. The Director of the School of Nursmg IS normally appointed for a five-year term and is responsible to the Dean of the Faculty of Health Professions for the leadership and administration of the School. It is expected that the candidate would have a doctoral degree. and show eVidence of suitable clinical. nursing education. and/or adminislrative experience. The incumbent would panicipate in some teaching and research. and maintain a liaison with the university community and related orgamzations outside the university. This posilion ofTers an exciting challenge in admimstration. programme development and research. Application. curriculum vitae and names and addresses of three referees should be fOIWarded to: Robert s. Tonks, Ph.D. Dean Faculty of Hellllh Professions SIr Charles Tupper Medklll Bulldlne DIIIbousle Unlvenlty HaUfax. Nova Scotia CaD8d& B3H 4H7 September 111711 511 OPPORTUNITIES Associate Director of Nursing Services The Victoria General Hospital. an 800 bed adult teaching hospital associated with Dalhousie University. provides tertiary care in all clinical specialties except pediatrics and obstetrics. Located in Halifax with a wide range of educational. cultural, and recreational opportunities. The Hospital operates its own school of nursing and seven other Allied Health Schools. Responsibilities: Works under the general direction of the Director of Nursing Services. One of the prime responsibilities will be for the personnel management aspects of this department of approximately 1200 employees. Qualifications: Education: Baccalaureate degree in nursing required. Masters degree preferred. E'\:perience: Minimum of three years experience in a senior nurse-manager position. Special Knowledge and Abilities: A ware of current concepts of nursing service, education and research. principles of administration and personnel development. Professional Opportunit}: The close liaison with Dalhousie School ofN ursing provides a ready opportunity to pursue professional interests. Salary and Benefits: 1978 salary to $24.237. - currently under review. Full Civil Service Benefits. Competition is open to both men and women. Please quote Competition Number 78-455. Enquiries should be addressed to: Chairman of the Search Committee for Associate Director of Nursing Services c/o Executive Director Victoria General Hospital 1278 Tower Road Halifax, Nova Scotia B3H 2Y9 eo September 1171 The C.medlan Nur.. Required Immediately for our Osler Campus: Project Director - Occupational Health Nursing Program -to assume responsibility for coordination and development of a modulized part-time post-diploma certificate program in Occupational Health Nursing. Recent experience in O.H. Nursing, Master degree and previous curriculum and teaching experience preferred. Refer to No. 79-057-F. This is a sessional appointment. Both These Positions require a candidate who has the ability to function in a creative self-directed manner in the developmental aspects of these programs. Salaries are based on the current academic schedule. Direct resume to: Humber O Faculty Relations OtrlCer Box 1900, Rexdale, Onto M9W SL7 . ';r:.;Jj- . ;W% Chisasibi Hospital Fort Georges' James Bay - Chisasibi Hospital, Fort George, James Bay, (located 70 miles west of LG2) requires the services of: Registered Nurses Requirements: . Registered nurse with practice rights . Standing member ofO.I.I.Q. . Experience in isolated post - an asset . Immediately available Salary . Collective agreement with M.A.S., plus isolation premIUm Marcel Bonenfant Northern Quebec Module 2100 Guy Street, Suite 204 Montreal, Quebec, H3H 3M8 Tel: (514) 933-2724 I ÆB I I OPPORTU\JITY Nurses Applications are invited for positions at Alberta Hospital, Edmonton, a 650 bed active treatment psychiatric hospital, located 4 km. outside of Edmonton. Successful candidates must be graduates from a recognized School of Nursing and eligible for registration in their professional association; willing to work shifts. Vacancies exist in Admissions, Forensic, Rehabilitation, and Geriatric Services. Note: Transportation is available to and from Edmonton. Accommodation is available in the Staff Residence. Salary $1,229- $1,445 per month (Starting salary based on experience and education) Competition #9184-9 This competition wiII remain open until suitable candidates have been selected. Qualified persons are invited to phone, write or submit applications to: Personnel Administrator Alberta Hospital, Edmonton Box 307 Edmonton, Alberta T5J 2J7 Telephone: (403) 973-2213 ... Moving, being married? Be sure to notify us in advance. Attach label from your last issue or copy address and code number from it here New (Name)/Address Street City Prov./State Postal Code IZip Please complete appropriate category D I hold active membership in provincial nurses' assoc. reg. no./perm. cert./Iic. no. D I am a personal subscriber Mail to: The Canadian Nurse, 50 The Driveway, Ottawa, Ontario K2P I E2 The Cenedlen Nur.. OurTradition is Excellence O'Connor Hospital San Jose, California We repre ent d 300-bed acute care facility that has teaching affiliations with major universities and other communit} colleges. O'Connor Hospital is located in the beautiful southern San Fmnci co Bay area. A community rich in parks, beaches, cultuml and educational recreational activities, new shopping centres, many exciting restaumnts and offers a very fine and diversified mode of living plu clo e by aredS of interest such as mountains and de ert resorts and "excitmg" Lake Tahoe. Experienced RN' can find challenging opportumties in the following pecialties: . I.CU. . c.eu. . Med-Surg Plus mdny other departments. As a key member of our nursing team, some of the extensive benefih you will receive are: . aclive on-going in ervice program . medical and health in urance . retirement and dental plan and many other excellent benefits. J-or further detail contact our Canadian Representative Miss Shore Nurse Recruiter Recruiting Registered Nurses 1200 Lawrence Ave.. E.. Suite 301 Don Mills. Ontario 13A lCI (416) 449-5883 Registered urses I ()O heJ ho"pital aJjacent to Uni\er"it) of Alhena campu" offer" emplo\ ment in medicine, !I urge ry , pediatrics. orthopaedics, obstetrics, psychiatry, rehabilitation and extended care including: · Intelhi\ e care · Coronar) ohsenation unit · CarJiova"cular "urger) · Hum.... anJ pla....tic" · Neonatal intclhi\ e care · Renal Jial) ....i" . Neuro-...urger) Planned Orientation and In-Service Education Programs. PostGraduate Clinical Courses in Cardiovascular- Intensive Care Nursing and Operating Room Nursing. \ ppl tll: Recruitment Ol1icer - 'ur in l ni\ersit of -\Iherta Ho pital H O- I 12th Street Fdmontlln. Alberta T6<; 2B7 [ September 111711 111 OPPORTUNITY 41-. Nurses/Psychiatric Nurses The ClaresholmCare Centre. a 320-bed residential and rehabilitation facility for psychosocially handicapped adults, invites applications from R.N.'s and R.P.N.'s for staff positions. Successful applicants will assist charge nurses in the operation of their units and participate in planning and implementing progmms for the rehabilitation and reactivation of long-tenn residents. Qualifications: Graduation from an approved school of nursing (R.N. or R.P.N.); must be eligible for registration with the appropriate professional Alberta Association. NOTE: Reasonable ingle accommodation available: rotating shift work involved. Salary Range: $13,608 - $15.996 per annum (currently under review). Competition Number: 9184-L-I Closing Date: Open For Application Fonn Contact: Personnel Administration Office Government of Alberta Room 401. Professional Building 740 - 4 A venue South Lethbridge. Alberta TlJ ON9 Telephone: 329-5420 [l]@ University of Alberta Hospital Edmonton, Alberta o 112 September 111711 The Cenedlan Nur.. .":.'.1: '\ .. . ... . ... I I -.'-, I ÍJ --r.. . - . 4i i . , . \t- \ '\ \ , ..þ can go a long way , . . to the Canadian North in fact! Canada's Indian and Eskimo peoples in the North need your help. Particularly if you are a Community Health Nurse (with public health preparation) who can carry more than the usual burden of responsi- bility. Hospital Nurses are needed too... there are never enough to go around. And challenge isn't all you'll get either- because there are ecfucational opportunities such as in- service training and some financial support for educational studies. For further information on Nursing opportunities in Canada's Northern Health Service, please write to: ........, I Medical Services Bnmch I Department of National Health and Welfare Ottawa, Ontario K1A OL3 I Name I I Address I I City Proll. I I .. Heallh and W.lla.... Santé el Bien-lire social I Canada Canada ........ Index to Advertisers September 1979 Abbott Laboratories Ayerst Laboratories Canadian Dairy Foods Service Bureau The Canadian Nurse' s Cap Reg' d The Clinic Shoemakers Cover 3 53 6. 7 9 4 Encyclopaedia Britannica Publications Limited 17 Equity Medical Supply Company 16 Glaxo Laboratories Frank W. Horner Limited J.B. Lippincott Company of Canada Limited Medical Personnel Pool 50 8.18,19 51 19 TheC.V. Mosby Company Limited 10, II. 12, \3 Nordic Laboratories Inc. 52 Parke, Davis & Company Limited 15 W.B. Saunders Company 47 Schering Canada I nc. Cover 4 G .D. Searle & Company Canada Limited 19 Smith & Nephew Inc. 24 Studio Clavet Inc. 16 White Sister Uniform Inc. Cover 2 Advertising Manager Gerry Kavanaugh The Canadian Nurse 50 The Driveway Ottawa. Ontario K2P I E2 Telephone: (613) 237-2133 Advertising Representatives Jean Malboeuf 60 I. Côte Vertu St-Laurent, Québec H4L IX8 Téléphone: (514)748-6561 Gordon Tiffin 190 Main Street U nionville. Ontario UR 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster A venue Ardmore. Penna. 19003 Telephone: (215)649-1497 Member of Canadian Circulations Audit Board Inc. Im:J EMBER [ 0 ) "IÐ TM .- ,. . ..-.... ..... '.- . .. \.' ...... ,. . \.- ,:: . . -. ., . .' ., . eo ., -. . . · .J "/ 00 . ... , , ::::--... -- - -. .. . \ . . \ . . . . . tp. ---< . - , . .. " , . .' \ '\ :' . I " , . " ._-.' \1 t ," I'. . I. " \' ".. ,., '-.... ... --- .... .: . .. ,. . . ... ..... -. t. .. ,. .. 1 .. . - . .. .: . :. r.;, , ..( " . ., , :' l , ., :", ., . , ,., r l:"l .. . . r " r ".. T. - . - øø . .. . . , , . . \ i: There is only one Butterf * ABBOTT o ..1- ," + ..-..... / a' I "When friends or patients ask your advice concerninQ relief of cold symptoms conside( the advan- tages offered ,by the CORICIDIN family of cold products, The various CORIClDIN*preparations are formulated to r:1tovide effec- tive relief of speciflc groups "- of symptoms that genèrally accorrfpany <:'oOIds: Regular CORICIDIN (antihistÖmine, analgesic, caffeine bom- .,. pound) is intended for use at the first sign of a cold where congestion is not a problem or when decon- gestants are contraindi- cated. CORICIDIN 'D is formulated for use when nasal or sinus congestion is pronounced.. For your younger patients CORICIDIN is available as CORICIDIN Pediatric MEDILETS* and CORICIDIN 'D' MEDILETS, both chewable tablets, and pleasant tasting COR IDIN Pediatric Drops for infants or very young children. '- --- j { 'Free Booklet Offer We've attempted to answer many questions about colds, their cciJ..ses, effects a d relief in an informative booklet entitled ''How to Nurse p Cold". It's yours, free of charge, if you'll simplyfiU in and mail the coupon on this page. I Mail to: Schering Canada Inc. I 3535 Trans Canada Pointe Claire, Quebec H9R 1B4 Please send me my free copy of your booklet "How to Nurse a Cold". Additional copies only available upon written request. Name: ( P lease print) Address: City: Postal Code: . Reg. T.M Provo r; f .+ :;:"- Bu. En nom ] thrd troe"'me cl... clll... t I053 _ ..'Ie an. · Nune . Special feature: CHILDBIRTH TODAY . Femoral allograft - a nursing challenge . Patient simulation as a teaching technique . Nine-page Fall book review roundup OCTOBER 1979 . . I BICLIOTHEQUE SCIENCES INFIRMIERES OCT 2S 1 ' (9 : D FA ... _ L desi ers A · LIMITED C olce EDITION A Division of White Sister Uniform Inc. ER'S CHOICE PRESENTI N FOR THE WOMAN OF TO -1} , , " \, \ . --- - " . . , . \ Style No. 43468 - Pant suit Sizes' 3-15 Royale "Caresse" 100% polyester warp knit White, Blue Style No 3436 - Dress Sizes: 8-18 Royale "Caresse" 100% polyester warp knit White, Blue cÞ r- en - l- e.) C) (1) ..... " - The Canadian Nurse October 1979 The official Journal of the Canadian Nurses Association published in French and English editions eleven times per year. Volume 75, Number 9 Input 6 Childbinh today Special Feature 17 Calendar 8 Countdown on O. B. nurses Peggv-Anne Field 18 - You and the law 10 Nurse-midwifery: are we missing the boat? JulianneN. Powis 21 News 12 Post graduate maternity nursing program Rosie Steele 24 Special supplement: Nova ScOlia's Reproductive A look at books 42 Care Program Joyce MacDonald 27 Research 55 The LeBoyer Method: What does it mean now? MarvGrossman 28 Library update 58 Here and there: a look at nursing in France Mary Grossman 31 Nursing grand rounds: Helen A lemany. Femoral Allograft Patrick Ferguson. Jean Grice. AllisonJ. Stuart 32 Time out! Betsv LaSor 36 Sharing the experience Valerie Willetts-Schroeder 39 ... I The stor) begins... Contented is the only word for the newborn featured on this month's cover. Within minutes of delivery. his tiny hand reaches for and finds his father's finger. Cover photo of a Le Boyer birth in Zurich. Switzerland by Colleen Stainton. associate professor of nursing. University of Calgary. The Canadian Nurse welcomes suggestions for anicles or unsolicited manuscripts. Authors may submit finished anicles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and carbon. All anicles must be submitted for the exclusive use of The Canadian NUrse. A biographical stalement and return address should accompany all manuscripts. The views expressed in the anicles are those of the alJlhors and do not necessanly represent the policies of lhe Canadian Nurses Association ISSN 0008-4581 Canadian Nurses Association. 50 The Dnveway. Ottawa. Canada, K2PIE2. Indexed in International Nursing Index. Cumulative Index to Nursing Literature. Abstracts of Hospital Management Studies. Hospital Literature Index. Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microform from Xerox University Microfilms, Ann Arbor. Michigan 48106. Subscription Rates: Canada: one year. $10.00; two years. $18.00. Foreign: one year. $12.00; two years. $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new, along with registration number. in a provincial/territorial nurses association where applicable. Not tesponsible for journals lost in mail due to errors in address. eCanadian Nurses Association,1979. - \ / .. =-:. .:. l : /J : . .. . . --...: .. . " \ .'. ',". . . 0.:.;" / .;::"t, :.r- ..... ....- .. / Number one...and still groYling! THE CLINIC SHO.: M ÏI\,\lJh.Ji,@ CHOOSE FROM MORE THAN 30 PATTERNS. . . SOME STYLES ALSO AVAILABLE IN COLORS. .. SOME STYLES 3%-12 AAAA-EE For a complimentary pair of white shoelaces, folder showing all the smart Clinic styles, and list of stores selling them, write: THE CLINIC SHOEMAKERS. Dept. CN-10, 7912 Bonhomme Ave. . St. Louis, Mo. 63105 Th. Cen-.lIW1 Nur.. OcIober 111711 Ii perspective Guest editorial intensive care level regimes to If nurses are to keep pace a graduate of the Ottawa Civic what is a natural process is with rapid change in health Hospital School of Nursing Contradictions: a 400 gram senseless and wasteful. care delivery, we must and received her B.Sc. in infant exists attached to life Consumer groups seem to acknowledge the need for Nursing from the University support systems - a 1000 agree, rebelling against what major change in our attitudes of Ottawa (summa cum gram fetus is aborted; a they see as unnecessary and our knowledge. laude). A Public Health Nurse newborn infant is welcomed medical intrusion, and in some -M. Colleen Stainton, with the Victorian Order of into a family after years of cases parents go so far as to Associate Professor, The Nurses for the past four years, infertility - a child is battered opt for home deliveries. University of Calgary, and she has also worked as a staff and abused: a mother who has (In Canada home 1979 World Health Fellow. nurse at the Montreal General attempted to smother her deliveries are still of Hospital (Cardiac Surgery and Down's syndrome child is questionable safety as we do General Surgical Intensive referred for ps ychotherapy, not have the necessary Care Unit) and at the Toronto only weeks after she was community support system.. herein General Hospital (Respiratory offered an abortion. that exist in Britain or Failure Intensive Care Unit). How can one provide an Denmark.) educational program to assist The issue at hand is the professional nurse to deal clearly not home vs. hospital . with these complex delivery, or what kind of EDITOR phenomena in obstetrical delivery method to use - the As the International Year of ANNE BESHARAH the Child draws to a close, nursing? real issue is how can nurses nursing leaders across the ASSISTANT EDITORS Parent-child nursing has dssist in providing the patient JUDITH BANNING changed markedly in just the with a childbirth experience country are becoming JANE BOCK past decade: increased that is both natural and safe? increasingly vocal about what What knowledge and skills do they see as a weak link in the PRODUCTION ASSISTANT technology has added new chain of health care - the GITADEAN dimensions to nursing care in we need in this age of the perinatal period, but while advancing technology to care that mothers and their CIRCULA nON MANAGER the neonatal death rates have provide good maternal health unborn children receive in the PIERRETTE HOTTE fallen, one must guard against care? The answer is that we months between conception ADVERTISING MANAGER believing in a cause and effect must use the technology as it and birth. at the hour of birth GERRY KAVANAUGH relationship. Something is still was intended, to help us care and in the weeks immediately missing: what about the child in new ways. after. In this issue, some of CNA EXECl TIVE DIRECTOR these nurses discuss the HELEN K. MUSSALLEM who survives a premature As a professional group, problems that they see in birth through life support nurses must be able to predict maternal/child nursing today EDITORIAL ADVISORS measures in the intensive care and plan for new trends in MATHILDE BAZINET, nursery only to return to health care, and to respond in and speculate on the direction chairman. Health Sciences hospital. dead, abused by a constructive way to that the profession might take Department. Canadore College, forgotten parents who found questions from the health care to improve this care. North Bay, Ontario. him a stranger in their home? consumer. To do this, nurses OOROTH'MILLER.public relations officer, Registered Nurses are concerned in maternal/child health care Nurses Association of Nova that technology is not serving must have the intellectual ... Scotia. them well in practice, and not skills and the practical JERRY MILLER, director of supporting the parents and knowledge to visualize as well communicmion services, children. During a recent tour as solve technical problems. .. Registered Nurses Association I made of Europe and Undergraduate programs at - of British Columbia. Scandinavia. I found that the best grdnt only a degree in JEAN PASSMORE,editor, concerns of nurses involved in learning; the real skills and SRNA news bulletin, Registered maternity care are universal: knowledge required for Nurses Association of competent leadership and Saskatchewan. midwives, and even \ PETER SMITH, director of physicians, say that once mature clinical judgement publications, National Gallery valued clinical skills are being come with graduate level of Canada. lost. How can one teach preparation - and this could FLORITA clinical judgement when a include midwifery. While New developments...CNJ VIALLE-SOUBRANNE, monitor is thought to give the in-service and continuing readers will have noted from consultant. professional best information? Those in education are helpful. we need changes in the journal inspection division. Order of favor of advancing technology more people who have masthead new developments Nurses of Quebec. say that every labor requires preparation at the master's on the production side of the all possible technical aids to and doctorate level in the magazine. With this October ensure safety, but surely the service setting. issue, we welcome assistant general application of editor Judith Banning. Judy is II October 1171 The Can-.ll.n Nur.. input The Canadian Nurse invites your letters. AU correspondence is subject to editing and must be signed, although the author's name may be withheld on request. Feet of clay? scope may be reached sooner International research (which involves simply The "You and the law" than originally planned. project completing a questionnaire) to column on patient advocacy The objectives of our Recently I have contact me at the address (June) was most interesting. association are: undertaken several listed below. We are very As a person with a . to promote and to epidemiological and excited about this project, master's degree in medical provide continuing education serological investigations of both because of its sociology, I would have as defined by the needs of the Crohn's disease, orregional international flavor and agreed that nurses have a members; enteritis; along with many because of the significant growing awareness of their . to promote awareness of other researchers we have involvement of the nursing responsibility in safeguarding professional accountability in failed to identify the cause of profession in epidemiological patients' rights. However. as Critical Care Nursing; the condition. but we have research. a person who recently spent . to improve the quality of noted an increase in incidence Many thanks. 10 days as a patient in B.c. 's patient care through the in recent years and believe -Dr. John Francis Mayberry largest hospital, I know that promotion of nursing research that infection may playa role Department of patients' rights are still an in Critical Care; in the etiology. If this is true. Gastroenterology unknown concept to some of . to compile a resource file it may be possible that nurses University Hospital of Wales the average staff nurses for reference and assistance in may have an increased Heath Park dealing with patients on a meeting the objectives of the exposure to such an agent. Cardiff, CF44XW day-in. day-out basis. Associ ati on. We are attempting an GreatBritain. While your magazine Membership fees are $12 international study to assess serves as a very positive force per year. whether the condition occurs Did you know... for nursing in Canada, I am Anyone wishing further more commonly among For those who are allergic to afraid you are too often guilty information is urged to nurses than in the general insect venom help is on the of the" ivory tower" contact us: population by comparing the way. A commercial syndrome. Most of your Niagara Association of frequency with which Crohn's whole-body insect extract for authors appear to be leaders in Critical Care Nurses, Box 61, disease occurs before and treating patients with serious your profession. Perhaps you Weiland. Ontario, L3B 5N9. after nursing education with allergic reactions to venomous should stop and ask the -Candace M. Paris, the rate for ulcerative colitis. bites and stings has been "average" staff nurse and the Secretary N.A.C.C.N. We would be grateful if experimentally tested and "average" patient about the you would ask any Canadian found successful in the U.S. state of patients' rights and Working with nurses who have either The extract will be useful patients' care. antihypertensives Crohn's disease or ulcerative against bumblebee. yellow I would suggest that in We enjoyed the recent colitis and who are interested jacket. honey bee and wasp some situations in Canada, article "Hypertension: in participating in this study stings among others. OW patients have no bill ofrights Antihypertensives and how and are treated as less than they work" by Pam Haslam, Working with antihypertensives first class citizens. but note that no mention is -Jeri Bass, Brentwood Bay, made of any of the numerous Reference - Compendium of Pharmaceuticals and Specialties - 13th B.C. combination drugs now on the Edition, 1978. market. A new addition From our experience as After certain drugs have been titrated to an individual patient, it is The Catalogue of special nurses in the Lloydminster possible to use one preparation that is a combination of several drugs. interest groups (June, 1979) is Hospital. and in the Some Antihypertensive Combination Drugs are: a valuable and long overdue Saskatchewan Heart compilation of professional Foundation Blood Pressure Aldactazide lt - (spironolactone + hydrochlorothiazide) - two groups for Registered Nurses Screening Program. we have diuretics, one of which is potassium-sparing. in Canada. compiled a list of some of the Aldoril1!> - (methyldopa + hydrochlorothiazide) - sympatholytic + diuretic. I would like to apprise more common Combipres" - (clonidine + chlorthalidone) - sympatholytic + you of our group -the antihypertensive combination diuretic. Niagara Association of drugs used in our area (See Diupres'" - (chlorothiazide + reserpine) - diuretic + sympatholytic. Critical Care Nurses - which box). Dyazide - (triamterene + hydrochlorothiazide) -two diuretics, one was formally inaugurated May We hope all nurses of which is potassium-sparing. IS, 1979. Our first meeting working with hypertensive Hydropres P) - (hydrochlorothiazide + reserpine) - diuretic + was enthusiastically received patients will find it useful. sympatholytic. by the local nursing -Leanne Sauer, R.N., Hygroton-Reserpine - (chlorthalidone + reserpine) - diuretic + community and our B.Sc.N and Vi\'ian Knisley, sympatholytic. membership. which now R.N., Nurse Rautractyl-4 or _2<'Ð - (rauwolfia + bendroflumethiazide)- sympatholytic + diuretic. numbers 88, is growing C oordi na tors-Lloydm ins te r, Ser-Ap-Es,lj) - (reserpine, hydralazine HCL + hydrochlorothiazide)- quickly. It appears that our Blood Pressure Screening sympatholytic, vasodilator + diuretic. goal of becoming provincial in Program, Lloydminster, Sask. Supres - (methyldopa + chlorothiazide) - sympatholytic + diuretic. Ie. risall cuts the cost of decubitus care by controlling infection fast Debrisan sucks bacteria and tox. ins out of decubitüs ulcers. The ulcer is quickly cleansed, healthy granulation appears, and healing can begin. These (wet, exudative ulcers) averaged two days to clear the superficial infection and five days from the onset of therapy to ap- pearance of good granulation tissue in the ulcer base."1 "" \ \ Day 0 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy exudating decubitus ulcer on Erythema and edema granulation base; grafted left hip. reduced. successfully. .... .. ... .. /1 by relieving pain and ooour fast -.. :a.,.-' ..... Day 0 Infected exudating Day 4 Clear, healthy decubitus ulcer on knee. granulation base. Day 14 Ulcer healing after Debrlsan discontinued. , All patients in whom rest pain was present at the start of treatment noticed almost immediate relief of the rest pain when Debrisan was applied to the wound."2 , Debrisan was commenced and the following day, the smell had disap- red "3 ' pea . Day 0 Undermined sacral Day 7 Surgically debrided Dåy 28 Appearance on decubitus ulcer infected with before Debrisan therapy and healing. Pseudomonas and E.coll. after 7 days, infection controlled. by saving valuable nursing time Only one Debrisan chenge a day. is needed. Debrisan therapy can "' be stopped as soon as all signs of infection have gone and the ulcer is clean and granulated. , Debrisan appears to be, in my opinion, just what we as nurses are seeklng."4 .. , .T-. H e.udlltion Is"" ....,. After removing crust or necrotic tissue, pour a thick (4 mm) layer of Debrisan on the ulcer. Cover with a dressing. When the beads are saturated (12 to 24 hours later) rinse and wipe them away. Apply a fresh layer of Debrisan. Debrisan e cleans decubitus ulcers fast. . Pharmacia (Canada) Ltd. U Dorval, Québec Rel_ 1. Um LT, Michudll M. Bergen JJ. Angiology 29:11, Sept 1978 2. Bewick M, Anderson A, tlin TrIIIls J 15:4, 1978 3. Soul J. Bri. J Clln Pract, 32:8, June 1978 4. DiM.scIo 5 RN. DecubItus C.. A N_ Appro8Ch: A Nursing Rnponslbllily, on "".1 .....mI8CIII (C....., lid. e Reg T M 8 October 111711 calendar October Third Annual Nursing Lecture Series sponsored by the University of Manitoba and the VON, Winnipeg Branch. Theme: Middle management in nursing: perceptions of health care providers. Guest lecturer: Rebecca Bergman, Tel Aviv University, Israel. To be held on Oct. II. 1979 at 2000 hours in the auditorium of the Winnipeg Art Gallery, Winnipeg, Manitoba. Nursing Symposium at Toronto General Hospital, Toronto, Ontario on Oct.24-25, 1979. As a celebration of the 150th anniversary of the hospital, the symposium will provide an historical review and update of contemporary nursing practice. Contact: Audrey Abbey, Assistant director of nursing, Staff development, 4 Elizabeth Wing, Toronto General Hospital, /01 College St., Toronto, Ontario. M5G I L7. ,... ., . ... I.," , .''' I " , . , ". ! - , , , The C.n8dlen Nur.. Third Nurse Educator Conference - Excellence in Education. To be held Oct. 14-17, 1979. Program will focus on curriculum and program development, evaluation, faculty and clinical work. Contact: Ruby Browne, Nurse Educator, 12 Lakeside Park, Wakefield, MA 01880. Scientific Meeting of the Inter-urban Stroke Academic Association to be held in Ottawa on Oct. 19-20,1979. The program is of interest to those working with stroke patients. Contact: Dr. B.E. Krysztofiak, Royal Ottawa Hospital, 1/45 CarlingAve., Ottawa, Ont., KIZ 7K4. Cardiopulmonary Care 1979: A Practical Guide for the Family Physician and Critical Care Nurse. To be held Oct. 18-20, 1979 at the Royal Columbian Hospital, New Westminister, B.c. Contact: Dr. R.C. MacPherson, Director of Medical Education, Royal Columbian Hospital, New Westminister, B.C., V3L JW7. þ- "', o/;: èØ'leP". \) .# 8 '11' THE LAST THING HE NEEDS IS GAS. r, \\ (\ November Canadian Association of Gerontology 8th Scientific and Educational Meeting to be held on Nov. 1-4, 1979 at the Hotel Nova Scotian, Halifax, N .S. Contact: Dr. M.K. Laurence, Dept. of Family Medicine. 5599 Fenwick St.. Halifax. N.S., B3H IR2. Radical head and neck surgery: a multidisciplinary approach. To be held at Mount Sinai Hospital in Toronto on Nov. 2, 1979. Contact:A.M. Zulis, Assistant Director, Nursing Education, Mount Sinai Hospital, 600 University A 'e., Toronto, Ontario, M5G IX5. CNA National Forum on Nursing Education. To be held Nov.13-15, 1979 at the Skyline Hotel, Ottawa. Theme: The nature of nursing education. Focus: Degree or diploma? Open to all registered nurses to a maximum of 300. Contact: The Canadian Nurses Association, 50 The Driveway, Ottawa, Ont., K2P IE2. Order of Nurses of Quebec Annual Meeting to be held on Nov. 7-9, 1979 in Montreal. Contact:ONQ. 4200 ouest. boul. Dorchester, Montréal, Québec, H3Z IV4. Canadian Intravenous Nurses Association 4th Annual Convention. To be held at the Inn on the Park Hotel, Toronto on Nov. 20-21,1979. Contact: CINA, 4433 SheppardAve. East, Suite 200, Agincourt, Ontario, MIS IV3. Special Scholarship The International Association for Enterostomal Therapy has announced the fOllTlation of new scholarships to be awarded to registered nurses interested in working in this specialty field and in improving quality care for the ostomy patient. Application deadline is December I, 1979. Contact: International Associationfor Enterostomal Therapy,Inc.. Central Office, 2506 Gross Point Rd., Evanston, Illinois, 60201. 'V When a patient can't move around, gas can be a problem, and a painful one at that. So for pa- tients who are immobile ..n_ _. following surgery or for I 0 ''' 01 ' post-cholecystectomy .' patients, give them extra ,80 strength OVaL 80mg, the ForGas chewable antiflatulent __ Cootre tablets that work fast to IesGaz 8 HORnER relieve trapped gas and lQIfER M",t..a' C. ,,,.,,, bloating. Pro uct mono!,:raph available on requeat. , . . .. IPiAil , , , Why change dressings several times a day when once a week is plenty? This is an Op-site dressing for non-infected ulcers. When it goes on, it stays on... for a whole week. Because Op-site is an adhesive, transparent dressing that breathes and sweats with the skin. So you can keep your eye on the entire healing process without the interruptions of frequent dressing changes. Op-site is easy on the patient too. It's neat, not bulky. Patients can take regular baths or showers without discomfort because Op-site is water-proof. Op-site is also bacteria-proof, protecting the ulcer from contamination. Because once a week is plenty, Op-site means fewer dressing changes. And that's less work and more time for you. -------------------- I 0 S . t !ô" .. I P _ I e For f';Jrther Informa!lon alx?ut I I Op-slte ulcer dressing. fill In the ultimate wound dressing and mail this coupon. I I I I Name I I I I Address I I I I City Provo_Code I I Mail to' [8] '---'. Sm,th f, Nephew Inc. 2100,52ndAvenue I . : Slll: M dicl!ll Division lachine. Qué.. ClInlldlil I I .'. _.: H8T2Y5 -------- ----------- 10 October 111711 The C.n.dI8t'l Nur.. ., YOU AND THE LAW --....... J .... r Hands that care: are they safe? Corinne Sklar Du you wash your hands between çare delivery to individual patients? Usually? Always? Are you sure that you always adhere to the principles of aseptic technique? Strict adherence to the fundamentals of aseptic technique and the broader principles of control of infection is an important requirement for aU those who work in hospitals. This applies not only to those who deliver health care directly to patients but also to everyone who works in a hospital: when infections or cross-infections result from the failure of the hospital staff to properly safeguard the patient, that hospital may be found legally resp nsible. Infections which are spread by hospital personnel or other health professionals are termed nosocoJ11ial; the prevention of such infections is of concern to both hospitals and people who work in them. Hospitals are responsible for maintaining a safe environment for their patients. including an environment which does not result in further illness to the patient. This responsibility extends also to providing a safe environment for its staff. Thus. our public hospitals statutes provide. either directly or by regulation. that hospital employees must undergo periodic health review. have regular chest x-rays. and. in certain circumstances. submit stools for culture. The reasons for the foregoing are self-evident: if members of hospital staff are ill or carriers of infection, they run the risk of communicating disease to others, whether employees or patients in that hospital. The hospital also bears the responsibility of instructing its employees with respect to proper technique to avoid cross-infection - the proper method of hand-washing ,.of care in mopping floors to avoid clouds of dust. of careful handling of waste products. etc. Such instruction is necessary so that !>taff can avoid harm to themselves as well as others. Hospitalliabilit) In an American case. an inexperienced orderly contracted hepatitis when his skin was accidentally punctured by some needles in the garbage bag he was delivering for disposal. The Court found that the hospital was bound to provide a safe place for its employees to work: a hospital. as an employer. has a duty to warn inexperienced employees of any dangers connected with their employment and this duty involves teaching the employees how to avoid such dangers. tIn such a case. the employees should be gi ven infonnation on the use of protecti ve clothing and gloves and any other pertinent data to ensure the safe handling of such waste. In another American case reported by Creighton,2 the death of a baby from miliary tuberculosis resulted in a finding of liability against the hospital. The nurse who cared for the baby in the nursery had a cough and was actually suffering from tuberçulosis. The nurse's supervisors faded to report her condition; the hospital was held to have been negligent in having pennitted that nurse to work. In a 1934 case (the only reported Canadian case in the area of infection control). the hospital was absolved of legal responsibility. 3 I n that case. a child was admitted to the hospital suffering from diphtheria. Smallpox was in the Vancouver area at the time and. subsequently. seven children were admitted to the same floor. all suffering from smallpox. The same nurses attended to all of the patients. When her mother complained. the little girl with diphtheria was transferred to another floor where there were no smallpox patients. This patient was later discharged. cured of diphtheria but nine days later she was ill with smallpox and was ultimately disfigured. The claim against the hospital did not allege negligence against the hospital employees. Instead, the complaint was based on the failure of the hospital to segregate its patients so as to avoid cross-infection. Because of expert testimony that the hospital had adhered to the accepted and widespread general practice prevailing at the time. the hospital was absolved of responsibility. Standard of care The events referred to above took place in 1934. If they had taken place in 1979. the result would probably have been different: if a Court today finds the generally prevailing standard of care wanting, then that Court may impose a higher standard of care and find liability. It is important to remember that cases are decided on their own facts and on the evidence presented to the Court: if there had been allegations that the hospital staff had been guilty of negligent breaches of sterile technique. this factor. even in 1934. might also have made a difference in the outcome. In commenting on this case, Lord Nathan said: 4 But, now that it is recoRnised that a hospital authority is liable for the neRliRence oflhe nursinx staffin such respects. it is as well to point out that. in circumstances such as those under consideration, the stronger the e1'idence that an infallible technique has been adopted to amid the possibility of cross-infection. the more compelling is the inference that, if cross-infection does occur, it must have been caused by a breach of that technique on the part of the hospital staff A patient miRht therefore succeed in an action on the Rrolmd that such a breach amounted to neRlixence for which the hospital authority was ,'icariously liable: an{J an inability to point to the specific member of the stajfresponsible and to the exact occasion of the breach would not necessarily be fatal to the action. The CuI-.llen NUrH Instruction in the proper technique to avoid infection and cross-infectIon is part and parcel of a nurse's education from the earliest days. Failure to adhere to these basic principles can result in hann to patients and may result in liability to the nurse and her employer. the hospital. In the 1963 case of He/man v. Sacred Heart Hospital,S the patient successfulIy sued the hospital for injuries resulting from a staphylococcus infection contracted in the hospital. The evidence was that the nurse caring for the plaintiff touched him after caring for his room-mate who was suffering from a purulent discharging boil. The lack of sterile technique in caring for these patients was held to have led to the plaintiffs injuries. Failure to pay due care and attention also resulted in liability in another American case. 6 A nurse brought a new mother a baby to nurse. This baby was suffering from impetigo but was not this mother's child. Later the mother's own newborn developed impetigo and suffered complications. The negligence of the nurse was found to have been the cause of the child's infection. Protecting yourself and the patient Nurses are a m or factor in infections or cross-infections through their adherence to (or breach of) the principles of aseptic technique. Nurses have a duty to adhere to these basic nursing principles so that infections that may be prevented by ordinary and reasonable care are duly controlled. In doing so they safeguard not only the health and welI-being of their patients, but also their own health and that of their co-workers. Handwashing between patients is time-consuming when you're busy - a simple task too easily overlooked. However. the time taken to fulfilI this basic responsibility is time welI spent: it serves to protect the health interest of both the patient and the nurse and the nurse protects the interest of both herself and the hospital against legal responsibility. Infection control is the responsibility of both hospitals and their employees :nufses have a major role to play in the control of infection. Failure to fulfilI this responsibility may result in an alIegation of negligence being brought against the hospital and its nurses. References I *Wall..er \'. Graham el al. 343 So.2d 1171 (La 1917). (In Hosp. Infection Control, Nov. 1978. p.174.) 2 Creighton. Helen. Law nerv nurse should know. 3d ed. Toronto. Saunders. 1975. p.I34. 3 *J'lIncou\'erGeneral Hospital v. McDaniel et al. [1934] 4 D.L.R. 593 L_ ... , ..... - j - . , -...r , 1 1 .r , ) ,.. -, I. , j , PJ 'I -If .. r J ; - I. .I .. .. , e 1 ... , I J .j ..., " CNA 's Tas/... Group on Nursing Practice Standards has met twice since it was set up early this Summer. Pictured during one of their meetings are members: (standing) Myrtle Tregunna, da\' care coordinator, St. Vincent's Hospital, Vanco/H'er; Karen Mills. associate director, City of Edmonton Local Board of Health; Jessica Ryan, head nurse, Chaleur General Hospital, Bathurst. N.B.: Louise Lévesque, director ofCNA projects; (seated) Evel}n Adam, associate professor of nursing, U ni,'ersity of Montreal; Louise Lemieux-Charles. director. Nursing Proce.çs Project, Registered Nurses Association of Ontario: Pat Wallace, director, CNA Nursing Practice Standards Project. "Continuing concern by the nursing profession to take steps towards developing sound evaluative measures of nursing care as well as societal expectations is having an impact on the direction the nursing profession is taking." says Pat Wallace. She is Project Director for the CNA Definition of Nursing Practice and Development of Nursing Practice Standards. Teamed with Pat Wallace is Louise Levesque. Director ofCNA Projects. She says that a vital factor is the concern of the provincial and federal governments in relation to value received for the health care dollar. and the role of consumers of health care services in relation to "assurance" of quality care. "The development of standards for nursing practice is a prerequisite in assessing nursing care because they provide a baseline for the determination of quality measurement," says Levesque. Levesque emphasizes that CNA does not intend to duplicate work already done at the provincial level. It will build on existing knowledge to complement the efforts of all. Both Levesque and Wallace have already been in contact with provincial/territorial associations as well as other organizations concerned with standards of nursing practice. Wallace says the objectives are two-fold: to develop a definition of nursing practice and to develop standards that are applicable to all fields of nursing practice. She says they will be concrete. achievable and understandable to nurses. to other health professionals and to consumers. Looking ahead, project plans include an Advisory Panel to provide expert guidance and critical analysis and a Reaction Panel to comment on all drdfts. Ways of obtaining feedback from many health related groups and from CN A' s general membership will be determined - the aim is to involve as many individual., and groups as possible without making the project structure too cumbersome. Wallace says completion date for the project is June 1980: "It will be the end and the beginning - phase II may focus on validation of standards and the effect on quality of care." The soft touch for tender tissues. . 100 TUCKS* Pre-Moistened Pads For hemorrhoids, feminine hygiene, piles and personal itching problems. C. "'e,..,ti.,-Aslr;.,'" I DIN 443646 "'tdemark of Parke DaVIS & C & u>mpany LId regl:.1. Relieve postpartum and postsurgical itching and burning with Tucks. PARKE-DAVIS 14 Oct_II178 Th. Cenadlan NUrH TilE .\'\',.\ PE(;O\T.\ PEELI:\G Sate Eff('(.tive "The Anna Pegovo Peeling'is renowned for its effectiveness on rei uvenescence, acne, and other rei ated ski n probl em s. It is the only internationally recognized peeling and is presently being markefed throughouf Europe. In France, in 1965, this product won the Gold Cup from Le Comité du Bon Goût Françai s. France Clovet, R.N. (Hôtel Dieu - Chicoufimi, affiliafe of Laval Universify) has the exclusive rights for thi s formula in Canada. Sfudio Clavet Inc., "ho has been serving Canadians for years in Montreal, is currently recruiting nurses inferested in increasing their income by becoming owners of a studio. Sfudio Clavet Inc. has qualified professionals who are ready to train you to become specialisfs in this field. If you have approximately 7 years nursing experience and wish fo discover new harizons, please contacf: Studio Clavet Inc. 1-115 Saint - Hubert Montreat (}uebec, H2L 3Y9 Tel.: 1-514,845-3046 We are a member of the Belter Business Bureau. Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE. QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 S THERESE,aUE.J7E4K3 To receive a free sample of our "needs no starch" cloth, and more information, please clip this coupon and mail today. Name ...................................................... (block II1II..) Address ................................................... City ................................... .Postal Code ....... Your graduation school .................................... Nurses review health needs of B.C. Corrections inmates The five nUTses who made up a Task Committee on Health Care Facilities within the B.c. Corrections System have completed their review of relevant federal and provincial studies and come up with a comprehensive series of recommendations intended to ensure that all correctional institutions in the province meet certain prescribed minimum standards. Chief among the recommendations is the suggestion that "within the Corrections Branch there be a nurse employed as Director of Nursing Operations for the province who would be responsible directly to the Commissioner of Corrections." The Director of Nursing Operations, the report recommends. should have a degree in nursing and an expressed commitment to research and the development of programs directed towards health promotion and disease prevention. The Task Committee Was established in June 1978 after passage at that year's RNABC annual meeting of a resolution directing the provincial nurses' association to "seek infonnation about the facilities and administrative system under which registered nurses are expected to carry out their duties within the corrections system. ,. The committee c nsisted of Chainnan Phillis Latowski of Richmond, B.c.. Linda Bishop of Pitt Meadows. Iris Passey of Burnaby, Olive Simpson of New Westminster and Areta Stewart of Surrey. Their report was adopted by RNABC directors early last Summer and has since been forwarded to. among others: the province's Attorney-General, Corrections Brdnch officials, B.c. Health Minister Bob McClelland, members of the provincial legislature. Registered Psychiatric Nurses Association of B.c., the B.c. Medical Association, the B.c. Association of Social Workers and the B.C. Branch of the Canadian Bar Association. Task Committee members also recommended establishment of a Forensic Health Advisory Committee to the Corrections Branch consisting of representatives from nursing, dentistry. social work, phannacy, the clergy and a consumer group. A total of 32 concerns were described by the task committee as requiring "prompt consideration" by the proposed Forensic Health Committee. These included recommendations that: . nursing needs of inmates be met by employing registered nurses and registered psychiatric nurses . the role and functions of forensic nurses be clearly defined and that nurses not be used for purposes of security . all nurses have current industrial first aid certificates . opportunity and funding for orientation. inservice and continuing education programs for nurses be made available . policy and procedure manuals with respect to health care be made available and that those policies and procedures pertaining to nursing care be fonnulated by nurses . nurses participate in planning health care facilities. NP AO Executive The Nurse Practitioners Association of Ontario has announced the names of their 1979-80 executive following their annual meeting held in Toronto this past spring. One hundred and ten nurse practitioners attended the 6th annual conference during which they participated in seminars and discussed current trends. clinical problems and techniques of patient management in primary health care. The new president is Susan Mackenzie-Miller. who is employee health nurse at the Toronto Western Hospital. She replaces past president Susan Finnie. who practices at the Flemingdon Health Centre in Don Mills. '" uniformity 1 . 1 . "'1. of- . 'Ii l-.... .. , .. .. / I "" '" . I Bramalea City Centre (416) 453-8300 Square One, Mississauga (416) 275-6470 Sunnybrook Plaza, Toronto (Bayview and Eglinton) (416) 485-1888 Oshawa Centre (416) 579-1123 unifo,ml ,.gi/t.,.d .... j \... fl . ......... \ t I , ) Orillia Square (705) 325-9394 545 Sherbourne St. Sherbourne North of Wellesley (416) 968-1808 PaofUSlOl'oIAL UNIFOII..' 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Inru lOn control valve operates electromagnetically to precisely regulate flow. [ ] ,rc:;::g r .. Trademark of The Dow Chemical Company t Trademark o' Bunon Medical Products Inc USA . 1 tC9 " Does Canada face a shortage of qualified O.B. nurses? The case for the nurse - midwife. Mothers and babies are safer now in the Atlantic provinces. A Canadian nurse visits a LeBoyer clinic. Countdown on 0.8. nurses . - .. I ,-_ " Is there a crisis developing in maternity nursing? After three years of research into maternal/newborn care in northern Alberta hospitals, this author says "Yes, there is." I , \ . Obstetrical care - including prenatal, labor and delivery and postnatal care - is, of course. a function of both physicians and nurses. It is also an area which is demanding more and more from the people who work in it - more knowledge, more skills. more preparation and more experience. High risk mothers today are detected early, critically ill newborns are cared for in neoflatal intensive care units, all reducing the maternal/newborn death rate. As well. new concepts offamily centred maternity care and early bonding are recognized as important elements to the psychological development of the family. With this increasing knowledge base, we have to wonder whether nurses in Canada are being prepared to adequately care for mothers and newborns. Do they get the clinical experience they need while they are students? It would seem that they do not. Right now, obstetrical nurses receive extra preparation in their specialty through on-the-job training, by taking advantage of the very few courses available in maternity nursing or by going to another country to take midwifery courses. Surely this is a far from satisfactory situation. -.. - -....., ,,-- . .. ' -.- - - - - f- ---I n Ie Field At the University of Alberta, a revised program in advanced obstetrical nursing was funded by the provincial department of Advanced Education and \1anpower in 1976. As a condition of the grant, a study of obstetrical nursing practice in Alberta was undertaken and, in all. three studies were completed. The first study examined the employment patterns of nurses in 70 hospitals in northern Alberta; the second validated the skills and behaviors necessary for registered nurses working with mothers and newborns and whether new graduates had these skills: the last study surveyed current educational programs and examined both content and clinical practice. STUDY NO.1 The first study looked at the employment patterns of nurses working in northern Alberta hospitals. Forty-nine ofthe 70 hospitals surveyed responded to a questionnaire sent to them. The hospitals were grouped according to bed sizes: 1-24; 25-49; 50-99; 100-299; and over 300 beds - and all of them reported at least 20 deliveries in 1976. * The survey examined three areas: . the qualifications of nurses presently giving maternal/newborn care; . the preferred qualifications of nurses working in this area; "The actual range of deliveries was between 20 and o\'er4,OOO. . .. þ . orientation period (the period of time before a new employee is put in charge of patient care on evenings and nights. ) Findings In terms of educational preparation. one third of all nurses employed in maternal/newborn nursing had midwifery or advanced obstetrical preparation while one quarter of the nurses employed in labor and delivery had similar advanced preparation. In all, 131 nurse-midwives were identified as working but of these only 19 were prepared in Canada. Employers stated a strong preference for nurses with advanced obstetrical preparation and there was a consensus that new graduates would not be employed in labor and delivery nursing unless no other applicant was a vailable. Hospitals with 500 or more deliveries per year indicated that lateral transfers were possible after nurses had worked for a year or more in postpartum or newborn nursing. Orientation periods for new employees varied widely depending on the size of the hospital. For hospitals under 100 beds, orientation ranged from 14-30 days. while new graduates might not be in charge for one to six months in hospitals over 300 beds. Th. C.n-.ll.n NUrH OcIøber Iln 11 TUDY NO.2 Pan one One question asked in this second study was. "What skills and behaviors are necessary and desirable for nurses working in obstetrics?"I n all. a total of 99Lbehaviors.. were identified from three sources: I) a search of the literature on roles and functions of maternal/newborn nursing 2) a perusal of nursing standards in the field 3) the responses of experienced nurses currently working in obstetrics. A questionnaire was sent to nurses involved in direct patient care for validation of the identified behaviors. To be considered a necessary or desirable behavior. 70 per cent of the respondents had to agree. Findings Antepartum care Relatively few skills were va'idated as necessary for hospital nurses in this area. Since many smaller hospitals refer patients with complications to metropol it an centers, the number of units in northern Alberta admitting prenatal mothers is relatively small. Also, because prenatal teaching is generally given by community health nurses. involvement of hospital nurses with mothers in the prenatal period is limited. Labor and delil'ery Almost one third of the behaviors validated in labor and delivery care were general nursing skills related to assessment on admission, assessment of the progress of labor. management of the second stage and immediate care of the newborn. In general. the skills validated as necessary fell short of published recommended standards for care. Postpartum care There was a split in the behaviors necessary for the staff nurse and those considered necessary for the head nurse. For example, behaviors related to physical care of the mother were necessary for the ..taff nurse while those relating to psychological support, teaching and counseling were necessary for the head nurse but only desirable for the staff nurse. I n general. behaviors and skills requiringjudgment were considered desirable for the staff nurse but necessary for the head nurse. ..555 behaviors were wlidaled as necessary 323 validaled as desIrable. To nurse the mother with postpartum complications, skills and behaviors related to physiological conditions (such as diabetes and thrombophlebitis) were considered necessary while those related to psycho-social factors (such as grieving and family planning) were considered desirable. Newborn ca re Most behaviors related to physical newborn care were considered necessary for the staff nurse. Skills in guidance and counseling of the parents were considered desirable. Physical assessment of the newborn was a desirable skill for staff nurses but necessary for head nurses. Only nine skills related to the care of the newborn including suctioning, giving oxygen by mask. gavage feeding and incubator care were validated as necessary for all nurses working in the nursery. However. hospitals with over 300 beds and 250 deliveries a year validated a wider range of skills as being necessary in the care of the ill newborn. U nl'lliidated skills Some of the identified skills were not validated by 70 per cent of the respondents. The unvalidated skills seemed to fall into four groups: . !>kills which are occasionally carried out by nurses but which nonnally fall in the medical domain, ego emergency delivery . skills no longer in common use, ego rectal examination . skills and behaviors associated with new techniques or tenninology. ego use of partograms to record progress of labor . use of specialized equipment or procedures. Pan two Another question considered in this study was "which skills and behaviors are required by nurses on employment and which are acquirable on the job?" Generally. behaviors identified as necessary were those that were considered to be a "requirement on employment". Desirable skills. ego psycho-social skills were thought to be acquirable on the job. However. there was a question concerning who would help the new graduate acquire these skills. The study found that the smallest hospitals needed the most highly skilled practitioners. However, these hospitals had short orientation periods. a lack of in-service facilities and relatively few obstetrical patients. They were not in a position to provide the experience that would allow the graduate to acquire skills on-the-job. Pan three This part of the study looked at the question. "Are new graduates perfonning the validated skills and behaviors satisfactorily or unsatisfactorily?" A new graduate could be from a hospital or college diploma program or from a basic baccalaureate program. Findings Antepartum In general. skills in antepartum care were perfonned satisfactorily by new graduates except in the case of physical care skills associated with antepartum complications. New graduates were not seen as perfonning these satisfactorily. Labor and delil'ery In labor and delivery care. hospital graduates were satisfactory on eight out of twenty-one grouped behaviors. However. they were unable to time contractions. assess the progress of labor. assess the need for medications or manage the second stage oflabor. College and baccalaureate graduates were seen to be even less successful in their ability to give care. Since the behaviors validated as necessary did not even meet minimal standards set by the American Nurses A..sociation (1973) and the Nurses Association of the American College of Obstetricians and Gynecologists (1975), these findings have serious implication.. for nursing care. Postpartum In postpartum nursing care, behaviors validated as necessary by all ho..pitals were generally satisfactorily performed by new graduates. Postpartum complications where the mothers required more extensive care were limited to the large hospitals and necessary skills were not always performed satisfactorily by new graduates. Newborn The behaviors and skills necessary in caring for the nonnal neonate were perfonned satisfactorily by new graduates. On the other hand, the nine behaviors validated as necessary for the care of the ill newborn were unsatisfactorily perfonned. No new graduates were prepared to work in centers where more complex care of the sick newborn was carried out. 20 OcIøber 111711 The C.nedlen NUrH STUDY NO.3 The last study was a survey of current nursing education programs (both diploma and baccalaureate) in Alberta and examined the content and clinical practice obtained by students in the area of maternal/newborn nursing. Findings Ten schools responded to the survey. All of them seemed to provide the student with an adequate knowledge base for maternal/newborn care. But clinical practice varied greatly among the schools, particularly practice in labor and delivery. The range of experience in this area spanned from 16 to 170 hours. Three of the four hospital programs offered an optional or a required senior experience in labor and delivery care as did two of the college programs. The majority of instructors indicated that they felt the experience (ifless than 40 hours) was inadequate. They stated they saw no way of increasing it within the current curriculum. Two instructors (from a school offering students 16 hours experience) stated that the graduates had the skill to function as beginning practitioners. I t is of interest to note that these instructors had only two years work experience between graduating and beginning to teach. Only two schools offered experience with the sick newborn. one offering seven hours. the second providing approximately 75 hours of experience. Generally the focus was on the well newborn in both theory and practice. Implications for nursing It appears that graduates from nursing education programs in Alberta have minimal competence in the care of the postpartum mother and well newborn. Most do not have even minimal competence in caring for the mother and newborn who develop complications (a problem generally restricted to large metropolitan centers) nor are they competent to care for the woman in labor. Not surprisingly. the hospitals with the least facilities for training nurses on the job required the best prepared nurses. Most hospitals indicated that they are reluctant to hire new graduate to work in labor and delivery nursing thereby inferring that only experienced nurses should work in rural hospitals. But if a nurse graduates without basic skills she is unlikely to have them five years later unless she has been persistent in her efforts to learn more about the care of the mother in labor. I n the meantime. the metropolitan hospitals suggest it takes three to six months to "orientate" the new graduate. In effect, she must learn labor and delivery nursing after she becomes a graduate. What to do? In my view, t is time that educators and nursing service personnel decide the purpose of obstetrical nursing in the basic curriculum. Does Canada need a second level program as is common in other countries? Such programs have provided much of the skilled nursing care Canadian hospitals have utilized in the past. For example. there is evidence that leadership in maternal/newborn care has been provided by nurses who have received advanced preparation in countries other than Canada. Generally this preparation has been midwifery and the majority of nurses have been recruited from the United Kingdom, Australia, New Zealand. India, Ireland and the Phillipines. Because overall immigration in Canada has decreased over the last few years. we do not have this source so readily available. How do we prepare nurses for neonatal intensive care and intermediate care units? In many cases. it has been on-the-job training. But is this good enough? Can hospitals afford to divert monies allocated for patient care to provide several months on-the::job training? Can an adequate pool of nurses be prepared in this way? As an alternative, should clinical certificate courses be offered and if so. by whom? Are continuing education programs available? It is my contention that if we do not find answers to these questions and find them quickly there will be a crisis in maternal/child nursing within the next five years. The development of nursing 'itandards will identify minimum competencies needed for registered nurses, but this is only the beginning. Nurse educators need to look at their accountability in terms of behaviors and skills of their graduates: they need to sit down with their peers in nursing service to decide what the real needs are. Then they must make a realistic plan that identifies content and competencies at the basic level and the type of educational program needed on a continuing education level. The agencies that should offer su h continuing education programs must also be identified. Good obstetrical care must be a priority in today's health system. The level of care given in the prenatal period. during labor and delivery and immediately after birth can vastly influence the health status of both the mother and child. The nurse's role in the delivery of this care in both the hospital and the community is of tremendous importance. It is ourresponsibility to provide the best care possible. OW Bibliography I American Nurses Association. Standards. Maternal-child health nursing practice. Kansas City, Mo, 1973. 2 Andrews, Heather A. Educational needs of registered nurses: a report commi.uioned by the Alberta Association o.fR egis tered Nurses. Ad Hoc Committee to Study Ways of Promoting Post-Basic Degree Program Studies in Alberta. Edmonton, Alberta Association of Registered Nurses. 1978. 3 Canada. Health and Welfare Canada. Recommended standards for maternity and newborn care. Rev. ed. Ottawa, I nfonnation Canada, 1975. 4 *Field, Peggy-Anne. A follow-up .wrvey ofgraduatesfrom the advanced practical obstetrics course. January 1972 to March 1977 (inclush'e). Edmonton, University of Alberta. Faculty of Nursing, 1978. 5 Supplement to a I'lliidation of skills and behaviors that are nece_uary and required for maternal-newborn nursing and their successful performance by new graduates. Edmonton. University of Alberta, Faculty of Nursing. 1979. 6 "Trends in obstetrical nursing employment. Northern Alberta. 1976. Edmonton, University of Alberta, Faculty of Nursing. 1977. 7 I nterprofessional Task Force on Health Care of Women and Children. Joint position statement on the de,'elopment o.tJamily-centered maternity/newborn care in hospitals. Chicago. 1978. 8 Modelforutili;:ation ofNAACOG standards. Washington. Nurses Association of the American College of Obstetricians and Gynecologists. 1977. 9 Obstetric, gynecolo}?ic and neonatal nursing functions and standards. Chicago. Nurses Association of the American College Obstetricians and Gynecologists. 1974. 10 Neonatal intensÏ\-e care. Supplement. Chicago, Nurses Association of the American College of Obstetricians and Gynecologists, 1978. *Unable to verify in CNA Library Peggy-Anne Field is an associate professor in thl' Faculty o.fNursing at the Uni,-ersitv of Alberta in Edmonton. She has bee'; el;lplo.ved at the U of A since 1964 and has responsibility for the A d\'anced Practical Obstetrics Program. S he has also taught maternal/ newborn nursing and nursin}? education. Field obtained her education at Addellbroo/..e's Hospital. Cambridge, England. recei,'ed a B.N. degree from McGill UnÏ\'ersitv and an M.N. from the Uni,-ersity of Washington. Currently, she is on educationallew'e to "'ork on a Ph.D. The C.n-.llen NUrH OcIøber Iln 21 Nurse -Midwifery are we missing tHe At 2336 hours on May3. 1978Annie Schmo/ze was born into the quiet atmosphere of the Booth Maternity Centre, Philadelphia. P A, U.S.A. Her parents. Jeanne and Ken, had both acti\'ely participated in the modified "LeBoyer" birth and as nurse-midwife,1 had attended at the deli\'ery of the baby. Throughout the labor Ken had been beside his wife pro\'iding support and encouragement during the contractions while Jeanne concentrated on her pushing and breathing until their daughter was born. Still covered with amniotic fluid and \'ernix, Annie was placed directly on her mother's stomach where she wriggled warmly against Jeanne's skin and gazed wide-eyed and bewildered at the excitement around her. Annie's birth was the culmination of months of prenatal preparation for Ken and Jeanne. Their first child, Kris, a bright-eyed little bov, was born in the conventional surroundings of a hospital. Jeanne "'as gÏ\'en antenatal. intrapartal and postnatal care by a physician. For their second child, howe\'er, they elected to participate in the birth experience to a greater extent and so they chose Booth Maternity Centre. They are just one of many couples who annually seek ollt the kind of care and birth etperience offered at the Booth, a centre runjointly by obstetricians and nurse-midwi\'es. The Canadian scene Similar birthing experiences are being carried out in a variety of settings in the United States* but. in Canada, the options are more limited. By far the largest number of births in Canada occur in hospital with its clinical routine and subsequent feeling of alienation for many parents. Because of growing consumer awareness. some parents are choosing to have their babies at home. Since very fe\\- physicians wiIl attend at a home birth. some of these couples are cared for by unqualified birth attendants who have no legal. medical or emergency backup: others use qualified attendants who. because of existing medical and legal regulations. are practising outside the law and who also have no emergency backup. Because of Canadian Julianne Powis demographic considerations, some births also take place in remote nursing stations with qualified nurse-midwives and outpost nurses practising within the jurisdiction of Medical Services. Health and Welfare Canada. Most of these alternatives provide various forms of perinatal care. Dissatisfaction and concern Evidence from public health agencies. hospitals. the media and my own personal observations suggests that many Canadian parents are unhapp} with their limited involvement in the birth process. This growing dissatisfaction cannot and should not be ignored. Childbirth is a natural process. not a pathological condition: why should barriers exist that prevent a woman from sharing this life experience with her partner. friends or children? More and more, mothers and fathers want a choice: they want a safe, satisfying birth experience that can be shared with those closest to them. Research suggests that total participation in the birth can have a significant bearing on the future stability of the family unit. Do we as health professionals have the right to withhold this choice from parents? Unfortunately. the alternatives to hospital delivery now being chosen by parents can be dangerous and needlessly jeopardize the lives of both mother and baby. Health care professionals are justifiably concerned. In May 1978 the British Columbia Medical Journal observed: "It was noted in the annual ....,J .Su: Cart)'. E/ain . A/t rnativ birth c nt rs. bv ... and Alison Rice. Canad.Nurs. 73://:3/-34. No>. /977. . . boat? report of the Maternal Welfare Committee of the Health Planning Council ofVancow'er, B.C., that out-of-hospital delÏ\'eries are becoming premlent. During 1965-1975, 2,253 registered home births were noted - the non-registered numbers may be significant. The report also indicated its continued condemnation of the practice of home deli\'ery - based on inadequate emergency facilities for the home, and the number of women eventually admitted to hospital from abandoned home deli\'ery with pre\'entable, life-threatening conditions." The World Health Organization places equal importance upon the medical and psychological aspects of health care. Consequently we must accept that the safety of mother and baby is paramount in both areas. Canadian families seeking out-of-hospital delivery sites or care offered by lay attendants, compromise their medical safety to achieve the psychological satisfaction which is important to their integrity. If the outcome of their decision is a healthy mother and baby. then their goal has been achieved. Ifcomplications arise. then what are the long term ramifications both medically and psychologicaIly? The \alue oftechnolog) In the majority of pregnancies. complications wiIl not arise but not all pregnancies turn out weIl. Advanced medical technology and emergency facilities must be readily available for those who need it. Tremendous advances have been made to improve maternal/infant mortality and morbidity and it would be a serious error to discredit the judgments of physicians expert in detecting pathology and in instituting appropriate interventions. However. future parents may well have justifiable complaints about physician insensitivity. the lack of encouragement to be involved in decisions for care. the over-use of technology and the dehumanizing aspects of hospital routines. There is no guarantee that a pregnancy. birth or post delivery will be without risk of unforeseen complications. Regardless of how normal progress may appear. we must be alert for any significant changes in the .,tatus of both mother and child and have 22 OcIøber 111711 The C.nedlen NUrH , the expertise and technology available. For the pregnant woman who is considered to be high-risk. technological intervention is a necessity for the healthy outcome of the pregnancy. But technology must be adapted to the individual, and the mother and family must be given support to decrease the adverse ps ychological effe'Ct of its use. For the mother who is low-risk. individualized care is still the key. Think about the rigid and coldly mechanical routines that often take place on obstetrical units? Could these not be substituted or modified for more individualized measures or even deleted completely? Each family's needs are unique; we must learn to accept that fact and to recognize its significance in the care that we offer the expectant family. both father and mother. Providing alternatives Considering the concerns of Canadian families, it is my contention that maternal/child nurses must evaluate how they can better meet parent's needs. Ideally. nursing involvement should begin early in the pregnancy - to provide information about nutrition, to answer questions and allay fears. to help them grow with their changing life-cycle and to support their preparation for parenting. Involvement should not stop at the delivery but extend into the early weeks and months that follow. In addition. activities or routines that "force" parents to consider unsafe birth experiences cannot be condoned. As an alternative. there is a need for a safe setting where parents can achieve their goals of involvement and satisfaction in the birth experience. For the low-risk pregnancy, the obvious answer lies in legally recognizing. educating and employing nurse-midwives in Canada's health care system. Safe and satisfying antenatal. intrapartum and postpartum care. with complementary parent education classes is. in my view, the mandate of this professional. The nurse-midwife is an expert in the normal aspects of the child-bearing cycle and is educated to recognize any abnormality. Canadian Nurses Association Statement on the Nurse-Midwife :' Position At the present time, the delivery of health services to Canadian women during the span of their reproductive life is fragmented, uncoordinated, and sometimes, inadequate. In addition, there exists a growing demand for more extensive counselling and educational programs in this area. CNA recommends recognition of the nurse-midwife as the health professional best equipped to meet the growing need for counselling services and for greater continuity of care within this area of the health system. Function The nurse-midwife provides a family-oriented service which offers comprehensive care to the mother and child during the entire maternity cycle. The nurse-midwife is prepared, through her education and experience, to give the supervision, care and advice that women require during pregnancy, labor, delivery and following birth. This care includes: supervision of uncomplicated pregnancies, conduct of normal deliveries, institution of preventive measures, detection of abnormal conditions in mother and child, procurement of medical assistance when necessary, execution of emergency measures in the absence of medical help, and care of the healthy newborn. The nurse-midwife provides counselling, not only for the individual woman. but also for the family and members of the community. This assistance includes advice on common gynecological problems, family planning and child care, as well as pre-natal education and preparation for parenthood. Preparation National standards regulating educational programs and practice should be developed joinlly by nurses, physicians and nurse-midwives and implemented by nursing regulatory bodies. Nurse-midwifery programs should be provided in institutions of nursing education. These programs should be offered at two levels: post basic (diploma or baccalaureate) and master's degree. Qualification A nurse-midwife is a person who is eligible for registration as a nurse in a province of Canada, has successfully completed a prescribed course of study in nurse-midwifery in a recognized educational program and has acquired the requisite qualification to be certified to practice nurse-midwifery. Practice and remuneration The nurse-midwife functions as a member of the health care team. The amount of physician participation and supervision depends on the degree of deviation of the maternity cycle from the normal. The scope of activities and responsibilities varies according to the setting. Remuneration should be on the basis of a salary which is adequate, competitive, and reflects responsibility, experience, educational qualifications and seniority. CNA supports the establishment of a national organization for nurse-midwives and agrees with the principle of formal liaison between this organization and CNA. February 1974 Reviewed August 1976 Reviewed June 1978 Satisfactory collegial relationships have been established in the United States where the nurse-midwife carries out antenatal and postnatal care in collaboration with an attending physician in a private office, clinic or community health setting. For such joint practices. in-hospital birthing rooms that have a home-like atmosphere appear to be the appropriate setting for nurse-midwife attended births. All emergency facilities are readily available though not intrusive. Intrapartal care is again given in collaboration with physicians. On-going continuity of care is best provided in a congenial atmosphere where everyone works together for the benefit of a safe outcome for mother and child. The nurse-midwife must be able to function interdependently with the family's physician. obstetrician and all members of the maternal/child health care team. Throughout the world. we find nurse-midwives practising in all manner of settings. But for the system of health care in Canada. it would appear that the nurse-midwife/physician practice and in-hospital birthing rooms would be the most practical and acceptable. The economic issues related to health care need to be evaluated carefully before any long lasting changes are implemented. The system will not The C.nedlen NUrH OcIober 117V 23 improve if nurse-midwives are just another add-on to the alread y crowded forum of health care workers. The economic implications of initiating improved nurse-midwifery programs in Canada and the updating of foreign trained nurse-midwives must be analyzed. In addition, a basic standard for nurse-midwifery education and practice must be fonnally established. Presently, there are three nurse-midwifery education programs in Canada: . the Advanced Practical Obstetrics Program at the University of Alberta in Edmonton: . the Outpost Nurse Practitioner program at Dalhousie University in Halifax, N.S.: . the Outpost and Nurse-Midwifery Program at Memorial University in St. John's, Nfld. Graduates of these programs generally work in remote areas of Canada. or in a foreign country. Some return to hospital or public health agencies to work in their respective maternal/child care areas. Others leave maternal/child health because of restrictions on nursing practice in this area. Conclusion There are no immediate answers to the dilemma that parents in Canada face today in seeking a more satisfying birth experience. Nor are there immediate answers for the numbers of nurse-midwives who face an unknown future in their professional lives. But perhaps there is hope: on the national level. the Canadian Nurses Association is currently meeting with the Society of Obstetricians and Gyneeologists to discuss the role of the nurse in obstetrics in Canada. Provincially, the Registered Nurses Association of British Columbia has established a task committee** studying the future of nurse-midwifery in that province and ha.. met with the B.C. Medical Association. Both of these are steps in the right direction. It is my belief that in Canada there is room for the satisfaction achieved by parents such as Jeanne and Ken. It is also my view that there is a very great need for the skills of the nurse-midwife who is a qualified health care professional and an important member of the maternal/child health care team. OW .ORNABC Nurse-Midwifery TaskCommillee Report is now QI'ai/able from: RNABC 2130 West 12th A"e. V ancou"er. British Columbia V6K 2N3 Allention: Margarl!l Lonergan. WILL B.C. BE THE FIRST? The Summer issue of the RNASC NEWS brought word to British Columbia nurses of action taken by directors of their professional association to formally approve the Report of the Task Committee on the Future of Nurse Midwifery in B.C., submitted to them after 10 months' work by committee members Julianne Powis. Elaine Carty and Norma Foster. The RNABC NEWS story notes: "Although the role of the nurse-midwife practitioner has been supported by the Canadian Nurses Association for more than four years, RNABC could become the first provincial body to attempt to foster the introduction of midwifery in its jurisdiction. Other associations across Canada will be watching to see how this proposed new role for registered nurses will be accepted by the medical profession and the health care consumer." The report recommends that: e the practice of nurse-midwifery be legally defined as "part of the ordinary calling of nursing" within the B.C. Medical Act and that RNABC join with the B.C. Medical Association in issuing a joint statement on nurse-midwifery. e practicing nurse-midwives meet RNABC-approved standards of practice and that their functions follow those oullined in the association's 1978 position statement. e development of the role of the nurse-midwife begin with registered nurses who are already midwifery program graduates and that RNABC encourage the introduction of refresher courses for them. e that practicing nurse-midwives be salaried, paid by their employers or by B.C. Medical Services Commission, instead of working on a fee-for-service basis. Once the new role is implemented. it should be studied in depth to assess its acceptance. validity and cost effectiveness within the health care system. Approximately 100 "qualified nurse-midwives" identified themselves to the association last Spring when the RNABC NEWS carried a questionnaire requesting this information. All but seven of these nurses expressed interest in a midwifery refresher course. The RNABC NEWS concludes: "Clearly, midwives are interested in practising in British Columbia. RNABC supports the concept, physicians accept the possibility, and the public seems ready for alternative delivery systems. From all appearances, nurse midwifery IS an idea whose time has finally come to Canada." Acknowledgement: Special tlllln/..s go to Jeanne, Ken and Annie Schmol;:e, Philadelphia; nurse-midwives and physicians at Booth Maternity Centre, Philadelphia; Vic/..i Walton, The Birth Place, Seattle, WashinglOn; andGary Dodd, Nanaimo. B.C. .- . Julianne N. Powis(R.N., Sault Ste. Marie, Ontario; C.N .M.) is a graduate of the Ad\'Gnced Practical Obstetrics Program. UnÙ'ersity of Alberta. She received cert{fìcation as a member of the American College of'Vurse Midwil'es after completing a refresher program at Booth Maternity Centre in Philadelphia. A ctil'ely illl'oll'ed in the Western Nurse Midwives Association of Canada and a member ofNAACOG, RNAO and RNABC, Powi.'. is the chairman of the Registered Nurses Association ojBritish C olumhia' s T as/.. Committee on Nurse-Midll'ifery. Powis has had ohstetrical etperience in a number ofllOspitals in Canada and M ll1'yland, U.S.A. and has wor/..ed as a nurse-midw{fe in the Canadian north. Currently she is a labor and delil'ery room nurse at Vancolll'er General Hospital, Vancoul'er, B.C. Phmos by Juhanne Powi and Ken Schmolze 24 OcIøber 1878 The C.nedlen NUrH Post graduate maternity nursing program: meeting the need in the Atlantic region Inservice programs are usually established to meet a need within the hospital in which they originate. The post diploma maternity nLrsing program at the Grace Maternity Hospital in Halifax, however, was set up to meet a much broader need - that of hospitals not just in Nova Scotia but throughout the Atlantic region. The need for such a program was identified by analysis of enquiries from nurses and hospital administrators throughout the region directed to the Grace Hospital. Confirmation came in the form of response to a questionnaire sent out in 1972 to 24 hospitals - 18 in Nova Scotia. five in New Brunswick and one in Newfoundland. Once the need for a cour"e of thi... nature wa., established. the provincial government was approached for approval and funding and. in the Spring of 1973. an eight-week course in maternity nurSIng was launched Course development The main objective of the new program was to meet the needs of hospitals in Nova Scotia specifically and the Atlantic region in general by providing nurse working in these institutions with specialized training and nursing care beyond the diploma level. The course was developed by assessing the changes in equipment. procedures. diagnostic tests, new programs, etc., occurring at the Grace Maternity Hospital five years prior to implemention of the course, and for the five-year period following implementation. The cUlTiculum was designed to include concurrent theoretical and clinical teaching and supervised experience covering all phases of maternity nursing care. Rosie Steele Content was developed bearing in mind that the basic knowledge of this nursing specialty had already been attained. The curriculum was flexible in that the nurses indicated the necessary learning they required in order to fulfill job positions more efficiently and knowledgeably in their particular nursing area. All aspects of maternity nursing were covered, with a concentration of classes in the first two weeks and clinical rotations in the remaining six weeks. Enrolment To be eligible for the course, nurses must be registered in their provincial association. have at least one year of experience in maternity nursing or equivalent and intend to continue in thi" field. The nurse"s receive certificates te'itifying to their successful completion of the course and their ability to fulfill its objectives. The course meets criteria .,et out by the Registered Nurses Association of Nova Scotia for an Approved Recognition Program: graduates are eligible for Continuing Education Units. Originally, the program was eight week., in length and was offered in the Spring and Fall of each year, with a limit of'iix students per course. From October 1973 to November 1917, 34 nurses graduated from "even courses. In the Fall of 1977, the course was extended to twelve weeks specifically to include more neonatal intensive care nursing. To date, a total of 63 nurses have graduated from the program. Lectures Planned, structured classes are arranged to cover a review and gradually progress to in-depth theory covering all aspects of the maternity cycle and the newborn ana neonatal period. Lecture topics include: . anatomy and physiology review . embryology . infertility and endocrinology . premature labor . high risk obstetrics . bleeding in pregnancy . anaesthesia and analgesia in labor . genetics . diabetes in pregnancy . hypoglycemia in neonate . toxemia in pregnancy and hypertensive diseases of pregnancy . fetal monitoring . Rh disease . gestational assessment of newborn . maternal aspects of Rh disease . temperature control . neonatal a'ipects ofRh di...ease . R.D.S. and other respiratory diseases of neonate . fetal malnutrition . physiology and nursin care In puerperium . resu citation of newborn . shock in newborn . drug addicted mothers and their newborn . complications oflabor CAPE BRETON Summerside' 'North Sydney NEW BRUNSWICK PEl. 'Sydney .Charlottetown Inverness T atamaglluche Moncton' 'Amherst 'New Glasgow 'Truro 'Windsor NOVA SCOTIA Kentville' Berwick A napolis 'Halifax Digby . Bridgewater .Sponsored Candidates Yarmouth' 'Shelburne The Cen-.llen NUrH Octoberll11 25 ITEM Returned to work on a maternity unit. Implemented acquired knowledge imo daily schedule. Used available equipment to better advantage. Given opponunity to teach new techniques. Suggested changes in unit. Changes favorably accepted by nursing staff. Changes favorably accepted by medical staff. Provided with a salary increment after course. Eight weeks WdS sufficiem for fulfillment of course objective... Table one Report of the Followup Questionnaire to Course Graduates, October 1973 - May 1977 (N = 26) YES 85.0% NO PARTIALLY 15.0% NO RESPO"VSE TOTAL. 100% 73.0% 11.5% 4.0% 11.5% 100% 96.0% 77.0% 15.0% 88.0% 8.0% 73.0% 4.0% 65.0% 4.0% 8.0%** 9:!.0% 31.0% 61.0% 4.0% 100% 8.0% 100% 4.0% 100% 23.0% 1 ()()% 4.0% 27.0% 100% 100% 11.0% 100% "Twenty-seven questionnaires were returned, one of which wa'i incomplete. **Following completion of the course, these two candidates became head nurses. Thus. the salary increment was related to the change in StdtuS rather than to succe..sful completion of the course. Conferences N ur.,es are gi ven assigned reading and study periods. Daily clinical confe-ence'i are held: conferences are al..o held with the ..ocial worker. nutritionist and physiothempist which enable the nurses to identify the role and need for these resources in their own hospital and/or community Teaching practice Planned teaching experience with the public health prenatal classes is provided. Each nurse prepares and presenl'i one class and participates in teaching prenatal exercises. Nurses also attend cla..ses at the Prenatal Clinic at the Grace Maternity Hospital and incorporate patient teaching on the following topics. into their clinical experience: baby bath. breast feeding, family planning, diabetic teaching cla..ses etc. Clinical experience Under the guidance of a senior resident or instructor the nurses are taught history-taking. abdominal palpation. vaginal examination. pregnancy assessment. laboratory tests. etc. on a 1:2 ratio (ie. one resident to two students). This experience covers a one-week period at the beginning of the clinical rotation to the prenatal clinic. Supervised clinical pmctice is provided in all areas of the hospital including the antepartum unit. Special classes Provision is made for the nurses to attend any addresses. conferences or lectures being held in the Halifax area which are of interest and pertinent to maternity nursing. A four-hour seminar on communications and handling critical incidents is given. Nurses attend general inservice presentations at theGrace Maternity Hospital as well as high risk. neonatal and chart round... Field trips to the Neonatal Intensive Care Unit at the Izaak Walton Killam Hospital for Children. the Planned Parenthood Association and the local university library are also arranged. Evaluation In an attempt to evaluate the effectiveness of the post graduate maternity nursing courses offered at the Grace Maternity Hospital between October 1973 and May 1977, two follow-up questionnaires were developed in June 1976. One questionnaire was sent to the directors of nursing service who had sent nurses to take the course; the second was sent to the graduates from the course. 21 OcIøber Iln For the most part. the directors of nursing felt the course had fulfilled their objectives in sending the candidates; they were very positive and supportive of continuation of the course. They also had suggestions to make for improvements in the content of physiology. fetal monitoring. and for assisting candidate to better utilize facilities in "home" hospitals as compared to the facilities available at the Grace Hospital. Directors felt the course should be lengthened but noted that allowing a candidate to attend for a longer period might present staffing problems. Most course graduates met course as well as individual objectives (see table one): they were better able to utilize available equipment and were encouraged to teach and implement changes in their units. They reported also that changes had occurred In all areas of maternity care from prenatal teaching, nursing care of complicated pregnancies. in the areas oflabor. delivery. postpartum, newborn care and the introduction of newer diagnostic tests and equipment. since the completion of the program (see table two ). The strength of the course appeared to be the confidence achieved to fulfill the role of the nur e as a teacher and the importance of teaching throughout the whole maternity cycle. Its weakness lay in the need for more theory in all given situations and the need for more neonatal content. A two-week update program for graduates of the initial eight-week course was offered last Winter to provide these nurses with the neonatal nursing content now offered in the l2-week course. The first of a series of two-day workshops for graduates of the program was held in March 1978. The value of the program offered at Grace Maternity Hospital is best realized from the changes implemented by graduates in their chosen field of maternal and child health care. These changes must be recognized as contributing factors in the steady decline of maternal and newborn morbidity rates that has taken place in recent years in the province of Nova Scotia. OW r, - The C.n-.llen NUrH Table two Graduates' Suggested Changes for Improving Quality of Care Which Have Been Implemented High Risk Pregnancy Improved assessment/care Labor Improved assessment/care Vaginal examinations Felal Monitoring Fathers in the delivery room Scrub nurse now circulates Nursery Improved assessment/care Changes in rigid nursery rules 6.85% 20.55% 15.07% 23.29% Improved assessment/care Family centered care Bonding Breast feeding Rooming-in Family planning Continuity of care between hospital and home Postpartum Teaching/Counseling I mproved teaching (general) Improved inservice Diagnostic Tests Kleihauer Dextrostix 8.22% 5.48% 9.59% Emergency can for nursery Fetal monitor Doptone Ictometer Phototherapy light Tool chest for neonatal transpon Equipment 9.59% General improvement in techniques I.V. therdpy Change in visiting policies Cooperation with physicians, public health nurses and other re ource personnel Changes in most things Other No Drdmatic Change Total (N = 26) 1.37% I 0ü'Æ Rosie Steele, the author of this article, has been an instructor with the Post Diploma Maternity Nuning Program for the past six Years. A graduate of Aberdeen Hospital in New Glasgow. N.S., she completed the post graduate course in obstetrics at the Royal Victoria Hospital in Montreal. Rosie has worked as a staff nurse, acting head nurse, clinical instructor in labor and delirery. and clinical instructor in postpartum (nursing students). With the exception of two years spent iI/ gynecology, all of her nursing experience has been in the area ofob. tetrics . · A complete report on the Maternity Nursing Program can be obtained by writing to the Nursing Education Department. Grace Maternity HospiJal, Halifax, N.S. B3H IW3. The cost of$3.00 covers handling and postage. Acknowledgement: The Maternity Nursing Program owes its continued etistence to the support andful/ding prodded by the Nova Scotia Departmeflt of Health; to the administration. medical ami nursing staff of the Grace Maternity Hospital who recogni e its ,'alue; to the Nora Scotia Reproducti,'e Care Program whose risiting nur, es recognize areas of cOl/cerl/ to I/urses and promote the course as a step further to their own exchange program; to the directors of nursing who COll1il/ue to sel/d candidates; and to the graduates who continue to request ongoing education and updating following the course. Those who plan and implement this program acf...nowledge this support and are gratefitl for it. - . I r... Closeup on Nova Scotia's REPRODUCTIVE CARE PROGRAM A 24-hour-a-day obstetrical service that offers advice on how to manage the high risk maternity patient? A toll free number to call for help in solving problems you encounter with the neonate? These are just some of the ideas that have been incorporated into a program for improving reproductive care in the province of Nova Scotia. The program is the brainchild of the Nova Scotia Medical Society and Dalhousie University personnel. and is supported by the provincial Department of Health. It got underway in 1974 and seeks to promote the highest possible standards of reproductive care for all women in the province. to ensure that both mothers and babies benefit from advances in care as soon as they become available and to provide all women and neonates. no matter where they are living in the province. with the same uniformly high standard of care. The program offers a variety of services. including visiting perinatal nurses who will, on request, survey nursery and case room facilities in a hospital and submit recommendations to the nursing service in that hospital; a project co-ordinator who will also help hospitals establish a family-centered maternity care program; a nurse exchange program which provides for replacement by a nurse from the central unit when a nurse from a community hospital wants to attend the central unit; prenatal and risk identification forms for use by physicians; on-site perinatal mortality and morbidity chart reviews with reports and recommendations by obstetrical and neonatal perinatologists; procedure manuals, reporting forms. and educational opportunities. The program is also closely associated (allied) with a post diploma maternity nursing program and a neonatal intensive care course for nurses. Results - in the form of vaslly improved perinatal mortality statistics - are encouraging. Since 1965 perinatal mortality has fallen from 21.2to 10.2 per 1000; full size stillbirths and neonatal deaths have been reduced by one-half; and underweight neonatal deaths by 60 per cent. The chance of a neonate dying in a small or medium size hospital was previously twice that in the central region; now these smaller hospitals, with adequate referral. are essentially "- able to equal results of the central hospital. Nurses and doctors throughout Nova Scotia have participated enthusiastically In the program. and made it work. If you would like to learn more. please contact: Joyce MacDonald, R.N. Project Co-ordinator Reproductive Care Program The Medical Society of Nova Scotia 5821 University Avenue Halifax, N.S. B3H 1W3. U :I I õ 0.. DO "- 7- "'" o Õ .c 0.. A few years ago, when Dr. LeBoyer's book Birth it, I' nee appea . I I urses and doctors chose sides according to their reactions to this revolutionary idea: that birth is essenf My a painful experience for the baby. Since then, delivery practises have been modified and we must all acknowledge Dr. LeBoyer's contribution. Mary Grossman was on hand for a LeBoyer delivery at a clinic in France and gives us an update on this once controversial method. ## "'''-0 a. , ,,-) The LeBoyer Method: What does it mean now? Frederic LeBoyer is the French obstetrician who introduced the "radical" approach to childbirth during the early '70's that rocked health traditionalists in both Europe and North America. He dimmed bright operating room lights. requested silence during delivery and placed the infant upon the mother's tummy even before the umbilical cord was severed. Neither did he believe in swinging baby by the feet in order to achieve a shrieking but breathing infant. He believed that voices. the first touch, first breath. are all initially painful to the infant. Consequently. he encouraged the baby to "set his own adaptive pace" and suggested soothing the transition from the secure world of the womb to the world of harsh and uncertain reality. by allowing the infant to finally relax in the familiar environment of a wann bath. * Many of the above approaches to childbirth have been familiar to us for a number of years now. Where LeMaze concentrated on helping women to cope with the pain of labor, LeBoyer focused *Fredénck LcBoyer. POllr lint' Na;f\ancl' wm Violf'IICI'. Edltlon!'\ du Seuil. J 976. Mary Grossman on the painful experience of the infant as it goes through the birth process. "It is painful for the child to be born." says LeBoyer. "No one has ever given consideration to this. My books are not about the pain of giving birth. but about the pain of being born:' His was a basic idea that had evolved through years of observation' and experience but LeBoyer's theories on childbirth have always remained suspect from the standpoint of medical safety. scientific validity and technical originality. ** As nurses we have a responsibility to potentiate the health and welfare of both mother and child - and part of that responsibility requires a sound knowledge base. Realizing that we can easily have input in changing various childbirth practices, I felt that I personally needed more information on LeBoyer and his ideas. As a result. I arranged to observe a "LeBoyer birth" at a clinic situated just outside Paris called 'The Maternity Clinic of Lilas" where the obstetrician's concepts are ..MO"iit recently the AS"iioclation of Obstetricians and Gynaecologists of the Province of Quebec pre..ented a pO'ioition paper agam..t LeBoyer".,. practices. August 2. 1978. regularly put into use in conjunction with a number of other childbirth theories. A small hospital. only 1.051 births were registered there for the year 1977. Interestingly, Nelly Boudoul. a midwife at the clinic said that the majority of the women patients were nonconformists in French society. They are often students and professors, and usually politically progressive, involved in various community projects or the arts. The LeBoyer technique The delivery I saw involved an overweight preeclamptic young woman of23. primagravida. whose pregnancy had been complicated by hypertension and edema that had manifested during her final trimester. She was admitted to the clinic ten days prior to delivery and placed on bedrest. Her status. as well as that of her unborn infant. was considered as being "at risk". The decision was finally made to induce labor. and a doctor, midwife, and nurse were in constant attendance. I n the event of any complications. the O.R. was alerted to prepare for a possible emergency Cesarean Section. The C8n8dlen NUrH Oct_ 1171 21 When I arrived, the mother had entered into the second stage of labor: she \\-as resting comfortably, her head supported by a pillow. Everyone was dressed in street clothes, except for the midwife who wore a protective plastic overcoat. The intrauterine pressure and fetal heart beat were being monitored electrically -this was interesting, given the general association of LeBoyer's name with a 'natural" childbirth. that is. no technical device. The father was present helping to guide his wife with the LeMaze breathing and massaging her stomach. back and forehead. The nurse had sho\\-ed him how to interpret the monitoring screen so he was able to follow the duration and severity of his wife's contractions. When the infant's head was detected. the nurse lowered the window shades so that the room was not really dark (as is often thought to be the case with a LeBoyer type birth) but the bright sunlight was cut off. The room was still bathed in natural light that did not compromise one's ability to make accurate and ongoing clinical assessments of the progress ofIabor. As the baby's head became even more visible with contractions, the nurse requested silence. The mother's legs were then placed in stirrups. Following an episiotomy the infant girl was brought into our world while the mother observed via a strategically placed mirror. Immediately the infant was placed prone on the mother's tummy and she was instructed to run her hand in an upward motion along baby's back. to help bring up any secretions from the baby's lungs. The midwife showed the father how to wipe the secretions from the child's mouth and the nurse closely observed that neither the parents nor child were having any difficulties. Within seconds the baby spontaneously began to breathe. The doctor and midwife quickly did their primary clinical assessment of the baby's heart beat. color, respirations, muscle tone and reflex response. The nurse then wrapped the baby in wanned blankets and continued her observations. Approximately twenty minutes after the delivery, a warm bath was prepared and again under the careful supervision of the staff the father slowly placed the baby in the water. The baby did not cry: her facial expression changed from a grimace to calm. First one leg extended, then the other and then the anns unfolded. She lay suspended in the water with her eyes open. The nurse checked the temperature of the water with her elbow, and after giving the little girl a few minutes "to relax" she instructed the father to gently place her into another wanned blanket. While the mother delivered the placenta the nurse instilled drops into the infant's eyes, and then returned her to her mother and put her to the breast. Within minutes, the baby was sucking. Controversy For all the public attention to LeBoyer's "technique" his primary contribution to delivery practice has less, I think, to do with methodology than with a general humanization of the childbirth process. It involves in particular a sensitivity toward the infant never seen before in the delivery room. However, in a profession that has measured its capability by purely objective means of measurement and assessment, LeBoyer's ideas have been translated into pure methodology and subjected to intense 'objective' scrutinization. Of course, it is right that any new approach to health and prevention in the health sciences be carefully assessed. It is equally important that the essence of a new idea or a new approach to practice not be obfuscated in the course of its examination. By defining LeBoyer in tenns of a scientific method, medicine has perhaps unwittingly misrepresented what he actually advocates. LeBoyer himself claims that 'There is no LeBoyer method. There is only a way of considering the newborn that is essential. ,. LeBoyer's own refusal to be categorized. along with an almost poetic manner of self-expression and a flair for the dramatic have resulted in a number of varied" Le Boyer" interpretations that have little or nothing to do with LeBoyer's own ideas, but which nevertheless have been attributed to him. For example, the presence and participation of families and friends at a delivery has often been associated with LeBoyer when in fact this was independently initiated by the Lilas clinic which felt the move was a natural development of LeBoyer's emphasis on humane awareness. On the other hand, many obstetricians criticize LeBoyer's egotistical approach in the delivery room and make particular reference to his criticism of the father's presence at the childbirth. In an interview with LeBoyer he said, "I do not want to say that the father should not attend the birth. But the way many people have approached this is something else. Everyone is saying, 'and me'?: the father, the mother, their friends, the doctor. All want to participate. All want to be a star. And all I am saying is not to forget the baby. The baby is the only star. His needs are the most important at the moment of his birth." An exhausted mother who must cope with an endless stream of visitors is not capable of fulfilling her first responsibility - meeting the emotional and physical needs of the infant. More criticism has centered around the cutting of the umbilicus. It is a polIcy at Lilas to encourage fathers to cut the umbilicus as a means, symbolic or otherwise, of including the father in what traditionally has always been a mother-child domain. This is not part of the LeBoyer approach for the simple reason that he feels too many needs cannot be met at once and lead to the detriment of the inarticulate and vulnerable baby. Moreover, LeBoyer speaks on an ethical, not psychological level. "At Lilas, they talk only in tenns of psychology, of binding, of the relation between the mother and child, the helplessness of the infant." As far as the timing for the cutting of the umbilicus- despite the flowery tenns described in his books - the separation of the baby from the mother occurs when the cord's pulsations cease which is not unlike conventional obstetrical theory. In an effort to fulfill LeBoyer's concern for the acute sensations the infant initially experiences, many of his closest followers have entered a debate on the pros and cons of administering prophylactic eyedrops. To date a concensus has not been reached. Following the delivery the midwife told me it was "not necessary to give the drops". Interestingly, the nurse a few minutes later did administer drops saying that she felt the prevention was worth the minimal affront to the child. An assessment The ambiguous publicity over LeBoyer and his ideas has ultimately raised fears about security. There are questions about the possibility of closely monitoring the mother and child in a Le Boyer delivery, the danger of his approach should an emergency arise, the implications of a "darkened room" in clinical assessment and the dangers of a wann tub bath. The birth which I witnessed was testimony to the anticipatory care and the precautions taken to assure safety no matter what course the delivery would follow. Despite the medical complications, the underlying priority was to anticipate the infant's feelings and sensations once the delivery had occurred. LeBoyerdoes not advocate any approach that compromises security for either mother or child. "What I am saying has nothing to do with security, but with the feelings of the newborn, and how we may offset the pain that is necessarily associated with his birth." Nevertheless, a humanistic approach has often played second fiddle to the all consuming attention to technology. The post partum bath so important to LeBoyer is a case in point. Skeptics worry about the chances of respiratory complications or illness resulting from bathing so soon after 30 Oct_ 1171 Th. Cen-.ll.n Nur.. delivery. It is also argued that the bath which LeBoyer feels simulates baby's fonner environment, thereby easing his/her transition from one environment into another, actually interl'eres with the natural childbirth process. But for LeBoyer, the wann bath is essential to assuage the infant's inarticulate fears at being shoved into a world he has never known. He feels this has been proven through observing the contracted, tense body of the infant relax visibly in the water medium. To LeBoyer, given that all clinical assessments are normal, a bath given whether twenty minutes after delivery or twenty-four hours later, requires little extra effort on our part and may mean a great deal to a frightened baby. What LeBoyer is actually trying to say is not so different from the basic tenet of the nursing profession - caring for patients through anticipation and meeting of emotional and physical needs in any individual. As Nelly Douboul, a midwife at the Lilas Clinic states, "What is important is that M. LeBoyer considered the baby not as a child of the mother, or an object of the doctor, but as a person with its own sensibilities, not something that cries, but a person who is expressing himself." In fact, the only real departure from traditional delivery practice may merely be the final acknowledgemem of the baby's sensitive needs. right from the moment of its birth. Le Boyer hopes that he will be remembered for having brought back "some of the art" to a profession that has increasingly prided itself on technological competence. I would venture to say too that M. LeBoyer has brought some nursing concepts to medical practice (with the focus in this instance on the newborn infant). In doing so, his sensitivity for the infant, understood in its proper context, may succeed in buffering the pain and trauma the newborn must surely expenence. People who question the originality of LeBoyer's technique (whether it was his idea first or not to put the baby on mother's stomach), or who exaggerate the question of safety in his attention to the feelings of the newborn baby, are perhaps missing the point. His, quite simply, is a common sense approach to what we already know about how a baby feels, senses and reacts. What is not known is appreciated through a simple process of identification. LeBoyer's "philosophy" is not motivated by any long term psychological cause and effect considerations. If anytning, it deals with the present; it is a humane reaction to a set of circumstances - the process of childbirth. How one approaches the human drama on a technical level is less significant to understanding LeBoyer's message than understanding how one should care for the principals involved: thz mother and then especially the newborn child. Henri Fontana, a Parisian psychologist interested in the significance of birth had this to say: "People should realize that some affront in life is necessary. But what counts is our attempts to deal with traumatic or violent acts. This. I think. is what LeBoyer is doing." OW Bibliography *1 Cheynier, J.M. Que sa naisscl1lce soit unfhe. Editions de laCourtille, 1978. 2 LeBoyer Frédérick. Pour une naissance sans \'iolence. Paris, Seuil, 1976. 3 Whitner. Willamay. The influence of bathing on the newborn infant's body temperature, by ... and Margaret Thompson.Nurs.Res. 19:1:30-36, Jan./Feb. 1970. 4 Cronenwett, Linda. Father's responses to childbirth, by... and Lucy Newmark. Nurs.Res. 23:3:210-217, May/Jun. 1974. *Not verified in CNA Library Mary Grossman,B. c.N., is a recent Rraduate of McGill UnÏ1'ersity, and has worked in the small J nuit community of hdoolik, and ill the surgical intellsil'e care unit ofa huspital in France. Since returtlinR to Montreal she has worked at the Montreal Children's Hospital and has beRl1n srudies toward her master's degree this fall. - , " " Here and there A decade ago, university students and workers in France took to the streets to protest the traditional intransigence and hierarchical character of the nation's political. industrial and academic institutions. One of the direct consequences of this turbulence was to bring the state of the nursing profession under scrutiny and since then there have been dynamic changes as the profession struggles to live up to increasing societal and medical expectations. There have been reforms at the scholastic level: a high school leaving certificate (baccalaureate) is now a minimum prerequisite for acceptance in a nursing program, for example, and the number of nurses, after a period of declining enrollment, has increased from 345,000 in 1974 to 425,000 in 1977, but serious problems still beset the profession. Traditional concepts Throughout France there is a strong national sense of tradition which has served to provide the foundation of the country's social order; nowhere is this attachment to traditional values more closely adhered to than within the nursing profession. Nurses in France have always emphasized nursing qualities- considerateness, punctuality, the ability to effectuate doctors' orders- as opposed to nursing presence. Consequently, subservience to authority is still valued as a measure of vocational service. Added to this is an observable tendency to perceive the world of health and illness strictly within a medical framework - thereby reinforcing the traditional subservience of the nurse to the doctor. Recently, however, a combination of events, including the International Women's Movement and increased emphasis on higher education, has lead to general disillusionment among the younger a look at nursing in France graduates and there are doctors but within the patient in detail-their here." A patient reinforced indications that these profession itself, from those history, diagnosis, these observations: concepts are changing. who are in positions of treatment and present "Neither the nurse nor the influence. Nurses are not status - as well as being doctor ever seem to have The new nursing order expected to have a capable of devising a daily time. But I think really that professional opinion. Not to nursing assessment. She they are just uncomfortable With few exceptions the think. Just to do." encourages her staff to have having to confront my organization ofthe nurses is a dir.ect line of fears." hierarchical, with the head An assistant head nurse on communication with the nurse and her assistant the total care service doctors, while continuing to The question of whether the delegating work on the basis mentioned above keep her informed. This profession is able to meet of task assignment. Nursing commented: "Unfortunately minimizes the risk of an the needs and growing Service means the our form of nursing incomplete or misinformed demands of its own implementation of doctors' organization has usually patient report and is also an members might also be orders. To that end, task worked to crush one's important step in the raised. Widespread feelings assignment is the realization self-bsteem and finally Our establishment of a new of job dissatisfaction and of that service. One nursing concern about the working relationship, low self esteem that I student in her final year of profession itself. Each nurse underlining the contribution encountered among those nursing told me that had a particular task to and capabilities of both who worked with me would throughout her 20 - month perform and the key to all professions to patient seem in themselves to apprenticeship in various knowledge of the patients assessment and care. indicate a lack of hospitals she had and their management was professional appreciation experienced nursing only as held guardedly by the head The future of nursing for one of the primary tenets a series of tasks. Now, quite nurse and her assistant." While general consensus in social psychological unexpectedly, she found exists between the concepts in growth and herself on a ward, where a An example of this was the government and the development - the need of "total patient care" (very way in which information profession on the need to all individuals to find an unusual by French nursing was communicated: no broaden the academic opportunity for self standards) approach had formal nursing report curricula in preparation for realization. recently been introduced. existed that included all an expanded role in the field "At first it was really difficult members of oncoming and of health and prevention, Nursing by task assignment to know how to approach off-going teams. Instead, the the subjects of primary within a strictly hierarchical nursing here without head nurse would emphasis are biology, and authoritative order does wanting someone to tell me communicate pertinent anthropology, and not allow for much self what to do next." administrative information, sociology; psychology (as expression. At best, it is The changes at the e.g. who was going for an opposed to the study simply mechanized work that calls scholastic level introduced operation, consultation, or of psychiatric illness) does into question the during the seventies also testing. Only critically ill not appear to hold a similar responsibility ofthe introduced new ideas that patients would be interest. It was my personal profession not only to its are inevitably at odds with mentioned on the basis of experience that social patient population but to the technique-oriented tt>eir medical status. A psychological concepts as those who provide the care approach still practiced in nursing kardex generally applied to nursing practice and service - the nurses most hospitals. Not recorded diagnosis, tests remain at an intuitive stage themselves. surprisingly young and operations and any at best - which in part may graduates are not only at unusual clinical be attributed to the widely Conclusion conceptual loggerheads developments. A social and skeptical attitude towards with the old nursing psychological assessment psychology taken by many All change requires time. It vanguard but they threaten was not routinely assessed. French people. is not realistic to expect that the hierarchical On rounds, the doctors also the 'old' nursing order will infrastructure that has addressed themselves to the A professor at a school of yield gracefully to the hitherto served as the head nurse rather than to nursing in Paris expressed present exigencies of the traditional base for their the particular staff nurse her belief that the present profession but for nurses in authority. who was responsible for the scholastic program does not France this is nevertheless a care and assessment of a do enough to help nurses period of expectation and Their older colleagues, given patient. understand the emotional hope. Slowly, through the having consolidated their needs of patients: "Basically school system and through authority through the I talked to a nurse who there is a real fear of the initiative of determined nursing hierarchy, are initiated the total care communicating and creative graduates, generally disinterested in approach on her service; meaningfully with patients. practice will come to be any exchange or sharing of she is a recent graduate of That is why they go and see equally based on a information that might the Nursing School for the patient only when there theoretical and practical threaten their own positions "Superior Training" (a is a specific nursing approach; there will be and traditional beliefs. One university nursing degree intervention to do." Another more assessment and less nurse who actually began still does not exist) and is teacher put it more bluntly: routine. French nurses have her studies as a medical attempting to upgrade the "Because of the close begun at last to carve out a student, and then switched role of nurses on her service working relationship ofthe new identity which will, it is to nursing had this to say: by making each one nu rse to the patient the to be hoped, more closely "What has been most responsible for the total care patient may very well need approximate the needs of difficult to accept is the lack of her assigned patients. It to discuss what his illness their patients and of respect with which a behooves every nurse on means to him and the themselves. nurse is held, not only by the her staffto know about each nurses could do a lot more Mary Grossman 32 Oct_111711 Th. Can-.ll.n Nur.. JOHN GRAN*, a 26-year-old native of Haiti. had immigrated to Canada with his family to further his studies in preparation for medical school in Spain. InJanuary 1977 he had undergone currettage and grafting of a lesion in the right femur. A diagnosis of giant ceIl tumor was made at that time. He was weIl until the Spring of 1978 when he developed weakness and pain in the right leg. In July. John heard his bone "crack" and he was unable to bear weight on his right leg. Investigations confirmed the diagnosis of a pathological fracture at the site of the bone graft. probably due to a recurrence of the tumor. The fracture was stabilized with a spica cast while alternative treatments were considered. The options were both limited and drastic: mid-thigh amputation or femoral aIlograft. The latter was an experimental procedure and depended on the availability of a suitable donor and the knowledgeable cooperation of an appropriate patient. John's case was assessed carefuIly and the proposed treatment was femoral aIlograft. The purpose of the surgery was to remove the tumor by performing an en bloc excision of the lower third of the femur with replacement by an allograft from a fresh cadaver. To supplement the aIlograft a segment of the patient's own fibula about 15 centimetres in length (autograft) was to be placed in an adjacent position and fixed to the aIlograft. The circulation of the fibular autograft was to be maintained by means of a microvascular anastomosis carried out between a small vessel left attached to the fibula and a blood vessel at the new femur site. The fibula autograft had two functions: to act as a living internal splint and to be a viable bone graft that would hasten union of the allograft to the femur. At this stage plans were not made to re-anastomose blood vessel.. to the allograft since this might promote an early rejection prohlem. ON THE ORTHOPEDIC UNIT Helen Alemany, head nurse: John first came to our orthopedic unit on July 21. 1978. Priorto his arrivaI.John's spica cast was removed and the fracture stabilized with a Steinmann pin through the proximal end of the tibia attached to twelve pounds of traction. Nursing grand rounds: FEMORAL ALLOGRAFT HelenAlemany, Patrie/.. FerRuson Jeaf! Grice, Alli.wn J. Stuart I nitially the nursing staff encountered a number of problems in their attempts to provide physical and emotional support to John. We soon learned that he was an extremely independent person; he identified himself as a "do-er", an achiever. one who was always in control. and now he was faced with immohility, dependency and loss of control. This theme of control appeared again and again throughout his hospital ization. At first we all found it difficult to communicate with John. He was an anxious. talkative. young man who tended to intellectualize a great deal. This was a source of concern for us and early in his hospitalization we asked our social worker to see him. We also .d.'. 4 r-:Y-- .....4.t'J."i'; '?Jir .. .. - ...pz.. ." .'" '" ",I 'ffi ,. {ft .) "C!' . '-- .J;!.' (.. Á _ ,,",. ' .. ""i; .... ,., . .., 1t>/1 ìíi: ",. v, ". .iG. "'i ..' ' . :;'-. :.', '<"..4 .' :: :- )" ..\ '7 _... . : ":'.\ ' . : ; :c. J.':; .t ÚfZ.. < 2,<. .r, '.. .' þ . <: ; 'i':i>;' ,;, :. ';J it Z4 :" .; . . .:. z ;'" . ;'1..;,.,.,.... ! ." '. ' ....,.::.< ..i:;:7J ( .: .. .r : ,"" f ..-. : "I':.... ...,....:..... _..... j.. ..l.- P'HÀ.-.. :. '........ ,. . '_. , ' , -taff on 24-hour call. A vailability of a donor A suitable donor was received in the operating room on August 26. This patient had died approximately four hours previously. In the case of a bone allograft with microvascular anastomosis of an autograft, rejection is not a problem. The autograft encourages new bone growth and also provides a living internal splint. THE SURGERY A team of surgeons removed the femur from the donor and prepared it for transplant to John Gran. Concurrently, Mr. Gran was receiving an epidural anesthetic in an adjacent OR suite. He was monitored with arterial and central venous pressure lines and cardiac telemetry. He was then placed in the supine position and his leg was prepped and draped. (A tourniquet was not used.) An anterior incision in the right thigh was made: rectus femoris and vastus lateralis muscles were separated. Care was taken to identify and retract proximally the neurovascular bundle into vastus lateralis at the upper end of the incision. The incision was extended to the capsule of the knee joint laterally around the patella to the tibial tuberosity. The patella was retracted, maintaining the insertion of the patellar tendon. The lower half of the femur was stripped, and ligaments were cut so that they remained attached to the tibia. The femur was then dissected out, a step-cut osteotomy being done through the middle third. The donor allograft was fixed with a 12-hole blade plate. Collateral ligaments were fixed with staples to the donor femur. The cruciate ligaments of the knee were not repaired. The fibula graft was then screwed to the medial aspect of the femoral graft. A branch of the peroneal artery was left attached to the fibular graft and was anastomosed to a branch of the femoral artery in the vastus lateralis using 10/0 nylon. The wound was closed in layers and four hemovacs were left in position. A plaster of paris cast was applied from the groin to the toes. By then, sixteen hours had passed. Mr. Gran spent the first twenty-four hours postoperatively in the intensive care unit. His vital signs were monitored closely as were blood loss, circulation and movement of the toes. Relief of pain was a major problem. At first, he complained of generalized body discomforts due to the long surgical procedure and intravenous Pantopon llÞ was used for pain control. But as the pain increased and localized at the sites of surgery, Pantopon was ineffective and Marcaine@, a local anesthetic agent. was administered by means of an epidural catheter. Later in the evening however he became quite agitated complaining of great pain and he wanted the cast cut. Pantopon in combination with diazepam was given and provided enough relief so that he was able to rest. By this time. the initial oozing through the cast had stopped and hemovac drainage was minimal. Vital signs were within normal limits and he was ready to be transferred back to the nursing unit. BACK ON THE WARD Helen Alemany, head nurse: When John returned to the unit, we were glad to see how well he had come through the long surgical procedure. For the next 4H hours however he continued to be in pain. At first he was very uncooperative but the staff found that he responded well to nursing measures such as frequent turning. repositioning and massage done in a wann, empathetic manner. These along with the judicious use of analgesics alleviated the pain. As before, John was very attention seeking even resenting the time nurses spent in caring for other patients in the same room. The nurses were patient with him. tried to be consistent in their responses to him and set limits on his behavior. We all recognized that this was an anxious time for John because the outcome of the surgery was still uncertain. X-rays and bone scans of the right femur were done on the 5th postop day, and then on a biweekly basis. The results were encouraging and 12 days after his surgery, John was allowed up for the first time. Because ambulation had to be very gradual, he could not bear Th. C8n8dlen Nur.. OcIober 1871 35 weight on the affected leg and was taught how to use crutches. The following week the cast was removed and a sand splint was placed under the leg. The splint could be removed for knee mobilization exercises and then re-applied and held in place with tensor bandages. This kept the leg supported between exercise periods. Gentle knee bending exercises were also initiated. John was very enthusiastic about his increased mobility and it was difficult to keep his activity in check. The need to proceed slowly with knee mobilization was reinforced and emphasis was placed on leg strengthening exercises. Our social worker continued to visit John regularly as did the Spanish speaking volunteer. Members of a local church group visited each Sunday and they provided him with a great deal of support. His faith seemed to have canied him through a very difficult period. REHABILITA TION Patrick Ferguson, slaffnurse: John came to our rehabilitation unit for the final phase of his treatment on October 11,46 days after having undergone surgery. He was apprehensive about the move to a new area but when he was recei ved on the unit by our head nurse, who is fluent in Spanish. he seemed to feel more at home. The common interest in the language provided an "acceptable" reason (in John's eyes) for her to spend some time with him every day. The nursing role in this phase of his treatment was to offer physical therapy to strengthen the muscles in the affected limb and increase knee mobility, and to assist him in adjusting psychologically to his physical limitations. At this time. he was still using crutches and was unable to bear weight on the right leg. John approached his exercise regimen earnestly and seriously. His independence and need to control the environment was very much in evidence in his experimental approach to pain control. Sometimes he would take an analgesic prior to therapy, sometimes after and sometimes not at all. In the same manner he adjusted his exercise regime from day to day in an attempt to increase the mobility of his leg and to strengthen the musculature. Although John spent more than 120 days in the hospital he never lost sight of his long term goals. He worked hard to get stronger and spoke often about what he would do when he left the hospital saying that he was looking forward to starting his medical studies the following September. John talked freely about his surgery and its impact on him physically. but he kept his feelings and emotions very much to himself. During his stay on our rehabilitation unit John spoke about his family. his church and his plans for the future. Because his family was in another part of Canada his main contact with them was by phone. John spent a great deal of time reading the Bible and frequentl} attended services on Sunday mornings. In addition many church members visited him in hospital. which was a great boost to him since his family was unable to do so. Probably the greatest difficulty John encountered during this period was waiting for a brace. John needed the added support of an ischial, weight-bearing. long leg brace that had to be custom made and fitted before he could be discharged but the cost was more than he could afford. Although he had been living in Ontario his health insurance was maintained by his family in another province and as a result the paperwork required to obtain funds was extensive and progress seemed slow. John's impatience grew since the only thing keeping him in hospital was the need for the brace. Happily a private donation made the purchase of the brace possible, but when the brace was delivered it did not fit correctly and John faced another seige of waiting. It took a great deal of reassurance and reinforcement about the need for the brace to convince John to wait for the brace again before discharge. At last, 120 days after his ani val. John was discharged from hospital with a well-fitting brace. A united approach I n summary. caring for John required a full range of nursing skills in all areas - orthopedics. operating room and rehabilitation. Powers of observation. assessment skills. communication and technical nursing functions were all put to use with this challenging patient. It is apparent to all of us who took part in his care that no area of nursing supercede" another but all mesh together to form a unified and all-encompassing approach to the nursing management of the complex patient. '" Ackno\\ledgement: The authors wish to express their apprecllltion to Dr. AI/an E. Gross, surReon-in-chief. Mount Sinai Hospital. Toronto. Ontario for his assistance. References I Taber's cyclopedic medical dictionary, 10th ed. by C. W. Taber (editor). Philadelphia. F.A. Davis. 1968. 2 Gross. Allan E. The immunogenecity of allograft knee joint transplants. I n Clinical orthopedics and related research by... etal. 132:155-162. May 1978. 3 Brigden. Raymond J. Operating theatre technique. Edinburgh, Churchill. Livingstone, 3d ed. 1974. p.20-2I. *The name of the patient is fictitious. Helen Aleman) (R.N.. B.S eN.) is head nurse at Mount Sinai Hospital, Toronto, Ontario; Patrick Ferguson (R.N .. B.A.) is a staffnurse at Mount Sinai Hospital, Toronto; Jean Grice (R.N.J is operating room co-ordinator at Mount Sinai Hospital. Toronto; and Allison J. Stuart (R.N.. B.Sc.N., D.HA.) is administrati,'e assistant. Mount Sinai Hospital. Toronto. 31 OcIOber 11171 The C8nedlen Nur.. The use of Simulation in Teaching Psychiatric Nursing Betsy LllSor , . A student's rIrst experience in psychiatry can be terrifying: "Who are the patients and who are the staff? What do I say if someone talks to me?" There is a method which the nursing educator can use to help prepare the student for that first encounter on a psychiatric rotation. ... I " " ) .--. . . ::I Z ,., "'" o ëi .<: .... ,'" ...... , The implications of large numbers of students practising in the clinical setting are being seriously questioned by some who believe the constant intrusions into patients' primte lives may be difficultfor them to accept. Students o..fnutrition, rehabilitation therapy, nursing, pharmacy and medicine all im'ade the patient's environment at some point. To help these students de 'elop needed assessment skills, patients are o..ften required to repeat their histories oJÞer and m'er, and relief comes only when a patient is .. too sick" to be assigned a student. But the need to educare the student, especially the student nurse, to perform safely and competently is imperative, and educators are obliged to lookfor high-quality alternate learning experiences. Teaching techniques The simulated hospital ward with the "Chase family" as practice patients has been used in nursing education as one alternative, and learning packages and audiovisual programs have enriched this particular technique. However, none of these techniques provides the real experience of interacting with another human being; asking personal questions, touching and penorming physical tasks produce anxieties when the neophyte nurse comes face to face with a person who is genuinely ill. Developing a basic foundation of skill in human interaction is crucial to the development of more complex skills later on. Medical education took the initiative in finding an alternative method - the 'practice patient'; Barrows in the early 1960's developed the use of the simulated patient. In simulation a person has been carefully taught how to mimic or present an accurate replica of a specific disorder. To all observers, the "patient" could actually be suffering from an illness as shown by various symptoms and responses to examination and questioning. 1 Th. Cen-.ll.n NUrH October 1179 37 Initially. actors. because they know how to perfC'rm well. were used as patients. but gradually it was found that many people in a community could take on the duties of simulation - retired people. housewives, students - anyone who has a little extra time. I nitially too, the primary use of the simulated patient was to examine student knowledge. This method can be usedjust as well for students to practise a beginning skill, and nowhere is this of more value than in teaching nursing students who are beginning a psychiatric experience. It must be noted at the outset that this teaching method with its use of people enacting patients is potentially expensive; the basic ideas are of value however. and nursing instructors may use their initiative and imagination to alter the method to suit their individual needs. Psychiatric nursing The initial experience in the psychiatric setting often provokes anxiety among both faculty and students. Instructors find it difficult to structure a student's first experience. and students are unaccustomed to the apparently unstructured nature of the psychiatric ward - no one wears uniforms. patients are up and walking around. and few technical skills need to be performed. Students want to move into this nev, experience comfortably and to develop new skills. but for the instructor this is a problem: responses in student-patient interaction are unpredictable. The prime task of the psychiatric nurse is to interact therapeutica:Jy. which is accompli!>hed in part by being able to interview well. How does the instructor control a student's initial contact with the psychiatric patient? How can she ensure that the student learns from the experience? All beginning interviewers benefit from practice time that allows the learner to develop different approaches. Ideally, the student should be able to step out at the moment she feels overwhelmed. explore what has happened, and then perhaps try again with a different approach. When the intensity of the moment is lessened. the learner is usually able to learn more, ask questions freely. and to become aware of alternative approaches. In this respect, a simulated patient, representing a given emotional disturbance by using typical verbal and behavioral responses, could give the student the experience of practising her therapeutic use of self and communication skills. 2 The major emphasis is on an initial encounter with a patient. The method Since it is not feasible for one "patient" to repeat an interview for each of 24 students. and since the emphasis on the experience is practice and not evaluation of performance. it was decided that one patient could be shared by several students at the same time. A student could step aside when she felt overwhelmed and turn the interview over to another. The method on the whole is comprised of a combination of two techniques regularly used in psychotherapy: role-playing, and video-tape (VTR) playback. We used the technique as follows. Three students. one faculty member and a "patient" sit in a studio with the remaining class in another room connected by closed-circuit television. The students and instructor sit in one comer of the room, the patient in another. One of the student volunteers begins the interview by approaching the patient in the manner she would use on the ward, and the interview progresses until the student feels uncomfortable or senses that things are going wrong, at which point she calls 'Time out!" The patients have been instructed to freeze at this signal. and to act as though they do not hear the ensuing discussion. The student returns to her group and discusses what is happening. When a new idea is developed, the next student approaches the patient; she is free to continue from where the first student left off or to start afresh. During the discussion the students frequently turn to the instructor for help, which is the ideal time to encourage them to use problem-solving to work through uncomfortable situations. Suggestions may be made too about the ways interviews can be conducted. how to make initial contact, and how to terminate an interview comfortably and therapeutically. A firm emphasis is placed on returning to lecture notes and reading, but the student is encouraged to avoid any actual intervention approaches at this stage. The major goal is to practice interviewing skills, the therapeutic use of self, and basic social skills in the context of an initial meeting with a psychiatric patient. The entire interview is taped and viewed simultaneously by the rest of the class in another room; at the end of the practice session, everyone, including the "patient". goes into the other room and views a reply of the video-tape on a cassette machine which can stop and restart at any point. Reviewing the situation for a second time reinforces the learning process and allows for questions and discussion from class or faculty. The tape is played until someone asks for it to be stopped. and some areas can be skipped entirely if there is no value in a second viewing. At the end of the playback the patient is asked to share how he or she felt responding to certain of the students' approaches; often the patients give invaluable insights. Sample situations The following example is an account of one simulation experience. The patient was programmed to be hyperactive. or "manic". The student timidly approached the patient. pulled her chair close and sat on the edge of the seat. She introduced herself but before she could finish the patient yelled. "Finally you got here." gave her a pad of paper and pencil and said. "Here. take a letter." The student continued to follow orders until. contrary to the usual practice. the instructor called. "time out". When the student rejoined the group she was asked if she knew why she had given all control to the patient so quickly and completely. She responded that she hadn't known what else to do and thought this was a good way to begin rapport. The students were at once horrified and very anxious about continuing the experience and spoke of their concerns in the discussion. A major fear of students in working with psychiatric patients is that they will be manipulated. and here they were face to face with an obviously powerl"ul manipulator. Once they had recognized this concern the group explored the different approaches they might use with the instructor's help. With several alternative!> established the next student approached the patient a little less timidly but with stubborn determination to avoid any controlling behavior the patient might try. A battle of wits began. The patient tried to interview the student and rambled from subject to subject while constantly moving about the room. The student in turn used silence as a control and the patient became more and more active until the student finally called "Time out". The concept of manipulation was again discussed along with the goal of the interview. The need to understand nursing process in each clinical rotation (which includes a detailed assessment) tends to make students overly anxious about data collection; the goal to establish some contact with the patient subsequently became mixed up with the goal to gather information. The students asked what could be done with a patient who defied contact thus making it impossible to meet either goal. This question was posed to the group. They were asked what they recalled about contact with this type of patient from previous lecture material on manic behavior. Transfer of learning frem the 31 October 11711 The Cenedlen Nur.. classroom to the clinical area was reinforced in this way and the theory gave them some structure to their problem-solving exercise. The next student, armed with new knowledge, made her entrance. She introduced herself and said she would spend a few minutes with the patient and then return to see her later. The patient attempted to engage her in some sort of conversation but the srudent's responses were smiles or simple yes or no answers. At "Time out" she fled from the patient without any termination explanation; she said she had felt extremely uncomfortable and could not think of a way to leave gracefully. The group adjourned to the rest of the class to be met with applause. The viewers become engrossed in the experience and frequently yell out suggestions and encouragement to the T.V. during the simulation. They had identified greatly with the manipulation and control theme and little playback was actually needed to stimulate a discussion. The patient's discussion revealed her alarm at how easily the student had followed her orders and that she had then felt compelled to test her limits. She had enjoyed the way the third student had introduced herselfbut had felt nervous about her reluctance to talk and she felt very much disliked. The discussion became somewhat intense but the group was generally able to empathize with both the patient's behavior and the students' attempts to interview her. Because the first patient was so radically different from any the students had ever had. the next was chosen with a view to easing their anxiety. Depressed patients are not unusual in other clinical settings although the verbalization of worthlessness is generally more evident in psychiatry. The students could easily make contact and get information as the patient was eager to talk. but the major concern here was what to do with the information. One might que<;tion why a 'manic' patient, who needs reduced stimulation and who is generally not assigned to beginning students, would be chosen; the reason is that often these patients, in their active role on the ward, are the first to approach the new students and engage them in a conversation. The overwhelming impact of that encounter often makes the students retreat and feel quite inadequate. Since the goal is interviewing, not intervention, it is felt that all situations warrant exposure and practice. Manipulation and control are major themes during the first few weeks and this is an excellent patient situation in which to begin a discussion about initial involvement with patients on a psychiatric ward. Students are frequently reminded that the simulation is a learning experience and that they are not being evaluated on interviewing skills. Students who have had the experience claim that they gained much more from being involved. Some students have said they were sorry they did not volunteer as they felt their skills were as good as those who risked interviewing before the class. Occasionally a student has felt humiliated and has commented several weeks later that the instructor must have thought she was inept; it is wise to be aware of this possibility and to give encouragement to those students who take the risk and thereby assist in everyone's learning experience. Developing the learning situation The details of setting up an interview practice lab can present difficulties. It takes time to program "patients" and to check them out to see if they are adequately prepared. and it is costly to hire someone to simulate a patient. There are five rotations in our academic year and each lab uses two patients. Faculty members share the load of preparing patients but our budget does not allow us to pay them. We have used volunteer staff nurses; because of their wealth of clinical experience, they require less preparation time. However, the free time they have available is limited and many more patients need to be programmed. Our students unanimously agree that the practice situation is of enormous value for them before they actually begin their clinical experience. Faculty time and energy, therefore, is directed towards this important teaching method in clinical practice. Value to students The use of simulated patients for teaching health care skills can have a variety of applications: this paper has shown one example, in teaching psychiatric nursing. The major value seems to be in the students' ability to retreat from a difficult situation and to explore what the difficulty was, rather than struggling through to an unsatisfying conclusion and then realizing what the alternatives were. Patient simulation can provide a range of pathological behaviors to which a student can respond and practice initial contact with a patient and the subsequent development of an interview. One added value to this learning experience is to encourage the student to draw on the theory she has learned about particular behavioral responses. The use of audiovisual equipment too is an invaluable aid that allows a large class to participate in the practice on two patients. Immediate playback gives the students further reinforcement oflearning in a new and perhaps anxious situation. The self-esteem of the student is enhanced when fewer initial blunders occur in the early part of any learning experience, and the implications of students practicing on genuine patients are diminished. '" Acknowledgement: The author would like to gh'e credit for the stimulus for developing this teaching technique to Leslie Degner of the V nh.ersity of Manitoba School of Nursing who presented a video tape on this method in 1973 at 0 Canadian Universities Schools of Nursing (CAUSN) meeting in Winnipeg. References * I Barrows. Howard. The programmed patient: a technique for appraising student pelformance in clinical pathology, by... and Stephen Abrahamson.J.Med.Educ. 39:803, Aug. 1964. 2 Curtis, Joy. An instructional simulation system offering practice in assessment of patient needs, by... and Marilyn Rothert.J.Nurs.Educ. 11:23-28. Jan. 1972. Bibliography I Lincoln, Ruth. Using simulated patients to teach assessment. by... et al. Nurs.outloo/... 26:5:316-320, May 1978. 2 Wallston, Kenneth A. A role-playing simulation approach toward studying nurses' decisions to listen to patients, by ... and Barbara S. Wallston. Nurs.Res. 24:1:16-22, Jan./Feb. 1975. *Unable to verify inCNA Library Betsy LaSorRN.. M.N., has varied experience wor/...ing in both surgical and psychiatric nursing in the U.S. and Europe. After coming to Canada she taught at the Unil'ersity of British Columbia for eight years. LaSor co-edited the book Issues in Canadian Nursing. We all know there is more to nursing than what we read in textbooks, but how does a student nurse learn what it is to truly care? One student's experience with a dying man helped her to understand not just the special needs of the terminally ill patient, but the special things a nurse can and must do to help. Sharing the experience Valerie Willetts-Schroeder "Death has become the pro\'ince of specialists - medical, pastoral and commercial. It is no lonRer the shared experience ofmanv. "t In recent years the dying patient in hospital has been the object of a great deal of discussion: critics claim that we have removed the naturalness from dying and left the dying patient alone with fear and alienation. By taking him out of his personal environment, awa} from the people and things that have special meaning for him, by placing him in a barren but noisy atmosphere surrounded by people who are paid to 'care' for him, we have, in effect. robbed him. Medicine. in its dedication to the saving and maintaining of life. leaves little room for dying. It seems to some as though aseptic technique has been absorbed into the very approach of hospitals. and more emphasis is placed on the perl"ormance of routines than on those aspects of caring that differentiate human compassion from mechanical performance. It is no surprise to us then to be told that we fail to deal satisfactorily with the dying patient: it should be recognized too that. when we shy away from caring for the dying. we miss out on an important experience and in so doing. we fail ourselves. I believe that the nurses who are with a patient the most during the terminal phase of life must accept the responsibility of meeting his particular needs. We must be "prepared to care". When I was a student. I had a brief but memorable experience which made me realize the importance of my role not onJy as a nurse who knew the technical things to do. but as a caring. sharing, persun. Mr. Schwegler*. aged 71 years. was admitted to hospital with a diagnosis of terminal cancer. He had had cancer of the bladder seven years before for which he was treated with a cystectomy and ileal conduit. However, the disease had metastasized to his lungs. Mr. Schwegler was a Dutch Canadian farmer who spoke and understood onJy a little English. And he was dying. . nam is fictitious When I met Mr. Schwegler he seemed to be in a stage of depression and partial acceptance of his prognosis. He shared his feelings with me one day after morning care. I was straightening up his unit while he rested. the curtains still pulled around the bed; with his eyes half open he watched me working and said he felt he no longer had any interest in anything. that all he did was sleep and still feel tired. He recalled that he had been a farmer and had worked long hours with plenty of energy, but - "no more". I asked him about his farm and family. He had a large family. he replied. and I answered. "You must be lonely." He burst into tears and sobbed that he and his wife had been married for 39 years and that he missed her. his children and home. One of his sons had died, he said, but he hoped to meet him again in heaven. He spoke of his religious faith. I sat down with Mr. Schwegler and took his hand firmly in mine. While he was crying he would frequently increase the pressure of his grip which made me feel he was trying to express his suffering while telling me too that he found my presence reassuring. As he talked he became calmer and began to quote from the Scriptures. He spoke often in Dutch, and even though I did not know exactly what he was saying. I felt that he was taking some comfort from his faith. He asked for the large-print book of verses he kept at hi<; bedside; the print in the Bible was too small for him to read. I cleaned his glasses and gave him the book and helped him to hold it as he read for awhile. Feeling that he was much calmer, I left him to pray in peace. A question offaith I had heard some of my classmates mention that they found shared prayer a comfort. so I sought out a classmate who spoke Dutch with the idea that. through their common language. she might enhance the experience of sharing with my patient. But she offered to find me scriptures in English instead. At coffee. I approached another Dutch-speaking classmate. but she said she would prefer not to meet Mr. Schwegler - she hated to see anyone cry. especially an older person. I talked then to the RN in charge and she told me that Mr. Schwegler's family visited him every day. and that they often prayed together. I went back to his room and found him sleeping with his book still in hand. and his glasses askew. I took them quietly away. but left them nearny. within his reach. I recalled from my readings of \1 urray 2 the guidelines for emotional support of the dying patient: relieffrom loneliness. the need for dignity. diverse everyday activities and, finally, the need for some hope to achieve an intellectual acceptance of the reality of impending death. I realized that, ifl were going to help my patient meet at least some of these needs. I would have to become more personally involved. As part of this objective. I encouraged him to take some initiative in his care: I got him to sit up and bathe his chest and arms. and shave himself. He appeared delighted when I applied aftershave and cologne, inhaling deeply and exclaiming "For me?!" I placed a basin on the floor and allowed him to soak his feet which he seemed to enjoy immensely. wriggling his toes and closing his eyes. I gave him analgesics a<; soon as he said he had pain: I checked him frequently for fecal incontinence and changed him immediately when required to keep him comfortable: I spoke in short simple meaningful sentences. enunciating clearly to ensure his comprehension; I gave morning care with rest periods as he needed them. and I kept his bed area orderly and neat with a minimum of confusion and noise. At the end of my tour of duty I went to say goodbye to my patient. He clasped my hand firmly and held it for a moment; I felt he was saying more thanjust thank you -I felt grateful too. and glad I was able to help. Inner strength "The individual who has learned to accept his life for what it was and who accepts the inevitability of death can meet death with less fear. "3 I think I actually saw this happen with Mr. Schwegler: he became physically more relaxed and emotionally composed as he spoke of his anticipation of heaven. I felt a sense of awe when I realized the power and depth of his conviction. Several years ago, the minister who conducted my father-in-Iaw's funeral service gave us a message that had considerable impact on my views about death. He pointed out that when we grieve we are mourning our loss. We have forgotten the basic Christian principle that the dead person has moved on to another, better life and that if we can we should be glad. We cry and become upset because we are in an atmosphere which is conducive to the expression of feeling without negative social sanction. But very little of our socialIzation prepares us for the shock or the finality of death. We are in an age of negotiators, of controllers and decision makers. We realize as never before that when we die, we are powerless in the face of forces over which we have no control- there is no bargaining for a better contract. Similarly, in life we are geared to postpone the unpleasant for as long as possible, and in dealing with death we tend to put off the personal and spiritual development required to meet and accept death with peace. Becoming involved wIth patients on a personal level exacts a toll. "Ifthe nursing staff were to become genuinely involved with the needs of each dying patient, and with the responses of the grieving family, much more emotional support of the staff would be necessary than now exists."4 My own experience with Mr. Schwegler was both exhausting and rewarding. I had perceived that he wa a lonely person who needed to express his sorrow and his pain. He didn't want answers or solutions from me,just company. I was deeply affected by his distress and by the realization that he needed me. We as nurses must reach into ourselves to find the faith and strength we need to help people deal with death. But our resources are not inexhaustible: they must be replenished. I n order to care for others we must first care for ourselves: we need reinforcement, feedback, and some sort ofreturn for our emotional investment. My experience helped me to realize that I am able to care for a person in the true sense of that word -I was able to fulfill some of his needs on one particular day. My feeling of exhaustion made me aware too that caring involves a kind of budgeting of inner resources,just as one would do with time or money. I f I find I am unable to meet someone's needs then I must find someone else who can, or help the person to help himself. The world is both beautiful and harsh: the key to a satisfying existence is to do our best within our personal limits and to accept, when we must. the reality that there is a great deal we cannot change. '" References I Murray, Malinda.Fundamental. of nursing. Englewood Cliffs, N.J., Prentice-Hall, 1976. p.491. 2 Op. cit., pages 487 - 501. 3 Op. cit., p.201. 4 Op. cit., p.494. Bibliography I Brunner, Lillian Scholtis. Lippincott Manual of Nursing Practice. by __. and Doris Smith Suddarth. Toronto, Lippincott, 1978. 2 Kübler-Ross, Elisabeth. On death and dying. New York, Macmillan, 1970. Valerie Willetts-Schroeder graduated from the nursing program at Red Deer College in Alberta this year. She i. loo/..ing forward to practising nursing in the city olVancolII'er. B.C , = :g l n Y:. .nd.bl. 10 . y..r guaranlee 01 aCcuracy to _ , 3 m m No slop-pin 10 hide .,.. errors Handsome Zippered case to III your pocket 121.11 comple'e. NURSES PENLlOHT. 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NOTE: ENGRAVED NAME-PINS IN 4 SMART STYLES - SIX DIFFERENT COLOURS... :.::::.t::: : .; ; ;; ;"E.;I ;. . .. ........ ....................... ......................... ........... ...... .... ........ ... s; .T ..E. u"'I;.; ;" ;;':l. P.P . .....;;E:";;... : . Fill IN LETTERINO P.O BOX 728 S, BROCKVILLE. ONT K8V 5V8 PRINTI : DESIRED.CtlECK 1aliine _____ 2ndlln.________________________ øe.un to enclo.. your name and addr..s . BOXES ON CHART PLEASE PRINT " NOTE: WE SERVICE AND STOCK SPARE PARTS FOR ALL ITEMS. CAP STRIPES Sell-.dh.slve type, removabl. and re-usable No 522 RED, No 520 BLACK, No 521 BLUE. No. 523 GREY All 1S'h , :.c Le; .red (14.) 12 .,rlpe. per csrd - - - -------------- - - - -------- AU ",NS HAVE BACKGROUND - 2PINS Quanl Item ( Ilour Pnce Amount : TYPE SAFETY ",NIACI'( COLOUR LETTERS PRICES 1 PIN (Sam. name) t. alZ8 SOLID PLEXIOLASS...Molded from solid Ple.lgla. Mother black 1 line 13.21 55.21 : ::; ; I: -:1 :qnu 7 . o :g y 01 blue leners P.arl ,eo 2 line 14.18 l8_el : -' green 1.II.ra :r :A g t: : hb :p,;t:1U [ While _ BI.ck 1 line ( 1218 13_72 I Black len.rs . contrasting colour cor.. B.velled edg.s match I Blu. I' While 2 linee 13.13 55.32 leUer. SaUn ',"Ish Excellent v.lue at this price. I.n.r. ONTARIO RESIOENTS ADD 7% TAX : white 1 0 Black ADD SOc HANDLING CtiARGE ------: MET At FRAMED.. .Similar to above but mountad 'n 1 Une 12_11 U.H IF LESS THAN '10 polished metal 'rame with rounded edge. aocl - old I I.nera COO ORDER ADD 12 00 corners. Engraved Insert can be changed or C Sliver : : k 0 Whi1. 2 line. 13_11 11.4' NO C.O.D. ORDERS FOR NAME-PINS ----: r.placed Our smarte.tand nea'e.t de.lgn. len.rs TOTAL ENCLOSED MO [- CHEQUE ICASH SOLID METAL.._Extramely .trong .nd durabl. but GOld black 1 lin. 13.11 55.el ASI( AeOUT OUA GENEAOUS OUANTITY DISCOUNTS FOA hghtwelght L.llers deeply engraved 'or ab.olute blue I.Uers : permanence and 'illed with your choice 0' laquer E SlIw.r ... 2 line. 14_71 l7.el CLASS GIFTS. GAOUP PUACHASES, FUfIID RAISING ETC COlour Corner. .nd edges smoothly rounded Salin green I.tt.rs smooth hnl.h USE A SEPARATE StiEET OF PAPER IF NECESSARY . .................................. ...................... To meet the expanding responsibilities of clinical nursing... 1 New! OPERATING ROOM TECHNIQUES FOR THE SURGICAL TEAM. A comprehensive reference for practicing operating room nurses, this book is designed to present overviews of the major surgical pro- cedures, including relevant anatomy, indications for each procedure, and the related nursing obligations. Based on operating room practice and the tenets of surgical nursing, this book provides a broad frame of reference from which each nurse can glean information according to her unique needs. Edited by Lois C. Crooks, R.N. Little, Brown. 459 Pages. Illustrated. 1979. Paper, $15.00. Cloth, $21.00. 2 New! MANUAL OF PEDIATRIC NURSING CAREPLANS. This handy spiralbound manual will help nurses in all areas of practice to provide total care for the sick child as a member of the family. Throughout, the manual emphasizes the parents' important role in the treat- ment program and offers specific guidelines for their involvement. The Hospital for Sick Children, Toronto. Little, Brown. 347 Pages. Illustrated. 1979. $15.00. 3 New! PHARMACOLOGY AND DRUG THER- APY IN NURSING, 2nd Edition. The new 2nd edi- tion has been so exhaustively revised that it is virtually a new textbook, yet it retains the lucid and readable style, and the comprehensive coverage, that put the first edition in a class by itself and made it "the book to beat" in nurs- ing pharmacology. By M. J. Rodman, B.S., Ph.D.; and D. W. Smith, R.N., M.A., Ed.D. Lippincott. 1085 Pages. 1979. $26.00. 4 New! PRIMARY CARE ASSESSMENT AND MANAGEMENT SKILLS FOR NURSES: A Self- Assessment Manual. This unique manual provides a self-evaluation in physical assessment, medical management of diseases, health counseling, and coordination of commu- nity resources for health promotion. By M. F. Stromborg, R.N., Ed.D., N.P.; & P. M. Stromborg, M.D. Lippincott. Abt. 500 Pages. 1979. Abt. $20.00. 5 New! A GU I DE TO PHYSICAL EXAM INA- TION,2nd Edition. This guide serves as an excellent working reference in patient care for specific techniques of interviewing and examination; for assessment of health status; and for differentiation among abnormal findings. By B. Bates, M.D. Lippincott. 440 Pages. Illustrated. 1979. $27.00. 6 New! NURSING MANAGEMENT FOR PATIENT CAREr 2nd Edition. Focusing on patient care, the authors analyze such behavioral aspects of nursing management as staff motivation and development, and the evaluation of staff performance. By M. Beyers, R.N., M.S.; and C. Phillips, R.N., M.S. Little, Brown. 292 Pages. Illustrated. 1979. Paper, $10.75. Cloth, $15.50. 7 THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 2nd Edition. This monumental second edition of a modern classic incorporates massive revision and updating to offer the latest and most accurate informa- tion available. By L. S. Brunner, R.N., B.S., M.S.N.; & D. S. Suddarth, R.N., B.S.N.E., M.S.N. With 9 Contributors. Lippincott. 1888 PaKes. Illustrated. 1978. $29.95. 8 New! CLINICAL GERIATRICS, 2nd Edition. New chapters in the second edition include discussions of the aging kidney, the lung, the female reproductive tract, and the oral cavity; also sexual functioning and noninvasive diagnostic technology. By I. Rossman, M.D., Ph.D. With 43 Contributors. Lippincott. 704 Pages. Illustrated. 1979. $45.00. 9 NURSES' DRUG REFERENCE. Finally, a fingertip guide to drugs organized with the nurse's needs in mind. More than 500 drugs, listed alphabetically, are described in a consistent, easy-to-consult format that in- cludes the drug's action and use, dosage and administration, cautions, adverse reactions, composition and supply and legal status. Edited by S. M. Brooks, M.S. Little, Brown. 625 Pages. 1978. $14.50. Lippincott J. B. LlPPINCOTI' COMPANY Of CANADA LTD. Serving the Health Professions in Canada Since 1897 75 Homer Ave., Toronto, Ontario M8Z 4X7 Books are shipped On Approval; if you are not entirely satisfied you may return them within 15 days for full credit. Current nursing catalogue available free upon request - -J IPPINCOTT OMPANi"OF CANAD LT 1 75 Horner Ave., Toronto, Ontario M8Z 4X7 Please send the following for 15 days 'on approval'; IP lCI 2 345 6P 6CI 789 o Lippincott Nursing Catalogue o Payment enclosed (postage and handling paid) o Bill me (plus postage & handling) Name Address City Provo Postal Code Prices subject to change without notice. CNI0/79 --------------------. 42 October 1171 The Cenedlen NUrH r, tf\,e 1 Emergency nursing, edited by Jeanie Barry. Toronto, McGraw-Hili Ryerson. 1978. Approximate price: $/9.95 To date little has been written about emergency department nurses and their particular knowledge needs. The text under review attempts to remedy this by providing information on the skills. background and judgment nurses need to provide care to critically ill and injured patients. Emergency nursing is divided into three sections. The first. entitled the Biological Basis of Emergency Nursing, consists of chapters on the anatomy and physiology of the nervous. cardiovascular, respiratory and renal systems. Two chapters deal with associated diagnostic tests. namely 12-lead electrocardiography and blood gas analysis. In each chapter many facts are presented but they are rarely integrated. As a result supplementary texts would be necessary for those nurses who desire a good understanding of biological function. For the less well-informed nurse, the information as presented could prove confusing. Section Two overviews the Psychosocial Basis of Emergency Nursing. Included are brief chapters that summarize current information about communication, anxiety and the grief process. The authors have related these concepts to the emergency setting which is useful. The final section of the book consists of chapters on the various urgent and emergent problems seen in an active emergency department; there are chapters on such diverse topics as orthopedic injuries, emergency care of driving accidents and respiratory distress in children. The pathophysiology, . I I I described. "The Patient's Bill of Rights" and the general duties of a hospital ombudsman give a view of rights in hospital. Another emphasis is practicality. Advice is given on what to take when admitted to hospital and how to recognize hospital personnel by their uniforms. Ranges in fees for various operations are listed. There is one section devoted to helping children through surgery. Topics are concisely presented in understandable lay language. This book is of v alue to those facing surgery. Health care workers and students would benefit from its review of concerns from the consumer's viewpoint. Re,'iewed by Cynthia Dobbs, Assistant professor "Laurentian U ni,'enity School of Nursing , Sudbury, Ontario. med-surg -- o assessment and management of each problem is presented. My concern with this section is the lack of organization of the otherwise helpful content. Few topics are dealt with completely in any chapter; instead the reader is referred to tables and content contained elsewhere in the book. For example, to benefit from all the content about cardiovascular problems, the reader must consult no less than six different chapters. The book is enriched by the large number of excellent diagrams and tables and by the references and bibliography that are found at the end of each chapter. Emergency nursing contains much valuable information. It will be a useful resource to any nurse interested in the initial assessment and management of patients who seek care in an emergency department, but to obtain maximum henefit from the text one would require time and patience. Re,'iewed hy Ek:abeth Rideout, assistant professor, educational program for nur. es in primary care, McMaster U lli,'ersity, F acultv ofH ealth Sciences, Hamilton, Ontario. The patient.s guide to surgery by Lawrence Galton, New York. Avon, 1977. Approximate price $2.50 This book describes over 150 operations for the surgical consumer. as well as psychological preparations for surgery, choosing a surgeon, and usual fees. An emphasis on patient rights is apparent throughout. The prospective patient is encouraged to ask questions that seem important to him. How to check a surgeon's qualifications and recognize male chauvinism are The Cen-.ll.n "UrN October 1171 43 ursing and the criticall ill patient by Nancy Meyer Holloway. 585 pages. Menlo Park. California, Addison-Wesley Publishing Company. 1979. Critical care nursing is concerned with individuals undergoing life-threatening physiologic crises. This book describes a conceptual framework ba ed on patient needs, to as ist the nurse in providing goal-directed. meaningful care to critically-ill patients. The material presented has been tested by nurses in clinical practice. The authenticity of material with emphasis on the "why" or rationale for nursing actions. as well as specific examples on "how-to" carry out patient assessments and nursing interventions, makes this a valuable reference text for all nurses and students in critical care settings. Content of the book is organized according to patient needs for fluids. aeration. nutrition, communication and 'itimulation. Each chapter begins with a list of behavioral objectives the learner should achieve upon application of content in clinical prdctice. Patient assessment based on knowledge of relevant anatomy and physiology is emphasized. Specific nursing interventions are discussed and criteria for evaluation of the patient's progres are provided. Application to clinical practice is facilitated by the relevance of the material. the specific directions provided and the use of the components of the nursing process to organize content. The final chapter deals with application of the framework in clinical practice and provides examples of nursing care plans. This comprehensive text on critical care nursing is a valuable reference book and one I would choose for my personal nursing library. The integration of content within a nursing framework makes it unique in the literature of a speciality area traditionally based on the medical model. Rel'Ïel<."ed bv Joan Royal, R.N., B.Sc.N., .W.Se.N., Assistant professor. .WeMllster Unil"ersity School of Nursing, and Clinical Nurse Specialist, St. Joseph's Hospital, Hamilton, Ontario. Cardimascular nursing: pre\ention, intenention and rehabilitation by Jeanne 1\1. Holland. 218 pages. Boston. Little, Brown and Co.. 1977. The main emphasis ofthis book is on developing the nurse's knowledge so that he/he is better able to aid in patient rehabilitation. The author presents an overview of the cardiovascular field. beginning with a review of phy iology. She then discu ses patient assessment before delving into the two major manifestations of heart disease - valvular defects and myocardial infarction. The author explains treatment regimes thoroughly so that nurses can understand the rationale behind them and explain them to her patients. She also takes a look at the complications which can follow myocardial infarction and at ways to prevent them. The problem of angina pectoris is described: methods of treatment are included. Exercise and drugs are emphasized and examples are given of how to be specific in teaching. A sample teaching guide for patients with myocardial infarction is included. Emphasis is placed on documentation and evaluation of the teaching in order to assess the level the learner has reached. This book. as described by the author. is intended to update and refresh the knowledge of the nurse who has been absent from active participation. as well as being dn aid in continuing education. I believe that it will also be useful as a reference for student nurses who undertake a course in this specialty. The one great fault is not in the content but in the physical presentation as the printing is very small. Many idea!> are developed on one page with little diversion in the way of pictures or tables etc. This is a drawback to reading the text in its entirety. but the book remains useful as a reference. Re,'iewed by Lorna Rankin. instructor. General Hmpital School of Nursing, St. John's, Ne>>foundland. AAC Organization and Management of Critical-care Facilites, by Diane C. Adler and Norma J. Shoemaker . Toronto. Mosby, 1979. Approximate price: $/6.75. Having personally been involved in the evolution of two critical care areas in the past few years. I found this book to be of tremendous support. The book has illustrated the changes in critical care nursing over the decades with emphasis on today's organization and management. The author has covered a lot of ground in a very concise fashion. and has made the information applicable to any level of hospital organization. The illustrations, from floor plans to nursing management, manage to reveal all the important points to consider when putting a new unit together. I feel the author has allowed this book to be useful to any level of nursing. paramedical or other health care personnel. The data is of use for a) implementation. b)understanding. and c)knowledge of what is a notably high cost center in any institution. It illustrates a tremendous effort to support a sensitive yet often intimidating area in the health care system. Through all the documentation. one main thought predominates in chapter conclusions: over the years procedures have improved technically. philosophies have broadened. and care has become more sophisticated asc.C.U.'s evolve. But with all these changes. the needs of the patient must be met through communication, and not just by one person but by the whole health care team. The book emphasizes today's methods. at whatever level ofC.C.U. management, based on the total team concept. The communication system is seen to be growing as "an ever widening circle" . Rniewed bv Margaret Zanin, R.N.. Head nurse, EA/CU, The Wellesley Hospital, Toron/o. Dealing with death and dying. 2d ed. Nursing Skill book Series, Series Editor Patricia S. Chaney. 189 pages.lntermed Communications. Jenkintown. Pa. Approximate price $7.95 The purpose of the book is stated in the forward: "this book single mindedly tackles the practical problems of thanatology, how to deal directly with the feelings and fears of the patient. the family. yourself and other staff members. ,. This has been achieved through the selection of published articles by well-qualified authors and the inclusion of Skillchecks at the end of each section. The book is introduced by a letter on death from Elizabeth Kubler Ross. Her message to health professionals is that. as they live every day fully. they are then able to become involved with the dying and to become comfortable in caring for them. The book is so organized that there are sections dealing with the patient, with the family and with yourself and the staff. The last section. "Some personal views" . is of particular note. The article, .. Surviving: four patients talk". gives added insight into the feelings of persons who are facing death. This book has something for everyone. There are articles of particular interest such as, "Children's special needs" by Robert E. Kavanaugh. or doing the Skillcheck. It is one that every health professional who is dealing with death and dying should have. Many will have read the various articles in other 44 October 11711 Th. Cen-.ll.n Nur.. publications but there is considerable merit in having a book that brings these together. This gives a more complete picture of the topic. Personally, I found new insight into the caring of the dying and would recommend this book for the health professional's own library. Re 'iewed by Ina Watson, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan. pharmacology Giving cardiovascular drugs safely, (Nursing Skillbook Series) edited by J. Robinson. Horsham Pa., Intermed Communications, 1977. The authors had three purposes for this textbook: to demonstrate that nurses in any field will encounter clients with cardiovascular disease; to emphasize what the nurse specifically needs to know about cardiovascular drugs; to emphasize the need for client education about cardiovascular drugs. The book succeeds in meeting its purposes. The chapters are constructed such that a client situation, within the community introduces the drugs involved in that chapter. Information about the drugs is presented in clear, concise language. Reinforcement is provided by charts regarding drug administration, drug interactions, span of action, and sample client-teaching aids. One of the book's most noteworthy points is its emphasis on client education. The publisher gives explicit permission to recopy each aid for distribution to clients. The aids are phrased in clearly understood lay terms. While they pertain mainly to drugs, there are also aids pertaining to diet therapy which may be prescribed. The other noteworthy point is the emphasis on the nurse's knowledge needs. The aforementioned charts provide quick, easy reference material. The chapters clearly explain what the drugs are doing, and what the nurse should look for specifically to judge the drugs' effects. There is a large element of self-directed learning present. Skill checks at the end of each section require use of the material presented in the section to answer questions about client care situations. Interesting points about the drugs are brought up, such as the role of magnesium in relation to digitalis therapy; and facts about body system functions, ego liver and kidney, which will affect the drug's metabolism and excretion. Nurses, particularly those working in a pharmacy and in the community, will find the emphasis on client teaching of great assistance. Nurses in all settings will find the information on drug actions and side-effects very useful. Reviewed by Phyllis Durnford, Clinical Coordinator, Algonquin College Nursing Program, Pembroke Centre, Pembroke, Ontario. Nurses drug reference by Joseph A. Albanese. 692 pages. Toronto, McGraw-Hili, 1979. The purpose of this book. dS the author states, is "to fulfill therapeutic nursing objectives of the current professional nursing model, the nurse must be knowledgeable in all aspects of pharmacology and therapeutics." The text is divided into four parts. Part One contains drug indexes which cross reference the drugs by generic name. brand name and pharmacological classifications. Part Two contains comprehensive drug monographs, containing such things as classifications, p:tarmacologic action, therapeutic uses, dose ranges, patient instructions, contraindications, adverse effects, clinical nursing implications and management of overdose. This particular format, with headings in red and specific information in black, al\ows one to locate information quickly and easily. Information contained in the monographs is accurate and complete. Especially helpful for student nurses are the drug interactions, clinical nursing implications and patient instructions. Part Three is a reference section containing units of measure of the metric and apothecary systems, but also of value are lists of drugs that induce certain adverse reactions such as agranulocytosis, thrombocytopenia and several others. A reference of laboratory values is also included. Part Four contains an appendix of nursing and drug related information, much of which applies to the U.S. The material in this book is well written and presented. The drug monographs which form the bulk of the book make it a valuable reference, which I am certain will be appreciated by nurses in clinical practice, students and instructors. Re 'iewed by Marlaine Finnegan, R.N., B.Sc., M.Ed., Ottawa, Ontario. pediatrics Comprehensive pediatric nursing (second edition) by Gladys M. Scipien, et al. New York, McGraw-HilI. 1979. Those familiar with the first edition of this text will note the addition of four new chapters, as well as significant revisions and updating in the remainder of the text; it remains an excellent reference text for educators, students and practitioners engaged in providing quality nursing care for children and their families. The text provides a wide scope of pediatric nursing content and an overview of specific bio-psycho-social knowledges, theories and concepts related to normal growth and development. These provide the baseline for nursing assessment and rationale for intervention. The text further discusses current health care issues in pediatrics, briefly exploring trends in today's health care delivery and the potential for nursmg. The third part of the text focuses on the nurse's role in assisting children and their families to deal effectively with illness and hospitalization. and the last section of the text discusses specific childhood pathology, providing significant information on medical diagnosis, treatment and associated nursing management. The authors of the text meet their objective of high-level pediatric practice through sharing of the expertise of multiple authors: recent research in pediatrics is incorporated into the text and presented with critical objectivity. Reviewed by PilviOolup, Lecturer, School of Nursing, McMaster University, H ami/ton, Ontario. Th. C...dlen Nurs. October 1171 45 Pediatric primary care second edition by Catherine De Angelis. 651 pages. Boston. Little, Brown and Co.. 1979. The first edition of this comprehensive text was published in 1975 under the title Basic Pediatrics for the Primary Health Care PrOl'ider. Both editions purport to" ...impart to members of the pediatric primary health team specific. pertinent knowledge that has been carefully selected from the broad field of pediatrics:' The original text was expressly written for the "non-physician care provider", particularly the pediatric nurse practitioner and the physician's assistant. This text probably met a felt need among nurses who were establishing new roles where an expanded "medical" knowledge base was mandatory. In the second edition, the author (a nurse turned physician) has added relatively little that will enhance pediatric nursing practice. Revisions and additions clearly reflect the decision to include physicians in the target audience. Offour new contributing authors one is a nurse and three are physicians. Improvements in the new edition include a more comprehensive discussion of the assessment of the child and the management of common childhood diseases and behavioral problems. End of chapter bibliographies have been greatly expanded but, although it would have enhanced the text significantly. no nursing literature is cited. The book is well organized and clearly presented in four parts titled I Data Base. II Health Management, III Common Signs. Symptoms and Diseases. and IV Problems of Behavior. The few illustrations and photographs contribute to the text but more would have been helpful. particularly in the section describing physical assessment. Several distracting charts and forms are interspersed throughout the text that could have been grouped in an appendix for easy reference. Unfortunately, the book lacks a family-centered holistic approach to the care of children and fails to stress health promotion and maintenance aspects of pediatric care. The book's "how-to" approach is simply unequal to the task of dealing with the extremely complex challenge of providing primary pediatric health care. I n summary. this text offers no new insights or creative intervention techniques that would significantly contribute to nursing education or practice. Rniewed by Patricia McKeel'er, R.N., M.N., lecturer, Faculty of Nursing. Unh'ersity of Toronto. Who speaks for the children: The plight of the battered child by Peter Silverman. Don Mills. Ontario. Musson Book Company, 1978. Approximate price: $8.95 1979 is the International Year of the Child, and this thought-provoking book leads the reader to take a hard look at the care of abused children in Canada. The writer is ajournalist who covered an inquest into the death of a child. and subsequently interviewed a wide range of people concerned with the child welfare system. His stated goal is to "present a layman's view of the weaknesses and strengths of the system, and the problems faced by dedicated men and women who try to make it work against great odds, public indifference and government apathy". It is not an academic paper. and some professionals might be critical of the relative lack of documentation of sources and research cited. However. the writer looks at many aspects of the situation. and gives an understanding portrait of those who work in child welfare. At the same time he clearly points out the failings of the system, the lack of resources. the ambiguity of laws and the ill-defined roles of various agencies. It becomes very clear that our society, while expressing Concern about child welfare, is unwilling to commit the money and resources needed to solve the prohlems. This book is of interest to any who work with children or families; it does not give solutions but provides a clear background for a debate of the issues. Nurses. along with other professionals, need to look at the rights of children. and how these can be protected. Rel'iewed by Helell Eifert. associate prl ressor, School ofNunillg. The U ni\'ersitv of British C olumhia, VaIlCOU\'er, B.C. Your bab} & child: from birth to age five by Penelope Leach. 512 pages. Toronto, Random House of Canada. 1978. Appro'âmate price: $19.95 The author's research has convinced her that the "whole baby business" is becoming unnecessarily serious and forbidding. and that parents now worry too much about their ability to cope and subsequently feel guilty about their inexperience and shortcomings. Leach's book is addressed primarily to parents and to others who care for infants and children on a regular basis. Its aim is to help these people find "positive courses of action" that will be heneficial to the child. and in turn give joy and reward to those responsible for the child's care. The book is organized into stages. beginning with birth and ending with age five. For each stage the author discusses developmental tasks. thought processes and the range of emotions. This is a large book and much of it is devoted to helping parents find solutions that work for them. For instance. when she discusses sleeping habits and patterns from six months to one year, she makes five sensible and plausible suggestions in the event that bedtime may be upsetting for the baby. This is not, however. a book of rules: it suggests rather that parents listen to the child and to their own feelings. and emphasizes the importance of flexibility and thoughtfulness in child reanng. The text i!> current and reflects contemporary concepts of feeding practices, toilet training and other aspects of child care. The hook is richly illustrated with photographs. dra ings. graphs and charts: the color illustrations in particular bring it to life. A special feature is the Encyclopedia/Index which is more than a reference index. containing technical information not dealt with in the main text. Your Baby & Child was originally puhlished in Britain, but the book has been very successfully adapted for North American readers. Obviously the book is meant for parents to use and enjoy. In addition. this sensitive. well-researched text would be a useful reference for community health nurses, pediatric nurses and student nurses. Rel'iewed by Eli';,aheth Stewart-He,Bel, former puhlic health lIurse and nursing educator, Ottawa, Ollt. Pediatric history taking and physical diagnosis for nurses. 2d ed. by Mary M. Alexander and Marie Scott Brown. Toronto, McGraw-Hill. 1979. Approximate price: $/2.45 The second edition of this excellent book is much more comprehensive and complete than the first edition. It contains a wealth of information necessary for nurse practitioners working with children. One of the purposes of the second edition is to improve nurses' skills in the recognition of age-specific differences in the comprehensive assessment of children; the authors have accomplished this purpose admirably. Many points referred to in the first edition are expanded upon and developed more fully in the second edition. For example, the pelvic exam is now included in the section on Looking for fresh, new ideas in nursing texts? Here they are: New 4 th Edition! C MPREHENSIVE CARDIAC CARE: A Test for Nurses. Physicians. and Other Health Practitioners. By Kathleen G.Andreoli. R.N.. B.S.N.. M.S.N.: Virginia Hunn Fowkes. R.N.. B.S.N.: Douglas P. Zipes. M.D.: and Andrew G. Wallace. M.D. Proven effective In the classroom. this volume Is the leading text In Its field. The new edition will give your students the Infonnatlon they need on all aspects of cardiac care - anatomy and physiology: coronary artery diseases: assessment of patient: complications: electrocardiography: and pacemakers. Emphasis throughout the book Is on prevention and early rehabilitation. New material covers risk factors In coronary artery disease: and current pacemaker therapy. March. 1979. 406 pages. 699 illustrations. Price. 813.25. A New Book! MOSBY'S MANUAL OF EMERGENCY CARE: Practices and Procedures. By Janet M. Barber. R.N.. M.S.N. and Susan A Budassl. R.N.. M.S.N.. M.I.C.N. This hea'-1ly Illustrated new book offers your students a quick reference to assessment skills and specific techniques for life support and stabilization of the critically 111 or Injured. Arranged In a handy outlined format. discussions stress signs and symptoms. Interrelationships of pathological phenomena. and critical criteria and decision-making. August. 1979. Approx. 704 pages. 493 illustrations. About 821.75- A New Book! STRESS AND SURVIVAL: The Emotional Realities of Life-Threatening IllneBB. Edl ted by Charles A. Garfield; with 51 contributors. A most comprehensive preSentation. this text anaJyzes stress and survlvaJ for heaJth care workers deaJlng with patients and families facing life-threatening Illness. Noted contributors Identify the seq uence of major emotionaJ events encountered by the professlonaJ and Ihe patient from diagnosis through cure or death. OptlmaJ means of giving emotionaJ support are closely examined to show students the ways In which they can be InstrumentaJln promoting quaJlty of life. longevity and. at times. survivaJ. March. 197' 406 pages. 9 illustrations. Price. 81 , A New Book! CARDIOPULMONARY RESUSCITATION: Procedures for Basic and Advanced Life Support. By Patricia Diane Ellis. R.N.. M.N. and Diane M. Billings. R.N., M.S. This new book Is designed for anyone responsible for administering life support measures In situations of cardiopulmonary arrest. Initial chapters cover anatomy and physiology of the respiratory and cardiovascular systems. The authors then describe procedures for assessment of cardiopulmonary emergencies. basic life support. and advanced life support (Including restoration of ventilation. restoration of circulation. and parenteral therapy). The flnaJ chapters describe the organization of an emergency medlcaJ system and provide hlstoricaJ. legal. ethical. and psychological perspectives. December. 1979. Approx. 272 pages. 161 illustrations. About 810.75-. STRESS ro;,, sU .......e>><<;.e>>no-. Th- - e>><<' .---..<<;.-- -<<;_....... Ii<<,_-<<;h'-- i.....--- .__ð41'" ;;;? _ .... $-!. :;;y Sc _Þ - r;;::r .J;;; - /' '$ #q$/ / - A New Book! MOSBY'S MANUAL OF CRITICAL CARE: Practices and Procedures. By Linda Feiwell Abels. RN.. M.N. Offer your students clear. concise Instructions on basic cIitical care techniques \\1th this useful new text. Emphasizing systems assessment. It details rationales and procedures necessary for maintenance of body homeostasis. Practical. comprehensive tables and useful appendices are Included - and margin Indicators highlight significant mateIial throughout the book. May. 1979.440 pages. 267 illustrations. PIice. 816.75. COMPRI!HI!NSIVI! CARDIAC CARE A POIIt ........... PI1. - -- .-...:>> ...-.c. I 61..a. ..... . . ---- _o-- .- __ø -' o. 0. 0...",0.- -8.-..... - .. .....-- A New Book! MEDICAL-SURGICAL NURSING: Concepts and Cliolcal Practice. Edited by Wilma J. Phipps. RN.. B.S.. AM.. Ph.D.: Barbara C. Long. RN.. M.S.N.: Nancy Fugate Woods. RN.. M.N.. Ph.D.; with 46 contIibutors. Using both a systems and a conceptual approach. this Innovative text reflecls the myriad changes In contemporary medical/surgical nursing. The first two parts discuss such general aspects as soclo-cuJtural perspectives. the nursing process. stress and adaptation. and POMR Part III analyzes specific medical/surgical problems. Students will partlcularlv value unique chapters on ecology and health. health care delivery systems. and an epidemiologic approach to health care. March. 1979. 1.648 pages.731IUustrations. PIice.830.oo. A New Book! BASIC PATHOPHYSIOLOGY: A Conceptual Approach. By Maureen E. Groer. RN.. Ph.D. and Maureen E. Sheklelon. RN.. B.S.N.. M.S.N. This conceptual approach I resents the basic biology of disease from the perspective of teratlons of normal physlolo - regarding the human ganlsm as an open system In continuous Interaction with the environment. Diseases are presented In terms of models of major concepts. rather than as a compilation of signs and symptoms. Helpful behavioral objectives begin each chapter. March. 1979.534 pages. 423 lUustrations. PIice. 819.25. ALSO OF INTEREST: A New Book! DEPARTMENT OF EMERGENCY MEDICINE GUIDELINE MANUAL: Policies and Procedures. By Jfjfrey R. Macdonald M.D. and Pat Kinder. RN. June. 1979.344 pages. lllUustrations. PIice. 828.75. - For more Infonnatlon. write us! The C. V. Mosby Company. Ltd. 86 Northllne Road Toronto. OntaIio M4B 3E5 A90833 Mosby has the answer to all your textbook needs. IVIOSBV TIMES MIRROR THE c. v MOSBY COMPANY. L TO B6 NORTH LINE ROAD TORONTO. ONTARIO M4B 3E5 48 October 111711 The Cenedlen Nur.. examination of the female genitalia including suggestions for peIforming a pelvic exam for the first time on a young adolescent. The musculoskeletal chapter also contains some new material relating to current information in the field of sports medicine as it relates to the school-age child. This book is unique in that it is written by nurses for nurses, and manages to discuss areas traditionally considered to be in the "medical" domain (history taking, physical exam, screening tests) while maintaining a nursing perspective throughout. It is a must for those nurses interested in peIfecting their skills in comprehensive assessment of children. Reviewed by D. Joan EaRle, associate professor, Faculty of Health Sciences, McMaster UnÏl'ersity, Hamiltoll, Olltario. community health Communitv health care and the nursing process by Margot Joan Fromer. 440 pages. St. Louis, Mosby, 1979. Approximate price: $/8.00 Community health care and the nursing process provides an overview of community health care in general. and community nursing in particular. The health care system, its history, institutions, agents, ethics and methods are explored in the first half of the book. Next, the health-illness continuum, mankind as an open system, and the effects of stress on the individual, the family and the community are developed. The nursing process and nursing audit and two particular areas of health care - school and occupational health nursing - complete the content. Fromer's book brings together a number of health care concepts and concerns which are perhaps more fully developed in other books. Aside from a brief reference to Keynes. Marx and Friedman in connection with economics and poverty there is little new material; the three pages on mental illness add little to our knowledge of a major health problem. As usual. the most serious drawback for Canad ian teachers and students is that the health care system described is American. On the credit side, the book is broad in scope, each chapter is followed by an extensive bibliography and some good models are discussed and illustrated. The format permits one to study systems, methods, family and nursing practice in a logical order. Community health care and the nursing process will assist teachers to give an overview of community health at a basic level. but the American content and high cost may make it undesirable as a required text. A Canadian text on this subject is badly needed. Rniewed by Alice Caplin. associate profeHor of nursillR, U nÏl'ersity of Saskatchewall, Sa. katooll, Sask. Care of the mentally retarded by Marian Willard Blackwell, Boston, Little. Brown and Co., 1979. This excellent text written by Marian Blackwell, RN. MS. who is a former staff nurse in a center for the mentally retarded in Massachusetts, and consultant to a government commission on retardation, is a comprehensive look at literally all facets of nursing care of the men tall y retarded. She begins with a brief discussion of the basic concepts and philosophies of care in this special field. followed by an excellent discussion of the pathophysiology of causes of retardation. genetic and external. Her research is current and covers a wide range of disorders from PKU to herpe.\ proRenitalis to malnutrition. Having thus laid out a groundwork of medical knowledge, Blackwell proceeds to discuss the nurse's role in care of the neonate, and in meeting the needs of the family of a retarded child: she details as well the care of institutionalized individuals. The nurse's role in the community is emphasized in the presentation of such progrdms as genetic counseling, birth control counseling to prevent teenage pregnancies. maintenance of retarded persons' personal rights. public education and research. Blackwell's book will appeal to all nurses, regardless of the degree of their actual involvement with the retarded: her information is both practical and theoretical. and is presented in a highly readable fashion. Re\'iewed by Jalle Bocl-... R.N., B.A., assistallt editor, CNJ. psychiatry \ Comprehensive psychiatric nursing by Judith Haber et aI., Toronto, McGraw-Hili, 1978. Approximate price: $2/.55 I consider this text to be a good one and a valuable contribution to nursing literature because of its eas y read ing style, its emphasis on the family and it.. behavioral approach to therapy. The purpose of the text is clear, but a more in-depth explanation of the espoused "comprehensive approach" would be helpful. The authors should also define more clearly the level of the "basic nursing student" for whom they are producing this text. They should also limit the scope of the text to either students, practitioners or educators but not to all three groups. The chapter headings are well outlined and the objectives stated at the beginning of each chapter are relevant and useful. The behavior approach to pathology is good. Examples of completed nursing care plans at the end of each chapter and behavior descriptions would have been very useful. I feel that the text is slightly long for a basic text but it is easy to read and would be suitable for a second year diploma or associate degree program. It is well-presented, interesting and current in perspective. This text would be useful for a school program because of its behavioral approach in terms of objectives and description of pathology. The format for content proceeds from simple to complex and normal to abnormal. The concepts of prevention are mentioned but are not integrated consistently throughout each chapter. Re\'iewed by Adam Ro/.., instructor, ADN ProRram, Northeast Wisconsin Technical/ nstitllte. Green Bay Wisconsin. The Cen.cllen Nur.. OcIober 111711 411 Principles and practice of psychiatric nursin by Wiscarz et al. Toronto. Mosby. 1979. Approximate price: $20.50 Rather than presenting psychiatric nursing as a practice to be based on the traditional model of disease. the author., have used the nursing process consistently in each of the chapters as the conceptual model for implementing psychiatric nursing practice. Current literature and recent research findings are quoted IiberaIly throughout the book The first section of the book focuses on principles of psychiatri . nursing practice applied to various common behaviors to patients in a variety of settings. The second section focuses on the practice of psychiatric nursing and current treatment modalities. It is the first section which is most impressive due to the material"s organization. chapter consistency and emphasis on nursing care. Certainly. some of the behaviors upon which the chapters are based are not new. However, in the chapter on a:1xiety nursing intervention is discussed in relation to levels of anxiety and relaxation interventions are included. Greatest originality is demonstrated in chapters on disruptions in relatedness and prohlems in expressions of anger. In the former. the concept of loneliness and the inability to develop mature interpersonal relationships is analyzed throughout the life cycle. Psychological and sociological stressors leading to loneliness and resulting behavioraIly as withdrawal. suspicion. manipulation and dependency are discussed. As in all of the chapters in this section long and short term goals are stated and appropriate nursing intervention emphasized: this is the first psychiatric nursing textbook to put any empha.,is on anger and to discuss the various behaviors which represent the expression of anger. and the appropriate interventions. The second .,ection of the book focuses on the practice of psychiatric nursing. Chapters on Group therap). Family therapy. Behavior Modification and Community Health Nursing are current and comparable to any Tecent text. The chapter on death and dying extends to include the nurse's own reactions and the family of the dying person. The chapter on psychiatric evaluation. crisis therapy and adolescent psychiatric nursing excel in their depth. use of examples and demonstration of the nursing process. The text is outstanding in its extensive chapter on counseling the victim ofrape. Because of the emphasis on nursing this textbook is of value to all nurses concerned with quality nursing care. The educator might wish for greater depth in theory and those who are not scholars less quotes and more simplicity of language. But all will be able to implement better nursing care plans and give better nursing care through the use of this book. Rniewed by Pac Heherc. teacher, Fanshawe Colle1!e, St. Thomas, Ontario. Mental health concepts in medical-surgical nursing: a workbook 2d ed. by Carol Ren Kneisl and Sue Ann Ames. Toronto. 1\10sby. 1979. Approximate price: $/0.25 The effects of physical illness on the psychological and interpersonal needs of individuals and their families has long been recognized by nurses practicing in general hospital settings. The authors intend this workbook to enhance the visibility of interpersonal needs of adult patients having medical or surgical problems and they have achieved their purpose by skiIlful integration of the psychosocial and physical components of nursmg care. In this edition. as in the first. content is organized in three subject areas: the patient experiencing anxiety. the patient with alterations in body image, and the patient with psychophysiological dysfunction. Individual patient case studies comprise each part: these presentations add validity to the workbook as they emphasize how people cope during periods of illness. and how nurses can assist patients to adapt and solve problems. A brief. but concise theoretical framework precedes each section which provides an information base for the reader to study the individual case histories. Each patient study has a series of multiple-choice and subjective questions which can be done as self-directed testing, in smaIl group discussion. or as teacher-directed tests. \10st of the questions test the reader's ability to apply principles and explain rationale. Some options in the multiple-choice questions do not require the reader to discriminate. as the incorrect answers are obvious, but this does not hinder the overall effectiveness This is an excellent book for all nurses involved in planning and giving direct patient care. Re\'iewed by Rae Malcolm. Instructor, Royal Jubilee Hospital, School of 'Vursing, Victoria. B.C. education Current perspectives in nursing: social issues and trends by Michael H. Miller and BeverlyC. Flynn. Toronto.c.V. Mosby. 1977. Approximate price $/ / .05 Many weIl-knov'n nursing leaders have contributed to this book edited by MiIler and Flynn. Consequently, the issues are well researched. very contemporary and presented in a scholarly fashion. Each chapter is replete with additional selected references for the reader to pursue. Chapter I discusses the ethical aspects of group level decisions and reminds the reader that in the past. nurses have been educated to consider the individual patient. Today. in our health context and respect for rights. we are urged to focus on "maximization of benefits for whole groups of patients" . Frank and Carolyn Williams carryon in their second chapter regarding social and moral concerns. discussing principles relative to human experimentation. Much background information is provided regarding statements from professional groups concerning this ethical issue. The 1966 Declaration of Helsinki is also noted. Part II, on research issues, contains Flynn's conceptual framework for evaluating community health nursing practice. Operational definitions and statistical tabulations suggest that this may not be for the average reader. Aydelotte's subsequent chapter on the need for well-conducted research in nursing not only makes this plea in order for nursing to achieve its purpose. but corroborates the need for many of us to increase our knowledge base. even to comprehend Flynn's previous concept as well as Aydelotte's message. Other significant issues fiIl the remaining chapters of the book. issues such a.., sexuality. death and dying, consumerism. preparation. role. function and legal aspects for the nurse practitioner. and myths of the nurse educator are explored. Joyce Passos describes and criticizes this latter issue. and notes that these "myths...relate in 50 OcIober 111711 The Cen.cllen Nur.. some way to the definition of nursing as an intellectual discipline..... For those interested in the American Nurses Association, special interest groups are outlined via an historical perspective. Who joins and why, based upon representation, should prove controversial reading as Miller and Flynn contend that this organization "should become more popular with the staff nurses it needs to attract. " This book, although an American publication, written by nursing leaders primarily from the U.S.A., clearly cites the need for more re earch in the social issues presented. It is scholarly reading, perhaps not for all readers. However, for those nurses who wish to acquire a better understanding of the areas of nursing in which most changes are occurring, it is recommended reading. Reviewed by Dol/yGoldenberg, chairman, Nursing Education, St. Clair College of Applied Arts and Technology, Windsor, Ontario. Clinical nursing techniques fourth edition by Norma Dison, St. Louis. Moshy. 1979. Approximate price: $/5.75 Clinical nursinR techniques is a comprehen ive manual. The author's stated purpose of providing "explanatory information and meaningful illustration!'. to facilitate learning. reviewing and modification of techniques used in the practice of nursing" has been well mer. Baseline information is provided which the nur e may then augment with the practices. policies and specific equipment of her agency. The text is clearly written and provides tables organized into technique. prohlems and solution or rationale. for quick reference. This fourth edition contain.. 703 illustrations which offer step-by-step instruction on such hasics as hed-making, toothhrushing. gloving. crutch-waking. etc. The author progresses through the spectrum of clinical practice to more involved techniques such as use of respirators or heparin lock : detailed u!'.e of mechanical equipment ..uch as hydraulic lifts is well depicted. This manual would he of valuahle as..i tance to students, heginning practitioners or nurse.. returning to practice, and as a ready reference for those who develop and revise dgency procedure manuab. However. it is technique.\ that are the focu and readers are advised to look elsewhere for detailed phy iological explanations. The text is organized into n chapters which are inconsistently titled o that those headed by patient needs. such as "Ventilation" or "Elimination" are interspersed among nursing functions. such as "Application of Topical Medications". "Irrigations", etc. In addition, the index at the back doe.. not always lend itself to easy access of material: for example. heparin locks are not listed as such but may be found under Intravenous Fluid Therapy- heparin. The 15-page section on C. P. R.. while basically sound, does not conform exactly to the standard., for one-man rescue as laid down by the American Heart Association and endorsed by the Canadian Heart Foundation. Redewed hy Penni Man.mur, R.N.. B.N.,/mtructor, St({t(Development, St. Michael's Hospital, Toronto, Olltario. Fundamentals of Nursing by Luverne Wolff. Marlene H. Weitzel and ElinorV. Fuerst. 6th ed.. New York, J. B. Lippincott Company, 1979 This text has been almost completely revised to meet the needs of today's students and practitioners. The content. although hasic. is appropriate at many leveb along the health-illne..s continuum. The hook is divided into five sections containing variou.. numhers of chapters. The chapters in turn contain behavioral ohjectives and a glossary of terms which can serve as an excellent source offeedhack for the student wishing to master a pecific section. The discussion of the law and nursing Acts are. in many instances, particular to the United States. and Canadian nur.,e educators will have to keep thi.. in mind if they wish to use thi.. text. The authors have quite uccessfully used General Sy tems Theory as the basis for the de cription of the nursing process and for the discussion of homeostasis. stre s and adaptation. The new chapter on Growth and Development and Behavior Modification are well presented and should be helpful adjuncts to the beginning student. Thi<; updated and revised edition of Fundamentals of Nursing is simply written and few words are wasted de..pite the volume. The authors have developed a workbook to accompany this or any other hasic texthook. rhe correct answers given for the questions posed are derived from scientific principles. Many of the que..tion refer to specific patient situations thereby providing for the application of knowledge. Both the text and workhook would be an as!'.et to classroom teaching and learning. Rn'iewed hy Elizaheth Holder, R.N., B.Sc.N.. M.Sc.N., instructor, Humher C ol/eRe of Applied A rts and T echnoloRY, Rexdale, Ontario. general Nutrition; proteins, carbohydrates and lipids, Nutrition; weight control and Nutrition; vitamins and minerals - sodium and potassium, by Clara H. Lewis. Philadelphia, Davis, 1978. The author gives a brief description in the introduction to each unit, in which the various aspects of the particular nutrient are identified: then a set of objectives is outlined which the student will meet when the unit is completed. Objectives are clearly and concisely stated. The programmed unit which follows is well structured and in some cases has good tables and diagrams including review questions. The effects of nutrients on the body and how these are affected in disease are also discussed. The role of diet in decreasing risk factors for specific conditions has also been included. The post-test at the end of each unit is a good learning tool for the student: it helps to recapture the important points that should be learned and remembered. The diagrams and charts given in the section on Sodium and Potassium are excellent in that they assist the individual to learn the causes of deficiency and the role of the particular mineral in the body. It also clearly states the effects of deficiency on the human body. The section on weight control deals with the physiological aspects of energy balance. the caloric needs of the individual and the caloric content of foods. This section is of particular help to nurses who will be involved at some time or other in helping patients who In tune with today's nursing practice J. B. LlPPllIoCOTT CO IPA:IIY OF CANADA LTD. Books are shipped On Approval; if you are not entirely satisfied Serving the Health Professions in Canada Since 1897 you may return them within 15 days for full credit. 75 Homer Ave., Toronto, Ontario M8Z 4X7 P ,______________ __ :n c : I :va bkfr PO qu : ' I J. B. LIPPI COTT COMPANY OF CANADA LTD. 75 Horner Ave., Toronto, Ontario :\18Z 4X7 I I Please send the following for 15 days 'on approval': I 1 2 3 4 5 6 7 P 7 Cl 8 , 0 Lippincott Nursing Catalogue City I 0 P yment enclosed (postage and handling paid) Postal Code , 0 Bill me (plus postage and handling) I I Prices subject to change without notice. CNlO/79 I ------------------------------------ 1 New! PERSPECTIVES ON ADOLESCENT HEALTH CARE. Here at last is a text that not only presents the major ideas and issues on this subject; it pro- vides many clinical examples and offers valid suggestions that can be put to use in a variety of clinical settings. By R. T. Mercer, R.N., Ph.D. Lippincott. 420 Pages. 1979. $ 15.50. 2 New! NURSES' HANDBOOK OF FLUID BALANCE,3rd Edition. Here is a handbook on the basics and practical application of knowledge of body fluid disturbances, designed for nurses and all members of the allied health sciences. The purpose of the book is to present the fundamental physiology involved in body fluid disturbances, employing a systematic yet simple approach to classification and diagnosis. By N. M. Metheny, B.S.N., M.S.N., Ph.D.; and W. D. Snively, Jr., M.D., F.A.C.P. Lippincott. 406 Pages. 1979. $15.00. 3 New! GERONTOLOGICAL NURSING. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. Com- mon diseases of each body system and their unique features in the aged are discussed in detail. By C. K. Eliopoulos, R.N., B.S., M.S. Harper & Row. 384 Pages. 1979. $15.00. 4 New! HIGH-RISK PARENTING: Nursing Assessment and Strategies for the Family at Risk. HIGH-RISK PARENTING is not intended for anyone particular clinical specialty but draws upon infonnation from many specialties (maternal-child, medical-surgical, community health, mental health, etc.) and is intended for nurses in any setting who work with families at risk. By S. H.Johnson, R.N., M.N. With 24 Contributors. Lippincott. 424 Pages. 1979. $17.75. Lippincott ... 5 New! CARDIAC REHABILITATION: A Comprehensive I'Jursing Approach. The purpose of this book is to provide a comprehensive yet practical refer- ence for a little-known but fast-developing field of nursing. By P. M. Comoss, R.N., C.C.R.N.; et al. Lippincott. Abt. 250 Pages. 1979. Abt. Sl6.00. 6 MATHEMATICS FOR HEALTH PRACTI- IONERS: Basic Concepts and Clinical Applica- tions. ThrouKh a simple approach to conversion called "the equation method", this important new text helps dis- pel the "math anxiety" that most students experience when having to deal with numbers. By L. Verner, Ph.D. Lippincott. 165 Pages. 1978. $ 7.5 O. 7 New! TEXTBOOK OF HUMAN SEXUALITY FOR NURSES. From its opening chapter to its closing pages of questions and answers, this text effectively incor- porates human sexuality into nursing practice at a level that can be understood by both practicing and student nurses. By R. C. Kolodny, M.D.; et al. Little, Brown. 450 Pages. Illustrated. 1979. Paper, $15.00. Cloth, $21.00. 8 New! COMMUNICATION FOR HEALTH PROFESSIONALS. This timely book identifies and describes problem situations stemming from communica- tion breakdowns that commonly affect health care person- nel. The two major objectives are to provide an overall understanding of the process of communication and its complexities in various contexts and to provide instruction- al techniques to enable the reader to develop greater communicative proficiency within those contexts. By V. M. Smith, Ph.D.; & T. A. Bass, M.A. Lippincott. 238 Pages. 1979. $ 7 .50. Name Address Provo 52 October 1171 The Cenadlen Nur.. may be undernourished or overnourished or who have problems controlling their weight. It explains by simple diagrams the effect of energy production and energy release by the body. I feel these books serve as a useful tool to the student; they aid in understanding and applying knowledge about nutrition. They allow the student to carryon independent study in nutrition and assist them in understanding the important role nutrition plays in the maintenance of optimal health for the individual. They also help the student to understand the role of deficiencies in the body and their effects on the individual. Re 'iewed by Doris Spain, Orillia, Ontario. Assertive skills for nurses by Carolyn Chambers Clark, Wakefield, Mass. Contemporary Publishing, Inc., 1978. Approximate price: $8.95. Carolyn Chambers Clark has developed a rather unique workbook to meet the needs of a variety of nurses. It focuses on assertive skills in the work setting, rather than on therapy for persons who have severe anxiety, aggressive or psychiatric problems. The book may be used for individual or group study. It is suggested for use as self-study, as a basis for a workshop for nurses, or introduced as a component in a nursing curriculum. The book is organized into seven modules. Each module contains a prelearning evaluation, a focus for learning, an infonnation section, learning activities and experiences, problems to solve or study, a postlearning evaluation, and an evaluation of the module. The modules are sequenced; the knowledge gained from one module provides a basis for learning from subsequent modules. The introduction emphasizes the importance of practicing assertive skills and obtaining feedback; whether the book is used by individuals or groups. It is felt by the author that assertive behavior is learned behavior. The focus of the seven modules are: understanding and use oftenninology, factors that hinder and necessitate assertiveness in nursing, assessment of one's level of assertiveness, suggested strategies to use to practice assertive behavior, assessment of job skills and goals, giving and taking criticism and help, and ways to control anxiety, fear, and anger. Although the use of assertive skills has only recently been emphasized for nurses, much of the content is not new. The requisite skills suggested for assertiveness exemplify skills in the areas of helping relationships and leadership. The development of increased self-awareness, and mobilization of individual potential through goal-setting are emphasized. The focus on practice provides much opportunity for introspection. The author suggests helpful ways of changing communication patterns and developing a more assertive approach with physicians, supervisors, co-workers and clients. In conclusion, I would recommend this book for nurses in service or an educational setting. It is most relevant to those persons who are interested in either developing or facilitating the development of "Assertive Skills for Nurses" . Reviewed by Janet Moore, Assistant Professor, Faculty of Nursing, University of Calgary , Calgary, Alberta. Expanding horizons for nurses edited by Bonnie Bullough and Vern Bullough, 360 pages, New York, Springer Publishing Company, 1977. Approximate price: $/0.50 This is the third volume in the series, "Issues in Nursing", by the Bulloughs. It deals with the opportunities opening up for nurses as professionals and with the problems related to the expanding nursing role. The selection of articles is relevant and most are very readable. They bring together a number of interesting viewpoints on the is!.ues being considered. In addition. most of the articles have good reference lists. All of the sections have well-chosen articles. The two sections that are especially interesting are Clinical Controversies, which deals with sexuality, abortion, insanity and euthanasia and, Women's Liberation and Nursing. which brings both historical and sociological perspectives to the consideration of nurs ing and women's role in society. This book would be a useful addition to any nurse's reference library, particularly if she did not have access to an extensive source of journals. Re\'iewed by Myrtle E. Crm..ford. Professor ofNursillg, College of Nursing, U Ilil'ersity ( f SasÅlItchewlIIl, SasÅatoon, SasÅatchewull. Family living and sex education: a guide for parents and youth leaders, 2d ed, by Dr. S.R. Laycock, Toronto, Mil Mac Publications Ltd., 1976. This edition of Laycock's guide contains a most unusual foreward which in actuality is a detailed summary and review of the text. It contains an encapsulation of the sociology of the present day Canadian family. Crowe, the author of the foreward, outlines explicitly the existing characteristics of today's family profiles that must be considered by educators to meet the specific needs in Family Life. Laycock's approach to family life education follows a life cycle and predominates in the sociological aspects of sexuality despite the fact that he states sexuality is a total need of man. Hence the reviewer's reaction is that Erick Fromm's text The art oflm'ing should be an adjunct to Laycock's text. The general informative and controversial topics of sexuality are dealt with in a respectful and sound way. The development of an individual's responsibility and sound values are encouraged. The role of parents as the prime educators offamily life is clearly identified as is the fact that the family life educator's role is determined by the parents and the public as well as public opinion. Laycock's guide has listed many references and resources to facilitate the reader's accessibility to data. Hence physicians and nurses involved in family health, as well as health educators would find the guide a valuable resource book. Rel'Ïewed hy Margaret T. OlJiak, B.Sc.N. Ed., M.Ed., Assistant Professor, Unh'ersity of Ottawa, School ofNuning. Childbearing: A Nursing Perspective, 2nd edition, by Ann L Clark and Dyanne D. Alfonso. 1052 pages. Toronto, McGraw-Hili Ryerson, 1979. Approximate price: $26.95 The authors' stated purpose is to "assist teachers in their endeavours to educate the nex t generation of nurses" and from this point of view the book is successful. This detailed volume is an excellent tool for the teacher rather than a basic textbook for the student. The book is actually a collection of work by 24 authors, each with expertise in a particular field. The result is a scholarly work which has been well-researched and is comprehensive. I n some areas, genetics for example, the content is very complex and may prove difficult to the reader who does not have prior knowledge. However, the book is well endowed with photographs, charts, tables and diagrams which are used to effectively interpret, support and substantiate the text. This is a reference text that will be useful to teachers of obstetrical nursing, for educators who are developing nursing curricula, and for libraries. Rel'iewed hy Eli aheth Stewart-Hessel, former public health nurse and nursing educator, Ottawa, Onto /" ""\ Top of the line from Saunders - ø : " ii .... : . ': 1 . .JI1 f ....., '; p"':1\ '" ...... t(.t ... \ Jl t ----- I ii i i ",tPJP Watson Medical-Surgical Nursing and Related Physiology 2nd Edition Thoroughly revised, this newedilion includeslhe latest information on topiCS rangIng from patient.s rights, response to illness and physical assess- ment-to immunologic respOnse. shock and much more The chapters on cardiovascular disease and the nervous system have been ex- tensively revised. An excellent choice for those preferring a smaller medical-surgiCal text. 8y Jeannelle E. Walson, RN. MScN, Prof. Emeritus Faculty of Nursing, Univ of Toronto. Can 1043 pp 161 ill. 523.95. Just Ready Order 119136-8. Methods in Critical-Care The MCN Manual by the American Association of Critical-Care Nurses In response to an increasing demand for informa- tion, the American AssocIatIon of Cntical-Care Nurses manual provides guidelines for the per- formance of over 100 advanced procedures at the heart of critical care nursing today. Using a step-by-step format, the book gives an overview and defines the purpose, special equipment, actions and rationales, precautions and related care for each of Ihe methods covered. Use of Ihe Swan-Ganz catheter, inlra-aortic balloon pump management. pacemaker management. peri- toneal dialysis and total parenteral nutrition are only a few of the topics you'll find covered in this unique manual. Bibliographic references are provided. 8y The American Asst":. of Critical-Care Nurses; Editor-in-Chief. Sally Millar, RN CCRN, Head Nurse, Respiratory/Surgical Intensive Care Unit. Massachusetts General Hospital: Leslie K. Sampson, RN, CCRN, Patienl Care Coordinator. Intensive Care Unit, Emergency Unit. and Recovery Room, Albert Einstein Medical Center, Northern Div., Phila ; Sisler Maurila Soukup, RSM. RN, MSN Critical Care Clinical Nursing Specialist, St. Luke.s Hospital. Cedar Rapids. IA: and Sylvan Lee Weinberg. MD, Clinical Prof. of Medicine and Co-Director. Group in Cardiology, Wright State Univ. School of MedIcine, OH. About 400 pp. Soft cover. Ready soon. Order 111006-4. Bamard. Clancy & Krantz Human Sexuality for Health Professionals This multi-disciphnary approach to the field stresses the need for sex education and sexual counseling and the importance of knowledge on the part of all health professionals, wllh emphasis on the nurse. Many nursing programs offer courses on the subject now Contributions include material from 28 leading authorities including physicians, professional counselors, clergy. psychologists, and nurses. By Martha Underwood Barnard. RN MN. Faculty- Nurse Clinician. School of Nursing 8arbara J. Clancy, RN MSN Assoc. Prof., School of Nursing and Kermil E. KranIz. MD. Prof. and Chairman. Obstetrics and Gynecology and Dean of Clinical Affairs all of Univ. of Kansas Medical Center Kansas CIty. 301 pp lIIustd Soft cover 511 95 April 1978 Order 111544-9. Expiration Date Interbank = Full Name AU I l PosItion and Affiliation If Applicable Home Phone Number l Home Address AU CIty State ZIP SIgnature ..M& "---- ..... .... . "",. Falconer et 01 Current Drug Handbook 1978-1980 Over 1500 drugs are included In thIs easy 10 use soft cover reference-grouped by usage and fUlly indexed by both proprietary and generic names. The book fotlows a format that lets you grasp pertinent facts at a glance, such as name, source, synonyms and preparations, dosage and admin- istration; uses, both primary and secondary; aClion and fate: side effectsandcontralndications 8y Mary W. Falconer, RN 8A MA Formerly Instructor of Pharmacology O'Connor Hospital School of Nursing, San Jose. CA. H. Robert Pallerson, 8S MS, PharmD Prof of 8,010gy and MicrObIOlogy. San Jose State Univ . Edward A. Guslalson. 8S. PharmD. PharmacIst Valley MedIcal Center. San Jose, and Eleanor Sheridan. RN 8SN. MSN, Asst Prof., College of Nursing. Arizona State Univ Tempe AZ.312pp Soft cover 5960 March 1978 OrderIl3568-7. Miller & Keane Encyclopedia and Dictionary of Medicine. Nursing and Allied Health 2nd Edition ConSiderably updated, the ever popular Mlller- Keane is now more complete, more meticulously revIsed, and easier to use than any other diction- ary available in the field. Wriffen on a health care team model. the book is patienl oriented rather than "disease oriented:. It addresses the palient in lerms of pSyChe and soma, goes beyond the definition to emphasize specific points, and in- cludes Important sCIentific principles and plenty of valuable illustrations Send for your copy today. 8y the Late Benjamin F. Miller, MD, and Claire B. Keane,RN 8S,MEd 1148pp.139ill.(16color plates) March 1978. Flexible-binding. thumb- Indexed. 521 00 Order 116357-5. Hardbound not thumb-Indexed 517 95 Order 116358-3 r-------- I I I I I I I I I I I L To order tItles on 3D-day approval, enter order ;t and author _ check enclosed - Saunders pays postage _ I\. 1 We accept VIsa and Mastercharge _ o Visa # o Master Charge :t Klaus & Fanaroff Care of the High-Risk Neonate 2nd Edition Patterned after the highly successful first edItIon this new rigorOUSly revised and up->iN E:D HEALTHCARE ___ SERVICES 1M :.- r Please send me your free booklet "Nursing Opportunities at Upjohn HealthCare Services." "'ame Address Phone Cltv ProvinCE' Postal Cod.. Mail to: Upjohn HealthCare Services Dept.A Suite 203 716 Gordon Baker Road Willowdale, Ontano M2H 3B4 ----------------------- 51 OcIober 1171 The Cenadlen Nur.. e Consumer rights Attitudes of Registered Nurses Towards Consumer Rights and Nursing Independence. Vancouver, B.C., 1978. Thesis (M.N.), University of British Columbia by Florence Grace Green. This study investigated the possibility that registered nurses working directly with the patient may hold attitudes towards consumer rights and nursing independence which are different from those in the literature and those of nurse leaders and activities. A questionnaire was sent by mail to a random sample of registered nurses with a return of 392. The attitudes expressed suggest that nurses are motivated to accept the patient as a participating member of the health care team but they need support to assume the risks associated with a self-image incorporating professional autonomy and interdependence. The mean of the total sample was sufficiently high to encourage nurse leaders to provide assertive leadership on: the issues of consumer rights in health care, informed access to information by the consumer, and nursing automy. e Genetic counseling Factors Involved in a Mother's Decision to Seek Antenatal Genetic Counseling and have an Amniocentesis at an Advanced Maternal Age. Toronto,Ont.,1978. Thesis (M.Sc.N.), University of Toronto by Barbara Lynn Davies. The study sought to identify factors involved in the decision of mothers of advanced maternal age to seek antenatal genetic counseling and to have or not have an amniocentesis. The factors involved in decision-making included benefits, barriers, perceived susceptibility, perceived severity, cues to action, motivation, abortion issue, religion, social influences, gestation at counseling. knowledge of genetic risk prior to pregnancy and employment. Comparisons were made between mothers who decided to have an amniocentesis and those who did not, mothers who were 35-39 and those over 40 years of age, and nulliparous and multiparous mothers. The total sample was 74 and included 66 mothers who decided to have an amniocentesis and 8 who refused. The study generated some implications for nursing and health care practices, education and research. It is recommended that nurses in various clinical areas counsel potential mothers of advanced maternal age to increase awareness and understanding of amniocentesis. Recommendations for future research are made including finding teaching methods most effective for amniocentesis counseling and studying the large group of mothers who do not seek counseling. Ovol Drops relieve infant colic. J I PAAB I ccpp Ovo} Drops contain simethicone, an effective, gentle antiflatulent that goes to work fast to relieve the pain, bloating and discomfort of infant colic. Gentle pepper- mint flavoured Ovol Drops. So mother and baby can get a little rest. (Ð)HpRn R ...... r- OYal am 9Æ1Im{CF/oJ..9Jff -.- e . fast actJng relief of infant colic al-üRnER Shhh. Ovol Drops. Also......blemtabletfonnforadullh OVOI@80mg Tablets OVOI@40mg Tablets Ovol@ Drops Anliflatulent Simethicone INDICATIONS OVOl is indicated to relieve bloating, lIatulence and other symptoms caused by gas retention including aerophagia and infant colic. CONTRAINDICATIONS None reported. PRECAUTIONS Protect OVOl DROPS from freezing. ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOl80 mg TABLETS Simethicone 80 mg OVOl4O mg TABLETS Simethicone 40 mg Adults: One chewable tablet between meals as required. OVOl DROPS Simelhicone (in a peppermint lIavoured base) 40 mg/ml Infants: One-quarter to one-hall ml as required. May be added to formula or given directly from dropper. Ð HQB1JgR The Cln8dl.n NUrH . Families OcIober 1171 57 Spinal Cord InjUI): Earl Impact on the Patient's Si niflcant Others. Vancouver. B.C.. 1978. ThesisIM.Sc.N.) by Geraldine Angela Hart. This exploratory study was designed to gather information about the needs and concerns of significant others of patients with recent spinal cord injuries. Seven respondenls were asked about the impact of the patient's injuries on their own lives and about their feelings in relalion to the treatment they and their patients were receiving from health care personnel. The findings of the study demonstrated the presence of selected needs and concerns in a small convenience sample of significant others of spinal cord-injured patients. Further research would be necessary to delermine whether the findings are representative and whether there is a relationship between expressed needs and concerns and the sex of pdtients and/or significant others. . Spinal cord injul) Experiences and Nursing fljeeds of Spinal Cord-Injured Patients. Saskatoon, Saskatchewan 1978, by RoseG. Kinash. University of Saskatchewan. This exploratory study was designed to describe the experience and needs of spinal cord-injured patients and to identify implications for nursing during Ihe hospital phase. The data were obtained through structured interview with eight persons who had experienced spinal cord trauma and who were at various stages in the adaptive process. The sample consisted of two individ uals with paraplegia, five with partial quadriplegia and one with complete quadriplegia. Experiences ofthese persons were described. physical and psychological needs were identified and implications for nursing were ascertained. . Nursing Audit The Development of a Nursing Audit Tool. Toronto.Ont.. 1978. Thesis (M.Sc.N.). University of Toronto by Doroth\' Margaret Craig. The purpose ofthis study was to develop an audit in trument. for use with discharged public health nursing records. which v.as relevant to the practice of public health nursing in Ontario. The development ofthe instrument was undertaken to promote excellence in the provision of nursing care in the community. On the assumption that the care provided was documented. the audit instrument was able to discriminale between poor. deficient. fair, good and excellent nursing care on the discharged records. It was able to identify strengths which could be maintained and weaknesses which could lead to recommendations regarding measures 10 improve the care provided. I mplications for nursing practice and nursing research were stated in the report and recommendations were made to be included in a guide for using the audit instrument. . Nutrition Factors Influencing the Construction of a '1utrition Knowledge Test for the Elderly. Calgary,Alta..1978. Thesis (M.S.) by Norma E. Thurston. This study examines several factors important to the development ofa nutrition knowledge test suitdble for a sub-population of non-institutionalized elderly persons who previously have demonstrated evidence of preventive health practises. A test blueprint was constructed, the initial preliminary test developed and advice and judgment solicited from specialists. A second preliminary test and then a final test called "Nutrition Information Survey" was written. The test has both measurement and educational purposes. Several recommendations for future practice with and test administralion to the elderly are di,cu' ed. . Perceptions of illness The \ oung Adult's Reported Perceptions of the Effect of Congenital Heart Disease on his Life St}le. Toronto.Ont., 1978. ThesisIM.Sc.N.) by Stella Burton Doucet. The purpose of this study was 10 identify the young adult's reported perceptions of the effect of congenital heart disease on his lifestyle. It was hoped that the knowledge gained could contribute to improved care aimed at the prevention of psychosocial problems associated with the cardiac condition. Twenty-five young adults, aged 18-30 years, who were diagnosed with congenital heart disea e during childhood were interviewed in their homes. The findings showed thaI the respondents experienced a variety of concerns and problems related to their perceptions oftheir condition, inlerpersonal relationships. activity, and school experiences during childhood and throughout their life process. . Continuing education An Asse sment of Selected Continuing Education Experiences for Professional Growth and Competence of urses. Fredericton. N.B.. 1978. The is( 1.Ed.). University of New Brunswick bv A lice Russ Wacintosh. This study was undertaken a a preliminary effort to assess the continuing education experiences for nurses in one New Brunswick city in terms of the programs available and the quality of the programs. Deficient areas identified would provide future focus for study and improvement. Questionnaires were administered to nineteen potential sponsors of continuing education experiences offered in 1977. From the sponsors who responded (95 per cent) there was no indicalion of an over-all plan to provide learning experiences for nurses. The programs reported were one-time offerings mainly conducted in response to an informal expression of need from nurses which was also recognized by the employer or sponsor. Conclusions in thi study uggest needed action in the selected city regarding continuing education through: I. Identification of nur es' real needs 2. Promotion of nurses' inlerest in continuing education 3. Co-ordination of continuing education progrdms 4. Planning for presenl and future need . . Education A Follow-up Study of Graduates from the Four \ ear B.Se. Program in Nursing, Unhersit} of Alberta. Edmonton. Alta.. 1978 by Peggy-Anne Field. (B.N., M.N.). A follow-up study of graduates ofthe four-year baccalaureate in nursing program. U of A was conducted one year after grdduation for the classes 1970-74 inclusive. The method utilized was a mailed Queslionnaire to graduates and employers. Findings indicated that graduates had problem-solving abilities and incentive to carryon their own education in the work situation. They suffered conflict between their ideals and the reality of work. The majority worked in first level positions in hospital or community health agencies. There appeared 10 be a movement toward community health when five-year trend were examined. The graduates participated in professional activities. Graduates had concerns about their abilities 10 function as nurses in relation lo clinical skills, administrative ability, organization of work. setting priorilies for patient care and leadership skills. As a group. they rated highly in the areas of communication skilb dnd interperUD>fI (p_Acl . _,. " Reg'd HIBITANE and SAVLON made ,n Canada by arrangement wIth IMPERIAL CHEMICAL INDUSTRIES LIMITED 1\ f I , I I II' · J t:-I- f I ......... ., ' 1 --__ - -- - . ---- "- - - -- - --.. , ----- - ""---------..--... , - -- ---- I - --_ IJ ,- .. - ---.! -."f II . ,1 '- ..11 LI' " ....... " " " I I .,., . \ =1 ... ...... . J , . SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetic equipment. 1-------------- TO AYERST LABORATORIES I 1025 Laurentian Blvd.. Montreal, Quebec. H4R 1J6 I I I I NAME I ADDRESS I NO I CITY I would like to receive information on: Hibitane* Skin Cleanser Savlon* Hospital Concentrate Hibitane. Gluconate 20% Solution Sonacide. (PLEASE PRINT) STREET 10 OcIober 18711 The Clnedlen Nur.. Classified Advertisements Alberta The Drumheller Heallh V nit requires a Supervløor or Nunes with experience and qualifications in Public Health for supervision of a staff of eight district nurses in preventive programs of community health to a population of 28,000 in an area of 4000 square miles. Main office is located in Drumheller, popula- tion 6,000. 85 miles from Calgary. For information or application forms please reply, giving curriculum vitae to: Agnes E. O'Neil, M.D.. D.P.H., Medical Officer of Health, Box 1180, Drumheller. Alberta, TOJ OYO. R.N.'s required by a 560 bed acute care hospital located in downtown Edmonton. Positions available in most clinical areas. Personnel policies and salary is in accordance with the A.A. R.N. contract. Applicants must be eligible for registration with the A.A. R.N. Apply to: Nursing Employment Office, Edmonton General Ho,pilal. 1II1I Jasper Avenue, Edmonton. Alberta T5K 01.4. Registered nunes required for 15-bed accredited active treatment hospilal in a lakeland resort area, 130 miles northeast of Edmonton. Salary $1211 - 1454 per month. Apply: Director of Nursing, St. Therese Hospital, Box 880. St. Paul, Alberta. TOA 3AO. British Columbia Experien<0" to b< AJIV"" NURSES Correctional Services. Caned. Saskatoon Sas.katchewan New 100 oea forenSIc psycm lnc .ac:;lIIty nG Ie\. Jlhy opened In Saskatoon and requires var.ous nurSing staft STAFF NURSE R N S.lary $14.456 $16326/YI and $1.ooo/yr P F A R P N S.lary $14312 $15973/yr lunder rev.ew) and 11.ooo/YI P F A Duties Provide direct nurSing care to patients on a 24 110ur belS aU.II'IC.tlons Ehglblilty for registration as a Registered Nurse or Rpgls tered Psychlatnc Nurse In a province or territory of Canada E penence In nu lng care Knowledge of English 15 essen hal TEAM LEADER Salary $15.117 $16.986/yr .nd $1.ooo/yr P_F A Duties RE"SPOns.ble for f.rst hne SuDef'VISlon of approximately 7 nurses dunng day and even.ng shifts In a unll of 12 or 24 beds aU.llflcatlom Ehglbility for reglstraho,.. as ReQlstered Nurse In a prOVince or terntory of Canada E xpenef\ce .n Psychlatnc Nurs.ng and the ability to Implement rut n!) programme techO! Ques Knowledge of Enghsh IS ntlal NURSING SUPERVISOR Sal.rv $17.180 to $19.669/vr .nd $1.ooo/yr P F A DUlies RE"Sponslble on a rotating shih basiS 'or the nurSIOg oper atlon 0' the tOlal l105pltal Qualdlc.llons Ellglblhty fOf reglstretlon as a Registered Nurse In a prOVin- ce or terntory of Canada Expenence'n Psychlatflc Nursing and superviSing a nurSing service unit United States Come 10 Tn.. - Baptist Hospital of Southeast Texas is a 400-bed growth oriented organization looking for a few good R.N.'s. We feel that we can offer you the challenae and opportunity to develop and continue your professional growth. We are located in Beaumont, a cily of ISO,OOO with a small town atmosphere but the convenience of the large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful Irees and inland lakes. Baptist Hospilal has a progress salary plan plus a liberal fring package. We will provide your immig- ration paperwork cost plus airfare to relocate. For additional infonnation, contacl: Personnel Ad- ministration, Baptist Hospital of Southeast Texas, Inc., P.O. Drawer n91, Beaumont, Texas 77704. All alftrmatln adiDa empklyer. '. " " CO-ORDINATOR OF NURSING IN- SERVICE EDUCATION AND CLINICAL NURSING Sal.ry" $17180 to $19 669/yr and $1 ooo/yr P F A Dutl. PrOVides ongomg 10 erVlce education to aU levels of nurSIOg staff aUalllle.llons Baccaleureate Degree or a Diploma 10 NursIOg from a recog nlzed school of NursIOg Ehglblhty for registration as a Re glstered Nurse In a province or terntory of Canada Acl t able expeJlence and expertise In the chnlcal teaching of PSV chlatflc and general nUfSIOg Proven abll.ty to plovlde PX pert professional advise In psychlatflc nurSing Knowledge of Enghsh IS essential Chanen. This new faclhty provides an opportunrty fOI you to par tlClpate 10 the opening and development of a new psych. .tflC facility the first of ItS type In Canada We requlle nurses. Mth 8n expeflence 10 p'ychlatry who ale Interested In ðC::eptlng responSibility and learnmg forensIc psych.atry nLlnlng skills Benefits EKcelient penSion plan free Llnr'orms and shoes good sick leave benefits, evenmg. OIght and INeekend premiums, 11 Sta tutory Hohdays 3 weeks vacation to start plus other bene fits too nWT'lerous to list Excellenl rnsef'Vlce .rarnrng pro gram Hours of Work Average 37 5 hours per 'M!ek For further mformatlon call DIIKtor of NLlrslng at 1306. 6654166 Rpglonal Psycmatflc Centre Sashnon. k "A.ddltlonal Job rnformatlon IS available by Wfltrng to the address below' "Toute rnformatlon lela1lvl\a ce concours est dlspomble en francaiS et peut étre oblenue en ecuvant a I'adresse SUI\, an te" (AnticIpatory Stall'"9) How 10 .pply Send 'lOur application form and/or résurT1@ 10 Keith Sincla.,. St.ffrnll Consult.nt Public Service Comml_lon of Canada 500 286 Smith Street Wlnnlpe;. M.mlob. R3C DK6 P/ .se quote th .ppllc.ble 'efe'enc numbe/.t all times 12 October 1878 The CIInedlen NUrH Nurses The Department of Social Services, Senior Citizen's Home Care Branch, Regional Care Centre, Battleford, requires several registered nurses for the new Level 4 Special Care Vnit. Applicants must be registered nurses with at least one year of professional nursing . experience. Registration as a general nurse in Saskatchewan is essential. Salary: $15,OOO-$t7,424 (Nurse 2) Competition: 604112-9-788. Closing: As soon as possible. Forward your application fOnTIS and/or resumes, quoting position. department and competition, to: Public Service Commission 1820 Albert Street ReJÚI., Suhtcbe...n S4P 3V7 Registered Nurses Operating Rooms Applications are invited from Registered Nurses with previous experience and/or PostGraduate in Operating Room techniques. Staff membersare rotated throughout all the various disciplines. Salary ($1,305 to $1,542 per month). Benefits as per the RNA BC Contract. Registration essential. Please send resume to: Mrs. J. MacPhail Employee Relations Vancouver General Hospital 8SS West 12th Avenue Vancouver, B.C. VSZ IM9 University of British Columbia Health Sciences Centre- Extended Care Unit Requi res General Duty Nurses To work as a member of an interprofessional team in a modem 300 bed extended care unit. Must be able to work well with elderly and handicapped patients in a long-term care setting. Nurses must apply and be accepted as eligible for licensure in British Columbia. Financial consideration lIiven for baccalaureate preparation in nursing. Interested persons may telephone or wrtte to: Hosplbl Employment Oll1cer Hellhh ScIences Centre Unlnrshy or BritIsh Columbi. V.ncouver, B.C. V6T IW5 Telephone: 604- 228-6764 Positions are open to both female and male applicants. United States Exdtement: Come and jom us for year around excitement on the border, by the sea, an unbeatable combination. Enjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed. acule care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. Excellent salary and fringe benefits. We invite you to share the challenge ahead. Assistance wilh travel expenses. Write or cllIl coDed: Joe R. Lacher, RN, Director of Nurses, Valley Community Hospi- tal, P.O. Box 4695, Brownsville, Texas 78521: I (512) 831-9611. Nurses - RNs - A choice of locations wilh emphasis on the Sunbe1t. You must be licensed by examination in Canada. We prepare Visa fOnTIS and provide assislance with licensure at no cost to you. Write for a free job market survey Or call collect (713) 789-1550. Marilyn Blaker. Medex, 5805 Richmond. Houston. Texas 77057. All fees employer paid. Israel Year in Israel for Registered Nurses - unique opportunity for English-speaking nurses with ICV- CCV, Operating Room Dialysis, or Neonatallnten- sive Care experience. For a one-year commitment program offers round-trip transportation, full salary and benefits. one month's orientation and language classes, and one month's paid vacation. Low cost housing available for single applicants. Send cur- riculum vitae to Mrs. Matjorie Korenblit. RN, Nurse Recruitment Coordinator, Personnel Office. Shaare Zedek Medical Center, P.O. Box 293. Jerusalem, Israel. Miscellaneous Get the r.cls....bout ..omen and .ddictions. Three graphic posters for display to give your clients important infonTIation aboul women and alcohol, minor tranquilizers and stress. Send for your free posters today. Available in English or French. Q.O.L. Resource Directions. 2466 Dundas St. W., #506. Toronto, Ontario M6P IW9. Graduates of 1975 Diploma Nursing Class from St. Clair College, Thames Campus, please contact Adrienne Clinansmith. Box 2. Birtle. Manitoba ROM OCO for reunion information. Department or Nursing, (;race Maternit Hospital, Halir.. _eeh Head Nurse for Special eonatal Care Unit ChaliengmgJob opportumly in nconi:l.tèl.l nur-...mg In Canada' "" Iargc'l oh'lclnul hv..ptlal ( OOOdcll\.ene",/)'ea.... IUUO adml....lon 10 peclaJ ",,",eonaldl (a...c l'ml/ ea"'l. MdJor ob..leln..al and neonalaJleadunø ho!!opltal for Diilh,lu"le l m\'er"lt ' and the cennal oÞ...tetn..al rcferral umt fo... No\.a cotla. Pnnce Ed\olra...d hland dnd part!!. of New Ðrun..w...k Re...pon .ble to thc Chm..al Co-o...dmator for orøam.latlon and .wmmlstrdtlon of climcal nu.....mø ..arc øiven to acutely III and con\.ale.-.cmø newhorn mfanl.... E,cellen. opportumty to perfcct prc cnl programme... and to dc\.elop new progrdmme... "limed iit impro\.'maand eJltcndmø the !!ocopeof ncondtdl nur...ml': Salary acco...ding to Nova Scotia N u.....e.... Union C ontn.ct Po,t a\'all..ble Immedlatel fhr ('8ndldale mu...t ha",e 3 yea...... expenencc 10 nconataJ nur...mg and mu.... he ehl':ll1lc fo... regl tration 10 Nova Oll.iiI Management e'prnencc and ...kl1l.... bl'"Oad knov.ledge of pcnn",\dl hc",lth com:epl" dnd grilldualion from a po..\ diploma neonataJ nur.-.ml! cou......C' de....raþlr ^ppl} 10 wnting to: \b 5 M.rl.n1 h"'luwn. R. "". DlrKlor of .....unlnR GrlliCc \i.lcrnh,. Hospd8l H..if... .....0". Scotia B.\H I"J Opcmng arc al..o available for 8cneral dUly nur..e... In Ihe neonataJ umt. 1 , J-. RN's and GN's Want to nurse in: Reno, with St. Mary's Hospital? Atlanta. with Piedmont Hospital? Cleveland, with St. Alexis Hospital? Or how about Apple Ri ver Valley Memorial. in Wisconsin? If you are considering a move south. contact us. We probably represent al least one hospital that has what you need. Wood, Watson Professional Search Suite 207 1962 Y onge Street Toronto. Ontario M4S IZ4 Supervisor of Community Health Nursing Vegreville Health Unit requires a suitably qualified and experienced nurse forthe above position. Responsibilities include planning, implementation. direction, co-ordination and evaluation of the Community Health Nursing Program. In the absence of the Director, assumes the duties of same. Salary range: $20.899 - $25,427. Excellent fringe benefils. Application in writing including curriculum vitae should be addressed to: Mrs. R. Cunningham Director VegreviUe Health Unit Box 99 Vegreville, Alberta TOB 4LO This position will remain open until a suitable candidate has been selected. Nursing Co-ordinator Applications for the position of Medical-Surgical Co-ordinator are being accepted for mid-September by this 300 bed fully accredited hospital. Experience in supervision with a Bachelor ofN ursing Degree preferred. Tempordry accommodation available. Please reply sending a complete resume to: Director of Personnel Stratford General Hospital Stratford, Ontario N5A 2Y6 The C8n-.llen NUrH McMaster University Faculty of Health Sciences Clinical Nurse Specialist - Gerontology Associate Dean of Health Sciences (Nursing) and Director of School of Nursing required for January I, 1980. The appointee will be expected to provide leadership for the further development of Nursing within the Faculty of Health Sciences and its programmes in education, research and clinical service. Excellent opportunity for a Masters' prepared Clinical Nurse Specialist with experience in Gerontological Nursing. The Clinical Nurse Specialist will function as a Change Agent, Researcher, and Educator promoting a high standard of care. Qualifications: Preferably a doctoral degree with some administrative experience in the University setting. St. Boniface General Hospital is a 880 bed acute care hospital. The Extended Care Unit 188 beds and Day Hospital provide a progressive Geriatric Rehabilitation Program. Salary and appointment level commensurate with qualifications and eAperience. Excellent salary and benefits. Applications including curriculum vitae and names of 3-4 referees should be sent to: Please send resume to: Dr. J. F. Mustard Dean Facult of Health Sciences McMaster t:ninrsity 1200 Main Street West Hamilton, Ontario L8S oU9 Mrs. L. Rivers St. Boniface General HospItal 409 Tache Avenue WinnIpeg, Manitoba, Canada R2H 2A6 EXPERIENCED RN'S & NEW GRADS "'THE PERFECT OPPORTl ITY" Saint o\nthon} Hospital, located in Columbus, Ohio. This 400-bed acute care facility offers excellent opportunities for furthering your nursing career. No Contracts to Sign Rotating Shifts Air Fare Paid One Month Free Accommodations Plus Exciting Challenges Saint Anthony. a medical-surgical institution. has a complele range of services. including: e Open Heart Surgery e Intensive and Coronary Care e Definitive Observation Unit e Renal Dialysis e Diagnostic and Therapeutic Radiology e 24 Hour Emergency Department Don't ait, call or rite immediatel}. Make the change to an institution that lets you be what you want to be. For further information. call our Nurse Recruiter, :'Iiorma Shore, Collect. EXCLlSIYE CANADIA/Ii REPRESE"iTATIYES RECRl ITI G REGISTERED "il'RSES J'IoC. '.1111 IRIII U'.IIL 1200 Lawrence Avenue East Suite 301, Don Mills Ontario M3A ICI Telephone: (416) .w9-5883 . OcIober 1171 13 r ""'" , U So HUP.SE RECAUITMENT AVI Offers R.N. 's An UNUSUAL OPPORTUNITY. A.MJ. Will FURNISH One Wly AIRLINE TICKET 10 Te.as end $SOO Inillel U ING EXPENSES on eloan Basis. After One Yeer's Service, This loan Will Þe Cancelled MI American Medical Inlernational Inc. . HAS 50 HOSPITALS THROUGHOUT THE U.S. I . Now A.MJ.II R.crulIlng R.N.'I lor HOlpll.llln TIIiI. I Ilmmediitl Oplnlngl. Slllry Rlngl 511.000 10 516.500 plr vllr.j . You can enJoy nurSing on General Medlcone. Surgery. ICC. CCU. Pedlatncs and Obstetncs . A M I provides an excellent ollentatlon program. on-servoce tralnong r------------" I - I U.S. Nurse Recruiter _ I P.O. Box 17778, Los Angeles, Cillif. 90017 I I . Wlthoul obligation. please send mé more _ I Inlormallon and an ApplicatIOn Form I NAME I AOOR ESS =========== I I ClTY_ --- ST.___ ZIP___I TELEPHONE (__1_ _ __ _ ____ I LlCENSES:____________ _ SPEClAlTY:________ ____ VEAR GRAOUATEO: _ _ _ STATE: _ _ __ '-____________rI ..--- ; , . I ' I . c - . S4 October 1878 The Cln-.llen NUrH Bermuda Hospitals Board Applications are invited for the position of Assistant Director of Nursing - Quality Assurance in our 320 bed hospital which is accredited with the Canadian Council on Hospital Accreditation. The successful applicant would be responsible to the Director of Nursing for the development and direction of a new Department of Quality Assurance. This department is being established as a support service to the Department of Nursing in particular as well as to other hospital departments, and will be responsible for coordination of new employer orientation; continuing and inservice education: quality control surveillance, including infection control and nursing audit; and patient education. the department will have a total staff of five persons. Applicants should be registered nurses with several years of nursing experience, preferably in both nursing education and nursing management positons, Master's Degree in Nursing or Nursing Education. Interested applicants should apply in confidence submitting resume and statement regarding desired salary. Director of Nursing King Edward VII Memorial Hospital P.O. Box 1023 Hamilton 5, Bermuda Senior Clinical Nurse COJLJLEGE OF NEW CAJLEDONIA Nursing Instructors Located in the geographic centre of beautiful British Columbia. the College of New Caledonia serves a region of 120,000 people. Applications are invited for positions of full-time nursing faculty at the College of New Caledonia with a start date in January 1980. Qualifications: Applicants must have a baccalaureate degree and must be registered or eligible for registration in British Columbia. Preferably applicants will have two years of nursing practice and teaching experience. In particular. medical-surgical nursing experience is preferred. Salary: $18.050.00 to $32.450.00 per annum. Placement dependent upon qualifications. Relocation assistance is also available. To apply. submit a curriculum vitae and the names of three references to: Ms. L. Winthrope Personnel Officer CoUege of New Caledonia 3330 - 22nd A venue Prince George. B.C. V2N IPS ., I rrv Æm Nurses/Psychiatric Nurses Graduates from approved Schools of Nursing with eligibility for registration with the appropriate Professional Association in Alberta are invited to apply for Nurse I and Psychiatric Nurse I positions at the Michener Centre in Red Deer. Alberta. Michener Centre provides residential care and trdining for 1.700 developmentally handicapped residents. Nurses will participate in life skills progrdmming for the residents in addition to providing general duty nursing services Red Deer is a progressive and growing community with a present population of 40,000. It is situated mid-way between Calgary and Edmonton in the heart of Alberta's beautiful Parkland area. Lakes. parks, and the Rocky Mountains are all in close proximity and recreational opportunities abound. Salary $14,748- $17,340 Competition #9176-10 This competition will remain open until a suitable candidate has been seIc ted. Apply to: Personnel Administrator The Michener Centre Box 5002 Red Deer, Alberta T4N 5Y5 Telephone: (403) 343-5611 CoUq:e of NursinR llniversit} of Saskatche"an Community Health Nursing Specialist This position will be a joint dPpointment between the College of Nursing. UniversIty of Saskatchewan and the Department of Heallh. City of Saskatoon. The purpose is to promote the development within the Depdrtment of Health. City of Saskatoon. pmctice facilities for students involved dt the University of s..skatchewdn dnd to do so in a way that protects the quality of service to clients. families dnd the community. Qualifications: e Masters degree with d major in Community Health Nursing. . Progres"veC.H. Nursing experience in which leadership ability. coordinating abIlity. teaching skills. dnd competence as aCHN have been dò:monstmted. . Current registration in Saskatchewan . Evidence of hedlth and emohonal stability required for the demands of the position. Salary level in accordance with university policy and the faculty mnk for which the candidate is qlldlified. '\pplicdtions including a detailed resume dnd names of three referees should be addressed to: Hester J. k.ernen Professor and Dean Collq:e of NursinR 1 nÏ\ersit} of Saskatche" an Saskatoon. Saskatche"an S7N OWO Required Salary -GN-4-$I3579.00 to $16506.00 annually. Applicalions are invited for Senior Clinical Nurse in normal newborn and neonatal intensive care nursery. Applicants must have post-basic preparation in neo-natology and a minimum of one year's recent clinical experience in a normal newborn nursery or two years' current clinical nursing practice in a neonatal intensive care unit. Applicants must possess leadership and teaching ability to integrate patient care and staff development. Must be actively registered or eligible for registration in New Brunswick. Please forward application and resume to: Nurse Recruitment Officer Dr. Everett Chalmers Hospital P. O. Box 9000 Fredericton, N. B. E3B 5N5 Telephone 452-5177 m . J< I. u-J ...JERES Nune NOV 231-"" 10539 . Canada's health assocIatIons work together to prevent handicap In newborns . Montreal's Hereditary Metabolic Disease Unit . An outreach program for Vancouver mothers . Ten days of tomato sandwiches? A healthier lifestyle for the chronic schizophrenic I'J" .: fßJ i\JG LIBRARY NOVEMBER 1979 - . , , , \ I "I \ , \ t II " , t , \ \ r \ , .. '\ ONE OF TODAY'S MOST PRESTIGIOUS LABELS " .. , t \ , ,\ , \ 'i \ ....- \ .- ":i - ... .I' Style No. 43741 - Skirt Suit Sizes: 3-13 Royale Stripe Sensations 100% textured woven Dacron. Polyester. White. Pink. I Style No. 43780 - Pant Suit Sizes: 3-1 3 Royale Stripe ensatio 100% Textured woven Dacron' Polyester. White, Pink. .. The Canadian Nune November 1979 The official journal of the CanadIan Nurses Association published in French and English editions eleven times per year. Volume 75, Number 10 Input 6 Healthiest babies possible Jennifer Warnyca, Susan Ross. Christine Bradley 18 News 7 A teenage pregnancy epidemic? Susan MacDonnell 22 You and the law 14 A regional program for the management T eTry Reade. of hereditary metabolic disease Caroline Clow 24 Names 45 The single mother: can we help? Jo Billung-Meyer 26 Books 48 Coalition for the Prevention of Handicap M. Anne Besharah 29 Calendar 62 O.B. staff alert Sheila Cameron 30 Diagnosis: Down's Syndrome LindaJ. Nixon 33 Closeup on Fetal Alcohol Syndrome Jane Bock 35 The nurse in the community: infant stimulation Judith Banning 36 Handicap: A parent's pen;pective Heather Rankin 38 Nut 'tion nd the chronic schizophrenic Jennifer Pyke 40 I r' . .a t \ l ' ' . " , J :'- . a L (=. t- ....' n ""IIovember morning in the marsh" might well be the title that l6-year-old Meena Boyal of Stratford, Ontario, had in mind when she painted this month's cover illustration. The painting is from the archives of AU About Us, a non-profit organization founded seven yean; ago to promote creativity in children. --, The Canadian Nurse welcomes suggestions for articles or unsolicited manuscripts. Authon; may submit finished articles or a summary of the proposed content. Manuscripts should be lyped double-spaced. Send original and camon. All articles must be submitted for the exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. The views expressed in the articles are those of the alJthors and do not necessanly representlhe policies of the Canadian Nun;esAssociation ISSN 0008-4581 Canadian Nurses Association, .sO The Driveway, Ottawa, Canada, K2P IE2. Indexed in International Nun;ing Index, Cumulative Index to Nun;ing Literature. Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microform from Xerox Univen;ity Microfilms, Ann Amor, Michigan 48106. Subscription Rates: Canada: one year. $10.00; two years, $18.00. Foreign: one year, $12.00; two years, $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address; Notice should be given in advance. Include previous address as well as new, along with registration number, in a provincial/territorial nurses association where applicable. Not responsible for journals lost in mail due to eITOn; in address. Canadian Nun;es Association. 1979. 4 November 11179 The C.n-.llen Nur.. perspective Guest Editorial sexuality that they hesitate to Nurses are in an excelIent Shirley Wheatley ask for information and position to effect a change. In direction from anyone, most many settings we are the How many times, in the past of all their family physician. primary contact. In schools, \ year, has your caseload The teen years are a time clinics, hospitals, even included a teenage for testing: teens test their socially, we can let teenagers mother-to-be? Experts now parents' authority in many know we are available to estimate that about two thirds areas and. even when the listen to their questions. Of of North American teenage communication channels are course, this means making ;.- women have had sexual open, there is often reluctance sure we understand our own intercourse by the age of 19; to discuss sexuality and values and attitudes. about 25 per cent of them wilI attendant values. At the same Fóllowing this, we must be pregnant before the age of time, teens are subject to ensure that the necessary 20. considerable pressure from services are available in the I n the province where I their peers and from the media community: clinics, About the author: Shirley work. a 1917 study of 486 to look and act "sexy". Many information centers, hospitals Wheatley is president-elect of teenagers attending birth teens are convinced that they and schools should have the /8,052-member Registered control clinics indicated that are the only one in their crowd volunteer and professional Nurses Association of approximately one third of not sexually involved. staff trained and available. Ontario. A graduate of the this number were sexualIy Just as there is no single Their manner mU.51 invite and Nurse Practitioner program active by their 15th birthday. cause, there is no single not intimidate the young at the University ofT oronto, In that same year, one third of solution to this dilemma. The people who need their help. she was until recently the 60,000 reported abortions question is not whether we As respected members of super\'isor of community performed on Canadian believe that teenagers should the community. nurses are in workers with Family Planning women were on teenagers. 30 or should not be sexualIy a position to lobby for these Services, Department of per cent of whom were under active; the fact is that large services through their local Public Health inToronto./n the age of 16. numbers of them are and they health units, school boards. this position, and as a As nurses and as parents, don't ask permission first. local government - any part-time nurse practitioner at we must ask ourselves: why is TelIing them about sex does mechanism available. In Don Mills Birth Control this happening? not condone irresponsible Ontario, Family Planning will Clinic, she has worked to The obvious answer is behavior; it simply shows that soon be a core or mandatory increase awareness of birth that teenagers today use you respect their ability, given program in all health units. control and sexuality in young contraception sporadicalIy or some guidance, to make ChalIenging local school people through seminars, not at alI: more than 80 per decisions for themselves boards at the elementary and wor/...shops, etc. cent of them use no effective based on adeq uate and secondary school level as to [/I September, Shirley contraception at first reliable information. We must what is being taught, and how, opened a private practice of intercourse and many do not let our teenagers know their is another strategy we can nursing from her home, .. Se f approach a clinic or doctor questions are valid and their pursue. Home and school Care Consultants". As an until after they have judgements sound. associations are an excelIent independent nurse experienced a pregnancy I believe kids have the medium for reaching parents. practitioner, she expects 10 be scare, ifat alI. right to express their I nvite yourself and/or another seeing "indh'idual clients for What do adolescents sexuality, at any age. and local expert to a meeting and health assessments. as well as actually know about today, when teens are invite parents to discuss their teaching and working with contraception? Outwardly maturing earlier and concerns with you. various groups on a contract they appear very remaining economically Team work is a concept hasis. " sophisticated and some of dependent longer, ifthey very familiar to nurses and in A graduate of Mack them in fact have some basic choose to express themselves this case it can be applied in a Training Schoolfor Nurses, knowledge of how their bodies through intercourse. perhaps community context. St. CatherinesGeneral work. What they don't have is they are simply being less Determine who your alIies are Hospital, Shirley has worked specific information about hypocritical than past in the community; work with in i'arious capacities at the how and when they can generations. AII young people them to lobby for good sex H ospitalfor Sick Children in become pregnant, where to experiment sexually and some education and services. Have Toronto, including head nurse get reliable information and include intercourse. We must a strong and united front for in the Teen Clinic where, she services that wilI prevent also support those who the inevitable opposition. says, "approximately 40 per pregnancy, and the choose not to be involved. We have nothing to lose cent of our clients were opportunity to dialogue with There must be a forum for and everything to gain from teenagers with problems in peers and experts in their own dialogue for all young people, improving the future the area of sexuality, community. As a society, we regardless of age or sex, emotional and sexual health of contraception, i'enereal make them feel so guilty ahout where they can test their our young friends. disease, pregnancy and any expression of their opinions and values. abortion." Th. C.nedlen Nur.. Novem.....'11711 5 for professional growth... 1 MANUAL OF PEDIATRIC NURSING CAREPLANS Deportment of Nursing, The Hospital for Sick Children, Toronto. The authors cover the entire spectrum of pediatric disorders and present two sets of interrelated care plans: one based on the hospitalized child's age; the other on his or her specific disease. Throughout, the manual emphasizes the parents' important role in the treatment program and offers specific guidelines for their involvement. little, Brown. 320 Pages. 1979. $13.00. 2 GERONTOLOGICAL NURSING By Charlotte Kopelke Eliopoulos, R.N., B.S., M.S. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. Specific coverage is given to measures designed to promote good respiration, elimination, and activity to compensate for age-related changes interfering with these functions. Common diseases of each body system and their unique features in the aged are discussed in detail. Harper & Row. 384 Pages. Illustrated. 1979. $15.00. 3 NURSES' DRUG REFERENCE Edited by Stewart M. Brooks, M.S. All nurses will welcome this fingertip guide to drugs, organized specifically with their needs in mind. It lists alphabetically over 500 generic drugs and describes-in an easy-to-consult format- each drug's action and use, dosage and administration, cautions, adverse reactions, composition and supply, and legal status. A glossary of drug classifications affords extensive cross-referencing for quick referral to hard-to-find information. Impeccablyorga- nized and absolutely reliable, NDR will serve as the standard ref- erence for any health practitioner who dispenses drugs regularly. little, Brown. 500 Pages. 1978. Paper, $14.25. Cloth, $27.00. 4 THE LIPPINCOTT MANUAL OF NURSING PRACTICE, 2nd Edition By Lillian Sholtis Brunner, R.N., B.S., M.S.N.jand Doris Smith Suddarth, R.N.., B.S.N.E.,' M .S.N. This monumental Second Edition of a modern classic-the most comprehensive single-volume reference on nursing practice ever published-incorporates massive revision and updating to offer the latest and most accurate information available. What this means is more detailed, substantive, and complete coverage of every phase of medical/surgical, maternity, and pediatric nursing! lippincott. 1868 Pages. Illustrated. 1978. $29.95. LIPPINCOTT'S NO-RISK GUARANTEE Books are shipped to you On Approvalj if you are not entirely satisfied you may return them within 15 days for full credit. 5 PERSPECTIVES ON ADOLESCENT HEALTH CARE By Ramona Thieme Mercer, R.N., Ph.D. With 72 Contributors. Counseling adolescents on their optimal growth and health requires a wide range of specialized knowledge and skill. Here at last is a text that not only presents the major ideas and issues on this subject; it offers valid, practical suggestions that can be put to use in a variety of clinical settings. Ramona Thieme Mercer together with twelve contributing authorities, develops several major themes in relation to specific perspectives on adolescent health. These themes include the special psychosocial needs of the adolescent, the interrelation- ships of his or her family members, and the effects of larger society on the adolescent's evolving adult identity. lippincott. 420 Pages. May, 1979. $15.50. 6 OPERATING ROOM TECHNIQUES FOR THE SURGICAL TEAM Edited by Lois C. Crooks, R.N., B.S.Ed. The first two chapters deal with aseptic technique and sterili- zation and with the anesthetized patient. The emphasis is on the underlying principles, as shown by the concentration on the four sources of contamination in the chapter on aseptic technique. The remaining ten chapters of OPERATING ROOM TECH- NIQUES FOR THE SURGICAL TEAM are devoted to precise descriptions of anatomy, disease entity, diagnostic measures, surgical techniques, and nursing responsibilities for the most frequently performed surgical procedures. little, Brown. 459 Pages. Illustrated. 1979. $ 21.00. Lippincott J. B. LIPPINCOTT COMPANY OF CANADA lTD. Serving the Health Professions in Canada Since 1897 : :: .o :::::_ o_ Please send me for 15 days 'on approval': 2 3 6 4 5 o Payment enclosed (postage & handling paid) o Bill me (plus postage & handling) Name Address City Postal Code Provo Prices subject to change without notice. CN" 179 II November 1979 Th. Cenedlen Nur.. input The Canadian Nurse invites your letters. AU correspondence is subject to editing and must be signed, although the author's name may be withheld on request. A course to follow Look at programs at home Apathy syndrome In the last paragraph of A As a nurse in Canada, I Although I agree in CNA MEMBERS AND Challenge in Office Nursing was astonished by an article in principle with the opinion ASSOCIATION (Frankly Speaking, Sept. '79) a recent Canadian Nurse expressed by Jessica Ryan in MEMBERS is the statement "I don't think entitled "Not all patients need Frankly Speaking, June 1979, there is a course anywhere in hospitals" (March 1979). I believe that the syndrome of CNA members and association office nursing." J have just The author seems to have apathy is a result of fast-paced members are invited to submit enrolled in a 30 hour course little faith in the Canadian living. The apathetic resolutions for presentation at offered at the Sir Sandford system of community health individual, let alone the the Annual Meeting and Fleming College in care. Granted, there may be apathetic nurse, is blasé about Convention, June 1980. Peterborough, Ontario which room for change and/or his/her environment. Resolutions must be signed by a is entitled 'The Medical Office improvement but the fact As a nursing educator J CNA member and forwarded to Assistant' . remains that there are new feel partly responsible for the the Resolutions Committee, CNA Topics covered include and exciting programs being lack of interest encountered in House by 31 March 1980. first aid in medical developed to shift health care the young nurse.lfthe student emergencies, assisting with into the community. For is not instructed sufficiently in Resolutions received after 31 examinations, special example, there is a current chapter and union affairs, how March 1980 cannot be presented diagnostic tests, diets, and interest in encouraging the can we hope that he/she will to the annual meeting. others. public to become more be interested as a professional I am hoping there will be involved in their own health nurse? Most teachers are more emphasis on care as well as the care of ill actively involved but how EDITOR nurse-patient communication family members at home. The often do we bring the students ANNE BESHARAH and follow-up care in the St. John Ambulance and the into our discussions? Perhaps ASSISTANT EDITORS program, and I inte, d to Canadian Red Cross have this could be one small step in JUDITH BANNING emphasize this nee in class traditionally offered courses diminishing apathy. JANE BOCK discussion. .' I in home nursing. In 19'77-1978, -Monique L. Levesque. PRODUCTION ASSISTANT -Jane (Holden) Allison, materials for a multi-media RN., B.ScN., Bathurst, GIT A DEAN Fraserville.Ontarió. home health care course were N.B. developed for the two CIRCULATION MANAGER Other side up agencies. The program is Comment on PIERRElTE HOlTE The drawings on page 23 called "There's No Place Like September's Editorial ADVERTISING MANAGER (July/August) are confusing to Home for Health Care" and Nursing today is a very GERRY KAVANAUGH some of us...You tell us the has been designed to teach stressful, taxing situation and patient is lying face down basic home health care I do not think the remedy is CNA EXECUTIVE DIRECTOR (almost semi-prone) but the through the media of for "tattletales" in our HELEN K. MUSSALLEM two little dots suggest eyes programmed learning booklets profession to upgrade it. We EDITORIAL ADVISORS looking towards the ceiling. and 16 mm color film. would like to give the care we MATHIlDE BAZINET, May I suggest that the ear At the present time a have been taught to give. chairman, Health Sciences would be more helpful in research study is being carried The problem today lies Department, Canadore College, placing the head in the correct out in a number of sites across more in the workloads and North Bay, Ontario. position. Canada to determine the paper work expected of us DOROTHY MILLER, public relations officer, Registered Also, just a little increase relative effectiveness of than in negligent care! Nurses Association of Nova in anatomical detail would various combinations of these -Linda Stevenson, R.N. Scotia. help show which body parts media in modifying the JERRY MILLER, director of are higher and which are knowledge, attitudes and communication services, lower. skills of the lay public who The case of the missing arrow: Registered Nurses Association These drawings, in short, partici pate. Author Bonnie Hartley of Bntish Columbia. are not up to your usual high Although J agree that it is (Hypertensive Disorders in JEAN PASSMORE, editor, standards. Otherwise, I hope important to consider what Pregnancy, July/August) SRNA news bulIetin, Registered you keep up the good work; I other countries like Britain are draws the attention of readers Nurses Association of Saskatchewan. myself always look for doing in health care, I think to the fact that an arrow was PETER SMITH, director of Corinne Sklar's column that we must carefully inadvertently omitted from publications, National Gallery before anything else but all the examine the service and the diagram on page 43 of her of Canada. articles are well worth educational programs that are article. This arrow should lead FLORITA reading. currently operating in our own directly from the word VIALLE-SOUBRANNE, -Anne Carney, BN, country, to make the home the "vasospasms" to the word consultant, professional Nursing coordinator (Days). place for health care. "hypertension". .., inspection division. Order of Montreal Neurological -Myrna I. Baker, B.Sc.N., Nurses of Quebec. Hospital. Health Care Research Unit. University ofT oronto. v Th. Cenedlen Nur.. news Former CNJ editor, educator dies in Florida Virginia A. Lindabury. editor ofT he Canadian N Ilrse from September 1965 to August 1975. died in Naples, Florida. on September 14th after fighting an eight-month battle against cancer. Lindabury's association with The Canadian Nurse began in 1962 when she joined the staff of the then Montreal-based publication as an English assistant editor under editor Margaret E. Kerr. On Kerr's retirement in 1965 after 21 years as editor, Lindabury became the sixth editor in the 6O-year history of the publication. V .A.L.. as she signed her editorials. Wd a champion of the rights of members of the profession to which she belonged. In her farewell editorial in the August 1975 issue ofCNJ. she paid tribute to "nurses who care...(who) can be found in hospitals, clinics. and communities from coast to coast in Canada. Along with their clinical expertise. these nurses still have time to show love. compassion. and sympathy to patients and to relatives. They make me proud to be a nurse. In our society, which often seems too impersonal. so competitive. and, indeed, even cruel. love and compassion for one's fellow human beings, are, in the last analysis, all that really matters....' A graduate of the Toronto General Hospital School of Nursing, Lindabury obtained her diploma in nursing education and her B.Sc.N. in Nursing from the University of Western Ontario. Before her appointment to the position of assistant director-nursing education at Brockville General Hospital in southeastern Ontario. she was a surgical instructor at the Wellesley Divi.,ion ofTGH and medical-surgical and pediatric instructor at the Royal Victoria Hospital in Barrie. After moving to Florida four years ago. Lindabury joined the staff of the magazines Naples Guide and Naples Now. In January 1977 she became managing editor of these publications. A year later she resigned to resume her nursing career after taking a refresher course that Summer. She worked as a nurse clinician on the staff of Naples Community Hospital until entering as a patient in January of this year. InJuly she returned to Canada to visit friends and relati ves in Ottawa and Toronto and to spend a month at the family cottage on Lake Erie. November 1979 7 Some people need to be cared for. Others need a chance to care. Upjohn HealthCare Services brings them together. \ " , \ ( '. -- r . . . \ . ... -- "-4", l ,- \ I I n any community, there are people who need health care at home. There are also people who want worthwhile part-ti me or full-time jobs. We work to bri ng them together. Upjohn HealthCare Services'" pro- vides home health care workers throughout Canada. We employ nurses, home health aides, homemakers, nurse assistants and companions. Perhaps you know someone who could use our service, or someone who might be interested in this kindofjoboppor- tunity. If you do, please pass this message along. For additional information, com- plete the coupon belovv, or call our local office listed in your telephone directory. r--------------------. ( ] UProHN R1j-.... HEALTHCARE ____ SERVICES. M Please send me your free brochures (check oneor both): o "Nursing and Home Care" o "Nursing Opportunities at UPJohn HealthCare Services" Name Address Phone City Postal Code Province Mail to: Upjohn HealthCare Services Dept.B 716 Gordon Baker Road, Suite 203 Willowdale. Ontario M2H 3B4 HM 641O-C @ 1979 HealthCare Services Upjohn, Ltd. L____________________ 8 November 1979 The Canadian Nurse news End stage renal disease: 1979 and beyond resources may be redeployed Health services division to offset negative effects of receives Kellogg grant Renal specialists from across reconstruction, i.e. it is this problem. the country met in Montreal, possible to remove areas of Karen Whitelaw, head The University of Alberta September 14 and 15, for the stenosis and insert new nurse, Renal Dialysis Unit, division of health services fourth annual national tubing. Ottawa Civic Hospital, administration is the recipient symposium sponsored by the .. transplantation: with a emphasized that a major of a $371.800, five-year grant Canadian Society of Dialysis first cadaveric alIograft, after nursing problem in this type of from the W.K. KelIogg Perfusionists. Nurses, a short period of dialysis. unit is frustration due to lack Foundation of Battle Creek, technicians, nephrologists. kidney transplantation failure of positi ve reinforcements. Michigan. The purpose of the dieticians. social workers, rates are very low. New With the initial help of a grant is to facilitate the industrial representatives, as immunosuppressant drugs and psychologist, group support development of two new welI as individuals suffering more recently the sessions have been academic programs: the first a from renal disease. discussed development of a fl uorescent established in their unit. for alI one-year program leading to a the many aspects of dialysis activated celI sorter which levels of staff. By alIowing post-graduate Diploma in and transplantation. alIows production of specific them to look at themselves Health Services Dr. Eli Friedman. of the antibodies, point to further more objectively. the Administration; the second a Downstate Medical Center. improvements in participants feel their ability Ph.D. program in Sociology State University of New transplantation success rates to set realistic goals and (Health Care Planning and York: was the keynote Dr. \. Shimizu. Director objectives for their patients as Evaluation) which wilI be speaker. He emphasized the of Dialysis, St. Joseph's welI as for themselves has jointly administered by the momentous changes that have Hospital. Hamilton. Ontario. improved tremendously. Department of Sociology and occurred in the treatment of described a Spouse Relief The Canadian Society of the Division of Health end stage renal disease in the Program which has been set Dialysis Perfusionists (CSPD) Services Administration. past twenty years. In fact. up to assist families in coping offers qualified nurses and A considerable amount of with the improved methods with home dialysis. This technicians a certification the KelIogg grant is and availability of dialysis. program. funded by a Canada program which is recognized earmarked as felIowship funds statistics in the U.S.A. now Works grant. prepares basic by the Canadian Society of for students enrolled in the show a decrease in the dialysis technicians capable of Nephrologists. Membership in Ph.D. program. The proportion of kidney assisting in the home in times the society is open to alI fellowships wilI vary in tran'.plants done annualIy. offamily illness, when persons actively concerned amount, -depending on the A panel of specialists important business or social with dialysis and training, experience and need from each of the fields of engagements arise and for an transplantation and current of each student. but begin at a treatment for renal failure optional two-week rest period information is disseminated baseline of approximately discussed the situation here in annualIy. Sixty percent of the through a bi-monthly $7,000 per annum for a Canada - now and in the spouses took advantage of the newsletter. When the society graduate of a master's degree future. Problems and program. While the was founded in Halifax in program and are open to refinements of treatments psycho-social problem.. of the 1968. the founding president students with a master's were discussed in the areas of: spouses decreased about five and vice-president were both degree in Health Services . acute hemodialysis use in percent. the most notable nurses concerned about Adrilinistration, or equivalent, severe medical or surgical effect was in hospital back-up education and communication or in Sociology. conditions has improved demands. The requirement of among those involved in this Did you know... prognoses greatly, however hospital back-up due to specialized field. the problem of malnutrition spouse-related problems Four years ago. the The Association of Registered with this treatment mode dropped about 65 percent. society bnke away from its Nurses of Newfoundland has rem.lins unsolved. A major issue at the American counterpart to been awarded a Certificate of . continuous am hula tory seminar was administrati ve establish a Canadian Commendation by Saint peritoneal dialvsis (C APD). It problems resulting from certification progmm. Since Francis Xavier University, now seems that nutrition increased demands for service then, membership has Antigonish. Nova Scotia, for nther than the threat of and a decreased amount of increased to 340. Fran its exemplary contribution to peritonitis is the chronic money with which to work. Boutilier. head nurse, Renal the field of adult non-formal problem due to the Representatives from the Dialysis Unit, Victoria education. improvement of dialysis federal government. hospital General Hospital. Halifax, The university colIected systems and procedures. administration. medicine, N .S. is currently the data on 3,040 associations, . use of PTFE [(raih when nursing and technology president. For membership or societies. councils, a suitable natural grafting site debated many facets of this newsletter information federations and clubs in the is not available. These grafts issue. Quality does not have contact: Canadian Society of four Atlantic Provinces: the have been found to be to suffer as financial restraints Dialysis Perfusionists, 1270 professional association was relatively resistant to infection are applied. Often, by Sherbrooke St. W., Suite m-7, one of the 450 .,e1ected to and amenable to reassessing priorities. Montreal. P.Q. H3G IH7. receive the award, ENGRAVED NAME-PINS IN 4 SMART STYLES - SIX DIFFERENT COLOURS... :.:.-:;:':: ................... ...... ... ...... .... ...... ....... ........... ...... ......... .......... ...... ...... ..... ........... .... ....... ... ............. ....... . : . T F O 'L O L R 'N D L E E R TT N E A R II , E NG "'''S " SEND TO EaUITY MEDICAL SUPPLY CO PLEASE : . POBOX 126-5. BROCKYlllE. ONT Key 5YI P"INTI : I::g: :i: '.'l1li. - - - - - ------______ - - - --___________ 2nd 11M - - - - - - - - - - -- -- - --- - -- - -- s....... to 1Iftdo.. ,out n.... aRd add....._ : . PLEASE PRINT TYPE :;. .::.v:c<< .A ND LETTIRI 1 IÞIN .. I::",.) au."t. lIem :; Price AmtMInl: SOLID PLEXIQlASS......olcMd from solid PIe.IDla. Smoolhly rounded ec:Ju-s and camera. Letlera; dNØlr IIf'Igraved and hlled "'11" laquer colOUr of your Choice , " For post-operative pa- tients, the bowel may need a little gentle prompting to begin functioning normally again, and that's where Metamucil can help. Why not recommend a laxative that works slowly, gently and effectively. That's the Metamucil way. a I -;:.... I .-... PAAB . ICCpp/ _ _, -= .... ''--- ...I . f ncal.TAYLOR ITETHOICOPES Femou. branG-nam. Inatrumen. truated by a pro'.Ulonale 11'1. .011(1 ower. DUAL.HEAD TYPE. In 5 pmty COlour. E. pll"n.1 aound tran.m...ion. Adluslablt! IIg""- .algh. bll'\8urJ,'a. h.. bolh Ø,.ph,.gm anø bell with non- I llu -:':.IKk. ReG. No sonsn.n.._ aINOLE-HEAD TYPE. Aa above bur ",'tIoOIJI 0.11. s.m. "',ga :cgr;.õi.. tM D'''L ;: H"6k o,:1 r:, :::o.. but not TYCOS brand Sama 2 ,M( gY8t1ln'" ComPlet. == ':f: &m. : I.PII Dual Heed No. 110 117_11.. LISTER ."NOAGE' SClnOR. WanulaC1urwd ol.lne....... A mua. tor nurN No. Me. J\IJ No BW,41Y.1 No.1(J(J.S . No 702.7...... J . =:::t FORCEPS (It...,. IdM' lor c,.mplng nJl. : SI.ln .. a..... locking Iy . 5\11" "'''11 P42Q a'ralghl ....ft P422 CUf'I'e(J 14." . is o : .",1 is. " . : o 0 a t . The Can-.llen Nur.. November 111711 11 Metamucil is made from (gluten-free) grain, " AvaIlable as a powder (low In \.. sodIUm) and a lemon-hme flavoured " . Instant Mlx (low in calones), \ Why not gIve your patients our " helpful booklet about constipation? \. Metalnucll@ The laxative most recommended by Physicians. - ,-I NUllaES CAP fA-C' GOld plated, holds ,"our up 11 ..,, IIrml, In place. Non- tW'a' '"Iure No JOt RN" "111'1 c.c.uceu. or No. 304 'n Cach..CåII! U. I JIIf. ' 11 DELUXE POCKET SAVER , .I. :o,:;:;: .ln; compartment. tor n.. 8Claaor. ate: plus chang. pocket and key chain Whit. c..' Pln.ahlel.. '\. No. 5Oð.' " NdI. \.. , MEABURINO TAPIE ' In .rrong p)..Uc ca.. Puatl bulton lor sVl .... return Wad. o' dU . !4 " linan .....ure. to 78 on one a.d.. 200 em on ,..,.,.. ...." MiCh. -, No 50. .:7::er:.:: :: No 502 PracUcal NUrMI NURSE' EARRINOS. For pierced No 503 Nu...... ...... .an Oalnl)' CaduC8\.Ia In ook! pia.. AIIU.51 Mch _111'1 gold filled poa.. e"uIIIUII)' .-g A'i;[ .".M... No. 320 ."...,.... .r; fml, acULPTUREDCADUCEuS 1 .o rau' .""....on.. II..... H..lly :.P':e(J..oII IN r. . N. No 401 MIEMO-T1ME.R. Tim. hot pecka, 1'1.., jJ tamps R ma.er. Remember to check vllal algna. 0'" macne..ion, etc. g e1 ,;,o::r:ct \I1 ndg ::. .. OIL .fj made 1.1.. NCh. r '. ......,,4- í OTOSCO'ESET.Onoof I Germany allnel1 Inalrumenla Wi"'"- - , po ::!.I:=: :: :I:.n:i ... __ ,. atandard aln apecuia Size C .. O:: :; f :ln : :: o - " .. No.:JOg ....e..d. No. 308A Aa abot'a bu' In pu.... --W...... IN."... " . ME"CU"'I" TYPE. Ttle ultlma'e In eccuracy Folda Inlo light but rugged melal caN H..vy (luly Velcro cult and Innatlon .y.'."" asl.1'5 MCtI. . \!I .... ... \II \ , . ] L.\j lea ANE..OID TYPE FluggeCf and cSependabl, 10 year guarenl_ 01 eccuracy to 3 m m No slop-pin to hide IØtOtI Hano.om. ZlppereØ caN to III WOI,jr pOCket 121." OCMII,... NU..aEa PENLIGHT_ Powerl'ul beam lor .umlnaUon 01 Uno.l. etc. Durable ala,"Je.. II." caw _/fit þOCII:et clip Wad. In U.S A. No. 28 U.II corn,.... wtttt .."..... Economy 17)0ÕII1 Wllh chromed b,.... caN No 2V 12 ft. NU"SEa WNITE CA' cLiPa. Meoe In Canada IOf Canedl.n nur... Slron,3 al.., bobby pins .,rh nylon r 2 3 :'; II 0115, 2 .Iu It 00 CIId Nu..sll 4 COLOU" PEN lor f'KOnllnq temperw.IUnl, blood pr..aure. ale One-hand operation Mlecla red, blKtl.. blue or g,..n No 32 &2 a .-eft. . ."ø NOTE: WE aERVICE AND aTOCK IPA..E PA"Ta FO.. A&.LITEM.. CA" ST'UPEa Sell eoh..I.... ty , Nmo.able ao(l ,.u..ble No 522 FlED, No. S2Q BLACK. No 521 BLUE. No 523 GREY. All 15\11' nl.lt;:s::. (14' '2 alrlpea per Clrd t: : :A g I ,, =f,jI:111 contraatlng colour core Bev.lleo .ag.. match ""81" S.lin IIn,a'" E_c.Uent walUie al thl. price o "'oU'l8l' Oblk,... .lIn. .ao o .... d. OblUie Jelle" .M" 0_ 211fM! 14." ..... -...... lenen o White - 0 alKk . line 12.11 ...z 8:::11: - White ""81'. 211n.. IJ.tS Oasl2 18I" ONTARIO RESIDENTS ADD 7% TAX ADO 50<: HANDLING CHARGE IF LESS THAN 110. coo ORDER ADO 12 00 NO C 0.0 ORDERS FOR HAilE-PINS TOTAL ENCLOSED C....O ::CHEauE OCASH METAL FAAMED.__S,mllar 10 above bUI mounted In pollahed ""elel Fram_ with rounded .rig.. and comera. Engraved InHft can e. chotngad or raplaced. Our amart..land n.....1 deSign. , Irne 18I" 12." .2 IIn.. lanen ...... 13 .. ..... ..... 1. 2- 3- 4. . II. saUD METAL...htreme'y sirong an(l durable bul IIght_.lghl LeUa,.. d"Ply angnl lor abllOlule permanenceano '1IIe(! willi your choice 01 faQuer coloor. COrners and eoge. amoolhly rounded Satin smOO'h F,nlsh 1 Itne t.ra 2 "n.. lOt.... o Silwer black -blUie =- ...... U.IO 11." _ 53._ ...n ASI( A.OUT OUIII GENEROUS OUAN"", DISCOUNTS FOR CLUI GIFTS. GROUP PUReH""S. FUNÐ RAISlNQ ETC USE A SEPARATE StoIEET OF PAPf.R IF NECESSARY 12 Novem.....,979 Th. C..nllCllen Nur.. news Health professionals learn more The study also shows that be encouraged to use whole about latest in infant nutrition the size of a baby is milk since a diet low in fat determined by the amount of means greater consumption of food and calories consumed other nutrients. This The milk of mothers giving adequate levels of many of and not by whether the baby is imbalance of nutrients, among birth to premature babies has these minerals to meet the breast or bottle fed nor the other things, could provide an unique properties that may be requirements of premature time solids are introduced into unnecessary stress to the advantageous to these rapidly babies during the early weeks its diet. kidneys of a young baby. growing infants, according to oflife. Although not all the data The study also shows that a Toronto pediatrician Zlotkin suggests that in from the study have been fully sodium (sah) intake of babies currently doing research in the future, rather than feeding analysed, a few other is much lower than figures this area. premature babies interesting facts about feeding reported in previous studies, Dr. Stanley Zlotkin was intravenously, "it is practices have emerged. mostly due to eating salt-free one of several authorities who conceivable that limited Dr. Yeung has found that commercial baby foods. addressed more than 300 nutrients which are missing in many mothers are feeding . 'Intake, although low, is public health nurses, the mother's milk of babies two per cent or adequate and meets the daily pediatricians, dietitians, premature babies could be skimmed milk, resuhing in a recommended level." said Dr. nutritionists and other health added to that milk. Using this lower than the recommended Yeung. 'V professionals attending two type of regime, the infant intake off at in the diet. He one-day symposia in would potentially benefit from suggests that mothers should Vancouver an in Edmonton not onJy the immunological this Fall. factors present in fresh human "The pre-term infant milk, but also the appropriate Closeup on represents a special nutrients for optimal growth." problem," Dr. Zlotkin says, a generation of non-smokers? "since he has missed three to Too many calories 14 weeks of gestation in which I nfants whose energy intake in More than 20,000 pre-teens in the province of Alberta have he is assured of an ideal their first year of life meets or good reason to think twice before taking up the nicotine habit. nutritional milieu from the exceeds Canadian Dietary The kids, all of whom live within a 200-mile radius of Calgary, mother. .. Standards recommendations, have been exposed to a special preventive program sponsored Referring to research are being overfed, nutritionist by the department of social development and community recently conducted by David Yeung told health health, division of tuberculosis control of Baker Memorial Stephanie Atkinson at the professionals attending the Sanatorium and the Alberta Lung Association. University of Toronto, symposia. Mona Zahara, nurse consultant for Baker Memorial, is Zlotkin said that the Dr. Yeung, who is just "the ladywith the black lungs" who has been taking her composition of breast milk completing a study involving half-hour program on the health hazards of smoking into grade from mothers of pre-term 403 babies in the five classrooms throughout southern Alberta for the past five babies, has been found to Montreal-Toronto area, years. Mona's 52-slide presentation features illustrations of the have a significantly higher reported that infants in his respiratory system, pictures of the normal lung, "lungs in level of nitrogen than the milk study "achieved normal danger", a cartoon of black lungs surrounded by items that from mothers who gave birth growth while consuming contribute to air pollution, microscopic views of lung tIssue, to full term babies. fewer calories than alveoli sacs, mucus glands and cilia and illustrations of the "For a given volume of recommended by CDS9" His effects of bronchitis, emphysema, lung cancer and heart disease milk, a premature infant findings, he says. support on the respiratory and circulatory systems. would recei ve 20 per cent those of other recent The children are also informed about the advantages of not more nitrogen than the full Canadian studies showing that smoking, ways to protect non-smokers and the long term risks term infant if both were fed his the CDS recommended that smokers run. own mother's milk." And energy intake is suitable for Mona says the program owes its start to the enthusiastic since two-thirds of the babies up to one month, but support she received in the early stages from public health nitrogen of a full term baby is excessive by 10 to 20 per cent nurses in her target area of rural Alberta. These nurses were required in the last two for babies from three to II successful in obtaining permission from the local school months of pregnancy, this months. districts to introduce the classes and also helped by contacting difference is important. Further results from the teachers at the grade five level and drawing up schedules for In addition to the protein study confirm findings that visits. composition of the premature breast feeding is on the "Only time will tell," Mona says, "how successful the infant's mother's milk, the upswing in Canada. "Not only program has been but I believe that if we want the adults of the milk was analysed for a are more mothers breast future to take more responsibility for their health habits, then number of important minerals. feeding, but the duration of we must help them by giving them the information they need Results showed that breast feeding has increased," early in life. This information should continue throughout their 'premature milk' contains said Dr. Yeung. educational years." ONE-STOP SHOPPING for most of your antiseptic needs l v \ HIBITANE* Skin Cleanser a sudsing, antiseptic cleaning solution containing 4 % w/v chlorhexidine gluconate for preoperative scrub-up and general hand washing. HIBITANE* Gluconate 20% Solution a multipurpose, broad-spectrum antiseptic cåncentrate for preoperative patient preparation, and general disinfectant use. Each product in the AYERST antiseptic line lives up to a well-earned reputation for quality which is backed by A YERST'S technical expertise. More and more Canadian hospitals are making A YERST their prime source of antiseptic products and information. If you would like to know more about any or all of these products. contact your AYERST representative or complete and return this coupon. AYERST LABORATORIES - - division of Ayerst. McKenna & Harrison Limited A\lØl'C.t Qual os Monlreal, Canada 'I no su Mute IPMA J _" . Reg'd HIBITANE and SAVLON made on Canada by arrangement wIth IMPERIAL CHEMICAL INDUSTRIES LIMITED , : -- _ '......'--(-. ..., '- '-- --- - .c:.... - - , I --::- .:...:: J ----- - ...;;;: - ---- --- ---.oIl! -. _ - I -1 ; - '- .f It !lilt --.. . ,1 '- '- 1 WWt... /" 41-- , ... ....... . . . ., .... " - . ,.* , /. ::: ./" .. , .-4.. . , ., t , '" SAVLON* Hospital Concentrate a detergent antiseptic combining the bactericide HIBITANE with the detergent properties of cetrimide B.P. for the majority of hospital antiseptic requirements. SONACIDE* potentiated acid glutaraldehyde 2%, a disinfecting and sterilizing solution for processing respiratory and anesthetic equipment. ,----------- TO AYERST LABORATORIES I 1025 Laurentian Blvd., Montreal, Quebec. H4R 1J6 I I Hibitane. Gluconate I 20% Solution I NAME I ADDRESS I NO I CITY I PROVINCE I would like to receive information on: = Hibitane. Skin Cleanser = Savlon* Hospital Concentrate L Sonacide. (PLEASE PRINT, STREET 14 Nov.mber 1979 Th. C.nedlen Nur.. YOU AND THE LAW Sinners or Saints? The Legal Perspective Corinne L. Sklar The decision of the Board of Arbitration in the caseRe Mount Sinai and Ontario Nurses Association I has resulted in much discussion and comment within the health profession. The decision, which was upheld on appeal to the Divisional Court,2 is of particular importance to the nursing profession, to hospitals and to their administrators. The editor of this journal discussed the issues confronting the profession as a result of this decision in a succinct and thought-provoking editorial on page four of the June issue. In her view, the issues which the decision raises are' 'fundamental to the direction of future growth and autonomy" within the nursing profession. The case was brought before the three-member Board of Arbitration on behalf of three nurses, employees of Toronto's Mount Sinai Hospital. The nurses complained that the hospital had disciplined them unjustly in suspending them for three tours of duty without pay. The disciplinary action resulted from the refusal of these nurses to accept on the I.e. U. and provide care for a cardiac patient. This refusal was based on the nurses' view that the admission of this patient to the I.e. U. would endanger the patients already under their care on the unit. The patient was brought to the 1.e.U. where his care. both medical and nursing, was delivered by the team of physicians. In a two to one decision, the Board upheld the disciplinary action taken by the hospital against the nurses. In the view of the majority: "I) the grievors (the three nurses) were given a valid work assignment; 2) the grievors refused to carry out that assignment; 3) thegrievors had, in all the circumstances, no justification for believing that the hospital was not looking to them to carry out the assignment; and 4) the grievors are unable to raise any of the known defences to the "obey and grieve" rule. Consequently, the employer has made out a prima facie case of insubordination.' '3 The minority position was expressed by W. Walsh in a strongly worded dissent. The Board reached its decision after hearing all of the facts and expert opinion in evidence, after hearing the legal arguments and after applying the relevant legal principles. Whether a case is heard by a court or a tribunal, the facts presented in evidence are crucial to its disposition. So in this case. the circumstances of this incident were highly relevant to the outcome. It is important that the profession be aware of the , facts of the case on which the Board made its determination. This column will focus primarily on the facts of the case and on the majority decision. Next month's column will examine the minority award in dissent and will discuss the legal implications of the decision for the nursing profession. ., -.4. L- .. i\ The decision of the Board has relevance to nurses across Canada; its effect may not be solely limited to Ontario. While the decision of the Board will be material to similar cases in Ontario, the decision will only be of "persuasive" force outside Ontario. In the hierarchy oflegal decision, the determination of a board or tribunal may be overturned or set aside by a superior court on appeal. Thus, within each province, the decisions of lower courts may be affirmed or overruled by superior courts. Decisions of the higher courts within each province are binding upon the lower courts only of that province. Decisions of the Supreme Court of Canada , on the other hand, are binding on all of the courts of this land in similar cases. The Board's ruling, therefore. will affect similar cases brought in Ontario. However, a different award might result if the facts of the case were sufficiently different to distinguish it from the Mount Sinai circumstances. The facts The following facts are taken from the reported decision: . The nurses' shift began at 1930 hours and terminated at 0810 hours - a 12 hour and 40 minute tour of duty. There were six nurses working on this shift - four were I.C. U. nurses and two were relief nurses (non-Le.U. nurses). Ofthe latter, one nurse had not had any experience in ventilating patients in the previous two years nor at Mount Sinai Hospital, while the other had no experience in ventilating patients. . There were eight patients already being cared for in the I.C.U. Five of these patients required ventilating. . The nurses' evidence was that this was "the busiest night they had ever experienced" . . The cardiac patient, R, was brought to Emergency and during investigation suffered respiratory arrest. R was intubated and ventilated manually. The senior medical resident decided that R 's admission to the I.c. U. was necessary and began to prepare him for admission. He telephoned the unit in order to advise the nursing staff of this admission so that the necessary admission preparation would be commenced. The nurses refused to accept the patient. . Telephone conversations ensued between the nurses and the physicians. The nurses informed the nursing supervisor that they felt that they could not accept another patient. The supervisor told the nurses on the unit that they' 'should cope" with the problem and "to do the best that you can". The supervisor later called the unit to report that Dr. H was coming in. Again the nurses protested to her that they could not take care ofthe patient R. The supervisor thereupon told them "to try anyway" . . The nurses did not provide nursing care to the patient R. Dr. H was advised by one of the nurses that "no nurse felt Th. Cenadlen Nur.e capable of taking responsibility" for R. Care for the patient R that night was delivered by the members of the medical team. The principle issue before the Board was whether or not the nurses' failure to provide the patient R with the nursing care he was entitled to expect from the hospital"s nursing staff amounted to insubordination. The affirmative finding of the Board upheld the disciplinary action of the hospital. The defence The nurses argued that they had not been clearly instructed to provide nursing care for the patient R and that they had honestly but mistakenly believed that the physicians had willingly agreed to deliver the required nursing care to the patient because the nurses felt incapable of so undertaking in the face of their heavy patient load. They further argued that their refusal was justifiable in the exercise of their professional judgment. Given their assessment of the condition of the patients already under their care on the unit and their concern that if they abandoned these patients, legal liability and professional discipline might result, the nurses felt that this refusal was justifiable. The majoril} decision In their consideration of the Mount Sinai case, the Board applied the principles of arbitration. In their application of these principl ", the Board also considered the extent to which the principles of arbitration law could be applied to the hospital employment setting. "It is a principle of arbitrable jurisprudence that, in order to succeed in a claim of insubordination, an employer must establish that the employee has wilfully refused to carry out a work instruction. The essence of the offence is that it represent" a challenge to the authority of the employer to order and direct the work-force. ". The Board went on to consider the nature of the instructions and the belief of the nurses that the physicians were assuming care for the patient R as stated in their defence. The Board considered this matter within the context of the hospital setting and noted that the nature of the work performed assumes that the employee is one who is self-directed and who, because of the professional skill and knowledge possessed, does not require dose and direct supervision. Such an employee does exercise some independent judgment as to what is required in the circumstances. In addition, the Board clearly stated that in a labor relations context (emphasis added), the medical staff have no supervisory authority o\'er the nurses (emphasis added). The employment relationship is between the hospital and the nurses and the supervisory authority here arises out of that relationship. "...it is the nursing office, in the person of the nursing supervisor, which 'directs' the nurses in what they do. "5 (Nurses should note that the discussion here relates to the. employment context and NOT to the legal aspects of physicians' orders to nurses with respect to a patient's medical care, e.g., the ordering of medications. Different principles and considerations apply to a nurse's refusal to carry out orders of that nature given by the medical staff.) "An issue of I insubordination can only arise where the nurses have failed to respond to an instruction of the nursing supervisor to whom they are accountable. "6 The majority ofthe Board concluded that the nurses had been given instructions by their supervisor to accept and deliver care to the patient R, even though the language used by the supervisor was not that of command. Her approach to supervision was tailored to recognize the professional nature of the relationship between herself and the nurses. Further, the nurses were familiar with her style of approach, having been told in the past to "cope", "to try your best". Therefore, the Board said that the nurses had no reasonable basis for assuming that the supervisor's instructions were not to be taken seriousl y . .. November 1979 15 iðe Hea\ÙI Cu tor Trav \0 \III arfO c,;".a\ Health Guide for Travellers to Warm Climates Second Edition (1979) .'" .'\.\C ("t.,." .., .,...- > .". ... 'i ...'\'-'\ j , -./' \_ 1,..c"'1 , "" .. ..,., ( Q'" 4\o4D1t......." The second -.lillon of the Health Guide lor Travallers to Werm Climetes. published by the Cenedlan Public Heelth Associetion. IS deSIgned to ecquelnt the IndIvIdual wIth the precaullons needed belore Irsvaillng to. and whIle In hot climates It IS a valuable resource publication that can be used by doctors. nurses. heslth educators snd other members 01 the health prolesslon who counsel Intending travellers to the tropics Bnd 5ubtroþlcs In addition 10 In'ormatlOn on proper clothing. how to avoid food. water and Insect-borne diseases. there IS a chapter on vanous medical problems Including stmgs and bltes_ Yellow-fever Vaccination Centres in Canada are listed and an Index to countnes and regions IS provided at the baCk of the GUide which enables the reader to easily Identify what Immunizations are needed for any part of the world and which countries Or areas are malaria-tree or have malaria risks. Caples 01 the Guide ere svelleble Irom Caned 'an Public Health Associstlon. 1335 Cerling. SUite 210. Onawa. Onleno. Csnsds KIZ SNS Tel.: (613) 725-3769 8S tollows Single copIes - $2.50 each 5Q-1()() cop.es - $225 each 101 and ovar - $2 ()() each Prepaid Oroers Only. Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE. QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth, and more information, please clip this coupon and mail today. Name ...................................................... (block letterw) Address ............ _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City ................................... .Postal Code ....... Your graduation school .....,........ .. . . . . . . . . . . . . . . . . . . . . 16 November 1979 The Cenadlen Nurs. The Board also concluded that it was not reasonable in all of the circumstances for the nurses to have inferred that the physicians had willingly agreed to deliver nursing care to the patient R because they agreed with the position the nurses had taken. The Board said that in the face of the statements made by the nurses during the course of the hearing that medical staff are not competent to assess the need for nursing care and to provide it, the nurses should have been concerned about the quality of the nursing care the patient R would receive from the physicians (emphasis added). In considering the judgment made by the nurses that they were unable to assume the responsibility of care for R without jeopardizing the care of their own critically ill patients, the majority of the Board concluded that the nurses did not possess better and more accurate knowledge of the needs of the patients than the medical staff. They based this conclusion on the following: I. The nurses had minimal knowledge of the needs of R, only that he had been intubated and required ventilating. 2. The nurses had no general knowledge of the condition of the other patients on the unit. Each was familiar with the condition and needs of her own patients: knowledge about the other patients was informal and not detailed. 3. There was no team leader designated within the group or charge nurse to make a general assessment of the needs of the patients and of the workload. None of the nurses conducted such a systematic review so that the needs of the unit could be assessed, evaluated and adjusted. 4. The physicians have more extensive training and are in a better position to assess and make judgments of the critical needs of patients. 5. The nurses did not seek the assistance of the intern who was familiar with the condition of all of the patients on the unit. The Board concluded that the medical staff was "in the best position to assess the global needs of the patient and the capacity of the I.C.U. to provide for those needs". 8 In considering the need in the work place for authority in the decision-making process, the Board examined the "obey and grieve" rule. The Board considered this rule in the context of both the hospital setting and the professional nature of the employees. The Board noted that the professional's exercise of independent expertise. knowledge and judgment are important factors to be considered in examining the question of whether or not an instruction ought to have been carried out. The Board carefully indicated that a hospital differs from an industrial setting for. in addition to the interests of the employer and the employee, there is a third interest, namely that of the patients. Thus the needs not only ofthe patient R, but also those ofthe patients on the unit had to be considered. The Board concluded that the medical staff were in a better position here to assess the needs of the patients. The nurses' judgment here failed to meet the test of arbitral review in that the nurses formed the judgment "rather hastily and on the basis of incomplete information" and the judgment did not "properly distinguish" between the needs of R and the other patients. 9 The "obey and grieve" rule permits employees to challenge a management decision. Its operation recognizes the interests of both the employer and the employee in the circumstances. There are exceptions to the strict application of this rule. However, care is taken not to unduly extend the limits of the exceptions. Thus. an employee may refuse to carry out an order where the task is unsafe or is reasonably believed to be unsafe or where the order would result in the employee's committing an illegal act. In such cases, refusal to comply attracts no disciplinary action: the refusal is justifiable. In this case, the Board upheld the unsafe limitation as applying only to danger or hazard to the employee. "We do not believe that the safety exception can be extended to protect persons who are not parties to the collective agreement from personal danger,"'U Under the second exception, illegality, the Board considered the nurses' argument concerning their exposure to potential civil liability and professional discipline. The Board stated that such legal liability of the nurses to the other patients on the unit was uncertain. "It is essentially a question as to whether or not the nurses conformed to the standard of care of the reasonable nurse in the circumstances and, while it is not our role to decide the question of the legal liability of the grievors. one would expect a Court of law would, in assessing this question. have regard to the circumstances. "\I The Board characterized as dangerous the recognition of the defence of illegality in this kind of case because of the uncertainty with respect to legal liability . In their view, to recognize the defence would interfere with the employer's interest in having work assignments completed. The Board recognized that this approach "puts employees at some risk". However, in its view, the risk was not substantial. . The employer as a hospital is under a statutory obligation to provide care for patients admitted into the hospital. Moreover. the employer may well be liable both originally and vicariously for damage which results to patients while in the institution. That circumstance requires that the employer be put in a position in which it can effectively insist that certain instructions be carried out. I f the employer were unable to so insist and were to be in the position of having to defer to the superior profess ional judgment of its employees it would be placed in an intolerable legal position, one in which it could not protect itselffrom legal liability ,"12 Having so determined. the Board di'imissed the nurses' grievance. The nurses appealed to the Divisional Court. That court upheld the finding of the Board. The legal implications of this decision will be the subject of next month's column together with an examination of the decision of the dissenting Board member. '" * References I (197M) 17 L.A.C. (2d) 24:!. 2 As yet unreported: reasons released Apr.18. 1979. 3 Supra, Note I. p.26!. 4 Ibid.. p.245. 5 Ibid.. p.246. 6 Ibid. 7 Ibid.. p.25!. 8 Ibid. 9 Ibid.. p.253. 10 Ibid., p.259. II Ibid., p.260. 12 Ibid.. p.26!. *U nable to verify in CNA Library -- "You and the law" is a regular column that appears each month in The Canadian Nurse and L'infirmière canadienne. Author Corinne L. Sklar is a recent graduate of the UnÏ\'ersity of Toronto Faculty of Law. Prior to entering law school, she obtained her B.Sc.N. and M.S. degrees in nursing from the University of Toronto and UnÏl'ersity of Michigan. - . a ..... """ Top of the line from Saunders .1 " ti I l!. ....II :; I" " ..1 !i ","'1-1 ': _ ,111 ;íll- ,.11 1 .)1'" ' JI i " I '- ;U J I ,.ØJ ; r--------------------, I I I I I I I I I I I I L _ W.B. 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The Nursing Clinics give you expl icit. in-depth coverage of the mosl recent advances in effective techniques. The concise, reliable information in first-hand reports by qualified contributors lells you how they cope. 1980 SYMPOSIA March 1. Central Nervous System Disorders in Children 2. The Self-Care Concept of Nursmg June 1. Community Health Nursing 2. Rehabilitation September To be announced December To be announced Published quarterly. Each ISSue averages 185 pages Hardbound Yearly subscription: 522.80 (by sending a checlo. or money orderfor 521 00 you can save 51 80 from the ordinary subscription priCe) ..-. "---- III"'" .... ., I "., .... Watson Medical-Surgical Nursing and Related Physiology 2nd Edition Thoroughly revised, this new edition includes the latest information on topics ranging from patient s rights. response to illness and physical assessment-to immunologic response. shock and much more. The chapters on cardiovascular disease and the nervous system have been extensively revised. An excellent choIce for those prefernng a smaller medical-surgical text. ByJeanne"eE. Watson. RN. MScN. Prof Emeritus. Faculty of NursIng. Unov. of Toronto. Can 1043 pp 161 III 52395 Sept 1979 Order 119136 6. Tilkian & Conover Understanding Heart Sounds and Murmurs Here s an exciting new package that provides a basic familiarity wilh normal heart sounds and allows recognition of life-threatening disorders manifested by abnormal heart sounds Package includes C-60 cassette plus soft cover book. By Ara G. Tllkian. MD. FACC Asst Clinical Prof of Medicine (CardIology). Umv. of California School of MedIcine. Los Angeles and Mary Boudreau Conover. RN. BSN. E<' Instructor 01 Crrllcal Care NursIng and Advanced ArrythmIa Workshops. West HIlls Hospital and West Park Hospital. Canoga Park. CA Book only: 122 pp IIlustd Soft cover. 510 75 Aprrl 1979 Order 118869-1. Package: 520 35. Order 118878-0. 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Topics include the physiology of anesthesia. the effects of various anesthetic agents, specific care after all types of operations and factors that affect recoverv from anesthesia in particular patients By Cecil B. Dram, RN. CRNA BSN. Major. Army Nurse Corps. Univ of Arizona. Tucson: and Susan B. ShIpley, RN. MSN. Major Army Nurse Corps; Nurse Researcher. Walter Reed Army Medical Center. Washington. DC 608 PD 167ill 52035 March 1979. Order fl3186-X. CN 11/79 I I ::J Enter my subscnpllon to the Nursmg Climcs with the next Issue Full Name l Position and Affiliation (If Applicable) I Home Phone Number Home Address ZIP City Signature State 18 November 1979 The Canadian Nurse healthy child, a sure future rHedlthiest dbies Possible The Vancouver Perinatal Health Project Sandra is eight weeks pregnant with her first baby. She appears pale and anxious. and has started her pregnancy 20 pounds (9.09 kg) underweight. Sandra and her husband, Bill. have recently moved to Vancouver from northern Briti h Columbia. This isolation from family and friends has escalated their concerns about becoming parents. Manjit, an East Indian woman. who speaks very little English. is pregnant for the fourth time in three years. Her first baby weighed 200U grams and ha been ill frequently. Her second pregnancy ended in a miscarriage and her third pregnancy resulted in another low birthweight haby. 2400 grams. Three months postpartum, she is now pregnant ........ - .- J . Jenfl({er Warnvca Susan Ron Christine Bradley dgain. Manjit and her husband came to Canada four years ago to join his parents and his brother's family. As her husband is a lahorer at the saw mill. it is difficult for them to make ends meet. What Sandra and Manjit have in common is that they were both part of the Vancouver Perinatal Health Project. This two-year project which began in November 197() was designed to identify and respond to such problems a<; 10\.\ birthweight. perinatal mortality and morbidity. In I 97(), approximately seven percent of the babie<; born in Vancouver weighed 2500 grams or less. This occurred despite excellent phy ician and ho pital resources. It compared poorly , '- .... . .. ... o to the low birthweight ratio of other developed countries such as the four to five per cent in Scandinavia and five per cent in France.' Obviously. it is not enough to rely olely on medical and hospital care to obtain the be<;t possible perinatal health. Many aspects of health involve personal respon<;ibility: poor maternal nutrition, smoking and alcohol consumption are known to have majoreffect<; on the health of newborns. Exi...ting programs did not deal with these problems fully. Therefore the Project wa<; planned and implemented with major priority given to assuring maternal well-being during pregnancy. / ---- ':;: " , " =' go -" õ õ -" c.. C '" o '" .s Ii: õ! " .2 ;;; z ;>, .D .E c.. .. ... ; The general purpose of the Vancouver Perinatal Health Project wa'i tv. o-fold: . to demon'itrate that the combined influence of specific and validated health mea,ure,>. initiated early in pregndncy, v.ould result in hedvier. healthier infants. . to determine a method by v.hich a more effective perinatal health system could be provided for the community. Tv. 0 programs were developed: Parents. Choice, a comprehensive perinatal health program for cla s attenders and Healthie t Babies Possible. an outreach nutrition program for the hard-to-reach woman. I. PARE:\TS' CHOICE This program v.as designed to plOvide comprehensive preventive sen ices during pregnancy, childbirth and the early postpartum period to the expectant couple. I n addition to eight prenatal and two postnatal cla'ises. it had several unique feature.. which di'itinguished it from regular prenatal cla....e... . A multidi_sciplÙwry team approach to perinatal care: The team consisted of a dietitian-nutritionist. a communit} health nurse. a research psychologi'it and an office manager. The participating ph} sicians and the ho pital staff of 5t. Paul"s Hospital. Vancouver were al..o part of the team. Communication betv.een team members wa.. a priorit}. . Early re.ferraland systematic llHeHment of clients: Client.. were referred to the program on confirmation of their pregnancy (six to 13 weeks gestation). Evaluation started at the initial interview and included asseS'iment of their medical. nutritional. social and emotional needs. The nutritional a'isessment wa'> augmented by a computer progrdm for diet anal}..i... which was designed specifically for prenatal evaluation u..ing current Canadian Dietary Standard! and the Higgins Method. ' for recommended intake. One seven day. one five day and one 24-hour diet and activity record was analysed for each client and follow-up counseling wa, given by the nutritionist . Continuit'- of care: The community health nurse. who taught the classes. visited the client.. in the hospital and made home visit, until six months postpartum. This facilitated as..e'i,ment of coping abilitie during the transition to parenthood. The team approach to perinatal care served to enhance this continuit} of care. The Canadian Nurse . Postpartum support :0. en-ices: As the postpartum period is a critical one for establishing new family relationship'" and as it i!oo especially important that new mothers and families have ready access to health care resources. postpartum services were developed by the project_ The,e included weel.Jy drop-in 'ie'isions. brea..tfeeding support, lending library, volunteer babysitting. cla'is reunions and publication of a newsletter. Sandra wa'i referred to Parent's Choice by her phy..ician when her pregnancy was confirmed. At an initial interview with Jennifer. the Project community health nurse (chn). Sandra and her husband. Bill. were given information about her pregnancy and the effects of her lifestyle on the growing fetu,> (11 ri'i!.. assessment). During Sandra's fir t trimester, the} attended three prenatal clas..es along \\ith several other couples, all of whom were expecting their first baby during the same month and \\ ho were delivering at the same hospital. The..e clas es were taught by Jennifer with help from Sue. the dietitian-nutritionist. While in the fir,t trimester, Sandr;l !..ept a se\-en day food record which wa, analysed b} computer for nutritiondl adequacy. She \\a.. then seen by Sue for indi \- idual nutrition coun..eling. Nutritional analysis wa'i repeated at 20 v.eeb and 34 wee!.., gestation. With counseling and encour;lgement, andra made great imprO\ emems in the quality and quantity of her food inta!..e. She gained 45 pounds during her pregnancy (a net gain of 25 pounds or 11.35 kg). Sandra wa.. given information about the effects of smoking on her baby and ..he h;ld an individual coun'ieling session with the Health Department physician. \-lotivated to have a healthy baby and \\ ith the ,upport of the Project staff and her hu..band, she managed to quit ,moking altogether by 20 \\ eeks gestation. Nov.mber 1979 19 In their first three prenatal classe.., Sandra and Bill learned about the anatomy and physiology of pregnancy. fetal development. nutrition. lifestyle and preparation for parenting. They practiced exer"i,e'i, breathing techniques and relaxation. The fourth clas,. given at 20 weeks gestation. focused mainly on preparation for brea..tfeeding. The last four clas'es occurred in the third trime,ter. They covered labor. delivery, the newborn. early postpartum and included a tour of St. Paul".. Hospital. After she had completed the cla..ses, Sandra came regularly to the weekly drop-in to practice her breathing and to meet other Project mothers. It was here that ,he made the decision to breastfeed after seeing so many happy nursing mothers. Here too. she had a chance to talk over and allay her many fears concerning childtlirth. She began her lahor prepared and confident. Michael was born after a ten hour labor \\eighing 3600 grams. He WdS alert and active and nursed vigorously on the deliver} table. Breastfeeding and infant care teaching. initiated hy the Project team. wa.. continued by hospital staff. They were very 'iupporti\-e of tichael rooming-in with Sandra, and Bill could vi'iit both hi' wife and child whenever he pleased. During Sandra'.. hO'ipitalization. Jennifer vi'iited to di..cuss her labor and delivery and to prmide continuity of care. Home vi its were made routinely at one week, three months and six months pO..tpdrtUm. At each visit. Jennifer weighed, mea,ured and examined \lichael and answered Sandra's many que,tion... Data wa'i collected regarding the baby', nutritional status and his health. At three and si, months. \-lichael wa' given the Denver Developmental Screening Test. Sandra and Bill came to two postnatal classes which covered infant development. infam feeding and postpartum adjustment. Sandra continued to attend the weekly drop-in. Table one BIRTHWEIGHTS 1975 1976 1977/78 1977/78 Comparison Project N=445 N=472 N=358 N=156 Average (g) 3340.9 3289.3 3319.1 3440.3 % 2501 (g) 7.4 6.6 5.6 3.8 & under % 3001 (g) 21.6 26.8 233 16.6 & under 20 November 1979 When she had difficulties with sore nipples. the support and advice from the other mothers and the Project staff helped her overcome them. She continued to breastfeed Michael for ten months. One lasting benefit of the Project was the babysitting cooperative started by Sandra and some of her classmates. The co-op allowed the mothers time to develop their own interests and the babies benefited through interaction with other infants. Results Outcome measures such as birthweight and infant health of the 156 Project babies were assessed and compared to information gathered about the infant'i of a nonproject group. This comparison group was formed from women who al,o delivered their first baby at S1. Paul's Hospital but who did not participate in the Parent's Choice program. Prenatal class attenders from within the comparison group were also studied. Maternal risks and the impact of psychological prohlems on the prenatal period were evaluated. · Birth outcomes: The Project group improved upon anticipated birth outcomes by achieving a mean birthweight of 3440 gram, and a low hirthweight rate of 3.R per cent. Table one shows the hlrthweight results for primipara at S1. Paul's for the year, 1975 to 197K I n addition. over 54 per cent of the Project infants attained an optimal birthweight of over 3400 grams as opposed to onl y 42 per cent of the comparison group infant.... However. the bir1hweight of the Project infants wa, not significantly greater than that of the infant, of the prenatal class attenders. · H ealth ( rthe infclf/t: There were statisticall} significant differences hetween the Project group and the comparison group in the area of mfant health. The PrQ;ect group had a higher rate of breast feeding at discharge from hospital. one week. three months and six months postpartum. At three months. the illness rate of the comparison group infants was three times greater than that of the Project group. As \-\-ell, the Project infants weighed more at six months, started solids later. and a greater proportion received fluoride drops. This improved infant health wa'i ,till apparent when Project infants were compared with the infants of the prenatal cia,.. attenders. The Canadian Nurse Table two RISK FACTOR ASSESSMENT Risk Factors Diet - calories (less than 90% rec. amount) protein (less than 90% rec. amount) Weight gain (poor, irregular) Underweight pregravid Infection (vaginal, respiratory) Under 18 years Smoking Significant alcohol (greater than 21 gm/day) Significant drugs Financial problems Previous poor outcome (miscarriages and abortions) Stress (marital, emotional, fatigue) Percentage 45 10 35 40 70 1 24 8 25 30 35 75 · Maternal ris" manaKement: A system of maternal risk factor a...sessment wa, developed in the course of the program'. Twenty-five risks ranging from diet to stress were a...sessed and totalled for each of the 156 women once each tJimester. The average risk score per trimester wa'i 4 and the average ri..k score per pregnancy was 13. O\-er one half of the women were considered to be moderate or high risk (score of 10 or more). See Tahle two for Risk Factor Assessment. De..pite thi...large percentage of women at risk. succe...sful birth outcomes were achieved through intensive nutrition and lifestyle counseling. For example: -The increase in diet for women at risk averaged 426 calories and 26 grams of protein. Caloric and protein intake were significantly related to birthweight. -The mean maternal weight gam for pregnancy was .. 5.6 pounds (16.2 kg.) with a net gain (when adjusted for underweight) of 32.5 pounds (14.S kg.). This higher net weight gain resulted in modification of the impact of low pregravid weight on hirthweight. -As well. there was a decre.lse in the numher of clients drinking alcohol from 76 per cent to 46 per cent and a decrea...e in the numher of ...mokers from 27 per cent to 15 per cent. · Psychological aspect.L Very little ha... heen written hnking psychological aspects of pregnancy with physical outcomes. In the Project group. it Was found that higher levels of anxiety and depression ,I'i measured by the State-Trait Anxiety Inventory' and the Depre-.sion Adjective Checklists 6 were a,sociated with: -less net weight gain of the mother -less weight gain and lower birthweight of the infant -a higher pregnancy risk score -a shorter length of ge,tation -fewer \-\-eek-. of breast feeding -longer stay in ho,pital (mother) -less positive dttitude, towards lahor, delivery and haby at one month and three month... II. HEI\L THiESr BABIES POSSIBLE Healthiest Rabie... Po..sible (HRP) wa, an outreach program to provide free prenatal nutrition counseling to women at risk. The program was dðigned to complement existing prenatal classes by predominantly reaching women who did not attend clas...es and by encouraging wider use of these and other health service.... Counseling wa.. provided by paraprofessional Nutrition Aides. The Aides functioned as "informed pee..... .. They were lay people with community work experience who were given a ...ix-week training program on nutrition. pregnancy and counseling. The bilingual Aides were all recent immigrants to Canada but with good English language skills; Native Indian and low income Aides had experienced living on Social A...sistance therehy gaining an understanding of the services dvailahle to low income families. Service was aimed at two target groups: cultural or language groups, e.g. East Indian. Chinese. Greek. Italian and Native Indian and women needing special intervention. e.g. lo\-\- income, teenagers. single women. nutritional ris",". Counseling was available in five language.. and wa.. open to hoth primigravida and multigravida. An exten,ive publicity progrdm and information 'pread by word of mouth re...ulted in many ...elf-referrals in addition to referral... hy physicians, ...ocial workers and puhlic health staff. \Ianjit is representative of the "omen seen by the HealthIest Bahies Possible Aides during the Project She "a" referred to H BP by a friend who was also receiving counseling. I-.amlesh. the Ea'it Indian Aide. visited her at home six time.. during her pregnancy and twice in the pO'itpartum period, counseling her in their common language. Punjabi. -'\s the primary aim of the counseling "a" to promote a health} life'ityle. e..pecially in the area of nutrition. Manjit's diet wa.. as'iessed using the 24 hour diet recall. her weight record. gener,tI ri..Io.. assessment and a detailed discu..sion of her food habit... <\nalysis of her protein intake wa, indicated because orthe vegetarian diet. Gift certificates for liters of milk a "eek were gi\-en to \larUit to supplement her diet. In addition to prenatal nutrition coun..eling, I-.amlesh advi'ied \larUit on budgetmg and infant feeding. She enrolled her in Engli..h cla....es for immigrant women and acquainted her with resource.. available in her community. After a fulltenn pregnancy. M,tnjit gave birth to a healthy son. Gurdeep. weighing 3350 gmms. Gurdeep wa.. hrea..tfed and had none of the feeding problem.. and re..pimtory illnesses seen in his sihling... Following the birth. \Ianjit had a tubal ligation. the re..ult of a decision she and her husband had made after a famil} planning discus..ion with !...amle..h. Nll\\ they were o.".uI SI..-n (;...-d.I 19!11 1gee The teenage birth rate I s the rate of teenage childbearing actually increasing? The teenage birth rate is a measure of the number of births per 1.000 females aged 15 to 19 years of age. It is used to determine the likelihood that a teenage woman will give birth and is the best parameter to assess changes in childbearing. as it takes into account alterations in the total teenage population. Canadian statistics over the pa'it 55 years (See Figure one) reveal a definite pattern throughout the entire country. Having reached a high in 1961, the teenage birth rate has actually been declining since then. as evidenced particularly in the 1976 rates. the last year for which figures are available. A smaller proportion of teenagers are having babies today than at any time since the 1940's. Clearly. we are not in the midst of an epidemic of teenage childbearing in Canada. I nstead. we appear to have made considerahle headway in halting what was a growing problem. The teenage birth ratio How then can we account for the recent attention given the whole area of teenage childbearing? The answer appears to lie in the kinds of statistics which have been used to measure changes in childbearing. The most common one quoted is what is known as the teenage birth ratio. Thi'i ratio i'i established by determining the number of teenage hirths per I ()()O births of the total population. rhis parameter i'i useful in determining the impact of teendge childhearing on service.. provided for the newborn since the -- ..-nt M" 0If ..-D ". " "'" AIC). \'lAM..... 0WI;1Il CAMADot. ,., I''''' --......... --......--..... "'. ..,- ---- ...- .... -....... ....... ..., ,.' '.. .... _ 1'71 "7\ --. ...,.. d -..... I!l-I''' - ....Rllllld........lOy-..-.JO'- "'r"d_""1S-1' ." ___d 'OOO_""I!t-" a.t't'..d_8gMI2O-6!!.........., &our.:. I_..F... _'--_'*'12 nP 1'1'&. The <;ituation in some province<; is quite alarming. British Columbia. for in<;tance. has a rate of abortion among ib teenage population that almost equals its childbearing rate. The conclusion is obvious: abortion is being used a.. a means of birth control. The teena e iIIe itimac rate In view ofthe e facts. can we infer that no problem exists concerning childbearing and pregnancy among our teenage population in Canada? The ano;wer to thi is an emphatic no We do have a problem and one that is continuing to grow in magnitude. I n the o;tati..tic relating to out-of-wedlock childbearing among teenagers. the percentage of teenage birth<; that are out-of-wedlod. hao; been mcreao;ing at an alanning rate over the pao;t :!O years (see Figure four). Twenty years ago. the respono;e to a premarital pregnancy was most often marriage. If the mother did not marry. adoption was generally the alternati\-e. Toda}. teenage mother.. are increasingly opting to remain single. Alternatively. they seek abortion. What increa..es the o;eriousness of the <;ituation i<; the fact that more and more oftheo;e young women are deciding to keep and raio;e their children on their 0\\ n. November 1979 23 .....- "l1li Cl:1I'T Of' OUT-()II' ...DI...OCII. ..,... TO 'UII"'aon CAfIADA '''' I_ .... .... -c........, __ 0.- o OudWlillolllllclla...s o .....1Ow.dP... Although no national figures are available on this trend. some indication of the numbers of single mothers Io..eeping their babies can be obtained from individual hospitals. All births in the Halifax-Dartmouth area of Nova Scotia. for instance. occur in a single maternity hospital. In 197().ju<;t overlWperC'ent of all babies born out-of-wedlock in this ho..pital were kept by their mothers. These percentages seem to be getting higher. In o;ummary. the situation is this: even though the actual rate of teenage childbearing is decreao;ing. ofthoo;e who do give birth. more and more are remaining o;ingle and keeping their infant . The implication of the situation are disturbing. !\Iany of these mothers are only children themselves. yet they are making the decision to keep their children. This decio;ion io; a\\eo;ome. con idering their immaturity and the tremendous responsihilitieo; that such a choice entails. What are the consequences ofthis decision? Should our health care o;erviceo; be giving special attention to this grov.ing population of young mothers ?The an wer muo;t certainly be }es. or;, Susan \lacDonnell.B.A., M.A.. is the Principallm'estiRator of a "Study (Jf Unmarried Jlother.l." which is current". hei/lR carried out hy the Nm'a Scotia Department ( fSocial Ser..;ces, u'ith fimdi/lR from Health aflll Welfare. Canada. 24 November 1979 The Canadian Nurse healthy child, a sure future A Regional Program for the Management of Hereditary Metabolic Disease Terry Reade allllCaroline Clow The authors describe a unique program designed for the treatment of patients with complex diseases due to inborn errors of metabolism. I nre.wiRation and treatmem of children with inborn errors of metabolism is relatirely nell' in the field o.{health care. The Hereditary Metabolic Disease unit at the Montreal Children's Hospital was one of the first o.{its /..ind to be established in North America and. since /967.. has been caring for an increasing numher of children with treatahle Renetic disorders who require speciali ed care and clo. e supen'ision. Techniques, de\'eloped lInd e\'aluated in the unit, depend on allied health per.\Onnel im'o/i'ed in the care ( { ambulatory patients. The re.mlt: an imegrated prugram that prol'ides optimum care to patienh at an acceptahle le\'el o{cost-e.f{ecti\'ene.u. I Our treatment center in Montredl is one offour in a regionalized network of Genetic Medicine formed in 1972 in the province of Quebec under the provincial Ministry of Social Affairs. In addition to treatment of hereditary metabolic disease, the Quebec Network of Genetic Medicine provides genetic screening. counseling. a prenatal diagnosis service and ongoing research." I t is operated by the four university medical schools in the province: Laval. McGill. Montreal and Sherbrooke. Each of the four regional centers of the network has individual areas of expertise and is free to design programs to meet the needs of its particular community. At the McGill center. located at the Montreal Children's HospitaL" patients are referred either by a physician. the hospital or they may have been detected in the newborn '\creening program (Figure one). Medical intervention provided by the Unit minimizes the effects of various metabolic diseases resulting from the expression of mutant genes. Non-physician personnel. one of whom is a registered nurse. perform moo;t of the health supervision and technical work in the management of the patients. The approach is predominantly aimed at ambulatory patients and many of the procedures for monitoring disease control are performed in the home. Two staff members work full time co-ordinating the daily care of70 patients with a dozen different types of hereditary metaholic disease; help is available from other members ofttle health team in the Biochemical and Medical Genetics Figure one: Relationship bet"een senices of screening b Quebec Net"ork of Genetic '\ledicinc and other health pro\iders. SCREE"III G '-. THE P TIE T \ \ TREAT'1E T r COl I'oSELING j Divi.,ions. Weekly team meetings are held to review the progress of patients and to discuss current m.edical problems. Community and hospital resources are used extensively and contact with patients is maintained on a continuing bao;is by mail and telephone. or through home visits if indicated. Medical care not directly relevant to the management of the genetic disease is provided by the family physician or pediatrician to whom periodic reports are sent. Treatment Most physicians. whose opportunitieo; to treat any single genetic disease over a lifetime of practice are limited. welcome the centralized treatment of genetic disease where teams of experts share their experience with several diseases. Once the appropriate diagnosis has heen made. the patient is officially entered into the program. One of the full time allied health personnel then becomes involved, along with the geneticist. in organizing and helping to carry out diagnostic procedures. The test results are collected and o;taff often attend discussions with the various consultants and the patient's parents. Subsequently. 2 þ REFERRAl h \10 HOSPIT<\L The Canadian Nurse November 1979 25 a suitable home program is organized for each patient who requires treatment, a program which varies according to the type of disease. The principles, however, are simple and employ four basic procedures. alone or in tandem.' 1. substrate restriction, when substrate accumulation is the principle cause of the phenotypic pathology 2. product replacement. when depletion of a metabolite is the important event 3. coenzyme supplementation when activity of the mutant enzyme can be enhanced by large amounts of coenzyme 4. enzyme replacement. A low intake of phenylalanine in classical phenylketonuria /PKU) and of branched-chain amino acids in maple syrup urine disease (MSUDI illustrates the principle of substrate restrictmn. Patients with these diseases require a permanent special diet: nutrient intake must be balanced in order to limit the intake of compounds potentially harmful to them while supplying the nutrients necessary to promote normal growth and development. Dietary products, which are made available for these patients through the "Food Bank", make it possible to treat rare hereditary conditions with success. Frequent blood monitoring is done in the home by the nurse for the infants with maple syrup urine disease -less often for older patients if good control is maintained. In children with phenvlketonuria. blood samples are taken by parents or the nurse. to monitor the phenylalanine concentration and to provide an index of biochemical control. These samples are collected on filter paper and mailed to the Net\\ork's control laboratory in Quebec City. After analysis the results are then phoned to the unit. Other patients. o;uch as those with X-linked hypophosphatemic rickets. require a different mode of treatment which follol.\oo; the principal of product replacement. Phosphorous. lost from the bOdy in the urine becauo;e of an inborn error of membrane trano;port in the kidney. is replaced by oral supplementation and with added vitamin D. The patient takes these medications periodicall} throughout the da} and blood levels are monitored in bi-monthly home visits. If the patient lives too far from our center. blood sampling is arranged at a hospital or clinic near their home and the results are mailed to us. The parents of children with various types of genetic disorders are trained, mostly by the health personnel. to manage their child's condition. When children are part of a home care program the burden of care is placed mainly upon the parent!> who have [0 cope seven days a week, year after year. with special diets or medication. Added to this heavy burden is often an underlying feeling of guilt and responsibility for their child's genetic defect. Parents are encouraged to telephone if help is needed but as their understanding of the disease and its treatment grows, most families become more and more self-reliant. Regular home visiting gives the nurse an opportunity, through her observations and communications, to assess the parents' ability to manage theirchild's medical regime. We have found that families welcome the mutual concern and exchange of information: they are reluctant to call a busy physician about the little things that worry them. A survey recently carried out by a third party independent of the program showed that most parents have developed preference for involvement with allied health professionalo; in the care of their children. The Food Bank Our e\penence with dietary treatment. and with the distribution of o;pecial diets through the centers of the Quebec Network. led to the development of a National Food Distribution Center for the Management of Hereditary Metabolic Disorders in Canada. The "Food Bank" has a networlo.. of treatment centers right acroo;s Canada and ensures regional availability of the special diet products necessary in the treatment of patients with hereditary metabolic disease. It also provideo; a system which permits collaborative evaluation of treatment programs. The development of the food bank was an important step in the care of patients requiring special diets: the semi-synthetic milk substitutes and special food items are absolutely necessary for treatment of some inborn errors of metabolism. In Quebec. the regional genetic center repre.,entative notifies the health center closest to the patient. and the diet products are made available at no cost to the patients through the Quebec provincial department of social affairs. The parents place their order every month and pick up the food when notified by the health center in their district of ito; arrival. Conclusion The Hereditary "Ietabolic Disea.,e Unit at the Montreal Children'o; Ho.,pital provides a much-needed service in the management of 'everal complex metabolic diseases. With the help of the home-vio;iting program and the food bank. personnel are able to initiate and carry out individualized treatment plans to improve and maintain the well-being of patients with hereditary metabolic disease. 'iI Hereditary Metabolic Diseases treated by Home Care Program phenylketonuria hyperphenyla1aninemia hereditary tyrosinemia homocystinuria cystinuria cystinosis Fanconi syndrome vitamin 0 dependency maple syrup urine disease histodanemia pseudohypoparathyroldism hypophosphatemic bone disease miscellaneous others Terry Reade i.\ a Rrtlduate of the H OJpitalfor Sick Childrell School c f Nursing ill Toronto. alld receil'ed her B.A. from C vncordia V llil'enity in 01ltreal. .\peciali::.illR ill community IIursÙIR. She i. currently Ùn'oll'ed with the Hereditary M etaholic Disease V nit and is a re. earch associate with the Faclllty( rMedicille. McGill Vnil'enity. Caroline Clow, is co-director oIthe etaholic Disease Vllit at the Montreal C hildrell' s Hospital alld is aleclllrer ill pediatrics at McGill Vllil'ersit.\". .\cknowledgements: The authors It'ould li/"e to expreu their appreciatiOll to Dr, C .R. Serher, director of the de Belle Lahortltory.f;,r Biochemical G elletin at the M vlltreal Childrell' s H ospitalfor his cOlltilluous adl'ice and enCOllrtlRemellt a lid to the Milli.\lry ,,(Social A.f.fairs. VII hell{l{rc f the Quehec N etwor/" ofG elletic edicille. which 11lI. helped /IS appl,' vur /"nowleciRe to patient. with Renetic disea. e more e.trectil'ely. References I Clow. C L. :\tanagement of hereditary metabolic di,ease. The role of allied health personnel. by Cl . Clo\\ et al. New EIIRIMed. 84:1292-1298. Jun.lO. 1971. 2 Scriver, C. R. Genetics and medicine: an evolving relationship. by CR. Scriver et al. Sciellce 200:4344:946-95 . May 26. 1978. 3 Reade. Terry. Home care of children with inborn errors of metabolism. by Terry Reade and Caroline Clo",. C Gllad.N une 66: 10:41-42. Ocr. 1970. 4 C low. C. L. On the application of knowledge to the patient with genetic diseao;e. by C L. Clo\\ et al. Prog.Med.Gellet. 9:159- IJ, 1973. 5 C ommiltee for I mprovement of Hereditary Di.,ease Management. Management of maple o;yrup urine disease in Canada. C wllId.M ed.A S.\' I 115:10:1005-1010. Ion. Nov.20. 1976. 26 November 1979 The Cenedlan Nurse health child, a sure future The single mother: can w-e help? More often than not, regular prenatal classes fail to meet the special needs of the young, unmarried expectant mother. What are their needs? How can nurses learn to recognize and do something about them? Jo Billung-Meyer In spite of sex education in the schools, more liberal access to birth control information and methods, and in spite of essentially legalized abortion, the single teenage mother is a definite entity in North America today. Observers disagree on the reasons behind this paradox. Why is it. for example. that almost all (95 per cent) of teens st:eking contraceptive advice at birth control clinics have already experienced unprotected intercourse? What observers do agree on are the substantial hazards - both mental and physical - that surround and threaten these young mothers and their offspring.. Dr. Sidney Segal. head of the division of maternal. fetal and neonatal medicine at the University of British Columbia. and director of neonatology at Vancouver General Hospital. observes: "the child born to a mother 16 years of age or younger is three times as likely to die before it reaches its first birthday; or if the baby survives. it is more likely to have brain or nervous disorders."2 Segal feels that some extra risks of pregnancy. such as hypertension. anemia. toxemia, or prolonged complicated labor. may arise because young mothers actually reject prenatal services and nutrition advice. Aside from the obvious physical dangers is the fact that an ever increasing number of these adolescent mothers decide to keep their babies but discover after a year or two they cannot cope and then give the baby up for adoption. This time lapse can result in irrevocable psychological damage to the child. Of the 5002 illegitimate births recorded in B.C. in 1977, only 865 babies were adopted out: less than half of these placements were made during the first month of the baby's life. Teenage mothers are seldom in a favorable position when it comes to providing the emotional and financial support their baby needs. Many are themselves the victims of inadequate parenting and are currently undergoing varying degrees of conflict with one or both of their own parents. A large majority are school dropouts, lacking marketable job skills or experience. Not surprisingly, the incidence of child abuse and neglect is higher in the homes of single teenage mothers than in the general population. 3 Obviously. the adolescent mother needs all the help she can get in the crucia! months before her baby is born. Why then. when childbirth education is very much the accepted thing these days, do single young expectant women reject the conventional support systems provided by society in the form of prenatal education classes? I think I found the answer in dealing with the few single expectant mothers who came to my prenatal classes for couples: I became aware of the guilt, fear. stress and often the sense of tragedy that attend<; these young girls. Many of them simply dropped out of the classes because they felt like outcasts in the atmosphere of togetherness and mutual support of the couple-oriented programs. Although they were very frightened by the prospect of childbirth. they tended to deny their fears: the deep sense of guilt they repressed often made them reluctant to disclose even their identities. Some came from other cities. hiding out during their pregnancies in the back bedroom offriends, isolated,lonely and very afraid. The project Observations such as these spurred me on. a few years ago, to introduce a pioneer program designed especially for single expectant mothers: I was convinced of the urgent need for this specialized type of program. After considerable study. planning, thought. and personal financial investment. I came up with a course which essentially used the group dynamics approach to promote peer support. A warm and relaxed atmosphere was to be created in which each girl would feel free to express her feelings and thoughts. and where mutual support could be both given and recei ved. My aim in conducting the classes was to prepare the single mother mentally and physically: to increase her knowledge of pregnancy and childbirth. to improve and maintain her health and that of the infant through nutrition counseling, and to build her self-esteem so that she might face her new role with greater strength and courage. A social worker was available whose counseling made each mother aware of her options to either keep her child or place the baby for adoption. Referrals were also made to the home visiting teacher employed by the Greater Victoria School Board, and the girls were encouraged to continue their education to increase their ability to provide adequately for the child. My overall objective was to help these girb turn their pregnancy from an utterly devastating crisis into an experience from which they might learn and grow. Planning considerations Any good prenatal course such as those suggested in the Teacher's Guide of the International Childbirth Education Association ManuaP may be adapted for single mothers if one keeps in mind their special needs. Erikson" points out that the failure of an adolescent to develop a sense of identity leads to role confusion and prevents the individual from attaining the next step in development- the ability to be intimate with others. "If any of these stages go unresolved, they can hinder the individual's development. contentment. and satisfaction with life. I n the pregnant adolescent. this will lead to difficulty in forming relationships and in parenting her infant." It was apparent that the single mother's greatest immediate needs were to be accepted, 10 develop a positive self-image. to belong to a supportive peer group, and to have her fears replaced by knowledge. It is important to relate to each mother on an individual. caring basis, as well as to strive 10 make the course acceptable to all. In the words of Steinman: Staff members should expect adolescents to become dependent in this new situation of pregnancy. but independence is the ultimate goal, for independence is essential to parenting capability. Meeting someone's personal needs mOl'es her in the direction of independence. Like a child. a patient learns to trust the person who is prm';ding for or nurturing her (dependence). Later she will be able to use this nurturance in establishing independence for herself and her off-spring. 6 A simplified psychoprophylactic method such as the modified Lamaze can readily be learned in an 8-week course. Since most single mothers tend 10 be tense due to their situation. more reassurance and word-imagery is required than usual to help them master the breathing and relaxation techniques. They can be motivated easily with the explanation that the purpose of the exercises is to make childbirth easier for them. Taking into consideration adolescents' liking of television. many films were utilized. and group discussions were preferable to the lecture method. It was not possible to eliminate the lecture altogether but I found the attentiveness and regular attendance of the group remarkable and encouragmg. It was planned that exercises should be taught in the first hour so that those who planned to place their baby for adoption could leave before the class on parenting the new baby. A short "bathroom and chat" break between the two sessions allowed the girls to mingle and talk privately. Iffunds pennit. a nutrition break would be of great benefit. Each class member was encouraged to bring a partner they knew and trusted: a friend (male or female). sister or mother. Those without partners knew they could call on me or one of the two volunteers to help. The Canad.an Nurse The program The first two classes were offered free to all single mothers so they would attend as early in their pregnancy as possible. .. ., \ - " " and then they were to return in the last trimester for the remaining six classes. Because there is often a tendency not to value anything that is free. a fee of ten dollars was charged. This was waived in the event of real financial hardship. A suggested reading list of book.. available from the public library Was handed out, but few of the girls in the younger age group used it. To overcome this, a personal letter was given to each one. describing in detail on a 14 to 17 year comprehension level. the hospital procedures they might encounter, the onset and stages of labor. and how to cope with each. To my surprise. every girl commented that she had benefited from this letter. The psychological reactions to pregnancy were presented in a skit in the first class in which two unwed teenagers discussed their own and their mothers' reactions to the pregnancy; one girl had an understanding and supportive mother, the other had to defy her mother's "we'll have you aborted" attitude. Both expressed a whole range of emotions: fear. guilt. loss of self-image and a sense of isolation. Most participants identified strongly with the emotions brought out in this skit. and were relieved to realize they were not alone with their fears. Before the end of the first class each participant was asked to write down all that she had eaten and drunk in the last 24 hours. including quantities. These were critically analyzed. and comments were written on each one encouraging the girls to meet their nutritional needs. The slips were returned in Class II before a discussion on nutrition. Emphasis was put on balancing a limited budget. while still providing the necessary nutrients. Keen interest was shown in the physical changes during pregnancy and in the growth and development ofthe fetus. The "do's and don'ts" of pregnancy , November 1979 27 including self-medication, drugs. alcohol, smoking and how to overcome minor discomforts were also discussed in this class. ,.L i 'IJ J1 I > " . Ai.. Class III covered the onset and stages oflabor. and how to cope with each pha..e. Hospital procedures from admission through delivery were thoroughly explained. and my "letter". described earlier. was handed out. A postscript was added for each girl who was planning adoption. or those who were still undecided, asking whether she would like to talk to a classmate in the same situation. Many were greatly relieved to discover they were not alone in this difficult decision; it is an unfortunate fact that the young mothers who were intending to keep their babies looked down upon those who were not. For this reason. it was important to offer extra support and encouragement privately. The class on parenting brought out many of the mothers' unrealistic expectations about their future roles. and about the baby. The change of roles. the responsibilities and demands of parenthood, and budgeting skills were discussed. Also considered were the emotional needs of both baby and mother. and how to meet them. I n another class. the importance of birth control was demonstrated. It is a fact that there is a type of "unwed mother syndrome" 7 which starts with out-of-wedlock pregnancy followed by school drop-out. becoming a welfare recipient. and then a repeat pregnancy resulting in loss of self-esteem and general failure to become a productive individual. Because of the documented high incidence of child abuse and the multitude of psycho-social and health problems that face these adolescent mothers, we decided to devote the last class to subtle encouragement of the young mothers to give their children for adoption. We accomplished this in a non-threatening manner by inviting to this class single mothers whose babies 28 Novem..... 1878 were more than a year old to answer questions. The discussions brought out the realistic struggles and frustrations of the unwed teenage parent in providing for her child, and the resulting sacrifice of time and money for her own interests and education. A single mother who had placed her baby for adoption described how she had taken great care to decide the type of family she wanted her child to have, and how painful this decision had been to make but that she realized her baby now had the love and security she could not have provided. Finally in the presentation, an adoptive mother expressed her deep appreciation for the love and courage it took for someone to give up a baby for her, and she told how the new baby had enriched her and her husband's lives. It was hoped that this presentation would realistically show the options open to each young mother, while leaving her free to draw her own conclusions and assess her own motivations and capabilities. Especially those who had been undecided about adoption were able to look at the situation from a new perspective. Results To promote these classes, a letter was written to every general practitioner and obstetrician listed in the Yellow Pages, as well as the principals of all junior and senior high schools in Victoria. Also notified were agencies such as Birthright, Adoption and Fostering Services, alternative schools, the Birth Control Clinic, etc. The response has been excellent. In the first set of classes, 12 girls enrolled, 18 in the second, and there are currently 16. The age ranged from 14 to 33, but 65 percent of the group Was in the 14 to 19 age bracket. All were single: the majority had left school, but two of the women in theirtwenties were university students. The regular attendance, participation in, and results of these classes have been most gratifying. Most of the mothers did remarkably well during childbirth and were ahle to remember and use the psychoprophylactic methods they had learned in class. Answering a questionnaire, all fell they had gained knowledge and confidence, and some comfort in knowing they were not alone: they felt good about the whole experience. Follow-up however has been difficult because these girls are constantly moving without leaving forwarding addresses or telephone numbers. Some have actually returned to the classes to show their babies, and some keep in touch with each other. Almost all the young mothers who kept their babies have expressed interest in a reunion. The CenMllen Nur.. Conclusions It is important that groups be organized to help pregnant adolescents acquire knowledge, good parenting skills, a renewed self-image, and to generally meet their emotional and educational needs so that the mothers can in turn meet the needs of their infants. Child care services should also be made available so that these women may continue their education and not fall prey to the syndrome which in the past has been responsible for some 80 per cent of teenage mothers not completing high school, and for the suicide rate which is seven times that of adolescents without children." Even when teenage mothers eventually marry, two thirds of these marriages end in divorce. 9 The alarming incidence of single mothers and adolescent pregnancies represents a serious social, economic and health prohlem which is compounded by the individual's rejection of regular prenatal services. By designing and presenting classes which are tailored to meet the specific needs of these young women and by presenting them in an : tmosphere in which they feel comfortable, it is possible not only to counteract some of these risks, but even to help each mother to use this life crisis positively. '" References I * Battaglia , F.C. Obstetric and pediatric complications of juvenile pregnancy, by... et al. Pediatrics 32:902-910. 1963. *Claman, A.D. Pregnancy in the very young teenager, by... and H.M. Bell. Amer.J.obstet .Gynecol. 90:350-354, 19M. Clark, J.F. Adolescent obstetrics- obstetric and sociologic implications. Clin.Dbstet.Gynecol. 14: 1O:!6-IOJ6, Dec. 1972. Coates, J. B. Obstetrics in the very young adolescent. Amer.J.Obstet.Gynecol. 14: 108:68-72, Sept.!,1970 *Nietsche, P. Schwangerschaft, geburt und wochenbett beijugendlichen, by... amlJ Wienold, Zentralbl.Gynaekol. 91 :348-353, 1969. 2 *VGH public forum looks at the need.. of the child.R.C. Med. J. 22:1, Jan., 1979. 3 *Gossage, J.D. Child abuse and neglect.R.C. Med.J. 21:5, May 1979. *N ye, F.I. S choul-age parenthood. Exten. Bull. 667, Washington State Univ.. Pullman, April 1976. Tonkin, R. Mortality in childhood. R.C. Med.J 21:5, May 1979. 4 *Bruneau, B. The childhearing year- teacher's guide by... et al. Mar. 1977. 5 Erickson, E.H./dentity: youth and crisis. New York, N.Y., WW. Norton, 1968. 6 Steinman, M. E. Reaching and helping the adolescent who becomes pregnant. MCN Amer.J. Matern. Child Nurs. 41:1:35-37,Jan/Feb. 1979. 7 Tankson, E. The adolescent parent: one approach to teaching child care and giving support.JOGN Nun. 5:3:9-15, May/Jun. 1976. 8 Nye. F.I. School-age parenthood. Exten. Bull. 667, Washington State Univ., Pullman, Apr. 1976. 9 *Kennedy, Edward, Senator. 1975 Congressional Record,121:154.0ct. 21. Additional bibliography 1 Ashdown-Sharp, Patricia. A guide to pregnancy and parenthoodfor women on their own. New York, N.Y., Random House, 1977. 2 Colman, Arthur. Pregnancy: the psychological experience. by... and Libby Colman. New York, N.Y., Bantam, 1977. 3 *Edwards, M. The new parent class. Seattle, Pennypress, 1978. 4 *Edwards, M. Teenage Parents. Seanle, Pennypress, 1978. 5 *Kitzinger, S. An approach to antenatal teaching. National Childbirth Trust, NCTTA 2,1968. 6 *Kitzinger. S. Education and counselling for childbirth. New York, N. Y., Macmillan, 1977. *References not verified by CNA Library Jo Billung-Meyer is a graduate of the Massachusetts General Hospital School of Nursing and has a post-graduate teaching certificate. She has worked a.f a head nurse in hospitals in Winnipeg and Vancouver andfor the past six years has been teaching prenatal classes at the Victoria General Hospital. She welcomes enquiries from other nurse.f who want to e.ftahlish classe.f in their community. Acknowledgement: G ra t eful acknowledgement i.f gil'en to the following personsfor their assistance and support: Dr. Janet Bavelast, Psychology Dept., Unil'enityof Victoria: Barbara Burke, Director of Nursing. Victoria General Ho.fpital: Mary Jane Maclachlin, Counselling Psychologist, Unh'ersity fVictoria: Barbara Dane, Ron Polstein, and Jan Wilson, social workers, Marilyr. Pazder and Hennie Nyholf. A healthy child, a . fu Closeup on Coalition for th Prevention of nd- a Healthier mothers and babies is a goal that . organizations in the health care field have support. The Coalition for the Preventi'1r r . of the Canadian InstItute of Chi! I Healtl embr r ces r approach to the problem of mal n9 prenatal-penn t understood and utilized r: he first, nurse tives of the C ctors of CNf II e Coall ''''1 ' ,eir whol hment of th <>d to share revIew, J and comma! Information papers no . Rh Isoimmunization . Hospital Perinatal Co . The Health Risks of T . NutritIOn and Pregnan . Teenage PregnanclÐ1 . Screening 01 Newborn. . Low-birthweightlnlant . Rubella. Members of the Coalition. in a t n to CNA. Includ . Canadian Pediatric Society . Canadian Hospital AssoC'latlJn . Canadian Society of Obstetnl"ans & C . Health and Welfare Canada . Canadian Association for the Mentally R rded . Canadian Rehabilitation Cot.ncll for the' -d . Canal,tian Medical Association . CanafjiaFl Public Health Association . College Q amily Physicians . L'As: J rJes médecins de la Ian. · Féd ilL S médeOll1s omnipraticiens d J The cti of the Coalition are. 1. to gi'(e recognition and support to the . . . ndicap It- oug 1 prograrrls health care and f many of the infants did not feed well. One parent who was unsuccessfully attempting to breast feed stated, "Staff always stayed for a few minute'i trying to get him to nurse; when he wouldn't they left for periods up to 45 minutes. At times I thought he'd drown from my tears, at other times I became so angry I wanted to drop him on the tloor. .. When a baby was too sick to be brought out for feedings, one parent appreciated being allowed in the nursery at feeding time. while another stated. "I needed to be close to my baby, I was never pennitted closer than the nursery window. and she was alway'i at the far 'iide of the room, never brought close." One young mother, when asked ifshe wanted to feed her baby. had said "no", but at the next feeding a nurse brought the infant to her and stayed while she fed him. She said she found this gentle encouragement to handle her baby hel pful. All mothers expressed the need to talk about their feelings. but only two felt free to talk to the nursing staff. One mother recalled that a well meaning nurse had brought her a pencil and paper to wlite down questions for the doctor. "Ifonly ,>he had realized I just needed a sympathetic listener to sit with me and let me express my.fl'elil/gs." Night-time was particularly difficult and falling asleep and staying asleep presented problems for all mothers. One mother appreciated ha vi ng staff keep her company in the night. The need for ex tra time with husbands. friends or family Wa'i expressed too by mo"t parenb. One parent who was pennitted unrestricted visiting hours said it wa" very comforting for her to have her husband with her. -- P.trents found it particularly helpful when nurses !>pent time talking with them ahout their infants as human beings. Bonding can be extremel) difficult for families with handicapped youngsters. yet the lack of it increa'ies mother's guilt and coping with the apparent lack of love i'in't easy. Mother.. felt staff were most supportive when they just dropped by to say how the babies slept in the night, how much feeding they had taken, or just how they had been during the afternoon. They noticed too how staff handled their infants. "One nurse brought him completely covered in the blanket and never opened it as though there wa something grotesque inside, while another carefully uncovered him for me and touched him and talked to him just like she did with all the other babies". "One nurse even used to sing to sooth him." These simple caring actions encouraged mothers greatly. All parents surveyed had their children in Infant Stimulation Programs and found them helpful for both themselves and their youngsters. (It is interesting to note that not one had been referred by a physician: five had been referred by hospital staff nurses or public health nurses. while the other five were referred by friends and relatives.) All parents felt it would have been helpful for hospitals to refer them to Infant Stimulation Programs. or A. 1.R.'s (Association for the :\fentally Retarded), so that they could learn more about their child's handicap. and the support services available. Other thing., the parents said were helpful. or which might have been helpful, "ere genetic counseling referrals. literature. pamphlets or books about the particular problem. and physicians or nurse'i "ho were informed about the condition. :\lany parents found staff to be poorly informed on the "hole about the problem of retardation- probably because retardation i'i really a learning problem rather than a health problem: while it may he caused by a specific genetic or physiological anomaly, usually retardation is not responsive to any medical treatment. We should not therefore be reticent in calling in A.:\1.R. statfto help with information about the learning disorder. The Cenedlen Nurse One group of parent!. not surveyed were those who did not take their infant... home. There are times even today when parents. for various reasons, do not want to take their children home. It is imperative that"e try to be empathetic with these people too. as this may be the best decision for them. yet it i!> too easy for us to be judgmental in such a o.;ituation. The e parent'i tend to vanish entirely from the professional's vie", and while they no longer require help for their child they are left to cope alone with the feelings they have after the experience. I spoke with one father who appeared to have unre'iolved feelings about the situation. even after 20 years. Referrab to mental health counseling facilities for the.,e parents should be considered too. Of interest is the fact that in one Infant Stimulation Program. in Wind or, after three and a half years of operation, of 56 children and familie'i serviced only one family had considered institutional placement of their child. One might conclude that with increased external ...upports mO'it families can learn to cope o.;ucces fully with a handicapped child. Ho" specificallycanO.8. staff help parenh most in tho e few first dayo.; after infant'i are horn? First. it io.; necessary to develop a better understanding of what exactly the e families are experiencing. then to assess each family one encounters and plan the appropriate nursing interventions. Understanding of the causes and effect... of mental retardation can be gained from reading appropriate information: there are several books availahle on the ubject and numerou'i publications may be obtained from a<;sociations for the mentally retarded hee below). A "ell infonned nur<;e is in a better po...ition to help her patient. Reaction The birth of a child with an identifiable mental defect cause very deep emotional trauma. It is highly unlikely that the ne" parents will have had much contact in the pao.;t with retarded people or their families. Probably they have had only minimal intere t in the "hole area - an attitude reinforced by the North American cu...tom of keeping retarded people of all ages separate from the rest of the population: they ta"e their education in ...eparate o.;chools. their recreation in segregated groups and many live in special residential settings. Though great strides have been made in the U. S. folio" ing the Kennedy interest in mental retardation and the Carter interest in mental illness. there is still a stigma in the minds of most people attached to mental problems of any kind. November 1979 31 Our own profession cares for many people with mental di'iorders, but in separate settings - mental hospitals, special schoob, residential schools for the retarded - so there is not that much exposure even during a nurse's professional life. While many new programs are being developed, the negative connotations of retardation will persi'it until individuals, families and communities come to accept the retarded person without hesitation or reservation. The parents of a retarded baby are experiencing a loss. a kind of death. Their hopes for a healthy normal child have been shattered and they are terrified. The nurse involved in their care is dealing with a ...ituational crisis. parents who are experiencing agrief reaction. The nur'ie must recognize the stages of grief and mourning and try to be understanding of the dynamics involvfd in this emotional experience. There is however. a difference: there has been no real death. there will be no funeral. no formalized mourning. Feelingo.; of guilt will be pre ent: "Did those antibiotics in the ...econd month cause this?"' and anger: '1 feel like dropping him on the tloor." The parent'i will be fearful too of what lies ahead: they are concerned for themselves and forthe siblings ofthe ne" infant. Adjustment As preoccupation with the lost child dimini<;hes. parent<; will be able to adjust and develop feelings of love for the new child. This acceptance will take o.;ome time but it is important that they do accept the child for until they do. they will not be able to adequately love and care for the baby. Many factor.. intluence the parents' eventual acceptance and there are many que'ition'i for the nurse to consider when trying to help. Wao.; the child planned for and wanted bv both parents. or unplanned and creating an "inconvenience"? Is the guilt that the parents are experiencing e.\cessive? With whom do the parents have meaningful relationships? lack of a spouse orclo'ie family memhers "ill place an added burden on a new parent. 32 November 1979 Parents will be affected too by previous losses and grieving experiences. How successfully have they been worked through?This new experience may revive unresolved past experiences. Finally, the physical and psychological health of mourners at the time of loss is important in determining their capacity to deal with it. It is obvious that a new mother. who may be debilitated by her nine months of pregnancy and the experience of giving birth. is not in the best physical or emotional state to deal with loss successfully. As is always the case with grief reactions. not all individuals go through every stage of the process: they may fluctuate back and forth or skip some stages. and all family members will progress at their own individual pace. It is also obvious that the whole of the reaction will not be experienced in the immediate postpartum period. but assessment and intervention at this time. with co-ordination with suitable external support services. will assist the family achieve a successful outcome. How to get there Assess all your data and make yourself available to the family for discussion. Listen and ohsen'e. Consider: How do the parents perceive the event and what behavior are they exhibiting? What is the physical and emotional 'itate of the parents? Can they identify previous loss experiences and discuss them? Do they have any knowledge of mental retardation - if so what do they know? What culturdl influences are present. and important, in the family's situation? What kind of support is being given by other family members. friends. physicians? Having collected your data,plall a team conference where all nursing and auxiliary personnel can share their findings. Plan intervention carefully considering that some staff may feel very uncomfortable in the presence of the family - help them express their feelings and do not assign them to the patient until they feel ready. If you work in a care setting where Primary Nursing is practiced you will have someone to co-ordinate care - if not, establish one person who i<; v.illing to do this. Principle ' ofinten'ellTion: . Show acceptance of the parents and their new child. . 8e available to them to permit them to express their feelings of grief- denial. anger. guilt, pain and fear. Recognize all the e feelings as normal. rhe Canadian Nurse . Help them to gain an intellectual understanding of their crisis - that their sadness is because of the child they have lost. as well as because of the anxieties created by the handicapped infant. Seek help from your Psychiatric or Social Work Department if you feel uncomfortable in this area. . Help the family find the facts - ego it isn't true that all Down's Syndrome children are alike. . Enquire whether there are concerns about future children: genetic counseling may be required. . Identify support services available in your community and help the family make initial contact with a suitable service such as an Infant Stimulation Program or a local Association for Retarded Persons. The initial contact with upport agencies i often difficult for parents. . Be a good co-ordinator of services. There will be no situations in which you have all the required information but know your resources and use them: physicians and psychiatrists for physical amI emotional concerns: local facilities for retarded persons for appropriate local programs: the social service department for financial or cultural concerns; priests, rdbbi or minister" for religious considerations. . Obtain literature for your nursing unit. Publication lists can be obtained from: National Association.fÒr Retarded Citi:.ens 2709 A\'elllle E. East P.o. Box 6109 A rlill?toll , Texas 76011 Natiollal /nstitllTe Oil Melltal Retardation 4700 Keele Street Kinsmen Bllildill.!! Dowll.H'iew.Olltario M3J IP3 I oo!..ing hac!.. Reflecting on the life of my own famil} over the past fi\e years, the first days. weeks and month'i were indeed the mo<;t difticult. As we worl..ed through our o\'. n grief reaction' we learned about ourselve<; and our child. We di'icovcred ourselves starting to love him, and care fin him. just as we do our other children. He returns this love and i<; indeed a human bcing and an individual in his o\'.n right. He shows concern for all f lmily members as they do for him. Certainly he is slow to learn. but when he finally succeeds at ne" tasl..s. we all experience great happiness. What we initially sa" a'i a great tragedy in our lives has developed into the most significant learning venture which we shall probably cver expericnce. ... Sheila Cameron, R.N., B.A., M.A.. is cllrrently assistant professor of nllrsin? at the Uni\'ersity of Windsor. She has a wide ,'ariety of clinical nllrsin? experience in Britain, the U.S. and Canada, and has become deeply illl'o/i'ed in associations for the mental/v retarded. She has been chairperson and prO?rlml consllitant of the l1 fant Edllcation program for the W illdsor llSsociarion and u member of the Child De\'elopment Sen'ices Committee in her commlinity. Bibliography I Aguilera. DonnaC. Crisis intervention, by DonnaC. Aguilera and Janice M. Messick. 2d ed. Saint Louis. Mosby. 1974. 2 Engel. George L. Grief and grieving. A mer.J.N IIrs. 64:9:93-98, Sep. 1964. 3 Howell, S.E. Psychiatric aspects of habilitation. Pediatr. Clin. North Am. 20:203-219. Feb. 1973. 4 I\.allop, F. Working with parents through a devastating experience. The birth of a mongoloid child.JUGN Nllrs. 2:3:36-4\, May/Jun. 1973. 5 Lindemann. E. Symptomatology & management of acute grief. Amer. J. Psychiarn'. 101: 141-148. 1944. 6 Menolascino. F.J. Parents of mentally retarded. An operational approach to diagnosis and management. J. Amer. Acad. Child. Psychiat. 7:589-60:!. Oct. 1968. 7 Miller. L.G. Helping parents cope with the retarded child. Northwest Med. 68:542-547, Jun. 1969. 8 -. Toward a gredter understanding of the parents of the mcntally retarded child.J.Pediat. 73:699-705. Nov. 1968. 9 Perske. Robert. New directions for parents of persons 11'/10 are retarded, by Robert Perske and Martha Pcrske. Na<;hville. TN. Abingdon, 1973. 10 Stutz. Sara D. The nursing challenges of 08: whcn the baby isn't normal RN 34: II :40-43. Nov. 1971. II *Wolfensbergcr. W. The principle ofnormali::'lItioll in human serl'ices. r oronto. National I nstitute on Mcntal Retardation, 1972. *Rcference not verified by CNA Library The Canadian Nurse November 1979 33 Diagnosis: Down's Syndrome Li 1ldo J. N ixo1l ..- . J , )0- , - '" .. .. .. \01 .., . , - , .:\ " ì - ---- - " \ - - , - Nine and one-half years ago in a large Canadian hospital, a daughter was born to a 24-year-old mother and her husband of the same age. At a time when "zero population growth" was the catch phrase, this was the daughter who would complete their family of two. "Perfect," they said. tÞ .. ," . . --.;: \.. ) c PhotoCilobe and Mall. Toronto 34 November 1979 The Canadian Nurse But it was not to be. The mother, who was a Registered Nurse. remembered giving a clinical presentation on Down's Syndrome in her third year of nursing school. After seeing her new daughter. an alarming question formed in her mind: could this infant be Mongoloid? After discussing this with her doctor. a consultation with a pediatrician was arranged. The diagnosis was clear, there was no doubt, the baby was mongoloid. With the baby present. the pediatrician reviewed the signs of the syndrome. The baby was hypotonic (less active than normal). The occiput was somewhat fiat and the head small. The nose was small too and from a profile was relatively tlat. Her eyes slanted upward slightly (slanting palpebral folds) and small folds of skin could be seen at the inside corners (inner canthal folds). The irises of her eyes were speckled with light colored "Brushfield" spots. Her ears were small and the helix folded over slightly. Her mouth was small making her tongue appear large. Her neck had loose folds of skin and seemed short. Her hands were small and bore no Simian Crease - a single crease (instead of the normal two) across the upper palms. Her fifth fingers were short but there was no c1inodactyly as is often apparent in Down's Syndrome. There were two creases on her fifth finger, not one as is common in Down's Syndrome but she had the traditional gap between her first and second toes. As a tinal check. he ordered x-rays of the baby's hip joints and blood was taken for chromosomal studies. The infant bore the signs of trisomy 21 as do the great majority of children with Down's Syndrome (D.S.). Normally there are 46 chromosomes or 23 pairs in each normal cell. Each pair is designated with a number from one to 22. The twenty-third pair is the sex chromosome pair. This child had 47 chromosomes with one extra chromosome added to the number 21 chromosome - hence, tri-somy. Over the next fev. weeks the child's condition was further assessed and the harsh medical facts were revealed to the parents. I remember it well because I was that baby's mother. Facing reality Knowledge of these facts helped us to face reality. We were grateful that our daughter's diagno'iis had been given to us and that all of our questions had been answered in a straight forward manner. However. it was unfortunate that we had not been presented with the whole story. There is a positive side to statistics that needs to be remforced in a situation such as this. We were told that approximately 30 to 40 per cent of D. S. children have heart defects. but we were never reminded that over 50 per cent do not. We were toldD.S. children are subject to respiratory illness and gastroenteritis. No one said "Down's Syndrome children vary in their susceptibility to infection. Pneumonia and gastroenteritis are much less common in all children today and antibiotics have greatly reduced the number of deaths. D.S. children seem to respond to treatment about as well as normal children". I About four per cent ofD.S. babies are born with incomplete development of the intestine they said. No one emphdsized the 96 per cent who do not suffer this way. No one said, "lfno problem becomes obvious during the first several months. there need be little concern. "2 Acute leukemia occurs in one percentofD.S. children, we were [Old. No one eased our worry by mentioning that the risk after the first two or three years is low. My medical text in Pediatrics contained an atrocious picture ofaD.S. child - the classical worst example. My Obstetrics text, still in use in the mid-sixties, gave the incredible advice that a D.S. child should be removed from his mother and placed in an institution before an attachment fonned. It is unfortunate that. armed as we were with such facts that we had been given or had been able to find on our own. there was no one to share another part of that reality with us, someone who had actually experienced living day-to-day with a retarded offspring and who had coped. I t is no wonder either that with the gloom and doom statistics hanging over the head of this newborn and with no support agency at hand for parents. m} husband and I spent several months in a grieving distressed state. This type of reaction is common to all parents ofD.S. children: a timeless description of the feelings of the people concerned can be found in "The Child Who NeverGrew" by Pearl S. Buck. Gradually the intense grief reaction began to fade. Our daughter. Jennie. contrary to our impression of the medical facts. began albeit slowly to grow and thrive. Yes. she had respiratory and gastrointestinal upsets and a minor heart murmur. but we managed. To our delight we found that Jennie Was capable of learning many "normal" behaviors: sitting. crawling. walking. speaking and even reading. Finding the methods that would help Jennie utilize her intellectual potential. helping herto make strides. despite developmental lags. took up much of my time. Today. Jennie is a relatively healthy. happy. contributing member of our family. She is particularly fond of her younger brother. Mark. whom we adopted two years ago and who is also a D.S. trisomy 21 child. If Jennie's birth were to take place today. I hope that we could anticipate: · Doctors and medical personnel who would present us with the facts realistically but not without hope. . A model of acceptance from those concerned. Even after these many years I remember that our daughter was given the gentlest handling and was wrapped in the brightest pink blanket in the nursery during those unforgetable hospital days. I remember the baby being brought at a time that must have been inconvenient for the staff, so I could hold her and weep. I remember the anxiety of the Head Nurse when she told me that she had prompted the pediatrician to give me his diagnosis and still wondered whether she had done the right thing. I remember the nursing staff who lingered an extra minute at my bed in case I should want to talk. I remember kindness and caring. . Contacts with the local Association for the Mentall y Retarded and Down's Syndrome parents who had coped, willing to tell me about their experience when I felt I wanted or needed this. . The name or names of doctors in the area particularly interested in working with and understanding Down's Syndrome children. . Recent and timely reading material for me to read when I craved knowledge about our child's affliction: notable is "The Child With Down's Syndrome (Mongolism): Causes. Characteristics and Acceptance" by David M. Smith. . An Infant Intervention Worker or Infant Stimulation Home Teacher such as Mark has had. who could visit on a regular basis while I adjusted to my baby's condition. She could provide me with a model of an accepting attitude by handling this baby gently and, at the same time. offer me emotional comfort and support and knowledge in time of crisis e.g. feeding problems. illness. Perhaps this would help decrease my infant's hospital stays and increase my confidence in my ability to handle some of her problems. She could help assess my child's level of development and teach me how to help her to master the next developmental steps. (Mark's Infant Stimulation Home Teacher had an R.N. background in pediatric nursing.) . I nfonnation sources about progress in education for D.S. children. I am particularly encouraged by the ideas from the Model Preschool Center for Handicapped Children - an experimental. educational unit at the University of Washington. This program is a highly organized. sequenced. diagnostic and prescriptive program whose goal is to help each D.S. child attain as nearly normal development as possible through early and continuous intervention. Victon o\er D.S. Altho gh the birth of a D.S. infant. on the average I :640 births. is inevitably a shock to parents, it does not have to be a totally negative experience for those who choose to keep their children and accept them as they are. Out of their stress can come positive attitudes. By \wrking through thi, grievou<; situation. my husband and I feel that we have gro\\-n closer: we know that we can handle whateverlies ahead. In fact, our attitude to all our children has changed. We now focus on more positive attitudes. i.e. what our children can do. not what they can't. The remarkably effortless development of an average child has tal..en on new meaning. "!though our D. S. children require extra attention in time and patience. we have learned that it is possible to maintain a balance that lets our two "normal"' }oung<;ters feel loved and secure. Noone can take from us those moments of victor} when. after long hours ofworl.. on their part as well as ours. Jennie and l\Iari.. accomplish a specific goal. How well we rememberthe da} Jennie attempted dinnertime grace at a time when speech \\-as still difficult for her. Our normal voung<;ters could singsong it so ",ell. so easily: "God i.. Great. God is Good. Let us thank Him for our food. Amen." Jennie's version. abbreviated but still a \ ictor}. brought a ne\\- meaning to us. "God IS:' she said, "Amen:' ... References I Smith. Ddvid W. The child I\'ith Du\\"n's !>yndrome (11IOn?olism), by Da\id W. Smith and Ann C. Wilson. Toronto. Saunders, 1973. 2 Ibid. Bibliograph} I Smith. David W. The child \\"ith Du\\"n's . yndrome (11I(mgoli. m), by Da'\ id W. Smith and Ann C. Wilson. Toronto. Saunders, 1973. 2 "'Orientation manual on mental retardation: Pt.l. Toronto. National Institute Iental Retardation. 3 Buck. Pearl S. The child \\"ho ne\'er gre\\". Scranton. P:\. John Day. 1950. xU nable to verify references in CN A Library Linda J. 'ii"on, a graduate of St. BOl1{face S cllOOI ofN ursing, is the mother offour children. including Jennie and .\1arl... Since obtaining a cert fìcate in Early Childhuod Educatiunfor the Mentally Retardedfrom Humber College. Toronto, she has acted a. a \'oluflteer/teacher in a small community nursery for handicapped children in Oromocto, N.B. and in a school for trainable mefltall\' retarded near Alliston. Olltario. She and herfamily are 1I0\\" li\'illg in Lahr. Germany. The Canadian Nurse November 111711 35 Closeup on Fetal Alcohol Syndrome Jane Bock The Fetal Alcohol Syndrome (FAS) is a term that has been used for the past dozen years or so to apply to a collection of defects and deficiencies found in babies born to chronic alcoholic women. Early researchers thought the syndrome was due in part to the malnutrition that frequently coexists in alcoholics, but more recent research has proven that there is likely no correlation. Further, and most alarming, it now appears that FAS can appear in the babies of women who are only moderate users of alcohol- the so-called "social drinkers". Common abnormalities in the Fetal Alcohol Syndrome include pre- and postnatal growth deficiency, microcephaly and a series of facial abnormalities such as thin upper lips, midfacial hypoplasia and shortened palpebral fissures (eyelid crease). 1 Although according to some studies, the complete FAS has never been seen in any but chronic alcoholic mothers , 2 evidence shows increasingly that any mother who drinks is at risk. "There is a spectrum here," says Dr. Henry Muggah at the Ottawa Civic Hospital, referring to the continuum of effects of alcohol ingestion in pregnancy; "Less than 2 ounces of alcohol- that's one drink, one beer or a three-ounce glass of wine - is probably okay, there's no evidence of harm, but 2 1/2 to 6 ounces? Who knows?" Who knows, indeed. Dr. Mary Jane AShley of the University of Toronto. quoted in the Canadian Family Physician, says: "A safe limit of drinking hasn.t been established," and she called "disturbing" the findings that even moderate drinkers may have babies with signs of FAS. She advises that "drinking in pregnancy should be considered hazardous until it's proven safe. The best advice when you don't know is 'don't do it'. "3 The variability of the teratogenic effects of alcohol on the developing fetus is probably due to varying exposure at various times during gestation, in conjunction with the genetic background of the individual fetus.. It is assumed that the level of alcohol that can be measured in the mother's serum is important, so 'binge drinking' may be considered to be the worst for the unborn child. However, according to Dr. Madeleine Maykut of Health and Welfare Canada, health protection branch, who has recently published two articles on the subject, no one knows what the minimum amount of absolute alcohol required to cause damage is. "We cannot predict who will be affected," she said, adding that in some cases women may be causing the fetus harm by drinking before they even know they are pregnant. "Some say, 'weill don't drink during the week, just on the weekend', but that may be too much. You might go out to dipner and have alcohol in your parfait for dessert, and that might be too much. Nobody knows." Dr Maykut said that both nurses and doctors should advise patients to give up smoking and drinking for the entire pregnancy. "It won.t kill anyone to stop drinking for nine months," she said. The nurse's responsibility is clear, and applies not only to those who work in doctors' offices or prenatal clinics, but to any nurse who comes in contact with women of childbearing age: patients, friends, family. . women should be encouraged to see their doctors early in pregnancy for nutritional and I!festyle counseling. . drinking and smoking should be discouraged, with adequate rational explanations. . the general public must be educated against the "another-little-drink-won't-hurt-you" argument that is no longer justified. Most prospective mothers don't have to think twice about making any sacrifice for their unborn child; it is up to us to see that they get fair warning. References 1 Hanson, J.W. Fetal Alcohol Syndrome. JAMA No. 14,235:1458-1460, Apr. 5, 1976. 2 Can.Fam. Physician. Discuss fetal alcohol effects in preconception counselling: MD, Vol. 25:695, June 1979 3 Ibid. 4 Clarren, SK and Smith, D. The fetal alcohol syndrome. New Eng. J. Med. 298:1063-1067,1978. Bibliography 1 Fielding, J.E. The pregnant drinker. Am.J.Pub.Health 68:835-836, 1978. 2 Morrison, A.B. and Maykut, M.O. Potential adverse effects of maternal alcohol ingestion on the developing fetus. CMAJ 120:826-828, Apr.7, 1979. The nurse in the community: infant stimulation J I 31 Novem.....111711 The CanMllan Nur.. - I \ y ) , t .. .... .. ., ..... 1- \ \ ). 111 a; ... - - - - " -- Louise works closely with mother Armande and two-year-old Cory. Cory standing alone and Increa'ted emphasis on reducing health costs through prevention and early problem intervention has meant that Infant Stimulation programs are recehing greater government financial backing and, as a result, are becoming more widely available. These programs are designed to enrich an infant's sensory experiences and promote the development of cognitive, social, emotional, language and motor skills. Is there a place for nurses within these programs? CNJ talked to Louise Mather, who was a community health nurse with the Centretown Community Resource Centre in Ottawa and is now an Infant Development Worker with the Infant Stimulation Programme at the Centre. We asked her about her contribution to the program. Case Study David, an infant boy, with Down's Syndrome was referred to us by his pediatrician at the age of three weeks. On my initial visit, I was greeted by both parents who seemed rather hesitant and unsure of my purpose and their present situation. Upon seeing David, I commented on how much he resembled his Dad. His father uttered an exclamation of surprise and said, "But he has Down's Syndrome, how can he look like me?" After discussing the infant's Down's Syndrome features, I reinforced that this was only part of his genetic makeup and that there is often a strong family resemblance. Judith Bannin[? CNj: HOI\' did )'OU as a nurse become interested in the field of infant stimulation? Louise: Before the program was set up. I worked as a community health nurse with the Centre. making home visits: counseling on birth control, diets and lifestyle: working in well baby clinics: administering Denver Developmental Tests, etc. I felt comfortable with babies and their families in their home environments and really wanted to become part of this program. As I have always felt that the developmentally handicapped child had a very positive role to play within the family and the community. thi.. was a way for me to promote this. As I worked with David and his parents, their relationship strengthened and David made many developmental gains. He sat alone at nine months, was pulling to stand at eleven months and surprised us all by walking when he was two years. By the time David was enrolled in a special preschool at age two and one half years, the other children in the neighbourhood considered him a welcome playmate and there were many knocks On the door to see if David could come out to play. CNj: Tel/us something about the staff of the prowam, Louise. Louise: Our staff includes three members. whose backgrounds are physio/occupational therapy. nursing and ps ychology. The physio/occupational therapist carries a case load of five to six families and coordinates the program. The nurses each carry a caseload of from 12 to 15 children who are visited at home. usually on a weekly basis. We coordinate our program with other services and utilize many community resources. i.e. pediatricians, social workers. speech therapists. public health nurses and nutritionists, to assist us in meeting these families' needs in a comprehensive way. CNj: What qualities do you consider necessary to wor within WI infant stimulation pro[?ram? Louise: As a group we have been readily accepted by parents. we have tried to be accessible, empathetic and neutral. We all ha ve a genuinely positive attitude towards quality of life and the potential of the developmentally handicapped child. However. some very definite skills are required to be effective in this role: . a 'iound knowledge of normal physical. emotional and social development. . counseling ability, i.e. kn0wing when a family is ready to face reality, is frustrated. angry or disappointed. and an ability to draw out these feelings. An ability to present a reality is a great asset. . problem identification: physical. emotional or social. . teaching skills, i.e. the ability to teach families and children as well as co-workers. . organizational skills. which may be used to assist parents to integrate the program into their daily routine as well as to organize a demanding caseload. . assessment skills. i.e. recognition of when a family needs your help or is just not coping and requires more assistance or other levels of service. . knowledge of community resources and the ability to make constructive referrals. The c.n-.llan Nur.. Nov_t>erI.79 37 [ . . "- .. .... .....- , " 't'A ... , ... taking steps forward with support. C J: How do \'ou determine what to include in a hume prox ram ? I ouise: Every home that we enter is different and the goals we set for each child and family vary accordingly. Sometimes it is impos ible to begin the obvious task ofintant stimulation without fi t dealing with other considerations. e.g. housing. money management or nutrition. When problems in these area.; exist we utilize resources within the community and make the appropriate referrab. Parents often have difficulty accepting their baby a'ijust a baby and thinking of him as a "handicapped baby" can interfere with healthy parent/child interaction. To facilitate this process. we reinforce the idea as much as possible that thi, baby should be treated a'i a "baby". So y"e act as role models and 'ihow the parents that it is alright to do all of the normal things. By talking. cuddling and playing with the baby, we are often able to elicit responses from the child that the parent!. have never seen. They are amazed. Sometimes on our next visit, these parents y" ill tell us that they were able to initiate that response again. thu'i providing encouragement for them. Actual goal-setting is accomplished between the parents and the y"orker. Initially. the worker may see groS'i motor coordination as a priority but the family may feel that social cognitive skills are more important. Since. in the end. it is the family y"ho must carry out the home program, we would focu'i on their major concern and later begin integrating the other areas a indicated. We U'ie time-dated goals and do a'\sessment'i every six months. CNJ: H 0'" do you see the role of the neonatal nurse in the huspital and the community? Louise: Hospital'i have changed greatly. Today, with the increa'iing number of children's hospitals, nurses seem much more aware of children's needs. We try to keep a fairly high profile and are in contact with neonatal and toddler hospital units and public health agencies regularly. Neonatal nurses are in a good position to assess both the needs of the child and the familv on discharge. The knowledge that infant 'itimulation is available has eased the pre'i'iure on the ho'pital nurses greatly. Now they can talk to parents, knowing that there is help and support in the community. Public health nurses give us many referrals now that they are aware of our program. Recognition of developmental delays frequently i'i not possible until six months of age and often it is the public health nurse who is in contact with the child at this time. ..:.. - l ..c o ..., :>, LJ ...ince we were already the parents of a five-year-old daughter. Vikki. Friends send cards and flowers. but they hesitate to visit. Your family tells you not to worry: '"Medical science can do such wonderful things now". or they keep repeating how "cute" the haby is. An aunt of mine voiced the opinion, and I have heard this since from other .,ources, that Bill and I were "chosen" to be the parent'i of a handicapped child becau'ie we pO'isessed such quantities of patience, love and compassion. Much more disturbing is the idea that your husband's parents may blame you while your family insists that there was never anything like this in your background. They, too. are groping for answers. Although we eventually became relatively familiar with Billy's care in the hospital. the first few weeks at home were an exhausting and frw'trating period of adjustment. Professionals warn us not to over-react, but it is difficult to remain calm when one is constantly on the alert for danger symptoms - fever. irritability, vomiting. drow'iiness. tense or bulging fontanelles and increased head circumference. We tend tQ forget that our child can also sutler from a cold or an upset stomach and any sign of illness becomes a matter of meriOlH emotional dÙ.1Iirbcmce is 10 he elI'oided."z Since a handicapped child cannot help but cause ten..ions within the family life. parents are not always able to meet the physical and emotional demands made upon them. The disabled child brings an added strain to a marriage. This stres" not only relates to anxiety about the child. but al"o affects the relationship between the husband and wife. The parents continue to require understanding and support if the family unit is to function in a way that is most productive to the handicapped child as well a.. other members of the family. The parents of a handicapped child must continually make adjustments. At first I dreaded making new friend" - people to whom I would have to explain Billy'" condition. I wa" embarrassed because he wore a hat ..0 that hi.. ..hunt would not be noticeable. I cringed when sales derks joked about his being lazy. "When are you gOing to learn to walk and help mommy'?" y"as the usual comment. It i., still difficult for me to visit friends with healthy new babies and to share their joy without "ome re..entment. I know that our lifestyle has changed since Billy wa" born: suppositories. medication, brace." walkers. therapy. doctors' appointments and. more recentlv. intermittent catheterization are all part of our live., now and. }-es. they are time-consuming and often exhausting. but we have become accustomed to them as part of our routine. I do not believe that our social life has become too restricted. but preventing thi.. from happening ha.. required a conscious effort on our part. Th. Cenedlen Nur.. Nov.mber 1979 311 , J , -- ,. '- k '" . t - We still go on holidays each year as a family. Everything take.. more planning now: there is more luggage and equipment but it is well worth the extra effort. Recently. Billy acquired a y"heelchair and we have had. perforce. to become conscious of accessibility. Last year. we were delighted to find that Disney World was a place that we could all enjoy: it was easy to manage with the wheelchair and we were able to use the ho"pital area off Main Street for Billy's personal needs. . 'The criticlII ear/y yellrs in the lijè c f the child ,,'ith spina h({ìda tend to be duminated b\. a succession of medical prohlem!>., hCJ.\pital admissions. surRical operations and cumplications of them all. A!> a re.mlt. it is ean to O\'er/oo/.. his hcüic emotional, sucial and educatiunal needs ,,'hich unh' differ from those uf any other child in that they are more dUTìcult tu sati 6' ."1 A child's adaptation to his disability is a., greatly influenced by the way in which his parents relate to him a.. it i" by the degree of his handicap. He need.. to participate in peer relationships. to develop "elf-control and social skill." to experience the feelings of participation and achievement and the opportunity to make choices. As parents. we recognize the need for Billy to experience as much independence as possible and are prepared to take "prudent risks" - an afternoon toboganning in the park. apple picking in the Fall and other activities which encourage his growth. However. Bill and I continue to need professionals and other parents of hdndicapped children to assist us in establishing realistic goals and to provide support during the crises.'" References I Gitler. David and Vigliarolo. Diane. The handicapped child and his family. I nstitute of Rehabilitation Medicine. New York University Medical Centre, 400 East 34th Street. New York. N.Y. 10016: July 1978. p.5. 2 Stark.G.D. Spina b({ìda prohlems and manaRement. Edinburgh. Blackwell Scientific Publications, 1977. p.139. 3 Ibid.. p.14 I. About the author: Heather Rcm/";'I is courdinator uft/le SpiflCl B(fìda Prowam at the Ontariu Crippled Children's Ce1l1re in Toronto. She is a memherof the Ontario A dl'isory Council on the Physically Handicapped and is the mother of two children, Vil..l..i(aRe Il) and Bill\' (age 7). Ontario Crippled Children's Centre Combined Spina Bifida Clinic For the 325 children and their families followed by the Combined Clinic, this program offers a multidisciplinary team approach to a long term problem that has a great impact on the whole family. Comprehensive care cuts down on the number of visits to various specialists: neurosurgeon, orthopedic surgeon, general surgeon (bowel management). and urologist. It also facilitates communication and cooperation between all of the team members, including nurses, physicians, therapists, social worker. orthotist, x-ray technician, volunteers and the coordinator. Cases are generally reviewed at intervals of from three to six months but the child does not see every doctor at each visit. Specialists amve for the clinics, which are held on the first and third Friday of each month, early in the afternoon. Morning appointments allow time for the therapists to assess each child and, during this time, allied health services are available to the families. 40 November 1979 The Canadian Nurse Nutrition and the Chronic Schizophrenic The current trend in psychiatric therapy is to minimize institutionalization and deal with patients on an out-patient basis. Unfortunately, the patient with chronic schizophrenia may not be able to handle the responsibility of almost total self-care, resulting in a poor quality of life. A study done at the Clarke Institute in Toronto reveals the implications of poor nutrition in these patients, and proposes ways for nurses to help. Jennifer Pyke Schizophrenia is a psychotic disorder characterized by the individual's withdrawal from social interaction, apathy and confusion of emotions. It occurs usually in young adults but may develop at any time in one's life; the exact causes are not known. Current treatment for schizophrenia includes the use of tranquillizers. supportive psychotherapy (either one-to-one or in groups), vocational rehabilitation and socialization activities. The period of hospitalization for schizophrenics has become progressively shorter. and current psychiatric practice is to deal with the chronic schizophrenic patient on an out-patient basis. and to offer therapy through mental health clinics and hospital out-patient departments. Schizophrenia remains a major problem in health care 2 and still represents the most frequently-made admission diagnosis in psychiatric institutions and the psychiatric units of general hospitals. It is unfortunate however that with the trend to releasing patients from their dependent status as in-patients to self-care that community housing facilities have failed to serve adequately the large numbers of discharged chronically-ill psychiatric patients. Consequently. community mental health workers - a large number of whom are nurses - find themselves trying to cope with chronic schizophrenics who are living in poor conditions, attempting an existence on welfare or small disability pensions. The irony of this from a treatment standpoint is that the chronic schizophrenic often exhibits the secondary symptoms of the disorder, namely apathy and a general lack of motivation. which are not compatible with almost total self-care. These particular symptoms generally result in poor self-care such as neglect of personal hygiene, poor or absent dental care, and an unsatisfactory diet. The special importance of this latter effect may be seen in a review of current literature on schizophrenia. In a review article, D.J. Kallen describes the difficulty in separating social and economic dysfunction from malnutrition 3 and one might theorize that the addition of a disease such as schizophrenia would intensify the problem. He notes that apathy. listlessness and unresponsiveness are symptoms of malnutrition in adults; these same symptoms are found, as previously noted. as secondary signs of chronic schizophrenia. Numerous studies have been carried out too on the relationship between folic acid deficiency and certain mental disorders. Kasowski and Kasowski in an article devoted to folic acid deficiency. note that many psychiatric disorders including schizophrenia have been associated with folic acid deficiency. but that it is still unclear whether folate deficiency is a cause or an effect of the mental disorder" The population studied in the article was chronically ill and so there was a continued use of neuroleptic drugs. Boullin observes that "adverse drug reactions are more likely to occur in the young, old, malnourished and obese" and that "since little is known about the effect of nutritional state and age upon drug actions and interactions. the physician should pay particular attention to potential hazards in susceptible elements of the population. "5 Since poor dental care is a part of general self-neglect and also somewhat related to diet. the summary by Stahl on the relationship between nutritional deficiencies and dental disease is also worth noting. "N utritional deficiencies apparently do not initiate periodontal disease. but may modify the severit.y and extent of the lesion by altering the resistance and repair potential of the affected local tissues." 6 Pauling, Hoffer and Dohan have each implicated eating habits in the pathogenesis of schizophrenia 7 . H . 9 ; while there is no firm evidence that poor eating habits contribute to the development of the disease there remains a probability that these habits take their toll in the subsequent deterioration of patients with longstanding schizophrenia. Tsuang and Woolson note that due to improvements in treatment and public health methods the life shortening effects of mania and depression have been alleviated. but remain unchanged in schizophrenia. 10 The focus of this article is on the importance of nutrition in the care and treatment of the c'hronic schizophrenic. and includes a study done at the Clarke Institute of Psychiatry in Toronto which provides some evidence to support the hypothesis that unhospitalized patients with this particular disorder are indeed subject to deficient nutrition. The Cenedl8n Nurse November 1979 41 , o g l- i- ,,. ;;; >- :f 'õ " " ' C o Õ .c: c.. The Clinic The active treatment clinic at the Clarke is designed to treat chronically iII psychiatric patients, the majority of whom are chronic schizophrenics. It is denoted as an "active" treatment area because the staffbelieves that in spite of the presence of a chronic illness, each individual can still achieve a relatively high level of function within the community and a better quality oflife. With this in mind, all facets of a patient's life are examined: vocational. recreational. housing, family and other social relationships, physical and emotional health. Thus, nutrition becomes one important aspect of the total treatment plan. Due to the large number of patients (130) and relatively small numbers of staff(one almost fulltime psychiatrist, two almost fulltime residents. four very part-time residents. three part-time nurses, one part-time occupational therapist and one part-time social worker) and the active treatment emphasis, the program is carried out in groups when this is both feasible and therapeutic. The average patIent at the clinic is young, male, white, and has been hospitalized at least twice for functional psychotic episodes. Allan, for example, . .... , / ... , -- / -... - ./ , .Þ " is 27 years old and was first diagnosed as suffering from a process schizophrenia when he was 22. At age 20 he dropped out of university and has since maintained a transient lifestyle, changing rooming houses frequently and holding unskilled jobs for only brief periods of time. Often he lives entirely on government a<;sistance. His life is characterized by aimlessness and apathy, and he finds little to maintain interest or to give him pleasure. In therapy, Allan's lifestyle has been the major focus: hygiene, nutrition and useful activities are discussed and planned. Allan's nutrition is of particular concern because he often "forgets" to eat when he is preoccupied, and when he does eat his diet is at a subsistence level. He recorded his dietary intake for two weeks as part of our study and for ten days, tomato sandwiches were his major meal of the day. Group obsenations Included in the groups at the clinic are two social groups and one cooking group: it was in these sessions that a number of observations were made about the nutritional status and food-related habits of chronic schizophrenics. The social groups are the largest with about 25 to 35 people in attendance at anyone session. To enhance the social atmosphere snack<; are made available: coffee, tea, and cookies, which were later supplemented with muffins, cheese, carrot sticks and juice. We noted that: . a significant number of the patients drank several cups of tea or coffee during the sessions, and often had more either before or after in the hospital coffee shop. . the social act of passing and sharing food is usually completely foregone unless patients are reminded by staff members. The patients often took their food directly from the dietary department wagon, and did not take the plates to the tables provided for them. . several patients have been observed to literally gorge themselves on the food presented. four or five muffins at a time, with little concern or even awareness of other group members. There was no apparent recognition of the fact that others might have to go without. These observations made in the social groups were significant in that they revealed a connection between certain symptoms of chronic schizophrenia and behavior exhibited at mealtimes. The excessive intake of caffeine noted in many patients is of special importance because, inasmuch as caffeine intake is a common problem in the general population, in the psychiatric patient the symptoms of high caffeine intake may be misinterpreted as symptoms of psychiatric illness. Effects such as "nervousness, irritability, tremulousness, occasional muscle twitching, insomnia (and) sensory disturbances" may be noted, and it is also reported that "caffeine seems to counteract the sedative/hypnotic effect of medications. "II 42 November 1979 Th. Canadian Nurse . -- 'J , The fact that the patients often neglect to pass food to other group members or that they take as much food as they want without thinking of others, is a reflection of the schizophrenic's lack of involvement with his environment, and his total concern with selL The cooking group was another excellent time in which to observe the schizophrenic's behavior concerning food. and led to several conclusions about the quality of the patients' diets at home. The group has been conducted by myself and a volunteer for about six years, and has included approximately eight patients who were to learn cooking skills as well as to work as part of a group and to improve food-related social skills After six years of observations, we concluded that not even the most basic food preparation skills should be assumed in the chronic schizophrenic. unless seen. Cooking group observations included the following: . New members were found to be unable to perform simple tasks such as beating an egg. slicing a cucumber or coring an apple. One young woman was asked to make sandwiches: she was able to butter the bread but she put the filling on the dry side and presented the group with a plateful of" inside-out" sandwiches. . Several people were noted to be impatient waiting for the food to cook and ate several slices of bread and sugar. or bread and peanut butter, sitting down less than fifteen minutes later to a meal. ... ::J .I . . , "' . Social skills were noted to be lacking during meals. dishes were often not passed and left inaccessible to other patients, condiments were just reached for. and food was not routinely wiped from the face and mouth. As in the social groups, the observations made in the cooking groups may be seen to be the effects of chronic schizophrenia. The apparent total self-concern and lack of awareness of others mark the schizophrenic's inability to perform as a member of a group. The failure to perform simple tasks too may represent the patient's general apathy and passi vity, or even that the schizophrenic's perceptual processes have been altered in some way: in other words, were these tasks never really learned or have the skills been lost as a result ofthe schizophrenic process? It was apparent to us from the observations we made in the various group sessions that the chronic schizophrenic patient's behavior in food-related areas such as food preparation and mealtime social conventions warranted further study. Validation of observations made in therapy was necessary to assess the importance of nutrition in the overall treatment plan of chronic schizophrenics. Uppermo t in our minds were the thoughts that malnutrition among these patients presented many of the same symptoms as did schizophrenia, and that certain of their food habits, such as excessive intake of caffeine, were actually interfering with therapy. Also to be considered was the fact that meals are both a social or group activity, and a means of structuring one's daily activities. . - .. , \ . ; .. ... ---- The project A controlled study offood intake and eating patterns of socially isolated chronic schizophrenics was carried out in the clinic in the summer of 1976 to test the following hypotheses: I. Chronic schizophrenics living alone have demonstrably poorer nutrition than a non-psychiatric group living in similar socio-economic circumstance!>. 2. Chronic schizophrenics have an excessive intake of calories. 3. Chronic schizophrenics have disorganized eating patterns in comparison to those of non-schizophrenics. The seven subjects all had a primary diagnosis of chronic schizophrenia which meant that they had each had at least two functionally psychotic episodes requiring hospitalization. The actual number of hospitalizations for the group ranged from two to 15 with the average being five. The subjects were all well-known to the therapist and were considered to be reliable recorders and were stabilized on neuroleptics at the time of the study. Selection of the subjects was based on the following criteria: age between 20 to 60 years: no other medical disorders: no history of drug or alcohol abuse: not to be on any special diet or vitamin supplements: to be living alone dnd on minimal income (that is, minimum wage. welfare or other subsidy): to be cooking for self or eating in restaurants. The control group for the study consisted of7 non-psychiatric patients who were well-known to a local public health nurse. and who also met all the above criteria. F or the study, both groups y" ere asked to keep an inventory of all food eaten in a two-week period. At the end of this time. the infonnation was analyzed and examined as to specific nutrients calculated from standard food tables and the Canadian Dietary Standards (C.D.S.),t2 These records were completed by four female and three male patients who were between the ages of 24 and 49 years, who recorded a total of 86 days. The control group consisted offour females and three males bety,een the ages of 20 and 58 years who kept records for 94 days. The results Our infonnation revealed that: . the psychiatric patients had an overall "poor" diet when compared to that of the control group . more subjects than controls were actually deficient in calories. Male subjects averaged less than 1500 calorie.. per day . there was a marked lack ofvariety in the subjects' diet . subjects tended to eat "empty calorie" foods such as coffee. carbonated drinks, doughnuts. or french fried potatoes . five of the subject'i lacked any kind of meal pattern. whereas control'i exhibited a pattern of three meals a day taken at regular intervals The Canadian Nurs. . all subjects showed a diurnal pattern offood intake. demonstrated by beginning to eat later in the day and stopping food intake earlier in the evening than the control group. No actual deficiencies of vitamin C. niacin or thiamine were noted in either group and no correlation could be found in the subject group between the number of psychotic episodes in a patient's history and intake of nutrients. Reviewing the findings of the !>tudy. it would seem reasonable to 'itate that a poor diet. particularly one deficient in calories. could playa significant role in the appeardnce of the secondary deficits in chronic schizophrenia. namely apathy and lack of motivation. Implications Looking at the general picture of nutritional status. eating habits and food-related behavior for chronic schizophrenics who live alone in their community leads to a better understanding of the relationship between poor !>ocial skills and nutrition In the general population much of our eating occurs in the context offamily and social interaction: food is served at parties as !>nacks or perhaps suppers: coffee breaks and lunches are taken with fellow workers: friends who visit are offered food and drink: dinner is often the central event of a social evening. MEDIAN DML Y NUTRIENT DEF ICIENCIES 0: CHRONIC SZP VS CONTRQS C. D. S. lor low activity Deficiencies greater than 5 ubjects fl M 12 M 13 '4 M 15 F 16 17 F Controls Ii F '2 F 13 M '4 F '5 M 16 M 17 F Protein Calcium Iron Vit A Rlblollavin Calories 9g-40g 500mg 16mg-lOmg 3700 i. u 1 (),-l. lmg 190:t-ZI50 59 loomg 2mg 500 i. u. O.lmg 500 - . - . - . . . . . . . . . . . . - I . T 1 - I . . . Recommended lor females November 1979 43 Thus. we can see that the behavior surrounding food consumption is a medium of social expression. and eating is an act around which communication and interaction takes place. For people who are socially isolated. such interaction is rare and for clinic-treated psychiatric patients. may take place only at group meetings in the clinic, or once a year when their estranged families invite them for Christmas dinner. Social isolation therefore can be seen to playa vital role in the poor nutritional status of these people. and unle!>s therapists become aware of measures to improve patients'living accommodations. diet. hygiene and concommitant social skills. the plight of the isolated chronic schizophrenic will continue and worsen. Treatment clinics can make u e of snacks offered in group meetings. ensuring the food offered has some nutritional value. Food can be used therapeutically to promote and strengthen social skills: '3 passing plates of food for instance increases aWarene'iS of other group members. and sharing reinforces group cohesion. The use of napkins and other social conventions increases a patient's acceptability, and personal hygiene. In addition. the importance of meals as a means of structuring the patient's day cannot be overestimated. In other psychiatric disorder... the severe secondary symptoms that are found in chronic schizophrenia do not exist;U the 'manic' patient. for example. returns to the degree of function he possessed at his pre-morbid level. Schizophrenics however tend to deteriorate after each episode. leading to increased apathy and lethargy. The schizophrenic's life cycle may be seen to be marked in part by chronically poor nutrition which in turn may well play an important part in the continuation ofthe disease process. '" Jennifer P) ke. R.N.. is a Rraduate of the K itchener-W ater/oo School of N ursinR if/ Ontario. She has wor"ed at the Clade IflStitute of Psychiatry for the past twelve years, and has been with the actÏ\'e treatment clinic since its inception in 1972. ACknoy,ledgement: This stud\' was funded by the Research Fund Committee. Clar"e IflStitute of Psychiatry. The author wishes to ac"nowledRe the assistunce and upport oj Dr. Mary V. Seeman. 44 November 1979 The Canadian Nurse THERAPEUTIC DRUGS FOR CHRONIC SCHIZOPHRENICS Phenothiazine drugs were introduced in the 1950's and several phenothiazine derivatives are commonly used today. Some oral anti-psychotics are: chlorpromazine (LargactiI OO ), trifluoperazine HCL (Stelazinel!!>) and perphenazine (Trilafonl!!>). Injectable drugs are fluphenazine enanthate (Moditenl!!>) and fluphenazine decoanate (Modecatel!!>). The side effects listed below have not been noted in every phenothiazine, but they have been reported in one or more and should be remembered when these drugs are administered. Adverse effects: . Behavioral: oversedation, impaired psychomotor function, paradoxical effects such as agitation, excitement, insomnia and toxic confusional states. . AutonomiC nervous system: dry mouth, fainting, stuffy nose, photophobia, blurred vision. . Gastrointestinal: anorexia, increased appetite, nausea, vomiting, constipation and others Dosage: when maximum therapeutic response is achieved, the dosage should be gradually reduced to a maintenance level. See CPS for further details. References I *Wing, J. K. The social context of schizophrenia.Amer.J. Psvchiatry 135 (II): 1333-1339, 1978. 2 Canada. Statistics Canada. Mental health statistics. 3 Kallen, OJ. Nutrition and society. JAMA;/ 215:94-/00, /97/. 4 *Kasowski, M.A. and Kasowski, W.J. International symposium reviews folic acid and the nervous system. Canad.Med.AssJ. 119(9):1134-1138, 1978. 5 Boullin, D.J. Nutrition and drug actions and interactions. Primary Care 4(1): 173-181, 1977. 6 Stahl, S.S. Nutritional influences on periodontal disease. World Rev. Nutr. Diet. 13:277-297, 1971. 7 Pauling, L. Orthomolecular psychiatry in Orthomolecular psychiatry: treatment of schizophrenia edited by David Hawkins and Linus Pauling. San Francisco, Freeman, 1973, pp.I-17. 8 *Hoffer, A, The chemical basis of clinical psychiatry, edited by I.N. Kugelmass. Springfield, 111., Charles C. Thomas, 1960. 9 *Dohan, F.C. Relapsed schizophrenics: more rapid improvement on a milk and cereal free diet. Br.J.Psychiatry 115-595, 1969. 10 Tsuang, M.T. Mortality in patients with schizophrenia, mania, depression and surgical conditions. BrJ.Psychiatry 130:162-166, 1977. II Greden, John F. Anxiety or caffeinism: a diagno tic dilemma. Amer.J.Psychiatry 131( 10): 1089-1092, 1974. 12 Canada. Dept. of National Health and Welfare. Nutrient \'alue of some common (oods, 1971. 13 M'asnik, R., et al. "Coffee and": a way to treat the untreatable. Amer.J.Psychiatry 128:164-167, 1971. 14 Tsuang, MT. op. cit. Yo UTe in control of your own career! Take your professional nursing career in your own capable hands. Medical Personnel Pool IS a dedi- cated. conscientious organization made up of skilled health care profes- sionals who demand and have the right to expect their own choice of assignments. flexibility in working hours. comprehensive insurance coverage. everything needed to tailor professional life to personal lifestyle Medical Personnel Pool has an established reputation for the highest standards of integrity and service to the health care community. We supply supplemental nursing per- sonnelto hospitals. nursing homes and private residences on an as- needed basis. With 130 offices in the United States and Canada. MPP is big enough and flexible enough to give you the kind of career control you've always wanted. Call your local MPP office today Hamilton 639 6 771 Toronto 964-0328 An International Nursing Service Bibliography I Reid, D. L. Food habits and nutrient intakes of non-institutionalized senior citizens, by D. L. Reid and J .E. Miles. Canad. J. Public Health 68(2):154-158,1977. *Unable to verify references in CNA Librdry The Canedlan Nurse Nov.mber 1979 45 names & faces Joan Gilchrist, Director of McGill University School of Nursing, was recently named Flora Madeline Shaw Professor of Nursing. The Flora Madeline Shay, Chair in Nursing. named after the first Director of McGiIrs School of Nursing, was established in 1957. Professor Gilchrist, Director of the School since September 1972, is a grdduate of the Wellesley Hospital, School of Nursing. Toronto; the University of Toronto (Diploma in Clinical Supervision); and McGill University /B.N. and M.Sc. Applied}. A fOllTler president of the Canadian Nurses Association from 1976 to 1978, she was awarded the Queen's Jubilee \1edal in 1977 for her contributions to Canadian health care. Joyce Ne,itt. founding director of the School of Nursing at Memorial University of Newfoundland. has written a history of the nursing profession in Newfoundland. Entitled White Caps and Black Bands the book traces the evolution of nursing from the time of Maria Nugent (Sister Joseph Nugent) who died in 1847 while nursing victims of the typhus epidemic in SI. John's. up to 1934 and the re-organization of the Graduate Nurses Assol.:iation under Lucy BaITon. fhe text is supported by old photographs from the collections of Dr. Nigel Rusted. the London Hospital. the International Grenfell Association and from the private collections of those connected with the medical profession. White Caps and Blac/.. Bands begdn as a sabbatical year research project with the . support of the Canada Council and Memorial University. "However I soon realized that the research would take much more than one year, so when I returned to teaching at Memorial I continued to work on the book through holidays and week-ends for four years." Nevitt said. Edna Rossiter of Vancouver, is the fourteenth Canadian nurse to receive the Florence Nightingale Award from the International Red Cros . A former RNABC president (1957-60, Rossiter retired from the pOMtion of Director of Nursing, Shaughnessy Hospital. Vancouver in 1968. Since 1978 she has served as honordI) secretary of the B.C.-Yukon Division of the Red Cross. Rossiter gradudted from Victoria's Royal Jubilee Hospital and rose to the rank of major while serving with the Royal Canadian Army Medical Corps in Europe during World War II. Phyllis Jones has been appointed dean of the Faculty of Nursing , University of Toronto for a five-year tellTl beginning July l. 1979 succeeding fOllTler dean Kathleen King. Jones is a graduate of the U ofT having received her B.Sc.N. in 1950 and her M.Sc. (health administration) in 1969. Prior to her appointment she wa'i a professor in the nursing faculty and has been responsible for graduate courses in community health nursing and nursing leadership, as well as the development and teaching of continuing education courses. "V GREAT DEBATES over controversies in the management of HIGH RISK PATIENTS TOPICS: "Invasive Vs. Non-Invasive Monitoring" "IMV Vs. Assist Control Ventilation" "Crystalloids Vs. Colloids" "Nytroglycerin Vs. Nilroprusside" "Central Venous Vs. Pulmonary Artery Pressure" "Tracheostomy Va. Endotracheal Intubation" "Programable Calculators Vs. Computers" "Pros and eons of Colloid Osmotic Pressure" "Pros and Cons of Steroids in ARDS" PARTIAL LIST OF FACUL TV JOHN B. DOWNS. M.D. JAMES FORRESTER, M.D. WILLIAM GANZ. M.D.. C.SC. RONALD L KATZ. M.D. GERALD S. MOSS. M.D. MYER H. ROSENTHAL, M.D. WILLIAM C. SHOEMAKER, M.D. H. J. C. SWAN, M.D.. PH.D. MAX HARRY WElL, M.D., PH.D. @@ CEDARS-SINAI MEDICAL CENTER DEPARTMENT OF MEDICAL EDUCATION January 11-13. 1980 CENTURY PLAZA HOTEL Los Angeles. California For ,ntormation call (213) 855-5541 or write to Room 2049 Cedars-Sinai MedIcal Center Box 48150 Los Angeles. Ca. 90048 This program offers a total 01 19 hours 01 Continuing Education credit for physicians and nurses. CHAIRPERSONS: JOHN DE ANGELlS, M.D. LAURA WORTHINGTON, RN., M.S. @ I Nutrition . nd diet therap o Clinical implications of laboratory tests L WL "AJØ UCONDmmoN o Health Assessment Ý.-Þ Æ R ð ,. ARE:Of .; .RE:N . ., , , - <<' ' 3." ...:.,..., -,<, ..." - .. _ _ 4Þ 4a _ .. .......-.. - --.. - --..;;.., .- - - - ... -.......... ... - .. ..,. - Mosby The Nursing Publishe "'hi' 1) ;;"" tti c r1r:t 0;' '--, 1I" 'It . , PlIIPrs I.()I\G WOODS --- IC.u.o\JGl __..GICU .' e r:/) == c: aJ.8: 2r')r') ... =' 8 r:/) .... =' .!:1i:n LO .. ......, '. .... :'11 ;- If' 01 / -. . .\t / ... - , --, - . J,."L ....-..;:..j .. .. .. . -t:i .. ... .. ft( .. \ 01 .:.. , --. '- ... MO 8' ?, IlAUf.I . STOIUS. _llNCJ U "0 - :E u "0 C .. ... - :3 "'0 I A CLI ENT .... . l < TO NU I NG THE NUIISE.1M_Y Basic pathophysiology A CIIIICIP'I1ML _ C.....d h__' '" I"'c-_n_..-.c. &. D ;, .. . .'" ,.;I" '-':..!!Io tc..__ . '\. . " -- ...- --...- .. - - \ --= , , ... Ir !) community health care and the I nursing process Fundamentals of nursing practice --- ...h ./ 1 Need we say more? IVIOSBV TIMES MIRROR THE C. V. MOSBY COMPANY, lTD. B6 NORTHlINE ROAD TORONTO. ONTARIO M4B 3E5 A90892 48 November 1979 books Emergency care, assessment and intervention edited by Carmen Germaine Warner. 2d ed. St. Louis, Mosby, 1978. Approximate price: $17.25 This book gives the reader a comprehensive review of emergency care with an emphasis on assessing the client and making decisions regarding necessary interventions. It would assist the graduate nurse in developing her The Canadian Nurse assessment skills, in setting priorities and in making decisions in various emergency situations. The book gives accurate and concise criteria for assessing a wide variety of emergency situations and provides guidelines for intervention based on scientific principles and recent medical research. More specifically, chapters one and two are definitely oriented to the American health care system and are of little operational use for Canadians. However. they do provide Canadian readers with insight into what is being done in some areas of the United States The first and last word in all-purpose elastic mesh bandage. ...,... , i.: .. Jf...;r - " J.-; " .,. . '" ,,_. ......,"'"sess a variety of emergency situations and give specific guidelines for planning intervention. I found no di<;crepancies or omissions in the chapters and thought they were very well presented. I was particularly impressed with the writer's ability to get the important facts and information across in such limited space. It is often difficult to determine what one should have for a knowledge base in emergency care. I n summary. the book provides a comprehensive re\'iew of knowledge and skills necessary in assessing and intervening in a variety of emergency situations. In order to benefit from this book, the nurse must have previous experience and knowledge regarding the topics covered. I would not recommend this book as a text in an undergraduate school of nursing. I would, however, recommend it for all graduate nurses working in critical care areas or as a text for continuing education in emergency care. Rniell'ed by Debbie Sutherland. M.S.N. Assistant Professor. Memorial V ni\'ersity of N ell{OIifldland. School of Nursing. St. John's. Nellfoundland. BOOKS RECEIVED Listin/< ( f a puhlication doe not preclude in subsequeflt rel'iew. Selection. .for rel'iew will be made accordinR to the iflterest. of our readers and a.\ space permits. A II rel'iew.\" are prepared on illl'itatioll. Readings in the sociolog) of nursing, edited hy Robert Dingwall & Jean I\.klnto!>h. Nev. York. Churchill Livingstone. 1978. Clinical nursing techniques, hy Norma Dison. 4th ed. Toronto. Moshy. 1979. Melloni's illustrated medical dictionaQ, by Ida Dox. Baltimore. WiIIi..m & Wilkings. c1979. Criteria for the determination of death; working paper:!3, by Law Reform Commission of Canada. Canada. Mini terof Supply and Services. 1979. Report of the Se,enty-Fïfth Ross Conference on Pediatric Research. The ductus arteriosus. Ohio. Ross LaNmuories, 1978. llnderstanding the rape victim: a synthesis of research findings. by Sedelle Katz. Toronto, Wiley,cl979. '\Iursing management for patient care, by Matjorie Beyers & Carole Phillips. :!d ed. Boston. Little. Brown, c1979. Care of the mentally retarded. by Marian Willard Blackwell. Boston. Little, Brown, c1979. Nursing care of infants and children. by Lucille F. Whaley & bonna L. Wong. Toronto, Mosby. 1979. Humanizing hospital care. by Gemld P. Turner & Joseph Mapa. Toronto, McGraw-Hili, c1979. Basic human anatomy and physiology, by Charlotte M. Dienhal1. 3rd ed. Toronto. Saunders, 1979. Elementary medical biochemistry. by J.M.I\1. Brown &G.G. Jaros. Durban, Buttersworths, 1977. Organisationat structure and the care of the mentally retarded, by Norma V. Raynes, Micheal Pratt & Shirley Roses. London. Croom Helm, c1979. '\Ieonatal pulmonary care, by Donald W. Thibeault...et al. Don Mills, Ont., Addison- Wesley. c 1979. Le nursing en ps}chiatrie: pour une vision globale, par Judilh Haber...et al. Montreal. HRW. c1978. M} body. m} health: the concerned woman's guide to gynecolog}, by Felicia Hance Stewart...et a1. Toronto. A. Wiley Medical, c1979. Primary nursing: a model for indhidualized care, by Gwen Marram & Margaret W. Barrett. 2d ed. Toronto. Mosby. 1979. Guide to nursing management of psychiatric patients, by Sharon Dreyer. David Bailey & Will Doucet. 2d ed. Toronto, Mosby, 1979. Current practice in nursing care of the adult issues and concepts. \ot. one, by Maureen Shawn Kennedy &Gail Molnar Pfeifer. Toronto. Mosby, 1979. 'Iatemal and child health nursing. by Joy A. Ingalls & M. Constance Salerno. 4th ed. Toronto, Mosby, 1979. Bachelor of Administration (Health Services) Degree Program Applications are now accepted for the program combining independent study with tutorials on weekends in Toronto, as well as for the competency based, external degree internship option offered for students at a distance. Credits toward advanced standing are given for practical managerial experience and prior education including B.A., B.Sc., B.Sc.N., R.N., R.T.. H.O.M. Certificate and University or College Courses. The School is a member of Ihe Association of University Programs in Health Administration and is supported by the Kellogg Foundation grant. For information and application forms, please write to: Canadian School or Management S-425. OISE BuDding 252 Bloor St., West Toronto. ODtario M5S I V5 The c.nadlen Nurae November 1979 49 Women's health and human wholeness, by Loretta S. Bermosk & Sarah E. Porter. New York, Appleton-Century-Crofts. 1979. Hope for hypoglycemia, by Broda A. Barnes. Fort Collins, Colorado, Broda A. Barnes, 1979. Self-assessment of current knowledge in oncology nursing. by Rosemary Wang & Ann Manchester Kelley. New York. Medical Examination, c 1979. The new nurse's work entry: a troubled sponsorship, by Patricia Benner & Richard Benner. New York, Tiresias Press. c1979. Natural childbirth the Swiss way. by ESlher Manlus. Englewood Cliffs, Prentice-Hall. cl979. The recovery room. by Cecil B. Drain & Susan B. Shipley. Toronto, Saunders. 1979. Practical notes on nursing procedures, by Jessie D. Britten. 7th ed. New York, Churchill Livingstone. 1979. General surgical nursing. by Jane Emily DeLoach. New York. Medical Examination, 1979. Body structure and function, by Sondra Von Arb. Mankato. Mn.. Minnesota Scholarly Press, 1979. Dept. of Emergency Medicine. Guidelines manual: policies and procedures, by Jeffrey MacDonald & Pal Kinder. Toronto. Mosby. 1979. Self-assessment of current knowledge in mental health nursing, by Doris J. Stoltzfus. Garden City. N.Y., Medical Examination,1979. Frogs into princes, by Richard Bandler & John Grinder. Moab. Utah, Real People Press, 1979. Orthopedic nursing: a programmed approach, by Nancy A. Brunner. 3rd ed. Toronto, Mosby, 1979. <'Mother can't talk too much, her throat's bothering her." deqyggio:. It's more than good-tasting, it's good medicine. Antibacterial, antifungal lozenges W ÇLl!!/!A!!!' fJ!l!lPljl!.!v D 1 DORCHESfER AVENUE TORONTO ONTARIO MBl 4WI 50 November 1979 Leadership in nursing, by Margaret M. Moloney. Toronto, Mosby, 1979. The cancer unit: an ethnography, by Carol P. Hanley Germain. Wakefield, Ma., Nursing Resources, 1979. Obstetrical nursing. Continuous education review, by Malo-Juvera, Dolores...et al. 2d ed. Garden City, N.Y., Medical Examination, 1979. Nurse practitioners: USA, by Harry A. Sultz, Henry, Marie & A. Judith. Toronto, Lexington Books, 1979. Health guide for travellers to warm climates, by Stanley S.K. Seah. 2d ed. Ottawa, Canadian Public Health Association, 1979. Maintaining cost effectiveness, by Elsie Schmied ed. Wakefield, Mass., Nursing Resources, 1979. Ovol Drops relieve infant colic. I ,. 'PAABI ccpp Th. c.n-.llen NUrH Nurses' handbook ofOuid balance, by Norma MilIiam Metheny & W.O. Snively. 3rd ed. Toronto, Lippincott, c1979. Introductory maternity nursing, by Doris C. Bethea. 3rd ed. Toronto, Lippincott. c 1979. Perspectives on adolescent health care, by Ramona T. Mercer. Toronto, Lippincott, 1979. Childbearing; physiology, experience, needs, by Jayne DeClue Wiggins. Toronto, Mosby, 1979. Work manual for introductory maternity nursing, by Doris C. Bethea. 3rd ed. Toronto, Lippincott, cl979. A guide to physical examination, by Bamara Bates. 2d ed. Toronto, Lippincott, 1979. The patient with end stage renal disease, by Larry E. Lancaster. Toronto, Mosby, 1979. 1 - _;r"" 15l1li Ovol Drops contain simethicone, an effective, gentle antiflatulent that goes to work fast to relieve the pain, bloating and discomfort of infant colic. Gentle pepper- mint flavoured Ovol Drops. So mother and baby can get a little rest. Oval am CAA. -.- ft I ng I . relief . I of infant colle 6HORr'Æ:R Shhh. Ovol Drops. AlooB'B,IBblemtabletronnrorBdulu eHQB R Maternal and child nutrition, edited by Jill s. Slattery, Gayle Angus Pearson & Carolyn Talley Torre. New York, Appleton-Century-Crofts, 1979. Current practice in critical care. Toronto, Mosby, 1979. Community decision making for social welfare; federafism, city government and the poor, by Robert S. Magill. New York, Human Science Press, cl979. Nurse's guide to drugs. Horsham, Pa., Intermed Communications, 1979. Programmed mathematics of drugs and solutions, by Weaver, Koehler. Toronto, Lippincott, 1979. Community development research, edited by EdwardJ. Blakeley. New York, Human Science Press, 1979. Drugs and pharmacology for nurses, by S.J. Hopkins. London, Churchill Livingstone, 1979. The doctor and the law; a practical handbook for the Canadian physician, by H.E. Emson. Toronto, Macmillan of Canada, cl979. Coping with neurologic problems proficiently. Horsham, Pa.,lntermed Communications, 1978. *THE LIBRARY'S ACCESSION LIST IS A V AILABLE ON REQUEST WITH A STAMPED, SELF -ADDRESSED ENVEWPE. 'iI OVOI@80mg Tablets OVOI@40mg Tablets Ovol@ Drqps Antiflatulent Simethicone INDICATIONS OVOl is indicated 10 relieve bloating, flatulence and other symploms caused by gas retention Including aerophagia and infant colic. CONTRAINDICATIONS None reported. PRECAUTIONS Prolect OVOl DROPS from freezing. ADVERSE REACTIONS None reported. DOSAGE AND ADMINISTRATION OVOl80 mg TABLETS Simethicone 80 mg OVOl4O mg TABLETS Simethicone 40 mg Adults: One chewable lablel between meals as required. OVOl DROPS Simelhicone (in a peppermint flavoured base) 40 mg/ml Infants: One-quarter to one-half ml as required. May be added to formula or given directly from dropper. e HQB R What's New? TEXTBOOK OF HUMAN SEXUALITY FOR NURSES By Roben C. Kolodny, M.D.; William H. Masters, M.D.; Virginia E.johnson;and Mae A. Biggs, R.N., M.S. While nurses fully realize that sexual health is an important com- ponent of the overall well-being of their patients, the effects of health problems on sexuality are less apparent. To explain the biologic and psychosocial impacts on sexuality of a variety of medical and surgical conditions, the authors of TEXTBOOK OF HUMAN SEXUALITY FOR NURSES draw on 25 years of clinical experience and research from the Masters & Johnson Institute. From its opening chapter, Sexuality as a Clinical Science for Nurses, to its closing pages of questions and answers, this text effectively incorporates human sexuality into nursing practice at a level that can be understood by both practicing and student nurses. Little, Brown. 450 Pages. Illustrated. 1979. Paper, $15.00. Cloth, $21.00. GERONTOLOGICAL NURSING By Charlotte Kopelke Eliopoulos, R.N., B.S., M.S. This practical new book provides a comprehensive review of the medical, surgical, and psychiatric problems associated with aging, accompanied by related nursing interventions. Specific coverage is given to measures designed to promote good respiration, elimination, and activity to compensate for age-related changes interfering with these functions. Common diseases of each body system and their unique features in the aged are discussed in detail. Harper & Row. 384 Pages. Illustrated. 1979. $15.00. A GUIDE TO PHYSICAL EXAMINATION, 2nd Edition By Barbara Bates, M.D. New chapters on interviewing and history-taking, and much expanded and updated content mark the new edition of this outstanding guide to physical assessment for health practi- tioners. Detailed and concise, it's an excellent on-the-job reference for interviewing and examination; for assessment of health status; and for differential diagnosis among abnormal findings. There are now more examples of abnormalities, more information on the cardiac chapter, a new section on the stuporous or comatose patient and revised chapter on the pediatric examination. Lippincott. Abt. 425 Pages. 1979. $25.00. NURSES' HANDBOOK OF FLUID BALANCE, 3rd Edition By Norman Milligan Metheny, B.S.N., M.S.N., Ph.D.; and W.O. Snively,jr., M.D., F.A.C.P. Almost totally rewritten and revised, with a wealth of new material, this edition is twenty percent larger than the previous one! It presents basic knowledge of body fluid balance distur- bances, with emphasis on practical application. New material and major revisions include: new knowledge of homeostasis; a summary of the latest information on nutrition; an expanded section on real-life case histories; greatly increased emphasis On acid-base disturbances; and greater coverage of elemental diets, tube feedings, diuretics, and adrenocortical steroids. Lippincott. Abt. 400 Pages. 1979. Abt. $15.00. NURSING MANAGEMENT FOR PATIENT CARE, 2nd Edition By Marjorie Beyers, R.N., Ph.D.; and Carole Phillips, R.N., M.S. In this second edition, the authors live up to the impeccable reputation established by NURSING MANAGEMENT FOR PATIENT CARE. Important new features include reports on recent theories of management, a deeper explanation of the nurse manager's relationship with staff members, an enlarged chapter on the plan of care, and timely discussions of the expanding role of the nurse manager, including her function in health-care organizations other than hospitals and in disputes with unionized employees. Little, Brown. 292 Pages. Illustrated. 1979. $10.75. COMMUNICATION FOR HEALTH PROFESSIONALS By Voncile M. Smith, Ph.D.; and Thelma A. Bass, M.A. This timely book identifies and describes problem situations stemming from communication breakdowns that commonly affect health care personnel. It relates the importance of communication to the maintenance of public confidence in health care institutions and personnel, and explains skills necessary to communicate effectively with patients and clients, co-professionals, supervisors, and subordinates. Lippincott. Abt. 200 Pages. 1979. Abt. $8.50. Lippincott J. B. LIPPINCOTT COMPANY OF CANADA LTD. Serving the Health Professions in Canada Since 1897 75 Horner Ave., Toronto, Ontario M8l4X7 LIPPINCOTT'S NO-RISK GUARANTEE Books are shipped to you On Approval; if you are not entirely satisfied you may return them within 15 days for full credit. ffld fu ; ------- o KOLODNY: Textbook of Human Sexuality for Nurses, Paper, $15.00. o KOLODNY: Cloth, $21.00. o ELIOPOULOS: Gerontological Nursing, $15.00. o BATES: A Guide to Physical Examination, 2nd Ed., $25.00 o METHENY: Nurses' Handbook of Fluid Balance, 3rd Ed., $15.00. o BEYERS: Nursing Management for Patient Care, 2nd Ed., Abt. $15.00. o SMITH Communication for Health Professionals, Abt. $850. o Payment enclosed (postage & handling paid) o Bill me (plus postage & handling) Name Address City Postal Code Provo Prices subject to change without notice. CNII/79 12 November 11711 Th. c.nMllan NUrH Classified Advertisements Alberta The Drumheller Health Unit requires a Supervbor of Nw.. with experience and qualifications in Public Health for supervision of a staff of eiøht district nurses in preventive programs of community health to a population of 28,000 in an area of 4000 square miles. Main office is located in Drumheller, popula- tion 6,000, 8S miles from Calgary. For information or application forms please reply, giving curriculum vitae to: Agnes E. O'Neil, M.D., D.P.H., Medical Officer of Health, Box 1780, Drumheller, Alberta, TOJ OYO. Realltered Nunes required for full or part time work for Medical and Surl!ical floors. To work rotating shifts. Positions available immedialely. Apply to: Mrs. S. Tiechreb, Director of Nursing, Pincher Creek Municipal Hospital, P.O. Box 968. Pincher Creek, Alberta, TOK IWO. Rqlltered nw.. required for 7S-bed accredited active treatment hospital in a lakeland resort area, 130 miles northeast of Edmonton, Salary 51217 - 14S4 per month. Apply: Director of Nursing, St. Therese Hospital. Box 880, St. Paul, Alberta, TOA 3AO. British Columbia Experienced General Duty Graduate Nurses required for small hospilal located N.E. Vancouver Island. Maternity experience preferred. Personnel policies according to RNABC contract. Residence accom- modation available 530 monthly. Apply in writing to: Director of Nursing, St. George's Hospital, Box 223, Alert Bay, British Columbia, VON IAO. O.R. and P.A.R. - Head Nurse required for an accredited 1000bed acute hospital in a fasl growing progressive community in B.e. Experience or advanced preparation required. Must be eligible for B.e. registration. Salary - 51S00 - 51772 per month. Benefits in accordance with R.N.A.B.e. contract. Apply 10: Director of Personnel, Fort St. John General Hospital, Fort SI. John, B.e. VIJ IY3; Phone (604) 78S-66 I I. General Duty Nurse for modem 3S-bed hospital localed in southern B.e. 's Boundary Area with excellent recreation facilities. Salary and personnel policies in accordance with RNABe. Comfortable Nurse's home. Apply: Director of Nursing, Bound- ary Hospital, Grand Forks, British Columbia. VOH IHO. General Duty RqI!ltered Nurses required for 108 bed accredited hospital. Previous experience desirable. Staff residence available. Salary as per R.N.A.B.e. Contract with northern allowance. For further information please contact: Director of Nursing, Kitimat General Hospital, 899 Lahakas Boulevard N.. Kitimat, B.e. V8C IE7. Registered Nurses required immediately for a 340- bed accredited hospital in the Central Interior of B.e. Registered Nurses interested in nursing posi- tions at the Prince George Regional Hospital are invited to make inquiries to: Director of Personnel Services, Prince George Regional Hospital, 2000- ISth Avenue. Prince George, British Columbia, V2M IS2. British Columbia Experienced Nurses (eligible for B.e. Registration) required for full-time positions in our modem 300-bed Extended Care Hospital located jusl thirty minutes from downtown Vancouver. Salary and benefits according to RNABC contract. Applicants may telephone S2S-0911 to arrange for an interview. or write giving full particulars to: Personnel Direc- tor. Queen's Park Hospital, 31S McBride Blvd., New Westminster, British Columbia, V3L SE8. Experienced Nurses (B.e. Registered) required for a newly expanded 463-bed acute, teaching, regional referral hospilal located in the Fraser Valley. 20 minutes by freeway from Vancouver, and within easy access of various recreational facilities. Excel- lent orienlation and continuing education program- mes. Salary-1979 rates-5130S.00--5IS42.00 per month. Clinical areas include: Operating Room, Re- covery Room, Intensive Care, Coronary Care, Neonatal Intensive Care, Hemodialysis, Acute Medicine, Surgery, Pediatrics, Rehabilitation and Emergency. Apply to: Employment Manager, Royal Columbian Hospital, 330 E. Co umbia St., New Westminster, British Columbia, V3L 3W7. Head Nunc for t6-bed Psychiatric Unit in a Northern B.e. hospital. Must be eligible for B.e. registration with a minimum of two years experience and proven administrative skills in a similar position. Apply in writinlJ to the: Director of Nurses, Mills Memorial HOSpital, 4720 Haugland Avenue, Ter- race, British Columbia, V8G 2W7. Experleac:ed maternIty, I.C.U./C.C.U., ud Operat- In. Room General Duty nunes required for 100-bed accredited hospital in Northern B.e. Must be eligible for B.e. registration. Apply in writinJl to the: Director of Nurses, Mills Memorial Hospital, 4720 Haugland Avenue, Terrace, British Columbia, V8G 2W7. Manitoba Public Health Nunc required immediately for com- munity health centre at Lac du Bonnet, Manitoba. Work on a team with other health disciplines. Tourist area 70 miles from Winnipeg. Apply to: Executive Director, Lac du Bonnet District Health Cenlre. Box 1030, Lac du Bonnet, Maniloba, ROE IAO. Challenging Career Opportunity ror Registered Nurses In Canada's North - A 100 bed acute care hospital in Nonhem Mdnitoba which services Thompson oind several small communities in the surrounding area has immediate vacan- cies in Pediatrics. Medicine/Surgery. Obstetrics and Critical Care. This opponunity will appeal to nurses who want to increase their existing ski11s or develop new skills through our comprehen!rr>ive inservice program. Many of our nurses have become experienced in flight nursing. Candidates must be eligible for provincial registration as d.ctive practicing members. We offer an rxcellent range of benefits. including frer dental plan. accident. health and group life insurance. Salary rnnge is SI.078 - SI.340 per month dependent on qualifications and experience plus a remoteness allowance. Apply in writing or phone: Mr. R.l. Irvine. Director of Personnel. Thompson General Hospital. Thompson. Man- itoba. R8N OR8. Phone: (204) 671-2381 Experienced ReJlltered N...... required for a fully accredited 200-bed Health Complex located in Northern Manitoba. Must be eligible for registration in Manitoba. Salary dependent on experience and education. For further infonnation contact: Mrs. Mona Seguin, Personnel Director, The Pas Health Complex Inc., P.O. Box 240, The Pas, Manitoba, R9A IK4. Manitoba Applications, including resume and name of referees are invited for Faculty whh prore.loaal competence In Community Health Nunln.. This full time position will commence September t, 1979 or as soon as possible. Candidates should have at least a Master's Degree, as well as teaching experience and a publication record. Salary and rank are negotiable and commensurate with qualifications. Considera- tion will be given to those with polential for teaching effectiveness in the Canadian health care scenes. Apply to: Professor June Bradley, Acting Director, The School of Nursing, University of Manitoba, 21S - 9S Curry Place, Winnipeg, Manitoba, RJf 2N2. Northwest Territories The Stanton Yellowknife Hospital, a 72-bed accre- dited, acute care hospital requires registered nurses to work in medical, surgical, pediatric, obstetrical or operating room areas. Excellent orientation and inservice education. Some furnished accommoda- tion available. Apply: Assistanl Administrator- NursinJl, Stanton Yellowknife Hospital, Box 10, Yellowknife, N.W.T.,XIA 2NI. Ontario P.H.N. - Registered Nurse qualified in Public Health Nursing with Degree or Diploma for generalized public health nursing programme. Apply in writing with resume to: Director of Nursing, Haldimand-Norfolk Regional Health Unit, Box 247, Simcoe, Ontario, N3Y 4LI. Director of Nursing required for an accredited 18S-bed Active Treatment General Hospital in Northern Ontario. Position: The Director will be responsible for planning, organizing, directing and evaluating the activities of the Nursing Departmenl: must be aware of current concepts of Nursing Service and have enthusiasm for initiating and following-up new ideas, projects and programs. Qualifications: Candidate must be currently regis- tered in the Province of Ontario and possess a Baccalaureate Degree in Nursing or have de- monslrated competence and ability in a senior level nurse management position. Salary is commensurate with qualifications and experience. Please forward applications to: Personnel Director, St. Mary's General Hospital, 41 Pine Slreet North. Timmins. Ontario. P4N 6K7. RN, GRAD or RNA, Y6" or over and strong. without dependents, non-smoker, for 18S lb. hand- icapped retired executive with stroke. Able to transfer patient to wheelchair. Live in 1/2 yr. in Toronto and 1/2 yr. in Miami. WaJles: 5200.00 to 527S.00 wkly. NET plus 590.00 wkly. bonus on most weeks in Miami. Write: M.D.e., 3S32 Eglinton Avenue West, Toronto. Ontario. M6M IV6. Saskatchewan Two RN's required for a 32 bed, fully accredited general hospital. For further infonnation contact: Director of Nursing, St. Joseph's Hospital, Gravel- bourg, Saskatchewan SOH IXO. Rqlstered Nunes required immedialely for penna- nent full time positions at a 30-bed accredited hospital in Esterhazy, Sask. Must be eligible for S.R.N.A. registration and willing to work rotating three shifts. Apply to: Director of Nursing, St. Anthony's Hospital, Box 280, Esterhazy, Sas- katchewan, SOA OXO; or phone: (306) 74S-3973. Saskatchewan R.N.'s and R.P.N.'s (eligible for Saskatchewan registration) required for 340 fully accredited ex- tended care hospilal. For further infonnation. contact: Personnel Department. Souris Valley Ex- tended Care Hospital. Box 2001, Weyburn, Sas- katchewan S4H :!L7. United States USA - Positions available in Texas, Arkansas and Nevada, for Reat.tered Nu.... For information please write to: Mrs. G. Nees, President, Pacific International Employment Service Inc., 7110 Dye Drive, Dallas, Texas, 7S248. R.N.'. U.S.A. - Dunhill with 2SO offices has exciting career opportunities for both recenl grads and experienced R.N.'s. Locations North, South. East and West. All fees are paid by Ihe employer. Send your resume to: 801 Empire Building. Edmon- ton, Alberta, TSJ IV9. Maternal Child Health Super>lsor -tf you think the time has come for you to select a new professional environme:ll, then Ihe time has come for you to seriously consider joining Kaiser-Permanente. a dynamic JACH accredited teaching hospital. At Kaiser. a superior benefit package is offered to all fun time RN's. and because we believe in the importance of continuing education. we offer 24 hour in-service training on all shifts. Our Maternal Child Health Dept. is seeking a leader: a licenset1 RN who has a strong background in Maternal Child Health, and who is accomplished in the ability to lead olhers. Send your resume for an earnesl review of your qualifications in confidence to: Ann Marcus. Dir. of Nurse Staffing. Kalser-Pennanente edlcal Center, 4867 Sunset Blvd.. Los Angeles, California 90027 (213) 667-6932. The Cen-.llen Nure. Offers R.N.'s An UNUSUAL OPPORTUNITY, A.M.I. Will FURNISH One Wly AIRLINE TICKET to Teus Illd S500 Inltll' LIVING EXPENSES on a loin Basis. Anlr Onl Y..r's Se",lcI, TIlls loan Will be Cancelled MI American Medical International Inc. . HAS 50 HOSPITALS THROUGHOUT THE U.S. . lIow A...I. II ".wang ".11:1 lor HOl,llIlllo T..II. Immel/al. D,lftlilfl. II'lry IIlng. 111.000 10 $16. SOD per Y.... . You can enloy nurSing in General MedIcIne. Surgery. ICC. CCU. Pedlalncs and Obstetncs . A M I provides an excellent onentatlon program. m-seMce training r------------.. I . . U.S. Nurse Recruiter . I P.O. Box 17778,los AnAeles. Calif. 90017 . , . WIthout obhgaÞOn. please send me more I InlormaÞon and an ApphcallOn Form , I !lAME I AODII ESS -======= === I I DTY_ --- ST.___ZIP___, TELEPHONE (_ _1_ _ _ _ _ _ _ __ I UCENSES:___________. . SPEDALTY:_ ____. __ ---I YEAR GRADUATED. _ _ _ STATE _ _ __ ,,____________rI EXPERIENCED RN'S & NEW GRADS "THE PERFECT OPPORTU ITY" Saint Anthony Hospital, located in Columbus, Ohio. This 400-bed acute care facility offers excellent opportunities for furthering your nursing career. No Contracts to Sign Rotating Shifts Air Fare Paid One Month Free Accommodations Plus Exciting Challenges Saint Anthony, a medical-surgical institution. has a complete range of services, including; . Open Heart Surgery . Intensive and Coronary Care . Definitive Observation Unit o Renal Dialysis o Diagnostic and Therapeutic Radiology . 24 Hour Emergency Department Don't wait, caD or write immediately. Make the change to an institution that lets you be what you want 10 be. For further information. call our Nurse Recruiter, orma Shore, CoDed. EXCLUSIVE CANADIAN REPRESENTATIVES RECRlTr....G REGISTERED Nl'RSES VIIC. 1.111- II III 11_ II. 1200 Lawrence A venue Easf Suite 301, Don Mills Ontario M3A IC] Telephone: 14]6) 449-5883 - November 11171 53 United States NunN - RNs - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa fonns and provide assistance with licensure at no cost to you. Write for a free job market survey Or call collect (713) 789-tSSO: Marilyn Blaker, Medex, SSOS Richmond. Houston, Texas 770S7. All fees employer paid. California - Sometimes you have to go a long way to find home. But, The White Memorial Medical Center in Los Angeles. California. makes it all worthwhile. The While is a 377-bed acute care teaching medical cenler with an open invitation to dedicated RN's. We'll challenge your mind and offer you the opportunity 10 develop and continue your professional growth. We will pay your one-way transportation, offer free meals for one month and all lodging for three months in our nurses residence and provide your work visa. Call collect or write: Ken Hoover, Assistant Personnel Director, 1720 Brook- lyn Avenue, Los Angeles, California 90033 (213) 268-S000, ext. 1680. t10rtda Nu...... Opportullltiel - MRA is recruiting Registered Nurses and recent Graduates for hospital posilions in cities such as Tampa, St. Petersbu . and Sarasota on the West Coast; Miami, Ft. Lauderdale and West Palm Beach on the East Coast. If you are considering a move to sunny Florida, contact our Nurse Recruiter for assistance in selectinl the riøht hospital and cilY for you. We will provide complele Work Visa and Stale Licensure information and offer relocation hints. There is no placement fee to you. Wrile or call Medical RKnaitenof "'-rica, lilt. (For West Coast) 1211 N. West shore Blvd., Suite 20S, Tampa, FI. 33607 (813) 87H)202: (For East Coast) 800 N.W. 62nd St., Suite SIO, Ft. Lauderdale, FI. 33309 (30S) 772-3680. . { I I I ..... , - . 54 Novem.....'979 50th Anniversary Celebration Seton General Hospital in Jasper National Park invites all ex nursing staff to attend their 50th Anniversary Celebrations May 5th to lith, 1980 Inclusive. A Gala Banquet and Ball at Jasper Park Lodge, May 10th. Come and renew old acquaintances and make some new ones! For further information contact: Mrs. Donna Lane, R.N. Box 1063 Jasper, Alberta TOE lEO I nternational Grenfell Association invites applications for the positIOn of Director of Nursing for an accredited 160-bed general hospital in SI. Anthony, Newfoundland. Travel expense borne by Association on minimum of one-year service. Fringe benefits. Applicants should have administrative experience and be eligible for registration in the Province of Newfoundland. Preference given to candidate with B.Sc. or masters in nursing. Salary in accordance with provincial government scale. Apply to: Mr. Scott SmIth Personnel Director International Grenfell AMoclatlon St. Anthony, Newfoundland AOK 4S0 McMaster University Educational Program For Nurses In Primary Care McMaster University School ofNurs- ing in conjunction with the School of Medicine. offers a program for regis- tered nurses employed in primary care settings who are willing to assume a redefined role in the primary health care delivery team. RequIrements Current Canadtan Regist- ration. Preceptorship from a medical practitioner. At least one year of work experience, preferably in primary care. For further information write to: Mona Callin, Director Educational Program for Nurses in Primary Care Faculty of Health Sciences McMaster University Hamilton, Ontario L8S 4J9 Th. c.n-.llen Nur.. United States RN'I - Bo6Ie, Idaho - How would you like a ew ng career in an environment which offers you unmediate access to unconlested recreation areas with. rivers, lakes and mountains? Do you eqjoy tennis, aolf, rackelball, camping, hiking, sküng and horseback riding? Sound exciting? It is. And there are many opportunities for satisfyinl work at one of Idaho's largest and most progressive medical complexes. SI. Alphonsus, located in Boise is a 229-bed. facility offering you position's in orthopedtcs, ophthalmology, dialysis, mental health, neurosurgery and trauma medicine. Excellent salary, ge!'erous benefits w:'d job security. Starting salary adjusted for expenence; benefits include tra el assistance, shift rotation, and free parking. Wnte or call collecl: Employment Supervisor, Personnel Office, St. Alphonsus Hospital, 1055 North Curtis Road, Boise, Idaho 83704, (208) 376-3613. EOE. ] NUrMI - RNI - Immediate Openinls in Califomia-Florida-Texas-Mississippi - if you are experienced or a recent Graduate Nurse we can offer you positions with excellent salaries of up to $1300 per month plus all benefits. Not only are there no fees to you whatsoever for placing you, but we also provide complete Visa and Licensure assistance at also. no. cost to . l ou. Write immediately for our appllcalton even I Ihere are other areas of the U. S. that you are interested in. We will call you upon receipt f you.r application in order to BlTange for hOspltalmtervlews. You can call us collect if you are an RN who is licensed by examination in Canada or a recent araduate from any Canadian School of Nursing. Windsor Nurse Placement Service, P.O. Box 1133, Great Neck, New York, 11023. (516 - 487-2818). "Our 20th Year of World Wide Service" Dallas, Houoton, Corpus ChrIsti, etc, etc, elc. The eyes of Texas beckon RN's and new grads to practice their profession in one of Ihe most prosperous areas of the U.S. We represenl all size hospitals in virtually every Texas and Southwest U.S. City. Excellent salaries and paid relocation expenses are just Iwo of many super benefits offered. We will visit many Canadian cities soon to inlerview and hire. So we may know of your interest. won't you contact us today? Call or write: Ms. Kennedy, P.O. Box 5844, Arlington, Texas 76011. (214) 647-0077. Come to Tnas - Baptist Hospital of Southeast Texas is a 400-bed growth oriented organization looking for a few good R.N. 's. We feel that we can offer you the challenge and opportunity to develop and continue your professional growth. We are located in Beaumont, a city of tSO,OOO with a small town atmosphere but the convenience of Ihe large city. We're 30 minutes from the Gulf of Mexico and surrounded by beautiful trees and inland lakes. aptist f:lospital has a progress salary plan plus a liberal fnnge package. We will provide your immig- ration paperwork cost plus airfare to relocate. For additional infonnation, contact: Personnel Ad- ministration, Baptist Hospital of Southeast Texas, Inc., P.O. Drawer 1591, Beaumont, Texas 77704. An amrmlltlft mloa employer. Exdtement: Come and join us for year around excitement on the border, by the sea, an unbeatable combination. Eqjoy the sandy beaches of So. Padre Island or the unique cultures of Old Mexico. Our new 117-bed, acute care hospital offers the experi- enced nurse and the newly graduated nurse an array of opportunities. We have immediate openings in all areas. Excellent salary and fringe benefits. We invite you to share the challenge ahead. Assistance with travel expenses. Write or calI collect: Joe R. Lacher, RN, Direclor of Nurses, Valley Community Hospi- tal, P.O. Box 469 , Brownsville. Texas 78521: I (512!831-961I. Don't be left out In the cold: RN's eqjoy the semi-tropical weather of Weslaco, Texas localed in the heart of the Rio Grande Valley. Close to South Padre Island's sunny beaches and the Mexican Border. Knapp Memorial Methodist Hospital cur- rently has 100 beds and we would like you to help staff an additional SO beds - 10 in an tCU..cCU unit. Also need nurses for Med/Surg, Nursery and OB. Contact Debby or Connie, Personnel Office, KMMH, 1330 E. Sixth St.. Weslaco, TX. 78 96. (512) 968-8567, Ext. 286 or 162. Nursing Co-ordinator Applications for the position of Medical-Surgical Co-ordinator are being accepted for mid-September by this 300 bed fully accredited hospital. Experience in supervision with a Bachelor ofN ursing Degree preferred. Temporary accommodation available. Please reply sending a complete resume to: Director of Personnel Stratford General Hospital Stratford, Ontario NSA 2Y6 Clinical Nurse Specialist - Pediatrics This position represents a challenging opportunity for a Maslers prepared nurse with experience in general and critical pedialric care. The successful applicant will serve as a role model and educator responsible for staff development in two pediatric units which provide quality family centered care in a primary nursing environment. Please send resume to: Mrs. L. Rivers Manpower Services St. Boniface General Hospital 409 Tache Avenue Winnipeg, Manltoblt Canada RZH ZA6 Assistant Director of Nursing required for N anaimo Regional General Hospital, a 360-bed acute general hospital. Duties to commence January 1st, 1980. Must have or be eligible for B.C. registration. BSN and previous experience preferred. Please direct applications to The Director of Nursing Nanaimo Regional General Hospital 1200 DutTerin Crescent Nanaimo, British Columbia V9S 2B7 The Can-.llan Nur.. Head Nurse Coronary Care ['nit Vancouver General Hospital Applications are being accepted for the above position. The Unit consists of a 3 bed Intensive Care Unit. 10 acute care beds and 8 sub-acute care beds. The successful applicant will be involved in the planning and development of an mterim Coronary Care Plan. Apþlicants should have a minimum of2 years previous experience in a related capacity and preferably hold a B.S.N. Salary scale and benefits according to the RNABC Agreement. Please submit applications to: Mrs. J. MacPhail Employee Relations Department Vancouver General Hospital 855 West 12th Avenue Vancouver, B.C. VSZ 11\19 Nursing Opportunities in Vancouver Vancouver General Hospital If you are a Registered Nurse in search of a change and a challenge - look into nursing opportunities at Vancouver General Hospital. B.c.'s ml\Ïor medical centre on Canada's unconventional West Coast. Staffing expansion has resulted in many new nursing positions at all levels. including: General Duty ($1305. - 1542.00 per mo.) Nurse Clinician Nurse Educator Supervisor Recent graduates and experienced professionals alike will find a wide variety of positions available which could provide the opportunity you've been looking for. For those with an interest in specialization. challenges await m many areas such as: Neonatology Nursing Intensive Care (General & Neurosurgical) Cardio- Thoracic Surgery Inservice Education Coronary Care Unit Hyperalimentation Program Renal Dialysis & Transplantation Burn Unit Paediatrics If you are a Nurse considering a move please submit resume to: Mrs. J. MacPhail Employee Relations Vancouver General Hospital 855 West J2th Avenue Vancouver, H.C. V5Z IM9 November 19711 55 ...... - - - "",,000' _ _ .... .....- ....., "9 , " City of Regina \ I I 1'1 I CAREER OPPORTUNITIES I I I I I I I I City of Regina I I reqUIres I I I I Director of Public Health I I Nurses I I A unique and challenging administrative position I I in a City Health Department serving a population I of 156,000. To assume responsibility for I coordination and administration of the nursing I division comprising a staff of 35 nurses who I provide service in the community and schools. I To assist in the developing of municipal public I health nursing programs and administer and I coordinate these programs with other health I functions and agencies. I I Prospective applicants should have a Master's I Degree in Public Health Nursing supplemented I by courses in public health administration, I coupled with at least five years experience in I public health nursing, including experience in a I supervisory or administrative capacity. The I incumbent must be eligible for registration with I the Saskatchewan Registered Nurses I Association. I I Salary: $23,976. to $29,988. per annum (1979 I I rate). I I Applications, including resume and salary I expected, may be forwarded to: I The Personnel Department I I City of Regina I P.O. Box 1790 I Regina, Saskatchewan I S4P 3C8 I I I I , ,.... I ....--------.", 56 Novttmber 1979 Department or Nurslnll, Grace Maternity Hospital. Halirax seeks Head Nurse for Special Neonatal Care Unit Challcnamajob oppor1unil)' In neonatal nu... inl in Canada.s la"'le " obstclnea) hO'ioplla11 ""000 dch...ene"'fycar. I admi slons 10 Special Neonatal Care Unit/ynl'"). MoUOT oÒ..lclncal and nconalallCachlnø hospltaJ for Dalhouslc LJni\lcI'"SII)'..nd the ccnl.-al obslclneal rcfCITal unit for NO\ia SCDlla. Pnnce Edward Island and part.. orNe... Brunswick Rco;.pom,lblc to the Climcal Co-ordinator for organl.latlon and admtnlsuarron of climeaJ nu.....UJI care gi1icn '0 acutely .11 and convalescing newborn Infants Excellent oppor1unity to perfect present programmes and to dC\lclop new programme.. aimed at Improving and extrndml the 'iCOpC ornconatal nurSmB Salary accord'OB 10 Nova Scotia Nu......c....UnionContracl PO"I available m\medlalely The candldales musl have years. e'penence In neonala) nu.....mlj: and mU"1 be ehlj:lblc fo... rell'll"alron In Nova Scolla Man..,emenl eJtpenence and skills. broad knowledøe of pennalal health (:onceplo;. and Iradualion from a posl diploma neonalaJ nursml Course desirable. Apply m wriling (0' \fig \farK_rel Frrluson. R.N Dirrctol' or uni... Grllte \falerntly Hospital Halltn. No". Scot.. 8JH 1\\3 Opcnmas arc a'!oo available for leneral dUly nurses In Ihe neonalal uml Foothills Hospital. Calgary, AI berta Advanced Neurological- Neurosurgical Nursing for Graduate Nurses A five month clinical and academic program offered by The Departmenl of Nursing Service and The Division of Neurosurgery (Department of Surgery) Beginning: March, September Limited 10 8 participants Applications now being accepted For further information, please write to: Co-ordinator of In-service Education Foothills Hospital 140329 St. N.W. Calgary, Alberta T2N 21'9 New Brunswick Applications are invited for the following position for the academic year beginning July I, 1980 in a basic baccalaureate prOllram. An experienced teacher in both the acute care clinical setting and the classroom in Medical-Surllical Nursinll to work with senior students. Applicants should be able to qualify for the rank of Assistant or Associate Professor. Doctoral degree preferred. Master's dellree essential. Salary is in accordance with qualifications and experience. Applications should be addressed 10: Dean I. Leckie Faculty or Nursinll University or New Brunswick P. O. Box 4400 Fredericton, N. B. EJB SAJ The c.nedlen Nur.. Director of Nursing For Kelowna General Hospital Required For May, 1980 The 459 bed (171 Extended Care) hospital has a wide ranII' of services and expects continued IIrowth. This is a senior management position reporting to the Executive Director. Applications are invited from those with appropriate experience and education. EligibIlity for relllStration with the R.N .A.B.C. essential. Reply with complete resume to: Mr. C.R. Elliott Execuli ve Director Kelowna General Hospital Kelowna British Columbia VIYITZ Administrative Supervisor (Nursing) Responsible for the complete operation of the hospital on the evening shift with some rotation to other shifts during the year. Quallncatlons: . Certificate of competence . Head Nurse or supervisory experience . B.Sc. Nursinll preferred This is an administrative position in an active 217 bed general hospital located in a university city. The position carries an attractive salary scale. Apply in writinll to: Personnel Department Guelph General Hospital 115 Delhi Street Guelph, Ontario NIE 4J4 Head urse - Adolescent Unit Children's Hospital. Vancouver A Head Nurse is required to assume a leadership role in our existing 18 bed Adolescent Unit and to plan for a 22 bed unit in a new tertiary care leachinll pediatric facility scheduled to open in Vancouver in mid-1981. This is a challenging opportunity for an experienced nurse (Baccalaureate preferred) with proven administrative skills, a sound knowledlle of medical and urgical nursing and a liking of adolescents. I n the development of this growing prollramme, the appointee will be a key figure in the Adolescent Care Team and will have an exciting opportunity to ,hape the future of adolescent care in this province. Interested candidate's possessing these qualifications should forward their resumes to: Miss Roselyn Smith Director or Nuninll Children's Hospital 250 West 59th Avenue Vancouver, B.C. I V5X IX2 Internalional Grenfell Association invites applications for Public Health Nurses and Registered Nurses Accommodation, fringe benefits and group life insurance. Salary in accordance with Newfoundland Nurses Collective Agreement. Travel paid for minimum of one year service. Apply: Mr. Scott Smith Personnel Director International Grenfell Association St. Anthony. Newfoundland AOK 4S0 MANIT BA This position is open to both men and women Apply in writing referring to Competition Number CN636 immediately. Assistant Director of Nursing Education The Department or Health and Community Services. Institutional Services, Brandon Mental Health Centre. requires a person to be responsible to Director, Nursing Educalion for planning, implementation, and assessment of a Psychiatric Nursing Diploma program. Duties include coordinating activities for both classroom and clinical experience. and committee work at middle management level. Baccalaureate degree in nursinll with teaching experience. Extensive backllround in psychiatric nursinll. preferably with RN and RPN licences. Salary Range: SI8.4S3 - S2S.IS2 per annum. Civil Service Commission 340 - 9th Street Brandon, Manitoba R7 A 6C2 Waterford Hospital Career Opportunities For Registered Nur""" The Walcnord HO\þllal. a fully accredltcd 400 hcd P\)'chialnc Inshtution. affilialed with \.temorid' Umversll)! School ofNlJr..lßgand Medical School. has openinl!l for Rrgl'liiilcl"ed Nurses :n all servicc!t. Including ncW. c'pandcd. õ:(nd acute ca...e "iocrviccs -\n oncmallon pTOsr.:rm is offered Sdlary i.. on Ihe ..calc ofSI::!. - 14. Ai 4i per annum A p..ychialric Service J1:.lIowancc or S 1.129 pCI" annum IS aVOIdable: ill addiflon 10 ba'ilc ..alar)'. Both Iary and "UoW.ancc pre'icntly under ...cvle.... The HosþltaJ is clo\c to aJl amenillcs ..hopping. lransponatlon dnd rCcreallon faclhlies. .t\ccommodallons a\pital x o - 112th Street Edmonton, '\Ibt'rta rM; 287 o Th. C.n.dlen Nur.. Supervisor Intensive Care Nursery Applications are being accepted for the above position. The incumbent will be under the direction of the clinical director and will provide leadership in the development and implementation of current clinical practice for the unit as well as being responsible for the nursing administration of the area. Qualifications: Registered Nurse (eligible for registration in B.C.). Baccalaureate degree or equivalent post basic education. Demonstrated highly successful work penormance within the specified field. Demonstrated skills in leadership and interpersonal relations. Demonstrated managerial abilities. Salary and benefits as per R.N.A.B.C. contract ($1,632 to $1,924 per month). Please send resume to: Mrs. J. MacPhail Employee Relations Vancouver General Hospital 8SS West 12th Avenue Vancouver, B.C. VSZ IM9 Tomorrow's Challenge .................. . Active Rehabililation (Neurological. Orthopedic and Arthritic) . Restoralive Care . Supportive Care . Pediatrics (Rehabilitation) . Domiciliary Care (D.V.A.) Registered Nurses expand your career with Wascana Hospital, a 269 bed Rehabilitation/Extensive Care I nstitution, the largesl of its kind in Western Canada. . Planned Orienlation . On-going Staff Development Programs . Rehabilitation Course olTered . Attracti ve salary and fringe benefits . Located in the heart of Regina surrounded by beautiful Wascana Park . An abundance of cultural, recreational and social leisure time activities . University city. For further information on nursing opportunities write to; Nursing Recruitment OlrlCer South Saskatchewan Hospital Centre 4101 Dr"dney Avenue Regina, Saskatchewan S4T lAS - Name Address City P rovo Postal Code November 19711 111 ... "\ .. ,.) . . 'II -=- \t- \ oj \ , , ., can go a long way . . . to the Canadian North in fact! Canada's Indian and Eskimo peoples in the North need your help. Particularly if you are a Community Health Nurse (with public health preparation) who can carry more than the usual burden of responsi- bility. Hospital Nurses are needed too... there are never enough to go around. And challenge isn't all you'll get either- because there are educational opportunities such as in- service training and some financial support for educational studies. For further information on Nursing opportunities in Canada's Northern Health Service, please write to: ........, I Medical Services Branch I Department of National Health and Welfare Ottawa. Ontario K1A Ol3 I Name I I Address.. I I City Provo I I . . Health and Welt".t! Sanlé et Blen-ftre social I Canada Canada ,........ 12 NGvember 111711 calendar November A Day on Diabetes. A workshop sponsored by the Waterloo-Wellington Chapter of the Professional Health Workers Section ofC.D.A. on November 12, 1979 at the Kitchener-Waterloo Hospital Auditorium. Contact: Dawn Best. Waterloo-Wellington Chapter, P.H.W.S. of C.DA., c/o Diabetic Education Center, Kitchener-Waterloo Hospital, 835 King Street W., Kitchener, Ontario, N2G IG3. Cardiac and PuJmonary Emergencies, a two day critical care symposium for nurses, will be held November 14-15, 1979 at Laurel Point Inn, Victoria. B.C. Contact: Doug Connell, Parkside Emergency Physicians, 928 Pandora Al'e., Victoria, B.C.. V8V 3P3. Canadian Intravenous Nurses Association 4th AnnuaJ Convention to be held on N ov . 20-21, 1979 in Toronto. Contact: C1NA, 4433 Sheppard Ave. Ea.ft, Suite 200, Agincourt, Ont., MIS IV3. December An Occupational Health Nurses Workshop to discuss the role oftheO.H. Nurse in a company safety and loss control program, will be held December 6-7, 1979. Fee: $85. Contact: Total Loss Control Training Institute, P.o. Box /085, Station B, Rexdale, Ontario, M9V 2B3. The Canadian Public Health Association invites submission of Abstracts for their 71st Annual Conference to be held in Ottawa, Ontario, June 23-26, 1980. The theme of the Conference is "Public Health in the 1980's - Opportunity or Demise?" Deadline for abstracts: December 31. 1979. Contact: Dr. John Hastings, Chairman, Scientific Program Committee, /335 Carling Ave., Suite 2/0, Ottawa, Ontario, KIZ 8N8. F our professional nursing associations and five university faculty/schools of nursing in the Maritimes will The Can-.llan Nur.. co-sponsor a conference, Research Basis for Nursing in the Eighties on October 22-24, 1980 at the Hotel Nova Scotian in Halifax, N .S. A call for papers will be in the fall of 1979 and there wilI be open registration. The four associations are: NBARN RNANS, ANPEI, and ' ARNN. The faculty/schools of nursing are Memorial University of Newfoundland, Dalhousie University, St. Francis Xavier University, University of New Brunswick and Université de Moncton. The American Thoracic Society/Canadian Thoracic Society AnnuaJ Meeting Committee invites submission of Papers on all Scientific Aspects of Respiratory Disease for presentation at the 1980 Joint Annual Meeting in Washington, D.C., May 18-21,1980. Abstracts must be submitted before December 31, 1979. Contact: Whitney W. Addington, Chairman ATS/CTS Annual Meeting Committee, American Thoracic Society, /740 Broadway, Ne York, N.Y. /OO19. 1980 Ontario Crippled Children's Center 7th AnnuaJ Conference - Multi-Disciplinary Approach to Management: Overview of Pediatric Rehabilitation. To be held January 21 - 25, 1980. Course fee: $100. Contact: Ann Campbell, Coordinator, The Education Department, Ontario Crippled Children's Center, 350 Rumsev Road Toronto, Ontario, M4G IR8. Canadian Orthopedic Nurses Association 3rd AnnuaJ Conference to be held February 19 - 22, 1980 at the Sheraton Center, Toronto, Ontario. Contact: Conference Publicity Committee, Canadian Orthopedic Nurses Association, 43 Wellesley St. E., Toronto, Ontario, The Third Annual Symposium on Patient Education organized by The Johns Hopkins University School of Hygiene and Public Health, will be held March 26-30, 1980. Contact: ll'Gn Barofsky, Hampton House 654, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland. Index to Advertisers November 1979 Abbott Laboratories Ayerst Laboratories The Canadian Nurse's Cap Reg'd Canadian Public Health Association Canadian School. of Management Career Dress (A Division of White Sister Uniform Inc.) Cedars-Sinai Medical Center Equity Medical Supply Company Glaxo Laboratories Frank W. Homer Limited J. B. Lippincott Company of Canada Limited Medical Personnel Pool TheC.V. Mosby Company Limited Nordic Laboratories Inc. Parke, Davis & Company Limited Pharmacia (Canada) Limited W. B. Saunders Company Schering Canada Inc. G.D. Searle & Company Canada Limited Upjohn Health Care Services Cover 3 13 15 15 49 Cover 2 45 II 49 50 5,51 44 46,47 48 to 9 17 Cover 4 II 7 Advertising Representatives Adverfising Manager Jean Malboeuf 601. Côte Vertu St-Laurent, Québec H4L lX8 Téléphone: (514) 748-6561 Gerry Kavanaugh The Canadian Nurse '\0 The Driveway Ottawa, Ontario K2P I E2 Telephone: (613) 237-2133 Gordon Tiffin 190 Main Street Unionville. Ontario UR 2G9 Telephone: (416) 297-2030 Richard P. Wilson 219 East Lancaster A venue Ardmore, Penna. 19003 Telephone: (215) 649-1497 Member of Canadian Circulations Audit Board Inc. mmJ M ' qfl:! ( - ) -:.. . . " . . . -0 . . .- ;.- \'. . + .....' .... ,. \.- l:.." \.. \. \ -. -. :'t Y ::. '. .. e. -.: 1 ' .. =- ' -=- . J. '4. e , . . , T øø k 0 . , . , '- ' - ; ., "'.... ,;I' I! - There is only one Butterf * .: .. . .. --0 \,', - \.'t'l :'1 0- , " " :: ..1#, . ,'. ,., ," ,', , . ' . .. :. ...- "-.:. - .:..: .\ , . 1# . . . .. \ / ..... . . . t.. " , ," '" 1 .. - ' , i. "'" . .. . . . .- e. .., "if. f . 6: .,.''\ ". " . .. I . (' ,#. r . . r ' . ABBOTT . - _. -- .- .. . .... .. I '\ ... ... / . ". When friends or patients ask your advice co ceming relief of cold symptoms consider the advan- tages offered by the CORICIDIN family of cold products. The various CORICI DIN*preparations are formulated to provide effec- tive relief of specific groups of symptoms that generally accompany colds. Regular CORICIDIN (antihistamine. analgesic, caffeine com- pound) is intended for use at the first sign of a cold where congestion is not a problem or when decon- gestants are contraindi- cated. CORICIDIN 'D' is formulated for use when nasal or sinus congestion is pronounced. For your younger patients CORICIDIN is available as CORICIDIN Pediatric MEDILETS* and CORICIDIN 'D' MEDILETS, both chewable tablets, and pleasant tasting CORICIDIN Pediatric Drops for infants or very young children. Free Booklet Offer ' We'Ve attempted to answer many questions about colds, their causes. Effects and relief in an informative booklet entitled "How to Nurse a Cold". It's yours, free of charge, if you'll simply fill in and mail the coupon on this page. , Mail to: Schering Canada Inc. 3535 Trans Canada Pointe Claire. Quebec H9R1B4 Please send me my free copy of your booklet "How to Nurse a Cold" Additional copies only available upon written request. Name: [Please print) Address: Provo City: Postal Code: . Reg TM . . Ë"_ ;:--=1 Bu. En nomDrtl 'lord ,....._ eta.. ct.... 10539 . Looking toward the future: CNJ salutes the children . Informing, supporting, reassuring the hospitalized child . Babies at the window: neonatal Jaundice and phototherapy . Necrotizing enterocolitis: theories and nursing management · Dangerl Children at play , - The an- - Nune DECEMBER 1979 "--- 1 . tr6 NT">! . I . ...L U:.I'I 'I:",;:) DEC lél"''1" J:: .'.rlf,I'r1IERES NURSING LIBRARY . .. \ OI \;11"""1 \7 trllO SlVI 3S nIl J3S ltJ VMVI10 ja lJS ^INn <;f.6l98Z')(.LS3 l\i3H '1J f'Lll OT:f '\.' .... . .. I. " f'1o. - - , rÞf}. ,: A Division of White Sister Uniform I '- Soft Flowing Skirt Sultl In our beautiful ne ROVA E SPUN-COTTA , .-- ......... '- , . , I , ""J -4 J " Styl No. 43.48 - Skirt SUIt Siz : 3-15 Roy I Spun-Cotta Spl,ln Textured Dacron Poly ter Knit Whit ,Apricot . bout $39 00 Styl No. 43.45 - Skirt Suit Siz : 5-15 Royal Spun-Cotta Spun Textured Dacron Poly Iter Knit Whit , Yellow about $38 00 The Canadian Nurse December 1979 The official journal of the Canadian Nurses Associallon published in French and English editions eleven times per year. Volume 75, Number II Commentary 5 Speaking out: A national child health policy? Joan Dawson 24 Input 6 Helping preschool children learn to be safe Helen Eifert 26 Here's How 8 Preparation of toddlers and preschool children for hospital procedures Judith A. Ritchie 30 Research 9 Hospital books for children Elizabeth Crocker 33 News 12 WPW Syndrome: A case study Coleen Manning 34 You and the law 16 What a little care can do Nicole Cave 38 Vancouver. here we come' Babies with necrotizing CNA's 1980 Convention 22 enterocolitis: what to watch for Beverle\ Hastings McBride 41 Calendar 51 Neonalal jaundice Faye Johnson. and phototherapy Frances Tufts 45 Books 53 Caring for the child with cancer: the nurse practitioner Barbara J. Price 48 Annual Index 55 . . .. .,. -.. - ... I "Come sing a song of joy" in hospital halls and wherever our fellow human beings are in need of cheer. The three nurses on the cover of our December issue are caroling in the halls ofQueensway Carleton Hospital in the Ottawa-Carleton region. Cover photo by John Evans Photography Limited. The Canadian Nurse welcomes suggestions for anicles or unsolicited manuscripts. Authors may submit finished anicles or a summary of the proposed content. Manuscripts should be typed double-spaced. Send original and carbon. All anicles must be submitted for the exclusive use of The Canadian Nurse. A biographical statement and return address should accompany all manuscripts. The views expressed in the anicles are those of the authors and do not necessarily represent the policies of the Canadian Nurses Association. ISSN 0008-4581 Canadian Nurses Association. so The Driveway, Onawa. Canada. K2P IE!. Indexed in International Nursing Index. Cumulative Index to Nursing Literature, Abstracts of Hospital Management Studies, Hospital Literature Index, Hospital Abstracts, Index Medicus, Canadian Periodical Index. The Canadian Nurse is available in microform from Xerox University Microfilms, Ann Arbor. Michigan 48106. Subscription Rates: Canada: one year, $10.00; two years. $18.00. Foreign: one year, $12.00; two years, $22.00. Single copies: $1.50 each. Make cheques or money orders payable to the Canadian Nurses Association. Change of Address: Notice should be given in advance. Include previous address as well as new. along with registration number, in a provincial/territorial nurses association where applicable. Not responsible for journals lost in mail due to errors in address. CJCanadian Nurses Association,1979. rite season's best wisltes to !Iou and !lollr entire stall wlto give patience and IInderstanding all !lear 'rollnd. Your Clinic Shoemaker Th. Cenedlen Nurs. Commentary on IYC Hold my hand, help me cross the bridKe, to a briKhterfuture. As 1979 dre\'. to a close, CNJ o;taff\'.ho have endea...ored during the year to keep the ca...e for children con..tantly in the minds and thoughts of nurses, wondered just what effect this special "year of the child" would have on the health oftomorrow's adult.., To find out, we asked some prominent Canadians \'. hose work is primarily concerned with protecting the righto; of children "to grow up in an atmosphere of affection and mOlal security... to have adequate nutrition and medical care", what they saw as the main accomplishments of 1'\ C .. :\far) Wilson.R,V. MA. Callac/ialllYC Commiuioller ami Coorc/illator, M allitoba /} C Steerillg Committee: "Although Canadians are blessed with a high standard of living - with universal health care and a broad range of health and social services - we nevertheless still have children who are poor, undernourished, ahused. neglected. diseased. undereducated. unsupervised and uncared-for. To meet the basic common needs of these children we need well defined. integrated action programs. Priorities within the health care system. a" I see them. are: . the reduction of infant mortality through primary health care measures reaching under-served groups . ensuring access of all children and their families to clean. "afe water o;upplieo; and adequate sanitation · ensuring the survival and sound development of children during their most vulnerable period - from birth to six years · reduction and eventual elimination of malnutrition. adolescent obesity and exceso;ive consumption of inappropriate foods · adequate immunization against preventable disease . improved and exp.mded programs for children with special need.... In addition. \'.e muo;t concern ourselveo; with the need to reduce: - accidental deatho; -detrimental efTecto; of alcohol. smoking. drug ahuse -emotional illness. loneliness. adolescent suicides. and - teen pregnancies." John \1. Elder..WD. presic/ellt, C all ac/ia II Pl'C/iatric Soden': "During lYe. the Canadian Pediatric Society has concentrated on its goal of increa"ing the number of Canadian infants who are breast fed up to the age of six month" or longer. Our task force. organized with the cooperation of the federal government and the LaLeche League. included nutritionists. ohstetricians and puhlic health nllr...es. Activities included production of 50.000 Breao;t Feeding Resource .....its. editorialo; and articles in Canadian publications. promotional buttons at our annual meeting and aso;io;tance in the production of a color film for the lay puhlic on hreao;t feeding:' Beatrice 1\1. Williams. Rt\i. H ealtl! Regioll Ac/milli. trator. Ro. etoll"ll-Biggar-Jo.. imlersley. Sas/..atcl!ewall..IÍJrmer IYC Commis it"'er: "I see 1979 as a heginning: each year in the eighties. more and more attention will be focused on the child and gradually changes will occur in lifestyles and attitude". resulting in more consideration being given to raising healthier. more wholesome children. Parent". professionals and the community can do much more to improve the quality of life for children. The decision to have children "hould carry with it a serious commitment: children should be given the opportunity to be born healthy and to thrive in an em ironment filled with lo"e and ...ecurity "0 thell they develop to their optimum level and foo;ter a healthy concept ofthem...elves. Professionals can predict "at risk infants" and strive to identify health problem... "0 that intenention 01 remedial action can take place earlier. Parents need to be better informed and kno\'.leligeahle in the techniques of child rearing. They must be supported in their effort... to provide a learning. loving environment for their youngsters. Parents are human and they cannot always cope with the demands placed on them. We need to offer an instant ...upport ...ystem to parento;. whether t hey are family, friends or co-workers. Shirle Post.RN. B.Sc. N.f-c/.. J1HA. execl/tit'e c/Ùector. Callac/iall II/.\"(itllte (?rCl!i!d H mltl!: "For the institute, every year is the year of the child. In 1979 we welcomed the preparation by the Canadian Commi'iSion for IYC of the background paper. "The Child and Health". setting out a national agenda for action. The commission makes it ahundantly clear that o;ociety is not adequately meeting the health and o;ocial needs of many Canadian children- needs such as . better prenatal and perinatal care . improvement of the immunization ...tatus of our children . "humanization" of our service" to mother... and children . reduction of the number of accidents to children, and . better health education for students. These are concerns that the Canadian Institute of Child Health had also identified as priorities for its program". I personally feel that IYC has helped Canadians to focus their attention on the children who are often forgotten in our society and has made them aware that many of our children are Ilot OK -that many of our health and social policies and programs need to be reviewed and updated. D8c:.mber 1979 5 In 19 O it i... e...sential that thi... momentum be maintained dnd that we find ways to wOlk cooperatively toward... thi... end. It i... clear from the problem... that ha"e been identified related to health and social iso;ues that the ...olutions \'. ill require the effort... of per...ono; in many dio;ciplineo;. national organizations. all levelo; of government and the general public. I would like to see nursing play an influential role in determining the direction that health care for mother... and children will tdke in the 19 (rs." TheCanadian Commi"sion puts it thi... way: "Let u... hope that the experience of ...haring a year with children will send all of uo; into 19 Oand beyond. encouraged and rene\'.ed." EDITOR ANNE BESHARAH ASSIST ANT EDITORS JUDITH nANNING JANE BOCK PRODlICTION ASSIST ANT GITA DEAN CIRCULATION MANAGER PIERRETTE HOlTE ADVERTISING MANAGER GERRY KAVANAUGH CNA EXECUTIVE DIRECTOR HELEN K. MUSSALLEM EDITORIAL ADVISORS MATHILDE BAZINET. chairman. Health Sciences Department, Canadore College. North Bay. Ontario. DOROTHY MILLER.public relations officer, Registered Nurses Association of Nova Scotia. JERRY MILLER, director of communication sen'ices, Registered Nurses Association of British Columbia. JEAN PASSMORE,editor, SRNA news bulletin. Registered Nurses Association of Saskalchewan. PETER SMITH,directorof publications. National GaUery of Canada. FLORIT A VIALLE-SOUBRANNE, consultant. professional inspection division. Order of Nurses of Quebec. 6 Dec:ember 1979 The Cenedlen Nur.. input A living tribute Nurses in Canada were saddened to learn of the death of Virginia Lindabury, fonner editor of The Canadian Nurse. I n her capacity as editor, Virginia had an important influence on nursing and nurses in Canada: she encouraged a sense of unity within the profession but at the same time solicited diverse opinions on issues that were controversial. She believed that "...change is an inevitable part of the evolvement of an association and that a decision to reassess goals is a sign of progress, not regression... Rigidity of purpose and fear of losing face by questioning goals, functions and even motives, can lead only to eventual extinction." She wrote hard-hitting editorials that challenged readers to do something either individually or collectively about such crucial issues as discrimination, pensions, strikes and collective bargaining, lobbying, a revised income tax act, etc., but her sense of humor was always present. Her tributes to other Canadian nurses were sensitive and thoughtful and provided the professional with a sense of history in very personal terms. Virginia Lindabury was a staunch supporter of the Canadian Nurses Foundation, not only making personal contributions but also promoting and soliciting support for CNF from nurses in Canada. As president of the Students & Graduates EXCLUSIVE PERMA-STARCH FABRIC "NEEDS NO STARCH" WASHABLE, NO IRON WEAR YOUR OWN. WE DUPLICATE YOUR CAP. STANDARD & SPECIAL STYLES SINGLE OR GROUP PURCHASE QUANTITY DISCOUNT. THE CANADIAN NURSE'S CAP REG'D P.O. BOX 634 ST. THERESE, QUE. J7E 4K3 To receive a free sample of our "needs no starch" cloth, and more information, please clip this coupon and mail today. Address Name ..,................................................... (block letters) City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Postal Code ....... Your graduation school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CNF I believe it is appropriate to suggest that those who share Virginia's belief in the future of nursing make a donation to CNF in her memory. -Louise Tod, president, Canadian Nurses Foundation. Reunion anyone? As a graduate of the Hamilton Memorial Hospital, North Sydney, N .S., I ask, "Who would like to plan a Reunion, to take place in 1980?" This question is directed to all graduates of Hamilton Memorial and St. Elizabeth Hospitals. A second question, "Who is interested in becoming involved in re-activating our alumnae association, and helping to make it once again, a viable operation?' ' Please write: "'-ay Flemming, 61 King Street, North Sydney, N.S. or: -Stella Doyle T ompÁi ns, 37 Colonial A\'enue, Stephe1l\'ille, Nfld., A2N IY9. Too tired to care? How much does a sympathetic smile, a soothing backrub. a heating pad or a drink of ice water cost? And how much do any of these "comfort measures" mean to you when you're feeling lousy? Enough to make you think "I'm feeling better", right? But what has happened to this kind of empathetic caring in our hospitals? I've been working in these institutions for close to 12 years now and it seems to me we've been letting ourselves become too mechanical. I know that there is more pressure on nursing staff, especially full time staff, these days...more patients, less money means more stress. However. we mustn't allow ourselves to become so regimented that we're cold. After all we are dealing with people, human beings like you and me! We can't operate them like puppets on a string and expect them to confonn passively to our daily routine because we're short on time. If there's one thing I've learned through working with people, it's that you get a lot further a lot faster if you make requests as though you were asking a favor. Say, please and give them time to accomplish it. Imagine yourselffeeling perfectly rotten on day one post-op. Your nurse comes bombing in after breakfast to tell you the doctor wants you to get up: she starts rushing around to collect your slippers and housecoat... Contrast this with the nurse who has the heart to tell you earlier, ie. as she is helping to pass breakfast trays or linen or even as she is helping you with your bath, that she knows you're uncomfortable but exercise is an important part of recovery to prevent post-op complications and the doctor really would like you to try getting up. She then proceeds to ask if you would like to take a go at it now or after she has done a couple of other patients. I'll bet you'd prefer the second approach that gives you time to contemplate the situation. I'd even be willing to bet that you'd find yourself saying something like, "Which would suit you better, nurse?" It works I ike a chann: take your most difficult patient, show him a little human compassion, give him some T. L.c. and I'll guarantee that the next day or the day after, your patient will no longer be so difficult. I can hear your cry: "But we don't have time for such Th. Canadian Nur.. D8c:.mber 1979 7 carrying on!" I don't believe it! :\Iost of", hat I'm saying does not require any additional time . It's mostly the attitude with which you approach what you are doing. How much time does it take to gently rouse a "troke patient before you turn him over? Or to warm up the back rub by rubbing your hands bri"kly before applying it'? Even the most confused patient appreciates this.I'm sure. If you are among those who already approach nursing in a compassionate humani"tic manner then I salute you. Keep up the good work! If. on the other hand. you are not. then I suggest you take a good long 10010.. at yourself. Ponder ". " , ., to t ,'.' ,j. ", \,' , , , , ,,' 0' " - , , , .' "/ , awhile on that familiar quotation: "00 unto others as you would have them do unto you'" If you have difficulty treating your patients with respect and understanding, try to imagine that your charge is your spouse. child or parent. Maybe then your attitude will change. The ultimate reward in nursing should not be the almighty dollar but rather a complimentary statement from a patient such as: ul\ly, you have such a gentle touch" or'" hope ifl'm ever ill again that you're my nurse" or even a simple sincere. "Thank you". We are professionals and in nursing being professional $e;"è;RnER Shhh. Ovol Drops. ....-.: . L Oval [)ffi) s..GBro; fs r actJllf . . relief of ,nfant col _ I &oo:R AI!!IO available In tablet form (01'" adults 11 IJ I . -J:: } I, . I ( , h The kidnapping was solved because the bab left prints at the scene of the crime. You could only describe it as a hellish nightmare. A three-day-ald infant had been snatched from his nursery crib, in the maternity section of a small Southwestern hospital. Mercifully, for his parents, the events of the drama unfolded rapidly. Within forty- eight hours the child had been found, unharmed. His kidnapper was in custody. But what of the lifelong uncertainty these parents might have been forced to endure? The gnawing suspicion that maybe-just maybe-the child returned to them was not truly their own. A Hollister product, the Disposable FootPrinter, spared this family-and hun- dreds like them-from needless worry and fear. FootPrinter provides hospitals with a permanent record of individuality. Perhaps the only record. tv\any experts believe footprints are often the single best means of establishing identity. And, indeed, in the case described here, posi- tive identification was obtained only after law- enforcement officials compared the baby's foot- prints with a set made at the time of birth, using the Hollister FootPrinter system. Of course, for Hollister, footprinting is only one of many ways we're leaving our mark on the health-care community. Hollister products touch millions of people. Nearly one mi II ion ostomates, for example, lead more meaningful lives due to Hollister technology. And we're still seeking answers. Because someday, that infant we helped reunite with his family may need our assistance once again. We plan to be ready for him. ..... . . ", . # Hollister r 12 December 1979 news Ji'" ... ' . -.. '" # - J c- o' I .... . , J The Canadian Nurae , .. \ , . t \\: NV .. --J) .... -;' . h. .... Canada was among 64 member countries participating in the largest-el'er biennial meetin!? o.f the Council ofN ational RepresematÏl'es of the Imernational Council of Nurses in Nairobi, Kenya. in September. Canadian nurses were represented by the presidem o.fthe Canadian Nurses Association, Helen Taylor, (left) and CNA executil'e director, HelenK. Muuallem. Nurses from 64 countries attend ICN meeting in Africa Salary and conditions of employment for nurses in all of the 89 member countries of the International Council of Nurses (ICN) will be the chief concern of that organization over the next two years. The decision to give priority to efforts to improve the social and economic status of nurses around the world was made by the Council of National Representatives of the ICN during its recent meeting in Nairobi, Africa. Another priority agreed on by Council members, according to CNA president Helen Taylor who represented Canadian nurses at the meeting, is the need to develop a greater awareness among members of the significance of nursing research in efforts to improve practice and meet the health and welfare needs of the people. TheCNA, which through the Canadian International Development Association (CIDAt provided financial assistance to some memher countries which would not otherwise have been able to attend the Africa meeting, will, according to president Taylor, "be sharing our expertise" with nurses in less developed countries to assist them in finding ways of using their power and influence to accomplish socio-economic goals for nurses and nursing. A total of 89 countries now belong to the ICN ; the decision to admit Cyprus as the 89th member country was taken by the CNR in Nairobi. A "Workshop on Primary Care", sponsored by the World Health Organization (WHO), was held in conjunction with the ICN meeting and also attended by the representati ves of the Canadian Nurses Association. The 17th Quadrennial Congress of the ICN, a year and a half from now, will be held in Los Angeles from June 28 toJuly 3,1981. The last ICN Congress in Tokyo, Japan, in June 1977, attracted more than 12,000 nurses from alI around the world. ARNN Remembers Past - Looks to the Future "Nursing education programs must be part of the general educational field: there must be provision for continuing education and equal emphasis must be placed on theory and practice in nursing education." said Dr. Virginia Henderson, research associate emeritus, Yale University, at the 25th anniversary annual meeting of the Association of Registered Nurses of Newfoundland. Dr. Henderson was keynote speaker at the meeting which took place October I to 3 in Corner Brook: the meeting theme was: "A past to remember- a future to shape". She said that administration should attempt to free everyone in the system to function as effectively as they can. In the future she feels health care systems and administration will be on a regional basis and therefore will be more government controlled. This, says Dr. Henderson, will be for the better as the public will have more input into the operation. More consumers will be placed on hospital boards and they will be able to present more effective criticism. "Every nurse must be a practitioner...it is the job of the nurse to get inside the skin of the person she is helping and do for him what he would do for himself if he had the health, will, and the knowledge." said Dr. Henderson. "It would be a sound idea to use the prototype of the midwife in envisioning the nurse of the future, as the nurse may well be responsible for primary care and the doctor utilized as a consultant. This presents the concern that the physician will then lose personal contact with his patient. " Marguerite E. Schumacher, dean, Faculty of Nursing, The University of Calgary told the meeting that nursing and educating systems are responsible for developing in today's nurse the characteristics of accountability, the ability to enquire systematically and a dedication to the ideal of a master craftsmanship. Schumacher feels that in preparing nurses for the future, a baccalaureate degree will be necessary. "We are slow to accept the fact that nursing includes discipline of the mind and the ability to question the researchable- to survive as a profession we must change." Alice Furlong, former ARNN assistant executive secretary, in her paper entitled, "Erosion of the nurse's role", said she questions whether it is need or lack of insight into our role that is making nurses delegate duties. Furlong feels that we must question and realize what we do: the responsibility for action must be assumed by nursing itself as we must preserve what is appropriately ours and we must be perceived as capable and competent by others. Other highlights The Minister of Health for Newfoundland, the Honorable H. Wallace House said that a "Future to Shape" in nursing must be the collective responsibility of the government and the ARNN. Dr. Shirley Stinson, CNA president-elect told the meeting that the business of organized nursing is important, that it would be very naive for nurses to think as long as they are doing the best they can, everything will be alright. She stressed the importance of education and being aware of changes that are taking place in nursing. Dr. Stinson said that interdependence of nursing groups in Canada is necessary and good, as the CNA requires constructive input from all factions of nursing to enable it to base decisions on nursing informatively and wisely. ARNN president, Margaret MacLean said that nurses must have cohesiveness and work together. "We must express our opinions to our association and not undermine Th. Caned Ian NUrH D8c:ember 1179 13 It function by voicing these opinion to other health personnel or as'iuciations." :\lacLean predicts. "a glorious future for nursing if \\-e increase our knowledge in nUl' ing and use our influence with the <\RNN to improve the health care of clients, the tatus of nursing and the individual nurse."' Resolutions approved by <\RNN members included xeparation of a brief to Mr. Justice Emmett Hall on the implications of the pre ent system of health care. the pre!o.ent delivery svstem and nurse utilization: an approach to the govemmentto resolve the matter of funding for nurses to further their education at a baccalaureate level. and continuing exploration with Memorial U ni versity of Newfoundland School of Nursing as to the po sibility of establishing a :\lasters of Nursing program. It was also resolved that the association actively consider the implications of adoption of the longtenn goal of placement of basic nursing education at the baccalaureate level in the general educational 'itream. I Women as health care consumers, a change and a challenge Women as health care consumers are challenging the svstem. demanding more control: as dissatisfied consumers the power that they wield can cause the health care system to change. Mary Vachon. RN. MA. PhD. keynote speaker at the District V NAACOG Conference. suggested in her address that nur!o.es often feel threatened by other women who appear to be usurping their power and, consequently. they are uncomfortable and not always empathetic when dealing with women in the health care system. Vachon, who is a Research Scientist. Clarke I nstitute of Psychiatry and Assistant Professor, Department of Psychiatry. University of Toronto, advised nurses in her audience that they could best face the future by thinking more about themselves - first as women and secondly as nurses. By reading about the history of women and of nursing, nurses will more readily understand their own reactions. as well as the reactions of women consumers to health care and their place in it. she noted. "As women. we must begin to like our'ielves more and try to understand and support each other. As nurses, we must begin to assume control over our own lives, we must try to hare control in the health care environment with the consumer. .. Examining the many changes and directions in obstetrical and gynecological nursing stimulated much dialogue among the 400 nurses from Canada and the United States who attended the District V annual conference of the American College of Obstetricians and Gynecologists in Ottawa, October 17 to 21. The nurses are among more than 20,000 nurses within NAACOG. The organization this year published ajoint statement with the American College of Obstetricians and Gynecologists on the role and educational development of the Ob'itetric-Gynecologic Nurse Practitioner and. in 1980, certification examinations will be available for Inpatient Obstetric Nursing Certification and Obs/Gyn Nurse Practitioner Certification. These examinations will he written in Toronto and many centers in the U.S. on April 18. 1980. with application'i required by February 8. 1980. Eligibility is dependent upon experience and employer documentation of perfonnance. F urt her infonnation is available from NAACOG Certification Corporation. One East Wacker Dr.. No. 2700, Chicago. Illinois. 60601. In 1981, a certification examination will be offered for the neonatal intensive care nurse. A sabbatical year in international development (-....\ :aJ \.......7 The LD.R.C. offers ten awards for training, personal study or im'estigation in international development to Canadian pro- fessionals in 1980-81. Candidate. - may already be working in international development or wish to become acquainted with the field through a sabbatical year. - must be at least 35 years old. Canadian citizens or landed immigrants with 3 years residence and have 10 years professional experience. Programme - to be developed by the candidate. May be any form of trai ning work/study or personal investigation provided: a) the programme has direct relevance to the prob- lems of developing countries. b) it provides increased professional competence as well as a greater familiarity with developing coun- try problems. Field or dlM:lpllne - Unrestricted INITRNA1l0NAL DEVELOPMENT RESEARCH CENTRE CANADA Length ot award Minimum 6 months - maximum one year Value Stipend up to $23,000, field travel and research costs up to $4,000, plus international travel costs and train- ing fees Application. - Available from: Professional Development Award - Canada International Development Research Centre P.O. Box 8500 Ottawa, Canada K1G 3H9 Deadline tor application. - February 15, 1980 Award. announced - May 15, 1980 The International Development Research Centre is a corpor- ation established by an Act of the Canadian Parliament, May 13th, 1970. t 12 1- The soft touch lor tender tissues. . 100 TUCKS* Pre-Moistened Pads For hemorrhoids, feminine hygiene, piles and personal Itching problems. e."i J.' ttil,.Astril,"1 N 443646 ...... mark 01 Parke DaviS & CornPd(1) & Company LId . regIstered uSE!!" [ Relieve postpartum and postsurgical itching and burning with Tucks. I PARKE-DAVIS Occupational health nurses attend alcoholism conference Four occupational health nurses shared their experiences in the largely uncharted field of establishing employee alcohol and drug abuse programs with close to 100 of their colleagues during Input '79 in Ottawa last September. The nurses, Norma Hooper of Halifax. Kay Lawther of V ancouver, Genevieve Tartre-Lemieux of Montreal and Neilia MacKeigan of Halifax, work for a variety of employers: a food chain, department store, communications company and the federal Department of National Defence. All four were instrumental in setting up early intervention drug and alcohol abuse programs within the framework of their employee assistance plans in their place of employment. Steps in each case included: . approval or activation of an existing company policy recognizing addiction as a health problem . selling management and unions on the advantages of · the program to both the employer and employee . education and sensitization of supervisors and employees in identification and detection skills . establishment of a system of counseling, community referrals, treatment and followup. Although approaches differ, according to the setting, the four nurses agreed that the crucial elements in establishing a successful early intervention program are: credibility, confidentiality and continuity. Close to 400 representatives of industry, business, government and the health and social services fields attended the three-day 3rd Biennial Canadian Conference on Occupational Alcoholism and Drug Abuse in Ottawa. The event was billed as the "largest, most knowledgeable gathering of Employee Assistance Program specialists in Canada." This year's conference was unique in tenns of both size and Canadian participation: registration was nearly double that of previous years and, for the first time, was almost exclusively Canadian. Estimates place the number of employees who might be assisted by primary prevention and early intervention programs at approximately 25 per cent of the total number of workers in any occupation or work setting. r- ::". \I" . I... ..:_ Infection control practitioners, people in the middle- p," . More than 200 doctors and nurses attended the second national infection control symposium held in Toronto October 17 to 20, for the Canadian Hospital Infection Control Association (CHICA). The symposium was preceded by three days of workshops and seminars comprising an introductory course in infection control. The event attracted some 350 registrants. One of the highlights of the symposium for nurses was a debate in which the rights and responsibilities of a ft\6' ;: .' .l2. . , hospital infection control committee were discussed by Drs. Dennis Maki of the University of Wisconsin, and Irving Koven of Toronto. The doctors noted that the infection control nurse often felt like the "person in the middle" having to work between the hospital committee and the "sometimes unfriendly preserve of the surgical unit". Dr. Koven stressed that communication was a skill of great importance, that doctors needed to know what is going on in their hospitals. regarding control of infection, and that doctoJ;. "ho have prohlems "ith infection need to kno" "what they're doing wrong". Dr. l\1al-..i added that the general goal of the infection control nur e and committee "as "not to assign blame. but to improve peIformance". Nursing sessions included presentations on the control of burn infections by Cheryl Leeder RN of London Ont.. infection control in the u...e ofiV devices hy Sharon Swain RN of Ajax-Pickering. and workshops on employee health programs and the professional training of the infection control practitioner. Of interest to nurses involved in dialysis was a workshop on the prevention of infections in both hemo and peritoneal dialysis patients; also offered "as a seminar on infection control in the long term care institution. Dr. Alistair Clayton of the Laboratory Centre for Disease Control, Health and Welfare Canada, outlined a new federal government program for infection control; nCaS-fAYLO" / STETHOSCOPES Famous brand-name tnstrument Irusteø by medical protesslonals Ihe _arId nwer I DUAL-HEAD TYPE. In5preny U COlOur. Exceprtona' sound - Ir.n8<<1I..,on Adjustable IiQht . we.ght binaural.. has bot" diaphragm and bell with non- '.nB'u G ,:'.Ck. Red. No 5079123.15_. SINOlE-HEAD TYPE. AaaþoYe but WI.nout bell Samelarge g öi.. . én;i s;: ';8,c : ':, :;: :- we but nOI TVCOS brand Same 2 ,.Nr Qua,..nr_. Comple.e ;1' ;I ':ohr:80ml ':. '.PS ? Dual-HMClNo 110117.as.. LISTER BANDAOE SCISSORS ManufaCtured 01 f nul a..._ A must tor every nUrN No 898. 3 No 699.""" No 700,5\'1 No 702,7.... Th. Canadien Nur.. among the priorities such a.. organizing response to ho pital epidemics and monitoring the prevalence of infectious diseases is the goal of a Canadian training program for nurses interested in practicing infection control. ursing home nurses work to improve care The way to stop complaint.. about nursing homes. according to Ontario's \1inister of Health, Denni Timbrell. is to do a better job of explaining to people what they can and should expect from them in the way of care before they need this information. Timbrell was addres ing 306 participants. including about O nurses. at the Oth annual convention of the Ontario Nursing Home Association in Ottawa in October. The health minister cited improved public perception of nursing homes as one of the major benefits of MERCURy TYPE. The uhlma.e In accuracy FOIOa .n10 Ilgl'It but ruggeo ma.al ca.. H_wy duly Velcro eulr and ,ntlallon ay.tem 158.15 Mch. '/ \ \\' \\..,\i " -----=.:.. i I/ . : :g l n :.Ep.ndable 10 . r'" guarantM 01 accuraocv 10 _ 3 m m No stop-pin to hide errors Handsome ZiPpered caae to tit your ket 121 N complete NURSES PENLIGHT. Powerful bum tor exan1lnat.on o. IhrO.1I ate Durable atamleS8-steel cas. w'lh pocket clip Made In USA No 28 S5.M comple.e whh tt.rt... Economy mode' with chrom<upeJ"\isor. Having done '>0. the reque'it for a\.,istance and the respon,ibility for remedial dction and/or direction falls upon nursing administration. The .,upervisor then hds the responsibility for decision, discussion, reas\essment of the needs of the unit etc. Both the nurse and the ,upervisor will tonn a profe."ional judgment ba,ed on the relevant facts. I n my vie\'.. the award did not proper!} dlstingui.,h between critical needs invoh,ing nursing care and critical needs involving medical care. Of course there i'i an area of overlap: it is one thing to as-.e'is the medical needs of the Pdtient on a unit. another to asseS'> the capacity of the unit to deliver the nursing care to meet tho'ie medical needs. A nursing assessment is necessary to consider the capacity of the unit to deliver nursing Cdre to fulfill the needs. both medical and nursing. of the patients. A medical reas,>essment of critical needs might alter the prevailing orders for care. For example. on rea'isessment, two patients might have had ventilator care discontinued. The capacity of the unit to deliver nursing care would then have been materially altered: two nurses \'.ould have been freed from con\tant observation of those patients. However. there was no medical reasseS'imenl. Even if there had been, there likely would not ha....e been the change in order contemplated above. That the unit did require additional staff was evidenced by the fact that on the next shift, the complement of the unit was increased to eight I.C. U. nurses and a charge nurse. Had there been a team leader that night who had made the global dssessment. it is unlikel} that the physicians' judgment would have been preferred. The reliance on the "more extensively trained" professionaJ"sjudgment occurred in the absence of the global assessment. With regard to professional disciplinary action being taken by the professional body (here the College of Nurses of Ontario), it is important for nurses to remember that they must report to the employer an inability to accept specific responsibility where special training is necessary or the nurse feels incompetent to function without supervision. Failure to so report is defined as professional incompetence. After this. the responsibility for direction and supervision falls again to the employer through the instrumentality of nursing administration. The award in this case has left many nurses feeling angry. reduced to a profession of complainers and "buckpassers". The decision doès squarely place legal responsibility upon the hospital-employer. The employer's ann with respect to nurses. is nursing administration. The decision also mdicates the route by which nurses can protect themselves in similar circumstances. The decision has not removed the independent exercise of professional judgment by the nursing profession. It bears repeating that nurses have a duty and responsibility to question physicians' orders that in their view are incorrect. e.g. wrong dosage ordered. The focus in this decision is an order by the employer not an order by the physician in regard to patient care. The award clearly indicates that orders directing the nursing workforce in the performance of their obligation to the employer arise from nursing administration (the hospital) not the medical stafT. This a\'.ard is only hinding in Ontario: it i, of per.,uil'iÎve force in other jurisdictions. Sub.,equent ca.,es may \'.ell alter thi'i result. The result, as always. is contingent on the facts and circum'itances of the ca.,e at hand. Here. the re'iult demand'i that nurses conduct themselves professionall} yet it does little to resolve the dilemma facing the professiondl nurse: obey first. grieve later. The professIon must apply the le\Son to he taken from the award and govern itself accordingly. References I (1978) I7 L.A.C. 4:! (Onl.). :! As yet unreported; reasons released April IS. 1979. 3 Note I. supra p.:!M. 4 Ibid.. p. 68. 5 Ibid.. p.:!63. 6 Ibid.. p.:!6:! (evidence of Dr. L). 7 Ibid.. p.:!63 (evidence of A'isi..tant DIrector of Nursing R) 8 Ibid.. p.:!6:!. 9 Ibid., p.:!63. 10 Ibid.. p.265. II Ibid.. p.:!65-:!66. 12 R.S.O. 1970c.378 a,> amended R.R.O. 1970 Reg. 729. s.16. 13 Sklar. C. L. Hospital hazards and the nur\e. Canael. Nurse 74:7: 16-18. JulylAugu'it 1978. "You and the la\\" is a reglliar coillmn that IIppelln ellch month in The Canadian N IIrse and L' in/irmière canadienne. A IIthor Corinne L. Sklar is a recem gradllate of the Um"'enit\ ofT oronto F aClllt\" 01 LlIw. Pri(}r to enterin/? law .\Chool. .çhe obtained her BScf'; and il,IS de/?rees in n/lrsin!? from the Unil'ersit\. of Toronto and Uni\ enit\' ( f Michigan. MARY DOE R. N. SUPERVISOR NAME PINSI Shipped 48 Hours from Receipt of Order Attractive first quality name pins for your uniform from the largest name badge company in the world. Name badges are our only business. All badges are unconditionally guaranteed and come with nickel plated jewellers locking pin. Variety of colours to choose from Please check colour combination below: B adge u ceB ; ge ffi et o White [] White 0 White o Black 0 Black 0 Black o Blue 0 Blue 0 Blue Name (1st line) C Plee.. prlnl cleerly) Title? (2nd line) PRICE: $2.50: with tille $3.25. Extra badges ordered at same time (same name) $1.00. No minimum order No handling charge. Enclose cheque or money order with your order and mail to: I BAC I _ (USE OFFICE CLOSEST TO YOU) P.O. BOil 2038. Sin. B., Scarborough M1N 1V3 9 Scholfield Ave., Toronlo M4W 2Y2 P.O. BOil 2195 Bramalea, Ont. L6T 354 P.O. BOil 3212 Tecumseh Stn., Windsor N8N1M4 P.O. BOil 3480 Regina Sask., 54P 3J8 P.O. BOil 35313 Stn. E., Vancouver V6M 4G5 (Add Appropriate Prov. Tall) I) .a -;1 ..' .. .... s . ', "J_II. ; '_ tt ... t 11 1 I t;...... r _\ '- -, I I ;1 . ;: , ' "t {- -.I r' t. I ---- IT'S TIME TO TALK CNA CONVENTION 22-25 JUNE 1980 IT'S VANCOUVER - BOOK NOW! YOU'LL NEED SHELTER TOO CNA s annual meetIng and conventIon sIte IS the elegant Hyatt Regency Hotel In downlown Vancouver. "offers superb accommodatIon and IS connected to a 6O-store shopping complex All the rooms on any lloor are SImIlar and Include a Indge and electnc blanket Upper lIoors offer breathtakIng VIewS and you'll reach Ihem on Polans glass elevators - 341100rs up. open to the mountaIns and the cIty sparkle below SpecIal CNA convent,on rate IS $44 sIngle - $58 double - that s lar below the usual guest rate at thIs super deluxe hotel There are several excellent restaurants offenng dInIng and atmosphere at low pnces that will surpnse you. And there's a pool so bnng your bathing su11 and lIve In luxury al modest CNA ConventIon Hyatt rates. Other excellenl holels are near Ihe Hyatt CNA has a specIal rale at Holiday Inn Centre, Harbours/de: $38 single - $42 double, thIS hotel only It overlooks the harbor, close to the lerry pIer - a 50 cent sea bus and transler bus wIll take you to one 01 the many stunning sealood reslauranls In North Vancouver, the .'Seven Seas" There IS a pool and sauna - all beds are double sIze in single or twIn accommooatlon. less than a block Irom the Hyatt.s the dIstinguIshed Hotel Vancouver, long a landmark In Vancouver and a lavonte wIth many convention goers Rates are $44-$64 single, $59-$79 double on a Ilrsl-corne basIs. Just lour blocks trom our conventIon sIte is the Century Plaza - It'S an apartment-type hotel wllh 30 tloors 01 overSIzed sUItes, perfect II you want to make up a CNA convention group, perhaps lour colleagues and Inends. Full kitchen, dInIng room ensulte II you really want to budget and whIp up your own gourmet treats. Each sUIte has a balcony wIth vIews that wIll keep your camera cllck.ng And, there s a JumpIng .d,sco" ,I you re In the mood. Rates $34 sIngle $40 tWIn and $46tnple (SpeCial CNA convention rate) The Hotel Grosvenor IS well known 10 B C travellers Slightly continental In appearance It has a reputation lor clean and restful accommooallon close to downtown hopplng and restaurants Ra(es appr $32 standard, sIngle or double and $34 deluxe wIth a 10 per cent discount " you show your 10 IndicatIng that you re a CNA conventIon delegate Irs only a short walk lrom the Hyatt IMPORTANT - MAKE YOUR ROOM RESERVATIONS NOW Because It offers so much Vancouver IS a popular convention center. II s Important to Plan Ahead - Make Your Resenlat,ons Now and In all cases mentIon that you're attending the CNA conventIon. (The Century Plaza and the Grosvenor wIll want a Ilrsl night depoSIt) Resenlat/on cards lor Ihe Hyatt and Holiday Inn are avaolable lrom CNA. 50 The Dnveway, Ottawa, OntariO, K2P 1 E2 or you can wrote direct 10 the hctels listed in the accompany'ng box. Looking ahead - we'll be tellong you more about B.G. tours, shoppIng, sightseeing and dInIng In luture Issues 01 CNJ. Watch lor Convantlon RegIstration Card In The January 'ssue Along Wllh An Outline Of What May Be The Most Exciting CNA Convention Program Yel. CNA CONVENTION ACCOMMODATION Hyatt Regency Hotel 655 Burrard St. Vancouver, B.C. V6C 2R7 (604-687-6543) CNA Convention Site... Century Plaza 1015 Burrard 51. Vancouver, B.C. V6Z1N5 (1-800-261-3330 Travelodge toll free) Hotel Vancouver Burrard St. Vancouver, B.C. V6C 1 P9 (604-684-3131 ) Holiday Inn Centre, Harbourslde 1133 West Hastings St. Vancouver, B.C. V6E 3T3 (604-682-4541) Hotel Grosvenor 840 Howe 51. Vancouver, B.C. V6Z1N6 (604-681-0141) / NeJv from Lippincott New! The first book of its kind. . . Pearls for Nursing Practice A Choice Collection of Tips, Hints, Improvisations and Bright Ideas That Make Nursing Easier and Patients Happier By Arlene Odom Nichols, R.N.) B.S.N., M.S.N.)'and Joy Day, R.N., B.S.N. Here is a thoroughly delightful book, written and edited by cannulating high pressure arterio-venous fistulae); tips a group of concerned, dedicated nurses who have gone from specialists; tips from generalists; and tips from the quietly about the business of caring for sick people and allied health professions, particularly on diet, physical noting little tricks. (actually innovative solutions) that therapy, and speech and hearing. seemed to make things work better. Their discoveries or An ideal gift, a practical problem-solver, a joy for all nurses "pearls" are shared with you in an organized fashion, everywhere, Pearls for Nursing Practice will above all faci- with the rationale for each nursing action clearly explained. litate the delivery of individualized care with the greatest Numerous illustrations accompany the text. ease and benefit to patient and nurse alike. Throu hout its two hundred and fifty pages, Pearls for Lippincott. 250 Pages. Nursing Practice will give you old tips (the easiest way to Illustrated. September, 1979. $10.50. put on a pillow case, or give a back rub); new tips (like Now Available! Nursing Management for the Elderly By Doris Carnevali, B.S., M.N.; and Maxine Lambrecht Patrick, B.S.N., M.S.N., D.P.H. A definitive treatment of normal aging in its many dimen- sions, this highly original handbook focuses on nursing's territory in assessment and diagnosis and on the nursing management of specific high risk pathophysiologic problem areas. The latter are arranged alphabetically for quick reference. Each chapter uses the same format-one that fosters the diagnostic/management approach: · A Quick Review of the most common problems precedes each chapter to afford the busy clinician a Now available. . . the (new) Second Edition rapid checklist of observations and areas to be consid- ered in management of evaluation. · Bibliographies contain items that will deepen the clini- cian's insight as well as provide some resources for patients or families. · The Index is designed to help the clinician move from symptom or drug to diagnostic/management consid- erations. Lippincott. 570 Pages. September, 1979. $22.50. Nursing Management of the Patient With Pain, 2nd Edition By Margo McCaffery, R.N., M.S. Nursing intervention for pain relief is the focal point of the all-new Second Edition of Nursing Management of the Patient with Pain. Clearly and explicitly it details pain relief methods for use in general nursing practice, empha- sizing palliative pain measures that the nurse can administer to-and in some cases with the patient. Most methods are applicable to both children and adults in a variety of clini- cal settings! Lippincott. 340 Pages. September, 1979. $19.00. ,-----------------------------------------l I J. B. LIPPINCOTT COMPANY OF CANADA LTD. Books are shipped On Approval; if you are not entirely I I 75 Horner Ave., Toronto, Ontario M8Z 4X7 satisfied you may return them within 15 days for full credit. I Please send the following for 15 days 'on approval': I I o Pearls for Nursing Practice, $10.50. I 0 Nursing Management for the Elderly, $22.50. Address I I 0 Nursing Management of the Patient with Pain, $19.00. City Provo I I 0 Payment enclosed (postage and handlinl: paid) Postal Code I I 0 Bill me (plus postage and handling) I I Prices subject to change without notice. I L_____________________________________ 12/ \ 24 December 1979 The Cenedlen Nur.. , f Speaking out: r " '- À national child health policy? , 0 "" '" ;: 0 " '" 0 ] . 0 :I: , .0 :!2 0 >>. " 1:: :I 1; 0 õ "" c.. Does Canada, as the Task Force on the Child as Citizen proposed in its report two years ago, need a national child health policy? Joan Dawson, a public health nurse, believes it does. She suggests that nurses !thould be helping now to "shore up the preventive components of the health system" I and make it truly child-centered. Joan DLHI'Sot/ "Since the early years are.m crucial to the healthy de\'elopment ( fthe child, children should enjoy a compulsory continuous rexular proRram l fhealth maill1enance and promotion throuxhout these years. Such a program shoulcl include: well chilcl care; immuni;:ation; comprehensi\'e early creeninx for de\'elopmental problems: nutrition and dental health; and day care. The. e programs should then be fÒllo wed up bv school health and physical {ì1lle.u programs which, particularlv as children grow older, encouraxe their indi\'idual re. ponsihilitvfÒr health anelfitness.. .the riXht of the child to helilth care is meaningle.fs unle.u unÍl'ersal health programs are {lI'ailahle and unless the child hm access to those proxrlllflS. It is not enough to leave program initiatives to selected clinics or parts of the public health service or to focus only on certain regions."2 (emphasÜ added) The more I read about and work in the public health field. the more I am convinced that the pre')ent system of health promotion, disease prevention and early intervention is in desperate need ofre-organization and leaden,hip. I am supported in this observation by member') of the Task Force who commented that: "Despite recent developments in health policy. acce s 10 health care and the appropriateness of health services are issues which remain in limho - neither adequately resolved nor energetically addressed."3 The 1977 review of public health services in Ontario, prepared by the Canadian Public Health Association, cites further proof. lis authors paint a depressing picture of: . muddled thinking: "11 is apparent that the fundamental issue is a lack of an agreed-upon goal or role for the public health system in Ontario.":; . erratic service:" ...there is a lack of common definition across the province as to what constitutes a program."6 . administrative confusion: .. ...management issues at the local level are identified a., critical at this point in time and there are a number of concerns relating to the effectiveness of local boards of health...a highly controversial issue is the proper role of the Medical Officer of Health."7 A health-oriented policy Nurses involved in health maintenance and promotion programs must realize both their opportunity and responsibility to become dominant in the decision-making of the future. This will only he acheived by becoming more knowledgeable. active and sophisticated politically. Not only is their existence as a viable profession at take. but the program., which they have carried out in the past with great benefit to the community are injeopdrdy. for they are controlled by politicians whose knowledge of public health issues is frequently questionable. Public health nurses must demand legislation that will both clarify their function and protect the public's right to receive their services. Two years ago. for example. in Ontario's Peel County, the local lay board of health was able, quite legally. to eliminate the area's public immunization program in the name of economy! That same year. a report from the Ontario Council of Health observed that: "A very wide range of immunization levels between the 44 Ontario Public Health U nits has been demon.,trated in a survey by Dr. Shirley Johnson. The variations range from one public health unit with less than 60 per cent D.T.P.polio to two with greater than 90 per cent; one public health unit with less than 30 per cent measles to one with greater than 80 per cent. The reasons for these variations have not been studied. "M The Canadian Medical Association Journal. in a recent editorial. addressed this issue: "(fchildren are not fully immunized because they do not have routine health care. then the private approach 10 immunization is not likely to succeed. If older school children are to receive the recommended boosters. school health programs should be given the responsibility and provided with the necessary personnel and funds. Serious attention should also be given to enactment of compulsory immunization laws associated with school attendance.'" A national immunization policy. with public health nurses legally responsible for its administration, would .,eem to be a vidble solution to this problem. The mechanism for this policy - in the form of a national recommended immunization schedule issued by the National Committee on Immunizing Agents in October, 1978 and subsequenlly endon-ed by the Canadian Pediatric Society - already exist. (see The Canadian N urse.January 1979). Th. Cenedlan Nurae D8c:ember 1971 25 The present Ontario Public Health Act specifies many duties for the public health inspector in terms of maintaining standards of water, food and sanitation. Their legal protection in performance of these duties is explicit. ,n I can find no such specific protection for public health nurses; their duties are as nebulous as "the promotion of the public health and the prevention or treatment of disease:'" It is interesting that the public health nurse is to be "subject to the direction and control of the M.D.H. ".2. Where is the Director of Nursing? \\ ell child care Unless nurses demand clear legislation regarding public health nursinl? activities and responsibilities, many invaluable programs will be abandoned, and others will be taken over by potentially less competent disciplines. . The pro1'Ísion of pre-natal classes by the local health department should be mandatory. with minimum qualifications required for the teacher; requirements including a degree or diploma in public health nursing, a course in adult education and at least six months obstetric experience. A maximum pupil/teacher ratio should be specified. probably I :20. Funding must be clarified. · The frequency and nature l f postpartum 'isits must be reassessed in response to the current move towards early hospital discharge and home deliveries. Public health nurses should have the legal responsibility to offer a home visit to every newly delivered mother. In the case of discharge before the third day postpartum. the nurse should be required by law to visit within twenty-four hours of discharge to record vital signs. fundal height, lochia and breast condition of the mother and the weight. feeding status and condition of the skin. eyes and umbilicus of the infant. · Mass screening of school children for vision and hearing problems should be mandatory, with the public health nurse responsible for all final checks and follow-up. The age group chosen could be left to the discretion of the local authority. but should be required at least twice in a child's school career. This type of program is justified by the numbers of defects identified in areas where well run programs are presently available. · Pre-school medicals with a full immunization history should also be compulsory with the local authority responsible for providing a physician for those children with no family doctor and the public health nurse being responsible for organizing and staffing any clinics necessary to ensure such medical examinations. \ \ · H il?h school health prol?ram. are inadequate at present since health and physical education are now optional credits in Ontario. An alarming number of student.. do not choose these courses and as a result many young people receive no health instruction at all from the age of approximately 14 years. All students not taking this credit should be required to enroll in formal instruction programs which include first aid, communicable diseases, nutrition and parenting skill" given by the public health nurse. The author of an article on health care cosh in the Financial Post noted: "An effective strategy must increase the emphasis on health promotion. concentrating where it will do the most good. First. health education in ,chools must be upgraded. In most provinces. instruction for young people is superficial and inadequate. Elementary first aid may not even be included. Children 'ihould have the primary skills to be responsible for their own health, rather than becoming passive adult consumers of sickness-treatment services. This means a major upgrading of health education at elementary and secondary levels, with the necessary facilities and teaching support to put the message across. ".3 Listen to the members of the Task Force on Children as Citizens again: "What we need are programs to implement a vigorous preventive focus. They should have a universal or potentially universal population base; they should use a mix of professions: they should recognize families and children at risk: they should suppon the family. Such programs are entirely feasible. Their development and implementation require no grand re-ordering of society... What is required is the political will 10 act on our much-vaunted principles of social justice. "14 Political will to act means lobbying. It means you as a nurse writing to your member of federal parliament. member of provincial legislature. local council. boards of health and even newspapers. It means attending meetings and speaking up. Ifthis is distasteful to you. consider the alternative of having decisions made for you by other disciplines. W. Harding LeRiche. professor of epidemiology in the Faculty of Medicine of the University of Toronto has written: .. ...in running a health service politics are as important as medical science. Politics and the political system is the way through which ideas in medicine and medical science can either be put into practice or can be wrecked. "I Ontario nurses should be particularly alen as revision of the present Public Health Act is 10 be debated in the newly opened provincial parliament. In this Year of the Child, I can think of no finer accomplishment for nursing than to successfully lot-by for legislation that will ensure that our services meet the needs of every child in our country. I urge you to examine the policies within your own pr0vince. We will only reach our goal when politicians everywhere. at every level. recognize the value of preventive medicine and legislate policies and functions that will ensure that the public continue to receive the benefit of our diverse nursing skills '" References I Canadian Council on Children and Youth. Task Force on the child as a citizen. Report. A dmittance restricted. the child as a citi;:.en ill Canada. Ottawa. Canadian Council on Children and Youth, 1978. p.60 :! Ibid.. p.7:! 3 Ibid., p.50. 4 Ontario public health; .wme current issues. Toronto. Mini'itry of Health, 1977. 5 Ibid., p.3. 6 Ibid.. p.5. 7 Ibid.. p.I3-14. 8 Ontario Council of Health. Task Force on Immunization. Immuni:;:.ation. Toronto. 1977. p.9. 9 Gold, Ronald. Immunization in Canada: 1979. (editorial) Canad.MedA.u.J. 1:!1:6:698. Sep.:!:!, 1979. 10 *Ontario. Laws and 'itatutes. Public Health Act. Rev. Statutes ofOnt.. ch 377. office consolidation.4:!. Oct. 1975. p.:!6. II Ibid..35 (6). p.:!:!. 12 Ibid.,35 (7), p.22. \3 *Bennett.James E. Perspective. health care services. pt.6. by James E. Bennett and Jacques Krasny. Financial Post May 7, 1977. 14 Canadian Council on Children and Youth.op.cit., p.73. 15 LeRiche, W. Harding. Seventy years of public health in Canada. (editorial) C anad.J.Public Health. 70:3: 162. May/Jun. 1979. *Unable to verify in CNA Library Joan Dawson, a I?raduate ofG u\" s Hospital in London. England and l {the public health nursinl? diploma program at the U nh'ersi1\' ofT oronto, is also a certified midwife. The mOlher of two teenage children, she is presently on staffwith the Etobicol..eCommunity Health Department. 21 December 19711 The Cenedlen Nur.. Four-year-old Jamie: "When I grow up,l'm going to get a police motorcycle. Sometimes you have to get a helmet, for a motorcycle you have to get a helmet. .. Mother: 'That's right." Jamie: "Then you won't fall down. .. This anecdote, although humorous, indicates one of the factors involved in child safety - children really do not understand how to be safe; they do not think logically about the cause and effect of events in their small lives. They need help. By the time children begin school their behavior varies widely from one child to another, as does the willingness of their parents to let them do things on their own. The common goal of parents is to raise children who are safe and free from injury, and this involves the gradual transfer of responsibility from parent to child. After the first year of life. accidents are the major cause of death and injury among children. Nurses work with families who are raising children and so they find that teaching accident prevention is an accepted part of their role. They care also for the victims of accidents in hospitals and clinics. It is important therefore to understand some of the theories about childhood accidents, and to be aware of the nursing implications in working with young families. Let us watch some first-grade children as they stream out the doors of their school into the sunshine and head home. How much have they learned about safety before they started school? Jean lives across from the school: her grandmother meets her at the classroom door and takes her hand to walk her home. James is also met by his mother; he lives half a mile away across two main roads. David waits for his sister who is in Grade three to walk the two blocks to his home. Grant's father is parked iñ a car across the street waiting for him; Grant dashes out of the school gate and runs across the street without Help in 9 presc ool c ildrel) learl) to be safe Helen Eifert "There is no such thing as an accident. What we call by that name is the result of some cause which we do not see." -Voltaire looking. Linda has to walk six blocks home alone; her mother is at home with a new baby. Linda is very shy, and waits around quietly looking for someone else going her way and then tags behind. Dennis is fiercely independent and has insisted to his mother that he can go back and forth alone: she lets him but at first followed behind him out of sight to see that he was alright. Peter hops on his bicycle and rides home through the traffic. Research Most accident research is based on study of accident victims. often comparing them with a matched control group of persons who are accident-free. Epidemiologists have looked at accidents by time of day, location. social class, age of child involved and so on Thus we learn that boys have more accidents than girls. white children more than orientals. children with siblings more than only children. The child accident victim is often described as daring, overconfident. competitive and extroverted. 1.2' ' There is some suggestion that children with repeated accidents more often come from disturbed family situations. Children who have repeated accidents seem to differfrom those who have a single accident. and some researchers suggest that accident repeaters also have higher rates of other illnesses. . .fi The accident victims we see in the Emergency department or doctor's office are only a small proportion of the children who fall. run into roadways. climb up to get mother's pills and so on. Children are frequently in unsafe situations or they behave in potentially injurious ways but in many cases no injury results. One study suggested a possible formula: accidents occur when an individual with poor decision-making . ability takes high risks in an unsafe environment. 7 Small children are only beginning to learn to assess risks and to make decisions about what to do in a variety of situations. and much of their safety depends on supervision by others and general environmental safety. Helping parents to raise children safely is a challenging and difficult task. and it involves the assessment of a variety of human and environmental factors. The child To learn to behave safely in a variety of everyday situations, a child must recognize the abilities and limits of his own body. and he must learn the rules. knowledge and skills which will help him to assess the hazard in any situation. As he learns, there must be a gradual shift of responsibility for his behavior from others to himself. A child learns about his body and its capabilities through the activities of everyday life. Often home and neighborhood allow a child to learn to run, climb, avoid obstacles, learn what is edible and what is not. identify how traffic moves and so on. However, some children live in severely restricted environments. in high rise apartments. The Cenedlen Nur.e D8c:ember 1971 27 \ for example. and have limited opportunity for exploring. Some helve familie'i "ho !.upervi!.e everything very c1osel} . uch a... the traditional oriental family:'other familie... push children to do things before they actually have adequate phv ical capability. In any ca'ie. by the early ...chool } ears most children have ...ome sense of them elves - their speed. strength and coordination, their acuity of vision and hearing. Thinking of safety, one might que'ition how accurate is this perception of self in relation to actual abilities'? b the child likely to avoid new situation!.. or to rush into anything'? Can he accurately judge his ability to accompli"h a particular ta!.k'? Cognitive development provides some tructure for the kind offormal teaching which "ill be effective with various ages of children. In infancy, ...afety is totall} dependent on the action of others, though a., the activity level of the child increases. so may the possiblity of accident occurrence. Thus it is the parent who has to assess the environment for haLards and adapt to the child's increasing motor abilities in turning. climbing, cra"ling. By age two most children can learn imple prohibitions if they are expressed clearly and consistently. With developing language skill. three- and four-year-olds are more amenable to explanation but their understanding may be limited, as was the case with Jamie who thought a helmet would prevent him from falling off his motorcycle. The thinking and logic of four-year-olds often reflech a magical notion of reality: they may believe that if they cross the road at a crosswalk, they cannot be hit. One four-year-old said. "If you don't do up your seatbelt. you'll crash." By age six. children think more logically but the tendency persists to think in extremes, and they have difficulty making judgments that involve shades of difference. For instance a Grade one child after listening to a policewoman discuss what to do when approached on the street by a stranger concluded "all strangers are sick." A study in Germany observed some differences in safety practices in the various age groups.' F our- to five-year-olds didn't look when crossing the street near school, they just crossed; six- to seven-year-olds looked once and then ran across without looking further; eight- to nine-year-olds walked across but continued to watch as they crossed the street. Obviously it is important in teaching child safety to have some awareness of developmental levels and children's understanding of the information pre ented to them. It i'i important too to consider the individual differences in children. Many researcher!. have !.hown that newborn infant differ in many behavioral characteristic.,. including general activity level. responsiveness, adaptability to change and there is thought to be some degree of persistence in these characteristics as a child develops. '" There can be little question that the child who crawls, climbs and wal"s early and displays vigor is expo'ied to a greater degree of hazard than the quiet child who sits and plays at length with an eggbeater. There !.eem!. to be considerable variability too in how close a child stays to his parent; !.ome remain close while others run off at the first opportunity. Watch a group of preschooler!. or kindergarten children in a playground; the differences both in approach to activities and in coordination and motor ability are great. Some stand at the side and watch; others try thing cautiously; still others rush into things without any real idea of their capabilities. Thus the child's need for supervision and teaching must be tailored to his individual characteristics. Three families Families greet their newborn infant with some preconceptions about what the child will be like. Many have definite views on how a boy or girl behaves and they may ascribe the personality characteristics of themselves or other family members. The experience of the child in the family is an outcome of a complex interaction of his own characteristics, his environment and the parents' well-being. preconceptions. beliefs and expectation.... Observations of parents and pre...chooler... reveal the existence of many different style., of childbearing with varying degrees of predictahility and consistency in the child's experiences. Sarah, for in!.tance, eemed more like a skillful playschool teacher than a mother. She had three children, ages two, four and six, who lived with her in a fairly small hou e. She had quit her job as a physiotherapist to stay home with her children. Sarah read books about children, and especially liked those showing creative activities and games. Her style of mothering involved quiet. unobtrusive watching as the children played, and as their interest waned she would smoothly suggest another activity bring in material., and then work nearby. As she expressed it, "if you don't keep some order, it gets out of hand." She took the children regularly to a playground and joined them in running, swinging from a bar and climbing. and she helped each child in turn to do things within his physical capability. She was quite conscious of hazards and always knew where the children were. When the six-year-old found a broken bottle she helped him pick up the pieces: "The only safe place is the garbage. " These children experienced a varied interesting environment, were challenged to use their bodies and yet they had consistent supervision and received help as needed. Their family life was pleasant and predictable. By contrast, Karen, another mother of three younger children, whose ages ranged from five months to three years, was quite unpredictable in her relations with the children. especially the three-year-old. Karen had experienced prolonged periods of depression after each pregnancy and even with the help of a loving and concerned husband, had a great deal of difficulty coping with daily activities. Within a single observation period of 90 minutes she was first warm and affectionate and then suddenly angry, hitting the eldest child for no obvious misbehavior half an hour later. She talked unceasingly to the children, often in a series of admonitions; for example, when the three-year-old was holding a piece of gum: "where is it...pick it up...Iook under the bed and pick it up and put it in the toilet... where is it...don't leave it there and let it get stuck in the rug... what will Daddy say if the gum gets stuck in the rug... were you in Mommy's room...1 thought the door was locked. During this monologue, Karen was feeding the baby and had her back to the child she spoke to; she never looked around or enforced any of her statements. The childjust sat picking up and dropping the gum. 28 December 1979 The Cenedlen Nurse These children had had a serie, of minor injuries during the ,ix months period of observation. On one vio;it Karen reponed: "Yesterday all three of them hdd accidents: Patty caught her finger in a door, Barb ferr down the ,tairs and Andrew fell off the che'tertield." Mother fell down the basement o;tairs while carr}ing the two-year-old and a basket of laundry at the same time- fortunately. neither wa, "eriou,1 y hurt. The family li\ed in a o;mall townhou,e and the children rdrely got out becau'ie of the problems involved in organizing outings with three small children. Thus theo;e children experienced a fairly restricted environment with erratic unpredictable attention and ,upervi,ion from their mother. Barbara. the third mother, had two children. the second of whom wao; an exceptionally lively three-}ear-old, who had had many near accidenh. Their interaction in the park ao; Daniel swing, consists of a ,eries of admonitions from the mother, followed by challenges from her child: Mother: "Be careful. you'll fall and hun your,elf. .. Daniel: "Me can do it." Mother: "Not too high." Daniel: "Me can go high by myself." Mother: "Yes. I know, but be careful." (Daniel Jumps l ff) Mother: "How many times do I have to tell YOll not to jump otJtillthe o;wing stop,." (later) "Don't go into the yard till I get there, the gate to the pool isn't locked." Daniel: "Mom, you dJdn'tlock it. you're supposed to lock it." Note here that the child pays little attention to mother's almost non-stop admonitions. but at the same time he holds her responsible for not locking the gate: the idea is that if he is hurt, it will be his mother's fault. The situation seems to involve a somewhat anxiouo; mother paired with a very lively child, and ,orne incongruence between her view of what he can do and his actual abilities. One sometimes ,ees almo,t the oppo,ite behavior, where the parent actually challenges the child to do daring things. and gives implicit approval- "his dad was really wild when he was a boy. climbing over the rooftops and everything, and Gary i,justlike him." Some significant variables in understanding how a child learns safety behavior in the family include the paren!', well-being. and the dissonance between the child's behavior and parental expectations or desire,. Accident rates have been ,hown to be related to family functioning, and such things as disturbed family relation,hips. lack of supportive interper,onal relations. and distress about living conditio no; can have an adverse effect Thus, in understanding the child's experience one must look at how the whole family functions and the specific interaction between the child and those around him. Emironment The home environment is full of hazards to the small child: community health nur,es have long provided guidance to parents on how to accident-proof the home. Interestingly. one study"showed that children who repeatedly ingested poisons did !JOt come from more hazardous homes than a control group, and in fact were more often under direct parental supervi,ion at the time of ingestion than children with a single episode of poison ingestion. The authors suggested that the children ingested the poison a, a challenge to their mothers. and that the event was purposeful. not accidental. Of course. it is difficult to identify and eliminate all hazards in a home as seen in the experience of a mother whose II-month-old child leaned over the toilet to reach the water and toppled in head first She was fortunately seen and rescued immediately. Another study5 suggests that infant injuries represent "true accidents" in contrast to accidents among older children: family functioning wa, found to be correlated with accident occurrence in three to ten-year-olds but not in infants. due perhaps to the difficulty of calculating accurately an accident rate in infants in a short time span. Environmental hazards around the home and neighborhood may be beyond the control of individuals. Social class is clearly related to hazard in that the Door are more likely to live in semi-industrialized. crowded neighborhoods and near major thoroughfares. Nelson Foote wrote of the' 'differential distribution of safety in society. as a concomitant of wealth and poveny" ." Parents and health workers have a two-fold task: to help children to learn to behave safely in a complex environment, and through community action to try to eliminate the more obvious hazards. Epidemiological studies of accident occurrence help in identifying vulnerable age groups, as well as times and places which are associated with increased accident rates. A study of traffic accidenb involving children showed higher rates in Spring and Fall, peak time of day to be between three and ,ix p.m.. and higher rates in semi-industrialized congested areas. The higher frequencies occurred in three-year-olds, (who often ran between cars in mid-block) and five-year-olds (who frequently crossed at interc;ections). "The type of accidental injury changes as children grow older: o;mall children experience more falls, suffocation. poisoning and bums while older children are more often involved in collisions, or struck by flying or thrown objects. and suffer injuries from handling sharp objects. !These studies help in identifying the hazards which are most imponant at various ages. Nursing approaches Observations of 15 families with small children concerning the development of health behavior showed that incidents related to safety and accident prevention constituted a quaner of all health-related interactions. The proportion was greatest among two- to four-year-olds. Thus it is apparent that a good deal of the interaction between a small child and his parents relates to safety. and it would seem important to know more about what learning is occurring and how parents can be helped to function effectively. In the family which is functioning well parents often express a need for some guidance in understanding the child's developmental level and capabilities. Sarah, the mother of three described earlier was particularly interested in resource materials and books which outlined suitable activities for various ages. Parents are interested too in comparing notes with other parents and so family drop-in centers and playgroups often serve to get parents together. Some community health nurses use the child health clinic as a place for mothers' groups. For many parents. the chief need is for information and for The Cen.dlen Nuree D8c:.mber 1878 211 \ reinforcement that they are doing a good job. (One reference on behavioral indi"iduality \\-hich is quite helpful is Your Child is a Person by Chess and Thomas.)12Thus. one goal of nursing can be to help the parents learn about their children, to appraise them realistically and to develop appropriate goals and expectations. When family functioning is disturbed the nursing role is much more complex: in many cases poor safety practices and accidents are pan of an individual family's functioning. Research has shown that families are at higher risk for childhood injuries when factors such as marital discord, physical or mental illness. extreme poveny, inadequate housing or alcoholism are present. There are no simple answers for problems such as these and teaching about safety may very well be ignored or considered irrelevant. Two activities might possibly be helpful: . help the family to build up a suppon network offriends or relatives who will help out at stressful times. This is not an easy task as many unhappy people with low self esteem resist attempts to involve them with others; for some. drop-in centers and mothers' groups provide a welcome opponunity to meet others and get out of the home. Community health nurses generally know neighborhood resources and activities, and can help neighbors get together to share babysitting and so on. . work with other social agencies in providing needed suppon services. Karen, described earlier, was helped greatly by the provision of homemaking s rvices. along with psychiatric care for herself. hon term family suppon service. 'ten take the pressure off for a time and he p he family to resolve basic difficulties. Unfonunately, when Karen initially sought help she was described by a nurse as lazy and unwilling to look after her own responsibilities. However. her underlying mental strength was indicated by her persistence in getting the help she needed. Social service agencies today are generally committed to the goal of strengthening family life. and nurses can work cooperatively with social workers in identifying needs and strengths. On a wider scale, nurses need to look at the community and the social and political forces which are a part of family functioning and childhood safety. One must be continually vigilant in awareness of environmental hazards. and knowledge of who or what agency can take action. There are a variety of government and voluntary agencies conce "l1ed with safety. but each individual has an ongoing responsibility to see that standards are enforced. and that new hazards are identified. What constitutes a hazard? One example is a child-proof medicine bottle which a six-year-old opened easily. Another is a defective crossing light near a school- corrected quickly by a phone call to City Hall. but not before several children narrowly escaped being struck by a car. Are you aware of safety standards for infant cribs and do you use these when talking to expectant parents? Nurses need to be totally involved in the community in which they work: focusing solely on an individual patient ignores the social and political realities which may in fact contribute to their illness and disability. Safety is but one facet of a complex interplay of individual behavior and environmental and social factors. Conclusion While it ha'i been suggested that self-injury may actually be an expression of the value of self-preservation and a testing of how much others value the victim, " most research suggest'i at least that the obvious non-random incidence of accidents implies a strong need for health professionals to focus on the characteristics of both families and individuals related to accidents. To do this. the nurse must have an awareness of child development. an understanding of family function and interaction, and be an active panicipant in the community. 'W References I "'Manheimer. Dean 1.50.000 child-years of accidental injuries, by Dean I. Manheimer et al. Public Health Rep. 81:6:519-533.Jun. 1966. 2 "'-.Personality characteristics of the child accident repeater. by Dean I. Manheimer and Glen D. Mellinger. Child Del't. 38:491-513.1967. ê '" t..I ." ;; '" c 3 "Read, John H. Pedestrian tra/fic accidents inl'Oll'inR children in the City ofVancoul'er, Callada by John H. Read et a!. Vancouver. B.C.. University of British Columbia Faculty of Medicine Child Health Programme. 1960. 4 Husband, Peter. Families of children with repeated accidents. by Peter Husband and Pat E. Hinton. Arch.Dis.Child. 47:396-400, Jun, 1972. 5 Plionis, Elizabeth Moore. Family functioning and child accident occurrence. Amer.] .Ort/wpsychwtn' 47:2:250-263, Apr. 1977. 6 "Sobel, Raymond. Repetitive poisoning in children: a psychosocial study, by Raymond Sobel and James A Margolis. Pediatrics 641-651, Apr. 1965. 7 "Suchman, Edv.ard A. Currem research in childhood accidents, by Ed\\-ard A. Suchman and Alfred L. Scherzer. New" ork, Association for the Aid of Crippled Children. /960. 8 .....urokawa. Minako. Childhood accidents as a measure of social integration. Call.Rel'.SocioIA nthro. 3:67-83, 1966. 9 "Limbourg, :\-1arie. Anicle cited in Psychological Abstracts no.2269, Jan. 1978, from Zeitsch,ijt fur Experimentelle Ulld AIlRewandte PS\'chologie 23:4:666-677, 1976. 10 Thomas. Alexander. B ehal'ioral individualit\' in early childhood. by <\lexanderThomas et a!. New York. New York University Pre'is. 1963. II "Foote, Nelson N. Sociological factors in childhood accidents.(/n Haddon, William. Accident research: methods and approaches, by William Haddon et a!. Nev. York. Harper. Ro\\-. 1964.) p.448-458. 12 Chess. Stella. Your child is a person: a pS\'c/lOlogical approach to paremhood wit/wilt guilt. by Stella Chess et al. New" ark, Penguin. 1976. '" '" ." " "'Unable to verify in CNA Library Helen Elfert.RN, BN, MA, is associate prl?fessor in the School ofNursillg at the Unil'ersity of British Columhia. She is a graduate of the Hospital for Sid.. Children in Toronto, and obtained her degrees at McGillalld Nell l"ork U nil'ersities, respectil'ely. M rs. EUert has a I'arie(\' l?f clinical experience in pediatric mining bOTh as a staff and head nurse, and is hene(f the mother of a six-vear-old. Da a used in this article K'as collected by the author with the anistance of May Yoshida. Marguerite Warner, and '\larie-France Thibeaudeaufor a project entitled The Del'elopment of Health Behlll'iour in Children. which was conducted under the guidance of Dr. Mo ra Allen. (National Health Rnearch and Dpl'elopment Program Grant no.605-/237-44). 30 D8c:.....t>er 111711 The Cenedlen Nurse Ð. Preparation of toddlers and preschool children for hospital proceaures Judith A. Ritchie What can we do to make a young child emotionally "ready" for hospital or health care experiences, and how do we do it? Books, films and lectures can pro\ide facts and ideas hut, to be really successful preparing children, the indhidual nurse, teacher, child-life worker or physician must approach the child and his family with a sensitive and open mind, obsenin the child's play, drawings, \erbal and non- verbal communications for signs of confusion and upset. What follows are some general guidelines for the preparation of children of any age and specific suggestions based on developmental considerations for the preparation of toddlers and preschoolers. 'C. -:IP" GENERAL PRINCIPLES Children of all ages need preparation for any event: this process may be brief and immediate, or detailed and spaced over a period of time, but even the very young child need some warning of what i'i .., going to happen to him. This preparation mU'it be geared to individual need and level of development: there is no one recipe for succe s. The level of development will indicate how the child may perceive and interpret procedures. and determines both the content and method of preparation. Previous experience does not necessarily mean a child will be able to cope without help. Indeed. the experience of past illnesses or repeat procedures may have a cumulative effect and overwhelm the child. I .., , -- , '1 .. / I - '- I - Prepamtion should always be brief. accurate and simple: extra details can be gIven according to need at any time. The amount of information given will depend on the child's age and the time available, and the child's individual ability to assimilate the information. Always remember, whatever you say either increases or decreases stress in the child. Who should do the preparing? Everyone has an imponant role to play in preparing a child and when each person involved in a child's care fultïlb his role. the child will feel like a human being who is important and about whom people care. The primary role in preparation is taken by the parents. /J '" " 01) nurses and child-life wor er'\. Next in line are phy ician . physic.!1 and occupational therapi ts ,md technici,m,: the'e people tend to operate in the ;;; 'þospital on a sort of" in-om" basis and are les li"ely to have opportunity to learn the complexities of a child's È particular information needs. Prepamtion must always begin "where the child i " instead of at the ð point an adult may con ider the logical starting place. To do thi" you must learn how the child explains events that have already occurred. and what expectation'i the child ha'i about \\ hat''i going to happen next. Assessments must be based on a sound knowledge of child development and ofchildren's usual conceptions of and reaction to illness and hospitalization. A basic guide to question.. to be addressed in preparation is simply what wi1l happen and what sensation.. win be experienced? In other words. what will the chird feel. see. hear, taste and ..mell?' :\Iso to be considered is the outcome. The child mU'it have the cycle completed for him: for example. a child going to the operating room needs to know that he will wake up in the Recovery Room and then return to hi.. room. The detail given in any ofthe..e areas may increase with the child"s maturity and as he indicate.. a need for more infonnation. Resources you can use include: . people who use both verbal and non-verbal means of communication to explain events and to comfort . books and drawings which graphically or verbally portray events and objects . modeb of organs. the human body. or the hospital . therapeutic play with specially adapted dolls. puppets. or ho pital equipment. THE TODDLER Developmental cOllsideralions: The toddler's perceptions of and reactions to illness and hospitalization are most ffected by the (]eyelopmental factors of autonomy and separation-individuãtion. The primary concern of the toddler is separation from familiar caretakers: lesser concern are loss of contrõf. inobffity or Integrity. The toddler's lack of ability to express himself verbally means he is open to being overwhelmed by the sights. sounds and sensations of procedures in hospital. Generally. we can expect fearful responses to-,my - proce dure- involv ing lou d noises õ;: unfamiliar or unpleasant sensafions such as pam, body intru-sìon. pre sure. hot or The Cenedlen Nur.e . D8c:.mber 111711 31 cold, and restraint. especially \\-hen he is Therefore. even smaller dolls with such in the back-lying position. The toddTer equipment may not be helpful in As soon as a procedure is ma} express fear either by screaming instruction. completed, the toddler should be frantically or with rigid control and wary he basic principle in preparation of released from restraint and permitted to \ igilance. the toddler IS to make him aware that we assume the upright pO'iition unless that is - re trying to tell him sometl.liI)g, --=- contraindicated. The toddler always Approaches: Prepare the child's parent" 'meihing we hope he will learn and reacts as if he feels very vulnerable in the and, ifat all possible, permit one of them remember. back-lying position. to accompany the child for the procedure. Be certain to determine what previous information the parents have and what preparation of the child they have already done. Parents need information too. not onl} about what will happen, but also what they can do to as i'it their child. With specific instruction about the nature of their role, most parents can (Olerate being actively present while their child undergoes treatment or procedure. The person \\- ho is preparing the child must use 'iimQI factual statements about \\-hat is happening, employing familiar. non-threatening words such as "fix" and "measure" mther than "take out" or "take"_ The use of play can help the child under'itand what is beyond his verbal capability: the young child approaches the world in terms of action and masters it through play. We can make use of the child's approach by letting him see and handle equipment such as 1eThoscopes, thermometers ,md suitably-equipped dolls may be used sO the child can act out what is happening (0 him. While the toddler may not understand the meaning of dressings. s(Omas, casts. etc., on dolls used for preparation, they do seem to identify with them once the procedure ha'i been carried out. For example, an 18 month old with an esophageal lye bum did not seem to understand efforts at preparation for insertion of a gastrostomy tube and string guide for dilations. However. following the procedure she literally "latched-on" (0 a doll with a "gastrostomy tube". string and a hole in the mouth in which to act out dilations. The timing of preparation for the (Oddler should be just prior (0 the e \ ent - but the child must always receive some warnmg. \ \\ Cautions: It is essential to be aware of a child's l"Cactions and to determine from these how much information he should be given: we must watch for cues that he is feeling overwhelmed or confused. The toddler is beginning the stage of fantasy development and this results in a difficulty in distinguishing between fantasy and reality. This may cause him to react with fear when faced with life-sized dolls or puppets which are "equipped" with realistic scars, casts, etc.: his cognitive abilities are not developed enough so he can easily transfer information to himself. Helping the child to cope: Maintaining contact with the child, whether it is visual. auditor) or- if possible - tactile. during the procedure \\-ill give him a feeling of security. By holding the child we can give as much body contact as possible: constant soothing talk will make him feelles'i alone and frightened. Toddlers usually cope with stress in their own individual and con istent ways. Some react by screaming throughout a procedure, others by rigid control or withdrawal. ... , t ..... " s ". - . ,- M, ... r # . . . Jason, aged two years, always stayed in rigid control during an\' e,((l1ninations. renipunclUres, x-rays or other procedures. He held the nurse' s hand. I .atc"ed care.f;llly. perspired and softl\' said "ooooh" ifhe were hurr. When it all became too muchfor him, he turned his head away and stared silently at the wall. . Barbara, aged eighteen months, screamed and required constant restraintfor her frequent abdominal dressing changes. The nurse del'eloped a rilUalfor each dressing change: Barbara was placed on her bacl.. with the nurse's arm under and around her and holding her hand. and Barbara'sfm'orite blanl..et was placed OI'er her face. This resulted in immediate cessation ofBarbara's struggle. and while the nurse tall..ed to her, Barbara remained still throughout the procedure. It seems that afm'orite blanl..et corning the face shuts out the threatening em'ironment and, at the same time, is afamiliar source of comfort and safety. 'It/> When it's over: "Preparation" must continue even after the procedure is completed: playing the experience out and acting out feelings with books. dolls and puppets help the child to come to terms with the experience. By age two years, the child practises repetition of events in an attempt to master the feelings surrounding them. Jason was hospitalized for a complete medical investigation; following his discharge, his mother noted he had developed a new game - he repeatedly used any pointed object (0 jab the paw of his fa vorite teddy bear, cried "00000" and picked up the bear (0 comfort it! When the nurse made a home visit and presented a play-kit to Jason. he immediately selected the syringe and needles and proceeded to inject one of his dolls more than twenty-fïve times. Older toddlers and young three-year olds use more symbolic play to help with mastery. For example. Michelle, aged 3 I/ had been critically ill for a long period following surgery. She reacted favorably (0 puppets. play and stories about getting better and going home. THE PRESCHOOLER Developmental considerations: The egocentric nature of the preschool child and his incomplete concept of body and self at this stage of his development results in concerns of body integrity and fear of intrusion when he is ill or hospitalized. Separation is of less Concern than in the toddler, but remains an important area. The child's ability to fantasize combined with his normal egocentricity may result too in general misconceptions about what is being done - he may view treatments and p rocedu res as punishment- and in feelmgs of guilt about being ill. - Forexample, Keith, aged four, said of the hospital. "This is a bad place for boys and girls to be," and later continued, "/11 never go on a 'mobile' (snowmobile) again. I promise." Kent, also four, was very upset during a difficult venipuncture. When the intern teasingly said, "Maybe you haven't got any blood:' Kent replied, crying, "You took too much yesterday! You took it all yesterday!" 32 December 111711 The Cenedlen Nur" J;). However, the same child might tolerate this infonnation if it is given through fantasy by applying the child's story to Use ofp/ay: Just as the toddler does, the puppets or dolls. Lisa, aged five, could pre-school child may use play before and tolerate no direct explanation about her after a orocedure in an att empt to condition, treatments or investigations. understand the event and tõñïãstèr -----n owe ver, she listened avidly and clearly - kehngs about it: such play seems to be identified with a situation in which the most therapeutic when not directed by same infonnation was given as if it were the adult. It is not important that the about hertoy donkey, Eeyore.: 1 child gives an irúection or places a dressing correctly. Almost any procedure can be implemented on a stuffed toy, doll or puppet: puppets have been made with scars and removable parts, etc. to aid the preschooler and school-aged child's understanding of surgery or condition or treatments. Even young children have enough manual âëX 1en ty to carry out procedures such dS injections, suture removal. dressmg changes, cast applications and removals, The older toddler's and preschooler's increa'icd ability to express himself verbally facilitates our determination of his concerns, and permits more detail in preparation and explanation. However. a child's vocabulary may be such that he_might misinterpret similar sounding words or be unnecessanly fnghtened when unfamilIar or thr eatening-soun ding words are used. Approaches to preparation: As for the toddler. parents of the preschool child 'ihould be helped to prepare their child for procedures. They normally explain events to their child and are therefore most familiar with the child's vocabulary and signs of confu,ion or distress. Beginning by determining what the child already knows and thinks. we can clarify and extend his understanding through verbal explanations, books, and, for the older preschooler, body outlines. The child tends to tolerate and assimilate information if it is given in smallcfoses- over time. We mustbe syste mat ic about what information will be given and certain that various personnel do not give different information. There is research evidence that preparation at the time of the stressful event (stress-point preparation>. opportunity to rehearse the event in play, and support given during the event, are the most effective means of reducing the child's degree of upset and increasing cooperation. 2 Both preschool and older children seem to respond favorably to preparation which consists of a "sketchy", but brief and accurate overview of what is expected. followed by more detailed explanations at the time of each event. Explanations may be aided by books 'iuch as Curious GeorRe Goes to Hospital by H. Rey, Mister ROKers Talks About by Fred Rogers andGoinK to the Hospital by B. Clark. Other useful aids are simple pictures such as body outlines which show very simple diagrams of the inside of the body and models of body parts, or hospital equipment. Cautions: The individual attempting to prepare the child for procedures must be alert to signals indicating "information overload". To continue explanations in spite of cues that the child is becoming frightened and overwhelmed only serves to heIghten anxiety and may in fact be \/orse than completely omitting - preparation. Preschool chIldren give ver.... clear signs of increasing anxiety sucn as long periods of silence. wide eyes and fixed facial expression, constant fidgeting or attempting to move away from the area. playing with toys unrelated to the topic under discussion, changing the subject of conversation and sudden disruptions. such as the need to void or an outburst of hyperactivity. GÞ .. ff ø'\ ,\ . removal of chest tubes on dolls or puppets. It is wise. for safety reasons, to conduct such play sessions with individual supervision and in a quiet place. I have made very crude adaptations of dolls to demonstrate ostomy stoma, amputations, gastrostomy tube and halo-femoral traction and cast, and children seem to identify readily with such dolls. Similarly, hospital models do not need to be elaborate to pennir the child to play out going to various hospital areas such as from own room, to operating room, to recovery room and back to own room. A wise precaution in adapting dolls or making model hospitals is to avoid including too much equipment as the preschool child may find it overwhelming and anxiety-producing. Some children may actually find a direct explanation of what is wrong or what is going to happen too threatening. In short Nurses who regularly deal with children who are faced with hospitalization seem to be increasingly aware of the need to explain their actions to the child. We -must also be aware of the needs of the ill child's siblings and can use any of the above approaches to clarify their misconceptions or alleviate their fears. If siblings cannot come to the hospital, parents may be willing to take home models or adapted dolls which would help prepare the siblings for the ill child's homecoming. In conclusion, successful preparation depends on the use of our imagination to creatively display informatIon, our knowledge of the child's developmental characteristics and our sensitivity to the child's . responses. At the same time, we must J: exercise caution about the extent and enthusiasm of the preparation so as not to overwhelm the child. We have a multitude of resources, both material and human, that we can and must use to spare the hospitalized child an episode of needless fear and anxiety. 'W Ë " c " " . :> 8 c .. > o " t: :> o u o Õ .c c.. Judith A. Ritchie,RN, BN, MN. PhD, is currently an associate professor in the Rraduate program of the School of NursinK at Dalhousie Uni\'ersity in Hal "ax, N.S. She has had pediatric nursing experience as a staff nurse. clinical specialist and uni 'ersity teacher. A pastCNF scholar, Ritchie is currently a member of the CNA committee on nursing research. and of the redew boardfor nursing papers. References 1 Johnson, J .E. Altering children's distress behavior during orthopedic cast removal, by J .E. Johnson et al. Nurs.Res. 24:6:404-410, Nov.{Dec. 1975. 2 Visintainer, M.A. Psychological preparation for surgery pediatric patients: the effects on children's and parents' stress responses and adjustment, by M.A. Visintainer and J.A. Wolfer. Pediatrics 56:2:187-202, Aug. 1975. 3 Ritchie, J. Fantasy in communicating concerns about body integrity. Matern. Child Nurs. J. 1:117-126, Summer 1972. Th. Cenedlen Nurs. D8c:ember 1979 33 Hospital b Q!s " for children Flizabeth Crocker is the dirl'c{or ( fthe Child Life Department. Thl' l.\Clac Walton A.i/lam Hospital for Children in Hal(fcn:. Nm a S 'o{ia. An annotated h t of books for children to give them an idea of what a ho pital eJ\.perience is all about. Clark. Bettina. Pop-up going to tire \c hospilal, Westminster :\ld.. Random \.-1 /". House. 1971. Children enjoy this "tory about Andy's tonsillectomy. The illustrations are bright and. in many cases. movable. Andy packs his own suitcase. is not allowed to eat before his operation. h,ts blood taken from his finger. sees people dres ed in green. breathe.. "special dir" in the operating room to make him fall a"leep. wakes up in the recovery room. and has a sore throat. Pre chool to Grade 3. *Falk, Ann Mari, The ambulance. Burke Publishing Co. Ltd.. 1966. Five-year-old Tom has appendicitis and an ambulance tales him to the hospital for an emergency operation. Tom reacts realistically to getting an injection. his parents leaving. oral medications. and walking for the first time after his appendectomy. Good illustrations and large, easy-to-read print male this an e'l(cellent book. Preschool to Grade 4. GydaJ. M., When Oily wenlto hmpital, b) ... and T. Danielson. Hodder and Stroughton, 1975. (Also a,ailable as Quand Olh.ier "8 a I'hôpital, distributed in Canada b) Editions Heritages) This is one of a series of books that deals accurately and compassionately with crises that may happen to small children. Oily has to go to hospital because he is sick While he does not have to have an operation. he learns about them and X-rays from other children. Included in the narrative are points such as Oily being upset wt en his parent" leave and being very "clingy" on return home. The accompanying illustrations offer further insight into both the activities and emotional aspects of hospitalization. Primary to Grade 6. \ *Haas. Barbara Schu}ler. The hospital book, Baltimore. The John Street Press, 1970. This i e ..entially a coloring book with the black and white illu trations and clear text providing a balanced and general vie" of ho\pitalization. The following are found in the 48 pages: admission procedures. ho pital food. bed . call bells. injection . finger stick. temperature, and blood pre., ure: otoscope. X-ray machine. oxygen tent, intravenou fluid therapy: traction for broken bone.. and wheelchair,,: play and school program : simple diagrams of major organs dnd bone". Pre choolto Grade 4. Jes'iel. Camilla, Paul in Hmpllal. by '" and Hugh JolI}. New York. Methuen Children.s books, 1972. Paul fall.. from a tree. hi.. finger becomes badly infected and he has to go to the ho pital. There he meets many other children and, through the text and excellent photograph . the reader learns about a wide variety of hospital taff. equipment and procedures. Although some of the word and pictures are specifIc to British hospitals. this is nonetheless an excellent portrayal of ho pitalization. Primary to Grade 6. Rey, H.A. and M. Curious George go.s to the hospital, Boston, Houghton :\1ifflin Comp: ny, 1966. Because Sl. man} children are already familiar with this mischievou\ monkey, this book i both entertaining and comforting to young children ... "If Curious George can go to the hos pital. I guess it's o.k.!" George 'iwallows a piece of jIgsaw puzzle which results in a visit to the hospital. a barium wallow in X-ray and finally an operation. Even though he takes along his favonte ball for comfort, George cnes when his visitor leaves and lets out a scream even before he gets his preoperative needle! Illustrations show details of a clinic waiting area. the operating room. children's ward and playroom. Preschool to Grade 3. Stein. Sara bonnett..-t hospital story. New York. Walker and Company, 1974. This book is one of a serie of" open family books" for children and pdrents to read together. Photographs drld large print conve} the story to children while 'imall t} pe in the margin focu'ie.. on guidelines for parents in helping a child cope with hospital experiences. Jill. the principal character, has her tonsils out. Preschool to Grade 3. *Weber, Alfon... Elizabeth gets well, Scranton, Pa., Thomas Y. CrowelI. 1970. The illustration., in this book are superb and convey a great deal about hO'ipitals and children' feeling . The stor y is well-told and accurate - it follows Elizabeth who ha to have her ,lppendix out. Reference is made to uch things a' the preoperative injection (and resulting drymouth). the operating room. IV fluids. thir t. stitche and blood tests. Through other patient . Elizabeth and the reader learn about ca't'i and X-rays Primary to Grade 4. X. Welzenbach, I.F. Wendy Well and Billy , )Jetter say" h.!/Io hospilal". Visitthe hospilal see through machine. Meet tire hospital sandman and.4sk a "mill-yun" hospital questIOns by... and N. Cline. Chicago, Med-Educator, 1970. In this series offour books, Wendy Well and Billy Belter walk across black and white photographs of hospital scene" and comment on how they perceive things. Technical terms and quipment are de cribed in both factual and child-like terms. As well as covering a wealth of information about hospitals and various procedures, these books provide insight into how children might see or understand things. Preschool to Grade 6 Wolde, Gunilla. Thomas goes to the doctor, Boston. Houghton Mifflin Company. 1972. (Also available as Titoll chez Ie docteur. distributed in Canada by Granger Frères). Thomas visits his doctor (a woman) for a check-up. Thi" is sÞ'Jwn to include undressing, weight and height. examination of throat and ears. use of a stethoscope and an injection. Thomas visibly dislike" the injection but gets support from his mother and the doctor Later pages show him at home giving his teddy needles. Preschool. * A I'ai/able in paperbac/... 34 D8c:ember 1979 Th. Cenedlen Nur.e '. " Syndrome: . .- , , , , '" " . , I ,. ' Co/een Manning ". -""* Ginger was seven years old when she was admitted to our Intensive Care Unit for the ninth and final time. Over the past five years this precocious little girl had been afflicted with stubborn attacks of paroxysmaJ ventricular tachycardia, the result ofa congenital cardiac condition, Wolff-Parkinson-White syndrome. Ginger is one of the lucky ones. Her story has a happy ending. CASE STUDY Ginger, age seven, was admitted to our unit with an episode of tachycardia. As this was her ninth admission in five years for the same problem, she was familiar with our routine and her condition. She told us that her admission was due to a "tachycardia", reminded us that she "took Digoxin" and "didn't like needles" . WPW syndrome was suspected and with every subsequent admission. an EKG and rhythm strips from her cardiac monitor were taken to confinn that the underlying cause of her tachycardia was WPW syndrome and not Digitalis intoxication or some other cardiac dysfunction. Ginger liked the "Happy Face" pediatric monitor electrodes that we applied "to watch her heart beat"; even when she was feeling well, she tolerated her monitor connection, wandering about as far as the cable would allow her. EKG suction electrodes had become known as cherries and we explained that this machine was actually" taking a picture of her heart beat". Ginger's episodes of tachycardia occurred most often when she was active, but occasionally developed when she was sleeping. Her tachycardia resulted in a cardiac rate of 230 to 250 beats per minute. At these times, Ginger complained of subjective feelings of palpitation. Initially. in order to tenninate the tachycardia, vagal manoeuvres such as carotid sinus and orbital pressure were applied with no success. This technique failed on all of her admissions. Digitalis treatment and subsequent digitalization had been helpful initially in correcting attacks oftachycardias and deterring further episodes. On several occasions Ginger required rapid digitalization, but minimal elevation of Ginger's Digoxin level above the therapeutic range resulted in evidence of sinus arrests and nodal and ventricular ectopic beats on her cardiac monitor. Minimal success was seen with various medication regimes which were initiated over her many admissions. Ginger's tachycardia was persistent. Consequently, electrical cardioversion was the only treatment which met with any success. Digitalized patients may not tolerate cardioversion, due to Digoxin's action on excitability of and conduction through heart tissue. The Cenedlen Nurs. D8c:.mber 1979 35 A V Node NORMAL CONDUCTION SYSTEM The normal electrical impulse of the heart begins in the sinus node. From this node, the impulse spreads through the atria. The P wave of the electrocardiogram (EKG) results from this activation. The impulse is then delayed at the atrioventricular node. allowing the atria to contract. The PR interval of the EKG represents the time for the impulse to reach the ventricles. After passing through the His bundle. the impulse travels to the bundle branches and PUr\(inje network to individual ventricular muscle cells, resulting in ventricular contraction. The QRS complex of the EKG represents this ventricular stimulation. Recovery of the muscle cells is represented by the T wave. Bundle of His Bundle Branches Ventricles R T I I r I I ,"" PR jQ "" .12-.20 I , I , sec. I I I I S......., QRS '....... .07-.12 sec. ........ \ Such treatment results in a high incidence of arrhythmias post cardioversion. So, Ginger's maintenance Digoxin dosage wa discontinued and a waiting period was established to allo" the Digoxin level in her body to fall to a safe level. Although Digoxin acts quickly upon administration, the plasma half-life is about thirty-six hours when renal function is normal. In preparation for the electrical cardioversion. Ginger fasted and was anaesthetized in the unit. The cardioversion necessitated an intravenous which was upsetting to Ginger. She would watch her monitor closely after her cardioversion. as the nurses promised her that the LV. would be removed once her pulse remained slow. Frequently. several attempts at cardioversion were required to convert her tachycardia as it became increasingly resistant to this treatment. Finally. her episodes of tachycardia became more frequent to the point where monthly hospital admission was required. Ginger's treatment was now at a standstill: in fact. she wao; regressing. Her pediatrician persisted in attempts to obtain further te..ting in a center capable of doing His bundle recordings. Such testing is"highly pecialized and at that time was not available in Canada. A local fund-rdising drive, organized to deferGinger's treatment costs, met with tremendous community support enabling Ginger to be referred to an American center which was experienced in mapping cardiac impulse conduction. Through the use of intra cardiac electrode catheter recordings. an accessory path was found in the right anterior atrioventricular groove. At the time of surgery, the Kent bundle was located superficially in the epicardial layer. and was divided by right atriotomy. Ginger was discharged on the eighth post-operative day in stable condition. WolfT-Parkinson-White (WPW) is a type of congenital cardiac anomaly known as pre-excitement syndrome. Pre-excitation exists ",hen all or some portion of the ventricular muscle is activated earlier than would be anticipated ifthe impulse reached the ventricles by way of the normal conduction system. I Conduction fibers in the atrium operate as accessory pathways for impulse transmission causing premature activation of the ventricles. The incidence of the syndrome is thought to be O.lto 3.1 per 1000 population 2 PathophysioloRY rhe classic fonn of pre-excitement associated with WPW syndrome involves an accessory pathway commonly called the Kent bundle. An impulse emanating from the sinus node not only follows the normal conduction system pathway but also stimulates the Kent bundle which conducts the impulse directly from the atrium to the ventricle (Figure one). The resulting electrocardiogram (EKG) shows a short PR interval (less than 0.10 seconds) and a wide QRS complex with a delta wave. The shortened PR interval is due to the early stimulation of the ventricle by the Kent bundle. The impulse once in the ventricle is passed slowly from muscle to muscle. This produces slurring at the beginning of the upstroke of the R wave and fonns a delta wave (Figure two). The accessory pathway opens and closes spontaneously, resulting, at times. in a normal EKG. Figure one: ACCESSORY PA THW A Y IN WPW Atrial Activation Accessory Kent Bundle 3S D.c....ber 1979 The Cen.dlen Nurs. ... PR Interval less than .11 sec. QRS Complex wider than .12 sec. RETROGRADE ACTIVATION OF ACCESSORY PATHWAY Premature Atrial Contraction I AV Node T Sinus Node Accessory \ His Bundle I \ FUSION OF IMPULSES RE-ENTRY CIRCUIT ESTABLISHED PRODUCING RECIì'ROCA TING TACHYCARDIA Accessory Pathway \;(,'. nth..... ..LOP " """" .., L Paroxysmal supraventricular tachycardias occur in 40 to 80 per cent of patiems with WPW syndrome.:' Usually this tachycardia is precipitated by a premature beat. In sinus rhythm, the impulse usually follows the normal and accessory pathways. This results in ventricular fusion of the impulse. At the time ofa premature beat, the normal and accessory pathways may be at different stages of recovery. Usually. the accessory pathway requires a longer recovery time than the atrioventricular node. Therefore. the premature beat may be blocked at the Kent bundle but be conducted via the normal conduction system to the vemricles. This impulse. as it spreads through the ventricles. finds the distal end of the accessory pathway excitable and so is propagated back through the Kent bundle to the atrium (Figure three). Consequently. the atria may be stimulated a second time by the same impulse. The resulting circuit initiates an episode of tachycardia. Treatment . Medical Therapy: Pharmacological therapy of supraventricular tachycardias associated with WPW is aimed at reducing the number of premature beats and changing refractory periods of the A V node and accessory pathways. Digitalis is the drug of choice. It's depressive action focuses mainly on the normal conduction system. prolonging or completely blocking A V node and His bundle conduction. Since large dosages are often required in treatment of WPW. signs of toxicity must be anticipated. In children the most reliable signs of digitalis toxicity are manifestations of cardiac arrhythmias especially paroxysmal atrial tachycardia with A V block. The gastrointestinal signs of nausea. vomiting and diarrhea are rdre. Children's dosages are 5 to 50 per cent that of an adult. 0.04 to 0.06 mgm/kg daily for children from 2 to 10 years. Digitalization is advised for a year after the tachyarrhythmia has been corrected to prevent a recurrence. Proprdnolol ((nderaP') or another amiarrhythmic drug is frequently required in addition to Digitalis. They prove effective by prolonging the refractory period of the A V node and therefore reducing the difference in refractory periods in the two pathways. Propranolol reduces heart rate, myocardial irritability and force of contraction. It is contraindicated in the presence of bronchial asthma. allergic rhinitis. sinus bradycardia. cardiogenic shock and cardiac failure. In WPW syndrome. the most common adverse cardiac effect is bradycardia. especially if digitalis intoxication is present. Some ofthe newer agents successful in treatment oftachydysrhythmias are not available in Canada. · When medical treatment fails. more drastic mea'iures must be utilized. · Cardiol'er.rion: Electric shock causes momentary depolarization of the majority of heart fibers, thereby terminating the tachycardia and allowing the sinus node to be re-established as pacemaker. . Surgical Treatment: Surgical imerruption of the accessory pathway is considered when a disabling tachycardia is unresponsive to medical therapy. Accessory pathways are identified by multiple intracardiac electrode catheter recordings. Complications In children and infants, congestive heart failure (CHF) almost always follows paroxysmal tachycardia. In older children the signs and symptoms ofCHF are almost identical to those experienced by adults. i.e. fatigue, exercise intolerance. anorexia, abdominal pain, cough. breathles'iness at rest. elevation of systemic and venous pressure, orthopnea. basal rales. edema of extremities. cardiomegaly and a gallop cardiac rhythm. HoweverCHF is much more difficult to recognize in infants. Edema in these infants is almost undetectable clinically. Signs may include tachypnea, feeding difficulties, poor weight gain. excessive perspiration. irritability, weak cry. dyspnea with costal and sub-costal retractions, pneumonitis with or without pneumothorax. hepatomegaly and cardiomegaly. The Cen.dlen Nur.. D8c:.mber 11179 37 ursing Care While in our unit. Ginger presented several unique nursing problems for us. '\s coronary pediatric admissions ",ere rare. we were faced", ith a challenge. 0\ er a fi ve- year span, Gi nger had numerous admissions and became endeared to the staff. Her familiarity with the unit routine reduced her level of stress greatly on admission, Even examinations by various personnel did not seem to disturb her overtly. She was very independent. a characteristic encouraged by her parents who wanted her to participate in the normal activities of her age group and tried not to let her cardiac condition interfere with this. During Ginger's admissions, the maintenance of bed rest proved to be the greatest nursing challenge. Since we recognized that immobilization is probably the most difficult aspect of a child's illness.:; the importance of providing age appropriate play material was ob\ious. Ginger's favorite toys and dra",ing needs were obtained. Her frequent drawings of home and family demonstrated her desire to be out of hospital. Ginger also played out her feelings by handling hospital equipment and by playing nurse. A realistic doll that had to suffer through the confines of bedrest and the torture of an intravenou helped Ginger to adapt to her environment. Fortunately forGinger and the nurses, Ginger's mother. although also caring for an infant at home, was able to spend a great deal of time at the unit and was deeply involved with Ginger's care. Nutrition proved to be another problem area for the nurses and Ginger. During hospitalization. Ginger's appetite was generally poor. Of course. trial medications frequently caused anorexia and naU'iea. Small. frequent feedings were attempted with little succes'i. However. because ofGinger's likeable nature and unfortunate situation. the nurses frequently succumbed to reque!>t'i for cookies and pop. In retrospect. the limiting of treat,> and sweet'i to after meals might have produced better results. Being the only child in a very active Intensive Care Unit produced bedtime problems forGinger and the staff. The nurses were easily manipulated into agreeing to reading one more story, playing one more game, drawing one more picture or having one more snack. We all felt sorry for her in her predicament. When it was recognized that we were all the victims of manipulation, a bedtime routine for Ginger was established. This evening regime consisted of a telephone call home. several read-aloud stories. a snack. h'i care and a soothing massage. The establishment of this regime usually produced success. When the regime was not followed, however, Ginger would often be awake much longer than the adults in the unit. It seems obvious now. that our approach toGinger's care could have been more consistent had we held team conferences. Even Ginger's mother was a source of information and advice that we did not utilize fully. Epilogue Surgery has brought about a dramatic change in events for Ginger. who it seemed would be condemned to a life of frequent hospitalization. Now. two years after surgery. she has remained tachycardia free. with an EKG that shows normal sinus rhythm.'" References I Gallagher. JohnJ. Wolff-Parkinson-White syndrome. The problem. evaluation. and surgical correction, by John J. Gallagher et al. Circulation 51 :5:768. :\lay 1975. 2 -. The Wolff-Parkin!>on-White syndrome and the pre-excitation dysrhythmias, by JohnJ. Gallagher et al. Med.Clin.North Am. 60: I: IOJ. Jan. 1976. 3 Ibid. 4 "Peretz. Dwight. Newer agents for the treatment of cardiac dysrhythmias. by Dwight Peretz and Michael Walker. B.C.Med.J. 21:2:60. Feb. 1979. 5 Marlow. Dorothy R. TntbooJ.. of pediatric /luning. 4th ed. Toronto. Saunders. 1973. p.630. Bibliography I Arnsdorf. !\.forton F. Electrophysiologic properties of antidysrhythmic drugs as a rational ba is for therapy. M ed.Clin.N ouh Am. 60:2:213-232. Mar. 1976. 2 Chung. Edward K. Tachyarrhythmias related to Wolff-Parkinson- White syndrome. Heart Lung 6:2:262-268. Mar./Apr. 1977. 3 Gallagher. JohnJ. Wolff-Parkinson-White syndrome. The problem. evaluation, and surgical correction, by John J. Gallagher et al. Circulation 51:5:767-785, May 1975. 4. -. The Wolff-Parkinson- White syndrome and the pre-excitation dysrhythmias. fedical and surgical management. by John J. Gallagher et al. Med.Clin.NorthAm. 60: I: 101-123. Jan. 1976. 5 Gillette, Paul C. The mechanisms of supraventricular tachycardia in children. Circulation 54: I: 133-139. Jul. 1976. 6 l\fantaka . Michael E. Natural history of Wolf f-Parkins on-White syndrome discovered in infancy. by Michael E. Mantakas et al. Amer.J.Cardiol. 41:6:1097-1103. May 22, 1978. 7 Marlow, Dorothy R. T e-abook of pediatric nursinl(. 4th ed. Toronto, Saunders. 1973. 8 "Peretz. Dwight. Newer agent'i for the treatment of cardiac dysrhythmias. by Dwight Peretz and Michael Walker. B.C. .Wed.J. 21:2:51'<-61, Feb. 1979. 9 Sung, Ruey J. Clinical and electrophy iologic observations in patients with concealed accessory atrioventricular bypass tract'i. by Ruey J. Sunget a/. Amer.J.Cardiol. .to:6:839-R47. Dec. 1977. "Unable to verify in CN A Library Coleen 'Ianning is a Rraduate of the Faculty ofN ursinI(, U 1Ii1'ersity of Toronto. After graduatioll, she 1\'0rJ..ed a.v a swff nurse ill the ICU /CCU at Trail Regiollal Hospital. For the past two \'ears she has held the positioll of Education Coordinator at this hospital. Ackno"ledgment: To Ginger' s parents, Dr. Paul GelpJ..e and the ICU nursinl( staff "'ho agreed to and assisted in sharinl(Ginl(er's story and to Mrs. Audrey Turller for her time at the t\'pewriter. 38 D8c:ember 1979 The Cenedlen Nurse What a I- can 10 I , r Nico/eCave .... ,.. . , ,') . '" J - - Photo byNFB PhotothequeONI- How can a nurse establish a trusting and helping relationship with a child who cries and screams at the sight of anyone in a uniform? How does a nurse communicate feelings of caring and understanding to such a child? The task is not easy. Author Nicole Cave, as a second year nursing student, successfully cared for such a child and says the secret lies in patience, perseverence, knowledge, good organization and individualized care. During my four week period in pediatrics, I cared for a little girl whom I will call Heidi. She had been admitted to hospital for treatment of congenital dislocated hips that consisted of operative bilateral hip manipulation and then the use of Buck's extension traction on both legs. Because of the traction she was confined to bed, lying prone or supine for most of the day. Her only "outing" was to the play area. Heidi had experienced several other hospitalizations for the same problem and had undergone surgery in the past. I first met Heidi on my touring and orientation day to the hospital. two weeks after she had been admitted. Although Heidi was four years old and her growth and development had progressed normally. she appeared tiny and delicate. She weighed I3. 7 kg (which was five times her birthweight of 2450 grams).t and she wa 99 cm tall. Her blue eyes were very expressive and her face was cute and round. but her color was pale due to a low hemoglobin level. Her short brown hair was the main attraction - she had a little ponytail sitting on the top of her head that fell over like a fountain. A difficult patient During the first week that I looked after Heidi. I noticed many things about her behavior that were disturbing. For example. she hardly ever smiled and kept her thumb in her mouth most of the time. Many children in hospital are happy to have someone come and talk to them, but not Heidi. Whenever someone approached her. she cried out, put her head down on the mattress, turned her head away or simply refused to talk. If people were outside her room. during rounds for instance. Heidi's facial muscles tensed up and she became very restless. If they entered the room Heidi would cry out and scream to me. "I don't want them to come and see me; tell them to go away." She calmed down only when they left. It was obviouo; that her attitude towards those caring for her and to hertreatment was very negative and unfortunately. she had been labelled as "a difficult patient" by the staff. Giving Heidi the necessary nursing care was not easy since she seemed to express all her fears. anger and frustrations during that process. A typical morning began with breakfast foIlowed by a number of nursing procedures: bath care which necessitated unwrapping the traction bandages. giving skin care to her legs with alcohol (the smeIl of which she disliked intensely), rewrapping the traction bandages. checking the dressing for oozing and checking for pedal pulses. During each of these procedures. Heidi either cried or screamed and her body tensed up from head to toe. "What are you going to do to meT'. she would ask in a very annoyed and yet frightened voice. The most upsetting period for Heidi and for me started after bath care when her medications were given. She hated the taste of her drugs - ferrous sulfate. penicillin VK, codeine and ASA '.In addition to the terrible taste. Heidi kne\\. that the administration of her medications signaIled the imminent arrival of the physiotherapist who would put her through a series of painful exercises. As soon as I brought her drugs. Heidi would commence to throw tantrums and cry. so much so that she coughed. gagged and sometimes vomited. At other times. she cried on and off for an hour. repeating through her tears. ''( don't want her to come; she's going to hurt me:' When the physiotherapist did arrive, Heidi cried and screamed: when I went over to hold her. she pinched my arms. The analgesic given to her prior to physio did not seem to make much difference since she was convinced that the exercises would hurt no matter what anybody said Or did. In the initial period after surgery. Heidi did experience a lot of pain but later on. the pain seemed to be anticipatory rather than actual. For example, Heidi started her crying and screaming "ouch" even before the physiotherapist touched her legs. Behavior problems Whenever Heidi felt threatened. anxious or frustrated, she regressed to sucking her thumb and roIling her miniature ponytail between her fingers. I n order to shift attention away from the treatment to be administered, she complained of a sore stomach. On two different occasions the physiotherapist stopped the exercises because of Heidi's stomach complaints. But after assessing that this was a strategy used by her patient to postpone or bypass the threat of pain. The CBnedlen Nurs. the physiotherapist continued the leg movements despite Heidi's protestations - not a comfortable situation for either of them. Heidi also tried the strategy of abdominal aches with me prior to receiving her medications. Another coping mechanism she used was anger: she often threw tantrums. screamed. cried. pinched.. .One day when her mother was visiting at medication time she yelled in a very angry tone of voice: 'The nurse is hurting me. Can't you stop h .,.. er. All of Heidi's reactions to the threat of pain were normal and understandable. She could not comprehend how her mother could stand by and let other people hurt her even if it was "for her own good"". The preschooler's most effective natural protection against threat is activity.1 an avenue not open to Heidi. Her regressive behavior and agressive manner were well justified considellng that Heidi was confined to bed. immobilized in traction and thus unable to actively protect herself from a perceived threat. Her external release to thi situation was to cry. yell. pinch etc. In this way she could release her frustrations instead of internalizing them. 3 \\ hat to do It is obvious from this description of Heidi that she was a frightened little girl who trusted no one on staff: she was indeed a chaIlenge for those of us looking after her. In planning my care for Heidi,l decided to use several approaches to alter her behavior. with the goal of making her hospitalization experience easier on her and on the staff. Establishing trust First I observed Heidi and her mother together. When I did. I realized that Heidi was actuaIly a very affectionate little girl and so I decided to emulate the approach her mother used in order to get closer to Heidi. to establish a familiar one-to-one contact and to gain her trust. I realized that I had been afraid to get too close to her because of the strong resistance she had offered initiaIly. Once I overcame this fear, I approached Heidi D8c:.mber 1979 311 more openly and allowed her to do things which I had noticed she liked doing with her mom such as letting her comb my hair, rub my face. hug me, kiss me or hold my hand, play imaginary games and look at family pictures together. As a preschooler, Heidi needed the kind of security and stability that a familiar nurse could provide during her mother's absence.' I became someone Heidi could identify with. had some control over and whom she trusted. Having met my goal that Heidi would begin to trust me. I started introducing other people into our sphere. in a non-threatening fashion. For example, I pointed out pretty colors of uniforms and asked Heidi's opinion about them. I emphasized that my teacher and classmates loved little children and how much they would like her to talk to them sometimes: I adopted a positive attitude toward everybody involved in the hospital setting who came in contact witn her directly or indirectly. I hoped this would help Heidi realize that they meant no physical harm to her. EventuaIly. Heidi let many people approach her. She no longer cried when someone came into the room and in fact was able to talk to them in a relaxed and happy manner. She still felt a little tense around doctors but she no longer cried at the sight of them. She even let them take a picture of her legs one day and she put on a big smile for the photographer. Decreasing anxiety Knowing of the association Heidi made between receiving her pain medication and the subsequent physio, my nursing instructor and I discussed the possibility of taking her off medication prior to her exercises. Since the codeine did not seem to make any difference to her perception of pain, we thought this would be a way to avoid upsetting her morning. After talking to the physician. we tried it. Our first attempt unfortunately was not successful because the pain was stiIl too severe for Heidi to endure without medication. This was 15 days postop. Our second attempt one week later. proved much more successful. The pain had now decreased enough to take her off the medication and the result was that Heidi could not wait for bath care to be over so that we could play games together. She was now able to delay the thought of her painful exercises until the physiotherapist actuaIly came, instead of becoming upset an hour beforehand. 40 D8c:.mber 1979 To further reduce periods of upset, J decided to evaluate her need for the other medications she was receiving. I discussed the possibility of discontinuing her penicillin VK with the team leader since Heidi no longer had a sore throat; I also suggested that another hemoglobin test be done because it had been three weeks since the last level was taken. The new results were within normal limits and one morning, Heidi greeted me with a big smile and said, in a very happy voice, that she no longer had to swallow any pills. Participation in care I encouraged Heidi to participate in her care as much as possible. For example, while I unwrapped the bandages I had her help me by cutting the tape or by holding on to the Ace@ bandages while I applied the tape. I had her check her hip dressings and tell me whether they were clean or dirty. She took great pleasure in the initiative I had allowed her to take on and she soon became a little expert at telling me how to do my job. By being allowed to take part in her own care, Heidi could identify with the hospital environment in a positive way.s Characteristic of her age and stage of development, Heidi was very much concerned with her body and its intactness. 6 Because I was aware ofher fears in this area, I made a point of telling her exactly what J was going to do- where I would touch her and why. As far as skin care was concerned, we had a compromise: I would apply the alcohol to her legs as quickly as possible while she held her nose to block out the odor. This worked out fine for both of us. Play therapy In order to shorten the waiting period before physio, I used various distraction techniques such as singing and playing cards with her. After awhile, Heidi no longer asked to go to the playroom before physio; in fact, there were times when I could have taken her but she refused. She insisted on staying in her room until the physiotherapist came. Again, allowing her to make decisions about how she would spend her time was very important in order to meet her need for independence that is evident in the preschooler .1 After discussing play therapy in greater detail during one of our ward conferences, J introduced a play doll to Heidi which looked very much like her. The doll had Buck's traction as did Heidi; they both had a hip dressing and Th. C8nedlen Nurs. both had their own crutches. The doll also had her own kit including alcohol (which was really water), dressmg material, tape, etc. The doll even had a ponytail just like Heidi's. Heidi's first reaction to the doll was that it was very funny. But she soon named it after herself and spent a lot of time playing with it, practising her nursing skills over and over until her kit ran out of supplies. The purpose of the doll was to allow Heidi to practise all the procedures that Heidi herselffeared so much on her own body. In this way, she could transfer some of her feelings to the doll and let her frustrations out. thus helping her adapt to her treatment. H When Heidi had noticeably adjusted more to the hospital environment, the doll became just an ordinary doll which Heidi shared with her roommates. Changes It was encouraging for me and the rest of the staff to see the change in Heidi's behavior. In part. the change was due to her decreased degree of pain. and to the physiotherdpist who had shown Heidi much affection and patience. In time, Heidi was able to return the affection since she had grown to like the physiotherapist very much. As well, Heidi became more mobile, and had developed self-confidence in using her crutches. She loved showing off her crutch walking and now called staff over to give them a demonstration of how well she did her range of motion exercises. The staff were thrilled with her progress and she was praised highly for her efforts. Heidi had changed from a shy, withdrawn, distant, whiny and frightened little girl to an open. cheerful. cooperative, pleasant and affectionate child. Everybody came to like Heidi because of her friendliness. Conclusion The change in Heidi's behavior did not occur overnight but over the period of a month. The goals set for Heidi and the interventions used varied as did her needs over this period of time. In dealing with Heidi, flexibility as well as patience, caring, gentleness and understanding were essential to helping her adjust to her situation. These qualiti::s as well as a sound knowledge of growth and development enabled me to foster Heidi's trust first in myself and then in others and eventually to help her master her many fears.'" A uthor. Nicole Cave, wrote" What a little care can do" in the summer of 1978 shortly after her pediatric rotation. At that time. she was in her second year of a B.Sc.N. program at McGill University in Montreal. She states, "I hm'e enjoyed caring for children very much and as a mother of two children / was able to blend some of my own experiences with the tremendous amount of knowledge learned while dealinR with other children." Cave has since graduated from the B.Sc.N. program and is now working in the Montreal General Hospital in the area of genera I surgery. She plans to go into community health nursing in the future. ACknowledgement: Thanks goes to Susan Zuijwijk,jì-Jrmer clinical instructor, McGill Unh'ersity School ofNursinf?,for her support and assistance in the preparation of this article. References 1 Comprehensh'e pediatric nursing, edited by Gladys M. Scipien et al. New York. McGrdw-Hill, 1975. p.14I. 2 Ibid., p.38:!. 3 Freud. Anna. The ego and the mechanism of defence. New York. International Universities Press, Inc., 1966. p.56. 4 Chadwick, BarbaraJ. Maintaining the hospitalized child's home ties. by... et a\. Amer.J.Nurs. 78:8: 1360-1362, Aug. 1978. 5 Kintzel, KayC.Ad}'anced concepts in clinical nursing. Philadelphia, Lippincott, 1971. p.51. 6 Beland. Irene L. Clinical Nursing, by... and Joyce Y. Passos. New York, Macmillan, 1975. p.390. 7 Erikson, E.H./dentity: youth and crisis. New York. Norton, 1968. p.116. *8 Erickson, Florence. Play interviews for four year old hospitalized children. Monographs of the Society for Research in Child Development,/nc., 23:3, Serial no.69, 1958. *U nable to verify references in CNA Library - -- - "..... Th. Cenedlen Nurs. D8c:.mber 1979 41 Babies with - - " " .""111"'" - ---- - - - -- - - --.--..-. =- -.-=- --=::=:- -=- - -:.. :- - - - - - - - ... .. w:.:.... ==-: = ---- =-- - what to watch for Although necrotizing enterocolitis. an ohscure disease affecting the neonate. can he traced back to U!91. it was not until the mid-60's that it "as recognized and diagnosed with much greater frequenc . Wh its sudden and recent ackno"ledgment and classification? One e'\planation is that new technolog in neonatal intensive care units along "ith laboratoQ ad\ances and ne" de\elopments in h peralimentation ha\e combined to saw many small infants" ho a numher of ears ago would ha\e died. -\ ph sician obsenes: "l\Ia he it is part of the price "e pa for increasing sunhal of 10" birth "eight infants. '" Reports on the incidence of EC indicate that three to eight per cent" of all babies admitted to neonatal units de\elop the disease and that of the infant deaths in neonatal units. two to the per cent.! can he attributed to necrotizing enterocolitis. Howe\er. statistics differ from one neonatal unit to another. from one city to another and from one countr) to the next. 4 Who get.. NEC? The very small preterm infant, in particular those who have suffered asphyxia or hypoxia at birth or perinatally, are at greater risk for N EC But babies of higher birth weight have been affected also. especially those who are small for gestational age (SGA), and those born with hyaline membrane disease or cyanotic heart disease. Babies who have suffered birth trauma or registered low Apgar scores are also at risk. What causes :\IEC? The etiology ofNEC appears [0 be related to hypoxia or asphyxia. When the infant suffers an oxygen deficiency. blood is shunted away from the mesenteric, renal and peripheral beds in order to satisfy the emergency needs of the brain. heart, liver and other organs. This shunting of blood severely compromises the integrity of the bowel. Vascular insufficiency in the mesenteric area leads to bowel ischemia and a loss Ben'rley Ha.\lil/gs McBride I\. Photograph ofx-rav shOl 'ing pneumatosis of protective mucosa followed by proteolytic autodigestion. This. in turn, predisposes the neonate to sepsis. a condition further complicated by the poor immunological responses of the infant, especially the preterm infant. Bacterial invasion of the mucosa and submucosa by gas-forming organisms such as E. Coli. Klebsiella and Pseudomona.. can occur. The final stage may be penoration of the howel with resultant peritonitis. On gross examination. the bowel will appear dilated with a brown or blue-grey hue. Microscopically. the bowel mucosa will appear edematous and hemorrhagic with necrosis extending through tht: submucosa and muscle layers. Villi and crypts will be absent, a sign which may be missed if examination is done during an acute inflammatory response. There may be thrombi formation in the mesenteric capillaries. arteries and veins. A positive sign of necrotizing enterocolitis is the presence of air in the bowel wall (pneumatosis) due to the activity of gas-forming bacilli. Because of the recent recognition of NEC as a common problem in neonates. a number of possible causes for the disease have been postulated but so far no single factor has been identified. Health care teams working with neonates are cautioned to provide treatment and care in light of current research knowledge: "Those wor\..ing in intensive care units must remain vigilant in case N EC represents a new iatrogenic disorder caused by some change in clinical practice." 5 Current theories One of the most popular theories about NEC concerns infant feeding. 6 The idea is that when high risk infants are fed with a high volume of milk formula and hyperosmolarelemental feeds, an increase in gastrointestinal secretions occurs making the formula isotonic. This causes the mucosaoftheGllumen to become i'ichemic. Many neonatal care units are experimenting with breast milk feeds (preferably fresh rather than frozen) but the only research to support the "breast-milk-only" theory has been conducted on rats. The studies show that fresh rat brea'it milk containing leukocytes protected newborn rats from experimental bacterial necrotizing enterocolitis. Frozen or thawed rat milk lacked these protective leukocytes and proved to be effective only when leukocytes were added. Researchers acknowledge that human studies must be done before these results can be applied to man. 7 Another hypothesis suggests that the polyvinyl-chloride in plastic feeding tubes may produce a toxic disorder affecting the vascular tone of the bowel. H While both these theories may have validity. N EC has also been found in infants who have only been fed intravenously. and who have never been fed by mouth. Other findings associated with NEC include the following: . NEC has been noticed with greater frequency in infants with an umbilical artery catheter line which may cause an obstruction of blood flow to the mesentery.9 But whether the catheter per 42 D8c:.mber 1979 The Cenedl.n Nur.. I \. se is the inciting factor or is incidental in distressed. hypoxic infants is not known;1O . There ha been an a sociation made between N EC and the hypervi cosity that results from polycythemia. Researchers have noted that a o;]udging ofred blood cell occurs with decreao;ed intestinal proficiency;\( . Research also show a relationship between infanh with N EC and coagulation abnormalities, especially in those infant with hypoxia. 12 Dia nosis Nurses. because of their :!4-hour contact with the high risk infant, are in a good position to detect the early igns and symptoms of necrotizing enterocoliti in the infant. Early diagnosis and treatment may shorten the course of the disea e and improve the survival rate. t . 1 NEC usually occurs four to ten days after the birth of the baby but can appear as early as four hours or as late as thirty days after birth. Some cases have even occurred after one month of age. The first insidious sign" ofNEC may include: . apnea . temperature instability .. . vomiting . lethargy . increase in abdominal girth. Thi la t sign whether sudden or gradual is an indication of abdominal dio;tention caused by the production of air in the bowel. With all infant fed by na"o-gastric tube, gastric aspiration should be done every four hour . A return of half or more of the previous feed indicateo; dige tion difficulties and the presence of bile in the aspirant is highly indicative of NEe. Ifbile is present. feeding should be stopped amI the infant observed for other "ign or symptoms ofN FC. Feedings should be restarted only when the dangerofNEC has been ruled out. Stools should be tested for reducing sugars (produced when the absorptive capacity ofIhe bowel is diminished) with Clinitest ) tablets and for occult blood (pre ent as a re ult of insult to the intestine or colon) with Hemate t ) tablets. A study done at McMaster University in Hamilton. Ontario reports that gastrointestinal bleeding occurred as an earl y indication of necrotizing enterocolitis in 86 percent of the infants in the study. H Blood serum values should be monitored for thrombocytopenia, other clotting abnonnalities and progressive metabolic acido is. For infanh with suspected NEC, a "septic workup" should be done. At Children's Ho pital of Eastern Ontario in Ottawa. this consists of swabs of the ear. throat. umbilicus and groin. blood cultures and a lumbar puncture. A conclusive diagnosis can be made by x-ray which will show generalized bowel distention with pneumatosis - the hallmark of NEe. The disease may involve short segments of the small intestine, and if allowed to progress. will spread further in theGI tract, eventually involving the stomach and the large intestine. The aim and purpose of the care of I. these infants is the early detection and treatment ofNEC in order to prevent a more serious situation and the trdgic consequences of penoration and peritonitis. Treatment and nursing care TJeatment of necrotizing enterocolitis generally consists of supportive medical care. To date. the role of o;urgery in the treatment ofNEC is controversial and has not been agreed upon. I;; When the disease i sllspected or diagnosed. complete rest of the intestine and bowel is imperative. Oral feedings are stopped and a na o-ga tric tube is inserted and attached to straight drainage to keep the stomach empty of ga.,tric contents. Because these babies are in electrolyte imbdlance. they are started on intravenous hyperalimentation consisting of an amino acid solution and a fat emulsion. The alimentation which aids in restoring and maintaining electrolyte balance is individuall) ordered for each infant on a daily basis. Serum electrolytes must be checked frequently and alimentation constituents altered as necessary. In addition. vitamin BI2'" and folic acid are administered 1M since these nutrients are unstable in hypemlimentation solution. Accurate intake and output records must be kept and losses or gains rectified. An accurate record of urine and stoollos" and amount of blood withdrawn is extremely important. The loss of even .4 cc of blood from a toOO gram infant is. in relation to size. a large one. Because of the frequency of blood tests. a complete blood count and differential count of these infants 'ihould be monitored. NEC babies show a tendency for anemia and any unnecessary blood loss will simply aggravate an already hazardous condition. A hemoglobin of I:! grdms or less may be an indication for a transfusion of packed cells. Other blood leveb that require monitoring are blood gas measurements, calcium and glucose. The Cenedlen Nure. D8c:ember 111711 43 SOME NORMAL BLOOD TEST VALUES Route "Blood values in babies with NEC can be either increased or decreased depending on electrolyte Imbalance" Result 35 mg/dl 3.1-25.5 mg/dl 133-146 mEq/1 4.6-6.7 mEq/1 100-117 mEq/1 6-11 mg/dl 0-1 day 6 mg/dl 1-2 day 8 mg/dl 3-5 day 12 mg/dl Values taken from: Avery, Gordon B. Neonatology. Toronto, Lippincott. 1975. Pierog. Sophie H. Medical Care of the Sick Newborn, by. . and Angelo Ferrara. 2d ed., SI. Louis, Mosby, 1976. Test Glucose BUN Sodium Potassium Chloride Calcium Total Bilirubin Venous or arterial Venous or arterial Venous or arterial Venous or arterial Venous or arterial Venous or arterial Capillary Blood Gases pH p.CO. p.O. Base Excess NAHCO. Arterial Arterial Arterial Arterial Arterial 7.35-7.45 35-45 mm/Hg 50-70 mm/Hg - 4 mEq/1 19-24 mEq/1 (See hCH). !\ntihiotic uch a Gentamycin 1!\1 and Ampicillin IV may he admini.,tered. Experiments have al o heen done with or,.1 kanamycin .16 Since necrotizing enterocoliti., will aggravate any tendency towards apneic or bmdycardiac spells. these infants should be put on apnea and/or ECG monitors if they are availahle. If monitors are unavailahle. these infant., must be watched extremely carefully for respiratory or cardiac difficulties. Continue to check for occult blood and reducing sugars and monitor blood glucose levels during each shift by the use ofDextro!'otix. Abdominal girth readings should he taken frequently for companson purposes. If the haby i., receiving lipids (fatty emulsion.,) in the alimentation. a lipidstick* te t should he done daily and the pla...ma checked for cloudine.,s. Cloudines!'o indicating an excess of fatty sub!'otance in the blood is a sign that lipid... should not be given until the cloudine...!'o disappears. Vital 'jigns should be taken frequently according to the !'oeverity of the disea...e: temperature readings are taken by axilla to prevent any further insult to the colon. After the crisis When oral feedings are ordered resumed. (when pneumotosis is no longer visible on x-ray) NEC infants should be fed fresh breast milk if available. If unavailable. several other feeds can be used !'ouch a., full or half strength Isomil"'. a soy protein i olate formula. or Pregestamil"'. a therapeutic formula for infants with malabsorption di orders. 1\ *L ipidsticks are obtained by taking approximately .03 cc of blood in a microcapillary tube. Block Ihe end of the tube containing the blood and re...t the tube upright. After one half hour, the plasma will have sepamted from the blood con...tituent.... Take a reading of the pla...ma. There are no hard and fast rules for feeding- each child is fed according to his or her need and condition. At our ho'>pital. mothers are encouraged to pump their brea!'ots to provide fresh breast milk for their baby. A room with an electric brea.,t pump is provided forthe use of nursing mothers. Breast milk is then refrigerated for up to 3 days and if not used. may then be frozen. In addition to the obviou!'o nutritional advantages for the infant. the mother also benefits from providing breast milk for her bdby. Because the child is critically ill. the mother may feel helpless because she ha!'o no control over the situation. Mothers have stated that by supplying hreaM milk, they feel they are doing something for their baby and an important bond between the mother and infant is formed. Nurses working in neonatal units are extremely busy and concerned ahout the critically ill condition of their patients. Nurses can tend to forget or not make time for one of the most important con.,idemtions - the parents. If admi!'osion takes place afterthe infant's birth it is more likely to be the father alone who ha,> initial contact with the NICU nursing staff. Parents not only ha ve to cope with the reality of their baby's illne!'o!'o hut mU!'ot also see their baby isolated in what one ofthe parent!'. called "a hotbox". I n more severe illness. the infant may be on a respirator neces!'oitating tubes in the infant's mouth leading from a large and noisy machine: add to that apnea and ECG monitors with their bell... and whistles and I. V. pumps that click and buzz. A nurse needs only to recall the first time she was oriented to an intensive care unit to begin to under.,tand the terror of these parents. Recently a most poignant letter describing the feelings of parents was sent to the neonatal unit at our hospital by the mother of one of the 'babies'. It describes their feelings dUlIng their daughter's stay: Personal(,'1 found it I'e/").' hard to go into the hospital el'ery da,.... to see Sheena, until I was ahle to chanRe and.féed her: then it meant something.lnfact we hoth hated it, hut felt that we I\'ould he looÁed dOl\'n on ({we did not go. You are tryinR hard to Áeep yourself emotionally together and gO;"1( in with all the equipment IlOoÁed onto her, just upset liS all the more. With all the bustle in the unit. many parent., feel that they are in the way. Nurses must remember that no matter how inconvenient the parent's presence may be. it is their right to be there, No matter how .,ick the infant, the parents should be encouraged to stroke. touch and talk to their child. Many parents 01 ust be shown how to enter the isolette: their terror of this situation and all that surrounds it. and their fear of hurting their tiny, ill infant is too great for them to manage on their own. Compassion. empathy and patience are emotions a nurse must po...sess if she or he is to work effectively in thi... type of unit. Because the cause ofNEC has not yet been firmly established dnd treatment is still the product of research. it i... difficult to provide direct answers to parent's questions. Relapses are frequent and a parent may leave the infant one day progressing well and feeding beautifully, only to return the next day to find the infant back on straight drainage and intravenous feedings. Growth and maturation is a long and tedious process in the healthy premature baby; in a preemie with NEC', it is longer and is a most tense time in the lives of parents. Some infants have remained in hospital for as long as six months. Parental support must never let up at any time. This support c . " 8 . " ji- ;> 'õ " -..... .. t: " 8 5 ...- '- '" .c Co. ... volunteer parents of former infant patients who are willing and interested to offer support when needed. Treatment is not always successful and in some cases, these babies die. In a number of neonatal units. therapy groups for grieving parents have been formed- coordinated by a nurse or a social service liaison worker from the unit. Emotions, feelings of guilt and other concerns can be sensitively and carefully dealt with during these sessions. Follo\\ up care Before the baby is discharged from the hospital. it is very important for the parents to establish contact with their own pediatrician or physician so that he or she is aware of the baby's condition. Liaison 'ihould also be set up from the ho!>pitalto the pediatrician by a letter containing details of the infant's illne!>!> and cour!>e of treatment. In addition, hahies who have had N EC accompanied by complicating factors !>uch a'i: . a history of respimtory distress necessitating a\si'ited ventilation . a history of cerebml anoxia or convulsions . a hirth weight of le...s than 1500 grams are seen in a follow up clinic at the Children's Hospital in Ottawa. dt three and six months and at yearly interval<. until at least two years of age. Followup care is most important with the!>e infants to detect any resultant prohlems: as well. careful notation of followup results is e'isential to aid in the further research of NEe. When the haby come., to the clinic. the neonatalogist takes a complete history and performs a physical and -neurological examination including an asse\sment of the correct gestational age. A Bayley developmental aSSeS'iment of the child is conducted by memhers of the psychology department and results are 'ihared at an . interdisciplinary conference following the clinic. Reports are sent to tl'le child's physician along with any recommendations for further treatment. Summar) Parents continue to be apprehensive about their baby's wellness for a long time after taking the infant home from the hospital. Sheena's mother summarizes the feelings of many parents whose babies have necrotizing enterocolitis: I am also aware that quite a lot of babies do not ma/..e it. I t is something a parent Ih'es with til/ the day thev actually and phvsical/y are ,fitting in the car taÁing the baby home. E,'en then YO/lli,'e with the crib deaths etc. Because you go thro/lgh the neonate part you are I/ot at ease till at least ;earch team. This must be kept in mind at all time!> when nursing these infants. OW Ackno\\ ledgment: The au thor wishes to tllll1lÁ Sue Stephenson. B.N., clinical inst/"llctorand BrocÁ MarM/lrl"l/y, M.D., neol/atoloRist. C hi/dren' s Hospital of Eastern Ontario, Ottawa. for their as.l"istal/ce and encoul"ll[.?ement in the writing of this article. References I Book, L.S. Comparison offa'it- and slow-feeding rate schedules to the development of necrotizing enterocolitis. by... et aLJ.Pediatr. 89;3:46 -466. Sep. 1976. 2 EditoriaLJ.Pediatr.90:458-46I, Mar. 1977. 3 Behrman, Richard. N eonawl-perinatal medicine: disease of the fews and infant. 2d ed. S1. Louis. Mosby. 1977. p.6to-614. 4 Report. Lancet. 1:459-460. Feb.26, 1977. 5 Ibid. 6 Book. op.cit. p.463. 7 Report. PedResearch. 2:906-909. Jan.-Dec. 1977. 8 Rogers. A.F. Intestinal perforation. exchange transfusion. and P.V.c.. by... and R.M. Dunn. Lancet 2: 1246. Dec.6, 1969. 9 Philip, AlistairG. Neonatologv-a practical guide. Flushing, N.Y.. Medical Examination Publishing Co. Inc.. 1977. p.185. to Avery.Gordon B.Neonatology: pathophysiology and management of the newborn. Toronto. Lippincott, 1975. p.M5. II Tudehope, 0.1. The haematology of neonatal necrotizing enterocolitis, by ... andV.Y. Yu.Aust.Paediatr.J. 13:3:193-199. Sep. 1977. 12 Ibid. 13 Ibid. 14 Ibid. 15 Philip, op.cit. p.185. 16 Egan, E.A. A prospective controlled trial of oral Kanamycin in the prevention of neonatal necrotizing enterocolitis. by... et aLJ.Pediatr. 89:3:467-470, Sep. 1976. Be\'erley Hastings McBride graduated from the Montreal General Hospiwl School ofNursinR and ubtained a diploma in teaching and administration from the Detroit Women's Hospital. She has had a ,'uriety of clinical e"(perience, doing Reneml duty nursing and teaching obstetric nursing. She wor/..edfor mal/Y vears in Montreal as afamily planning coursel/or. and at the time ( fwriting this article ,\.he It'as a staffmember i/1 the neonatal i/1tel/si,'e care unit at the Childrel/'s Hospital of Eastern Ol/tario. \1cBride is currently afill/-time stlldent swdyinR C cl1Iadian History at Carleton V ni,'ersity in Ottawa. - - \ ., The Cenedlen Nur.. D8c:....ber 1979 45 , tI " tI . I - and phototherapy Frances Tufts Faye Johnson Babies at the indow: we've known for more than 20 years that sunlight helps dissipate jaundice in newborns, but how does it work? What is jaundice? The authors discuss phototherap} in light of cunent medical research and outline specific nursin measures for care of the jaundiced newborn. u \ i ",-'- .... ..... It. f .u . "" .,;' I Exchange transfu\ion\ have. for the la'\t 30 years. heen the routine treatment for <;evere hyperbiliruhinemia or neonatal jdundice. In the early 1951rs. an English nur<;ing sister made the <;erendipitous ohservation that bahie<; on the sunnv side of the nursery had less of a prohlem \\ ith jaundice. The phenomenon wa<; imestigated by Dr. Cremer, whose conclusions were puhli'ihed in 1958. and further by Dr. lucev in 1968 who demonstmted the effectiveness of phototherapy in the hyperbilirubinemia of premature infants. I Since that time, the increasingly widespread use of phototherapy had reduced markedly the need for exchange tran<;fu.,ions. . ...-. ... -... - - -. "! Bilirubin metabolism Prior to a discu<;sion of phototherap}'. It is helpful to review hilirubin metaholi<;m and normal neonatal jaundice and it'> potential consequences. Biliruhin i., the end product ofthe cataholism of heme (hematin), the major source of which is circulating hemoglohin. The normal life expectancy of an infant's erythrocyte is 90 days while that of an adult's red blood cell is 120 days. This !>horter life\pan raises the production of bilirubin in the infant to leveb two to three times greater than in an adult on a per kilogram body weight basis. !.In addition, the ne\\ horn has a limited ahility to clear the bilirubin from his system due to an immature liver. The bilirubin thus produced is called unconjugated or indirect. Before pd'ising through the liver it is carried in the plasma bound to a large albumin molecule. and is highly lipid soluble. The pare[lcl1ymal cells of the liver have the apacity to efficiently select unconjugated bilirubin and render It water soluble or conjugated, for excretion in the bile. The unconjugated bilirubin which is bound to albumin cannot leave the vascular space: any unconjugated bilirubin which is unbound is free to leave the bloodstream and permeate tissues. Because it is fat soluble. the unconjugated bilirubin has a high affinity forfauy tissue. particularly brain. 3 Jaundice. or the yellowish discoloration of the skin becomes apparent at serum bilirubin levels of ahout 5 mg/lOO'mls. 46 December 1979 The Cenedlen Nur.e Among the factors which predispose to the development of jaundice are prematurity. dehydration (often as a result of poor feeding or po.,t maturity) and sepsis. The amount of bilirubin which can be carried by the albumin, another critical factor in development of jaundice. is dependent on three factors: I. the amount of albumin 2. the affinity of the albumin for bilirubin or binding capacity of albumin 3. the presence of other substances which compete with the bilirubin for sites on albumm. I Nur'ies should note that. among orientals. a certain percentage of babies lack the enzyme G6PD (gl ucose-6-phos phate dehydrogenase) essential for metabolism of bilirubin by the liver and are thus more prone to development of neonatal jaundice. ' Consequences of neonatal jaundice The severity of consequences for the normal newborn depend on the maturity and weight of the baby, the level of the serum bilirubin. the time of onset of jaundice and its duration. Jaundice appearing during the first 24 hours is usually considered to be a sign of an underlying pathological process. The "physiologic" jaundice most often seen in the normal newborn nursery usually appears between two and three days; jaundice which develops after five days should alert the nurse to the possibility of sepsis. Of grave concern is the development of kernicterus. So long as it remains bound to albumin. the unconjugated bilirubin is confined to the vascular bed but unbound unconjugated bilirubin can cross into the basal ganglia of the brain. where it is thought to interfere with the cells' oxygen uptake and utilization. The resultant kernicterus is characterized first by CNS depression. lethargy and diminished Moro and sucking reflexes and is followed by a period of excitation and seizures. I nfants who survive the neonatal period usually have serious CN .S. sequellae in the form of severely impaired intellectual and motor function. 6 Even low levels of serum bilirubin. well within the "physiologic" range (< 15 mg/lOO mls) may cause kernicterus in particularly vulnerable infants. . Babies with Rh incompatibility are more at risk; the increased hematin, produced as a result of excessive hemolysis. competes with the bilirubin for sites on albumin. . The preterm infant is especially vulnerable due to the immaturity of liver enzymes. and a decreased albumin-bmding capacity - the result of acidosis. The hypoglycemia, common in pre term infants. results in an increase in circulating free fatty acids which compete for sites on albumin. These problems are often compounded by hypoalbuminemia. - . The cold-stressed baby is more at risk as a result of circulating non-esterified fatty acids, byproducts of chemical thermogenesis, which compete for binding sites. . Certain drugs given to either baby or mother during later pregnancy, compete with bilirubin for albumin. Such medications include ASA. sulfonamides. oxacillin and parenteral drugs containing .,odium benzoate." . Infants with complications due to asphyxia. sepsis and meningitis are also at risk due to their generalized weakened condition. Phototherap) The routine use of phototherapy in the management of rising or high bilirubin levels is increasing. Advantages include the following considerations: I. It is convenient and easy to use. requiring no special skills in administration. 2. It is relatively inexpensive as it uses economical fluorescent lights. 3. Its administration makes no great demand on the time of the nurses and physicians involved. 4. It is a safe, non-invasive and effective means oflowering serum bilirubin. One ,>tudy concluded that this form of treatment is equally effective in infants of all races. regardless of skin pigmentation. "' Likewise. gestational age and birth weight do not appear to have any influence on infam response to therapy; the degree of illness or health of an infant has no effect on the outcome of treatment. The actual process whereby phototherapy lowers serum bilirubin levels is not known for certain; it is thought that a photodegradation process at the skin surface renders the bilirubin water soluble and thus able to be excreted in the urine and stool. II Three types of light are most commonly used m phototherapy: the daylight fluore.,cent tubes. the standard blue light and special "superblue"lights. The daylight fluore'icent allows for greatest observation of the infant. but the rate of absorption of effective rays is the lowest of the three. The .,tandard blue lights are more effective; however. they make accurate observation of baby's color more difticult and could re'iult in undetected cyanosis. The superblue lights. although mo..t effective in reducing bilirubin levels. have the rather distressing di'iadvantage of causing headaches. nausea and even vomiting in nursing staff caring for the infant.. under the'ie lights. With adequate .,hielding to protect nur.,ing staff. these lights can be used effectively and an additional incande'icentlight 'iource improves visibility of the baby's color. I! A difference of opinion exists regarding the most effective use of phototherapy, either through continuous exposure or intermittent use. Investigators at the University of Pad ova in Italy have concluded recently that continuous exposure to the lights is most effective. I.! Nursing implications No long term adverse effects of phototherapy have been documented. The nursing implications of caring for the infant undergoing phototherapy are directed mainly toward the immediate undesirable effects of exposure to the lights. Support and teaching of parents of the jaundiced infant too is of primary importance. In most instances the infant is separated from the mother except for feedings which tends to disrupt the important acquaintance process of the first fey, days of life. Nursing action.. to facilitate maximum parental involvement with the infant during this time is important; ,>ome hospitals allow phototherapy to be given in the mother's room. In any case, teaching parents ahout the transient untoward effects of phototherapy i essential. Some doctors request that mother interrupt breastfeeding to hasten the drop in serum bilirubin levels. This may be upsetting for the mother: the nurse must support her. allowing free expression of her feelings of frustration. The nurse must take the initiative too in teaching the mother how 10 maintain lactation either through manual expression of breast milk or through use of a breast pump. The Cenedlen Nur.. One of the side effects of phototherapy is an increased metabolic rate which necessitates an increa.,ed caloric intake. The nurse should prepare for more frequent feedings and keep accurate records of amounts fed to infants. Babies may fail to gain weight during the course of treatment and mothers need to be told that following treatment the amount baby eats may decrease for a short time, but that he will gain weight. Insensible fluid loss increases due to dilatation of capillaries at the skin surface and means the baby's fluid requirements are increased. Water can be given bet\\-een feedings to prevent dehydration: the nurse must be aware of the signs of dehydration and intervene appropriately should they occur. Loose, green watery stools. the result of the rapid breakdown of bilirubin by phototherapy. are a common occurrence. and another source of water loss. Mothers and fathers need an explanation of this and reassurance that stools will return to normal following cessation of therapy. Temperature problems range from hyperthermia m the infant in a heated isolette'. to hypothermia in the baby exposed in an open cot. The baby's unit should-not be placed against a cold outside wall. Temperatures should be checked q2h during the course of phototherapy: axillary temperatures are best as they not only reflect a change in- skin temperature beforé a change in body core temperature, but they are also less traumatic to a rectum already irritated by frequent loose stools. When a thermistor probe is used. it should be covered by opaque tape which ensures that the probe reflects accurately the baby's skin temperature and not heat produced by the lights. Eye shields are an e!\sential aspect of caring for the baby undergoing phototherapy. Data on the possible effect of high intensity light on the eyes of human infants are lacking but evidence from animal studies indicates a potential for retinal damage. For this, reason. it is imperative that the eyes of an infant undergoing phototherapy be protected by opaque eye shields (see photo). Care must be taken to ensure that the infant's eyes are closed under the patches to avoid any corneal abrasions and the eyes must be inspected regularly (q4h) for signs of conjunctivitis. The nurse must also see that the eyeshield does not slip down over the nose. blocking air passages. Since the photodegradation reactIon takes place in the skin. it is important that the max imum amount of skin surface is exposed to the light. Baby girls .,hould remain undiapered: baby boys may be covered by a bikini diaper which allows maximal skin exposure while ensuring protection of the environment and any close neighbors during voiding! No evidence yet exists to support the belief that sterility results in boys ex posed to phototherapy. Once phototherapy has begun. the skin becomes less jaundiced and can no longer be u ed as a guide for estimating bilirubin levels. The nurse must be aware of lab results of serum bilirubin levels and report these to the physician. The "bronze baby syndrome" wherein the skin turns a grey-brown color is an uncommon but very distressing adverse effect. Parents need reassurance that this is harmless and will disappear within two or three months after cessation of treatment. A plexiglass shield will protect the infant from ultraviolet rays which would otherwise produce an erythematous reaction in the skin and incidentally prevents injury from accidental explosion of any of the bulbs. As with all electrical equipment. the nurse must take care to ensure proper grounding. and that worn or frayed cords are repaired or replaced. U .. Treatment of choice The use of phototherapy in the munagememof hyperbilirubinemia has reduëQdthe need fo exchange . ,transftlsions so that it remains the tréåtment of choice often for only severe hyperbilirubinemia, especially when duë to pathologic processes. Phototherapy affords the nursery nurse an opportunity to apply her knowledge and skills of observation to provide a high standard of nursing care to both the jaundiced infant and his family. A knowledge of bilirubin metaþolism,jaundice and the role played by phototherapy is essential: the implementation of these nursing guidelines will. it is hoped. be rewarded in practice. 4. References I Seligman. Jerry. Recent and changing concepts of hyperbilirubinemia and it., management in the newborn. Pediatr. Clin. North Am. 24:3:509-527. Aug. 1977. p.518. D8c:ember 1979 47 2 Harris. Thomas R. Major risks to the neonate. (In Clark, Ann L. Childbearing: a nursing perspective, by Ann L. Clark and Dyanne Affonso. Philadelphia. F.A. Davis, 1976.) p.693. 3 Korones, Sheldon. High ris" newborn infants: the basis for intensh'e nursing care. 2d ed. Toronto, Mosby, 1976, p.193. 4 Harris, op.cit. p. 692. 5 Schaffer. Alexander J. Diseases of the newborn, by Alexander J. Schaffer and Mary E. Avery. 3d ed. Philadelphia, Saunders. 1971. pA98. 6 Korones, op.cit. p.198. 7 Harris. op.cit. p.692. 8 Ibid. 9 Lucey, J.F. The unsolved problem of kernicterus in the susceptible low birth weight infant. Pediatrics 49:5:646-647. May 1972. p.646. 10 Tan. 1\.. L. Phototherapy in the management of neonatal jaundice. Nurs.J.Singapore. 16:1:22-23, May 1976. II Avery, Gordon B. .Veonatalogy: pathophysiology and management of the newborn. Philadelphia, Lippincott. 1975. p.355. 12 Seligman. op.cit. p.524. 13 Rubaltelli, F.F. Effectiveness of various phototherapy regimes on bilirubin decrement, by F.F. Rubaltelli et al. Pediatrics 61 :6:838-841, Jun. 1978. 14 Gartner, Lawrence. Jaundice and liver disease, by Lawrence Gartner and Lee Kwang-Sun. (In Behrman, Richard E. Neonatal-perinatal medicine- disease of the fetus and infant. 2d ed. Toronto. Mosby, 1977.) pA12. F.am:es Tufts, RN, BN. is a graduate of the Ñ ;ghtingale School of Nursing in .;70ronto, and obtained her Bachelor of Nursing from McGill Vnh'ersity, Montreal. Until recently she was teaching obstetrical nursing in stl{ff education at the Ottawa Cil'ic Hospital, and now resides in Don Mills, Ontario where she awaits the birth of herfirst child. Faye Johnson, RN. graduaredfrom the Victoria General Hospital School of Nursing in H al fax, N.S., and has a wide "ar e,-\' of clinical experience in hoth pediatric and obstetric nursing. S. preparing lectures herself and participating in conferences. attending appropriate rounds regularly and by taking advantage of spare time to read current literature. The role of the nurse practitioner affords a tremendous challenge to the nurse willing to actively participate in the care of the child with cancer. Her skills and knowledge and personal vitality ensure that comprehensive quality health care is delivered to these children and their families. Barbara J. Price, R.N.. is a graduate of the St. Michael's School of Nursing in Lethbridge. Alberta. She has worked in various clinical settings at the Foothills Hospital and completed a post graduate program in pediatric oncology. When this article was written she was a nurse practitioner with the Southern Alberta Pediatric Oncology program, and she has recently taken a position at the Foothills Hospital as an instructor. She hopes that other nurses might be encouraged through opportunities to perform in an extended role to de\'elop better health care standards for their communities. ..; ... \ .f The Cenedlen Nure. D8c:ember 111711 51 calendar Notice o{upcoming nuning e.'ents, to be included in Calendar, should be forwarded to CNJ at least two months prior to the desired publication date. 1980 Canadian Orthopedic !\urses Hotel, Toronto, Ontario. 3()and 31. 1980. Contact: AS'iociation 3rd Annual Contact: Vir[.?inia Garc/hOlue, Marilyn Me\'er. Mineral Ontario Crippled Children's Conference to be held C om'ener, Puhlicity Sf'rin,;.. Hospital. Box 1050, Center 7th Annual Conference February 19-22. 1980 at the Committee, 5lW The East Bm!ff. Alherta TOL OCO. - l\tulti-I)isciplinar Sheraton Center, Toronto. Mall. Apt. 404, IslinglOn, Approach to Management: Ontalio. Contact: COI!{erence Ontario. M9B 4A 7. The Second World Conference O\eniew of Pediatric Puhlicit\' Committee. American College of of Operating Room Nurses will Rehabilitation. To be held Canac/ian Orthopedic Nurses Nurse-Midwives, 25th Annual be held in Lausanne, January 21-25. 19HO Coup;e A.Hociation.43 Wellesle\' St. Meeting will he held May Switzerland on August 12-15, fee: $100. Contact: Ann E.. Torol/fo, Ol/fario. 10-15. 19HO in Minneapolis. 1980. Contact: AORN Camphell. Coorc/inator. The The Journal of Nursing Minnesota. Contact: J1eeting Serl'ice Ec/ucation Department, Administration's Third American College ( ,. Department, to170E. Ontario Cripplec/ Children's National Conference will be Nune-Mic/lI'il'e.\'.801-1012 Missi.Hippi AI'e., Dem'er. Cellter. 350 RUl1ue\' Roac/. C %rado 80231 . held March 30-ApnI2. in New 14th St. N. W .. Washin[.?toll. TOrollto, Ontario. M4G IR8. York with a theme of Nursing DoC. 20005. Administration in the 19HO' Third World Conference on The Gerontological Nursing -Meeting the Challenge\. The annual National Teaching Medical Informatics, To be AS'iociation of Ontario 1980 Contact:Jo-Anne Latino. The Institute of the American held in Tokyo, Japan on Sept. Conference will he held Jou,."al ( "NursiIlR As.'iociation of Critical Care 29-0ct. 4, 1980. The February 12, at the Royal Ac/mini.\fration.lnc.. 12 Nurses will be held May 20-23, conference is concerned with '\ ork Hotel. C ontdct: La/...esic/e Par/..., Wa/...e.fìelc/. in Atlanta, Georgia. Contact: the application of computer Christine Souter, MA 018RO. AACN, P.o. BorC-19528, technology to all fields of GerontoloRical NursillR In'ille CA 927/3 (7/4) medicine. A session on A ssociatioll, c/o 65 The Operating Room !'Jurses of 752-8191. Informatics in Nursing is Haw/...sheac/ Crescent. Greater Toronto are Banff \1ineral Springs Hospital planned. Contact: Or[.?anbllR Scarborou[.?h.Ol/fario, presenting the sixth National Reunion to celebrate their 50th Committee, Medillfo 80 MIW 2Z4(416)46/-825I, Conference to be held Aplil28 anniversary, will be held May To/...yo. P.o. Bor40, HOIIRO. Local 226. - May I, 19HO, at the Skyline To/... \'0, Japan. CA 1980 DEPARTURES EGYPT/KENYA ENCOUNTER - 16 Days Monthly departures throughout 1980 from U.S. $2250.00 all inclusive from Toronto SENEGAL - A WEST AFRICAN WilDLIFE SAFARI - 15 Days January 12/80, February 9/80, March 8/80 from U.S. $1830.00 all inclusive from Toronto ONLY 71/2 HOURS FROM TORONTO AND 50% OF THE AIRFARE TO EAST AFRICA KENYA lUXURY SAFARI - 16 Days Monthly departures throughout 1980 from U.S. $2200.00 all inclusive from Toronto KENYA/SEYCHEllESfTANZANIA - NATURAL HISTORY, WilDLIFE AND CONSERVATION SAFARI - 22 Days January 14/80, February 18/80 plus monthly departures throughout 1980 from U.S. $2990.00 all inclusive from r-oronto 7th ANNUAL SUMMER EDUCATIONAL SAFARI - 25 Days Egypt & Kenya - July 28 to Aug. 21/80 from U.S. $3150.00 all inclusive from Toronto SPECIAL MEETINGS AND GUEST LECTURERS INCLUDED. OPEN TO PERSONS FROM ALL WALKS OF LIFE Brochures on these and other African Safaris available from: . . EAST AFRICAN TRAVEL CONSULTANTS INC. "'t.: 1'.\ 33 Bloor Street East, Suite 206 .. Toronto, Ontario M4W 3H1 (416) 967-0067 r pj;;to';"a;d'b h;;;tc;:- - - --, I NAME I I ADDRESS I I I I TELEPHONE I I SERVING CANADIANS YEAR ROUND I L... _ _ _ E R T.:... _ _ _.J F.A. DAVIS COMPANY INTER-OFFICE MEMO TO Canadian Nurse Educators Re: Saperstein & Frazier: INTRODUCTION TO NURSING PRACTICE. FR ITID.UT (r\WU)iIng WxI IiU1I u.p-d.arað rb . By Arlene B. Saperstein, MN, RN, Assistant Professor, Division of Nursing Studies, Curry College, Milton, Massachusetts; and Margaret A Frazier. MS, RN, Director, Learning Resources Laboratory, Boston University, Boston, Massachusetts; with 43 other contributors. (A new. fundamental nursing text that up-dates the basIcs). 1. Does this book cover concepts adequately for a Baccalaureate program? Yes. Appropriate concepts are selected and thoroughly discussed. Concepts relating to the client, health and illness, and the health care system are covered extensively. Concepts are applied to the practice of nursing and many examples, covering a variety of clinical settings, are interwoven throughout. Strengths of the book's conceptual approach: 1. Emphasizes a wellness approach to heal.th care and nursing rather than being disease-oriented. 2. Discusses the latest concepts, e.g., material on homeodynamics and stress, crisis, group process, client as consumer, legal aspects of nursing. 3 Provides detailed, in-depth coverage that is organized and presented in such a way as not to confuse the student 4. Follows through on concepts and integrates them throughout the text. 5. Explains psychosocial aspects as well as physical aspects and emphasizes their interaction. 6. Presents the client as an active participant in his health care. rather than a passive recipient of care. 7. Presents the nurse as a person with the necessary knowledge and skills to assess the client"s health care needs, coordinate health care efforts and resources, and plan and provide health care measures to meet the client"s needs, including providing client education and acting as client advocate. 8. Helps the student to better understand herself as a person and as a nurse, and to make optimum use of her potential. 2 Does this book adequately cover the skills and nursing procedures for a Baccalaureate program? Yes. A unit on the nursing procedure presents a step-by-step process of obtaining data, formulating a nursing diagnosis and care plan. implementing the plan of care, and evaluating nursing care. Not merely a check list of what to do, this unit explains how and why. The next unit discusses. in-depth, specific clinical skills and procedures. The student is introduced to: the procedure, when and why it is used, the necessary equipment. the preparation of the client. the skills utilized, and what and how to monitor during and after the procedure. Strengths of the book's approach to this material: 1. Consistently focuses on helping the client. not merely being able to perform procedures. 2. Chapters Include glossaries as a helpful reference for students. 3 Includes the latest procedures and equipment. 4. Excellent tables present step-by-step descriptions of the procedures, the scientific principles/rationale upon which they are based, and specific suggestions and nursing considerations. 3. Does the book attempt to cover physical assessment/physical examination? If so, how well is it done? Should this be included in a fundamentals text? Yes. Separate chapters on physical examination of the adult and assessment of the child allow more extensive discussions of theories, scientific principles, implicatIons, and special considerations, along with the step-by-step specifies of a physical examination. Nurses are performing more and more physical assessments and a fundamentals book including such material is most appropriate for a Baccalaureate program. 4. Does the book adequately cover human sexuality, legal aspects, communication skills and interviewing techniques, preventive health care, psychosocial aspects, and group process? Yes. Two of the strong features of the book are the thorough treatment ofthese topics in individual chapters and the application of the material throughout the book. JMK:cd -Al1Mi1i.on ÑWtbimo EwtrOTO'lb: Write to our textbook marketing department in Philadelphia. Pennsylvania. on your school s letterhead. to receive copies for adoption consideration. Be sure to include the title of the course you will be teaching, enrollment, and the name of the text you currently require for the course. :::J F. A. DAVIS COMPANY Ñ, 1915 ARCH STREET ':: PHILADELPHIA, PENNSYLVANIA 1 . DIstributed in Canada by McAJnsh II C. . lid We c 'm Branch IS:- 5 Yonge :"ue ,t 730 W st Broadwa Toronto Ontallo M4S 1 L6 Vancouver BC V 1r books Admittance restricted: The Child as a Citizen in Canada. Repon: published by the Canadian Council on Children and Youth. 1978. 172 pages. Approximate price: $8.95. This repon is about children, about the attitudes. policies and practices that affect the quality of life for children in Canada: the title itselfsignifie!> that current practices in providing for the need.. of children have grave limitations. The Task Force which authored the repon is a group of practicing professionals from the fields of health. education. child welfare, child protection and la\\. and they present their examination and opinions of a variety of issues. Generally. they repon on the status of children in Canada. looking at four area.. of concern: health care. protection, economic suppon and education. The purpose of the repon is to give a holistic approach to the needs of children and to spark a debate from which changes might evolve. as well as to provide a !>ource book from which communitie.. can identify their own areas of concern. The repon is a valuable source book, and one chapter in panicular. 'The Child's Need for Health Care" is of relevance to nurses. especially those working in community programs. Rniewed b\" Karin ,'on Schilling, RN, MScN. Associate Professor, School of NursinR. McMaster Uni\'ersity, Hamilton. Ontario. Canadian Standards Association C.S.A.'s Committee on Sterilization has recently published two handbooks on standards for sterilization which might be helpful for nurses working in C.S.R., O.R.. or small surgical clinics or offices. The books include guidelines for packaging materials, sterility testing. record-keeping, and various sterilization methods. The books are Effecthe Sterilization in Hospitals b) the Eth)lene Oxide Process ($8.50) and Effective Sterilization in Hospitals by the Steam Process ($7.50). For infOimatior. On ordering, contact the Standards administrator. Health Care Technology Program. C.S.A.. 178 Rexdale Blvd., Rexdale, Ontario. M9W IR3. Th. Cenedlen Nur.. Care of Children in Health Care Setting A Re ource and Self E\aluationGuide i..sued by the Canadian 1 n titute of Child Health. This text !>ets out to do e"actly a.. de!>cribed - act as a re ource and ..elf-evaluation guide. Becau e it doe not get sidetracked. 1 feel it ... one of the beM planned and most down-to-eanh tool.. available to pediatric unit.. in general ho!>pital.. \\ hich are trying to survive and. at the <;ame time. offer high qualitv care to children \\ ithin a setting that i e entially geared to adult... I nits appendices. the text offers guideline!> 10 a polic} manual. a \ ital tool in any depanment. Also D8c:ember 1979 53 included i.. a li..t of procedure.. that <;hould be ..et out. a teaching 1001 on CPR. and a ..erie.. of Profile Sheeh \\ hich are very well done. The text offer.. too d collection of lists: available boob. organization<; \\hich deal with children. and information about film rental from theCiCH. -\11 in all thi<; boo"- !>eem<; to be a busy head nurse's dream. and anyone !>taning out a<; a ne\\ head nurse or etting up a new unit hould cenainly appreciate it. Rt','iewed hy J eHica Ryan. head nurse. Chaleur General Hospital, and 11Ie11lher-at-larRefor nur inR practice. CNA Board ( rDirect(}rs. "When I was thirteen, I really wanted to be a nurse. Today I remembered why:' / ( . "Patient contact. That's what nursing meant to me all along. And that's what I get as an Upjohn HealthCare Services SM nurse. f'+ j .- , .. ,....., . t- ........ ''I'm the kind of person who needs that special one- on-one relationship with a pa- tient. I also need some control over my work schedule, for my family's sake. And I thrive on variety...it keeps me growing. "Working with Upjohn has turned out to be a different kind of nursing than I'd ever known. But it's the kind I always had in mind." HMb402.C@; 1979 HeolthCore Stotv,c", UPlohn.l.d r Interested? Find out what others say about Upjohn HealthCare Services. Oppor- tunities in home care, hospital staffing and private duty. Of- fices in 14 communities across Canada. Write for our booklet today. ----------------------- [A] K)HN E:D HEALTHCARE -.- SERVICES SOl , " - I. Please send me your free booklet "Nursing Opportunities at Upjohn HealthCare Services." "'ome Addreso:. Phone City Provmce Postal Code Mail to: Upjohn HealthCare Services Dept.A Suite 203 716 Gordon Baker Road Willowdale, Ontario M2H 3B4 ----------------------- 54 D8c:ember 1979 F o OSe. ) 'f Fe.. \. 'I Obb'f p 'f c,O ' POSEY MODESTY APRON \, Help your patients cover up with the Posey Modesty Apron. Attractive, colorful prints In nylon jersey material. Waist strap helps keep them sitting comfortably In chair. Each apron has a handy pocket. No. 4550 ) ") "- (j POSEY HEEL PROTECTORS All the features of higher priced heel pro- tectors plus a simplified design make this Posey the most popular heel protector for the budget minded Completely ventilated. Washable No. 6121 ,c- J POSEY COMFORT VEST Difficult to remove but comfortable to wear For use in bed or wheelchairs. Non- slip waist belt adjustmenl allows you to fit the waist belt to Ihe patient quickly and securely. Sm., med., Ig. No. 3614 Health Dimensions Ltd. 2222 S. Sheridan Way Mississauga, Ontario Canada LSJ 2M4 Tél.: 416/823-9290 "'4 Th. Cenedlen Nur.. BOOKS RECEIVED Listing of a publication does not preclude its subsequent review. Selections/or re 'iew will be made according to the interests of ollr readers and as space permits. A /I rel'iew sa re prepared on im'itation. Teaching and learning strategies for physically handicapped students, by Mary Lynne and Calhoun & Margaret F. Hawisher. Baltimore, University Park Press, c1979. Recreation programming for developmentally disabled persons, edited by Paul Wehman, Baltimore, University Park Press, cl979. Gastroenterology in clinical nursing, by Barbara A. Given & SandraJ. Simmons. 3rd ed. Toronto, Mosby, 1979. Basic drug calculations, by Meta Brown. Toronto, Mosby, 1979. Handbook for infectious disease management, by Come lis A, Kolff & Ramon C. Sanchez. Don Mills, Ont., Addison-Wesley, c1979. Compliance and excellence, edited by W.T. Singleton. Baltimore, University Park Press, c1979. Vocal resonance; its source and command, by M. Barbereux-Parry. North Quincy, Mass., The Christopher Publishing House, c1979. Instructional guide to the nature and managementofstress, byG. Maureen Chaisson. Tucson, Arizona, University of Arizona Health Sciences Center, c 1978. (54 color slides, I audio cassette, I instructional guide booklet, I duplication master copy of the post-test) Childbirth education: a nursing perspective, by Jeannette L Sasmor. Toronto, Wiley Medical Publication, c1979. Review of hemodialysis for nurses and dialysis personnel, by e.F. Gutch & Martha H. Stoner. 3rd ed. Toronto, Mosby, 1979. Mosby's manual of emergency care; practices and procedures, by Janet M. Barber & Susan A. Budassi. Toronto, Mosby, 1979. Bacteriology and immunity for nurses. by Ronald Hare & E. Mary Cooke. 5th ed. New York,Churchill Livingstone, 1979. Notes on gynaecological nursing, by William C. Fream. New York, Churchill Livingstone, 1979. Combatting cardiovascular diseases skiUfuUy. Hosham, Pa., Intermed Communications, c1978. The human heart; a guide to heart disease, by Brendan Phibbs. 4th ed. Toronto, Mosby, 1979. Free yourselffrom pain, by Dr. David E. Bresler & Richard Trubo. New York, Simon & Schuster, c1979. Infant and toddler learning episodes, by John H. Meier & PaulaJ. Malone. Baltimore, University Park Press, c1979. Learning episodes for older preschoolers, by John H. Meier & Paula J. Malone. Baltimore, University Park Press, c1979. The &Cute abdomen for the man on the spot, by J.e. Angell. 3rd ed. London, Pitman Medical, cl978. Psychological aspects of myocardial infarction and coronary care, edited by W. Doyle Gentry & Redford B. Williams. 2d ed. Toronto, Mosby, 1979. A vision fulfilled; the story of the child ren' s hospital of Winnipeg 1909-1973, by Harry Medovy. Winnipeg, Man.. Peguis Pub., 1979. Writing scientific papers in English; an ELSE-Ciba Foundation guide for authors, by Maeve O'Connor & F. Peter Woodford. London, Pitman Medical, cI977. Child abuse and family-centered care, by Rosella Cunningham. Toronto. University of Toronto. c1979. Geriatric care for nurses, by F. Barrowclough & e. Pinel. London. William Heinemann, c1979. Sanctit" of life or quality of life in the context of ethics, medicine and law. Ottawa. Supply and Services. 1979. The nursing process a humanistic approach, by Elaine Lynne La Monica. Don Mills. Ontario. c1979. Pediatric cancer therapy, edited by Carl Pochedly. Baltimore, University Park Press, c19",9. ECG arrhythmia interpretation: a programmed text for health care personnel, by Harold A. Braun & Gerald A. Diettert. Reston, Virginia. Reston Pub. c1979. New directions in patient compliance, edited by Stuart J. Cohen. Toronto. Lexington Books. c1979. One in ten; the single parent in Canada, edited by Benjamin Schlesinger. Toronto, University of Toronto, c 1979. The pocket medical encyclopedia and first aid guide, byDr. James Bevan. New York. Simon & Schuster. 1979. Classroom evaluation strategies, by Elizabeth C. King. Toronto, Mosby, 1979. Care of the high-risk neonate, by Marshall H. Klaus & Avroy A. Fanaroff. 2d ed. Toronto. Saunders, 1979. .THE LIBRARY'S ACCESSION LIST IS AVAILABLE ON REQUEST WITH A STAMPED, SELF -ADDRESSED ENVEWPE. Overseas Opportunities NlIRS[S CLISa has openings for public health nu"es and nursing instructors in Africa and Papuà ;'I;ew Guinea. Applicants must hà e Canadian qualifications and be pre- pared to "ork with limiled supplies and eljuipment. TraHI is an important COm- ponent of communih health care "ork. "hile nurse instructors are usuall\ a((àched to nursing colleges. Qualifications: Degree and or Public Health .r-; ursing experience is essential. Contract: 2 ears. ."'alar}': I 0" b\ Canadlàn standards but sufficient for an adequate lifcst Ie. Couples will be considered if there are positions for both partne". For more information. "rite. ClISO Health-DI Program 151 Slater Street O((a"a. On!. KIP 5H5 Th. Cenadlan Nur.. D8c:ember 111711 113 Classified Advertisements Alberta urw Coordinator For l.nhersity- d Genelíc Coun Ulng Programme. Duties include data collec- tion and pedigree drawing, followup Questionnaires or ,isits. inservice and undergraduate teaching. public education. and bibliographic searches. Suita- ble candidate with Master's degree will also be appointeð to Faculty of Nursing at the level of instructor or assistant professor. Send curriculum vitae and 3 references to: Director. Northern Alberta Programme for Prevention oflnherited Diseases. 4th Floor. Clinical Sciences Bldg.. Edmonton, Alberta, HG Xi3. British Columbia Experienced LeneraJ Duty Graduate urses required for small hospital located N .E. Vancouver Island. Maternity experience preferred. Personnel policies according to RNABC contract. Residence accom- modation available 530 monthly. Apply in writing to: Director of Nursing. St. George's Hospital, Box 223, Alert Bay. British Columbia. YON IAO. General Duty Nurse for modem 35-bed hospilaJ located in southern B.C's Boundary Area with excellent recreation facilities. Salary and personnel policies in accordance with RNABC Comfortable Nurse's home. Apply: Director of Nursing. Bound- ary Hospital, Grand Forks. British Columbia. VOH IHO. General Duty Registered urse, required for 108 bed accredited hospital. Previous experience desirable. Staff residence available. Salary as per R.N.A.B.C Contract with northern allowance. For further information please contact: Director of Nursing. Io.itimat General Hospital. 899 lahakas Boulevard N.. Kitimat. B.C V8C IE7. Experienced urses (B.C Registered) required for a newly expanded 463-bed acute. teaching. regional referral hospital located in Ihe Fraser Valley, 20 minutes by free"'ay from Vancouver. and within easy access of various recreational facilities. Excel. lent orientation and continuing education program- mes. Salary-1979 rates-51305.()0-51542.00 per month. Clinical areas include: Operating Room. Re- covery Room. Intensive Care. Coronary Care. Neonatal Intensive Care. Hemodialysis. Acute Medicine. Surgery. Pediatrics. Rehabilitation and Emergency. Apply to: Employment Manager. Royal Columbian Hospital. 330 E. Columbia St.. New Westminster. British Columbia. V3l 3W7. Experienced Nurses (eligible for B.C Registration! required for full-time positions in our modem 300-bed Extended Care Hospital located just thirty minutes from downtown Vancouver Salary and benefits according to RNABC contraCI. Applicants may telephone 525-0911 to arrange for an interview. or write giving full particulars to: Personnel Direc- tor. Queen's Park Hospilal. 315 McBride Blvd.. New Westminster. British Columbia. V3l5E8. Registered Nurses required for both acute and extended care in a 125-bed hospital in the South Okanagan. Experience in obstelrics and medical- surgical preferred. RNABC contract in effect. Apply stating Qualifications and experience to: Nursing Administrator. South Okanagan General Hospital. Box 7f1J. Oliver. British Columbia. VOH \TO. Phone: 498-3474. Hud 'l/une for male medical/surgical ward required for early 1980. Experience as a Head Nurse. N.U.A. and university preparation desirable. Also. general duty nurses for all services in 156-bed accredited a ute care hospi 1 are required. Apply in writing to: Director of Nursmg. West Coast General Hospital, 3841 8th Avenue. Pon Alberni, British Columbia. V9Y 4S I. British Columbia (;eneral Duty RN's or Greduete 'l/urses for 54-bed Extended Care Unit located six miles from Dawson Creek. Residence accommodation available. Salary and personnel policies according to RNABC Apply: Director of Nursing. PouCe Coupe Community Hospilal. Box 98. Pouce Coupe. British Columbia or call collect (6041786-5791. Regis1ered Nurses required immediately for a 340- bed accredited hospital in the Central Interior of B.C Registered Nurses interested in nursing posi- tions at the Prince George Regional Hospital are invited to make inquiries to: Director of Personnel Services, Prince George Regional Hospital. 2()()() - 15th Avenue. Prince George. British Columbia, V2M IS2. Registered Nurses required for penn,ment fulltime position at a 147-bed fully accredited regional acute Care hospital in B.C Salary at 1979 RNABC rate plus non hem living allowance. One year experience preferred. Apply: Director of Nursing. Prince Rupert Regional Hospital. \305 Summit Avenue, Prince Rupert. British Columbia. VSJ 2A6. Tele- phone (collecf) (604) 624-2171 local 227. ExPerienced maternity, I.C.l,fC.C.U.. end rat- Ing Room General Duty aunes required for IOJ-bed accredited hospital in NOrlhern B.C Must be eligible for B.C. registration. Apply in writing to the: Director of Nurses. Mills Memorial Hospital. 4720 Haugland Avenue. Terrace. British Columbia, VIIG 2W7. Head Nurse for 16-bed Psychiatric Unit in a Northern B.C hospital. Mu" be eligible for B.C. registration with a minimum of two years experience and proven administralive skills in a similar position. Apply in writing to the: Director of Nurses. Mills Memorial Hospilal, 4720 Haugland Avenue, Ter- race, British Columbia. VIIG 2W7. Registered Nurses - Full-time and casual relief positions are available at the University of British Columbia, Health Sciences Centre. Extended Care Unit. The 12 hour shift. the problem oriented record charting system. and emphasis on maintaining a normal and reality based clinical environment, and an mterprofessional approach to management are some of the features offered by the Extended Care Unit. Interested applicants may enquire by calling 228-6764 or 228-2648. Positions are open to both male and female applicanls. Manitoba Challengine Carftr Opportunit) fGr Rrgistered 'Junes in C'nutda' 'orth - A JlX) bed aCUle Care hO!.Pll..tJ In !\,ol1hern Manitoba ",hlch services Thompson and "eve.-al small communities in the "ufToundmg area has immediate \lacan- cie!. in Pediatric . Medicine/Surgery. Obstetrics and Cntìcal Care. This opponunit}l will appe4flto nurses who want 10 increase their e'\lstìng skdl\ or de\.clop new skills through our comprehensive ìnsen ice program. Many of our nUl'"Ses have become e perienced in flight nursing. Candidates must be eligible for pro\.incial registration as acti\.e practicing membel'"S. We offer an excellent range of benefits. in.::luding free dental plan. accident. health and group life Insurance. Sala'). range is SI.078 - SI.J O per month depeooen' on qualifications and experience plus a remoteness allowance. Apply in "",riting or phone: Mr R L Irvine. Director of Pel'"Sonnei. Thompson General Hospital. Thompson. 'tan- itoba. R f',OR8. Phone: t2(4) 677-2Jgl Northwest Territories The Stanton Yellowknife Hospital. a 72-beå accre- dited. acute care hospital requires registered nurses to work in medical, surgical, pediatric. obstetrical or operating room areas. Excellent orientation and inservice education. Some furnished accommoda- tion available. Apply: Assislant Adminislrator. Nursing. Stanton Yellowknife Hospital, Box 10, YeUowknife, N.W.T., XIA 2NI. Saskatchewan Registered !\iurse required for l3-bed acute care hospital in Southweslern Saskatchewan. Salary as per current S.H.A.-S.U.N. Agreement. Please send resume to: Mrs. G.P. W,lliamson, Secretary- Treasurer. Kincaid Union Hospital. Kincaid, Sas- katchewan. SOH 2J0. Telephone - Office (306) 264-3227 or Residence (306) 264-3349. R.1Ii. 's and R.P.N.'s (eligible for Saskatchewan regIStration) required for 340 fully accredited ex- tended care hospital. For further information. contaCI: Personnel Department. Souris Valley Ex- lended Care Hospital. Box 2001. Weyburn. Sas- katchewan S4H 2l7. Vnited States R.N.', l;.S.A. - Dunhill with 250 offices has exciting career opportunities for both recenl grads and experienced R.N. 's. locations Nonh. South. East and West_ All fees are paid by the employer. Send your resume to: 801 Empire Building, Edmon- ton. Albena. T5J IV9. Nunes - RNs - A choice of locations with emphasis on the Sunbelt. You must be licensed by examination in Canada. We prepare Visa fonns and provide assistance wilh licensure at nO cost to you. Write for a free job market survey Or call collect (713) 789-1550. Marilyn Blaker, Medex, 5805 Richmond. Houston. Texas 77057. All fees employer paid. California - Somelimes you have to go a long way to find home. But. The White 'femorial Medical Center in los Angeles. California. makes it all worthwhile. The White is a 377-bed acute care teaching medical Center with an open invitation to dedicated RN's. We'll challenge your mind and offer you the opponunit) to develop and continue your professional growth. We "ill pay your one-way trnnsportation, offer free meals for one month and all lodging for three months in Our nurSes residence and provide your work visa. Call collect or write: Ken Hoover. Assistant Personnel Direclor. 1720 Brook. Iyn Avenue, Los Angeles, California 90033 (213) 268-5000. ext. 1680. t10rlda Nunlq Opportuallies - MRA is recruiting Registered Nurses and recent Graduates for hospital positions in cities such as Tampa, St. Petersburg. and Sarasota on the West Coast; Miami, Ft. Lauderdale and West Palm Beach on the East Coast. If you are considering a move to sunny Florida. contact our Nurse Recruiter for assistance in selecting the right hospital and city for you. We will provide complete Work Visa and State licensure mformation and offer relocation hints. There is no placement fee to you. Write or call MedkaJ R<aScotia IItPt.H.. Registered Nurses Full and part-time vacancies in a new expanding hospital with progressive programmes in long tenn care. rehabilitation and geriatrics. Must be eligible for Ontario registration. Write to: Assistant Director of Nursing West Park Hospital 82 Buttonwood Avenue Toronto, Ontario \'16M 2JS Th. Cen-.llen Nur.. D8c:ember 1971 17 R.N. 's AMERICA We have over three hundred openings throughout the U.S.A. If you are interested in working in: florida. Virginia, Maine, New York, New Jersey, .:\Ussouri, California, !\Iass., or an} other areas we can offer you the opportunity to broaden your professional experience in either teaching or community hospitals. Your preference in specialty areas will be considered. . Complete licensure and visa service · Hospital brochures. areas. benefits. housing. etc. will be provided to you Please send your resume to: International Nurses Registry, Ltd. 1003 Park Blvd. Massapequa Park, Ne\t York 11762 (516) 798-1300 We place you in a position that fits your requirements. not just a spot. I CJPPORTUIJITY .dl.m Nurses Applications are invited for positions at Alberta Hospital, Edmonton, a 650 bed active treatment psychiatric hospital, located 4 km. outside of Edmonton. Successful candidates must be graduates from a recognized School of Nursing and eligible for registration in their professional association; willing to work shifts. Vacancies exist in Admissions, Forensic, Rehabilitation, and Geriatric Services '\Iote: Transportation is available to and from Edmonton. Accommodation is available in the Staff Residence. Salary $I,:!:!9 - $1,445 per month (Starting salary based on experience and education) Competition #9184-9 This competition will remain open until a suitable candidate has been selected. Qualified persons are invited to phone, write or submit applications to: Personnel Administrator <\-Iberta Hospital, Edmonton Box 307, Edmonton. Alberta TSJ 2J7 Telephone: (403) 973-2213 You'll step into "tomorrow's" nursing when you enter our internationally famous teaching, research and acute care facility. Progressive, interested in your ideas: nursing at Stanford can be all YOIl want it to be. YOU have a major say in your career advancement. You have time for patient care: to explore new techniques: to research new procedures. The Stanford Nurse never stops learning. Enjoy the advantages of a university medical environment. Talk with us. Chances are you'll like the looks of tomorrow. We offer an outstanding salary and benefit package, today! And under our innovative benefit program, we will even pay you for your time off! For more information, please send your resume and salary requirements to: Nurse Recruiter, Stanford University Hospital, Stanford, CA 94305. or call COLLECT: (415) 497-7330. An equal opportunity affirmative action emplover male/female --Tomorruw.. is just 38 mites trom San Francisco ...---------------- ------- ,.._.._'.1 I would like to know more about Nursing Opportunities S1 Santa Monica'HoSJ'üal I Mecßtal C,nter, r! I --, 1. _ I., . , CA 10404 ( ....,..:..... bL 2537 Name I urrlIlIllII1IflrrI : IH!Hl:T1!lllllilI1ll.n I )1 L ., 'l.:=- gH " An Equal O nity EmploveZ l.f ...... -f spé.cific groups of symptoms that generally accompany colds. Regular CORICIDIN (antihistamine, analgesic, caffeine com- ..,. pound) is intended for use at the first sign of a cold where congestion is not a problem or when decon- gestants are contraindi- cated. CORrCIDIN 'D' is formulated for use when nasal or sinus congestion is pronounced. For your younger patients CORICIDIN 's available as COR/CiDIN Pediatric MEDILETS* and ORICIDIN 'D' MEDILETS, both chewable tablets. and leasant tasting CORICIDIN Pediatric Drops for infants or v- young children. Fr= - Booklet Offer We" - attempted to answer many questions about colds. their causes, effects and relief in an informative booklet entitled "How to Nurse a Cold". It's yours, free of charge, jf y 'II si ply fill in and mail the Coupon on this page. I .. Mail to: Schering Canada Inc. 3535 Trans Canada Pointe Claire. Quebec H9R 1B4 Please send me my free copy of your booklet "How to Nurse a Cold". Additional copies only available upon written request. Name: ( Pl ease pnnt) Address: City: Postal Code: . Reg. T.M Prov. La B.ibUo;thè.que Universit d'Ottawa EcMance OCT 28 19& OC1 OCT 2 1 8 MAR 1 2 1983 tI\ R - 9 '983 MAR 1 7 1983._ MAR 1 5 1983 t\ -1 \9 \ The L.ibJz.aJty University of Ottawa Date Due f I $., U d'/ of Ottawa lfiir l ' I, III " l :" l ll I " If 1 ' 1/1 11 '.11 :1."-. ;//'"111111 II;; III "II" I I I Ilillll 39003009805713