THE CANADIAN NURSE
The official journal of the Canadian Nurses
Association published in French and English
editions eleven times per year.
1980
ANNUAL AUTHOR, SUBJECT INDEX
Vol. 76, No. s 1-11
January December
LEGEND
A Abstract
AV- Audiovisual
Ja - January
Fe February
Mr - March
Ap - April
My May
Je - June
E
Editorial
port
portrait
J/A -
S
Oc -
July/August
September
October
N
November
D
December
ABBOTT, Susan
CNF Scholarship, 2SOc
AGED
Hypothermia and the senior citizen, 33Fe
AGED - NUTRITION
Seniors: A target for nutrition education
(Gillis) 28J/A
AGGRESSION
Torture and the nurse, lOJa
AGING
A self-help guide to the aging process
(Morden) 19J/A
ALBERTA ASSOCIATION OFREGISTERED
NURSES. SCHOLARSHIPS
AARN scholarship winners, ISJa
ALCOHOLICS - REHABILITATION
AWS: recognition and rehabilitation
(Kolesar, Shaw) 49N
ALCOHOLISM
A health-oriented approach (Paech) E, 18N
A learning program in the addictions
(McGee) 22N
AWS: recognition and rehabilitation
(Kolesar, Shaw) 49N
Breaking the cycle of abuse (Casselman)
30N
It could happen to you! (Kolesar) 20N
Understanding the physiology of alcohol
abuse (Gaerlan) 46N
ALLEN, Marion
A practical goal for the 80 s (Slater) E, 6S
ANNABLE, Mary Lou
CNA Ticket of Nominations (port) 28Ap
ANTISEPSIS
Man versus microbe: a case for the
Infection Control Nurse
(Ratsoy, Beaufoy) 30D
ANXIETY
Care for the caregiver (Vachon) 28Oc
AUDIOVISUAL AIDS
SOJa, 54Ap, 49Je, 48J/A, 23Oc, 14D
Alcohol and your patient, 49Je
A catalogue of audiovisual resources in
psychiatric mental health nursing, 23Oc
A special place, 14D
Autism, minority of one, SOJa
Burns, SOJa
Can I take this if I m pregnant - brochure,
23Oc
Childbirth, a labor of love, SOJa
Childbirth, pregnancy: two people, SOJa
Choking: to save a life, SOJa
Continuing education, SOJa
Fit to sing, 54Ap
General nursing care, 49Je
Health Computer Applications in Canada,
14D
Help for special services, 14D
Lifestyles, SOJa
Material on breast feeding, 23Oc
Maternity Care Checklist, 14D
Medications, 49Je
Patient education, SOJa
Periodic health examination, 14D
Reports - The Canadian Institute of Child
Health, 23Oc
Resuscitation, SOJa
Shopping for audiovisuals (Carver) 48J/A
The fit-kit: The Canadian Home Fitness
Program, 54Ap
The ups and downs of blood sugar, 48J/A
Videocassettes on patient education, 14D
-B-
BAJNOK, Irmajean
Perspective, E, 6Ap
BANNING, Judith
A personal commitment to fitness results
in healthier clients, 38My
How NOT to be a victim, 31Fe
BARD, Rachel
Awarded the Marjorie Hiscott Keyes
Medal for 1979, 48Je
BARR, Frances
Are your students positive about their
experience in the clinical area? 48Oc
BARRY, Laura
Guillain Barre Syndrome, 26Mr
BARRY, N. Patricia
Appointed director of nursing of the
Hamilton Psychiatric Hospital, 6N
BEATON, Janet
CNF Scholarship, 25Oc
BEAUFOY, Ann
Man versus microbe : a case for the
Infection Control Nurse (Ratsoy) 30D
BECKER, Constance
The postpartum period, 24D
BELLEVILLE, Jean-Paul
CNA Public Representative (port) 8D
BENTLEY, Kendy
Tomorrow s nurses shape up for a healthy
future (Friesen) 49Ap
The Canadian Nurse
December 1980 63
BESHARAH, M. Anne
CNJ talks to Gordon Friesen, on the side
of the angels, 45Je
Perspective, E, SJa, SFe, SJe
BIOFEEDBACK (PSYCHOLOGY)
Biofeedback-does it work? (Burdis) 44Fe
BLADDER, NEUROGENIC
Bladder retraining (Whittington) 26Je
BLAKER, Gloria
Some of us are more equal than others, E,
6My
BLAU, June L.
Bk. rev., 52Je
BLISS, Joy
New baby in the family, 42Oc
BLOOD
Hemostasis and the nature of its defect in
hemophilia (Hedlin) 15D
BLUNDELL, Heather
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
BOCK, Jane
Bafflegab-are we the next victims? E, 6D
Herpes: scourge of the seventies, 22Ja
Mirror, mirror on the wall, E, 5 Mr
Stroke: a review, 47My
University programs for RN s, 36Ja
BOOK REVIEWS
53Ja, 54Mr, 52Je, 44D
Abels, Linda Feiwell. Manual of critical
care, 56Ja
Anthony, Catherine P. and Thibodeau,
Gary A. Basic concepts in anatomy and
physiology, a programmed
presentation, 54Je
Bates, Barbara. A guide to physical
examination, SID
Bathea, Doris C. Introductory maternity
nursing, S4Je
Brooker, Andrew M.D. and Schmeisser,
Gerhard Jr., M.D. Orthopedic traction
manual, 48D
Chenevert, Melodie. Special techniques in
assertiveness training for women in the
health professions, 53Ja
Comoss, P., Burke, E. and Swails, S.
Cardiac rehabilitation: a
comprehensive nursing approach, 47D
Current practice in critical care, 48D
Diers, Donna. Research in nursing
practice, SOD
Dreyer, S. Guide to nursing management
of psychiatric patients (Bailey, Doucet)
53Ja
Fotheringham, John B. and Morris, Joan.
Helping the retarded child in the
elementary school years, SOD
Gutch, C.F. and Stoner, Martha H. Review
of hemodialysis for nurses and dialysis
personnel, SOD
Hilt, Nancy and Cogburn, Shirley. Manual
of orthopedics, 48D
Hinchliff, S.M. ed. Teaching clinical
nursing, 54Ja
Hood, G. and Dincher, J. Total patient
care-foundations and practice, 48D
Kolff, Cornelis and Sanchez, Ramon.
Handbook of infectious diseases
management, 45D
Ingalls, S. Joy and Salerno, M. Constance.
Maternal and child nursing, 47D
Lancaster, Jeanette. Community mental
health nursing: an ecological
perspective, 44D
Lee, Eloise R. Concepts in basic nursing: a
modular approach, SID
Litwack, Lawrence, Litwack, Janice M.
and Ballou, Mary B. Health counseling,
44D
Marriner, Ann. The nursing process a
scientific approach to nursing care,
54Je
Mason, Elizabeth J. How to write
meaningful nursing standards, SSJa
McCormick, Rose-Marie Duda and
Gilson-Parkevick, Tamar. Patient and
family education: tools, techniques
and theory, 44D
Metheny, N. and Snively, W.D. ed. Nurses
handbook of fluid balance, SSJe
Mirin, Susan Kooperstein. Teaching
tomorrow s nurse: a nurse educator
reader, SOD
Olds, London, Ladewig and Davidson.
Obstetric nursing, 47D
Pearson, L.J. and Kotthoff, M.E. Geriatric
clinical protocols, SID
Pochedly, Carl. ed. Pediatric cancer
therapy, S2Je
Riehl, Joan P. and Roy, Callista.
Conceptual models for nursing
practice, 48D
Rozovosky, Lome Elkin. The Canadian
patient s book of rights, 45 D
Schwartz, Jane Linker, ed. Vulnerable
infants: a psychosocial dilemma
(Schwartz) SSJa
Skillbook Series. Documenting patient
care responsibly, S6Ja
St. John Ambulance. Emergency first aid,
safety oriented, 56Ja
Wehrmaker, S. and Wintermeute, J. Case
studies in neurological nursing, 52Je
Wilting, Jennie. People, patients and
nurses: a guide for nurses toward
improved interpersonal relationships,
SOD
BOUCHARD, Jeannette
Contract learning (Steels) 44Ja
BOURBONNAIS, Frances
Adult respiratory distress syndrome, SlOc
BRAMWELL, Lillian
CNF Scholarship, 25Oc
BRANDT, Shirley, L.
Appointed director of continuing
education in nursing at the School of
Nursing, University of B.C., 48Je
BREAST DISEASES
Breast disease in nurses, a 30-year study
(Elwood, Hislop) 38D
BREAST FEEDING
Nursing mothers then and now
(Wallace) 44Oc
BURDIS, Cris
Biofeedback-does it work? 44Fe
BURNS, Katharina A.
Bk. rev., 54Je
BURNS, Margaret
Day care: the selective alternative for
psoriasis patients (Schachter) 36Fe
BURRY, Muriel
Antidiuretic hormone and its inappropriate
secretion (Martens) 41Fe
-C-
CAHOON, Dr. Margaret C.
Appointed Rosenstadt Professor in Health
Research in Faculty of Nursing at
University of Toronto, 6N
CALENDAR
70Ja, 62Fe, HMr, 17Ap, 5J/A, 14S
CALOREN, Heather
Appointed Assistant Director-Nursing
Service for the Elderly with the VON,
14Ja
CAMERON, Sheila
Bk. rev., SOD
CAMPBELL, Margaret A.
CNA Ticket of Nominations (port) 24Ap
CANADA. HEALTH SERVICES REVIEW 79
Putting "health" into health care, CNA
brief promotes more use of nurses,
20My
CANADIAN ASSOCIATION OF
UNIVERSITY SCHOOLS OF
NURSING. WESTERN REGION
CAUSN registration over the 100 mark
(Hilton) 22My
CANADIAN DIABETIC ASSOCIATION
The ups and downs of blood sugar, color
poster, AV, 48J/A
CANADIAN INTRAVENOUS NURSES
ASSOCIATION
IV nurses exchange information, ideas,
16Fe
CANADIAN NURSE-HISTORY
A capsule history of your journal, 20Mr
CANADIAN NURSES ASSOCIATION
Annual meeting roundup, 6J/A
CNA directors finish 1978-80 business,
prepare for new biennium, 24S
Meet your new executive! 22S
News from the CNA boardroom, 8D
The end of an era at CNA, Tribute to
Helen K. Mussallem, 23S
CANADIAN NURSES ASSOCIATION.
BIENNIAL MEETING, 1980
Public safety, professional excellence, 18S
CANADIAN NURSES ASSOCIATION.
BOARD OF DIRECTORS
CNA directors approve nursing ethics
code, 1980 budget and health services
brief, 18My
Putting "health" into health care, CNA
brief promotes more use of nurses,
20My
CANADIAN NURSES ASSOCIATION.
CONVENTION 1980
Program highlights, lOAp
Ticket of Nominations 1980-82, 2 1 Ap
CANADIAN NURSES ASSOCIATION.
TASK GROUP
Development of a Definition of Nursing
Practice and Standards for Nursing
Practice, 11 My
CANADIAN NURSES ASSOCIATION
TESTING SERVICE
The integration syndrome (Rajabally) 42Ja
CANADIAN NURSES FOUNDATION
Ten Canadian nurses receive scholarships,
25Oc
CANADIAN NURSES FOUNDATION
VIRGINIA A. LINDABURY
SCHOLARSHIP
CNF announces special scholarship, 9Mr
CANADIAN ORTHOPEDIC NURSES
ASSOCIATION
Fun and fitness featured at orthopedic
nurses meeting, 22My
CANADIAN PUBLIC HEALTH
ASSOCIATION
Nurse heads CPHA, 15S
CARDIOVASCULAR DISEASES
Cardiac rehabilitation: applying the
benefits of exercise (Naimark) 41Ap
The stress test (MacFarlane) 39Ap
CARMICHAEL, Susan J.
Bk. rev., 56Ja
CARVER, Joyce
Shopping for audiovisuals, AV, 48J/A
CASSELMAN, Gwen
Breaking the cycle of abuse, 30N
CATHARTICS
Health and Welfare issues warning, 14Je
CEREBROVASCULAR DISORDERS
Perceptual disorders (Hart) 44My
Stroke: a review (Bock) 47My
CHATER, Kathy
Dangerous equations, 23N
Dealing with the disruptive patient, 26N
The drug abusing patient in the ER, 28N
CHEMOTHERAPY
Successful chemotherapy (Law) 19Fe
CHUNG, May
Surgical tattooing (McKenzie) 26My
CIBA-GEIGY PHARMACEUTICAL
COMPANY
Six nurse coordinators help international
study, HJe
CLARKE, Heather
CNF Scholarship, 25Oc
CNA CODE OF ETHICS
CNA Code of Ethics: an ethical basis for
nursing in Canada, My (insert)
64 December 1980
The Canadian Nurse
CNA PROJECT REPORT
Development of a Definition of Nursing
Practice and Standards for Nursing
Practice, HMy
CNA S TASK GROUP
CNA s Task Group-a set of Principles
for Standards, 14Ap
COCHRANE, Elizabeth
Awarded 1979 Judy Hill Memorial
Scholarship, lOJa
Awarded 1980 Judy Hill Memorial
Scholarship, 6N
COMMUNICATION
Bafflegab -are we the next victims? (Bock)
E, 6D
Wanted! A new interface between
administration, nursing and medical
staff (Monaghan) 42 D
COMMUNITY HEALTH NURSING
A postpartum program that really works
(Freeman) 40Mr
Gasoline inhalation: a community
challenge (Daubert, MacAdam) 24N
The body shop (McMurray) 46Ap
COMPUTERS
Locating nursing research data via
computer (Zelmer) 14Je
CONGRESSES
Nurses, doctors co-operate for closer look
at critical care, 10D
Public safety, professional excellence, 18S
Third international seminar looks at death
and dying, 10D
CONSENT (LAW)
Was the patient informed? (Sklar) 18Je
CONSUMER PARTICIPATION
The body shop (McMurray) 46Ap
COOPER, Linda
CNF Scholarship, 2SOc
CORMIER, Simone-Marie
CNA Ticket of Nominations (port) 23Ap
COWAN, Deborah
Halo traction (York) 28Ja
COWAN, M. Kathleen
Bk. rev., 44D
CRAWFORD, Myrtle E.
CNA Ticket of Nominations (port) 23Ap
CRISTALL, Brian
Do as I say! 40Ja
CRITICAL CARE
Nurses, doctors co-operate for closer look
at critical care, 10D
CROLL, Senator David A., Q.C.
A geriatric crisis, E, 2J/A
CULTURE
Checking out your own "cultural
awareness" (O Neill) 25Je
Transcultural nursing (Hodgson) 23Je
CUSO
Health around the world (Johnson) 48My
-D-
DAUBERT, Marie
Gasoline inhalation: a community
challenge (MacAdam) 24N
DAVIES, Elizabeth
CNF Scholarship, 25Oc
DEAS, Sister Anne
Appointed director of nursing, St. Paul s
Hospital, Saskatoon, 14Ja
DEATH
A time to be born, a time to die (Mclver)
38S
Third international seminar looks at death
and dying, 10D
DEGNER, Lesley
CNF Scholarship, 2SOc
DELIVERY
The birth room (Rosen) 30Mr
DEPRESSION
An open letter to the nurses of Canada
(White) 33Mr
DEVINE, Barbara
The House of Respect, 41S
DISASTER PLANNING
HELP! (Yantzie) 33Je
DOBSON, Karen
A second chance, 37Je
DRUG ABUSE
A health-oriented approach (Paech) E,
18N
It could happen to you! (Kolesar) 20N
The drug abusing patient in the ER
(Chater) 28N
Use? Or Abuse? (Henderson) E, 19N
DRUG ABUSE - PREVENTION AND
CONTROL
A learning program in the addictions
(McGee) 22N
DRUG DEPENDENCE-REHABILITATION
Breaking the cycle of abuse (Casselman)
30N
Dealing with the disruptive patient
(Chater) 26N
Primary nursing in the addictions
(Fitzpatrick) 29N
DRUG INTERACTIONS
Dangerous equations (Chater) 23N
DRUGS
A programmed learning package: Living
and working with drugs (Gaerlan) 35N
Dangerous equations (Chater) 23N
DRYSDALE, Arlene
Awarded 1980 Judy Hill Memorial
Fund Scholarship, 6N
DURNFORD, Phyllis
Bk. rev., S2Je
-E-
EADES, Margaret
Bk. rev., 48D
EARLE, Margaret
CNF Scholarship, 25Oc
EATON, Connie
Nursing care plans and the private duty
home care patient, 2SJa
EDGREN, Marilyn D.
Bk. rev., 48D
EDITH DICK FUND
Established in memory of the late Edith
Rainsford Dick, 14Ja
EDUCATION, CONTINUING-CANADA
Planners ready for continuing ed meeting,
14Je
EDUCATION, NURSING
Are your students positive about their
experience in the clinical area? (Barr)
48Oc
Back to basics, Nursing educators face up
to needs of the eighties, 16Ja
Contract learning (Bouchard, Steels) 44Ja
Grading student nurses (Wood, Wladyka)
30Je
The expanded role of the handmaiden
(Logan) 34Ja
EDUCATION, NURSING,
BACCALAUREATE
University programs for RN s (Bock) 36Ja
EDUCATION, NURSING-CANADA
CAUSN registration over the 100 mark
(Hilton) 22My
EDUCATION, NURSING, CONTINUING
C.A.R.P. A new way to learn (Murray)
42Je
Continuing ed challenge topic for national
meet, 15S
EDUCATION, NURSING, GRADUATE
University programs for RN s (Bock) 36Ja
ELLERTON, Mary-Lou
Health hotline makes house calls in
Halifax, 22Oc
ELLIS, Donelda
Whatever happened to the spiritual
dimension? 42S
ELWOOD, J. Mark, M.D.
Breast disease in nurses, a 30-year study
(Hislop) 38D
EMERGENCIES
Fire (Squires) 49S
EMERGENCY HEALTH SERVICES
Accidental hypothermia: emergency
rewarming techniques (Rae) 28Fe
EMERGENCY NURSING
The drug abusing patient in the ER
(Chater) 28N
EMPLOYMENT
Income tax and the self-employed nurse
(Garbutt) 35J/A
ETHICS. MEDICAL
The need to know? 30My
ETHICS, NURSING-CANADA
CNA directors approve nursing ethics
code, 1980 budget and health services
brief, 18My
CNA Code of Ethics: an ethical basis for
nursing in Canada, My (insert)
EXERCISE
Cardiac rehabilitation: applying the
benefits of exercise (Naimark) 41Ap
Exercise: how the body responds (Hedlin)
30Ap
EXERTION
The stress test (MacFarlane) 39Ap
EYE INJURIES
What s the score on sports and eye
injuries? (Moses) 43Ap
-F-
FAWDRY, M. Kaye
Bk. rev., SOD
FENWICK, Diana
Awarded 1980 Judy Hill Memorial
Fund Scholarship, 6N
FETAL DEATH
Letting go (Parrish) 34Mr
FIELD, Peggy Anne
CNA Ticket of Nominations (port) 26Ap
FITZPATRICK, Eileen
Primary nursing in the addictions, 29N
FLIESSER, Yvette
CNF Scholarship, 2SOc
FORTIN, Fabienne
CNA Ticket of Nominations (port) 27Ap
FREEMAN, Kathleen
A postpartum program that really works,
40Mr
FRENCH, Eileen
Bk. rev., SOD
FRENCH, Susan
Appointed associate dean, Health Sciences
(Nursing) at McMaster University, 6N
FRIESEN, Bonnie
Tomorrow s nurses shape up for a healthy
future (Bentley) 49Ap
FRIESEN HOSPITALS
CNJ talks to Gordon Friesen, on the side
of the angels (Besharah) 45 Je
FROSTBITE
How NOT to be a victim (Banning) 31Fe
The Canadian Nurte
December 190 65
-G-
GAERLAN, Marylou
A programmed learning package: living
and working with drugs, 35N
Understanding the physiology of alcohol
abuse, 46N
GAME THEORY
HELP! (Yantzie) 33Je
GARBUTT, Maureen
Income tax and the self-employed nurse,
3SJ/A
GASES, ASPHYXIATING AND POISONOUS
Gasoline inhalation: a community
challenge (Daubert, MacAdam) 24N
GENETIC COUNSELING
The need to know? 30My
GERIATRICS
A geriatric crisis (Croll) E, 2J/A
A self-help guide to the aging process
(Morden) 19J/A
Nurses look at new ways of helping
young old and old old , 15Ap
Reality orientation (Nepom) 26J/A
Seniors: A target for nutrition education
(Gillis) 28J/A
The House of Respect (Devine) 40S
GERONTOLOGICAL NURSES
ASSOCIATION 3RD ANNUAL
MEETING
Nurses look at new ways of helping
young old and old old , ISAp
GILLIS, Doris
Seniors: A target for nutrition education,
28J/A
GLASS, Helen
Awarded YWCA Woman of the Year
award for Education, lOJa
CNA Ticket of Nominations (port) 22Ap
GLUA, Emma C.
Bk. rev., 56Ja
GOERTZ, Phyllis
CNA Ticket of Nominations (port) 28Ap
GRANT, Nancy
Bk. rev., 48D
GRASSET, Stephany
Elected president of the RNABC, 14Ja
GRIEF
Letting go (Parrish) 34Mr
-H-
HANSON, Patricia Gaye
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
HARRIS, Janet B.
Bk. rev., 47D
HART, Geraldine
Perceptual disorder, 44My
HAYES, Marjorie W.
Appointed director of the Health
Computer Information Bureau, 48Je
HAYNES, Barbara
Institutionalization. What happens to
patients in a long term treatment
center, 43Mr
HEALTH COMPUTER INFORMATION
BUREAU
Did you know, 14Ap
HEALTH EDUCATION
Save your own life (Logan) SOAp
HEALTH SERVICES-CANADA,
NORTHERN
Perspective (Besharah) E, SJe
Transcultural nursing (Hodgson) 23Je
HEDLIN, Anne
Exercise: how the body responds, 30Ap
Hemostasis and the nature of its defect in
hemophilia, 1SD
HEMOPHILIA
A special hemophilia program (O Neill)
18D
Hemostasis and the nature of its defect in
hemophilia (Hedlin) 15D
HEMOSTASIS
Hemostasis and the nature of its defect in
hemophilia (Hedlin) 15D
HENDERSON, Dr. Ian W.D.
Use? Or Abuse? E, 19N
HEPATITIS B
Hepatitis B: an occupational risk
(Keck, Swerhun) 33D
HERE S HOW
S2S
HERPESVIRUS INFECTIONS
Herpes: scourge of the seventies
(Bock) 22Ja
HISLOP, T.G., M.D.
Breast disease in nurses, a 30-year study
(Elwood) 38D
HOBDEN, Elizabeth
Bk. rev., 48D
HODGSON, Corinne
Transcultural nursing, 23Je
HOGANSON, Carol
Won Deknatel Educational Award for
Canada, 14Ja
HOME CARE SERVICES
Nursing care plans and the private duty
home care patient (Eaton) 2SJa
Shirley A success story (McNairn) 40D
HOME, Elfriede
Bk. rev., 4SD
HOSPITAL FOR SICK CHILDREN,
TORONTO
Help is as close as the phone, 13D
HOSPITALS-LEGISLATION AND
JURISPRUDENCE
Hospitals and nurses: the evolution of
legal responsibility (Sklar) SOMy
HOTLINES (COUNSELING)
Health hotline makes house calls in
Halifax (Ellerton) 22Oc
HYPERTENSION
Six nurse coordinators help international
study, IlJe
HYPOTHERMIA
Accidental hypothermia: emergency
rewarming techniques (Rae) 28Fe
Controlled hypothermia: a treatment for
an acute anoxic incident (Thomas)
24Fe
How NOT to be a victim (Banning) 31Fe
Hypothermia and the senior citizen, 33Fe
-I-
INAPPROPRIATE ADH SYNDROME
Antidiuretic hormone and its
inappropriate secretion
(Burry, Martens) 41 Fe
INCOME TAX
Income tax and the self-employed nurse
(Garbutt) 35J/A
INDIANS OF NORTH AMERICA -
CANADA - WOMEN
Perspective (Besharah) E, SJe
INFANT, PREMATURE
Self-help groups for parents of premature
infants (Shosenberg) 30J/A
INFECTION
Man versus microbe: a case for the
Infection Control Nurse
(Ratsoy, Beaufoy) 30D
INFORMATION SERVICES
Help is as close as the phone, 13D
INPUT
13Fe, 6Mr, 8My, 7Je, 10S, 6Oc, 69N
INSERVICE TRAINING
C.A.R.P. A new way to learn (Murray)
42Je
INSTITUTIONALIZATION
Institutionalization. What happens to
patients in a long term treatment
center (Haynes) 43Mr
INSURANCE, LIABILITY
The extension of hospital liability (Sklar)
8Fe
INTERNATIONAL ASSOCIATION OF
ENTEROSTOMAL THERAPISTS
Enterostomal therapists hold Canadian
meeting, lOJa
INTERNATIONAL COUNCIL OF NURSES
ICN sets Congress fees, 1SS
-J-
JACK, Susanna
Bk. rev., 44D
JARGON (TERMINOLOGY)
Bafflegab are we the next victims? (Bock)
E, 6D
JOB SATISFACTION
Wanted! A new interface between
administration, nursing and medical
staff (Monaghan) 42D
JOHNSON, Maureen
Health around the world, 48My
JUDY HILL MEMORIAL FUND
SCHOLARSHIP, 1980
Awarded toll nurses, 6N
-K-
KAM, Simon
Bk. rev., 48D
KECK, Jean
Hepatitis B: an occupational risk
(Swerhun) 33D
KELLOGG SALADA NUTRITION
SYMPOSIUM
Nutritionists share findings on diet and
health, 23My
KERMER, Gisele Fontaine
Denial, 43S
KOLESAR, Gregory
AWS: recognition and rehabilitation
(Shaw) 49N
It could happen to you! 20N
KUCINSKAS, Angela
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
-L-
LABARGE, Margaret
CNA Public Representative (port) 8D
LABOUR RELATIONS
Nurses unions, professional associations
and YOU (Rowsell)
Part one: Nurses take the union route,
44J/A
Part two: The role of the nurse-manager in
labor relations, 30S
LADYSHEWSKY, Angela
Increased intracranial pressure: when
assessment counts, 34Oc
LALIBERTE, Marie-Therese
Awarded Warner-Lambert Canada Ltd.
nursing fellowship, lOJa
LANDRY, Teresa
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
LAPP, Cheryl Ann
Bk. rev., 56Ja
LAROSE, Odile
CNA Ticket of Nominations (port) 27Ap
LAW, Diana
A developing framework for oncology
nursing (Price) 44S
Successful chemotherapy, 19Fe
66 December 1980
The Canadian Nu
LEBLANC, Antoinette
Bk. rev., SSJe
LEDUC-GRAND MAISON, Rosette
Received United Nurses Award of Merit,
14Ja
LEGIONNAIRE S DISEASE
Legionnaire s disease. An old enemy with
a new name (Schilder) 46Mr
LEGISLATION
Hospitals and nurses: the evolution of
legal responsibility (Sklar) SOMy
"Nurse, you did this to me!" (Sklar) ION
Student nurses and the law (Sklar) 7Oc
The responsibility of the patient (Sklar)
14J/A
LICENSURE, NURSING
The integration syndrome (Rajabally) 42Ja
LICENSURE, NURSING - U.S.
Canadian nurses to write CGFNS exams to
work in U.S., 16Fe
LIFESTYLE
Perspective (Bajnok) E, 6Ap
The body shop (McMurray) 46Ap
LIVINGSTONE, Jean
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
LOGAN, Jo
The expanded role of the handmaiden, 34Ja
LOGAN, Marion
Save your own life, SOAp
LUNG DISEASES, OBSTRUCTIVE
A second chance (Dobson) 37Je
-M-
3M INTERNATIONAL COUNCIL OF
NURSING FELLOWSHIP
Maria Zinck wins 3M scholarship, HJe
MACADAM, Carol
Gasoline inhalation: a community
challenge (Daubert) 24N
MACFARLANE, Patricia
The stress test, 39Ap
MACINTYRE, Gail
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
MACLEAN, Bruce
Nerve palsies: the preventable sort
(McNamee) 38J/A
MACLEOD, Shirley
Bk. rev., 47D
MACNAMARA, E. Lee
Fitting nursing into fitness, 33Ap
MALIGNANT HYPERTHERMIA
Malignant hyperthermia need not be
lethal (Noble) 33S
MALPRACTICE
Hospitals and nurses: the evolution of
legal responsibility (Sklar) SOMy
The extension of hospital liability (Sklar)
8Fe
MANITOBA ASSOCIATION OF
REGISTERED NURSES.
ANNUAL MEETING
Annual meeting roundup, 7J/A
MARTENS, Lydia
Antidiuretic hormone and its
inappropriate secretion (Burry) 41Fe
MATERNAL HEALTH SERVICES
A postpartum program that really works
(Freeman) 40Mr
MATERNAL-INFANT BONDING
Six steps to better bonding (Rhone) 38Oc
MAY, Thelma Jane
Appointed director, Nursing Service at
Bloorview Children s Hospital,
Toronto, 14Ja
MAY, Thelma R.
The light still shines in Elora (May) 42My
MAY, Wendy J.
The light still shines in Elora (May) 42My
MCEWEN, Janet
An employee fitness program, 36Ap
MCGEE, Arlee D.
A learning program in the addictions, 22N
MCGEE, Marian
CNA Ticket of Nominations (port) 27Ap
MCGILL UNIVERSITY
Nursing in a university health service
(Tracy) 40Je
MCIVER, Vera
A time to be born, a time to die, 38S
MCKENZIE, Julie
Surgical tattooing (Chung) 26My
MCMURRAY, Anne Esler
The body shop, 46Ap
MCNAIRN, Noreen
Shirley-A success story, 40D
MCNAMEE, Christine
Nerve palsies: the preventable sort
(Maclean) 38J/A
MCPHAIL, Irene Ross
Elected president of St. John Ambulance
Federal District Council, ISJa
MEAGHER, Donna
Co-winner of Frances MacDonald Moss
Scholarship, 14Ja
MEDICINE SHOW
Health happenings, 16Fe
MENTAL RETARDATION
Consent, sterilization and mental
incompetence: the case of "Eve"
(Sklar) 14Mr
MENZIES, June
CNA Public Representative (port) 8D
MILLS, Karen
Appointed director of nursing of
Edmonton Local Board of Health, 6N
MONAGHAN, Gabrielle
Wanted! A new interface between
administration, nursing and medical
staff, 42N
MOORE, Janet L.
Bk. rev., 53Ja
MORDEN, Patricia
A self-help guide to the aging process,
19J/A
Bk. rev., SID
MOSES, Susan
What s the score on sports and eye
injuries? 43Ap
MURPHEY, Mary E.
Appointed vice-president, Nursing at
Vancouver General Hospital, 14Ja
CNA Ticket of Nominations (port) 24Ap
MURRAY, Margaret E.
C.A.R.P. A new way to learn, 42Je
MUSSALLEM, Helen K.
A surprise presentation (port) 8D
CNA executive director addresses "nurses
in the marketplace", 8Ja
The end of an era at CNA, 23S
-N-
NAMES
14Ja, 48Je, 6N
NATIONAL HEALTH CARE INSTITUTE
CNA directors ready for 1980, Health
Minister fields questions, 7Ja
NATIONAL SYMPOSIUM OF PERINATAL
NURSING
US, Canadian nurses attend perinatal
symposium, 14Oc
NEOPLASMS - NURSING
A developing framework for oncology
nursing (Law, Price) 44S
NEPOM, Rosalie
Reality orientation (Walker) 26J/A
NERVE PALSIES
Nerve palsies: the preventable sort
(McNamee, Maclean) 38J/A
NEW BRUNSWICK ASSOCIATION OF
REGISTERED NURSES.
SCHOLARSHIPS
Nurses in the news, lOJa
NEWS
6Ja, 16Fe, 9Mr, 14Ap, 22My, IlJe, 6J/A,
15S, 14Oc, 8D
NEYLAN, Margaret S.
Admitted as a Servicing Sister of the Most
Venerable Order of the Hospital of
St. John of Jerusalem, 48Je
NIGHTINGALE, FLORENCE
The light still shines in Elora, (May, May)
42My
NOBLE, Elizabeth
Malignant hyperthermia need not be
lethal, 33S
NOLAN, Eleanor
Awarded 1979 Judy Hill Memorial
Scholarship, lOJa
Awarded 1980 Judy Hill Memorial
Scholarship, 6N
NURSE ADMINISTRATORS CONFERENCE
Nurse administrators hold first national
conference, 1SS
NURSE CLINICIANS
Are your students positive about their
experience in the clinical area? (Barr)
48Oc
NURSE-PATIENT RELATIONS
Dealing with the disruptive patient
(Chater) 26N
Do as I say! (Cristall) 40Ja
Guillain Barre Syndrome (Barry) 26Mr
Successful chemotherapy (Law) 19Fe
NURSES
A little crystal ball gazing, 24Mr
It could happen to you! (Kolesar) 20N
Mirror, mirror on the waJJ (Bock) E, 5 Mr
NURSES-CANADA, NORTHERN
Perspective (Besharah) E, SJe
NURSING AUDIT
Nursing audit. What s it all about? (Sultan)
33My
NURSING CARE
A special hemophilia program (O Neill)
18D
An open letter to the nurses of Canada
(White) 33Mr
Perspective (Besharah) E, SFe
The postpartum period (Becker) 24D
NURSING HOMES
The House of Respect (Devine) 40S
NURSING - RESEARCH AND STUDIES -
ALBERTA
Locating nursing research data via
computer (Zelmer) 14Je
NURSING - STANDARDS - CANADA
Development of a Definition of Nursing
Practice and Standards for Nursing
Practice, 11 My
Standards group, 16Fe
NURSING, SUPERVISORY
Nurse administrators conference, 14Je
Nurse administrators hold first national
conference, 1SS
NUTRITION
Nutritionists share findings on diet and
health, 23My
Seniors: A target for nutrition education
(Gillis) 28J/A
-O-
OBSTETRICS
The Birth Room (Rosen) 30Mr
When experience counts (Segal) 38Mr
The Canadian Nurse
December 1980 67
OCCUPATIONAL HEALTH NURSING
CNA executive director addresses "nurses
in the marketplace", 8Ja
Occupational health nurses urged to take
aggressive stand, 12D
O NEILL, Gail
A special hemophilia program, 18D
Checking out your own "cultural
awareness", 25Je
ONTARIO OCCUPATIONAL HEALTH
NURSES ASSOCIATION
Occupational health nurses receive
$95,000, lOMr
ONTARIO TASK FORCE FOR
PREVENTION OF HIGH RISK
PREGNANCIES
Prevention pays, PHN tells committee,
9Mr
OPERATION BOOTSTRAP
CNA directors ready for 1980, Health
Minister fields questions, 7Ja
ORDRE DBS INFIRMIERES ET
INFIRMIERS DU QUEBEC
Quebec nurses pay tribute to children
round the world, 6Ja
ORGANIZATION AND ADMINISTRATION
Wanted! A new interface between
administration, nursing and medical
staff (Monaghan) 42D
ORTHOPEDICS
Halo traction (York, Cowan) 28Ja
-P-
PAECH, Gail
A health-oriented approach, E, 18N
PARENT-CHILD RELATIONS
New baby in the family (Bliss) 42Oc
Self-help groups for parents of premature
infants (Shosenberg) 30J/A
Six steps to better bonding (Rhone) 38Oc
PARKINSON DISEASE
Shirley A success story (McNairn) 40D
PARRISH, Sheila
Letting go, 34Mr
PARROTT, Eric G.
CNA s Director of Testing Service
responds, 43Ja
PATIENT ADVOCACY
"Nurse, you did this to me!" (Sklar) ION
PATIENT CARE PLANNING
Institutionalization. What happens to
patients in a long term treatment
center (Haynes) 43Mr
PATIENT COMPLIANCE
Do as I say! (Cristall) 40Ja
Was the patient informed? (Sklar) 18Je
PATIENT PARTICIPATION
The responsibility of the patient (Sklar)
14J/A
PATIENTS RIGHTS
The responsibility of the patient (Sklar)
14J/A
PATTERSON, Dawn
Bk. rev., S4Je
PECHIULIS, Diane
Bk. rev., 58Ja
PERINATOLOGY
US, Canadian nurses attend perinatal
symposium, 14Oc
PERIPHERAL NERVES
Nerve palsies: the preventable sort
(McNamee, Maclean) 38J/A
PERRIN, Joyce
Appointed administrator of Bloorview
Children s Hospital, Toronto, ISJa
PERSPECTIVE
SJa, SFe, SMr, 6Ap, 6My, SJe, 2J/A, 6S,
18N, 19N, 6D
PHYSICAL FITNESS
A personal commitment to fitness results
in healthier clients (Banning) 38My
An employee fitness program (McEwen)
36Ap
Fitting nursing into fitness (Macnamara)
33Ap
Fun and fitness featured at orthopedic
nurses meeting, 22My
Perspective (Bajnok) E, 6Ap
Tomorrow s nurses shape up for a healthy
future (Bentley, Friesen) 49Ap
PICK, Jeanette
Honored last Fall, lOJa
POETRY
Denial (Kermer) 43S
POLYRADICULONEURITIS
Guillain Barre Syndrome (Barry) 26Mr
PRICE, Barbara
A developing framework for oncology
nursing (Law) 44S
PRIMARY NURSING CARE
Primary nursing (Roberts) 20D
Primary nursing in the addictions
(Fitzpatrick) 29N
PROULX, Lissa Jane
Bk. rev., SID
PSORIASIS
Day care: the selective alternative for
psoriasis patients (Burns, Schachter)
36Fe
You re in hospital with what? (Steen) 34Fe
PUERPERIUM
The postpartum period (Becker) 24D
-Q-
QUALITY OF NURSING CARE
Nursing care plans and the private duty
home care patient (Eaton) 25Ja
-R-
RACINE, Barbara A.
Appointed administrator of the Inpatient
Division and Director of Nursing of the
Alberta Children s Hospital in Calgary,
48Je
RADIOTHERAPY
A race against time: caring for a patient
with radiation enteritis (Ronayne) 38Fe
RAE, Donna
Accidental hypothermia: emergency
rewarming techniques, 28Fe
RAJABALLY, Mohamed H.
The integration syndrome, 42Ja
RATSOY, M. Bernadet
Man versus microbe: a case for the
Infection Control Nurse (Beaufoy)
30D
REALITY ORIENTATION THERAPY
Reality orientation (Nepom) 26J/A
REGISTERED NURSES ASSOCIATION OF
BRITISH COLUMBIA.
ANNUAL MEETING
Annual meeting roundup, 6J/A
REGISTERED NURSES ASSOCIATION OF
NOVA SCOTIA.
ANNUAL MEETING
Annual meeting roundup, 10J/A
REGISTERED NURSES ASSOCIATION OF
ONTARIO. ANNUAL MEETING
Annual meeting roundup, 9J/A
RELIGION
Whatever happened to the spiritual
dimension? (Ellis) 42S
RESEARCH
52Ja, SOJe, 56N
A research report on the development and
validation of the PCTC System (Bay)
S2Ja
An empirical investigation of the
relationship between nurse s level of
self-actualization and ability to develop
positive helping relationships with
hospitalized patients (Logan) 56N
Assimilative and accommodative responses
of mothers to their newborn infants
with congenital defects (Kikuchi) SOJe
Child rearing concerns of first time
mothers (Kirkwood) 56N
Commitment to the nursing profession: an
exploration of factors which may
explain its variability (Flannery) 56N
Development and validation of
information needs inventory (MI
patient) (Lamb, Payne, Thorpe) 45N
Factors influencing dietary adherence as
perceived by patients on long-term
peritoneal dialysis (Hume) S6N
Familial strain and the development of
normal and handicapped children in
single and two parent families (Burke)
SOJe
Health-related problems of elderly people
attending senior citizen clubs/centers
(Milton) S2Ja
H.E.L.P. Health evaluation and lifestyle
promotion (Yeo) 56N
Knowledge of prescribed medical regime,
concerns and unanswered questions
reported by wives of aortocoronary
bypass patients in early convalescence
(Sikorski) SOJe
Problems of the independent elderly in
using the telephone to seek health care
(Caloren) SOJe
Punishing the pregnant innocents. Single
pregnancy in St. John s, Newfoundland
(Toumishey) 52Ja
Self-actualization in retirement (Kingston)
SOJe
The development of health sciences
education programs in metropolitan
Toronto Region Colleges of Applied
Arts and Technology, 1967-1977; a
study of selected factors influencing
this development (Peszat) S6N
The effects of two types of fetal
monitoring on ability to maintain
control during labor (Hodnett) 56N
The relation of constraint and situational
theory to diploma nursing program
leadership (Goldenberg) 56N
The use of written simulations to measure
problem solving skills of nursing
students (Munro) SOJe
RESEARCH - NURSING
A practical goal for the 80 s, (Allen, Slater)
E, 6S
RESPIRATORS
A second chance (Dobson) 37Je
RESPIRATORY DISTRESS SYNDROME,
ADULT
Adult respiratory distress syndrome
(Bourbonnais) SlOc
RHONE, Margaret
Six steps to better bonding, 38Oc
RICE, J. Alison
Bk. rev., 58Ja
RIDLEY, Una
Appointed professor of nursing and dean
of the College of Nursing at the
University of Saskatchewan, 48Je
ROACH, Sister Marie Simone
CNA Ticket of Nominations (port) 25Ap
ROBBINS, Marilyn
Bk. rev., 5 SJa
ROBERTS, Carol
Appointed nursing consultant-Practice
with ARNN, ISJa
ROBERTS, Laverne E.
Primary nursing, 20D
ROBSON, Beverley Ann
Awarded 1980 Judy Hill Memorial Fund
Scholarship, 6N
CNF Scholarship, 25Oc
68 DMMMtarllM
The Canadian Nurse
RODGER, Ginette
Appointed to position of executive
director (port) 25S
CNA Ticket of Nominations (port) 24Ap
Elected vice president of Board of
Directors of the Canadian Council on
Hospital Accreditation for 1980-8 1 , 6N
RONAYNE, Roberta
A race against time: caring for a patient
with radiation enteritis, 38Fe
ROSE, Jean
Appointed nursing consultant-Education
with ARNN, 14Ja
ROSEN, Ellen L.
The Birth Room, 30Mr
ROSS, Sheila
Co-winner of Frances MacDonald Moss
Scholarship, 14Ja
ROTHWELL, E. Sue
CNA Ticket of Nominations (port) 23Ap
ROWSELL, Glenna
Nurses unions, professional associations
and YOU
Part one: Nurses take the union route,
44J/A
Part two: The role of the nurse-manager in
labor relations, 30S
-S-
SANDERS, Marvel Miller
Stressed? Or Burnt Out? 30Oc
SASKATCHEWAN REGISTERED NURSES
ASSOCIATION. ANNUAL MEETING
Annual meeting roundup, 8J/A
SCHACHTER, R.K.
Day care: the selective alternative for
psoriasis patients (Burns) 36Fe
SCHILDER, Erna J.
Legionnaire s disease. An old enemy with
a new name, 46Mr
SCHOLARSHIPS
Ten Canadian nurses receive scholarships,
25Oc
SCHOLDRA, Dr. Joanne
Appointed director of University of
Lethbridge School of Nursing, 48Je
SCIENCE COUNCIL OF CANADA AGENDA
The need to know? 30My
SEGAL, Sylvia
When experience counts, 38Mr
SEX DISCRIMINATION AGAINST WOMEN
- CANADA
Some of us are more equal than others
(Blaker) E, 6My
SHAW, Joanne M.
AWS: recognition and rehabilitation
(Kolesar) 49N
SHOCK
Adult respiratory distress syndrome
(Bourbonnais) SlOc
SHOSENBERG, Nancy
Self-help groups for parents of premature
infants, 30J/A
SIBLING RELATIONS
New baby in the family (Bliss) 42Oc
SKLAR, Corinne
Consent, sterilization and mental
incompetence: the case of "Eve",
14Mr
Hospitals and nurses: the evolution of
legal responsibility, SOMy
"Nurse, you did this to me!" ION
Student nurses and the law, 7Oc
The extension of hospital liability, 8Fe
The responsibility of the patient, 14J/A
Was the patient informed? 18Je
SKULL FRACTURES
Increased intracranial pressure: when
assessment counts (Ladyshewsky) 34Oc
SLATER, Myma
A practical goal for the 8) s (Allen) E, 6S
SOCIAL SECURITY
A geriatric crisis (Croll) E, 2J/A
SPORTS
What s the score on sports and eye
injuries? (Moses) 43Ap
SQUIRES, Cathy
Fire, 49S
STANOJEVIC, Patricia S.B.
CNA Ticket of Nominations (port) 25Ap
ST ANTON, Sheila
Bk. rev., SOD
STEED, Margaret
Appointed associate dean of the faculty of
nursing, University of Alberta, 6N
CNA Ticket of Nominations (port) 26Ap
STEELS, Marilyn
Contract learning (Bouchard) 44Ja
STEEN, Maureen
You re in hospital with what? 34Fe
STERILIZATION, SEXUAL
Consent, sterilization and mental
incompetence: the case of "Eve"
(Sklar) 14Mr
STINSON, Shirley M.
CNA Ticket of Nominations (port) 22Ap
STOBIE, M. Michele
Bk. rev., SID
STRESS
Care for the caregiver (Vachon) 28Oc
Stressed? Or Burnt Out? (Sanders) 30Oc
STRESS, PSYCHOLOGICAL
The stress test (MacFarlane) 39Ap
STUDENT HEALTH SERVICES
Nursing in a university health service
(Tracy) 40Je
STUDENTS, NURSING
Student nurses and the law (Sklar) 7Oc
SULTAN, Shirley
Nursing audit. What s it all about? 33My
SURGERY
A race against time: caring for a patient
with radiation enteritis (Ronayne) 38Fe
SURGERY, PLASTIC
Surgical tattooing (Chung, McKenzie)
26My
SWERHUN, Peggy
Hepatitis B: an occupational risk (Keck)
33D
-T-
TATTOOING
Surgical tattooing (Chung, McKenzie)
26My
TEACHING MATERIALS
A self-help guide to the aging process
(Morden) 19J/A
TERMINAL CARE
A time to be born, a time to die, (Mclver)
38S
Third international seminar looks at death
and dying, 10D
THOMAS, Margot
Controlled hypothermia: a treatment for
an acute anoxic incident, 24Fe
THORNE, Anne D.
Bk. rev., 45 D
TRACTION
Halo traction (York, Cowan) 28Ja
TRACY, Florence
Nursing in a university health service, 40Je
-U-
UNITED STATES-EMIGRATION AND
IMMIGRATION
Is there a move in your future?
(Worthington) 32Ja
-V-
VACHON, Mary L.S.
Care for the caregiver, 28Oc
VENEREAL DISEASES
Herpes: scourge of the seventies
(Bock) 22Ja
VICTORIA HOSPITAL, LONDON,
ONTARIO
The Birth Room (Rosen) 30Mr
VIRUSES
Virus: pirate in the body, 24Ja
VOLUNTARY WORKERS
When experience counts (Segal) 38Mr
-W-
WALKER, Marion
Reality orientation (Nepom) 26J/A
WALLACE, Anne
Nursing mothers - then and now, 44Oc
WEBER, Kirsten
Bk. rev., 44D
WESTERN NURSE MIDWIVES
ASSOCIATION
Nurse-midwives solicit members, lOMr
WHITE, Jane Melville
An open letter to the nurses of Canada,
33Mr
WHITTINGTON, Lori
Bladder retraining, 26Je
WILTSE, Marcia
Bk. rev., SOD
WLADYKA, Joanne
Grading student nurses (Wood) 30Je
WONG, Shirley
Bk. rev., 54Je
WOOD, Vivian
Grading student nurses (Wladyka) 30Je
WORTHINGTON, Laura
Is there a move in your future? 32Ja
WRIGHT, Margaret Scott
Appointed dean of nursing at University
of Calgary, ISJa
-XYZ-
YANTZIE, Nelda
HELP! 33Je
YORK, Nelly
Halo traction (Cowan) 28Ja
YOU AND THE LAW
8Fe, 14Mr, SOMy, 18Je, 14J/A, 7Oc, ION
YOUNG, Kathleen
Bk. rev., S4Ja
YTTERBERG, Lorea A.
Appointed vice-president (Nursing) for the
University of Alberta Hospitals, 6N
Bk. rev., 47D
ZELMER, Dr. Amy
Appointed associate vice-president
(academic) of the University of
Alberta, 48Je
ZINCK, Maria
Maria Zinck wins 3M scholarship, IlJe
The C< nadlan Nurx
December 1>M 69
When you feel a patient should cut
down on saturated fats and watch his
cholesterol intake, you probably recommend
Fleischmann s 100% Corn Oil Margarine -
and perhaps Egg Beaters, too.
You may also suggest more fresh air and
exercise as part of a general fitness program.
Fleischmann s margarine, salted or
unsalted, contains no cholesterol. Its high
liquid corn oil content gives it an excellent
polyunsaturated/saturated fats ratio. The
natural ability of corn oil to inhibit serum
cholesterol makes Fleischmann s margarine
well worth recommending.
What about compliance? Are your
patients taking your advice?
Yes. Canadians are getting out and
exercising like never before. And they re
becoming much more diet conscious. As a
result, health concerned Canadians have
made Fleischmann s their No. 1 margarine.
And here s a fact that bears thinking
about: the overall CV death rate for people
under 65 is down by 27% since 1933.*
Whatever Canadians are doing, they are
doing something right. So it makes sense to
continue with the same good advice and
recommendations.
Fleischinaiiifs
Your patients are
making it part of their life.
" Heart Facts & Figures". Canadian Heart Foundation.
100% Corn Oil Margarine and Egg Beaters
Bulk Ennombre
third troisiem
class class*
10539
Up the career ladder: your
guide to post-RN programs in
Canada
Herpes simplex, scourge of the
seventies
Home care my way, a plan for
private duty nurses
Moving south? Tips on what to
avoid
s nn ,
VHVJ.IJ -JD
Nurs
KT^fl-:
.Style No. 44412 Dress
Sizes - 3-13
"Wonderfeel"
100% Fortrel"
Polyester Warp Knit
White, Mint.
Style No. 4478 - Pant Sui
Sizes -8-1 8
derfeel"
rel
:ter Warp Knit
, Mint
desi
A
LIMITED
EDITION
ers
A Division of
White Sister Uniform Inc.
Available at leading department, stores and specialty shops across Canada
Fortrer and Won Qir *~~ l " ~ *--- J -
Get ready, get set, GO
Vancouver, just in time for
CNA s annual meeting next
June. Our cover photo of the
Vancouver skyline is courtesy
of Beautiful British Columbia
Magazine, published quarterly
by The Ministry of Tourism
and Small Business
Development. Government of
B.C.. who kindly supplied the
artwork.
The
Canadian
Nurse
January 1980 Volume 76, Number 1
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
O
~
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
Mathilde Bazinet.c/iairman, 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 Britisn
Columbia.
Jean Passmore, editor, SRNA news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith, director of publications,
National Gallery of Canada.
Ftorita Vialle-Soubranne, consultant,
professional inspection division. Order
of Nurses of Quebec.
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 m advance. Include previous
address as well as new. along with
refc.slration number, in a
provincial/territorial nurses
association where applicable. Not
responsible for journals lost in mail due
to errors in address.
Canadian Nurses Association, 50 The
Driveway, Ottawa, Canada, K2P 1E2.
Herpes
Halo traction
42
16
Back to basics, nursing educators face
up to needs of the eighties
Special Report
*\A The expanded role of the handmaiden
Jo Logan
^^ Herpes: Scourge of the Seventies
~ Jane Bock
l^T University programs for RN s
J" Jane Bock
J f Nursing care plans and the private duty
^3 home care patient
Connie Eaton
/\f\ Do as I say!
ivf Brian Cristall
TQ Halo traction
** Nelly York and Deborah Cowan
A 1 ^ The Integration Syndrome
^ Mohamed H . Rajabaily
Is there a move in your future?
Laura Worthington
44
Contract learning: the experience of two
nursing schools
Jeanne tie Bouchard and
Marilyn Steels
6 News
14 Names
53 Books
1 2 CNA moves West
Get ready-get set-Go
50 Audiovisual
70 Calendar
52 Research
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
Indexed in International Nursing Index. Cumulative
Index to Nursing Literature, Abstracts of Hospital
Management Studies. Hospital Literature Index,
Hospital Abstracts, Index Medicus, Canadian
Periodical I ndex . The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor, Michigan 48106.
Canadian Nurses Association. 1980.
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
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perspective
It is November. The streets of
Montreal are beginning to fill
with homeward bound
commuters as I leave them
behind. As the bus hisses
through the rain along the four
lane highway linking Montreal
to Ottawa, lights from farms
along the way shine out of the
dark.
The meeting I have just
left is the fourth provincial
annual meeting that I have
attended in the past six
months. I am thinking about
the comment of the nurse who
sat beside me at today s
luncheon and remarked on
how lucky I was to have the
chance to visit all of these
different provinces. I think of
meetings over the last five
years in Toronto, in
Vancouver, in Regina, in
Winnipeg, in Edmonton, in St.
John s fromKelowna, B.C.
to Bridgewater, N.S.
herein
Collaboration is the lifeblood
of every magazine. This is
particularly the case when
that journal is intended to
reflect what is going on in a
profession like nursing.
These days, most of the
manuscripts that cross the
editor s desk bear the
hallmarks, not just of good
intentions, but also of creative
and innovative thinking,
conscientious effort and
considerable skill and
ingenuity in putting it all
together.
Nurses are using the
written word to share their
experiences with their
colleagues. This sharing does
not always have to be
confined to words, however.
Are you an amateur
photographer looking for a
new vehicle to display your
talents? Are you a nurse
whose most exciting camera
I think of the nurses I
have met and talked with at
these meetings nurses who
care about their profession,
care about their colleagues,
nurses who are willing to give
up some of their precious free
shots are ones that emphasize
the caring aspect of health
care?
If so, we d like to see
some samples of your work,
with a view to sharing with
other nurses the moments
you ve captured. The
Canadian Nurse is looking for
high quality color negatives or
prints that might be featured
on the cover, as well as good
black and white prints for
possible inside illustrations.
Enquiries should be directed
to The Editor, The Canadian
Nurse, 50 The Driveway,
Ottawa, Ontario, K2P 1E2.
Did you know...
There are 10 hospitals in Canada
that have incorporatedFriesen
concepts in their designs. Gordon
Friesen, a London, Ontario health
consultant, believes hospitals
should be supermarkets of health,
and emphasize preventive care first,
curative care second. One hundred
and fifty hospitals around the world
have used some of Friesen s ideas,
one of which is that doctors offices
should always be inside a hospital
to save duplication of health records
and doctors travelling time.
time to work for goals as
intangible and elusive as the
ones their professional
associations have adopted.
These are nurses working with
other nurses to promote
higher standards of nursing
practice so that people in this
country can have better
nursing care. Nurses whose
aim it is to make sure that the
educational programs
available to nursing students
and to graduates who want to
add to their skills and
knowledge are the best that
can be offered. Nurses who
are trying to find ways of
helping other nurses to
understand, support and
encourage each other. Nurses
who are willing to speak out
on behalf of their colleagues at
all kinds of meetings here in
this country and abroad.
I think of the nurses at the
national and provincial level
If Winter comes, can Spring be
far behind? Maybe your
reflections about the weather
outside, the state of the
economy or your attempts to
finance a trip to warmer
climes, leave you somewhat
depressed. Well, cheer up,
CNJ has some goodies in store
for you that can t help but
make 1980 a better year.
For starters, flip through
this January issue to find out
what s new and exciting on
the education front. We ve got
news of the first ever national
nursing education conference
in Ottawa last November. We
have some tips for nurses
considering the job scene
south of the border. And
we ve got a useful list of
what s available at Canadian
universities for RN s who
want to upgrade their
education credits.
Next month, you can
look forward to a fine
selection of clinical nursing
articles on Legionnaire s
Disease, Hypothermia,
Psoriasis and Antidiuretic
Hormone, among others.
who put these goals ahead of
personal needs and desires so
that they can run for office. I
think of the members of
boards and committees who
ask questions, read, study and
travel in order to make a
success of their particular
project. I think of members
who turn out faithfully for
chapter meetings on nights
when the roads are bad or
they are tired after a
particularly demanding shift.
I realize that these nurses
are unusual: commitment at
this level is a rare and special
thing. And I think, yes, I am
lucky to have the chance to
get to know these nurses.
And, what is more important,
their colleagues and their
clients are lucky that nurses
like these exist and that they
still care.
Photo by Studio Impact
M.A.B.
Then, in March, help us
celebrate CNJ s 75th
anniversary three score
years and fifteen of providing
Canadian nurses with the
latest in nursing news.
In April, CNJ marches to
the tune of the health
enthusiasts with a special
fitness and lifestyle issue-. This
one promises to be a
collector s item: it s a lifestyle
approach that s tailored to
your unique needs and
interests as a member of one
of the health-giving
professions nursing. *
The Canadian Nurse
January 1980 5
news
Quebec nurses pay tribute to children
round the world
Choosing the central theme of
a tribute to the International
Year of the Child, theOrdre
des infirmieres et infirmiers du
Quebec held their annual
meeting in Montreal last
November. In an opening
ceremony attended by some
1000 nurses, 80 Montreal
schoolchildren, each carrying
a flag representing the country
of his national origin, were
introduced to symbolize
children everywhere. The
guest of honor was Dr.
Estafanis Aldaba-Lim,
assistant secretary general of
the UN and special
representative for the Year of
the Child.
With I YC nearly over,
Dr. Lim focused her attention
on the work that had been
done during the past year but
she emphasized that the spirit
of I YC must not be allowed to
die, the work must carry on.
She called upon the nurses of
Canada to continue their role
of commitment, cooperation
and leadership to ensure the
well-being of children.
Following Dr. Lim s
speech, Nicole David, clinical
nurse specialist in pediatrics
at Maisonneuve-Rosemont
Hospital, gave a presentation
on one aspect of the nurse s
role in the community, dealing
with the problem of child
abuse. She said that the
problem is much larger than it
appears: the awesome
statistics of maltreated
children represent only the
cases that are reported, not
the actual number. She said
that nurses must examine
closely the kind of parent
model they are propagating in
their practice. The nurse s
role in the prevention of child
abuse cannot be ignored
either, she said; problems can
be picked up even in prenatal
classes and in the immediate
perinatal period, as well as
later in a child s life at home,
in schools or clinics.
Two other presentations
were of interest: RobertGary,
a specialist in Asian life,
discussed the Chinese outlook
on health care, and Michel
Roy, editor of Le Devoir,
spoke on the image of the
nurse in the media.
Resolutions
During the conference,
Quebec nursing delegates
passed a vote to raise their
membership fees by $57,
bringing the total fee for 1980
to $147. Some delegates had
promised their sections that
they would not favor an
increase, but they recognized
that the OIIQ was in a difficult
financial situation with an
accumulated deficit of
$1,285,473.
Other proposals included
the request that the Order s
publication Nursing Quebec
take a more active role in
providing information to
members. Delegates asked too
that the Order reinforce its
liaison role, and apply
pressure in the university
setting to contribute to issues
of nursing education. It was
proposed also that the
contribution of Quebec nurses
to the CNA be proportional to
the number of nurses in other
provinces.
Attitudes
Of particular interest to many
delegates was the presentation
of a report by Secor Inc.,
commissioned by the OIIQ to
research the Quebec nurses
self image. A representative of
the firm, a Montreal-based
organizational consulting
company, cautioned nurses
against interpreting the report
too negatively . The basic
conclusion, after analyzing
the results of a mail
questionnaire returned by
2 157 Quebec nurses, was that
the level of professional
satisfaction is quite high. If
they had to do it over again,
three out of five of the
responding nurses said they
would choose the same
profession. More than
two-thirds of the nurses said
that they were satisfied with
their jobs 70 per cent of the
time, although the younger
nursing graduates tended to be
less satisfied. Less positive
statements appeared when the
nurses were asked about the
perception of their role by the
public and doctors. Fifty-two
per cent of the respondents
said that in practice, doctors
didn t differentiate between
RN s and auxiliary nurses.
Further, as far as the average
patient could see, nurses were
nothing more than doctors
assistants, claimed 59 per cent
of the nurses.
President Jeannine
Tellier-Cormiermade special
note of the report s conclusion
that nurses tended to be
poorly informed and had
difficulty getting away from
their work to attend
professional meetings; she
said that the Order intends to
undertake an in-depth study
based on this important
report.
The next annual meeting
of the OIIQ will be held in
Montreal, November 5 to 7,
1980.
CNA MEMBERS AND
ASSOCIATION
MEMBERS
CNA members and association
members are invited to submit
resolutions for presentation at
the Annual Meeting and
Convention, June 1980.
Resolutions must be signed by a
CNA member and forwarded to
the Resolutions Committee, CNA
House by 31 March 1980.
Resolutions received after 31
March 1980 cannot be presented
to the annual meeting.
6 January 1980
CNA directors ready for 1980
Health Minister fields questions
A visit from Canada s Minister of Health to explain plans for the
proposed National Health Care Institute and to answer questions from
CNA directors about the current review of public health insurance plans
in Canada was one of the highlights of the last regularly scheduled 1 979
meeting of the Board of Directors of the Canadian Nurses Association.
Directors, too, were looking ahead, trying to determine the
direction that growth and development within the nursing profession
should take in the eighties. Based on their decisions at the October
meeting at CNA House in Ottawa, nurses can anticipate action on their
behalf this year on at least four fronts all related, either directly or
indirectly, to nursing education and to nursing practice.
Getting going
The first of these, "Operation Bootstrap", is a short term funding
proposal aimed at developing a nation-wide systematic plan for
improving the basis of nursing practice in Canada. The project, which
carries a price tag of just over $5 million, calls for CNA to establish a
seven-member Operation Bootstrap Committee consisting of
representatives of CNA, the Canadian Nurses Foundation (CNF) and
the Canadian Association of University Schools of Nursing (CAUSN).
The author of the preliminary report on Operation Bootstrap, Dr.
Shirley M. Stinson, president-elect of CNA, explained to directors that
the choice of name for the project was deliberate. "The nursing
profession must itself take the initiative to get going using whatever
resources it can currently muster and within whatever constraints
currently exist. " The committee will be responsible for carrying out the
preparatory phases of all five steps of the project:
obtaining "starter grants" for establishing a PhD nursing program
assisting interested institutions in obtaining initial funding for at
least two nursing research centers
obtaining funds to introduce a Communicating Nursing Research
project
creation of a reliable system for obtaining essential data on
Canadian nurses with doctoral preparation, and
setting up an emergency doctoral fellowship program.
The proposal is an outgrowth of the Kellogg National Seminar on
Dbctoral Preparation for Canadian nurses which took place in Ottawa in
November, 1978.
Funding for Operation Bootstrap will be sought from the W.K.
Kellogg Foundation, "the single most important outside source of funds
in the history of Canadian nursing".
Accreditation
Another long term project, accreditation of nursing education programs,
will also be submitted to the Kellogg Foundation for possible funding as
a result of a decision of CNA directors. A request from the association s
ad hoc committee on accreditation that directors re-affirm the priority of
this project was, however, turned down by the board.
Health and Welfare Minister David Crombiejoined directors of
the Canadian Nurses Association for a question and answer
session during their recent three-day board meeting. Pictured
above are (left to right): Dr. Shirley M. Stinson, CNA
president-elect; Mr. Crombie; Helen Taylor, president of CNA;
Dr. Helen Mussallem, executive director of CNA and Sheila
O Neill, the association s first vice-president.
Continuing education
A third area which directors agreed should receive special attention in
1 980 is that of continuing education. Members gave their wholehearted
support to a resolution arising out of the National Continuing Education
Conference in Winnipeg last Spring (see The Canadian Nurse June
1 979) and supported by various provincial associations, "that 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 1980-82 biennium." Directors agreed that, although they were
not in a position to make a commitment on behalf of the board which will
be elected for the coming biennium, they could and should endorse the
presentation of this resolution to the first meeting of the new board
following the CNA annual meeting in Vancouver in June.
Standards
Members of the board were brought up-to-date on work on development
of a definition of nursing practice and standards for nursing practice,
recognized by CNA directors and membership as a priority in 1 979. The
project director reported that a seven-member task group is now
meeting on a monthly basis in preparation for release of the final report
in June, 1980.
Ministerial visit
Recently appointed Minister of National Health and Welfare, the
Honorable David Crombie, joined CNA directors for lunch on the second
day of the meeting. The occasion marked the first official visit of a
Minister of Health and Welfare to the headquarters of Canada s national
organization of professional nursing associations.
In response to questions from the CNA directors, the Minister
described some of the concerns prompting the current review of the
status of publicly financed health insurance programs in Canada and
said that the responsibility of the federal government in developing
alternate methods of health care services and delivery systems, the cost
of services and project funding will be determined after the Hall
Commission review has been completed.
Mr. Crombie agreed with CNA directors who argued that the review
to be carried out under the direction of Mr. Justice Emmett Hall should
be called a report on "health care services 79", a term the directors
preferred to "medicare". He emphasized that the Hall Commission is not
a Royal Commission and that its terms of reference have an overriding
objective to achieve more efficient health care delivery at less cost
while still maintaining quality. Directors informed the minister that CNA
would be submitting a brief to be considered in the review process and
that work has already begun on this project.
Mr. Crombie also discussed his proposal to establish a National
Health Care Institute of Canada, an independent, non-profit corporation
whose purpose would be to serve as a clearinghouse for information on
the Canadian health system, monitor national health needs and report
their assessment of the effectiveness of the system in meeting these
needs. He described the institute as "an objective third-party that will
guard the interests of users and providers of services."
Mr. Crombie and the directors discussed the expanding role of the
nurse as well as federal and provincial responsibilities related to health
care services. The minister said that he has been and will continue to
meet with natbnal health care organizations to establish productive
working relationships.
Other business
Directors approved a resolution requesting the Canadian Institute of
Child Health to convene a task force whose members would investigate
the redefinition of roles of the nurse and physician in the light of changes
that are occurring in maternity care in Canada today. Members of the
task force would also be asked to look at the changing role of the
nurse-midwife.
Members of the board welcomed two new directors to their Fall
meeting : Stephany Grasset and Jeanette Pick, presidents of the British
Columbia and Alberta associations respectively. NBARN executive
director, Bonnie Hoyt, was also attending her first CNA board meeting as
provincial adviser.
The Canadian Nurse
January 1980 7
Some people need
to be cared for. Others
need a chance to care.
Upjohn Healthcare Services
brings them together.
r
In 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 bring them together.
Upjohn HealthCare Services" 1 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 kind of joboppor-
tunity. If you do, please pass this message
along. For additional information, com
plete the coupon below, or call our local
office listed in your telephone directory.
UPJOHN
HEALTHCARE
SERVICES 5 "
Please send me your free brochures (check one or both):
D "Nursing and Home Care"
D "Nursing Opportunities at Upjohn HealthCare Services
Name
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Mail to: Upjohn HealthCare Services
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716 Gordon Baker Road, Suite 203
Willowdale, Ontario M2H3B4
HM 6410-C 1979 HealthCare Services Upjohn, Ltd.
CNA executive director addresses
"nurses in the marketplace"
"Creative caring" was the
theme of the 8th annual
Ontario Occupational Health
Nurses Conference held in
Toronto last October and
attended by close to 400
nurses. Dr. Helen Mussallem,
executive director of the
Canadian Nurses Association,
gave the keynote address. Her
speech prompted a standing
ovation and comments
afterwards on the "exciting"
quality of her address.
Dr. Mussallem said she
believes that occupational
health nurses have perhaps
"the greatest and most unique
opportunity to demonstrate
and be involved in creative
caring." The promotion of
"healthful lifestyles" is
important, she said, rather
than concentration solely on
the curing of illness . Dr.
Mussallem regretted that the
true "potential of nurses has
never been realized... nurses
are trapped in bureaucratic
systems in the hospital and in
the community." She closed
by saying that in life the tragic
people are those who "elect to
be spectators" while
occupational health nurses are
in the dramatic position of
practicing creative caring "in
the marketplace".
Occupational health
nurses are often the first
contact an employee has with
a health professional; these
nurses therefore feel the need
to be aware of all the
possibilities in illness or
dysfunction and all the
resources available to them.
The choice of speakers for the
conference reflected this
concern: presentations
included an overview of
communication techniques for
use in relationship therapy,
the importance of
pre-retirement counseling and
a discussion by Dr. John
Jameson of Toronto on
common phobias and their
treatment.
One of the problems
commonly experienced by
OHN s is a result of their
position vis a vis management
and fellow employees;
difficulties are encountered in
getting health programs "off
the ground", and employees
frequently see the nurse as
part of management with
whom they do not feel free to
discuss personal problems.
Evidence of this problem
surfaced when Justice Horace
Krever spoke about the
confidentiality of medical
records and nurses in the
audience told him they are
often under pressure to reveal
confidential information to
employers. Justice Krever
asked the nurses to send him
more information.
A presentation entitled
Management s View of the
Nurse was given by Dr. G.H.
Collings, medical director of
New York Telephone. Dr.
Collings stated that the image
of an industrial health service
ranged from that of a regular
department with its own
important function to that of a
mere overhead expense
required by law. The nurse s
role varies correspondingly,
he said, from a skilled worker
with no influence to an
integral member of the
management team. To be fair,
Dr. Collings said, "only rarely
can a business afford the
generosity of affording
services that are not directly
aimed at running the
business." He emphasized
that the nurse must
understand this and work not
only at providing good health
care to the employees but also
offering the company realistic
help that it cannot refuse on
economic grounds. In short,
he said, how management
views the company nurse is in
fact, up to the nurse.
Columnist Corinne Sklar, author of You and the law,
will return next month with another of her regular
columns on legal issues affecting the nursing
profession.
January 1980
The Canadian Nurse
FOR
THE
CANADIAN
NURSE
Lippincott
J. B. LIPPINCOTT COMPANY OF CANADA LTD.
Serving the Health Professions in Canada Since 1897
75 Horner Ave., Toronto, Ontario M8Z 4X7
1 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.
With nine contributors.
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. Every chapter in every
area has been updated and expanded. Numerous new
procedure-guidelines (more than 60!) along with nursing
care and management sections and treatment modalities
have been added. Over 100 superb new illustrations
beautifully complement the text. What this means is
more detailed, substantive, and complete coverage of
every phase of medical/surgical, maternity, and pediatric
nursing!
Lippincott. 1,868 Pages. Illustrated. 1978. $32.25.
2 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 a group of
concerned, dedicated nurses who have gone quietly about the business
of caring for sick people and noting little tricks (actually innovative
solutions) that seemed to make things work better. Their discoveries
or "pearls" are shared with you in an organized fashion, with the
rationale for each nursing action clearly explained. Numerous illustra
tions accompany the text.
Lippincott. 250 Pages.
Illustrated. Sept. 1979. $10.50.
3 NURSES DRUG REFERENCE
Edited by Stewart M. Brooks, M.S.
Little, Brown. 625 Pages.
1978. $14.50.
4 NURSING MANAGEMENT FOR
THE ELDERLY
By Doris Carnevali, B.S., M.N.;and Maxine
Lambfecht Patrick, B.S.N. , M.S.N., D.P.H.
Lippincott. 570 Pages.
Sept. 1979. $22.50.
5 GERONTOLOGICAL NURSING
By Charlotte K. Eliopoulos, R.N., M.S.
Harper & Row. 384 Pages.
Illustrated. 1979. $15.00.
6 A GUIDE TO PHYSICAL
EXAMINATION, 2nd Edition
By Barbara Bates, M.D.
Lippincott. 440 Pages.
Illustrated. 1979. $27.00.
J. B. LIPPINCOTT COMPANY OF CANADA LTD.
75 Horner Ave., Toronto, Ontario M8Z 4X7
Please send the following for 15 days on approval :
1 23456
D Lippincott Nursing Catalogue
D Payment enclosed (postage and handling paid)
D Bill me (plus postage & handling)
Name _
Address .
City
Prov.
Postal Code .
Prices subject to change without notice.
CN1/80
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.
The Canadian Nurse
January 1980 9
Enterostomal
therapists
hold Canadian meeting
The 12th annual conference of
the International Association
of Enterostomal Therapists
(IAET) will take place next
year in Washington, DC, from
May 22 to 25.
Last year s conference,
in May 1979, was a huge
success, drawing 500
registrants from Canada, the
US, Mexico, Sweden,
Australia, Germany and South
Africa. The event, which was
held in Vancouver, was
hosted by the British
Columbia ET group. More
than half of the total Canadian
membership of close to 100
ET s were in attendance.
Nurses interested in
obtaining more information
about the Canadian branch of
the ET s should contact Linda
Thomas, public relations
chairman, 3768 Bathurst
Street, Apt. 214, Toronto,
Ontario, M3H 3M7.
Any Question About Pediatric
Nursing? The Department of
Nursing of the Hospital for Sick
Children, Toronto, would like to
help. Nurses are invited to call for
information or consultation . Call
the Medical Information Center
(416) 597-1500, Extension 2620
and you will be referred to the
appropriate resource nurse.
Torture and the nurse
The Canadian Medical Group,
part of Amnesty International,
has sponsored a seminar for
health professionals dealing
with the victims of political
torture. The meeting took
place in Toronto last October.
A number of nurses attended
the seminar and in groups
discussed the role of the nurse
in the rehabilitation and
treatment of torture victims.
Sponsors pointed out that
nurses and doctors in Canada
deal with torture on two
levels: in treating the victims
as they arrive in Canada from
other countries, and in
collaborating with
professionals from nations
where torture is prevalent.
Topics of discussion
ranged from the physical and
psychological results of
torture, and proposed
government response to
refugee applications where
torture has been medically
assessed.
Did you know...
Vancouver s St. Paul s Hospital
has now certified 38 enterostomal
therapists, all graduates of their
Enterostomal Therapy
Educational Program for Nurses.
The only Canadian I.A.E.T.
approved program currently
available, St. Paul s is now
accepting applications for the
seven week program beginning
November 3, 1980.
Notice of meeting
CANADIAN NURSES
FOUND A TION
In accordance with Bylaw, Section 36, notice is given of an
annual general meeting to be held on Sunday, 22 June 1980,
commencing at 14:00 at the Hyatt Regency Hotel, Plaza
Ballroom, (East/Center), Vancouver, British Columbia.
The purpose of the meeting is to receive and consider the
income and expenditure account, balance sheet and annual
reports.
The election of the CNF Board of Directors for the 1980-82 term
of office will be conducted during the meeting.
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
Nurses in the news
Helen Glass, director of the
School of Nursing, University
of Manitoba was awarded the
YWCA Woman of the Year
award for Education. She is
nationally and internationally
recognized for her work as a
nursing educator and has
made a significant impact on
the nursing profession as a
whole. Glass is a strong
protagonist on behalf of
women s rights and for the
professional status of nursing.
Jeanette Pick, president of the
Alberta Association of
Registered Nurses, was one of
six "Women of the Year"
honored last Fall by the
Calgary branch of the YMCA.
Pick, who is assistant director
at the Foothills Hospital
School of Nursing, was
winner in the health category
of the awards which were
given to mark "50 years of
personhood".
Marie-Therese Laliberte, a
Master s level student at the
Faculty of Nursing,
University of Montreal, was
recently awarded a
Warner-Lambert Canada
Limited nursing fellowship
award by the Parke-Davis
Division. This $750 grant is
made to selected candidates
for the degree of Master of
Science in Nursing at
Canadian universities.
Eleanor Nolan and Elizabeth
Cochrane, who have been
awarded the 1979 Judy Hill
Memorial Scholarship, will
each receive $3500 to continue
their nursing education for
eventual service in the
Canadian Arctic. Eleanor
Nolan, who began her nursing
service in St. John s, Nfld.,
has worked in Labrador,
Frobisher Bay, Australia and
Ireland. She is enrolled in the
Outpost Nursing and
Midwifery program at
Memorial University, Nfld.
Elizabeth Cochrane, a
graduate of Conestoga
College, Kitchener, Ontario,
is presently studying
midwifery at the Aberdeen
Maternity Hospital, Scotland.
The New Brunswick
Association of Registered
Nurses has announced the
names of 1 1 scholarship
recipients for the 1979-80
year. These scholarships are
awarded on the condition that
the recipient work in New
Brunswick for a specified
period of time after
graduation.
Karon Croll was awarded
$1250 for studies toward a
Doctorate in Adult Education
at Florida State University
and Lynne McGuire, who is
enrolled in the Master s in
Education of Nursing
Program at the University of
New Brunswick, received a
$750 scholarship.
The Muriel Archibald
Scholarship, valued at $1200
will be shared equally by
Frankie Fung, RN, Saint John
and Nicole Roy
RN, Shediac, who are
working towards their
Baccalaureate of Nursing
Degrees at the University of
New Brunswick and the
Universite de Moncton,
respectively.
NBARN scholarships
valued between $300 and $775
have been awarded to the
following who are studying
towards a Baccalaureate of
Nursing Degree: Jane Bartlett,
Woodstock; Elaine Bell,
Woodstock; Pierrette Brun,
Cap-Pele; Sylvie Parise,
Caraquet; Sandra Stever,
Bathurst; Francine Thibault,
Ste. Anne de Madawaska;
Mariette LeBlanc, Moncton.
Did you know...
A 42-year-old grandmother from
Windsor, Ontario, was among 32
Canadians who received bursaries
from the St. John Ambulance last
year, enabling them to pursue or
advance their nursing careers.
Marilyn Roberts, mother of five
and grandmother of four children,
was awarded the Margaret
MacLaren Memorial Bursary in
August and is now attending St.
Clair College in Windsor. Nine
other winners are taking post
basic training and one is studying
for her Master s. Deadline for
applications for this year s
bursaries is May 1, 1980. Write:
St. John Ambulance, National
Headquarters, P.O. Box 388,
Terminal A , Ottawa, Ontario,
KIN 8V4.*
10 January 1980
The Canadian Nurse
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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.
What s more, Zincofax is economical, even more
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Please see special introductory offer
in the back of this magazine.
Contains Anhydrous Lanolin and 15% Zinc Oxide.
Available in 10 and 50 g tubes and 1 15 g and 450 g jars.
Trade Mark kcrpl W-8005
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RESERVE NOW
Post convention
tours
CNA moves West for 1980 meetin
Today s issues - tomorrow s nursin
Plan your holidays around the
convention! Post convention tours and
travel packages* now being arranged
include:
Hawaii
San Francisco
14 days $600-900
4 days $290
8 days $440
7 nights $300
1-3 days from $40
Reno - Tahoe
Seattle
Alaska
"The Island Princess cruise"
June 27- July 5
U.S. $1500-1600
Victoria 1 -3 days from $40
The Royal Hudson Steam Train
Excursion 1 hours $30
Details will be in the February issue of
The Canadian Nurse and advance
reservations will be essential.
In the meantime, the RNABC Hosting
Committe e needs your help in estimating
demand.
Cut and return to:
RNABC Hosting Committee
2130 West 12 Avenue
Vancouver, B.C.
V6K 2N3
Yes, I am planning to extend my stay.
I want to tour (list choices)
(1)
(2)
(3).
The time I have is
Name.
Address -
I
Something for everyone. That s the
claim of this year s program
organizers who have been hard at
work on planning an action-packed
agenda for CNA s annual meeting
and convention in Vancouver.
Highlights will include:
A special Kellogg Lecture on the
nurse s role in delivering primary health
care by Dr. Lea Zwanger, head of the
division of Allied health professions,
Ministry of Health, Tel Aviv, Israel,
"Who shapes nursing in the
eighties?", the keynote address for the
convention, will be delivered by Lorine
Besel, director of nursing at the Royal
Victoria Hospital in Montreal.
A special session on the health care
dollar featuring a noted commentator
from the Canadian economic scene.
A panel presentation on the labor
movement vis a vis the professional
association featuring discussion between
a labor analyst and two members of the
nursing profession.
A debate on the always
controversial question of mandatory
versus voluntary continuing education.
Asocial program that will include a
wine and cheese reception as well as a
dinner featuring entertainment with a
B.C. flavor.
I This year s theme Today s
I issues tomorrow s nursing
leaves no doubt about the relevance
I of the 1980 program. So, plan on
keeping up, keeping informed.
\ Make sure you re there.
REGISTER ME
NOW
forCNA s
Annual meeting and convention
Hyatt Regency Hotel
Vancouver, B.C.
June 22-25, 1980.
Registration Fee
(includes Monday luncheon and Tuesday
dinner)
Three days Daily rate
CN A member $100/ 40
Non-member $150/ 60
Nursing student $40/ 20
I wish to attend (days circled)
Monday
Tuesday
Wednesday
Please mail my receipt, admission card
with convention kit, ticket and
procedure for registration to:
Name.
( Surname first) .
Address.
Present employer.
I Prov/TerrofReg n.
Reg n No. .
1 enclose cheque or money order payable
to Canadian Nurses Association, 50 The
Driveway, Ottawa, Ontario, K.2P 1E2.
I 1 wish to receive a reservation card
for accommodation at the Hyatt Regency.
(See December CNJ for details of other
accommodation)
names & faces
Stephany Grasset of
Vancouver has been elected
president of the RNABC for a
two year term. A nursing
instructor at the British
Columbia Institute of
Technology, she has a long
record of participation in
association affairs and is
experienced in both hospital
and public health nursing.
Heather Caloren, BScN,
MScN, has been appointed
Assistant Director - Nursing
Service for the Elderly with
the Victorian Order of Nurses
for Canada. A graduate of the
University of Toronto School
of Nursing, she will be
providing advisory and
consultative services related
to program development at
the branch level, developing
and establishing educational
programs for VON staff and
maintaining liaison with
government departments and
other voluntary agencies.
The Edith Dick Fund has been
established in memory of the
life and work of the late Edith
RainsfordDick, an inspector
and director with the Ontario
Department of Health from
1932 until 1964. Widely
respected for her contribution
to health services and nursing
in Ontario and Canada, her
efforts in the Second World
War were recognized by King
George VI in 1944 with the
Royal Red Cross, first class.
The fund will be administered
by the RNAO Foundation to
develop and promote nursing
practice in response to
changing health needs.
Carol Hoganson, RN , a former
employee of the Halifax
Infirmary operating room, has
won the Deknatel Educational
Award for Canada for her
invention of an intravenous
clamp which more accurately
controls the flow of
intravenous solutions.
Western Australian Institute of Technology
Department of Nursing
SENIOR TUTOR/LECTURER - COMMUNITY
HEALTH NURSING (Ref. 248)
Teach and arrange clinical placements for nursing
students in the diploma and Bachelor of Applied
Science courses (Community Nursing Practice).
Applicants must be registered general nurses with
recent experience of health care delivery in com
munity settings. Preference given to applicants with
degree or additional appropriate qualification.
Salary Range: Lecturer: SC21.067 $27,677 Senior Tutor:
SCI 8, 158 SC20.801 (October 26 Exchange Ratel
Tenure: The above position is available with permanent tenure.
However the Institute is interested in receiving applications from
persons preferring a limited term appointment.
Condition* Include: Four weeks annual leave, fares for appointee and
family plus some assistance for removal expenses Superannuation
is available for staff with permanent Tenure. Return fares are provided
for staff appointed for a Limited Term.
Applications: Detailed application including the names and addresses
of three referees should be submitted not later than 31st January to
the Appointments Officer, Western Australian Institute of Technology,
Hayman Road, South Bentley 6102, Western Australia.
When applying please quote position reference number and media
code CN3.
Donna Meagher (B.Sc.N.,
Mount St. Vincent
University) and Sheila Ross
(B.N., McGill University)
both of Halifax, are
co-winners of the Frances
MacDonald Moss Scholarship
awarded annually by the
Registered Nurses
Association of Nova Scotia.
The scholarship of not less
than $3000 is awarded to
members of the Association
wishing to undertake further
education in nursing. The
winners will each receive
$1500.
Meagher, currently on
the Faculty of the School of
Nursing at Dalhousie
University will begin studies
for a Master s degree in
Health Sciences at McMaster
University, Hamilton,
Ontario. Ross, who is
assistant director of nursing at
the VictoriaGeneral Hospital,
Halifax will begin studies for
an M.N . at the Dalhousie
School of Nursing.
Sister Anne Deas, s.s.a..
formerly Director of Nursing,
St. Joseph s Hospital,
Victoria and St. Boniface
General Hospital, Winnipeg,
has been appointed Director
of Nursing, St. Paul s
Hospital (Grey Nuns ) of
Saskatoon, Saskatchewan.
She is a graduate of Gonzaga
University, Spokane,
Washington (BScN), and the
Catholic University of
America in Washington D.C.
(Master of Nursing Service
Administration).
Jean Rose has been appointed
to the position of Nursing
Consultant-Education with
the Association of Registered
Nurses of Newfoundland. A
graduate of Sydney City
Hospital School of Nursing,
Sydney, N.S., Dalhousie
University (B.N.) and Boston
University School of Nursing,
Boston, Mass. (M.Sc.N.), she
has had a variety of clinical
experience and has chaired
the Nursing Education
Committee of the RNANS
and the Nursing Education
Committee of the College of
Cape Breton, N.S.
Mary E. Murphy has recently
been appointed
Vice-President, Nursing at the
Vancouver General Hospital.
A graduate of St. Joseph s
School of Nursing, London,
Ontario; University of
Windsor (BScN) and the
University of Ottawa (MHA),
she has held many
supervisory and
administrative positions. Most
recently, she has been
Vice-President, Nursing with
the University of Alberta
Hospital in Edmonton,
Alberta.
Always active in her
professional associations,
Murphy is currently Chairman
of the Ad Hoc Committee on
Graduate Education of the
Alberta Association of
Registered Nurses.
Thelma Jane May (R.N.,
School of Nursing, Hospital
for Sick Children; B.Sc.N.,
University of Toronto) has
been appointed director,
Nursing Service at the
Bloorview Children s
Hospital, Toronto. She first
went to Bloorview in 1975 and
since then has served as
administrative supervisor and
assistant director of Nursing
Service. Previously, May held
administrative positions at the
Hospital for Sick Children and
at Women s College Hospital
in Toronto.
May is also actively
involved in the St. John
Ambulance Brigade and is
currently chairman of the
Nursing Advisory Committee
of that association.
Rosette Leduc-Grand Maison
has received the United
Nurses Award of Merit for
having rescued a child from
drowning in 1978. The United
Nurses Inc., P.Q., annually
honors a nurse whose
achievement during the past
year has warranted public
recognition and has enhanced
the profession of nursing.
Certificates of merit have also
been awarded to Diane Roy of
Ste-Justine Hospital and
Yvette Pratte-Marchessault of
Notre Dame Hospital,
Montreal.
14 January 1980
Tha Canadian Nuraa
Margaret Scott Wright, the
present director of the School
of Nursing at Dalhousie
University, Halifax has been
appointed dean of nursing at
the University of Calgary.
Scott Wright obtained her
doctor of philosophy degree in
the faculty of medicine at the
University of Edinburgh
where she later became
director of the department of
nursing studies in the faculty
of social science. In addition
to serving on many
government and professional
committees in the U.K. and
Europe, she was
vice-president of the
Internationa] Council of
Nurses and acted as an
advisor and consultant to the
World Health Organization on
many occasions.
Scott Wright begins her
five year appointment as dean
of nursing at U of C on Sept.
1, 1979 succeeding Marguerite
Schumacher who will remain
in the faculty.
Joyce Perrin, BScN, DHA,
has recently been appointed to
the position of administrator
of the Bloorview Children s
Hospital, Willowdale,
Ontario . A graduate of the
University of Alberta School
of Nursing and the University
of Toronto School of Hospital
Administration, she has held
many nursing and
administrative positions, most
recently Assistant Executive
Director of the Canadian
Council on Hospital
Accreditation.
Three Alberta nurses received
scholarships from the
professional association in
that province this year.
AARN scholarship winners
are: Walter Bredlow and Linda
Reutter. Bredlow, a clinical
nurse specialist in Medicine
Hat, is now enrolled in the
second year of a doctoral
program in marital and family
therapy in California; Linda
Reutter, a community health
nurse in Edmonton, has
entered the University of
Colorado this Fall to complete
a Master of Science degree in
Community Health Nursing.
A third scholarship was
received by Elizabeth
Millham, instructor/
coordinator at the Holy Cross
School of Nursing in Calgary,
now enrolled in the final year
of a Masters in Educational
Administration Program at the
University of Calgary.
Irene Ross McPhail, R.N., was
recently elected president of
the St. John Ambulance
Federal District Council, the
first time that this position has
been held by a woman.
McPhail, a graduate of the
University of Alberta Hospital
and the Medical Centre of
Cornell University, joined the
Federal District Council in
1964 as provincial nursing
officer and two years later
became the provincial
superintendent of nursing. In
1972 she was appointed
provincial commissioner
another first for a woman.
Apart from her
outstanding service to the
Federal District Council,
McPhail has also contributed
substantially at the national
level. Through her active
interest in the field of health
care, she has provided
valuable consultation in the
development of the expanded
St. John Ambulance home
nursing program.
In recognition of her
contributions to St. John
Ambulance, McPhail holds the
grade ofDame ofGrace. one of
the highest honors awarded by
the Order of St. John.
Carol Roberts, a graduate of
the Royal Victoria Hospital
School of Nursing, Memorial
University (B.N.) and Boston
University, Mass. (M.Sc.N.)
has been appointed Nursing
Consultant-Practice with the
Association of Registered
Nurses of Newfoundland. She
has worked in various
capacities in medical, surgical
and pediatric nursing and
most recently taught
medical-surgical nursing at the
University of Ottawa School
of Nursing.
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PARKE-DAVIS
Back to basics, nursing educators face up
to needs of the eighties
Reaction panel members at CNA s national forum on nursing education were (left
to right): JocelynHezekiah, Cecile Lambert, keynote speaker Alice Baumgart,
chairman Margaret McCrady, Dorothy Kergin and Ann Hilton.
Canada s top nursing educators, faced
with the warning that they do not have
unlimited time to debate the issues
involved in preparing tomorrow s
practitioners, came up against a wall of
words at their first national seminar in
Ottawa in mid-November.
The warning that the clock was
running out came on the first day of the
three-day conference and was delivered
by keynote speaker, Alice M. Baumgart,
dean and professor at Queen s
University School of Nursing in
Kingston, Ontario. Baumgart reminded
her 350 fellow nurses attending the
meeting of "the growing urgency of
setting out clearly the differences in the
roles and competencies of the various
types of nursing practitioners."
"Time is running out for nursing to
put its educational house in order," she
warned. "Out of enlightened
self-interest, nursing educators should
get on with this task. Otherwise,
necessary choices will be made
increasingly by others, often to the
detriment of nursing and patient care."
Baumgart called on nurses to begin
work on the development of a
"comprehensive and long term systems
approach" to planning basic nursing
education and predicted that critical
questions related to basic nursing
education in the eighties will center
around the overall responsibilities of the
system, specifically, the problems of
managing with increasingly limited
resources and the need to develop
political processes that encourage
responsiveness and accommodation,
rather than confrontation and restricted
action.
The National Forum on Nursing
Education, the first of its kind in Canada,
was sponsored by the Canadian Nurses
Association and grew out of a resolution
approved by delegates to CNA s annual
meeting in Toronto last June. More than
200 of the 343 participants were
educators who represented a total of 41
community colleges, 22 university
schools of nursing and 21 hospital
schools of nursing from right across the
country.
The conference theme, "The nature
of nursing education", gave rise to
speeches and debate on the following
subjects:
basic nursing education
implementing the curriculum based
n a nursing model
basic nursing service
nursing skills/competencies
perceptions of the new practitioner
specialization in nursing
national accreditation of nursing
education programs.
In the end, following three days of
discussion, delegates approved the
principle of holding other similar
conferences on nursing education, with
the proviso that in the future one or two
issues be chosen for examination at each
conference. They suggested that the
focus for the next conference should be
an examination of the clinical component
in basic nursing programs.
Speakers taking part in the panel
discussion that followed the keynote
address focused on some of the key
issues facing nurse educators today.
"Nurses must realize they cannot be all
things to all people," Dorothy Kergin,
director of the University of Victoria
School of Nursing, warned her audience.
The former associate dean of Health
Sciences (Nursing) at McMaster
University spoke of the growing need for
collaboration and close working
relationships between nurse
practitioners and educators. Two of the
critical questions that nurses must ask
themselves, she said, are who is going to
set standards for nursing education and
what are the health needs that nursing
must address.
The three other members of the
panel included the president of the
Registered Nurses Association of
Ontario, Jocelyn Hezekiah, who is
chairman of basic nursing programs in
the Health Sciences Division of Humber
College of Applied Arts and Technology
in Toronto; Cecile Lambert, professor at
Maisonneuve College in Montreal and
provincial coordinator for diploma
nursing programs in Quebec; and Ann
Hilton, assistant professor, Faculty of
Nursing at the University of British
Columbia.
What is nursing?
"What is a nurse, what does a nurse
do?" The answer, according to Evelyn
Adam, associate professor of nursing at
the University of Montreal, lies in our
mental picture of nursing, how we
conceptualize our profession. Nurses
now want recognition of not only their
dependent role, but also their
independent or autonomous role a
role which is not entirely clear and
therefore not easily communicated to
others. The solution according to Adam,
whose address was titled "Issues in
implementing the curriculum based on a
nursing model", lies in adoption of a
conceptual model, ie. a way of looking at
nursing that is precise and explicit
enough to give nurses direction for
practice, education and research.
Nursing skills and service
Four nurses, Marie Cruise, Ginette
Rodger, Lucille Parent and Marie White,
presented four different aspects of
"Nursing service what is it?" on the
morning of the second day of the
conference. Marie White, director of
inservice education at Sir Thomas
Roddick Hospital in Stephenville,
Newfoundland, spoke on nursing service
IB Janimrv 1000
ThC
Nurse
Evelyn Adam
in a small hospital and commented that
the character of service depends on a
number of factors such as management
philosophy, accreditation status and
available manpower. She said that
nurses told her they felt nursing service
was becoming more task-oriented
because of manpower constraints, and
many felt unhappy that they were
performing those tasks for which they
would be held accountable by
supervisory staff in other words, they
were "just doing the things that
showed". In discussion afterward, Alice
Baumgart commented that nurses were
still performing the "housewife and
mother" function in health care, keeping
everything together and going. Ginette
Rodger, director of nursing at Notre
Dame Hospital in Montreal, said that "it
is useless for us to get together like this
(nursing service and educators) and just
complain at each other," and she added
that practice and education must go hand
in hand to keep pace with the kind of
service nurses wish to provide.
The theme of skills versus theory
continued when Margaret Steed,
associate professor at the University of
Alberta, gave a paper on "Whatever
happened to nursing skills?" She made
note of the controversy about the new
nursing graduates, that critics say
today s new grads are not prepared to do
real nursing . She acknowledged that
"the basic nursing programs cannot and
will not be able to provide all the skills
essential to work in health care." The
answer in part has been to develop the
trend toward competency-based
education which attempts to provide
graduates with marketable skills based
on the needs specific to a particular
situation. Steed concluded by saying that
educators cannot be smug about the
needs of the new nursing graduate, but
neither can those involved in nursing
practice fail to acknowledge the
necessity of a theoretical knowledge
base; education and service must work
together to build professional nursing
practice.
Following this presentation two
recent nursing graduates, Margaret
Edmonds, staff nurse at Victoria General
Hospital in B.C.. and Heather Smith,
who is studying for her post-RN BScN
degree, spoke on their experiences as
new practitioners; both stated that they
wondered if the transition from student
to graduate wouldn t have been easier if
they had had more clinical experience
during their education period. Patricia
Stanojevic, special projects officer at
George Brown College in Toronto, in her
paper "Reducing Reality Shock"
allowed that this phenomena was not
unique to nursing, that the graduates of
many professions experienced the same
Heather Smith
sort of feeling once thrust into the role of
practitioner. An RNAO project
investigating reality shock identified the
need to sensitize the nursing student to
the real world through planned learning
activities and the need for nursing
education programs and health care
agencies to work together to ease the
transition for new practitioners. This
might be accomplished through
individualized hospital orientation
programs, she said.
Margaret Edmonds
The nurse specialist
Specialization in nursing was the theme
of Madeleine Blais presentation on the
final morning of the conference. She
defined the nurse specialist as "one who
has acquired specific knowledge either
by formal education or by the kind of
experience which fosters the
development of specific knowledge and
skills." Blais is the nurse responsible for
nursing education research for the Order
of Nurses of Quebec, and is also
vice-president of the Commission for
Adult Education of the Quebec Council
of Advanced Education.
A chequered history
The notion of a system for the
accreditation of educational programs in
nursing goes back to the thirties when
nursing associations in this country first
suggested that there should be a body
charged with responsibility for
Dominion-wide registration for nurses.
The Canadian Nurses Association,
according to CNA s second
vice-president Myrtle Crawford, who is
also professor and assistant dean of the
College of Nursing of the University of
Saskatchewan, approved the principle of
accreditation in 1945 and, at that time,
set up the first of numerous committees
charged with examining the question.
Crawford described the procedure since
then as one of "alternately approving the
principle, appointing a committee or
study group to consider the question and
then, finally, backing away from the
decision."
Along the way there have been
several noteable landmarks, including an
evaluation of Canadian schools of
nursing carried out by the current
executive director of CNA, Helen
Mussallem, which resulted in publication
of the report, "Spotlight on nursing
education".
The most recent attempt involves an
ad hoc committee set up by CNA
directors in response to a resolution
passed at the association s 1978 annual
meeting. This committee, working with
representatives of the Canadian
Association of University Schools of
Nursing who have had an accreditation
project underway for several years, has
now come up with a proposal that CNA
directors approved at their last board
meeting. Funding for the project, which
will cost in the neighborhood of
$800,000, is being sought from the W.K.
Kellogg Foundation.
Crawford warned, however, that the
outlook for this proposal is "not over
whelmingly favorable" since the p.20>
Tha Canarilan MM
Mosby is the nursing publisher.
A New Book!
NURSING CARE
OF INFANTS
AND CHILDREN
By Lucille F. Whaley. R.N., M.S.
and Donna L. Wong. R.N.. M.N..
P.N.P.; with 5 contributors.
This outstanding volume
provides a comprehensive
approach to the care of the well,
ill and handicapped children.
By applying principles of
normal growth and develop
ment, it discusses the
implementation of physical
assessment in planning care
. . . offers a conceptual
understanding of pathologic
processes . . . and describes
those nursing interventions
essential to restoring health/
functioning.
Consistent throughout,
chapters reflect a dual concern
Of IM1TS
4DOHDK11
for promoting the health of the
well child and caring for the ill
or disabled child. Highlights
include:
a distributive nursing
care approach:
summaries of nursing
care that offer guidelines for
action follow major sections;
emphasis on and guide
lines for communicating with
children and their families;
lab data and pharmacol
ogy are incorporated
throughout.
Numerous quality tables
and illustrations clarify
common conditions and
nursing care. This volume
presents both an effective
developmental framework, and
a systems orientation. Why not
evaluate it for yourself?
March. 1979. 1,734 pages.
746 illustrations. Price. S26.50.
A New Book! FAMILY-
CENTERED MATERNITY/
NEWBORN CARE: A Basic
Text By Celeste R. Phillips,
R.N.. M.S. This modularized text
offers a family-centered
approach to basic maternity
care. Well-illustrated units
cover all aspects from
pertinent anatomy/physiology,
conception, the antepartum
family, and preparation for
childbirth to the intrapartum
family with complications, the
newborn, and trends in
childbearlng. Each unit: states
goals; identifies behavioral
objectives (keyed throughout
the text); and concludes with
evaluation exercises. April.
1980. Approx. 432 pages, 323
illustrations. About S 1 4.50.
MATERNITY CARE:
The Nurse
and the Family
By Margaret Duncan Jensen,
R.N.. M.S.: Ralph C. Benson.
M.D.; and Irene M. Bobak, R.N.,
M.S.; with 2 contributors.
Both contemporary and
humanistic in approach, this
important volume can help the
student function more effec
tively 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 postpartum
period, and both normal and
high-risk infants. Throughout,
the authors:
integrate diagnostic,
therapeutic, and educational
objectives;
present intervention plans:
and combine clinical and
psychosocial aspects to provide
a unique view of total patient
and family care.
Timely discussions explore
such key topics as genetics, legal
factors, fathering, and P.O.M.R.
Over 600 illustrations highlight
plans for nursing intervention.
1977. 784 pages. 684
illustrations. Price, $24.00.
A New Book!
HANDBOOK OF
MATERNITY CARE:
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By Margaret Duncan Jensen,
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A convenient, practical
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explains how to care more
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unit:
presents prenatal, natal
and postnatal care plans for
normal childbirth:
delineates assessment
and care of the normal
newborn:
cross- references all
material for ready reference.
February, 1980.Approx. 304
pages, 133 illustrations. About
812.00.
New 2nd Edition! CHILD
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Concepts in Family-Centered
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the new edition of this 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
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March. 1979. 948 pages. 377
illustrations. Price. 824.00.
Child health
maintenance
New 2nd Edition! CHILD
HEALTH MAINTENANCE: A
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By Peggy L. Chinn, R.N., Ph.D.
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Ph.D. This concise text serves
as both a student-oriented
learning guide for comprehen
sive 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
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. . .
Back to basics (continued)
4p.l7
association is already committed to two
high profile, high priority projects
development of standards for nursing
education and promotion of doctoral
education for nursing in Canada.
"Canadian nursing will be
successful in obtaining funding for this
project and in finally establishing an
accreditation program for nursing
education in Canada only if it is
wholeheartedly supported by Canadian
nurses. If there is little enthusiasm for
the goal of a national accreditation
program this should be determined now
and the question of accreditation put to
rest for the next 30 years so that energies
can be directed towards other high
priority items of the profession. In my
view it would be a serious mistake if this
were to happen."
Finale
Canada s first nursing education
conference closed with
recommendations from the floor
touching on various aspects of the
discussion during the preceding three
days. Among the concerns voiced by
participants were:
the need to examine the clinical
component in basic nursing education
programs
the need for collaboration between
inservice departments in places of
employment for nurses and educational
programs
the need for the national association
to take a stand on whether basic
preparation for entry into nursing should
be at the baccalaureate level by a certain
date
the need fora "rotated internship"
for new graduates that would be the
responsibility of nursing education rather
than the employing agency
the idea of a mandatory clinical
practice component for nursing
instructors to be completed annually
the need for increased
communication between diploma and
university nursing levels of education,
along with consultation with the service
component in the development of
nursing education programs.
Members of the committee
responsible for planning the forum are:
chairman Margaret McCrady, director of
educational services. Nursing, Health
Sciences Centre, Winnipeg; Jessica
Ryan, head nurse, Pediatric Service,
ChaleurGeneral Hospital, Bathurst,
N.B.; Marie-Therese Choquette, director
of professional nursing for the Order of
Nurses of Quebec; Pat Kirkby,
coordinator of the Diploma Nursing
program, Cambrian College, Sudbury,
Ontario; Ruth Elliott, assistant
professor, Faculty of Nursing,
University of British Columbia.
"Back to basics", a report on the
conference proceedings, including the
text of all the papers presented,
discussion and commentary, is now
being prepared. Information on this
publication will be carried in a
subsequent issue of The Canadian
Nurse. _
M.A.B.
THE
LAST
THING HE
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
following surgery or for
post-cholecystectomy
patients, give them extra
strength OVOL 80mg,the|
chewable antiflatulent
tablets that work fast to
relieve trapped gas and
bloating.
Product monograph available on request.
20 January 1980
The Canadian Nurse
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Scourge
of the
Seventies
Jane Bock
Herpes simplex type 1
500,000 x
Photograph of Herpes Simplex Type 1 Virus ( types 1 and 2 have similar appearance)
HERPES, a viral infection which
manifests in distinctive skin lesions, or
fever blisters, has been around for a long
time. AGreek word meaning to creep ,
herpes is responsible for the common
cold sore . Now the herpes virus is
causing concern because the type which
affects the genital area, herpes genitalis
(or simply, genital herpes) has been
affecting young men and women in
North America at an alarming rate.
Transmitted through sexual contact,
genital herpes is a venereal disease and is
thought by some researchers to be
responsible for some 13 percent of cases
of venereal disease in the U.S. 1
However, genital herpes is not a
reportable disease, and so no statistics
are likely to be accurate.
There is good reason for the
concern: because all types of herpes are
a latent infection, (see Virus) once an
individual contracts a herpes infection he
has it for the rest of his life. In addition to
this danger of recurrence, genital herpes
can cause severe problems in newborn
babies, and can endanger the life of the
unborn fetus. Further, some medical
researchers believe genital herpes is
linked to cervical cancer in women .
It is obvious then that nurses need to
have some knowledge, not only of the
genital type of herpes, but of the other
types of this virus as well, especially
since serious misconceptions exist about
all forms of herpes.
There are four types of herpes virus
that are most common. Varicella-zoster
virus, often called shingles, appears as
small reddened bumps on the skin of the
trunk, arms and legs. Herpes is what is
known as a neurotropic virus, meaning
the virus lives in or remains latent in
nerve tissue, and in some cases of herpes
zoster this fact is most apparent. The
bumps can be seen to follow networks of
nerves, and on a patient s back may form
a tree-like pattern. It is a common belief
that if the "shingles meet, you ll die".
This of course is not the case, and a
nurse must ensure that her afflicted
patient does not believe in this old wives
tale. Herpes zoster may appear later in
life as a recurrence of chickenpox, which
is caused by the same varicella zoster
virus. The recurrence can be a very
painful experience and herpes can in
fact be life-threatening in patients
receiving immuno-suppressants such as
transplant patients and in newborns.
Cytomegalovirus is also a member
of the herpes virus family. It rarely
causes symptoms in adults but can cause
a congenital infection in infants.
A third is the Epstein Barr virus,
which is related to Burkitts lymphoma, a
malignant tumor of the ly mphoreticular
system, which is found mainly in
children in Africa.
The fourth type of herpes is herpes
simplex, of which there are two groups,
called simply 1 and 2. Herpes simplex 1
is responsible for most of the small sores
appearing as blisters on the face, around
the lips, often called "cold
sores . Contrary to popular opinion ,
genital herpes is not always caused only
by herpes simplex 2 (HSV2) usually,
but not always. In genital herpes the
virus is spread generally through sexual
contact, 2 and the viruses pass through
the skin and mucous membranes to the
nerve tissue. Incubation period is
thought to be two to 20 days, with six
days being the mean; duration of the
initial infection is up to three weeks,
while recurrences last usually about 10
days.
22 January 1980
The Canadian Nurse
Figure one: Latent stage
A person who is suffering an initial
attack of genital herpes may complain of
any or all of the following symptoms:
general malaise, fever,
lymphadenopathy (sore glands) and
painful swelling of the genital
area. 3 Transient blister-like sores and
then characteristic ulcers will appear on
the labia in women, and on the penis and
scrotum in men. Urethritis commonly
occurs, and voiding, especially for
women, may be extremely painful and
difficult. If urinary retention exists,
patients may have to be hospitalized.
Satellite lesions , blister sores similar to
the ones found on the genital area, may
appear on other parts of the patient s
body.
Treatment
It is an unfortunate fact that there is no
real treatment for genital herpes
nothing works. 4 The best course at the
moment is to treat the patient s
symptoms which includes giving
adequate analgesia, ASA for fever, and
to recommend rest. Sitz baths may be
suggested, and patients may benefit from
being told to try voiding while sitting
either in the Sitz or a tub bath of warm
water. Under no circumstances should
any steroid or anti-inflammatory
preparations be used!
Doctors are researching new
methods of treatment, but so far none
has proved totally effective. One method
involved applying ether to the herpes
lesions, but patients concluded that the
treatment was worse than the disease.
Others have been trying light treatments,
various cream preparations, 5 even
contraceptive foam 6 but, as one doctor
from the Centre for Disease Control in
Atlanta wrote in the New England
Journal of Medicine, "Every drug that
has been subjected to a properly
controlled trial in genital herpes has
proved to be ineffective." 7
The current aim in finding a cure is
to stop the herpes virus from becoming
latent, or from reaching the ganglia
where it remains for the duration of a
patient s life; this means that whatever
treatment is going to be tried, speed is
important, and patients must seek
treatment as soon as possible.
Recurrence
Because the herpes simplex virus is
neurotropic, it can remain inside the
ganglion of nerve tissue in a latent state,
and recur again at any time. It is not clear
what precipitates recurrence stress,
illness, menstruation but about half of
all patients with genital herpes
experience some form. The lesions may
reappear once every six months, or once
a month.
Figure two: Recurrence
Diagrams are schematic
Special danger
Genital herpes is an especially dangerous
infection for a number of reasons. It
spreads rapidly and unlike other diseases
spread by sexual contact, cannot be
stopped or cured with a course of
antibiotics. There are dangers especially
to women: there is a one in three chance
that a woman who contracts genital
herpes while pregnant will abort; the
virus can spread to the fetus at delivery
from the vagina, so Caesarean delivery is
indicated for women who have either
active or recurring cases of genital
herpes. 8 Infants delivered from women
who have genital herpes lesions should
be isolated in the nursery for 10 to 12
days. 9
Herpes in the neonate is, in one
doctor s words, "devastating". The
herpes simplex virus is also a causative
organism in encephalomyelitis," and the
newborn infant is especially susceptible.
The virus attacks the baby s entire
nervous system, and death can result.
Much has been written about a
possible connection between genital
herpes and cervical cancer in women,
based on certain animal studies.
Although it is true that the majority of
women who have genital herpes do have
cervical involvement, one physician
suggests that both herpes and cancer are
"co-variables of a certain sexual
lifestyle", 12 and that one does not
necessarily cause the other. Still, it is
recommended that women with a history
of genital herpes have regular Pap
smears done.
Herpes and the nurse
One might ask, what can a nurse do to
help people who have this disease when
there is no adequate treatment and even
doctors are at a loss to help their
patients? That, according to Dr. Ian
Tummon, a resident in gynecology at the
Ottawa General Hospital who is doing
research with herpes patients, is exactly
the reason why nurses are so important.
"People with genital herpes have special
emotional problems," Dr. Tummon
says, and he adds that due to the
depressing prognosis of recurrence
without treatment, and the means of
transmission of the disease, "these
people need a lot of support and
reassurance." He said that it might be of
help to patients for them "just to know
that you know they re suffering."
A patient might feel that her having
contracted genital herpes means that she
is "paying" for having had a casual
sexual encounter; there may be strong
feelings of anger and hurt directed
against the person who gave her the
virus. One patient, whose herpes recurs
every month with her menstrual period
said, "Every time I get it I don t know
whether to kill myself or to find Richard
and kill him." One must not forget too
that these patients suffer from the stigma
of having a social disease , and that they
have to guard forever after against giving
it to other partners. "This is difficult,"
Dr. Tummon points out, because
admitting that one has an infectious
venereal disease means they run the risk
of losing the relationship. "But if you
care about someone," he says, "they
have to be told."
Another problem according to Dr.
Tummon exists in the relationship where
both people have genital herpes . "If
each partner has recurrence once a
month at different times, that means no
intercourse for perhaps ten days, which
means out of every month there are 20
days when they can t have a normal
sexual relationship."
The Canadian Nurse
January 1980 23
Dr. Tummon cautions both nurses
and doctors against being judgmental of
genital herpes patients; they re suffering
enough. He says the role of both nurses
and physicians is to be supportive,
well-informed, and to urge people to
seek diagnosis and treatment as soon as
possible when herpes first appears. *
References
I Blough, Herbert. Successful
treatment of human genital herpes
infections with 2-Deoxy-D-glucose, by
Herbert Blough and Robert Guintoli.
JAMA 241:26:2798-2801,Jun.29, 1979.
Persad, Ralph. The new venereal
disease. Health 45:1:16, 24-25, Spring
1979.
3 Ibid.
4 Blough, op. cit.
5 Ibid.
6 Donsky, Howard J. Nonoxynol 9
cream for genital herpes simplex . New
EngJ.Med. 300:7:371, Feb. 15, 1979.
7 Goodheart.G.L. Treatment of
genital herpes simplex, byG.L.
Goodheart and M. Guinan. New
EngJ.Med. 300:23:1338, Jun. 7, 1979.
8 Blough, op.cit.
9 Check, William A. Route of
herpesvirus spread traced with aid of
DNA-cleaving enzymes. JA MA
242:7:591-593, Aug. 17, 1979.
10 Donsky, op.cit.
I 1 Koenig, Harold. Post-infectious
encephalomyelitis after successful
treatment of herpes simplex encephalitis
with adenine arabinoside, by Harold
Koenig et al . New EngJ.Med.
300: 19: 1089-1093, May 10, 1979.
12 Tummon, Dr. Ian. Interview at
Ottawa General Hospital, Sep. 19, 1979
Jane Bock is an assistant editor at CNJ.
Gratefully acknowledged is the
assistance of Dr. Ian Tummon, resident
in gynecology at the University of
Ottawa.
VIRUS: Pirate in the body
hat are viruses, and how do they differ from other disease-causing organisms? Why
haven t scientists been able to find a cure for the common cold?
Viruses are the smallest known living organisms; they affect plants, animals, and
even bacteria to cause infectious diseases. They vary considerably in size and appear in
various shapes but generally the viruses that affect man are spherical (see photo).
Viruses that are agents of infectious disease are what is known as obligatory cellular
diseases , which means that they cannot live and reproduce outside a cell.
The cells of plants and animals possess both RNA and DNA in their chromosomes
true viruses contain only one, either DNA or RNA.
I
Life cycle
When a virus invades the human body, it attacks and actually parasitizes a susceptible
cell. The virus, which is enclosed by a protein coat, attaches itself to the cell and strips off
its coat as it enters the host cell. What happens next is an act of piracy the virus
shanghais the host cell into doing its metabolic work to form new virus particles. Because
the virus has only one of DNA or RNA, the viral nucleic acid combines with the nucleic
acid of the host cell ; the virus can multiply only within the host cell. As a by-product of this
process, the host cell is rendered immune it cannot be reinfected by the same or
related type of virus.
New viral particles are released, and groups of mature viruses escape from the host
cell. For example, a host cell parasitized by poliovirus can produce 100,000 new
poliovirus particles in a few hours. The new viruses can survive outside the cell until they
reach new host cells, where the reproductive process once again begins.
Pathogenicity
The disease symptoms of viral invasion are the result of cell injury. Many viral infections
are silent and show no signs of existence, while others, such as the herpes simplex virus,
may be latent and appear or reappear long after the initial infection.
Some viruses can cause the host cells to reproduce in ways which are not normal cell
reproduction, which gives rise to the theory that viruses are a possible cause of cancer. Of
the 550 known viruses, approximately 200 cause 50 diseases in humans, some of which
are extremely communicable and life-threatening.
Transmission
Viruses may spread from one human to another directly through contact, as in the herpes
simplex virus, or indirectly in nose or throat secretions (the common cold), or in fecal
material (hepatitis).
Other types of infection may be transmitted in water or food such as poliomyelitis and
hepatitis, or by insects such as the mosquito which may carry equine encephalitis.
Immunity
After some types of viral infection, such as the diseases of childhood mumps and
measles the human body develops a permanent immunity to the virus. For others,
there is no immunity, as in the common cold. The mechanism by which the body resists
viral infections is poorly understood, but involves a substance called interferon, which
serves as a sort of blocking agent. Interferon actually stops the synthesis of the viral
nucleic acid by some means; because of the theoretical importance of viruses in the
development of cancer, cancer researchers are very interested in the action of interferon.
Prevention
Viruses can be destroyed by several other means: high heat for example, or
formaldyhyde, hydrochloric acid, elemental iodine, phenol, radiation and ultra-violet light
all have some effect on various viruses. To prevent viral infection, normal methods of
sterilization are effective influenza viruses for instance can be simply washed off the
hands with warm water and soap before they infect the body. Immunization is an
important means to control viral infections such as measles, smallpox and polio.
Of great importance to all health professionals is the fact that except to treat
bacterial complications that may be secondary to viral diseases, antibiotic or
antimicrobial drugs have no effect on viruses.
Source: Principles of microbiology by Alice L. Smith, 8th ed., St. Louis, Mosby, 1977.
pp.487-503.
24 January 1980
The Canadian Nurse
A nurse s package of skills and knowledge has to be portable, as every nurse knows, and nothing is
of more value in sorting out the chaos of a home care assignment than a basic nursing care plan.
Nursing Care Plans and
the Private Duty
Home Ca^se Patient
Connie Eaton
In the spring of this year I was
summoned to my first private duty home
care patient. Wearing a pale
lemon-colored uniform, white stockings
and sensible shoes, I sallied forth. I was
pleased to be able to do some nursing on
home ground, so to speak, even though
my only information was my patient s
name, age and phone number it would
be a bit like public health nursing, I
thought, where one ventures out to make
the kind of discoveries and observations
that most people think only detectives
are trained to do!
Armed wiih my purse and plastic
shopping bag containing the agency s
guidelines and policies, 1 arrived at the
house and found no one there ! I am a
fairly resourceful person and not one to
give up easily, so I did what any normal
public health nurse would do in such a
situation: down the street I saw two
women chatting and I decided to
approach them about the use of a
telephone, hoping at the same time that I
might glean a little information about the
house and family I was visiting. The
women were discussing gardening as I
approached, and apparently thought I
was either a missionary or the Avon lady
because they began to retreat to the
house. I caught up with them and asked
to use the telephone explaining that I was
a registered nurse trying to locate a
patient on the street. The one woman
laughed then, saying it was obvious I was
a nurse, intimating by her tone that no
one else in their right mind would dress
up in such a costume. I made two phone
calls and was assured by my agency that
I was indeed in the right place, that my
patient was being delivered home shortly
by her two sons after a visit to her
doctor.
I returned to the house and
introduced myself to the patient s sons
who in turn introduced me to their
mother. Another son and daughter-in-law
arrived on the scene and before long all
were talking and trying to put together
the chain of events that had necessitated
home nursing care and, in fact, crisis
intervention. I admit to becoming a little
confused trying to sort out the fragments
of five people s conversation, and as it
was by now supper time, things like
Initial Assessment and Nursing
Objectives seemed relatively
unimportant next to the task at hand.
I did gatherthat my patient, Mrs. P.,
was 65 years old, that she had been a
widow for just over a year and that she
had one son living at home who needed
to be fed daily on his return home from
work. I also learned that my patient had
been depressed for some time, had been
self-administering a number of
medications, had fallen at home the week
before and again while out shopping a
few days ago, thereby fracturing her jaw.
My patient and her son insisted on
having steak cooked for dinner and so,
not wanting to be disagreeable by
wondering aloud how someone with a
broken jaw could chew meat, I
acquiesced. I decided to share the salad I
had brought spinach, tomatoes,
mushrooms and cheese with my
patient, and I was not surprised to learn
that she enjoyed it more than the meat.
At least it was easier to chew !
Next came the business of sorting
out my patient s medications, which
made up quite an assortment:
Aldactazide 1 tablet daily, Lanoxin
0. 125 mg daily, Inderal 1 tab. b.i.d.,
Cogentin 1 tab. daily. There were
immediate orders to discontinue the
Cogentin, and to gradually reduce the
I nderal over a period of several days .
H.S. sedation was Nozinan 12. 5 mg and
imipramine 50 mg.
Examining my patient s medication
regime I was able to postulate that she
had a heart condition, required a diuretic
and a tranquillizer, an anti-depressant
and an anti-Parkinson s agent. I thought
that aside from giving the medications,
my main duty with this patient would be
to observe her, and attempt to help her
meet basic human needs.
The Canadian Nurse
January 1980 25
For instance, the family did not
know when Mrs. P. had last had a bath.
In any case, she did not want to have
one, not that first night anyway, so I did
not pursue the issue. As far as I was
concerned, it would be best to wait until
she indicated some willingness to have a
bath, and that would be in her own good
time.
Yet another problem was apparent
from the beginning: the need to keep
records. As there were to be nurses in
the home around the clock, continuity of
care was important, and this meant
sharing information as to what kind of
things were being done, with what
responses from the patient. Given that
Mrs. P. s problems seemed to be
predominately psychiatric in nature, this
was of added importance.
But, as far as I could determine, the
agency had no particular forms for
medications, nursing progress notes or
patient care plans. My responsibility to
the agency was to submit a weekly
progress summary and time sheet. I was
provided with Guidelines for Home Care
and aCode of Ethics. ..period.
My patient went to bed and while I
sat in the adjoining sitting room to see
that she did not get up unattended, I
thought about the nursing challenge that
this patient presented. Here was an
opportunity for independent functioning,
decision-making, and accountability
all dependent on the formulation of a
patient care plan!
During the next several days, I made
my observations of the patient and her
situation prior to an assessment. I
re-read the College of Nurses of
Ontario s Standards forNursing Practice
and noticed the inclusion of a specimen
patient care plan. Once I had the
guidelines drawn up, I was able to
quickly formulate a care plan for Mrs. P.
The agency made several copies of this
and none of the other nurses involved in
Mrs. P. s care had any alterations or
counter-proposals to make.
Progress notes recording each day s
activities had to be left in the home to be
available to each nurse; this meant the
notes were available to the family and
the patient as well. I know that the family
did read the notes since on one occasion
someone corrected a spelling error and a
fact of the patient s history
presumably to set us straight !
The total length of time this patient
required home nursing care was five
weeks; nurses wore street clothes when
it was considered appropriate. The night
shift was dispensed with after nine days
and after four weeks only one nurse,
working a split shift, was required for
Mrs. P. s care.
Realizing nursing objectives
Independence and autonomy
From the second day of home care the
patient was able to make decisions about
meal planning and cooking, although
initially with supervision. Her judgment
regarding mobility however was poor
and she had to be prevented from going
down the basement steps alone. She
needed constant reminding too to change
her position slowly, as she experienced
dizziness after moving quickly.
Normally being a very independent lady,
used to making her own decisions, it was
important to reassure her that the nurses
watchfulness was not a reflection of her
incapability, but rather a concern for her
safety.
She had no recall of her accidental
fall or injury; her memory began to
improve after the tenth day and she
began to ask questions about the
experience. By the end of the second
week of care she was able to write
cheques and pay bills. She had made a
hair appointment on her own by the third
week, and assisted in baking at the end of
the month. At this time too she initiated a
visit to a friend s home, and was able to
travel there and back on the bus, alone.
Grooming and appearance
At first, Mrs. P. had no interest in the
selection of her clothes although she
always commented on the nurses
clothing and appearance. She would put
on a dress but without belt, and when the
belt was located for her, she would
fasten it in place with a paper clip.
However, it was observed that whenever
she was going to visit her doctor she
made an extra effort with her
appearance. Gradually she showed more
interest in dress choice, and in applying
light make-up. She was uninterested in
looking at new clothes, saying "I can t
be bothered."
Appetite
Regular, small attractive meals were
planned daily for Mrs. P. , using informal
table settings in the kitchen. It was noted
that she was more inclined to eat
properly when she had company; her
poor eating habits of the past few months
were likely due to her depressed state
and, more recently, to her constipation
and lack of exercise. Roughage and fresh
fruits were encouraged daily: prunes,
whole grain cereals, fresh fruit and
vegetables and plenty of fruit juice.
As the mother of a large family, it
appeared she had always enjoyed being a
provider of wholesome meals; she was
less interested in providing for herself
alone.
Elimination
Due to her memory loss, Mrs. P. had no
recollection of the frequency of her
bowel movements; she complained of
abdominal fullness and nurses suspected
she was impacted. We informed the
physician on the second day and he
ordered Dulcolax suppositories which
were not effective. On the fifth day he
examined her and diagnosed a bowel
impaction for which he ordered enemas.
It wasn t really until the 1 1th day when
preparation for a barium enema was
given that her bowels started to move.
She was finally started on Metamucil,
one tsp. daily injuice, to be taken until
normal bowel function returned.
Care of skin, nails and hair
On the second day a tub bath was taken
with supervision. As the patient was
observed to have very dry skin, baths
were taken subsequently every two to
three days rather than daily. She
accepted hair and scalp treatment for
encrustation at the end of the first week,
and required several more treatments.
After this she preferred to go to her
hairdresser. Her toenails had grown
unchecked into large horny curved
growths, and an appointment with a
chiropodist was made.
Sleep
Mrs. P. had a history of a disturbed
sleeping pattern for a number of years,
and she tended to sleep a lot during the
day. It was not possible to interest her in
relaxation exercises, nor in quiet music
or reading before bed. Various sedatives
were prescribed for her by her
psychiatrist, and she eventually settled
on Dalmane 15 mg which was at least
helpful, if not totally effective. She said
that noises outside disturbed her, or that
she began "thinking of things", which
interfered with her sleep. She was
encouraged to sleep less during the day,
and was happy with a rest on the bed.
A ctivity and exercise
Mrs. P. had always enjoyed the outdoors
and walking, so accompanied walks were
commenced by the fifth day of care. It
was difficult to assess, bearing in mind
her hypertension and irregular pulse
rate, how much activity could be
tolerated; she was not pushed, and
gradually began to take longer walks
each day, often with a purpose in mind
such as visiting a friend, and she began to
feel and look better.
26 January 1980
The Canadian Nurse
NURSING CARE PLAN
Needs
Problems
Nursing Actions
Expected Outcome
Independence and autonomy
-short term memory loss
-physical weakness
Encourage participation in
planning and care.
Encourage independent action
when ready.
increased independence (eg.
unaccompanied outings)
Nutrition
loss of appetite due to depression
Use meals to structure day.
Plan small, attractive meals of
good nutritive value.
improved appetite
better nutrition
Elimination
constipation and bowel impaction
Give medication as ordered by
M.D.
Encourage roughage etc. in diet,
and exercise.
return to normal bowel function
Grooming and appearance:
skin
nails
hair
depression ^neglect
dry skin
toe-nails overgrown
neglect scalp encrustation
baths q2 or 3 days
use of lotions, creams etc.
good diet,
make app t for chiropodist
shampoos and oil massage
improved skin, and interest in
personal hygiene
patient responsible for regular hair
care
interest in appearance increases
Sleep
depression ^disturbed sleep
pattern
Give sedatives as ordered.
Discourage sleep during day.
Encourage physical activity.
Exercise and activity
depression -loss of interest
Accompany on outings of
increasing length.
Encourage quiet purposeful
activity.
improved general health and
interest in external world
Depression
difficulty with expression of
anxieties and sadness lead to
inversion
Encourage gradual ventilation by
establishment of trusting, friendly
relationship.
return to self-sufficiency and
interest in others.
Depression
During the first two weeks, verbal
communication was restricted to
planning daily activities; her affect was
mainly flat, her facial expression sad,
and she looked extremely tired for a
period of four weeks. Her level of
communication varied with each of the
nurses involved in her care, but
gradually she began to express some of
her feelings. She was concerned most
about the recent deaths of three close
family members, and agreed that she
tended to "bottle things up" rather than
share with her family. She said she had
recognized some time ago that she
needed help in coping with her situation,
but was unable to make the effort. It was
observed however that whenever
members of her family asked how she
was, she would quickly give a trivial
answer and change the subject.
Her need for companionship was
discussed and she recognized that the
fact one son was living at home, although
not often around to be company, meant
she was not entirely alone at home. In a
rare show of assertiveness, she said she
was not prepared to wait on him hand
and foot .
Mrs. P. was a challenging patient
because it was readily apparent that
while she would not likely change her
lifestyle to any great extent, she needed
some assistance to get her life back on
the rails, as it were. While she could not
change her personality to become more
assertive, she was interested in learning
more about her medical care at least.
Signing off
I feel Mrs. P. s case emphasizes several
points about care of a patient within the
home. First, rehabilitation of a patient
tends to start immediately in familiar
surroundings, and a patient seems able to
function more independently in a familiar
role. It is easier for the family too to take
part in the care and rehabilitation
process.
One might speculate too about the
cost factor: in Mrs. P. s case, her short
term inability to care for herself and her
depression might have required a stay in
hospital, followed by a period of assisted
care and rehabilitation. Home care in
this case provided an economical and
feasible alternative to
institutionalization .
In any case, it is clear that in the
situation where a private nursing agency
does not provide guidelines as to goals
and objectives in patient care, especially
in the home, the basic Nursing Care Plan
is of in valuable assistance to the nurse
seeking to organize priorities of care. S>
Connie Eaton, R.N., has been nursing
for more than thirty years since her
graduation in Lancashire, England.
Mrs. Eaton has lived in Canada since
1963 and has held a variety of positions
ranging from public health nurse in
Nova Scotia and Ontario to psychiatric
staff nurse. She returned to England to
practice nursing in the fall of 1979.
References
1 College of Nurses of Ontario.
Standards of nursing practice: for
registered nurses and registered nursing
assistants. Re v.ed. Toronto, 1979. p. 19.
2 Silverthorn, Alida. Nursing care
plans: a vital tool.Canad.Nurse
75:3:36-39, Mar. 1979.
3 Goffman, Erving. Presentation of
self in everyday life. New York,
Overlook Press, 1973.
The Canadian Nurse
January 1980 27
HALO
TRACTION
Nelly York
Deborah Cowan
Mrs. Stewart was a prime
candidate for application of
the halo cervical traction
device. In the two months
that she wore her tiara, we
learned a lot about handling
the special problems of
patients who are in halo
brace traction.
Halo cervical traction is a device
consisting of a circular metal band
screwed into the skull to which metal
rods are attached; the rods are attached
to a cast or ajacket worn on the patient s
trunk. The halo traction device provides
rigid stabilization while allowing early
mobilization, thus preventing many of
the complications that result from the
prolonged immobilization of orthopedic
patients.
Halo traction is used for
stabilization after:
fusion of unstable cervical spine
injuries secondary to trauma
extensive fusion of cervical,
thoracic or lumbar spine with associated
scoliosis
osteotomy and revision of previous
spinal fusion sites
Jefferson fracture
fracture of the atlas
decompressivelaminectomy.
There may be variations in the halo
apparatus in that it may be used with
either a cast frame or a brace frame fitted
over the trunk, and the frame may be
extended to the pelvic girdle, depending
on the area of the spine that requires
stabilization. Basically however, the
halo brace is as described briefly above:
the aluminum tiara is fixed to the
cranium with four threaded pins, two
anterior and two posterior. When the
halo itself is tightened into position, the
fitted brace is applied and positioned
with the anterior and posterior rods
which join laterally at the shoulder, and
with the transverse rods which extend
upward to join the halo (see photo); the
rods may be adjusted in three directions.
28 January 1980
The Canadian Nurse
Potential complications of use of
this device include head pin migration in
which one of the anchoring pins in the
skull shifts in position and misalignment
results, local infection at the pin sites,
and paralysis due to pressure on the
brachial nerve from the brace.
Nursing care involves positioning
the patient in halo traction in such a way
that there is no pressure exerted on
either the rods or the ring of the halo. In
addition, care must be taken to avoid
hitting the rods with anything metallic, as
the conduction of sound through the
skull bones is quite uncomfortable.
CASE STUDY
A candidate for the halo
Mrs. Stewart, aged 60, was admitted
walking to our nursing unit in January,
with a provisional diagnosis of cervical
myelopathy and instability associated
with cervical spondylosis and Swan
Neck deformity, S-shaped curvature of
the cervical spine. It was noted in her
history that she had had a decompressive
cervical bilateral laminectomy with the
removal of C5, C6, C7 spinous processes
more than ten years previously for relief
of a pain syndrome which involved her
arms. In addition she had had
enucleation of her right eye performed
more than 30 years previously, due to
glaucoma. She described a ten-year
history of progressive neck pain and
cervical fatigue with weakness and
numbness in her legs .
Mrs. Stewart s presenting
symptoms on admission were right leg
numbness, a right foot which felt cool to
touch, episodic right arm weakness with
a limited range of motion, occasional
dizziness and even "blackouts".
Intermittent urinary incontinence was
also a problem. She told the admitting
nurse that her condition had become
increasingly worse over the past three
years.
Admission blood tests and urinalysis
revealed results within normal limits,
and after consultation with a
neurosurgeon a cervical myelogram was
ordered. Findings of radiological
investigations of Mrs. Stewart s cervical
spine were:
narrowing of C5-6, C6-7, C7-T1 disc
spaces with partial fusion of C6-7 and
C7-T1
narrowing of the anterior-posterior
diameter at the C6-7 level and associated
distortion of the spinal sac with the cord
resting anteriorly against C5-6, C6-7
cervical lordosis centered at C6
degenerative disc disease detected
at the lumbar-sacral level: possibly a
factor in Mrs. Stewart s occasional
urinary incontinence.
Together in consultation, the
orthopedic and neurosurgeons went over
Mrs. Stewart s history and test results,
and confirmed her diagnosis as being a
combination of cervical myelopathy
aggravated by kyphosis,
post-laminectomy kyphosis, and Swan
Neck deformity which resulted in a
kinking of the vertebral artery
manifesting in dizziness.
Treatment
The doctors discussed their findings with
Mrs. Stewart and she agreed to the
course of treatment they recommended.
This was to be two weeks of intermittent
cervical traction to decrease the
kyphosis followed by surgery to fuse
anteriorly C5 toTl with possible
decompression of C5-6, and
immobilization post-operatively.
Two weeks after admission, Mrs.
Stewart s chest circumference was
measured for her halo vest. Five pounds
of cervical halter traction was applied,
with four inch blocks placed under the
bed to provide counter traction.
Nursing priorities at this time
included teaching Mrs. Stewart the
importance of lying flat while in traction,
without pillows. Log-rolling was used
every two hours so we could give good
skin care, and bony prominences were
carefully observed for signs of pressure.
In a cervical halter, these sites included
her mandible, ears, and the sides and
back of her head . The traction and
weights were checked frequently to
ensure proper alignment.
Mrs. Stewart was allowed to remove
the halter at meal times when deep
breathing and coughing routines were
encouraged.
On the whole, Mrs. Stewart
tolerated the cervical traction poorly due
to increasing neck pain and severe
headaches. She asked for the halter to be
removed often, and she required
increasing amounts of analgesia. After
five days, the doctors ordered the
traction reduced to three pounds, but
this gave only minimal relief of pain.
After a week we began to ambulate her
to promote lower limb strength and
circulation pre-operatively. She
continued to use the halter traction, but
she was encouraged now to use pillows
under her shoulders to hyperextend her
neck. This measure provided comfort
and actually maximized the effect of the
traction on the cervical spine .
The doctors discussed the halo
traction apparatus with both Mrs.
Stewart and her family, and she decided
to accept this form of treatment
following surgery for cervical fusion.
Wearing a halo
After nearly a month in hospital Mrs.
Stewart went to the O.R. for application
of the halo cervical traction under a local
anesthetic. Seven pounds of traction
were applied immediately, and increased
to ten pounds the next day to increase
neck extension.
Mrs. Stewart was now on complete
bedrest and had folded towels and small
pillows positioned behind her shoulders.
Positioning the pillows was tricky: one
was at the back of her neck and the other
under her head, leaving space for the
halo pins while at the same time
preventing her head from resting on the
bed. Counter traction was provided by
elevating the head of the bed on four inch
blocks.
We nursed Mrs. Stewart in the
supine position at this time, log-rolling
her for skin care and positioning her on
her side for meals. The cervical traction
was reduced after a time to seven pounds
to prevent hyper-extension and to
promote comfort. Two days before
surgery the halo vest was applied and
Mrs. Stewart was ambulated wearing the
whole brace to familiarize her with the
apparatus, and to decrease her anxiety.
The first week of February Mrs.
Stewart underwent an anterior spinal
fusion of C5-C6-C7 in the O.K., after
which the halo cervical traction was
reapplied. Traction weight was started at
two pounds then increased to five and
again to ten within hours.
The Canadian Nurse
January 1880 29
Post-op care
Immediately after surgery, nursing care
included frequent neurological
assessments, checking for movement
and sensation in Mrs. Stewart s
extremities, and monitoring of her vital
signs. Intravenous therapy was
continued for three days post-op until
Mrs. Stewart s oral fluid intake was
adequate.
The third post-op day she began to
complain of an extremely sore throat
with aperiodic "choking" sensation; a
throat swab sent for culture and
sensitivity and gram stain was negative,
so she was treated symptomatically with
elevation of the head of her bed 30
degrees, the use of throat lozenges, sips
of fluids progressing to soft foods, and
crushed or liquid medications.
Again, log-rolling was done every
two hours for skin care routine and to
allow for use of a slipper bedpan. Chest
physiotherapy was being given at this
time, and the nursing staff encouraged
frequent deep breathing and coughing.
Passive and active exercises were
provided in order to maintain good
circulation and muscle tone.
Mrs. Stewart was encouraged to
drink 3000 cc s of fluids daily, and she
required a bowel routine to prevent
constipation.
The fourth post-operative day Mrs.
Stewart s cervical traction was
discontinued and the halo vest apparatus
was reapplied and correctly adjusted.
Convalescence
Our patient was transferred to the
convalescent rehabilitation unit for
ambulation and preparation for the
activities of daily living. Ambulation was
initiated by providing proper positioning
of Mrs. Stewart s head and neck while in
a high Fowler s position in bed. From
here she went to a high back recliner
wheelchair (using a standing transfer
method), with pillows to support her
back, sides and arms. Initially she was
up for just five minutes, but this was
increased every two days by five to ten
minutes, as tolerated. At first she found
it uncomfortable to sit in the high
30 January 1980
The Canadian Nurse
Fowler s position, due to the halo
apparatus, but gradually her tolerance
increased. With the use of supporting
pillows she was eventually able to sit up
for two hours at a time.
With the increased activity, Mrs.
Stewart s previous bowel constipation
became less of a problem. She started to
use the commode chair too which
ensured complete emptying of her
bladder but she remained apprehensive
about incontinence.
Team nursing
We held a team conference to discuss
Mrs. Stewart s problems. In caring for
her, we had ascertained that these
included a difficulty with feeding, a need
for increased ambulation, apprehension
about urinary incontinence, and a need
for some teaching about the care of her
eye prosthesis. In addition, there was a
problem with use of the bedpan, due to
her fear of being incontinent; Mrs.
Stewart would sit on the pan for long
periods of time, and we feared that
decubiti would result if this practice
continued. During the day, we removed
the bedpan from her reach, making it
necessary for her to call for assistance.
Then she was ambulated to a commode
with two nurses helping.
We increased her walking time each
day, and we used even short walks to the
bathroom to progressively increase the
amount of her activity. Gradually, as her
strength and bladder control returned
she was able to get up with only one
person for support, and then by herself.
In order to assist Mrs. Stewart at
feeding time and to help her regain her
independence, we positioned her at
mealtimes in the high Fowler s position
and arranged her food tray so that all her
food was in full view; she had difficulty
drinking from a cup so we gave her a
straw. Here too her strength and
co-ordination increased, and soon she
was virtually independent at meals.
Dressing was another problem for
Mrs. Stewart, we knew, but fortunately
she was able to obtain loose-necked
nighties from her family, and later
blouses, so that she could dress herself
with a minimum of assistance. While the
halo brace was in place, we used dry
shampoo to keep her hair clean, and we
combed her hair for her. Skin care was a
priority in our discussion as even with
increased ambulation, Mrs. Stewart
developed pressure sores on her
scapulae which were relieved with the
use of padding and skin ointment.
Physiotherapists were teaching Mrs.
Stewart range of motion exercises for her
arms, using the patient helper for
pull-ups and weight-lifting to increase
arm muscle strength. She had a problem
of tilting backward when walking which
was corrected by the use of parallel bars
and a mirror in the physiotherapy room.
Nursing staff were aware of the physio
program and reinforced the exercises
and her need for correct posture
whenever we ambulated our patient.
We discussed the Stewart family
and their relationship to Mrs. Stewart;
she had two sons and a daughter as well
as her husband. Her family was very
supportive and concerned about her
health, visiting frequently. They were
able to give her a good deal of
stimulation by taking her for short trips
to the hospital cafeteria, and touring
other areas of the hospital . Near to the
time of her discharge Mrs. Stewart was
able to go out of the hospital on weekend
passes to visit her son who lived in
Calgary. .
Going home
Nearly two months after the halo had
been applied, Mrs. Stewart s halo brace
traction was removed, and a fitted
plastizode collar was put on in its place.
Once the tiara was removed Mrs.
Stewart was totally independent and able
to walk with only a cane for assistance.
Teaching for discharge included
instructions to avoid long rides in a car,
not to do any lifting, and to generally
beware of any flexion or extension of her
spine. She was taught to turn her whole
body instead of just her head, and to
avoid any jerky movements. We asked
her to continue to do her
muscle-strengthening exercises and to
watch her posture; she had to wear the
cervical collar at all times, except when
lying down, and she would have to keep
it for three to six months.
Mrs. Stewart was discharged after
1 1 weeks in hospital and went to live
with her son until she was well enough to
make the trip home to her husband in
B.C. We didn t see her again until the
summer when she came in to see her
doctor and she visited the unit where she
had spent so long working toward her
goal she wore no collar and was
happy, independent and strong. *
Bibliography
1 *Harrel, Thompson. The halo
traction apparatus a method of external
splinting of the cervical spine after injury.
J.Bone Joint Surg. 448-3:653-671, Aug.
1962.
2 *Nickel,V.L. The halo, byV.L.
Nickel et al. J.Bone Joint Surg.
50A: 1400- 1409, 1968.
3 Patient chart.
4 Prolo, J. The injured cervical spine:
immediate and long term immobilization
with the halo, byD.J. Prolo et -A. JAMA
224:5:591-594,Apr.30, 1973.
5 Tuber s cyclopaedic medical
dictionary. 1 2th ed. Edited by Clayton L.
Thomas. Philadelphia, Davis, 19?.
6 Wilkins, Charles, Cranial nerve
injury from the halo traction, by Charles
Wilkins and G.D. MacEwen. Clin.Onhop.
no.126, p.!06-110,Jul./Aug. 1977.
7 Zimmerman, Eric. Treatment of
Jefferson fracture with halo apparatus.
Report of two cases. JNeurosurg.
44:3:372-375,Mar. 1976.
8 Zwerling.M.T. Use of the halo
apparatus in acute injuries of the cervical
spine, by M.T.Zwerling and R.S. Riggins.
Surg.Gynecol.Obstet. 138: 189-193,Feb.
1974.
*Unable to verify in CNA Library
Nelly J. York,RN, and Deborah Cowan,
RN, are staff nurses working on the
orthopedic rehabilitation unit of the
Calgary General Hospital. It has
become apparent in their work that halo
cervical traction is a device being used
increasingly for immobilization in spinal
injuries, and they hope their case study is
of benefit to nurses across Canada.
Deborah Cowan is a graduate of the
Mount Royal College in Calgary, and
Nelly York graduated from the Hotel
Dieu Hospital, St. Joseph s School of
Nursing, Kingston, Ontario.
The Canadian Nurse
January 1980 31
A MOV
ISTH
IN YOUR
FUTURE?
^=^f
Some practical tips on relocation problems,
pre-planning, where to stay and who to contact.
Laura Worthington
The law of supply and demand is an old
one in the business world, well
understood by financial analysts. It is
only in the last year or two, however,
that nurses across Canada have begun to
realize how that law applies to them: too
many nurses and not enough jobs!
Sometimes, in order to remain in
nursing, relocation seems to be the only
answer.
Since my own move to California a
year ago I have met and talked to a
number of displaced Canadian nurses.
My friendship with them and my growing
familiarity with the health care scene in
Los Angeles have influenced me to write
POSTSCRIPT: Canadian nurses now
working or planning to work in the
U.S. should be aware o/rece/
changes in the U.S. Immigration
Service which will require all foreign
nurses (including Canadians) to pass
the screening examination given by the
Commission on Graduates of Foreign
Nursing Schools. Filing deadline for
the next CGFNS exam, in April, 1980,
has been extended from January 2 to
January IS, 1980. For more
information, consult CGFNS, 3624
Market Street, Philadelphia, Pa. 19104
or your provincial nurses associations.
More details in next month s issue of
CNJ.
this article, hoping it will facilitate the
planning of anyone with relocation in
mind.
First the bad news
Let s face it: relocation is not for
everyone. Many of the Canadians I ve
met in the past year are genuinely
distressed by their move. Some of this
unhappiness could have been avoided
with a little self-insight.
If you love living in the Northwest
Territories, love working in a 50-bed
community hospital in the Canadian
North, there is about an 80 per cent
chance your move to "the biggest
teaching hospital West of the
Mississippi" will be a mistake. It may
not, but chances are pretty good that it
will. Stick with what you like. If a
small-town flavor is for you, apply to
community hospitals. Do you live for the
first snowfall?Don t go to Palm Springs.
How many times have I heard "but I
miss the leaves turning color and the
snow." Likewise if you come from a
high powered teaching hospital in
Toronto you may think that
one-horse-town in Montana sounds
wonderful. Better think again!
A unique environmental problem in
Southern California is the lack of mass
transit. You must be able to drive and
have access to a car. It doesn t matter
that the new hospital where you ll work
is "five short miles from the beach". It
might as well be 500 without a car.
And by the way, don t believe all
you read in the ads about the attributes
of a specific hospital. For example,
Come work on our team. You ll love
the true California quality of our
locale. Minutes from the beach.
One nurse who did believe a similar ad
moved without a pre-visit, and ended up
being very surprised. She got the large
teaching center atmosphere she wanted.
Unfortunately it was in a bad area of
town, the beach was covered with oil
riggings, and without a car, she was a
captive in her hospital housing. There
may be similar unique problems in the
community where you wish to go. Do a
little footwork and find them out before
you arrive.
Patients in American hospitals have
a different outlook on health care from
that of their Canadian counterparts.
Most people in the LJ.S pay large sums
of money for the health care they
receive. This makes them consumers in
the true sense of the word. Be prepared
for detailed critiques of the food,
furnishings and medical care. Naturally
this is not true of all people and the
situation is different at state-funded
institutions. But it does happen and, if
you re ready for it, the shock won t be so
great.
And now the good news
Whatever your personal reasons and
thoughts on relocation, the good news is
32 January 1980
The Canadian Nurse
that you will be received with open arms
pretty much wherever you go. Los
Angeles Sunday papers carry three or
four pages of job ads for nurses every
week. Some of the ploys the hospitals
use to attract you are:
4-8-12 hour shifts. You can pretty
much choose but be prepared to start on
nights. Many hospitals have this policy;
to be sure, ask what shifts are available
to new hires.
20 per cent shift differential for night
work; 15 percent shift differential for
PM work.
application to a specific hospital may
net you:
a round trip ticket for an onsite visit
(especially if you have a specialty or
management skill).
expedition of your visa by the hospital
after you have signed on.
provision for interim housing after you
arrive at your new job.
Pre-Planning
Is a move part of your career future?
Start planning now! There are lots of
things to learn and do before you
consider going any where.
/. Finances
If you have just enough money in your
pocket to get to your new destination,
don t go! Relocating is filled with hidden
expenses. Most apartment owners in big
cities require first and last month s rent
in cash plus a cleaning deposit. In the
beach communities of Southern
California that means: $300 (rent per
month, one bedroom) x 2 (first and last)
+ $50 (cleaning deposit). This translates
into $650 that the manager expects in
cash or money order unless you already
have your new bank account. (Don t
count on that, it takes longer than you
think. See below.)
Having your Canadian bank wire
money to the new U.S. one is a safe way
of money transferral. However it is not
as speedy as bank officials may claim. I
was nearly evicted from my brand new
San Francisco apartment because the
money I had wired from Vancouver
didn t arrive at my new bank in time.
Would-be landlords are not impressed
when your first cheque "bounces".
Do wire large amounts of money.
But be sure to take sufficient travellers
cheques with you to cover expenses
within the first month of your move.
2. A place to lay your head
Nothing is worse than arriving in a
strange town and not knowing where to
stay your first night. So arrange this in
advance.
Staying at reasonable
accommodations for a week or two
allows you to see the city leisurely before
you decide on a place to live. The
YWC A (or YMCA) is always a cheap
and usually a good choice. Most Y s are
situated in the city center which allows
you to immediately get acquainted with
your new environs. The only drawback
to this arrangement is that some
YWCA s are in the seedier area of
downtown.
If the YWCA isn t your style, try
writing to the department of tourism (or
city hall if it s a small town) in the city
you ve chosen and ask for hotel
information. This should help you select
your first accommodation.
5. Who to contact
You must contact the nursing association
in the state where you propose to go:
through them you will learn about state
licensure requirements. Obviously this is
something you do in your planning stage.
Be sure the state accepts your provincial
license : if it does not you may be
required to take the national boards
exams in the U.S. and/or repeat certain
parts of your clinical training, (i.e.
pediatrics, public health, psychiatry).
And when you arrive all set to work, but
without a license to practice, this can be
very upsetting.
3. A pre-move visit
As I ve mentioned, writing ahead to the
hospital or hospitals of your choice may
net you a round trip onsite visit; even if it
doesn t, you should try to go see your
new locale before you actually move. I
knew a nurse who left the "mainland" to
go to Hawaii for an excellent job in
nursing. This nurse "just knew" she
would love it there. Unfortunately she
and her 4,000 pounds of furniture
returned three weeks later because
things weren t all she had expected. Save
yourself that expense a pre-move visit
is a crucial step in planning.
Another way of doing this is to
attend a medical conference in the city of
your choice; this gives you a preview of
what you can expect. You get to see the
area and rub shoulders with some of your
future colleagues. Initial work contacts
can be made at this time too. One side
benefit the trip is tax deductible if the
conference furthers your profession.
4. Visas
Arranging for a work visa in the U.S.
takes a little time since nurses along with
everyone else are subject to the quota
system. To start the wheels turning, visit
or write the American Embassy nearest
you. If your pre-trip visit has already
helped you select a hospital and you
have been assured employment there,
this can expedite matters. Most nurse
recruiting departments in the U.S. are
able to help you obtain a work visa and
entry papers. It is accepted practice for
them to expect you to sign a work
contract at that time.
The American Hospital Association
can supply you with the names of
teaching and non-teaching facilities
across the nation. You can learn from
them the size of the hospital, whether it
is an acute care facility, and its location.
State
Board of Registered Nursing
1020 N Street
Sacramento, Calif. 95814
National
American Hospital Association
840 N. Lakeshore Dr.
Chicago, Illinois 606 11
Once you have the names of the
hospitals in your new locale you can
make another contact: the nurse
recruiter. She will be someone with
whom you can correspond prior to your
onsite visit. Through this
correspondence you can set up an
interview date, which saves time when
you do arrive in town. Your nurse
recruiter will also often get you a packet
of information about the hospitals you
are interested in before you arrive. This
can be a big help in deciding where to
work.
And last but not least, if you
correspond with her, the nurse recruiter
may agree to provide you with
references. When you "don t know a
soul" and everyone from the telephone
company to the landlord wants an
in-town reference, this can be
invaluable.
Conclusion
Whatever your reasons, relocation
should be the best move you can make.
And , if you know what you want and
how to get it, it will be. I hope this article
helps you toward that goal. *
Laura Worthington, the author of "Is
there a move in your future?" , is a
Canadian nurse now working in the
United States where she is employed by
Cedars-Sinai Medical Center in Los
Angeles as coordinator of their critical
care programs.
Three years ago, when she
represented the Canadian Nurses
Association at that year s International
Conference on Medical Devices in
Ottawa, her report was featured in the
October 1977 issue of the Canadian
Nurse Journal.
Before moving to California,
Worthington was nurse clinician in the
recovery room andlCU of the Royal
Victoria Hospital in Montreal. A
graduate of the University of San
Francisco and of the University of
California, where she received her
Master of Science in cardiopulmonary
medicine, she has worked in intensive
care units across Canada and the U.S.
The Canadian Nurse
January 1980 33
The
expanded
role of the
handmaiden
Jo Logan
Is equality among our fellow workers destined to be the
chimera of the nursing profession? Always just beyond our
grasp? Not content merely to serve the doctor, the nurse
has now expanded her handmaiden role to include the
pharmacist, social worker, physiotherapist, occupational
therapist, dietician. ..in fact, most of the people she works
with.
Why? And what to do about it? Is education the
answer? Perhaps the only answer? I believe it is.
The role of doctor s handmaiden had some advantages for the
nurse: everyone knew that a good handmaiden was worth her
weight in gold. But times have changed, as have healthcare
needs, the educational preparation of other health disciplines
and the nature of nursing. For awhile it seemed that nursing did
not want to fulfill the handmaiden role any longer, opting instead
for a more independent role in the health field. But now it looks
as though, as a group, nurses are choosing to function as
handmaidens after all. Of course, in order to meet current
demands, the handmaiden role is expanding: nurses are now
providing this service to all members of the health team.
This has come about because, of all the members of the
team responsible for direct patient care, the nurse is the least
educated. As such, she is subject to pressures from outside the
profession which distract her from practicing in a way that is
congruent with current nursing expectations. Today s nurse is, in
fact, inadequately educated to undertake the activities required
by modern health care standards.
How can the nurse be considered a professional colleague
and an equally contributing member of the health team when the
disparity in their educational preparation is so obvious? Doctors,
dieticians, physiotherapists, occupational therapists,
pharmacists or social workers are all educated in a university.
Even technologists prepared at community colleges consider
their three-year program superior to most nursing education
programs and, of course, three years concentration on one
system does provide a depth of knowledge impossible to
acquire in a two-year course designed to teach humanistic care
for a patient who possibly harbors multisystem problems.
There are some within these groups who think that nursing
consists of changing soiled linen and believe therefore that
present nursing education is adequate. In my opinion, based on
what I witness in my work, nurses do not have any less critical or
complex decisions to make than many of these other
professionals. Nursing assessments save lives!
I am tired of hearing from detractors of nursing. There are
some uncaring and incompetent nurses in the field but there are
also many excellent nurses. Given their education and the
demands of current health care, it is a wonder nurses succeed in
meeting any patient needs at all. Consider what a nurse is
expected to accomplish on a medical or surgical ward on an
average evening shift:
juggle the demands of families, doctors and other
personnel, all of whom have a "me first" attitude
coordinate the activities of all her so-called "colleagues"
and, almost as an afterthought, plan, implement and
evaluate care for each and every individual patient in her
charge.
I do not believe that the service provided by nurses is so
inconsequential that the educational preparation can afford to be
limited.
The magnitude of that which nurses face daily is such that
they often appear incompetent. This situation is frequently
exacerbated because other groups tend to judge nurses by
criteria from their own discipline: nurses do not know as much
medicine as doctors, nurses do not know as much about
nutrition as dieticians. They do not even know as much about
respiratory technology as members of this group. The
conclusion is that nurses do not know very much about anything
at all and must be carefully directed; direction is required not
only on how to implement the orders from other disciplines but
also on how to function in the area some of us still think of as
nursing. I have heard a physiotherapist, for example, remind an
experienced surgical nurse to be sure to let the patient sit on the
side of the bed for a few minutes before getting up for the first
time. The nurse smiled graciously if a touch wearily. I have also
heard a respiratory technologist vehemently insist on a nurse
giving comfort to a family member; the hassled nurse declined
because she knew that particular visitor had absolutely no
connection with her deceased patient. The range of guidance
seen as necessary for nurses extends from simple physical
assessment to complex psychosocial interventions.
Nurses not only serve as handmaidens, they also make
convenient scapegoats. Errors in patient care have increased
along with the number of care providers. That nurses should be
held accountable for the mistakes of other groups is one of the
myths by which we all live. The nurse is the patient s last line of
defence: she is the final safety filter for any patient therapy. This
puts the nurse in a position where she must act as an expert in
every discipline, plus her own. Impossible!
Unless the nursing profession is going to be content to
restrict its practice to carrying out delegated functions for other
groups, we must educate all of our members to a professional
level. If we do not, the plans of nursing educators and
administrators for a profession comprised of members able to
use nursing process with consummate skill will never
materialize; nursing process is still a fragile concept, easily
destroyed as real nursing is continuously subordinated to the
demands of others.
If basic preparation provided the expertise necessary to
practice in the manner nurses think appropriate, nursing would
be in a better position to withstand the distractions created by
others. Nursing education does not now provide the skills and
in-depth knowledge nurses need when expectations "...include
knowledge and skill related to the assessment, planning,
implementation and evaluation of nursing problems in both
social-psychological and physiological realms." 2 Many studies
have tried to determine why nurses do not consistently use care
planning in their practice. One conclusion is that they lack the
necessary theoretical knowledge.
As nursing research becomes more clinically oriented, it
creates a science of nursing; nursing students will have to learn
new concepts which must be incorporated into existing practice.
In addition, utilizing concepts from other sciences will continue
to be a necessity for nurses. Although nursing reflects the
contemporary focus on health, the ability to care for patients in
acute care agencies will always be essential. How long does it
take to learn the knowledge, skills and attitudes required by
existing nursing standards? Whether operating in a community
milieu, in the mechanized world of critical care or elsewhere on
the continuum, nursing must provide more depth and
sophistication to the education of the new practitioner.
We have failed in our attempt to provide two levels of
registered nurse practice. Nurses in North America are no
longer committed to dividing nursing practice into two groups:
34 January 1980
The Canadian Nurse
the so-called professional/technical split. The professional and
technical functions of the nurse can be separated in a classroom
but not while giving care to a patient. McClure laid bare this
issue with decisive clarity, describing the technical functions as
an integral part of professional nursing practice. 4 Schlotfeldt
agreed, stating that "...technology is an important aspect of all
professional practice and professional practitioners are
expected to be highly competent, technically. " r
Both diploma and degree programs of nursing education
have been accused of failing to produce a graduate with
sufficient technical expertise. To pit one type of program against
another is futile; each was right for its time but that time is past.
The question now is: how long can experienced nurses continue
to bridge the ever widening gap between their educational
preparation and the demands made upon them? How will each
succeeding year of graduates cope? Can a new graduate
realistically be expected to manage her own increasing
responsibilities as well as those imposed upon her by others?
The nurse educator s lament that nursing administration expects
too much will grow to a wail as nursing administration valiantly
tries to keep afloat amid the financial constraints and empire
building now in vogue in many agencies.
None of this is to be interpreted as a vindication of some
previously existing program or as testimony that people with
university educations are superior people to those with diploma
or community college credentials! I know that the level of care
nurses give depends on many things, however, I feel strongly
that education is one variable over which nurses exercise
control as a method of defending and strengthening their
profession. Nurses without university preparation are having to
utilize every possible means to fill in the gaps in their education
and acquire new expertise: many use formal continuing
educational programs as a method of development; others solve
the frustrating problems of work by escaping to a university
setting, choosing a nursing degree in the hope that it will lead
them away from the bedside. A more serious loss to clinical
nursing is the brain drain of nurses who prefer a professional
career in some other field.
University nurses from generic programs present another
problem: there are those within this group who clearly and
frequently proclaim their superiority over other nurses. This
denigration of one nurse by another is destructive and more
offensive than disparagement by other professionals.
Paradoxically, these are the very nurses who fail to realize that
all nurses are perceived as being the same regardless of
education or experience.
Basic nursing education must move towards a solution to
these problems. There must be a shift from the community
college to the university. But, if currently registered nurses
regard such a change in educational preparation as a threat
rather than a necessity for practice and survival, this change will
be slow to happen. The decision is whether to settle for an
expanded handmaiden role or to strive to achieve a professional
role for all nurses; there cannot be two groups of registered
nurses. We must explore flexible approaches to adding to the
educational base of each individual. At the same time, we must
determine methods of providing security for current registrants.
This is a more valuable use of energy than opposition to such a
desperately needed change.
University faculties will have the task of designing a
curriculum which meets the standards of the real world. Inherent
in this change is provision for articulating interested registered
nurses into the university and supplying encouragement for
them to do so. A realistic program for the education of all nurses
will provide practitioners with the expertise to cope with new
frontiers of knowledge in all the sciences and the concomitant
increase in legal and ethical issues. Unified preparation will also
provide the professional solidarity that is needed for a viable
support system.
Community college faculties should assume more
responsibility in several areas of nursing. Expanding their
continuing education services would provide all practitioners
with the information and skills to prevent obsolescence. The
need for refresher courses will increase as nurses continue to
drop temporarily out of clinical practice and as licensing
regulations become more rigorous. Community colleges should
specialize in nursing other than that given at the graduate
university level. Smoyak states that "specialization is the
inevitable result of new knowledge within fields and demands
from the public for new services." 6 As medicine becomes more
specialized, nursing must become likewise specialized; every
time a doctor initiates a new therapy or surgical procedure, a
nurse must be present to give expert care, whether the focus is
on cure or helping the patient to cope.
The nursing profession in Canada can forestall disaster and
diminish the external pressures that now threaten the profession
by making some crucial decisions about educational
preparation. Nurses need to be better prepared; when their level
of expertise rises, nurses will be able to resist the handmaiden
syndrome. As an educator, I would rather teach a nurse to write
and implement nursing orders than teach her to carry out the
directions of a multivariate group of professionals and
para-professionals.
The nursing role is expanding but, unless the profession
educates its people to a sufficient level, nurses functioning in
this expanded role will grow increasingly subservient, and
nursing as a profession will never live up to its potential. *
References
1 Campbell, Gilbert S. Where are the nurses of yesteryear?
(editorial) Amer.J.Surg. 133:2:145, Feb. 1977.
2 Bullough, Bonnie. The associate degree: beginning or
end? Nurs. Outlook 27:5:325, May 1979.
3 Aspinall, Mary Jo. Nursing diagnosis the weak link.
Nurs.Outlook 24:7:433-437, Jul. 1976.
4 McClure, Margaret L. Entry into professional practice: the
New York proposal. J. Nurs. Admin. 6:5:12-17, Jun. 1976.
5 Schlotfeldt, Rozella. On the professional status of nursing.
Nurs. Forum 13:1 :25, Jan. 1974.
6 Smoyak, Shirley A. Specialization in nursing: from then to
now. Nurs.Outlook 24:1 1 :678, Nov. 1976.
Jo Logan, author of "The expanded role of the handmaiden", is
a guest lecturer at the University of Ottawa and teaches in the
Vascular Unit, Staff Education, at the Ottawa Civic Hospital. A
graduate of the Ottawa Civic Hospital, she received her B. Sc.
N.Ed, and M.Ed, from the University of Ottawa. Her experience
includes employment as a general staff nurse and assistant
head nurse at Johns Hopkins Hospital in Baltimore, USA, and
as a teacher at the Ottawa Civic Hospital School of Nursing and
Algonquin College School of Nursing. Readers of CNJ may
remember her previously published article, "The handmaiden is
not dead" (The Canadian Nurse, May 1976).
1 -. Canadian Nurse
January 1980 35
UNIVERSITY
PROGRAMS
FOR RN S
Going back to school need not be drudgery: nursing programs today offer a wide
variety of courses covering many interests as well as the core nursing subjects
literature, philosophy, sociology all these are available.
For the RN who is interested in upgrading her educational qualifications, CNJ
has compiled a catalogue of programs both degree and certificate available in
universities across Canada. Of special note is the number of universities now offering
part-time study.
Interested nurses should write to the institution of their choice for a calendar and
further information, and apply early. It is a good idea too to enclose with the
application a thorough resume of past education and experience.
Good luck!
UNIVERSITY
DEAN
PROGRAMS FOR REGISTERED
NURSES
POST-GRADUATE
PROGRAMS
Alberta, University of
Room 3- 118
Clinical Sciences Bldg.
Edmonton, Alta. T6G 2G3
Amy E. Zelmer, PhD
Deadline for application
May 15
BScN 2 years (to be completed within 5
years of admission, one year must be
full-time)
Adv. Practical Obstetrics
1 calendar year
Nurse-practitioner
orientation period plus 4 months clinical
experience
Despite a policy to support university
level nursing programs, the Government
of Alberta has refused to fund expansion
at the University of Alberta.
MN 2 years (in acute illness)
M.Ed. \
MA 2 years, I not offered by
I Faculty of Nursing
M.Sc /
M.H.S.A. Master of Health
Services Admin.
2 years
diploma in Health Services
Administration
British Columbia, University of
2075 Wesbrook Mall
Vancouver, B.C.
V6T 1W5
BSN one summer course (May, June,
July) followed by 2 years
Marilyn D.Willman, PhD
MSN 2 years
M.Sc (Health Services Planning)
2 years
MA and M.Ed. 1 year
EdD 2 years
Calgary, University of
2920 24th Ave. N.W.
Calgary, Alta.
T2N1N4
Margaret Scott-Wright,
PhD
Deadline for application
April 1st
BScN
UN 2 years
Note: certain courses taken at Athabasca
University in Edmonton are acceptable
toward a post-RN degree. For more
information, contact Athabasca
University, Box 10001, Edmonton, Alta.,
T5J 2P4.
36 January 1980
The Canadian N "
UNIVERSITY
DEAN
PROGRAMS FOR REGISTERED
NURSES
POST-GRADUATE
PROGRAMS
Concordia University
7141 SherbrookeSt. West
Montreal, P.O.
H4B1R6
Muriel Uprichard, PhD
Director Health Ed
BA specialization in community nursing
90 credits
Certificate community nursing 45 credits
Certificate health education 45 credits
Dalhousie University
Halifax, N.S.
B3H 4N8
Margaret L. Bradley
director
School of Nursing
BN 3 years part-time study possible
Outpost and Public Health Nsg
15 months (one year + 28 wk internship
in North)
MN 1 calendar year
Lakehead University
Thunder Bay, Ont.
P7B 5E1
Honors BScN 4 years RN s may
challenge certain courses for credit.
Margaret Page
director
School of Nursing
Laurentian University
Ramsey Lake Rd.
Sudbury, Ont.
P3E 2C6
*courses available in French
Wendy J. Gerhard
director
School of Nursing
Correspond before
August 1980
BScN 2-3 years, depending on success
of student in challenge exams taken after
1 year of study in nursing, science, social
sciences and humanities.
some part-time courses available: also
in North Bay, Kirkland Lake and New
Liskeard through colleges
McGill University
3506 University Street
Montreal, P.O.
H3A 2A7
Joan M. Gilchrist
director
School of Nursing
BScN 3 years (RN s with diplomas from
hospital schools may have to make up
some sciences)
M.Sc. (applied) 2 years
M.Sc. (applied) for non-nurses
with a BAorB.Sc.
2 years plus preceding
qualifying year
McMaster University
Health Sciences Centre
1200 Main Street W.
Hamilton, Ont. L8S4J9
M.H.Sc. 3 academic terms, full-time
applicants assessed individually;
baccalaureate degree not necessarily
required, but applicants must have
successfully completed some university
credit courses and have at least 2 years
clinical practice.
Write:Graduate Program Office, Rm. 3N8
Primary Care Nurse Program 1
academic year
leadsto diploma in Primary Care
Nursing
combination of practice and study
Manitoba, University of
Winnipeg, Manitoba
R3T2N2
June M. Bradley
assoc. professor and
acting director
BN 4 years
RN s may challenge courses for credit in
1st, 2nd and 3rd years of program.
MN 2 years clinical
specialization
community health nursing
The Canadian Nurse
UNIVERSITY
DEAN
PROGRAMS FOR REGISTERED
NURSES
POST-GRADUATE
PROGRAMS
Memorial University of
Newfoundland
St. John s, Nfld.
A1C5S7
Margaret D. McLean
director
School of Nursing
BN(post-RN) RN s are granted 15
non-specified credits on admission.
Program is 6 to 7 semesters
Diploma in Mental Health and psychiatric
nursing
2 semesters plus clinical experience
Diploma in community health nursing
2 semesters plus clinical experience
Degree and/or diploma program in
Midwifery and Outpost Nursing
8 semesters or 3 years, 5 semesters or
2 years, respectively
New Brunswick, University of
Fredericton, N.B.
E3B 5A3
Irene Leckie
UN 3 years (RN s join basic students
after 1st year)
part-time study available.
Ottawa, University of
Ottawa, Ontario
K1N6N5
Marie des Anges Loyer
director
Faculty of Health Sciences
Deadline for application
June 1
BScN 3 years. *courses have changed,
check 80-81 calendar
may be taken part-time; courses must
be completed within 8 years of start
M.H.A. Health administration
2 years
Queen s University
Kingston, Ontario
K7L3N6
Alice J. Baumgart
BScN Basic program is 4 years; RN s
may receive some credit for 1 st and 2nd
year courses
St. Francis Xavier University
Antigonish, N.S.
B2G 1 CO
BScN 3 years
Ellen Murphy
chairman
Dept. of Nursing
Saskatchewan, University of
Saskatoon, Sask.
S7N OWO
Hester J. Kernen
BSN 1 5 credits, 3 years (u p to 9 cou rses
available through University of Regina)
up to 2/3 of the program may be taken
in Regina through University of Regina
Diploma in continuing
education 1 year
M.C.Ed. 1 year plus thesis
M.Ed, in continuing education
1 year plus thesis, or 2 full
years
Toronto, University of
50 St. George St.
Toronto, Ontario
M5S1A1
Phyllis Jones
BScN 3 years
first and second years are available on a
part-time basis through Woodsworth
College to graduates of diploma nursing
school only
MScN 2 years, focus on
clinical specialization and
research
Victoria, University of
P.O. Box 1700
Victoria, B.C.
V8W 2Y2
Dorothy J. Kergin, PhD
Associate dean
Health Sciences
Deadline for application
January 31st
BSN 2 years full-time, or up to 6 years
part-time (with at least one full-time year)
X January 1980
The Canadien Nurse
UNIVERSITY
Western Ontario, University of
London, Ontario
N6A5C1
DEAN
BeverleeCox, PhD
Deadline for application
May 1st
PROGRAMS FOR REGISTERED
NURSES
BScN 3 years (may be taken part-time)
POST-GRADUATE
PROGRAMS
MScN (administration) 1
calendar year
MScN (education) 1 calendar
year
Windsor, University of
Windsor, Ontario
N9B 3P4
Anna Temple
BScN 3 years
Diploma in public health nursing 1
academic year may be done part-time,
finish within F years of start
FRENCH-LANGUAGE UNIVERSITIES
Laval, Universite
Cite universitaire
Quebec, P.O. G1K 7P4
Therese Fortier
B.Sc.Inf 3 ans
Moncton, Universite de
Moncton, N.B.
E1A3E9
Marcelle Dumont
B.Sc.Inf
Le programme d integration pour les
infirmieres autorisees peut se faire & plein
temps deux ans ou a. temps partiel.
Montreal, Universite de
Case postale 6128
Succursale H
Montreal, P.O. H3C 3J7
B.Sc . if 3 ans
Diane Goyette
Quebec, Universite du
Trois Rivieres, P.O.
G9A 5H7
Chicoutimi, P.O.
G7H2B1
300 Ave des U rsu I i nes
Rimouski, P.O. G5L 3A1
Case postale 1250
Succursale B
Hull, P.O. J8X 3X7
Louise Migneron
Brenda Dutil
Denis Rajotte
Fernande Viens
BScN 3 ans
BScN 3 ans
BScN temps partiel
B.Sc.Inf plein temps ou temps partiel
Sherbrooke, Universite de
Centre Hospitalier Universitaire
Sherbrooke, P.O.
J1K5N4
*voiraussi Laurentian University,
Sudbury
BScN 90 credits
DeniseLalancette
The Canadian Nurse
January 1980 39
an essay on motivation
Brian Cristall
"And when you have determined what is to be done under the
circumstances, still you will usually have no power to compel the
necessary course of conduct, except through those motives to
action which are consonant with the hopes, the fears, the
prejudices of your patient... you must be able to judge quickly as
to these motives. This judgment can only be founded on a
thorough knowledge of human nature, and this knowledge and
the use of it, therefore, constitute important elements of
professional skill and tact."
- Thomas Laycock (1 81 2-1 876)
Recently, I was asked by the supervisor
of the public health nurses in my
community to give a lecture on
motivation. I was very reluctant to do so
because motivation is such a large and
general topic, but she explained to me
that what the PHN s were interested in
was the question of how to motivate their
patients. I began to search for an answer,
but after a short while came to the
frightening conclusion that/ didn t have
any answers to this question and
therefore couldn t possibly give the
nurses a lecture. I told this to the
supervisor.
"That s good," she said, and went
on to say that she expected my
presentation in two weeks.
Perhaps that s an important way of
motivating people, I thought: don t let
them think about what you re asking,
just tell them to do it and perhaps they
will. But there had to be more to it than
that. What she did that was even more
powerful as a motivating force was to let
me know she believed I could give such a
lecture, when I had been wallowing in
uncertainty. I went on to prepare the
lecture because I felt better having her
confidence in me. People have to believe
they can do what is asked of them.
Obviously, there is a great deal to
motivating people, more than the two
suggestions I have made, and neither of
these is very helpful to the nurse who
wants an answer to the question, "How
can I best motivate someone?"
One can easily understand the
nurse s preoccupation with motivation
and the facilitation of change. Nurses are
constantly looking for solutions to the
problems people present in their work.
It is important though for anyone
involved in helping other people to
acknowledge just how dependent any
therapist is on being able to come up with
solutions; a lot of anyone s self-worth is
tied up in being able to do something
concrete to help. Problems without
solutions tend to make a person feel
inadequate.
A tentative answer then to the
question, how can I help, might be
simply listen to your patient . And by
this I mean really listen, and hear what
the person is saying to you. Listen to the
problems that are very real to that
individual, to the sadness and
helplessness they feel. But remember
it is not your responsibility to decide
what that person should do, or where he
should go.
40 January 1980
The Canadian Nurse
Once you understand this, you have
grasped the fundamental truth, that you
cannol in fact motivate anybody to do
anything, you can only allow them to
motivate themselves.
You have no power to cure anyone
of his problems, and indeed it is an
interesting paradox that when you try to
motivate someone to change, you end up
actually interfering with his natural
motivating forces. If you start believing,
as a patient or his family might, that you
have the power to motivate or to change
them, then you are getting trapped by the
people you are working with.
Understand for instance the message you
might get from a distraught mother: "My
world is broken and only you can fix it."
Not true. Only the mothercan fix it. only
the mother has the motive power to
repair her own life.
Listening to people will provide you
with clues as to what is wrong with their
own strength of will; you will hear in
their stories about the conflict and fear of
change: "I can t do that, I ve never done
that." Active listening is the key to basic
contact with another person, and honest
and genuine response is another.
There is no one response that will fit
every patient: one must respond
differently to different people, and even
at different times with the same person.
There is no right or wrong response
either, there is only a response that is the
result of sensitive listening. If someone s
problem is such that you can t offer any
help, say that, share that fact with the
person. It may be a relief for him to hear
that a professional doesn t know what to
do either.
Any individual in a helping
profession has a most difficult task. We
must work with multi-problem situations
and families where the very real
economic and social realities are such
that the problems are probably
impossible to solve. If a
fourteen-year-old native giri s father ran
away with another woman, and her
mother was a drunk; if men take
advantage of her sexually and beat her to
relieve frustrations, then we have a very
real problem but one that s impossible to
solve. There s nothing that you can do to
change the economic and social realities.
But you can make the kind of basic
contact with the native girl which will
allow that girl to explore her life s story,
and come to accept the fact that life dealt
her a bad hand; that s rough, but that s
it. Only by establishing the kind of
human contact in which the girl can
safely explore her feelings toward her
horror story, will she ever be able to
begin to make the kind of changes
necessary for her to find fulfillment in
her life.
But the motive power for change
and for working against these very bad
odds must come from within that girl and
can never come from the outside.
What I have been saying then is not
that there are ways to motivate people,
but that there are ways for a professional
person to help people motivate
themselves. In relating to a patient you
do one of three things: you either
motivate them, do absolutely nothing for
them, or you actually block their
motivation. To understand this, it is
helpful for nurses to know what kind of
things contribute to health care workers
blocking patients motivation.
Values. Many professionals find the
personal values of the people they work
with vary greatly from their own. An
example: you enter a house for the first
time and you find a filthy mess. The
dishes are dirty, clothes are scattered
everywhere, and the baby s diapers are
full. You think: this house is a mess, how
do I motivate this woman to get this
place cleaned up? But the dirty house
isn t her problem, it syowr problem.
Culture. Nurses and other
professional workers come most often
from middle class backgrounds and are
unable to understand the characteristics
and pressures existing in other social
groups.
Sensitivity. Unlike psychotherapists
in private practice, health care workers
cannot choose the people they work
with, and they cannot be sensitive to all
the people they come in contact with.
Expert whiplash. Many of one s
clients or patients will have had
numerous experiences with experts or
professionals and may have had bad
experiences, making them less
cooperative.
The "I ll help you" hang-up. Many
workers unconsciously display an
attitude that says let me rescue you,
which is in essence a top dog-underdog
situation, with the professional having
the upper hand. In this situation, the
underdog may win by not being helped.
All of these are important factors to
remember, as is the idea mentioned
before that health care workers often
have a great deal of their own personality
invested in coming up with a solution for
people. If you find yourself giving lots of
advice instead of really listening and
responding genuinely, it s a certainty the
patient s motivation is being blocked.
Back at the beginning of this article I
said that nurses usually want to know,
"How can I motivate someone?" And
my answer to that is, you can t. The
question is all wrong; when you ask how
can/... you are taking responsibility for
your patient, and that s the first wrong
move.
Well, you ask, how can a nurse be of
any use? How can a nurse in hospital
motivate the patient with an ileostomy to
learn how to use his appliance himself? .
How can the community health nurse
whose diabetic patient is still dependent
on her persuade that patient to give his
own injections? What to do?
The nurse can be helpful in many
ways, not the least of which is just being
there. You are another human being
capable of the same emotions and
subject to the same stresses as your
patient. You can provide the acceptance
and support that nurtures motivation and
personal growth, and you can listen
actively and with purpose.
While it would seem there isn t any
magic answer to the problem, there is
one word that describes the nurse s role
here: that word is "Caring". Knowledge
and technical skills are all very well, but
without real personal caring there is no
power in them. As long as one chooses
always those actions which reflect
caring, one cannot go wrong.
As Don Juan tells Carlos in Journey
to Ixtlan , "All paths lead to the same
place, and that s nowhere, so always
follow the path with a heart . " *
Brian Cristall,./4., M.Ed., is a
psychology instructor at Northern Lights
College inDawson Creek, B.C. He is
also a counsellor for both students and
members of the community.
Bibliography
1 Bugental , James F . Psychotherapy
and process: the fundamentals of an
existential-humanistic approach.
Reading, Mass., Addison- Wesley, 1978.
2 Dass, Ram. Grist for the Mill.
Santa Cruz.Ca., Unity Press, 1977.
3 Egan, Gerard. The Skilled Helper:
a model for systematic helping and
interpersonal relating. Monterey, Ca.,
Brooks/Cole, 1975.
4 Kopp, Sheldon E. Back to One: a
practical guide for Psychotherapists.
Palo Alto, Ca., Science and Behavior
Books, 1977.
Kopp, Sheldon E.Guru:
Metaphors from a psychotherapist. Palo
Alto, Ca., Science and Behavior Books,
1971.
6 Kopp, Sheldon B. If you meet the
Buddha on the road, kill him! The
Pilgrimage of Psychotherapy patients.
Palo Alto, Ca., Science and Behavior
Books, 1972.
The Canadian Nurse
January 1980 41
MohamedH . Rajahally
This year, after almost a decade of
co-operative planning and
preparation, the Canadian Nurses
Association (CNA) will introduce its
new comprehensive examination for
nurse registration. (See The
Canadian Nurse, May, 1979). As a
result of this commendable
achievement, Canada will become the
first nation in the world to implement
a nursing examination of this nature
for persons wishing to enter the
profession. Obviously, the leaders of
Canadian nurses know something
that their American counterparts do
not.
Underlying introduction of the
comprehensive examination is the
rationale that change in our present
system of examinations is necessary in
order to keep pace with the changes that
are taking place in nursing education.
These changes have occurred because of
the movement in recent years towards
integrating nursing programs and the
preparation of general practitioners at
the basic level. The comprehensive
examination will permit the national
Testing Service for beginning
practitioners to reflect these changes and
to test more realistically the applicant s
ability to solve the nursing care problems
typically found in nursing practice.
Under the new system, aspiring
candidates who fail any part of the
comprehensive examination will have to
rewrite the entire exam. Compared to the
soon-to-be-deposed five-part
examinations which allow students to
rewrite only the subject(s) in which they
fail to obtain a passing mark, this
undoubtedly imposes a new degree of
difficulty on prospective members of the
profession. The director of the CNA
Testing Service, Eric Parrott, comments:
"The old registration examinations
were based on a medical rather than a
nursing model. " That same medical
model has been under constant attack by
nurse educators and has divided nurses
into opposite camps of incompatible
loyalty to the old and so called new .
42 January 1980
|3||^^ should t
CNA contends that the new
comprehensive examination will test the
candidate s cognitive abilities by
requiring the writer to demonstrate the
integration of the elements of knowledge
basic to a discipline in solving problems
presented in a series of situations. 2 Many
educators will confirm, with some degree
of justification, that up to now there have
been no examinations which really
separate the competent from the
incompetent with any degree of
accuracy. Also, in assessing through
examinations whether or not a person
will make a good nurse we are looking at
probabilities, not certainties.
What magic spell has the word
integration cast over the nursing
profession in Canada that would
influence it to invest 10 years and untold
sums of money on the development of an
examination to accommodate the
concept of integration? Within the
framework of nursing curriculum, the
word integration implies blending the
nursing content in such a way that the
parts of specialties are no longer
distinguishable. This involves
concentrating on the generalizations
relating to nursing rather than specifics/ 1
It is obvious that the old examination
for registration does not meet this
criterion. Is this a handicap of such
magnitude that it has to be eradicated as
a pest? Or is it a reality compatible with
today s practice of nursing?
The Canadian Nurse
keep hearing that emphasis
should be placed on the promotion of
health rather than on the treatment of
disease. Theoretically, this emphasis is
sound but in actual practice it is
incompatible with today s practice
mode. Call it shortsighted if you like but
if you ponder for a moment, you soon
realize that it is the treatment of disease
which, much to our chagrin, is still
keeping the majority of our colleagues
employed and thus, indirectly, keeping
our professional hopes and aspirations
alive by providing us with time and space
tomanoeuver.
I wonder how many nurses today
remember the introduction of the
two-year diploma program in schools of
nursing in the late sixties? During that
trying time, many nurses were accused
of being shortsighted and labelled
obstacles in the path of progress and
change. Now, a few years later, we have
commission after commission being set
up to assess the merit (or demerit as the
case may be) of the two-year program.
Is it any wonder that practicing
nurses look with suspicion upon nurse
educators? Is it any wonder that they
tend to think of them as ivory tower
architects who have been known to be
wrong in their design but who refuse to
admit their mistakes? Let us be realistic.
The wards and units of the hospitals we
work in today are still designated as
medical, surgical, obstetrical and
gynecological, pediatric and psychiatric.
Should nurse educators be pushing for
integrated wards or units to
accommodate the products of our
integrated exam system? Nursing service
or administration does not recruit an
integrated nurse to fill a specific
vacancy. Nor do educational
institutions. Also, where are we going to
find an integrated textbook to teach our
integrated nursing students? Why do
educators acknowledge the presence of
the medical model and yet defy its
existence?The only thing that appears to
be integrated is the CNA examination.
While the CN A Testing Service is
forging full speed ahead on the
integration bandwagon, the trend in the
United States, where the concept of
integration was conceived and born and
where we got our ideas from in the first
place, is reversing itself. A few schools
of nursing have already jumped the
integration track and are headed off in
other directions. As more faculties feel
comfortable and secure in openly
conceding the limitations of the
integration syndrome, new avenues will
be explored and new compromises
made. 4 The school of nursing at the
University of Kansas, for one, has opted
for compromise between integrated and
logistic tactics, which is a
disease-centered or body systems
approach to teaching. Had nurse
educators been realistic earlier, perhaps
we would not have been swayed by the
magic word, integration . 5
I am convinced that if we look
closely, we will find that the wheel has
turned full circle and if, in turning with it,
we have learned anything at all, we must
change our behavior to accommodate
this newly acquired knowledge. It is
about time that as educators we put our
act together so that we can command the
respect of practicing nurses . *
References
1 CN A Testing Service.
Canad.Nurse 75:5:44-45, May 1979.
Ibid.
Torres, Gertrude. Educational
trends and the integrated curriculum
approach in nursing. (In National League
for Nursing. Dept. of Baccalaureate and
Higher Degree Programs. Faculty
curriculum development. Pt.4. Unifying
the curriculum the integrated
approach. New York. c!974.) P.2.
4 Styles , Margretta M . I n the name
of integration . Nurs. Outlook
24: 12:738-744, Dec. 1976.
Veith, Shirley. Rethinking the
integrated curriculum. Nurs. Outlook
26:3:187-190, Mar. 1978.
About the author: MoliamedH.
Rajabally is probably best known to CNJ
readers as the author of "N ursing
Education: AnotherTower of Babel?"
which appeared in the September 1977
issue of this journal. He is a lecturer in
the Faculty of Nursing at Okanagan
College in Kelowna, B.C. and is also a
PhD student in the College of Education
at Washington State University,
Pullman, Wa.
CNA s Director of Testing Service Responds:
I have difficulty deciding what message the author is trying to
convey about integration, examinations and nursing education.
Is he recommending that examinations should be abolished, or
questioning whether we have yet found the right techniques to
develop examinations that will separate competent from
incompetent nurses with accuracy? Does he believe the
registration examination should measure specialities, or that
integrating content only allows the testing of generalizations? Is
it his contention that nursing cannot support the "promotion of
health" and "treatment of disease" at the same time, and
because so much of today s health care is related to curing
disease, that we should not strive for change in trying to
promote healthier lifestyles?Does he believe that two-year
diploma programs are educationally unsound and that somehow
this is related to the integration of nursing content, or to the fact
that nurse educators implemented such programs against the
better judgment of experienced practitioners?
While I can understand that the expectations nurse
educators and nurse practitioners have of new graduates may
not be congruent (though I hope their broad goals or objectives
are), to suggest that educators should "push for integrated
wards or units to accommodate ... (the) products of
integration" leaves me puzzled. I hope that a nurse who has
been educated in an "integrated" program would make positive
transfers of learning and perform competently in a variety of
settings (medical, obstetric, and so on), once any additional
preparation needed to work in a particular setting has been
acquired. Although it might be useful for hospitals and
educational programs to have the same organizational structure
(either integrated or divided into clinical areas), I don t see that
it is essential. It seems to me that the aim of many integrated
programs to place nursing in a problem-solving context so that
knowledge and nursing care are not fragmented is most
appropriate, and just as relevant in practice on a psychiatric unit
as on a surgical unit.
As for the statement that "we get our ideas in the first
place" from the United States, I have a lot of affection and
respect for my American friends and colleagues, but I don t
think a Canadian idea has eighty-fi ve cents worth of merit while
an American idea is worth one dollar. Nor do I think that
Canadian nurses are unable to generate new approaches to
nursing education and practice. I hope that the American
schools which have "jumped off the integration track" are not
like the horseman who rode off in all directions at once. I
suspect that no school of nursing. American or Canadian, has
discovered the "ideal" curriculum. Therefore, to find that an
integrated program has some limitations is not surprising. My
hope is that nursing educators will design curricula to reflect
theirown individual beliefs and needs ... notjumpon the
integration bandwagon just because the CN A Testing
Service is integrating examination content, or because it seems
to be the popular thing to do. A variety of educational
approaches might be more interesting than trying to fit all
programs into the same mold. Whatever approach a school of
nursing uses, I earnestly hope the nurses graduating from it are
"integrated". If not, who will put HumptyDumpty together
again?
I predict that well-prepared candidates, whether from an
integrated program or not, will be able to pass the
comprehensive examination. The key concept is competency in
nursing not integration.
Eric G. Parrott
Director of Testing Service
The Canadian Nurse
January 1980 43
Contract
Learnin
The Experience of Two Nursing Schools
Jeannette Bouchard, Marilyn Steels
The nurse as a change agent! Coping
with change! Can nursing educators
afford to take the risks involved in
inviting students to participate in the
selection of their own learning
experiences?
Preparation of the student for
on-going learning is a major
responsibility of the educational
system in our rapidly changing world.
Given the short half-life of
professional knowledge in the health
field, it seems imperative that nursing
educators no longer strive to provide
a finite package of knowledge.
Opportunities to be self-directed
within the security of an academic
milieu should facilitate the
development of skills needed to
assume responsibility for change.
Self-directed learning has been
promoted in two nursing science
programs in Ontario through the use
of contracts. Two nursing educators
share their experiences using contract
learning in year two of the four year
program at Me Master University
(1976-7) and year four of the nursing
program at Laurentian University
(1977-8).
"A learning contract is a document
drawn up by a student and his instructor
or advisor which specifies what the
student will learn, how this will be
accomplished and within what period of
time, and what the criteria for evaluation
will be. " Contract learning, like
independent study, places more
responsibility on the learner for planning
his own work and pursuing his own
objectives, while the instructor remains
responsible for developing abroad
framework of course objectives and
expectations within which each student
develops his specific contract. The detail
and scope of this necessary framework
varies according to the experience and
developmental level of the learner.
Without such a framework, the student
may experience anxiety when making
basic decisions which should be the
responsibility of the educational system.
44 January 1980
The Canadian Nurse
A learning contract has many
positive attributes; it
supports the learner s self-concept
as an autonomous adult with a
background of personal experience and
expectations for the future which help
him identify personal learning needs.
permits the identification and
confrontation of real and relevant
problems rather than confinement within
a prescribed subject-centered learning
mode.
promotes a sense of personal
responsibility for learning.
permits more relevant and
meaningful learning experiences.
allows the instructor, being freed
from the constant strain of content
transmission, to focus on the individual
student and his progress.
promotes competition with self to
meet self-formulated standards rather
than competing with peers.
provides a vehicle for
communication between student and
teacher.
assures on-going personalized
feedback between student and teacher.
provides a clear record of the
student s personal learning process.
promotes expression of creativity
by inviting and encouraging students to
take risks in designing their learning
experience within the boundaries of the
course objectives.
However, effective contracting
requires several essential basic
conditions, such as compatibility with
the school s philosophy; commitment
and security on the part of the
instructors: a clear set of general course
objectives; an acceptable and
well-delineated set of requirements and
expectations and an explicit procedure
for contract development; intensive
facilitative interaction between student
and instructor: formative rather than
punitive evaluations: peer support within
both student and teacher groups: and
effective public relations with resource
individuals and agencies.
The authors experiences
The contract learning process was
applied in two nursing courses which
combined theory and practice. The year
two course focused on human growth
and development throughout the lifespan
with the students working with well
children and families at varying stages in
the maternity cycle in one term and with
individuals and families experiencing
situational crises related to surgery in the
second. Core plans brought students
from both rotations together to discuss
broad concepts relevant to all areas of
nursing. The year four course, taken in
one term, focused on the analysis of
individual practice by selecting and
exploring in depth one theory of nursing
and applying it clinically with several
patients and families. A research study,
used as a theoretical base, was carried
out and small group seminars considered
the application of the theory clinically
and implications of the research.
Initially, terminal objectives were
presented and discussed. In a group
setting, the students were asked to
identify factors which helped and
hindered their learning; using this input,
beliefs about the adult learner and
self-directed learning were identified.
This paved the way for the introduction
of contract learning. In both instances, a
class was devoted to the purpose of this
too) and details of its implementation.
Handouts were given explaining
expectations and clarifying the steps of
contract development. These guidelines
included examples of appropriate
learning activities, suggestions for
suitable types of evidence of learning in
each domain and suggestions for the
development of criteria and means for
validating this evidence. As well, options
were described for students who failed to
meet their contracts.
Although the process remained
similar in both courses, it was in the
application of the specific expectations
that differences occurred. The "givens"
fell into five categories: final dates for
contract negotiation and submission of
evidence, content, requirements for
specific types of evidence, a requirement
for a grade "C" contract, and provision
for work in groups. In both groups,
contracts were to be finalized three
weeks before the end of the term with a
final date for submission of evidence also
specified to allow faculty time to
complete an evaluation. The content
givens guided the students to develop
objectives and select learning
experiences relevant to the course.
In year two, we intended that the
contract:
focus on health, not pathology
relate to an age group within the scope
of the student s current clinical rotation
show the application of one of the
core concepts under study in class that
term
and show the relationship of the
planned learning activities to the
conceptual framework of the course.
In year four, the contract was to:
develop a personal framework of
nursing practice
reflect an analytical approach to the
process of nursing care
and utilize a selected concept in the
scientific investigation of a nursing
problem.
In year two, a formal essay was
required as partial evidence of contract
fulfillment and in year four, a formal
research paper was to be completed.
The grade C contract requirement
was included to ensure that students who
overextended themselves would have a
more easily attainable contract to fall
back on. However, a grade A or B
contract could be negotiated based on
changes in or additions to objectives,
learning activities, as well as evidence
and/or criteria for evaluation.
Criteria for group projects were
established to assure each group member
of a personal evaluation. Each student
was expected to develop his own
contract and was held accountable for
producing evidence congruent with his
objectives and negotiated grade.
Faculty strategies to facilitate the process
of contracting
Certain provisions were made in advance
to assure that the experience of
contracting proceeded as smoothly as
possible for both students and faculty.
Regular appointment schedules were
established with a specific weekly time
assigned for second year students to
meet with their instructor, while fourth
year students were expected to set up
their own appointments as they deemed
necessary. An average of 20 to 30
minutes were spent weekly with each
student discussing matters related to the
contract; this time investment was
necessary for both groups.
Provisions were made for mediation
of contract disputes in both cases. In
year two, time was spent in team
meetings almost every week discussing
contracts, with student representatives
involved in much of the discussion. In
addition, a special time was set aside just
before the date for contract finalization
to resolve any impasses. The fourth year
students were informed that if an
impasse in contracting occurred, another
fourth year faculty member would be
invited to serve as mediator.
Class size and attendant faculty
numbers did not constitute a problem at
Laurentian University. At McMaster
University, however, a major concern
for students and faculty alike was the
issue of achieving fairness when six
faculty were involved in setting 70 or
more learning contracts. When the
diversity of projects is such that
equivalence of work is difficult to assess,
students become competitive with each
other and faculty are forced into the
difficult task of trying to be consistent
not only with each other but with
themselves. Time spent in team
meetings, as well as one to one
discussions amongst faculty, were used
to ensure consistency.
The Canadian Nurse
January 1980 4?
To avoid frustrating and
non-productive delays in the student
learning process, students were
encouraged to begin to pursue their
learning activities before their contracts
were finalized. Their learning
experiences during this period of
contract evolution lessened their
anxieties and helped them clarify their
specific areas of interest and learning
needs.
Although anything that was legal,
ethical and feasible within the contract
requirements was encouraged, some
guidance was provided to year two
students in relation to appropriate topics
and learning resources. This guidance
was provided through sets of
thought-provoking questions, lists of
faculty and community expertise, and
packages containing written resources in
a variety of areas. Students were
encouraged to add to these packages and
to use a special bulletin board that was
set up for conveying information relating
to various learning experiences. In both
situations, letters of introduction were
prepared on school of nursing letterhead
for students wishing to establish contact
with persons not previously solicited by
the school. For the fourth year students,
resources were provided but not
categorized under specific topics perse;
LEARNING CONTRACT FOR COURSE:
NSG 2004
Student: Jane Myles
Date Evidence Will Be Submitted: April 16,
1979
Instructor: Marilyn Steels
Learning Objectives (include
relationship to course
expectations)
Learning Resources and
Strategies
Evidence of Accomplishment of
Objectives
Criteria and Means for
Validating Evidence
FOR C GRADE
1 . To discover what community
resources are available for
colostomy patients.
Interview Board of Directors of
Ostomy Association. Interview
ostomy nurse.
Bib. card: listing and describing
community resources available to
ostomy patients.
Name of resource person.
Description of community service,
location, function for ostomy
patients, group activities.
2. To identify resource personnel,
their contributions to patient care.
To share this knowledge with
peers and other health team
members.
Arrange with ostomy nurse to
come and speak to a group of
nursing students and other health
team members.
Presentation by ostomy nurse
takes place on March 25.
Evaluate whether knowledge has
been passed on to peers through
a questionnaire given after the
presentation.
Summarize in chart form the
response to the questionnaire.
Tutorial leader comes to
presentation.
Questionnaire: general questions
concerning knowledge gained
from the presentation.
Chart representation of response.
3. To learn to conduct an
information gathering interview
with resource personnel.
Interview an ostomy patient
concerning any
physical/psychological adaption
problems encountered after the
operation.
Written evaluation of interviewing
skills.
Analyze adaptive process.
Consider the effects of the
colostomy on the developmental
tasks of the adult interviewed.
Criteria for good interviewing
skills.
Introduction of self and topic of
study.
Open-ended questions.
Summarized interview and
concluded interaction.
Evaluation of interview.
Stages of adaption patient went
through; difficulties; present
stages.
FOR B GRADE
1 . Same as 3. (above)
Same as above.
Same as above.
As above item plus refrain from
giving advice /being judgmental.
Identifying and validating verbal
and nonverbal cues. Utilizing this
data, maintain the interview.
Evaluation of interview.
Stages of adaption.
2. To plan and implement a
teaching approach for peers so
that they gain a basic
understanding of the
psychological stages of adaption
which a colostomy patient
progresses through.
Poster
Discussion following presentation
of poster, focusing on anecdotes
in which there were
manifestations of the
psychological adaption stages.
Include the effects of the
colostomy on the growth and
development of the adult.
Presentation on Tuesday, April 5.
Presence of tutorial leader to
make sure psychological adaption
and growth and development are
included in presentation. Clarify at
presentation. Helping group to
problem solve through anecdotes.
Response of group to discussion
of anecdotes. Ability of group to
identify stages of adaption as
presented in anecdotes: will either
teach or help in problem solving.
A. Contract successfully negotiated Mar.25, 1 979
for a B grade.
B. Contract successfully met for a April 1 6, 1 979.
B grade.
Student: Jane Myles
Instructor: Marilyn Steels
Student: Jane Myles
Instructor: Marilyn Steels
46 January 1980
The Canadian Nurse
it was left to the student s initiative to
seek out pertinent resources as well as
letters of introduction .
Guidelines were provided for
students in both settings in relation to
expectations for the fulfillment of grade
A. B and C contracts. It was hoped that
students would grasp the idea that
quality of work was at least as important
as quantity. Examples were given
showing how different words and
phrases used to describe learner
behaviors can reflect the quality and
complexity of the learning process. Also
suggestions were given describing types
of evaluation tools available for specific
types of evidence. The use of external
appraisers for evaluation of evidence
was encouraged. By including the name
of the proposed e valuator and his/her
qualifications in the contract, the idea
was reinforced that the teacher was not
necessarily the best qualified person to
evaluate the student in all areas, but
remained the person responsible for the
overall evaluation of student
performance.
Evaluation of the experience
The gains from contracting exceeded the
investment of time and effort by all .
parties involved. Released from the
restraints of traditional course
requirements, students and faculty freely
expressed their creativity. Although
initially students were hesitant and
insecure in making their own decisions
about learning, contracting provided an
outlet for creative drives. Students who
had previously viewed themselves as
creative, were almost immediately
enthusiastic, while others discovered
within themselves their potential for
innovation. In this latter group, an
almost metamorphic change was noted
when self-pacing was allowed. An
inevitable effect on faculty was a feeling
of excitement and pride. A by-product of
the wide range of activities generated by
this atmosphere was the increased
visibility of both schools within their
respective communities.
The time required to work with
individual students in contract
development, while necessary, proved to
be a continuous drain on faculty time and
energy. At certain peak periods, such as
just before contract signing, this demand
became a source of frustration,
especially for those faculty with less
flexible schedules, with the result that
time spent discussing contracts in team
meetings frequently took precedence
over other pressing business.
In neither case did contract disputes
occur in the true labor relations sense.
Because of the large number of students
and faculty involved in the McMaster
experience, however, some degree of
inconsistency was inevitable. Although
some students did question the degree of
fairness, generally concerns were
resolved through discussions in team
meetings and consultation with faculty.
Informal consultations were more
effective than the formal mechanism set
up for resolving impasses.
Most students began to implement
their learning plan early in the term, and
as anticipated, the process of contracting
helped them focus their energies as the
term progressed. As with all
assignments, there were some students
who were slow starters, resulting in
stress for both students and faculty.
The mechanisms set up to assist
students in securing learning resources
varied in their effectiveness. In year two,
the packages of learning resources
proved useful, but the response of
students to the suggestion that they add
resources to these packages was
somewhat disappointing. As few
students used the bulletin board to
inform others of their intent to contact
community resource people, many
resource persons were approached
several times with similar requests.
These situations were not encountered
with the fourth year students given the
numbers and variety of interests and
endeavors involved. The learning
resources that were provided, such as
various research instruments,
bibliographies specific to certain
concepts, lists of resource persons and
guidelines for the use of local libraries,
proved helpful. In both situations, letters
of introduction were useful in
establishing student credibility.
The guidelines describing
expectations for A, B and C grades were
essential as this was the first exposure to
contracting for both groups. As with any
individual learning experience, however,
a certain degree of subjectivity was
inevitable. This posed a problem,
particularly when faculty and students,
inexperienced with the contracting
process, set evaluation criteria that were
so general that the judgment regarding
their achievement had to be subjective.
Because contracts were finalized three
weeks before the end of the term, an
unforeseen problem arose. Some
students submitted evidence which
exceeded specifications of their contract
and there was no provision in the process
for upgrading their mark . This seemed
unjust, particularly in view of the
reasons for contracting and the fact that
a lower grade could be negotiated if the
student failed to meet the stated
requirements.
The requirement that each student
begin by writing aC contract became a
cumbersome and redundant exercise for
students who had their sights clearly
focused on achieving an A or a B from
the outset. Those who saw themselves as
C students at the beginning would
probably have chosen to begin with aC
contract anyway, although they often
changed their self-expectations as the
term went on.
In both groups, faculty were
impressed by the creativity displayed by
the students. One form this creativity
took was the development of original
tools for evaluation. The use of external
appraisers for evaluation was more
common in year four than year two but in
neither case, did students take full
advantage of the resources available
outside of the school of nursing,
probably partially due to a lack of
previous exposure of service personnel
to this role.
More students seemed to opt for
working in groups in year two than in
year four, which probably was indicative
of the developmental level of the learners
and the fact that year four students were
in individualized clinical placements
according to their personal interests.
When students did choose to work in
groups, it became difficult in both
situations to clearly differentiate the
work of one student from the work of the
other and frustrations in contract writing
and in evaluation of evidence resulted.
Recommendations
Contract learning has now been
implemented in all four years of the
nursing science program at McMaster
University and its use at Laurentian
University is increasing. For those
interested in integrating this type of
learning experience into their nursing
program, these are our
recommendations .
1 . As creativity is inherent to
contracting, provisions for its expression
must be provided, as early as possible in
the experience . However, guidelines are
essential, with the need for detail and
specificity varying with the
developmental level of the learner.
2. The time commitment necessary in
contract learning precludes the use of
this strategy by faculty who function in
situations demanding a large
student-teacher ratio. A maximum ratio
of 12 to one is recommended. Provision
must also be made for discussion among
faculty, with the most effective
communication frequently taking place
on a one-to-one level.
The Canadian Nurse
January 1980 47
3. A formal mechanism to deal with
contract disputes, although rarely
required, will give both students and
faculty a sense of security.
4. Initial contracts should be signed
within the first six weeks of the term to
help the students pace their learning
experiences. By incorporating
provisions for contract negotiations until
the termination of the course, difficulties
which arise when evidence submitted
does not match the specifications of the
contract are eliminated.
5. Several mechanisms to assist students
secure learning resources should be
provided with a continuing emphasis on
the responsibilities of faculty and
students to build shared resources.
Methods to ensure community resource
persons are not overloaded with student
requests should be devised.
6. Faculty groups must predetermine
common expectations for quantity and
quality of work required for the
fulfillment of A, B and C contracts.
Students should be permitted to
negotiate at any contract level, with
provisions for up or down grading.
7. As external appraisers are identified
they must be oriented to their role in
student evaluation through a basic
orientation to the philosophy and
mechanics of contracting.
8. Resource persons outside of the
school system should be given feedback
through letters of thanks or copies of
student work.
9. Although evaluation of individuals
working within a group is difficult, group
work should be supported, perhaps by
accepting group contracts and giving
group grades. This would place the onus
on the students to ensure that all
members of the group contributed
equally; failure to contribute to the full
extent, would mean that the individual
would not benefit from internalization of
the learning experience. The tedious
process of settling on grades for
contracts left the authors questioning the
appropriateness of assigning grades to
contracts at all.*
Reference
*Donald, J.G. Contracting for learning.
Learning Development, April, 1976. p. 2.
"Unable to verify in CNA Library
Jeannette Bouchard, a graduate of St.
Elizabeth School of Nursing, Sudbury,
Ontario, received her BScN from the
University of Ottawa and her MScN
from Boston University School of
Nursing. She is currently an assistant
professor with Laurentian University
School of Nursing, Sudbury, Ontario.
Marilyn Steels, BScN, a graduate from
McMaster University, received a
Canadian Nurses Foundation
Fellowship in 1970 to continue her
studies for a MSN at Case Western
Reserve University, Cleveland, Ohio.
While teaching, as assistant professor
with the McMaster School of Nursing,
she took part in this project on contract
learning. Currently, she is senior nurse
with the Niagara Branch of the Victorian
Order of Nurses.
Students & Graduates
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Notice of meeting
CANADIAN NURSES
ASSOCIATION
1980 Annual Meeting and Convention
22-25 June 1980
Vancouver, British Columbia
The 1980 annual meeting and convention of the Canadian
Nurses Association will be held 22-25 June 1980 in the West
and Center Blocks, Regency Ballroom, of the Hyatt Regency
Hotel, Vancouver, B.C.
The opening ceremony will be held Sunday evening, 22 June
1980, at 20:00, followed by a reception for members and
students. Sessions (business and program) will begin at 09:00,
Monday, 23 June 1980, continuing daily and concluding Wed
nesday afternoon, 25 June 1980, with the President s Recep
tion.
Students enrolled in schools of nursing in Canada are invited
to register to observe the proceedings of this Annual Meeting
and to participate in the program and social events.
48 January 1980
The Canadian Nurse
More than
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65 miles east of Montreal, Mont Sutton is the largest complex
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elevation, over 1.500 vertical. . . Long runs. . . sous-bois
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NURSES WHITE CAP CLIPS. Made in Canada for
Canadian nurses. Strong steel bobby pins wifrr nylon
tips. 3" size $1.29 / card of 15. 2" size $1.00 / card
of 12. (Minimum 3 cards).
NURSES 4 COLOUR PEN for recording tempt
blood pressure, etc. One-hand ope
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iQht. compact {IV dia ), sets
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ASK ABOUT OUR GENEROUS QUANTITY DISCOUNTS FOR
CLASS GIFTS. GROUP PURCHASES. FUND RAISING ETC.
USE A SEPARATE SHEET OF PAPER IF NECESSARY
The Canadian Nurse
January 1980 49
audiovisual
Burns
Prints of the highly regarded
CBC film "The Other Child"
are now available for
borrowing or purchase from
offices of the National Film
Board across Canada. The
1 6mm color film deals with the
burn unit at the Izaak Walton
Killam Hospital in Halifax,
N.S. and follows the story of
several burned children from
admission to surgery and
discharge. This film, which
has affected everyone who
has seen it, is not listed in the
regular NFB catalogue; for
information contact the NFB
office nearest you.
Resuscitation
CPR: to save a life
Each year in Canada,
almost a million people suffer
heart attacks. And in
thousands of accidents
involving electrical shock,
drowning and suffocation,
people stop breathing. Cardiac
arrest follows the cessation of
breathing in a matter of
minutes. Many people can be
saved by effective
cardiopulmonary
resuscitation.
In this film, simulated
rescue scenes demonstrate
basic emergency techniques to
be used in the event of cardiac
arrest. Each step of the
procedure is simply and
vividly demonstrated by
paramedics and reinforced
with illustrations. Adult and
pediatric resuscitation
included. For information
write: Visual Education
Centre, 75 Horner Avenue,
Unit One, Toronto, Ontario,
M8Z 4X5.
Lifestyles
A large number of
medical visits are
hypochondriacal in nature.
Hypochondriacs are people
who will not get well. They
have a need to hold onto their
symptoms. Doctors and
nurses have a need to cure.
What develops is a "tug of
war"...
Tht British Medical
Associati-n sGok \wardfor
1978 has been awarded to
"Hypochondriacs and Health
Care: A Tug of War" . This
film is about health care
professionals treating patients
who have acquired a lifestyle
of sickness. It was produced
by Workshop Films in
cooperation with Dr. Robert
R. Rynearson, Chairman of
the Department of Psychiatry,
Scott and White Hospital,
Temple, Texas. An excellent
audiovisual aid for all health
care professionals.
A 38 minute color 16 mm
film or videotape, 1978.
Rental: $40. Sale: $400 (16
mm), $350 (video). For further
information write Workshop
Films, 4 Longfellow Road,
Cambridge, MA 02138.
Choking: to save a life
A film that clearly
explains choking rescue
techniques to apply to others
and to oneself. Trained
paramedics demonstrate the
back blow, the abdominal
thrust and the finger probe.
The film also presents ways to
avoid choking situations.
For information write:
Visual Education Centre, 75
Horner Avenue, Unit One,
Toronto, Ontario, M8Z 4X5.
Autism
Minority of one
A film that takes a look at
behavioral modification
techniques that aim at
diverting today s autistic
children away from mental
institutions and into normal
adulthood. For information
write: Visual Education
Centre, 75 Horner Avenue,
Unit One, Toronto, Ontario,
M8Z 4X5.
Childbirth
Pregnancy: Two people
A 16 mm color film, 35
minutes in length. A visual
record of the pregnancy of
uanne and Richard Clarke. A
documentary record of
conversations, visits with
friends and families, and of
the changing feelings of the
couple towards each other and
the growing baby . The film
approaches theClarkes, the
institutions and the people the
pregnancy put them in contact
with, in an objective way.
For information contact:
Richard andJuanne Clarke,
Change Productions,
ISAhrens Street West,
Kitchener, Ontario,
N2H 4B7.
Childbirth
A Labor of Love
A sensitive motion picture
dealing with family-centered
childbirth and focusing on the
impact of pregnancy on an
entire family. The film covers
expectant parent classes,
discussions about pregnancy,
birth and post-natal situations
with parents to be, the
obstetrician, a psychiatrist
and a registered nurse
childbirth educator, prenatal
exercises, animation that
demonstrates the normal
mechanisms of labor and
delivery, father participation
in the labor and delivery
rooms and more. A 31 -minute
color sound film.
For further information write:
M education Inc., 683 Beacon
Street, Newton Centre,
Massachusetts, 02159.
Patient education
A new system of patient
education is being developed
by Medifacts and the College
of Family Physicians of
Canada, based on the
patient s use of audio
cassettes and illustrated
rochures as learning aids.
This system involves the
patient, and often members of
his family as well, listening to
a cassette dealing with his
medical problem.
Subsequently the patient is
able to discuss his problem
more intelligently with his
physician, with greater
understanding of the need for
patient compliance.
Among the cassettes
produced so far are these titles
which have a direct
application to patients or their
family:
1 . Growing Up (Adolescence)
46 minutes $6. 95
2. Birth Control
(Contraception) 41 minutes
$6.95
3. Drinking and Drugs
37 minutes $6.95
4. Talking about Sex
89 minutes $9. 95
Each cassette presents
information in lay language in
the form of dialogue, narrative
and dramatized vignettes
which often enable the patient
to see himself as others see
him.
Members interested in
further information on these
patient cassettes should write
to Medifacts Ltd., 43 Eccles
Street, Ottawa, Ont.,
K1R6S3.
Continuing education
The Renal Series, a functional
review for nurses, is now
being offered by the
University of Kansas Division
of Continuing Nursing
Education. The sequence of
nine modules and
accompanying slides is
designed to increase the
nurse s understanding of renal
function and to apply this
understanding to the care of
patients with kidney
impairments. It can be used in
independent study, discussion
groups, tutorials, or
traditional classrooms.
For further information write:
Independent Study,
Continuing Education,
University of Kansas,
Lawrence, Kansas 66045. *
50 January 1980
The Canadian Nurse
TORONTO GENERAL HOSPITAL
NEEDS NURSES FOR
SPECIALTY CARE
Canada s premier university affiliated teaching hospital (1,000
beds) requires experienced nurses for a variety of clinical areas
primarily in intensive care settings
In 1979 Toronto General celebrated 150 years of excellence in
patient care and a history of medical firsts
In 1980 Toronto General moves into new, modern facilities and
we want you there to start our second 150 years
The TGH environment provides an opportunity to work in
any nursing specialty (with the exception of paediatrics) and
to actively participate in patient education
A quality assurance program enables you to plan, implement
and evaluate the care your patients receive
A comprehensive orientation combined with a continuing in-
service program provides you with what could be your greatest
professional challenge
TGH provides an attractive salary and benefits package
coupled with the opportunity to work and play in one of North
America s greatest cities
If interested please call Toronto General
Hospital at (416) 595-4182 or write "Nurs
ing Opportunities", Personnel Department,
Toronto General Hospital, 101 College Street,
Toronto, Ontario, Canada, M5G 1L7
research
Patient classification
A Research Report on the Development and
Validation of the PCTC System. Edmonton,
Alta., 1979 by K.S. Bay et al., University of
Alberta.
A system of patient classification by types of
care (the PCTC system) was developed and
validated to improve decisions for longterm
care patients and to provide information
required for planning and resource allocation.
In order to evaluate the PCTC system as
a feasible mechanism for making rational
placement decisions, it is proposed that a
centralized placement service unit (PSU) be
established for a suitable region of Alberta
and a demonstration project be carried out.
An overall summary of the project, findings
and conclusions and recommendations for
policy consideration, PSU demonstration
project and research in general are provided.
"Limit yourself to kitchen knives
for a few days"
dequadin
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Antibacterial, antifungal lozenges
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Single pregnancy
Punishing the Pregnant Innocents. Single
Pregnancy in St. John s, Newfoundland. St.
John s, Nfld. 1978. Thesis (M.S.), Memorial
University of Newfoundland by Laura Hope
Toumishey.
The primary objectives of this study are to
determine from data obtained from 40 single
pregnant girls in the city of St. John s
a)to what extent social and emotional factors
inhibit a healthy pregnancy outcome; and
b)whetherthe established and generally
accepted social norms for sex-related
behavior are relevant to the attitudes and
behavior of young people living in St . John s .
The primary concerns of those
interviewed were closely related to their
perceptions of anticipated responses from
parents, sexual partners and social groups etc.
Data analysis also served to identify
significant emotional milestones during an
illegitimate pregnancy.
A discussion of the role and
responsibility of a society to prepare its youth
for future sex relationships and parenthood
revealed that there were serious discrepancies
in attitudes and services within the existing
socialization process.
The extent to which specific punishments
are imposed upon pregnant, single girls are
described in this study.
Recommendations for changes in social
attitudes and approaches to the problems
associated with illegitimate pregnancies in St.
John s are included.
Gerontology
Health-Related Problems of Elderly People
Attending Senior Citizen Clubs/Centers.
Mississauga, Ont. 1979, by Isabel Milton.
The purpose of this comparative study was to
investigate the nature, frequency and severity
of the health-related problems of elderly
people attending senior citizen clubs/centers.
Data was collected in three senior citizen
clubs/centers; 24 suburban and 36 rural
subjects completed a questionnaire with the
investigator present and 25 of the 32 urban
subjects completed the questionnaire as a
structured interview guide as they were
unable to read English.
Across settings, more than one-third
reported health problems related to vision,
medication therapy, indigestion, appropriate
diet, appetite and blood pressure and
one-quarter reported health problems related
to self-esteem and life satisfaction.
Health professionals were used to cope
with health-related problems to a much
greater extent than the social network, with
the physician being utilized the most
frequently. The least utilization of the nurse
was reported in the rural setting.
This study emphasizes the increased
need of nursing services to the "well-elderly"
in geographically convenient and established
settings.*
52 January 1980
The Canadian Nurse
Special techniques in assertiveness
training for women in the health
professions by Melodic Chenevert,
St. Louis, Mosby, 1978.
Approximate price: $9.75
The author. Melodic Chenevert,
B.A.. M.S., formerly an instructor at the
University of Wisconsin, School of
Nursing, indicates in the preface that
within the health care system women
account for more than eighty percent of
all health care workers. She suggests that
women have been the silent majority,
rarely voicing opinions concerning
patient care. Women have traditionally
been nonassertive and it is now time to
prepare to challenge the authorities in
health care to provide a responsive and
responsible system.
The chapters of the book have
unique titles (e.g.. Of Chickens and
eagles. Chicks and roosters. How to tell
a turkey to stuff it!), and excellent
photographs complement the content.
An annotated bibliography provides
additional resources for the reader.
This book provides a perspective on
the reasons women tend to be
nonassertive in the health care field, and
gives numerous examples of situations
with which every nurse can identify.
Throughout the book positive
examples and strategies are provided to
assist in developing assertiveness.
Overall, the book provides light
interesting reading for all women.
But. 1 cannot recommend the book
for educational purposes because while it
focuses on women s nonassertiveness, it
does not in turn adequately delineate the
activities necessary to change this
situation.
Reviewed by Janet L. Moore, Associate
professor. Faculty of Nursing,
University of Calgary, Calgary, Alberta.
Guide to Nursing Management of
Psychiatric Patients by S. Dreyer, D.
Bailey and W. Doucet. 2nd ed.
Toronto. C.V. Mosby Co., 1979.
Approximate price: $12.00.
This book is intended primarily for
undergraduate psychiatric nursing
students and to be used as a teaching tool
for nursing instructors. It utilizes a
workbook format based on clinical cases
to facilitate the transfer of applied
theoretical material from an intellectual
exercise to the actual clinical situation.
The second edition has been
updated in view of the trend to treat
patients in their own communities
books
instead of in centralized treatment
centers, the greater awareness of
potential danger in treating individuals
simply as diagnostic entities, tightened
criteria for involuntary admissions and a
greater awareness of the rights of the
mentally ill.
The conceptual framework utilized
for presenting the major psychiatric
disorders is anxiety and defense
mechanisms, which is sometimes
inadequate in teaching schizophrenia and
affective disorders.
This guide is recommended for
students preparing for their exams but
not alone as a reference as it requires
prior reading and/or supplemental texts.
Reviewed by Marilyn Robbins,
educational consultant, Hamilton
Psychiatric Hospital, Hamilton,
Ontario.
Can you name
the i.v. fat emulsion
you are using?
NUTRALIPID is the new name for the I.V. fat emulsion
that you have known and trusted for years. From now on,
it s NUTRALIPID- , but your patient will be getting
the only fat emulsion that has been safely used for more than
15 million patients world-wide.
Only the name has changed.
NUTRALIPID
The name to remember
for i.v. fat emulsion.
Pharmacia
Pharmacia (Canada) Ltd.
Dorval, Quebec -RegdT*
The Canadian Nurse
January 1960 53
Teaching clinical nursing ed. by
S.M. Hinchliff. New York,
Churchill-Livingstone, 1979.
Approximate price: $15.00
This British paperback attempts to
give practical help to the nurse teacher in
both the clinical area and community.
Basic information and guidelines on
many aspects of teaching are discussed
by various contributors, making the
book useful for a new teacher.
Hinchliff initially discusses "the
process of clinical nursing" in which
excellent guidelines are given for
obtaining a very thorough nursing
assessment and a clear, comprehensive
outline of all phases of the nursing
process.
Despite differences in nursing
education between Britain and Canada,
many problems encountered on the ward
are of a similar nature and useful
information is given for planning a
teaching program on the unit.
One main theme throughout is the
emphasis on the need for good
communication between the ward staff
Ovol Drops
relieve
infant colic.
:-:..
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.
Shhh. Ovol Drops.
Also available in tablet form for adults
and the students and teacher. Another is
that of student anxiety in the clinical
setting which can adversely affect
student growth, independence and
performance and which all too often may
be overlooked by an experienced ward
staff or teacher.
There is some repetition of
educational theories and approaches to
learning which tends to lessen the intent
of the reader; however, there are many
good ideas discussed in the chapter on
"Teaching resources", and guidelines as
to using the many resources available
today. A chapter on "Teaching
psychiatric nursing" is applicable to any
clinical situation and not specific to
psychiatry; the use of role play as a
teaching device, however is discussed on
a most superficial level. Guidelines
which would have been useful for
teachers are missing which is
unfortunate since this method can offer
so much toward the development of
empathy, self-awareness and
attitude-change. Few books are written
on teaching clinical nursing and this is a
useful library addition because of the
many practical guidelines it offers for
sound planning.
Reviewed by Kathleen Young, R.N.,
B.Ed., Teaching master, Seneca College
School of Nursing, Willowdale, Ontario.
OVOlSOmg
Tablets
OVOl4Omg
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 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.
8 HORneR
Montreal Canada
M January 1980
Tha Canadian Nurse
Books for a new
decade of nursing.
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
management in neonatology. Popular
features, such as critical comments
on controversial points, case material
and question-answer exercises that
apply information from each chapter
have been retained.
By Marshall H. Klaus, MD. Prof, of Pediatrics;
and Avroy A. Fanarott, MB. (RAND). MRCPE.
Assoc. Prof, of Pediatrics, both of Case Western
Reserve Univ. School of Medicine. Cleveland.
OH. 437 pp. Illustd. $23 40. July 1979.
Order #5478-9.
SIMULATIONS
IN NURSING
PRACTICE
Here s an approach that allows readers
to apply problem-solving skills to
medical-surgical nursing and it s been
class-tested as well! Corbett &
Beveridge offers an exhaustive
treatment of six decision trees in a
unique learning format. Readers are
guided through these clinical situations
using a series of self-testing questions
to examine decision-making skills.
As readers progress, they encounter
rationales for both correct and incor
rect action. The volume functions as
an aajunct to courses on any level, as
well as for self-teaching and review.
By Nancy Ann Corbett, RN, EdM. Assoc Prof.,
College of Allied Health Sciences. Thomas
Jefferson Univ., Phila., PA; and Phyllis Beveridge;
RN. EdM. Lecturer. College of Health Sciences.
Univ. of Bridgeport, CT. 332 pp. Soft cover.
$11.95. January 1980. Order #2722-6.
Keane & Fletcher
DRUGS AND SOLUTIONS:
A PROGRAMED
INTRODUCTION
4th Edition
This unique programed text presents
material in short steps with immediate
feedback and reinforcement. You ll find
ratio and proportion for solving all
problems with nofomulasto memorize.
Additionally, you ll find all mathematics
necessary for you to know in medication
administration.
By Claire B. Keane, RN, BS. MEd; and Sybil M.
Fletcher, RN. BS. About 170pp. Illustd. Soft
cover. About $9.00. Ready soon. Order #5343-X.
Tilkian&Conover
UNDERSTANDING HEART
SOUNDS AND MURMURS
Here s an exciting package that pro
vides a basic familiarity with 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. Tilkian, MD. FACC, Asst. Clinical Prof,
of Medicine (Cardiology), Univ. of California
School of Medicine, Los Angeles; and Mary
Boudreau Conover, RN, BSN, Ed, Instructor of
Critical Care Nursing and Advanced Arrhythmia
Workshops. West Hills Hospital and West Park
Hospital, Canoga Park, CA Book only: 122 pp.
Illustd. Soft cover. $10.95. April 1979.
Order #8869-1. Package: $20 35 Order #8878-0.
Drain & Shipley
THE RECOVERY ROOM
Two leading experts provide clear,
accurate coverage of the recovery room
in this exciting 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, 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 pp. 167 ill. $20.35.
March 1979 Order #3186-X.
Lee
CONCEPTS IN
BASIC NURSING:
A MODULAR APPROACH
A unique new learning concept for
nurses! This one-of-a-kind manual pro
vides an excellent foundation for
studying the nursing process in main
taining basic functions, from respiratory
and nutritional ... to psycho-social
and electrolyte status. Six major units
are divided into modules, each with its
own glossary, objectives, self-tests,
post-tests, and answers. Excellent for
use in a traditional learning environ
ment, or for an independent, self-paced
program. Instructor s guide available
now.
By Eloise R. Lee, RN, MEd, Asst. Prof., Cedar
Crest College, School of Nursing, Allentown, PA.
About 450 pp. Soft cover. About $13.80. Ready
soon Order #5697-8.
To order titles on 30-day approval,
enter order and author
AU AU
check enclosed Saunders pays postage
CN1/80
-J Enter my subscription to
the Nursing Clinics with
the next issue
All onces differ outside
U S and subject to change
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Signature.
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L - W.B. Saunders Company.
1 Goldthorne Ave., Toronto, Ontario M8Z 5T9
Documenting patient care
responsibly Skillbook Series,
Nursing 78 Books, Horsham,
Pennsylvania, Intermed
Communications, Inc., 1978,
191 pages.
Approximate price $8.95,
hardcover.
Documenting patient care
responsibly is one volume of the Nursing
Skillbook Series intended for education
in nursing in order to provide quality
patient care. There are nine authors, and
more than twenty-five contributors, but
the presentation style remains consistent
and well integrated throughout. Like the
previous Nursing Skillbooks, this book is
rich in the use of visual aides,
caricatures, anecdotes, charts, graphs
and summaries. The text is easy to read,
easy to follow and enjoyable to learn
from.
Self assessment of learning is
provided in the form of Skillchecks
which are multiple choice questions at
the conclusion of each section.
Answering the Skillchecks requires
synthesis and application of information
in simulated situations. Answers and the
appropriate rationale are provided at the
end of the text.
Not a book intended to teach or
improve skills in traditional
source-oriented charting, it explains and
clearly outlines a viable alternative
which is gaining increasingly widespread
acceptance the SOAPIER method: S -
subjective data (what the patient says he
feels), O - objective data (what you
observe and inspect), A - assessment
(ongoing), P - plan, I - implementation of
the plan, E - evaluation of the
implemented plan and R - revision.
Problem oriented medical records
(POMR) first introduced by Dr.
Lawrence L. Weed in 1958, is the basic
theory upon which the text is based.
The book begins with an overview
of the nursing process; this is a valuable
and concise review for students and
active graduates or a sound introduction
for nurses returning to practice. The
authors emphasize throughout that
charting according to the nursing process
is essential in order to provide quality
patient care.
The text proceeds systematically
and progressively through the phases of
data collection, assessment, identifying
needs, planning care, recording progress
and evaluating the plan. Legal
considerations are also incorporated
within each section.
The bias of this text is clearly
against source-oriented charting and
toward POMR. It would appear that the
use of POMR is becoming increasingly
popular and it is therefore imperative for
nurses to update their skills
independently or as part of a continuing
education program. Documenting patient
care responsibly is suitable for use in
either way and would also be a valuable
reference source for those individuals or
institutions interested in implementing
the POMR system of documentation.
Reviewed by Susan J. Carmichael,
Instructor, Faculty of Nursing, St. Clair
College of Applied Arts andTechnology,
Windsor, Ontario
Manual of Critical Care by Linda
Feiwell Abels, R.N., M.N. St.
Louis, Mosby, 1979.
This book is geared to the critical
care practitioner; it may serve as a
technical reference for those involved in
a variety of critical care settings or as a
resource for nurses being introduced to
intensive care nursing, and for
instructors in the special care areas.
The format is well organized and
comprehensive. Various aspects of
critical care are discussed, from life
maintenance to disaster planning. There
is, however, limited content on coronary
care. Since this is purely a technical text,
it lacks an individualized patient care
approach and does not provide
description and specific management of
major disease processes encountered in
critical care areas.
Of special interest is the chapter on
physical assessment which is very
informative and systematically
approached and there is a thorough
description of laboratory tests commonly
used in intensive care areas for quick
reference.
The author also presents an in-depth
discussion of basic and complex nursing
procedures and equipment which would
be useful, not only in critical care areas,
but also in a general ward setting.
Included are numerous illustrations and
pictures.
Each chapter has a comprehensive
bibliography and the book ends with
appendices on cardiac rhythms with
indications for treatment, as well as a
summary of various drugs.
Overall, this book is worthwhile
reading for anyone providing care to the
critically ill patient.
Reviewed by Emma C.Glua, R.N.,
Nurse Clinician, Coronary Care Unit,
Vancouver General Hospital.
Emergency first aid, safety oriented
[Ottawa] St. John Ambulance,
C1977.
This new St. John Ambulance First
Aid Manual is dedicated, as its title
would indicate, to the teaching of
emergency first aid and personal safety
precautions. As expressed in Dr. Sailer s
foreward, the "ultimate goal of St. John
in Canada is to provide at least the basic
concepts of First Aid and Safety to every
trainable citizen in the country" . To
achieve this purpose, the practice of first
aid is presented within the framework of
loss control; in its effort to prevent loss
of life, of health, of productive time and
of money to the individual, to the
community, and to the country at large.
The manual subscribes to the belief that
accidents leading to the need for first aid
are often avoidable when reasonable
precautions are exercised.
Indeed, the most unique feature of
this first aid manual is its attention to
safety and preventive measures
throughout. Together with descriptions
and illustrations for practical modes of
emergency treatment, the authors have
presented methods of preventing injury
such as common household and
industrial accidents, as well as our
classic environmental injuries. For
example, the chapter which includes
cold exposure comes complete with
temperature chart, index of wind chill
factors, and advice on suitable clothing.
The information presented is readily
understandable, and would well serve as
a handy reference manual for
professionals and non-professionals
alike. I was pleased to see the inclusion
of the abdominal and chest thrust
procedures for victims of choking, and
would recommend that anyone likely to
make use of cardiopulmonary
resuscitation should explore the St. John
Ambulance special course or request
additional instructional materials as
explained on page forty of the manual.
Pertaining to safety in another
dimension, the authors do not fail to
point out situations where the first aider
is limited in his intervention skill, and
thus where professional help must be
sought immediately.
Several strong features of this
publication are the modification of
various emergency procedures when
applied to children versus adults, an
explanation of the importance of
listening and talking to the conscious
victim, of making assessments, and
setting priorities.
However, my highest
recommendation of the book would be
given for its promotion of personal safety
attitudes and practices, which most of us
violate from time to time.
The rationale upon which this safety
oriented manual is based, can best be
summarized in this introductory quote:
"First Aid strives to minimize or
overcome the effects of unsafe acts or
unsafe conditions which have in the past
been considered uncontrollable."
Reviewed by Cheryl Ann Lapp, graduate
student, Advanced Public Health
Nursing, School of Public Health,
University of Minnesota.
56 January 1980
The Canadian Nurse
When your questions
involve clinical
laboratory tests,
turn to Wiomann
for guidance!
The brand new eighth edition of Widmann s Clinical Interpreta
tion of Laboratory Tests gives you immediate access to the data
you need to better understand the selection and interpretation of
laboratory tests. Widmann covers the wide range of problems en
countered in community or hospital practice, discussing widely avail
able tests of proven value. No matter what your questions concern,
you ll find answers in Widmann. From bilirubin tests, blood cultures,
and oral glucose tolerance tests, to how to establish the fetal
chromosome complement or how to determine lactose intolerance,
you will discover clearly written, helpful advice reflecting the latest
clinical understanding of the tests and their significance. And, the
author is particularly careful to explain where and how each lab
test applies to your patient s clinical problems.
For the eighth edition, Dr. Widmann has completely reorganized the
book, making it much more practical to use. The book is now di
vided into sections, including Hematology, Immunology, Chemistry,
and Microbiology. The full table of contents (reproduced elsewhere
on this page) will show you the new organization of the book.
The author has also added a great deal of new material to this
edition. The section on Immunology has been updated to include
new tests and new understanding of the body s defenses against
external and internal attack. The new material included on blood
banking explains what happens to blood when it is stored. The sec
tion on Chemistry deals more extensively than ever with tests that
are important clinically.
No matter the area of your practice, maternal-child care, primary
care, or medical/surgical nursing, you ll find Widmann s Clinical
Interpretation of Laboratory Tests a handy and reliable source
of information.
Titles of Related Interest-
Primary Care
Cynthia JoAnn Leitch, editor of the journal, The Nurse Practitioner, and
Richard V. Tinker have organized a team of 1 9 highly qualified nurses
and doctors to produce a text ideal for today s nurse practitioner. It ranges
from evaluation and management of primary care problems, and primary
health care of the child, through the management of medical emer
gencies, and mental health in primary care, to rehabilitation. By Cynthia
JoAnn Leitch, PhD, RN; and Richard V. Tinker, MD. 589 pp. Illustd.
$30.00.1978.
TABER S* Cyclopedic Medical Dictionary, 1 3th Edition
With over 47,000 entries. Taber s is unexcelled as a medical and nursing
dictionary It features phonetic spelling for most entries, it includes basic
health questions and answers in 5 languages, and it gives quick access
to conversion tables, abbreviations, first aid treatments, etc. You ll find
nutritional values for many foods, an informative appendix and 1 50 two-
color illustrations rendered specifically for this edition.
Edited by Clayton L. Thomas, MD, MPH. 1 784 pp. Illustd. Thumb-
indexed. $19. OO.Not thumb-indexed: $17.50. 1977.
Prices are subject to change.
By Frances K. Widmann, MD, Associate Professor of Pathology Duke
University School of Medicine, Durham, North Carolina.
656 pp. Illustd. $14.50. January 1979. Order #9322-2.
Table of Contents
I Hematology: Hematologic Methods; Hemostasis and Tests of Hemo-
static Function; Diseases of Red Blood Cells; Diseases of White Blood
Cells; Disorders of Hemostasis. II Immunology: Principles of Immunol
ogy and Immunologic Testing; Serology: Selected Immunologic Tests;
Immunohematology and Blood Banking. Ill Chemistry: GeneralChem-
istry; Acid-Base and Electrolyte Regulation; Serum Enzymes of Diagnostic
Importance; Liver Function Tests. IV Microbiology: Microbiologic Ex
aminations; Serologic Tests in Microbiology. VEndocrine System: The
Endocrine Glands; Pregnancy. VI Other Tests: Urine, Feces; Sputum;
Gastric and Duodenal Contents; The Cerebrospinal Fluid. Index.
r Please send^e~a~o~y~f~9~2~2^ idmanrVs"T;i inical"
Interpretation of Laboratory Tests, 8th Edition ($14.50).
Also send the books I have checked below:
D #5535-5 Leitch & Tinker s Primary Care ($30.00).
D #8304-9 Taber s Cyclopedic Medical Dictionary, 13th Edition
(thumb-indexed $19.00).
D #8305-7 Taber s Cyclopedic Medical Dictionary, 13th Edition
(not thumb-indexed $17.50).
An invoice will accompany the book and will include a small charge for
postage and handling.
If you re not completely satisfied, you may return the books in 30 days,
in good condition.
Full Name_
Home Address.
Ccry_
Published in U.S. by:
.Province.
_Postal Code.
Our Canadian customers
should write to:
McAinsh & Co., Ltd.
1835YongeSt.
Toronto. Ontario M4S 1 L6
F. A. DAVIS COMPANY
1915 Arch St., Philadelphia, Pa. 19103
Vulnerable infants: a psychosocial
dilemma. Edited by Jane Linker
Schwartz and Lawrence H.
Schwartz. 378 pages. New York.
McGraw-Hill Inc., 1977.
Approximate price $10.95
The editors of Vulnerable Infants
have compiled a volume containing
twenty-one articles and editorial
comment. The collection of articles
contains both classic studies and more
recent observations from an impressive
list of contributors. As well as providing
evidence of the effects of various
parameters on the outcome of pregnancy
and the subsequent growth and
development of the high risk infant, the
book draws attention to current moral,
legal and ethical dilemmas encountered
in the health care of high risk infants.
The focus of the book is on the
psychosocial aspects surrounding high
risk infancy. Although management of
the problems is not the theme, the
various studies, both because of their
findings and the variables measured,
provide a wealth of data pertinent to both
preventative and management
approaches.
In the introductory chapter, the
editors point out the dramatic increase in
the survival rate of low birth weight
babies as a result of technological
advances . The crisis of coping with the
high risk infant and his family is thus
encountered with increasing frequency
by health care professionals both in
hospitals and in the community. U.S.
statistics are used to illustrate the scope
of the problem and the economic and
social costs in that country.
The remaining chapters are well
organized. Each contains a group of
articles dealing with one aspect of the
problem preceeded by an editorial
comment highlighting the content of the
articles and bringing findings of related
research studies by other authors.
The volume is a carefully chosen
selection of articles which clearly
illustrates the problems, encourages
further study and provides direction for
health care. The articles and their
extensive bibliographies provide a rich
and convenient source for any
professional concerned with the
problems of the high-risk newborn.
Many of the readings are a must for
anyone involved in the planning and
implementation of perinatal health care
services. In addition the many questions
raised by the editors and contributors
call out for more research and the
volume should, therefore, provide both
background and impetus for further
study of problems related to the
vulnerable infant.
Reviewed by J. Alison Rice, Assistant
Professor, University of British
Columbia, School of Nursing,
Vancouver, B.C.
How to write meaningful nursing
standards by Elizabeth J. Mason,
355 pages. Toronto, John Wiley and
Sons, 1978.
Presented in workbook format, this
book is designed to help nurses write
meaningful and explicit nursing
standards which can be evaluated.
Three types of standards are
examined within relative parameters.
The type of standard is clearly defined,
and information is provided on how to
write the particular standard being
discussed in a step-by-step format. An
opportunity for practice is provided for
the reader to apply the information
gained and answers are also supplied so
that the reader can evaluate his or her
progress.
Chapters are developed
independently, so that the reader can
choose a starting point, without having
to follow a chapter by chapter sequence.
The chapter on "Validating
Standards" demonstrates some
ambiguity and vagueness and at times is
confusing as to procedure. In addition,
although each chapter contains an
introduction of content, and a summary
(as well as an acknowledgement in
some), there is no bibliography for
references. The absence of an index also
makes it difficult to locate specific
information.
Despite the shortcomings, this book
is of value to nurses who are concerned
with developing criteria for evaluating
nursing practice in all settings, and
should be useful to nursing associations
who are attempting to determine
standards for practice.
Reviewed by Diane Pechiulis, Associate
professor, Faculty of Nursing,
University of Calgary.
BOOKS RECEIVED
Listing of a publication does not preclude its
subsequent review. Selections for review will
be made according to the interests of our
readers and as space permits. All reviews are
prepared on invitation.
Le bruit industriel; ses mefaits et son
controle, parGuy Lescouflair. Quebec,
Presses de 1 Universite Laval, 1979.
Manuel de therapeutique medicale, par
Nicolas V. Costrini. Traduction et adaptation
de la 22e edition americaine. Paris, Edisem,
1979.
Kertilite-con t racept ion-a vortement ; guide
pratique, par Ecole de Service social.
Quebec, Universite Laval, 1979.
Mieux vivre avec son enfant, par Nicole
Dumas et Danielle LeHenaf. Quebec,
Departement de sante communautaire, 1979.
A history of the council for the education and
training of health visitors, by Elaine Wilkie.
Boston, George Allen & Unwin, c!979.
Learning about epilepsy, by William B.
Svoboda. Baltimore, University Park Press,
C1979.
Anatomy of an illness as perceived by the
patient; reflections on healing and
regeneration, by Norman Cousins. New York,
W.W. Norton, C1979.
Manual of advanced nursing, by Lorna A.
Schreiber & Marie E. Vlok. 3rd ed.
Johannesburg, Juta&Co., 1979.
Techniques infirmieres: une demarche locale
d analyse du programme d enseignement, par
Madeleine Bureau-Brien. Quebec, College de
Sherbrooke, 1979.
Dying in an institution; nurse/patient
perspectives, by Mary Reardon Castles &
Ruth Beckmann Murray. New York,
Appleton-Century -Crofts, c!979.
Cancer-causing agents; a preventive guide,
by Ruth Winter. New York, Crown Pub.,
C1979.
Report of the Ninth Ross Roundtable on
critical approaches to common pediatric
problems in collaboration with the Ambulatory
Pediatric Association. School-related health
care. Columbus. Ohio, Ross Laboratories,
c!979.
Voyager en sante sous les tropiques, par
Pierre Viens. Montreal, Le medecin du
Quebec, 1979.
Naitre aujourd hui. Montreal, Le Medecin
du Quebec, c 1979.
The treatment of hypertension, edited by
E.D. Freis. Baltimore, University Park Press,
c!978.
Baby surgery; nursing management and
care, by DanielG. Young, Eleanor J. Martin
& Barbara F. Weller. 2d ed. Baltimore, Ma.,
University Park Press, c!979.
Alcoholism in perspective, edited by Marcus
Grant & PaulGwinner. Baltimore, Ma.,
University Park Press, c!979.
Clinical simulations in nursing practice, by
Nancy Ann Corbett & Phyllis Beveridge.
Toronto, Saunders, 1980.
Manual of pediatric nursing careplans.
Department of Nursing. The Hospital for Sick
Children, Toronto, Canada. Edited by U.F.
Matthews. Boston, Little, Brown, c!979.
Research in nursing practice, by Donna
Diers. Toronto, Lippincott, c!979.
Pharmacology and drug therapy in nursing,
by Morton J. Rodman & Dorothy W. Smith.
2ded. Toronto, Lippincott, c 1979.
Medical-surgical nursing and related
physiology, by Jeannette E. Watson. 2ded.
Toronto, Saunders, 1979.
The developmental therapist, by Barbara
Sharpe Banus...et al. Thorofare, N.J.,
Charles B. Slack, c!979.
Alcohol and your patient; a nurse s
handbook, by Madelaine Coates &Gail
Paech. Toronto, Addiction Research
Foundation, 1979.
Leadership in nursing, edited by Marjorie
Beyers. Wakefield, Ma., Nursing Resources,
c!979.
The clinical performance examination;
development and implementation, by Carrie B.
Lenburg. New York,
Appleton-Century-Crofts , c 1 979. *
*THE LIBRARY S ACCESSION LIST IS
AVAILABLE ON REQUEST WITH A
STAMPED, SELF-ADDRESSED
ENVELOPE.
58 January 1980
The Cinadlan Nurse
Classified
Advertisements
Alberta
Registered Nurses required for full lime and part time
employment. Must be eligible for registration with
AARN. Salary and benefits as perU.N.A. Contract.
Apply in writing to: Miss J. James, Director of
Nursing, Elnora General Hospital, Elnora, Alberta
TOM OYO or phone: (403) 773-3636.
Head Nurse for Operating-Emergency Department
required in a 66-bed active treatment hospital. This
nurse must have a number of years of experience in a
management position, have a Bachelor of Nursing
Diploma in Administration or post graduate course
in Operating Room and a Unit Management course.
Leadership abilities and administration skills essen
tial. Salary commensurate with qualifications and
experience. Position available immediately and will
remain open until a suitable candidate is selected.
Apply to: Director of Nursing, Taber General and
Auxiliary Hospital, Taber. Alberta TOK 2GO.
British Columbia
Experienced General Duty Graduate 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 writing to:
Director of Nursing, St. George s Hospital, Box 223,
Alert Bay, British Columbia, VON 1AO.
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 & District General Hospital,
Ashcroft, British Columbia, VOK 1AO.
The "boom" of our northern city continues! We still
require beginning or experienced practitioners for our
nursing departments. If experienced, we will give
you opportunity to try some of your ideas. If
beginning, we will give you opportunity to expand
your skills and knowledge. Contact: Mrs. A.
Henriksen. Nursing Director, Dawson Creek and
District Hospital, 1 1 100 13th Street, Dawson Creek,
British Columbia V 1G 3W8.
General Duty Nurse for modern 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 Nursing, Bound
ary Hospital, Grand Forks, British Columbia, VOH
1HO.
General Duty Registered Nurses required for 108 bed
accredited hospital. Previous experience desirable.
Salary as per R.N. A. B.C. Contract with northern
allowance. For further information please con
tact: Director of Nursing, Kitimat General Hos
pital, 899 Lahakas Boulevard N., Kitimat, B.C.
V8C 1E7.
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 $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.
Experienced Nurses (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 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
Nursing personnel required immediately for a
number of positions, all areas, full time and relief
available. Eligibility for registration in B.C. re
quired. Contact: Director of Nursing, Mission
Memorial Hospital, 7324 Hurd Street, Mission,
British Columbia V2V3H5. Phone:(604)826-6261.
Registered Nurses required for both acute and
extended care in a 125-bed hospital in the South
Okanagan. Experience in obstetrics and medical-
surgical preferred. RNABC contract in effect. Apply
stating qualifications and experience to: Nursing
Administrator, South Okanagan General Hospital,
Box 760, Oliver, British Columbia, VOH 1TO. Phone:
498-3474.
Experienced General Duty Nurses required for
130-bed hospital. Basic Salary $1,305.00 $1,542.00
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.
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 1S2.
Registered Nurses required for permanent fulltime
position at a 147-bed fully accredited regional acute
care hospital in B.C. Salary at 1979 RNABC rate
plus northern living allowance. One year experience
preferred. Apply: Director of Nursing, Prince
Rupert Regional Hospital, 1305 Summit Avenue.
Prince Rupert, British Columbia, V8J 2A6. Tele
phone (collect) (604) 624-2171 Local 227.
General Duty RVs or Graduate Nurses 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
Hospital, Box 98, Pouce Coupe. British Columbia or
call collect (604) 786-5791.
Experienced materntty, I.C.L./C.C.l., and Operat
ing Room General Duty nurses required for 103-bed
accredited hospital in Northern 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, V8G
2W7.
Instructor-Post Bask Obstetrical Nursing. Full time
instructor required immediately to help develop and
teach a unique and innovative Post Basic Obstetrical
Nursing course with an emphasis upon the intrapar-
tum period. The successful applicant will be
responsible for working cooperatively with another
full time instructor to develop and implement a
curriculum for nurses working with both normal and
high risk mothers and fetus/newborns. Non tradi
tional methods of teaching will be used, including
independent learning modules and distance learning.
The instructor must be willing to look beyond
traditional methods of nursing education to reach
working nurses and nurses throughout the province.
Preference will be given to Registered Nurses with
post basic preparation in obstetrics or midwifery,
recent clinical experience in the caseroom or high
risk nursery. A BScN, and experience in teaching
and curriculum development. Competitive salary
and excellent fringe benefits. Please submit resume
to: Barbara Mills, Coordinator, Continuing Nursing
Education, Vancouver Community College, Lan-
gara Office, 100 West 49th Avenue, Vancouver,
British Columbia V5Y2Z6. Phone: 324-5406.
British Columbia
General Duty Nurses required for an active, 103-bed
hospital. Positions available for experienced R.N s
and recent Graduates in a variety of areas. RNABC
Contract in effect. Accommodation available. Apply
to: Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace. British Columbia
V8G 2W7.
University of Victoria, School of Nursing. Applica
tions are invited for positions on the faculty of the
School of Nursing. University of Victoria. The
School offers a two-year post-R.N. programme
leading to a B.Sc.N. and plans to develop both a
basic and a master s programme. Qualifications:
Master s degree required, doctorate preferred. Ex
perience in university teaching an asset. Apply to:
Director, School of Nursing, University of Victoria,
P.O. Box 1700. Victoria, British Columbia V8W
2Y2.
Manitoba
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 vacan
cies in Pediatncs, Medicine/Surgery, Obstetrics and Critical
Care. This opportunity will appeal to nurses who want to
increase their existing skills or develop new skills 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 - 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: C04) 677-2381.
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: Assistant Administrator-
Nursing, Stanton Yellowknife Hospital, Box 10,
Yellowknife, N.W.T..X1A2N1.
Ontario
Applications are now being accepted by the Ontario
Society for Crippled Children for Registered Nurses,
Graduate Nurses and Registered Nursing Assistants
for their Resident Summer Camps located near
Collingwood, Port Colbome, Perth, Kirkland Lake
and London. Ten weeks mid June to late August,
1980. Various positions available Supervisory,
Assistant supervisory, and general cabin respon
sibilities. Contact: Camping and Recreation De
partment, 350 Rumsey Road, Toronto, Ontario M4G
1R8. (416)425-6220, ext. 242.
RN, GRAD or RNA, 5 6" or over and strong,
without dependents, non-smoker, for 185 Ib. hand
icapped retired executive with stroke. Able to
transfer patient to wheelcl.air. Live in 1/2 yr. in
Toronto and 1/2 yr. in Miami. Wages: $200.00 to
$275.00 wkly. NET plus $90.00 wkly. bonus on most
weeks in Miami. Write: M.D.C., 3532 Eglinton
Avenue West, Toronto, Ontario, M6M 1V6.
Quebec
Registered Nurse for summer camp in the Lauren-
tians, mid-June to end of August. Congenial sur
roundings. Resident doctor. Contact: Myron Good
man, Executive Director, YM-YWHA Wooden
Acres Camp, 5500 Westbury Avenue, Montreal,
Quebec H3W 2W8. Telephone: (514) 737-6551,
Local 51.
January 1980 59
Quebec
Camp Nurses required for children s 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
I M6, or telephone (514) 735-3669.
Saskatchewan
Required immediately three full time Registered
Nurses for 26-bed general duty active treatment
hospital in northwestern Saskatchewan. Salary and
benefits per current S.U.N. Contract. Apply to:
Miss Theresa Ste. Marie, Director of Nursing.
Riverside Memorial Union Hospital. Turtleford,
Saskatchewan SOM 2YO.
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. Souris Valley Ex
tended Care Hospital. Box 2001. Weyburn, Sas
katchewan S4H 2L7.
United States
R.N. s U.S.A. Dunhill with 250 offices has
exciting 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, T5J 1V9.
Total patient care with all licensed personnel is our
goal! Staff RNs currently interviewing for part-time
and full-time positions. Full service, except psych,
progressive 156-bed accredited acute general hospi
tal. Located within 60 minutes from LA, the ocean,
mtns., and the desert. Orientation and staff de
velopment programs. CEUs provider number.
Parkview Community Hospital, 3865 Jackson Street.
Riverside, California 92503. Write or call collect
714-688-221 1 ext. 217. Betty Van Aernam, Director
of Nursing.
Honda Nursing Opportunities 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
information and offer relocation hints. There is no
placement fee to you. Write or call Medical
Recruiters of America, Inc. (For West Coast) 1 2 1 1 N .
Westshore Blvd.. Suite 205, Tampa, Fl. 33607 (813)
872-0202; (For East Coast) 800 N.W. 62nd St., Suite
510, Ft. Lauderdale, Fl. 33309 (305) 772-3680.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoying
Florida s Gulf Coast beaches, sun, and exciting
recreational activities. We will provide work visas,
help you locate a position, find housing, and arrange
your relocation. No Fees! Call or write: Medical
Recruiters of America, 1211 N. Westshore Blvd.,
Suite 205. Tampa, Florida 33607 (813) 872-0202.
Nurses RNs 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 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.
that you are interested in. We will call you upon
receipt of your application in order to arrange 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"
MANIT1BA
Department of Health and Community Services
The School of Psychiatric Nursing,
Selkirk Mental Health Centre
is offering a Post - Bask Course in
Psychiatric Nursing
Registered Nurses currently licensed in Man
itoba or eligible to be so licensed, with
University credits in Introductory Psychology
and Introductory Sociology.
The course is of ten months duration Sep
tember through June, and includes theory and
clinical experience in hospitals and community
agencies, as well as six weeks nursing of the
mentally retarded.
Successful completion of the program leads to
eligibility for licensure with the R.P.N.A.M.,
as a Registered Psychiatric Nurse (R. P. N.).
For further information please write:
Director of Nursing Education
School of Psychiatric Nursing
Box MOO
Selkirk, Manitoba R1A 2B5
United States
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the U.S.A.
B) Extensive information regarding
Hospital 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 0. Box 1 133 Great Neck. N.Y. 11023
(516)487-2818
Our 20th Year of World Wide Service
Waterford Hospital
Career Opportunities For
Registered Nurses
The Waterford Hospital, a fully accredited 400
bed Psychiatric Institution, affiliated with
Memorial University School of Nursing and
Medical School, has openings for Registered
Nurses ;n all services, including new,
expanded, and acute care services
An orientation program is offered.
Salary is on the scale of SIMMS - 14. < per
annum A Psychiatric Service Allowance of
SI. 329 per annum is available iti addijion to
basic salary. Both salary and allowance
presently under review.
The Hospital is close to all amenities:
shopping, transportation and recreation
facilities.
Accommodations available in Hospital
Residence at nominal cost
Applications in writing should be addressed to
the undersigned
Personnel Director
Waterford Hospital
Walerford Bridge Road
SI. John s. Newfoundland
A1E4J8
Telephone Number: |7I) Mtt-6061. em. 341
Dallas, Houston, Corpus Christi, etc. etc, etc. 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. (2 14) 547-0077.
Come to Texas 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 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 1591, Beaumont, Texas 77704. An
affirmative action employer.
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 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; 1
(512)831-9611.
Registered Nurses. We invite you to join our health
care team at Leon County Memorial Hospital, Inc.,
a 36 bed acute care facility in Buffalo, Texas, located
in the Lone Star State s scenic country hillside of
east Central Texas. We will provide you with a
challenging professional opportunity as a nurse
involved in our high level, quality patient care
programs. Excellent starting salary; equitable shift
differentials; group employee benefits; educational
opportunities; and reasonable relocation expenses.
H-l Visa assistance provided. Please contact:
Director of Nurses, P.O. Box 159, Buffalo, Texas
75831. Phone 214/322-4231.
Nurses RNs 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 Or call collect
(713) 789-1550. Marilyn B laker. Medex, 5805
Richmond, Houston, Texas 77057. All fees employer
paid.
Nurse Midwives Overseas: Project HOPE seeks a
Midwife Nurse Educator for Egypt. This person
would need a Master s Degree, Midwifery Certifica
tion and 2-5 years teaching experience. It will offer
the challenge of working with an Egyptian counter
part in curriculum development and expansion of the
midwifery program. Project HOPE provides excel
lent benefits, negotiable salary, travel, shipping and
storage. Send resume to: Personnel Department,
Project HOPE, Millwood, Virginia 22646. E.O.E.
Miscellaneous
1 wish to contact any members of the student nurses
class at The Toronto East General Hospital.
Toronto, Ontario, for the years 1960 to 1963. Write
to: Basement Suite, 424 East 37th Avenue, Van
couver, British Columbia, V5W IE9.
SO .lununrv 1Q.RH
IMPORTANT MEMO
To:
From:
Subject:
Registered Nurse Applicants For Overseas Jobs
Hospital Corporation International
Some Advice On Seeking Employment In The Field Of
International Nursing.
Many organizations are offering overseas job opportunities in the health and hospital field these days. If you
are interested and seriously considering an overseas or international assignment, here are some important
points to consider and questions to ask before and at your interview:
Who is doing the interviewing
and recruiting? What is their
experience and background?
Make sure you are dealing with a
reputable organization that is a true
representative of your prospective
employer. Be sure they have first
hand knowledge of the location and
facilities where you d be living and
working.
Will I have to pay an
employment fee? If so,
for what and why?
Some independent agencies will
charge you a sizeable fee just to
send your resume somewhere else
and can make no commitment to
you. Other organizations do their
own recruiting or can make
commitments and they won t charge
you an employment fee.
What kind of organization or
company am I dealing with? What
is its primary business?
If it isn t the Health Care Business,
first and foremost, you may want to
investigate further: What are their
qualifications, experience,
standards, quality, etc?
How realistic is the
information and how much is offered
about the job, the working
conditions, culture, etc?
If it all sounds exciting, glamorous,
and positive, then the picture isn t
realistic, it s "rose-colored", \lcan
be adventurous and rewarding, but
there are day to day drawbacks,
frustrations, and difficulties to
consider before you decide to go.
And you should be told about all the
details don t accept
generalizations.
Will I be offered any
assistance in preparing for overseas
relocation, employment, and
adapting to the new environment?
Experienced, reputable
organizations will show concern for
you as an individual and for your
ultimate success by assisting you
with pre-departure processing
requirements and preparations and
by providing comprehensive
pre-departure and post-arrival
orientation programs.
Will I be offered any
assistance to relocate in another job
when my contract is finished?
Find out if the company can help
you "get back in touch" after being
away from home for two or more
years. It s an important point that
many individuals overlook and so
do many companies.
Hospital Corporation International, a member of the Hospital Corporation of America Group, is one of the most experienced and
professional organizations providing international recruitment and human resource services in the health care and hospital related field.
If you are thinking about an overseas assignment, we invite you to explore the possibilities by exploring Hospital Corporation
International. Ask us the questions; we ll give you the answers. You owe it to yourself.
If you are interested and would like more information, please send your resume to:
International Human Resource Management (7)
Hospital Corporation International
One Park Plaza
Nashville, Tennessee 37203
HOSPITAL
CORPORATION
" ^r;- : .y .y\
An Equal Opportunity Employer
Centracare Saint John, Inc.
This 500-bed Psychiatric Hospital is inviting applications
from:
Registered Nurses
for
All Units - Acute, Rehabilitation, Geriatric and Infirmary
Qualifications Required:
Graduation from an approved School of Nursing, registered
or eligible for registration in the Province of New Brunswick.
Post-graduate preparation in Psychiatric Nursing would be an
asset. Competence in English is essential.
Salary:
$1 1 ,208 to $16,740 per annum, commensurate with
qualifications and experience.
Benefits:
As per the Collective Agreement, including pension plan, sick
leave and vacation leave.
Apply To:
Personnel Office
Centracare Saint John, Inc.
P.O. Box 3220
Saint John
New Brunswick
E2M 4H7 Competition No. CSJ 79-28
Assistant Supervisor
Psychiatric Nursing
Applications are being accepted for the above position. The
successful applicant will provide innovative, creative
leadership in the planning, development, implementation and
evaluation of quality assurance and staff development
programs for the department. The incumbent will also give
clinical supervision in the areas of special expertise.
Applicants must be eligible for registration in British
Columbia. MSN degree is preferred and BSN degree is
required. Demonstrated administrative ability, including
skills in leadership and interpersonal relations is required,
plus expert specialized clinical nursing skills. Advanced
competence in nursing education is essential. Salary and
benefits as perRNABC contract.
Please submit applications to:
Mrs. J. MacPhail
Employee Relations Department
Vancouver General Hospital
855 W. 12th Avenue
Vancouver, B.C.
V5Z 1M9
Tomorrows
Nursing...
is a short drive
away from
R Sherman s >Vharf
The colorful tastes, sights and sounds of Fisherman s Wharf
are some of the fascinating things you ll find, a short drive from
Stanford University Medical Center.
You will also find "tomorrow s" nursing today in an exciting
teaching hospital where non-clinical personnel handle
administrative and support tasks so you can concentrate on
progressive nursing. You can apply new techniques,
participate in research and work with leading authorities in
every medical specialty.
We d like you to know more about our career development
programs and our excellent compensation package which
includes an innovative time-off program. For additional
information, send the coupon to Nurse Recruiter, Personnel
Department, Stanford University Hospital, Stanford, CA
94305. Or call collect to (415) 497-7330. For immediate
consideration, send your resumeand salary requirements. We
are an affirmative action, equal opportunity employer, male &
female.
Stanford University
Medical Center
62 January 1980
The Canadian Nurse
Are You a Nurse?
Here s an Opportunity To Be One.
Primary Nursing
at the New Regional Hospital means having direct
responsibility for the nursing care of your patient, his family,
and working with the doctor as a colleague.
Accountability
as a primary nurse means the outcome of your patient s
care is the measure of your effectiveness.
Satisfaction
results from your role as a professional and the significant
part you play in the care of your patient.
PUT IT TOGETHER with the new 300 bed Fort McMurray
Regional Hospital Opening in November, 1979.
Want to know more about your opportunities in our total
patient care facilities?
CaU Penny Albers at (403) 743-3381
or
Write for an information package:
Personnel Department
Fort McMurray Regional Hospital
Fort McMurray, Alberta
T9H 1P2
r
OPPORTUNITY
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 will remain open until a suitable candidate has
been selected.
Qualified persons are invited to phone, write or submit
applications to:
Personnel Administrator
Alberta Hospital, Edmonton
Box 307, Edmonton, Alberta
T5J2J7
Telephone: (403) 973-2213
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.
JWV
1200 Lawrence Avenue East
Suite 301, Don Mills
Ontario M3A 1C1
Telephone: (416) 449-5883
The Canadian Nurse
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed, J.C. A.M. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differential
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 90% under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-551 1
Good Samaritan Hospital
Flagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
Head Nurse
Coronary Care Unit
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 a new
Coronary Care Unit.
Applicants should have a minimum of 2
years previous experience in a related
clinical area plus previous administrative
experience and preferably hold a BSN.
Salary scale and benefits according to
the RNABC agreement. Please submit
applications to:
Mrs. J. MacPhail
Employee Relations Department
Vancouver General Hospital
855 W. 12th Avenue
Vancouver, B.C.
V5Z 1M9
Advertising
rates
For All
Classified Advertising
$20.00 for 6 lines or less
$3.00 for each additional line
Rates for display advertisements
on request.
Closing date for copy and
cancellation is 8 weeks prior to
1 st 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
K2P 1E2
Health Sciences Centre
Winnipeg, Manitoba
invites applications for the position of
Assistant Director
Maternal-Child Nursing
This position is open to females and males.
The Health Sciences Centre , one of the continent s largest
health care facilities with 1300 beds, is Manitoba s principal
referral institution for complex health problems and the
Province s major hospital for teaching and research.
The incumbent shall be responsible for the administration of
nursing services in the Women s Centre, the major high risk
referral unit for Obstetrics, Neonatology and Gynaecology.
The Women s Centre has approximately 3500 deliveries a
year, and 48 gynaecology beds.
We are seeking an individual who can co-ordinate nursing
with medical programmes in implementing a common
philosophy of care, who can participate in the planning of
new facilities, who can direct and develop nursing staff in the
use of systems which affect patient care and can develop
strong interpersonal relationships.
Candidates require a B.N. (M.N. preferred), demonstrated
success in an administrative position, a background in the
above clinical specialities and registration or eligible for
registration in Manitoba.
Interested persons should apply in writing including a
complete resume detailing education and experience to:
Manager Employment & Training
Health Sciences Centre
700 William Avenue
Winnipeg, Manitoba R3E OZ3
Registered Nurses
Come to work in scenic Corner Brook !
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
WestCoast of Newfoundland.
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January, 1979 $12,771.00 15,429.00
1 January, 1980 $13,410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
A Completely
Modern Teaching Hospital
Requires
Registered Nurses
This 500 bed general hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered -
Critical Care, Medical, Surgical Coronary Care,
General Surgery, Urology, Gynecology,
Medicine, Nephrology, Clinical Teaching,
Neurosciences, Cardiology, Cardiovascular
Surgery, Orthopedics, Hemodialysis (kidney
transplants), Emergency and Out Patient
Services, active Rehabilitation Program (adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in Critical Care Nursing,
Neurosciences, Operating Room Nursing.
Located in St. John s, Newfoundland the
oldest city in North America with a population of
120,000, offering cultural and recreation
activities in a friendly atmosphere.
Fishing, hunting, boating available
approximately 10-14 miles outside the city.
For information regarding salary and relocation
expenses and other conditions of employment
write or call -
Miss Dorothy Mills
Staffing Officer - Nursing
The General Hospital
Prince Philip Drive
St. John s, Nfld.
A1B3V6
Telephone # (709) 737-6450
MANIT
DEPARTMENT OF EDUCATION
This position is open to both men and women.
Apply in writing referring to Competition
Number VT 749 immediately.
Instructor/Curriculum
Co-ordinator
Diploma Nursing (Term Position)
The Department of Education, Keewatin
Community College, The Pas, is currently
developing a Diploma Nursing program to train
northern residents who, upon completion, will be
eligible to meet M.A.R.N. registration
requirements. The focus of the program will be
expertise required to meet health needs of
northern Manitobans. The Instructor/Curriculum
Co-ordinator will be responsible for subsequent
curriculum development. She/he will also
co-ordinate the implementation of the program;
target date September 1980. Following
implementation she/he will co-ordinate program
activities plus carry out instructional activities.
Master s Degree preferred, or a Bachelor of
Nursing with relevant experience acceptable.
Salary Range: $17,759 - $26,496 per annum (Plus
Remoteness Allowance)
Personnel Department
Manitoba Community Colleges
Room C-416
2055 Notre Dame Avenue
Winnipeg, Manitoba
R3H OJ9
Th* Canadian Nurse
January 1980 65
University of Western Ontario
Faculty of Nursing
Applications are invited for teaching positions in
undergraduate and graduate programs. Rank Open.
Master s or doctorate degree required. Preference will be
given to candidates with teaching experience and clinical
specialization. Candidates must be eligible for registration in
Ontario.
Salary commensurate with preparation and in accordance
with the University of Western Ontario policies.
Appointments are subject to availability of funds.
Send complete resume to:
Dr. Beverlee Cox, Dean
Faculty of Nursing
Health Sciences Addition
The University of Western Ontario
London, Ontario. N6A 5C1
Nursing Opportunities in Vancouver
Vancouver General Hospital
If you arc a Registered Nurse in search of a change and a challenge
look into nursing opportunities at Vancouver General Hospital, B.C. s
major 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 in many
areas such as:
Intensive Care
(General & Neurosurgical)
Cardio-Thoracic Surgery
Burn Unit
Paediatrics
Neonatology Nursing
Inservice Education
Coronary Care Unit
Hyperalimentation
Program
Renal Dialysis & Transplantation
If you are a Nurse considering a move please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C. V5Z 1M9
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education Programs.
Post Graduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Apply to:
Recruitment Officer Nursing
I niversity of Alberta Hospital
S440 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
86 .Jgnuiuy 19jp
The Canadian Nurse
Health
Sciences Centre
Intensive Care Nursing
Myocardial Infarction
Arrhythmias
Renal Failure
Respiratory Failure
Neurological
Dysfunction
Trauma
Shock
MED. OR SURG. INTENSIVE CARE UNITS
IN A 1,400 BED UNIVERSITY-AFFILIATED
HOSPITAL
Offer
A CLINICAL COURSE
SPONSORED JOINTLY WITH THE
ST. BONIFACE HOSP. IN INTENSIVE
CARE NURSING FOR ALL REGISTERED
NURSES IN THE INTENSIVE CARE UNITS
OPPORTUNITIES TO LEARN -
Nursing care of critically ill
Resuscitative measures
-Use of monitoring and other advanced equipment
MuJtidisciplinary approach
THROUGH -
Planned orientation
-Supervised clinical experience
-Continuing education program
-Concentrated study and hard work
FOR FURTHER INFORMATION WRITE TO:
Course Co-ordinator
Intensive Care Nursing
Health Sciences Centre GH601
700 William Avenue
Winnipeg, Manitoba R3E OZ3
Dalhousie University
School of Nursing
Halifax, Nova Scotia, Canada
Faculty Positions Available July 1, 1980
Graduate Programme
Doctorate in Nursing and experience in practice , teaching,
and research a requirement. Clinical expertise in care of
adults (medical/surgical) a necessity.
Undergraduate Programmes
Conceptually based curriculum for basic and registered nurse
students.
Positions available for faculty with experience in:
a) community health nursing
b) maternal-child care nursing
c) fundamentals of health and basic nursing
d) community and mental health nursing
Qualifications: Masters in Nursing a requirement. Doctorate
degree desirable. Salary and academic rank will depend on
qualification and experience. These positions are subject to
budgetary approval.
Applicants should send curriculum vitae, and names of three
referees to:
Margaret L. Bradley
Acting Director
School of Nursing
Dalhousie University-
Halifax, Nova Scotia
B3H 3J5
THE UNIVERSITY OF CALGARY
FACULTY OF NURSING
Applications are invited from nurses with
doctoral or master s degrees for the following
appointments:
i) Chairman of the Baccalaureate Degree
Programme with experience in pro
gramme planning, curriculum develop
ment and team leadership
ii) Faculty positions for nurses with ad
vanced clinical preparation in:
medical-surgical nursing
mental health-psychiatric nursing
parent-child nursing
community health nursing
A Master of Nursing Degree programme is at an
advanced planning stage.
Salary and rank will be commensurate with
education and experience. Applications with a
curriculum vitae and the names and addresses
of three referees should be sent to Dr. Margaret
Scott Wright, Dean, Faculty of
Nursing, The University of Cal
gary, 2920 - 24th Ave. N.W.,
Calgary, Alberta, T2N 1N4.
i, an/ 1OBJ1
Canadian Lung Association
Nursing Fellowship
The Canadian Lung Association offers
Nursing Fellowship awards up to the
amount of $8,500.00 per year for
Masters or Post Masters study in the
clinical specialty of pulmonary nursing at
an approved University.
Completed applications must be received
by February 8th to be eligible for the
1980-81 allocation.
For further information and application
form please write to:
The Canadian Lung Association
75 Albert Street
Suite 908
Ottawa, Ontario
KIP 5E7
University of Ottawa
School of Nursing
Positions available for the 1980-81
academic year in:
Maternal and Child Nursing
Psychiatric Nursing
Doctorate or Master s degree in
clinical specialty and teaching
experience required. Preference will
be given to bilingual candidates
(French and English). Salary
commensurate with preparation.
Send curriculum vitae and
references as soon as possible to:
The Director
School of Nursing
Faculty of Health Sciences
University of Ottawa
770 King Edward Avenue
Ottawa, Ontario KIN 6N5
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
ing in conjunction with the School of
Medicine, offers a program for regis
tered nurses employed in primary
care sellings who are willing to
assume a redefined role in the primary
health care delivery team.
Requirements Current Canadian 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 L8S4J9
The Grande Prairie Hospital
Complex is recruiting full-time
and casual nurses.
Current vacancies are in
Out-Patients, Intensive Care,
Medical, and Auxiliary.
Anticipated vacancies in other
units.
Apply to:
Personnel Director
Grande Prairie Hospital
10409 - 98 Street
Grande Prairie, Alberta
T8V 2E8
Telephone: 532-7711,
Extension 78
University Faculty
Applications are invited for clinical faculty
positions in an integrated baccalaureate
program. Subject to budgetary approval,
positions will probably be available for the
1980-81 academic year in the fields of
community, long term care, maternal-child and
Psychiatric nursing. Candidates should have at
least a Master s degree, demonstrated clinical
proficiency, leaching and scholarly
capabilities. Eligibility for registration with the
College of Nurses of Ontario is essential.
Candidates of both sexes are equally
encouraged to apply.
Salary and rank are negotiable and
commensurate with qualifications and
professional achievement.
Interested persons should send a full resume
and the names of three professional referees to:
A. J. Baumgart, Dean
School of Nursing
Queen s University
Kingston, Ontario K7L 3N6
Closing date of applications: April I, 1980.
Psychiatric Nursing
Post Diploma Program For
Registered Nurses
This 16 week full-time program combines
clinical experience with studies in
comparative theories of Personality
Development, Predisposing/
Precipitating Factors, Crisis Theories,
Nursing Process, Therapeutic Modalities
such as Counselling and Group work,
Outreach programs, Community
psychiatry and Professional
Development.
Winter program begins February 4, 1980
Fall program begins September 2, 1980.
For further information contact:
Michelle Nichols
Department Head
Health Sciences Division
Durham College
P.O. Box 385
Oshawa, Ontario L1H 7L7
Foothills Hospital, Calgary,
Al 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
Foothills Hospital
1403 29 St. N.W. Calgary, Alberta
T2N2T9
Prince George
Regional Hospital
Positions available for experienced nurses or
nurses interested in developing their skills in
specialty nursing Operating Room,
ICU/CCU, Neonatology Nursing. Must be
eligible for B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and Obstetrical
Suite
10 bed ICU/CCU
Prince George Regional Hospital is a 340 bed
acute regiona! referral hospital with a 75 bed
extended care unit and has a planned program
of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000 - 1.1th Avenue
Prince George, British Columbia
V2M 1S2
Director of Nursing
Applications are invited for the above
position in a 45-bed general hospital
located in the Saint John River Valley, 90
miles northwest of Fredericton, New
Brunswick.
The successful applicant will be
responsible for planning, organization,
and administration of the hospital s
nursing service.
Qualifications: Candidates should
preferrably possess a B.Sc.N. but
equivalent combination of nursing
administration education and experience
will be considered.
Apply with complete resume to:
D. F. Maclver
Administrator
Northern Carleton Hospital
P. O. Box 95
Bath, New Brunswick EOJ 1EO
64 January 1080
Head Nurse - Medical Nursing
Vancouver General Hospital
Applications are invited for the above position. The
successful candidate will be responsible for providing
innovative and creative leadership in the development of
clinical practice within the unit by teaching, consulting and
demonstrating specialized nursing skills. She/He is
responsible for the quality of nursing care and the nursing
administration of the unit.
The incumbent must be eligible for registration in B.C. and
have experience in the specific clinical field, hold a BSN or
equivalent post basic education. This person must
demonstrate skill in leadership and interpersonal relations.
Salary and benefits in accordance with the RNABC contract.
Please submit resume to:
Mrs. J. MacPhail
Employee Relations Department
Vancouver General Department
855 W. 12th Avenue
Vancouver, B.C.
V5Z 1M9
Government of
Newfoundland & Labrador
Public Notice
Cottage Hospital Nurse 1 s
Applications are invited for appointment on a permanent or
short term basis to the Nursing Staff of the Cottage Hospitals
at:
Bonne Bay
Harbour Breton
Salary for Cottage Hospital Nurse I, annual, sick leave,
statutory holidays and other fringe benefits in accordance
with Nurses Collective Agreement .
Living-in accommodations available at reasonable rates, also
laundry services provided.
Applications should be addressed to:
Director of Nursing
Cottage Hospitals Division
Department of Health
Confederation Building
St. John s, Newfoundland
A1C 5T7
Lome A. Klippert. M.D.
Deputy Minister
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:
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1AOL3
Name
Address
I
Prov.
Health and Wellai e Sanle et Blen-etre social
Canada Canada
I
I
The Canadian NurM
January 1980 69
calendar
January
The Faculty of Nursing, University
of Toronto is offering the
following courses in early 1980;
Anatomy and Physiology: The
Cardiac System, Wednesday
evening, January 16-30.
Anatomy and Physiology: The
Nervous System, Thursday
evening, January 17-31.
Group Dynamics and Group
Process, Monday evening,
January 28-March 27.
Anatomy and Physiology: The
Respiratory System and Acid
Base Balance, Thursday evening,
February 7-28.
Anatomy and Physiology : The
Renal System and Fluids and
Electrolytes, Thursday evening,
March 6-27.
Health Assessment Week,
February 18-22.
Quality Assurance: The Use of
the Nursing Audit, March 6-7.
1980.
Contact: Mrs. Dorothy Miles,
Continuing Education
Programme, Faculty of Nursing,
University of Toronto, 50 St.
George St., Toronto, Ontario,
M5S 1A1.
February
Two 16-week post-Diploma
Certificate Programs in Psychiatric
nursing are being offered by
Durham College and Whitby
Psychiatric Hospital February 4
to May 23, 1980 and September 2
to December 19, 1980. For more
information on this full time day
course contact: Durham College
of Applied Arts and Technology,
Registrar s Department, P.O.
Box 385, Oshawa, Ontario,
L1H 7L7, telephone 576-0210,
ext.342.
Nursing Care of the Sick Newborn,
current concepts of neonatal care;
a five day program, a choice of:
February 11-15, April 14-18 or
June 9-13. Contact: B. Cragg,
Co-ordinator, Nursing Education,
The Hospital for Sick Children,
555 University Avenue, Toronto,
Ontario, M5G 1X8.
March
The Nurses Practitioners
Association of Ontario will be
holding a workshop "Challenge of
the 80V, March 27 and 28 at the
Holiday Inn, downtown Toronto.
Cont&cf.TrudieTumber, 1132
HavendateBlvd., Burlington,
Ontario, LIP 3E3, telephone
845-9430, ext. 254.
Therapeutic Compliance,
Generalization and Maintenance is
the topic of the Twelfth Banff
International Conference on
Behavioral Medicine to be held
March 16-20, 1980, Banff,
Alberta. Contact: Park
Davidson, Department of
Psychology, University of British
Columbia, Vancouver, B.C.,
V6T 1W5.
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: Ivan Barofsky,
Hampton House 654, The Johns
Hopkins University, School of
Hygiene and Public Health,
Baltimore, Maryland.
Looking Ahead
" Interdisciplinary Approaches to
Mental Health" will be the theme
of the 57th annual meeting of the
American Orthopsychiatric
Association to be held April 7- 1 1 ,
at the Sheraton Centre Hotel,
Toronto. Contact: American
Orthopsychiatric Association,
1775 Broadway, New York, N.Y.
10019.
The fifth Annual Congress of the
Oncology Nursing Society will be
held May 28-30 at the Sheraton
Harbor Island Hotel in San Diego,
CA 92101. Contact: JVarccy
Berkowitz, Oncology Nursing
Society, 701 Washington Rd.,
Pittsburgh, PA 15228.
Perspectives in Psychiatric
Care 80, first national
psychiatric/mental health nursing
conference, to be held at the
Fairmont Hotel, Wakefield, MA,
May 28-31, 1980. Contact: Carol
Forsythe, Nurse Educator, 12
Lakeside Park, Wakefield, MA
01880.
The fifth Canadian Summer
Workshop in Electrocardiography
sponsored by the Rogers Heart
Foundation will be held May3-6at
the Hotel MacDonald, Edmonton,
Alberta. Contact: Anne S. Criss,
Executive Coordinator, Rogers
Heart Foundation, 601 12th St.
N., St. Petersburg, FL 33705.
All graduates of Highland View
Hospital, Amherst, Nova Scotia
are invited to attend a reunion
tentatively planned for July 11 to
13. All interested in attending are
asked to contact: The Reunion
Committee, cjo48 Regent St.,
Amherst, Nova Scotia, B4H 3T1.
Index to
Advertisers
January 1980
The Canadian Lung Association
68
The Canadian Nurse s Cap Reg d
48
F.A. Davis Company
57
Designer s Choice (A Division of
White Sister Uniform Inc.)
IFC
Encyclopaedia Britannica Publications Limited
Equity Medical Supply Company
49
Glaxo Laboratories
52
Frank W. Horner Limited
20,54
J.B. Lippincott Company of Canada Limited 9
Mont Sutton 49
The C. V. Mosby Company Limited
18, 19
Parke, Davis & Company Limited
15
Pharmacia (Canada) Limited
53, IBC
W.B. Saunders Company
55
Schering Canada Inc.
OBC
Smith & Nephew Inc.
Toronto General Hospital
51
Upjohn Health Care Services
Wellcome Medical Division
(Burroughs Wellcome Inc.)
Western Australian Institute of Technology
11
14
Advertising Representatives Advertising Manager
Jean Malboeuf
601, Cote Vertu
St-Laurent, Quebec H4L 1X8
Telephone: (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: (2 15) 649- 1497
Member of Canadian
Circulations Audit Board Inc.
Gerry Kavanaugh
The Canadian Nurse
50 The Driveway
Ottawa, Ontario K2P 1E2
Telephone: (613) 237-2133
70 January 1980
The Canadian Nurse
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
by relieving
pain and
odour fast
* 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
peared." 3
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
Two, if exudation is very heavy.
After removing crust or
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Cover with a dressing.
Debrisan cleans
decubitus ulcers fast.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dqrval, Quebec
LimlT, Mic
Bewick M. /
I J, Brit .
ascioS
Rpr
roan JJ, Angiology 29:9, Sept 1978
. CUn Trials J 15:4, 1978
. 32:6, June 1978
uLitus Care A New Approach:
ity, on file at Pharmacia (Canada) Ltd.
Coricidirf.
A traditional family approach
to cold relief .
For over a quarter of a century
Coricidin has been a traditiona
approach to relieving cold
symptoms . . . with Canadian
nurses and families alike.
Coricidin, a combination of a
trusted analgesic, antihistamir
and an effective decongestant
Coricidin D * ), offers a produi
form for virtually every age gr<
Pediatric drops are available f
children two years and over;
chewable Medilets* for childn
up to the age of 12; and Corici<
and Coricidin D for teenageri
and adults.
We would like to tell you what
we ve learned about colds. It s
in a comprehensive 20 page b
let compiled specially for nun
"How to nurse a Cold" answel
most of the questions you fan
every day: L
What exactly is a cold . 1
Do children get more co
than adults?
Are some serious diseas
easily confused with the
common cold?
Send for your free copy of "H(
Nurse a Cold"
Full information is published in the t ompi
of Pharmaceuticals and Specialties and av
on request from Schering Canada Inf. Poi
Claire. Quebec H9R 1B4
r p \ A R I I PMAC I
REG.T.M. 1 PAAB J I >
SCHE
Bulk En nombre
third Iroisteme
class classe
10539
Hypothermia the silent killer
Radiation enteritis, a race
against time
A holistic approach enhances
chemotherapy treatment
The syndrome of inappropriate
antidiuretic hormone secretion
Biofeedback, does it work?
The
Canadian
Nurse
FEBRUARY 1980
BIBLIOTHEQUE
SCIENCES INFIRM1ERES
M.?r 261980
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Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Production Assistant
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communication services, Registered
Nurses Association of British
Columbia.
Jean Passmore, editor, SRN A news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith, director of publications,
National Gallery of Canada.
Florita Vialle-Soubranne, consultant,
professional inspection division. Order
of Nurses of Quebec.
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*
Is the solitary skier so
strikingly silhouetted on this
month s cover aware of the
dangers of hypothermia? Does
he know that hypothermia is
an all-to-often overloaded
feature of our Canadian
Winters? For that matter,
what do you know about
hypothermia? Our special
feature begins on page 23 of
this issue. (Cover photo
courtesy of NFB Phototheque
ONE).
The
Canadian
Nurse
February 1980 Volume 76, Number 2
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Hypothtrmi* 23
O YOU AND THE LAW
C The extension of hospital liability : a
landmark decision in the making
Corinne Sklar
\ A PSORIASIS
^ * You re in hospital with what?
Maureen Steen
~| Q Successful chemotherapy
- ^ Di . w
5/1
J"
Day care: the selective alternative tor
psoriasis patients
Margaret Burns and Dr. R.K.
Schachter
syt HYPOTHERMIA A Special Feature
~J Taking the bite out of winter
I O A race against time: caring for a patient
^O with radiation enteritis
Roberta Ronavne
JA Controlled hypothermia: A treatment for
an acute anoxic incident
Margot Thomas
41 Antidiuretic Hormone and its
"T 1 Inappropriate Secretion
MurielBurry and Lydia Martens
"1C Accidental hypothermia: Emergency
O rewarming techniques
Donna Rae
A A Biofeedback does it work?
Christie M. Burdis
J -| How not to be a victim
5 A Judith Banning
13 Input
49 COME TO THE COAST
It s the CNA in B.C.
a pot pourri for you to see
62 Calendar
16 News
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
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.
Canadian Nurses Association, 1980.
MEN IN w urn:
THE CLINIC SHOEMAKERS Dept. CN-2, 7912BonhommeAve. St. Louis, Mo. 631O5
perspective
"Good nursing saves lives."
There it is, in a nutshell. But
what, exactly , is good
nursing? Certainly there s
more involved than simply
knowing what has to be done
and following correct
procedures.
"Good" nursing is good
from three points of view: it
affords satisfaction to the
nurse as a practitioner of her
profession, to the patient as
the recipient of her care and to
the family of the patient
whose care they have
relinquished to that nurse.
It was this triangular
relationship between nurse,
patient and family that Laura
Barry, the author of next
month s feature article on
Guillain-Barre Syndrome, set
out to investigate. The article
is based on work she carried
out in order to meet the
requirements of a post basic
program in neurological and
neurosurgical nursing she was
enrolled in at the time.
Watch for and read The
Guillain-Barre Syndrome" , in
your March issue of The
Canadian Nurse.
The comment that "Good
nursing saves lives" was
made by the father of the
patient, Linda, whose illness
and subsequent
hospitalization provided
material for her study. When
Laura set out to write her
paper she decided that the
aspect of Linda s case that
interested her most was the
dynamics of the relationship
that existed between the
patient Linda, Linda s family
and the nurses who cared for
her. So she wrote to all of
them, explaining her project
and asking for their
interpretation of what had
happened during the three
weeks that Linda was in
hospital.
When she wrote to her
colleagues this is what she
said: "I would like you to
think back to the time when
Linda was a patient. As I
recall, the
nurse-patient-family
relationship did become quite
strained at times... Why did
things deteriorate between
Linda and ourselves, as well
as her parents? There were
times when the relationship
was good. Why was that?
How did we make things
better? What did we do that
made things worse?"
Establishing a caring
relationship with a patient is
never easy. One of the nurses
Laura talked to during her
project listed some of the
problems she had recognized
in caring for Linda:
inability to understand
what the patient is trying to
communicate
inability to alleviate a
patient s fears
difficulty in making a
patient physically comfortable
knowing that the patient
depends on you for survival
helping the patient to
develop confidence in other
staff members.
All of the nurses she
interviewed recognized the
need for peer support, and the
benefits to be gained from
nursing conferences: "By
talking with their peers,
nurses come to realize that it
is alright to get angry and
frustrated at times. They
realize they need not feel
guilty about these
feelings... Nurses are human
and everyone has bad days. It
is comforting to know that you
are not alone. A nursing
conference can give a nurse
the encouragement she needs
to go out and try one more
time."
Linda s comment on her
perception of the
nurse-patient relationship is
instructive: "The most
important thing to remember
is that you are dealing with a
human being, not a patient. A
human being has
moods. . . sometimes
everything is okay and you are
in a good mood but sometimes
things will make you
depressed or frustrated and
therefore nurses should be
able to pick up on vibrations
and react accordingly."
Good nurses, as we all
know by now, are good
communicators. Linda says:
"Talking to the patient like a
person is a thing some of the
nurses did but not all. To feel
apart of the world, you need
to know what is happening in
the news and life in general. A
patient needs to feel a part of
the outside world."
When a family abandons
one of its members to the
ministrations of hospital staff,
they do so with mixed
feelings. Gertrud Ujhely put it
this way: "Those who
assumed quite a bit of
responsibility before for their
relatives who are now ill, as a
wife would for her husband or
a mother for her child, are
liable to feel especially
helpless now that the nurse
has taken over so exclusively
and efficiently... They fight
down their tears, which are a
mixture of concern about the
outcome of the illness, their
own helplessness and their
rage against the efficient
machine in white who has
taken over as if the patient had
always belonged to her as if
they, the relatives, had never
played any role in the
patient s life."
Good nursing involves
recognition of the contribution
that the family can make. As
Linda commented: "My
family played a very big part
in my time in hospital and, if
the family is willing, I think
they should be included in
most aspects of the
hospitalization."
It also involves
recognition of the nurse s role
as leader in this triangle of
nurse-family-patient. Linda s
father had this to say:"It was
the nurses that helped her and
us keep up our spirits. They
were calm and always
optimistic. They had humor
and sympathy. They gave out
courage and hope. They
exuded confidence and faith."
Listen to Linda s father
again: "Good nursing saves
lives. The non-medical aspect
is enlisting all the help you can
get from the patient, the
family and friends and then
with you (the nurse) as the
focal point, willing the patient
to live with all the strength
that you can muster... All
Linda s nurses in Intensive
Care did just that: they
cared intensively." M.A.B.
Seventy-five years ago next
month, in March 1905, Vol. 1,
No. 1 of The Canadian Nurse
rolled off the press and into
the eager hands of the small
group of graduate nurses
responsible for its
appearance. "Devoted to the
interests of the nursing
profession in Canada, and to
the protection of the public,"
its founders were staunch
advocates of legislation
enabling properly qualified
nurses to be registered by law.
Most of them were
graduates of Toronto General
Hospital School of Nursing.
The decision to undertake
publication of a journal for
nurses had been taken at a
meeting of their Alumnae
Association three months
earlier; members approved by
a standing vote a resolution
that: "We undertake the
Journal, placing our pin on the
cover, and that while keeping
the management in our own
hands we make the other
Alumnae Associations feel
they are welcome to work
with us."
Within six months, the
business manager was able to
report that the venture was an
"undoubted success" and
plans were already underway
to enlarge the quarterly to "a
Dominion journal, produced
monthly".
In March, as part of its
anniversary celebrations, CNJ
takes a look at those early
journals, as well as a look
ahead to the year 2000.
Introducing New
they stay twice
Why It s Better
for Baby
,& / t Softer surface next to
! baby s skin
./ & D Embossed topsheet looks
/and feels softer. . reduces
skin contact and increases
separation of skin from
moisture in pad.
ty A drier, more
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D Polyester fibre topsheet is
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lope... provides 225 percent
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Proof Positive That Quilted Pampers
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Equal amounts of A blotter is placed A weight is placed on Quilted Pampers is
water are placed on over each wetted each blotter twice as dry as cloth
each diaper area
Quilted Pampers
as dry as cloth
Why
It s Better
for Nurse
and Better
for Mother
\ Saves time and
work
The superior contain
ment of New Quilted
Pampers versus cloth
benefits both nurses and
mothers with:
D Fewer changes of
bed linen and
baby s clothing.
D More time for
other important
tasks for nurses,
more playtime
with baby for
mothers.
Easier than cloth to
fit and change
A one-piece system
more convenient than
cloth to change and clean
up easy to fit with tape,
not pins.
Pampers
used more often than cloth
in hospital nurseries
For further information write to.
Pampers Professional Services
PO. Box 355, Station "A"
YOU AND THE LAW
The extension of hospital liability:
a landmark decision in the making 1
Corinne Sklar
In caring for her comatose patient, a
nurse detected a fruity odor on her
patient s breath and alerted the
physician. The diagnosis at this time of
diabetes as the cause of the patient s
coma came too late for the patient. In his
decision the trial judge found that the
damage caused to this patient was the
result of the negligence of the internist,
an endocrinologist; he also found that the
hospital was legally liable for the
negligence of this physician.
This decision is important because,
in holding the hospital responsible, the
trial judge extended the liability of
Ontario public hospitals beyond previous
limits: the physician in this case was not
an employee paid by the hospital. He
was a member of the medical staff and
was an "independent contractor" billing
patients either directly or, more
commonly, through the provincial
medical insurance plan. Previously,
physicians in this position did not fall
within the area of the hospital s legal
responsibility for negligence. Instead,
the physician was legally responsible to
the patient directly. However, the
patient and his family did not sue this
physician as a separate defendant. Under
the law as it stood until this decision of
Mr. Justice Holland, the hospital would
not have been liable for this negligence.
If the limitation period for bringing a suit
against the individual physician had
expired, then the patient would have
been unable to bring a law suit against
this physician and receive financial
redress from him.
The case is presently under appeal
to the Ontario Court of Appeal and at
this writing had not yet been heard.
Because of the important ramifications
of this trial decision for hospitals, it is
likely that the final determination of this
important legal decision will fall to the
Supreme Court of Canada.
Direct hospital responsibility
The liability of hospitals can arise either
directly or vicariously, that is, through
the act of another for whom the hospital
is legally responsible. Direct
responsibility may result where there is a
failure of the hospital to fulfill its legal
obligations (duties) to the patient. Such
failure may result from either a breach of
contract or negligence (i.e. tort) or a
combination of these . The duty or
obligation to the patient results from the
relationship between the hospital and the
patient and damages may be awarded to
the patient from the hospital where the
hospital has failed to fulfill its
undertaking to the patient. The direct
responsibility of a hospital exists alone
and is not contingent upon the nature of
the relationship between the hospital and
the person whose conduct resulted in the
patient s harm. Hospitals are required to
provide as part of their undertaking such
services as nursing services, bed,
laundry and dietary services, control of
infection, reasonable facilities and
equipment for diagnosis, investigation
and treatment. The latter may vary from
hospital to hospital depending on the
scope and function of the facility.
Hospitals are legally required to
exercise reasonable care in selecting
competent staff members. For
physicians, such responsibility is
delegated to the medical Chief of Staff or
the committee of physicians designated
to perform this function. In Ontario,
appointment to the hospital s medical
staff is for one year at a time and may be
renewed annually or the privilege may be
revoked. The supervision of the medical
staff is in the hands of such committees
as well as part of the supervisory and
"quality control" function. Physicians
may be characterized as full time
hospital employees under a contract of
service, part time consultants, or
"independent contractors" attached to
the active medical staff roster; other
variations of physician-hospital
relationship may exist.
Vicarious responsibility
U nder the doctrine of respondeat
superior" (let the master answer),
hospitals are vicariously liable for the
conduct of their employees, servants and
agents acting in the course of their
employment. The primary element in
fixing liability here is the nature of the
relationship between the hospital and the
employee (or individual whose conduct
is in question) and not the relationship of
the hospital and the complainant. The
view is that the master/employer by
virtue of his position is able to control
both the type of work performed and its
manner of performance.
Originally, hospitals were not held
responsible for the negligence of
professionals in the performance of their
professional responsibility; this liability
has developed gradually over the past
sixty years. In 1909, 2 the prevailing
judicial view was that a hospital was only
legally responsible to its patients for due
care in the selection of competent
personnel. The hospital was not
considered legally responsible for the
negligence of physicians and nurses
acting professionally in the course of
delivering patient care. Thus, a
dichotomy developed whereby hospitals
were legally vicariously responsible for
negligence in the performance of
"administrative" functions by
professional employees such as nurses
because such duties were part of the
hospital s undertaking. However, there
was no hospital responsibility if the task
under consideration was performed in
the exercise of "professional" skills
because the master/hospital did not
control the professional in such exercise.
Such a view could not be sustained
as the role and function of the hospital in
the community grew more complex and
diverse and as increased social
responsibility and accountability were
imposed. Over the years, the
"administrative" versus "professional"
dichotomy was discarded and hospitals
became vicariously liable for the
negligent acts of their professional
employees acting in the scope of their
employment;- nurses, interns, residents,
anesthetists, radiographers, etc.
However, within the expanding
umbrella of hospital responsibility for its
professional staff, some limiting aspects
were retained until Yepremian. The
distinction continued to be drawn
between the relationship of a hospital
with a professional on a "contract of
services" and a "contract for services".
The former attracted the hospital s
responsibility because the relationship
was one of employment, ie. master and
servant. The latter was excluded because
the individual was an independent
contractor and outside of the hospital s
control of the work and manner of its
performance.
In 195 1,- 1 the English Court of
Appeal brought the "contract for
services" into the ambit of hospital
liability holding that where a physician is
employed and paid by a hospital,
whether under a contract of service or
for service, the hospital will be liable for
his negligence. Thus, the nature of the
relationship between the hospital and the
professional is also considered in the
context of the remuneration of the
professional if the patient selects and
pays the professional, then the hospital
may not be responsible.
A Canadian decision illustrates this.
In the case ofAynsley v. Toronto
General Hospital, a the patient s brain
damage was held to have been caused by
the negligence of both the senior resident
in anesthesiology and the privately
employed anesthetist. The hospital was
found responsible only for the negligence
of the resident and therefore had to pay
only for the percentage of fault
apportioned to his conduct. The private
anesthetist personally bore his
apportioned cost of the negligence; he
was directly legally responsible to the
patient who had selected and employed
him. The hospital was vicariously
responsible for the negligence of the
resident whom the hospital employed.
The hospital was not responsible either
directly or vicariously for the negligence
of the private anesthetist. Similarly, a
hospital is not responsible for the
negligent acts of the private duty nurse
who is selected and paid by the patient or
his family. Hospitals are responsible for
the negligence of their staff nurses in
their delivery of patient care.
Very often today, a patient may be
admitted to hospital under the care of a
physician who is not a hospital employee
and who has not been specifically
selected by the patient. This was the
situation in Yepremian, as we shall see
below.
The facts
The patient, Tony, was a 19-year-old
apprentice bodyshop repairman who
lived at home with his family. On
October 9, 1970, he returned home from
work complaining of not feeling well. He
was very weak and over the weekend his
polydipsia and polyuria increased. The
family took him to see Dr. G. , the
physician covering the practice of their
family physician who was away that
holiday weekend. A diagnosis of
tonsillitis was made and erythromycin
prescribed. The physician s notes
presented in evidence did not mention
the excessive thirst and urination of the
patient. The patient was too drowsy and
ill to respond to questions. The family
testified that the doctor had been
informed of these symptoms.
That evening , October 1 2 , Tony ,
who had continued to vomit and to drink
and urinate excessively, began to
hyperventilate. Alarmed, his family
rushed him to Scarborough General
Hospital emergency, where he was
admitted in a semi-comatose state. The
family testified that again Tony s
symptoms had been reported. When
asked about drugs (the hospital received
many cases of young people with drug
overdoses at that time), the staff were
shown the medication prescribed earlier
byDr.G.
Dr. C. was the general practitioner
on duty in emergency that night. The
"diagnosis" he recorded that night was
the symptom "hyperventilation".
Phenobarbital and valium were
administered. Tony was already
comatose.
Dr. R., the internist on call and a
specialist in endocrinology, ordered
Tony transferred to the I .C.U. in the
early morning hours of October 13. No
urinalysis was yet done. The case report
contains a partial summary from the
medical record of the treatment and
observations. 6 The normal saline I.V.
was changed to 5 per cent glucose at 4:00
a.m. and a foley catheter was inserted.
The patient was comatose. His
potassium level was recorded at 5.5 at
8:a.m., within normal limits. His vital
signs during this period ranged as
"When I was thirteen, I really wanted
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"Patient contact. That s
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over my work schedule, for my
family s sake. And I thrive on
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"Working with Upjohn
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HMM02-C 1979 HealthCare Services Upiohn, Lid
UPJOHN
HEALTHCARE
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Please send me your
free booklet "Nursing
Opportunities at
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Address
City Province Postal Code
Mail to: Upjohn HealthCare Services
Dept. A
Suite 203
716 Gordon Baker Road
Willowdale, Ontario M2H 3B4
follows: B.P. 138/80 - 102/60; Temp. 99.4
- 100.7; R. 40-36.
At 12:20 p.m. on October 13, the
diagnosis of diabetes was made upon the
nurse s report of her patient s fruity
breath odor. A STAT urinalysis showed
4+ sugar.Thel.V. containing soda
bicarbonate was discontinued and insulin
was given STAT.
The patient remained comatose or
semi -comatose until he suffered a
cardiac arrest about 12:55 a.m. on
October 14. Severe permanent brain
damage resulted.
Apportioning the responsibility
The trial judge considered the negligence
and liability of the following: 7
Dr. G. (named as defendant)
The nurses and laboratory staff (and
hence the hospital under the vicarious
responsibility doctrine)
Dr. C.
Dr. R.
The hospital (for the negligence, if
any, ofDrs. C. andR.)
Dr.G. Mr. Justice Holland found that
Dr. G. had not met the standard of care
required of the reasonable prudent
medical practitioner and hence was
negligent in failing to diagnose the
diabetes of his patient. However, the
cause of Tony s injuries was the cardiac
arrest. Therefore, liability would be
imposed on Dr. G. if his negligence
caused or contributed to the cardiac
arrest.
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The judge found that the intervening
acts of negligence "insulated" Dr. G.
from liability. Dr. G. s failure to
diagnose the diabetes did not affect or
contribute to the treatment Tony
received at the hospital. He therefore
dismissed the action against Dr.G.
The nurses and hospital laboratory
staff The trial judge found that there
was no negligence attributable to these
hospital employees for which the
hospital could be held vicariously liable.
The laboratory staff was not
responsible for the interval in processing
of routinely ordered samples requested
during the night shift. Such procedure
was in accordance with accepted
hospital standards.
It was suggested that the nurses
should have initiated a STAT urinalysis
on the patient s admission toI.C.U.
Only a routine urinalysis was ordered.
The trial judge found that the nurses
complied with the prevailing hospital
standards: such STAT orders were only
done on doctor s orders. Hence, the
hospital was relieved of vicarious
liability here.
Dr. C. The trial judge found that Dr.
C. was negligent in his assessment and
treatment of Tony. However, as withDr
G., the intervening negligence of Dr. R.
in the handling of Tony s case insulated
Dr.C. from legal liability. Dr. R. s
negligence was not foreseeable and Dr.
C. s diagnosis did not contribute to Dr.
R. s subsequent conduct of the case.
Dr.R. Because Dr. R. was an internis
and specialist in endocrinology, a
specialty in which the care and treatmeni
of diabetes falls, he was held to a higher
standard of care than would have been
expected of a general practitioner. The
trial judge indicated that a serum
potassium level below 3.5 creates a
serious risk of cardiac arrhythmia
leading to cardiac arrest. 8 The trial judge
found Dr. R. negligent in failing to
diagnose the diabetes earlier. He further
found that Dr. R. ought to have been
alert to the danger to Tony s serum
potassium level in ordering sodium
bicarbonate to deal with Tony s acidosis
(which lowers potassium levels) and thei
ordering the insulin in response to the
diagnosis of diabetes (insulin also lowers
serum potassium). The record showed
that Tony s potassium level was 5.4 at
8:45 a.m. and by 2: 10 that day it had
fallen to 1.5 and it remained below 3.5
thereafter. Potassium replacement was
begun at about 3:30 p.m. that day. In the
view of Mr. Justice Holland, Dr. R.
failed to effect proper management of
Tony s treatment once the diagnosis of
diabetes was made, thereby resulting in
the cardiac arrest.
" ...It is my view that Dr. R. s negligence
in his treatment of Tony Yepremian was
the cause of the cardiac arrest. If this
young man had been properly treated
after the diagnosis had been made, he
would, in my opinion, have recovered
without harm . I consider Dr. R. s
negligence to have been extreme and I
have no doubt that he would have been
held liable if sued." 9
The hospital s liability for the negligence
of Dr. C. and Dr. R. Dr. R. s
negligence being the cause of the
patient s damage, hospital liability for
Dr. C. s negligence was not considered.
The trialjudge stated that "The plaintiffs
can sue whom they choose and I must be
careful in deciding the issue of the
liability of the hospital not to let myself
be influenced by the result of the failure
to sue Dr. R.". 10 (Note: If the hospital
had not been found legally responsible
here, and if the limitation period for
bringing a suit against Dr. R . had
expired, then there would have been no
one legally responsible to compensate
the plaintiffs for their loss. If Dr. R . had
been a named defendant then the
following alternatives might have
resulted: (a)Dr.R. solely liable and the
hospital freed of liability or (b) both the
hospital and Dr. R. liable and hospital
liability extended as ultimately
occurred.)
Mr. Justice Holland, in finding the
hospital legally responsible for the
negligence of Dr. R., reviewed the
relevant English, U.S. and Canadian
case law and the relevant legislation. In
his view, the following principles
resulted, "except in exceptional
circumstances:
1 . a hospital is not responsible for
negligence of a doctor not employed by
the hospital when the doctor was
personally retained by the patient;
2. a hospital is liable for the negligence of
a doctor employed by the hospital;
3. where a doctor is not an employee of
the hospital and is not personally
retained by the patient, all of the
circumstances must be considered in
order to decide whether or not the
hospital is under a non-delegable duty of
care which imposes liability on the
hospital." 11
The instant case lies in the third
category. The patient, his family, and the
public-at-large, in the trial judge s view,
looked to the hospital for a complete
range of medical attention and treatment.
The patient did not select the hospital
and physicians in the usual manner.
Here, the urgency of the situation
dictated the "choice" of this hospital
it was the closest one. The decision
refers to the expectation of the public: a
high standard of care is anticipated from
all, and especially from the physicians,
"skilled medical attention and
treatment." 12 Similarly the admission to
I.C.U. resulted in Tony s receiving care
by the medical staffman on call at the
time ("the luck of the draw" or rotation
list).
The trialjudge found that the
hospital had selected Dr. R. as a member
of the hospital s specialist staff. 13 The
hospital had a legal responsibility to
admit the patient and underThe Public
Hospitals Act (Ontario), 14 the hospital is
directly responsible to the patients
therein for the quality of care delivered.
In the view of Mr. Justice Holland, both
The Act and common sense underscore
this obligation of a hospital and the
hospital has the opportunity of
controlling the quality of medical service
delivered. 15 The trialjudge concluded
that in accepting the patient, the hospital
undertook to him a duty of care that
could not be delegated. 16 He awarded
damages assessed at $390,262. 1 1 and
costs.
Implications
It is not clear from the decision whether
the finding of hospital liability results
from an extension of direct corporate
responsibility or from vicarious
responsibility. What does emerge is the
position that hospitals have greater
accountability to the public for medical
treatment. (continued on page 48)
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That s the Metamucil way
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input
Out of sight, out of mind
The October issue of
CNJ, with its focus on
maternal-child nursing, raised
many important
considerations.
One critical aspect of the
potential crisis in OB nursing
which was not addressed in
the issue is the depressing fact
that the maternity
(postpartum, nursery and
antepartum) area continues to
be a repository for nurses who
are, for any number of
reasons, unable to function in
other areas.
How often is the
following statement included
in an evaluation or transfer
notice:
"Ms. X has had considerable
difficulty in carrying out the
nursing process on this busy
medical (surgical, orthopedic,
neuro, etc.) unit. She would
benefit from the opportunity
to develop her nursing
potential in an area with an
easier (lighter, less hectic, i.e.
lower status and priority)
pace."
When N urse X has shown
her inability to function in any
other area, she is sent to the
OBS unit. (I suspect that
geriatrics may suffer from the
same problem.) Thus
maternity units come to be
staffed with an
overabundance of nurses who
"don t fit in" anywhere else
and the talented and capable
nurses in that area end up
carrying the load.
Head Nurses, reluctant to
play the role of hatchet
women, do not document
these less than satisfactory
nurses out of the area, but
rather attempt to carry on,
thus lowering the overall
standard of nursing care on
their units.
We must look to
education and inservice to
develop the skills and
knowledge necessary to
improve the standard of
nursing care in OBS nursing.
We must also look at our
image as a low status and low
priority nursing area. As long
as we are content to be the
"dumping ground", it will be
difficult to attract and keep
nurses who are able and
anxious to keep pace with the
many changes and challenges
affecting OBS nursing.
Frances M. Tufts, RN , BN ,
Don Mills, Ontario.
Counseling today s teens
Author Shirley Wheatley
(guest editorial, November
1979) suggests that "kids have
the right to express their
sexuality at any age". Is the
role of the nurse to become
that of social engineer for a
society freed from morality
and controlled by
professionals ?
More contraception,
more abortion, more sex
education will not solve any
problems. They haven t in
Denmark, Sweden or Britain.
Self-appointed experts
have manipulated parents by
using terms such as family
life , values education and
responsible education into
thinking these courses will
enhance responsible moral
behavior. In fact, their basic
philosophy is that there are no
rights or wrongs, the family is
dispensible and all lifestyles
are equally valid. Parents who
object are archaic
oppressors . Much of
education is intended to
encourage youth to discredit
their parents and put them at
the mercy of peer pressure in
rap sessions manipulated by
these biased professionals .
People today have lost
their concept of right and
wrong; they are operating in
moral confusion. This is
tragic. It is even worse when
these same people have a
missionary zeal to impose
their confusion on others
through legislation, schools
and through the health
services.
John R. Caswell (student
nurse) andGay White
Caswell, Saskatoon, Sask.
Information please
I have heard that some
hospitals in central Canada
have day care facilities for
children of their staff and I
would like information
regarding this.
Where I am employed we
have a severe nursing
shortage and I m sure if there
were a day care center more
nurses with young families
would be able to return to the
work force, part-time or
full-time.
For myself, the logistics
of arranging care for a
four-year-old and a
16-month-old so that I can
work part-time are
overwhelming.
Perhaps if I had
something concrete to put to
my hospital, I could get
approval to set up a facility. I
have even heard that they
make money !
I look forward to hearing
from colleagues .
Gwendolynne Kavanagh,
RN, S.S. No.2. Kamloops,
B.C., V2C6C3.
Strength in numbers
One of my
responsibilities as assistant
director of nursing is the
Quality Assurance Program. I
would like to form an
Association of Quality Care
Coordinators to promote
educational and research
programs in the area of quality
assurance.
Could you publish this
request in The Canadian
Nurse? Interested
respondents could write
directly tome.
Brian R. Rogers, RN , BSc.,
St. Joseph s General
Hospital, North Bay, Ontario,
P1B 3L9.
Did you know...
Chloramphenicol and
acetaminophen should not be
used concurrently as the rate
of elimination of
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body is reduced almost five
times by the presence of
acetaminophen. If this
combination must be used, the
dose of chloramphenicol
should be reduced or serum
chloramphenicol levels
monitored closely.*
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TWO CAREERS
IN ONE.
Being a nurse and an officer in the Canadian Forces offers
many advantages. If you re a Canadian citizen and a graduate
nurse (female or male) of a school of nursing accredited by
a provincial nursing association and a registered member of a
provincial nurses association with two year s experience
why not combine two careers in one?
For more details, contact your nearest Canadian Forces
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or return the coupon.
ASK US
ABOUT YOU
THE CANADIAN
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Director of Recruiting and Selection
National Defence Headquarters
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Name
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NEW EDITIONS
FOR THE
CANADIAN
NURSE
* CONCEPT FORMALIZATION IN NURSING
PROCESS AND PRODUCT, 2nd Edition.
By the Nursing Development Conference Group. Edited by Dorothea E. Orem, R.N., M. S.N.Ed.
LIPPINCOTT~The Leader for over 100 years through it s
publications to the Canadian Nurse.
The 2nd edition of Concept Formalization in Nursing:
Process and Product reflects the progress made to date.
This volume refines previous conclusions and moves on
to descriptions of the individual or group dynamics
associated with formulation, expression, and acceptance
of nursing s conceptual structure. Orem s general theory
of nursing is used to provide the conceptual framework
for research and the structuring of nursing knowledge.
Throughout the text, drawings, tables, charts, and graphs
are used to illustrate key points.
Because Concept Formalization in Nursing: Process
and Product, 2nd Edition, represents the significant and
continuous advance of nursing sciences, it will serve as
an important reference for teachers and students of
nursing, nurse practitioners, nursing administrators, and
all who have an interest in nursing as a unique discipline.
Little, Brown. 313 Pages. Illustrated. 1979. $15.50.
* PEDIATRIC PRIMARY CARE L le Bown 676Pages Illustated
1979. Paper, $15.00. Cloth, $21.00.
By Catherine DeAngelis, M.D., R.N., M.P.H., F.A.A.P.
The common goal of all textbooks is to impart know
ledge in a particular field. The purpose of this book is to
fulfill that function in a special way. It is written to
impart to members of the pediatric primary health care
team specific, pertinent knowledge that has been care
fully selected from the broad field of pediatrics.
Certain areas, such as clinical nutrition, growth and
+ NEURONURSING
For nurses in neurological and neurosurgical acute-care
settings, medical-surgical and pediatric wards, and reha
bilitation units. A useful text for nursing education and
clinical practice, it addresses the complexities of neuro
logical nursing that require nurses to know the precipi
tating factors, symptoms that often do not reflect
etiology, and the required nursing care that often is the
same for patients with different conditions. Contents:
development problems, and health education, are presen
ted in depth. Whenever possible, physiologic processes,
behavior problems, and diseases are explained from the
developmental standpoint. The reference lists at the end
of each chapter, however, contain many key articles to
which the reader can refer for in-depth discussions.
2nd Edition.
By Susan Fickertt Wilson, M.N.
Neuroanatomy and Physiology; Assessment of the
Neurological Patient; Care of the Patient with Increased
Intracranial Pressure; Care of the Unconscious Patient;
Care of the Patient with Seizures; Care of the Patient
with Aphasia; Principles of Neurodiagnosis; Injury to
the Central Nervous System; Disruption of Circulation in
the Brain; Infections of the Central Nervous System.
Springer. 272 Pages. Illustrated. 1979. $21.00.
* CARDI AC REHABILITATION
A COMPREHENSIVE NURSING APPROACH.
By Patricia McCall Comoss, R.N., CCRN.; et. al.
One of the most exciting features of the rehabilitative
approach to the patient with symptomatic coronary
disease has been its progressive incorporation into the
mainstream of traditional medical care.
Nursing roles within the health care team may vary con
siderably, depending on the size of the patient popula
tion served, the scope and mode of organization of
rehabilitation services, the extent of participation of the
other health care disciplines in the rehabilitation team,
the community medical practice customs, and so on.
Lippincctt. 334 Pages. Illustrated. 1979. $20.25.
J. B. Lippincott Co. of Canada Ltd.
75 Horner Ave., Toronto, Ont. M8Z 4X7
Please send me the following on app I:
D Concept Formalization in Nursing
D Pediatric Primary Care (P) or (Cl)
LJ Neuro-nursing
CH Cardiac Rehabilitation
D Payment enclosed
(post. & hand, pd)
G Bill me
(plus postage and
handling)
Name
Address .
City _
Prov.
Postal Code
Prices subject to change without notice.
CN2/80
news
Canadian nurses to write
CGFNS exams to work in U.S.
The U.S. Immigration and
Naturalization Service has
announced that, contrary to
earlier statements, Canadian
nurses will not be exempted
from the screening
examinations all foreign
nurses wishing to work in the
U.S. must write.
The examinations, which
are necessary in order to
obtain an occupational
preference visa(H-l), are
given by the Commission on
Graduates of Foreign Nursing
Schools (CGFNS),
established under the
sponsorship of the American
Nurses Association and the
National League for Nursing.
The April, 1980 exam will be
the fourth such screening
offered by CGFNS.
The day-long CGFNS
exam tests the foreign nurses
in nursing proficiency and
English comprehension. Both
sections of the test are in
English. The nursing portion
covers the same five subjects
included in U.S. state
licensing exams, namely,
medical, obstetric, pediatric,
psychiatric and surgical
nursing. The CGFNS exam is
not a substitute for the state
board licensing exam. After
passing the CGFNS test,
applicants are required to take
and pass the state licensing
exam in the U.S.
According to Virginia
Jarratt, RN, PhD, president of
the CGFNS board of trustees,
by determining nurses ability
to pass a state licensing exam
before they come to the U.S.,
the CGFNS exam helps
foreign nurses who are not
fully prepared for professional
practice in this country to
avoid the disappointment,
relocation costs and possible
exploitation foreign nurses
have experienced in the past.
"The CGFNS screening
procedure also helps assure
the American public of
minimum safe health care,"
Dr. Jarratt said.
Consideration will be
given to exempting foreign
nurse graduates, including
those from Canada, who have
already passed the state
licensing examination
(SBTPE) in one of the states
of the U.S., from having to
take the CGFNS exam.
The next CGFNS
examination will be given
April 2, 1980 in 28 cities
outside the U.S. Exam sites in
Canada will include Montreal,
Toronto and Vancouver.
Examination applications and
Guidebooks for Applicants
are available from CGFNS,
3624 Market Street,
Philadelphia, PA. 19104, and
from U.S. embassies and
national nurses associations
in foreign countries. Filing
deadline for the April exam
was January 15, 1980. The
next CFGNS exam will be
held October 1st, 1980;filing
deadline for this exam is July
14.
On the same day the April
exam is given outside the
U . S. , it will be given in Los
Angeles, Houston, Chicago,
Miami and New York for
foreign nurses who have not
yet passed state licensing
examinations in this country.
Testing in the U.S. is an
accommodation for foreign
nurse graduates who are
applying to the U.S.
Immigration and
Naturalization Service for an
extension or a change in visa
status. The exams in the U.S.
will eliminate the need for
these nurses, from Canada
and other countries, to return
to their homes to take the
CGFNS exam.
IV nurses exchange
information, ideas
"Relationships are very
important: nurses must take
the time to speak to their
patients... many nurses and
doctors seem to be forgetting
this." Laura Legge, RN,Q.C.
reminded intravenous nurses
at the recent C.I.N.A.
conference that although they
may not be doing bedside
nursing, they are very
important and may be the only
registered nurses that the
patient sees. She emphasized
that patients do matter as she
commented on the increased
incidence of legal suits
involving hospitals, doctors
and nurses.
The fourth annual
convention of the Canadian
Intravenous Nurses
Association in Toronto last
November brought more than
160 nurses together from
across the country, including
the Northwest Territories .
With the objectives of
facilitating idea exchange,
upgrading knowledge and
making available information
on much of the new
technology of IV therapy, the
conference presented a group
of highly qualified speakers
and a varied selection of
exhibits.
Standards group
"CNA is taking an innovative
and leadership role in the
development of a definition
and standards of nursing
practice," says Pat Wallace,
project director. Speaking on
behalf of the group of seven
(see The Canadian Nurse,
October 1979), Wallace
reported to CNA directors last
Fall that the committee has
adopted the principle that a
conceptual model for nursing
should be used to guide
practice regardless of the
setting in which that practice
occurs. It wants this principle
built into the definition and
standards.
The Task Group has
based its decision on a belief
that the emphasis in nursing
has shifted from a
predominantly dependent role
toward a more independent
role, one that requires
clarification in order to
specify nursing s unique
contribution to societal health
needs. This uniqueness is
made explicit in any one of
several conceptual models for
nursing.
The development of
Standards for Nursing
Practice represents a
beginning phase in an attempt
to answer the question: "Does
nursing make a difference?"
The Task Group believes that
standards must be tested and
validated in practice settings
to assure their usefulness.
Meetings will be held
monthly from January through
April 1980; the final report is
expected to be completed for
presentation to CN A s Board
of Directors in June.
We invite and welcome your
comments, questions,
suggestions or criticisms.
Write: Pat Wallace, Project
Director, The Canadian
Nurses Association, 50 The
Driveway, Ottawa, Ontario,
K2P 1E2.
Health happenings
On January 1 7th the first of a
series of programs devoted to
"demystifying health care"
for the Canadian consumer
was aired. Plans now call for
the series, The Medicine
Show, to consist of at least ten
half-hour programs to be
shown weekly, dealing
magazine-style with a wide
variety of topics related to
medicine and health care in
Canada.
Of special interest to
nurses will be the program
filmed in Winnipeg in which
the host, author and
broadcaster Ken Lefolii,
interviews a group of nurses
and asks for their frank
opinion about the
effectiveness of systems of
health care delivery in
Canada. Also planned is a
program which deals with the
image of the nurse as
presented in contemporary
popular literature, including
Harlequin romances.
The Medicine Show is
scheduled to be seen on major
CBC stations Thursday
evenings at 9:30, but local TV
listings should be checked for
time and availabi ity. *
Hie CHOICE IS YOURS
The
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K Cl is the single most common drug additive used in
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were required to add KCI to solutions manually which
can be extremely time consuming. New Pre-Mixed KCI in
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CONTAMINATION
Pre-mixed K Cl solutions greatly reduce the potential for
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prepping agents or manipulations reduce the need to enter
the system for the addition of potassium chloride.
SAFETY
The red potassium labels are clearly printed on the container.
Labels cannot fall off thus reducing the possibility of a K Cl additive error,
PROVEN
The Viaflex Container System, a non air-dependent delivery system
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fimes
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help from us, today s diabetics
can enjoy better health
and a healthier outlook.
Ames
Division
IN/1 1 LI
Ames Division, Miles Laboratories. Ltd.,
Rexdale, Ontario M9W 1G6.
We helped make urinalysis
the science it is today.
Successful
Chemotherapy:
quality care
for the cancer patient
A complex relationship exists between the skilled and
knowledgeable nurse and the well-informed patient
receiving chemotherapy. Here s how a holistic approach
can enhance your treatment plan and encourage
patient compliance.
Diana Law
From diagnosis to death, cancer patients
face one crisis after another in life: the
initial diagnosis of a life-threatening
illness, the discomfort of treatment, the
unknown of a treatment regimen and
possible recurrence of the disease
followed by more treatment. Patient
responses to any form of medical
treatment are always both physiological
and psychological; in cancer patients the
latter effect is aggravated severely by the
gravity of their disease and the
continually investigative nature of their
therapy. Disturbances in interpersonal
relationships result along with
physiological changes and psychosocial
problems:
"equally as stressful as a confrontation
with mortality are the other threats that
cancer holds. Feelings of worthiessness
due to the patient s feelings of
unproductivity while ill, dependency,
altered body image, role dysfunction,
fears of alienation, social isolation and of
stigmatization and anxiety over the
physical symptoms such as pain, all may
plague the patient concurrently."
The nurse who is equipped with
knowledge and skill can offer support to
the patient on chemotherapy through a
holistic approach to patient care. But, to
accomplish this, you must look at and
care for the patient as a whole person;
his care cannot be atomized into
different parts.
Remember, chemotherapy does
work: to the patient receiving the drugs
they offer hope, and what you know
about cancer and chemotherapy can be a
determining factor in how the patient and
his family adjust to the fearful
circumstances of his illness and
treatment regime.
People are more sophisticated in
their awareness of medicine these days,
and our patients now come to us fairly
well-informed, and with questions that
demand intelligent answers. The nurse
who stays current with her skills and
knowledge has a better understanding of
the whole treatment process and this in
turn gives her a degree of confidence and
control which she can communicate to
her patients.
Chemotherapy how it works
Cancer has been defined as uncontrolled
proliferative cell growth which is harmful
to normal physiological function. For
example, in acute lymphocytic leukemia
there is rapid proliferation of the
lymphocyte stem cell line with a
resultant rise in the number of circulating
lymphocytes and decreased cell quality.
Normal growth of other stem cell lines is
greatly affected.
The basics of the cell cycle may be
reviewed by means of a simple diagram
(See Figure one).
GO in this stage the cell is at rest until
some internal mechanism triggers the
cycle.
Gl RNA and protein synthesis begin
here.
S in this phase DNA synthesis occurs.
DNA is housed in the nucleus of the cell
and contains all the genetic requirements
for regulation of the vital cell processes
such as growth, differentiation,
specialization, etc.
Th*> Panarila
G2 little is known about what goes on
in this fairly quiet period except that
some RNA synthesis occurs.
M mitosis occurs at this stage; the cell
divides into two "daughter" cells
containing all genetic information. Each
cell will now mature and repeat the
cycle , or go into the GO stage .
A complete cycle is referred to as
one generation time.
Cancer is a disease of the cell and so
the chemotherapeutic agents work in
different ways on the life cycle of the
cell. Some drugs are cell-cycle specific
that is, they interfere with cell activity
at a specific phase while others are
not. The drugs may be grouped into four
categories according to their mechanism
of action.
l)Antimetabolites These drugs are
cell-cycle specific in that they interfere
with metabolites essential forDNA
synthesis. For example, methotrexate
interferes with the enzyme dihydrofolate
reductase, which is necessary forfolic
acid synthesis and subsequent synthesis
ofDNA.
2) Antibiotics Non-cell-cycle specific,
these drugs react by binding to DNA at
any stage of the cycle and interfere with
the transcription of RNA and protein
synthesis. Example: Adriamycin.
3) Alkaloids Cell-cycle specific drugs
which interfere with the mitotic spindle
in cell division. Example: vincristine.
4) Hormones These drugs alter the
cellular metabolism of the body by
changing the hormonal milieu and
making it unfavorable for tumor growth.
Example: the use of estrogens in patients
with cancer of the prostate gland .
Each drug dose kills some but not all
the neoplastic cell population; the effect
is more noticeable when a high
percentage of cells are actively and
rapidly dividing within a malignancy.
The bone marrow and lymphoid
components are good examples of highly
proliferative tissues that are sensitive to
chemotherapeutic agents. Nerve tissue,
on the other hand, has a low percentage
of cells dividing and is therefore less
sensitive to these drugs. The goal of drug
therapy is to destroy every abnormal
cell, but the toxicity of the drug imposes
limits on the dose that can be
administered. Combinations of drugs are
designed to maximize the therapeutic
benefits of each drug in the combination,
but to avoid overlapping toxicities; for
example, vincristine causes little bone
marrow depression as a side effect while
Adriamycin causes significant bone
marrow depression.
Unfortunately antineoplastic agents
also attack normal cells. They will do
most damage to highly proliferative cells
and consequently their toxic effects are
felt most keenly on the G.I. mucosa,hair
follicles, bone marrow and skin.
To allow the normal tissues to repair
themselves, drugs are given in cycles to
provide drug free intervals.
A positive attitude
The patient receiving cancer
chemotherapy does much better during
treatment when he knows what to
expect. Patients who are well-informed
about their disease and its treatment,
about the possible adverse effects and
results, generally take appropriate action
on their own at the first sign of
complications. The nurse s knowledge of
drug toxicity, psychological trauma and
the nursing care of both can play a major
role in allaying much of the fear and
anxiety brought on by the unknown.
Both the nurse and the patient and
his family need to know what can be
done to prevent complications of
treatment both in hospital and at home,
and how to treat the unavoidable side
effects. Both need to know the difference
between a tolerable side effect and an
acute toxic reaction.
A useful tool in patient teaching is
the pamphlet or booklet used on a
nursing unit which describes in clear
language the basics of chemotherapy.
Not meant to be a substitute for the
nurse s presence in explanations,
reading material can be an excellent
facilitator to information assimilation if
nurse and patient go over the material
together.
It is important however to consider
not only the negative aspects of cancer
chemotherapy, but to help your patient
develop as positive an attitude toward
his therapy as possible. You can ensure
that both he and his family are aware of
the potential benefits as well as the risks.
Chemotherapy requires a high degree of
co-operation among all concerned, and
patients and families should be partners
with hospital staff in the care process.
At the outset, assess the patient s
attitude and general level of anxiety.
Listen to him, watch his body language
and try to understand just how he
perceives his disease and treatment plan.
In this way you can gear your teaching
plan to suit his individual level of
tolerance and understanding, taking into
consideration all the factors of culture,
personality and psychosocial
inter-relations.
Knowledge of his disease and
treatment gives the cancer patient some
measure of control over a potentially
uncontrollable situation. Through
participation in his own treatment and
good teaching, nurses can strive to
increase the degree of patient
compliance. This is possible only if, as
mentioned earlier, both the patient and
his family are fully cognizant of
chemotherapy and its implications.
20 February 1980
The Canadian Nurse
Eighteen-year-old Alex, for
example, who has a diagnosis of
osteogenic sarcoma, returns to the
hospital at regular intervals for his
chemotherapy which involves high doses
of methotrexate with citrovorum rescue.
After each session of chemotherapy,
Alex is discharged providing that his
laboratory results are within normal
limits, to complete his treatment cycle at
home. This includes taking the oral
citrovorum rescue drug on time every
day, keeping himself adequately
hydrated according to the protocol and
testing urine pH. The latter is a good
example of Alex s self-care; if his urine
pH falls below 7, he takes an appropriate
dose of soda bicarbonate to alkalinize his
urine.
All patients benefit from a card or
handout given at the time of discharge
that outlines their responsibilities at
home. Patient compliance is very
important in chemotherapy, and
successful treatment requires that all
involved be well-educated, informed and
responsible about the home phase of the
treatment cycle.
Toxicity: how it affects the nurse and the
patient
Here is a short review of the most
common side effects of chemotherapy,
along with the nursing actions that can be
taken while the patient is in hospital and
simple remedies the patient himself can
use at home.
Leukopenia
Leukopenia results from suppression of
bone marrow function and is one of the
most serious toxic effects of cancer
chemotherapy. The white cell count is
lowered, particularly the neutrophils that
combat bacterial infection; thus
susceptibility is increased and the patient
may be infected by his own normal body
flora.
Nursing actions include inspection
of all body orifices for early signs of
infection, and instruction to the patient
on how to keep himself clean and avoid
problems. Rectal abscesses and fistulas
are common in leukopenic patients
whose nutritional status is compromised.
Temperature and the white cell count
should be monitored closely; if the WBC
falls below 1000/cu mm the patient may
be put on reverse isolation.
Reverse isolation, obviously, is the
reverse of usual hospital isolation the
goal is to protect the patient from outside
infection sources. He may be put into a
private room, and all persons entering
the room will have to wear masks; gowns
may be worn when direct contact is
made and strict handwashing technique
used.
Another area of concern with the
leukopenic patient is the preparation of
venipuncture sites: betadine solution
followed by alcohol is used prior to
puncture. The needle is secured in place
with tape, but tape is not placed over the
needle site itself; a sterile 2x2" gauze
dressing with betadine ointment may be
used and changed daily. The IV site
should be changed every 48 hours if this
is possible, to avoid infection. Any
dermal abrasions sustained by the
patient may be treated as for
venipuncture.
Not to be forgotten are the
psychological repercussions of reverse
isolation; the patient will need more
support than ever to combat fear and
loneliness and the anxieties that come
from social isolation and increased
dependence.
The patient himself can do a number
of things to ameliorate leukopenia: he
can keep himself clean and report any
pain or discomfort such as on voiding
etc. While in reverse isolation, he can
use saline and hydrogen peroxide
mouthwashes every three hours. These
take the place of using a toothbrush
which injures sensitive gum tissue.
Mycostatin mouthwashes may be
prescribed to prevent Candidas infection.
Thrombocytopenia
This is also an effect of bone marrow
depression, the principal sign of which is
bleeding. In some patients, bleeding may
occur at platelet counts of 50,000/cu mm
(normal range is 140,000 to 400,000/cu
mm) while not in others until counts are
below 20,000.
Nursing actions include watching
for obvious signs of bleeding, as well as
observing for joint pain, petechiae,
hematuria and headaches which may
herald a bleed into the brain. Patients
rooms should be uncluttered to prevent
accidental falls or bruises and IM
injections and ASA should not be
administered.
DNA
RNA Protein
Essential
Metabolites
ie Folic Acid
Cell Division
The Canadian Nurse
February 1980 21
The patient himself can watch for
and report any signs of bleeding such as
nosebleeds or bruising. He can take care
in his activities to avoid cuts or any kind
of trauma; in addition he should know
not to use a toothbrush to prevent gum
bleeding, and not to use alcohol or ASA
unless his doctor approves.
Thrombocytopenia can sometimes
be temporarily improved with platelet
transfusions, but often after a number of
these transfusions patients develop
antibodies and need to be premedicated
with a drug such as Benadryl prior to
further transfusion.
Erythropenia
This side effect of chemotherapy is yet
another result of bone marrow
depression evidenced by decreased red
blood cell count and anemia.
Nursing actions include planning
patient care to allow for frequent rest
periods, and provision of adequate
nutrition, especially foods high in iron.
The nurse should watch for signs of
anginal pain on exertion in patients who
are otherwise already compromised
those who are elderly or who have
infection.
The patient himself should know not
to tire himself and when at home to plan
frequent rest periods; he can watch his
diet as well and use liquid protein
supplements if necessary.
Anorexia, nausea and vomiting
These side effects, alone or all together,
are common to almost all the
chemotherapeutic agents, but they can
be alleviated with relative ease in
intelligent management.
It is useful for the nurse to assist the
patient to develop an eating pattern so
that at certain times following
chemotherapy and/or antiemetic
medication, he will feel able to eat. Other
apparently minor but helpful nursing
actions include making the patient as
comfortable as possible at mealtimes,
presenting attractive meals food
cooked at home is excellent if not
contraindicated and the provision of
liquid protein supplements in the form of
eggnogs or Sustacal* when solid food
cannot be taken. Mouth care before and
after meals helps too to overcome the
bad taste that may adversely affect
appetite.
The patient himself can report to the
nurse any nausea or vomiting he
experiences so that he may be given
antiemetics before meals, and he can
encourage his family to bring food from
home if this is allowed.
Diarrhea
Patients receiving antibiotics and
antimetabolite chemotherapy drugs are
commonly afflicted with this side effect.
Nursing actions are aimed at
treating the symptoms which can be
accomplished by providing the patient
with a low roughage diet high in foods
that tend to constipate, such as cheese
and boiled milk. Fluid loss must be
replaced and good skin care is imperative
if diarrhea is severe, antidiarrheals such
as Lomotil may be necessary.
The patient should be asked to
report the incidence of diarrhea as soon
as it starts to his nurse or doctor, and he
can watch his diet and fluid intake.
Stomatitis
Inflammation of the mucous membranes
of the mouth often appears as a sign of
toxicity from the antimetabolite and
antibiotic drugs. Painful mouth ulcers
make eating difficult and may progress to
severe infections.
Good oral hygiene is an important
nursing action using frequent
mouthwashes of 1 : 1 saline hydrogen
peroxide solution; these will improve
taste and reduce bacteria. A topical
anesthetic such as viscous Xylocaine
may be helpful before meals in severe
cases, and antacids may be helpful when
esophagitis is also present; bland foods
of medium temperature and high protein
fluids should be provided.
Reporting the appearance of mouth
sores or pain is the patient s
responsibility and he can initiate the
mouthwashes mentioned above.
Alopecia
Hair loss can be devastating to the
patient s self-image, especially when it
occurs suddenly. Hair follicles
proliferate cells rapidly and are
consequently damaged as much as
malignant cells in chemotherapy.
The nurse can assure the patient that
the condition is reversible and that once
chemotherapy is stopped hair growth
will resume in four to six weeks. Recent
research has shown that the application
of a tourniquet around the head or an ice
bag to the scalp while chemotherapy is
being given actually reduces hair loss;
the blood flow to the scalp is restricted
and so the chemotherapeutic agent does
not reach the hair follicles in the same
concentration. Of obvious benefit too are
wigs.
The patient, once informed by
nursing and medical staff that alopecia
may occur, can prepare his family and
friends for the change in his appearance.
These are only the most common of
the side effects of chemotherapeutic
agents; several others exist effects on
the reproductive system for instance
and nurses should be aware both of the
actual effects and of how to help the
patient alleviate them.
Creative caring
The patient with cancer who is
undergoing chemotherapy is a
tremendous challenge to a nurse; besides
continuously updating her basic
knowledge of drugs, their actions and
interactions, she must draw on her
personal talents and resources, plus
those in the community around her, to
foster a positive and hopeful attitude in
her patient. How both nurse and patient
perceive and accept the disease of cancer
and its treatment have a profound effect
on the success of chemotherapy. <
References
1 Welch, Deborah. Assessing
psychosocial needs involved in cancer
patient care during treatment.
Oncol.Nurs. Forum 6:1:13, Jan. 1979.
Bibliography
1 Chemotherapy of cancer. Adria
Laboratories, Sep., Oct., Nov. 1976.
2 Marino, Elizabeth. Cancer
chemotherapy, by Elizabeth Marino and
D.H. LeBlanc./V>ig 75 5:11:22-23,
Nov. 1975.
3 Peterson, Barbara H. Current
practice in oncologic nursing, by
Barbara H. Peterson and Carolyn J.
Kellogg. Vol. 1. St. Louis, Mosby, 1976.
4 Welch, Deborah. Assessing
psychosocial needs involved in cancer
patient care during treatment.
Oncol.Nurs. Forum 6:1:12-18, Jan. 1979.
Diana C. Law, RN , BScN , is a graduate
of the Toronto General Hospital School
of Nursing and has completed a
post-graduate course in psychiatric
nursing as well as her baccalaureate
degree which she obtained from the
University of Alberta. She is presently
working as the medical nursing
co-ordinator at the Foothills Hospital in
Calgary where, she writes, "we are
developing staff and patient teaching
programs related to oncology.
22 February 1980
The Canadian Nurse
HYPOTHERMIA
t
Taking the bite out of Winter
The Canadian Nurse
February 1980 23
Controlled
Hypothermia:
A treatment
for an acute
Anoxic Incident
Stephanie and her six-year-old playmate, Marc, were fascinated by the
spring thaw. Playing on the brink of the river, poking with sticks at pieces of
floating ice and throwing rocks into the murky water, they were feeling the
freedom of spring. Suddenly, Stephanie lost her footing and fell into the icy
water. Marc, terrified by her screams, ran for help. Ten minutes later,
Stephanie was pulled from the water, not breathing and without a pulse.
Cardiopulmonary resuscitation was initiated by a rescuing policeman while
bystanders waited for an ambulance. What followed for Stephanie s parents
and the medical staff that cared for her were ten days of anxious waiting
ten days of not knowing what the results of their treatment and the eventual
outcome would be.
sni
M argot Thomas
Controlled hypothermia
The treatment of choice fora victim of
accidental hypothermia and acute anoxic
episode is controlled hypothermia and
barbiturate induced coma until cerebral
edema is resolved.
Controlled hypothermia, the
external regulation of body temperature
to below 33.3C, is used in medicine for
several purposes:
to lower excessively high fevers of
febrile disease entities, including drug
and anesthetic reactions, such as
malignant hyperthermia
to reduce oxygen consumption and
control bleeding intraoperatively, such
as in cardiac surgery
to reduce cerebral edema secondary
to metabolic or mechanical injuries of the
brain.
Use of hypothermia results in a
reduction of basal metabolism,
decreased respiratory rate, pulse, blood
pressure, hormonal response and cellular
oxygen requirements. As hypothermia
tends to reduce cerebral blood flow, the
fluid shift from intravascular to
intracellular areas is decreased and the
nervous tissue need for oxygen is
reduced. For these reasons, controlled
hypothermia is frequently used in
conjunction With other supportive
measures in the care of patients with
cerebral edema secondary to brain
injury.
Barbiturate induced coma
Continuous coma produced purposefully
by hourly infusions of barbiturates,
usually thiopental sodium (Pentothal
Sodium), pentobarbital sodium or
phenobarbital (dosage of 1-5 mg/kg/hr)
has been shown to reduce intracranial
pressure (ICP) in patients having
increased ICP due to cerebral edema.
Although the exact mechanism that
reduces the intracranial pressure is not
well understood, a reduction of cellular
cerebral metabolism and cerebral blood
flow have been identified as important
aspects of the process.
Barbiturate induced coma renders
the patient without cerebral function (no
reflexes or spontaneous movement) and
can produce a temporary flat (isoelectric)
electroencephalogram (EEC) and fixed,
dilated pupils. This treatment is used in
conjunction with intracranial pressure
monitoring, mechanical ventilation,
anticerebral edema medication and
frequently hypothermia until the critical
period for cerebral edema has passed. At
that time barbiturates are discontinued
and while the ICP is carefully monitored
the patient is "allowed to wake up".
Monitoring intracranial pressure
Intracranial pressure is the cumulative
force exerted within the skull by the
brain, cerebral blood flow and
cerebrospinal fluid (CSF). This pressure
is readily affected by any change in
volume of any of these three elements, as
the fixed and rigid nature of the cranium
does not allow compensation for
variations. Any increase in these
volumes results in an increase in ICP.
commonly seen with space occupying
lesions, intracranial hemorrhage, build
up of CSF secondary to a blockage of the
skull drainage system and cerebral
edema.
Cerebral edema is the pathologic
shift of water and sodium from
surrounding blood vessels into brain
cells in response to brain injury either
mechanical (closed head injury) or
metabolic (acute anoxic incident). The
edema fluid is rich in proteins which
have leaked through the capillaries into
the cells and thereby cause an osmotic
pull of more fluid into the intracellular
and interstitial fluid spaces.
With increased ICP. cerebral
function is threatened. If the ICP is not
adequately controlled, severe brain
damage can result. With new monitoring
devices that place a small probe in the
CSF surrounding the brain. ICP can be
measured directly. The indirect signs of
ICP level of consciousness, size and
reaction of pupils to light, vital signs and
motor response are essential in
evaluating neurologic status but are not
usually evident until some pathologic
change has occurred to the brain. ICP
monitoring is a useful adjunct in the care
of patients with head trauma, pre and
post operative craniotomies, intracranial
hemorrhage and disease processes
characterized by cerebral edema.
Measured in the same scale as
arterial blood pressure to allow for
comparisons, normal ICP ranges from
4-15 mm/Hg 2 . Elevations of ICP can be
treated with medications such as
Mannitol and Dexamethasone; with
barbiturate induced coma, hypothermia,
hyperventilation and in some cases
neurosurgery (skull decompression and
CSF drainage).
Stephanie s story
Stephanie, aged five and one-half years,
was brought to the Emergency Room of
a nearby general hospital by ambulance
after submersion in a very cold
freshwater river for ten minutes. Mouth
to mouth resuscitation and cardiac
massage were started at the scene and
continued until the child was intubated
and ventilated in the E.R. and heart
function had returned to sinus
bradycardia with a rate of 46 per minute.
On arrival at the E.R., Stephanie
was described as being apneic and
asystolic. with pupils fixed and dilated.
Rectal temperature on admission was
26C. Following initial resuscitation and
stabilization, large loading doses of
intravenous Pentothal* Sodium were
given and a paracentesis involving
instillation of warmed saline into her
abdomen was performed in an attempt to
raise her body temperature above the
critical level of 30C. Below this
temperature, cardiac arrhythmias and
ventricular fibrillation which are difficult
to reverse are common.
At the local children s hospital, to
which she was transferred, Stephanie
was taken immediately to the ICU and
placed on a hypo/hyperthermia blanket
and under an overbed heater as the
attempt continued to raise her core
temperature to 30C. She was ventilated
with 1 00 per cent oxygen initially and
PEEP (Positive End Expiratory
Pressure) was used to reduce pulmonary
edema. PEEP maintains inflation of all
areas and segments of the lungs. By
maintaining positive pressure in the
alveoli on expiration, the normal
transudation of fluid across the alveolar
capillary membrane is retarded.
Stephanie was attached to cardiac
and respiratory monitors, vital and
neurological signs were watched closely
and a foley catheter and naso-gastric
tube were inserted. On admission,
fulminant pulmonary edema was treated
with stat doses of intravenous
furosemide(Lasix"). She was then taken
to the neurosurgical operating room
where an intracranial pressure probe was
inserted. As the probe was covered with
an occlusive dressing, the only nursing
care of this closed system involved
accurate readings and awareness of
implications of changes.
Stephanie s care, day-to-day
condition, her ongoing medications and
treatments during her stay in ICU are all
illustrated on the accompanying chart.
The barbiturate induced coma which
had been initiated at the general hospital
E.R. was maintained with hourly
injections of Pentothal" 150 mgm
intravenously which were reduced to 40
mgm/hr. Decadron " . a long-acting
synthetic adrenocorticoid. was
administered routinely as its intense
anti-inflammatory activity is especially
effective in reducing cerebral edema.
Ampicillin therapy was also begun at this
time.
Controlled hypothermia was
initiated once Stephanie s temperature
had been raised to 32C and until day
four her temperature was regulated
between 30 and 32C.
With the use of hypothermia and
barbiturate induced coma, Stephanie s
blood pressure was very low and
unstable. To determine that there were
no other causes of her labile status, tests
indicated on the chart were completed
regularly with a special focus on serum
Pentothal" levels. Any measurement
outside of the desired 2.5-5 mgm per cent
range resulted in adjustment of the
hourly infusion dosage. By day three, the
unstable blood pressure recordings
coupled with a low hematocrit resulted in
the infusion of packed cells. Even though
the cause of this persistent blood
pressure problem was probably the
treatment regime. Stephanie s
management could not be continued
without further infusions of fresh frozen
plasma and then albumin.
On day four, a gradual and slow
rewarming process was initiated. Over
24 hours. Stephanie s temperature was
increased to the normal range, although
she did require external regulation of
body temperature until day six. As
cerebral function returned, the brain
could then regulate body temperature
without external assistance. Concurrent
with rewarming, the Pentothal 1 * infusions
were discontinued. Consequently,
pupillary response to light returned fully
within 24 hours. Note that with
rewarming and the discontinuing of
barbiturates, the effects of hypothermia
were reduced, that is. the apical pulse
and blood pressure increased and the
intracranial pressure rose slightly. The
following day, day five, spontaneous
respirations were noted and by day
seven. Stephanie was opening her eyes
to command, withdrawing limbs to
painful stimulation and breathing at a
rate of 30-36 per minute. Complete
recovery from the effects of the
barbiturate induced coma and
hypothermia was evident on day eight
when Stephanie was extubated and she
started to speak.
During this period. Stephanie s
general care involved all of the normal
aspects of nursing care of the
unconscious, mechanically ventilated
patient, including eye. mouth and skin
care, passive exercises, etc. Chest
physiotherapy was initiated only on day
four as active chest physio is sometimes
contraindicated for the individual with an
unstable ICP. At this time physio was
given every two hours to minimize the
severe problem of atelectasis that had
developed despite the use of PEEP.
Thg Canadian Nurse
February 1 980
Admission
Day one Day two
Day three
Day four
Body C
temperature
Initially 26
warmed to 32
Controlled Hypothermia
3032 3032
30.531
30.5 then warmed to
37 over 24 hours
Vital signs
Apex
Blood pressure
(Systolic)
4870
50-60
Respirations
mechanically ventilated
at 21 /minute
6880 60-80
6080 60-80
Mechanically ventilated Mechanically ventilated
at15/minute at12/minute
5264
70-80
Mechanically ventilated
at 12/minute
5690 After warming
6090 After warming
Mechanically ventilated
at 12/minute
Neurologic signs
Pupils
Eye opening
Verbal response
Motor response
Fixed and dilated
None
None
None
Fixed at 0700 hrs
Reacting sluggishly
at 1200
Reacting moderately
at 2200
ICP(mmHg)
Normal (5 15mm Hg)
13
15 2-5
15
2-8
Medications
Pentothal*
150mgmlVQ1H
Decadron
6 mgm IV Q6H
Ampicillin
1 Gm IV Q6H
Pentothal
reduced to 40 mgm Q1H
Decadron
reduced to 3 mgm Q8H
Dilantin 30 mgm IV Q8H
Pentothal*
discontinued
at 0700 hrs
Cloxacillin
475 mgm IV Q6H
Stat Medications
Lasix* 20 mgm IV
Dilantin 100 mgm IV
Lasix* 20 mgm IV
Tests
Arterial Blood Cases*
CBC*, Platelets,
Bun*, Electrolytes*
Calcium*, Creatine
Serum and Urine*
Osmolarity
Chest X-Ray
EEG EEC
ECG ECG
Serum Pentothal Levels Tracheal Aspirate
(desired levels for C & S
2.5-5 mgm%)
Cross and type
EEG
Serum Pentothal Levels
Notes
"Done daily and more
frequently during
days 1 5 as needed
Done daily for
days 18
Packed cell infusion
of 200 cc
Fresh frozen plasma
infusion of ISOcc
Physiotherapy (chest)
Q2H
Stephanie s labile blood pressure
precluded prolonged turning and change
of position, so fastidious skin care every
two hours was necessary to protect her
from problems arising from pressure or
cold to her poorly nourished skin.
A happy ending
The demands of the technical
management of a case such as
Stephanie s are outweighed only by the
psycho-emotional demands. For seven
days Stephanie s prognosis was very
guarded, no one could predict whether or
not she would be extremely brain
damaged as a result of her severe anoxic
accident. Both medical and nursing staff
were working in an apparent void:
feedback to their treatment course was
non-existent. Of course, this was most
difficult for Stephanie s parents. They
could never be given much reassurance;
all we could say was that her condition
was unchanged and would remain that
way until the treatment was over. Even
by day 10, after active treatment had
been discontinued and Stephanie was
reacting fairly normally, the possibility
of residual brain damage was not
completely ruled out.
Now, a year later, Stephanie is at
home, a full-time grade one student, with
no apparent disabilities. Her EEG,
respiratory function and cardiac status
are all normal . Her only regular
follow-up is with a local psychiatric
clinic which is looking at some minor
problems with "acting out". It would
seem that the root of her problem is more
likely to be a reaction to her instant
"stardom" in the community than an
organic manifestation.^
EflUrliBrv. 1 QQO
Day five
Day six
Day seven
Day eight
Day nine
Day ten
36.537
36.537.3
36.537 Maintained
without
hypothermia blanket
36.537.5 37 (oral) 36.737
86100
8090
Mechanically ventilated
at 13/minute
spontaneous resp. noted
80100
86100
Spontaneous respiration
with ventilator at a
rate of 20/minute
86100
90100
36 Spontaneous
respirations with
mechanical ventilation
70100
90100
2434
Not ventilated
Equal and reacting
briskly to light
3-10
Attempting
To command
To command
Playing and reading
books
Crying
Spontaneous movement
gag and cough reflex
present
Withdrawal to
pain
Mouthing words
Hand grips strong
toe pushes strong
Talking
Alert and oriented
to person
and place
"Want to go home"
010
513
211
ICP Probe Removed
Decadron* decreased
to 2 mgm IV Q8H
Decadron* decreased
to 1 mgm IV
asix 20 mgm IV
EG
erum Pentothal levels
Tracheal aspirate
for C and S
.Ibumin infusion
f40cc
Hypothermia blanket
turned off
Extubated Nasogastric tube
removed
Foleycatheter removed
Physio decreased to Q4H
Up out of bed
Transferred to
floor!
References
1 Marshall, L.F. Pentobarbital
therapy for intracranial hypertension in
metabolic coma, by L.F. Marshall et al.
CritJCareMed. 6:1: 1-5, Jan. /Feb. 1978.
2 Johnson, M. The subarachnoid
screw, by M. Johnson and J. Quinn.
AmerJNurs. 77:3:448-450, Mar. 1977.
Bibliography
1 Beaumont. Estelle.
Hypo/hyperthermia equipment. Nursing
-74 4:4:34.41, Apr. 1974.
2 *Conn, A.W. "The role of
hypothermia in near-drowning."
Toronto, Hospital for Sick Children.
1976.
*Unable to verify in CNA Library
Margot (Brown) Thomas, a graduate of the
Faculty of Nursing, University ofToronto,
was part of the team who cared for Stephanie
(the pseudonym chosen for the little girl in
her article). Margot has worked in the
Surgical Intensive Care Unit of the Montreal
General Hospital and is presently on staff in
the Intensive Care Unit of the Children s
Hasp ita I of East e rnOnta rio .
Stephanie s seven-year-old companion
who went for he Ip has since received a $100
award presented annually to a person who
has made a special contribution to the
community and the policeman who dove into
the frigid waters and rescued Stephanie will
receive the Ontario Medal for Police
Brave>y, his fourth bravery award for this
incident. He was quoted by a local
newspaper as saying My biggest award
was saving her life.
February 1980 27
Accidental Hypothermia:
Donna Rae
Emergency
Rewarming
Techniques
The correlation between a society, its physical environment and the type of
high risk activities its members engage in often affects the type of emergency
treatments that must be perfected. In Canada, as our society becomes
increasingly fitness oriented, outdoor activities in the most inclement
conditions frequently result in accidental hypothermia.
As an acute life-threatening emergency,
accidental hypothermia requires
immediate and active therapy. Although
the ethical nature of inducing
hypothermia for experimental reasons
has restricted the amount of and quality
of research that has been documented,
the statistics that are available along with
the relevant case histories, have helped
to identify reasonable approaches to
emergency treatment.
Accidental hypothermia occurs
when the body s core temperature falls
to less than 35C (95F) as a result of
exposure to cold. Immersion in water or
prolonged exposure to cold weather may
result in this hypothermic state. Infants
with poor thermoregulatory mechanisms
and elderly people whose lower basal
metabolic rates are coupled with
debilitating disorders are particularly
susceptible.
Pathophysiology
Bodily response to cold involves several
reactions.
Heat Conservation: Reflex
responses which are activated by cold
are controlled by the posterior
hypothalamus and either increase heat
production or decrease heat loss.
Shivering, hunger, increased voluntary
activity and increased secretion of
norepinephrine and epinephrine are all
mechanisms which increase heat
production; while cutaneous
vasoconstriction, curling up and
horripulation (goose flesh) decrease heat
loss.
Shivering, an involuntary response
to cold and fear, is mediated by the
shivering center in the posterior
hypothalamus. As skeletal muscle tone
increases throughout the body, the
individual begins to tremble when a high
level of muscle tension is reached. These
tremors may vary from slight quivering
to violent contractions which result in an
increase in muscle cell metabolism and a
consequent elevation of heat production.
The catecholamine hormones,
norepinephrine and epinephrine,
released primarily from the adrenal
medulla as a response to any stressor
including cold, increase the force and
rate of contraction of the heart.
Norepinephrine produces
vasoconstriction in peripheral vessels
while epinephrine released into the
circulation increases the rate of cellular
metabolism. As basal metabolism
increases with decreased temperature,
the need for oxygen consumption
increases and the cardinal sign of
increased respiratory rate becomes
apparent.
Horripulation, goose flesh, raises
the hairs on the skin thereby providing
pockets of insulation. This is an effective
means of conserving heat in lower
animals who have an abundance of hair,
however, the effectiveness of this
response in man would seem to be of
little consequence.
Despite compensatory mechanisms,
prolonged exposure to cold results in
heat loss, lowered core temperature,
declining metabolic rate, reduced
shivering and muscle rigidity.
Circulatory System: Initially with
the response of increased metabolic rate
and sympathetic activity, an increase in
8
respiratory minute volume, heart rate
and cardiac output is evident. Continued
exposure to cold, however, results in
depression of the medullary respiratory
center, cardiac pacemaker activity and
conduction, causing decreased
respiratory rate, heart rate and cardiac
output which may lead to hypotension.
When core body temperature falls below
32C, the ensuing myocardial irritability
may induce arrhythmias or heart block.
In fact, "Once cardiac temperature falls
to about 31 "XT, the cardiac output
declines. At about 25C. it often becomes
insufficient to meet even the reduced
requirements of the body tissues for
oxygen and with further cooling the heart
may stop completely." 1
Hypothermic victims are at high risk
to develop ventricular fibrillation and
cardiac dysrhythmias due to a decrease
in oxygen supply to the cardiac muscles.
As the body temperature drops, it
becomes more difficult for oxygen to be
released from hemoglobin resulting in a
reduction in oxygen available for cell
use. 2 The consequent irritability of the
heart places the patient at risk to cardiac
standstill.
Nervous System: Below 32C a
progressive depression of the central
nervous system including altered mental
state, depressed reflexes and advancing
coma may be noted as hypothermia is
prolonged.
Renal Responses: As hypothermia
develops, renal arterioles constrict and
cardiac output decreases causing a
decline in renal blood flow, glomerular
filtration rate and finally, oliguria. As
renal tubular function is depressed, the
transport mechanisms are impaired
resulting in deviant regulation of volume
and concentration of fluids, acids, bases
and waste products such as creatine,
creatinine and uric acid.
Acidosis: Carbon dioxide, not
effectively exhaled as a result of
decreased respiratory minute volume
and tissue hypoxia, which predisposes
anaerobic metabolism, result in acidosis,
both respiratory and metabolic.
Assessment and treatment
In an emergency situation such as this,
assessment and treatment must be
established according to priorities.
1) Airway: Utilizing the A(airway),
B(breathing). C(circulation) guidelines
for determining priorities, a patent
airway and respiratory adequacy must be
assessed and treated first. Movement of
air may be evaluated by observing the
patient for respiratory effort and
movement of chest or upper abdomen.
When dubious air exchange is assessed,
treat the patient by tilting the head back
as far as possible by placing one hand
under the neck while placing the other
hand on the forehead. Forward
displacement of the lower jaw in addition
to head tilt may be required to extend the
neck and lift the tongue away from the
back of the throat. If movement of air is
not established by these methods it is
necessary to utilize mouth to mouth
resuscitation or aids such as airways,
ambu bags orendotracheal equipment.
2) Circulation: In the event of cardiac
standstill, external cardiac massage may
be given. It has been suggested that
massage be "at about half the normal
rate", 3 that is, eight compressions to two
ventilations every twelve seconds in a
one man resuscitation. This reduced
cardiac massage rate is indicated by
several factors. First, as blood volume
decreases, a longer period of time is
required to allow adequate filling of the
heart chambers. As well, as cell
metabolism slows, less oxygen is
required at the cell level and the
inevitable cardiac irritability prevalent in
these states may be aggravated by
aggressive cardiac massage and
arrhythmias may ensue.
3 ) General Baseline Data: Data for the
hypothermia victim should include vital
signs using deep body temperature, level
of consciousness, shivering response and
urinary output. Information from
laboratory analysis and
electrocardiograms may also be
required. The goals of this monitoring
are to detect early warning signals; to
establish any reason for deterioration
and to evaluate response to treatment.
All data should be recorded immediately
upon admission and monitored
frequently during recovery.
4)Temperature: Deep core body
temperature may be obtained rectally or
at the tympanic membrane . A normal
clinical mercury thermometer is of
limited use as temperatures below 35C
are not recorded and deep rectal
insertion is not possible. Electronic
probes such as the "Electronic
Thermometer Modes 43TA, Yellow
Spring Instrument Company, scale range
20C (68V) to 42C (100F)," facilitate the
recording of lower temperatures at the
tympanic membrane. Accurate data is
provided, but specialized equipment is
required and skilled personnel must be
available to place the probe against the
tympanic membrane and seal off the
auditory meatus.
Continual temperature data
collection is essential as often there is an
"after drop" of the body core
temperature when cold blood from the
periphery reaches central areas.
5) Blood Pressure: Frequent monitoring
and recording of blood pressure will
detect early warning signals of
"rewarming shock". Cardiac output is
reduced with hypothermia and as
peripheral vessels dilate with rewarming,
blood pressure may drop further. 4
6) Shivering Response: Shivering base
line data upon admission of hypothermic
victims will vary according to the body s
core temperature and cause of
hypothermia. Victims of immersion
hypothermia tend to exhibit less
shivering than victims of slow exposure
hypothermia due to their rapid loss of
body heat and subsequent loss of
consciousness.
When shivering thermogenesis is
used as the method of rewarming for
these victims, ongoing monitoring of the
shivering response should be recorded.
Some non-shiverers require treatment in
warm whirlpool baths when shivering
thermogenesis does not appear to be
adequately affecting the "afterdrop" in
temperature. 5
7) History: Upon admission, obtain a
history from family, friends or
observers, as treatment management will
depend on any existing chronic or
debilitating disorders as well as the cause
of the hypothermia. Victims of slow
exposure hypothermia more frequently
present with mood changes which may
range from confusion to a state of
profound aggression. These persons are
also predisposed to hypovolemia due to
fluid shifts.
Rewarming techniques
Treatment for hypothermia consists of
rewarming. Three main techniques are
now being used.
Central Body Rewarming by means of
peritoneal dialysis, hemodialysis or
cardiopulmonary by-pass. Internal body
warming reduces the possibilities of
cardiac arrhythmias and ventricular
fibrillation, a prime consideration as "a
heart below 28C can rarely be
defibrillated by drug therapy and/or
electric shock... although the heart does
seem to have an increased tolerance for
prolonged fibrillation when hypothermia
exists..." 6
The primary advantage of this
technique is that the warmth, with
resultant vasodilation of vessels, reaches
the primary organs of the body first. This
is of major consequence to the heart as it
attempts to restore a normal cardiac
output. The heart s own cell metabolism
increases and thereby generates its own
increased oxygen demands. However,
the complexity of core rewarming
requires constant health team expertise
and the risk of infection is a constant
threat.
Active Surface Rewarming through
baths or heating pads. Warm baths raise
body temperature by convection, which
is the transference of heat by means of
currents in liquids. Therefore if the bath
water can be circulated with compressed
air the effectiveness of the bath is
increased. Vasoconstriction is relieved
in peripheral vessels and venous return
to the heart is increased by means of this
application of exogenous heat. However
the sudden return of cold blood to the
body core areas may precipitate an
"after drop" in core body temperature,
which can potentiate the possibility of
ventricular fibrillation, due to further
cooling of the myocardium. Excessive
peripheral vasodilation may be reduced
if extremities, that is arms and legs, are
initially kept out of the warm bath.
This is a very efficient method to
raise skin temperature. By reducing
shivering and decreasing cell
metabolism, the cellular demand for
oxygen is minimized. Using this
technique, body temperature is raised
much more quickly than with core
temperature rewarming. Water
temperature should be maintained
between 40-44C and treatment
terminated when forehead sweat is
noted.
Passive Surface Rewarming, whereby
body temperature is restored through
shivering thermogenesis. Spontaneous
rewarming or wanning by endogenous
means is simple and can be established in
or out of an institutional setting.
Shivering, one of the body s mechanisms
to increase heat production, in
combination with insulation by blankets
to decrease heat loss causes less trauma
to the patient who is susceptible to
complications such as arrhythmias.
Spontaneous rewarming is slow and
for this reason this technique is not
always the method of choice for treating
the hypothermic patient who is hypoxic
and at risk, but for the elderly and
enfeebled patient who has slowly
become hypothermic passive rewarming
is recommended. "...In a patient with a
stable rhythm, whether bradycardia or
atrial fibrillation, stable vital signs, and
near normal blood gases, passive,
peripheral rewarming during monitoring
can be successful..." 7
Victims of accidental hypothermia
may simulate death. Nurses should
always remember, however, that there
have been many reports of successful
revivals after one hour of active
rewarming and supportive care. Death
should not be a diagnosis unless there is
a failure to revive after one hour of
resusciation and rewarming to 30C. *
Clinical Features of the
Accidental Hypothermia
Patient
Moderate Hypothermia
(Most frequent)
cold skin
hypopnea
cyanosis
bradycardia
irregular pulse
hypotension
poorly reactive dilated pupils
polyuriaoroliguria
shivering
muscle rigidity
altered mental state
edema
Profound Hypothermia*
(Rare)
cold skin
apnea
cyanosis
cardiac standstill
pulseless
unresponsive
fixed dilated pupils
no urine output
Profound clinical features are
indistinguishable from death, therefore,
death may be defined if there is failure
to revive after one hour of attempted
resuscitation and core body
temperature has been raised to 30 C.
References
1 Keating, W.R. Accidental
immersion hypothermia and drowning.
Practitioner 219:1310:184, Aug. 1977.
2 Ibid., p. 184.
3 Ibid., p. 185.
4 O Keeffe, Kevin, M. Accidental
hypothermia: a review of 62 cases.
JACEP 6: 11:492, Nov. 1977.
5 Collis, M.L. Accidental
hypothermia: an experimental study of
practical rewarming methods, by M.L.
Collis et al.Aviat. Space Environ. Me d.
48:7:625, Jul. 1977.
6 I bid., p. 627.
7 O Keeffe,op.cit.,p.495.
8 Ibid.,p.495.
Bibliography
1 Allen, ET. Hypothermia:
prolonged immersion in cold water.
Nurs. Mirror 70:50: 1928-1929, Dec. 12,
1974.
2 Anderson, S. Accidental profound
hypothermia, by S. Anderson et al.
Brit.J.Anaesth. 42:653-655, Jul. 1970.
3 Collis, M.L. Accidental
hypothermia: an experimental study of
practical rewarming methods, by M.L.
Collis et al.Aviat. Space Environ. Med.
48:7:625-632, Jul. 1977.
4 Keating, W.R. Accidental
immersion hypothermia and drowning.
Practitioner 219:1310:183-187, Aug.
1977.
5 Knapman, Y. Nursing care study:
out in the co\d.Nurs.Times 70:2:56-57,
Jan. 10, 1974.
6 Ledingham, I. Accidental
hypothermia (letter), by I. Ledingham
andJ.G. Mone. Lancet 1:8060:391,
Feb. 18, 1978.
Mallin, R.E. The Alaska Thermal
Treatment Centre at Providence
Hospital, by R.E. Mallin andD.B.
Addington./f/<w/l<3 Med. 18:6:79-80,
Nov. 1976.
8 Marcus, P. Laboratory comparison
of technique for rewarming hypothermic
casualties. Aviat. Space Environ. Med.
49:5:692-697, May 1978.
9 Meriwether, W.D. Severe
accidental hypothermia with survival
after rapid rewarming. Case report,
pathophysiology and review of the
literature, by W.D. Meriwether and
R.M. Goodman. Amer.J.Med.
53:505-510, Oct. 1972.
10 O Keeffe, Karen M. Accidental
hypothermia: a review of 62 cases.
JACEP 6: 11:491-496, Nov. 1977.
1 1 Rewarming for accidental
hypothermia (editorial). Lancer
1:8058:251-252, Feb. 1978.
12 Shanks, C. A. Heat gain in the
treatment of accidental hypothermia.
Med.J.Aust. 2:9:346-349, Aug. 30, 1975.
13 Stewart, T. Treatment after
exposure to cold, by T. Stewart and H.
Hittman. Lancet 1:140-141, Jan. 15, 1972.
14 Stine,R.J. Accidental
hypothermia. JACEP 6:9:413-416, Sep.
1977.
15 Treating accidental hypothermia
(editorial). Lancet 1:8066:701-702,
Apr.l, 1978.
Donna Rae,RN, BScN, is a graduate of
the Winnipeg General Hospital and the
University of Saskatchewan. After
several years of Emergency Room
nursing, she is presently a lecturer with
the School of Nursing of the University
of Saskatchewan. Along with her normal
teaching duties, she has taken part in
several Emergency Care Workshops
throughout Saskatchewan.
JJP
The Canadian Nur
A.
Janet strikes out for a long run on a sunny March
afternoon. The wind is at her back and Spring is in the
air. On her return trip, however, the sky has clouded
over, the wind is in her face and her clothes are wet with
perspiration. She is shivering with the cold and wonders
if she can make it home.. .
Out for a day s cross country ski expedition, your
companion, who is constantly dieting, begins to
complain that she is tired and cold, that she wishes she
had eaten breakfast or brought a snack. By now, you
are ten miles from your car. . .
Whether you ski, jog, climb, paddle a canoe or just
enjoy a peaceful walk in the outdoors, you should be
aware of hypothermia. Knowing how to prevent and
treat both hypothermia and frostbite makes living in our
northern climate safer. In fact, it COULD save your
life.
Judith Banning
Since hypothermia strikes
quickly and is potentially
lethal, prevention is obviously
better than cure. Whether the
cause is cold (not necessarily
extreme cold, since problems
usually occur between and
10 C) wetness (including fog,
melting snow, immersion or
perspiration) or wind, the
typical victim is exhausted
and unprepared to protect
himself. Hypothermia may be
a threat in Spring, Summer or
Fall, not just Winter, so
persons engaging in outdoor
activities should always be
prepared for changing weather
conditions and be realistic
about their personal ability to
cope with the environment.
How NOT
to be a
victim
Prevention begins with
recognition of the subtleness
of cold:
Never overestimate your
strength or ability or that of
your companions.
Dress for changing
temperatures, wind and wet
by wearing peelable layers
which include underwear that
breathes, does not absorb
moisture and produces an
insulating layer of warm air; a
wool layer and a windproof
well- ventilated jacket .
Always carry an extra
garment and wear a hat.
Remember to carry
liquids and food, especially
carbohydrates and stop for
nourishment frequently, as
food is a vital source of heat.
If you feel fatigued, stop and
rest.
The first signs of
hypothermia usually include
shivering and slow or slurred
speech; you may recognize it
in yourself, perhaps by
noticing instances of sloppy
grammar. Loss of memory
and confusion may also be
noted; some victims become
very obstinate and insist that
the right direction to take is
really the opposite to the
obviously correct one. Often
at this point, the individual
cannot be dissuaded. Babbling
and euphoria are eventually
followed by stumbling and
loss of agility, then muscle
rigidity, loss of alertness and
eventually unconsciousness.
As soon as initial signs are
recognized, efforts must be
made to prevent further heat
loss and then to rewarm the
victim. The key is to start
treatment early before
coordination and judgment are
impaired.
Th Canadian Nurse
Fdhnmrv 19M1 31
In an area protected from
the wind, remove all wet
clothing and replace with dry.
Insulate the individual from
the ground as much as
possible using branches,
space blankets, sleeping bags,
etc. The most efficient method
of rewarming on the trail is to
place the victim nude in a
sleeping bag with one or two
rescuers, also nude. A
hypothermia victim alone in a
cold sleeping bag will not
generate enough heat to
rewarm himself. If no sleeping
bag is available, external heat
may be generated by the
rescuers huddling around the
victim. Isometric exercises
are invaluable at this time as
little energy is expended and
activity is maintained.
If the victim is conscious,
warm liquids and foods high in
carbohydrates are indicated.
However, alcohol should
never be consumed before or
during activities in cold or
variable weather conditions as
it causes peripheral
vasodilation, resulting in
cooling of greater quantities of
blood.
When hypothermia is
recognized, treatment must be
initiated immediately and on
the spot. Attempting to move
a hypothermic victim to a
treatment area, if there is a
chance that the hypothermia
will progress, is usually futile
and may end in tragedy.
Immersion hypothermia,
occurs much more quickly
and leaves little time for
intervention. If you find
yourself a victim of immersion
in cold water, do not remove
any layers of clothing, they
will provide insulation. Assess
the distance to shore before
deciding to swim: studies have
shown that an individual will
cool much faster swimming
than floating motionless. The
University of Victoria, in
studying immersion
hypothermia, reports a 1 C
drop in temperature for every
quarter mile the victim swims.
Since your priorities are to
remain afloat and to reduce
heat loss from chest and groin
areas, treading water is your
most efficient lifesaving
technique. If you have a
personal flotation device, hold
your arms tight to the sides of
the chest and your knees tight
together, then draw your legs
up towards your abdomen,
thus rolling yourself into a
ball.
When assisting with the
rescue of a victim of
immersion hypothermia,
follow the steps outlined
above: that is, remove wet
clothing (if have no dry
clothing available, wring out
wet and reapply especially if
wool) and prevent further
cooling. Since in this instance,
the temperature drops more
quickly, chances of caring for
a victim with a temperature as
low as 30 C or lower are
great. In these cases cardiac
instability must be respected.
Jostling when moving or
undressing must be avoided;
at this stage arrhythmias and
ventricular fibrillation cause
most of the fatalities. Even if
the victim is conscious, he
must remain inactive for 20
minutes to one hour after
rewarming is initiated, since
after a rescue core
temperature may drop up to
three degrees Centrigrade
with the "after drop"
phenomenon. This movement
of cold blood from the
extremities to the core and the
excitable myocardium is
increased with any activity.
All submersion victims,
even if conscious and alert
should be admitted to an
observation unit, as statistics
show 1 5 per cent of near
drowning victims who are
conscious at the time of
hospitaladmission die of
"delayed" drowning from
pulmonary and cerebral
causes.
Frostbite
Usually, frostbite is restricted
to the extremities of the body,
including hands, feet, nose
and ears, and exposed areas
such as cheeks and chin.
Sudden cessation of cold or
discomfort from a sensitive
area and perhaps a feeling of
warmth, often indicate the
beginnings of frostbite.
Treatment is determined by
the depth of tissue affected.
Superficial frostbite which
involves only the skin and the
tissues immediately below, is
recognized by sudden
blanching and then a white
waxy appearance. Usually the
area will appear frosty and
frozen on the exterior but
gentle pressure will reveal
softness and resilience of the
tissues below. This type of
frostbite can be treated
immediately by rewarming;
apply steady pressure (no
rubbing) with a warm hand,
tuck frostbitten fingers into
your axilla, or remove boots
and socks and rewarm toes
and heels by placing them on
the abdomen of a companion,
meanwhile protecting them
from the wind.
With rewarming, the area
will become numb, mottled
blue or purple and then will
begin to swell, sting and burn.
In more severe cases, blisters
will appear in one to two days
and will turn black as they dry
over the next two weeks.
Aching and burning may
persist for several weeks and
once swelling disappears, the
skin will peel.
Deep frostbite involves
the skin, subcutaneous tissue
and often extends deep into
the tissue to include the bone.
In these cases, the injured part
is hard and solid and cannot
be depressed.
Severe cases of frostbite
should not be rewarmed on
the trail. A strong individual
can walk a great distance
without inflicting further
injury to a frozen foot, but
once a frozen part is
rewarmed, refreezing may
occur very quickly. Weight
therefore should never be
placed on the rewarmed part
and an individual whose
frozen feet or toes are
rewarmed on the trail is
automatically reduced to a
"litter case" a situation
which may create a crisis for
the remainder of the group.
If a fracture or severe
sprain occurs in extreme cold,
the extremity beyond the
fracture is susceptible to
frostbite, especially if traction
is applied. Immobilize the
fracture with a well padded
splint, remove shoes or boots
from the foot below the injury
and wrap loosely in warm dry
clothing.
To rewarm an area with
deep frostbite, remove all
clothing from the affected part
and place in warm water (no
warmer than 44 C) or wrap in
towels and pour warm water
constantly over the area. Pain
will increase to a fairly high
level by the end of the
rewarming process; this will
be worse in individuals
suffering from circulatory
problems. If no water is
available, rewarm with warm
air, wrap loosely in warm
blankets or use contact with
warm human flesh (abdomen
or axilla) . Never rewarm by
exercising, as this will
increase the extent of the
injury. Never rub the injured
area at any point during the
process or afterwards. Never
rub the frozen area with snow
or thaw it in cold water, and
finally, discourage smoking or
consumption of alcohol.
After rewarming huge
blisters will develop over the
next three to seven days and
the injured area will be
blue-violet or grey in color.
Aching, throbbing and
shooting pains begin about
day two and persist for two to
eight weeks. Mobility of the
affected joints is further
hampered by swelling of the
entire extremity; this swelling
may last up to one month.
In these cases,
prevention of infection
becomes a priority. No
pressure should be exerted on
the rewarmed area; expose
the area as long as it is warm
or wrap in loose, soft, dry
dressings. Do not prick or
break blisters. Passive
physiotherapy is
32
February 1980
Tha Canadian Mur
contraindicated as the depth
of injury is usually difficult to
assess. However, the
individual should be
encouraged to move the
affected part when possible; a
whirlpool bath (37 C) is
sometimes helpful. Initially
the injured area should be
kept horizontal with the body,
changes in elevation may be
increased with recovery.
Prevention
If you want to avoid frostbite,
keep in mind the following
tips:
always dress properly for
outdoor activity
ensure an adequate
intake of food for heat
production
avoid tight-fitting
clothing
avoid dampness (wet
feet, perspiration, etc.)
wear mitts instead of
gloves
be careful when loading
cameras or handling metal
objects
carry extra socks, mitts,
etc. and wear two pairs of
socks
be aware of windchill
factors
do not smoke or consume
alcohol outdoors
remember that previously
frostbitten areas are extra
sensitive and subject to the
cold. *
Suggested reading
1 Bange, Cameron. Do s and don ts
of immediate treatment. RN 42:11:42-44,
Nov. 1979.
2 Baughman , Diane . The frozen
patient: handle with care. RN
42: 11:38-42, Nov. 1979.
3 *Kathrop, Theodore G.
Hypothermia: killer of the unprepared.
Mazamas, Oregon, 1975.
4 Nordic World Editors. Winter
safety handbook. Mountain View, CA,
World Pubns., 1975.
*Washburn, Bradford. Frostbite.
Boston, Boston Museum Science, 1975.
*Unable to verify in CNA Library
Hypothermia and the senior citizen
Fact or fancy: If you or your patient is over 65, you are more susceptible to
hypothermia than a younger person. (Answer: Fact)
For many years, public health nurses in Britain have been aware
of this problem and have taken steps to overcome it. Now, community
health nurses in Canada are faced with caseloads that include a
disproportionate number of elderly individuals subsisting on fixed
incomes, who have adopted a sedentary lifestyle, eat poorly, dress
inadequately and, for the most part, spend their time in quarters that
are not properly heated.
As nurses we are programmed to look for elevations in
temperature; all too frequently we ignore the implications of lower
temperature readings. Naturally the implications of hypothermia are
magnified when paired wit h disease entities such as diabetes or heart
trouble or with drugs such as anti-psychotics which may potentiate
hypothermia. It is all too easy, for example, for an elderly person to
slip on a bit of ice when he/she steps outside to get the mail or to forget
to close a door or a window.
What can we do? As nurses we must be aware of the signs of
hypothermia and act to identify persons-at-risk. We can suggest
increased layers of clothing, encourage daily exercise, ensure that
adequate food is available and that the individual is actually eating.
Remember, a lower thermostat setting means an extra sweater for
most of us. For the elderly it can spell danger, even death.
The Canadian Nurse
You re in hospital with what?
Maureen Steen
Psoriasis. It means different things to
different people: to the stand-up
comedian it is cause for reference to the
heartbreak of psoriasis , but to the
anguished and depressed hospitalized
psoriasis patient, it means loss of
self-esteem, loss of self-confidence
maybe even the loss of his job.
This year I found myself between
these two extremes, hospitalized for
three w.eeks treatment of widespread
psoriasis. The all-too-familiar red itchy
patches, plaque and endless scales had
been with me for years, but this year was
different. After an almost total clearing
of my skin in the summer, a sudden
flare-up did not respond to the usual
corticosteroid treatment. My thighs, anal
area and scalp were covered with thick
hard scales, and the guttae, or drop-like
lesions, covered the rest of me except for
my face.
I was, in short, a mess. My
dermatologist suggested hospitalization
for the standard treatment which I knew
was messy, uncomfortable and
time-consuming. How could I get away?
My job as a public health nurse had
become particularly demanding since I
had taken on the role of team leader; the
university course I was taking was a real
heavy one, and my busy household of
husband, three teenagers and a dog could
not do without me for three weeks.
Thanks, I said, but no thanks.
The Christmas that followed was
definitely not merry; shopping, baking
and mid-term exams left me drained.
After the holidays I saw my physician
who prescribed an antidepressant. This
was both good news and bad news my
mood elevated, my skin worsened. A
drug reaction is spotted a good deal
sooner in someone with clear skin. By
the time I stopped taking the
antidepressant I had good reason to be
depressed I was a swollen,
uncomfortable, itchy mass of psoriasis.
More tests showed that the fatigue and
nausea were not due to nerves, but to a
problem with liver function.
I was scared. I would go into
hospital I decided, but I was told it was
too late... all the dermatology beds were
full.
1 waited two months for a bed and in
the meantime dropped my university
course, and cut my family and social
obligations to a minimum. I still worked
my reasoning was that I would just
feel sorry for myself at home waiting,
and my doctors agreed but I was
performing at less than my usual
standard.
Finally, the call came to go to
hospital, and I learned I was to go on the
Goekerman regime. This treatment was
first used at the Mayo clinic 50 years ago
and is a conservative but messy
treatment of psoriasis. Basically, it
involves the use of coal tar ointments,
coal tar baths and exposure to ultraviolet
light. The tars are antipruretic and
antimitotic, but most of all they act to
increase the photosensitivity of the skin
so that the ultraviolet light can reach and
alter the affected cells.
My routine in hospital was as
follows:
7:00 A.M. Bath in special tar solution
and shampoo with tar.
8:00 A.M. Breakfast.
9:00 A.M. Physiotherapy for
ultraviolet treatment.
Stripped, 1 was baked for
increasing periods of time,
like a chicken on a barbeque
now front, sides, back.
First annointing with "the
goop" . This stuff is
incredible. My room smells
like railroad ties and I look
like a coal miner. It stains,
it smells, but it works!
Special potions and lotions
went on scalp and
peri-anal areas because
tars are contraindicated in
these areas where they
may burn the skin.
12:30 P.M. Lunch.
2:00 P.M. Reannoint with "goop" . It
is amazing how much of this
stuff wears off. Because of
this, sheets are not changed
daily for the psoriasis
patient. You sleep in your
blackened, greasy, scaly
envelope fora week. This
not only saves laundry but
every time you get into bed
more tar is rubbed in.
3:00 P.M. Nap.
4-6:00 P.M. Read, listen to radio or
contemplate black, greasy
navel.
6:00 P.M. Supper.
7:00 P.M. Visitors "Don t touch me
it stains!"
9-10:00 P.M. Last tar ointment of the
day. I put on my
ointments myself but the
nurses do me where 1
cannot reach. Believe
me, touch as a therapy
should not be
underestimated.
PSORIASIS the disease
Psoriasis is a chronic recurring skin disease
that manifests as papulosquamous lesions;
primary lesions form as papules, and the
remainder are covered in scales."
Approximately one to three per cent of the
general population is affected by psoriasis, but
reporting is inaccurate because minor cases
often do not seek treatment. Psoriasis occurs
more frequently in colder climates, and in the
winter months.
The cause is unknown. What happens is
that the DNA in the skin cells is somehow
programmed to increase the speed of the cell
cycle so that mitosis, or proliferation of cells,
occurs much more rapidly than usual. The
buildup of cells results in the extra skin or
scales that appear. Koeberization is the
process by which guttae-type psoriasis
seems to spread; an abnormal skin reaction
appears in areas of previously normal skin.
TREATMENT
The purpose is to alter the cell cycle to slow
proliferation; treatment may be systemic or
topical.
Topical
Steroids 6 mild : 1 % HCI
medium: Synalar, Betnovate
strong: Lidex, Halog
Anthra/in
Tars: coal tar ointment", Estarjel
Ultraviolet light alone
UV light with tar (Goekerman regime)
UV light with Arithralin (Ingram regime)
Systemic
steroids
Methotrexate this drug is a folic acid
antagonist which reduces the amount of DNA
available to epidermal cells; because it inhibits
cell growth it is commonly used to treat
malignancies, and is a powerful
immunosuppressant. The drug has many side
effects (see CPS) especially impaired liver
function, and is used only in patients with
severe psoriasis who are being monitored.
PUVA" Psoralen taken in conjunction
with UV light treatments. Methoxsalen. a
photosensitizer, is taken two hours before light
therapy, and helps to disrupt DNA replication.
Side effects include premature aging of the
skin and opthalmic problems.
*lt should be noted that in animal studies, coal
tar skin treatments have been found to be
carcinogenic; in human use however, the
benefits gained by tar treatments for psoriasis
patients are thought to outweigh the risk of
skin cancer. 9
When one s body image is such
that one is repulsed by his or her own
appearance, acceptance by another is
wonderful. There is little time for nurses
on any busy medical floor to stop and
chat, but I did appreciate the few times
anyone did.
Amazingly, I could see and feel real
progress; the slight sunburn from the
light was uncomfortable but never
actually painful.
There are many misconceptions
about psoriasis ; even some of my
colleagues were skeptical about the
length of my treatment, although, on the
whole, 1 found the hospital staff very
understanding. The most serious
misconception is that psoriasis is caused
by nerves . In a study done by Drs.
Sobel and Baughtom. 2 the role of stress
and emotional factors was demonstrated
to be not a casual one; however, the real
question that arose was, which comes
first, the disease or the stress? Yet
another study of some 5600 psoriasis
patients examined over a period of ten
years failed to identify a particular
psoriasis personality type. 3
This is not to say that the severity of
psoriasis does not vary with life stresses,
but that stress is only one of several
factors that serve to trigger the disease
process. Others include infections,
trauma, and drug reactions.
Day care facilities for psoriasis
treatments are becoming increasingly
popular. Various methods have been
employed but some medical researchers
emphasize the importance of group
therapy as part of the overall treatment. 4
Psoriasis remains an enigma
chronic, persistent and resistant to
treatment. Research has failed to
discover what causes psoriasis although
heredity seems to be important; while
new Pharmaceuticals and new methods
of treatment are being developed
psoriasis patients just have to learn to
live with their affliction. For the nurse, it
is important to be aware of the deep
psychological effects of this disease,
especially for teenage patients. A little
acceptance, support and understanding
can go a long way.
For myself, my hospital stay has
given me a reprieve, a temporary cure ;
I know that I have but to live one
itch-free day at a time.*
References
1 Farber, Eugene M. Hospital
treatment of psoriasis. A modified
anthralin program, by Eugene M. Farber
andD.R. Harris. Arch. Derm.
101:381-389, Apr. 1970.
2 Farber, Eugene M. Emotional
factors in psoriasis, recent findings, by
Eugene M. Farber and Alvin Cox. (In
International symposium, 2nd. Psoriasis:
proceedings. Eugene M. Farber and
Alvin Cox, eds. New York, Yorke
Medical Books, 1977.) p. 180-188.
3 Farber. Eugene M. The natural
history of psoriasis in 5, 600 patients, by
Eugene M. Farber et al.Dermatologica
148:1-18, 1974.
4 Cram, D.L. Psoriasis day care
centres, by D.L. Cram and R.J. King.
JAMA 235:2: 177-178, Jan. 12, 1976.
5 Loose Leaf Reference Services.
Clinical dermatology. Joseph D. Demis
et al, eds. New York, Harper Row, 1974.
Vol. 1, Unit 1-2, p. 1-4.
6 MacKenzie, A. W. Topical
therapy, by A. W. MacKenzie andD.S.
Wilkinson. (In Rook, Arthur. Recent
advances in dermatology, no. 4. New
York, Churchill Livingstone, 1977.)
7 Roenich, Henry H. Methotrexate,
where are we today? (In International
symposium on psoriasis, Stanford
University, 1971. Psoriasis: proceedings.
Eugene M. Farber and Alvin Cox, eds.
Stanford, CA, Stanford Univ. Press,
1971.)
8 Van Scott, Eugene. Therapy of
psoriasis, 1975. JAMA 235:2:197-198,
Jan. 12, 1976.
9 Ibid.
Bibliography
1 *Br.J.Dermatol. 70:139-145, 1958.
2 Goodwin, P. The cell cycle in
psoriasis, by P. Goodwin et al.
BrJ.DermatoL 90:517-524, May 1974.
3 Manicelli, Mario. Koebner
reaction in psoriasis. (In International
symposium on psoriasis, Stanford
University, 1971. Psoriasis: proceedings.
Eugene M. Farber and Alvin Cox, eds.
Stanford, CA, Stanford Univ. Press,
1971.)
4 Miller, Benjamin F .Encyclopedia
and dictionary of medicine and nursing,
by Benjamin F. Miller and Claire B.
Keane. Toronto, Saunders, 1972.
5 Moschella, Samuel. Dermatology,
by Samuel Moschellaet al. Isted.
Toronto, Saunders, 1975. Vol. 1., p.424.
*Unable to verify in CNA Library
Maureen Stetn,RN, is a graduate of the
St. Joseph s School of Nursing, Hotel
Dieu Hospital, Kingston, Ontario; she
has a diploma in public health nursing
from the University of Ottawa, a
diploma in Family Life Education from
Algonquin College, and is currently
completing a B.A. degree in psychology
atCarleton University. Steen has
worked for the past nine years as a PHN
with the Ottawa-Carleton Regional
Health Unit.
Acknowledgement: The author gratefully
acknowledges the assistance of the staff
of the Dr. G.S. Williamson Medical
Library, Ottawa Civic Hospital and Dr.
Nancy Mayer of Ottawa, in the
preparation of this article.
ran?;
./the selective alternative for
psoriasis patients
Margaret Burns
R.K.Schachter
The Psoriasis Education and Research
Centre located in Toronto is a unique
facility in Canada. It was developed
expressly for the purpose of education,
research and the treatment of patients
with psoriasis. Affiliated with the
Women s College Hospital and the
University of Toronto, under the
direction ofDr. R.K. Schachter, the
center is staffed by a nurse-coordinator,
2 RNA s, a secretary, a medical
photographer and research personnel as
well as a staff dermatologist.
The center (PERC) is a day hospital
which operates from Monday to Friday
in two shifts : 0800 to 1600 hours, and
1 300 to 2 1 00 hours . This arrangement
allows patients to continue with their
regular work, family and social patterns
as much as possible . The center has been
able to treat the average patient for
approximately one-third of the cost of
inpatient hospitalization.
Along with the program of active
treatment, the staff at PERC has
organized a three-part education
program for patients.
Treatment
Any patient who attends the center must
be referred by a dermatologist or family
doctor; everyone referred is assessed
initially by the staff dermatologist and a
decision is made about treatment at that
time. There are two types of psoriasis
that cannot be treated in a day hospital
erythroderma and generalized pustular
psoriasis.
The patients treatment regimen is
for three weeks duration and they may
attend either the morning or the
afternoon session, whichever is most
convenient for them.
A typical routine includes: tar bath,
tar shampoo, ultraviolet light,
application of medications and an
education session. After a lunch break,
medications are re-applied, followed by a
relaxation hour and then removal of
medication, tar bath and tar shampoo.
During the three weeks, the patients
are seen regularly by the dermatologist
who assesses their progress and looks
after any treatment problems.
Education
A unique facet of PERC is the
individualized education program, the
goal of which is to help patients learn
about psoriasis, self-care and means of
coping with stress. In a large center like
Toronto, our patients come from a wide
range of backgrounds, and we try to
tailor each patient s program to his or her
individual requirements.
To do this, the nurses use a detailed
history and interview form to aid in
assessing the patients knowledge of the
condition, and how well each person has
been coping with his diagnosis. By
analyzing the information, t is possible
to outline each patient s specific
educational needs. Basically the program
consists of discussion in several areas.
The pathophysiology of psoriasis is
explained, along with factors that may
aggravate the condition, and an overview
of present-day therapy. A pharmacist
gives a session on both the prescription
and proprietary (over-the-counter) drugs
that are used in psoriasis treatment,
discussing drug action and possible side
effects. Instruction is given regarding
proper use of the drugs most commonly
used.
A yoga class is held weekly to
provide patients with a means to relax.
A dermatologist conducts an
informal question and answer session,
which gives the patients an opportunity
to ask a doctor any questions about
psoriasis that may occur to them during
their treatment. Small informal groups
are organized periodically throughout
the treatment schedule, led by the
nurses, which aim to increase the
patients independence and ability to
care for themselves at home. Good
general health promotion is stressed, and
community resources available to the
patients are discussed, along with any
subjects that may come up.
A physiotherapy session
demonstrates exercises that can be used
as part of a program for good general
health, and an occupational therapist
sees patients individually about lifestyle
activities.
An important part of the group
sessions is discussion of the role stress
plays in each individual s home, work
and social life, and patients are
encouraged to discuss openly the
problems they encounter because of
their psoriasis. Commonly discussed is
the sense of frustration many patients
feel as well as embarrassment, due in
part to the fact that the general public has
been poorly educated about this chronic
skin disease.
Family members are included in the
educational sessions and they are shown
how to apply the medications.
Research
The nurses at PERC assist in the ongoing
research by aiding in the collection of
data and participating in the clinical trials
evaluating effectiveness of new drugs
and modes of treatment. Research
meetings are held regularly to discuss
research and the plans for future
projects.
More than skin deep
Work at the Psoriasis Centre is
very satisfying and rewarding for the
nursing staff; looking after patients
physical and emotional needs is a very
challenging experience. When patients
are admitted we see how low their
self-esteem is, and how they need
support and encouragement. It is our job
to gain their confidence in three short
weeks and to watch them as their
outlook on life and their self-image
changes, for the better. <>
Acknowledgement: The authors wish to
acknowledge the help of Liz Rosenberg,
research co-ordinator, Glynis Sheppard,
librarian and Peter Moore for his
illustrations.
Thanks go to the Atkinson
Foundation, National Health and
Welfare, and Women s College Hospital
for financial assistance to the Centre.
Bibliography
1 Baughman. Richard. Psoriasis,
stress and strain, by Rkhard Baughman
and R. Sobe\.Arch.Dermatol.
1 03: 599-605, Jun. 1971.
2 Hodge, L.D. Psoriasis: current
concepts in management, by L.D.
HodgeandJ.SCamaish. Drugs
13:4:288-2%, Apr. 1977.
3 Holgate, M.C.The age-of-onset of
psoriasis and the relationship to parental
psoriasis. Br.J.Dermatol. 92:4:443-448,
Apr. 1975.
4 Moschella, Samuel. Dermatology,
by Samuel Moschellaet al. Isted.
Toronto. Saunders, 1975. 2 vols.
Seville, R.H. Psoriasis and stress.
II. Br J.Dermatol. 98:2: 151-153, Feb.
1978.
A RACE AGAINST TIME
caring fora patient with
How do nurses cope with a patient who just gets worse in spite of everything that s done? A group of nurses in Moose
Factory found they had no choice but to organize themselves to give the best possible care to their patient, to give as
much of themselves as possible, and to hope.
Nursing in a small northern Ontario
hospital means caring forCree Indian
and Inuit patients whose culture,
lifestyle and language are foreign to
nurses educated in southern Canada.
Because of the distance from large urban
centers, most of the medical and nursing
staff is generally in Moose Factory on a
short term basis, but this does not
prevent the formation of close bonds
between staff and patients, resulting in a
greater understanding of the culture of
northern peoples. Such was the case
with Mrs. K.
Mrs. K., a56-year-oldCree Indian,
was admitted to hospital in the Fall with
a diagnosis of abdominal pain and
pneumonia. She appeared pale, thin, and
in considerable discomfort, finding
difficulty even in walking.
We knew from previous admissions
to our surgical unit that Mrs. K. had been
an insulin-controlled diabetic for 20
years, that she had a history of
congestive heart failure and vascular
insufficiency which had resulted in a
below-the-knee amputation, and that she
had received a full course of radiation
more than two years ago for Stage II
carcinoma of the cervix.
Just prior to admission, Mrs. K. had
been living at home caring for her family
and her aged ill mother; she had been in a
great deal of pain, receiving analgesia
parenterally on visits from her physician,
while her condition worsened.
At first, we assumed Mrs. K. was a
terminally ill cancer patient and prepared
to support her towards a peaceful and
dignified death, but this was not to be the
case. Mrs. K. s symptoms, which
included a low grade fever, elevated
WBC, nausea, vomiting and abdominal
pain, necessitated a small bowel x-ray
series which revealed a bowel
obstruction requiring surgical treatment.
Roberta Ronayne
Photo courtesy of Health and Welfare Canada
SURGICAL PROCEDURE NO. ONE
During Mrs. K. s first surgical procedure
2 1/2 feet of small bowel were removed
because of an obstruction due to the
effects of radiation enteritis: adhesions
between the omentum and the bowel as
well as necrosis were found at the
junction of the ileum and jejunum. The
remainder of the bowel showed some
effects of radiation, along with an
inflamed peritoneum and a distended
gallbladder. There was, however, no
evidence of pelvic metastesis.
Following major surgery, Mrs. K.
required intensive nursing care. We
organized our priorities into the
following headings:
nutrition and fluid balance
relief of pain
psychological support
infection control.
Nutritional fluid balance
When Mrs. K. had first been admitted to
hospital she was on a regular diet, able to
choose foods she liked to eat; her
diabetes was controlled by daily
injections of Lente insulin.
Post-operatively, Mrs. K. was on
intravenous therapy with naso-gastric
drainage and her Lente insulin was
discontinued, replaced by p.r.n. doses of
Regular insulin, to be given according to
doctor s orders after urine testing.
Monitoring Mrs. K. s electrolyte
balance was a medical priority, and
unfortunately at this time, our laboratory
machinery was malfunctioning. Blood
samples for chemistry had to be sent to
another hospital on a
regularly-scheduled airplane flight, and
the results were phoned back to us the
same day. Although inconvenient, this
was effective until our equipment was
repaired.
Based on the electrolyte results, the
doctors ordered potassium supplements
for Mrs. K. s I.V. solutions; she did not
do well however, and developed
post-operative diarrhea (due to
prolonged antibiotic therapy), nausea
and vomiting. The doctors treated her
with anti-emetics, but Mrs. K. lost
weight rapidly, until she had lost a total
of 16.2 kg in five weeks.
Pain relief
Mrs. K. had been living with pain fora
long time, but after surgery her need for
analgesia increased. The nurses were
alert to non-verbal signs of the need for
medication in the patient s behavior such
as rubbing her abdomen and guarding, as
well as more obvious signs such as
moaning. As the need for relief of pain
increased further, recognizing the
patient s need became less of a problem
than locating sites for injection. Mrs. K.
was already receiving anti-emetics
intramuscularly, and injections of insulin
subcutaneously, and with her muscle
wasting and peripheral vascular disease,
the choice of sites was limited. There
was the question too of the degree of
absorption of medication; within a few
weeks, the patient was started on
intravenous analgesia.
Noting the exact location and
severity of Mrs. K. s pain was of great
importance post-operatively, as it
became obvious after her first surgery
that she had developed more problems.
Infection control
With a history of diabetes and
pneumonia, the prevention of infection
was an important priority in nursing
care. On admission we had instituted a
routine of chest physiotherapy to be
done q4h which was primarily deep
breathing and coughing, and use of an
inspirometer. Post-operatively, she was
treated with intravenous broad-spectrum
antibiotics.
Pre-operative infection control
measures used on our unit are the
standard PhisoHex & baths twice daily for
48 hours pre-op and washing hair the
night before surgery.
At the time of surgery, Mrs. K. s
WBC had fallen to within normal limits,
and remained so for several weeks
post-operatively. Wound cultures taken
in theO.R. were negative, as were
subsequent cultures of drainage during
the early post-operative period.
Psychological support
During "freeze-up" when boats can no
longer be used, Mrs. K. was isolated
from her family as the ice was not safe to
carry motorized vehicles to our island
hospital. Once the ice had frozen solid,
however. Mrs. K. s daughters arrived
and stayed in constant attendance for the
entire period of her hospitalization.
Language differences posed
problems for the nursing staff in that
none but the ward aides and secretaries
on the unit spoke Cree. Mrs. K. did
speak and understand some English, but
to ensure accurate transfer of
information we often used an interpreter.
Mrs. K. offered little spontaneous
communication, however, and she
seldom complained of anything not
the pain she had constantly, nor the
nausea nor the diarrhea. Even when we
knew she was in pain and asked about it.
she would not answer "yes", so it
became a challenge to anticipate her
needs.
We tried to keep her and her family
informed about her progress, and to
prepare her for the various tests and
procedures.
A grand-daughter was hospitalized
for a time and we ensured family contact
by wheeling Mrs. K. out to the ward
phone as often as she desired it.
We encouraged independence too
by gradually giving her more
responsibility in her own care bathing,
feeding and putting on her leg prosthesis.
SURGICAL PROCEDURE NO. TWO
It became increasingly obvious in the
post-operative period that Mrs. K. was
not improving: her abdominal pain was
worsening, her nausea and vomiting
persisted, she exhibited abdominal
distention, and her wound issued
purulent drainage. A fluid diet was
started but was not tolerated. She was
scheduled for a second laparotomy in
which another 2 1/2 feet of bowel was
resected. The bowel showed ischemic
necrosis of the jejunum as a result of
vascular occlusion in the terminal
portion of the superior mesenteric
artery. A cholecystectomy was
performed at this time as the
inflammation and distention seen in the
gallbladder in the first surgery had not
improved.
After surgery Mrs. K. required
constant nursing care, which meant
since our ward staff was comprised of 4
RN s, 1 RN A and several aides totally
readjusting the time schedule to provide
adequate care. As it happened, several of
the nurses were anxious to see that
constant quality care was provided, and
so worked double shifts or extra hours.
Medical priorities at this time were
the prevention of further vascular
occlusion through heparin therapy, low
doses parenterally q!2h. and
maintenance of a good nutritional state
through Total Parenteral Nutrition
(TPN) or hyperalimentation. consisting
of lOpercentTravesol and Intralipid
solutions. This was to be given Mrs. K.
intravenously through catheter inserted
in an antecubital cutdown site.
For the nursing staff who were
unfamiliar with such things as
hyperalimentation and the mixing of the
special solutions, this was a time of great
anxiety. We had to arrange therefore a
special inservice program to deal with
the basics of TPN and the nursing care
involved. In order to ensure adequate
flow rates of the intravenous infusion,
infusion pumps were used, and the use of
these mechanisms had also to be taught
to the nurses.
We had the same basic priorities in
organizing Mrs. K. s nursing care, but
due to the seriousness of her condition at
this time, tasks were more complex than
before.
Nutrition and fluid balance
Oral intake was obviously impossible
and so Mrs. K. was on total parenteral
nutrition; she also had a straight
intravenous line for antibiotic therapy.
Both were aided by the use of infusion
pumps. Nursing responsibilities at this
time included maintenance of flow rates
and mixing of the I.V. solutions. Of no
small importance too was the charting of
intake and output, monitoring of tube
drainage, results of urine testing, and
laboratory results such as Hgb,
electrolytes, BUN and glucose levels.
Infection control
Due to Mrs. K. s debilitated condition
and diabetes, infection was an
ever-looming problem. The patient was
maintained on strict isolation of
dressings and bedlinens, and her wound
dressings which were changed nearly
q2h.
Psychological support
As her condition worsened and her pain
increased. Mrs. K. became convinced
she would never recover. She asked to
receive the last rites of the Catholic
church, which we arranged, and she was
permitted to have her family nearby as
much as possible.
It was a difficult time for the nurses:
they cared very much for their patient,
and yet they had to cope with continually
changing doctor s orders, and the
evidence that Mrs. K. was in fact not
improving. It was difficult for them to
adopt a supportive positive attitude with
Mrs. K. and her family when it was
apparent to all that her wound was not
healing, that her nutritional status
remained poor, and that she could not
get full relief from her pain.
The situation became still worse
when, 48 hours after surgery, the doctors
decided she must return to the O.R. for
yet a third time for surgical debridement
of an infected wound; the wound swabs
had shown the presence of clostridium
perfringens, pseudomonas and E. Coli.
The surgeon was available at our hospital
in Moose Factory only two or three days
a week, and to attend to Mrs. K. the
hospital had to arrange for a chartered
plane to bring him from his home base.
The doctors agreed that Mrs. K. would
be better in a hospital in the South, under
the circumstances, and planned a
transfer for her post-operati vely .
FINAL SURGICAL PROCEDURE
Pre-operatively, we notified Mrs. K. s
family, and the priest; the doctors
explained to Mrs. K. with her family
both the necessity and the risks of the
proposed surgery. The nurses wanted to
offer as much support as possible; we
were able to arrange a room for the
family to sleep in until after the
operation.
The final surgery involved
debridement of the wound and further
bowel resection necessitating an
ileostomy, and Mrs. K. returned to the
unit with numerous drainage tubes
N/G, Foley catheter, duodenostomy and
multiple abdominal drains as well as a
subclavian intravenous line. She was
also on oxygen by mask.
Our priorities were as before: to
prevent infection by maintenance of
strict isolation technique (which was
difficult to accomplish while allowing her
family liberal visiting privileges, and with
the large numbers of medical and nursing
staff in attendance), good skin care,
relief from pain, nutrition and emotional
support.
The next development was
disheartening: Mrs. K. had a myocardial
infarction post-operatively and went into
congestive heart failure. In spite of the
obvious negative aspect of this
development, Mrs. K. was actually
pleased because it meant her condition
was too serious to allow her to be
transferred to a hospital in southern
Ontario as the doctors wished; the family
unit in Cree culture is often very close,
and Mrs. K. did not want to leave those
who were closest to her.
Psychologically, she was prepared to
die, and fought the sedatives and
analgesia to remain alert. She rejected
our constant care, saying that we were
"waiting for her to die".
And it was true, Mrs. K. s prognosis
was grave; her white count rose to over
40,000/cu mm, her congestive heart
failure worsened, and she developed
frequent paroxysmal ventricular
contractions and had diminished
response to stimuli.
Seven weeks after her admission she
died.
For the nursing staff, her death,
though inevitable, was a great
disappointment; they had come to know
Mrs. K. and her family so well, and had
learned a great deal about the Cree
people and their culture. We all felt we
had participated actively, giving as much
as we could, to help Mrs. K. in her battle
against the insurmountable odds of
diabetes, heart disease and radiation
enteritis.*
RADIATION THERAPY
The goal of radiation therapy is to destroy malignant cells without unduly harming the
surrounding tissues.
Adverse reactions are influenced by:
intensity of prescribed dose and degree of exposure : exposure to greater amounts of
radiation may cause necrosis of intestine, malabsorption, intestinal obstruction and
neoplasia.
radiosensitivity of cells: most radiosensitive cells are
a) rapidly dividing
b) poorly differentiated, embryonic, immature
c) have increased metabolic activity.
individual differences: the rate of injury increases in the presence of pre-existing
vascular disease, diabetes mellitus, arteriosclerosis, hypertension or existence of past
injury to the intestinal tract.
Specific G.I. effects of radiation:
jejunal and ileal injuries are evidenced by crampy periumbilical pain, nausea,
vomiting, abdominal distention and obstipation;
pathological lesions are usually ulcers which may bleed, perforate and stenose.
Symptoms are malabsorption, acute and chronic obstruction, abdominal pain.
Bibliography
1 American Hospital Association.
Committee on Infections within
Hospitals. Infection Control in the
Hospital. 3d ed., Chicago, 111. 1974.
2 Luckmann, Joan. Medical-surgical
nursing: a psychophysiologic approach,
by Joan Luckmann and Karen C.
Sorenson. Toronto, Saunders, 1974.
3 Meakins, J.L. Pathophysiologic
determinants and prediction of sepsis.
Surg. Clin. North Amer. 56:4:847-857,
Aug. 1976.
4 Sabiston, D.C. David-Christopher
textbook of surgery. Vol.1. lOthed.
Toronto, Saunders. 1972.
5 Schmitz, R.L. Intestinal injuries
incidental to irradiation of carcinoma of
the cervix of the uterus, by R.L. Schmitz
et al. Surg.Gynecol.Obstet. 138:29-32,
Jan. 1974.
At the time this article was written
Roberta Ronayne,/?/V, BScN, was head
nurse on the surgical unit at the Moose
Factory General Hospital. She is a
graduate of the Ottawa Civic Hospital
and the University of Ottawa; she has
returned to Ottawa and now teaches
nursing.
Acknowledgment: The author would like
to thank Dr. D. Allan/or his assistance in
the preparation of this article.
TK* r~j-i*rtln I
Antidiuretic Hormone and its
Inappropriate Secretion
Optic
Chiasm
Pituitary
Hypothalamus
LOCATION OF PITUITARY GLAND
Mr. Fisher was admitted to the neurological unit with a diagnosis of head
injury; he is irritable and complaining of a headache. Mrs. King had major
abdominal surgery three days ago; she is lethargic and anorexic. These two
apparently normal reactions to two obviously different causes are, in effect,
responses to the Syndrome of Inappropriate Antidiuretic Hormone
Secretion.
Long thought of as a hormonal imbalance that only concerned
neurological personnel, this syndrome is now being recognized as playing a
very important role in many other conditions. Malignancies, especially
involving the lungs, anesthetics, stress and pain have all been associated
with an overproduction of this hormone.
Muriel Burry Lydia Martens
Antidiuretic hormone (vasopressin)
regulates the body s fluid balance by
altering the permeability of the renal
tubules and affecting water reabsorption
rates. This hormone, which is made up of
eight amino acids, is synthesized in the
supraoptic nuclei of the hypothalamus
(See figure one). It is then transported
through the hypophysial stalk to the
posterior lobe of the pituitary gland
where it is stored and eventually
released.
Osmoreceptors located in the
hypothalamus control the synthesis and
release of antidiuretic hormone (ADH).
These receptors, which are sensitive to
the concentration of the plasma are
assured an excellent blood supply by the
hypothalamic artery which arises from
the Circle of Willis. Thus, each minute
change in osmolality is readily available
to the osmoreceptors. (Osmolality is the
measurement of the solute concentration
per liter of solution.)
The normal stimulus for the
production of ADH is an increase in
plasma osmolality, such as in
dehydration. The osmoreceptors
stimulate the supraoptic nuclei to
increase synthesis of the hormone and to
transmit impulses to the posterior
pituitary to release appropriate amounts
of ADH. The hormone enters the general
circulation by way of the inferior
hypophysial vein and is carried to the
kidneys where its potency is realized.
In the distal convoluted tubules of
the kidneys, ADH increases the tubules
permeability to water, allowing a greater
reabsorption to take place, thus diluting
body fluids. With this dilution, plasma
osmolality is decreased and
osmoreceptors signal the hypothalamus
to reduce the production and release of
ADH.
ADH levels are also influenced by
baroreceptors in the left atrium of the
heart which respond to changes in blood
pressure. In the event of hypovolemia,
ADH secretion is increased and body
fluids conserved through the increased
reabsorption of water. Baroreceptor
response may also be influenced by
one s position; an unconscious patient
being nursed supine tends to have high
serum levels of ADH because of
inadequate atrial filling. This same
stimulation may also occur when
positive pressure breathing is being used
and conversely ADH levels may
decrease with negative pressure
ventilation.
Syndrome of Inappropriate Antidiuretic
Hormone Secretion
Although ADH is normally secreted in
response to stimulation by plasma
osmolality there are times when there is
an excess produced without this
stimulus. This pathophysiological state is
termed Syndrome of Inappropriate ADH
(S.I.A.D.H.).
Causes are both intracranial and
extracranial, ranging from neurological
disorders that produce cerebral edema,
to malignant diseases, particularly of the
lung if the tumor secretes a substance
similar to ADH , and to pharmaceutical
agents such as anesthetics, morphine and
chlorpropamide (Diabinese). Because
of the wide variety of causes , the
syndrome is not always recognized until
it is fairly well advanced.
Since S.I.A.D.H. occurs when the
serum osmolality is normal (280-295
mOsm/kg), the increase in ADH which
stimulates an increase in the amount of
circulating body fluid results in a relative
hyponatraemia (normal serum sodium is
135-145 mEq/1) and a reduction in urine
volume, as low as 400 ml/day . This
phenomenon is commonly termed "salt
wasting" as the body responds to the
increased blood volume by reabsorbing
less sodium through the renal tubules.
Diagnosis
The diagnosis of S.I.A.D.H. rests on the
combination of a low serum sodium and
osmolality with a high urine sodium
(normal is 27-287 mEq/24 hr) and a urine
osmolality greater than that of the serum.
This relationship must exist in the
presence of a normal blood urea nitrogen
and creatinine.
Mild hyponatraemia (120 mEq/1)
causes lethargy, irritability, anorexia and
headache. If this is not corrected, the
hyponatraemia becomes severe (110
mEq/1) and nausea, vomiting and
confusion may lead to convulsions, coma
and death. Cardiac fibrillation becomes a
very real threat .
Treatment
Fluid restriction, the principal treatment
of this syndrome, usually corrects the
hyponatraemia within seven days.
However, as fluids are given only to
make up insensible fluid loss, a restricted
intake of 500-800 mis/24 hrs is distressing
to the patient and family who may not
fully comprehend the reasons for the
regime. Chronic conditions of
S.I.A.D.H. such as inoperable
malignancy of the lung, magnify these
problems.
Two drugs have been used to relieve
the necessity of fluid restriction. Lithium
Carbonate, an anti-manic medication,
has a side effect of producing a
nephrogenic diabetes insipidus.This
drug seems to interfere with the ADH in
the distal tubules , causing a water loss
and a sodium retention secondary to
increased aldosterone. The
recommended dosage is 900 mg/24 hrs in
divided doses. However, many
sometimes harmful side effects may be
experienced, such as digestive upsets,
cardiac arrhythmias, peripheral
circulatory collapse, diffuse thyroid
enlargement and central nervous system
irritation including dizziness, drowsiness
and seizures. Lithium is considered to be
effective only on a short term basis as
with prolonged use it seems to interfere
with the action of aldosterone, resulting
in further sodium loss. Consequently it is
not useful in the treatment of chronic
S.I.A.D.H.
Demethylchlortetracycline
(demeclocycline) 300 mg, four times
daily, has been reported to cause a
reversible decrease in renal urinary
concentrating ability and thus increases
water excretion and resolves the
hyponatraemia, again producing a
nephrogenic diabetes insipidus.
Effectiveness of demeclocycline is noted
only after several days of treatment, but
few side effects, such as nausea and
photosensitivity, are produced. As a
result, it is used most frequently with
chronic S.I.A.D.H.
If hyponatraemia is so pronounced
that the central nervous system is
affected, an initial treatment of
intravenous hypertonic saline may be
given in an attempt to reduce cellular
swelling which could cause irreversible
cerebral damage. Usually, 500 mis of five
percent sodium chloride is given. The
rate should not exceed 75 mis/hour and
50 to 60 mis/hour is considered optimum.
As the plasma volume is increased, the
proximal tubules of the kidney excrete
the sodium so that there is no long term
effect to be derived from this method of
treatment. Lasix (furosemide) may also
be given at this time to induce a rapid
diuresis.
Nursing responsibilities
Monitoring of fluid balance: Intake,
output and specific gravity of urine
should be measured for all patients with
cranial disorders in order to detect this
syndrome in its early stages.
Once adiagnosis of S.I.A.D.H. has
been made, fluid restriction assumes
ultimate importance. Fluids should be
allocated throughout the twenty-four
hours, taking into account medication
regimes; giving pills with meals allows
fluid rations to be more flexible. Good
mouth care and frequent mouthwashes
help to alleviate thirst but confused
patients must be observed carefully as
they may swallow the mouthwash
solution.
While body fluids are being
retained, urine volume and specific
gravity are essential measurements; the
specific gravity will be high ( 1 .025) and
volume low. Fluid retention is also
indicated by daily weight gains that are
out of proportion with caloric and fluid
intake. Although restless head-injured
patients present problems with daily
weighing, this measurement is essential
to determine if changes in cerebral
function are being caused by the disease
or injury or by an electrolyte imbalance.
Collection of specimens: Serum and
urinary electrolyte and osmolality
measurements must be taken on a daily
basis. The diagnosis is determined from
these levels and the response to
treatment is monitored in the same way.
Collection of specimens, recording of
results, awareness of normal values and
significance of variations are all nursing
responsibilities.
Administration of medications:
Intravenous hypertonic saline with or
without Lasix may be ordered at the
critical stage of fluid retention to prevent
cerebral damage. Once an initial diuresis
has been achieved, treatment may be
continued with lithium or
demeclocycline. If lithium is used, serum
lithium levels should be checked daily,
usually before the morning dosage is
administered. If the level exceeds 1.5
mEq/1, the physician should be notified
before continuing therapy. Mood
changes, dizziness, headache and other
CNS complaints usually indicate
impending toxicity. While methyldopa
administration during lithium therapy
predisposes the individual to lithium
toxicity, aminophylline and
acetazolamide decrease its effectiveness.
Lithium excretion can be promoted with
an adequate fluid and salt intake, and
gastrointestinal symptoms may be
minimized by administering the
medication at mealtimes.
The Canadian Nun*
Optic
Chiasrn
Supra Optic Nuclei
Of
Hypothalamus
Inf. Hypophysial
Vein
Figure one: PITUITARY GLAND
Demeclocycline, a tetrocycline
antibiotic, must be administered no less
than one hour before nor sooner than
two hours after meals. Its absorption
may also be impaired by milk and other
calcium containing foods. Chronic
sufferers of S.l.A.D.H. using long term
demeclocycline therapy should be
advised to avoid exposure to sunlight or
ultraviolet light to prevent severe burns.
Education of patient and family:
Understanding the reasons for fluid
restriction is of ultimate importance for
patient and family compliance with
therapy. Cooperation of some
neurological patients is not a problem as
awareness of thirst is very low with a
depressed level of consciousness.
However, with other neurological
patients the opposite may be true, a lack
of concentration and a poor memory
demand frequent repetition of
instructions. For these patients, family
teaching is of prime importance;
relatives and friends find it difficult to
accept that it is not necessarily good to
give someone a drink when it is
requested. Both patient and relatives can
usually be assured that this is only a
temporary restriction.
Summary
Neurological nurses are generally aware
of S.l.A.D.H. syndrome as it is a
commonly recognized complication of
many neurological disorders. However,
since the causes of the inappropriate
secretion may be so diverse, nurses in all
fields must be aware of its possibility and
be able to recognize the signs and
symptoms at their onset, thereby
preventing the complications and
distress of hyponatraemia.
As it is difficult and sometimes
impossible to differentiate between
lethargy and confusion caused by the
disease entity and that caused by
inappropriate secretion of ADH, the
careful monitoring of electrolyte values,
daily weights and intake and output
records of all patients should become an
established regime. *
Bibliography
1 *American Association of
Neurosurgical Nurses. Core curriculum.
Maryland, 1977.
2 Auger, R.G. Position effect on
antidiuretic hormone blood levels in
bedfast patients, by R.G. Auger et al.
Arch.Neurol. 23:513-517, Dec. 1970.
3 *Bartter, F.C. The syndrome of
inappropriate secretion of antidiuretic
hormone, by F.C. Bartterand W.B.
Schwartz. AmJ.M, 42:790-806. May
1967.
4 Canadian Pharmaceutical
Association. Compendium of
Pharmaceuticals and specialties, 1979.
1 4th ed. Toronto, 1979.
5 Cherrill.D. A. Demeclocycline
treatment in the syndrome of
inappropriate antidiuretic hormone
secretion, by D.A. Cherrill et al.
Ann.Intern.Med. 83:5:654-656, Nov.
1975.
6 DeTroyer. A. Demeclocycline.
Treatment for syndrome of inappropriate
antidiuretic hormone secretion. JA MA
237:25:2723-2726, Jun. 20, 1977.
.Correction of antidiuresis by
demeclocycline , by A . De Trouer and J .
Demonet.NewEng.J. Med.
293: 18:9 15-9 18, Oct. 30, 1975.
8 Dila, C.J. Cerebral water and
electrolytes. An experimental model of
inappropriate secretion of antidiuretic
hormone, by C.J. Dila and H.M.
Pappius./lrr/i./WMro/. 26:85-90, Jan.
1972.
9 Fox, J.L. Neurosurgical
hyponatraemia: the role of inappropriate
antidiuresis, by J.L. Foxetal.
J.Neitrosurg. 34:506-514, Apr. 1971.
10 Graze, K. Chronic
demeclocycline therapy in the syndrome
of inappropriate A.D.H. secretion due to
brain tumour, by K. Graze et al.
J.Neurosurg. 47:6:933-936, Dec. 1977.
11 Hantman, D. Rapid correction of
hyponatremia in the syndrome of
inappropriate secretion of antidiuretic
hormone. An alternative treatment to
hypertonic saline, by D. Hantman et al.
Ann.Intern.Med. 78:870-875, Jun. 1973.
12 Kuchel, O. Inappropriate
response to upright posture: a
precipitating factor in the pathogenesis
of idiopathic edema, by O. Kuchel et al.
Ann.Intern.Med. 73:245-252, Aug. 1970.
13 Martin, Joseph B. Clinical
neuroendocrinology, by Joseph Martin
et al. Philadelphia, F.A. Davis, 1977.
(Contemporary neurology series, v.14)
14 Netter, F. The Ciba collection of
medical illustrations. Vol. 1. 1 he
nervous system. Summit, N.J., Ciba
Pharmaceutical, 1975.
15 Rymer, M.M. Protective
adaptation of the brain to water
intoxication, by M.M. Rymer and R.A.
Fishman. Arch.Neurol. 28:49-54, Jan.
1973.
16 Vander. Arthur J. Human
physiology: the mechanisms of body-
functions, by Arthur J. Vander et al.
Toronto, McGraw Hill, c!970.
17 White, M.G. Treatment of the
syndrome of inappropriate secretion of
antidiuretic hormone with lithium
carbonate, by M.G. White and C.D.
Fetner.NewEngJ.Med. 292:8:390-392,
Feb. 20, 1975.
This paper on ADH was presented by the
two authors at the annual meeting of the
Canadian Association of Neurological
and Neurosurgical Nurses in Halifax,
June 1979.
Muriel Burry, a graduate of St.
Bartholomew s Hospital, London,
England, is presently head nurse of
neurology and neurosurgery at the
Health Sciences Center, Winnipeg.
Lydia Martens, a staff nurse in the
neurological and neurosurgical unit at
the Health Sciences Center, Winnipeg, is
a graduate of the Grace General
Hospital, Winnipeg.
Th* CniMlln MM,.,
Cris Burdis
What type of patients benefit from
biofeedback and behavioral therapy?
Do psychiatric patients continue to
practice relaxation techniques after
discharge and do these techniques
remain effective? Can behavioral
treatments be carried out effectively
by nursing staff?
Members of the Behavior Modification
Treatment Program of the University
Hospital, London, Ontario, when they
realized the answers to these and similar
questions were not readily available in
current literature, 1 decided to do some
research on their own. Through practical
analysis, a nurse, in consultation with a
psychiatrist and a psychologist, obtained
some interesting results.
Biofeedback what is it?
Biofeedback is the term used to describe
a relatively new group of techniques
whereby an individual is made aware of,
and taught increased control of, what are
normally considered involuntary
physiologic responses.
In psychiatry, biofeedback is used
to measure and make an individual aware
of tension levels within his body. 2 These
tension levels may be controlled by the
autonomic or skeletal muscle system e.g.
tachycardia frequently accompanies or
results from high anxiety, however
through the use of relaxation techniques
the tachycardia may be decreased with a
consequent reduction of anxiety. 3
To record the physiological
measurements associated with high
levels of arousal or tension, a polygraph
which includes recordings of heart rate
(electrocardiograph), muscle tension
(electromyograph), cerebral activity
(electroencephalograph), respiration rate
and galvanic skin response, is used. This
polygraph is used in both the diagnosis
and treatment phases.
The Canadian Nurse
Diagnosis
In order for biofeedback to be used
effectively in the treatment of any
condition, a high activity level from one
of the graphs must be noted. If an
individual reporting with a migraine or
tension headache, for which no organic
base has been established, is found to
have excessively high tension levels in
his head and neck muscles, then it is
likely that by learning to relax these
muscles he may be able to control pain
and headaches. However if there is no
visible elevation of tension level , the
benefits of biofeedback use are
questionable and other treatment
modules should be investigated, for
example psychotherapy.
High tension levels involving a
specific organ may indicate a
predisposition to disease. Future heart
disease may be predicted when
polygraph recordings of an anxious
patient reveal heart rate increases with
conflict or stress.
Treatment
Once it is determined that an individual
should respond to biofeedback use,
treatment is initiated. The individual is
instructed in measures to control or
reduce tension levels by means of an
auditory tone or visual feedback. Using
the polygraph, tension levels are
measured and a tone which varies with
the changing levels of tension recorded,
is played back. As the patient uses
relaxation techniques, the sound lowers
in pitch giving him continuous feedback
about the degree of relaxation he is
attaining. Often biofeedback is only one
of a number of behavioral techniques
used as a result of an initial general
behavioral assessment.
The study
Individuals studied had psychiatric
diagnoses of migraine headache, tension
headaches, anxiety neurosis and
conversion reaction. They were referred
by their family physician to the
Behavioral Modification Treatment
Program at University Hospital. In all 49
persons were studied, both male and
female, ranging in age from 21 to 78
years; 24 with the diagnosis of anxiety
neurosis, 14 with the diagnosis of tension
headache, five with migraine headaches
and six diagnosed with conversion
reaction.
In an initial interview with the
behavioral therapist, the patient was
given the rationale of behavioral therapy.
Then a history of the complaint and a life
history were documented with emphasis
on behaviors, either learned or genetic
which influenced the presenting
problem, e.g. complaint of migraine
headache with family history of similar
complaint. Situational analysis was used
to investigate the behavioral components
of the pain where stimulus response
patterns were evident, i.e. non-assertive
behavior leading to the patient s anxiety.
In these situations, the patient was asked
to keep a log recording the frequency of
his pain and the emotional and cognitive
components which might exacerbate or
prolong this pain. Physiological
measures on the polygraph were also
considered part of the assessment
procedure.
Once all of this information had
been collected, the history was
presented to a team of behaviorally
oriented therapists that included a
psychologist and psychiatrist. A
treatment module was then set up and, at
regular intervals, the team would meet to
discuss ongoing therapy and receive
feedback from all disciplines, as the
patient might be also undergoing other
therapies such as marriage counseling or
group psychotherapy at the time.
Biofeedback treatment
The actual treatment consisted of the
application of electrodes to skin surfaces
of the muscles near the area where pain
was experienced; for instance, the
trapez^ius muscle is often used for
occipital headaches and the frontalis
muscle for frontal headaches. A sensitive
bioelectric amplifier was used to amplify
the minute signals generated by muscle
cell depolarization and to present them in
the form of a line graph. This sensitive
measurement can be gauged quite
accurately and converted intaa tone.
The individual, hearing this tone, was
told that when he relaxed the involved
muscles the pitch of the tone would
decrease. To accomplish this, the patient
learned relaxation exercises, most
commonly the autogenic method devised
by Wolfgang Luthe, 4 although
other methods such as breathing
techniques, hypnosis, yoga exercises,
increasing sensory awareness and
physical activity, such as jogging may
also be recommended.
Autogenic relaxation is based on a
method known as passive concentration.
The individual reduces tension in one
area of his body by concentrating in a
passive and casual way on phrases
suggesting feelings of heaviness and
warmth in that specific part of the body.
Passive concentration implies functional
passivity towards the intended outcome
of the concentrated activity rather than
active concentration which demands
goal-seeking and interested, alert
attention. He says to himself, for
example, "my forehead is cool" or "my
arm is warm/hot" as opposed to "1 want
my arm to be warm". Once the patient
has mastered the ability to relax in the
laboratory situation, he is encouraged to
use relaxation exercises at home and
prior to facing anxiety situations in his
life. A tape recording of the exercises
was available for each patient to take
home.
In a relatively short number of
sessions, averaging about eight, the
patient was generally able to relax with
concomitant lowering of arousal as
measured by the polygraph. All of the
patients in this study were treated
behaviorally and responded reasonably
positively to treatment. Treatment
sessions were spread over a period of
time ranging from one to six months.
Following termination of therapy, a
follow-up questionnaire and interview
were administered at three and six
months. Physiological base rate
measurements were also made of present
tension levels. These follow-up sessions
included:
a questionnaire to be filled out
before the interview asking about life,
mental, environmental or interest
changes since therapy
patient s overview of his therapy
description of any physical
symptoms still present
degree of relaxation still being
practiced
continued use of coping mechanism
learned in therapy
any changes in sexual behavior
patterns
any mood changes.
All the information collected was
recorded briefly and summarized on a
graph. Six levels of effectiveness were
recorded ranging from level one
indicating that the patient was very much
worse, level three indicating the same as
pretreatment, to level six indicating
exceptional improvement.
Results
Results were examined by dividing the
group into diagnostic categories (see
Table one). As a group, those with the
diagnosis of conversion reaction
responded most favorably to
biofeedback treatment and six months
after therapy were doing better than
pretreatment. Patients suffering from
migraine headaches also seemed to be
coping adequately and as a result were
relatively headache-free six months
following discharge.
This type of treatment seemed to be
exceptionally beneficial in the case of
tension headaches. Unfortunately many
of these patients did not report for the
second follow-up interview. Those
suffering from anxiety neurosis proved
to be an interesting group that showed
more variability in their graphs.
Although generally the patients showed
an overall improvement, this group had
more complex problems than the others,
of which physical tension and its
reduction played only a small part in
their overall personality structure.
Th Cinadlan Hurt*
Table one Effectiveness levels following biofeedback
Diagnosis
Follow -up
1 2 3
4
5
6
7
Conversion
Reaction
n.6
Three months
1
5
Six months
5
1
Migraine
Headaches
n.S
Three months
1
3
1
Six months
3
2
Tension
Headaches
n.14
Three months
2
4
2
4
2
Six months
1
3
1
3
6
Anxiety
Neurosis
n. 24
Three months
2
9
8
3
2
Six months
2
7
7
5
8
_ 49
Levels
1 . very much worse
2. somewhat worse
3. same level as pretreatment
4. slight improvement
5. much better
6. exceptionally better
7. no show, refused follow-up
or unable to contact
Conclusions
Generally it would appear that most of
the 49 patients in our study improved
considerably in a variety of ways and
continued to remain at least at a
better-than-pretreatment level six
months after discharge. Most of them
continued to practice relaxation
techniques at home at least twice weekly
and to utilize relaxation training and
coping mechanisms, i.e. cognitive
therapy (an exploration into maladaptive
thinking patterns that caused anxiety) or
assertive skills they had learned, to deal
with anxiety.
The muscle tension levels measured
at the interview were generally much
lower than pretreatment levels, although
often slightly higher than at discharge.
This would seem to support the theory
that lowered physical tension levels
occur with increased ability to relax and
result in a lowering of pain, as in a
tension headache.
Since these results are based only on
individuals who were deemed suitable
for biofeedback therapy, and only on
those who completed the treatment
program, it is not possible to do more
than delineate some broad categories
that describe the type of individual who
would not respond well to this type of
treatment. These categories are: actively
psychotic, severely depressed,
unmotivated to therapy and at
lower-than-average intelligence.
This study should not be considered
a research project as it was not strictly
controlled in many areas, since results
were gathered from ongoing therapy.
However, the comparatively high
success rate of treatment, the very few
treatment hours required, plus the fact
that treatment was carried out by a
registered nurse, could contribute
considerably to the planning of treatment
modules by hospital personnel. With
monetary resources at a minimum in
most hospital budgets, and the indication
that many patients who are difficult to
treat with conventional psychiatry may
respond well to biofeedback, a viable
alternative is now available.*
References
1 Tarler-Benlolo, L. The role of
relaxation in biofeedback training: a
critical- re view of the literature.
Psychol.Bull. 85:4:727-755, Jul. 1978.
2 Dollard, iohn. Personality and
psychotherapv, by John Dollard and
NealE. Miller, New York,
McGraw-Hill, 1950.
3 Rimm, David. Behavior therapy:
techniques and empirical findings, by
David Rimm and John C. Masters. New
York, Academic Press, 1974. p. 6.
4 Luthe, Wolfgang. Autogenic
therapy, Vol. 1 . Autogenic methods, by
Wolfgang Luthe and Johannes H.
Schultz, New York, Grune, 1969.
Bibliography
1 Benson, Herbert. The relaxation
response. New York, Morrow, 1975.
2 Biofeedback and self control,
1972-1977: anAldine annual on the
regulation of bodily processes and
consciousness. Chicago, 1L, Aldine,
1972-1977.
3 Ellis, Albert. A new guide to
rational living, by Albert Ellis and
Robert A. Harper. North Hollywood,
CA, Wiltshire, 1975.
4 Jonas , Gerald . Visceral learning.
New York, Pocket Books, 1974.
5 Karlines, Marvin. Biofeedback:
turning on the power of your mind, by
Marvin Karlins and Lewis M. Andrews.
Toronto, Lippincott, 1972.
6 Knapp, Terry J. Behavior analysis
for nursing of somatic disorders, by
Terry J. Knapp and Linda Whitney
Peterson. Nurs.Res. 26:4:281-287, Jul.
1977.
7 Luthe, Wolfgang. Autogenic
therapy, Vol.1 . Autogenic methods, by
Wolfgang Luthe and Johannes H .
Schultz. New York, Grune, 1969.
8 Rimm, David. Behavior therapy:
techniques and empirical findings, by
David Rimm and John C. Masters. New
York, Academic Press, 1974.
Cris Burdis, a graduate of the York
School of General Nursing, England,
worked in the Behavior Modification
Clinic at the University Hospital,
London, Ontario and set up a psychiatry
liaison nursing service there. Currently,
she is working part-time in the
Outpatient Department of Psychiatry at
the University Hospital, studying at the
University of Western Ontario and also
teaching assertiveness training classes
at Fanshawe Community College.
4fi -obruarv 1980
The Cnn5dln Nurse .
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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
by relieving
pain and
odour fast
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
peared." 3
Day Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
Two, if exudation is very heavy.
After removing crust or
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Cover with a dressing.
Debrisan cleans
decubitus ulcers fast.
*?
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dorval, Quebec
1. Lim LT, Michuda M, Bergan JJ. Angiology 29:9, Sept 1978
2. Bewick M, Anderson A, Clin Trials J 15:4, 1978
3. Soul J, Brit J Clin Pract, 32:6, June 1978
4. DiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on file at Pharmacia (Canada) Ltd.
(You and the Law continued from page 1 1 )
Concern has been expressed that
such an extension of hospital legal
liability will result in undue interference
in medical practice and, in particular, in
the implementation of medical
innovations and novel procedures. In
respect of the latter, it is feared that
hospitals, mindful of legal risks, will
prevent the use of such techniques,
thereby severely hampering the
development of medicine and the
potential benefits to patients. On the
other hand, the decision has been viewed
as a positive step in protecting the public
interest and expectation in ensuring that
the public does not receive substandard
health care .
The direction the law takes from
here will depend on the outcome of the
review of this landmark decision by our
appellate courts. <
"You and the law" is a regular column that
appears each month in The Canadian Nurse
and L infirmiere canadienne. Author Corinne
L. Sklar is a recent graduate of the University
of Toronto Faculty of Law. Prior to entering
law school, she obtained her BScN and MS
degrees in nursing from the University of
Toronto and University of Michigan.
Ovol Drops
relieve
infant colic.
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.
Shhh. Ovol Drops.
|HORnR
Also available in tablet form for adults
References*
1 Yepremianv .Scarborough
General Hospital (1978), 20O.R. (2d).
p.510.
2 Hillyer v. St. Bartholomew s
Hospital, [1909] 2 K.B. 820(C.A.).
3 Fleming, i.S.The law oftorts. 4th
ed. Sydney, Law Book Co., 1971. p. 318;
and see ahoDarling v. Charleston
Community Memorial Hospital (1965)
211N.E.2d. p.253.
4 Cassidy v. Ministry of Health,
[1951] 2 K.B. 343(C.A.).
5 [1972] S.C.R. 435.
6 Yepremian, op.cit. p.517.
7 Ibid.,p.518.
8 Ibid.,p.521.
9 Ibid.,p.521-522.
10 Ibid.p.522.
11 Ibid.,p.533-534.
12 Ibid.,p.522.
1 3 The hospital established the
importance of personal staff selection
before the same trial judge in Re: Board
of Governors ofScarhoroughGeneral
Hospital and Schiller (1974) 4 O.R. (2d)
201.
14 The Public Hospitals Act, R.S.O.
1970,c.378s.41.
15 Yepremian, op.cit., p. 534.
16 Ibid.
*Unable to verify in CNA Library
OVOlSOmg
Tablets
Ovol4<X
Tablets
Ovol 9
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 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 HORRR
^ifr Montreal Canada
It s the CNA in B.C. - a pot pourri for you to see
The RNABC is looking forward to June
and the CNA biennial meeting here in
Vancouver. Vancouver is one of the most
beautiful cities in North America: it boasts
a natural harbor, a rugged mountain
backdrop, lush forests and sandy
beaches. Culturally, the city has an
abundance of art galleries, museums,
theatres and clubs. Restaurants are
many and varied, specializing in seafood
and ethnic cuisine such as WestCoast
Indian, Hungarian, Indonesian, French,
Greek, Italian. ..the list is endless.
The RNABC is planning to offer
delegates a number of local tours during
the off-hours of the June convention.
Specific details and registration for these
tours will be available once you arrive. In
the meantime, however, here are just a
few of Vancouver s interesting
attractions.
Vancouv
aterfront
Stanley Park
Located within walking distance of
downtown, Stanley Park is 404 hectares
of natural woodland, nature trails,
gardens, picnic sites and playing fields.
There s a zoo with monkeys, polar bears
and otters. Tennis courts, a miniature golf
course, a giant checkerboard and lawn
bowling provide lots of recreational
options.
The largest and most exciting
aquarium in Canada is also located in
Stanley Park. Most popular is the Marine
Mammal Complex where up to 700
spectators can enjoy performances by
playful dolphins and killer whales. The
McMillan Tropical Gallery houses a
variety of ocean and freshwater fish.
Stanley Park has been described as
one of the greatest parks in the world and
it certainly lives up to that description.
Museum of Anthropology
Situated on the Point Grey cliffs
overlooking Howe Sound and the North
Shore Mountains, the Museum of
Anthropology contains a famous
collection of Indian artifacts. It is unusual
in having most of its collections on
permanent view, either in exhibition
galleries or in special storage areas
accessible to the public. The collection
features a unique group of totem poles
displayed in the splendid Great Hall.
While the best known artifacts represent
coastal Indian art, there are other
collections from elsewhere in North
America, the Pacific Islands, Asia and
Africa.
Chinatown
Vancouver s Chinatown is the second
largest in North America, exceeded only
by that of San Francisco. Its commercial
center is concentrated in a three block
Oriental "bazaar" where the treasures of
the East are displayed: ivory, jade,
colorful brocades and exotic foods. One
corner boasts a structure designated by
"Ripley s Believe it or Not" as the
"World s Thinnest Office Building". Some
of Vancouver s most popular restaurants
are located in Chinatown.
Chinatown
Gastown
Gastown is a must for the Vancouver
visitor. It is a prime example of urban
renewal. Because the area is designated
as an historic site, shops are allowed to
remain open on Sundays. With its mews
and intriguing cul-de-sacs, Gastown is an
interesting blend of past and present.
Boutiques, specialty shops, antique
stores, art galleries and colorful street
vendors provide a wide range of choice
to the shopper.
Shopping Malls
Several underground shopping malls are
within blocks of each other. Pacific
Centre Mall, the largest, connects
through its lower floor with the Bay,
Eaton s, Four Season s Hotel and the
Vancouver Centre Mall which is below
Birks. The two malls are below Granville
Mall, where most of the downtown movie
theatres are located. The Royal Centre
Mall, two floors of shops and restaurants,
is below the Hyatt-Regency Hotel where
the convention is being held. Harbour
Centre Mall is below Simpsons-Sears on
the waterfront and connects with
Gastown.
Downtown Vancouver
Grouse Mountain Skyride
This aerial tramway takes you to an
elevation of 1 1 00 m (3700 feet) and
provides spectacular view of the city, day
or night. The mountain is only 15 minutes
from downtown; also at the peak are
nature walks, special gift shops, chairlift
rides, a restaurant and lounge and a
cafeteria.
Post-conference tours
Here are some brief descriptions
and costs for the post-convention trips.
More information is available directly
from Kanata Conference Consultants.
Kanata Conference Consultants Inc.
307 - 837 W. Hastings Street
Vancouver, B.C. V6C 1B6
Note also that Kanata will make your
plane reservations for you. You should
plan on booking your flight from your
hometown with a stop-over in Vancouver
for the CNA conference. This will save on
air fare. *
Books for a new
decade of nursing.
Tilkian & Conover
UNDERSTANDING HEART SOUNDS
AND MURMURS
Here s an exciting package that provides a basic famil
iarity with 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. Tilkian, MD, FACC. Asst. Clinical Prof, of Medicine (Cardiol
ogy), Univ. of California School of Medicine. Los Angeles, and Mary
Boudreau Conover, RN, BSN, Ed, Instructor of Critical Care Nursing
and Advanced Arrhythmia Workshops. West Hills Hospital and West
Park Hospital. Canoga Park, CA. Book only: 1 22 pp. Illustd Soft
cover. $10.75. April 1979. Order #8869-1. Package: $20.35.
Order #8878-0.
Lee
CONCEPTS IN BASIC NURSING:
A MODULAR APPROACH
A unique new learning concept for nurses! This one-of-a-
kind manual provides an excellent foundation for study
ing the nursing process in maintaining basic functions,
from respiratory and nutritional ... to psycho-social and
electrolyte status. Six major units are divided into
modules, each with its own glossary, objectives,
self-tests, post-tests, and answers. Excellent for use in
a traditional learning environment, or for an independent,
self-paced program. Instructor s guide available now.
By Eloise R. Lee, RN. MEd. Asst. Prof.. Cedar Crest College, School
of Nursing, Allentown, PA. About 450 pp. Soft cover. About $13.80.
Ready soon Order #5697-8.
Corbett & Beveridge
SIMULATIONS IN NURSING PRACTICE
Here s an approach that allows readers to apply problem-
solving skills to medical-surgical nursing and it s been
class-tested as well! Corbett & Beveridge offers an
exhaustive treatment of six decision trees in a unique
learning format. Readers are guided through these
clinical situations using a series of self-testing questions
to examine decision-making skills. As readers progress,
they encounter rationales for both correct and incorrect
action. The volume functions as an adjunct to courses on
any level, as well as for self-teaching and review.
By Nancy Ann Corbett, RN, EdM, Assoc. Prof , College of Allied
Health Sciences, Thomas Jefferson Univ., Phila.. PA; and Phyllis
Beveridge, RN. EdM. Lecturer, College of Health Sciences, Univ.
of Bridgeport, CT. 332 pp. Soft cover $11.95. January 1980. Order
#2722-6.
Wood & Rambo
NURSING SKILLS FOR ALLIED HEALTH SERVICES
Volume 3
2nd Edition
Getting down to basics is what this new second edition is
all about! It features a complete reorganization of con
tents leading from general hospital setting, to simple
skills, to more complex ones. This volume covers more
advanced skills, breaking each skill into step-by-step
segments supported by scientific information and
practical hints. Post-tests, performance tests and per
formance check-lists for each unit are included.
Edited by Lucile A. Wood, RN, MS. Director of Nursing, Bay Area
Hospital. Coos Bay, OR: and Beverly J. Rambo, RN, MA, MN, Asst.
Prof of Nursing. Mt St. Mary s College. Los Angeles, CA About
525pp. Illustd. Soft cover. About $13.80. Ready soon. Order #9607-4.
Keane & Fletcher
DRUGS AND SOLUTIONS:
A PROGRAMED INTRODUCTION
4th Edition
This unique programed text presents material in short
steps with immediate feedback and reinforcement. You ll
find ratio and proportion for solving all problems with
no formulas to memorize. Additionally, you ll find all
mathematics necessary for you to know in medication
administration.
By Claire B. Keane, RN, BS, MEd, and Sybil M. Fletcher, RN, BS.
About 170pp. Illustd. Soft cover. About $90O. Ready soon
Order #5343-X.
LeMaitre & Finnegan
THE PATIENT IN SURGERY
4th Edition
This excellent revision provides an outline of operative
procedures for the student, graduate nurse, and O. R.
technician. The fourth edition includes many new chap
ters including one on surgical stress, and expanded
information on post-operative assessment for many of
the procedures. Order now!
By George D. LeMaitre, MD, FACS. Diplomate AM BDof Surgery.
Surgeon-in-Chief, Lawrence General Hospital; Senior Surgeon,
Bon Secours Hospital, and Janet A. Finnegan, RN. MS. Assoc. Prof.,
Northeastern Univ. College of Nursing. Boston, MA. About 545 pp..
12O ill About $16.20 Ready soon Order #5724-9.
Drain & Shipley
THE RECOVERY ROOM
Two leading experts provide clear, accurate coverage of
the recovery room in this exciting 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 8. Drain, 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 pp. 167 ill. $20 35 March 1979 Order #3186-X.
W.B. Sounders Company
1 Goldthorne Avenue, Toronto, Ontario M8Z 5T9, Canada
Send on no-risk, 3Oday approval :
D Corbett #2722-6
D Keane #5343- X
D Lee #5697-8
D LeVaitre #5724-9
D Drain #3186-X
D Wood #9607-X
D Tilkian #8878-0
D check enclosed Saunders pays postage
Please Print
FULL NAME
POSITION & AFFILIATION (IF APPLICABLE)
ADDRESS
STATE
ZIP I
CN 2/80
The Best of Waikiki and Maul
This exciting 14-day package costs $905
per person. You will stay seven nights in
Waikiki and seven nights in Maui.
Your hotel in Waikiki is right across
from the famous Waikiki Beach. All
rooms are air-conditioned with private
baths and color television. The hotel has
a large freshwater pool with a spacious
sun deck. You will enjoy elegant dining
and live entertainment nightly.
In Maui, your hotel room will have a
porch overlooking the grounds or the
ocean. Each room has a private bath,
air-conditioning and color television. This
hotel is a haven for the golf or tennis
enthusiast. It has 1 1 tennis courts and is
within easy walking distance of a golf
course. Eight freshwater pools with
adjacent snack bars will add to your
vacation comfort.
San Francisco Cable Car Caper
This package includes three nights/four
days, with a price per person of $290.
You depart from Vancouver on a
Thursday and return in time to connect
with flights to Eastern Canada.
Once in San Francisco, you are
taken right to the city s center,
Fisherman s Wharf and given a choice of
several tours, such as a bay cruise or a
tour of the city. Your trip to the "city by the
Bay" can be extended to seven
nights/eight days for a price of $439 per
person. That gives you four additional
days and nights to shop, explore or just
rest.
Reno/Tahoe
Seven nights of excitement,
entertainment and fun await you in Reno.
You depart from Vancouver on a Sunday
and return the following Sunday in time to
connect with eastern flights. For $299,
you are offered a modern room in one of
the largest hotels in downtown Reno. The
hotel includes a fine casino, restaurant,
For those who would like to develop
further their professional potential and to
earn University credits while working
full-time
Canadian School of
Management
in affiliation with
Northland Open University
offer two programs:
Bachelor of Professional
Studies or
Bachelor of Management
Nurses, technicians, technologists and
all holders of Community College
diplomas may apply to the Upper Level
of the Program. Credits are given for
prior learning and experience.
Saturday tutorials or study at a distance
(for those who reside outside of Toronto)
available.
For more information please write to:
Canadian School of Management
S-425, 252 Btoor St. W.
Toronto, Ontario
M5S 1V5
pool and lots of bars. A casino package
valued at over $1 00 and a hearty snack
and open bar/champagne flight, are just
a few of the added items included in this
vacation.
Scenic Victoria
Several options are offered if you are
interested in visiting the distinctive city of
Victoria on Vancouver Island. A one-day
excursion to the city costs $38.50 and
includes your ferry trip, the Butchart
Gardens, the city center, parliament
buildings, provincial museum, Uplands
and Oak Bay. If you want to spend two
days in Victoria, you can see all of the
above plus more. A guided walking tour
of the city center is also provided. Total
cost of the two-day trip is $1 25 per
person.
Royal Hudson Steam Train Trip
This 10-hour excursion costs $29.50 per
person. You will be picked up at your
hotel at 8:45 a.m. and transferred to the
Royal Hudson. This old steam train
travels along Howe Sound to Squamish,
where you will enjoy a leisurely lunch. On
the return trip, there are stops at
Britannia Beach Mining Museum,
Shannon Falls and Alice Lake.
Alaska Cruise
This eight-day cruise aboard the Island
Princess departs Vancouver on June 27
at 8:00 p.m. There are six ports of call
during the cruise. Shore excursions at
these ports are sold aboard ship.
Two types of accommodation are
offered type "F" staterooms include
outside two bedded rooms with private
facilities on Aloha deck, for a cost of US
$1 608 per person, type "G"
accommodation includes outside two
bedded room with private facilities on the
Fiesta deck, for a cost of US $1512 per
person. Fare includes transportation,
meals and entertainment.
TIT^E f< * t
Vancouver skyline and mountains in the distance
POSEY SOFT BELT
Comfortably prevents patients from slid
ing in wheelchairs or geriatric chairs. Soft
potyurethane cushion is so soft your pa
tient will hardly know it s there. Wash
able. Snr, med-, Ig.
No. 4125
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 stabilizes foot.
No. 6412
POSEY PATIENT RESTRAINER
Get the added plus of shoulder loops and
straps. Comfortable vest criss-crosses in
front or rear and waist belt ties to bed
spring frame Excellent in wheelchairs too.
Sm., med., Ig
No. 3111
Health
Dimensions Ltd.
2222 S. Sheridan Way
Mississauga, Ontario
Canada L5J 2M4
Phone: 416/823-9290
ippincott
Serving the Health Professions in Canada Since 1897
WORTHY EDITIONS
FOR YOUR NURSING
LIBRARY
1 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. With nine
contributors.
This monumental Second Edition of a
modern classic the most comprehen
sive single-volume reference on nursing
practice ever published incorporates
massive revision and updating to offer
the latest and most accurate informa
tion available.
Hundreds of illustrations depict the
highlights of treatment and nursing
management (over 100 illustrations
are new!).
Lippincott. 1,868 Pages.
Illustrated. 1978. $32.25.
2 THE EVALUATION OF
NURSING COMPETENCE
By Harriet Lucille Schneider, R.N.,
B.S.N.E., M.A., M.Ed., Ed.D.,
This intriguing text explores all facets
of an old and perplexing problem the
evaluation of clinical nursing compe
tence. Thoroughly researched sections
present the major evaluation theories
and analyze the effectiveness of such
specific situational methods as mock
laboratories, programmed patients,
videotapes, and computer-assisted
simulations. Specific forms, check
lists, and sets of questions are provided
for evaluative purposes.
Little, Brown. 175 Pages.
Illustrated. March, 1979. Abt. $8.50.
3 NURSES DRUG
REFERENCE
Edited bv Stewart M. Brooks, M.S.
A comprehensive reference on all
drugs commonly encountered in nurs
ing practice. Section I CLASSIFI
CATION OF DRUGS reviews all of
the standard drug classes relative to
action and use, listing (and cross-ref
erencing) its members. Section II,
STANDARD AND COMMONLY
USED DRUGS, presents in alpha
betical order more than 500 mono
graphs covering all drugs which the
nurse will encounter in normal prac
tice.
Little, Brown. 500 Pages. 1978.
Paper, $14.50. Cloth, $27.00.
4 GERONTOLOGICAL
NURSING
By Charlotte Kopelke Eliopoulos,
R.N., M.S.
GERONTOLOGICAL NURSING gives
comprehensive treatment of the sub
ject with a balanced coverage of psy-
chosocial factors, pathophysiology and
nursing considerations. Specific cover
age is given to measures designed to
promote good respiration, elimination
and activity and to compensate for
age-related changes interfering with
these functions. Illness conditions of
each body system and their unique
features in the aged are discussed in
detail.
Harper & Row. 384 Pages.
Illustrated. 1979. $15.00.
5 COMMUNICATION FOR
HEALTH PROFESSIONALS
By Voncile M. Smith, Ph.D.; and
Thelma A. Bass, M.A.
This timely book identifies and des
cribes problem situations stemming
from communication breakdowns that
commonly affect health care
personnel.
Lippincott. 236 Pages. March, 1979.
$7.50.
6 TEXTBOOK OF HUMAN
SEXUALITY FOR NURSES
By Robert Kolodny, M.D.; et. al
This comprehensive work on human
sexuality provides the nurse with a
knowledge of human sexuality that
will enable her to care for her patient
in the emotional and social, as well as
the physical realms.
Little, Brown. 431 Pages. Illustrated.
1979. Paper, $15.00. Cloth, $21.00.
7 CARDIAC
REHABILITATION:
A Comprehensive
Nursing Approach
By Patricia McCall Comoss, R.N.,
C.C.R.N., et. al.
Although comprehensive in its nursing
practice descriptions, this book is not
a primer on basic cardiac care. The
how s and why s of this modern trans
formation span all the chapters in
between,
Lippincott. 334 Pages.
Illustrated. 1979. $20.25.
J. B. LIPPINCOTT COMPANY OF CANADA LTD.
75 Horner Ave., Toronto, Ontario M8Z 4X7
Please send me the following on approval :
1 2 3-P 3-C1 4567
Prices subject to change without notice.
D Payment enclosed (postage and handling paid)
D Bill me (plus postage and handling)
Books are shipped On Approval; if you are not entirely
satisfied you may return them within 15 days for full credit.
Name
Address
City
Postal Code
Prov.
Prices subject to change without notice.
CN2/80
Classified
Advertisements
Alberta
British Columbia
British Columbia
Reftatered None* required for full time work on
Medicine and Pediatrics as well as Surgery and
Maternity. To work rotating shifts. Positions availa
ble immediately. Apply to: Director of Nursing, St.
Joseph s General Hospital, P.O. Box 490, Veg-
reville. Alberta TOB4LO. Phone: 1-403-632-2811.
Registered Nurses required for a 560-bed acute care
hospital in Edmonton, Alberta. Positions available in
most clinical areas. Candidates must be eligible for
registration in Alberta. Current salary rates under
review. Apply to: Personnel Department, Edmonton
General Hospital, 11111 Jasper Avenue, Edmonton,
Alberta T5KOL4
British Columbia
Experienced General Duty Graduate .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 writing to:
Director of Nursing, St. George s Hospital, Box 223.
Alert Bay, British Columbia, VON 1AO.
The "boom" of our northern city continues! We still
require beginning or experienced practitioners for our
nursing departments. If experienced, we will give
you opportunity to try some of your ideas. If
beginning, we will give you opportunity to expand
your skills and knowledge. Contact: Mrs. A.
Henriksen. Nursing Director, Dawson Creek and
District Hospital, 1 1 100 13th Street, Dawson Creek,
British Columbia V1G 3W8.
General Duty Nurse for modern 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 Nursing, Bound
ary Hospital, Grand Forks, British Columbia, VOH
1HO.
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 $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.
Experienced Nurses (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 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.
Registered Nurses required for both acute and
extended care in a 125-bed hospital in the South
Okanagan. Experience in obstetrics and medical-
surgical preferred. RNABC contract in effect. Apply
stating qualifications and experience to: Nursing
Administrator, South Okanagan General Hospital,
Box 760, Oliver, British Columbia, VOH 1TO. Phone:
498-3474.
General Duty RN s or Graduate Nurses 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
Hospital, Box 98, Pouce Coupe, British Columbia or
call collect (604) 786-5791.
Experienced General Duty Nurses required for
130-bed hospital. Basic Salary $1,305.00 $1,542.00
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.
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
I5th Avenue, Prince George, British Columbia,
V2M 1S2.
Registered Nurses required for permanent fulltime
position at a 147-bed fully accredited regional acute
care hospital in B.C. Salary at 1979 RNABC rate
plus northern living allowance. One year experience
preferred. Apply: Director of Nursing, Prince
Rupert Regional Hospital, 1305 Summit Avenue,
Prince Rupert, British Columbia, V8J 2A6. Tele
phone (collect) (604) 624-2171 Local 227.
General Duty Nurses required by an active 80-bed
acute care and 40-bed extended care hospital located
in the Cariboo region of B.C. s central interior.
Year-round recreational activities in this fast grow
ing community. Applicants eligible for B.C. registra
tion preferred. Apply in writing to: The Director of
Nursing, G.R. Baker Memorial Hospital, 543 Front
Street, Quesnel, British Columbia V2J 2K7.
Registered Nurses required immediately for perma
nent full time positions at 10-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 1WO. Telephone:
(604) 636-2221 Collect.
General Duty Nurses required for an active, 103-bed
hospital. Positions available for experienced R.N s
and recent Graduates in a variety of areas. RNABC
Contract in effect. Accommodation available. Apply
to: Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British Columbia
V8G 2W7.
Experienced maternity, l.C.L./C.C.t., and Operat
ing Room General Duty nurses required for 103-bed
accredited hospital in Northern 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, V8G
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 interprofessional 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 applicants.
University of Victoria, School of Nursing. Applica
tions are invited for positions on the faculty of the
School of Nursing. University of Victoria. The
School offers a two-year post-R.N. programme
leading to a B.Sc.N. and plans to develop both a
basic and a master s programme. Qualifications:
Master s degree required, doctorate preferred. Ex
perience in university teaching an asset. Apply to:
Director, School of Nursing, University of Victoria,
P.O. Box 1700, Victoria, British Columbia V8W
2Y2.
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: Assistant Administrator-
Nursing, Stanton Yellowknife Hospital, Box 10,
Yellowknife, N.W.T., X1A 2N1.
Ontario
Operating Room Nurse A position exists in the
Operating Room for a Regular full-time Registered
Nurse. Minimum of two years recent experience in
an Operating Room. Preference will be given to
applicants with recent post graduate education.
Interested applicants should submit their resume to:
Ms. D. Roscoe, Director of Nursing, Welland
County General Hospital, Third Street, Welland,
Ontario L3B 4W6.
Quebec
Registered Nurse for summer camp in the Lauren-
tians, mid-June to end of August. Congenial sur
roundings. Resident doctor. Contact: Myron Good
man, Executive Director, YM-YWHA Wooden
Acres Camp, 5500 Westbury Avenue, Montreal,
Quebec H3W 2W8. Telephone: (514) 737-6551,
Local 51.
Camp Nurses required for children s 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
1M6, ortelephone(514) 735-3669.
Saskatchewan
Four R.N. s urgently needed for 8 bed modem
hospital in southern Sask. Must be eligible for
S.R.N.A. registration. Please apply to: Administra
tion, Beechy Union Hospital, Box 68, Beechy,
Saskatchewan SOL OCO or Telephone (306) 859-
-2118.
Director of Nursing required for 10-bed hospital
located in Pangman, Saskatchewan. Pangman is
situated 65 miles south of Regina and 35 miles west
of Weyburrt. Housing facilities available at present.
For more information please contact and apply to:
Kathy Beach, Administrator, Pangman Union Hos
pital, Pangman, Saskatchewan SOC 2CO.
Applications are invited for the position of Regis
tered General Duty Nurse in a small 18-bed hospital
located in the beautiful rural northwestern Sas
katchewan. Salaries, fringe benefits, etc., as per
S.U.N. Agreement. Apply to: Margarete Lathan,
Director of Nursing, Box 179, Paradise Hill,
Saskatchewan SOM 2GO or phone: (306) 344-2255.
Saskatchewan
United States
University of Saskatchewan, College of Nursing.
Faculty positions will be available in the College of
Nursing July 1, 1980. Applicants with doctoral or
master s degree will be considered for tenurable
appointment. Limited-term appointments will also
be available to replace faculty on leave of absence.
The undergraduate baccalaureate program is integ
rated and conceptually based. Team teaching is the
mode used in most classes and all faculty are
expected to have specialization in a clinical area and
to participate in clinical supervision of students.
Level of appointment and salary will be commensu
rate with previous experience in teaching, research,
and clinical nursing. Further information may be
received from: Hester J. Kernen, Professor and
Dean, College of Nursing, University of Saskatche
wan, Saskatoon, Saskatchewan S7N OWO.
United States
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 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 opportunity to 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)
268-5000, ext. 1680.
Total patient care with all licensed personnel is pur
goal! Staff RNs currently interviewing for part-time
and full-time positions. FuU service, except psych,
progressive 156-bed accredited acute general hospi
tal. Located within 60 minutes from LA, the ocean,
mtns., and the desert. Orientation and staff de
velopment programs. CEUs provider number.
Parkview Community Hospital, 3865 Jackson Street,
Riverside, California 92503. Write or call collect
714-688-221 1 ext. 217. Betty Van Aemam, Director
of Nursing.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoying
Florida s Gulf Coast beaches, sun, and exciting
recreational activities. We will provide work visas,
help you locate a position, find housing, and arrange
your relocation. No Fees! Call or write: Medical
Recruiters of America, 1211 N. Westshore Blvd.,
Suite 205, Tampa, Florida 33607 (813) 872-0202.
Florida Nursing Opportunities 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
information and offer relocation hints. There is no
placement fee to you. Write or call Medical
Recruiter* of America, Inc. (For West Coast) 121 1 N.
Westshore Blvd., Suite 205, Tampa, Fl. 33607 (813)
872-0202; (For East Coast) 800 N.W. 62nd St., Suite
510, Ft. Lauderdale, Fl. 33309 (305) 772-3680.
Nurses RNs 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 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.
that you are interested in. We will call you upon
receipt of your application in order to arrange 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"
RN s and/or GRAD nurses wanted immediately for
sunny Florida in active accredited hospital. Reply
to: Philcan Personnel Consultants at 327-9631 or
The International Group 324-4932 (24 hour line)
B.C. Telex: #0455333. Area Code (604) Vancouver.
Nursing Positions Available: At a replacement facility
due to completion in early 1980. Diversified services
in a small community setting 6 miles from the
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) 457-6664 between the hours of 8:00 -
4:00 p . m . Monday thru Friday .
Dallas, Houston, Corpus Christ), etc, etc, etc. 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.
Come to Texas 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 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 1591, Beaumont, Texas 77704. An
affirmative action employer.
Nurses RNs 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 Or call collect
(713) 789-1550. Marilyn Blaker, Medex, 5805
Richmond, Houston, Texas 77057. All fees employer
paid.
University Faculty
Applications are invited for clinical faculty
positions in an integrated baccalaureate
program. Subject to budgetary approval,
positions will probably be available for the
1980-81 academic year in the fields of
community, long term care, maternal-child and
Psychiatric nursing. Candidates should have at
least a Master s degree, demonstrated clinical
proficiency, teaching and scholarly
capabilities. Eligibility for registration with the
College of Nurses of Ontario is essential.
Candidates of both sexes are equally
encouraged to apply .
Salary and rank are negotiable and
commensurate with qualifications and
professional achievement.
Interested persons should send a full resume
and the names of three professional referees to:
A. J. Baumgart, Dean
School of Nursing
Queen s University
Kingston, Ontario K7L 3N6
Closing date of applications: April 1, 1980.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the US A.
B) Extensive information regarding
Hospital 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 1 133 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer trips
from one week to 3 months in: Canada, USA,
Europe, Africa, Asia, South and Central America,
Australia, New Zealand and the Caribbean. For free
catalogue, apply to: Goway Travel, 53 Yonge St.,
Suite 101, Toronto, Ontario M5E 1J3. Phone:
416-863-0799. Telex: 06-219621.
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed, J.C. A. H. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differential
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 90% under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-5511
Good Samaritan Hospital
Flagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
MANITOBA
CIVIL SERVICE COMMISSION
These positions are open to both men and women. Apply
in writing referring to Competition Number immediately.
Director, School of Nursing
Competition No. NC-937
The Department of Health and Community Services,
Institutional Services, Brandon Mental Health Centre,
requires a person to be responsible for organization and
implementation of Psychiatric Nursing education
programs, including affiliating, refresher and other
programs; liaising with external agencies in arranging
academic and field experience; overall supervision and
direction of faculty and other related activities of the
School, including general administrative duties and
involvement in educational research.
Degree in Nursing with psychiatric nursing experience,
and several years experience in nursing education.
Salary Range: $19, 168-526,168 per annum.
Assistant Director of Nursing
Education
Competition No. CN-636
The Department of Health and Community Services,
Institutional Services, Brandon Mental Health Centre,
requires a person to be responsible to Director, Nursing
Education 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 nursing with teaching
experience. Extensive background in psychiatric nursing,
preferably with RN and RPN licences."
Salary Range: $18,453-525,152 per annum.
Civil Service Commission
340 - 9th Street
Brandon, Manitoba
R7N 6C2
Wish
you were
here
...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
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 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 information on any, or all. of these career
opportunities, please contact the Medical Services
office nearest you or write to:
Medical Services Branch
Department of National Health and Welfare
Ottawa. Ontario K1AOL3
Name
Prov.
Sante el Bien-etre social
Canada
Health and Welfare
Canada
I
I
Offers R.N. s
An UNUSUAL OPPORTUNITY.
A.M.I. Will FURNISH One Way AIRLINE TICKET to Teas
and $500 Initial LIVING EXPENSES on a Loan Basis.
After One Year s Service, This Loan Will be Cancelled
^Afitt American Medical International Inc.
fc HAS 50 HOSPITALS THROUGHOUT THE U.S.
tr Now A.M.Us Recruiting R.N. s lor Hospitals in Tias
lmm.UI.te Openings. Slliry Ring. Jtl.OOO to $16,500 per Year.
* You can enjoy nursing in General Medicine, Surgery, ICC,
CCU, Pediatrics and Obstetrics
A.M.I, provides an excellent orientation program,
in-service training.
U.S. Nurse Recruiter
P.O. Box 1 7778, Los Angeles, Calif. 90017
# Without obligation, please send me more
Information and an Application Form.
NAME
ADDRESS
CITY ST._. ZIP
TELEPHONE ( )
LICENSES:
SPECIALTY:
YEAR GRADUATED: STATE:
Head Nurse
Operating Room
Applications are invited for the above
afternoon shift position. The Department
is comprised of 30 surgical theatres
covering all specialties including open
heart, neurosurgery and kidney
transplants. The incumbent would be
responsible for co-ordinating emergency
cases and for completion of the elective
slate.
Applicants must have B.C. Registration
plus a minimum of four years clinical and
administrative experience. Post basic
nursing administration course or BSN
preferred. Demonstrated leadership and
interpersonal skills essential. Weekends
and statutory holidays off. Current 1979
rate $1,500 - $1 ,772 per month (1980 rates
under review). Excellent benefits
including medical, dental coverage and
four weeks vacation after one year.
Please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C.
V5Z 1M9
CM)
COLLEGE OF
NEW CALEDONIA
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 for the
1980-81 academic year.
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.
Letters of application with the names of
three references should be submitted to:
L. Winthrope
Personnel Officer
College of New Caledonia
3930 - 22nd Avenue
Prince George, B.C.
V2N IPS
Phone enquiries to the Personnel Officer
at
604/562-2131
Are You a Nurse?
Here s an Opportunity To Be One.
Primary Nursing
at the New Regional Hospital means having direct
responsibility for the nursing care of your patient, his family,
and working with the doctor as a colleague.
Accountability
as a primary nurse means the outcome of your patient s
care is the measure of your effectiveness.
Satisfaction
results from your role as a professional and the significant
part you play in the care of your patient.
PUT IT TOGETHER with the new 300 bed Fort McMurray
Regional Hospital Opening in November, 1979.
Want to know more about your opportunities in our total
patient care facilities?
Call Penny Albers at (403) 743-3381
or
Write for an information package:
Personnel Department
Fort McMurray Regional Hospital
Fort McMurray, Alberta
T9H 1P2
Co-Ordinator
Surgical Nursing Services
This 1 100 bed community and teaching hospital invites
applications for the position of Co-ordinator - Surgical
Nursing Services. The area components are five nursing
units plus a four bed intensive care unit, totalling 146
beds.
This person will be responsible for the overall delivery of
quality patient care and management of the surgical
services including budget control, staffing, staff
development and other administrative duties.
Applicants must have an appropriate degree and
significant clinical experience.
Please forward a resume detailing experience and
qualifications to:
Vivian Walwyn
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767, local 271
Registered Nurses
Come to work in scenic Comer Brook !
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
West Coast of Newfoundland.
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January, 1979 $12,771.00 15,429.00
1 January, 1980 $13,410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
OPPORTUNITY
Clinical Nurse Specialist
Alberta Hospital, Ponoka, a 500 bed accredited active treatment
psychiatric facility , is now seeking applications from creative
nurse specialists seeking a challenging career opportunity.
Duties: Acts as a consultant by assisting the nursing team in
nursing diagnosis, and by assisting other nurses who are seeking
new care approaches. Acts as an Educator in order to optimize
HealthCare Standards. Acts as aChange Agent in orderto
improve the quality of care by utilizing skills and theories of
human relations. Acts as a Researcher by utilizing valid research
findings for patient care and by contributing to research activities
in orderto develop and test concepts and nursing theories.
Performs other duties as required.
Qualifications: Graduation from a recognized School of Nursing
plus considerable related experience, including consultative
experience. Must be eligible for registration in an Alberta
Association. Equivalencies considered. Baccalaureate or
Masters Degree in Mental Health and/or Behavioural Sciences
preferred.
Salary: $18,024 -$22,5%
Competition #9212-5 This competition will remain open until
a suitable candidate has been selected.
Apply to:
Personnel Director
Alberta Hospital
Box 1000
Ponoka Alberta
TOC 2HO
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education Programs.
PostGraduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
\ppl> to:
Recruitment Officer Nursing
Lniversit\ of Alberta Hospital
8440 11 2th Street
Edmonton, Alberta
T6ti 2B7
University of
Alberta Hospital
Edmonton, Alberta
Tha Canadian Nuriut
Overseas Opportunities
NURSES
CUSO has openings for public health
nurses and nursing instructors in Africa
and Papua New Guinea. Applicants must
have Canadian qualifications and be pre
pared to work with limited supplies and
equipment. Travel is an important com
ponent of community health care work,
while nurse instructors are usually
attached to nursing colleges.
Qualifications: Degree and or Public
Health Nursing experience is essential.
Contract: 2 years
Salary: Low by Canadian standards but
sufficient for an adequate lifestyle.
Couples will be considered if there are
positions for both partners.
For more information, write:
CUSO Health-DI Program
151 Slater Street
Ottawa. Ont KIP 5H5
Part Time
Hospital Representatives
For
Montreal Toronto Vancouver Edmonton
Winnipeg Reglna Calgary
We are a new company formed to sell
specialized equipment and apparatus primarily
to Hospitals and Clinics.
We need part time representatives in the above
seven territories and invite applications from
qualified nurses, or persons with a suitable
medical auxiliary qualification, who are keen
to sell for about four (4) hours per day. Full
training will be given in all aspects of our
limited but technical product line.
We will provide a car and we will pay good
commission on all sales achieved.
This is a unique opportunity particularly for
mature people, with suitable medical
backgrounds, to embark on a new and
rewarding career pathway, despite some daily
domestic commitments.
Please send your resume to:
Circomedlc Laboratories Limited
12285 Yonge Street
Richmond HIU. Ontario L4C 4V6
InternationalGrenfell Association
requires
Registered Nurses, Public Health
Nurses and Nurse-Midwives
(R.N.)
for Northern Newfoundland and Labrador.
The International Grenfell Association
provides Medical Services in Northern
Newfoundland and Labrador. It staffs
four hospitals, seventeen nursing
stations and many public health units.
Our main hospital is a 150 bed accredited
hospital situated in scenic St. Anthony.
Newfoundland. Active treatment is
carried on in Surgery, Psychiatry.
Medicine . Pediatrics. OBS/GYN . and
IntensiveCare.
Orientation and active Inservice
Program provided for staff. Salary based
on government scales; 37 1/2 hrs. per
week. Rotating shifts. Excellent
personnel benefits include liberal
vacation and sick leave. Accommodation
available. Return air fare paid on a
completion of a one year service .
Apply to:
Scott Smith
Personnel Director
Curtis Memorial Hospital
International Grenfell Association
St. Anthony. Newfoundland AOK 4SO
The Grande Prairie Hospital
Complex is recruiting full-time
and casual nurses.
Current vacancies are in
Out-Patients, IntensiveCare,
Medical, and Auxiliary.
Anticipated vacancies in other
units.
Apply to:
Personnel Director
Grande Prairie Hospital
10409 - 98 Street
Grande Prairie, Alberta
T8V 2E8
Telephone: 532-7711,
Extension 78
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, PartTime and Casual Employment.
Benefits in accordance with R.N. A. B.C.
contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
V8R U8
Registered Nurses
Shaughnessy Hospital is an 1 100 bed
multi-level teaching hospital. We offer
B.C. Registered Nurses the following
employment opportunities.
Full-time, part-time or on-call
positions: Spinal Cord Injury Unit,
Intensive Care areas, Rehabilitation and
Assessment, Long Term Care,
Psychiatry, Medical and Surgical.
Please apply in writing or phone:
Vivian Walwyn
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767, local 271
Waterford Hospital
Career Opportunities For
Registered Nurses
The Waterford Hospital, a fully accredited 400
bed Psychiatric Institution, affiliated with
Memorial University School of Nursing and
Medical School, has openings for Registered
Nurses in all services, including new.
expanded. and acute care services
An orientation program is offered
Salary is on the scale ot $I2.04 - I4.<55 per
annum. A Psychiatric Service Allowance of
$1.329 per annum is available iii addition to
basic salary Both salary and Hllowance
presently under review.
The Hospital is close to all amenities:
shopping, transportation and recreation
facilities
Accommodations available in Hospital
Residence at nominal cost
Applications in writing should be addressed to
the undersigned:
Personnel Director
Waterford Hospital
Walerford Bridge Road
St. John s. Newfoundland
AIE4J8
Telephone Number: nm, 368-606I. ext. 341
Registered Nurses
418 bed fully-accredited general hospital in
Sudbury is looking for nurses who are willing
to be challenged with a wide variety of nursing
care.
Candidates must be eligible for registration
with the Ontario College of Nurses.
Bilingualism is a definite asset.
Positions are opened for medical/surgical,
rehabilitation and long-term care for full-time
and part-time employees immediately; and
part-time in our Renal Dialysis Unit. More
positions will be available in January due to the
expansion of our Long Term Care Program.
Salary: according to O.N. A. contract
Please apply in writing to:
Director of Personnel
Hdpltal I-aurentien - Laurentlan Hospital
41, ch. du lac Ramsey
Sudbury, Ontario
P3E SJ1
-.Director of Nursing
Palmerslon and District Hospital
Applications are invited for the position of
Director of Nursing of this fully accredited 40
bed active treatment Hospital.
Position
The Director of Nursing is directly responsible
to the Administrator for the quality of nursing
care, the development and maintenance of the
nursing care program, the overall
administration and staffing of patient services
of the unit including O.R. and ambulatory care
unit.
Person
The applicant must be eligible for registration
in the Province of Ontario.
The selection will place strong emphasis on the
applicants philosophy of administration and
the applicants combination of demonstrated
administrative skills, appropriate experience
and educational background.
Please send confidential resume to:
Mr. R. G. Emmerson
Administrator
Palmcrslon and District Hospital
P.O. Box 130
Palmersfon. Ontario MX, 2PO
Fnhrimrv 1&JU)
Assistant Director
Nursing Service
The Calgary General Hospital invites applications for the
position of assistant director for the Division of Obstetrics,
Gynecology . and Pediatrics in the Department of Nursing
Service. This Division consists of six (6) nursing units, including
an Intensive Care Nursery and has a total of 180 beds and 65
bassinettes. The Division is committed to the family centred
approach to patient care.
The successful applicant will be a registered nurse with advanced
preparation and considerable experience at the supervisory or
management level.
The 1979 salary range for this position is from $21,760 to $24,180
per year and is subject to review in January. 1980. A
comprehensive range of employee benefits is offered including
full family dental care.
Applications, with a detailed resume of education and
experience, may be submitted in confidence to:
Director of Personnel
Calgary General Hospital
841 Centre Avenue East
Calgary, Alberta T2E OA1
Registered Nurses
Join us at one of the three Hospitals of the South
Saskatchewan Hospital Centre, Regina.
Saskatchewan.
Provincial Capital
University Centre
Nursing Areas: Intensive Care
Medicine
Chronic Care Obstetrics
Coronary Care Orthopaedics
Emergency Paediatrics
Interested applicants should be eligible for
registration in Saskatchewan.
For further information on nursing opportunities
write to:
Nursing Recruitment Officer
South Saskatchewan Hospital Centre
4101 Dewdney Avenue
Regina, Saskatchewan S4T 1A5
Plastics
Psychiatry
Rehabilitation
Surgery
Urology
Name
Address
City
-Prov.
OPPORTUNITY
Postal Code
Nurses
Applications are invited for positions at Alberta Hospital,
Edmonton, a 650 bed active treatment psychiatric hospital
located 4km. 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 #91 84-9
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
Alberta Hospital, Edmonton
Box 307, Edmonton, Alberta
T5J2J7
Telephone: (403) 973-2213
Newfoundland
Public Service
Psychiatric / Mental Health Nursing Consultant
Duties: Maintains a working relationship with community
agencies and government departments involved with mental
health programs, the position acts as consultant in the
developmental, administrative and clinical aspects of psychiatric
nursing in hospital based programs in the province and assists in
the development of professional standards for education and
practice.
Qualifications: Experience in Psychiatric nursing, a master s
degree in psychiatric nursing, eligibility to register as a nurse in
the province of Newfoundland or any equivalent combination of
experience and training.
Salary: $22.761 - $28,178 (EFFECTIVE January 1, 1980)
Competition Number: H. PNC. 190
Financial Assistance towards relocation is available.
Applications may be submitted in confidence to:
Public Service Commission
16 Forest Road
St. John s, Newfoundland
A 1C 2B9
This Competition is open to both men and women.
Government of
Newfoundland & Labrador
Public Notice
Cottage Hospital Nurse 1 s
Applications are invited for appointment on a permanent or
short term basis to the Nursing Staff of the Cottage Hospitals
at:
Bonne Bay
Harbour Breton
Salary forCottage Hospital Nurse 1, annual, sick leave,
statutory holidays and other fringe benefits in accordance
with Nurses Collective Agreement.
Living-in accommodations available at reasonable rates, also
laundry services provided.
Applications should be addressed to:
Director of Nursing
Cottage Hospitals Division
Department of Health
Confederation Building
St. John s, Newfoundland
AIC5T7
Lome A. Klippert, M.D.
Deputy Minister
Head Nurse
Spinal Cord Injury Unit
The Spinal Cord Injury Unit is a tertiary care referral
center. We take a multi-disciplinary team approach to
patient care.
This is a challenging career opportunity for an individual
who will be responsible for the management of a 22 bed
area which includes an Intensive Care Unit. Preference
will be given to applicants with a Baccalaureate degree.
If you have:
proven administrative experience in a Head Nurse
capacity,
effective communication skills,
proven abilities in leading and developing staff,
and clinical expertise in neurology, neurosurgery or
orthopedics
Please apply, including a resume to:
Vivian Walwyn
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C., V6H 3N1
876-6767, local 271
The University of Lethbridge
invites applications and nominations for
Director of the School of Nursing
The School will develop and offer a post-basic
baccalaureate program leading to a Bachelor of
Nursing degree.
Desirable qualifications include:
1. an advanced degree and experience in
Nursing,
2. experience in Nursing education and
curriculum development at the University
level,
3. the capability of dealing effectively with
external organizations involved in health care
education and delivery.
The appointment will commence on July 1, 1980 or
earlier.
Applications and nominations will be accepted until
February 28, 1980, and should be sent to:
Vice-President (Academic)
University of Lethbridge
4401 University Drive
Lethbridge, Alberta
T1K3M4
Director of Nursing
Applications are invited for this senior management
position in a fully accredited multi-disciplinary treatment
complex of 406 beds, including extensive out patient
programmes. Reporting to the Executive Director, fully
responsible for organization, planning, administration and
operations of nursing care functions.
Candidates must have current registration in Ontario,
B.Sc.N. or Masters degree preferable, with demonstrated
competent leadership abilities and previous nursing
administrative experience at a senior level.
Applicants are requested to submit a comprehensive
resume and salary expectations to:
G. E. Pickard
Executive Director
Windsor Western Hospital Centre Inc.
1453 Prince Road
Windsor, Ontario
N9C 3Z4
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
major 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 in many
areas such as:
Neonatology Nursing
Inservice Education
Coronary Care Unit
Hyperalimentation
Intensive Care
(General & Neurosurgical)
Cardio- Thoracic Surgery
Burn Unit
Paediatrics
Program
Renal Dialysis & Transplantation
If you are a Nurse considering a move please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C. V5Z 1M9
The Holy Cross Hospital, a 500 bed fully accredited hospital with
regional Cardiovascular services in Southern Alberta invites
applications for the position of Director of Nursing.
I The Director of Nursing is responsible for administration and
professional activities of the Nursing Department. This position
requires leadership in planning, developing and evaluating
nursing programs. This leader also assumes responsibility for
quality assurance of nursing practice throughout the hospital.
Qualifications: Registered in the Province of Alberta. A Master s
degree preferred but consideration will be given to a
baccalaureate candidate. The successful candidate will have
demonstrated leadership abilities and accomplishments with
progressive and creative approach.
Experience: A minimum of 5 years progressive nursing
experience.
Please send a complete resume indicating qualifications,
experience, date available and salary expected to:
Director of Nursing
Director of Personnel
Personnel Department
Hospital District #93
940 - 8th Avenue S.W.
Calgary, Alberta T2P 1H8
General and Psychiatric Nurses
Hong Kong Up to HK$3,745 p.m.
Applications are invited for appointment as
Registered General Nurses or Registered Psychi
atric Nurses. Successful candidates will perform
nursing and supervisory duties in Government
hospitals and clinics in Hong Kong.
Qualifications required:
A. (i) General Nurse:
Certificate of Registration (Part I) issued by
the Nursing Board of Hong Kong,
(ii) Psychiatric Nurse:
Certificate of Registration (Part II) issued
by the Nursing Board of Hong Kong.
B. Fluent Cantonese essential; knowledge of
other Chinese dialects an advantage.
C. Applicants possessing other professional
qualifications should enclose detailed tran
script of their nursing training and state
qualifications obtained in their applications.
Salary scale:
(i) General Nurse: HK$2,46s to HK$3,s6s p.m.
(ii) Psychiatric Nurse: HK$2,6os to HK$3,745
p.m.
Starting salary will depend on post-qualification
experience.
Successful candidates will be appointed on
probation for two years and if their service is
satisfactory, they will be confirmed to the
permanent and pensionable establishment. They
will be provided with a passage to Hong Kong
plus a baggage allowance. Other benefits include
generous paid leave, medical and dental attention,
free uniform and laundry and in appropriate
cases, education allowances for children.
Applicants should send full resume of training,
qualifications and experience to the Hong Kong
Government Office, 6 Grafton St., London WiX
3LB, England before 2gth February, 1980.
Hong Kong Government
calendar
February
An Emergency Nursing
Symposium will be held at the
University of Calgary , February
20-21 . Contact: Mary Hammond,
Coordinator, Continuing
Education for Nurses, University
of Calgary, 292024 Ave. N.W.,
Calgary, Alberta, T2N 1N4.
"A Day in Rehabilitation", a
seminarfor nurses, therapists and
physicians, will be held February
20 at the Oshawa General
Hospital. Contact: M. Papp,
Oshawa General Hospital, 24
Alma St., Oshawa, Ontario,
L1G 2B9.
The Learning Disabled: A
Community Affair is a seminar
presented by Simon Fraser
University, February 21-23 at the
Bayshore Inn, Vancouver.
Contact: Continuing Studies,
Simon Fraser University,
Burnaby,B.C,, VSA IS6.
Occupational Health-Toxic Agents,
a five-day seminar will be held at
the Citadel Inn in Halifax , N.S. on
February 25-29 and will be
repeated in Toronto, March 24-28.
Contact: Conference & Seminar
Services, H umber College, Box
1900, Rexdale, Ontario,
M9W 5L7.
March
Critical Care Nursing, Level 1,
designed for registered nurses
working in a non-specialized
critical care unit, will be offered in
Nanaimo, March 17-April 21 and
in Vancouver, April 30-June 3.
This course requires 60 hours of
pre-course independent learning
and five weeks of concentrated
classroom and clinical study.
Contact: (for the Nanaimo
course) Division ofContinuing
Nursing Education, P. A.
Woodward JRC, University of
British Columbia, Vancouver,
B.C., V6T lW5or(forthe
Vancouver course) Continuing
Education, Vancouver
Community College, Langara
Campus, 100 West 49th Avenue,
Vancouver, B.C., V5Y 2Z6.
Nursing Job Fair
NURSES &
NURSING STUDENTS
Looking for a job Now or Later?
The Second Annual Toronto Area
NURSING JOB FAIR offers...
...Over 5,000 nursing positions at 70 hospitals and medical centers
from all over the U.S. and Canada. The NURSING JOB FAIR nursing
employment convention will be held February 21 - 23 at the Toronto
Harbour Castle Hilton, One Harbour Square. Admission is FREE to all in
the nursing profession-LPNs, all RNs with diplomas, AS, BSN, MSN, and
all students, administration and faculty. An open invitation is provided
to all.
Come and find out what kind of nursing positions and opportunities
are available. Learn about living conditions, education reimbursement
plans, relocation assistance and nursing innovations.
The NURSING JOB FAIR runs three (3) days, February 21 - 22
(Thursday and Friday) from 10 a.m. to 7 p.m.; Saturday, February 23 from
9a.m. to 2 p.m.
On Thursday and Friday a one-hour Career Seminar will be given at the
convention by Bernard J. Smith, RN, MSN, (former assistant Professor of
Nursing) for all nursing students at 9 a.m., 12 noon, and 3 p.m.; and for
experienced nurses at 10:30 a.m., 1:30 p.m., and 4:30 p.m. The Career
Seminar is free of charge and covers all aspects of nursing career
development.
Come alone or with a busload of friends, but don t miss this once-a-
year chance to meet representatives from over 80 hospitals and medical
centers and discuss your long and short term nursing employment
interests and needs
Hospitals and Medical Centers attending from the U.S. are from the
states of: Alabama, California, Washington D.C., Florida, Georgia,
Indiana, Louisiana, Maine, Maryland, Michigan, New Mexico, Nevada,
North Carolina, Ohio, Pennsylvania, Tennessee, Texas, Utah, and
facilities from the Toronto area.
Sponsored as a service of NURSING JOB NEWS monthly newspaper
for the nursing profession, 470 Boston Post Road, Weston, MA 02193.
For further subscription and convention information call 1 (617)
899-2702, 9 5 weekdays. I 1980 PNPC
OVER 5000 JOBS
Index to
Advertisers
February 1980
Ames Division, Miles Laboratories Limited
18
Baxter Laboratories
17
The Canadian Nurse s Cap Reg d
Canadian School of Management
51
Career Dress (A Division of
White Sister Uniform Inc.)
IFC
The Clinic Shoemakers
Department of National Defence
14
Equity Medical Supply Company
12
Frank W. Horner Limited
12,48
J.B. Lippincott Company of Canada Limited 15,52
Nursing Job Fair
62
Pharmacia (Canada) Limited
10,47
Posey Company
51
The Procter & Gamble Company
6, 7, 1BC
W.B. Saunders Company
50
Schering Canada Inc.
OBC
G.D. Searle & Company Limited
11
Upjohn Health Care Services
A dvertising Representatives A dvertising Manager
Jean Malboeuf
601, Cote Vertu
St-Laurent, Quebec H4L 1X8
Telephone: (5 14) 748-6561
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (4 16) 297-2030
Richard P. Wilson
P.O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (2 15) 363-6063
Gerry Kavanaugh
The Canadian Nurse
50 The Driveway
Ottawa, Ontario K2P 1E2
Telephone: (613) 237-2133
Member of Canadian
Circulations Audit Board Inc.
INTRODUCING
a new skin moisturizing lotion that merits
your consideration and recommendation
Promotes the natural
healing of dry skin
Healing help for dry skin
WONDRA works to help the skin restore
itself to an improved condition, softening the
skin and helping to eliminate roughness,
chapping, flaking, and scaling.
Clinically proven effectiveness
Three six-week, double-blind clinical studies
involving 574 men and women proved that
WONDRA was significantly effective in
alleviating dry skin problems.
Provides immediate relief
WONDRA quickly lubricates the skin to
provide immediate relief from rough, dry skin
Long-
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Cosmeti
Patients wi If
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both seer
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protection with regular use
i occlusive film on the surface of
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are, providing long-term protection
bblems caused by dr\ skin.
r preferred
feciate WONDRA s
tic qualities: rapid ru
afterfeel, and non-r
, WONDRA is availa
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Bt-Tore \VONDRA
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Mail to:
Wondra Profession
P.O. Box 355, Stati
Please send me a 2
moisturizing lotio
ices
Toronto, Ontario M5W 1
sample of WONDRA, the
personal trial.
A traditional family approach
to cold relief.
For over a quarter of a century,
Coricidin has been a traditional
approach to relieving cold
symptoms . . . with Canadian
nurses and families alike.
Coricidin. a combination of a
trusted analgesic, antihistamiiN
and an effective decongestant (
Coricidin !)" ). offers a product
form for virtually every age gnu
Pfdiatric drops are available fo
children two years and over;
chewable Medilets* forchildrei
up to the age of 12; and Coricidi
and Coricidin !) for teenagers
and adults.
We would like to tell you what
we ve learned about colds. It s ;
in a comprehensive 20 page bo<
let compiled specially for nur sc
"How to nurse a (. old" answers
most of the questions you face
every day:
What exactly is a cold .
Do children gel more cold
than adults .
Are some serious disease. ;
easily confused with the
common cold .
Send for your free copy of "Hov
Nurse a Cold"
BCHERING
Canada s national nursinn
journal celebrates its 75th
anniversary!
Guillain-Barre Syndrome
how it affects the nurse, patient
and family
Dispelling the mystique that
surrounds Legionnaire s
Disease
Assisting bereaved parents
The
Canadian
Nurse
MARCH 1980
BIBLIOTHEQUE
SCIENCES JNFIRMIERES
M- 261980
LIBRARY !*
EXCLUSIVELY WHITE SISTER OF COURS
Beautiful Royale Silcotta. Luxurious woven 80% Polyester, 20^
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r
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A TRADITION OF CARING -
With this March issue, CNJ
celebrates 75 years of
continuous communication
with the nurses of Canada.
Our cover photo, taken in
1905, the year the first issue
appeared, is of a nurse at the
Lakeside Home for Little
Children located on Toronto
Island. Toronto, Ontario.
Photo courtesy Public
Archives Canada, C-91 153.
The
Canadian
Nurse
March 1 980 Volume 76, Number 3
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
Mathilde Baziaet, chairman, Health
Sciences Department, Canadore
College, North Bay. Ontario.
Dorothy Miller. public relations
officer. Registered Nurses Association
of Nova Scotia.
.Jean Passmore.?</i/or, SRNA news
I bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith, director of publications,
National Gallery of Canada.
Florita Vialle-Soubranne. consultant,
professional inspection division. Order
of Nurses of Quebec.
Diamond jubilee 20 Birth room 30
Volunteers on OB 38
14
YOU AND THE LAW
Consent, sterilization and mental
incompetence: the case of "Eve"
Corinne Sklar
34
Letting go
Sheila Parrish
20
CNJ s 75th anniversary
A capsule history of your journal
A little crystal ball gazing
38
When experience counts
Sylvia Segal
26
Guillain-Barre Syndrome
Laura Barry
40
A postpartum program that works
Kathleen Freeman
30
The Birth Room
Ellen L. Rosen
43
Institutkmalization
Barbara Haynes
33
An open letter to the nurses of Canada
Jane Melville White
46
Legionnaire s disease: an old
with a new name
ErnaJ. Schilder
enemy
5
Perspective
9 News
\\ CNA annual
meeting/convention
6
Input
1J Calendar
54 Books
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Canadian Nurses Association, 1980.
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Mirror, Mirror on the Wall
A look at nursing s image - now and in the future
The stereotypes are
everywhere: on the soap
operas of daytime television,
nurses are damp-eyed
creatures who pine for the
love of the nearest eligible
doctor; a television
commercial several years ago
advertising a well-known
toilet bowl cleaner featured an
actress dressed as a nurse
claiming, "We don t fool
around, we use a
professional!"; heart-throb
fiction churned out by the
paperback thousands centers
on nurse-heroines in love with
doctors who remain oblivious
to their charms. A movie
theatre in Hull, Quebec,
features a film entitled "Des
infirmieres tres privees" (very
private nurses) with the
caption find out what to do
until the doctor comes!
There can t be a nurse
who hasn t seen and been
annoyed by the image of
nurses in the media the
nurse of stage, screen and
paperback is a weak-willed
creature who relies on the
doctor for direction, both
personal and professional, and
whose only real aim in life is
to find some nice man, get
married and have children.
We don t believe in these
stereotypes, but does the
average member of the
public?Do doctors? Several
recent studies say no.
A study in the United
States quizzed a number of
people about what they
thought nurses jobs really
involved and how much
education they had to have.
The result was, according to
Nursing Outlook, "the public
as represented by these
respondents generally
believed that nurses are better
educated than they actually
are." An informal survey
conducted by Nursing last
year asked doctors and nurses
for their opinions on the
nursing profession and came
to the somewhat startling
conclusion that doctors often
have a higher opinion of
nurses than nurses do. One
statement the nurses made
was doctors don t have the
slightest idea of the care we
give, adding that they thought
they spent more than 50 per
cent of their time doing direct
patient care. The doctors
surveyed agreed. Countering
the assumption that doctors
viewed nurses as assistants,
not colleagues, was the
information that the 225
doctors surveyed ranked
nurses higher in their esteem
than the other helping
professions such as
pharmacists, dietitians or
hospital administrators.
What does all this mean?
That nursing doth protest too
much ?
The roots of nurses
rather discouraging tendency
to downgrade their own
profession probably lie in the
history of the nursing
profession as a whole. It is
true that the first nurses were
often prostitutes or at least
vulgar women who did not
mind doing physical tasks for
other people. It is also true
that the profession has
traditionally been made up
chiefly of women. This
explains a great deal. As
Marjorie Keller wrote in her
essay on the effect of sexual
stereotyping on the
development of nursing
theory, the stereotype has
been that women s work was
non-intellectual and centered
in practice: "Perhaps nursing
was long considered a practice
discipline not only because it
was practiced by women, but
also because it was slow to
move into universities." She
added that women have
historically tended to
downgrade or underplay their
intellectual abilities and to
display "excessive humility".
True enough, many a
nurse can recall being
discouraged by her family and
friends from going into
nursing because of the feeling
that she would be wasting her
intellect "You re too smart
to be a nurse." Denise Benton
wrote in "You Want to Be
a What?" that "nursing has a
history of attracting applicants
by a passive rather than active
choice."
It does not help that
nursing itself is divided today
on the question of what
nursing really is. Many feel
that the only real nursing is
direct bedside care of the sick;
others see the development of
nursing theory and research as
a priority . There is some
suggestion that the nurses
produced by the educational
systems today are not as
good as in the old days, that
they do not have the same
sense of devotion or
dedication. If this is true, is it
the fault of nursing programs,
or merely a reflection of the
kind of people going into them
today? As one nurse admitted,
no young woman in her right
mind would volunteer today
for the hospital-based
programs of twenty years ago
(ten?).
The profession has
undergone enormous changes;
it will probably see many
more. It must if it is to
survive, say many educators.
An excerpt from the book
Nurse by Peggy Anderson
telescopes the
metamorphosis:
"Another problem for
many nurses is that nursing is
undefined. What is a nurse?
Nurses have been debating
that question for years. A
nurse used to be a physician s
handmaiden. My husband s
grandfather... remembered a
time when nurses stood up
and saluted doctors. Central s
director of nursing, a woman
in her forties, remembers the
days when nurses had to stand
and give doctors their chairs
when they came into the
nurses stations.
"This attitude has not
disappeared. But nurses are
stepping out of that
mold. ..Many nurses want to
bring their own intelligence to
the job and are becoming
more aggressive about doing
so. I think a nurse must make
decisions that affect what
she s doing. If she s a robot,
she s nothing."
There are many nurses
who welcome this change and
the accompanying increase in
responsibility, but there are
others who are content to just
do the job . grouse about how
little the public and doctors
seem to think of nurses, and
go home to their social lives.
There are those who actually
impose negative sanctions on
their colleagues who want to
improve themselves or who
have an obvious need to learn.
A staff nurse tells of how she
was discouraged by other
nurses on her floor from going
to see a cardiac
catheterization with one of her
patients; she had never seen
one and it was quite a
common procedure on her
unit. Her colleagues asked,
"What do you want to do that
for?", and the head nurse was
reluctant to grant her the time
off the ward. Benton
emphasizes this in her paper,
saying that nurses tend to
exert pressure which "serves
to deny individual nurses
rights and responsibilities to
develop their interests and
abilities to their fullest
potential, for the ultimate
benefit of the health care
consumer."
Alice Baumgart, dean of
Queens University s School
of Nursing, made note of this
idea in a speech to the RN AO
last year, and added that
nurses need to support each
other through informal
networks to help build and
reinforce professional
identity.
It is clear then, for
whatever reasons, that the
blurred image of the nurse
reflected in popular literature
and television is perhaps a
reflection of how nurses still
see themselves someone
who is there, who can be
molded into whatever the
situation requires of her. but
whose aims and personal
goals may not always be
apparent.
"Nursing is changing,
and we can make it whatever
we want it to be," Principal
Nursing Officer Josephine
Flaherty told nurses at CNA s
Nursing Education Forum last
year. Her words might serve
as a guideline for nurses in the
years to come: if it s an image
change we want, we re the
only ones who can do it.*
Jane Bock
input
Help for D.S. parents
As a nurse with a
woyear-old foster Down s
yndrome child, I must
commend The Canadian
Nlurse for publishing an
up-to-date report on a
syndrome surrounded by
)re-conceived prejudices. I m
sorry it didn t appear sooner!
Living in a remote region
of B.C. , we have had to
actively look for the support
services and resources to help
us care for the baby we ve had
since the age of three weeks.
As recently as 1977, we were
given information that
emphasized the negative
rather than the positive
aspects ofD.S.; his parents
received little encouragement
to keep him.
We heard about the
Experimental Education
Unit s work with Down s
Syndrome at the University of
Washington, Seattle and the
information and
encouragement obtained
from them has been
invaluable; I would highly
recommend contact with this
model program for any new
parent with aD.S. baby.
Our active two-year-old
has developed into a curious
little boy who is a pleasure to
know and work with. Early
education intervention does
make a difference, and there is
indeed a "new image" of
Down s Syndrome.
5. Coolbaugh, RN, Fernie,
B.C.
Saints or sinners
It is with great pain and
distress I read about the
situation in Ontario ("You
and the law" November);
thank you for bringing it to my
attention.
For me it epitomises the
problem of hospital nursing
we the caregivers are
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Your graduation school
impotent "mops" for all the
wrongs in the health care
delivery system.
Any nurse who wishes to
stay (in the hospital situation)
in a so-called profession
which prevents her/him from
executing her/his trained
beliefs and acquired related
knowledge is either a
masochist, a victim of sex role
stereotyping or really into the
"plug inforapaycheque"
mentality.
I say to the I.C. U. nurses
of Mount Sinai "right on" and
to the Canadian N urses
Association "wake up now"
to the parody of a profession.
Helen L. Morgan, Victoria,
B.C.
\ labor of love
Midwifery has long been
recognized as a specialized
facet of nursing as evidenced
through the additional studies,
training and practice required.
Employers, through
specifications in their
advertisements for staff, also
recognize it. Yet the
remuneration for such
service, awarded by all of the
major hospitals in this city, is
a paltry $2. 15 per week on top
of our regular salary .
Midwives in northern
areas of our country, where
doctors are not readily
available, provide complete
medical attention throughout
the maternity cycle. In our
high risk maternity case
rooms, and in most delivery
suites in Edmonton, the
nurse/midwife supervises
both normal and complicated
labors; she institutes required
preventive or remedial
measures and, when the
doctor is absent, acts in
emergencies.
Our employment requires
shift work and irregular days
off, work hours that are only
required of those providing
emergency services.
Fortunately recompense
is obtainable in the knowledge
that we provide an essential
service, in friendships formed
with co-workers and in the
acknowledgements of our
patients. The extra
remuneration probably would
not excite the newspaper
delivery boy.
Perhaps the time has
come for a concerted effort on
our part. Are we
over-emphasizing
professionalism at the
expense of obtaining recourse
for our grievances?
Judy Rogers, RN,
Edmonton, Alberta.
Realities of motherhood
I thought that readers of
your audiovisual page might
be interested in learning of a
slide-tape presentation I
produced last year during the
International Year of the Child .
As an occupational
therapist, I have worked with
burned and battered babies
and been saddened to see the
anger and blame their young
mothers are subjected to by
medical and paramedical staff
in hospitals. It is seldom
anyone focuses on her as a
desperate, lonely and
neglected person.
I wondered how to
prevent this situation and, as a
result, produced a
photo-essay on the realities of
motherhood which I have
titled "Raising kids is hard:
when you re alone it s harder."
The slide-tape
presentation is intended
primarily for unwed mothers
who must decide whether or
not to keep their baby . It is
now being used by Terra, an
association assisting unwed
mothers, whose members
helped me produce the
slide-tape. The purchase price
for the package is $80
(including 100 slides, cassette
and script); rental fee is $12,
plus $4 for postage and
insurance.
If your group wishes to
buy a copy but lacks funds,
might I suggest approaching a
service club in your
community such as Rotary or
Kinsmen.
For more information,
write: Mufty Mathewson,
BPT,OT Reg. ,10322-132
Street, Edmonton, Alta.,
T5N 1ZI.
6 March 1980
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input
U of A Postscript
I was very pleased to note
the summary of university
programs for RN s in the
January issue, and would just
like to add, for the record, that
some courses taken at
Athabasca University are
transferable to The University
of Alberta s Post-RN
Program.
AmyE. Zelmer, PhD, Dean,
Faculty of Nursing.
A non-traditional route
I sincerely hope that the
person who compiled "Your
guide to Post-RN University
Programs in Canada"
(January), did not
intentionally disregard the
many innovative and valuable
certificate programs being
offered to nurses by
community colleges which are
flexible and innovative
enough to respond to the
needs of Canadian nurses who
are becoming more adamant
in demanding post-RN
educational opportunities
specific to their specialized
area of nursing.
1 hope that a similar
article in the near future can
be done on college-based
programs, or at least some
form of recognition for what is
being done in other than the
traditional university
programs (some of which
haven t changed their content,
faculty, or presentation
format in twenty years).
1 think that all nurse
educators fully realized that
university-based programs are
more prestigious and of higher
status than their "poor
country" cousins, the
colleges. 1 urge you to give
equal space to some of the
newly developing programs
such as the Co-operative
College Program For
Occupational Health Nurses
in the metro-Toronto area.
Yes, even we in the West are
involved in some new
off-campus delivery programs
such as the Occupational
Health Nursing Certificate
Program offered by Grant
MacEwan Community
College in Edmonton and
Calgary, and the Extended
Care Program developed by
the same college. The latter
will soon be available to
nurses on a distance delivery
method which allows nurses
who cannot attend lectures
nine to five, Monday to
Friday, to participate in
post-RN education.
I look forward to articles
that will dispel the myth that
only universities offer
post-RN education.
LizDawson, RN, M.Ed.,
Program Head, Occupational
Health Nursing Certificate
Program, Grant MacEwan
College, Edmonton, Alt a.
Editor s note:/! complete list
of all the programs offered by
community colleges across
Canada would obviously be
too vast an undertaking for
our limited resources.
Security is...
Jo Logan s article
(January 1980) is both
thought-provoking and
mind-boggling. She tells
nurses that they are
handmaidens to other
members of the health
inter-disciplinary team
doctors, pharmacists, social
workers, physiotherapists,
occupational therapists and
dieticians because most of
them do not have a
university-based education.
She supports her position
with a few personal examples.
If anecdotes can lead to
generalization, then I can
safely state that nurses are far
from being handmaidens. I
myself have witnessed nurses
telling other health
professionals where to "get
off or "go and fly a kite".
If our insecurity is so
intense and we keep telling
ourselves that our salvation as
a profession lies in a
university degree, it will not
be long before this insane,
poorly documented notion
becomes reality.
In all the years I have
been a professional nurse, I
have never heard a remark
made to this effect by doctors
or other members of the
health team. What in God s
name is wrong with nursing?
Nurses as a group of
highly trained professionals
are respected and they know
it . I do not know of a single
patient who has shown more
respect to a particular nurse
because she graduated from a
university generic program.
Again, no disrespect has been
shown to a nurse by a patient
because she has a diploma
from a hospital-based or
community college program.
Nurses will be respected
solely for the kind of care they
give, knowledge they have
and the attitude with which
they care.
If nurses are
handmaidens, then this also
includes university-prepared
nurses. Logan should explain
to readers how university
nurses have succeeded in not
being handmaidens.
It may be that
professional salvation lies in
university preparation, but, as
we are clamoring for scientific
status, let us use some of that
knowledge to support our
belief.
MohamedH. Rajabally,
RN, EdM, Lecturer, School of
Health Education, Okanagan
College, Kelowna, B.C.
Career highlight
Scanning 1979 CNJ s, I
came across the January issue
with an article entitled "A
New Role for the Psychiatric
Nurse" by Kathy Hegadoren
of Edmonton. Ms. Hegadoren
states that the admittance of
emotionally disturbed
children to a general ward is
an "experiment" and a "new
role for the psychiatric
nurse".
For your readers, I wish
to state that in 1951-54, an
almost identical project was
instigated by child psychiatrist
Dr. Gordon Stephens, M.D.,
at the Children s Hospital,
Winnipeg, and I was the
psychiatric nurse.
In this position I
observed and counselled
children and parents; taught
nurses and interns both
formally and informally; took
social histories; recorded
conferences; gave reports and
home visits, and did much to
change peoples attitudes
regarding the emotionally ill
child and his needs.
This was the first attempt
in Canada to have emotionally
disturbed children treated in a
hospital setting with a
psychiatric nurse. We had a
tremendous success story
which, in retrospect, was the
highlight of my nursing career.
Dorothy (Campbell)
Mulder, RN, RPN, Part-time
supervisor in Geriatrics,
Beacon Hill Lodge, Winnipeg,
Man.
Kudo from afar
I would like to take the
opportunity to say how much
I enjoy reading The Canadian
Nurse, and that it has proved
to be most beneficial to me
throughout my nursing
courses. Thank you.
Tanya Mark, Holder,
Australia.
Nurses in primary care
There seems to be a
rumor at large in the nursing
community that McMaster s
Educational Program for
Nurses in Primary Care
(Nurse Practitioner Program)
has been discontinued.
I am pleased to deny the
rumor and to confirm that the
Ontario Ministry of Colleges
and Universities, with the
support of the Ministry of
Health, has agreed to continue
supporting the program for at
least another year.
The program continues to
receive strong support from
the Faculty of Health
Sciences, McMaster
University.
Mona Callin, Director,
Educational Program for
Nurses in Primary Care.
news
Prevention pays,
PHN tells committee
In December 1979, a
nurse-consultant in southern
Ontario resigned from a
committee set up to study
ways to lower the death rate
of premature and newborn
babies. Her reason for
quitting? The Medical Officer
of Health in Toronto, where
she was working, had refused
to show her dissenting report
to the provincial committee of
which she was a member.
Doreen Hamilton, a nurse
with degrees in sociology and
education and varied
experience in community
health projects, had written a
"minority" report for the
committee showing that an
education program for new
mothers and teenage women
would be effective in the city s
goal of reducing the number of
high risk pregnancies. The
majority report submitted by
the provincial committee, the
University Teaching
Hospitals Association and the
Hospital Council of
Metropolitan Toronto (UTHA
HCMT) had recommended
instead a central
computer-based patient
information registry and had
also advocated improving
neonatal intensive care
facilities in Toronto. The cost
of the proposed program was
estimated at $6 million a year;
comprehensive education
programs would cost about $1
million.
Hamilton stated at the
time that she felt the emphasis
on high technology was an
enormous waste of money and
she favored the introduction
of preventive programs. Also
included in her plan were
subsidized prenatal classes,
genetic counseling studies of
out-of-hospital birthing
centers and the legalization of
midwives.
Recently, CNJ spoke
with Hamilton, who has since
been rehired as a member of
the Task Force for the
Prevention of High Risk
Pregnancies. She referred to
the Healthiest Babies Possible
Program (see CNJ October
1979) which has been running
in Vancouver and as an
experiment in Toronto.
"That s the kind of program
that s needed," she said, and
she remarked that preventive
programs with the emphasis
on education reflected "a
different attitude toward
health care." In Ontario the
Foundation for the Mentally
Retarded recently sponsored
an advertising campaign
focusing on the effects of
pregnant women s habits on
unborn children, and she said
the success of this campaign
should serve as a lesson to
professionals involved in
public health. "We ve tried
selling beer on television and
we know that works, why not
sell health too?"
The controversy will not
be resolved until after
Hamilton and the new task
force submit their report to
the Toronto Board of Health
at the end of April this year,
but clearly the report will
recommend preventive
programs which will limit the
number of high risk births
rather than estimate and plan
for a large number of high risk
infants to be born in the city.
Asked for her views on
nurses becoming more
politically active and getting
involved in the actual decision
making in health care policies,
Hamilton pointed out that
this, while desirable, was
difficult: "It s probably easier
to do as a private person
rather than as a nurse," she
said. "As a nurse you re
always working/or somebody
and you re not really free to
say what you feel. For
instance, I know that a large
number of obstetrical nurses
in this city are not comfortable
with current obstetrical
practices in the hospitals but
they really have no choice."
The Task Force for the
Prevention of High Risk
Pregnancies plans a series of
citizens meetings in the City
of Toronto this spring, and the
health care professionals
involved hope to find out
more about what consumers
really want and expect from
their health care system.
CNF announces
special scholarship
The Canadian Nurses
Foundation has announced
that it will name a nursing
scholarship in memory of
Virginia A. Lindabury, editor
of The Canadian Nurse from
1965 to 1975, who died last
September.
"Throughout her years
with the magazine, she
supported the foundation s
purposes and goals in aid of
nursing scholarship and
helped make the work of the
foundation known to nurses
throughout Canada," Louise
Tod, CNF president said in
announcing the scholarship.
The Registered Nurses
Association of British
Columbia has supported the
foundation s move with a
$10,000 donation in memory
of Virginia; individual nurses
across Canada have also
expressed the wish to donate
to a memorial fund in her
honor.
CNF is the only Canadian
foundation that deals
exclusively with support to
nursing scholars. Since its
inception in 1962, 216 nurses
have benefited from more
than $673, 000 in funding.
Moneys now come mainly
from personal donations and
bequests from individual
nurses and from provincial
nurses associations.
Tax deductible donations
should be sent to the CNF, 50
The Driveway , Ottawa,
Ontario, K2P 1E2.
Health happenings
Who decides the duties of a
nurse working in an
institutional setting?
An Ontario Divisional Court
has ruled that it is hospital
management, rather than the
College of Nurses, the
licencing body in that
province, that has the right to
decide what these duties shall
be. The court has overruled an
Ontario College of Nurses
finding that the director of
nursing at an Ottawa Hospital
performed incompetently in
directing RNA s to carry out
certain functions previously
reserved for registered nurses.
At stake is the key issue
of whether a member of the
management team (such as a
director of nursing) is subject
to discipline by the
disciplinary body of that
profession while acting in an
administrative capacity and
carrying out the duties
attendant on the
administrative function of that
position.
Singer Delia Reese will
perform a benefit concert in
London, Ontario, this Spring
to raise funds for a new
neuro-treatment microscope
for University Hospital in that
city. Reese is recovering from
neurosurgery performed at
University Hospital after she
collapsed during a taping of
Johnny Carson s "Tonight"
show.
A Bonus from RNABC
The RNABC has announced
that funding is available to
RNABC members to develop
post-basic clinical nursing
courses, or to study the need
for such courses. To meet the
association s requirements, a
post-basic course must
prepare nurses to function in
clinical specialties which
require expertise beyond the
basic level.
At the time of writing,
RNABC has provided funds
for the development of three
programs: in Occupational
Health Nursing, Pediatric
Nursing and Obstetrical
Nursing. The association has
budgeted $100,000 for the
total program, and up to $5000
is available for each course.
For more information,
contact Ruth Burstahler,
Continuing Education
Consultant, RNABC, 2130 W.
12th Ave., Vancouver, B.C.,
V6K 2N3.
Some people need
to be cared for. Others
need a chance to care.
Upjohn Healthcare Services
brings them together.
A
In any community, there are people
who need health care at home. There are
also people who want worthwhile part-time
or full-time jobs.
We work to bring them together.
Upjohn HealthCare Services " 1 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 kind of job oppor
tunity. If you do, please pass this message
along. For additional information, com
plete the coupon below, or call our local
office listed in your telephone directory.
UPJOHN
HEALTHCARE
SERVICES SM
Please send me your free brochures (check one or both):
D "Nursing and Home Care"
D "Nursing Opportunities at Upjohn HealthCare Services"
Name
Address Phone
City Province Postal Code
Mail to: Upjohn HealthCare Services
Dept. B
716 Cordon Baker Road, Suite 203
Willowdale, Ontario M2H 3B4
HM 6410-C 1979 HealthCare Services Upjohn, Ltd.
news
Two-way closed circuit TV the next best thing to being there? A
first for nursing is the course in advanced analysis of trends, issues and
problems in nursing that Dr. Shirley Stinson of the University of Alberta is
teaching simultaneously to two groups of students one in Edmonton,
the other 185 miles away at the University of Calgary.
There are 5 M.N. (Master s in Nursing) students in the Edmonton
group and 6 graduate students (nu rses taking a variety of master s
degrees) in the Calgary group.
Each viewer group can see what is being transmitted from their
studio, via two TV screens; through two additional screens they can see
the other group via a "split screen", plus obtain close-ups on a second
screen. Even visual aids as small as the title of a book and
"blackboard-type" writing on the flipchart are readable on the close-up
screens.
Simultaneous visual and audio transmission between Edmonton
and Calgary is via microwave. A direct phone line is also available in the
TV studios and all transmission is as confidential as a phone call.
Occupational health
nurses receive
$95,000
The Ontario Occupational
Health Nurses Association is
$95,000 richer after receiving
a grant from the Ministry of
Labor for the development of
a certification program for
occupational health nurses in
that province.
The award, out of the
Ministry s Provincial Lottery
Funds for ManpowerTraining
and Development, will be
used to develop the various
program components. Target
date for implementation will
be January, 1982.
"Occupational health
nurses have, through their
initiative and commitment,
been granted both an
opportunity and a challenge;
they can be justifiably proud
of this expression of
confidence. " OOHN A
president Madeleine
Wenman, commented, "This
is a tangible recognition of
their efforts to expand their
contribution toward the goal
of reducing the incidence of
injuries and illnesses in the
workplace."
Nurse-midwives
solicit members
The Western Nurse Midwives
Association has announced
their executive for 1980:
president is Peggy Anne Field
of Edmonton, president-elect
is Carolyn Fumalle of
Victoria, B.C. , and the
secretary-treasurer is
Margaret McKenzie of
Edmonton.
The association is
actively canvassing for new
members this year, and invites
inquiries to be sent to the
Association at P.O. Box 4268,
Edmonton, Alberta, T6E 4T3.
The membership committee
chairman is Judy Friend of
Edmonton. *
1Q
Tbt Panafllan tiuut
calendar
March
The Confectionery Manufacturers
Association of Canada is
sponsoring a one-day invitational
seminar on nutrition, including
such topics as the role of nutrition
in competitive sports, new
perspectives on nutrition and
health disorders, the psychology
of eating and the snacking
syndrome. To be held March 10 at
the Four Seasons Hotel in
Toronto. Contact: Jane Hope,
Suite 101. 1185EglintonAve.E.,
Don Mills, Ontario, M3C 3C6.
Continuing Nursing Education
focusing on Nursing and
Geriatrics, a seminar, will be held
March 26 at McMaster
University. Contact: Patricia
Carter, Program Assistant,
Program in Continuing Medical
Education, Room 1M6,
McMaster University, Health
Sciences Center, Hamilton,
Ontario, L8S 4J9.
The Shifting Medical Paradigm:
From Disease Prevention to Health
Promotion, a conference for
health professionals, planners and
consumer advocates, will be held
March 20-21. Contact -.Lifestyles
Programs, Centre for Continuing
Education, 5997 1 ona Drive, The
University of British Columbia
Campus, Vancouver, B.C.,
V6T 2A4.
The Faculty of Nursing and
Extension of the University of
Alberta is offering the following
courses: Teacher Effectiveness in
Nursing, Feb. 28-29; Nursing
Aspects of Intravenous Therapy ,
March 26 or May 5; Management
of Inflammatory Bowel Disease,
AprilTBA; Advanced Obstetrics,
April 21-25; Nursing Management
of Pain, May 16; Introduction to
E.C.G. Interpretation, June TBA.
Contact: Marg Steed, Director,
Continuing Nursing Education,
Faculty of Extension, The
University of Alberta, Corbet!
Hall, Edmonton, Alberta,
T6G 2G4.
April
Respiratory Rehabilitation in the
Eighties is a seminar sponsored by
the York -Toronto Lung
Association on April 2 at the
Royal York Hotel. Pre-register by
March 3. Contact: Nancy
Blackburn, York-Toronto Lung
Association, 157 Willowdale Ave.,
Willo^dale, Ontario, M2N 4Y7.
Clinical Electrocardiology with
Leo Schamroth, M.D..a
workshop for general
practitioners and critical care
nurses will be held on April 10-11,
Dartmouth Inn, Dartmouth, N.S. ;
April 14-15. Park Plaza Hotel,
Toronto, Ontario; and April
21-22, Four Seasons Hotel,
Vancouver, B.C. Contact:
Conference & Seminar Sen ices,
Humber College, P.O. Box 1900,
Rexdale, Ontario, M9W 5L7.
The North West Territories
Registered Nurses Association will
hold its third biennial meeting
April 16-18 in Yellowknife. The
theme will be "Legal Aspects of
Nursing" . Contact: Rusty
Stewart, Secretary, NttTRNA,
Box 2757, Yellowknife, N.W.T.,
XOE I HO.
The Head Injured Patient, a
workshop presented by the
Canadian Association of
Neurological and Neurosurgical
Nurses - Manitoba Chapter, wfll
be held April 15-16. Contact :7Vi<>
Manitoba Association of
Registered Nurses, 647 Broadway
Ave., Winnipeg, Manitoba,
R3C 0X2.
An Extended Care Nursing
Certificate Program designed to
prepare registered nurses to
provide quality care to the aged,
disabled and chronically ill, will
be available by spring, 1980.
Nurses may complete modules at
home by means of individualized
study packages. If you are
interested in the program contact:
JuneGolberg, Acting Program
Head, Extended Care Nursing
Certificate Program, Grant
MacEwan Community College,
Box 1796, Edmonton, Alberta, *
The CNA Audited Financial Statements, which
normally appear in the March issue of this journal, have
been dropped from the 1 980 publication as an economy
measure. The statements will, as usual, be included in the
association s annual meeting and convention report
available to registrants at CNA s annual meeting in
Vancouver, June 22 to 25. In addition, members wishing
to receive a copy of the statements may write to CNA, 50
The Driveway, Ottawa, Ontario, K2P 1E2.
Canadian Nurses Association
annual meeting
and convention
Late news flash
Israeli Nursing Leader
To Deliver Kellogg Lecture
Dr. Lea Zwanger, head of the
Division of Allied Health
Professions in the Ministry of
Health, Tel Aviv, Israel, has
agreed to deliver The Kellogg
Lectureship scheduled for the
opening day of this year s CNA
convention.
Dr. Zwanger s address will
focus on the nurse s role in
delivering primary care, a role that
may be seen as a solution to one
of society s current and emerging
problems in the area of health and
the spiralling costs of health care
in Canada.
In accepting the invitation, Dr.
Zwanger said: "Primary Health
Care - Nursing, is one of my major
educational and service interests.
The statements you provided
about CNA s beliefs fit my own
convictions. Therefore, I hope that
my presentation will reinforce
those of CNA."
Dr. Zwanger who was born in
Jerusalem received her Diploma,
Graduate Nurse from
Henrietta-Szold Hadassah School
of Nursing. She earned her B.Sc.,
MA and EdD from Columbia
University, Teacher s College in
New York City.
PROGRAM HIGHLIGHTS
Sunday
Kellogg Lectureship:
"Primary care nursing"
Wine and cheese reception.
Your host: RNABC
Monday
Keynote address: "Who
shapes nursing in the 80 s?"
Lorine Besel, Royal Victoria
Hospital, Montreal.
Panel presentation:
"Financing health care"
Meet your candidates
Tuesday
Panel discussion: "Labor
movement vis a vis the
professional association"
Dinner and entertainment
Wednesday
Debate: "Continuing
education: should it be voluntary
or mandatory?"
Guest speaker Dave Broadfoot
Member for Kickinghorse Pass,
Renfrew the Mountie, Member of
the Royal Canadian Air Farce and
Canada s Ambassador of
Laughter.
The Canadian. NUTM
March J980 _ 11
Introducing New
they stay twice
Why It s Better
for Baby
Softer surface next to
baby s skin
D Embossed topsheet looks
and feels softer. . . reduces
skin contact and increases
separation of skin from
moisture in pad.
A drier, more
comfortable baby
D Polyester fibre topsheet is
more hydrophobic . . . does
not absorb fluids itself but
encourages passage
through into absorbent
padding below. . .resists
backflow.
D Stronger absorbent pad
with stronger tissue enve
lope... provides 225 percent
more wet strength for a
60 percent reduction in
tearing and shredding.
Proof Positive That Quilted Pampers
Stay Twice as Dry as Cloth
Equal amounts of
water are placed on
each diaper
A blotter is placed
over each wetted
A weight is placed on
each blotter
Quilted Pampers is
twice as dry as cloth
area
Quilted Pampers
as dry as doth
Why
It s Better
for Nurse
and Better
for Mother
Saves time and
work
The superior contain
ment of New Quilted
Pampers versus cloth
benefits both nurses and
mothers with:
D Fewer changes of
bed linen and
baby s clothing.
D More time for
other important
tasks for nurses,
more playtime
with baby for
mothers.
Easier than cloth to
fit and change
A one-piece system
more convenient than
cloth to change and clean
up easy to fit with tape,
not pins.
Pampers
used more often than cloth
in hospital nurseries
For further information write to.
Pampers Professional Services
PO Box 355, Station "A"
YOU AND THE LAW
Consent, sterilization and mental
incompetence: the case of "Eve"
Corinne Sklar
Fearing that her 24-year-old,
physically mature, potentially
sexually active, mentally retarded
daughter, "Eve", might become
pregnant, Mrs. E. applied to the
Court for authorization of consent to
the performance of a tubal ligation on
her daughter. Her application was
denied 1 but the reasons for the denial
are at least as important as the
outcome since the decision champions
the interests of the individual unable
to make the decision himself to
undergo such a procedure. The
observations of the P.E.I. Supreme
Court (Family Division) judge who
heard the case, Mr. Justice C. R.
McQuaid, are noteworthy for their
sensitive and careful examination of
the issues, rights and concerns of both
mother and daughter.
The area of sexual activity is of major
concern to those responsible for the care
and well-being of the mentally retarded.
Unfortunately, the topic generally
becomes charged with an overlay of
individual emotional responses; similar
responses may be precipitated when
teenage sexual activity is under
discussion. 2 Although there is
considerable mythology and
misinformation about the sexuality and
fertility of the mentally retarded and the
potential transmission of genetic defects
to their offspring, there is in fact the
practical problem of what, if any, \
contraceptive measures can be provided
for such a sexually active individual. Jn
many cases, traditional methods of
contraception (oral contraceptives,
I.U.D., foams and creams, etc.) are only
as effective as the user s adherence to
the method selected. Sometimes,
complete supervision of the individual is
necessary to ensure that the method
selected is effective. Because the usual <
contraceptive methods may be
ineffective for retardates, sterilization
may be viewed as the major viable
alternative. Such an approach is indeed
not surprising in a society where
vasectomies and tubal ligations are
frequently sought by competent
Canadian adults in consultation with
their physicians.
Note, however, the use of the key
word "sought": the individual seeks and
consents to the performance of this
surgical procedure upon his or her body.
In the case of "Eve" and others like her,
this ability to give such consent may be
lacking. Can others give consent to such
a procedure on this person s behalf?
How do we balance the interests and
rights of this individual against those of
society or against the concerns of the
individual s family?
^ It is a cardinal principle of the law
that the adult individual has the right to
control his body from invasion and
interference by others: failure to respect
this individual right may result in the
commission of the legal wrong of
battery. If the individual consents to
interference with his body, then the tort
(or wrong) of battery is not committed.
Similarly, if there is legal justification for
the touching (such as in a health- or
life-threatening emergency), then no
wrong is committed. Thus for those
delivering health care, consent or other 1
legal justification are necessary ,
prerequisites to commencing treatment.
This consent may be expressly given or it
may be implied but always, in order for it
to be legally valid, the following
requisites must be present: 3
The consent must be voluntary,
freely given and must be obtained
without misrepresentation or fraud.
The act performed must be
relatively consistent with the act for
which the consent was obtained.
The act for which the consent is
obtained must not in itself be an illegal
act.
The consent must be informed: the
patient must be given sufficient
information regarding the nature and
consequences of the proposed treatment
to permit the patient to come to a
reasoned decision whether to accept or
reject the treatment.
Finally, to give consent the patient
must have the legal capacity to do so
(capacity referring to both age and
mental competence).
Traditionally, it is the mentally
competent adult who may give consent
to treatment. Adulthood is attained at
age 21 (common law age) or at the age of
majority (18 or 19 depending on the
specific provincial legislation
applicable). In the area of medical
treatment, some provinces have enacted
legislation which further lowers the age
of consent, thereby enabling minors
(those under 18 or 19) to give consent to
medical treatment. Thus, for example, in
British Columbia and New Brunswick,
under certain conditions, a minor of 16
may give consent to medical treatment. 4
It is the second aspect of the
prerequisite of capacity that is of
concern here: mental competence. The
law requires that an individual must have
the ability to understand the nature and
effect of the treatment being proposed. If
this ability is lacking either by reason of
age, immaturity or illness or other mental
disability, then those providing health
care must look to others for such
consent. At common law, the persons
having authority to give such consent are
a parent, guardian or the Supreme Court.
The law imposes another safeguard to
protect the person who is unable to give
consent on his own behalf: the procedure -
in question must be therapeutic, that is,
for the benefit of the incompetent
individual.
The person wishing to provide
consent for the incompetent individual
must attempt to place himself in the
position of that person and arrive at the
decision that person would have made if
able to do so. While almost impossible to
do with any high degree of certainty,
nevertheless, this imposes upon the
substitute decision-maker the
responsibility of acting in the best
interests of the incompetent person. In
the case of Eve" , the parent asked the
Court to authorize her consent to her
daughter s sterilization as a
contraceptive measure. The Court
followed the trend of judicial
determination and examined the
proposed procedure in the light of its
inherent benefit to the individual "Eve".
Since there is no specific legislative
authority permitting such sterilization, it
was held that sterilization of a mentally
incompetent person solely for the
purpose of contraception is not a
therapeutic procedure justifying the
Court s authorization of the consent of
another to its performance.
The case of "Eve"
Eve (a pseudonym designated by the
Court) is moderately retarded. The Court
was told that she is an individual "having
some limited learning skills".
She suffers from extreme expressive
aphasia, making her unable to
communicate to others any thoughts or
concepts she might perceive inwardly.
No one knows, therefore, whether Eve
has inwardly perceived a thought or
concept , nor her degree of understanding
of this idea or concept. The retardation
further compounds this difficulty.
Eve attends a school for retarded
adults during the week and lives at home
with her mother on weekends. Her
mother, Mrs. E., is a widow, nearing60
years of age. At school, Eve developed a
close relationship with another student, a
young man. On being informed of this
situation, Mrs. E. became concerned
that Eve could become pregnant and that
she would therefore have the
responsibility of any child born to her
daughter. At Mrs. E. s age, and in her
circumstances, such a responsibility
would present overwhelming difficulty.
Thus, Mrs. E. instituted this application
to the Court. In considering these facts
the Court was sympathetic to the bona
fide concerns of this mother for the
well-being of her daughter and the
potentially harmful emotional effects of a
pregnancy and subsequent birth upon
Eve. Eve would have no concept of
either the idea of marriage or of the cause
and effect relationship between sexual
activity, pregnancy and birth. While Eve
might be able to care for a child under
close supervision, she would have no
concept of motherhood other than in a
mechanical sense.
Before considering the legal
principles involved, Mr. Justice
McQuaid examined specific evidence
and concluded that Eve was incapable of
providing informed consent and would
be unable to undertake effective
alternate means of birth control. It was
also established that the psychological
effect upon Eve of such a procedure
would probably be minimal.
The decision reviewed the basic
legal principles regarding consent to
medical treatment, the judge indicating
the "gray area" surrounding the
question of consent on behalf of a
mentally incompetent individual. While
valid substitute consent could be given
for a strictly therapeutic procedure on
behalf of the retardate (e.g. consent IOP&
an appendectomy), the nature of this >
proposed treatment demanded stringent
consideration.
His Lordship quoted from the case
of Murray v. McMurchy:* (In that case,
while delivering a young woman by
Cesarean section, the physician
observed fibroid tumors in the patient s
uterus and proceeded to tie off her
Fallopian tubes. Because there was no
evidence of emergency in the situation,
the Court held that such a drastic
procedure should not have been
undertaken without prior discussion with
and the consent of the patient. The
doctor was found liable for exceeding the
patient s consent.)
"We get tremendous satisfaction
from doing our jobs well
It s more than worth the effort
we put in?
Suzanne and Larry knew that working as a flight atten
dant meant taking on a lot of responsibility and hard
work. But they were confident they could meet the
challenges. And they were right.
What got them their jobs was not simply the fact that
they met our basic criteria. Suzanne and Larry displayed
the important "extras" we look for in candidates. They are
both self-starters with outgoing personalities and a real
desire to provide a high standard of customer service.
It s people like them who make us one of the world s
leading airlines. And the rewards pf the job in every
sense make them proud to work with us.
If you think a career as flight attendant offers the kind
of challenge and job satisfaction you re looking for, take
a close look at the minimum requirements listed below.
Then, only if you meet them all, write to: Air Canada, Cabin
Personnel Employment Office, P.O. Box 11,000, Dorval
Airport, Dorval, P.O. H4Y 1B6.
In return we ll send you our brochure, together with
a detailed application form that lets you tell us what you
have to offer.
Canadian citizen or landed immigrant
High school graduate or equivalent
Minimum one year permanent work experience, or one
year post-secondary education in lieu thereof
Willing and able to relocate
High standard of appearance; excellent health and
stamina
Unaided vision should not be below 6/15 (20/50) in each
eye. Glasses not permitted. Contact lenses are accept
able provided visual acuity is not weaker than 6/30
(20/100) uncorrected in each eye. You may wish to
check with your eye care specialist
158.7 cm (5 2")-186.8 cm (6 1 ") height (without shoes),
with weight in proportion
Must be able to interact and work effectively with people,
sometimes under difficult and stressful circumstances.
Al R CANADA
"/r must be remembered that the effect
of the procedure here was to deprive the
plaintiff of the possible fulfillment of one
of the greatest powers and privileges of
her life."
His Lordship stressed the scrupulous
caution that must be taken before
similarly depriving Eve even though she
might not be able to understand and fully
appreciate that fulfillment and privilege. 6
On consideration of the legality in
general of sterilization for contraceptive
purposes, His Lordship concluded that
such sterilization is not illegal if the
patient voluntarily agrees to the
procedure, if the consent is informed and
if there is found a benefit to the patient
having regard to either the patient s
health or to other justifiable reasons, eg.
socio-economic factors. 7 While such
surgery may be necessary to preserve or
protect life or health, it may also be
legally undertaken to preserve the
quality of life of the patient. This was the
result inCataford v. Morea, 8 acase in
which the plaintiff sued when the tubal
ligation performed after the birth of her
tenth child was faulty and she
subsequently delivered an eleventh
child. However, Mr. Justice McQuaid
cautioned that purely contraceptive
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Dorval, Quebec
sterilization, even with consent, may not
necessarily be legal in all situations. As
always, the facts of each case are
determinative.
The permanence of this
non-therapeutic procedure was the major
concern of His Lordship. He considered
the English case of Re D (a Minor). D
was a retarded child suffering from Sotos
Syndrome. Her parents had decided to
have her sterilized at age 18 to prevent
her having children who might also be so
afflicted. Their family physician
concurred in their views. WhenD
reached puberty at age 10, the family
sought to have her sterilized at once. The
Court denied the application, stating that
sterilization involves the deprivation of a
woman s basic human right, the right to
reproduce, and performance of such a
procedure for non-therapeutic reasons
without her consent would constitute a
violation of that right. In that case, the
evidence was that while D presently was
unable to appreciate the nature and
consequences of this procedure because
of her age ( 1 1 years), there was a strong
likelihood that she would be able to
understand its implications when she
reached 18. The Court refused to deny
her the opportunity and right to make
this choice on her own behalf in later
years. The Court further stated that any
decision to undergo surgical sterilization
for non-therapeutic purposes was not
solely within the clinical judgment of a
physician." Here Mr. Justice McQuaid
found that the test of the therapeutic
benefit of such a procedure is neither the
subjective view of parents nor the
clinical judgment of a physician. An
objective position with regard to benefit
must be taken.
In the case of Eve, the request for
court authorization of the consent
invoked the traditional jurisdiction of the
Court s&parens patriae, that protective
responsibility toward the Queen s
subjects (i.e. the State) which is
delegated to the Courts by the State.
This protection is given to those who are
unable to take care of themselves and is
exercised where injury has occurred or
where there exists a likelihood of harm
occurring. His Lordship quoted from the
words of Lord Eldon in 1827:
. . .and it has always been the principle
of this Court not to risk the incurring of
damage to children which it cannot
repair, but rather to prevent the damage
from being done.. . " "
Because of the irreversible nature of
sterilization, the denial to Eve of her
fundamental human rights, and the
possibility of future medical remedy for
Eve, His Lordship concluded that the
Court did not have the authority or
jurisdiction to authorize a surgical
procedure such as sterilization for purely
(Continued on page 52)
There is only one Butterfly.
ABBOTT
Texts they ll learn from noi
Dorothy A. Mereness
Cecelia Monat Taylor
Essentials of
psychiatric
nursing
TENTH EDITION
10th Edition
ESSENTIALS OF
PSYCHIATRIC
NURSING
By Dorothy A. Mereness,
R.N., Ed.D. and Cecelia Monat
Taylor, R.N., MA
Updated, revised and
reorganized, this comprehen
sive text emphasizes the
community health movement
and discusses the nurse s
expanded role in various
mental health settings and
interpersonally based treat
ment modalities. It includes
timely information on crisis
therapy, intervention, and
psychosomatic illness. Two
revised chapters help students
better understand the psycho-
dynamics of observed behavior.
Several case studies are also
new to this 10th edition.
1978. 614 pages. 11 illus
trations. Price. S20.50.
7th Edition
PSYCHIATRIC
NURSING
By Mary Topalis, R.N., Ed.D.
and Donna Conant Aguilera,
R.N., Ph.D., F.AAN.
Now in an extensively
revised and updated edition,
this comprehensive text reflects
the growing emphasis on
community mental health and
explores the nurse s expanded
role. Two new chapters
consider modern psycho-
therapeutic techniques/
applications and patients with
antisocial behavior patterns.
Students will also find new
material on crisis intervention,
community psychiatry, and
suicidal behavior, along with 16
helpful case studies.
1978. 460 pages, 4 illustra
tions. Price, 816.75.
A New Book!
PRINCIPLES AND
PRACTICE OF
PSYCHIATRIC
NURSING
By Gail Wiscarz Stuart, R.N.,
M.S.. C.S. and Sandra J.
Sundeen, R.N., M.S.: with 15
contributors.
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,
disruptions in the communi
cation process, grief, etc.
Various therapeutic modalities
presently in use are the focus in
Part II. These topics reflect the
comparatively independent and
expanded role of today s
psychiatric nurse. The authors
stress nursing interventions
and application of the nursing
process throughout. Selected
bibliographies and the latest
research findings assist
students with further study.
April. 1979. 656 pages. 24
illustrations. Price. S20.50.
11 Mrrh 1QIU1
. . and refer to later.
3rd Edition
CRISIS
INTERVENTION:
Theory and
Methodology
By Donna C. Aguilera. R.N..
Ph.D.. FAA.N. and Janice M.
Messick. R.N.. M.S., FAA.N.
This widely used text
thoroughly describes the
evolution of crisis intervention
methodology and uses: explores
differences in psychothera-
peutic techniques: and provides
an overview of therapeutic
groups. The authors also
discuss sociological factors
adversely influencing the
psychotherapeutic process: the
problem solving process:
stressful events precipitating
crisis: and changes during
maturation.
1978. 206 pages, 16 illus-
trations. Price. S 1 2.00.
A New Book!
COMMUNITY
MENTAL HEALTH
NURSING:
An Ecological Perspective
By Jeanette Lancaster. R.N..
Ph.D.
This new book uses a unique
ecologically- oriented approach
to describe various interventions
with populations and clients.
Discussions cover high risk
populations plus innovative
treatment modalities.
January. 1980.Approx. 320
pages. 31 illustrations. About
SI 3.25.
Community
health care
and the
nursing process
Margot Joan Fromer
A New Book!
FAMILY-CENTERED
COMMUNITY
NURSING:
A Sociocultural
Framework, Volume II
Edited by Adlna M. Reinhardt
Ph.D. and Mildred D. Quinn, R.N..
M.S.: with 27 contributors.
The original articles
presented in this new volume
reflect the growing importance
of the community health nurse
and offer valuable insights into
wide ranging areas of the field.
The contributors are all active
practitioners and educators
and the articles focus on
current opportunities, cultural
influences affecting care at the
community level, services
specific to today s society, and
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April. 1980.Approx.272
pages. 1 3 illustrations. About
812.75.
Current practice in
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community nursing
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COMMUNITY
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By Margot Joan Fromer.
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contributors.
Help your students stay
informed of the exciting new
changes In community health
nursing with this comprehen
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provide a holistic view of
human development by
stressing three basic concepts:
the health-illness continuum:
humankind as an open system
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and the effects of various
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and stressors on the health and
development of the individual,
family and community.
1979. 484 pages. 110
illustrations. Price. SI 9.25.
ANewBookJ
THE CHRONICALLY
DISTRESSED
CLIENT:
A Model for
Intervention in the
Community
By Frances Power Rowan.
R.N..M.S.
Your students can deal more
effectively with chronic
psychiatric clients In the
community with this prag
matic text! Organized around
the nursing process, it features
actual case studies to present
usable guidelines for devel
oping and implementing new
coping behaviors. For each, the
author includes complete
information on assessment,
diagnosis, intervention and
evaluation. Particularly inter
esting chapters provide an
overview of the nursing process
. , . outline a rationale for
intervention and approaches to
client care . . . and show "how
to" evaluate results.
January. 1980. 232 pages.
About SI 1.50.
ASP022
Because practical information never loses its usefulness.
TH Panni-Unr-i Kin ma
A capsule history of your journal
The need to communicate has been the motivating force behind the development of newspapers, magazines and
journals of all types. Depending on the nature of the information to be communicated, the publication may become
specialized and develop specific aims but the simple hunger of the people to know what others with similar interests
are doing is always the underlying if unspoken raison d etre."
Margaret E. Kerr, editor The Canadian Nurse
1905 The first, 32-page issue of The Canadian Nurse
appears, largely at the instigation of Mary Agnes Snively,
Toronto General Hospital superintendent of nurses. Sponsored
by theTGH alumnae, the operation is in the hands of a business
firm, Commercial Press. A member of the medical profession,
Dr. Helen McMurchy, is chosen to act as editor on a part-time
basis, a move calculated to deflect criticism being voiced by
doctors who were "at a loss to understand this show of
independent thinking". Journal policy is governed by an
editorial board composed entirely of nurses and a registered
nurse, M. Christie, is named business manager.
1907 The Canadian Nurse goes monthly.
1910 In May, Bella Crosby, a graduate nurse, is appointed
associate editor part-time of The Canadian Nurse. Crosby
begins to meet with nurses throughout Ontario and in Montreal
to stress the national character of the journal and solicit
support.
1916 The Canadian Nurse is purchased by the Canadian
National Association of Trained Nurses (later to become the
Canadian Nurses Association). The editor of the journal is
Helen Randall, a graduate of the Royal Victoria Hospital in
Montreal. Subscribers now number 1,800.
1924 Randall resigns, with the subscription list at 1,950.
Jean S. Wilson becomes executive director of CN A and editor
of The Canadian N urse .
1932 CNA headquarters moves to Montreal from
Winnipeg.
The Canadian Nurse
A QUARTERLY JOURNAL FOR THE NURSING PROFESSION IN CANADA
VOL. I. TORONTO, MARCH, 1905.
No. 1
THE CANADIAN NURSE will be devoted
to the interests of the nursing profession
in Canada. It is the hope of its founders
that this magazine may aid in uniting and
uplifting the profession and in keeping
alive that esprit de corps and desire to
grow better and wiser in work and life
which should always remain to us a daily
ideal.
For the protection of the public and
for the improvement of the profession
THE CANADIAN NURSE will advocate
legislation to enable properly qualified
nurses to be registered by law.
Vol.1, No.1, The Canadian Nurse,
March, 1905.
Mary Agnes Snively
Lady superintendent, Toronto General Hospital
20 March 198O
The Canadian Nurse
1933 Ethel Johns of the Winnipeg General Hospital is
appointed editor and business manager of The Canadian Nurse,
the first full-time appointment to this position. Johns concern is
with ways to increase subscriptions. She makes changes in the
format of the journal and improvements in advertising
contracts.
1944 - Johns retires; the mailing list stands at 5,000
subscribers. Margaret E. Kerr becomes editor, a position she
will hold for 21 years.
1946 At least one article and all releases from the National
Office, are to be in the French language for every issue of the
journal.
1949 Kerr begins her campaign for subscription through
association fees.
1950 NBARN becomes the first provincial association to
accept a plan to include journal subscriptions in the annual
registration or licensing fee paid by members. Other provinces
follow New Brunswick s lead.
1955 Journal staff is increased to include its first full-time
assistant editor, a circulation manager and advertising manager.
1958 Kerr s title is changed to executive director and
editor of the journal. Editorial advisors are appointed, with each
province appointing one member (two from Quebec).
1959 In June, the first issue ofL infirmiere canadienne is
published. The mailing list stands at:
English: 48,797 subscribers
French: 7,958 subscribers.
1 965 The journal is reaching 1 1 3 countries outside Canada.
Margaret Kerr resigns as editor. The number of subscriptions
has risen to 59,985 (English) and 14,1% (French).
1966 On April 1, the entire CN A operation is centralized in
the new CN A House in Ottawa.
1975 In August, Virginia A. Lindabury, editor of The
Canadian Nurse for the past ten years, resigns, to be succeeded
by the present editor.
1979 In September, official count puts combined
circulation of The Canadian Nurse 3indL infirmiere canadienne
at 132,989. A total of 88,865 nurses in Canada receive copies of
the English edition of the journal. Close to 2,000 copies are
distributed in the U.S. and abroad. *
input
To the Editor Canadian Nurse.
There have been cases where
sickness has come suddenly
in the early part of the day and
the servant has left, "bag and
baggage" before the nurse
could arrive. Other cases also
occur, where the servant
engaged to go to a home,
suspecting the mistress of
becoming a mother soon, will
simply never even let the
mistress know she doesn t
intend to fill her engagement.
These cases make the nurse
see the varied conditions of
work, and she has to be
always on the alert for such
emergencies. Consequently a
nurse must be a capable
housekeeper, cook,
companion, dishwasher, a
general "factotum"; also
giving the requisite amount of
attention her patient demands,
besides keeping an eye on
any children there may be and
seeing they get off to school
and are behaving properly.
All this seems a
tremendous amount of work
not called for by the "nursing
code" but itftas to be done in
the West for the majority of
patients are not in a position to
keep more than one maid of all
work and often not that, and
true woman cannot and will
not see a "home" suffer for
lack of a few extra hours work.
When a nurse goes out of the
city on a case, she finds still
another kind of life. There are
no conveniences in the farm
house, as a rule, and if it is in
the winter time she has to melt
ice for water and will often
have to do the necessary
washing to keep things going
until the farmer can get help,
but I must say the western
farmer is as good as a woman
in the house and can keep
house, cook meals, and do a
hundred things that would be
like "Greek" to an easterner.
A Winnipeg Nurse
What is the solution?
Will some one give information
regarding the system carried
out by the Toronto Registry as
to the payments for nursing
cases, where full fees cannot
be charged? There are quite a
number of patients who are
unable to pay the regular
charge, but who prefer to be
nursed in their own homes
instead of going to the
hospital, and could afford a
graduate nurse providing the
charges were moderate. I am
speaking of the West, where
there are so many young
couples and small families
starting in life, where the
charge of $18 a week is a
terrible drawback, and yet
where the patient could pay a
smaller amount and not feel
under a charity obligation. Of
course, I know many of the
nurses charge $18 for the first
week and give their services
free for say two weeks more,
but that again places the
patient in the "pauper class".
Then, there are some nurses
who take a note of hand with
interest for the full amount,
and it takes years to pay it.
Surely there must be some
solution to the problem of the
wage-earning class to employ
graduate nurses and satisfy
both sides. If there is not
would it not be better for the
graduates to study this class
of patient and solve the
problem of the employment of
"untrained or in experienced
nurses, because their charges
are lower?"
Dear Madam, Our Training
School is yet in its infancy, and
has had difficulties to
overcome incidental to most
beginnings, but promises to do
well. The term of training is for
three years, the age limit 21 to
30. Candidates come for a
month on trial, which may be
extended, and, if necessary,
they sign an agreement for
three years. Our present staff
consists of sixteen nurses,
which number will be doubled
when the new wing now in
contemplation will be finished.
We do not take infectious
cases, but there is a hospital
for infectious diseases just
finished and standing in the
same grounds, to which we
hope to send our nurses for
special training.
We have an X ray
department and a Finsen light
for the treatment of lupus
cases. We get a great variety
of surgical cases, and our
operating theatre is used daily.
Being the only hospital for the
whole island, we have to
refuse cases constantly that
ought to be admitted, and our
number of patients always
equals the number of beds.
With kind regards. Believe me,
yours sincerely,
M. Southcott, Supt. of Nurses.
General Hospital, St. John s,
Newfoundland. <
The Canadian Nurse
Uarr-h 1 Qft/1
books
AILMENTS OF WOMEN AND GIRLS. By
Florence Stacpoole. (Bristol: John Wright
& Co.) 2s.
"Suffering is not woman s necessary
lot." These true and simple words are the
keynote of this book. It is not a book for
children, but for mothers and aunts and
others who are, or ought to be, grown-up.
The author is well known as a lecturer for
the National Health Society and for the
Councils of Technical Education, and in
this book she has stated in clear and
suitable language the principal
physiological facts which women
especially ought to know, and the usual
causes of various ailments from which
many women suffer. We have often
wished for such a book, and there are
many women to whom it would be a help.
There is in the preface a necessary
caution against any attempt at
self-treatment.
SIMPLE LESSONS ON HEALTH, FOR
THE USE OF THE YOUNG. By Sir
Michael Foster, K.C.B., M.P. (London:
Macmillan &Co.) 1s.
From his home at Ninewells, in
England, one of the greatest men of the
age writes a preface to a little book on
health he has prepared for the use of
children in which he tells how he came to
write it. There are four chapters Fresh
Air, Food and Drink, Light,
Cleanliness simple with the simplicity
characteristic of a great mind. This primer
is a model, and we can only thank the
"distinguished friend" who induced Sir
Michael to write it, by objecting to his
"destructive criticism".
(Vol.1, No.4, December, 1905).
TRJjNMRSES
I TO THEIR PATIENTS. >
Junket is a delicious,
;y, healthful dessert
." It can be safely
given to invalids, sick
people, children, dyspeptics
and all people who have weak
tomachs. It will be retained wht
n t ,
laird.
fishing and quick-
itienls like it because it is so dainty and
tlie truest sense of the word Junket is a "Pure
Health Food "consisting as it doesof pure milkand cream
with the addition only ofa small quantity of Rennet Per-
A great varietvof delicious, hrallhful desserts can be
juicltly and easily made with Junket in conduction with
properties of milk be so safely and enjoyably taken.
JUNKET
makes exquisite, velvety ice cream, at small expense. Ten
and flavors to suit the fancy.
For sale by jll leading grocers. If yout grocer doei not
Ve CMR. HANSEN S LABORATORY,
Box 34)7, Little FUJ, H- T.
Nursing practice
"Some makeshifts", Vol.2, No.2. June,
1906.
Preparation of Room. Sometimes an
operation has to be performed in a room
whose walls are covered with a dirty wall
paper which cannot be washed, and
which, if swept, would probably send out
into the air thousands and legions of
bacilli and cocci to infect the wound. To
prevent the dust from flying fill the room
with steam, by putting into it pans or tubs
of hot water, and dropping into them
bricks, almost red hot, this will send out
clouds of steam. Shut the door at once
and keep it closed as long as possible.
Papers spread upon the floor and pinned
or tacked down will, if there is a carpet
which cannot possibly be taken up,
prevent the carpet from being soiled, and
the dust and infection, lodging in the
carpet, from being stirred up by the feet.
"A short historical retrospect,
Montreal General Hospital", Vol.2,
No.1, March, 1906.
Perhaps the great difference that would
strike a stranger on entering the hospital
would be the size of the wards and the
neatness with which they are kept by that
modern institution, the trained nurse. In
my early student days the wards were all
small, none holding more than a dozen
beds, and most much less, and the
nurses or Sarah Gamps I cannot
describe them! Some were good
creatures and motherly bodies, all
uneducated, but mostly kind which
was considered a great desideratum.
The day nurses were fairly good, but the
night nurses were as a rule
untrustworthy. One nurse attended to
three flats, and she often appropriated to
herself the stimulants deemed necessary
to support some sinking patient, and if a
patient was obstreperous he was
strapped down hand and foot to his bed.
How different is the conduct of the ward
now and how carefully each patient is
guarded and cared for, and how strictly
our most minute orders are carried out by
our most zealous and intelligent staff of
nurses.
Now the operating room is presided over
by a nurse who knows more about
asepsis than the surgeon, who is deeply
versed in all kinds of instruments and
their uses, and who knows how to
prepare sutures and ligatures, dressings
and bandages, lotions and antiseptic
paints, so that germs have no place in
her kingdom, but are driven out by her
coadjutor angel, Heat, whose fiery sword
does not drive them to the bottomless pit,
but destroys them utterly.
"Our responsibility re Tuberculosis",
Vol.2, No.1, March, 1906.
The great battle of the twentieth century
against tuberculosis demands the help of
every trained nurse. The average nurse
has very little opportunity for studying
phthisis in its incipient stage owing to
restrictions in many hospitals against
accepting tuberculous cases, and
generally regards a consumptive as an
emaciated, coughing, and hopelessly ill
patient.
Nurses must fully comprehend a few
leading facts about consumption. The
person suffering with tuberculosis may
not be a "patient". He may be a visitor to
the family, or one of the household who
"has a cold that he cannot shake off," or
who "seems to have a slight cough, but
does not think anything of it," or who is
"run down and has indigestion and feels
lazy all the time."
Let the nurse be ready to speak quietly
but firmly and tactfully to the one who has
aroused her attention, and urge him to
see his physician, pointing out that
serious lung trouble may sometimes first
manifest itself in that way. If this were
done throughout the country surely many
and many a man or woman, acting on the
trained nurse s suggestion, would consult
his medical adviser and his disease
would be discovered before his chance of
recovery was gone.
"Count the forceps", Vol.1 , No.3,
September, 1905.
On June 1 st, 1 902, a patient was
admitted to be operated on for an ovarian
cyst. The patient was a woman weighing
one hundred and seventy pounds, and
there were many adhesions. Sutures
were removed on the seventh day, and
patient went home on the twenty-first
day. During the next two years the patient
lost flesh rapidly, was troubled with
constant diarrhea, and had different
medical men to attend her, but without
relief. On June 4th, 1905, patient passed,
per rectum, one handle of an artery
forceps, and on the following week was
brought to the hospital, where a second
incision was made and the other part of
the forceps removed from the intestine.
Patient improved for two days, then died
of post-operative peritonitis.
Some people severely criticize the
nurses for not counting the forceps.
There were four doctors present.
Forceps are now counted in this hospital.
22 March 1980
The Canadian Nurse
Hospital
administration
Volumes could be written on the question
of prevention of waste in hospitals, and
many of us could contribute from our own
practical experience and observation
what would help to lessen the
expenditure, especially for food. Some
hospitals dispose of their food garbage to
contractors for stipulated sums.
In one hospital at least in Canada,
where the white of the egg only is
required for making drinks, the yolk is
consigned to the garbage pail. Waste
willful waste. The yolks should be put in
water and sent daily to the kitchen where
they could be used in the making of
puddings, cakes, salads, omelets, etc.
Waste, breakage, misappropriation.
How can these conditions be remedied or
improved? No amount of worrying or
scolding will improve matters but if the
value is known, then responsibility and
economy will be practised.
Nursing education
In our little training school of ten pupil
nurses we have an admirable course of
lectures, extending over eight months of
each year, and on the following subjects:
Anatomy and physiology, 12; materia
medica and therapeutics, 6; hygiene,
toxicilogy and medicine, 9; surgery, 6;
gynecology, 4: obstetrics, 6, and urinary
analysis, 4.
With one lecture a week, it is obvious
that these cannot all be given in one
session; so my plan is to have them
cover two years. One evening each week
is devoted to class work with the
Superintendent, where the Public School
Anatomy and Physiology, with
Hampton s "Nursing", are the text-books.
This is also the time for talks on ethics,
hospital etiquette and kindred subjects. I
begin each session with the younger
nurses, but all attend except the senior,
who relieve during class. Then on lecture
night the juniors relieve, and all the
second and third-year nurses attend.
One evening each week is thus devoted
to class work, and one to lectures. I find
this plan works out very well.
We have a diet kitchen, but I regret
that I have not yet been able to arrange
for any special instruction in dietetics.
From an Ontario Hospital, "The
Contributors Club", Vol.1, No.3,
September, 1905. *
news
During the early part of April
Winnipeg suffered from a
street car strike which, for a
week, tied up the service, and
was decidedly inconvenient
for the District Nurses and the
Victorian Order Nurse. The
only satisfaction they got out
of it was the fact that the men
cheered them and
encouraged them "to walk",
which was really hard work, as
Winnipeg covers an immense
area.
The Secretary of War, Mr.
Haldane, has been asked in
the House of Commons why
military nurses should not be
allowed to go to dances. Mr.
Haldane explained the evil
effects of late hours. Nurses
have been expressing
themselves in their own paper
to the effect that the
discussion was unnecessary,
as no good nurse on duty
wants to go to balls.
The Training School for
Nurses in connection with the
Hospital for the Insane at
Brockville, has closed its first
year with gratifying success.
Arrangements have been
made to have the
examinations conducted
uniformly with the Asylum
Nurses Branch of the British
Medico-Psychological
Association, so that graduate
nurses will be recognized as
members of the British
Association. This arrangement
will likely be very satisfactory,
and the Brockville institution
deserves credit for taking the
lead in Ontario in securing
recognition to Canadian
nurses who train in this special
work of nursing mental and
nervous cases.
Did you know?
During the past year no less
than 39,223 patients were
treated in the hospitals of
Ontario? There are now 64
public hospitals in Ontario
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Professional Image
Trained nurses are regarded by the
public with very mixed feelings. As a
class their position, and the good they do
in the hospital is now unquestioned,
although individuals may be prejudiced
against some particular nurse and her
ways. But outside the hospital the trained
nurse is still regarded as a not altogether
unmixed blessing, and the public will
need several more years of education
in which, perhaps, proper legislation by
which the standard requirements for
members of the profession will be more
precisely defined, will be of no little
assistance before they can be brought
to thoroughly appreciate her position or
the relative value of the services of the
trained nurse, and those of the untrained
attendant and the well-meaning,
enthusiastic, but untaught amateur.
And after years of toil, after nurses as
individuals, and as a united profession
have shown themselves to be necessary
for the public welfare, it will most
assuredly come about that more and
more people will come to the conclusion
that capability in nursing does not come
by chance, and that a natural liking must
be supplemented by education and
practical training; they will gradually
appreciate the fact that a trained nurse
has spent time, money and much
physical effort in acquiring her education,
that the mental and physical strain of the
work are more arduous than perhaps any
other kind of work done by women, and,
therefore, that this expenditure deserves
suitable recognition at their hands. *
The Canadian Nurs
March 1980 23
A little crystal ball gazing
Nursing in the year 2000 what
will it be like? To find out, CNJ
asked some of today s nurses to
do a little crystal ball gazing and
let us in on what they saw.
Helen Taylor, president of CNA
for the past two years and director
of nursing at Montreal General
Hospital, sees nursing as
changing in response to societal
pressures: "In keeping with the
belief that health is a fundamental
human right and that every person
should have access to a complete
range of health services and
social services from the cradle to
the grave, nurses will be expected
to assume increased
responsibilities as our health care
structures change to meet these
goals. These responsibilities will
include more primary care settings
in which nurses provide
management of therapeutic
regimens, education and
counseling.
"Nurses will also be expected
to take more responsibility for
coordinating care, for promoting
the continuity of care and for
intervening in crises situations. As
more nurses move into a greater
variety of settings family
practice settings both inside and
outside of hospitals, group
practice centers, occupational
health programs they will
become more independent and
will be directly involved in complex
decision making. Nurses will
become more innovative and
creative as they learn community
skills such as consultation,
community organization,
convening of various service
networks, monitoring
environments and collecting and
communicating feedback
information. The nurse
epidemiologist will carve out a
special role for herself.
"As our youth-centered
society becomes more
adult-oriented, attention will focus
more on the needs of the aged
and chronically ill. Emphasis on
acute illness and efficiency will
lessen and more of our efforts will
be directed to control instead of
cure, to management rather than
total recovery. By the year 2000,
the special nursing skills required
for care of the elderly and the
dying will be more fully
appreciated."
Taylor predicts an expanded
role for nurses at all levels of the
health care system: "They will be
planners, administrators,
specialists, generalist
practitioners, teachers, evaluators
and researchers. Nurses will have
even greater responsibility for
utilization and interpretation of
technological monitoring devices
and for functioning in lifesaving
and life-sustaining situations.
Nurse managers, particularly in
hospitals, will have increased
skills in budget control, labor
relations and computer
programming. Nurses will see
their roles overlap more and more
with those of other professions
and will develop increased ability
for interprofessional and
intraprofessional consultation.
Just as their knowledge will need
to be wider and deeper and their
collaboration with others more
sophisticated, attention to
standards and quality will have
increased importance. Basic
baccalaureate preparation for the
professional nurse and continuing
education programs will become
the order of the day."
Sheila Embury of Edmonton, one
of the few nurses in Canada
elected to public office, is a
Member of the Legislative
Assembly of Alberta. She agrees
with the CNA president that
baccalaureate preparation will be
the minimum requirement for entry
to the profession by the year 2000
and predicts that by then one
nurse in ten will have completed
studies at the master s or doctoral
level. (The current figure is one in
140.)
"Educational opportunities
will have expanded so there are
more avenues for health care
workers to move upward:
technicians becoming
professionals and baccalaureate
nurses moving on to graduate
studies, majoring in clinical
specialties and a variety of other
disciplines such as business
administration, computer
sciences, medical technology and
political science."
What about independent
practice, job satisfaction and
salaries? Embury predicts that by
the turn of the century one nurse
in 20 will be in private practice,
working alone or in a clinic,
consulting in direct client care,
conducting home visits and doing
patient teaching.
"After a prolonged and
difficult struggle, some nurses in
some provinces will be permitted
to collect fees from provincial
health care payment schemes.
Salaries will improve, too, as the
competitive market for nurses is
strengthened by the number of
nurses employed by private
enterprise (occupational health).
As salaries improve, there will be
higher patient and client care
standards and greater personal
accountability on the part of each
individual nurse to evaluate her
own care for her clients.
"Job satisfaction will be high
even though we will see a great
deal of mobility across Canada.
Nurses will work a four-day week
(or less). Although salaries will be
higher and nurses will have the
satisfaction of earning more
money, the cost of living will
continue to rise and a higher
proportion of nurses salaries will
go into taxes.
"The practicing nurse in the
year 2000," Embury concludes,
"will be an integral part of the
health care system and will have
attained a correspondingly high
status level as a result of her
professional contributions."
"The key person in making health
care the promotion and
maintenance of healthful lifestyles
and the prevention of illness
accessible, available and
affordable to all." That s how
CNA s executive director, Helen
K. Mussallem. sees the nurse in
the year 2000. Her vision focuses
on "the nurse who is the initial
contact for everyone in her
segment of the community."
Between now and the turn of
the century, Mussallem predicts,
Canadian nurses will recognize
their opportunity and responsibility
to work within the framework of
government policy to expand the
health component and change the
course of events that presently
encourages misuse of illness
centers such as hospitals and
emergency facilities. Working
through their national
organization, nurses will develop a
new model of health services that
are, in fact, "accessible, available
and affordable" to all citizens.
They will be assisted in this effort
by the spirit of government policy
developed following the national
"Health Services Review of
1979".
"The primary health care
facilities of the year 2000 will be
similar in principle to those
envisioned in the early 1 980 s,
except for the fact that they will
also act as education centers for
individuals chosen by their
community to become health care
workers. These workers will assist
the nurse who will be the initial
contact for persons in her
segment of the community.
Eventually, each city block, rural
area and isolated community will
have its own complement of
persons at their elbow who can
provide health guidance and act
as interpreters of service for the
health centers."
The primary health care
programs developed by Canadian
nurses will, Mussallem predicts,
be recognized by countries all
around the world which are
seeking ways of achieving the
target of the World Health
Organization "Health for all by
the year 2000". These
governments will invite Canadian
nurses to assist their own health
personnel in developing and
implementing similar plans in
these countries.
"In this way, by the year
2000, Canadian nurses will have
spent two decades in assisting
with the development of policies
and programs that helped to win
the struggles for universal health
in Canada and abroad."
In a lighter vein. New
Brunswick nurse, Arlee McGee of
Fredericton, tries her hand at
poetry to forecast the fate of
nursing in the year 2000:
"What of the Nightingales of years
that are past,
Human beings who nurtured and
cared?
Can the crystal vial tell us how
they fared?
The nurses of yesterday are in a
broad range
They correlate health with the
stresses of change.
They delve into research and
direct the whole plan.
As Careologist Consultants , they
know about man.
They know about needs,
emotions and fee/ings.
They advise the technicians on all
client dealings.
The picture fades. . . but there s
one more view...
50 The Driveway. What s this?
Something new?
A microwave tower emits to the
nation
Holistic Health from our own TV
station.
Unique public programs appear
every day
Under now famous call letters
TON A"
But the last word goes to CNA
president Helen Taylor who
summed it up this way: "Above all,
wherever nurses work in the year
2000, they will maintain the
essential caring role that has
always been the substance of all
nursing functions and activities." *
24 March 1980
The Canadian Nurse
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Its 47,000 entries give you the current knowledge
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It teaches pronunciation. Phonetic spelling is
given for more than 90% of the main entries, to
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It s also an interpreter. Taber s aids you in
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extensive selection of basic questions in five
languages (Spanish. French. German, Italian.
English) to aid in diagnosis and treatment of
patients with an English language barrier.
Its first aid information gives you the accepted
treatments, a vital time and life saver, along with
the definition of practically every type of accident.
Its helpful nursing procedures facilitate
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Plus these and many other features: etymologies;
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Other nursing dictionaries come and go, but Taber s
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>he
four, 07
Photo courtesy of VancouverGeneral Hos
Laura Barry
Treatment of this often terrifying disease which renders young and healthy
people nearly totally paralyzed for weeks or months is palliative, and depends a
great deal on good nursing care. The author discusses the importance of the
triangle of nurse-patient-family, and how to use this relationship to the utmost
n creative caring.
ht
pla
spe
prac
Guillain-Barre Syndrome is also known
as acute infectious polyneuritis, acute
polyradiculoneuropathy, or the
Landry -Guillain-Barre Syndrome. The
unusual nature of this disease lies in the
fact that it attacks people who are
apparently healthy and vibrant, leaving
them totally dependent on others for
their very existence.
The main factor in the etiology of
this disease seems to be the fact that
there is an unusually high incidence of its
2 Match 1980
The Canadian Nurse
occurrence after a viral infection, or a
patient s receiving influenza vaccine.
However, no real cause and effect
relationship has been established
between the vaccines and
Guillain-Barre. After an infection, the
body could produce antibodies which
attack its own myelin; these antibodies
then attack the nerve roots as they exit
from the dural space, resulting in patchy
degeneration. Lymphocytes accumulate
at these sites and occasionally cause
inflammation great enough to compress
the nerve. Serum proteins transude into
the subarachnoid space and the
cerebrospinal fluid, which produces a
rise in protein in theCSF.
Guillain-Barre Syndrome is not
specific to any one age group: it affects
infants as well as the elderly. Although
no actual figures are cited, most medical
literature states that more males than
females are afflicted.
Onset occurs generally within two
weeks after a viral infection (influenza-
infectious mononucleiosis or an upper
respiratory infection or tonsillitis).
Frequently, the initial complaint is of
"stocking-glove" parasthesia, or of
facial weakness and weakness of the
muscles in the lower extremities. Cranial
nerve involvement occurs in some 50 per
cent of the cases; involvement of the
vagus nerve, the principal
parasympathetic nerve in the body, leads
to widespread autonomic nervous
system dysfunction. -
The syndrome is self-limiting, and
recovery generally begins within two to
three weeks after the disease has reached
its zenith. The recovery process works in
reverse of the disease symptoms; it may
take from six months to a year for a
patient to recover all muscle strength.
Because any disease named a
syndrome is a collection or set of signs
and symptoms that appear with
reasonable consistency, certain criteria
have been established for making the
diagnosis of Guillain-Barre Syndrome.
lheseare: :l
progressive motor weakness of
more than one limb, ranging from
minimal weakness to total muscle
paralysis. Signs of weakness develop
rapidly but cease about four weeks into
the illness.
areflexia.
relative symmetry of symptoms. If
one limb.is affected, the opposite one is
as well.
mild sensory signs or symptoms.
cranial nerve involvement. This
occurs in 50 per cent of patients and is
frequently bilateral.
recovery usually begins two to four
weeks after progression of disease
symptoms has ceased.
autonomic dysfunction, such as
tachycardia or other arrhythmias,
hypertension, postural hypotension all
support the diagnosis.
These are the principal signs of
Guillain-Barre Syndrome, but other
signs may exist in a number of patients:
fever at onset.
severe sensory loss with pain.
progression of symptoms beyond
four weeks.
progression may cease without
recovery.
sphincter function is not usually
affected but in some cases transient
bladder paralysis may occur.
CNS involvement. The disease is
thought to involve only the peripheral
nervous system, but there has been some
evidence of CNS involvement as well.
There are only a few laboratory
diagnostic procedures necessary for the
diagnosis ofGuillain-Barre Syndrome.
Of prime importance is examination of
the cerebrospinal fluid, obtained by
lumbar puncture, for protein levels.
Often the CSF will appear normal, but
the total protein is increased. A white
cell count and sedimentation rate are
useful, but often they will be within
normal limits, unless still affected by the
patient s previous illness. 4 Pulmonary
function tests may be done to assess the
degree of paralysis in respiratory
muscles. Nerve conduction studies too
may determine which nerves are
affected.
Treatment of Guillain-Barre is
palliative and supportive. At this point in
time, there is no known treatment or
drug that can halt the disease process
and speed the patient s recovery.
Steroid therapy has been tried, but
its use is as yet controversial. The
principle behind the use of steroids is
their ability to control autoimmune
response , but the value of this therapy
in Guillain-Barre Syndrome has not been
established.."
Ventilation assistance may be
required depending on the degree of
respiratory embarrassment from
muscular weakness.
One cannot overlook the importance
of good nursing care in the treatment of
patients with this disease: frequent
turning, good skin care, chest
physiotherapy, passive exercises and
accurate monitoring are all of vital
importance.
The nurse-patient-family relationship
The relationship between the nurse, her
patient and the patient s family is
important in the treatment of any disease
and subsequent rehabilitation, but
especially so in Guillain-Barre
Syndrome. Not only must the patients
with this disease endure an intense
physical adjustment, but they must make
a profound psychological one as well.
The patient looks to the nurse to meet
her physical needs just to keep her alive;
Guillain-Barre Syndrome is no less
agonizing for the family. Often they wish
they could trade places and alleviate
their loved one s suffering. They feel
helpless as they watch their spouse,
parent or child go through stages leading
to eventual acceptance, similar to the
five stages of accepting death.
Consider this you are a healthy
young girl. The only recent medical
problem you ve had is a little cold. Now
you have a "pins and needles" sensation
on your hands and feet and are feeling
weak: the doctor is telling you that this
may progress to the point where you
require a tracheotomy and a respirator
just to breathe! You think to yourself
"not me, I m healthy".
It must be a terrifying experience.
You keep denying the fact that you are
suffering from this disease but all the
while you are getting weaker and
weaker. "No, ItCan tBe HappeningTo
Me!"
Unfortunately, the disease
progresses to the point where the patient
can no longer use verbal denial as a
defense mechanism, and anger takes
over: "Why me!?" This anger is a
natural protective mechanism, not a
personal attack on anyone. It is directed
at the disease itself and the nursing staff
must keep this in mind, forif they
interpret the anger as a personal attack,
they will become frustrated with and
resentful of the patient.
The point at which the patient
realizes she cannot control her disease
and that she has no choice but to see it
run its course is when she begins to
bargain with the nurses. The realization
that she has lost control, however,
frequently leads to depression which, in
the case of the patient with
Guillain-Barre Syndrome, can be
overwhelming. The patient needs a great
deal of support, from both nurses,
friends and family, if he or she is to pass
through this stage successfully. Support
doesn t have to be a soliloquy of
encouragement just spending time
with the patient, just touching, are as
effective.
With good nursing care and
emotional support, the patient with
Guillain-Barre Syndrome can reach a
stage of acceptance; hopefully, by this
time the disease will have reached its
zenith and ceased to progress further.
But what exactly makes a good
nurse-patient-family relationship ?
Without some concrete suggestions, this
phrase is just an auspicious-sounding
title for something that may or may not
truly exist. What factors contribute to
the development of a good, therapeutic
nurse -patient-family relationship?
One must look first at what the
nurse contributes. She is an individual, a
person with her own set of moral
standards and values; she has her own
unique ideas of what a nurse should be.
Too often though, the nurse has
unrealistic expectations of herself. She
The Canadian Nursp
tries to be all things to all people and in
the end, drained both physically and
emotionally, she can no longer help the
people she wants to. The nurse fills a
variety of roles: she can be a social
worker, mother, problem-solver and
healer, all in the course of one day.
Unless she looks after her own needs
too, and recognizes the potential drain
on her system, she may become merely a
task-oriented functioning unit an
apathetic frustrated shell.
The patient, second partner in the
relationship, is an individual too and his
or her contributions to the interactions
are affected by his own cultural
background, moral standards, his
perception of disease and by the nature
of the illness itself. Obviously the degree
of alertness or awareness on the part of
the patient is going to be a major
determinant in what he can contribute
to any relationship; a comatose patient
will not be able to contribute a great deal.
The third member of the triangle is
the family whose importance should not
be underestimated. Depending upon the
closeness of the family unit, the family
and the patient can sometimes be
considered as one entity. Frequently
doctors and nurses alike feel as though
they are treating the family as well as the
patient. The family s contribution to the
nurse-patient relationship is immense. At
times, the family can act as a pivotal
point around which the nurse can
function; they may be invaluable as a
source of information, for example. The
family s needs must be considered too
and met in order to promote a
comfortable environment for all
concerned.
By recognizing the importance of
the family unit, the nurse can see how
the family can help or hinder a patient s
acceptance of her condition, how they
can support or undermine the intentions
of the medical and nursing staff. If the
nurse does recognize the family s
importance, then she can use it to her
advantage.
Once the triangular relationship
between nurse, patient and his family has
been recognized and assessed, how does
the nurse caring for the critically ill
patient with Guillain-Barre Syndrome
enhance this relationship to work for the
benefit of the patient?
It has been said that language is
God s gift to man, and certainly, in the
hospital as nowhere else, communication
is of prime importance.
The nurse should converse in a
calm, reassuring manner at all times,
exhibiting not only her professionalism
but the fact that she too is an individual
who cares. While guiding conversation,
she should give opportunity for patient
or family to ask questions; answers
should be as specific as possible, not
broad generalizations that might apply to
anyone. Interactions should be
encouraged, not cut off. Phrases such as
"yes, go on," or repeating what a person
has just said show that the nurse is really
listening and interested in what she has
heard.
Needless to say, it is just as
important for the patient and his family
to be good listeners, but when anxiety
levels are high, understanding and full
comprehension of all that has been said
by nurse or doctor is often difficult to
achieve. Staff should be aware of this,
and be ready to repeat information if
necessary.
Also true is the edict that "actions
speak louder than words". In the
working phase of a good
nurse-patient-family relationship, all
three partners work together toward a
common goal. Although not always the
case, family members are usually eager
to assist in the care of their loved ones.
Helping the nurse with such simple tasks
as the daily bath or making the bed can
make a family member feel that there is
something he or she can do to help, even
in this overwhelming situation. The
family will not feel they have
relinquished ownership of the sick
individual to the hospital.
Nurses tend to react to
Guillain-Barre Syndrome on two levels:
first, from a humanistic point of view, it
is difficult to watch this disease attack a
healthy young person and gradually
render them totally immobile and
dependent upon machines and
care-takers for their survival. Secondly,
nurses look at the illness from a medical
viewpoint, recognizing that the patient is
a challenge to all the nursing skills they
possess. Hopefully, these two different
outlooks can be integrated.
Linda A Case Study
Linda was just 20 years old when she
was admitted to hospital with signs of
Guillain-Barre Syndrome. Her earliest
symptoms were a "pins and needles"
sensation in her legs and arms, feeling of
thickness in her tongue and loss of sense
of taste, nausea and vomiting and
weakness of girdle muscles, all of which
occurred rapidly in a 48-hour period.
Noting her past history, the
admitting physician wrote in her chart
that Linda had had infectious
mononucleiosis five years previously but
had been well until three weeks before
admission when she had caught a cold
which lasted for about two days. One
week before admission she had had a
wisdom tooth or third molar extracted
under local anesthesia.
What follows are excerpts from the
medical progress notes which indicate
the development of Linda s illness.
30/5/77 Patient admitted. On
examination: sensory. Touch
intact; vibration, intact; pinprick.
parasthesia extends 2 inches
above knees and 6 inches above
wrists.
Reflexes decreased both sides,
Babinski not evident. Gait can
no longer walk , too weak .
Motor strength decreased both
sides.
5/6/77 Motor weakness slowly
progressive.
6/6/77 Tracheotomy performed.
7/6/77 Patient put on respirator at 0400
hours due to respiratory distress.
9/6/77Mild improvement of neuro
status.
10/6/77 Gradual improvement of
polyneuropathy beginning. Main
problem now is dependence on
respirator which is probably
psychological.
20/6/77 On assisted ventilation during the
day and on automatic ventilation
at night. She is nervous when off
respirator, has tendency to
hyperventilate.
26/6/77 Continues to improve in muscle
strength in all extremities.
2/7/77 Tracheostomy tube corked.
4/7/77 Tracheostomy removed.
1 5/1 111 Progressing well. Eager to go
home and pushing herself.
22/7/77 Discharged.
In reading these notes, one can see
how Linda s illness followed the pattern
described earlier for the development of
this disease: gradual worsening to a
peak, and then improvement, slow at
first, but soon more dramatic. She was
hospitalized fora total of seven weeks,
during half of which she was almost
completely without voluntary
movement.
After Linda had returned home, I
interviewed her, her family and the staff
nurses on the unit where Linda had been
hospitalized, to discover how the
nurse-patient-family relationship had
figured in her supportive care.
Linda said, "My family played a
very big part in my time in the hospital
and if the family is willing, I think they
should be included in most aspects of
hospitalization..." Herfather
commented that "Our role was
supportive, we could do nothing else.
We wanted to be there at all times and
we felt she wanted us to be there."
For the nurses, an honest appraisal
of the experience led them to admit that
although Linda s hospitalization had
ended successfully, there had in fact
been times when the nurses relationship
with both patient and family had been
strained.
Looking back helped them to
understand what they had done when
things were going well, and what had
caused things to go wrong.
One nurse outlined the problems she
felt important in caring for Linda: she felt
28 March 1980
The Canadian Nurse
frustrated when she was unable to
understand what Linda was trying to tell
her, and she often felt unable to alleviate
her fears. Difficulty in making Linda
physically comfortable was expressed
too, and in helping her to cope with
certain things that had to be done such as
tracheotomy care and suctioning.
Helping the family to understand the
illness and assisting them in coping with
it was another problem. But underlying
all these problems was the very basic and
frightening knowledge that Linda
depended totally on the nursing and
medical staff for survival.
Another nurse listed what she
thought Linda s emotional needs had
been during her illness: there was the
need to talk and to be listened to, to feel
safe, to be free of pain, worry and
fatigue, to feel accepted despite her
condition, and the need to be
independent.
The nurses wished they had had
more conferences about Linda s care: all
the nurses interviewed realized the
importance of these conferences, noting
that they benefit not only patient care,
but meet the nurse s needs as well. By
talking with their peers , nurses come to
realize that it is alright to get angry and
frustrated at times. They realize that
they need not feel guilty about these
feelings and they become aware of the
dangers of always suppressing their ill
feelings. Nurses are human after all, and
everyone has "bad" days; it is
comforting to know that one is not alone.
A nursing conference can give a nurse
the encouragement she needs to go out
and try one more time.
One nurse in particular noted the
fact that the patient withGuillain-Barre
Syndrome requires a consistent
approach from nurses, and in retrospect,
she had a suggestion:
"Perhaps there could have been a core
group of nurses assigned to Linda. For
example, a group of six or eight nurses
could have been selected when Linda
was first admitted. The schedule could
have been planned or the nurses picked
from the rotation so that one of the
special nurses would always have been
on duty."
Other nurses involved in Linda s
care said they had at times felt resentful
of or actually afraid of the family s
presence, but at least one was finally
able to understand the family s position:
7 wanted to make Linda and her family
more at ease and comfortable. I thought
a lot about how I would feel in Linda s
position and came to the conclusion that
I would want the same kind of things
one being my parents near b\."
And, as Linda s father said, the
family wanted to be near Linda too; he
spoke of the hope the nurses gave him
and his wife, and felt the nurse s air of
confidence and faith in Linda s treatment
to be important. It was a time of great
trial for Linda s family:
"Almost instantly it seemed a healthy,
vibrant, aware girl is transformed into a
being that was so immobile she could not
fully close her eyes. Rolling her over was
like trying to move a garbage bag full of
water. A machine was pumping air into
paralyzed lungs. Not only couldn t she
talk, almost all communication came to
a halt.
To the family, this is mind-bending.
It was evident that a trusting
relationship between Linda and her
nurses was necessary for her to be able
to regain her independence, even after
the worst of her illness was over. In the
doctor s notes, her psychological
dependence on the respirator was
well-documented, and the nurses had to
work hard to encourage Linda to wean
herself from the machine. Knowing that
the nurses would not force her to do
anything before she was ready was
important to Linda; they made her feel
that the choice was hers she could
stay off the respirator for as long as she
felt it was possible.
" . . .Nobody wants to stay attached
to a machine forever. When the nurses
explained that the tests showed that I
was strong enough to breathe on m\
own, I didn t want the machine any
more."
What does it all mean?
In a disease likeGuillain-Barre
Syndrome where the treatment can only
be supportive, that basic philosophy of
care applies to both physical and
emotional care. For nurses, this means
not only using basic nursing skills to their
utmost, but developing a good
relationship with the patient and her
family to support everyone through to
the resolution of this frightening illness.
A good nurse-patient-family
relationship can have excellent
therapeutic effects, and it behooves
every nurse to be aware of how she can
foster such relationships.
Linda s father spoke of what he
thought the care given to his daughter
meant:
"Good nursing. ..is enlisting all the
help you can get from the patient, family
and friends, and then with (the nurse) as
the focal point willing the patient to live
with all the strength you can muster. All
of Linda s nurses in Intensive Care did
just that they cared, intensively." *
References
1 Gilroy, John. Medical Neurology.
by JohnGilroy and John S. Meyer. 2nd
ed., Toronto, Collier-Macmillan, 1975,
p. 667.
2 Ibid.
3 *Plum, Fred, (editor) Annals of
neurology, 3:6, June 1978, p. 565-566.
4 Gilroy, op. cit., p. 668.
5 Ibid.
Bibliography
1 * American Association of
Neurosurgical Nurses. Core curriculum
for neurosurgical nursing. Baltimore,
American Association of Neurosurgical
Nurses, 1977.
2 Brunner, Lilian Shohis. Textbook
of medical-surgical nursing, by Lilian
Sholtis Brunner and Doris Smith
Suddarth. 2nded. Philadelphia,
Lippincott, 1970.
3 Carini, Esta. Neurological and
neurosurgical nursing, by Esta Carini
andG. Owens. 6th ed. St. Louis, Mosby,
1974.
4 Erikson,ErikH.C/!/W;?00/
society. New York, Norton, 1964.
5 Gilroy , John. Medical neurology,
by John Gilroy and John S. Meyer, 2nd
ed. Toronto, Collier-MacMillan, 1975.
6 Rubier-Ross, Elisabeth. On death
and dving. Toronto, Collier-MacMillan,
1969.
Lewis, Garland K. Nurse-patient
communication. 2nd ed. Dubuque, Iowa,
Wm.C. Brown, 1973.
8 *Lockerby, Florence K.
Communication for nurses. 3ded. St.
Louis, Mosby, 1968.
9 O Brien, Maureen J.
Communications and relationships in
nursing. St. Louis, Mosby, 1974.
10 * Plum, F red ( editor). Annals of
neurology. 3:6, June 1978.
11 Travelbee, Joyce. Interpersonal
aspects of nursing. Philadelphia, Davis
Co., 1966.
12 Ujhely.Gertrud E. Determinants
of the nurse-patient relationship. New
York, Springer, 1968.
13 .The nurse and her problem
patients. New York, Springer, 1963.
* Unable to verify in CNA Library
Laura Barry is a graduate of George
Brown College in Toronto, St. Michael s
Hospital campus and has recently
completed the post-basic clinical
program in Neurological and
Neurosurgical Nursing at the Montreal
Neurological Hospital. She is currently
working on staff at the MontrealGeneral
Hospital, in the neuro unit.
Implementation of an alternative
. ^ v tmrnam^mm ---
Birth
flpfe mm^ mmmm
Room
Ellen L. Rosen
Last October, CNJ featured a special section called Childbirth Today in which several nurses spoke
of the need for alternate birthing procedures for their patients. Here is how
one hospital with a family-centered philosophy implemented the concept of the Birth Room.
The recent rise in consumer interest in
childbirth practices has led to the
development of several alternative
delivery methods: a small group has
chosen home delivery as their
alternative, but the majority
recognizing that the hospital setting
provides the maximum opportunity for
physical safety and psychological
well-being have been working to
encourage hospital administrators and
physicians to offer a more satisfying
birth experience within the hospital.
3fl.
The rationale for these consumer
demands varies: the most frequent
complaint refers to the sterile
institutional appearance of the average
hospital delivery room which many
patients say increases their anxiety, and
suppresses the natural expression of
emotion in the birth process. Women add
that they feel the excitement of the
moment is sometimes lost in the sterile
environment, and they reject the sick
role inferred in becoming a patient in
hospital.
Another common complaint derives
from the transfer from labor bed to
delivery table necessary in
traditionally-designed labor-delivery
areas. In most hospitals, labor is
managed in one room and delivery in
another; however, this practice
interrupts the continuity of birth.
Practically, mothers find it very difficult
and uncomfortable to move from one bed
to another at a time when they should be
devoting all their energy to the
experience of giving birth.
Complaints in general reflect a
desire on the part of women to have
more control over their labor, and to be
more actively involved in the
management of their labor and birth.
They wish to "deliver" their babies,
rather than to "be delivered of infants.
As a logical extension of the
family-centered philosophy of
maternal-child care of our hospital, the
Victoria Hospital in London, Ontario, a
combined labor/delivery room seemed to
us to be an idea that was worth trying.
Planning
Prior to actually planning the facility, we
had to undertake several pre-planning
activities, including ward conferences
with staff nurses and meetings with the
chief of the obstetrical service and the
nursing service co-ordinator. Their
cooperation was essential and their
response to the idea was enthusiastic.
Additional legwork included calls on
other health care agencies with existing
Birth Rooms and talks with infection
control personnel about logistics.
With a better idea of what was
required, we decided to undertake a
three to six month trial period. We chose
the largest labor room to use as our
alternate Birth Room in this period,
where the patients and their birth
partners would labor, deliver and
recover, all in the same room.
During the trial period, patients
were selected according to the following
criteria:
They must be self-selected: ie.
they must expressly request this type of
delivery and discuss alternatives with the
physician.
They must have completed a
childbirth education course.
They must have had adequate
prenatal care.
They must have a clear
understanding of guidelines for initiating
the move to the delivery room if
necessary.
There must be no evidence of risk
factors.
Presentation must be vertex.
Patients must be prepared for
natural childbirth. Epidural anesthesia
would necessitate delivery in routine
fashion.
Guidelines detailing the philosophy,
criteria and implementation were drafted
and circulated to the nursing and medical
staff; they specified that any patient
requiring fetal monitoring, induction of
labor or any other intervention, was to
be delivered in a traditional delivery
room. However, even with our
guidelines, several conferences and
mock set-ups, there were still problems
to solve after the first few deliveries.
There were questions regarding the
sterile technique and extensive draping
that are the norm in a traditional delivery
room. We stressed the importance of
handwashing and perinea! preparation
but it was decided that extensive draping
of the patient was not necessary . The
nurses continued to set up a sterile
instrument table and gloves were worn
by the physician.
Another problem was related to the
definition of "high risk" and "low risk".
Some physicians were using
Syntocinon* (oxytocin) to augment labor
and did not agree that this disqualified
the patient from delivery in the Birth
Room. Some felt too that artificial
rupture of membranes without the use of
oxytocics was an acceptable means of
induction for patients in this room, while
others believed it disqualified the
patient, based on the criteria outlined in
the guidelines.
The physicians had concerns about
adequate space within the room should
an emergency occur. This turned out to
be a valid point as even with a minimum
of essential equipment in the room, with
father and a nurse and physician, it did
prove to be cramped.
Back to the drawing board
At the end of the trial period, we
evaluated our interim Birth Room based
on feedback received from both patients
and professional staff members involved
in the project.
Records had been kept of each labor
and delivery, and during the trial period,
of the 15 patients who delivered in the
Birth Room, all their infants had had
apgars of 8 to 10 at 5 minutes.
One-minute apgars were 6 to 9 with the
majority scoring 8. Where no episiotomy
was performed, patients all had perineal
tears of first or second degree. Nine
patients were not able to deliver in the
Birth Room; 6 of these were primiparas,
3 multiparas. In all but one case the
reason for the change was that the
patient had opted for epidural anesthesia
during the course of labor. However,
those who did deliver as planned were
very pleased with the room.
Feedback from the professionals
revealed ongoing concerns about
inadequate lighting, cramped space and
relative distance of resuscitation
equipment. The most persistent problem
was that some of the patients who had
requested the service did not meet the
department s criteria of "low risk".
They may have been acceptable at an
earlier stage of pregnancy , but upon
admission, were found to be at some
degree of risk. These patients were then
faced with disappointment and a
situation which they did not fully
comprehend. Those who required
intervention during the course of labor,
such as intravenous therapy, fetal
monitoring or Syntocinon augmentation,
were frustrated by their inability to meet
their personal goals. A few even delayed
the decision to have prescribed clinical
intervention because of their desire to
deliver in the Birth Room.
We decided that further study was
required in order to achieve a more
workable alternative. Increased
flexibility and additional space were the
most important features. After additional
discussion, we decided to renovate a
traditional delivery room. With some
renovations and redecorating, we would
be able to achieve all the objectives of
the Birthing Room. We drafted plans,
met with the maintenance department
and planning board and finally received
approval for renovations.
The renovations were accomplished
with relative ease: the ceiling was
lowered, a washroom added and we
decorated with some finishing touches of
soft-colored wallpaper and sheer
curtains. Equipment is stored behind a
wallpapered screen, and built-in
O.R. -style glass cupboards were draped
with fabric. Oxygen, suction and
anesthesia equipment were left in place.
The labor-delivery bed is a convertible
model made by Stryker* and has an
adjustable back support, stirrups and
other features that allow for flexibility in
the case of a more complex delivery. A
sitting area in the room was provided for
the mother and her coach with soft
indirect lighting.
We felt the advantages of the new
room would be the increased space and
the increased flexibility of use, both of
which would allow for birth in a
home-like atmosphere which allowed for
emergency intervention if necessary.
The criteria for the Birth Room
patients were revised; as before, they
emphasized the preference for natural
childbirth. New guidelines indicated that
*available in Canada from Down
Surgical Ltd., Toronto
patients selected for the Birth Room
must have a clear understanding of the
indications for clinical intervention if it
were needed; it was decided too that
although presentation of the fetus should
be vertex, breech presentations could be
assessed on an individual basis. Patients
do not have to be moved to another room
for intervention, such as fetal
monitoring.
At the time of writing, 51 patients
have requested to deliver in the
newly-renovated room, and 47 have been
successful. (The four patients who could
not were delivered by Cesarean section
in our Section Room.) For all the
patients, a family-oriented birth was
achieved in a subdued and relaxed
environment.
Organizing motherhood Once a patient
and her partner have decided they wish
to have their birth in this facility, they
usually discuss their plans with their
physician. A meeting with the head nurse
or clinical nurse specialist is then
arranged to:
familiarize the couple with the
facilities
gain understanding of the couple s
objectives
inform couple of the hospital
guidelines, to decrease discrepancy
between their personal philosophies and
that of the hospital
answer questions
inform the couple of alternatives in
postpartum care such as mother-baby
care, rooming-in, early discharge and
home care.
After getting acquainted, the patient
and her partner are given a tour and a
further opportunity to ask unanswered
questions. The name of the patient, her
E.D.C. and doctor s name are recorded
in a log in the delivery room. This log is
useful for information and for prediction
of Birth Room use which is helpful to the
staff; however, the Room is assigned on
a first come, first served basis.
A copy of the guidelines was sent to
each physician practicing at our hospital
and when the renovations were
completed, additional publicity was
undertaken in order to inform the public
about the changes that had taken place.
Notification was also sent to Childbirth
Education Groups which aroused further
interest and resulted in many calls about
our service.
Conclusion
The labor-delivery or Birth Room has
proven to be a quiet and relaxing
environment which enhances the
experience of childbirth.
The original plan was to meet the
needs of a very small group of patients
who wanted a natural birth in a
home-like atmosphere that provided the
safety of the hospital; the result was that
we are now serving the needs of a much
larger group of patients.
The attention devoted to the project
and the discussions between physicians
and nurses have increased professional
awareness of the desires of many
mothers and their partners to be actively
involved and in fact to participate in the
birth of their child. Now, we are able to
give them increased flexibility and
individualization of care inside the
hospital environment.
Having a baby today is safer than
ever before. Today s obstetrical health
care consumer has a far broader
knowledge base than did mothers of the
past: people want a shared birth
experience and childbirth with dignity.
Humanization of the hospital
environment can help to enhance
childbirth one of the most beautiful
and satisfying of all human experiences.
Bibliography
1 Carlson, B. Hospital "at home"
delivery: a celebration, by B. Carlson
and Philip E. Sumner. JOG/V Nurs.
5:2:21-27, Mar /Apr. 1976.
2 *Ferris, Carolyn. Alternative birth
center at Mt. Zion Hospital. Birth Family
J. 3:3, Fall 1976.
3 Grad, Rae Krohn. Breaking ground
for a birthing room. MCN
AmerJ.Matern.CMdNurs. 4:4:245-249,
Jul./Aug. 1979.
4 Hardy, C.T. Hospital meets patient
demand for "home-style" childbirth.
Hospitals, JAHA 52:5:73-74, 79-80,
Mar.l, 1978.
5 Interprofessional Task Force on
Health Care of Women and Children.
Joint position statement on the
development of family-centered
maternity I newborn care in hospitals.
Chicago , 1978.
"Unable to verify in CNA Library
Ellen L. Rosen, RN, BScN, MScN fed.),
received her basic education in Montreal
as well as her baccalaureate from McGill
University. She studied for her master s
degree at the University of Western
Ontario, and has been a general duty
staff nurse and nursing instructor in
several institutions. Currently, she is
clinical nurse specialist in Obstetrics and
Gynecology at the Victoria Hospital in
London, Ontario. Rosen has had several
other articles relating to obstetrics
nursing and research published.
32 M.rrh 1
An open letter to the nurses of Canada
Jane Melville White
I ve been wondering how I could show
my appreciation for your kind care
during my recent hospitalization,
especially for your help during the month
before my baby was born and later, when
I was re-admitted to help gain control
over the grief resulting from his stillbirth.
My talents run mostly in the
direction of writing; that is why I ve
chosen to express my thanks this way.
Whenever I have entered hospital
because I have been depressed, at least
one staff member has expressed the
concern that "we aren t trained to deal
with mental health patients." I
sympathize and wish that I could make it
easier for you, but at the same time,
accept the fact that my coming into
hospital makes life easier for me.
The purpose of this letter is to
reassure you that you do so many things
right. I won t name names I hope
you ll recognize yourself but I want all
of you to feel, "Yes. I ve done (could do)
that."
About names...! appreciate name
tags and/or nurses who introduce
themselves, "Remember me, I m "
It is difficult to talk to someone whose
name you don t know or, worse yet, feel
guilty about forgetting.
The decision to enter hospital
always adds panic, guilt and a sense of
failure to the other emotions I m already
finding impossible to handle. This is
followed by relief when I actually reach
my room and know "somehow it will be
okay." A verbal reinforcement from the
nurse to that effect is very encouraging at
that moment.
The admission form gives you the
chance to find out what is really
bothering me. I appreciate your allowing
me to get to my room and calm down
before trying to complete the form. Also,
it s nice that you waited to come into my
room until you had time to listen, instead
of when you had to rush: this was better
for both of us. In those first few hours,
when all the feelings I d bottled up so
long had to be aired, the admission
questions provided an opening.
Another thing you do right is
allowing me to talk to you: all those
leading questions and that prompting
really help. For example. "Did you want
to be pregnant?" "It s okay to admit you
don t feel able to care for a baby." And
later, "How did you feel about losing the
baby?" "It is going to take awhile to get
over it."
You recognize that there is no easy
answer but imply that I will be able to
work things through.
Most nurses understand the value of
touch. You used it so effectively in so
many ways: like catching my lower leg to
gain my attention without startling me if I
were resting at thermometer time: like
using both hands to take my pulse the
second to hold my fingers in a gentle
"surrounding". When I was having a
bad time, I appreciated the firm grasp of
a hand helping me to hang on to reality.
Back rubs feel so good when the
tension builds up, especially when
coupled with leading questions like, "Is
something bothering you tonight?" or
more generally, "How was your day?"
The latter is a good question because
sharing what I ve figured out the
positives of a hospital stay reinforced
them so that I went to bed feeling I had
grown in understanding that day.
"Can I get you anything?" is not an
opening to talk. On the other hand,
"We re here if you need anything. Just
ring or stop us in the hall" is appropriate
to both physical and mental needs. The
pulling down of the call bell arm really
reinforces those words.
Once, right after visiting hours when
she was usually rubbing backs. I stopped
one nurse in the hall. "Have you
time..." (I hated to ring the bell and tried
hard not to.) She sat and listened. Both
of us realized the time limitation but as
she left, she reassured me, "We all need
someone to talk to sometimes."
Comments like these are helpful:
"You re not the only (or first) person
who feels like that." "It s normal to
react that way to this situation." "I ve
felt that myself." Such statements
reassure me that: a) I m not a "freak",
and b) I m still accepted despite the
thought.
Of course, some nurses feel more
comfortable listening than others, and
naturally I looked forward to the shifts
when these nurses were on duty. I
especially appreciated the nurses who
sat down saying (or implying by their
question), "I finally got a couple of
minutes to visit with you." The nurses
who gave time when they had, or made
time, really helped. Time so often it
boiled down to that when you seemed to
be running up and down the halls with so
much to do. In spite of that, I had to
admire the personal attention you
managed to give to each of your patients.
The smiling, "You re lookin good" as
you passed my room or met me in the
hall, the "how are you doing?" as you
took blood pressure helped to prevent a
sense of isolation.
Once, I knew it was report time, but
I also knew I needed someone. A nurse
answered my call and, as things began to
get better for me, I apologized, "You
have so much to do." She gave a helpful
reply, "If my staying will help you regain
control, I ll stay a little longer."
1 could mention other things you did
that were helpful... things like bringing
me a cup of tea when I needed it, like
letting me have my sewing machine in
my room, like screening visitors. But the
best support came from simply knowing
that you were pulling for
me. ..encouraging me to be well and
happy again.
"... help you regain control ..." That
was the phrase that you used. It made me
realize why I was in hospital, that what I
needed was a breathing space, a
rethinking place, and you and your
hospital gave me that. The responsibility
for control is mine: it isn t something you
or anyone else can give, so you have no
reason to feel inadequate or guilty.
You helped me when I needed help,
in all the ways you could and now that
I m out, I want to say "thank you". I
hope I won t be back for a long time but
it is nice to know that you are there. *
""""
Jane Melville White originally wrote this
letter for the nurses at Kindersley Union
Hospital in Saskatchewan after being
hospitalized there. Jane describes
herself as a freelance writer, wife and
mother of a youngster who just started
school this year. She is active in her
community and her church.
MafCh_1980_. 33
Rose is expecting her second stillborn
child after intrauterine death was
confirmed five days ago. At 38 weeks
gestation, she is now awaiting the
induction of labor by the intrauterine
saline method. Rose knows that her baby
will not be born alive and speaks often of
wanting to see the baby when it is born.
She recalls the birth of her first baby, also
stillborn: "Actually no one ever asked me
if I wanted to see the baby. I wished I had
seen him. This time I must see the baby."
Anna is delivered of a stillborn male
infant; the cause of death appears to be
torsion of the cord. She refuses to see the
baby, but states that perhaps her husband
will want to see the baby when he arrives.
Anna s husband Paul declines despite
being told that the baby is perfect in
appearance. The next evening, following a
discussion with the nurse and Pastoral
Care worker, Anna and Paul ask if they
may have the baby present with them in
the chapel for a short memoi ial service.
Unfortunately the baby is already under
the care of the local funeral director,
burial having been planned for the
following day.
Eva gives birth to a premature male infant
of 22 weeks gestation. She is heavily
sedated, having been brought to the
hospital convulsing, with a diagnosis of
severe eclampsia. She was unaware that
within a few hours of birth, her baby was
transferred by air ambulance to a center
equipped to provide intensive care for the
very premature infant. Within 48 hours,
her baby dies. In the days that follow, Eva
cries often, has long periods of silence and
appears severely depressed. Her most
frequent comment or conversation is
centered around the fact that she has
never seen her baby. "I ll never know
what he looked like. Other people have
seen my baby, but I ll never see him. I
don t feel I ve had a baby. I don t
remember anything!"
Sylvia and Charles have just lost their first
child because of a spontaneous abortion at
16 weeks gestation. Sylvia does not see the
fetus, she lies passive and unresponsive
following the abortion, sleeping most of
the first 12 hours. Only when her husband
is present does she show any signs of
interest.
Letting
"The nrimarv pnal in sunnnrt nf thp afl Laak afl Lam ^^^^^^
"TVie primary goal in support of the
mourner is to be genuine and
realistic about death, his loss and to
help him face the psychological
present, whatever it is." }
Sheila Parrish
All of these women have something in
common, they are grieving the loss of
their babies through stillbirth or early
neonatal death, a situation which is
compounded by the inherent nature of
the mother-baby relationship. How can
nurses help these bereaved parents to
commence the process of "letting go" ,
an essential phase of grief work?
The specific circumstances
surrounding perinatal death warrant
special consideration in the management
of grief. By considering the significance
of visual and tactile experience for the
parents and the stillborn infant, and
secondly the value of participatory
inclusion of the parents in a memorial
service that places their loss in a spiritual
and religious context, I believe bereaved
parents may be assisted to face the
reality of death and move towards
resolution of their grief.
As health professionals, we have
become increasingly aware of the need to
become more knowledgeable about the
needs of the dying and the bereaved,
however, death is not a frequent
experience in the obstetrical unit.
Shorter hospitalization and earlier
discharge of the postpartum patient into
the community, where other support
systems take over, means that the
obstetrical nurse seldom sees the
resolution of the grief process in the
bereaved parents following stillbirth or
early neonatal death. Hopefully 1
nurses intervention at the time c
crisis will result in the healthiest
adjustment for all concerned.
Research into the long term effects
of grief management has revealed that
many people become sick, either
physically or emotionally following the
death of a loved person. 2 The death of an
infant may have a permanent effect on
the parents, as they internalize their
feelings of helplessness, acting them out
in their social life and marriage, with a
subsequent increase in marital
problems. 3 Studies of adolescent
pregnancies have shown that
"Adolescents who do not fully address
the process of mourning, after abortion,
miscarriage or infant loss, may face a
greater risk of subsequent pregnancy." 4
Grief is a complex emotion that
varies from one individual to another.
Each person has his or her own unique
style of grieving; the existing skills for
coping with death are determined in part
by cultural attitudes and personal beliefs
and the individual circumstances
surrounding the loss. The mother and
father may face the same loss but be at
different stages of grieving. This problem
of grief resolvement is compounded in
the case of the stillborn or early neonatal
death, by the special nature of the
relationship between mother and baby
existent at every birth.
34 March 1980
The Canadian Nu
New dimensions in assisting bereaved parents
All pregnant women experience
some fear that the baby will not be
normal and may die, nevertheless, the
infant is usually anticipated with joy.
Both parents develop a fantasy image of
a perfect infant that may not be at all like
the infant they eventually have. The
mother moves through the normal
phases of the pregnancy, acknowledging
the fetus within her as real, then a feeling
that she and the baby are one and finally
accepting the reality of the baby as a
separate being. However a state of
anxiety normally exists at the end of the
pregnancy when acceptance of the
reality of the baby as a separate being
and a future love object cannot
completely overcome an inner
unwillingness to give up this gratifying
union of mother and baby as one . This is
usually resolved after the birth when the
love relationship is established. 5
During the pregnancy it is difficult
for parents to picture their baby in an
objective form; consequently after the
birth there is an intense need to examine
the new baby directly to give him an
identity. Doing this allows the parents to
organize their concepts and feelings of
the baby in relation to themselves and
their behaviors or responses to the
child." At birth, the mother who is able to
hold, see and hear her baby quickly
accepts the reality of the baby as a
separate individual. Complete
identification, however, may take
several hours, days or even weeks.
Despite the happiness and excitement
following the birth of the healthy baby,
there is already a form of grief in
process. The normal childbirth
experience has been described as one in
which bereavement, often not
acknowledged, exists.
In the case of a stillborn or neonatal
death, the mother must face the reality of
the death plus the fact that the outcome
of the pregnancy was not successful. She
will need to break the ties to the lost
child, but she will also need to have first
identified and accepted the child as hers.
Current childbirth practice places heavy
emphasis on the need for the mother and
baby to be physically close immediately
after the birth. Should not the same
effort be made in the case of the stillborn
infant? Consider also the premature or
sick infant who is whisked away to
receive appropriate care and may die
before the mother has a chance to claim
her living child.
In the hushed, uncomfortable
atmosphere that follows the stillbirth, the
delivery room nurse does her best to
support the motherand, if he is present,
the father but, in my experience, the
subject of seeing the baby or holding the
baby is not often broached, especially if
the infant is disfigured or abnormal. The
parent has usually been the one to ask to
see the baby and, in retrospect, I feel
that not too many did! How many would
have chosen not to experience their dead
baby will never be known, of course, but
on the other hand, how many more
would have seen or held the baby had
someone suggested to the parents that
this was an acceptable and normal thing
to want to do? Naturally, not all
bereaved persons want visual or tactile
experience of the deceased, and the
wishes of each individual must be
respected. As well, the bereaved person
may be so overwrought that he or she is
unable to comprehend the situation or
even listen to the discussion in order to
make a decision.
Viewing the body
What is to be gained by seeing the body?
Two important purposes served in the
custom of viewing are realization and
recall. "The bereaved are more aware of
the death in that seeing is believing, and
an image is provided for recall of the
deceased. "The image becomes the
working basis from which reorganization
of life takes place. When the image is not
clear and the deceased is put out of the
mind, the mourner may begin to create
illusory pictures that serve ill as a
foundation for rebuilding life.""
Where there is no proof of death,
denial is apt to be prolonged. It is not
difficult to understand why the mourners
who have the most difficulty resolving
their grief are those who never get to see
the body because of drowning, air
tragedy or other situations in which the
body is never found. In a study of war
widows in Israel, the lack of presence of
the body of the deceased delayed even
the start of the bereavement process for
many of the wives. Death became a
reality only after some physical evidence
or encounter occurred such as seeing the
grave or receiving something that
belonged to the deceased." Often persons
who are suffering illness as a result of
unwisely managed grief cannot
remember very well the image of the
deceased. "The recognition of death is a
necessity for continuing life, and grief is
a necessary and unavoidable process in
normative psychological functioning." 10
Because of her toxic condition, Eva
was under heavy sedation and did not
become alert MI time to see her infant
before he was transported by air
ambulance to a larger center for intensive
care. The baby died two days later. Eva s
constant cry of anguish was that "I never
even saw my baby. If only I could have
seen him once." I attempted to give Eva
some visual idea of what her baby had
looked like, in terms of development. By
showing her pictures of a 2 4- week-old
fetus, she was able to understand some of
the problems of prematurity. She smiled
for awhile and was grateful, but she
wanted to see some resemblance of her
family in the baby. I was acutely aware of
the importance of identification for Eva
and wished that someone had taken time
to take a photograph of her baby before
the transfer. As far as Eva was concerned,
it was as if she had "never had the baby".
Physical symptoms that could possibly be
related to unresolved grief caused Eva to
be readmitted to hospital twice in the
postpartum period and currently she is
under psychiatric follow-up.
Viewing the body is never pleasant
and sometimes we think it is kinder to
spare the bereaved this additional agony.
As I look back, I realize it has often been
the first reaction of the father of the baby
to say he doesn t want his wife to see the
baby, saying "she will be more upset" or
"she can t take it". Some nurses and
doctors operate from their own feelings,
unconsciously not wanting to be part of
the discomfort involved and accept the
parents initial reaction too readily. A
parallel can be drawn in the case of those
who advise the single parent giving up
her baby for adoption not to see the
baby, thinking that it will be less painful.
They do not realize "that the choice is
not between pain and no pain; but
between wisely managed suffering and
unwisely managed suffering"." In a
study of unwed teenage mothers, those
mothers who saw their babies were able
to work through their feelings more
quickly and had fewer long term adverse
effects whereas women who did not see
their babies developed disturbed
emotional patterns of behavior and
tended to withdraw from human
relations. Denying the reality of the basic
relationship between mother and child,
prevented the normal process of
mourning from being employed. 12
The Canadian Nurse
March 1980 35
At an appropriate moment and as
soon as possible the nurse should make
the parents aware of the opportunity to
hold, see or touch the stillborn baby if
they wish. In the last three years, I have
witnessed 37 stillbirths. The initial
reaction of 25 of these mothers was not
to see the baby, but, following gentle
explanation of the value of seeing the
baby and allowing the parents some time
alone to discuss how they felt,
approximately 20 changed their minds.
None have regretted the decision, the
usual comments being, "I was afraid to
look and it was hard, but I m so glad I
did." "I feel that he was really mine." "I
would have resented it later if my
husband had seen the baby and I
hadn t."
If the mother is under sedation and
unable to participatte, or if she changes
her mind after the baby has been
transferred to the funeral home, it is
important that she receive concrete
information about her baby, including
sex, weight, coloring and so on. Positive
comments concerning the formation of
nails, hair and peaceful expression are
especially needed in the case of a
deformed baby. In addition most
mothers treasure receiving the name
bracelet and an information card
normally placed on the crib. Following
baptism of the baby, a certificate of
baptism should be offered to the parents;
this comforts them in their spiritual need,
helps the mother unable to see her baby
accept the reality of birth and the finality
of death and also places the baby in the
context of a church community .
Whenever possible, the parents
must be prepared to see the body.
Asking them if they have ever seen a
dead body before and discussing
expectations, opens up opportunities to
explain about skin change, maceration,
rigidity and coldness. In addition, the
nurse must recognize and face her own
feelings since how the nurse perceives
the baby will affect the parents
response. Wrapping the baby in a warm
blanket, holding the baby in a caring way
close to her body, the nurse conveys to
the parents that the baby is acceptable to
her, especially important if the baby is
disfigured or abnormal; and in turn the
parents may be influenced in their feeling
toward the baby as desirable to hold.
Rose had repeatedly informed the
nursing staff that regardless of how the
baby looked, she wanted to see her child.
She had been denied seeing her first
stillborn at another hospital, two years
previously. Following the delivery of a
macerated stillborn female infant, Rose
received the routine post delivery care and
was transferred to the recovery room to
await the arrival of her husband whom
she felt would also want to see the baby.
She did not wait however. About 15
minutes later she called me, said she was
ready to see the baby and was it possible to
have her mother present. Rose was
prepared for what she was to see as we
had talked about this on several occasions
during the days before delivery.
When I brought the baby to her, Rose
sat upright in bed but kept her arms and
hands close to her body. I unwrapped the
blanket to expose the body which was
moderately macerated and misshapen.
Although the skin was peeling and some
fluid escaping, I had deliberately left my
gloves off not wanting to convey anything
to Rose that might suggest I found the
baby undesirable. I lifted the baby s
hands and feet and we counted the toes
and fingers together. Rose asked to see the
baby s back. Since the fetal skull had
collapsed, the baby had very little
resemblance to the baby once fantasized.
Rose wistfully remarked that she had
hoped to see some family resemblance. I
gently encased the baby s head in my
hands, molding as much as possible to
create some facial symmetry. Rose
suddenly responded with a cry of delight,
"Yes, there is a resemblance. She looks
like John! Oh yes, I can tell this is our
baby!" Then she held her hands out and
asked if she could touch the baby in the
same way. Gently she explored the baby
with her fingertips. Finally she wrapped
the baby in the blanket, held her close for
a moment and then with a peaceful look
said, "Thank you nurse, this has meant so
much to me. You see, I never saw my first
baby."
Rose has since corresponded with
me. It appears that she has completed
her grief work. Hopefully this experience
has helped her to resolve her grief for the
first child. Rose, because of her prior
knowledge of the intrauterine death, had
gone through some anticipatory grief,
and some of the tasks of mourning may
already have been completed prior to
delivery.
Anticipatory grief can also mean
that the relatives are prepared. The nurse
needs to be sensitive to the family that
has become so well prepared that its
members might not be as supportive of
the mother at the time of delivery as
would be expected. Sometimes the
mother in an attempt to deny reality may
stop investing in a relationship with the
baby prior to birth, feeling that she has
suffered enough and will have nothing to
do with the baby. She may blame the
baby for the stress and painful
procedures and then feel guilty about the
resentment. Unless she understands that
this is a normal reaction, her grieving
may be impeded.
Touching and looking "symbolically
helps to close the mystic gap between life
and death more realistically, although at
times more harshly, if the baby is
disfigured. " l;i This is especially true if
the parents are unable to view the baby
until after an autopsy has taken place.
Preparation in this instance is extremely
important.
Mothers or parents of the
spontaneously aborted fetus may also
have a need to view the fetus. The need
will obviously be dependent on the
length of the pregnancy and the usual
variables. I realize there may be a degree
of impracticality in my suggestion; my
gynecological nursing colleagues inform
me that in the majority of abortions the
mothers show very little curiosity or any
interest in seeing the fetus. I suspect that
for some mothers, further exploration as
to their feelings would have revealed a
need for imagery.
Sylvia and Charles were parents of a
16 week fetus delivered in the obstetrical
unit following which Sylvia appeared to be
coping reasonably well. However, 24
hours after the abortion Charles asked to
speak to me. He said that he and his wife
were really distressed about the loss of the
baby and he wanted to know how he could
help his wife who was having great
difficulty talking about the situation. I
spent some time with both of them. Sylvia
eventually broke down, saying, "I ve lost
a baby just because it was only a few
weeks developed doesn t mean it wasn t a
baby. It doesn t even get buried! I think of
him as my baby, I ve even given him a
name after his grandfather." I asked
Sylvia and Charles if it would be helpful
for them to have a brief memorial service
for the baby. They expressed interest in
this, and following a visit by the chaplain
of the hospital, the four of us attended a
service in the hospital chapel prior to
Sylvia s discharge. Both parents
expressed relief and gratitude for this
opportunity; their grief work was
facilitated by this acknowledgement of
Bobby as an individual human being.
Tha Canadian Nurse
Placing loss within a spiritual and
religious context
Placing the loss of the baby within a
spiritual and religious context in keeping
with the individual beliefs of the parents
also facilitates the grieving process. It is
well known that supportive interpersonal
interaction takes place during religious
mourning practices and the funeral itself
is another means of assisting the
bereaved to let go. The funeral meets
often very personal needs and at the
same time may represent the religious
beliefs of the deceased and the family .
"The funeral is not only a declaration of
a death that has occurred, but it is also a
testimony of a life that has been lived." 14
In my experience, however, some
bereaved mothers have experienced
further distress by not being able to be
present at a burial service for the baby.
Angela, who gave birth to a male
child that lived for only a few minutes,
was asleep during the birth. She was
severely hypertensive and under sedation
and had very little recall of the events
surrounding the delivery. Two days later
she asked to be discharged from the
hospital in order to attend a burial service
for her baby; in fact, she threatened to
discharge herself if not given permission.
Despite the persistent hypertension, the
physician understanding Angela s need,
temporarily released her from the
hospital. Angela understood the risk she
was taking, but for her the need to face the
reality of losing her baby took priority
over her own health. In her own way,
however, Angela was looking after her
health!
The memorial service
Evaluating the effectiveness of the
current support system for bereaved
parents within my hospital led to my
sharing some concerns with the Director
of Pastoral Care. We reviewed local
funeral practices, became more aware of
the flexibility of services, learned about
alternatives for those for whom burial of
the baby meant economic hardship, and
became more organized in our plan to
help parents with special needs; for
example, we advised parents who
wished to bury the baby without the
services of the undertaker, directed
parents in transportation of the body
according to provincial requirements,
and so on. We also offer parents and
other family, including siblings, an
opportunity to participate in a memorial
service held in the hospital chapel.
Awareness of the philosophy of life
held by the parents is essential as their
attitude toward death will follow closely
their feelings about life. In our hospital
the nurses and Pastoral Care worker
share information in the interest of
planning the best approach for the
bereaved. The parents are made aware of
the availability of a memorial service and
in no way are pressured to make a
decision at first conversation. The
service may be conducted by the
family s own minister or priest or by the
hospital Chaplain or a Sister from the
Pastoral Care Department. A memorial
service differs from a funeral service in
that it is acknowledgement after death,
without the body present. Not all parents
choose a memorial service but those who
have are unanimous in their comments
that the service is helpful and had special
meaning for them. One family asked
instead that the nurse pray with them at
the bedside. Regardless of the location or
format of the service , some positive
things can come about for the mourners
and staff attending the memorial service.
The service itself can be of
therapeutic value as it recognizes the
grief of the parents and helps them to
experience the grief together and in the
presence of other supportive,
individuals. It can help to prevent
pathological denial and later difficulties
by helping the parents to openly face the
reality of the loss . It can be a significant
point in the letting go process. Not only
is the mother able to be present, but she
is able to receive physical support from
the nurse if she becomes weak or ill.
There is no cost factor involved for the
parents. In addition the memorial service
provides an opportunity for the staff to
share in more than just physical and
emotional care; it helps them to place
their own sense of loss in a religious and
spiritual context.
As inner acceptance is considered a
very positive and constructive stage in
the process of mourning, 15 the memorial
service can be an effective means by
which the bereaved are able to face the
reality of death, accept it and then move
on into resolution of grief. The service
offers an opportunity for the family to be
sustained through the expression of their
religious faith and an acceptable setting
within which they can let out their
feelings. Finally, it provides a means by
which the hospital staff can convey to
the family their belief in the worth and
dignity of the human person and indeed a
reflection of the value we place on life
itself. *
References
1 *Murphy,G. The meaning of
death. (In Vforano, Nicholas. Blessed
are the mourners. The Way 16:2:109,
Apr. 1976).
2 *Lindman, Erich, Grief and grief
management - some reflections.
J. Pastoral Care 30:3, Sep. 1976.
3 Kavanaugh, Robert E. Children s
special needs? (In Dealing with death
and dying. 2d ed. Jenkintown, Pa.,
I ntermed Communications, 1976)
p.33-46.
4 * Horowitz, Nancy Heller.
Adolescent mourning reactions to infant
and fetal loss. Social Casework Nov.
1978.
5 Rubin, Reva. Binding-in in the post
partum period. Matern.ChildNurs.J.
6:2:70, Summer 1977.
6 Ibid., p. 68.
7 Raether, Howard C. The funeral
and the funeral director, by Howard C.
Raether and Robert C. Slater. (In
Grollman, Earl. Concerning death: a
practical guide for the living. Boston,
Beacon Press, 1974).
8 *Jackson, Edgar N . For the living.
Des Moines, Iowa, Channel Press, 1963.
p.41.
9 *Golan, Naomi. Wife to widow to
woman. Social Work Sep. 1975.
10 *Rakoff, Vivian. Quote. (In
Gerson, Gary. The psychology of grief
and mourning in Judaism. J. Religion
Health 16:4:264, Oct. 1977).
1 1 Jackson, Edgar N . When
someone dies. Philadelphia, Pocket
Counsel Books, 1973. p. 12.
12 Ibid.
13 Glaser, Barney G. Time for dying,
by Barney G. Glaser and Anselm L.
Strauss. Chicago, Aldine Pub., 1968.
p.27.
14 Grollman, op. cit., p. 190.
15 Morano, op. cit.
*Unable to verify in CNA Library
Sheila Parrish,RN, a graduate of The
General Hospital, Nottingham,
England, worked as a hospital and
district midwife in England before
coming to Canada. Presently, she is
Head Nurse of the Obstetrical Unit, St.
Joseph s Hospital, North Bay, Ontario
and is working towards a Bachelor s
Degree in Sociology.
Acknowledgement: Thanks are expressed
to Rev. James McHugh, C.R., Director
of Pastoral Care, St. Joseph s General
Hospital, for his valuable help and
guidance; to the Sisters of the Pastoral
Care Department and to the nursing
staff of the Obstetrical Unit.
Tha Canadian Nuraa
21-year-old Francesca whose mother
tongue is Italian, was upset: her
two-day-old son was very
sleepy and wouldn t wake
up for his feeding. Everyone
seemed so busy and her English
was not very good. She wished
her mother were here to help. Why was
she having so much trouble? Was there
something wrong? Maybe she didn t
have any milk and the baby was
starving?
When
experience
; wrt.v ^^^^
counts
33-year-old Mrs. P. didn t know how she
was going to cope; she felt so ridiculous
asking the same questions over and over
again. The nurses reassured her this was
normal and she shouldn t worry about it,
but how could she be such a
scatterbrain? Why was she having so
much trouble? Breastfeeding seemed so
natural when they discussed it in
prenatal classes, and she had read the
recommended books. But now tears
rolled from her eyes as she gazed at her
hard, aching breasts and watched her
screaming three-day-old daughter trying
to grasp the nipple. She winced with
pain as the baby finally got hold, and
thought, Is it really worth it?"
Mrs. J. was very anxious: she had lost
two previous babies and now her
premature daughter, Andrea, seemed so
tiny and fragile. The doctor said Andrea
was strong and healthy but Mrs. J.
wished the nurses could stay with her
until she finished her bottle. The nurse
told her to burp the baby after every half
ounce, but it was difficult to tell when
half an ounce had gone. Andrea always
seemed to gulp her bottle so quickly and
then she seemed to spit most of it back
up. Would she ever be alright?
Helping new mothers sort out their
questions and problems is easier when
you ve been there yourself. That s one
reason why, in our hospital, we have
come to depend on specially trained
volunteers to bolster the support that
nurses on the obstetrical unit are able to
provide to patients.
York Finch General Hospital (300
beds, 38 OB) in Toronto is like hospitals
everywhere these days a victim of
increased consumer demands and
spiralling costs. Staff freezes and
cutbacks are making it increasingly
difficult for nurses to devote as much
time as they would like to patient
education.
Sylvia Segal
I T
>
The charge nurse takes time out to
discuss patient problems with a
volunteer.
It was three years ago that I
approached the director of volunteer
services, Elsa Ann Lee, about the
possibility of initiating a volunteer
program for new mothers. As
coordinator of obstetrics, I wished to
maintain our unit s family-centered
approach with its relaxed and flexible
schedule that made demand feeding
possible. We both could see the
advantages of an in-hospital, one-to-one
counseling program on infant feeding
practices by trained volunteers.
As a pilot project, we trained one
volunteer who introduced the service to
some of the mothers in hospital at the
time. The program was an overnight
success: soon we had volunteers *
working on the OB Unit every weekday,
responding to the needs and concerns of
our new mothers.
Duties
The volunteers taking part in this
program are expected to:
support and encourage
mothers in their infant
feeding practices by assisting
and counseling them about
minor breastfeeding and bottle feeding
problems as they occur in hospital.
sell articles such as nursing bras,
nighties and books on breastfeeding and
child care (Maturnisales, we call them).
Articles and books for sale have been
suggested by the nursing and medical
staff. The exchange provides a good
opportunity for teaching and there is
more stress on teaching than on making a
sale.
assist nurses with discharges by
helping the patients gather their
belongings together and escort the family
to the hospital door.
Selection
Volunteers are interviewed and selected
by the Director of Volunteer Services. A
subjective evaluation by the interviewer
is made regarding attitude toward
breastfeeding, modern feeding practices
and childrearing. Successful candidates
are expected to have a positive,
"family-centered", outlook; other
characteristics we look for are those of
any volunteer: a caring attitude and a
friendly, outgoing personality. Facility in
a second language has also proved a
definite asset at York Finch which
serves a multi-cultural population.
Training
Before being allowed to counsel on her
own, each volunteer has to complete a
training period which includes the
following:
1. the concept of family-centered care
2. the philosophy of the obstetrical unit
3. hand washing technique and general
hygiene
4. infection control theory and practices
5. process of lactation
6. common breastfeeding problems
encountered in hospital and how to deal
with them
7. common bottle feeding problems
encountered in hospital and how to deal
with them
8. discharge procedure the limitations
of the volunteer.
Each volunteer must also complete
six on-the-job training sessions with a
trained volunteer. At the end of the
training period, each volunteer
completes a written take-home
examination, and is evaluated by her
trainer and by the programs s nursing
consultant.
38 March 1980
The Canadian Nurse
On the job
Volunteers wear a rose-color dress
uniform while on duty; these uniforms,
which can be purchased or rented, must
be laundered or dry cleaned before each
day s shift begins. A lab coat, supplied
by the Volunteer Department, is worn
over the uniform whenever the volunteer
is off the unit.
All volunteers are required to have
an annual chest x-ray orTB skin test
provided by the hospital.
Each volunteer is assigned to a
specific shift 9:00 a.m. to 11:30 a.m.
or l:00p.m. to 3:00p.m. and is
responsible for notifying the unit and the
Volunteer Department if she is unable to
report for her shift. Replacements are
obtained by either the volunteer who is
unable to work or the program convenor.
Not surprisingly, the Summer months
are the most difficult to ensure full
staffing.
As the program evolved, a daily
routine was developed by the volunteers
and hospital staff; these routines are
checked annually and revisions made as
needed. Good communication is the key
to the success of the program and this
aspect of the work is stressed in all our
activities.
Volunteers check with the team
control center for any "problem notes"
left by the general nursing staff in an
envelope provided for this purpose. The
charge nurse of Postpartum or Nursery
Departments is then contacted (orTeam
Leaders in their absence) for a report on
any other problems. The first visits of the
shift are with mothers reporting
problems or mothers requesting supplies
from Maturnisales. If time permits, the
volunteer then systematically visits as
many patients as possible, telling them
about the service, asking if there were
any problems or questions, and showing
them Maturnisale supplies. Notes are left
for the afternoon or following day
volunteer to ensure further follow-up of
problems and to identify how many
patients were visited that shift.
Ongoing training
Every six or eight weeks we schedule
meetings on topics related to
breastfeeding and modem infant feeding
and care practices. A volunteer must
attend two out of three of these sessions
to remain active on the service.
Listening, communication skills,
consistency and recognizing the
limitations of the volunteer role are
stressed during these discussions and
ongoing training. Volunteers were
actively involved in developing the
original program and continue to have
say in its direction.
A volunteer from Maturnisales helps a patient choose a nursing bra.
If an active volunteer is off the
service for three months or longer she
must again attend on-the-job training
sessions and be re-evaluated before
counseling on her own again .
Evaluation
For the patients, the service means an
interested, caring, empathetic
"experienced mother" who has that
extra time to listen and help.
For the nurses, the service provides
a well-informed co-worker who can be
trusted to give much needed support and
accurate information to an anxious
mother.
For the volunteer, the service
provides the opportunity to offer help, to
keep up-to-date on modem infant feeding
practices and care, and also to develop
her problem-solving and counseling
skills. The service has also helped to
create a positive encouraging
atmosphere toward breastfeeding which
is very evident on the unit ; much of the
volunteer s time is taken counseling and
supporting the breastfeeding mother.
Obstetrical units, I m sure, are not
the only areas of the hospital where
volunteers could provide services. Each
hospital needs to examine its own
situation and needs. Our program owes
much of its success to the enthusiasm of
its volunteers whose interest, in turn, is
maintained by keeping them active in
their service. Programs such as ours
could not exist without the support and
guidance of the nursing staff. Someone
on the unit must take the interest and the
time to motivate the volunteers and keep
them up-to-date in their theory and
practice knowledge.
Today there is a good deal of
consumer pressure for greater flexibility
on obstetrical units. I hope that our
example will encourage other hospitals
to open their doors to volunteers, since
these programs provide an excellent
opportunity for hospitals to bring a bit of
the "home touch" atmosphere to their
environment. *
Author Sylvia Segal graduated from the
University of Alberta in Edmonton,
Alberta, in 1964. She has experience in
armed service, public health, teaching,
prenatal education and general duty
nursing. Much of her teaching and
practical experience has been in the field
of obstetrics.
At the time the program she
describes in this article was set up, she
was Coordinator ofObstetrics and
Gynecology at YorkFinchGeneral
Hospital in Toronto. Segal is married
and has two boys. She retired from
full-time duty in the summer of 1978 but
continues to provide training and
guidance for the volunteers at York
Finch.
Acknowledgement: The author wishes to
acknowledge the contribution ofElsa
Ann Lee, Sheila McKewen, Willy Wallis,
PatThorburn and Helen Fronzak, whose
enthusiasm and support of the program
since its conception motivated her to
write the article.
Thn Canadian Miirc
rh 1QJn 1Q
A post par turn pr ogam
that really works
Help for new mothers is as near as the
phone in this small community
in north central B.C.
Kathleen Freeman
How could six community nurses, each
already as busy as the next with
immunization schedules, pre-school
health assessments, long term care for
senior citizens and home care for
convalescents, possibly take on close to
500 new family units annually without
seriously compromising the care they
were expected to give?
What is the most efficient and
effective way of making sure that new
mothers get the help they need when
they need it the crucial days and
weeks immediately following delivery?
How can postnatal problems be
spotted and solved before they reach
crisis proportions?
How can nurses serving a scattered
rural community keep non-productive
"travel time" to a minimum?
These were some of the questions
that our office of the regional health unit
was faced with five years ago. Our
search for the answers, which continues
to this day, took into account two major
considerations:
our unique demographic situation as
a small town (pop. 23,000, including the
surrounding area) about halfway up the
BCR railway line that links Vancouver to
Fort Nelson, B.C.
our philosophy and objectives
which might be summed up by the belief
that knowledge, to be preventive, must
be available before, or at least at the time
that it is needed.
The problem
Before we could begin to find answers to
the questions that confronted us, we had
to define the dimensions of our problem.
As a preliminary step, we undertook the
development of a profile of community
needs and trends based on demographic
data that we assembled ourselves. At
first, the only statistics we had were
those relating to the number of births and
school entrances. Then, from the census,
we obtained more information about the
various age groups in the area; a survey
by the provincial department of
economics on local industry gave us
information about occupational
characteristics. Once this method of
planning was used successfully, each
application to additional programs
became easier. Through yearly updating
and the addition of demographic data, as
it became available, we soon had a fairly
comprehensive profile of community
needs and trends.
When we looked at this profile, we
saw a steady influx of young couples into
Quesnel to work in local industry,
balanced by a steady outflow of families
after the wage-earner gained more
experience and higher qualifications.
During the time these young couples
were living in Quesnel, they would begin
their families ; in the community there
were about 450 births per year. This
number could be expected to remain
constant or even to rise slowly. If we
continued our present system of home
visits, this would mean at least 450 hours
of contact time, plus 200 hours of travel
time, just for initial home visits each
year. Due to the* high number of births
and the system for referral, home visits
were often made when the infants were
three or four weeks old, after many
crises had already passed.
Our objectives
In a rural area such as ours, where there
is no routine physician follow-up until six
weeks postpartum, the role of the
community health nurse is very
significant. Thinking about this role and
our new program, we reiterated as a
group some of our fundamental beliefs
about the philosophy of community
health nursing. We believe in prevention.
We believe that people need a variety of
types of support and that they are
capable of choosing and using the type of
support that best fits themselves as
individuals. Also, a maximum amount of
nursing time should be available to
counsel high risk families.
Keeping these considerations in
mind, we drafted our objectives for the
postnatal program as follows:
to have contact with every mother
giving birth prior to discharge from
hospital, and again one week after
discharge.
to provide each mother with
information regarding maternal and child
care, enabling her to function effectively
at home with a young infant.
to identify as early as possible any
mothers and/or infants who are at risk of
developing problems.
to use the most efficient and
effective methods of meeting the needs
of both high risk and "normal" mothers
and infants.
to provide an ongoing, easily
utilized resource where information and
group support are available to mothers as
needed.
to obtain feedback on the usefulness
of the postnatal program through parental
assessment and formal evaluation.
The tools
The postnatal program that we
developed in response to these needs
consisted of four distinct elements.
These are, in the order in which we make
them available to most families:
1. In-hospital classes
2. A telephone check six to ten days
postpartum
3. New infant classes at the Health Unit
4. Home visits
/ . In-hospital classes The first line of
support for the mother is knowledge of a
newborn s needs and behavior and of the
maternal changes postnatally. To
provide this knowledge to every mother
in the most efficient method, we
arranged with the local hospital to
conduct classes on the maternity floor
twice a week just before lunch. This time
was made available through the
cooperation of OB nursing staff and the
physio department which reduced daily
postpartum exercises to three times a
week to accommodate our classes.
Studies have shown that maximum
learning takes place at the time of crisis
and need and, for this reason, the
hospital stay provides a highly
appropriate learning situation.
Postpartum mothers can be gathered
together as a group using a ward or
lounge as meeting place. The C.H.N.
uses a combination of discussion and
didactic instruction to present
information concerning the care of a
newborn baby and the needs of a mother
after discharge. The group setting makes
it easy for mothers to ask questions,
share concerns and obtain support from
one another. Further reinforcement of
learning takes place if mothers discuss
class content afterwards.
Prior to the classes, mothers
complete cards providing us with
information on the family, prenatal class
attendance and method of feeding.
Problems that arose during the
pregnancy or factors that might indicate
risk are filled in by the C.H.N. before
she returns the cards to the health unit.
These cards help our nursing staff plan
the appropriate follow-up contact with
the mother; clerical staff use them to
prepare agency records, and they are
used as part of the program evaluation.
During the class, mothers are given a
folder containing a collection of
pamphlets that they can read now and
keep for future reference, (see Box).
The staff of the Quesnel Branch of the Cariboo Health Unit (left to right): author Kay
Freeman, Marilyn Hurrell, Susan Brown, Terry Stevenson, Mary Gradnitzer and Eileen
Kosior. Former staffer, Debra Little, who was since moved to Kelowna, is missing
from the photo.
Resource material
postpartum classes
1 . Planned Parenthood Federation of Canada.
Birth control that works.
2. British Columbia. Ministry of Health. Your
public health services.
3. International Childbirth Education Assoc.
Instructions for nursing your baby.
4. Johnson & Johnson. Baths and babies.
5. British Columbia. Ministry of Health.
Common variations in the newborn. CHU # 16.
6. British Columbia. Ministry of Health.
Infant feeding.
7. British Columbia. Ministry of Health.
Blender baby foods. CHU #16.
8. G.R. Baker Memorial Hospital. Diet for
nursing mothers.
9. Infant food guide. B.C. Diet Manual 1976.
During the classes, we actively
encourage all the mothers to call the
health unit if they have questions or
problems after discharge, and invite
them also to attend our new infant
classes at the health unit. These
postpartum classes take approximately
two hours of nursing time a week.
2. Telephone check The majority of
mothers in Quesnel are discharged on the
fourth or fifth day postpartum. Between
the sixth and tenth day, we make a
"phone visit" to all mothers with
telephones during which we enquire as to
how the mother and baby are doing.
Initially, we use open-ended questions.
If the mother s responses remain
general, we proceed to more specific
questions such as condition of the cord,
feeding and sleeping patterns and the
amount of rest the mother is obtaining.
This allows us to counsel appropriately
and to offer a home visit if problems
indicate a need. We find, however, that
the majority of mothers are coping well
at the time of the initial phone call.
Mothers are again invited to bring
their infants to the new infant classes or
to contact the health unit if new
problems arise. Phone calls generally
take about ten minutes each. If the
family has no phone, C.H.N. s decide on
the basis of risk whether to make a home
visit or to send a personal note inviting
the mother to come to the new infant
classes.
3. New infant classes When the
mothers arrive at a new infant class, they
are greeted by a volunteer who obtains
records from the clerk, escorts each
mother to the class and introduces her to
the others. Frequently mothers have
been in the hospital at the same time or in
prenatal classes together and have an
interest in each other.
The first ten or 15 minutes of each
class is devoted to review care of the
infant and mother in the postpartum
period. This allows us to discuss the
materials we would normally present
during a home visit. Following this, we
offer a short talk on some aspect of
preventive health care lasting from ten to
15 minutes. Topics currently rotated are:
baby s nutrition
exercises with baby
safety through the eyes of a child
toys for baby
baby s sleep patterns
Mothers identify with these topics,
which reflect anticipatory guidance into
growth and development of the infant,
and the discussion is usually lively.
After this discussion, babies are
weighed and each mother has the
opportunity to discuss individually any
concern she may have been hesitant to
bring before the group. Some mothers
return for all five of the discussion
topics. Others come only once for
reassurance. New infant classes take
about one and a half hours of C . H .N .
time per session.
Sometimes during discussion of
topics or individual discussion, the
C.H.N. will find a mother or infant who
needs ongoing service: often the mother
is cognizant of the difficulties but doesn t
know where or how to obtain help. Other
mothers, through lack of knowledge of
growth and development, do not
perceive potential problems. These
families are referred to the district
C.H.N. for further individual follow-up.
4. Home visits Home visits are made
in the traditional manner to high risk
mothers and those whose telephone
conversations refl ;ct definite problems.
The difference between the old and new
system lies in the fact that those needing
this type of service now receive it
promptly; the C.H.N. arrives at the
home more prepared for the specific
situation, at a time when the mother is
wanting to learn. Further follow-up may
be through additional home visits, new
infant classes or phone calls.
The results
Before we arrived at the format we are
now using, we conducted an informal
evaluation of each new infant class
during the initial shakedown session. We
also tried to obtain written consumer
feedback but with poor results; we did
receive positive feedback verbally and
the increased utilization of the program
speaks for itself.
The first formal evaluation of the
program took place six months after it
was initiated and input from all nurses
concerned was obtained. We found that,
during the first six months, 79 per cent of
the mothers in the hospital had attended
postpartum classes, and 31 percent of
mothers had attended the new infant
classes.
One of the reasons for not reaching
our objective of 100 percent contact with
mothers in the hospital is that classes are
held only on Tuesdays and Thursdays
with the result that some mothers are not
able to attend. We have not been able to
arrange optimum spacing as yet, due to
workloads of hospital and health unit
staff. The ongoing communication
between hospital staff and ourselves
about improving the effectiveness of the
classes, has promoted an important
feeling of mutuality in providing care to
new families.
Many mothers who wanted to attend
the new infant classes could not make it
at the time scheduled so we began to
have classes on a weekly basis which
helped overcome this problem.
Our evaluation indicated the need
for a system of tabulating telephone calls
with home visits and a form was
designed and implemented to meet this
need. We also recognized the need to
standardize priorization of high risk
criteria and have been collecting
information regarding various systems of
identifying high risk, but have not yet
worked through our own
standardization: each nurse still has to
use her own judgment.
The results of our second formal
evaluation, which took place after the
program had been in effect for 18
months, indicated that:
the number of mothers attending
postpartum classes had increased from
79 to 8 1 per cent of those eligible .
we were able to reach 90 per cent of
new mothers by telephone.
almost one quarter (23 per cent) of
these mothers were experiencing
difficulties that warranted a home visit.
38 per cent of new mothers attended at
least one new infant class; the average
number of classes attended was three.
three-quarters of those attending
classes had concerns which, if they had
not been dealt with in class, would have
necessitated a home visit.
These results have left us feeling
very positive about our program even
though we know that we have not yet
succeeded in reaching all of our goals.
The steps that we have taken since then
are:
to institute monthly meetings between
maternity nurses andC.H.N. s
promoting understanding and continuity
and resulting, eventually, in improved
service in both community and hospital.
Table One
New infant problems
observed in classes
Problem Percent
Feeding difficulties 26
Rashes 16
Inadequate weight gain 1
Acute illness 10
Jaundice 7
Eye discharge 6
Other 25
N = 119
to request a summer student to update
and prepare more attractive educational
materials for both postpartum and new
infant classes.
to continue to work on a priority
system that will allow better
identification of risk factors.
We estimate that implementation of
our new program has saved
approximately 200 hours of nursing time
each year that it has been in operation.
The services we have been able to
provide under it have been at least equal
to, if not better than, those that were
previously available; high risk mothers
and babies, in particular, have benefited
from the program. In short, we feel that
through our postpartum program we
have found an innovative way of utilizing
our resources for the benefit of the
community as a whole. *
About the author Kathleen Nicely
Freeman, RN , BS, is one of six
community health nurses working out of
Quesnel branch office of the Cariboo
Health Unit in British Columbia. This
article, A postpartum program that
really works" , was written with the
assistance of all of the QuesnelCHN s
who participated in the design and
development of the program.
Kay is a graduate of St. Anthony s
School of Nursing and of the University
of Oregon. She has been involved in
community health nursing in a variety of
positions, including teaching and
administration in Canada and the US.
INSTITUTIONALIZATION
What happens to patients in a long term treatment center
Barbara Havnes
The fact that a hospital is an
institution which serves large
numbers of people in what is, for the
most part, an orderly and efficient
fashion is beneficial to the
community-at-large. However, when
people are in hospital for an extended
period of time, perhaps for the rest of
their life, the goals of rehabilitation
and personal independence are often
hindered by certain of the
institutional aspects of that hospital or
chronic care facility.
The sociological definition of an
institution is
"an organized system of social
relationships that embodies certain
common values and procedures and
meets certain basic needs of society.
When applied to a hospital, one can
see that the common goals or values of
the people who work in that institution
are the cure of illness and the return of
patients to a level of functioning at least
as high as before their admission. To
meet these goals as efficiently as
possible, hospitals regulate activities by
developing specific policies or routines
for procedures which are applicable to all
situations occurring within that
institution. This includes not only
diagnostic tests but also nursing
procedures such as dressing changes,
catheterizations and even bowel
routines.
In other words, the institution
requires the simplification of actions
the organization of human behavior into
a harmonious pattern. The result is that
all individuals connected with the
institution become used or conditioned
to these patterns or routines. The longer
the association in the patient s case,
his hospital stay the greater the degree
of conditioning.
Why? Part of the reason is that
patients are not as physicially active as
they would be normally, nor are they
required to use their individual
personalities and intelligence to make
decisions and solve problems within the
highJy regulated atmosphere of the
institution. -The institution takes over
many of the individual s former
functions.
Institutionalization then "involves
the replacement of behavior that is
spontaneous with behavior that is
expected, patterned, regular and
predictable. " :f
THE GALLBLADDER
IN 69
THAT LAPY
IS SENILE.
The process of institutionalization
does serve a function: the "processing"
of large numbers of people in an efficient
fashion. At the same time, it may have a
detrimental effect, in that it works
against the long term rehabilitation of
dependent patients and may even have a
negative effect on hospital staff.
The pattern takes shape
Factors promoting institutionalization
range from the simple physical realities
to the more complex issue of human
behavior. Physical characteristics of a
hospital ward include uniform decor and
a generally limited environment. An
important factor too is the rigid daily
ward routine of fixed times for meals,
medications, bathing and bedmaking.
However, it is agreed that in the
interest of practicality and patient safety,
many of these physical realities cannot
be changed, and for the short term
patient they do not matter that much. In
a large hospital with a central kitchen for
instance, meals have to be mass
produced for distribution at specific
times; similarly, it is easier and safer to
fix times for medications to be given so
that time is not wasted and medications
are not forgotten.
It is the more important factor of
human interaction that in fact makes the
process of institutionalization a negative
one for the long term patient.
What behavior then, especially on
the part of nurses, contributes
specifically to the dehumanization of
patients during institutionalization? At
least four attitudes have been found to
have a profound psychological effect on
patients:*
where a nurse feels uncomfortable, such
as when a patient is angry or sad.
Because she is uncomfortable dealing
with psychological needs, the nurse
employs this method unconsciously to
make ventilation of feelings difficult for
/"YCtT GOM/A^>
(MSWEK THAT 1
\CALL LI6HT? y
V-
OH, MRM.-
COULD
I M DOING MX
OWING.
labelling. Institutional workers
often tend to classify or label patients,
which serves to make the patient less
than human for both himself and the
staff; often after a label is applied, a less
than human response is required for the
labelled patient.
intellectualism. Similar in a way to
labelling, intellectualism is the focusing
on a specific problem rather than a
holistic look at the person with the
problem. Mr. Jones becomes his
gallbladder... or hip... or lumbar disc.
distancing. Nurses may spend as
little of their time as possible interacting
with patients, preferring to give only the
necessary physical care and no more.
humor. While often useful as a
safety valve for built-up tension,
humorous remarks made at the expense
of patients often ensure that staff
members do not get seriously involved
with their patients as people.
Communication
It is helpful too to look at the specific
communication techniques used by
nurses to examine how dehumanization
of patients really occurs. >
One such style of communication
can be described as source-oriented.
People who use this style are generally
concerned more with themselves than
with others, and think predominately
about how they are "coming across".
This insecurity is manifested in several
ways: superficial conversation,
disjointed phrases ornon sequiturs, use
of exaggerated gestures and lack of
direct eye contact. Source-oriented
communication is common in situations
the patient. In a rehabilitation setting this
is detrimental as unmet emotional needs
can impede progress.
Message-oriented communications
reveal a strong task orientation on the
part of the staff member; 5 she believes
that the patient s feelings have little
relevance to the task to be accomplished,
and shows little interest in how a
message is received by a patient. This
situation frequently occurs when nurses
have a large workload to cope with, or
when there is not time to handle
emotional problems effectively. Patients
then see the staff as non-spontaneous,
mechanical and generally preoccupied
with the task at hand.
How the patients feel
"Without the little things the smile or
touch on the arm the patient feels
alone and afraid, and really no longer
human. " R
In a long term care or rehabilitation
setting, emotional needs are great;
patients are often depressed at facing a
long hospital stay or perhaps a lifetime
disability. Ignoring these emotional
needs may result in decreased
motivation in patients, lessened
performance and longer hospital stays.
Basically, the problem is one of loss
of control. A patient is no longer free to
choose what to eat or when to eat it (or
even whether to eat at all), his daily
schedule is plotted for him, privacy is
negligible and noise levels
tension-provoking and distracting. In
many ways, the person in hospital is
forced to regress and to relinquish the
personal independence and control over
life that he has been handling for years.
He may exhibit behavior indicative of
the stress that he is experiencing, for
example, excessive complaining,
frequent and unusual demands, and
refusal to comply with treatment or
routines. All these are attempts to regain
control; unfortunately, he risks being
branded as a nuisance who is
uncooperative .
In the case of the long term patient,
the length of his stay within the
institution usually results in compliance
"if you can t beat em, join em"
and there comes a characteristic
AMP WHEN
DID YOUR 00WLS
LAST MOVE:
dependence, loss of clarity in thinking
and a decline in physical functioning.
Changes in routine cause upset and the
suggestion of discharge may result in
regression. The patients generally feel
unable to care for themselves. 7
The positive aspects of a strictly
regulated atmosphere deserve mention:
it is true that some elderly patients feel
lost in a strange environment and a daily
routine serves as a framework to keep
them in the real world; younger patients
too who perhaps have less maturity and
self-discipline benefit from the limits
imposed by a schedule agreed upon with
their nurse.
Obviously, the only way to prevent
the downgrading of individuals into
inhuman uniformity is for each nurse to
develop care plans around the special
needs of each of her patients, in short, to
treat them as individuals.
How to do it?
To prevent institutionalization, it is
important basically to recognize the
effects that certain factors within the
hospital can have on patients, and to
remain sensitive to them. Measures that
promote individuality dressing a
patient in his own clothes when possible,
for example should be encouraged.
Anything that helps to create a brighter,
more stimulating environment will help.
Control over and responsibility for
bodily functions such as sleep and
elimination should be returned to the
patient, and his participation in
rehabilitation goal setting should be
encouraged.
Most important though, is the
nurse s attitude to the patient and the
realization that her priorities start with
UP AW /tr M/
TIME FOR BATH NOW
COME ON...
G/T MOVIN 1 !
the patient as an individual, not the
institution. This basic principle prevents
the occurrence of source- and
message-oriented communication and
encourages instead a type of
communication which may be called
receiver-oriented/ This style of
communication recognizes the
importance of the patient and his
psycho-emotional needs; he is the
"receiver" of the messages. The nurse
who wishes to employ this type of
communication to her patient s benefit
must be an active listener; direct eye
contact, physical proximity and the
clarification of things not fully
understood are all important.
Patients in hospital, especially those
in long term facilities, need to know that
they are not only cared/or but cared
about; only then can they return to a high
level of wellness, both physically and
mentally. Institutionalization is
counter-productive, and if the nurse
wishes truly to perform her role of
patient advocate not hospital
advocate she must be aware of the
mechanics of this process.*
*Source; Bakal, Donald A. Psychology
for the Health Sciences: an introduction.
References
1 Horton, Paul B. Sociology and the
health services. New York,
McGraw-Hill, 1965. p. 179.
2 Taylor, Carol . In horizontal orbit;
hospitals and the cult of efficiency .
Toronto, Holt, Rinehart and Winston,
c!970.
3 Horton, op.cit.
4 Veninga, Robert.
Communications: a patient s eye view.
AmerJ.Nurs. 73:2:321, Feb. 1973.
5 Ibid.
OTTA
THOSE WfUL
GERMS!
6 Ordeal. Edited by Patricia Chaney.
Nursing 75. 5:6:27-40, Jun. 1975.
7 Jones, Claudella A. Burns: the
home stretch... Rehabilitation, by
Claudella A. Jones and Irving Feller.
Nursing 77. 7: 12:54-57, Dec, 1977.
8 Veninga, op.cit., p. 322.
Bibliography
1 *Bakal, Donald A.. Psychology for
the health sciences: an introduction.
2 Bernard , Jessie . Sociology: nurses
and their patients in a modern society,
by Jessie Bernard and Lida F.
Thompson. St. Louis, Mosby, 1970.
3 Horton, Paul B. Sociology and the
health services. New York,
McGraw-Hill, 1965.
4 Jones, Claudella A. Burns: the
home stretch. ..Rehabilitation, by
Claudella A. Jones and Irving Feller.
Nursing 77 7:12:54-57, Dec. 1977.
5 Lundberg, George A. Sociology,
by George A. Lundberg et al. 4th ed.
New York, Harper Row, 1968.
6 Mclver, Vera. Freedom to be: a
new approach to quality care for the
aged. Canad. Nurse 74:3:19-26, Mar.
1978.
Mclvor, Janet. One day the door
closes, by Janet Mclvor and Lois
Sorgen. Canad. Nurse 74:3:30-33, Mar.
1978.
8 Ordeal. Edited by Patricia Chaney.
Nursing 75 5:6:27-40, Jun. 1975.
9 Taylor, Carol . In horizontal orbit;
hospitals and the cult of efficiency.
Toronto, Holt, Rinehart and Winston,
c!970.
10 Veninga, Robert.
Communications: a patient s eye view.
AmerJ.Nurs. 73:2:320-322, Feb. 1973.
*Unable to verify inCNA Library
Barbara Haynesuro/e this article while
enrolled as a student at the Foothills
Hospital School of Nursing in Calgary.
Since graduating, she has been working
at the United Church Hospital in Bella
Bella, B.C.
The Canadian Nurse
Mrrh 1QJW1
LEQiOMMfllRE 5
DISEASE
An Old Enemy with a New Name
ErnaJ. Schilder
Since its first appearance in North American news headlines in 1976, Legionnaire s Disease has been regarded by the
public as a mysterious and frightening killer. This nurse reviews medical literature to help dispel some of the mystique.
Three years after the first reported
outbreak of Legionnaire s Disease, the
disease is once again in the headlines. In
August 1976, newspapers excited the
public with reports of the existence of a
mysterious and fatal disease. The news
stories followed the development of the
disease after the American Legion
Convention held in Philadelphia,
Pennsylvania, July 21st to 24th, 1976.
Twenty-nine people died, and the
mysterious pneumonia-like entity was
named Legionnaire s Disease.
Since that time, outbreaks of the
same disease have been identified in
other parts of the U.S. and Canada, most
recently in Toronto. Just last Summer,
The Globe and Mail reported on August
7, 1979 that 10 to 12 residents of
Metropolitan Toronto were believed to
have contracted Legionnaire s Disease;
several of these cases were later
confirmed. 2
While it is true that not a great deal
is known about this particular disease
organism, Legionnaire s Disease is not
quite as mysterious nor as terrifying as
the newspapers make out.
Etiology
Legionella pneumophila is the causative
organism in Legionnaire s Disease; there
are 4 sero-groups, and the symptoms
manifested are as with any pneumonia,
together with GI andCNS symptoms.
The reservoir for the organism is not
known; excavation sites are believed to
be implicated and once, in Bloomington,
Indiana when 19 people contracted the
disease, the organism was cultured from
water in a roof-top air conditioning unit.
The bacteria is probably air-borne, and
its incubation period is not known for
certain but is possibly one to ten days.
It was in January 1977 that the
Center for Disease Control in Atlanta
Georgia announced it had discovered the
organism. :i Problems encountered in
identifying the disease were due to the
huge number of studies that had had to
be done to rule out all other possibilities,
before focusing on the search for a new
causative organism.
Studies have found that legionella
pneumophila grows slowly, in five to 10
days, when incubated at 35C on
chocolate agar plates, after being
obtained from pleural fluid or lung
tissue. A more expedient means of
establishing the diagnosis has since been
developed: serum of an affected patient
can now be tested for antibodies, and a
definite diagnosis can be made if there is
a rise in litre.
Clinical manifestations
Two to 1 days after exposure to the
organism, a patient may exhibit
symptoms of malaise, myalgia and slight
headache. Within 24 hours a high fever
of 39C to41C may develop associated
with chills, dyspnea, and a
non-productive cough. Other symptoms
of chest pain, abdominal pain andGI
disturbances may also be present. Many
patients have rales on auscultation
without other evidence of consolidation.
Laboratory findings include
leukocytosis, proteinuria, an elevated
ESR greater than 80 mm/hrin most.
In some patients there may also be
hyponatremia, mild azotemia and
elevated SGOT and alkaline phosphatase
levels.
Chest x-rays commonly
demonstrate unilateral involvement and
pleural effusion; the one-sided lung
consolidation rapidly expands into lobar
involvement. " The disease usually
worsens over the first two to three days;
the cough becomes productive at this
time, but the sputum is rarely purulent.
Although both sexes are
susceptible, mortality due to
Legionnaire s Disease is higher in male
patients. Gastrointestinal bleeding is
frequently present, and the patient
eventually succumbs to either shock,
respiratory failure, or both. Renal failure
has been reported in several patients and
is probably secondary to the respiratory
involvement. In patients who recover,
improvement generally lags several days
behind the evidence in x-rays.
The description of this disease might
give one the impression that there is little
difference between Legionnaire s
Disease and the usual bacterial
pneumonia. The distinguishing features
of this disease, however, are high fever,
non-productive cough, no
micro-organisms cultured or seen in
smears from sputum, leukocytosis,
evidence of consolidation in chest
x-rays, and significantly there is no
response to the usual anti-microbial
treatment for pneumonia.
Since the mortality rate currently
rests at 15 percent, a firm diagnosis at an
early stage of the disease is of crucial
importance in implementing appropriate
therapy.
Treatment
Medical treatment of Legionnaire s
Disease is aimed at the relief of
presenting symptoms and the prevention
of complications.
46 March 1980
Th Canadian Nurse
After several studies, researchers
have concluded that erythromycin is the
antibiotic that is currently most effective
in treatment of this disease. Patients who
do not respond well to erythromycin
alone should receive a combination of
erythromycin and rifampin.
Of particular importance in therapy
is the maintenance of metabolic and fluid
requirements to support the restorative
processes in the acutely ill febrile
patient. Respiratory care must be aimed
at maintenance of adequate oxygenation,
good tracheal-bronchial hygiene, and
support of the dyspneic patient.
Nursing care of the patient with
Legionnaire s Disease has two distinct
goals: first is the promotion and
maintenance of a comfortable and safe
(i.e. hygienic) environment. Isolation is
not necessary in the care of these
patients, but steps must be taken to
avoid secondary infection.
Second, observation of the patient is
crucially important for the nurse. The
patient must be observed for any change
marked restlessness associated with
severe dyspnea and a respiratory rate of
more than 40 per minute are signs that
the partial oxygen tension (PO 2 ) has
fallen below 60 mm Hg in arterial blood.
This must be prevented as respiratory
failure and shock are the final outcome.
Vital signs too should be closely
monitored as they are indications of
impairment of physiological function;
intake and output measurements,
evaluation of cough, noting the presence
of pain, and monitoring laboratory
findings are other important nursing
functions.
Finding out
Contrary to the impression created by
the press. Legionnaire s Disease is an
old disease with a smart new name. It
was simply one more unidentified killer,
until 29 people died from it at once in
1976; it is thought thatLeg/one//a
pneumophila affects an estimated 25.000
people a year in the U.S.. 2500 in
Canada, but most of the patients
diagnoses are only suspected, not
confirmed.
Information about the disease is
now available and it behooves the
nursing profession to learn more about
this old enemy. *
References
1 *New York Times Index, 1 977 .
2 "Globe and Mail, Toronto. Aug.
7th and 8th. 1979.
3 *Ne w York Times Index, 1977.
4 *Center for Disease Control.
Legionnaire s disease: preliminary
report on its diagnosis, etiology,
pathology and therapy. Atlanta. Ga..
U.S. Dept. of Health, Education and
Welfare. Public Health Service, Center
for Disease Control, 1977.
5 *Dietrich,P.A. The chest
radiograph in legionnaire s disease, by
P. A. Dietrich et a\.Radiologv
127:3:577-582, Jun. 1978.
6 *Waters. J.R. Legionnaire s
disease. Winnipeg, Grand Rounds
Health Sciences Centre, Oct. 1977.
Fraser, D.W. Antibiotic treatment
of guinea-pigs infected with agent of
Legionnaire s disease, by D.W. Fraser et
al. Lancet. 1:8057: 175-178, Jan. 1978.
8 *GIohe and Mail, Toronto, Aug.
8th, 1979.
Bibliography
\ Fraser, D.W. Antibiotic treatment
of guinea-pigs infected with agent of
Legionnaire s disease, by D.W. Fraser et
al. Lancet 1:8057:175-178, Jan. 28, 1978.
2 *Globe and Mail, Toronto, Aug.
7th and 8th, 1979.
3 *Morbidity and mortality. Weekly
Report, Aug. 11, 1978.
4 *New York Times Index
1977.
5 *Center for Disease Control.
Legionnaire s disease: preliminary
report on its diagnosis, etiology,
pathology and therapy. Atlanta, Ga..
U.S. Dept. of Health, Education and
Welfare. Public Health Service, Center
for Disease Control. 1977.
6 *Waters. J.R. Legionnaire s
disease. Winnipeg. Grand Rounds
Health Sciences Centre, Oct. 1977.
*Unable to verify in CN A Library
Erna Josefine Schilder,fl7V, BN, MA, is
currently an assistant professor at the
University of Manitoba School of
Nursing. She has a varied clinical
experience, having worked in hospitals
inGermany, Holland and England, and
since in Canada has been involved in
staff nursing, nursing administration and
teaching in Manitoba.
The Canadian Nurse
March 1980 47
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Barbara Kozier, R.N ,
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Presents concepts and skills actually
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the text ideal tor study or review and
this handsome, gold-stamped
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Psychiatric Nursing
Holly S.Wilson, RN Ph.D.
Carol P. Kneisl. P.N. M.S.
Written from a perspective of
humanism and symbolic interac-
tionism, this text is specifically de
signed to enhance holistic nursing
philosophies while providing a
thorough presentation of the content
and concepts of psychiatric nursing.
Attractive gold-stamped volume will
become an enduring part of your
reference library
8340-X $25.25
Obstetric Nursing
Sally B. Olds, R N , MS
Marcia London, R N., B.S.N., M S.IM.
Patricia Ladewig, R.N., MSN.
Sharon V Davidson, R N., M Ed
A comprehensive exposition of the
theory and practice of obstetric
nursing with emphasis on the
biological needs of the "whole
patient and her family A useful,
well-illustrated, reference for
practicing nurses or students
2718-6 S2750
The Nursing ProcessiA
Humanistic Approach
Elaine L Lamonica, R.N , E d D
A humanistic approach, designed to
increase the nurses empathy with
and sensitivity for clients and col
leagues. Comprehensive coverage
of topics makes this text a valuable
reference tool
4138-3 $15.75
Nursing the Critically III Adult
Nancy Holloway, R N , M.S
Written by a critical care nurse
Helpful in reviewing problems related
to patient s nursing care needs.
Containing patient outcome criteria
to help you evaluate the quality of
your care Tested, pragmatic, and
practical!
2948-0 $22.75
Communicable Disease
Manual for Primary Health
Care Professionals
Case Kolff, M D , M P H
Ramon Sanchez, M.D., M PH.
Provides care information to assist in
diagnosing, managing and
controlling infectious diseases
commonly seen in a primary care
setting A quick reference for nurses,
health educators and public health
technicians
3892-7 $1725
Computers in the
Practice of Medicine
Part I: Introduction
Part II: Issues in Medical
Computing
H Dominic Covvey
Dr. Neil H. McAhster
This unique sourcebook introduces
basic computer hardware and
software, with relevant computer uses
and applications in medicine Other
special features include a glossary of
technical terms; numerous photos of
computers; a reference of people
now active in medical computing;
many humorous illustrations provide
effective visual aids, and medical
examples throughout complement
computer programming text
The second volume introduces the
relevant issues in developing and
implementing computers in a
medical environment
An excellent self-improvement text for
health care professionals.
1251-0 Part I $24.00
1249-9 Part II $18.00
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TWO CAREERS
IN ONE.
Being a nurse and an officer in the Canadian Forces offers
many advantages. If you re a Canadian citizen and a graduate
nurse (female or male) of a school of nursing accredited by
a provincial nursing association and a registered member of a
provincial nurses association with two year s experience
why not combine two careers in one?
For more details, contact your nearest Canadian Forces
Recruiting Centre in the Yellow Pages under "Recruiting"
or return the coupon.
ASK US
ABOUT YOU
THE CANADIAN
ARMED FORCES
Director of Recruiting and Selection
National Defence Headquarters
Ottawa, Ontario, K1A OK2
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Prov,
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CN-3-80
The Canadian Nurse
March 1980 49
WHAT S NEW
IN NURSING?
LOOK TO LIPPINCOTT
NURSING MANAGEMENT OF THE
PATIENT WITH PAIN, 2nd Edition
By Margo McCaffery, R.N., M.S.
Since more information was available but pub
lishing space was limited, it was decided that
the greatest contribution to nursing practice
could be made by restricting the focus of this
edition to nursing activities for pain relief and
covering this content in more depth. The
first edition encompassed all phases of the
nursing process, from assessment and diagnosis
through intervention to evaluation. This edi
tion focuses primarily on nursing intervention,
elaborating on most of the intervention me
thods included in the first edition. Lippincott.
338 Pages. Illustrated. 1979. $19.00.
NURSING MANAGEMENT
FOR THE ELDERLY
Edited by Doris L. Carnevali, R.N., M.N.;and
Maxine Patrick, R.N., Dr.P.H.
This book is written for practicing registered
nurses and students who care for older people
as part or all of their case load. We expect our
readers to have a variety of educational and
experiential backgrounds. To this end the areas
are presented with sufficient depth to encour
age more than a superficial approach to nursing
management.
Lippincott. 569 Pages.
Illustrated. 1979. $22.50.
PRIMARY CARE ASSESSMENT AND
MANAGEMENT SKILLS FOR NURSES:
A Self -Assessment Manual
By Marilyn Frank-Stromborg, R.N., Ed.D., NP;
and Paul Stromborg, M.D.
This workbook/text is designed to provide a
self-assessment of skills in physical assessment,
medical management of diseases, health coun
seling and coordination of community resour
ces for health promotion. The material is
oriented to the nurse involved in primary health
care in an adult and adolescent ambulatory care
setting. It may be used to supplement class
room studies in a nurse practitioner program, as
a continuing education device for the graduate
nurse practitioner, or as a senior level manual
for baccalaureate programs involved in the pre
paration of nurses for the primary care setting.
Lippincott. 329 Pages.
Illustrated. 1979. $16.50.
*% KMk-SBOKltaj,- M tUmlMf
Primary
care
Assessment
and Management
Skills /0r Nurses,-
ALSO IN DEMAND...
1 CONCEPT
FORMALIZATION IN
NURSING: Process and
Product, 2nd Edition
By the Nursing Development
Conference Group. Edited by
Dorothea E. Orem, R.N., M.S.N.Ed.
This volume refines previous conclu
sions and moves on to descriptions of
the individual or group dynamics asso
ciated with formulation, expression,
and acceptance of nursing s conceptual
structure.
It will serve as an important reference
for teachers and students of nursing,
nurse practitioners, nursing adminis
trators, and all who have an interest in
nursing as a unique discipline.
Little, Brown. 313 Pages.
Illustrated. 1979. S15.50.
2 PEDIATRIC PRIMARY
CARE, 2nd Edition
By Catherine DeAngelis, M.D., R.N.,
M.P.H., F.A.A.P.
Written to impart to members of the
pediatric primary health care team
specific, pertinent knowledge that has
been carefully selected from the broad
field of pediatrics.
Little, Brown. 676 Pages. Illustrated.
1979. Paper, $15.00. Cloth, $21.00.
3 NEURO-NURSING
By Susan Fickertt Wilson, M.N.
For nurses in neurological and neuro-
surgical acute-care settings, medical-
surgical and pediatric wards, and
rehabilitation units. A useful text for
nursing education and clinical practice.
Springer. 272 Pages.
Illustrated. 1979. $21.00.
4 CARDIAC
REHABILITATION: A
Comprehensive Nursing
Approach
By Patricia McCall Comoss, R.N.,
CCRN.;et. al.
One of the most exciting features of
the rehabilitative approach to the
patient with symptomatic coronary
disease has been its progressive incor
poration into the mainstream of
traditional medical care.
Lippincott. 334 Pages.
Illustrated. 1979. $20.25.
5- 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.
With 9 Contributors.
The most comprehensive single-volume
reference on nursing practice ever
published. Hundreds of illustrations
depict the highlights of treatment and
nursing management (over 100 illus
trations are new!).
Lippincott. 1,868 Pages.
Illustrated. 1978. S32.25.
6 THE EVALUATION OF
NURSING COMPETENCE
By Harriet Lucille Schneider, R.N.,
B.S.N.E., M.A., M.Ed., Ed.D.
This intriguing text explores all facets
of an old and perplexing problem the
evaluation of clinical nursing compe
tence. Specific forms, checklists, and
sets of questions are provided for
evaluative purposes.
Little, Brown. 175 Pages.
Illustrated. 1979. $8.50.
J. B. Lippincott Company of Canada Ltd., 75 Homer Ave., Toronto, Ontario M8Z 4X7
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7 NURSES DRUG
REFERENCE
Edited by Stewart M. Brooks, M.S.
A comprehensive reference on all
drugs commonly encountered in nurs
ing practice. More than 500 mono
graphs covering all drugs which the
nurse will encounter in normal prac
tice.
Little, Brown. 500 Pages. 1978.
$14.50.
8 GERONTOLOGICAL
NURSING
By Charlotte Kopelke Eliopoulos,
R.N.,M.S.
Gerontological Nursing gives compre
hensive treatment of the subject with
a balanced coverage of psychosocial
factors, pathophysiology and nursing
considerations.
Harper & Row. 384 Pages.
Illustrated. 1979. $15.00.
9 COMMUNICATION FOR
HEALTH PROFESSIONALS
By Voncile M. Smith, Ph.D.; and
Thelma A. Bass, M.A.
This timely book identifies and des
cribes problem situations stemming
from communication breakdowns that
commonly affect health care person
nel.
Lippincott. 236 Pages. 1979. $7.50.
10 TEXTBOOK OF HUMAN
SEXUALITY FOR NURSES
By Robert Kolodny, M.D.; et. al.
This comprehensive work on human
sexuality provides the nurse with a
knowledge of human sexuality that
will enable her to care for her patient
in the emotional and social, as well as
the physical realms.
Little, Brown. 431 Pages. Illustrated.
1979. Paper, $15.00. Cloth, $21.00.
Lippincott
You and the law (continued from page 16)
contraceptive reasons on a mentally
retarded person. He further concluded
that in the absence of clear and
unequivocal statutory authority, except
for clinically therapeutic reasons
(preservation of life, safeguarding of
endangered health) neither parents nor
those standing in loco parentis can give
consent to such surgery on behalf of
minors or retarded adults who
themselves are unable to give informed
consent.
In the words of His Lordship:
"The Eves of this world, regardless of
how retarded, are, nevertheless, persons
with rights which the Courts must
preserve and protect. One of these rights
is the inviolability of their persons from
involuntary trespass. ..While the
preservation of this right might well, and
even predictably, result in no little
inconvenience and expense, and indeed,
even hardship to others, the Court must,
regardless of its own natural sympathy
to those others, ensure that the law have
the care of those who are not able to care
for themselves, and ensure the
preservation of the higher right...
...The fundamental issue here is not
Eve, per se. Rather it is whether, under
"Just as I thought.."
dequadin
I deaualinium chloride E
I dequalinium chloride B.P
It s more than good-tasting, it s good medicine.
Antibacterial, antifungal,lozenges
Glaxo Laboratories [*
A GLAXO CANADA LIMITED COMPANY
the law as it now stands, the state,
through the instrumentality of the
Courts, or otherwise, or the family, be its
members parents, or in the case of the
elderly, children, have the right to take
upon themselves the subjective
prerogative of altering irreversably by
medico-surgical procedures the lives of
others who may, for whatever reason, be
incapable of making that decision for
themselves, in a manner which will
deprive them of any of their faculties as
human beings, other than for the
preservation and protection of health, or
the preservation and protection of
quality of life. The law, as I see it, does
not permit this to be done. " " <
References
1 In the Matter of "Eve", a mentally
incompetent person, in the Supreme
Court (Family Division) of Prince
Edward Island, June 14, 1979 published
in the Report of the Ontario
Interministerial Committee on Medical
Consent, (Part one) Gilbert Sharpe,
Chairman, September 1979, p. 39. In ReE
(1979)10R.F.L. (2d)317.
2 Sklar, C. Teenagers, Birth Control
and The N urse . Canad. Nurse
74:10:14-16, Nov. 1978.
3 Sklar, C. Legal Consent and the
Nurse. Canad.Nurse 74:3:34-37, Mar.
1978.
4 For more specific detail see Sklar,
C. Minors in the Health Care System.
Canad.Nurse 74:8:18-20, Sept. 1978.
5 (1949) 2D.L.R. 442.
6 In the Matter of "Eve", p. 321.
7 Idp.324.
8 (1979) 7C.C.L.T. 241 (Quebec
S C )
9 ReD(aMinor),[\916]\AllE.R.
326.
10 "Eve", p. 328.
11 Id p. 329.
"You and the law" is a regular column that
appears each month in The Canadian Nurse
andL infirmiere canadienne. Author Corinne
L. Sklar is a recent graduate of the University
of Toronto Faculty of Law. Prior to entering
law school, she obtained herBScN and MS
degrees in nursing from the University of
Toronto and University of Michigan.
SI March 1 MO
The Canadian Nurse
Introducing the 1980
NURSING BLOCKBUSTER
As an essential part of the health care team, more is
demanded of today s nurse ... so you demand more of your
text. Updated, revised and expanded the new Second
Edition of MEDICAL-SURGICAL NURSING: A Psycho-
physiologic Approach keeps pace with the needs of
today s nurse ... to supply nurses with the knowledge and
confidence to undertake ever-increasing responsibilities.
Just a sample of the updated and expanded chapters: A
rigorously revised and expanded section on Shock in
cludes such topics as hemodynamic monitoring central
venous pressure peripheral and central arterial moni
toring the use of the Swan-Ganz catheter the intra-
aortic balloon pump external counter-pulsation device
and hyperbaric therapy. The unit on a Holistic Approach
to Illness, including responses to stress-producing
factors, discusses such topics as Benson s relaxation
response transcendental meditation hypnosis auto-
genie training biofeedback and yoga. While all material
has been thoroughly revised, particular attention has
been given to rewriting, updating and expanding the
cancer, immunology, renal and liver, and male repro
ductive system sections.
Completely new material: Entirely new units on psycho-
social and physical assessment, emergency nursing, and
dependency on alcohol and other substances are in
cluded. In addition, the opening chapters emphasize the
importance of nursing as an art and a process. Plus many
new illustrations provide a balance with the textual
material . . . and an Instructor s Manual has been prepared
to accompany this text.
Concise, yet comprehensive: MEDICAL-SURGICAL
NURSING can be used in conjunction with or inde
pendently from Sorensen & Luckmann s BASIC
NURSING. Content has been carefully divided between
the two texts, reducing unnecessary repetition . . . and
therefore eliminating wasted reader time and book space
crucial factors in a dynamic profession with a rapidly
expanding knowledge base. Plus important material on
fluid-electrolyte acid-base, pain, physical assessment
and emergency life support bridge both books. ..the
fundamentals in BASIC NURSING and the more ad
vanced principles in MEDICAL-SURGICAL NURSING.
Luckmann & Sorensen
MEDICAL-SURGICAL
NURSING
a psychophysiologic approach
New 2nd Edition
By Joan Luckmann, RN, BS, MA, Formerly, Instructor of
Nursing, University of Washington, Highline College,
Seattle, Oakland City College, and Providence Hospital
College of Nursing, Oakland, CA; and Karen Creason
Sorensen, RN, BS, MN, Formerly, Lecturer in Nursing,
University of Washington; Formerly, Instructor of Nursing,
Highline College; Formerly, Nurse Clinical Specialist,
University Hospital and Fj land Sanatorium, Seattle, WA.
About $40.80.
March 1980
2276 pp.
Illustrated
Order #5806-7
W.B. Sounders Company
1 Goldthorne Avenue. Toronto, Ontario M8Z 5T9, Canada
Send on no-risk. 30-day approval:
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING 2/E
D check enclosed Saunders pays postage
Please Print:
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For hemorrhoids, feminine
hygiene, piles and personal
itching problems.
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Parke, Davis & Company. Ltd.. registered u
Relieve postpartum and postsurgical
itching and burning with Tucks.
PARKE-DAVIS
Book Corner
Publications recently received in the
Canadian Nurses Association Library are
available on loan toCNA members, schools
of nursing and other institutions.
Requests for loans, maximum 3 at a time,
should be made on a standard interlibrary loan
form or on institutional letterhead if the
institution has no library.
If you wish to purchase a book, please contact
your local bookstore or the publisher.
Alcoholism
Occupational alcoholism and drug abuse;
employer responsibility, by Mary S.
Lamontagne. n.p., 1979. Iv. (various pagings)
Child Care
Maternity and child care services:
relationship to parent/infant and parent/
child relationship; a clinical study. A report to
World Health Organization, by Colleen M.
Stainton. Geneva World Health Organization,
1979. 55p.
Community Health Services
Community health today and tomorrow by
the National League forNursing. New York,
c!979. 130p. (NLN Pub. no. 52-1768)
Diabetes
A practical education program for the diabetic
client within the rehabilitation setting, by
Nancy Dyer and Pat Homeyer. New York,
American Foundation for the Blind, 1979.
147p.
Dictionaries, Medical
English-French dictionary of medical and
paramedical sciences by William J.
Gladstone. St. Hyacinthe, Edisem, 1978.
1153p.
Education, Nursing
Instruments for use in nursing education
research by Mary Jane Ward and Mark E.
Felter. Boulder, Colo., Western Interstate
Commission for Higher Education, 1979.
846p.
Emergencies
An atlas of diagnostic and therapeutic
procedures for emergency personnel by
James H. Cosgriff. Toronto, Lippincott,
c!978. 315p.
Gynaecology
Health care of women by Leonide L. Martin.
Toronto, Lippincott, c!978. 391p.
History of Nursing
Nursing: a world view, by Huda Abu-Saad.
Toronto, Mosby, 1979. 227p.
Leadership, Nursing
Nursing management and leadership in action
by Laura Mae Douglass and Em Olivia Bevis.
3rd ed. Toronto, Mosby, 1979. 289p.
Nurse- Patient Relations
Dying in an institution; nurse/patient
perspectives, by Mary Reardon Castles and
Ruth Beckmann Murray. New York,
Appleton-Century-Crofts, C1979. 356p.
Spiritual care: the nurse s role, by Sharon
Fish and Judith Allen Shelly . Downers Grove ,
111.. InterVarsity Press, c!978. 178p.
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
by relieving
pain and
odour fast
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
peared." 3
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 1 4 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
"Two. il exudation is very heavy.
After removing crust or Cover with a dressing,
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Debrisan cleans
decubitus ulcers fast.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dorval, Quebec
1. Urn LT, Michuda M, Bergan J J. Angiology 29:9, Sept 1978
2. Bewick M, Anderson A, Clin Trials J 15:4, 1978
3. Soul J, Brit J Clin Pract, 32:6, June 1978
4. OiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on file at Pharmacia (Canada) Ltd.
Decubitus Ulcers
An audio-visual
presentation available
on loan, free of charge
This presentation describes treat
ment and dressing techniques for both
simple cutaneous and deep decubitus
ulcers, using BenOxyl 20% (benzoyl
peroxide) Lotion.
The taped narrative, by W.E. Pace,
M.D., M.Sc., F.R.C.P.(C)and Heather
Hanson, R.N., runs for approximately
30 minutes and is supported by a series
of before-and-after illustrative colour
slides.
To complement the slide-tape pre
sentation a folder illustrating the dress
ing techniques is available in quantity.
For any of the above material,
including a complete script, please
write to:
Scientific Services Dept.
Stiefel Laboratories
(Canada) Ltd.
6635 Henri-Bourassa Blvd. VV.
Montreal, Quebec H4R 1E1.
OVOlSOmg
Tablets
OVOl4Omg
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 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.
Nursing Care
Nursing assessment and health promotion
through the life span, by Ruth Beckmann
Murray and Judith Proctor Zentner. 2d ed.
Engle wood Cliffs, N.J., Prentice-Hall, c!979.
448p.
Obstetrics
The cesarean birth experience: a practical,
comprehensive, and reassuring guide for
parents and professionals, by Bonnie
Dona van. Boston, Beacon, c!977. 240p.
Occupational Health Nursing
Report on the feasibility of establishing a
post-registration designation or certification
program for occupational health nurses in
Ontario by Ontario Occupational Health
Nurses Association. Mississauga.Ont., 1979.
120p.
Paediatrics
Care of the high risk neonate by Marshall H.
Klaus and Avroy A. Fanaroff. Toronto,
Saunders, 1979. 437p.
Child health maintenance ; concepts in
family-centered care by Peggy L. Chinn. 2d.
ed. Toronto, Mosby, 1979. 934p.
A healthy child, a sure future by the World
Health Organization. Geneva, 1979.
Pharmacology
Pharmacology and drug therapy in nursing by
Morton J. Rodman and Dorothy W. Smith. 2d
ed. Toronto, Lippincott,cl979. 1085p.
Single- Parent Family
One in ten; the single parent in Canada, by
Benjamin Schlesinger. Toronto, University of
Toronto, 1979. 150p.*
Ovol Drops
relieve
infant colic.
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.
Shhh. Ovol Drops.
Also available in tablet form for adults
Industrial Psychologists - Management Consultants
DIRECTOR OF NURSING
This newly-created Edmonton position offers the opportunity to contribute to the development of a well recognized
nursing management system. Our client, an innovative 500-bed active treatment and teaching hospital, offers a wide
range of patient care services. The individual appointed to this senior position will plan, organize, direct and evaluate the
nursing care throughout the hospital.
Competitive candidates will have proven nursing management experience, strong leadership and interpersonal skills,
and good communication abilities. Required is a Bachelor s degree in Nursing; preferred is a Master s degree with
experience at Director or Associate Director levels.
Rewards include an excellent salary and benefits package, a challenging and stimulating work environment with a
professionally accomplished nursing team.
To inquire in strict confidence, contact Larry Pelensky in our Edmonton office by writing or Collect phone with an outline
of your education and accomplishments.
1 1 207 - 1 03 Avenue, Edmonton, Alberta, T5K 2V9. (403)428-8578
SPHYGMOMANOMETERS
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ANEROID TYPE
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$32.60 complete.
NURSES PENLIGHT. Powerful beam for examination of
throat, etc. Durable stainless-steel case with pocket
clip Made in U S A No 28 $5 98 complete with
batteries.
NURSES WHITE CAP CLIPS. Made m Canada for
Canadian nurses Strong steel bobby pins with nylon
tips 3" size $1 29 /card of 15.2 s.ze$! 00 . card
of 12 (Minimum 3 cards)
NURSES 4 COLOUR PEN for recording temperature,
blood pressure, etc One-hand operation selects red
black, blue or green No 32$297each
lit*
NURSES CAP TACS
Gold plated, holds your cap
stripe tirmly m place Non-
twist feature No 301 "RN 1
with Caduceusor No. 304
plain Caducous. $395/pr.
DELUXE POCKET SAVER
No n
tains or frayed edges
::. compartments (or pens,
xicissors, etc . plus Change
pocket and key chain
White call Plastahide.
No 505 Ji95each
MEASURING TAPE
In strong plastic ca
return Made of Our-
hnen Measures to
on one side. 200 C
reverse $5 95 each
NOTE: WE SERVICE AND
STOCK SPARE PARTS FOR
ALL ITEMS.
CAP STRIPES
SeK-adhesive type, removable and
re-usable No 522 RED, No 520 BLACK.
No 521 BLUE. No 523 GREY All 15 6"
long except red H4") 12 stripes per card
$4 69 C3^a
(ety ciaso
-_ 500 Registered Hurt*
No 501 Licensed Practical NurM
No 502 Practical Nur
NURSES EARRINGS. For pierced No 503 Nurt AM*
ears Dainty Caduceus m gold ptate All $8 59 eaci
with gold filled posts Beautifully
gift boxed No. 325 $11 49/pr.
CADUCEUS PIN GUARD
led to your professional letters
gold plated, gift boxed No 400 RN, No
LPN. NO 402 PN AU$9 iSeach
MEMO-TIMER. Time hot packs, heat :
lamps parx meters Remember to
check vital signs, give medication, etc. :
Lightweight, compact (1 v" dia ), sets :
to bun 5 to 60 min Kay tmg Swiss- :
made $i395each
OTOSCOPE SET. One of
Exceptional illumination,
powerful magnifying lens. 3
standard size specula. SizeC
batteries included Metal carry
ing case lined with soft cloth
No 309 $79 95 each
No 309A As above but m plastic pou
$6595
r
ENGRAVED NAME-PINS IN 4 SMART STYLES -SIX DIFFERENT COLOURS...
Up lo 23 letter*
pace* per line
TO ORDER NAME PINS
FILL IN LETTERING
DESIRED & CHECK
BOXES ON CHART
PLEASE PRINT
SOLID PLEXIGLASS. ..Molded from solid Plexiglas
Smoothly rounded edges and corners Letters deeply
engraved and filled witn laquer colour of your choice
PLASTIC LAMINATE. ..Lightweight but strong V
not break or Chip. Engraved through surface into
contrasting colour core Bevelled edges match
letters Satin finish Excellent value at this price
METAL FRAMED. ..S<mnar to above but mounted in
polished metal frame with rounded edges and
corners Engraved insert can be changed or
replaced Our smartest and neatest design.
SOLID METAL... Extremely strong and durable but
lightweight Letters deeply engraved for absolute
permanence and filled with your choice of laquer
colour Comers and edges smoothly rounded. Sati
Mothei
of
Pearl
SiacK
black, I
blue =* White
letters
2 lines
letters
$359
$457
$248
$322
$3.99
$522
SEND TO EQUITY MEDICAL SUPPLY CO ALL ORDERS SHIPPED
P.O BOX 726-S, BROCKVILLE, ONT K6V 5V8 WITHIN 24 HOURS
Be ure to nelo your nam and address
$573
$729
. $405
I $5 79
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. $835
SORRY
C.O D 4 billing
for institution*
Only
Total for merchandise
Ontario residents add 7% .. ...
Add 50 handling if less than $10.
Total enclosec
USE A SEPARATE SHEET OF PAPEH IF NECESSAHr
A NURSE S STORY. IT COULD BE YOURS.
> These children speak an international
language of love. With one smile, they remind me
why I became a nurse in the first place. < ~ ~
DOROTHY REDDEN, R.N., HEAD NURSE, PEDIATRICS
The Arabian Peninsula.
Different, Demanding. And
most decidedly gratifying.
(( When I first went to Saudi
Arabia I expected to always
be giving. I never expected to
get so much in return. From
grateful parents. Smiling
children. And a government
that respects everything that we
Americans can do to help.
The hospital itself was really
comparable to most Canadian
facilities. And, when my shift
was over, I went home to an
attractive, free, air-conditioned
apartment. The travel benefits
were tops too. And my salary
and year-end bonus were great.
All in all, the experience was
invaluable. Which is why I m
REVERSING
THE CHARGES:
(519) 376-68W
361 II Hh St.W.
Owen Sound,
Ontario N4K3R4
Dedicated
to a world of health
WhittakeR
Whittaker International Services Company
A Subsidiary of Whittaker Corporation
An Equal Opportunity Employer M/F
talking to other Canadian
nurses about it. And some day
I m going back there. 55
Dorothy Redden s reactions
are typical. And Whittaker,
a leader in international health
care, is now offering contracts
in either Saudi Arabia or Abu
Dhabi. If you re a Canadian
trained RN with 2-3 years
postgraduate experience, call
us today on our Toll Free line.
Classified
Advertisements
Alberta
British Columbia
British Columbia
Registered Nurees required for a 560-bed acute care
hospital in Edmonton, Alberta Positions available in
most clinical areas. Candidates must be eligible for
registration in Alberta. Current salary rates under
review. Apply to: Personnel Department. Edmonton
General Hospital. 1 1 1 1 1 Jasper Avenue, Edmonton,
Alberta T5KOL4
Registered Nurses required for full time work on
Medicine and Pediatrics as well as Surgery and
Maternity. To work rotating shifts. Positions availa
ble immediately. Apply to: Director of Nursing. St.
Joseph s General Hospital, P.O. Box 490, Veg-
reville. Alberta TOB4LO. Phone: 1-403-632-2811.
British Columbia
Associate Director of Nursing required for a 142
acute, 75 Extended Care bed Eraser Valley Hospital.
Excellent career opportunity for a qualified, innova
tive individual involving responsibility for a broad
area of nursing service. Principle role will be patient
care co-ordination (Clinical). Administrative experi
ence and B.S.N. preferred. Apply in writing to:
Director of Nursing, Matsqui-Sumas-Abbotsford
General Hospital, 2179 McCallum Road, Ab-
botsford. British Columbia V2S 3P1. Phone 853-
2201.
Staff Nurses required for the following areas:
Psychiatry, Extended Care and Medical. Eligibility
for Registration in B.C. required. Formal training
and/or experience preferred. Apply in writing to:
Director of Nursing, Matsqui-Sumas-Abbotsford
General Hospital, 2179 McCallum Road, Ab-
botsford, British Columbia V2S 3P1. Phone: 853-
2201.
Experienced General Duty Graduate 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 writing to:
Director of Nursing, St. George s Hospital, Box 223
Alert Bay. British Columbia, VON 1 AO.
The "boom" of our northern city continues! We still
require beginning or experienced practitioners for our
nursing departments. If experienced, we will give
you opportunity to try some of your ideas. If
beginning, we will give you opportunity to expand
your skills and knowledge. Contact: Mrs. A.
Henriksen Nursing Director. Dawson Creek and
District Hospital, 1 1 100 13th Street. Dawson Creek
British Columbia V 1G 3W8.
Operating Room Head Nurse Must be RNABC
registered. Must have experience in all O.R.
procedures. Salary: according to the RNABC
Agreement. Please apply in writing to: Mrs. A.
Houghton, Director of Nursing, Fort St. John
General Hospital. 9636 100th Avenue, Fort St
John. British Columbia VU 1Y3.
General Duly Nurses Must be registered with
RNABC. Salary according to the RNABC Agree
ment. Please apply to: Mrs. A. Houghton, R.N.,
Director of Nursing, Fort St. John General Hospital,
%36 100th Avenue. Fort St. John. British Colum
bia VU 1Y3.
General Duly Nurse for modern 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 Nursing. Bound
ary Hospital. Grand Forks, British Columbia, VOH
1HO
General Duty Registered Nurses required for 108-bed
accredited hospital in northwest B.C. Previous
experience desirable. Salary as per RNABC Con
tract with northern allowance. For further informa
tion, please contact: Director of Nursing, Kitimat
General Hospital, 899 Lahakas Blvd. N., Kitimat,
British Columbia V8C 1E7.
Permanent Part Time and Holiday Relief General
Duty Registered Nurse preferably with one year s
experience including obstetrics and geriatrics. Sal
ary, benefits as per RNABC contract. Small hospital
in scenic West Kootenays skiing, fishing, golfing,
boating, hiking, swimming. Apply: Slocan Commun
ity Hospital and Health Care Society. Box 129, New
Denver, British Columbia VOG ISO.
Experienced Nurses (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 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, V3L5E8.
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 $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.
General Duty RN s or Graduate Nurses 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
Hospital. Box 98, Pouce Coupe. British Columbia or
call collect (604) 786-5791.
Experienced General Duty Nurses required for
130-bed hospital. Basic Salary $1,305.00 $1,542.00
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.
Registered Nurses required for permanent fulltime
position at a 147-bed fully accredited regional acute
care hospital in B.C. Salary at 1979 RNABC rate
plus northern living allowance. One year experience
preferred. Apply: Director of Nursing. Prince
Rupert Regional Hospital. 1305 Summit Avenue,
Prince Rupert. British Columbia, V8J 2A6. Tele
phone (collect) (604) 624-2171 Local 227
General Duty Nurses required for an active, 103-bed
hospital. Positions available for experienced R.N s
and recent Graduates in a variety of areas. RNABC
Contract in effect. Accommodation available. Apply
to: Director of Nursing. Mills Memorial Hospital.
4720 Haugland Avenue, Terrace, British Columbia
V8G 2W7.
Experienced maternity, I.C.U./C.C.U., and Operat
ing Room General Duty nurses required for 103-bed
accredited hospital in Northern 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, V8G
2W7.
General Duty Nurses required by an active 80-bed
acute care and 40-bed extended care hospital located
in the Cariboo region of B.C. s central interior.
Year-round recreational activities in this fast grow
ing community. Applicants eligible for B.C. registra
tion preferred. Apply in writing to: The Director of
Nursing. G.R. Baker Memorial Hospital. 543 Front
Street. Quesnel. British Columbia V2J 2K.7.
Registered Nurses required immediately for perma
nent full time positions at 10-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 1WO. Telephone:
(604) 636-2221 Collect.
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 interprofessional 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 applicants.
University of Victoria, School of Nursing. Applica
tions are invited for positions on the faculty of the
School of Nursing. University of Victoria. The
School offers a two-year post-R.N. programme
leading to a B.Sc.N. and plans to develop both a
basic and a master s programme. Qualifications:
Master s degree required, doctorate preferred. Ex
perience in university teaching an asset. Apply to:
Director, School of Nursing, University of Victoria,
P.O. Box 1700, Victoria, British Columbia V8W
Manitoba
Challenging Career Opportunist 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 vacan
cies in Pediatrics, Medicine/Surgery. Ohstemcs and Critical
Care. This opportunity will appeal to nurses who want to
increase their exist ing skills or develop new skills 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 - 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)677-2381.
Head Nurse Operating
Room
Required for a 222 bed acute general
hospital. The operating room consists of
4 theatres and one cysto room with a
staff comple ment of 22 .
Applicants must have demonstrated
leadership and administrative skills,
B.Sc.N. or post graduate education in
O.R. preferred.
Qualified applicants are invited to submit
their resumes to:
IVrsonnel Director
Hummer Memorial Public Hospital
969 Queen Street East
Sault Ste. Marie, Ontario
P6A2C4
Port Saunders Hospital
Port Saunders, Newfoundland
Requires
Registered Nurses
commencing April 1980 through to
September 1980.
Applicants must be registered or eligible
for registration with the Association of
Registered Nurses of Newfoundland.
Salary scale: $13,923.00 $16,819.00.
Please forward application, curriculum
vitae and references to:
Mrs. Madge Pike
Director of Nursing
Port Saunders Hospital
Port Saunders, Newfoundland
AOK 4HO
Operating Room
Registered Nurses
The Kentville Hospital
Association requires staff nurses
with experience and/or a post
graduate course in operating
room techniques.
Please send complete resume to:
Director of Personnel
Kentville Hospital Association
186 Park Street
Kentville, N. S.
B4N 1M7
Registered Nurses
Registered Nursing
Assistants
Openings currently exist in a 788
bed hospital specializing in
convalescent, long-term
rehabilitation and chronic care
patients. Easily accessible by public
transit, day care facilities available.
Applicants must be prepared to
work two shifts.
Apply:
Personnel Department
The Riverdale Hospital
14 St. Matthews Road
Toronto, Ontario
M4M 2B5
(416) 461-8251 Ext. 292
New Brunswick
University of British Columbia
Health Sciences Centre Hospital
Ex tended Care Unit requires
Clinical Nursing Consultant
-Education (Staff Nurse HI)
Reporting to the Director of Nursing, plans
and implements orientation and on-going
in-service programs for nursing and other staff
members, coordinates pre-admission
assessment activities, provides direct patient
care to selected patients as arranged.
facilitates clinical nursing research,
participates in School of Nursing activities in
the unit as requested, represents E.C.U. in
Nursing Education areas and maintains an
effective working relationship with nursing and
other health professionals. Requires Masters
degree in Nursing or Nursing Education,
registration with the RNABC, evidence of
clinicaJ competence in the care of
elderly /disabled patients, demonstrated skills
in program planning, implementation and
evaluation and successful work experience in
clinical nursing and nursing education. Salary
range $ 1 500 - J 1772 per month plus differential for degree.
Applicants should submit detailed resume to:
Coordinator of Hospital Employment
Health Sciences Centre Hospital
University of Brit Kh Columbia
Vancouver, B.C. V6T 1W5
Position open to both male and female applicants.
Regina General Hospital
Requires
Registered Nurses & New
Grads
Come Join Our Staff!
Interesting challenges are experienced in our
acute care 483 bed hospital. We have started a
regeneration program to replace existing
facilities. These new facilities will be enjoyed
in the near future.
Salary in accordance with Union Agreement
Progressive Personnel Policies
Paid planned programs in:
General Orientation
Coronary Care
Intensive Care
Other specialty areas
Continuing In-Service Education
Friendly working atmosphere
Apply to:
Personnel Services
Regina General Hospital
Regina, Saskatchewan S4P I)W5
Director of Nursing required for a 60-bed Nursing
Home facility (N.B. Registration or eligible) and
must be bilingual and have extensive experience in a
senior nursing administrative position. Apply to:
Administrator, Grand Falls Manor Inc., P.O. Box
2000, Grand Falls, New Brunswick EOJ 1MO.
Faculty members required with teaching and clinical
experience for an integrated undergraduate program.
(1) Medical-Surgical Nursing, to work with team
who teach seniors in an acute care setting; (2)
Maternal and Child Health Nursing, to teach second
year students in pediatrics, and third year students in
the Nursery; (3) Community Nursing, to teach
freshman students in the classroom, with observa
tions in the community in the first term and clinical
teaching in geriatrics in the second term. Directing
community experiences for second year students.
Applicants should be able to qualify for the rank of
Assistant or Associate Professor. Master s degree
essential. Salary in accordance with qualifications
and experience. Apply with curriculum vitae and
names of referees to: Dean I. Leckie, Faculty of
Nursing, University of New Brunswick, P.O. Box
4400, Fredericton, New Brunswick E3B 5A3.
Newfoundland
The General Hospital A newly opened teaching
hospital located in historic St. John s offers to
Registered Nurses who seek specialized and profes
sional growth a twenty-four week course of integ
rated academic and clinical experience in the
following: Critical Care Nursing; Neurosciences
Nursing; Operating Room Nursing. Applications
now being accepted for September 1980. Please
contact: Director, Staff Development & Training
Dept., The General Hospital, Prince Philip Drive,
St. John s, Newfoundland A IB 3V6.
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: Assistant Administrator-
Nursing, Stanton Yellowknife Hospital, Box 10,
Yellowknife, N.W.T., X1A 2N1.
Ontario
RN, GRAD or RNA, 5 6" or over and strong,
without dependents, non-smoker, for 185 Ib. 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. Wages: $200.00 to
$275.00 wkly. NET plus $90.00 wkly. bonus on most
weeks in Miami. Write: M.D.C., 3532 Eglinton
Avenue West, Toronto, Ontario, M6M IV6.
Applications are now being accepted by the Ontario
Society for Crippled Children for Registered Nurses,
Graduate Nurses and Registered Nursing Assistants
for their Resident Summer Camps located near
Collingwood, Port Colborne, Perth, Kirkland Lake
and London. Ten weeks mid June to late August.
1980. Various positions available Supervisory.
Assistant supervisory, and general cabin respon
sibilities. Contact: Camping and Recreation De
partment, 350 Rumsey Road, Toronto, Ontario M4G
1R8. (416) 425-6220, ext. 242.
Quebec
Camp Nurses required for children s 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 (5 141 735-3669.
Saskatchewan
United States
United States
Director of Nursing Inviting applications from
Nurses. This will be an opportunity for a Nurse who
b Intel-tiled In management. Related experience and
education will be considered. Apply in confidence
to: Administrator, Eastend Union Hospital, Eas-
tend, Saskatchewan SON OTTO, or call collect (306)
295-3242/3239.
Two Registered Nurses are needed for 12-bed
hospital 430 miles northwest of Saskatoon. Wages
and benefits as per SUN contract . Trailers available
as living accommodations. Apply to: Sister Helen
Desmarais, Director of Nursing, St. Martin s Hospi
tal, La Loche, Saskatchewan SOM 1GO.
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 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 opportunity to 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)
268-5000, ext. 1680.
Florida Nursing Opportunities 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
information and offer relocation hints. There is no
placement fee to you. Write or call Medkal
Recruiters of America, Inc. (For West Coast) 1211 N.
Westshore Blvd., Suite 205, Tampa, Fl. 33607 (813)
872-0202; (For East Coast) 800 N .W. 62nd St. , Suite
510, Ft. Lauderdale, Fl. 33309(305)772-3680.
Four R.N. s urgently needed for 8 bed modern
hospital in southern Sask. Must be eligible for
S.R.N.A. registration. Please apply to: Administra
tion, Beechy Union Hospital, Box 68, Beechy,
Saskatchewan SOL OCO or Telephone (306) 859-
-2118.
United States
Total patient care with all licensed personnel is our
goal! Staff RNs currently interviewing for part-time
and full-time positions Full service, except psych,
progressive 156-bed accredited acute general hospi
tal. Located within 60 minutes from LA, the ocean,
mtns., and the desert. Orientation and staff de
velopment programs. CEUs provider number.
Parkview Community Hospital, 3865 Jackson Street,
Riverside, California 92503. Write or call collect
714-688-2211 ext. 217. Betty Van Aemam, Director
ofNursing.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoying
Florida s Gulf Coast beaches, sun, and exciting
recreational activities. We will provide work visas,
help you locate a position, find housing, and arrange
your relocation. No Fees! Call or write: Medical
Recruiters of America. 1211 N. Westshore Blvd.,
Suite 205. Tampa, Florida 33607 (813) 872-0202.
Appraise our Miami Hospital What can Victoria
Hospital offer you? We can give you a modern
300-bed progressive, acute care hospital as a
stimulating work environment. We offer excellent
salaries, benefits, CEU s, tuition refunds and reloca
tion assistance. For pleasure, Miami has great
beaches, boating, dining, discos, tennis, golf, snor-
keling, etc. Our Hospital also has apartments
available. Want to leam more? Call Ms. McDonald,
R.N., person-to-person, collect at (305)772-3682, or
write Nurse Recruiter, 800 N.W. 62nd St., Suite 5 10,
Ft. Lauderdale. Fla. 33309.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the USA
B) Extensive information regarding
Hospital 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 0. Box 11 33 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
Nurses:
Try Canada s
Northland
This Summer
Infirmieres:
Decouvrez les
Terres
Septentrionales
du Canada cetete.
Join the team providing health
care to the residents of the
Northwest Territories. Medical
Services, Northwest Territories
Region will be offering a number
of term positions for qualified and
experienced nurses.
Positions are available at nursing
stations, health centres and
hospitals for the period, May
through September.
Knowledge of the English
language is essential.
For more information write to:
Nursing Advisor,
Human Resource Planning,
Medical Services Branch,
Health and Welfare Canada,
Room 1972,
Jeanne Mance Building,
Tunney s Pasture,
Ottawa, Ontario K1 A OL3
NOTE. Permanent positions are
also available.
Open to both men and women
Joignez-vous a I equipe medicale
qui soigne les habitants des
Terntoiresdu Nord-Ouest. La
direction des Services medicaux.
region des Territoires du
Nord-Ouest, offre des postes
d infirmieresdiplfimees, pourune
periode determinee
Les postes offerts se trouvent
dans des postes de soins
infirmiers, des centres samtaires
ou des hopitaux; la periode de
travail va de mai a septembre.
La connaissance de I anglais est
indispensable.
Pour de plus amples
renseignements, priered ecrireS
I adresse suwante
Conseillere en soins infirmiers,
planification des ressources
humaines
Direction generale des services
medicaux
Sante et Bien-etre social Canada
Piece 1972,
Immeuble Jeanne Mance
Pare Tunney
Ottawa, Ontario K1 A OL3
REMARQUE Des postes
permanents sont ega/ement
offerts.
Appel de candidatures mixtes
^ Health and Welfare
Canada
Sante et Bien-etre social
Canada
Canada
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed, J.C. A. H. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differential
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 90% under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-551 1
Good Samaritan Hospital
Flagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
United States
Offers R.N. s
An UNUSUAL OPPORTUNITY.
A.M.I. Will FURNISH One Way AIRLINE TICKET to Texas
and $500 Initial LIVING EXPENSES on a Loan Basis.
After One Year s Service, This Loan Will be Cancelled
American Medical International Inc.
HAS SO HOSPITALS THROUGHOUT THE U.S.
* Now A.M.I. Is Recruiting R.N. s tor Hospitals in Teias.
Immediate Openings. Salary Range $11.000 to $16.500 per Year.
* You can enjoy nursing in General Medicine, Surgery. ICC.
CCU, Pediatrics and Obsietncs
A.M I provides an excellent orientation program
in-service training
U.S. Nurse Recruiter
P.O. Box 17778, Los Angeles, Calif. 90017
# Without obligation, please send me more
Information and an Application Form
NAME
ADDRESS
CITY ST ZIP
TELEPHONE ( )
LICENSES.
SPECIALTY: _
YEAR GRADUATED: _ _ STATE: _
Nurses RN Immediate openings in California-
Florida-Texas-Maryland-Virginia and many other
States if you are experienced or a recent Graduate
Nurse we can offer you positions with excellent
salaries up to $ 16,000 per year 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. that you are interested in. We
will call you upon receipt of your application in order
to arrange 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 Place
ment Service, P.O. Box 1133, Great Neck, New
York 11023, (516)487-2818).
"Our 23rd Year of World Wide Service"
The Best Location in the Nation The world-
renowned Cleveland Clinic Hospital is a progres
sive, 1030-bed acute care teaching facility committed
to excellence in patient care. Staff Nurse positions
are currently available in several of our ICU s and 30
departmentalized medical/surgical and specialty di
visions. Starting salary range is $14,789 to $17,056,
plus $1248/year ICU differential and premium shift
differential, comprehensive employee benefits and
an individualized 7 week orientation. We will
sponsor the appropriate employment visa for qual
ified applicants. For further information contact:
Director-Nurse Recruitment, The Cleveland Clinic
Hospital, 9500 Euclid Avenue, Cleveland, Ohio
44106 (4 hours drive from Buffalo, N.Y.); or call
collect 2 16-444-5865.
Come to Texas 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 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 1591, Beaumont, Texas 77704. An
affirmative action employer.
Nurses RNs 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 Or call collect
(713) 789-1550. Marilyn Blaker, Medex, 5805
Richmond, Houston, Texas 77057. All fees employer
paid.
Nurse Midwfves Northern Africa & Central
America: Bachelor s Degree, Midwifery Certifica
tion, 5 + years experience and an interest in clinical
and classroom teaching. Project HOPE provides
excellent benefits, travel, shipping and storage,
salary commensurate with experience. Short and
long term positions available. Send resume to:
Personnel Department, Project HOPE, Millwood,
Virginia 22646. E.O.E.
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer trips
from one week to 3 months in: Canada, USA,
Europe, Africa, Asia, South and Central America,
Australia. New Zealand and the Caribbean. For free
catalogue, apply to: Goway Travel, 53 Yonge St.,
Suite 101, Toronto, Ontario M5E IJ3. Phone:
4 1 6-863-0799. Telex : 06-2 1 962 1 .
Electrolysis Successful Electrolysis Practice for
Sale. 6 months specialized included. Write or phone:
Margot Rivard, 13% St. Catherine Street West,
Suite 221, Montreal, Quebec, H3G 1P9. Telephone:
(514)861-1952.
Brandon General Hospital
School of Nursing
Requires
Program Co-ordinator
- July 7, 1980
Teachers
- August 1, 1980
Applications are invited for these
Faculty Positions in a Hospital based
two-year diploma nursing program which
uses an individualized teaching-learning
approach.
Eligible for M. 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:
Mrs. Shirley J. Paint
Director of Nursing Education
School of Nursing
Brandon General Hospital
150 McTavish Ave. E.
Brandon, Manitoba
R7A 2B3
Head Nurse
Neonatal Intensive Care Unit
The Victoria General Hospital, a 422-bed
community hospital invites applications from
B.C. Registered Nurses for the challenging
position of Head Nurse Neonatal Intensive
Care Unit.
The hospital is currently involved in a total
rebuilding programme and upon completion of
the new facility in 1982 will be the major
referral hospital for Obstetrics for the Victoria
region.
Reporting to the Director of Patient Care
Services, the Head Nurse assumes
responsibility for patient care, staffing, and
operating efficiency of the Unit. The Head
Nurse, in cooperation with other Obstetrical
staff, will also be involved in developing
procedures, staffing requirements, etc. for the
new facility.
Commitment to family-centered obstetrical
care is essential. Post-graduate training in
Neonatal Intensive Care or equivalent
experience and demonstrated leadership
ability required. Teaching experience an asset.
Apply to:
Personnel Manager
Victoria General Hospital
841 Fail-field Road
Victoria, B.C.
V8V 3B6
THIS IS NO
ORDINARY
HOSPITAL . . .
It s The Hospital of the Future!
Featuring:
. FRIESEN CONCEPT
. NO NURSING STATIONS
. TOTAL NURSING SUPPORT from
Central Supply - Pharmacy
Dietary - Medical Records
Laundry
. UNIQUE DESIGN CONCEPTS
. COMPUTERIZED SYSTEMS
. TOTAL PATIENT CARE
. PRIMARY NURSING
The emphasis is on NURSING at Holy Cross
Hospital, a 259-bed acute care facility located just
north of Los Angeles. Call us collect for full
information on The Hospital of the Future.
Contact Marian Williams, Nurse Recruiter,
at (213) 365-8051, ext. 1488
Holy Cross Hospital
15031 Rinaldi Street
Mission Hills, Ca. 91345
Equal Opportunity Employer M/F
Exploring the Many
Faces of Opportunity
Opportunity wears many faces at
Santa Monica Hospital Medical Center in
Southern California It can be the excite
ment and challenge of working as part of
our Operating Room or Critical Care teams
It can also be in the achievement of your
goals as you begin to play a more active
role in management and/or supervision
However, opportunities expand be
yond your professional life in Southern Cal
ifornia The total scope of the active life is
virtually unlimited from wide, sunny beaches
to near-by winter slopes . the opportunities
are here
If you would like more information
about exploring the many opportunities now avail
able to you, please forward the below coupon
Who knows, you may find a new definition
for "opportunity"
Santa Monica Hospital
Medical Center
1225 15th SI Santa Monica. CA 90404
(213) 451-1511 Ext 2537
Phone
An Equal Opportunity Employe W F
CN-3
TbmomowV
Nursing...
...is a short drive
a*vay from
Monterey Bay
Searching for a place where your spare time can be a true source of
adventure? This one-time Spanish seaport will capture your spirit with
scores of historical sites as well as easy access to the wonders of the Giant
Redwoods. It s one of the fascinating places you ll find, a short drive from
Stanford University Medical Center
You will also find "tomorrow s" nursing today in an exciting teaching
hospital where non-clinical personnel handleadministrativeandsupport
tasks so you can concentrate on progressive nursing. You can apply new
techniques, participate in research and work with leading authorities in
every medical specially.
We d like you to know more about our career development programs and
our excellent compensation package which includes an innovative time-
off program For additional information, send the coupon to Nurse
Recruiter. Personnel Department, Stanford University Hospital
Stanford. CA 94305. Or call collect to (415) 497-7330 For immediate
consideration, send your resume and salary requirements We are an
affirmative action, equal opportunity employer, male and female
Stanford University
Medical Center
Thonanartlar, Ni,
Foothills Hospital, Calgary,
Alberta
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
Foothills Hospital
1403 29 St. N.W. Calgary, Alberta
T2N2T9
Intensive Care Nurses
300 bed Accredited general
hospital in Vancouver requires
full-time R.N .s for 4 bed I .C.U.
Candidates should be eligible for
registration with the RNABC.
Previous l.C.U. experience
required.
Please apply in writing to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C. VST 3N4
ntssj
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, Part Time and Casual Employment.
Benefits in accordance with R.N. A. B.C.
contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
V8R 1J8
Waterford Hospital
Career Opportunities For
Registered Nurses
The Waterford Hospital . a fully accredited 400
bed Psychiatric Institution, affiliated with
Memorial University School of Nursing and
Medical School, has openings for Registered
Nurses ;n all services, including new.
expanded, and acute care services
An orientation program is offered.
Salary is on (he scale of $12. (M8 - 14.555 per
annum. A Psychiatric Service Allowance of
S 1 .329 per annum is available hi addtiion to
basic salary. Bolh salary and allowance
presently under review.
The Hospital is close to all amenities:
shopping, transportation and recreation
facilities.
Accommodations available in Hospital
Residence at nominal cost .
Applications in writing should be addressed to
the undersigned:
Personnel Director
Waterford Hospiul
H aterfbrd Bridge Road
SI. John s, Newfoundland
AIE4J8
Telephone Number: ntxi J68-IMM1, ext. .Ml
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
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 Canadian Regist
ration. Preceptorship from a medical
practitioner. At least one year of work
experience, preferably in primary care.
For further information write to:
Mona ( all in. Director
Educational Program for Nurses
in Primary Care
Faculty of Health Sciences
McMaster University
Hamilton, Ontario L8S 4J9
Registered Nurses
Full and part-time vacancies in a
new expanding hospital with
progressive programmes in long
term care, rehabilitation and
geriatrics.
Must be eligible for Ontario
registration.
Write to:
Assistant Director of Nursing
West Park Hospital
82 Buttonwood Avenue
Toronto, Ontario
M6M2J5
IntemationalGrenfell Association
requires
Registered Nurses, Public Health
Nurses and Nurse-Midwives
(R.N.)
for Northern Newfoundland and Labrador.
The International Grenfell Association
provides Medical Services in Northern
Newfoundland and Labrador. It staffs
four hospitals, seventeen nursing
stations and many public health units.
Our main hospital is a 150 bed accredited
hospital situated in scenic St. Anthony,
Newfoundland. Active treatment is
carried on in Surgery, Psychiatry,
Medicine, Pediatrics, OBS/GYN, and
Intensive Care.
Orientation and active Inservice
Program provided for staff. Salary based
on government scales; 37 1/2 hrs. per
week. Rotating shifts. Excellent
personnel benefits include liberal
vacation and sick leave. Accommodation
available. Return airfare paid on a
completion of a one year service.
Apply to:
Scott Smith
Personnel Director
Curtis Memorial Hospital
International (irenfell Association
St. Anthony, Newfoundland AOK -ISO
Prince George
Regional Hospital
Positions available for experienced nurses or
nurses interested in developing their skills in
specialty nursing Operating Room,
ICU/CCU, Neonatology Nursing. Must be
eligible for B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and Obstetrical
Suite
lObed ICU/CCU
Prince George Regional Hospital is a 340 bed
acute regional referral hospital with a 75 bed
extended care unit and has a planned program
of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000 - 15th Avenue
Prince George, British Columbia
V2M 1S2
OVERSEAS OPPORTUNITIES
JLJSO has openings in Africa, Papua New
Guinea and Latin America for nurses with:
Public Health
BSc and Master Degrees
Midwifery
Qualifications: All except the midwifery
positions require Canadian qualifications.
Contract: 2 years
Salary: Low by Canadian standards but
ufficient for an adequate lifestyle. Couples
will be considered if there are positions for
both partners. For more information, write:
CUSO Health D-1 Program
151 Slater Street
Ottawa, Ontario
K1P5H5
University of British Columbia
Health Sciences Centre
requires
Registered Nurses
Opportunities for nurses interested in working as
members of the interprofessional team in the new 240 bed
Acute Care U nit , of the H . S .C . on the U . B .C . campus .
Positions available in:
Operating Room Suite
Intensive/Coronary Care
Medicine
Surgery
Emergency
Nurses must be registered or eligible for registration with
the RN ABC.
Applicants should apply in writing with detailed resume
to:
Coordinator of Professional Employment
Health Sciences Centre
University of British Columbia
Vancouver, B.C.
V6T 1VV5
Positions open to both female and male applicants.
OPPORTUNITY
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 #9 184-9
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
Alberta Hospital, Edmonton
Box 307, Edmonton, Alberta
TSJ2J7
Telephone: (403) 973-2213
Nursing Unit Coordinator
Required By The Thompson
General Hospital,
Thompson, Manitoba
The Thompson General is a fully accredited
100 bed acute care hospital located in a modem
community of 18,000 in North Central
Manitoba.
The successful applicant will be given the
responsibility of planning, organizing and
directing the activities of a 46 bed
Medical/Surgical Unit.
Applicants must be eligible for registration
with M.A.R.N. Preference will be given to
those with Administrative training and/or
experience.
The salary range for this position is $17,600 -
$22,200 per year. Other benefits include Group
Life, Pension Plan, free dental program,
income protection and remoteness allowance.
Those interested are asked to apply, in
confidence, giving details as to experience,
education and references to -
Mr. R.L. Irvine
Director of Personnel
Thompson General Hospital
Thompson, Manitoba K8N OCX
Telephone (204) 677-2381
The University of Alberta
seeks a
Dean of Nursing
Candidate should have earned doctoral
degree, demonstrated scholarship,
professional achievement and
competence in administration.
Salary commensurate with qualifications
and experience.
Nursing is one of five Health Science
Faculties and offers Baccalaureate and
Master s level programs.
Starting date: July 1, 1980. Applications
and nominations should be received
before April 1 1th, 1980 and should be
sent to:
Dr. R. G. Baldwin
Vice-President (Academic)
The University of Alberta
Edmonton, Alberta
T6G2J9
The University of Alberta is an equal
opportunities employer.
COLLEGE OF
NEW CALEDONIA
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 for the
1980-81 academic year.
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.
Letters of application with the names of
three references should be submitted to:
L. Winthrope
Personnel Officer
College of New Caledonia
3330 - 22nd Avenue
Prince George, B.C.
V2N IPS
Phone enquiries to the Personnel Officer
at
604/562-2131
Registered Nurses
Come to work in scenic Corner Brook!
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
West Coast of Newfoundland.
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January, 1979 $12,771.00 15,429.00
1 January, 1980 $13,410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
Registered Nurses
Planning your summer vacation?
Then by all means, include a visit to beautiful
Vancouver in your plans. And while you re here,
drop in and discuss your nursing career
opportunities at Shaughnessy Hospital, an 1 100 bed
multi-level community teaching hospital.
We have full-time, part-time and float positions
available as well as a 2 week orientation for RN s
who wish to work on a casual basis only.
When you re in Vancouver please call:
Jane Mann
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
N euro-surgery
Planned Orientation and In-Service Education Programs.
Post Graduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Apph to:
Recruitment Officer Nursing
I niversit) of Alberta Hospital
8440 II 2th Street
Edmonton, Alberta
T6CJ2B7
University of
Alberta Hospital
Edmonton, Alberta
Are You a Nurse?
Here s an Opportunity To Be One.
Primary Nursing
at the New Regional Hospital means having direct
responsibility for the nursing care of your patient, his family,
and working with the doctor as a colleague.
Accountability
as a primary nurse means the outcome of your patient s
care is the measure of your effectiveness.
Satisfaction
results from your role as a professional and the significant
part you play in the care of your patient.
PUT IT TOGETHER with the new 300 bed Fort McMurray
Regional Hospital Opening in November. 1979.
Want to know more about your opportunities in our total
patient care facilities?
Call Penny Albers at (403) 743-3381
or
Write for an information package:
Personnel Department
Fort McMurray Regional Hospital
Fort McMurray, Alberta
T9H 1P2
Director of Nursing
The Calgary General Hospital invites applications for the
position of Director of Nursing Service . The Director will
assume responsibility for a large nursing department covering all
services in a 960-bed fully accredited active treatment teaching
hospital. The nursing department is organized into seven clinical
divisions.
This position will appeal to Nursing Managers who have
demonstrated their leadership and organizational abilities in
progressively senior administrative positions. Advanced
preparation at the Master s level and experience in a large
teaching hospital would be definite assets.
Applications may be submitted in confidence to:
Mr. E. H. Knight, Executive Director
Calgary General Hospital
841 Centre Avenue E.
Calgary, Alberta
T2EOA1
Telephone: (403) 268-9311
CALGARY GENERAL HOSPITAL
841 Centre Avenue E.
Calgary, Alberta T2E OA1
Government of
Newfoundland & Labrador
Public Notice
Cottage Hospital Nurse 1 s
Applications are invited for appointment on a permanent or
short term basis to the Nursing Staff of the Cottage Hospitals
at:
Bonne Bay
Harbour Breton
Salary forCottage Hospital Nurse 1, annual, sick leave,
statutory holidays and other fringe benefits in accordance
with Nurses Collective Agreement.
Living-in accommodations available at reasonable rates, also
laundry services provided.
Applications should be addressed to:
Director of Nursing
Cottage Hospitals Division
Department of Health
Confederation Building
St. John s, Newfoundland
A1C 5T7
Lome A. Klippert. M.D.
Deputy Minister
Director of Nursing
Applications are invited for this senior management
position in a fully accredited multi-disciplinary treatment
complex of 406 beds, including extensive out patient
programmes. Reporting to the Executive Director, fully
responsible for organization, planning, administration and
operations of nursing care functions.
Candidates must have current registration in Ontario,
B.Sc.N. or Masters degree preferable, with demonstrated
competent leadership abilities and previous nursing
administrative experience at a senior level.
Applicants are requested to submit a comprehensive
resume and salary expectations to:
G. E. Pickard
Executive Director
Windsor Western Hospital Centre Inc.
1453 Prince Road
Windsor, Ontario
N9C3Z4
The Canadian Nurse
Murch 19RO 7
A Completely
Modern Teaching Hospital
Requires
Registered Nurses
This 500 bed general hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered -
Critical Care, Medical, Surgical Coronary Care,
General Surgery, Urology, Gynecology,
Medicine, Nephrology, Clinical Teaching,
Neurosciences, Cardiology, Cardiovascular
Surgery, Orthopedics, Hemodialysis (kidney
transplants), Emergency and Out Patient
Services, active Rehabilitation Program (adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in Critical Care Nursing,
Neurosciences, Operating Room Nursing.
Located in St. John s, Newfoundland the
oldest city in North America with a population of
120,000, offering cultural and recreation
activities in a friendly atmosphere.
Fishing, hunting, boating available
approximately 10-14 miles outside the city.
For information regarding salary and relocation
expenses and other conditions of employment
write or call -
Miss Dorothy Mills
Staffing Officer - Nursing
The General Hospital
Prince Philip Drive
St. John s, Nfld.
A1B 3V6
Telephone # (709) 737-6450
The University of Alberta
Faculty of Nursing
Invites
Applicants for positions beginning 1 July 1980. Master s degree
and relevant clinical experience required; Post-Master s
preparation or Ph.D. preferred. Teaching primarily in
under-graduate programs (Basic and/or Post-R.N.), but some
graduate teaching possible for suitable candidates; joint clinical
appointments may be arranged for interested candidates.
Two continuing vacancies exist; appointment possible at
Assistant or Associate Professor rank depending on
qualifications. Prefer candidates with some combination of
pediatric, nurse-midwifery and/or community health
background.
Three full-time sessional appointees (8 month period) to replace
staff on leave; rank and salary will depend on qualifications.
Prefer candidates with administration, adult acute care or
pediatric background.
The University of Alberta is an equal opportunity employer.
Please send enquiries and applications to:
Dr. Amy Zelmer
Dean
Faculty of Nursing
The University of Alberta
Edmonton, Alberta
T6G 2G3
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
major 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 in many
areas such as:
Intensive Care
(General & Neurosurgical)
Cardio- Thoracic Surgery
Burn Unit
Paediatrics
Neonatology Nursing
Inservice Education
Coronary Care Unit
Hyperalimentation
Program
Renal Dialysis & Transplantation
If you are a Nurse considering a move please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue Vancouver, B.C. V5Z 1M9
. 980.
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:
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1A OL3
Name
Address
I
Health and Welfare
Canada
Prov.
Sante et Bien-etre social
Canada
I
I
The University of Western Ontario
Graduate Program Coordinator
Applications are invited for the above position
coordinating an expanding graduate program
currently enrolling 35 students. Canada s first
M.Sc.N. program offers majors in Nursing
Education and Nursing Administration.
Duties involve overall program coordination,
delegated administrative functions, curriculum
development and teaching.
Qualifications include Ph.D., university teaching
experience, and demonstrated clinical competence.
Previous administrative experience is desirable.
Salary is commensurate with academic and
experiential background.
Send curriculum vitae and references to:
Dr. Beverlee Cox, Dean
Faculty of Nursing
The University of Western Ontario
London, Ontario, Canada
Association of Nurses of Prince Edward Island
Executive Director /Registrar
This position offers a unique challenge to nurses who have a
broad background in all aspects of nursing. As this is the only
professional nursing position in the employ of the association, it
requires that the incumbent function in the capacity of advisor to
educational programs in nursing, promote and direct research
projects, write reports and briefs on diverse topics, as well as
carry out the administrative and legislative functions of an
Executive Director and Registrar of the professional association.
Qualifications:
Master s Degree in nursing or related discipline strongly
preferred.
Progressive nursing experience in which leadership and other
educational and administrative skills have been demonstrated.
The candidate must be eligible for licensure as a registered nurse
in P.E.I.
Salary: Negotiable, commensurate with education and
experience. Contract available.
Applications giving full details of education, qualifications and
experience should be sent by March 25, 1980 to:
Beth Robinson, Chairman
Search Committee
Association of Nurses of Prince Edward Island
41 Palmer s Lane
Charlottetown, Prince Edward Island
CIA 5V7
Judy Hill Memorial Scholarships
Applications are being received for two annual Scholarships, details of which are as
follows:
Value
Up to $3, 500.00 each.
Purpose
To fund post-graduate nursing training (with special emphasis on public health
nursing, outpost nursing and midwifery) for a period of up to one year commencing
July 1st. 1980.
Tenabk
In Canada, the United Kingdom. Australia and New Zealand.
Applicants
Should possess the following qualifications:
Fluency in English;
* R.N. Diploma, or equivalent;
A desire to work for the Government of Canada or one of its Provinces at a fly-in
nursing station in a remote area of Northern Canada for a minimum period of one year
following completion of the scholarship year.
Required
A resume of academic and nursing career to date, together with a brief statement of
the applicant s outside interests;
Copies of educational qualifications submitted on entry to nursing school;
A statement as to date of birth, marital status, dependents (if any) and citizenship;
Verification of R.N. Diploma, or equivalent;
* The proposed course of study and verification as soon as acceptance is received;
Two character reference letters. One of these should be from a Health Service
Professional (preferably a Nursing Supervisor) familiar with the Applicant s recent
nursing experience. In reaching their decision, the Trustees attach considerable
importance to the advice of the referees.
Apply To
Mr. Philip G.C Ketchum, Chairman. The Board of Trustees, Judy Hill Memorial
Fund, 15325 Whitemud Road. Edmonton, Alberta. Canada (T6H 4N5).
Closing date for completion of applications- May 31st, 1*80.
* The Scholarship is contingent on the successful applicant being registrable by a
nursing association in one of the Canadian Provinces and being a Canadian citizen or
able to meet current Canadian requirements for employment with the Public Service
of Canada. Information regarding these requirements and regarding courses available
in Canada may be obtained from the Regional Nursing Director, Medical Services,
NorthwestTerritories Region, Yellowknife, Northwest Territories, Canada.
Advertising Rates
For All Classified Advertising
$20.00 for 6 lines or less
$3. 00 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 N urses 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
K2P 1E2
Index to
Advertisers
March 1980
Abbott Laboratories
17
Addison- Wesley Publishers
48
Air Canada
15
Baxter Travenol Laboratories of Canada
(Division of Travenol Laboratories Inc.) OBC
The Canadian Armed Forces
49
The Canadian Nurse s Cap Reg d
The Clinic Shoemakers
F.A. Davis Company
Equity Medical Supply Company
Glaxo Laboratories
25
57
52
Frank W. Horner Limited
56
J.B. Lippincott Company of Canada Ltd.
TheC.V. Mosby Company Limited
Parke, Davis & Company Limited
50,51
18, 19
54
Pharmacia (Canada) Limited
Procter & Gamble
16,55
13,IBC
W.B. Saunders Company
Smith & Nephew Inc.
_53
7
Stiefel Laboratories (Canada) Ltd.
Upjohn Health Care Services
56
10
White Sister Uniform Inc.
1FC
Advertising Representatives Advertising Manager
Jean Malboeuf
601, Cote Vertu
St-Laurent, Quebec H4L 1X8
Telephone: (514)748-6561
Gordon Tiffin
1 90 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P.O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215) 363-6063
Gerry Kavanaugh
The Canadian Nurse
50 The Driveway
Ottawa, Ontario K.2P 1 E2
Telephone: (613) 237-2133
Member of Canadian
Circulations Audit Board Inc.
"SB Match..! 980
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Three six-week, double-blind clinical studies
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By formingwi occlusive film on the surface of
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Exercise: how the body responds
The ups and downs of an
employee fitness program
Personalizing your fitness program
Marketing a healthy lifestyle
Incorporating lifestyle teaching
into education
The
Can
Nurse
WltNCES INFIRMJEKI
APRIL 1980
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Today s diabetics have a healthier out
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That s where Ames helps out
Our Diastix or Keto-Diastix*tell them day
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so there s less risk of complications than
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cents and a few seconds a day.
Our free Daily Diary
helps them keep a record of their
condition, so they can begin to see
how, when and why it changes.
And our free Diabetic Digest offers lots
of useful information that may help them
understand their condition more clearly and
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The only other thing they need is your
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help from us, today s diabetics
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and a healthier outlook.
tev
Ames
Division
Ames Division, Miles Laboratories, Ltd ,
Rexdale, Ontario M9W 1G6.
We helped make urinalysis
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"Trademarks of Miles Laboratories. Inc Miles Laboratories, Ltd., authorized user
1979, Miles Laboratories Inc.
HOLLISTER INTRODUCES
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our
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Because your ostomy system is just that
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This is what blanket protection
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And, as the name suggests, the sys
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Best of all, it offers you choices:
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Not a bad system, right?
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Hollister
Hollister Incorporated 21 1 Easl Chicago Avenue. Chicago. IL 60611 Distributed in Canada by Hollisler Limited.
322 Consumer* Road. Willowdalc, Ontario M2J 1P8 1980 Hollister Incorporated AM rights reserved.
V - i m&i
Fit to travel Lifestyle is
a matter of choice and
that s what this issue is all
about whether you re
backpacking in Kootenay
National Park in Alberta
or walking to work. Our
cover photo is courtesy
of fellow hiker Janet
McEwen, RN, of Ottawa.
The
Canadian
Nurse
April 1980 Volume 76, Number 4
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaueh
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.
Jean Passmore. editor. SRNA news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith. director ol publications.
National Gallery of Canada.
Florita Vialle-Soubranne. consultant.
professional inspection division. Order
of Nurses of Quebec.
Personal fitness
The body shop 46
Tomorrow s nurses 49
30
Exercise: How the body responds
Anne Hedlin
A * What s the Score on Sports and
^3 Eye Injuries?
Susan Moses
33
Fitting Nursing into
E. Lee Macnamara
Fitness
4/C The Body Shop
Anne Esler Me Murray
l/^ An Employee Fitness Program -
^* Hospital Style
Janet McEwen
/iQ Tomorrow s nurses shape up for a
^-* healthy future
Kendy Bentley
Bonnie Friesen
IQ The Stress Test
Patricia MacFarlane
CA Save your own life
Marion Logan
41
Cardiac Rehabilitation: applying
the benefits of exercise
Barbara Naimark
10 Today s issues
tomorrow s nursing
CNA convention
u Np , 21 Candidates for CNA
Office 1980-1982
17 Calendar 54 Audiovisual
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.
Canadian Nurses Association. 50 The
Driveway. Ottawa. Canada. K2P 1E2.
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
\ urse. A biographical statement and return address
should accompany all manuscripts.
The view-s expressed in the articles are those of the
authors and do not necessarily represent the policies of
the Canadian Nurses Association.
ISSN 0008-458 1
Indexed in International Nursing Index. Cumulative
Index to Nursing Literature. Abstracts of Hospital
Management Studies. Hospital Literature Index.
Hospital Abstracts. Index Medicus. Canadian
Periodical I ndex . The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor. Michigan 48106.
Canadian Nurses Association. 1980.
perspective
Guest editorial
In order to promote a
particular point of view, I
believe that it is necessary to
value it, by which I mean to
give it high priority, gain
knowledge about it, and role
model or demonstrate
associated behaviors. I
question whether the nursing
profession truly values fitness
and healthy lifestyles to the
extent that we give priority
to, have knowledge about,
and role model healthy
lifestyle behaviors.
If we valued healthy
lifestyle behaviors, we would
take time to promote health
behaviors in all clients. Health
teaching related to smoking,
diet, exercise, stress
management and coping skills
is seen as a nursing activity.
How many of us consistently
focus on this area of our
practice? How much
importance do we place on
health teaching? Or is this
something that we do only if
there is time left over?
Nursing claims to be
involved in health promotion,
yet the majority of us are
illness oriented and indeed
have more knowledge about
the unhealthy body than the
healthy body. Can we be a
((health-giving profession))
unless we have a knowledge
base in health, nutrition,
exercise and life skills, and
skill in assessment, planning
and intervention related to
promotion and support of
health behaviors?
In relation to role
modelling, I must ask
whether we ourselves
demonstrate healthy
lifestyles. By this, I mean a
lifestyle that contributes to
both mental and physical
fitness. Sporadic exercise is
not enough. Let s take an
honest look. A word of
caution though, before you
assess your lifestyle. The
important thing is to strive to
attain a healthier lifestyle, to
attempt to maintain balance
in your life, not to become
perfect.
The following are
important areas to assess:
Do you smoke?
Do you overindulge in
drugs or alcohol?
Do you overeat, eat
non-nutritious foods, or
undereat?
Do you have a
sedentary style of life?
Are you overweight?
Do you deal in an open
way with problems and
feelings?
Do you identify and
manage stress periods in your
life?
Do you balance activity
with rest, work with play,
thought with action?
We do not often
recognize how non-healthy
lifestyle behaviors interfere
with our ability to set goals,
take risks, make decisions and
handle conflicts.
Right now lifestyle and
fitness are terms that are
regarded positively by the
general public. Some of us in
the nursing profession have
responded by focusing on
health promotion as a major
nursing function. When the
fad aspect of lifestyle and
fitness has faded will the
nursing profession still be
there and will it have the
credibility to work with
others to maintain the high
visibility of fitness and
health?
This April issue of CNJ
marks a special effort to
sensitize nurses to fitness and
lifestyle. The authors focus
on both knowledge and role
modelling. We see evidence
that some nurses are indeed
diagnosing problems and
developing interventions
related to fitness and
lifestyle. But this is not
enough. Nursing education
programs must develop and
build curricula on nursing and
health models. We must
convince our employers and
the government that fitness
and lifestyle do pay off. We
must begin research in this
area to identify indicators of
health and test out
interventions related to
promotion of health. Some of
our closest colleagues in this
work will be found in the
areas of physical education,
kinesthesiology, nutrition
studies and health education.
To promote a greater
and lasting focus on health,
the total nursing profession
must be involved. I hope that
this journal will help you
look at your own lifestyle
but, more than that, I hope
that it will motivate you to
I
take the steps to make health
promotion a function of
every nurse and a focus of
our health care delivery
system.
Irmajean Bajnok is assistant
professor. Faculty of Nursing,
University of Western
Ontario. A member of the
Middlesex North Chapter of
the Registered Nurses
Association of Ontario, she is
past president of the RNAO.
Irmajean is a graduate of
the Winnipeg General
Hospital School of Nursing
and received her BScN from
the University of Alberta and
her MScN from the
University of Western
Ontario.
A year ago, in February
1 9 79, she addressed
community health nurses
attending the National
Workshop on Fitness and
Lifestyles at Geneva Park,
Ontario.
We care about the shape
you re in and so do the
members of the Registered
Curse s Association of
Ontario and the board of the
VON for Canada. They
ndicated this when they
proposed similar resolutions
;o CNA suggesting a special
issue of the journal focusing
on fitness and lifestyle.
Initially, CNJ staff
approached the project with
the goal of presenting a
complete look, a handy guide
to encourage nurses to look
at their own fitness level
and lifestyle objectively and
as well to incorporate some
how to s for change both
personally and professionally.
It soon became apparent that
this was an impossible task
and that really all we could
do was to attempt to
stimulate some dialogue
among Canadian nurses.
Now, that this special
issue is a reality, we look
back on what has turned out
to be a very rewarding
experience for all of us. The
experts whom we contacted
for assistance responded with
eagerness and, as word of the
project spread, enthusiasm
grew and we received
contributions from nurses all
across Canada.
Next month we will
continue our look at fitness
and lifestyle as we explore
what Canadian nurses are
doing in their work areas:
Judy Proulx of Cochrane,
Alberta, has coordinated a
"fun and fitness" obesity
clinic for children age six
through fourteen; Frances
Welch tells of her experiences
with the Thunder Bay,
Ontario Community Fitness
campaign, a two-year project
in which 22,000 citizens have
already participated and Jean
Nickerson, along with several
of her Nova Scotia colleagues
look at the impact of the
fitness and lifestyle boom on
occupational health nursing
in that province.
These and other nurses
share their goals and
experiences along the rocky
road to program implemen
tation. Then to complete our
look at lifestyle, we will
be reporting on a national
nutrition symposium taking
place in Toronto in March.*
6 April 1980
The Canadian Nurse
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Apply Op-Site to pressure areas at the first sign
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DAY 3. Conventional
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A choice of sizes
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Clean and dry the area.
Apply Op-Site.
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Lachine, Que. H8T 2Y5
Reg. T.M
GET READY, GET SET - GO!
^0- -^_- vjc,i ivr,/\L i , VJE, i ajdi vnJJ
Vancouver 1980
Here it is...
\
Lorine Besel: assistant professor,
Faculty of Medicine (School of
Nursing), McGill University;
director of nursing, assistant
executive director, Royal Victoria
Hospital, Montreal.
Norma Fulton: associate professor
and director, Continuing Nursing
Education, College of Nursing,
University of Saskatchewan,
Saskatoon.
Louise S. Lemieux-Chailes: under
contract with College of Nurses
of Ontario tp develop a
Blueprint for the Future of
Nursing in Ontario)) - part-time
counsellor, individuals and
couples.
Aline Michaud: coordinator
advisor, Labor Relations,
Federation des Syndicats
Professionnels D Infirmieres et
D Infirmiers du Quebec
(Federation des SPIIQ).
AN INVITATION FROM THE RNABC
The Registered Nurses Association of British Columbia is looking
forward to the CNA biennial meeting in Vancouver this June. As your
hosts, we are planning a number of social activities. These will include
breakfasts and lunches, as well as evening dinner tours to the Harbour
Centre and Gastown, Grouse Mountain and Chinatown. A theatre
evening and harbour cruise will also be offered during your stay.
In addition to a variety of local tours during non-business hours
of the convention, delegates will be offered post-convention tours to
Waikiki and Maui, San Francisco, Alaska, Reno and Victoria.
Vancouver is a beautiful city with its stunning mountains and
sandy beaches. Its art galleries, museums, theatres and clubs are among
the finest in the world. The cuisine is varied but specialties are the
ethnic foods and seafoods.
More information about social activities planned for you, both
during the convention and after, can be found in the February issue
of the Canadian Nurse. Additional details on activities will be sent to
all registrants. We hope you enjoy your stay in Vancouver and that
you see as much as you can of our lovely city.
Phyllis Barrett: executive
secretary, Newfoundland
Association of Registered Nurses.
Kathleen M. Clark: education
co-ordinator, Registered Nurses
Association of Ontario.
Jessica Ryan: head nurse,
Pediatric Service, Chaleur General
Hospital, Bathurst, N.B.
and...
Judy Fraser, occupational health nurse,
Winnipeg; Shelly Kremer, general duty
nurse, Port Moody, B.C.; Roland Foucher,
Universite de Quebec; Ruth Burstahler,
consultant in continuing education,
Registered Nurses Association of B.C.;
Rita Lussier, conseiller en formation
professionnelle, OIIQ; Margaret Steed,
associate professor, director, Continuing
Education, Faculty of Nursing, University
of Alberta.
PROGRAM HIGHLIGHTS
Today s issues: tomorrow s nursing
Sunday, June 22
14:00 Canadian Nurses Foundation annual meeting
19:30 Opening ceremonies
Address, Primary Care Nursing , Dr. Lea Zwanger, Tel Aviv.
(Kellogg Foundation Lecture)
RNABC reception for all registrants
Monday, June 23
09:00 Keynote address: Who Shapes Nursing in the 80 s?,
Lorine Besel
10:30 Annual meeting
12:30 CNA luncheon for all registrants (Guest speaker to be announced)
14:30 Feature presentation, Canada s health care system and how it is
financed, Malcolm G. Taylor, professor of public policy,
Faculty of Administrative Services, York University (Toronto).
Reaction panel
Phyllis Barrett (Nfld.)
Judy Fraser (Man.)
Shelly Kremer (B.C.)
Jessica Ryan (N.B.)
17:00 Mtet your candidates* (An opportunity for all registrants to meet
candidates for 1980-82 term of office.)
Tuesday, June 24
09:00 President s address
Executive director s report
12:30 Election and luncheon
14:30 Labor movement vis-a-vis the professional association*
Professor Roland Foucher, labor analyst.
Aline Michaud. nurse.
Louise Lemieux-Charles, nurse.
19:30 Dinner and entertainment (RNABC sponsored) for all registrants.
Wednesday, June 25
09:00 General Session
1 1:15 Debate, Continuing education: mandatory vs. voluntary*
Ruth Burstahler (B.C.)
Kathie Clark (Ont.)
Rita Lussier (Quebec)
Norma Fulton (Sask.)
Margaret Steed (Alta.)
12:30 Luncheon
1 4:30 Installation of officers
President s address
RESERVE NOW
Hyatt Regency Hotel *$ 44.00 single
655 Burrard St. 58.00 double/twin
Vancouver, B.C.
V6C 2R7
(604-687-6543)
CNA Convention Site...
D I wish to receive a reservation card for
accommodation at the Hyatt Regency.
Holiday Inn Centre
Harbourside
1133 West Hastings St.
Vancouver, B.C.
V6E 3T3
(604-682-4541)
Century Plaza
1015 Burrard St.
Vancouver, B.C.
V6Z 1N5
(1-800-261-3330
Travelodge toll free)
Hotel Grosvenor
840 Howe St.
Vancouver, B.C.
V6Z 1N6
(604-681-0141)
*CNA convention rate
*$38.00 single
42.00 double/twin
*$ 34.00 single
40.00 twin
46.00 triple
$ 32.00 Standard
34.00 deluxe
single or double
REGISTER NOW
Registration Fee
(includes Monday luncheon and Tuesday
dinner)
Three days Daily rate
n CNA member $100 40
D Non-member 150 60
D Nursing student 40 20
I wish to attend (days circled) Monday
Tuesday Wednesday
Name
Surname First
Address .
Present employer.
Prov/Terr of Reg n.
Reg n No..
I enclose cheque or money order payable to
Canadian Nurses Association, 50 The
Driveway, Ottawa, Ontario, K2P 1E2.
Quality cane
comes from
quality texts .
PHIPPS LONG WOODS
Medical-
surgical
nursing
CONCEPTS AND CLINICAL PRACTICE
-o
I
BARBER STOKFS BIIUNCS
A CLIENT APPROACH
TO NURSING
New 7th Edition!
SKATER S MEDICAL-
SURGICAL NURSING
By Wilma J. Phipps, R.N., PH.D.: Barbara
C. Long. R.N., M.S.N.; and Nancy Fugate
Woods, R.N.. M.N., Ph.D. Through six
editions, this classic has provided a clear
understanding and approach to applied
nursing care. The new 7th edition
reflects a more logical progression of
clinical-surgical problems. You and your
students will appreciate these key
features:
instead of two sections, there are
now five that allow students to more
firmly grasp the correlation between
body systems
six completely new chapters cover
"Perspectives on health and illness,"
"Sexuality in health and illness,"
"Nursing process an overview,"
"Quality assurance programs toeval-
uate nursing care." "Death and
dying," and "The patient requiring
intensive care nursing"
emphasizesanursingcareapproach
presents up-to-date research on
neoplasia. pain, sexuality, plus fluid
and electrolyte balance/ imbalance
March, 1980.Approx. 1,088 pp., 587 illus.
About $28.75.
MEDICAL-SURGICAL
NURSING: Concepts
and Clinical Practice
Edited by Wilma J. Phipps, R.N.. B.S.,
AM., Ph.D.: Barbara C. Long, R.N.. M.S.N.;
and Nancy Fugate Woods, R.N., M.N.,
Ph.D. : with 46 contributors. Using both a
conceptual and a systems approach, this
innovative text reflects the myriad
changes in contemporary
medical/surgical nursing. Highlights
Include:
a systems approach within a con
ceptual framework your students
will be able to locate important
information quickly and better
understand how specific medical
details relate to total patient care
abeginnlngsectionon"Perspectives
for Nursing Practice" examines
important Issues students will face
a vital section on stress and
adaptation
emphasizes total patient care
throughout
You won t find a more useful
combination of concepts with clinical
practice! Assess this valuable text for
yourself then make It part of your
classroom. 1979. 1.648 pp., 731 illus.
Price, S32.50.
2nd Edition. ADULT AND CHILD CARE:
A Client Approach to Nursing. By Janet
Miller Barber, R.N., M.S.: Lillian Gatlln
Stokes. R.N.. M.S.; and Diane McGouem
Billings, R.N., M.S. Focusing on the
patient as client, 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). You ll find:
in-depth information on patho-
physiologic processes
valuable material on cardiovascular
illness, pathophysiology of cancer,
and assessment techniques for
congenital anomalies
important data on nursing assess
ment of breast cancer, venereal
disease, and rape
More than 100 new illustrations and 72
tables complement this 2nd edition.
1977. 1,050 pp., 738 illus. Price. $28.75.
12 April 1980
The Canadian Nurse
2nd Edition. PATIENT CARE STAN
DARDS. By Susan Martin Tucker. R.N.,
B.S.N.. P.H.N.: Mary Anne Breeding. R.N..
B.S.: Mary M. Canobbio . R.N.. B.S.N.:
EleanorVargo Paquette. R.N.. B.S.:
Marjorie E. Wells, R.N., B.S.: and Mary E.
Willmann, RN. Formulated to provide
the needed guidelines for developing and
planning quality nursing care, this
helpful text covers medical conditions,
surgical interventions, diagnostic pro
cedures, chemotherapeutic agents, and
related supportive mechanical
equipment. Highlights of this thoroughly
revised edition include:
definitions and laboratory valuesfor
each condition
thirty-two new standards have been
added
assessment tools, such as body
system assessment, nutritional and
psychosoclal assessment
expanded patient teaching sections
to include "discharge outcome"
Don t miss this important new edition!
March, 1980.Approx.608pp.. 168 Illus.
About S20.50.
BASIC PATHOPHYSIOLOGY: A Con
ceptual Approach. By Maureen E. Groer,
RN., Ph.D. and Maureen E. Shekleton.
RN.. B.S.N.. M.S.N. The authors of this
useful text have organized the vast field
ofpathophysiologyinto major conceptual
areas. Students will study various
disease entitles 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.
Noteworthy discussions investigate:
Immunopathology
aging as a genetic process
atherosclerosis
diabetes and obesity
Immune viral organisms of human
cancer
Helpful behavioral objectives begin each
chapter. 1979. 534 pp., 423 illus. Price.
SI 9.25.
A New Book! CLINICAL MANUAL OF
HEALTH ASSESSMENT. By June M.
Thompson. R.N.. M.S. and Arden C.
Bowers. R.N., M.S. March, 1980. Approx.
544 pages. 487 illustrations. About
S19.25
HEALTH ASSESSMENT. By Lois
Malasanos. R.N.. Ph.D.: Violet
Barkauskas. R.N., C.N.M., M.P.H.: Muriel
Moss. RN.. MA.; and Kathryn
Stoltenberg-Allen. R.N., M.S.N. 1977. 538
pages, 769 Illustrations. Price. S26.00.
Let Mosby
give your students
the up-to-the-minute
medical-surgical
information
they can depend on.
2nd Edition. CLINICAL IMPLICATIONS
OF LABORATORY TESTS. By Sarko M.
Ttlkian, M.D.: Mary Boudreau Conover,
R.N..B.S.N.Ed.:andAra G. Tilklan.M.D..
FA.C.C. Answer your students questions
on the significance of laboratory test
results with this concise resource! Using
an effective, step-by-step approach, the
text emphasizes physiological
implications, variations, and interrela
tionships of laboratory values. This 2nd
edition:
offers handy sections on patient
preparation, instruction, and
aftercare
replaces the chapteronserodlagnos-
tlc tests with two new chapters on
rheumatoid and infectious diseases
provides an extensively revised
chapter on gastroenterology
reflects the latest research in the
table of normal values
1979. 334 pp., 45 illus. Price. SI 2.00.
A New Book! INTRAVENOUS THERAPY:
A Handbook for Practice. By Charlene
Coco, R.N., B.S.N. Your students can
unravel the Intricacies of IV therapy with
the help of this handy guide!
Emphasizing the nursing process, this
long-awaited book explores adult IV
therapy. Up-to-the-minute discussions:
present the rationale underlying IV
therapy and venlpuncture
teach students to recognize both
therapeutic and deleterious effects
examine nursing actions relating to
therapy
outline legal aspects
study pharmacodynamics
Both chapter and general references add
to the usefulness of this comprehensive
new text. February, 1980. 182 pp., 55
illus. Price. 81 2.00.
ASP042
For more information, please write:
MOSBY
TIMES MIRROR
THE C. V. MOSBY COMPANY. LTD.
86 NORTHLINE ROAD
TORONTO, ONTARIO
M4B 3E5
The Canadian Nurse
April 1980 13
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nursing abstracts
nursing abstracts
keeps the busy nurse current,
aids the student, the
researcher and the teacher.
nursing abstracts
covers 45 nursing journals.
nursing abstracts
written by R.N.s for R.N.s.
nursing abstracts
aims to meet the need of our
subscribers.
for information:
nursing abstracts, co. inc.
P.O. box 295
forest hills, n.y., 11375
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Students & Graduates
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CNA s Task Group a set of Principles for Standards
The definition and standards
for nursing practice Task
Group has established a set of
principles upon which to base
the development work
underway.
"We recognize and
endorse the use of a
conceptual model for nursing
practice, education and
research in any setting,
acknowledging that
administration is an integral
component in each area.
Respecting the freedom
of informed choice, we will
not impose upon others, our
choice of any one of the
various nursing models that
exist. This freedom of choice
will allow for the utilization
of a number of nursing
models, their eventual testing
and further refinement, as
well as the construction of
new models.
We believe that the use
of a conceptual model will
contribute to improved
quality of nursing practice,
since it provides direction for
the development of
behavioral indicators required
to evaluate that practice.
We perceive the nursing
process to be the means by
which the conceptual model
will be applied in nursing
practice.
Since nursing education
prepares future practitioners
and nursing research
contribures to both education
and practice, a conceptual
nursing model is equally
important to each field of
activity."
This project is one of
the most important CNA
Biennium priorities moving
into the final phase and
aiming at an Annual
Meeting/Convention target.
Research in the 80 s
Fall Conference Theme
Four professional nursing
associations and five
university Faculty/Schools of
Nursing in the Maritimes will
co-sponsor a conference,
"Research Basis for Nursing
in the Eighties", October 22,
23 and 24 at the Hotel Nova
Scotian in Halifax.
A call for papers
describing basic or applied
research in the practice of
nursing has been announced
by project coordinator, Dr.
Ruth MacKay. Some papers
on research in nursing
education and nursing
administration where the
connection is made to
nursing practice may be
included. Any nurse
researcher practicing in
Canada may submit papers
which must be accompanied
by an abstract of 100-175
words and a current
curriculum vitae.
Applications to attend
the conference are invited
from interested nurses and
researchers from other
disciplines involved in
multidisciplinary research
with nurses. Registration is
limited to 200 persons. (Fee
is $140 rising to $160 after
September 15. Registrants
should make their own hotel
accommodation).
The four sponsoring
associations are: New
Brunswick Association of
Registered Nurses, Registered
Nurses Association of Nova
Scotia, Association of Nurses
of Prince Edward Island and
Association of Registered
Nurses of Newfoundland. The
Faculty/Schools of Nursing
are Memorial University of
Newfoundland, Dalhousie
University, St. Francis Xavier
University, University of New
Brunswick and Universite de
Moncton.
Information: Coordina
tor, Research Nursing in
the 80 s Conference, School
of Nursing, Dalhousie
University, Halifax, N.S.
B3H4H7.
Did you know...
The Health Computer
Information Bureau in
Ottawa is the first attempt in
the world to establish a
central facility for
information on computer use,
and users, in the health
field. The Bureau wishes to
facilitate the exchange of
information by publishing a
catalogue of user names and a
description of the types of
computer applications in
Canada. To give information
or to learn more about the
Bureau, contact Marjorie
Hayes, RN, BScN, MScN,
director, 410 Laurier Avenue
West, Suite 800, Ottawa,
Ont. KIR 7T6.*
14 April 1980
The Canadian Nurfte
news
Nurses look at new ways of helping young old and old old .
Gerontological nursing is
working on a new image,
one that can t help but
result in happier patients
and happier nurses. The
new image is based on a
positive attitude towards
aging, the belief that
mental health can and
must be maintained and
restored in the elderly.
"Resist the
tendency to identify with
the helpless, hopeless
attitude of many of the
elderly," nurses at the
third annual meeting of
the Gerontological
Nursing Association were
urged. "One of the most
important nursing
measures in maintaining
mental health in the
elderly is continuing to
believe that there is
something there that is worth
maintaining," another guest
speaker, Pat Morden, told her
audience of close to 200
nurses who work in hospitals,
homes for the aged,
community agencies and
psychiatric institutions
throughout Ontario and some
agencies outside the province.
Morden urged nurses to
get away from the tendency
to stereotype elderly patients,
to refuse to accept the label
of "senile" pinned on an
aging patient without
reference to an adequate data
base.
A nurse clinician at St.
Peter s Hospital in Hamilton
and consultant in
gerontological nursing at the
School of Nursing at
McMaster University, Morden
shared the a.m. session of the
program with Dr. Don
Wasylenki, consulting
psychiatrist in the
psychogeriatric program at
West Park Hospital in
Toronto.
The meeting was the
first for the Gerontological
Nursing Association since its
official incorporation last
Fall. Past president
Pam Dawson, a clinical nurse
specialist with Sunnybrook
Medical Centre, introduced
the eight members of the new
board of directors: chairman
Merron Mclsaac, Arlene
Randall, Fran Morris and
Marie Hannum, all of
Toronto; Betty McCallum
and Margaret Black of
London and Rhona Lampart
and Glynnis Gardiner of
Hamilton.
The GNA was
recognized as an official
affiliate of the Registered
Nurses Association of Ontario
in May, 1979. The latest
chapter to join the
association is in Hamilton;
other cities that have
indicated interest in setting
up chapters include Ottawa
and Winnipeg, as well as a
group in Nova Scotia.
Dr. Wasylenki, who
described old age as a "season
of loss", touched on several
significant new findings in his
review of normal and
pathological changes that
accompany aging. Of special
significance to nurses is the
notion that, contrary to
popular belief, there does not
appear to be any decrease in
the ability of the individual
to leam as a person ages.
Reaction time, however, may
very well increase and nurses
should allow for this in
assessing the mental function
of their patients.
Contemplating the losses of
aging, Dr. Wasylenki pointed
out that research now
indicates that conjugal
bereavement rather than
retirement is the most
significant loss threatening
the social organization of the
aging individual. "We are also
seeing more and more marital
conflict among the elderly,"
he said, observing that often
the individual who has
trouble adjusting to
retirement transfers this
conflict to the marital
situation.
Nurses should
remember that the decision
to institutionalize a family
member is one of life s most
stressful events, resulting
often in guilt or depression
on the part of the
decision-maker a feeling
compounded by the
realization that the event is a
harbinger of one s own fate .
Helping the family to
recognize this as a crisis
situation and to deal with it
appropriately is an important
part of the nursing role, Dr.
Wasylenki said.
Speaker Pat Morden
had several constructive
suggestions to offer nurses in
the area of reducing the
negative effects of
institutionalization, including
identification of the caregiver
as an individual the patient
can call by name, respect for
the privacy of a patient,
recognition of the continued
significance of sexuality in a
patient s lifestyle and
attention to the appearance
of the patient.
Morden identified
mindlessness as the chief
threat to the mental
well-being of the elderly, a
condition encouraged by the
fallacy that senility is
inevitable, by sensory
deprivation resulting from
loss of sight, hearing and
other senses and, often,
over-medication. She urged
nurses caring for the elderly
to provide their patients with
the time and the information
they need to make their own
decisions, to assume as much
responsibility for their own
care as possible and to give
them meaningful tasks.
The conference
committee was headed by
Christine Souter, staffing
supervisor, Riverdale Hospital
in Toronto. Also participating
in the program were Mary
Kay Harrison, clinical
specialist, psychiatric nursing,
coordinator of the
psychogeriatric program at
West Park Hospital and
Marguerite Williams,
coordinator of special
projects and consultant in
gerontological nursing,
Rosedale Pain Treatment
Centre, Toronto.
More information on
the GNA may be obtained by
writing to:
Gerontological Nursing
Association
PO Box 368, Station "K"
Toronto, Ontario, M4P 2G7.
Did you know...
The Ontario Deafness Research
Foundation, newly formed to
assist research in the cause and
treatment of deafness, will be
awarding grants annually for
research in these fields. This
year s grants totalled $68,000.00.
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CONSIDER THESE OUTSTANDING
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It defies water hazards, so that rain,
snow, slush or dew cannot remove or
streak if
It can be cleaned with a damp cloth,
even using a mild cleaner tf necessary
It is resistant to soiling and smudges,
outlasting ordinary white polishes and
making your shoes remain whiter
longer (saving you from frequent
polishing)
// imparts an almost l\ke new look to
your shoes
It does not promote leather cracking
as do many white polishes
It gives consistent hiding power, with a
pleasant shine, smooth appearance,
and Luifhouf buffing.
As a nurse or other hospital or medi
cal professional in white leather
footwear, you recognize these out
standing Dura White 91 qualities as
those you have sought after in a
white polish. When you use Dura
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HOW TO BUY
Dura White is available directly
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ml(l U.S. fl.oz.) bottle with an appli
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B.C. residents please add 4% Provin
cial sales tax, American customers,
send $3.00 U.S. funds and we pay
the customs duty.
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The Canadian Nurse
April 1980 15
NURSING 80
Three superior references written and edited by nurse educators
for fast access to essential nursing facts and techniques. Each
gives far more useful nursing data than other volumes now in use.
A. McGRAW-HILL HANDBOOK OF CLINICAL NURSING
Editorial Board: Margaret E. Armstrong, R.N., M.S., Asst.
Prof., U. of Rochester School of Nursing; Elizabeth J. Dickason,
R.N., M.A., Assoc. Prof., Queensborough Comm. Coll. Nursing
Program; Jeanne Howe, R.N., Ph.D., Assoc. Prof., Western
Carolina U. School of Nursing and Health Sciences; Dorothy
Jones, R.N., M.S.N., Assoc. Prof., Boston College School of
Nursing Graduate Program; M. Josephine Snider, R.N., B.S.N.,
M.N., Ed. D.. Asst. Prof., U. Florida College of Nursing.
Based on contributions from 41 other nurses.
featuring
H six chapters on psychiatric nursing
D four chapters on emergency nursing
n three chapters on geriatric nursing
D ANA Standards of Nursing Practice blended into almost
every chapter
Available, 1,600 pages, 8" x 10", $31.20 (045020-X)
B. McGRAW-HILL NURSING DICTIONARY
Editorial Board: Margaret Armstrong, R.N., M.S., Asst. Prof.,
U. Rochester School of Nursing; Jeanne Howe, R.N., Ph.D.,
Assoc. Prof., Western Carolina U. School of Nursing and Health
Sciences; Ann P. Smith, B.S.N., M.N., Director, Nursing
Service, North Florida Regional Hospital; Marilyn M. Smith, R.N.,
Asst. Prof., Northeastern U. Public Health Nursing Program;
M. Josephine Snider, R.N., B.S.N.. M.N., Ed.D., Asst. Prof.
U. of Florida College of Nursing.
featuring
D over 50.000 entries 18,000 more than the next
largest nursing dictionary
D concentration on the data nurses need most because its
edited by nursing specialists
D entries all arranged alphabetically for easy location instead
of by confusing categories
D special longer entries for vital nursing terms
D syllable breakdowns and pronunciation aids
Available, Thumb-indexed, 1,232 pages, $17.45 (045019-6)
C. NURSES DRUG REFERENCE
Editorial Board of Nursing Drug Specialists: Joseph A. Albanese,
R.Ph., Ph.D., who teaches pharmacology to nursing students
at the College of Staten island, where he is Adjunct Assoc.
Professor. He has a Ph.D. in Drug Education from Fordham
U., where he conducts additional pharmacology courses.
Contributors: Thomas Bond, MT. (ASCP), B.S., M.S.; Carita
Y. Klindtworth, R.N., B.S.N., M.S.; Marilyn J. McDonald,
R.N., B.S.N., M.A.; Anthony R. Scalisi, R. Ph., B.S. in Pharmacy.
featuring
D detailed clinical nursing implications
n indexes for generic names; for brand names; and for bc th
names within each drug category
n legal status of controlled substance drugs
Available, 512 pages, 7 1/2" x 9 1/4", $14.95 (000766-7)
D. COMPREHENSIVE PEDIATRIC NURSING, SECOND EDITION
Edited by Gladys M. Scipien, Martha Underwood Barnard, Marilyn
A. Chard, Jeanne Howe, and Patricia J. Phillips (055540-0)
This in-depth study of both the healthy and ill child from
conception through adolescence stresses growth and development
in easily understandable terms. 1979, 1,100 pp., $26.20
E. MATERNAL AND INFANT CARE: A TEXT FOR NURSES,
SECOND EDITION
Jean Dickason and Martha Schult (016796-6))
Completely revised and updated to reflect all the most recent
developments in maternal and infant care. Covers the healthy
mother and infant, those at high risk, family planning, education
for childbirth, midwifery, the fourth trimester, pharmacology,
genetic considerations, preterm infants, and problems of
pregnancy, labor, delivery, and infancy.
1979, 640 pages, $22.45 (Instructor s Manual available)
F. CLINICAL PHARAMCOLOGY AND THERAPEUTICS IN NURSING
Edited by Matthew Wiener et al. (070138-5)
This sophisticated treatment of the nurse s growing role in
drug therapy presents the general principles of pharmacology
in readily understandable terms, and then applies them to
specific symptoms and problems such as electrolyte disorders,
infections, labor and delivery, psychiatric dysfunction, adverse
reactions and more. 1979, 704 pp., $24.95
G. COMPREHENSIVE PSYCHIATRIC NURSING
Edited by Judith Haber, Anita M. Leach, Sylvia M. Schudy,
and Barbara Flynn Sideleau (025384-6)
An integrated family-centered approach to care of psychiatric
patients in hospitals, clinics, and the community. Reciprocal
interaction and the nursing process are emphasized throughout.
1978, 768 pp., $22.45
H. MEDICAL-SURGICAL NURSING: A CONCEPTUAL APPROACH
Edited by Dorothy A. Jones, Clair Ford Dunbar and Mary
Marmoll Jirovec (032785-8)
Focuses on assessment, intervention, and community health
education as it synthesizes contemporary theories into a workable
understanding of human interaction. 1978, 1440 pages, $31.20
NURSING: PRETEST SELF-ASSESSMENT
AND REVIEW SERIES
Each volume contains 500 exam-type, multiple-choice questions with
answers, explanations, and current references.
1978,
I. MATERNAL-NEWBORN NURSING (051570-0) 213 pp., $7.50
J. MEDICAL-SURGICAL NURSING (051567-0) 188 pp., $7.50
K. NURSING CARE OF CHILDREN (051568-9) 199 pp., $7.50
L. PSYCHIATRIC NURSING (051569-7) 193 pp., $7.50
M. PRACTICAL NURSING (051571-9) 1979, 210 pp., $7.50
N. NURSING (051574-3) 1980, 824 pp., $14.50
Combines in one book the above listed four nursing review
books (Maternal-Newborn, Medical-Surgical, Nursing Care of
Children and Psychiatric Nursing). Contains 2,000 exam-type
questions referenced to the most recent major texts.
Please send the following for 30 days on-approval:
ABCDEFGHIJK
D Payment enclosed (postage & handling paid)
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McGRAW-HILL RYERSON LIMITED
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330 Progress Avenue
Scarborough, Ontario M1P 2Z5
CN4/80
calendar
Provincial Annual Meetings
The Registered Nurses Association of
Ontario will hold its annual meeting
May 1-3 at the Royal York Hotel,
Toronto. Contact: RNAO, 33 Price
Street, Toronto, Ont. M4W 1Z2.
The Saskatchewan Registered Nurses
Association will hold its annual meeting
May 6-8 at the Sheraton Cavalier Motor
Inn, Saskatoon, Sask. Contact: SRNA,
2066 Retallack St., Regina, Sask.
S4T2K2.
The Alberta Association of Registered
Nurses will hold its annual convention
May 6-9 at the Capri Centre, Red Deer.
Contact: Brenda Laing, Information
Officer, AARN, 10256, 112th St.,
Edmonton, Alberta T5K 1M6.
The Registered Nurses Association of
British Columbia annual meeting will be
held May 7-9 in Vancouver. Contact:
RNABC, 2130 W. 12th Ave., Vancouver
B.C., V6K2N3.
The Association of Nurses of Prince
Edward Island will hold its annual
meeting May 7 at Summerside. Contact:
ANPEI, 41 Palmer s Lane,
Charlottetown, Prince Edward Island
C1A5V7.
The Manitoba Association of Registered
Nurses will hold its annual meeting at
the Winnipeg Convention Center, May
22 & 23, with a theme of Spotlight on
Nursing-The Year 2000. Contact:
MARN, 647 Broadway Ave,, Winnipeg,
Manitoba R3C 0X2.
The New Brunswick Association of
Registered Nurses will hold its annual
meeting at Keddy s Motor Inn,
Fredericton June 3-5. Contact:
NBARN, 231 Sounders St., Fredericton,
New Brunswick, EBB 1N6.
"Expectations of the Nurse in the
Eighties is the theme of the 71st annual
meeting of the Registered Nurses
Association of Nova Scotia, which will
be held June 11-13 at Acadia
University, Wolfville, N.S. Contact:
RNANS, 6035 Coburg Rd., Halifax,
Nova Scotia, B3H 1 Y8.
April
Therapeutic Touch: An Ancient Nursing
Intervention, given in two parts, with
separate registrations for both days,
April 17 and 18. Contact: Mrs.
Dorothy Miles, Director, Continuing
Education Programme, Faculty of
Nursing, University of Toronto, 50 St.
George St., Toronto, Ontario.
Pediatric Emergency Conference
presented by The Hospital for Sick
Children, Toronto, will be held April
24 and 25, 1980. Contact: Betty Cragg,
Coordinator, Nursing Education, The
Hospital for Sick Children, 555
University Avenue, Toronto, Ont.
M5G 1X8.
"Mental Health or Mental Illness?" is
the theme of the Greater Vancouver
Mental Health Service Conference,
April 22 & 23. Contact: G.V.M.H.S.
Conference Committee, 201-828 West
8th Ave., Vancouver, B.C., V5Z 1E2.
The British Columbia Operating Room
Nurses Group will present their seventh
biennial Institute April 24-26 at the
Hotel Vancouver. Contact: Registration
Chairman, Mrs. Sheila Giles, 8-1385
W. llth Ave., Vancouver, B.C.
The Operating Room Nurses of Greater
Toronto are presenting the sixth
National Conference to be held Apr. 28
-May 1, 1980 at the Skyline Hotel,
Toronto, Ontario. Contact: Virginia
Gardhouse, Convener, Publicity
Committee, 580 The East Mall,
Apt. 404, Islington, Ont. >
"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.
Interested? Find out
what others say about Upjohn
HealthCare Services. Oppor
tunities in home care, hospital
staffing and private duty. Of
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today.
"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."
HM6402-C 1979 Healthcare Services Upjohn, Ltd
UPJOHN
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free booklet "Nursing
Opportunities at
Upjohn HealthCare
Services."
Address
Phone
Mail to: Upjohn HealthCare Services
Dept. A
Suite 203
716 Gordon Baker Road
Willowdale, Ontario M2H 3B4
The Canadian Nurse
April 1980 17
TODAY S TEXTS
FOR TODAY S
NURSE
TOP OF THE LINE TEXTS FOR A
CHANGING AND CHALLENGING
PROFESSION!
MATERNITY NURSING,
14th Edition
By Sharon R. Reeder, R.N.,
Ph.D.; Luigi Mastroianni, Jr.,
M.D., F.A.C.S., F.A.C.O.G.;and
Leonide L. Martin, R.N., M.S.
Featuring expanded coverage
of the numerous facets of
maternity, neonatal and perina
tal nursing care with emphasis
on assessment and management
throughout the antepartal, intra-
partal and postpartal periods
the new 14th edition of this
highly regarded text begins with
a philosophy of family centered
care and an exploration of cul
ture, society, maternal care and
the family in a changing world.
It then progresses through units
on the biophysical aspects of hu
man reproduction, reproduction
control and sexuality, ante
partal, intrapartal and postpar
tal assessment and management,
maternal disorders related to
pregnancy and labor, and prob
lems of the high risk neonate.
Lippincott. Abt. 623 Pages,
lllus. Feb. 1980. Abt. $22.00.
FUNDAMENTAL SKILLS
IN PATIENT CARE,
2nd Edition
By LuVerne Wolff Lewis, R.N.,
M.A.
The purpose of this leading in
troductory text is to present
basic nursing skills that all nurses
need to know regardless of the
type of educational program in
which they are enrolled practi
cal, associate degree, diploma or
baccalaureate.
New material in the Second Edi
tion includes: a brief descrip
tion of the nursing process and
problem-oriented records; a pa
tient s bill of rights; sensory
deprivation; preparation of the
patient for common diagnostic
procedures; urinary diversion;
basic cast care; cardiopulmonary
resuscitation; introduction of a
nasogastric tube; the living will;
and hospice care.
Lippincott. Abt. 612 Pages,
lllus. March 1980. Abt. $15.00.
WORKBOOK FOR
FUNDAMENTAL SKILLS
IN PATIENT CARE
By LuVerne Wolff Lewis, R.N.,
M.A.
Follows the textbook chapter-
by-chapter but can be used
separately as a self-evaluation
manual in basic care skills.
Lippincott. Abt. 250 Pages,
lllus. March 1980. Abt. $8.50.
NUTRITION: Principles
and Application in Health
Promotion
By Carol Jean Suitor, M.S.,
R.D.; and Merrily Forbes
Hunter, B.A., R.N.
Completely different in focus
and organization, outstanding
for its clear, non-judgmental
approach, Nutrition will guide
students in acquiring relevant
information about nutrition that
they can use professionally and
personally. Significantly, the
central focus is on promoting
good health rather than on
treating sick people.
Section one emphasizes the prac
tical aspects of normal nutrition,
Section two discusses nutrients
from a physiological perspec
tive, Section three shows how
concepts from the behavioral
sciences are applied to help the
student effectively use the cli
nical care process, Section four
focuses on interrelationships a-
mong physiological changes, diet
modifications and roles of health
professionals in providing nutri
tional care.
Lippincott. Abt. 640 Pages,
lllus. Feb. 1980. Abt. $21.50.
TEXTBOOK OF
MEDICAL-SURGICAL
NURSING, 4th Edition
By Lillian S. Brunner, R.N.,
M.S.N., Sc.D.; and Doris S.
Suddarth, R.N., B.S.N.E.,
M.S.N.
Fully updated and expanded,
the Fourth Edition of this fa
mous, best-selling text, inte
grates concepts and clinical
content throughout, accenting
assessment and management in
nursing practice.
The biophysical and psychso-
cial concepts underlying health
and illness are explored in the
opening units in chapters dealing
with: the nursing process,
patient education, homeostatic
mechanisms, fluid and electro
lyte balance, nutritional consid
erations in health, immunology
and psychosocial needs associa
ted with stress and illnes.
These concepts are then applied
to the clinical material related
to the management of various
patient populations with differ
ent physiologic dysfunctions.
Physiology and pathophysiology
have been expanded, offering an
overview of normal function and
providing an understanding
deviations from normal.
Lippincott. Abt. 1500 Pages,
lllus. March 1980. $34.75.
1 FUNDAMENTALS OB
NURSING, 6th Editioi
By LuVerne Wolff, R.N., M.A.,
et. al.
Massively revised, reorganize
and updated with much ne
material and artwork, the 6
edition of this leading text
heavily patient-oriented and ei
phasizes the role of the famil
Lippincott. 702 Pages.
Illustrated. 1979. $19.95.
2 STUDENT SELF-
EVALUATION
MANUAL IN
FUNDAMENTALS Ol
NURSING
By LuVerne Wolff, R.N., M.A.
et. al.
This self-evaluation manual \\
correlate chapter-for-chapl
with the sixth edition of Func
mentals of Nursing.
Lippincott. 340 Pages.
1979. $9.00.
3 THE LIPPINCOTT
MANUAL OF
NURSING PRACTICE
2nd Edition
By Lillian Sholtis Brunner, R.?>
B.S., M.S.N.; and Doris Smith
Suddarth, R.N., B.S.N.E..
M.S.N.
Every chapter in every area h
been updated and expande
Numerous new procedure-guic
Suitor
I TEX TBO K F
four*****
lines along with nursing care and
management sections and treat
ment modalities have been ad
ded. Over 100 superb new
illustrations beautifully comple
ment the text. This means more
detailed, substantive, and com
plete coverage of every phase of
medical/surgical, maternity, and
pediatric nursing!
Lippincott. 1,868 Pages.
Illustrated. 1978. $32.25.
4 PEARLS FOR
NURSING PRACTICE
By Arlene Odom Nichols, R.N.,
B.S.N., M.S.N.;and]oy Day,
R.N.,B.S.N.
A choice collection of tips,
hints, improvisations and bright
ideas that make nursing easier
and patients happier. Numerous
illustrations accomany the text.
Lippincott. 250 Pages.
Illustrated. Sept. 1979. $14.50.
5 Manual of PEDIATRIC
NURSING
CAREPLANS
Department of Nursing. The
Hospital for Sick Children,
Toronto. Edited by U. F.
Matthews.
Manual of Pediatric Nursing
Careplans enables new nurses
and relief nurses to care for
children with conditions they
may not have encountered re
cently or for children in age
groups they may not be used
to treating.
Little, Brown. 347 Pages.
1979. $15.50.
6 LIPPINCOTT S STATE
BOARD EXAMINA
TION REVIEW FOR
NURSES
By L. W. Lewis, R.N., M.A.
This new review book appears in
the same format as the licensure
examinations themselves. 2568
questions cover five major nurs
ing areas: medical, surgical,
obstetric, pediatric, and psy
chiatric.
Lippincott. 745 Pages.
Answer sheets. Illustrated.
1978. $13.75.
7 ATLAS OF DIAGNOS
TIC AND THERAPEU
TIC PROCEDURES
FOR EMERGENCY
PERSONNEL
By J. H. Cosgriff, Jr., M.D.
Compact and lavishly illustrated,
this superb guide lists and des
cribes in detail the key diagnos
tic and therapeutic procedures
essentials for clinical personnel
in an emergency situation.
Lippincott. 316 Pages.
303 Illustrations. 1978. $23.75.
8 TEXTBOOK FOR
CHILDBIRTH
EDUCATORS
By Patricia Hassid, R.N., B.A.
At last - a significantly dif
ferent, professionally oriented
book specifically designed for
the childbirth educator.
Harper & Row. 227 Pages.
Illustrated. 1978. S15.50.
9 ILLUSTRATED
MANUAL ON
NURSING
TECHNIQUES
By E. M. King, R.N., M.Ed.;
et. al.
Prepared in outline form and
heavily illustrated, this handy
guide to basic nursing proce
dures covers virtually every as
pect of basic nursing practice
from the psychosocial aspects
of hospitalization and admission
of the patient to post-operative
and post-illness care, and patient
education.
Lippincott. 432 Pages.
Illustrated. 1977. S13.75.
J. B. LIPPINCOTT COMPANY OF CANADA LTD.
75 Horner Avenue, Toronto, Ontario M8Z 4X7
Please send me the following books on approval :
D Maternity Nursing, 14th Edition, Abt. $22.00.
II Fundamental Skills in Patient Care, 2 Ed., Abt. $15.00.
D Workbook for Fundamental Skills, Abt. $8.50.
H Nutrition, Abt. $21.50.
D Textbook of Medical-Surgical Nursing, 4 Ed., $34.75.
Name
Address
City
Postal Code
Prices subject to change without notice.
Prov.
CN4/80
Calendar (continued from page 17)
May
Assertiveness in the Nursing Process:
A Training Seminar will be held in
Vancouver, May 3 1-June 1 ; Toronto, May
3-4; Ottawa, May 24-25, and Winnipeg,
June 7-8. Contact: The Centre for
Behaviour Therapy and Assessment,
1704 Curling Avenue, Ottawa, Ont.
K2A 1C7.
The fifth Canadian Summer Workshop
in Electrocardiography sponsored by
the Rogers Heart Foundation will be
held May 3-6 at the Hotel MacDonald,
Edmonton, Alberta. Contact: Anne S.
Criss, Executive Coordinator, Rogers
Heart Foundation, 601 12th St. N.
St. Petersburg, Fl 33705.
The Alberta Occupational Health Nurses
Association will hold their third annual
meeting on May 6, at the Capri Centre,
Red Deer. Competency analysis, confi
dentiality and marketing of O.H.
programs will be discussed. Contact:
Elizabeth Butler, Secretary A.O.H.N.A.
Workers Health and Safety, Medical
Services Branch, Oxbridge Place,
9820-106 St., Edmonton, Alberta,
T5K 2J6.
Pediatric Nursing Conference, current
problems and approaches, May 14-16,
1980. Contact: B. Crags, Coordinator,
Nursing Education, The Hospital for
Sick Children, 555 University Avenue,
Toronto, Ont. M5G 1X8.
Maternal and Perinatal Care 1980
sponsored by the Departments of
Anaesthesia, Obstetrics and Gynecology
and the Perinatal Unit of Mount Sinai
Hospital will be held May 16-17, at
Mount Sinai Hospital. Contact: E.
Hew, Course Co-Director, Mount Sinai
Hospital, 600 University Avenue,
Toronto, Ont. M5G 1X5.
Looking Ahead
The fifth annual International Flying
Nurses Convention is to be held on
June 25-28 at the Henry the 8th Motor
Lodge and Inn, 4690 N. Lindberg,
St. Louis, MO. 63044. Contact: Jenny
Cook, 3-420 Kings Ave., Brandon,
Florida 3 3511.
Continuing Nursing Education: Planning
for the 80 s is the theme of the Second
National Conference on Continuing
Nursing Education to be held June 26
and 27 at the Hyatt Regency Hotel,
Vancouver, B.C. Contact: Ruth
Burstahler, Planning Chairman,
Continuing Education, Registered
Nurses Association of British Columbia,
2130 West 12th Ave., Vancouver,
B.C. V6K2N3.
The Nursing Sisters Association of
Canada will hold its biennial meeting,
Tuesday, June 24 at 1300 hrs. followed
by a reception and dinner at the Four
Seasons Hotel, 791 W. Georgia,
Vancouver, B.C. Contact: Mrs. Eileen
Shaw, 8500 Francis Rd., Richmond,
B.C. V6Y 1A6.
The International Conference of
Psychiatric Nursing will be held Sept.
8-12 at Imperial College, London.
Contact: International Conference of
Psychiatric Nursing, Miss Pat Young,
Conference Consultant Nursing Times,
4, Little Essex Street, London,
WC2R 3LF.
The Second International Conference on
Cancer Nursing will be held Sept. 1-5
at the Queen Elizabeth Hall, London.
Contact: International Conference on
Cancer Nursing, Conference Adminis
trator, IPC Business & Industrial
Training Ltd., Surrey House, 1
Throwley Way, Sutton, Surrey,
SMI 4QQ.
The National Conference on Continuing
Education in Nursing will have as its
theme "Power and Politics: A Summit
for Action" and will be held Sept. 28-
Oct. 2 at Denver Colorado. Contact:
Colorado Nurses Association, 5453
East Evans Place, P.O. Box 22138,
Denver, Colorado 80222. *
SPHYGMOMANOMETERS
NURSES CAP TAGS
Gold plated holds your cap
stripe (irmly m place Non
iwist feature No. 301 RN
with Caduceus or No 30
plain Caduceus $3.95pr
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$69 92 each
ANEROID TYPE
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NURSES PENLIGHT. Powerful beam for examination c
throat, etc Durable stainless-steel case with pocket
cup Made m U S A No 28 $5 98 complete with
batteries.
NURSES WHITE CAP CLIPS. Made m Canada lor
Canadian nurses Strong sieel bobby oms with nylon
tips 3" size $1 29 I card of 15. 2" size $1 00 i card
of 12 (Minimum 3 cardsl
NURSES 4 COLOUR PEN for recording temperature,
blood pressure, etc One-hand operation selects red.
biach, blue or green NO 32 $2 97 each
Vu
edges 3
jmpartments for pens,
iors, etc . plus change
pocket and key chain
White caff Plastahioe
No 505 si 95 each
CAP STRIPES
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NURSES EARRINGS. For pierced No 503 Nurse s Aide
ears Dainty Caduceus in gold plate All $8 59 each
- - - illy
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gold plated, gift boxed No 400 RN No
LPN. No 402 PN Aii$9i5each
MEMO-TIMER
re-usable No 522 RED. No 520 BLACK,
No 521 BLUE, No 523 GREY All 15 V 1
I long except red |14 ") 12 stripes per card I
1 M " J j.
_ ymg lens, 3
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uded Met.
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o 309 $79.95 each.
pouch $65 95
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Thff Canadian
CANADIAN NURSES ASSOCIATION
TICKET OF NOMINATIONS
1980-82 Mandate
President Elect
(1 to be elected)
Helen Preston Glass
Vice-Presidents
(2 to be elected)
Simone-Marie Cormier
Myrtle E. Crawford
E. Sue Rothwell
Member-at- Large
Nursing Administration
(1 to be elected)
Mary E. Murphy
Ginette Rodger
Member-at-Large
Nursing Education
(1 to be elected)
Margaret A. Campbell
Sister Marie Simone Roach
Patricia S. B. Stanojevic
Margaret Steed
Member-at-Large
Nursing Research
(1 to be elected)
Peggy Anne Field
Fabienne Fortin
Odile Larose
Marian McGee
Member-at-Large
Social and Economic Welfare
(1 to be elected)
Mary Lou Annable
Phyllis Goertz
Member-at-Large
Nursing Practice
(1 to be elected)
Committee on Nominations
(3 to be elected)
The Canadian Nurse
April 1980 21
President
Candidate: President elect
Shirley M. Stinson, BScN (U of
Alberta), MNA (U of Minnesota),
EdD (Columbia U)
Present Position:
professor, Faculty of Nursing and
Division of Health Services
Administration, U of Alberta,
Edmonton.
Association Activities:
AARN member of committee on
nursing research (1973-77);
member of ad hoc committee on
the Chichak Report (1971-72).
CNA president-elect (1978-80);
1st vice-president (1976-78);
member-at-large for Nursing
Education (1974-76); chairman
(1971-73) and member (1972-76)
of special committee on nursing
research.
Professional Affiliations:
Economic Council of Canada,
member, health services
committee (1973-74); Kellogg
National Seminar on Doctoral
Preparation for Canadian Nurses
(1 978), project director. Author of
numerous articles and reports.
The question is not, "Do we
need a national professional
nursing organization?" for in this
day and age every occupation that
would deem itself a profession
needs some sort of collective
national voice, but, "For what
ought we, and ought we not, use
CNA?" It is toward providing
leadership for answering that
question in terms of concrete
relevant actions that I am
prepared to commit myself as
president.
Helen Preston Glass, BS, MA,
M.Ed., EdD (Columbia U)
Present Position:
co-ordinator, Graduate Program in
Nursing, School of Nursing,
University of Manitoba, Winnipeg.
Association Activities:
MARN president, board of
directors (1966-68); chairman,
Committee of accreditation
(1963-68); chairman, Committee
on Education (1963-68);
chairman, Committee on the
Development of Nursing
Education in Manitoba (1963-68);
chairman, Ad Hoc Committee on
Nursing Research (1971-76);
chairman, Committee to prepare a
Position Paper on Nursing
Education (1974-76); member,
Blueprint Committee, Transition of
Diploma Schools of Nursing into
the Educational Sector (1976);
member, Board of Examiners
(1966); member, Directors of
Schools of Nursing Interest Group
(1975); member, Committee to
study the Report of the Joint
Ministerial Task Force in Nursing
Education (1978); member,
National Health Research
Programs Development Review
Committee 48 (1975-79);
chairman, Committee on Careers
(1963-68).
CNA board of directors,
(1966-68, 1976-78);
Sub-Committee on Nursing
Education (1964-66); Special
Committee on Nursing Research
(1970-76); chairman, Special
Committee on Nursing Research
(1976-78); Committee to Develop
Standards for Nursing Education
in Canada (1975- ); Committee
on Doctoral Preparation for
Nurses in Canada (1 977- ).
Professional Affiliations:
Canadian Nurses Foundation;
Canadian Association of
University Schools of Nursing;
National Nursing Committee, The
Canadian Red Cross Society;
National League for Nursing,
Council of Baccalaureate and
Higher Education; Task Force on
Euthanasia and Definition of
Death, Law Reform Commission
of Canada. Author of numerous
papers and reports.
The profession of nursing has
developed into a viable effective
force in Canada, in response to
unmet health needs. I believe
nurses are in the best position in
the health field to develop new
avenues of care and to initiate
changes rather than react to them .
Nurses will be called upon
increasingly, to practice nursing
on an intellectual level and to
demonstrate excellence in
practice. As we move into an era
of substantial independence there
is need for research to determine
the effectiveness of various forms
of nursing intervention and their
impact on practice. Further, there
is need to unravel ethical
dilemmas in the increasing moral
and scientific complexity of our
society. We will be required to
assure Canadians of the quality of
our nursing care and our
willingness to work with
governments and other
professional and allied groups to
attain that quality.
In endorsing these beliefs it
would be my desire, if elected, to
further educational developments
in nursing, particularly the
Canadian Nurses Association s
efforts towards ensuring doctoral
preparation for nurses. I was
involved in the Kellogg Proposal in
this regard, and also instrumental
in the initiation of the first National
Conference on Nursing Education
held this past year. I would
endorse further forums extending
these to nursing practice and to
nursing administration so that
ideas and concerns in these areas
can be explored by nurses. I
support continuing conferences
on nursing research and the
expansion of research to involve
more of the nursing population.
The development of
standards of nursing practice is
launched but needs to be followed
by close liaison with social
security measures for nurses to
augment quality assurance in the
provision of nursing care. There is
much to be done. My
qualifications and experience
would enable me to put my efforts
in these directions if elected.
22 April 1980
The Canadian Nurse
Candidates:
Vice-president
Simone-Marie Cormier, Diploma
in Nursing (L Ecole
d inf irmieres St. Joseph and
L institut "Deux Alice", Bruxels,
Belgium)
Present Position:
director of nursing, H6tel Dieu
Hospital, Campbellton, N.B.
Association Activities:
NBARN president (1975-77); 1st
vice-president (1974-75); 2nd
vice-president (1973-74); Nursing
Committee (1973- ).
CNA Board of Directors
(1975-77).
I have accepted the nomination
as vice-president of the Canadian
Nurses Association because, as a
nurse, I am interested in nursing
and in health care.
To me, as long as a nurse is
actively involved in nursing, she
must be an active member of her
association.
I believe that nurses are
unique in their contribution to
health care and therefore, I want
to become involved in the
activities and in the decisions that
involve nurses and the profession.
Our future belongs to us and I
would welcome the opportunity, if
elected, to serve for nurses and
nursing.
Myrtle E. Crawford, BSN (U of
Saskatchewan), MA (Columbia
U)
Present Position:
assistant dean, College of
Nursing, University of
Saskatchewan, Saskatoon.
Association Activities:
CNA Board of Directors
(1963-65); member of various
committees, including. Standing
Committee on Nursing Education,
and Special Committee to Review
the Task Force Reports on Health
Services in Canada; presently 2nd
vice-president, member of board,
chairman, Ad Hoc Committee on
Accreditation.
Professional Affiliations:
Canadian Association of
University Schools of Nursing;
National League for Nursing;
Medico-Legal Society of
Saskatoon.
It has been said that nursing is at
a crucial stage in the development
of the profession. Decisions that
are made now are expected to
have implications for health care
into the 21 st century. There is an
appreciation of the increasing
need for assertiveness so that we
may provide the best services for
our clients. The national nursing
association must be ready to
supply both support and
leadership in approaching the
health care issues that arise.
CNA has recently sponsored
a National Forum on Nursing
Education. Papers were given and
discussions were held that
underlined the necessity for
nursing practitioners,
administrators and educators to
plan together so that the nurse of
today will be well prepared to deal
with the problems of tomorrow.
The need to research in nursing
was also apparent. This is a very
challenging time for nursing and
CNA should be prepared to meet
the challenges.
A heavy responsibility is
placed on the members of the
Board of Directors to make
decisions on behalf of the larger
membership of CNA. I feel that my
current term on the Board of
Directors has given me a good
basis for decision-making in the
coming biennium.
E. Sue Rothwell, BS (Cornell
U), MS (U of California)
Present Position:
director of nursing and assistant
professor. Cancer Control Agency
of British Columbia, Vancouver,
Association Activities:
RNABC president, (1977-79);
numerous committees.
CNA board of directors
(1977-79).
Professional Affiliations:
American Association for the
Advancement of Science (AAAS);
Oncology Nurses Society.
I have accepted the nomination
for the office of vice-president of
the Canadian Nurses Association
because I think that the
experience I gained as president
of the Registered Nurses
Association of British Columbia
and concomitantly as a director on
the board of the Canadian Nurses
Association has prepared me to
serve Canadian nurses well as a
member of the executive of their
national association. The nursing
profession in Canada needs a
strong national association. And, if
you elect me, I will see as my
overriding objective the
strengthening of our national role.
Today in Canada, changes in
politics, economics, health care
and the attitudes toward
professions force us to critically
examine our national presence.
We need better communication
and cooperation among provincial
nursing associations to address
national issues in health care.
Economic constraints will mean
more cutbacks in health care and
research dollars. Nurses need to
shape tomorrow s health care and
to do this we will have to work
closely with other health
professionals at national policy
making levels.
Among ourselves, we are
questioning the relationship of
professionalism to the labor
relation function. The public has
asked repeatedly if professions
are, in fact, self-interest groups.
We need to talk openly among
ourselves and with the public
about our own perspective and
what is expected of us.
These are some of the issues
which I would be prepared to deal
with as a member of the Canadian
Nurses Association executive. I
think our national association has
built a strong education and
research base within the
profession of nursing. If the
Canadian Nurses Association is to
realize its potential as a national
association, we must begin now to
build a strong nursing presence
for the public, government and
other professions.
The Canadian Nurse
April 1980 23
Candidates:
Member-at-large,
Nursing Administration
Mary E. Murphy, BScN (U of
Windsor), MHA (U of Ottawa)
Present Position:
vice-president, Nursing,
Vancouver General Hospital,
Vancouver.
Association Activities:
AARN member, Ad Hoc
Committee on Continuing
Education, chairman, Ad Hoc
Committee on Graduate
Education.
RNAO.
Professional Affiliations:
Association of Nursing
Administrators of General
Hospitals in Edmonton; Western
Council of Teaching Hospitals;
Council of the Faculty of Nursing,
University of Alberta; College of
Nurses of Ontario.
Without diminishing the caring,
concern and commitment which
are at the core of professional
nursing, one must constantly
strive to bring the most relevant
and current information available
to the task at hand.
The development of nursing
is best served by diversity of
educational preparation, the
implementation of precise
research findings, the acquisition
and support of highly prepared
and skilled practitioners and
knowledgeable administrators.
The 60 s addressed the
quality of our caring. The 70 s
advocated dialogue and
collaboration; hopefully the 80 s
will see the implementation of
these plans and aspirations.
I
Ginette Rodger, BN (U of
Ottawa), M. Nurs. (Admin.)
(University de Montreal)
Present Position:
director of nursing, Notre Dame
Hospital, Montreal.
Association Activities:
OIIQ.
CNA member-at-large, Nursing
Administration (1978-80).
Professional Affiliations:
Comitd d etude sur la Formation
en Sciences Infirmieres, Ministere
de I education, president;
Canadian Council on Hospital
Accreditation; Conseil sur le
maintien des Services de Sante et
des Services Sociaux;
CNA-CHA-CMA-CPHA
Quadripartite Committee;
Association des hOpitaux de la
province de Quebec; Federation
of Administrators of Quebec
Health and Social Services;
American Society for Hospital
Nursing Service Administration.
I have accepted the nomination
as member-at-large for Nursing
Administration because I believe
that, as director of nursing in a
very active 1 ,000 bed university
hospital, I can make a valuable
contribution to the Board of
Directors. During my five years as
a director of nursing, I have gained
varied and valuable experience.
Facing up to the realities of
the administrative field of the 70 s
and 80 s has been part of my
everyday responsibilities.
Adapting to rapid change in a
world of unrest, professionalism,
politically-oriented unionism,
research and teaching, while
ensuring quality and quantity of
care in spite of limited resources is
the nursing administrator s daily
challenge.
Furthermore, being a
member of the Board of Directors
at the national level is a rewarding
professional experience which
can only prove to be positive as far
as acquiring and sharing
knowledge is concerned and can
only lead to my better serving my
profession.
If you think I can adequately
represent nursing administration
on the Board of Directors, I can
assure you of my continued
interest and availability.
Candidates:
Member-
at-large,
Nursing
Education
Margaret A. Campbell, BA,
BASc(N)(U of British
Columbia), MS in Nursing
(Western Reserve University),
EdD (Columbia U)
Present Position:
professor, School of Nursing,
University of British Columbia,
Vancouver.
Association Activities:
RNABC member, executive and
board (1958-64, 1965-67);
chairman, Committee on
Legislation, Constitution and
Bylaws (1958-60, 1965-67);
chairman, Committee on Nursing
Education, (1960-64); chairman,
Bursary Loan Committee
(1960-64); member, Board of
Examiners (1971-74); member,
Committee on Bursaries, Loans
and Scholarships (1972-75);
chairman, Committee on Approval
of Schools of Nursing (1972-76);
chairman, Task Committee to
Identify the Critical Components of
a Basic Nursing Program
(1974-76); member, Steering
Committee on Roles and
Functions (1977- ); chairman,
Task Committee to study the
Kermacks Report on Nursing
Education (1979); chairman, Task
Committee to Review and Revise
Policies, Procedures and Criteria
for Approval of Schools of Nursing
(1974-76).
24 April 1980
The Canadian Nurse
CNA member, Committee on
Nursing Education (1960-64);
member, Committee and
Subcommittee on Legislation and
Bylaws (1964-66); member, CNA
Testing Service Master Blueprint
Committee (1970-73); member,
CNA Testing Service Ad Hoc
Committee on Comprehensive
Examinations (1973); member, Ad
Hoc Committee on Accreditation
(1979).
Professional Affiliations:
Canadian Nurses Foundation,
member, selections committee,
1974; Canadian Association of
University Schools of Nursing
Western Region.
As a federation of provincial and
territorial associations, the
Canadian Nurses Association
represents nursing both nationally
and internationally. As nursing s
representative, the CNA speaks
for those who, in Canada,
comprise the largest group of
professional workers in the health
care field. I believe that the
association has not only the
prerogative but also the
responsibility to be instrumental in
helping to shape the health care
services in Canada to be
proactive, not just reactive to what
is occurring in health care today.
Internationally, the Canadian
Nurses Association must continue
to support other national nursing
associations as they strive to
effect changes in health care
delivery in their countries.
To meet its commitment to
quality health care in Canada
requires a Board of Directors
which has the vision to identify
nursing s role in the changing
health care scene and the wisdom
to establish policies and to take
positions which will clarify and
promote the role. Structurally, the
board has the potential to fulfil this
requirement: all facets of
professional nursing
administration, education,
practice, research and social and
economic welfare are
represented. I believe that those
nurses who represent these facts
are responsible for being sensitive
to the health care scene and the
forces impinging on it, for
recognizing the implications for
nursing, and for responding
appropriately.
In particular, the
member-at-large for nursing
education must be alert to those
issues which have or could have
significance for the preparation of
nurses in all types of educational
programs. I believe that my
experiences in teaching and in
professional association
committees would help me to
contribute to the challenging work
of the CNA Board of Directors.
Sister Marie Simone Roach,
BScN (St. Francis Xavier U); MS
Admin. Nursing Education
(Boston U), PhD Foundations of
Education (Catholic University
of America).
Present Position:
On two-year study leave from St.
Francis Xavier University,
Antigonish.
Association Activities:
CNA currently director, Code of
Ethics project.
RNANS chairman, Nursing
Service (1 956-58).
Professional Affiliations:
Canadian Association of
University Schools of Nursing,
secretary, 1 972-74.
This is an exciting time, first of
all, to be a Canadian. It is also a
challenging time to be a nurse,
given the dynamically changing
nature of society, and the impact
of societal changes on the
profession of nursing.
To be involved with the
Canadian Nurses Association
through its Board of Directors,
would provide a singular
opportunity to be part of the
process that will shape nursing in
this country. It would, most
importantly, provide an
opportunity to fulfill a personal
responsibility to contribute to this
process by sharing my own
insights and skills.
During most of my
professional career, I have been
interested in the philosophical
basis of nursing. In the wake of
increasing ethical issues in
nursing, I am concerned about the
basis for, and the process of,
ethical decision-making. I believe
that I can make some small, but
important contribution to the
discernment of some of the issues
that face the profession, and to the
deliberations about what we want
nursing to be in Canada.
Patricia S.B. Stanojevic, BScN,
(U of British Columbia), M.Sc
(App), (McGill U)
Present Position:
staff development officer, George
Brown College, Toronto.
Association Activities:
RNAO vice-president,
Alexandra Chapter (1 977-78);
member-at-large, Education
(1978-80); chairman, Working
Party on approaches to facilitate
the fit of the new two-year
graduates - 1 978; past chairman,
Toronto area Nursing Education
Administrators Group (1975-77).
Professional Affiliations:
College of Nurses of Ontario,
member. Finance Committee.
Nursing must face the
challenges of the 80 s as a united
force in society. For this reason, I
have accepted the nomination for
the office of member-at-large,
Nursing Education, because I
believe my background has
prepared me to appreciate the
issues facing nursing throughout
Canada.
Nursing s unity comes from
its common goal of assisting the
client to achieve his/her optimum
state of health. Nursing service
contributes to that goal by
providing direct services to the
client. And nursing education is
responsible for providing
educational opportunities to
achieve that goal.
I would promote the fostering
of colleagueship, collaboration
and cooperation among all
practitioners of nursing. Nursing
administration, service and
education must agree on realistic
goals for nursing education
programs. In particular, we must
work closely to assist the student
to move into the new role of
worker.
Another challenge we face as
nursing educators is to provide a
wide variety of vehicles by which
all nurses, regardless of where
they live, may maintain their
competence throughout their
lifetime in nursing. We must assist
nurses to keep pace in a rapidly
changing world.
The Canadian Nurse
April 1980 25
Margaret Steed, BN Admin,
(McGill U), MA (Columbia U)
Present Position:
associate professor, director,
Continuing Education, Faculty of
Nursing, University of Alberta,
Edmonton.
Association Activities:
AARN chairman, Nursing
Research (1974-77); Nursing
Education Planning Committee,
(1969-75); Nursing Practice
Planning Committee (1969-75);
Council (1978-80); Executive of
North Central District (1978-80);
Standing Committee, Legislation
(1979- ); Ad Hoc Committee,
Continuing Education (1978- );
"Dialogue" planning for nursing
education service, coordinated
seminars, (1979).
Professional Affiliations:
University Coordinating Council,
board of examiners of nursing
(1964-74); Canadian Nurse
Registration Examinations,
master blueprint committee,
(1971-73); Directors of Inservice
Edmonton Hospitals; Directors of
Continuing Nursing Education in
Alberta; Canadian Association of
University Schools of Nursing;
author of many documents,
studies and articles.
I am pleased to accept the
nomination for the office of
member-at-large representing
nursing education for the
Canadian Nurses Association.
I accept this nomination
having taught in every major type
of educational program offered for
nurses, from two-year diploma to
graduate school. In addition I have
been involved in a wide spectrum
of activities related to nursing
education including consultation
services (planning and
implementation aspects, .
curriculum, teaching and
evaluation); assisting with or
preparing briefs, position papers
and commission reports and
conducting workshops. These
activities have been carried out at
international, national and
provincial levels.
I believe the total of my
personal and professional
experiences helps me to relate to
the many facets of nursing
education and makes it possible
for me to conceptualize
professional nursing with its
interrelated ramifications for
education and practice.
Selected personal high
priorities include:
a continued search for means
to ensure competency of nurses in
face of rapidly changing
technology and the expansions of
medical and scientific knowledge.
a cognizance of the need for
nursing education to be
responsive to the changing health
and illness needs of society while
still providing sound basic
education.
the need for the organized
profession of nursing to maintain a
stronger role in determining the
destiny of the profession.
the establishment of a
national accreditation program for
nursing education programs.
continued efforts to enlarge
and strengthen continuing
education offerings for registered
nurses.
concentrated efforts to
provide doctoral preparation for
nursing in Canada.
increased support and
activities for the inclusion of
administrative skills in nurse
preparatory programs at various
levels.
increased support and
activities for advanced study in
clinical nursing practice in
graduate nurse education.
the promotion of collegial
relationships between education
and service institutions.
the promotion of collaborative
relationships and the sharing of
ideas for the development of
graduate nurse education,
between the various universities in
Canada.
I see nursing education in
Canada at the threshold of great
steps forward with the introduction
and strengthening of both basic
and graduate education, a clearer
delineation of professionalism and
a sounder research base. I would
like to be involved in the dynamics
of the continued evolvement.
Candidates:
M e m be r-at- large
Nursing Research
Peggy Anne Field, BN (McGill
U),MN(U of Washington),
Doctoral Candidate in
Ed ucat ion (U of Alberta)
Present Position:
associate professor (on leave),
University of Alberta, Edmonton.
Association Activities:
AARN Nursing Committee
(1975-78); chairman, Ad Hoc
Committee to Study Post RN
Education (1977-78); Advanced
Education Liaison Committee
(1977-78).
Professional Affiliations:
Western Nurse-Midwives
Association, president, (1978- );
Canadian Association of
University Schools of Nursing,
member, Committee on
Accreditation, Royal College of
Midwives; National Association of
College of Obstetricians and
Gynecologists.
It is my belief that Canadian
nursing research should
encourage a wide range of
approaches to investigation. Both
qualitative and quantitative
methodologies have their place in
answering questions posed in
response to identified nursing
problems. While clinical nursing
research should be given priority,
research based on philosophical
and historical issues must not be
ignored.
The current concerns of CNA
with nursing practice standards
and with accreditation of schools
of nursing demonstrate the need
for research input. This is
necessary for the association to
take a firm and well documented
stand on nursing issues. This
requires prepared nurse
researchers capable of generating
a body of knowledge.
Research in the practice of
nursing must involve both
researchers and practitioners in
the identification of problems for
study and in the collection of data.
More encouragement must also
be given to practitioners to read
and to examine studies for their
significance for practice. There is
a need to provide education for
practitioners so that they are able
to become intelligent consumers
of nursing research.
Support must be given to
programs which educate nurse
researchers. This preparation
must be at both masters and
doctoral level. The national
association must continue to work
toward the establishment of a
doctoral program in nursing so
that nursing research capabilities
will be expanded.
Another area of concern must
be the identification of funding
sources for research. Funding
bodies must be persuaded of both
the viability and the urgency of
nursing research.
Research must be seen by all
CNA members as a responsibility
of nursing if it is to be viable. We
as nurses must identify problems;
we must collect data; we must
read research reports; and we
must implement findings.
As CNA member-at-large I
would encourage a national policy
that looked at the needs of the
practicing nurse, the researcher,
the educational programs and the
resources for nursing research.
26 April 1980
The Canadian Nurse
Fabienne Fortin, BScN
(Universite de Montreal), M.Ed.
(U of Ottawa). M.Sc. (McMaster
U), PhD(McGMIU).
Present Position:
assistant professor, Faculte des
sciences infirmieres, Universite de
Montreal.
Association Activities:
OIIQ
RNAO.
Like other professions seeking
to enhance their professional
image, nursing undertakes the
continual development of a body
of scientific knowledge
fundamental to its practice. As a
body of knowledge, nursing still
has many of the signs of an
immature discipline. Whether or
not it grows to maturity in the next
decade or two will depend very
much on the wisdom with which
we choose the focus of our
research. An immature discipline
is characterized by J.R. Ravetz as
one lacking in a body of stable
factual knowledge. For many
years nurses cared for patients
where practices were largely
intuitive and prescientific.
Although, at present, nursing
does not possess a body of
structural scientific knowledge,
R.M. Schlotfeldt wrote that nurses
are convinced that they need a
scientific base with which to guide
their practice. It is only when the
practitioner has a body of scientific
nursing knowledge upon which to
rely that she will feel confident that
the way in which she cares for
patients is designed to bring about
the best results in the recipients of
care.
One essential activity of the
scientific method rests on theory
building. It is theory which
organizes and gives meaning to
data, helps to formulate problems,
and provides the basis for the
interpretation of empirical findings.
As a science matures, its body of
factual information becomes
embedded in an explanatory
theory of increasing power and
significance. Our research must
be based on sound principles and
a clear understanding of the
nature of nursing as a body of
scientific knowledge.
An immature discipline can
make a useful contribution to
knowledge if it concentrates on
three areas of nursing: research,
practice and education. The
question of how research in
nursing practice relates to patient
care and teaching is of great
interest. Attention should be
directed to the role of the nurse in
research and how cooperative
and collaborative relationships
can be established to facilitate
research in both university and
community settings. To conclude
with Ravetz: "Immature fields with
the hope of imminent maturation
are, with all their attendant
hazards, the place where the
greatest challenge is to be found."
Odile Larose. BN, M. Nurs.
(Admin.), (Universite de
Montreal)
Present Position:
director of Nursing Sector, Ordre
des Infirmieres et Infirmiers du
Quebec.
Association Activities:
OIIQ credential committee
(1976-77); committee on permits
(1978).
CNA member-at-large, Nursing
Research (1978-80); Special
Committee on Nursing Research
(1974-78).
Professional Affiliations:
Association des hOpitaux de la
province de Quebec, committee
on shortage of nursing staff;
author of numerous articles in
nursing and hospital
administration publications, as
well as OIIQ documents.
After four years as member of
CNA s special committee on
nursing research and the last two
years as member-at-large,
nursing research, I can only say
that my deepest convictions
concerning the necessity of
developing nursing research at
the national level have been
verified, confirmed and sustained.
If my nomination was
confirmed in 1978 it is because
there was confidence that I would
emphasize research and thus
orient nursing to a style adapted to
the needs of a population living in
an ever changing social context.
I will only mention in passing
that the marked interest I have in
research stems from both the
individual s and the community s
needs in the health field, needs
which can best be served by
nurses who because of the very
nature of their profession, are in
the best position to intervene while
taking into account all the
individual s bio-psycho-social
dimensions in relation with the
health-sickness continuum.
Being close to the
community, finding out its health
needs and adequate nursing
answers presupposes continued
action and firm positions by the
national association at the level of
the working environment of the
nurse as well as within the various
organizations. It would certainly
be deplorable to witness
apragmatism in our profession
due to ignorance of the value of
research and lack of interest in
giving it the importance it needs in
order to serve as an historical
beacon for our profession.
As I said in 1978, nursing
research is a prime component
and must serve as a base for our
profession by making it live not
only at the university level but also
in the whole health field and in
nursing associations.
If a step was taken since
1 978 through noticing the
importance of setting up a position
of director of research projects for
the CNA and by establishing
certain essential mechanisms
promoting nursing research, many
other things remain to be done. I
would like therefore to continue
what I have already undertaken by
promoting research in Canada
and participating in the elaboration
of prospectives for nursing,
among other things, through my
support for the setting up of a
doctoral program in nursing in
Canada.
Also, since 1978, 1 can frankly
say that I have been available and
very much involved in consultation
concerning research programs for
different organizations as well as
actively engaged in developing
the different components of the
nursing profession. I have also
participated in different decisions
concerning the future and the
direction to be given to the roles
and functions of nursing in society
as a whole.
If the future of our profession
is in the hands of nurses, our
representatives at the national
level are there to guarantee our
motivation in promoting our
nursing way of life. Therefore, I
sincerely hope I will be able to
work once again with all the other
members of our profession by
being given a further mandate on
the Board of Directors of the
Canadian Nurses Association.
*
Marian McGee, BNS (Queen s
U), MPH (Johns Hopkins U)
Present Position:
associate professor, Faculty of
Nursing, University of Western
Ontario, London.
The Canadian Nurse
April 1980 27
Association Activities:
RNAO
CNA member, Special
Committee on Nursing Research
(1978-80).
Professional Affiliations:
American Nurses Association;
American Public Health
Association; Maryland Public
Health Association; Canadian
Public Health Association; Ontario
Public Health Association.
If one accepts the assumption
that all disciplines require a base
set of knowledge/
information-generating activities,
then one must also accept the
notion that these activities require
nourishment, facilitation and a
constant reinforcement of their
legitimacy.
One of the payoffs that the
Canadian Nurses Association
should be able to realize in having
a research committee (whose role
is to attend to the care and feeding
of the information-generating
activities) is an increased
probability that the knowledge
base will be strengthened. The
committee attempts to identify the
fuel or funding sources, offer
guidance in the use of
mechanisms and methods for
successful application and
facilitate the diffusion of newly
acquired information/knowledge
to relevant sectors.
The executive and board of
the Canadian Nurses Association
can appropriately expect
advisement on issues of
methodology and analysis as the
bases for many of their decisions.
As they shepherd the disciplines
into and through relationships of
ever increasing complexity in the
health care system, a high level of
research literacy is required of
them, and their constituents. It
behooves us to be available to
render necessary support.
Candidates:
Member-at-large,
Social and
Economic Welfare
Mary Lou Annable, B.Sc. Nurs.
Ed. (U of Ottawa)
Present Position:
teaching master, Algonquin
College, Ottawa.
Association Activities:
RNAO Provincial Committee on
Socio-Economic Welfare, member
(1971-76) chairman (1976-78);
member-at-large,
Socio-Economic Welfare
(1979- ); Board of Directors
(1976- ); Ottawa West Educator
Committee (1974- ); Executive
Committee (1976-79).
I believe that we as nurses are
beginning to take our well earned
place in the economic structure of
our country. But we have just
begun and we must continue our
efforts in this regard.
I am also concerned about
nurses as social beings and
believe we must pay increased
attention to nurses as
individuals whether in our place
of employment or in our role in the
community.
As nurses we are frustrated
with the quality and quantity of
care we are able to provide our
clients. We face the need to
balance a heavy work load with
the need to act as patient
advocates and to be accountable
as professionals for our actions.
We add to this the need to update
our skills to remain competent.
While this may seem more than
enough, we must also become
more involved in health care
decisions in the community.
I do believe that nurses must
become more active. We must
contribute as professionals, as
citizens, and as employees.
As professionals, we must
ensure that nursing continues to
be attractive both to those already
in the profession and to those
considering it. As a profession, we
must direct the factors that affect
our social and economic welfare. I
accepted the nomination for
member-at-large, Social and
Economic Welfare on the CNA
Board of Directors because I
believe I can contribute to this
goal.
Phyllis Goertz, BSN(U of
Saskatchewan)
Present Position:
coordinator, Special Nursing
Projects, University Hospital,
Saskatoon.
Association Activities:
SRNA member-at-large, Council
(1977-79); Committee on
Chapters (1977-79);
Saskatchewan Union of Nurses
(1975-77); Provincial Negotiating
Committee (1977-78).
Professional Affiliations:
Saskatchewan Union of Nurses;
Canadian Nurses Respiratory
Society.
I believe that nursing care is a
critical component of patient care
at every level of the health care
system.
All levels of government feel
the need to contain costs and
health care is a major government
expenditure. Nurses recognize the
reality of this cost containment
and are willing to work within
reasonable constraints. Too
severe restraint, however, affects
the social and economic welfare of
both nurses and their clients.
Workloads must be such that not
only are patients needs met, but
the nurses needs for professional
satisfaction are also met.
Standards are the key to
resolving the conflicts at the
interface of the nursing
profession, the community, and
the health care system. Once
standards are set, the quality of
care can be measured. Based on
this measurement, discrepancies
can be identified objectively and
solutions explored. One of the
roles of the CNA then, is to foster
the development of nursing care
standards wherever nurses work.
Nurses must work together
presenting a unified front to
promote the professional and
personal goals of nurses. The
CNA can be the catalyst for such a
unified thrust.
I am eager to work with
nurses from all over Canada and I
am interested in becoming more
involved with the issues in nursing
by being the member-at-large for
Social and Economic Welfare on
the CNA Board.
28 April 1980
The Canadian Nurse
Books for a new decade
of nursing.
Receptor Cell membrane
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ILLUSTRATION FROM LUCKMANN a SORENSEN
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING:
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HANDBOOK OF TOTAL PARENTERAL NUTRITION
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EXERCISE:
How the body responds
Anne He dim
There was a time when post-myocardial patients were kept virtually immobile for weeks; post part um women and those
who had surgery were confined to bed for days. It is now known that rather than being injurious, appropriate exercise is
actually beneficial. In this article, the author discusses the body s reaction to exercise and the benefits derived from
regular physical activity.
No one system of the body operates in
isolation: the skeletal muscles, the
primary mechanism in exercise, are
supported by several other systems to
produce efficient muscle action. The
central nervous system controls and
gives direction to all skeletal (voluntary)
muscle as well as regulating and
coordinating cardiovascular and
respiratory function to satisfy the
increased demands of muscle during
exercise. Subsequently, the
cardiovascular and respiratory systems
provide a ready supply of oxygen for
energy production and to facilitate the
removal of carbon dioxide and lactic acid
following muscle activity.
Muscles adapt to the demands made
upon them through daily exercise, by
increasing in strength and efficiency to a
level which satisfies the individual s
lifestyle. Similarly a decrease in use will
result in loss of tone and even atrophy.
Consequently, the patient confined to
complete bedrest for a few days could
experience marked loss of muscle
efficiency as well as a reduction in
competence of cardiorespiratory
performance, a loss of calcium from the
bone and changes in body fluids.
Oxygen supply
As the demand for oxygen increases
during exercise several adjustments are
made to meet the needs of the tissues.
Oxygen diffuses from the lungs to the
blood and then to the tissues only when
there are pressure differences and only in
the direction of high to low pressure.
With inspiration of air, the partial
pressure of oxygen (P0 2 ) in the lungs
rises to about 100 mm Hg resulting in
diffusion of oxygen to the pulmonary
capillary where venous blood P0 2 is
about 40 mm Hg. The P0 2 in the
pulmonary blood rises to 95 to 100 mm
Hg and the oxygen is transported in
combination with red blood cell
hemoglobin to the tissues where again it
diffuses in response to a pressure
gradient, but this time the gradient is
from the blood to the tissues (See Figure
one).
In exercise these diffusion gradients
are increased; that is, more oxygen is
being consumed in the tissues so there is
a greater difference between the PO, of
blood and the P0 2 of tissue. Therefore,
more oxygen is given up by the blood;
the P0 2 of the venous blood falls below 40
mm Hg and remains there until it reaches
the lungs again where its P0 2 is restored
to the 95-100 mm Hg level.
A second means of providing more
oxygen to the tissues is through a change
in factors which promote an increased
dissociation of oxygen from hemoglobin.
Hemoglobin, a molecule composed of
the protein globin and an iron-containing
pigment (heme) found in the red blood
cells, provides the major means of
oxygen transport as oxygen is poorly
soluble in water, the liquid portion of
blood. The oxygen dissociation curve
(See Figure two) illustrates the
relationship of hemoglobin saturation,
partial pressure of oxygen and oxygen
content (mis per 100 mis of blood). At
"a", with a normal acidity (pH 7.35 -
7.40), a normal carbon dioxide content of
blood and a normal body temperature,
the hemoglobin is 70% saturated with a
PO, of 40 mm Hg in venous blood.
However, if the acidity or carbon dixoide
levels are elevated or the body
temperature increased, the curve will
"shift to the right" resulting in lower
hemoglobin saturation at the same P0_,
(40 mm Hg), as shown at "b". Exercise
causes the curve to "shift to the right"
and the hemoglobin to give up more
oxygen to the tissues. The P0 2 may fall to
as low as 20 mm Hg during strenuous
exercise at which level the hemoglobin
would be about 30% saturated having
given up 70% of its oxygen.
Under normal conditions the
arteriovenous difference of the oxygen
level is about 5 mis perdl, that is, about 5
mis of oxygen per 100 mis of blood is
given up to the tissues with each circuit.
In exercise with venous blood P0 2 falling
below 40 mm Hg and a shift to the right
of the dissociation curve, a much larger
volume of oxygen is made available to
the tissues.
As a result of exercise more oxygen
is also provided to the tissues through
local changes in blood flow. A rise in
body temperature accompanied by an
increase in carbon dioxide and decrease
I
LUNGS
P0 2 100mm Hg
TISSUES
1
1
Pulmonary P0 2
Capillary 40
mm Hg
Systemic P0 2
100 Cap Nary 95 40
mm Hg mm Hg mm Hg
Figure one: Diffusion of oxygen in
response to pressure gradients
in oxygen level in the tissues, causes
local vasodilation of the arterioles. This
dilation of the vessels lowers resistance
to blood flow and increases the volume
of blood which reaches the working
tissue. The extent of blood flow increase
will be limited by the ability of the heart
to increase its. output of blood.
Oxygen utilization
Oxygen is used in the production of
energy from glucose which is stored in
muscle in the form of glycogen and can
be metabolized to provide energy in the
form of adenosine triphosphate (ATP). If
oxygen is present this is called aerobic
metabolism and 38 units of ATP are
formed.
Exercise ^ Lactic acid
ose Oxygen lack xv - Oxygen
V X W , / ^- Carbor
Liver
Carbon dioxide
Glucose + Oxygen-
ATP H 2 - CO,
The size of the oxygen debt will
depend on the "fitness" of the individual
and the type of exercise: with training
the amount of the debt incurred through
a specific exercise will decrease.
Blood pH changes
In mild or moderate exercise there is
very little change in pH (the hydrogen
ion concentration) but with strenuous
exercise the blood pH may fall a
significant degree, primarily due to lactic
acid production. During anaerobic
metabolism lactic acid diffuses out of the
cells into the blood where it reacts with
100
.0
I
80
60
40
20
P 02 mmHg 20
-20
10
.a
E
o
o
5
CM
O
40
60
80
100
Figure two Oxygen dissociation curve indicating the relationship of PO, (mm Hg) to
percentage of oxygen saturation of hemoglobin and oxygen transport in 1 00 mis of blood.
The curve on the left represents oxygen dissociation under normal conditions This curve is
shifted to the right with exercise. At a" with a P0 2 of 40 mm Hg the oxygen saturation of
hemoglobin is about 70 o while at the same P0 2 , with exercise, the saturation of hemoglobin
falls to about 50%. Corresponding changes in oxygen content of blood can be determined
from the vertical axis on the right side of the graph.
If oxygen is not available ATP can
still be produced through anaerobic
metabolism, but in this case the yield is
only 2 units of ATP and the byproduct,
lactic acid, is accumulated.
ATP Oxygen
" Lactic acid
Glucose
Pyruvic acid lack
In mild or moderate exercise
sufficient oxygen is usually available for
aerobic metabolism but in strenuous
exercise, the energy requirements may
exceed the oxygen supply and by
necessity ATP will be limited to that
produced by anaerobic metabolism. If
this anaerobic metabolism is prolonged a
considerable amount of lactic acid will be
produced and since oxygen is required
for disposal of this lactic acid, an oxygen
debt will be incurred. An oxygen debt is
the amount of oxygen in excess of the
resting level of 0_> intake consumed at the
end of exercise which is used to dispose
of lactic acid. Lactic acid, in the
presence of oxygen may be completely
metabolized to carbon dioxide, yielding
energy (as in aerobic metabolism), or it
may be returned to glucose, through
reactions performed in the liver.
sodium bicarbonate to form sodium
lactate and carbonic acid, the sodium
bicarbonate acting as a buffer to reduce
the pH change. Carbonic acid can
subsequently be broken down to form
water and carbon dioxide, the latter
being transported to the lungs for
excretion.
Carbon dioxide, as well as being
formed from lactic acid, is also being
produced from aerobic metabolism. This
may result in hypercapnia, excessive
carbon dioxide in the blood, the degree
being related to the severity of the
exercise. IfC0 2 elimination is hindered,
acidity will increase, that is, the pH will
drop as hydrogen ion levels in the blood
increase. However, normally theCO L ,
production and elimination are kept in
balance and therefore, the major
contribution to acidity is that of lactic
acid and other acids and not to carbon
dioxide.
Respiratory contribution
The respiratory system is a major
contributor during exercise, as oxygen is
provided and carbon dioxide is removed
through respiratory action.
In normal quiet respiration the
average adult breathes about five litres of
air per minute (minute ventilation) and
from this extracts 0.25 to 0.30 litres of
oxygen (oxygerrxiptake). The maximal
oxygen uptake may be measured during
exercise as a means of determining an
individual s efficiency of performance
since there is a direct relationship. With
training oxygen uptake can be improved,
with a corresponding improvement in
performance, a champion marathon
runner may have a maximal oxygen
uptake of 5 to 6 litres while an untrained
man may have only 3 litres. 1 To provide
this increase in oxygen, the untrained
person depends mainly on an increase in
rate of respiration while the trained
person relies more on an increased tidal
volume (amount of air exchanged with
each breath).- Obviously, any
interference with oxygen diffusion in the
lungs such as lung disease, could
seriously reduce the maximal oxygen
uptake.
With exercise there is a change in
the rate of respiration for which there is
no clear-cut explanation. It does not
appear to be due to chemical changes
such as POj, PCO_, or acidity. The arterial
oxygen level does not decrease
significantly in spite of the marked
increase in consumption, in fact, with
very strenuous exercise the P0 2 may be
slightly elevated. A build-up of carbon
dioxide does not appear to be the
stimulus as C0 2 is eliminated as rapidly
as it is produced and in strenuous
exercise the PC0 2 may actually be
decreased. The acidity of arterial blood
would not provide a stimulus either as in
mild or moderate exercise it is either
insignificant or absent .
Another reason to doubt that the
respiratory stimulus is chemical in origin
is that an increase in ventilation occurs
long before there can be any change in
blood chemistry. It has been shown that
the respiratory rate increases as soon as
exercise begins and also that passive
exercises, in which the muscle isn t
obliged to contract and therefore isn t
producing C0 2 or lactic acid, can induce
respiratory changes.
It is now believed that the major
control over respiratory activity during
exercise is neural in origin. Anticipation
of exercise will arouse theCNS,
including the sympathetic nervous
system, and may, by way of the motor
cortex, hypothalamus and reticular
formation, induce an increase in
ventilation. Muscles and joints contain
sensory receptors which send
information to the respiratory centers in
the CNS. This would explain the
Cerebral Cortex
Respiratory and
Cardiovascular
Centers
Muscles
and
Joints
Adrenal
Gland
Heart and
Blood Vessels
Respiratory
Structures
Adrenalin
Figure three: Neural control of respiration
increased respiratory activity with the
onset of active or passive exercise. (See
Figure three). The sudden increase with
the onset of exercise, as well as the
abrupt decrease in respiratory activity at
the cessation of exercise also points to
neural control as other controlling
factors would be unable to adjust so
rapidly.
This increased respiratory activity is
associated with cardiovascular changes
as the movements of the diaphragm and
thorax during respiration promote
venous return and the dilation of
pulmonary capillaries results in an
increased blood flow through the
pulmonary system.
Cardiovascular adjustments
The efficiency of the heart in pumping
blood to the lungs and working tissues is
a limiting factor in exercise. If the muscle
does not obtain a continuous supply of
oxygen, its energy production will be
decreased, and therefore its performance
will be compromised.
The cardiac output, a measure of the
heart s efficiency, is the product of heart
rate and stroke volume (amount of blood
ejected with each contraction), that is,
Cardiac output = Heart rate x Stroke
volume. This is normally 5 to 6 litres per
minute.
At rest a heart rate of 72 per minute
and a stroke volume of 70 ml provides a
cardiac output of 5040 ml. During
strenuous exercise this may rise to
25,000 to 30,000 ml, a 5 to 6 fold
increase. With mild or moderate exercise
the predictions about cardiac output are
more difficult as it is not necessary to
have simultaneous increases in heart rate
and stroke volume. Moderate exercise
may produce an increase in either one or
the other. It is believed that the
untrained person tends to rely on
increases in heart rate while training
promotes an increase in stroke volume.
In fact, the improved efficiency of heart
action, with training, may be reflected in
a reduced resting heart rate because of
an increased stroke volume.
An increase in cardiac output, if the
increased blood flow resulted in a
proportional increase to all parts of the
body, would not be particularly helpful
in providing oxygen to muscle. In
exercise, the sympathetic nervous
system vasoconstrictor and vasodilator
activity shifts the blood flow to send a
much greater proportion to muscle. The
extent of the increase is related to the
severity of the exercise. Resting muscle
receives about 25 percent of the cardiac
output of 1200 ml per minute; in light
exercise this increases to about 4500 ml,
and in maximal exercise to about 22,000
ml out of a 25, 000 ml cardiac output. This
increase to muscle is at the expense of
blood flow to some tissues but
exceptions are the heart and brain. The
heart receives increasing volumes of
blood with increasing cardiac output but
brain blood flow remains constant.
The increased blood flow in muscle
is associated with a dilation of the muscle
arterioles and opening of many
capillaries which would otherwise be
closed. This shortens the distance for
oxygen diffusion to the cells. An increase
in the capillary flow also results in a
greater movement of fluid into the
muscle tissue and a reduction in blood
volume or hemoconcentration. This
increased movement of fluid into the
muscie contributes to the stiffness of
muscles experienced by the untrained
person who exercises too zealously.
Blood pressure, primarily systolic
pressure, rises during exercise due to the
increased cardiac output and
sympathetic nervous system activity.
There is little change in the diastolic
pressure and in fact, if there is extensive
peripheral vasodilation in tissues such as
muscle, the diastolic pressure may
actually decrease.
Body temperature change
The increase in metabolic activity causes
an increase in body temperature since
about 80 per cent of the energy
expenditure is in the form of heat. To
dispose of the heat generated by exercise
the skin blood vessels open and deliver
heat to the surface so it can be
dissipated.
Most athletes "warm up" before
their performance as a means of
improving their efficiency. By increasing
the temperature in the tissues the oxygen
dissociation curve will be shifted to the
right so more oxygen can be unloaded in
the tissues.
Effect of inactivity
The harmful effects of lack of exercise
are not confined to patients. The person
who leads a sedentary life cannot expect
to compare in fitness to the physically
active person. Nor can the one-time
athlete, who left athletic competitions to
lead a sedentary life, expect to perform
at an athletically-trained level without
re-training. Physical activity can
contribute much to health and
well-being, but to obtain the benefits one
must be prepared to commit both time
and effort on a regular basis.*
Anne M. HedlinffiSdV, University of
Saskatchewan; M.Sc., University of
Saskatchewan; PhD, Physiology,
University of Toronto) is a research
associate in the department of
physiology and a lecturer in the faculty
of nursing at University of Toronto. She
has had experience in general duty
nursing, public health nursing and
nursing education. Hedlin has published
numerous articles on blood coagulation
and blood Jlbrinoly sis, her main area of
research. Her most recent article in CNJ
was published in July/August 1979
entitled "The Immune System" .
References
1 Vander, Arthur i. Human
physiology: the mechanism of body
function, by Arthur J. Vander etal. 2nd
ed. New York, McGraw-Hill, 1975.
2 *Chapman,C.B. The physiology of
exercise, by C.B. Chapman and J.H.
Mitchell. Sci-Amer. 212:2-8, 1965.
Bibliography
1 Bailey, D. A. A current view of
Canadian cardiorespiratory fitness, by
D.A. Bailey et al. Canad.Med.Ass.J.
11 1:25-30, Jul. 6, 1974.
2 Selkurt, Ewald E.Basic physiology
for the health sciences. Boston, Little
Brown, 1975.
3 Shephard. Roy J. Endurance
fitness. Toronto, University of Toronto
Press, 1969.
*Unable to verify in CNA Library
L l
Is the current high level of interest in physical fitness simply a
passing fad? I don t think so. Who can forget the excitement in
the late 1950 s when the Royal Canadian Air Force Pamphlets
5BX and 10BX became international bestsellers? It may also be
difficult to accept, but Participaction s famous 30-year-old
Canadian and 60-year-old Swede will turn 38 and 68
respectively in 1980, and it really was six years ago when the
Lalonde White Paper "A New Perspective on the Health of
Canadians" put "lifestyle" into our professional vocabulary. And
yet, the question is still being asked, "Where does nursing fit into
physical fitness?".
Nurses, as health professionals practising across the whole
health care spectrum education, assessment, prevention,
treatment and rehabilitation have a special responsibility and
are in an ideal position to provide leadership in the promotion of
physical fitness. They can contribute through:
provision of information and counseling in school,
occupational and public health settings;
initiation and operation of fitness programs in schools,
hospitals, offices, plants and communities;
personal example, by attitude toward and participation in
exercise programs.
In whatever capacity a nurse intends to meet this responsibility,
it is important to have a perspective and understanding of the
scope of fitness, the benefits of exercise and the components of
an exercise program so that each individual nurse may select a
role to meet her responsibility of fitting into fitness.
The Scope of Fitness
The foundation of physical fitness is contained in the World
Health Organization definition of health as a state of physical,
mental and social well-being, and not just the absence of
disease or disability. Although I will focus on the exercise
component of a fitness program, it is extremely important to
recognize that the concept of physical fitness embodies the
examination of the whole of one s lifestyle for factors that may
contribute to a lowered state of health. Integral to an overall
fitness program, therefore, will be the capacity to assess and
counsel individuals on adequate medical and dental care,
nutrition, rest and relaxation, adverse work environments and
excessive use of drugs, alcohol and tobacco.
The physical, physiological, psychological and social
benefits of an exercise program have been well recorded. - 2
(See box) Taking these into account, a physical fitness program
should ultimately provide the individual with an ability to carry
out daily tasks with vigor and alertness, without undue fatigue,
and with ample energy to enjoy leisure time activities and meet
unforeseen physical demands. 3 Fitness varies among
individuals and within the same individual at different times in
life. It is a dynamic state rather than a static one and must be
maintained by regular and frequent challenges and assessment.
The objectives of a fitness program should therefore aim to:
develop more energy to meet daily needs, remove aversion to
physical work and participation in sports or exercise, develop
Warm-up
Fitting
nursing^,
,. r into
fitness
E. Lee Macnamara
primary components of fitness (cardiorespiratory endurance,
muscular strength and endurance, flexibility, agility, balance,
power, coordination, speed and per cent body fat composition),
promote relaxation, improve overall outlook and personality,
protect the body against suddenly imposed stress, aid in weight
control, slow down the aging process and physical deterioration,
e.g. arthritis, and protect against premature heart disease, low
energy capacity, back problems and premature failure of all
physiological systems.
While all of the above deserve attention in an exercise
program, the most important from a preventive perspective is
cardiorespiratory fitness as measured by the maximal oxygen
uptake, that is, the body s capacity to supply oxygen to working
muscles.
Approaching Exercise
Notwithstanding the long term benefits to be derived from an
exercise program, the following are absolute
contraindications to exercise
congestive heart failure, acute myocardial infarction,
active myocarditis, angina pectoris with effort,
dissecting aneurysm, recent systemic or pulmonary
embolism, thrombophlebitis, ventricular tachycardia
or other dangerous dysrhythmia, severe aortic
stenosis, and acute infectious disease.
Prior to undertaking an exercise program, a medical
examination will eliminate reasons precluding participation and
a fitness evaluation will provide a baseline against which
progress can be measured.
An exercise program should not be seen as a competition.
Participants should begin and proceed slowly lest a muscle or
Light exercise
ligament strain cause discomfort and discouragement. Exercise
sessions should be performed at regular intervals (initially at
three and rising to five times per week), should begin with a
warm-up period and end with a cool-down period. Proper
clothing will permit free movement. Since proper footwear is
most important, seek advice on footwear from a fitness
counselor or instructor.
Quality and quantity of exercise
The American College of Sports Medicine recommends the
following guidelines for developing and maintaining
cardiorespiratory fitness in healthy adults.
1. Frequency of training: initially three days increasing to five
days per week.
2. Intensity of training: 60 to 70 per cent of maximum heart rate
(MHR) [MHR = 220 minus age in years]. For example, for a
40-year-old, initial training intensity should not permit heart rate
to exceed 0.7 x (220-40) i.e. 0.7 x 1 80 = 1 26 beats per minute
but should reach a lower level of 0.6 x (220-40) or 1 08 beats per
minute.
3. Duration of training: 1 5 to 60 minutes depending on the
intensity, i.e. the lower the intensity of training, the longer the
period of training permitted.
4. Type of activity: any activity that utilizes the large muscle
groups, is continuous in nature and raises the heart rate to the
desired level.
5. Monitoring heart rate: radial or carotid pulse should be
monitored before, during and after exercise (count for 10
seconds and multiply by six). Pace or intensity should be
adjusted to bring heart rate into target range.
The exercise period
Whether you are involved in your own personalized exercise
program or an organized one, a typical 35 to 40 minute exercise
period should include the following steps.
A warm-up (5 minutes) which includes large muscle
movement to prepare the body for exercise.
Light exercise (5-8 minutes) including flexibility, bending,
stretching, balance and coordination.
Heavier exercise (5-8 minutes) involving a work-out of legs,
arms, shoulders, back and abdominal muscles to develop
strength and endurance.
Cardiorespiratory exercise (1 5-20 minutes) the peak period
of a work-out to promote conditioning of heart and lungs, utilizes
rhythmic exercise such as running, brisk walking, skipping,
bouncing, skating, cross-country skiing and rowing.
The cool-down (5-8 minutes) is facilitated with slow easy
movements to allow the body to return to the resting state.
Special programs for special people
The above guidelines are those recommended for healthy
adults. The benefits of exercise can be extended to special
groups and indeed special fitness programs including lifestyle
instruction, have been developed and are operating successfully
Heavier exercise
tor post-coronary patients, asthmatics, the physically and
mentally handicapped, pre and post natal, the overweight and
chronic back pain sufferers.
By understanding the basic physiology and
pathophysiology underlying these conditions, the basic exercise
program may be adjusted to strengthen weakened muscles and
improve cardiorespiratory endurance as in a post coronary
program or adjusted to strengthen muscles which will be
required to increase their workload, such as the perineal,
abdominal and lower back muscles in the prenatal state.
It is in these programs that the nurse can be particularly
valuable as an instructor. In addition to understanding the
conditions, their pathology and therapy, the nurse is also familiar
with possible emergencies and their treatment. The very
presence of a nurse can provide the participants with additional
confidence in both the environment and the program. As well,
the nurse s experience in maintaining a rapport with persons
concerned with their health is an added "plus".
Fitting into fitness
As I suggested earlier, nurses are in an ideal position to provide
leadership in the promotion of physical fitness in the course of
their normal practice. However, for those who wish to be more
directly involved as fitness instructors , obtaining the necessary
qualification through a Community College or YM-YWCA course
is a prerequisite. Although the opportunities for full-time
employment are limited, exercise programs are often largely
community sponsored and based on the participation of
volunteers or part-time employees.
Information on fitness programs can be obtained from a
variety of sources including the local YM-YWCA, municipality
sports or recreation departments, community centers, private
Fitness Institutes , businesses or industries operating employee
fitness programs or university departments of physical or sports
medicine.
In conclusion, the nurse has an important role in the
promotion of physical fitness as a counselor, advisor, instructor
or most important as an example. This responsibility can
only be discharged by obtaining an appropriate understanding of
the scope, purpose, benefits, contraindications and components
of a properly planned exercise program, followed by a personal
decision on where to fit into fitness. *
Lee Macnamara, RN, CPHN, is a graduate of the Victoria
Hospital School of Nursing, London, Ontario and the University
of Ottawa (Public Health). In addition to general duty and
intensive care nursing, she has practiced occupational health
nursing in industrial and academic settings. Currently, Lee is on
staff of the Offawa YM-YWCA Department of Physical
Education where she has special responsibility for the
post-coronary, pre and post natal and overweight programs.
Along the jogging trails and in the gymnasium, Lee is an
inspiration to all women, not just nurses, to get fit.
Cardiorespiratory exercise
Anrll 1Qttn
Tho Pnnartlan Mnrne
WHAT S IN IT FOR ME?
Television, radio and newspapers are all inundating us with
demands to get fit, to stay young, to get out and enjoy life. Do
you respond by promising to start next week, or when your cold
is better, or after you have lost 1 5 pounds? Or excuse yourself
by saying that you are too old or just no good at that sort of
thing?
Everyone knows that exercise is beneficial and works many
wonders but here s what it can really do for you!
Physical Benefits
increased muscle tone, power, strength and endurance
increased range of motion and coordination
reduction of stiffness, fatigue, weakness, incoordination
facilitation of good posture and flexibility
Physiological Benefits
reduction of heart rate and blood pressure, increase in stroke
volume
reduction in serum triglycerides and free fatty acids, some
reduction in serum cholesterol
improved pulmonary and cardiovascular function i.e.
increased exercise and work tolerance at less oxygen cost
a factor in prevention of obesity redistributes body fat
improved sensory perception and motor response
decreased incidence of degenerative disease
retardation of physical and mental effects of aging
prevention of cardiorespiratory and cardiovascular disease (in
post-coronary patient helps develop supplementary capillary
vessels)
Psychological Benefits
relief of tension, stress, frustration and aggression
improvement of self-confidence, improvement of attitude and
mood
promotion of relaxation and encouragement of emotional and
social adjustments
Social Benefits
development of activities for daily living, life skills
meeting ground for social interaction (team and individual
sports)
an aid in rehabilitation of psychiatric disorders self
expression, social integration with a group, relaxation
rehabilitation of hemiplegics, paraplegics and amputees is
accelerated when patients respond to physical activity.
References
1 Hader, W.J. Sports as a prescription. Canad.Fam.Phys. 23:73-75,
May 1977.
2 "Larson, L.A. International guide of fitness and health, by L.A.
Larson and H. Michelman. New York, Crown Publishers, n.d. Chapter 1 .
3 Vitale, Frank. Individualized fitness programs. Engelwood Cliffs,
N.J., Prentice-Hall, 1973. p.2.
4 American College of Sports Medicine. Guidelines for graded
exercise testing and exercise prescription. Philadelphia, PA, Lea and
Febiger. 1975. p.10.
Fitness Resource Kit
American College of Sports Medicine. Guidelines for graded exercise
testing and exercise prescription. Philadelphia, PA, Lea and Febiger,
1975.
Amsterdam, E.A. Exercise in cardiovascular health and disease, by
E.A. Amsterdam etal. New York, Yorke Medical Books, 1977.
Astrand, P.O. Health and fitness. Published by authority of Minister of
National Health and Welfare, Amateur Sport Branch. Ottawa, 1978.
Collis, Martin L. Employee fitness. Ottawa, Health and Welfare Canada,
1977.
* . Moving into the teens. Ottawa, Health and Welfare Canada, Fitness
and Amateur Sports, n.d.
Kavanagh, Terence. Heart attack? Counterattack! Toronto, Van
Nostrand Reinhold, 1976.
Lalonde, Marc. A new perspective on the health of Canadians; a
working document by... Minister of National Health and Welfare. Ottawa,
Information Canada, 1974.
Larson, L.A. International guide of fitness and health by L.A. Larson
and H. Michelman. New York, Crown Publishers, n.d.
"Meyers, C. R. The official YMCA physical fitness handbook. New York,
Popular Library, 1975.
* Standard test of fitness. Ottawa, Minister of State, Fitness and Amateur
Sport Canada, 1 979.
"Stothart, J. Shape up and live. Edmonton, Hallamshire Publishers,
1975.
Vitale, Frank. Individualized fitness programs. Englewood Cliffs, N.J.,
Prentice-Hall, 1973.
Periodic Bulletins
Physical fitness research digest. (Quarterly) Presidents Council on
Physical Fitness and Sports.
Cardio-gram. La Crosse Exercise Program, School of Health and
Physical Education and Recreation, University of Wisconsin, La Crosse,
Wisconsin.
Sports Medicine Bulletin. American College of Sports Medicine,
University of Wisconsin; La Crosse, Wisconsin.
Pamphlets
Aerobic fitness. Ottawa, Fitness and Amateur Sport, Health and
Welfare Canada.
Canada. Health and Welfare Canada. The fit-kit. Ottawa, Information
Canada, 1975.
Canada. Health and Welfare Canada. Par-Q- Physical activity
readiness questionnaire. Medical evaluation kit. Ottawa, 1975.
Exercise at the office. Ottawa, Fitness and Amateur Sport, Health and
Welfare Canada.
Food and fitness. Chicago, Blue Cross Association, 1973.
Good, R. Fitness for the fun of it. Toronto, Ontario Ministry of Culture
and Recreation, Sports and Recreation Division.
A guide to personal fitness. Toronto. Ontario Ministry of Culture and
Recreation, Sports and Recreation Division, 1978.
*/f s your move. Waterloo, Mutual Life Assurance Company of Canada.
Montgomery, D.L. Exercise: your heart depends on it. Montreal,
Canada Starch Co. Ltd., Best Foods Division.
Seaman, R. Physical activity and weight control. Ottawa, Fitness and
Amateur Sport, Health and Welfare, Canada.
You and your heart rate. Ottawa, Fitness and Amateur Sport, Health
and Welfare.
Your lifestyle profile. Ottawa, Health and Welfare, Operation Lifestyle,
Information Directorate, 1978.
Unable to verify in CNA Library
Cool-down
If hospitals have a responsibility to promote preventive health measures among their patients, do they not also have a
responsibility to encourage their own staff in this direction? To date, only a handful of Canadian hospitals (less than ten in
Ontario) have accepted this challenge. Here is the story of one of these the ups and downs of establishing and
maintaining a fitness and lifestyle program in a large and complex institution.
An employee
Fitness Program
0r\ ^U ^^
Hospital Style
Janet McEwen
JL
Every year, billions of dollars are
spent on our illness-oriented health care
system. A recent provincial government
study estimated that 31 million Ontario
Hospital Insurance Plan dollars could be
saved annually if all adults had at least an
average level of fitness, ie. they were not
overweight and under-exercised. 1
In 1975, Canadians lost 745 million
production hours through sickness,
tardiness, fatigue and casual absenteeism.
The cost, in terms of wages, salaries and
other payments for work not performed,
is estimated at close to 4 billion dollars.
More than eight times as many man-days
were lost through absenteeism than
through strikes. 2
Is there a relationship between these two
sets of figures? In 1977, a two-year
comparison study of individuals
participating in the Metropolitan Life
Fitness Program indicated beneficial
effects for the participants in terms of
health, favorable lifestyles and attitudes.
Among the benefits from the company s
point of view were improved morale,
performance and a decline in
absenteeism. 3 These results have been
corroborated by Canada Life Assurance
which, in 1979, published initial findings
from an experimental fitness program. 4
Physiological post-program results
demonstrated significant improvement in
body flexibility, decreased absenteeism
and more positive attitudes towards
health. Other studies have also reported
finding that, in addition to definite
physiological benefits, an increase in
well-being, morale and company rapport
is evident.
In these days of budgetary restraints
and financial cutbacks, are these
statistics not sufficiently convincing to
persuade hospital administrations of the
positive effects of fitness programs?
Some hospitals are making attempts to
establish programs, but the task is not an
easy one. I would like to briefly describe
the steps we have taken at the Ottawa
Civic Hospital in the development of our
employee fitness program.
June, 1978. The Canadian Public
Health Association, with Loto Canada
funding, placed 50 kinanthropology
students in institutions across Canada in
an attempt to initiate fitness and lifestyle
programs. Throughout that summer I
worked with our student to establish a
program at our hospital. Together we:
organized an exercise facility in a
recreation area of the nurses residence
arranged for shower and change
facilities
designated a Fitness Promotion area
outside the cafeteria for dissemination of
lifestyle literature
published a bi-monthly newsletter
organized film and lecture
presentations on topics related to fitness
and lifestyle
established fitness testing with the
facilities of a YMCA van and
sold fitness T-shirts.
My secretary and I, both certified
fitness instructors, organized two
exercise classes which we held after
working hours. My class from 1530 to
1630 hours primarily attracted nurses,
the majority being head nurses and those
with consistent hours, while the 1630 to
1730 hour class attracted employees
from lab medicine, other allied health
professionals and secretaries. Bicycling
and jogging clubs were established,
mileage charts were placed outside of the
cafeteria in the fitness promotion area
and crests were awarded for attainment
of specific mileage milestones.
September, 1978. The hospital
administration decided to retain the
original student, and, as well, hired a
second university student, both on a
part-time basis to assist with continuing
the program. An Administrative
Assistant was appointed to coordinate
the program and the four of us met
weekly to plan and organize activities.
During this period, we received
consultative services from an employee
fitness consultant from Fitness Ontario.
Over the next few months our programs
grew and enthusiasm seemed
contagious.
October, 1978. Our first ten-week
exercise programs were completed and
we celebrated with a dinner for all
participants featuring a speaker on
aerobic exercise and the presentation of
awards. Fun, commitment and
enthusiasm were obvious. We continued
the two afternoon programs with an
enrolment now of 70, and a noon hour
program was added for employees who
were able to take an hour for lunch, thus
eliminating the nursing population.
December, 1978. The completion of
another program series was celebrated
with a wine and cheese party and an
awards presentation. This time
questionnaires were completed.
Participants indicated that they were
enjoying the program, feeling decreased
stress levels, increased energy,
increased awareness of their lifestyle,
Improved sleep and digestive patterns,
increased flexibility and more positive
self images.
January, 1979. Just over 100
employees registered in the three fitness
classes. Ski lessons at a local ski center
and yoga classes were also organized. A
hospital-wide survey indicated sufficient
interest to continue and expand the
program. With the resignation of one of
the part-time students, a committee of
volunteer employees was established to
carry on promotion, operation and
finance functions. Promotion continued
through noon hour presentations,
newsletters and distribution of lifestyle
literature.
April, 1979. Approximately 200
employees registered in three exercise
classes, disco dancing, women s self
defence, yoga and behavior modification
for weight control, the latter programs
taught by community instructors.
Twenty employees, including nurses,
x-ray and lab technicians, an orderly and
a secretary, registered in a Fitness
Instructor s course which I taught under
the direction of a local University
Athletic Center. Eleven employees
graduated from this program.
Another successful social event was
held, this time featuring a pot-luck
vegetarian dinner contributed to by
employees, a lively presentation by a
dietitian, and, as was becoming
customary, the presentation of awards.
Many came expecting radishes and
carrot sticks and were quite amazed at
the assortment of tasty casseroles and
salads available. Our social event was
the talk of the cafeteria the next day. At
this time our second fitness student
resigned and the Carleton University
Athletic Centre was established as a
consulting service.
The program reached its "high"
point at this time. The noon hour
program was probably the most popular
and the growing number of management
participants, including three medical
department heads, lent credibility to the
program. It was most gratifying to see
participants from all areas and levels of
the hospital staff having fun together. No
longer was the Chief of Nephrology a
physician, he was now "Gerry", jogging
in his shorts and T-shirt with the group.
It was interesting to see the Chief
Purchasing Officer doing the "polka"
with the Infection Control Nurse, the
Director of Plant Operations jogging with
the Director of the Admitting
Department and the Chief of Cytology
helping his fellow laboratory technicians
with their stretching exercises. An
amusing anecdote resulted from one of
our Spring jogging sessions: the Director
of Psychiatry noted that if any of his
patients saw him "tiptoeing through the
tulips , they would wonder which one of
them required treatment.
During the summer, formal classes
were discontinued but we attempted to
maintain interest through individual
bicycling and jogging clubs.
September, 1979. The program was
dealt a serious blow when our location
was taken over for the new Ambulatory
Care Facility. We submitted a proposal
for a new area in another basement area
of the hospital, but this was rejected due
to the demands of the hospital s
redevelopment program.
This was the "low" point of the
program. It would have been so easy just
to discontinue the whole project our
budget was depleted, we had no outside
assistance, our new fitness instructors
had no place to practice their new skills
and some of our good volunteers had
either left the hospital or indicated lack
of interest due to the lack of facilities. At
this point, my personal commitment was
also sorely questioned, as I was feeling
increased demands in my own job.
However, with the excellent support of
the small group of remaining volunteers,
we decided we could not abandon the
project after all the efforts of the past
year.
Space was found in our Education
Building to continue the 1630-1730 hour
class and new shower and change rooms
were established in the "redeveloped"
nurses residence. We were allotted a
room for exercise, but it was too small
for the large formal classes, so it was
only used by the individual noon hour
joggers for a warm-up and cool-down
area. Even this activity was relatively
unsuccessful as former participants
missed the group spirit.
We decided to increase our
emphasis on our weekly noon hour
educational program.
November, 1979. A series of six
lectures on stress management brought
several interesting comments. An aide in
the OR instrument room stated "The
program came at an excellent time for
me. I was having personal problems and
I learned some new techniques to help
me deal with them." The Business
Manager of the Cancer Clinic
commented, "The program helped me to
understand the physiological effects of
stress, methods of relieving stress and
made me aware of identifying stress
related staff behaviors."
Also in November, a Fitness
Promotion Advisory Committee was
established which I chair and includes
representatives from the Fitness
Promotions Committee, dietetics,
physiotherapy, nursing education, media
coordination, social service, cardiac
r rehabilitation, occupational therapy,
health service and the recreation
committee . The goals of this committee
are to coordinate fitness and lifestyle
education with other hospital programs,
to collaborate on how to present monthly
themes and to improve communication
about our programs throughout the
hospital.
At this time our fitness program was
placed under the administration of the
Director of Personnel. We continued
fitness promotion through literature and
newsletters, a "design a logo" contest
was held and a new logo established.
Plans were made to start a back program
for the Housekeeping staff in January.
This was to be given by the employee
health nurse who had attended a
"healthy back" instructor s program at
the local YM-YWCA.
December, 1979. Former
participants complained that they were
really missing the classes, were not
feeling as well and were gaining weight.
The Chairman of the Promotions
Committee and myself felt we could no
longer carry the load on a volunteer
Tn Canadian NUTM
April! 9*0 37
basis, so I prepared a submission to our
Executive Director requesting that a
part-time fitness consultant be hired to
attempt to rejuvenate the program within
the boundaries of the existing lack of
exercise facilities.
At the time of compiling this short
history of our program, a graduate of the
B.Sc. Kinesiology program of the
University of Waterloo has just been
hired on a part-time basis. Due to the
small size of our facility we have
increased the number of fitness classes
being offered. To date we have
registered 85 people and our newly
trained fitness instructors will be utilized
in teaching the programs. The only other
program we have offered is disco
dancing, but registration so far has been
poor; actually interest in disco dancing
seems to be waning and belly dancing
might have proved a more popular
choice.
Our new consultant is currently
conducting individual fitness appraisals
for each registrant in the fitness classes
and he will also assist with educational
presentations on heart disease and
exercise for our February heart month
educational program. In March, the
physiotherapy department with his
assistance will present a "prevention of
back injury program" for all employees.
Plans are being made for a primarily
audiovisual presentation that will be
readily accepted by the various ethnic
groups employed. Photos of faulty lifting
and work methods are now being taken
in the housekeeping, dietetics and
laundry departments (we already have
many slides of these poor techniques in
nursing) for use in the presentations. It is
expected that the program will be
presented at least 60 times with at least
one course in Italian.
We also foresee our consultant
cooperating with the employee health
nurses in planning back exercise
programs, weight control programs and
implementing "exercise breaks". Thus a
whole new dimension to the employee
health nurses role may be opening up.
Their enthusiasm for this is evident.
Finally, we hope that our fitness
consultant can work with the
architectural planners to make the dream
of anew fitness center a reality.
So that is the story of one hospital s
difficult, but rewarding activities along
the road to developing an ideal program.
We are not close to that point yet, but I
feel hopeful that the ground work has
been laid.
My work with the program has been
an excellent learning experience. A few
suggestions for those attempting to
establish programs would include:
1 . Adequate personnel to provide
leadership. In an institution as large as
ours, I do not feel this can be done totally
on a voluntary basis, however volunteer
leadership participation must be
What About Nurses and
Fitness?
On the strength of her own personal
experience and commitment to fitness,
author, Janet McEwen, comments:
"At the Ontario Hospital Association
fitness conference, most hospitals with
established programs indicated that they
were having difficulty enticing nurses to
participate. Whether this phenomenon is
due to shift changes, fatigue or feelings
that sufficient physical exercise is done
during the working day, we also found
that most of the few staff nurses who
enrolled in our classes dropped out as
their shifts changed, leaving only the Head
Nurses as our regular participants.
I would like to encourage all nurses,
management or general staff, to
participate in some type of exercise and
lifestyle program whether at work or in
the community. A personal commitment
to a more active and healthier way of life is
the first step in fulfilling our role as
lifestyle educators."
provided by energetic committed
employees. Contributions from
departments associated with preventive
health (e.g. Health Service ) is essential,
as is inter-departmental communication
and cooperation.
2. Facilities. A well organized,
sufficiently large, preferably onsite
facility which is safe and well-equipped,
including adequate shower and change
rooms, is a necessity.
3. Administrative support. Fitness
programs belong under the umbrella of
Personnel Administration and will
probably not survive without the interest
and support of the Executive Director.
4. Research. A survey of employees is
essential to determine interest in
participation and providing leadership,
the type of programs wanted and the
times suitable.
5. Budget. Employees may be charged
small fees for classes, but usually this
will not finance the entire program. The
institution must assume the
responsibility of committing some funds
for ongoing operational and equipment
expenses.
6. Program. The exercise program
should be based on the latest scientific
principles (sufficient warm-up, static
stretching, aerobic period and suitable
cool-down). Adequate consultation with
exercise physiologists should be utilized
and exercise leaders, preferably from
within the hospital, should be trained
under their direction. Fitness education
can be included in the classes and music,
variety and fun are important
components, as are social events and
motivational gimmicks. In addition to
exercise, classes geared towards back
pain and weight control are important.
7. Program evaluation. Quantitative and
qualitative measures should be
developed to determine if established
objectives are being met.
8. Promotion. Lifestyle awareness must
be kept alive with promotion through
literature, newsletters, posters, films,
speakers and most importantly personal
encouragement.*
Bibliography
1 *Quasar Systems Ltd. The
relationship between physical fitness and
the cost of health care. Toronto,
Ministry of Culture and Recreation,
1976.
2 *Blum, R. Physical fitness.
FinancialTimes of Canada. 65:1, Mon.,
Sept. 13, 1976.
3 Garson, R.D. Pilot project on
Metropolitan Life fitness program. Jan^
1977.
4 Minister of State, Fitness and
Amateur Sport. Employee fitness and
lifestyle project. Toronto, 1977-78.
*Unable to verify inCNA Library
Janet McEwen, BScN, Ed. , has held both
teaching and administrative nursing
positions and is presently Director of the
Registered Nursing Assistant Program
Ottawa Civic Hospital. Janet s
commitment to fitness stems from a car
accident several years ago, after which
her prognosis for future involvement in
athletic pursuits was poor. Two years of
personalized exercise programs,
physiotherapy, support and
encouragement and lots of hard work
has left Janet fitter than ever. She has
assumed a volunteer leadership role with
the Ottawa Civic Hospital Fitness
Program, holds two fitness instructor s
certificates, and is a committed runner
having completed her firs! 26-mile
marathon in 1979. Janet also enjoys
cross country skiing, canoeing,
backpacking and playing tennis.
Acknowledgement: The author would like
to thank Peter Carruthers, Executi ve
Director, Ottawa Civic Hospital, for his
interest and support, Betty Lo wry,
Administrative Assistant, Ottawa Civic
Hospital, for her organizational
assistance, Greg Poole, Carleton
University Athletic Centre, for his
advice, and Larry Greene, the
kinanthropology student, who helped to
make the program a reality.
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The cardiac patient who is trying a treadmill or stress test for the first time is often extremely anxious
because he doesn t know what to expect. Does his nurse?
The physician today frequently uses the
services of a "non-invasive lab" to assist
him in the diagnosis of cardiac disease.
The tests performed in such a lab include
stress testing, ambulatory monitoring
and cardiac ultra-sonography. No test
requires that a patient be hospitalized,
although these tests are often ordered
during hospitalization. Since the skin is
not punctured during any test the name
applied generally to this group of
diagnostic services is "non-invasive".
The nurse has an important role in such
testing, both in preparation and
monitoring of the patients.
There are both diagnostic and
therapeutic implications in performing a
stress test. The procedure may be
ordered by the physician as a means to
document an episode of cardiac ischemia
or to determine the physiological
mechanism causing angina, functional
valve incompetence or extreme rise in
blood pressure in a particular case.
Therapeutic reasons for stress testing
include documentation of the response to
medical or surgical treatment and
determination of the functional capacity
of the patient for work, sport or
participation in rehabilitative programs.
Principles of stress testing
Dynamic vs Isometric exercise
All stress tests whether step, bicycle
ergometer or treadmill follow the
same principles. The tests are aerobic in
design which means that they all
measure the amount of oxygen
consumed by the heart muscle. The tests
are designed to utilize dynamic rather
than isometric exercise. In dynamic
exercise a large muscle mass (the legs)
moves without a significant resistance;
dynamic exercise increases cardiac
output which in turn increases the
transport of oxygen. Isometric exercise,
on the other hand .where the muscles
move against a resisting force, increases
the blood pressure without significant
increase in cardiac output.
Patricia MacFarlane
Not all patients can undergo stress
testing; those who may exhibit clinical
signs of congestive heart failure because
the left ventricle of the heart is already
stressed beyond its capacity are
excluded, or those with obstruction of
the left ventricular outflow tract as in
restrictive cardiomyopathy. Patients
with severe chronic obstructive
pulmonary disease (COPD) will be
unable to perform aerobic exercise to
any degree. Patients with severe
peripheral vascular disease or acute
myocardial ischemia are also excluded.
Patients with certain musculoskeletal
limitations as in CVA, ataxia or multiple
sclerosis are not suited for stress testing.
Electrocardiographic findings which
exclude patients from stress testing are
uncontrolled arrhythmias such as atrial
fibrillation with uncontrolled ventricular
response, PAT, junctional rhythm, A-V
block and ventricular arrhythmias. Other
indications are acute ischemic changes
and ECG changes due to digoxin,
quinidine compounds or the use of
diuretics.
Establishment of endpoints
The duration of a test is generally not
longer than 15 minutes; this time limit
prevents having to discontinue the test
due to leg fatigue rather than cardiac
indications of stress. A pre -determined
set of endpoints is established in each
lab; the endpoints are divided into two
groups, clinical and
electrocardiographic.
ECG determinants for endpoints are:
ST depression 1.5 mm or greater
ST segment elevation
PVC s (multiple pairs, multi-focal,
jigeminy)
ventricular tachycardia, fibrillation
supraventricular tachycardia
advanced heart block.
Clinical determinants are:
chest pain
severe dyspnea
syncope
dizziness
excessive fatigue
abnormal blood pressure (systolic &
260mm Hg, diastolic 3= 1 10. or a systolic
drop of 20mm Hg)
severe musculoskeletal pain
(claudication)
patient s desire to stop.
The test itself
The patient should fast and refrain from
smoking for two hours prior to taking the
test. Comfortable clothing such as shorts
or slacks should be worn and well-fitting
footwear is a necessity for safety while
exercising. Slingback shoes or slippers
increase the chance of the patient losing
his balance during the test.
Due to the slight risk involved every
patient should be required to sign an
informed consent after the procedure has
been explained to him to his satisfaction.
The stress lab must have emergency
resuscitation equipment close to the
testing area and a qualified physician
within two minutes call.
Electrodes are placed on the chest in
accordance with the 12 lead cardiogram
positions. The test begins at a workload
far below the estimated level of cardiac
impairment. The patient is then able to
"warm up" to the exercise while
becoming familiar with the equipment.
Starting at a low level will help to limit an
episode of angina due to nervous
tension.
The test proceeds according to the
protocol chosen by the physician. The
various treadmill protocols deal with the
combinations of elevation and speed of
the treadmill. In the Bruce protocol, for
example, the speed and elevation
increase at three-minute intervals until
an endpoint is reached.
Whichever test is chosen, it is
important that the patient understand
what is expected of him. A
demonstration of the procedure by the
technologist will help to clarify any
questions. If time permits the patient
may try a short walk on the treadmill.
When a patient feels comfortable with
the procedure he is able to maintain a
constant level of work thus giving a
standardized response to each exercise
level. If someone finds he cannot walk at
a constant speed a metronome may be
used to set the pace.
It is important that the blood
pressure, heart rate and
electrocardiogram be monitored before,
during and after exercise. The
parameters measured prior to the test
determine whether the patient is able to
perform the test. The blood pressure and
pulse are measured at the end of each
exercise level to determine if the heart is
performing satisfactorily. During the
recovery phase these parameters should
return to the baseline measurements. In
the Bruce protocol it is expected that
measurements will return to the baseline
levels in six minutes; the recovery period
is extended if these levels are not
reached in that time.
Exercise physiology what s normal
Four factors influence the cardiovascular
response to exercise: (l)type of exercise
(2)duration of exercise (3)age of
individual and (4)environment.
As the body ages certain physiologic
changes occur: the stroke volume of a
twenty-year-old man is greater than that
of a seventy-year-old. Due to the aging of
the lungs, less oxygen is transported
across the alveolar membranes thus
reducing the amount of available oxygen.
Stress testing must be carried out in
a controlled environment. If the
temperature is too hot, the patient s
resting heart rate will be higher, stroke
volume and blood pressure will be lower
and the tone of the capacitance vessels
(large veins in the thorax and abdomen)
will be less. The body tries to keep its
temperature constant and responds by
increasing the flow of blood to the skin,
causing the patient to perspire. On the
other hand, if the testing room is too cold
the heart rate and cardiac output will
remain unchanged but the blood pressure
will increase due to cutaneous
vasoconstriction.
In upright dynamic exercise, the
vascular system undergoes certain
changes as it adapts to the increased
workload. Here s what happens:
Arterial blood vessels dilate,
causing a fall in peripheral resistance (an
initial drop in blood pressure may be
seen).
The body s blood supply is
redistributed to increase cardiac output;
blood is diverted from the spleen,
stomach, etc.
Venous return increases.
There is constriction of the
capacitance vessels to increase flow of
blood to the heart.
The increased flow of blood to the
heart increases stroke volume.
Increased stroke volume increases
strength of muscle contraction
(Frank-Starling law).
Exercise physiology what s abnormal
There are two abnormal physiological
responses that can be measured during
exercise testing. There may be a drop in
systolic blood pressure due to inotropic
incompetence of the left ventricle: the
left ventricle is unable to contract
efficiently and the systolic pressure falls.
Auscultation of the heart at this point
would reveal the presence of a gallop
rhythm. Abnormal precordial motion
may also be seen.
The other abnormal response relates
to heart rate. A patient with severe
coronary disease may rapidly increase
his heart rate at low workloads. Due to
lack of contractile muscle tissues, the
heart functions at a fixed stroke volume.
To increase cardiac output the heart rate
must increase quickly. The heart rate
will quickly reach a plateau and only a
minimal increase will occur at higher
workloads. If the exercise is continued
this minimal increase is usually followed
by a drop in heart rate .
The positive stress test
If the stress test is positive the
electrocardiogram may show one or all
of the following abnormal responses: ST
segment depression or elevation,
conduction disturbances and
arrhythmias.
The patient may experience chest
pain, faintness or dyspnea. He may also
exhibit signs of pallor, cyanosis and cold
sweat. When the heart is auscultated
murmurs or gallops may be heard.
Hemodynamic changes usually occur if
an artery is 75 per cent or greater
occluded.
When reviewing the positive stress
test the physician must take into
consideration the duration of the test
(patient s functional capacity) and the
time of onset of clinical signs. A patient
with a mildly positive stress test may
benefit from a rehabilitative exercise
program. Regular, supervised exercise
will help the patient to reduce stress and
tension, lose weight and increase
exercise endurance.
A patient with a moderately or
strongly positive test may need further
investigation such as coronary
angiography to determine the extent of
the disease. *
Patricia MacFarlane,fi/Y, is a graduate
of the Royal Jubilee Hospital School of
Nursing in Victoria, B.C., and has a
certificate in cardiovascular nursing
from the University of Alberta Hospital.
She was formerly head nurse in the
University of Ottawa Cardiac Unit, and
is currently part time nursing care
coordinator in the ortho-neuro program
at the Ottawa General Hospital. She is
also assisting in a post-myocardial
infarction study being done at the
University of Ottawa Cardiac Unit.
She wishes to acknowledge the
assistance ofM. McKinlay-Key and A.
Guthrie, technologists at the University
of Ottawa Cardiac Unit Non-invasive
Lab, in the preparation of this article.
40 Anril 1980
The Canadian Nl rse
Cardiac
rehabilitation:
applying the benefits of exercise
For many years exercise testing has been used
,11 II
Barbara Naimark
The Winnipeg cardiac rehabilitation
program got underway in 1973 with five
post myocardial infarction patients. The
program grew rapidly and soon included
individuals, post infarct and following
aorto coronary bypass surgery, as well
as those with stable angina pectoris. As it
grew, it became evident that systematic
and regular exercise resulted in
significant improvement not only in the
work capacity of the individual but also
in the general ability of that person to
cope with his disease in psychological
terms.
Initially, the program facilities were
housed in the bowels of a physical
education building at the University of
Manitoba, affectionately termed the
"gritty grotto" . These facilities soon
became inadequate and with the help of
the Kinsmen Club of Winnipeg, private
donors and government support, new
quarters were built. In February, 1979.
the program moved to these quarters a
spacious, airy, temperature controlled
to measure the functional capacity
of persons with cardiac disease.
A more recent development
has been the systematic use of
physical training as part of the
rehabilitation of these individuals.
\VhiIe much remains to be learned
about the long term benefits
of this form of rehabilitation,
the short term benefits are
often striking and have stimulated
increasing interest among
those involved in the management
of cardiac problems.
IT ff I
center consisting of a 200-meter, four
lane track with a uniturf surface,
hardwood vollyball and badminton
courts, large carpeted infield exercise
area, variable resistance equipment,
fully appointed locker and changing
rooms, clinical assessment area and
laboratories and a comprehensive sports
medicine section.
With new facilities came the
opportunity to add a second major
dimension to the program. Because we
believed that regular exercise is an
important ingredient in preventive
cardiology, we designed a second fitness
training program for individuals who
displayed no clinical evidence of
coronary artery disease. This program,
called Pre-Fit, does not require a medical
referral but is under general medical
direction. At the present time a total of
650 persons are enrolled in Reh-Fit and
750 in Pre-Fit.
All participants in Reh-Fit. the more
closely supervised program, must be
referred by their personal physicians.
The individual then undergoes a
thorough medical evaluation including
history, physical examination, 12 lead
EKG, spirometry, fasting blood sugar,
serurn lipids, CBC. percentage body fat
estimation by skin caliper method and
graded exercise stress testing utilizing a
modified Balke technique. This is
supplemented by direct measurement of
L , consumption. This evaluation is
Table one
Serum Lipids
Triglycerides
Total cholesterol
HDL cholesterol
LDL cholesterol
Fasting Blood Sugar
Body Fat
Weight
Blood Pressure
Stress Test
September 19, 1979
378 mgm%
237 mgm%
87mgm%
92mgm%
102mgm%
21.5%
97kg.
132/90
7.42mins.
1 1 .Omets
May8, 1979
486 mgm%
217mgm%
33mgm%
107mgm%
1 55 mgm%
30%
107.8kg.
145/100
4.52mins.
8.2 mets
A met represents the measurement of the normal resting oxygen uptake i.e. 3.5
ml/kg/min. At a given workload the multiple of the oxygen cost of rest or number
of METS can be directly measured or estimated and is a useful way to
characterize work done.
repeated four months after the client
starts the program and each year after.
Following initial assessment, the client is
placed in an introductory exercise class
conducted by physical education staff; as
he progresses in capability and
understanding of the basic principles and
becomes more independent, he moves to
an intermediate and then senior class. In
most instances, clients are free to
exercise on their own after several
months in the program. Each client
exercises three times a week, each
session lasting approximately one hour.
The emphasis is on aerobic training, that
is, exercise involving large muscle
groups designed to produce a
cardiovascular training effect . Fast
walking, jogging, or running according to
ability and supplemented by certain
upper body exercises are the major
components. Some stretching and
calisthenics are included and we also
emphasize cardiovascular risk factor
modification through avoidance of
smoking, diet control , hypertension
monitoring and management of undue
emotional stress.
The Ren-Fit health care team
includes a medical director, nurse
coordinator, part time physicians,
physiotherapist, nutritionist, laboratory
technicians and physical educators. The
Sports Injury clinic, which is housed in
the Reh-Fit building is available for the
care of those requiring musculoskeletal
assessment and/or treatment.
As nurse coordinator I serve several
functions in the Reh-Fit program but the
most important involves acting as the
main contact point for the participants.
In consultation with the physician I plan
their individual programs, monitor their
progress and maintain liaison between
the clients, the various members of the
program staff and their referring
physician. When necessary I refer
individuals to diabetic, hypertension and
lipid clinics at a nearby teaching hospital.
During every phase of the program I act
as patient counselor, advisor and
educator on a wide range of issues : from
explaining basic concepts of aerobic
training to actions and side effects of
medications; from discussing and
exploring family relationships to helping
someone cope with news that bypass
surgery is indicated.
The following case history
exemplifies the often remarkable results
which can be achieved in the Reh-Fit
program. Jim Redmond, an obese 35
year old man with hypertension,
coronary artery disease, high blood
sugar and hyperlipidemia was hostile,
resentful and embittered. He drank and
smoked heavily and at the insistence of
his family physician grudgingly agreed to
enroll in the program. Within five
months of enrolling, his serum
triglycerides, blood sugars, body fat,
weight and blood pressure were all
significantly reduced and his exercise
tolerance was significantly increased
(SeeTable one). Although total
cholesterol was slightly elevated the
marked increase in high density
lipoproteins indicate clear improvement
in lipid risk factors. Despite his initial
lack of motivation, he soon began to see
and feel changes, his self image and
sense of well-being improved and he
reduced his alcohol consumption and
managed to stop smoking.
Jim Redmond is one of the many
examples of successful rehabilitation we
have observed in the Reh-Fit program.
The rate of recividism on the whole is
extremely low, participants appear to be
able to achieve major and continuing
lifestyle modifications. While the
reasons for this are not fully understood
we believe that group participation, the
multi disciplinary approach and the
Modified Balke Technique, as used in
Stress Testing
Treadmill speed is fixed at 5.4 kmph and
the grade increased 2 per cent each
minute until a symptom or fatigue
limited end point is reached, providing
that an arrhythmic or an abnormal blood
pressure response does not occur first.
When marked disability is anticipated,
lower speed and if necessary I per cent
grade increments are used. This
approach, using small load increments
and brief test stages, is, in our view, the
safest and most precise means of
measuring exercise tolerance in disabled
people. At the same time it is efficient for
stress testing those with normal exercise
tolerance.
commitment, dedication and caring
attitude of staff members are all
important positive factors. <
Bibliography
1 *American Heart Association.
Committee on Exercise. Exercise testing
and training of individuals with heart
disease or at high risk for its
development. New York, 1975.
2 * Astrand , Per-Olof . Textbook of
work physiology, by Per-Olof and Kaare
Rodahl. New York, McGraw-Hill, 1970.
3 Gordon, T. High density
Lipoprotein as a protective factor against
coronary heart disease. The Framingham
study, by T. Gordon et al.Amer.J.Med.
62:5:707-714, May 1977.
4 Streja, Dan. Moderate exercise and
high density Lipoprotein-Cholesterol
observations during a cardiac
rehabilitation program, by Dan Streja
and David Mymin.JAMA
242:20:2190-2192, Nov. 16, 1979.
*Unable to verify in CNA Library
Barbara Naimark,/?iV, BN, a graduate
of the Winnipeg General Hospital School
of Nursing and the University of
Winnipeg, has worked in medicine and
outpatient departments in Canada and
the U .S. Currently she is the nurse
coordinator of the Reh-Fit program.
What s
the
score
sports
injuries?
^^^^^^WwBfci
Susan Moses
More Canadians are becoming
active in sports; some of them
suffer the needless trauma of
a serious eye injury. Here s a
review of the types of injury that
can result, treatment and what
to look for in protective
equipment.
Squash, racquetball, handball, hockey,
lacrosse, tennis, badminton and skiing
what do all these popular Canadian
sports activities have in common? They
often result in eye injuries. Most people
are not aware of their susceptibility to
eye trauma, nor are they familiar with
the use of protective equipment which
can prevent sports-related injuries.
There are several types of eye
injuries, some more common than
others, which will be described along
with the appropriate nursing care
following a brief review of the internal
structure of the eye.
Physiology
The cornea is the transparent anterior
part of the sclera, which is the white
non-transparent fibrous material
covering the eye, except at the back
where the optic nerve enters. The cornea
serves as the main refracting medium for
the eye, and is completely avascular.
There are five distinct layers in the
cornea; the epithelium layer has more
pain nerve fibres than any other part of
the eye.
The iris is the colored
doughnut-shaped structure surrounding
the pupil; a muscle structure, it serves as
a sphincter and a dilator, adjusting the
pupil according to light conditions. The
crystalline lens consists of transparent
fibres surrounded by a strong elastic
capsule, and is suspended directly
behind the pupil by zonules which attach
it to the ciliary body . The contracting
and relaxing action of the ciliary body
allows the lens to accommodate to light
rays and focus them on the retina.
The ciliary body encircles the eye
behind the iris, and has several
functions: the circular layer assists the
lens in accommodation, while the
longitudinal layer opens the trabecular
spaces allowing aqueous fluid to leave
the eye. The ciliary process produces the
aqueous fluid which fills the anterior and
posterior chambers.
The choroid is a richly-vascularized
layer situated between sclera and retina;
the retina itself is a very complex
network of nerve cells and fibres and is
perhaps the most essential part of the
eye. Images are received in the retina
and transmitted via the optic nerve to the
brain where all the visual information is
"decoded" and assembled to give one
image.
The vitreous is a transparent viscous
fluid behind the lens which helps give
form to the eye and support to the retina;
it is relatively inert and formed only
during eye growth if lost it can never
be regenerated. The aqueous humour
flows between two chambers, anteriorly
between the iris and cornea, and
posteriorly between the lens and the iris.
Essentially a nutritive solution that
bathes and feeds the lens, it flows
through the pupil into the anterior
chamber and then out through the
trabecular spaces. The trabecular spaces
are like a fine sieve, and serve to give a
certain resistance to the outflow of
aqueous fluid, maintaining intraocular
pressure at about 15 to 25 mm Hg.
The conjunctiva is the mucous
membrane covering the exposed part of
the eye and the inner surface of the
eyelids. Tears are produced by the
lacrimal glands in the upper outer part of
the orbit, and cleanse and moisten the
cornea, after which they drain off into
the lacrimal sac through small ducts in
the inner canthus.
The eye itself is enclosed in a bony
orbit within the skull, surrounded by fat
and fibrous tissue; six muscles outside
the eyeball, inserted into the sclera allow
for up-down, side to side and diagonal
movement.
Games people play
As Canadians become more aware of the
need for personal fitness and exercise,
the trend is to participate in active sports
or games that are both fun and healthful.
Some games are more competitive than
others, requiring a greater degree of
body contact, or of mind-body
coordination. Basically, most injuries are
caused by either a blow to the face or
eyeball, or by cuts and lacerations across
the front of the eye.
Squash is one such sport activity in
which serious eye injury can result:
because the game is played in an
enclosed area with a small hard ball
bouncing off any one of six different
walls, there is a significant potential
hazard. The ball itself is a high-velocity
missile, while the racquets too can cause
injury. Players need to be alert and
attentive at all times, and warm-up with
more than one ball in play is not
advisable. In squash protective goggles
are highly recommended, especially for
people who wear glasses and are more
likely to incur permanent damage when
the glass shatters and is projected into
the eye.
Hockey and lacrosse are two
fast-moving games which require
aggressive action, body contact and the
use of sticks and a hard object, the puck.
Injuries have decreased due to the use of
face masks, but they still occur, the
majority being caused by sticks. Most
hockey injuries can be prevented by the
use of protective equipment.
Unlike squash, tennis and
badminton are played in an open area,
with opponents on opposite sides of a net
and so injuries are less likely to be as
severe. Racquets in both sports are
potentially dangerous, as is the tennis
ball.
Skiing poses a different sort of
danger: skiiers should be constantly
aware of the ability of those skiing
around them, and avoid people who are
apt to lose control or who are trying out a
hill which is beyond their capabilities. A
wildly flailing pole can cause serious
damage, as can a fall onto a pole or other
hard object.
Skidooing too can be hazardous:
riders who wear helmets without a visor
can brush past tree branches at high
speed, causing injury to their eyes.
Injuries
Ocular trauma resulting from sports
activities may be divided into two
categories: impact or contusion injuries,
and lacerations or abrasions. (There are,
of course, other forms of general ocular
trauma, such as exposure to corrosive
solutions etc.) In reading the various
types of injuries one must keep in mind
the existence of protective equipment
available which can absorb the impact of
most objects and save the eye from
punishment. Goggles used for racquet
sports are virtually indestructible:
ordinary eyeglasses are not meant to
withstand much pressure, and
consequently they may break or cause
brow laceration. Contact lenses are no
better: they just transmit impact directly
onto the eye and occasionally shatter.
The injuries listed below apply to the
unprotected eye.
Hyphema. Frank bleeding into the
anterior chamber may result from a
sudden blow to the eye: the blood does
not clot, and there may be a second
episode of bleeding 24 to 72 hours later.
Hyphema can lead to secondary
glaucoma, traumatic uveitis
(inflammation of the choroid, ciliary
body and iris), orcorneal opacity. There
is some controversy about treatment, but
generally bedrest is prescribed for up to a
week. Healing is promoted by having the
patient remain quiet and in an upright
position gravity aids re-absorption of
the blood in the constant changing of
aqueous. Both eyes may be patched to
decrease stimulation; topical
corticosteroids may be applied to treat or
prevent uveitis.
Secondary glaucoma. This complication
of hyphema is the result of tears or
lacerations in the iris and ciliary body
with subsequent hemorrhage into the
anterior chamber. This causes an
increase in intraocular pressure which
may be treated with Diamox 11 (usually
250 mg p.o. q.i.d.) which decreases the
production of aqueous fluid. If the
General eye care
Ciliary body
Central artery and veiny
of retina ///AQptic Retina
Optic Nerve
Optic Disc
Vitreous Body
Ciliary zonule
(Suspensory liq.)
Cornea
Sclera
^/Ciliary
Body
Ciliary processes
Loose foreign bodies can be
removed from the eye by dabbing with
clean gauze; otherwise, flush out with
water moving from inner canthus
outward. Imbedded material should be
removed by an opthalmologist.
Chemicals splashed in the eye need
to be diluted immediately to prevent
permanent damage; wash thoroughly
with running water before heading to
emergency.
NEVER apply pressure to the
eyeball to stop bleeding. Go to
emergency department immediately.
Persistent pain, redness, swelling,
or blurred vision may be signs of serious
problems go to an ophthalmologist as
soon as possible. In the case of trauma,
always assume there may be more than
a simple black eye when bruising of the
eyelids is present.
Rectus
muscle
Flashing lights, floaters or a curtain
across the field of vision may be signs of
retinal detachment seek medical
attention.
People with family histories of
diabetes or glaucoma should have yearly
eye examinations.
Promote the use of protective eye
gear in sports activities and if required in
the workplace. Look for:
Goggles should be clear hardened
plastic or, if metal, covered with rubber.
They should project over the brow and
cheekbone so the frame takes all the
force of a blow, not the eye.
For those who wear glasses, nylon
sports frames with plastic lenses are
available.
anterior chamber fills completely with
blood causing a persistent increase in the
intraocular pressure the trabecular
spaces will be blocked there will be
progressive staining of the cornea
leading to permanent opacity and visual
impairment. The hyphema may have to
be evacuated surgically, in which case
l.V. mannitol may be given
pre-operatively to decrease the
intraocular pressure.
Blowout or orbital fracture. In this type of
injury, which results from a blow to the
eye, the eye is pushed against one of the
orbital walls, usually the orbital floor;
the muscle which allows the eye to look
upward becomes entrapped. The maxilla
bone may or may not be fractured in this
injury; if so, lowering of the eyeball may
result, causing the patient to complain of
diplopia (double vision). Surgery is
required only if there has been muscle
prolapse, otherwise the patient is on
bedrest. Blowout fractures are seen less
frequently than hyphema.
Retinal tears and detachment. Again the
result of a severe blow or trauma to the
eye, retinal tears or detachment can
cause loss of vision if left untreated.
There may be accompanying vitreous
hemorrhage which means that there is
bleeding from the retinal tears into the
vitreous fluid. Continued hemorrhaging
will decrease visual acuity and treatment
may involve vitrectomy, a surgical
procedure to remove the blood and
replace vitreous fluid with an isotonic
solution. In the case of detachment,
strict bedrest is prescribed both to stop
and to settle hemorrhage. If a tear is
present in the superotemporal or
superonasal area of the eye, the patient
must remain flat to prevent gravitational
pull from aggravating the situation.
Surgical treatment for retinal detachment
is called a scleral buckle in which an
implant or encircling element may be
used to push the sclera toward the retina.
Diathermy may also be used this is a
form of electro-cautery which causes
scar tissue to form to which retinal layers
adhere. Laser photocoagulation seals off
areas around retinal tears and stops
hemorrhage.
In addition to the contusion injuries
described, injuries to the cornea,
abrasions and lacerations may also
occur.
Corneal abrasion involves removal
of epithelial cells when an object is
scraped across the cornea. The chief
danger here is infection and treatment
includes the application of topical
antibiotics. An eye patch is used to
lessen discomfort and to promote healing
by lessening eyelid movement over the
affected area.
Corneal laceration may result when
a contact lens or piece of glass enters the
eye and a laceration deep enough to
cause leakage of aqueous fluid will result
in prolapse of the iris. This seals off the
wound but closes off the anterior
chamber and means secondary glaucoma
may result. Surgery to reform the
anterior chamber and prevent permanent
adherence of the iris to the cornea is
necessary along with removal of the
prolapsed portion of the iris. Air or
isotonic saline may be injected into the
anterior chamber to help reform the
chamber: the air is gradually absorbed
and replaced with aqueous fluid.
It seems obvious that with
protection available in the form of sport
or safety goggles, these serious injuries
should not be happening. Nurses should
inform people of the risks involved to the
eye in certain sports and warn of the
consequences of leaving eyes
unprotected. Before we can start
spreading the word however, we
should see that we set an example when
we take part in our own favorite sports
Equipped with proper gear and
adequate knowledge of safety, we can
continue to enjoy the trend in Canada
toward more healthy lifestyles: eyesight
is not something to be taken for granted ! *
Susan Moses, KN, is a graduate of the
Vancouver General Hospital School of
Nursing, and before moving to Kitimat
B.C. worked as a staff nurse at VGH in
the ophthalmology sen-ice.
The author wishes to thank M.
Carmichael RN and M. Bickford as well
as Dr. J.S.F. Richards for their
assistance with this article.
Bibliography
1 Chaffee, Ellen. Basic physiology
and anatomy by Ellen Chaffee and
Esther M. Greisheimer. 3d ed. Toronto,
Lippincott, 1974.
2 Easterbrook. Michael. Eye injuries
in squash: a preventable disease.
Canad.Med.AssJ. 118:3:298, 303-305.
Feb.4, 1978.
3 Newell, Frank W.
Ophthalmology principles and
concepts. 3d ed. St. Louis, Mosby, 1974.
4 Saunders, William. Nursing care in
eye, ear, nose and throat disorders by
William Saunders et al. 2d ed. St. Louis,
Mosby, 1968.
5 Seelenfreund. Morton H . Rushing
the net and retinal detachment by
Morton H . Seelenfreund and Dennis B.
Freilich.y/lA//4 235:25:2723-2726,
Jun.21, 1976.
6 *Stevens, Elaine. Seeing what we
can do. Lifeline Magazine Vancouver
General Hospital. l:3:Sept. 1979.
*Vaughan, Daniel. General
ophthalmology by Daniel Vaughan et al.
5th ed. LosAltos.CA, Lange, 1968.
8 Vinger, Paul F. Ocular injuries in
hockey. Arch.Ophthalmol. 94:1:74-76,
Jan. 1976.
9 .Racket sports. An ocular hazard
by Paul F. Vinger and Daniel W. Tolpin.
JAMA 239:24:2575-2577. Jun. 16, 1978.
*Unable to verify in CNA Library
POSEY FINGER CONTRACTION
CUSHION
Separate fingers with this high strength
palm grip. 100% textured polyester filled
with synthetic fur. One size fits all hands.
Attractive blue color.
No. 6560
POSEY SAFETY BELT
A gentle but effective reminder to the
patient not to get out of bed. Restrain
patients from thrashing about and poss
ibly hurting themselves while sleeping.
Sm., med., Ig.
No. 1322
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 L5J 2M4
Phone: 416/823-9290
The Canadian Nurse
April 1980 45
A Canadian nurse working in Australia
is involved in a community health project
that uses proven advertising techniques
to sell health to the consumer.
The
Body SKop
Marketing a Healthy Lifestyle
u u f
JL TI I r
J_ B II |J
As part of Healthy Lifestyle, a pilot
program started by the Health
Commission of New South Wales in
Australia, a retail outlet for health has
been established in a busy downtown
shopping arcade, in the small town of
Lismore. This "body shop" has created
a showcase for healthy lifestyles and is a
focal point for people who can be
influenced by advertising messages.
The project itself is an adapted
version of the Stanford California
three-town model, and it is intended that
the effects on identified health risk
behavior be compared with a second, or
control, town. (A third town will be
exposed to the media campaign, but will
have no group intervention.) To do this
the Commission had to assume two
things: first, that the major cause of
health problems in Australia are lifestyle
or behavior-based and second, that
behavior has to be modified on a wide
scale using techniques of the mass
media, along with provision of self-help
material, and intensive group
intervention.
Lismore is a town in New South
Wales on the east coast of Australia,
population 29,000, which combines the
youthful activity of a college town with
the sleepy conservatism of a rural dairy
farming community . The major health
problems of the North Coast area and
related risk factors were identified: heart
and circulatory disease, carcinoma,
hypertension and/or stress, and
accidents. The principal risk factors
associated with these ailmelits are
if, April 1900
Anne Esler McMurray
smoking, poor diet (leading to
hypercholesterolemia), lack of exercise,
obesity and drug and alcohol abuse.
Healthy Lifestyle is aimed at active
and vigorous re-education of the public
through the use of current accepted
advertising techniques; health was to be
treated as a product which must be sold
to the health consumer. The program is,
in effect, marketing health. The hope
was that people would change their idea
of health care from the medical
cure-based model to that of preventive
health care and the promotion of good
health.
The prime targets of the program
were not to be those who were already
ill, but people who might be converted to
using healthier modes of living. The
campaign started with the super-healthy
ideal and intended to pull people toward
realizing this goal for themselves.
Setting the stage
As a community health nurse, I was
actively involved in devising, organizing
and implementing the Anti-Hypertension
Program within the framework of the
Healthy Lifestyle project.
At the time of my inclusion in the
team, Healthy Lifestyle had already
established its place in the community
via the media. One of the key figures in
this success has been our media
coordinator who had already established
a reputation in ground level media
operation and who could "speak the
language". Our Anti-Hypertension
Program was therefore planned in and
The Canadian Nurse
around tried and proven marketing
methods: using the media as a vehicle for
information we would treat the desired
behavioral change like a product and
saturate the newspapers, radio and
television with our message as would any
other advertiser.
After much discussion a slogan
emerged "Down With High Blood
Pressure", from an article title in the
Medical Journal of Australia 1 which was
considered to express the sentiment
appropriate to our purposes. A proposal
was then submitted to the Health
Commission outlining the format of the
program; an important feature was
"Down With High Blood Pressure"
week which would inaugurate
proceedings. During this week,
screening would be carried out in our
body shop, and all community members
were invited to have their blood pressure
taken. Following this, blood pressure
screening would be offered at the shop
one day a week, the objective being to
screen as many community members as
possible in the weeks to follow.
In preparation for "Down With
High Blood Pressure" week an all-out
media campaign was launched; radio
interviews were conducted, a newspaper
feature was printed, containing factual
information on hypertension and radio
commercials were made in which I
invited "all of you out there" to come
downtown to have blood pressure
checks, followed by a 30 second sell on
how easy it was to eliminate any worries
about hypertension by having a reading
taken. We found that the radio and T.V.
afforded much room for creativity and
over the next few months we altered the
commercials, constantly updating them
and trying new approaches.
I felt it necessary too to have a
personal visit with each of the family
practitioners in the area; preventive
health care, no matter how it is
promoted, is really what nurses have
been doing all along with the technical
guidance of the medical profession, and
so I thought the cooperation of the
doctors would be crucial to the success
of our program.
An introductory letter was sent to
each, outlining aims and aspirations of
the program and ending with the thought
that I would appreciate a personal visit; I
followed up in one week with a telephone
call and got an appointment with each
practitioner in town. Meeting the doctors
was quite a pleasant experience most
were anxious to discuss the healthy
lifestyle concept, and they had many
positive comments.
As screening for high blood pressure
was to be done simultaneously with
education on hypertension, the
physicians were also given a description
of the proposed classes dealing with
hypertension (the group intervention
aspect). Modelled on a health education
research study conducted in Perth, we
would be conducting a course entitled
"Living With High Blood Pressure". 2
This consisted of four 90 minute sessions
giving facts about hypertension; its
management, practice in simple
relaxation techniques and overcoming
stress, advice on exercise, diet and
weight control and group discussion of
problem areas, such as patient
compliance. Copies of the proposed
course content were offered to the
doctors in the hope of encouraging them
to refer detected hypertensives to the
program, and to become involved
themselves.
On the whole, the doctors were
happy that a community agency was
educating hypertensive patients in
aspects of control as this was an area
they found difficult to handle themselves
due to time constraints. Each physician
wanted to know the specific details of
our program: what criteria were to be
used in the screening program, what kind
of self-help material was going to be
distributed? What demands would be
placed on the patients, and would the
program be flexible? Information was
given to each, and written materials sent
to all those who requested it.
An avenue of communication was
established between myself and the
medical community of Lismore that I
found most gratifying in the months to
come; comments and suggestions that
came from the doctors I had met
personally were instrumental in updating
and re-directing the program. One doctor
said that he thought the fact that patients
were getting information from another
source served to reinforce what he had
been trying to tell them all along.
The next step was to package our
self-help information into a Blood
Pressure Kit. The kits were composed of
literature with hints on ways to alter
lifestyle, advertisements for our classes
and a questionnaire to aid in the patient s
self-evaluation. Developing the kit was a
cooperative effort that involved all team
members; we came up with a Relax Kit
with a relaxation record, information on
how to reduce stress and notices about
relaxation classes. The Get Fit Kit
followed, as did a Weight Control Kit
and aQuit Smoking Kit. There was some
overlapping information, naturally, but
the basic idea was to give the relevant
information in each package.
Timing of the kit distribution was
regarded as being crucial to success;
individuals seemed more highly
motivated to absorb information at the
actual time of detection. At no time were
the kits marketed as cures or
treatments, but they were regarded
rather as the first step to an individual s
assuming responsibility for his own
health. By charging a nominal fee (20
cents) we felt we might increase the
buyer s level of commitment to reading
and using the kit.
There is a large display of kits in the
Body Shop and in the future we plan to
set up other displays in doctors offices
and perhaps pharmacies. A further
development is the pre-printed
prescription pad which the physician can
use to check off any number of Healthy
Lifestyle programs he feels may
supplement his patient s medical
treatment. These pads have a two-fold
benefit in that they increase the
physicians involvement in lifestyle
counseling, and they encourage the
patients to take responsibility for
improving their health.
Nursing and health promotion
As well as dispensing the information
kits, liaising with doctors, and helping to
advertise the program, the function of
the nurse in our Down With High Blood
Pressure program specifically included
taking clinical information from the
health consumers, or patients, and taking
blood pressures.
Each person sat with me at a desk
and together we filled out a history form,
noting basic background information
such as age and sex , and whether or not
there had been a history of hypertension
in the past. A set of questions designed
to determine the presence of lifestyle risk
factors is asked; these cover obesity,
irregular meal patterns, exercise routines
if any, smoking or drinking habits and
if the individual is a known hypertensive
what his medication regime is, and
how well he has complied with it.
The history -taking session usually
takes about five minutes, after which the
person is sufficiently quiet and relaxed to
have his blood pressure measured.
Actually, most people who come
into the Body Shop have to wait fifteen
to twenty minutes before being seen, but
this time is not wasted. The waiting area
is dominated by a video-tape machine on
which tapes on fitness, relaxation and
smoking are run. All the tapes are
realistic, portraying healthy lifestyles as
attainable goals. One film in particular,
produced locally, shows an "average
bloke" who progresses from spending
time in smoke-filled pubs to playing on
the rugby field.
Several days we have had salt-free
cooking demonstrations for those
waiting to have their blood pressures
taken. With the help of the team
nutritionist, recipes were printed for
distribution; each contains a salt-free
recipe, hints on herbs or spices that can
be substituted for salt to enhance flavor,
and a cooking tip.
People who have a blood pressure of
140/90 or below are given a brief
The Canadian Hurt*
April! 980 47
explanation of what blood pressure is
along with a pamphlet produced by the
Australian Heart Foundation. Those
whose pressures are above this level are
given the same physiological explanation
along with a mention of how stress can
affect a reading, and they are asked to
return in two weeks fora re-check. If on
the return visit, their blood pressure is
still above 140/90 they are referred to
their personal physician for diagnosis. A
few cases have presented in which
readings of 200/100 were found these
people were asked to see their doctors
without are-check or further delay.
Findings
To date, in the Lismore Body Shop we
have found 55 people who were
previously undetected hypertensives and
who were subsequently positively
diagnosed by their doctors . This figure
represents 4 per cent of the number of
people (just under 2000 people) screened
in the first four months of the program. It
is interesting to note that there is no
correlation proven in our findings
between designated risk factors and
hypertension, but this is quite likely a
function of the type of people who are
volunteering for the screening program.
One nursing study 1 reported that
shopping center screening programs
scanned less than one-tenth of the local
adult population , and our experience has
corroborated these findings. Therefore,
we are now planning to take the program
to the workplace and we are hoping for
some interesting results in treating Down
With High Blood Pressure as an
occupational health project.
The ideal, or the goal we give our
clients to strive for, is to metamorphose
completely the stereotyped
swashbuckling Aussie who is
overweight, smokes heavily and has a
prodigious capacity for alcohol, into a
1980 s model of glowing good health and
well-being. I am not convinced that this
can occur quickly on a large scale, but
we hope for some transformations.
The Federal government and the
Cancer Council of New South Wales has
funded a panel of research experts to
study the effects of Healthy Lifestyle,
and the program will be evaluated in the
spring of 1980. But the team involved in
the Body Shop has noticed a few changes
already. By using cooperative media,
maintaining a high profile, delivering
information and working with existing
community resources we hope we have
affected attitudes about lifestyle.
We have seen some developments: a
newspaper column devoted to fitness
and lifestyle now appears regularly,
soccer, cricket and other sport teams are
now wearing T-shirts that say Be Nice
to Your Body", and cars are seen on the
main street of town with bumper stickers
advising "Kiss aNon-Smoker Taste
the Difference". Not one local merchant
is unaware of Healthy Lifestyle, and
while health food shops are springing up,
butchers are bothered by requests to
trim the meat . The local brewery has
produced a low-alcohol beer, salt
substitutes and vegetable steamer
baskets are in heavy demand, and when I
see the number of joggers around town I
feel I am back in Saskatoon!
We move into the 1980 s on a wave
of change from treatment to prevention,
from the institution to the community.
Belloc and Breslow in studying adult
Americans have demonstrated the
relationship between good lifestyles
and good health regular sleep, meals
and physical activity, moderate drinking
and smoking and conversely the
negative relationship to poor lifestyles. 4
The time to broaden health horizons is
now. Perhaps numerous avenues exist
out there to explore in the way of support
systems for delivering health care:
marketing health as a product is only
one. Whatever the system, nurses in all
countries must focus on a lifestyle for the
future. We have conquered many
diseases caused by heredity and the
environment now it is on to those
which are man-made. *
References
1 Lovell, R.R. Down with high blood
pressure (editorial). Med.J.Aust.
1:7:365-366, Apr. 8, 1978.
2 *"The effectiveness of a health
education programme as a supplement to
medical management of hypertension."
Presented at Anzersch Annual
Conference, University of Western
Australia, Perth, May 21-24, 1979.
3 McCulley, Mary. Hypertension:
questions and answers. Canad.Nurse
75:4:24-25, Apr. 1979.
4 Belloc, H.B. Relationship of
physical health status and health
practices, by H.B. Belloc and L.
Braslow.Prev.Med. 1:409, Aug. 1972.
*Unable to verify in CNA Library
Anne Esler McMurray is a graduate of
the St. Joseph s School of Nursing in
Guelph, Ontario, and will be returning to
Canada in 1980 to complete her studies
toward a BA in Psychology at the
University of Manitoba. Her nursing
experience includes occupational health
nursing in Manitoba and Saskatchewan,
and she has had an article published on
an occupational health research project
she conducted. She says that her interest
in fitness was influenced by her
attendance at the VON sponsored
fitness camp at Lake Couchiching in
1978, and by the ideas on lifestyle
changes as presented by Mall Peepre
and organizers of Fitness and Amateur
Sport, Ottawa.
48 April 1980
The Canadian Nurse
Tomorrow s nurses shape up for a healthy future
Kendy Bentley Bonnie Friesen
Twice a week, at about four-thirty in the afternoon, huffing,
puffing, grunts and groans, mixed in with a good deal of
laughter, can be heard emanating from the gymnasium of
Foothills Hospital School of Nursing in Calgary as
approximately 60 students and several courageous instructors
participate in their own special fitness program.
Development of the program is directly attributable to
the enthusiasm generated by nursing instructor Bonnie
Friesen, BScN, on her return from one of the three National
Workshops on Fitness and Lifestyle for nurses held at Geneva
Park, Ontario in 1977, 1978 and 1979.
Bonnie was instrumental in forming a committee to
develop a curriculum component in this area and Kendy
Bentley, BScN, a nurse and fitness consultant was hired to
assist in planning and presentation of the program package.
The program, as it now exists, is in two parts: a
compulsory lecture series and voluntary exercise sessions.
Students attend a total of ten hours of lectures on topics such
as: fitness for the nurse, as a person and as a practitioner;
aerobics; weight control; dangerous exercises and fitness
throughout the family cycle.
The activity sessions are voluntary and include two
45-minute sessions of exercise to music each week. The
"fun" aspect of fitness is emphasized, although the activities
are vigorous and include exercises for all components of
fitness: flexibility, muscular strength and endurance,
cardiovascular endurance and weight control.
The program is still expanding: a jogging group has been
formed and a special fitness bulletin board, "The Health
Hoedown", has been set up. The committee continues to work
on ideas to improve the program and would enjoy
communicating with other schools of nursing which
incorporate the concepts of health, lifestyle and fitness into
their programs.
For more information, you can write to:
Bonnie Friesen, Nursing Instructor
Foothills Hospital School of Nursing
1403 -29 Street, N.W.
Calgary, Alberta T2N 2T9. *
The Canadian Nurse
Aprlll 980 49
With the focus on preventive health teaching becoming stronger, learning
about lifestyle counseling and community health involvement is imperative
for today s nursing students. Here s how the nursing faculty at the
, University of Ottawa managed to develop a learning experience for both
students and clients.
A Community Health
As the teacher responsible for organizing
the community nursing clinical
experience for third year baccalaureate
students, 1 was interested in developing a
useful experience for the students, an
experience that would involve the
co-operation of services within the
university community and provide an
opportunity for student involvement in
group organization and application of the
nursing process.
During meetings with the Field
Secretary for the Ontario Division of the
Canadian Cancer Society, it became
obvious to me that clinics on self breast
examination are of major importance in
any efforts to detect and treat breast
cancer during early stages of the disease.
When I investigated, I found that a clinic
on this topic had never been presented at
the university ; a review of the size and
age range of the female population of the
community confirmed that the subject
would be appropriate.
Teaching Project
for Students
Marion Logan
The nursing students developed a
plan with teacher assistance that focused
on two objectives: first, to identify and
obtain the assistance of key areas or
resources within the university
community; second, to identify and
delegate essential tasks into four
committees.
The areas identified for contact were
the Women s Centre, Health Service,
the Student s Federation, the personnel
department, supply and services
department, communication department
and the local branch of the Canadian
Cancer Society.
To co-ordinate and delegate
responsibilities we formed four main
committees advertising, volunteer,
audiovisual and equipment. A student
co-ordinator was elected for each
committee and students volunteered to
participate in at least one of four
committees. Each committee developed
a plan of action and met as often as
required to implement the plan. Teacher
contact was maintained with each group
and assistance was provided when
needed.
The A dvertising Committee
The principal focus of this group was
obviously directed at publicizing the
event. As the topic of the clinic was of
interest to all females on campus, the
advertising was directed broadly at
students, support staff and academic
personnel . The co-ordinator of the
Women s Centre was actively involved
with this particular committee. Activities
included a successful application for
funds from the students federation,
50 April 1980
The Canadian Nurse
editing and translating material received
from the Cancer Society so that it was
available in both English and French,
and the design of a poster. Public service
announcements were also written and
distributed to local press and radio, and
the poster was published in the campus
newspapers. The personnel department
distributed a letter about the clinic to all
female support staff members at the
university and each female professor or
teacher received a flyer . In addition,
the advertising committee organized and
assisted in the running of information
booths open the week prior to the clinic
day, and arranged for all employees to
receive sufficient time off work to attend
the clinic.
Volunteer Committee
The job of this committee was to identify
the areas at the clinic that would require
volunteers registration, pamphlet
review and demonstration. The
responsibilities included determining the
number and rotation of volunteers
needed, recruitment and training, and
general co-ordination of the activities at
all three stations on the clinic day.
Audiovisual Committee
With the assistance of the
communications department, this
committee focused its efforts on the use
of audiovisual aids for the clinic. This
involved the selection of appropriate
films for showing Vos Seins, ilfaut y
\ oir and Something Very Special and
identifying the needed equipment. After
the committee obtained the equipment
and trained the volunteers, it supervised
the station s activities on clinic day.
Equipment Committee
The activities of this committee were
centered on equipment needed for actual
operation of the clinic which required
determination of exactly what was
needed and where one could obtain it,
followed by the delivery, setting up and
return.
Clinic Day
The most accessible and obvious place
was the main foyer of the University
Centre at the heart of our campus which
was where our clinic was held on a
Thursday at the end of January from
0900 to 2 1 00 hours . Two stations ,
"Registration" and "Pamphlet Review"
were held right in the foyer while the
other two stations, "Films" and
"Demonstration" were located in
private rooms off the main area.
The room used for demonstration
was divided into four private cubicles
with a large sitting area adjoined. Next to
the sitting area was a table with the
demonstration model (Betsy) and
another table where clients could fill out
an evaluation form.
Each station had two volunteers
except the demonstration area which
required one volunteer for each private
cubicle and table. An effort was made to
provide client assistance in either the
English or French language, according to
the needs of the individual.
Each client attending the clinic was
welcomed by a hostess and then directed
to the various stations: first to
Registration to complete a form and
receive a brief explanation of the format
of the clinic, then to station two where
she received a pamphlet on self
examination. At the third station, each
client could view a film on breast
examination, in either French or English,
and finally she could practice what she
had learned on the model and on herself
in one of the private cubicles we
provided.
While the clients were encouraged
to visit all the stations, they were free to
choose as many as they wished. At the
final station they were asked to write
brief comments evaluating the usefulness
of the clinic, and to tell us how they had
learned about its existence. It was
estimated that the time required to
complete all the stages of the clinic visit
was about twenty minutes.
Client comments
The comments we received from our
clients were very helpful. They included:
the model was greatly appreciated;
attenders felt that practicing on a model
first helped them feel more comfortable
before proceeding to self examination.
the majority commented that the use
of the films was excellent.
many women felt encouraged in the
belief that they were responsible for
maintenance of their own health.
more French services should be
available, specifically French-speaking
nurses and literature.
the variety of teaching methods was
appreciated.
the most successful means of
publicizing the clinic seemed to be by
letter or personal communication.
the clinic, some clients felt, should be
repeated every six months or annually.
clinics on other health topics should
be encouraged.
Student evaluation
As part of the assignment, students too
were asked to comment on the success of
their community health project. Among
their comments were the following:
January was a poor month for a clinic
due to poor weather and the lack of time
after Christmas holidays for proper
advertising.
more cubicles were needed in the
demonstration area.
the need for privacy in the
demonstration area cannot be
overestimated.
clients seemed to need extra
encouragement to attend the
demonstration area but once they did
they felt it was the most beneficial.
more spacing was needed between
French and English tables as voices
carried and were distracting.
Looking back
A discussion session was held after the
clinic and all of the students who had
participated agreed that they had gained
a tremendous amount of knowledge from
this learning experience. They felt that
key areas within the university had been
more than willing to assist and had
actually helped considerably with the
clinic . They felt there had been the added
bonus in that many areas of the
university community were now more
aware of activities in the School of
Nursing. *
Marion S. Logan is assistant professor at
the School of Nursing, Faculty of Health
Sciences, University of Ottawa, where
she obtained herBScN in Public Health
and her master s degree in education.
Her nursing experience in the past
includes work as a hospital staff nurse,
public health nurse and nursing educator
at both the diploma and baccalaureate
levels.
The author hopes that in describing
the project that was used at the
University of Ottawa other educators
will be assisted in planning health
teaching clinics. She states that the
effort is certainly worthwhile; although
the planning, implementing and
evaluating of such a clinic takes a
considerable amount of time and energy,
she feels it is a most rewarding
experience for both the student
organizers and their clients.
arnr
The Canadian Nurse
April 1980 51
Introducing New
they stay twice
\
,40- /
Why It s Better
for Baby
4 Softer surf ace next to
1. baby s skin
d Embossed topsheet looks
and feels softer . . reduces
skin contact and increases
separation of skin from
moisture in pad.
4% A drier, more
^.comfortable baby
D Polyester fibre topsheet is
more hydrophobic . . . does
not absorb fluids itself but
encourages passage
through into absorbent
padding below. . .resists
backflow.
D Stronger absorbent pad
with stronger tissue enve
lope... provides 225 percent
more wet strength for a
60 percent reduction in
tearing and shredding.
Proof Positive That Quilted Pampers
Stay Twice as Dry as Cloth
Equal amounts of
water are placed on
each diaper
A blotter is placed
over each wetted
A weight is placed on
each blotter
Quilted Pampers is
twice as dry as cloth
area
Quilted Pampers
as dry as cloth
Pampers
used more often than cloth
in hospital nurseries
For further information write to
Pampers Professional Services
PO Box 355, Station "A"
Why
It 7 s Better
for Nurse
and Better
for Mother
Saves time and
work
The superior contain
ment of New Quilted
Pampers versus cloth
benefits both nurses and
mothers with:
D Fewer changes of
bed linen and
baby s clothing.
D More time for
other important
tasks for nurses,
more playtime
with baby for
mothers.
Easier than cloth to
fit and change
A one-piece system
more convenient than
cloth to change and clean
up easy to fit with tape,
not pins.
audiovisual
"he Fit-Kit: The Canadian Home
itness Program.
The Fit-Kit contains information for
Janadians to develop and maintain an
exercise program suited to their
ndividual needs. The program consists of
Fit-tips", which explain with pictures
;leven different stretching and warm-up
exercises, a "Walk/Run Distance
Calculator" which helps the individual
determine how far he/she should walk or
run in 15 minutes at least three times a
week to maintain or improve personal
fitness levels and a booklet demonstrating
the need for minimum aerobic fitness
including a list of pleasant and fun
activities which build up endurance. The
Nurses:
Try Canada s
Northland
This Summer
Infirmieres:
Decouvrez les
Terres
Septentrionales
du Canada cetete.
Join the team providing health
care to the residents of the
Northwest Territories. Medical
Services, Northwest Territories
Region will be offering a number
of term positions for qualified and
experienced nurses.
Positions are available at nursing
stations, health centres and
hospitals for the period, May
through September.
Knowledge of the English
language is essential.
For more information write to:
Nursing Advisor,
Human Resource Planning,
Medical Services Branch,
Health and Welfare Canada,
Room 1972,
Jeanne Mance Building,
Tunney s Pasture,
Ottawa, Ontario K1 A OL3
NOTE: Permanent positions are
also available.
Open to both men and women
Joignez-vous a I equipe medicare
qui soigne les habitants des
Territoiresdu Nord-Ouest. La
direction des Services medicaux,
region des Territoires du
Nord-Ouest, offre des postes
d infirmieresdipl6mees. pourune
periode determinee.
Les postes offerts se trouvent
dans des postes de soins
infirmiers, des centres sanitaires
ou des hopitaux; la penode de
travail va de mai & septembre
La connaissance de
indispensable.
anglais est
Pour de plus amples
renseignements, priere d ecrire a
I adresse suivante:
Conseillere en soins infirmiers,
planification des ressources
humaines
Direction generale des services
medicaux
Sante et Bien-etre social Canada
Piece 1972,
Immeuble Jeanne Mance
Pare Tunney
Ottawa, Ontario K1 A OL3
REMARQUE Des postes
permanents sont egalement
offerts.
Appel de candidatures mixtes
Health and Welfare Sante et Bien-etre social
Canada Canada
Canada
information on the Exercise Program is
sound and accurate.
"The Canadian Home Fitness Test"
section of the kit includes a progress
chart, an evaluation chart and a record
with music tempos which differ for most
sex and age groups. The test is adminis
tered by the "step-test" and the fitness
level is measured by the pulse rate at the
end of each three minute stepping
exercise.
A word of caution here; all steps
that I measured were only 7" high as
opposed to the 8" or 20.3 cm height
required by the test. This can alter
results significantly. Also research has
shown that the test is not a good
indicator of cardiorespiratory fitness, due
to errors in stepping rates and palpated
heart rates.
The Fit-Kit could be useful as a
motivational and educational tool to
stimulate interest in fitness but caution
should be used lest the test lead the
person to believe he is more fit than he is.
Reviewed by Marilyn S. Riley, Associate
Professor, Dalhousie University, School
of Nursing and President, Registered
Nurses Association of Nova Scotia.
Fit to sing by Martin Collis. (Long-
playing record) Phactory Phresh Phitness
Corp., 2415 Alpine Cres., Victoria, B.C.
V8N4B5.
Approximate price: $7.98.
Fit to sing gives a unique fitness and
lifestyle message. Martin Collis, a well
known Canadian physical education
expert, has put together a mixture of
songs and commentary on a number of
different topics including diets, risk
factors in heart disease, exercise, sporting
competitions, exercise equipment and
donations to the Heart Fund. The music
ranges from folk to country to rock,
and Martin Collis vocals are backed by
some excellent musical arrangements. Fit
to sing would be useful to anyone giving
talks on fitness and lifestyle. The variety
of the songs would allow selection of the
most appropriate message for each
audience. As well as being a useful
teaching aide, Fit to sing would be an
enjoyable addition to a record collection.
Reviewed by Ruth McKenzie, RN, MN,
Research Assistant, VON for Canada,
Ottawa, Ontario. *
Nature gives it. ^^/Ir^Jl
Zincof ax* keeps it that way.
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.
What s more, Zincofax is economical, even more
important now vmh a new baby at home.
Zincofax ;
keeps a family s
smooth skin smooth
Please see special introductory offer
in the back of this magazine.
Contains Anhydrous Lanolin and 15% Zinc Oxide.
Available in 10 and 50 g tubes and 1 15 g and 450 g jars.
\ Wellcome Medical Division
-. i ; ? Burroughs Wellcome Inc.
%,, -.<- LaSalle, Que.
Trade Mark kcppl W-8005
A NURSE S STORY. IT COULD BE YOURS.
P These children speak an international
language of love. With one smile, they remind me
why I became a nurse in the first place. 4| 4|
DOROTHY REDDEN, R.N.. HEAD NURSE, PEDIATRICS
REVERSING
THE CHARGES:
Peter Dow
(519) 376-6809
WRDow&
361 IDthSt.W
Owen Sound,
Ontario N4K3R4
The Arabian Peninsula.
Different. Demanding. And
most decidedly gratifying.
C When I first went to Saudi
Arabia I expected to always
be giving. I never expected to
get so much in return. From
grateful parents. Smiling
children. And a government
that respects everything that we
Americans can do to help.
The hospital itself was really
comparable to most Canadian
facilities. And, when my shift
was over, I went home to an
attractive, free, air-conditioned
apartment. The travel benefits
were tops too. And my salary
and year-end bonus were great.
All in all, the experience was
invaluable. Which is why I m
Dedicated
to a world of health
WhittakeR
Whittaker International Services Company
A Subsidiary of Whittaker Corporation
An Equal Opportunity Employer M/F
talking to other Canadian
nurses about it. And some day
I m going back there. 99
Dorothy Redden s reactions
are typical. And Whittaker,
a leader in international health
care, is now offering contracts
in either Saudi Arabia or Abu
Dhabi. If you re a Canadian
trained RN with 2-3 years
postgraduate experience, call
us today on our Toll Free line.
Classified
Advertisements
Alberta
British Columbia
British Columbia
Registered Nurses (4) required for full-time employ
ment in modern 30-bed hospital situated 90 miles
north of Edmonton, Alberta. Require three full-time
nurses to replace part-time nurses and one full-time
nurse to fill fourth vacancy of nurse that is
re-locating in February 1980. Residence accommo
dation available for ninety dollars per month, room
and board. Salary and benefits as per U.N.A.
contract. Excellent recreation facilities and fringe
benefits. Must be eligible for registration with
A.A.R.N. Apply to: Director of Nursing, Boyle
General Hospital, P.O. Box 330, Boyle, Alberta
TOA OMO.
Registered Nurses required for a 560-bed acute care
hospital in Edmonton, Alberta. Positions available in
most clinical areas. Candidates must be eligible for
registration in Alberta. Current salary rates under
review. Apply to: Personnel Department, Edmonton
General Hospital. 1 1 1 1 1 Jasper Avenue, Edmonton,
Alberta T5KOL4
Registered Nurses required immediately for 36-bed
hospital in Northern Alberta. Salary is in accordance
with the A.A.R.N. contract, plus northern allo
wance. Subsidized single staff housing available.
Applicants must be eligible for registration with the
AARN. Apply to: Personnel Department, North
western Health & Social Services. Bag 400, High
Level, Alberta TOH 1ZO.
Wanted R.N. s for 75-bed accredited hospital in
northern Alberta. Policies as per A.A.R.N. contract.
Apply in writing, including telephone number to:
Personnel Department, High Prairie Regional Health
Complex. High Prairie, Alberta TOG 1EO.
Registered Nurses required in a 68-bed active
treatment hospital in northeastern Alberta. Salaries
and benefits in accordance with negotiated provin
cial agreement. Accommodation is available in the
Nurse s Residence. Apply in writing to: Director of
Nursing, Lac La Biche General Hospital. Box 507,
Lac La Biche, Alberta TOA 2CO.
Required Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treatment
66-bed Hospital. Apply to: Director of Nursing,
Taber General Hospital, Box 939, Taber, Alberta
TOK 2GO.
British Columbia
Experienced General Duty Graduate 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 writing to:
Director of Nursing, St. George s Hospital, Box 223,
Alert Bay. British Columbia. VON IAO.
Operating Room Head Nurse Must be RNABC
registered. Must have experience in all O.K.
procedures. Salary: according to the RNABC
Agreement. Please apply in writing to: Mrs. A.
Houghton, Director of Nursing, Fort St. John
General Hospital, 9636 100th Avenue, Fort St.
John, British Columbia V1J 1Y3.
General Duty Nurses Must be registered with
RNABC. Salary according to the RNABC Agree
ment. Please apply to: Mrs. A. Houghton, R.N.,
Director of Nursing, Fort St. JohnGeneral Hospital,
9636 100th Avenue, Fort St. John, British Colum
bia V1J 1Y3.
General Duty Nurse for modern 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 Nursing, Bound
ary Hospital, Grand Forks, British Columbia, VOH
IHO.
General duty nurses required for all clinical areas and
O.R. in a 360-bed acute care general hospital. Salary
and fringe benefits in accordance with RNABC
contract terms. Apply to. The Director of Nursing.
Nanaimo Regional General Hospital, Nanaimo, B.C.
V9S 2B7.
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 $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.
Experienced Nurses (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 to RNABC contract. Applicants
may telephone 525-091 1 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.
General Duty RN s or Graduate Nurses 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
Hospital, Box 98. Pouce Coupe, British Columbia or
call collect (604) 786-5791.
Registered Nurses required for permanent fulltime
position at a 147-bed fully accredited regional acute
care hospital in B.C. Salary at 1979 RNABC rate
plus northern living allowance. One year experience
preferred. Apply: Director of Nursing, Prince
Rupert Regional Hospital, 1305 Summit Avenue,
Prince Rupert, British Columbia, V8J 2A6. Tele
phone (collect) (604) 624-2 1 7 1 Local 227.
General Duty Nurses required by an active 80-bed
acute care and 40- bed extended care hospital located
in the Cariboo region of B.C. s central interior.
Year-round recreational activities in this fast grow
ing community. Applicants eligible for B.C. registra
tion preferred. Apply in writing to: The Director of
Nursing. G.R. Baker Memorial Hospital, 543 Front
Street, Quesnel, British Columbia V2J 2K7.
Registered Nurses required immediately for perma
nent full time positions at 10-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 1WO. Telephone:
(604) 636-2221 Collect.
General Duty Nurses required for an active, 103-bed
hospital. Positions available for experienced R.N s
and recent Graduates in a variety of areas. RNABC
Contract in effect. Accommodation available. Apply
to: Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British Columbia
V8G 2W7.
Experienced maternity, I.C.t./C.C.U., and Operat
ing Room General Duty nurses required for 103-bed
accredited hospital in Northern 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, V8G
2W7.
Registered Nurses for summer camps for the disabled
at Winfield. Squamish and Shawnigan Lake, starting
May or June for 3-4 months. Apply Co-ordinator,
B.C. Lions Society for Crippled Children, 171 W.
6th Ave., Vancouver, B.C. V5Y 1K5; Telephone
(604)873-1865.
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 interprofessional 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 applicants.
Manitoba
Registered nurses required for a fully accredited
100-bed general hospital and a 72-bed personal care
home 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, St.
Anthony s General Hospital, The Pas Health Com
plex Inc., P.O. Box 240, The Pas, Manitoba R9A
I K.4; or phone collect to: 1-204-623-6431, Ext. 179.
Challenging Career Opportunity for Registered Nurses in
Canada s North A 100 bed acute care hospilal in Nonhern
Manitoba which services Thompson and several small
communities in the surrounding area has immediate vacan
cies in Pediatrics. Medicine/Surgery. Obstetrics and Critical
Care. This opportunity will appeal to nurses who v/arU to
inc rease I heir existing skills or develop new skills 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. Man
itoba. RSN ORH. Phone: (204) 677-2.18 1
Newfoundland
Director of Nursing Applications are invited for
the Director of Nursing position at this 135-bed
general hospital. The position must be filled by June
1980. The incumbent will be a member of the senior
management staff, will report to the Administrator
and will be responsible for all activities related to the
Nursing Department. The applicant should- hold a
Bachelor s degree in nursing and have extensive
experience in managing a nursing department.
Registration, or eligibility for registration, in New
foundland is essential. Salary: $18,654 - $23,807.
Applications with resume outlining experience and
educational background should be addressed to: The
Administrator, Carbonear General Hospital, P.O.
Box 20, Carbonear, Newfoundland AOA 1TO.
April 1980 57
New Brunswick
United States
United States
Faculty members required with teaching and clinical
experience for an integrated undergraduate program.
(1) Medical-Surgical Nursing, to work with team
who teach seniors in an acute care setting; (2)
Maternal and Child Health Nursing, to teach second
year students in pediatrics, and third year students in
the Nursery; (3) Community Nursing, to teach
freshman students in the classroom, with observa
tions in the community in the first term and clinical
teaching in geriatrics in the second term. Directing
community experiences for second year students.
Applicants should be able to qualify for the rank of
Assistant or Associate Professor. Master s degree
essential. Salary in accordance with qualifications
and experience. Apply with curriculum vitae and
names of referees to: Dean I. Leckie, Faculty of
Nursing, University of New Brunswick, P.O. Box
4400, Fredericton.New Brunswick E3B 5A3.
Come to the beautiful N.J. seashore! Burdette Tomlin
Memorial Hospital in Cape May Court House, N.J.
(10 miles from Wildwood by the Sea) has 6
immediate RN openings on the 11-7 shift in the areas
of med/surg, CCU, 1CU & OB. Orientation and
education will be provided for qualified profession
als. Applicants will be required to speak good
English; to sign a 2-year contract and pass N.J. State
Boards within two testings. Good benefits and
salary. Apply in writing and send copies of nursing
school grades, high school grades, Canadian license
and other pertinent data to: Mrs. T. Karter, Ass t.
Admin. - Nursing, Burdette Tomlin Memorial
Hospital, Stone Harbor Blvd., Cape May Court
House, N.J. 08210.
Nurses RNs Immediate openings in California-
Florida-Texas-Maryland-Virginia and many other
States if you are experienced or a recent Graduate
Nurse we can offer you positions with excellent
salaries up to $16,000 per year 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. that you are interested in. We
will call you upon receipt of your application in order
to arrange 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 Place
ment Service, P.O. Box 1133, Great Neck, New
York 11023, (516)487-2818).
"Our 23rd Year of World Wide Service"
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: Assistant Administrator-
Nursing. Stanton Yellowknife Hospital, Box 10,
Yellowknife, N.W.T., X1A 2N1.
Career Opportunities
Ontario
Registered Nurse required immediately mostly
day shift for Home for Mentally Retarded Children.
Apply to: Director of Nursing, Lakewood Nursing
Home Inc., Box 1830, Huntsville, Ontario POA 1KO.
R.N. Grad or R.N.A., 5 6" or over and strong,
without dependents. Non-smoker for 180 Ib. hand
icapped retired executive with stroke. Able to
transfer patient to wheelchair; live-in 1/2 year in
Toronto, 1/2 year in Miami. Wages $250.00 to
$300.00 weekly NET plus $100.00 weekly bonus on
most weeks in Miami. Write: M.D.C., 3532 Eglinton
Avenue West, Toronto, Ontario M6M 1V6.
Quebec
Registered Nurse required beginning of September
1980in 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 stating qualifications and experience
to: Comptroller, Bishop s College School, Lennox-
ville, Quebec JIM 1Z8.
Camp Nurses required for children s 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
1 M6, or telephone (514) 735-3669.
Nurses for Children s^ummer Camps in Quebec. Our
member camps are located in the Laurentian Moun
tains and Eastern Townships, within 100 mile radius
of Montreal. All carrtps are accredited members of
the Quebec Camping Association. Apply to: Quebec
Camping Association, 2233 Belgrave Avenue,
Montreal. Quebec. H4A 2L9, or phone 489-1541.
Saskatchewan
General Duty Registered or Graduate Nurses required
for 19-bed Active Hospital in Central Saskatchewan.
Salary and fringe benefits as in effect with S.U.N.
Contract (1980 under review). Residence accommo
dation available at nominal costs. Please apply in
confidence to: Mrs. Doreen M. Smart, D.O.N.,
Maidstone Union Hospital, Box 160, Maidstone,
Saskatchewan SOM 1MO.
THE CITY OF *
monton
CONSULTANT PATIENT CARE
SERVICES
(HOME CARE)
(one position)
The Edmonton Home Care Program requires one Program
Consultant in the area of patient care services. Position to be filled
immediately.
FUNCTIONS: Promotion of program development and quality
assurance in the Edrr^nton Home Care Program. The incumbent
works under the administrative authority of the EHCP Administrator
and is responsible for Nursing activity guidance to the Director of
Public Health Nursing.
QUALIFICATIONS:
1. Registered nurse in the Province of Alberta.
2. Baccalaureate degree in public health nursing.
3. Post graduate training at the Master s level desirable.
4. At least three-years relevant experience.
5. Added preparation in a relevant specialty an asset.
CLASSIFICATION:
Comparable with:
1 . Supervisors who act in a supervisory and general consultant
capacity to general staff of a number of public health units in a
given area.
2. Program consultants with the municipal Local Boards of Health.
SALARY: $19,601 - $25,004 per annum, according to
qualifications with additional recognition for a Master s degree in a
related field.
Applications are encouraged from both men and women.
Applications with curriculum vitae should be submitted to:
Mr. J.B. Worsfold
E.H.C.P.
6th Floor C.N. Tower
10OO4- 104 Avenue
Edmonton, Alberta
T5J OK1
CITY COMMISSIONERS
58 April 1960
The Canadian Nurse
Pulling
together to
help people.
At Kaiser-Permanente Medical Centers
we all pull together. Our nurses, physi
cians, and other professionals are
people caring about people. They
team up to deliver high quality health
care.
As a team member, you ll be respected
for your nursing skills. That means you
can exercise independent thinking.
What s more, there s our extensive
orientation and continuing education
programs. That means you can ad
vance to your fullest potential. Both
new grads and seasoned pros. And
our benefits package is nothing short
of superb.
If the challenge of total nursing care
has slipped through your fingers, con
sider Kaiser-Permanente. We re the
largest Health Maintenance Organiza
tion in the U.S. Once on board, you
can move around. From department
to department, center to center, even
region to region. All without affecting
your service.
Our nine southern California Medical
Centers have openings now for all
levels of nursing. We ve got a variety
of stimulating challenges, including:
OB/GYN
PEDIATRICS
ONCOLOGY
PSYCHIATRY
ICU&CCU
MED/SURG
HEMODIALYSIS
OPERATING ROOM
We invite you to join us and accept
the challenge of professional nursing.
For more information on any one of
our 9 medical centers contact:
KAISER
PERMANENTE
MEDICAL CENTERS
PULLING TOGETHER TO HELP PEOPLE
JanWuori, R.N. CN 480
Regional RN Program Recruiter
4747 Sunset Blvd.
Los Angeles, CA 9OO27
Equal Opportunity Employer M F H
United States
RN s - California. Registered Nurses interested in a
career in California working in both acute hospitals
and skilled nursing facilities. Salary comparable to
Canadian wages. CGFNS certificate and transporta
tion expenses paid. Write to: M. Cameron, c/o
Ramona-Care Hospital, 485 West Johnston Ave.,
Hemet, California 92343; or call (714) 925-2645.
Total patient care with all licensed personnel is our
goal 1 Staff RNs currently interviewing for part-time
and full-time positions. Full service, except psych,
progressive 156-bed accredited acute general hospi
tal. Located within 60 minutes from LA, the ocean,
mtns., and the desert. Orientation and staff de
velopment programs. CEUs provider number.
Parkview Community Hospital , 3865 Jackson Street ,
Riverside, California 92503. Write or call collect
714-688-2211 ext. 217. Betty Van Aemam, Director
ofNursing.
California Sometimes you have to go a long way
to find home. But, The White Memonal 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 opportunity to 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
268-5000. ext. 1680.
Appraise our Miami Hospital What can Victoria
Hospital offer you? We can give you a modem
300-bed progressive, acute care hospital as a
stimulating work environment. We offer excellent
salaries, benefits, CELTs, tuition refunds and reloca
tion assistance. For pleasure, Miami has great
beaches, boating, dining, discos, tennis, golf, snor-
keling etc. Our Hospital also has apartments
available Want to learn more? Call Ms. McDonald,
R N person-to-person, collect at (305)772-3682, or
write Nurse Recruiter, 800 N.W. 62nd St., Suite 510,
Ft. Lauderdale, Fla. 33309.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoying
Florida s Gulf Coast beaches, sun, and exciting
recreational activities. We will provide work visas,
help you locate a position, find housing, and arrange
your relocation. No Fees! Call or write: Medical
Recruiters of America, 1211 N. Westshore Blvd.,
Suite 205, Tampa, Florida 33607 (813) 872-0202.
The Best Location in the Nation The world-
renowned Cleveland Clinic Hospital is a progres
sive 1030-bed acute care teaching facility committed
to excellence in patient care. Staff Nurse positions
are currently available in several of our ICU s and 3(
departmentalized medical/surgical and specialty di
visions. Starting salary range is $14,789 to $17,05<
plus $1248/year ICU differential and premium shift
differential, comprehensive employee benefits and
an individualized 7 week orientation. We will
sponsor the appropriate employment visa for qual
ified applicants. For further information contact:
Director-Nurse Recruitment, The Cleveland Clinic
Hospital 9500 Euclid Avenue, Cleveland, Ohio
44106 (4 hours drive from Buffalo, N.Y.); or call
collect 216-444-5865.
Come to Texas 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 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 1591, Beaumont, Texas 77704. An
affirmative action employer.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
theUS.A
B) Extensive information regarding
Hospital 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 Box 1 1 33 Great Neck. N. Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
United States
Nurses RNs 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 Or call collect
(713) 789-1550. Marilyn Blaker, Medex, 5805
Richmond, Houston, Texas 77057. All fees employer
paid.
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer trips
from one week to 3 months in: Canada, USA,
Europe. Africa, Asia. South and Central America.
Australia New Zealand and the Caribbean. For free
catalogue, apply to: Goway Travel. 53 Yonge St.,
Suite I0l Toronto, Ontario M5E IJ3. Phone:
4 1 6-863-0799. Telex: 06-219621.
Electrolysis Successful Electrolysis Practice for
Sale 6 months specialized included. Wnte or phone:
Margot Rivard, 1396 St. Catherine Street West,
Suite 221, Montreal, Quebec, H3G 1P9. Telephone:
(514)861-1952.
R.N. s Required
Applications are invited for full time nurses to
work rotating shifts in new 40 bed active
treatment hospital. High level of activity in
Emergency, Surgery and Obstetrics offers
challenge and the benefit of valuable
experience for conscientious nurses. Previous
experience an asset. Must be registered or
eligible for registration in Alberta.
AHA/AARN policies in effect.
Hinton is a modern, progressive, industrial
town on the eastern slopes of the Rockies, 50
miles east of Jasper. Population 7.600.
Unlimited year round recreational facilities.
Apply with full resume including experience
and references to:
Director of Nursing
Hinton General Hospital
Box 40
Hinton, Alberta
TOE 1BO
MOUNT ROYAL COLLEGE
Post Basic Mental Health
Nursing Program for
Registered Nurses
A one-year clinical and academic pro
gram intended to prepare clinical practi
tioners in Mental Health Nursing will be
offered by Mount Royal College com
mencing September 1980 This program
has been designed to meet university
transfer requirements.
Enrollment is limited to 20 students. Ap
plications for the September class close
May 15, 1980.
A limited number of bursaries ($315/mo)
plus tuition are available.
Admission Requirements: Current Cana
dian Registration.
For further information write to:
Marlene Meyers, Director, Post-Basic
Mental Health Nursing Program, Allied
Health Department, Mount Royal
College, 4825 Richard Road S.W.,
Calgary, Alberta T3E 6K6
Director of Nursing
A Director of Nursing is required for Slave
Lake General Hospital, an accredited 34 bed
active treatment hospital 250 kilometres
northwest of Edmonton.
Applicants must have an enthusiasm for
initiating and following up new ideas, projects
and programs with a desire to participate in
clinical nursing. The Director of Nursing is
also responsible for orientation and in-service
education.
The successful applicant should have
experience in the administration of a nursing
program and possess a B Sc N Degree, but an
equivalent combination of formal education
and experience will be considered.
Salary negotiable. Position available
immediately. Please direct resume to:
B. R. Popp
Administrator
Slave Lake General Hospital
Box 330, Slave Lake, Alberta TOG 2AO
Director ofNursing Service
Required For
Macleod Municipal Hospital
Applications are invited immediately for the
above position in a 32-bed active treatment
hospital situated in South Western Alberta.
Present plans are to commence construction of
a totally new 42 bed facility in September 1980.
The successful applicant must be eligible for
registration with the A.A.R.N. and should
have administrative experience and training.
B.Sc.Nursing most welcome.
Address all inquiries in writing together with a
complete resume to:
Mr. G. Neil McMartin
Administrator
Macleod Municipal Hospital
P.O. Box 520
Fort Macleod, Alberta
TOL OZO
Phone (403) 553-4024
Intensive Care Nurses
300 bed Accredited general
hospital in Vancouver requires
full-time R.N .s for 4 bed I .C.U.
Candidates should be eligible for
registration with the RNABC.
Previous l.C.LJ. experience
required.
Please apply in writing to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C. VST 3N4
msj
Summer Employment
Registered Nurses
Nursing opportunities will he available
for a 3 or 4 month period during the
months of May. June, July. August 1980.
Nurses will provide primary nursing
care, be able to exercise clinical
judgement and participate in a
patient-family oriented program in our
modem 300 bed teaching extended care
unit. Interested nurses, who are eligible
for registration in British Columbia
should write to:
Hospital Employment Officer
Health Sciences Centre Hospital
University of British Columbia
Vancouver, B.C.
V6T 1W5
Positions open to both female and male
applicants.
Clinical Instructors for
Paediatric I nit and for the Obstetrics
Cnit
Required by Royal Inland Hospital, a 400
bed regional referral acute general
hospital located in the B.C. interior.
Excellent skiing and recreation area.
Responsible for patient care oriented
educational activities and staff
development in the department of
nursing service. Degree preferred but
will consider post graduate with
advanced experience. Must be eligible to
register in B.C. Salary and benefits as
perR.N.A.B.C. contract. 1979 rates
SI 500 to SI 772 per month 1980 being
negotiated.
Send resume to:
Personnel Director
Royal Inland Hospital
311 Columbia Street
Kamloops, B.C.
V2C 2T1
Careers in Nursing Services in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime* largest teaching
hospital associated with Dalhousie University. The close University liaison and our own
extensive Continuing Education Program provides excellent avenues for learning.
Our nursing staff numbers in excess of 1,000 and we provide multiple opportunities for
careers in the following areas:
General Duty Nurses: Our general nursing units cater to many specific sub-specialties
in medicine and surgery.
Intensive Care Nurses: We have 5 specialized units; Coronary, Cardiovascular, Medical,
Surgical, and Neurosurgery.
Specialty Area Nurses: This includes Burn Unit, Renal Unit, Emergency, Operating
Room, Recovery Room, Out-Patients, and others.
Nursing Administration: Promotion is encouraged through an ongoing program of
leadership development.
Full Civil Service Benefits.
For details contact:
Mrs. Elizabeth Elliot, R.N.
Personnel Department, 7th Floor
Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H 1 V8
Telephone: 1 (902) 428-3484
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed. J.C. A.M. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differentia)
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 909? under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-5511
Good Samaritan Hospital
Klagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
Offers R.N. s
An UNUSUAL OPPORTUNITY.
A.M.I. Will FURNISH One Way AIRLINE TICKET to Texas
and $500 Initial LIVING EXPENSES on a Loan Basis.
After One Year s Service, This loan Will be Cancelled
VIM I American Medical International Inc.
r
# HAS 50 HOSPITALS THROUGHOUT THE U.S.
* Now A.M.I. Is Recruiting R.N. s lor Hospitals in Texas
Immediate Openings Salary Range $11. 000 to $16,500 per Year.
* You can enjoy nursing in Generai Medicine. Surgery ICC
CCU, Pediatrics and Obstetrics
AMI provides an excellent orientation program.
in-service training
U.S. Nurse Recruiter
P.O. Box 17778, Los Angeles, Calif. 90017
Hfr Without obligation, please send me more
Information and an Application Form
NAME
ADDRESS
CITY ST._ _ ZIP
TELEPHONE I )
LICENSES:
SPECIALTY: _
YEAR GRADUATED: STATE: _
The Canadian Nurse
April 1980 61
MANITiBA
Department of Health
The School of Psychiatric Nursing,
Selkirk Mental Health Centre
is offering a Post - Basic Course in
Psychiatric Nursing
Registered Nurses currently licensed in Man
itoba or eligible to be so licensed, with
University credits in Introductory Psychology
and Introductory Sociology.
The course is of ten months duration Sep
tember through June, and includes theory and
clinical experience in hospitals and community
agencies, as well as six weeks nursing of the
mentally retarded.
Successful completion of the program leads to
eligibility for licensure with the R.P.N.A.M.,
as a Registered Psychiatric Nurse (R.P.N.).
For further information please write:
Director of Nursing Education
School of Psychiatric Nursing
Box 9600
Selkirk. Manitoba R1A 2B5
Waterford Hospital
Career Opportunities For
Registered Nurses
The Walertiird Hospnal. .1 !i.ll> accredilej JIHI
bed PswhMlric Institution. affiliated with
Memorial fni\ersit\ School of Nursing and
MeJic.il School, h.is openings for Registered
Nurses in ali services, including neu .
expanded .>mi ,icu:c c.ire services
An orientation program is offered.
S.il.nv isonthescaleofSIMUK- 14. per
annum A Psichratric Sen ice J .llov,ance of
SI. 329 per annum is available in addi .ton to
hasic salary. Both salary and tllowance
presently under review
The Hospital is close to all amenities:
shopping, transportation and recreation
facilities.
Accommodations available in Hospital
Residence at nominal cost.
Applications in wnling should be addressed to
the undersigned:
Personnel Director
Waterford Hospital
Waterford Bridge Road
St. John s, Newfoundland
MK4.IH
Telephone Number: |709| .Vi8-6(W.l. e\t. 341
The Izaak Walton Killam Hospital for Children
Staff Nurses
Intensive Care and Neo Natal Units
The Izaak Walton Killam Hospital forChildren
is a modern, progressive, 324-bed complex
located in downtown Halifax. The I.W. K. is a
teaching hospital affiliated with Dalhousie
University and is the pediatric referral centre
forCanada s Maritime Provinces.
Opportunities are available to work in our
Intensive Care and Neo Natal Units.
Extensive orientation and continuing
education programs are offered in these
specialities. Previous pediatric experience
would be a definite asset.
If you are eligible for registration in Nova
Scotia and are interested in a challenging
position in pediatrics, please forward resume
to:
Personnel Officer
The Izaak Walton Killam Hospital for Children
P. O. Box 3070
Halifax, Nova Scotia B3J 3G9
Challenging Opportunity
Memorial University of
Newfoundland
for a faculty member with a doctorate
degree and demonstrated creativity
and competence in curriculum
development, research and teaching at
the graduate level
salary commensurate with
qualifications and professional
achievement
graduate program in early stages of
development
Send complete resume to:
Margaret D. McLean
Director & Professor
School of Nursing
Memorial University of Newfoundland
St. John s, Newfoundland
A 1 C 5S7 Telephone ( 709 ) 737-6695
Applications are invited for
Faculty Positions
in the following areas
Community Health Nursing
Medical-Surgical Nursing
Parent-Child Nursing
Mental Health - Psychiatric Nursing
Qualifications:
Preference will be given to advanced
preparation in the clinical specialties
Salary and Rank: Commensurate with
education and experience
For further information contact:
Miss Phyllis Jones
Dean
Faculty of Nursing
University of Toronto
50 St. George Street
Toronto, Ontario
M5S 1A1
St. Francis Xavier University
Department of Nursing
Antigonish, Nova Scotia
B2G ICO
Telephone 902-867-2266
902-867-3955
Applications are invited for the following
positions for the academic year beginning
August 1 , 1980 in a basic baccalaureate program.
Experienced teachers in both the acute care
clinical setting and the classroom, in
Medical-Surgical and/or Child Care.
Doctoral degree preferred. Masters degree
essential.
Salary is in accordance with qualifications
and experience.
Applications should be addressed to:
Ellen Murphy, Chairman
Department of Nursing
St. Francis Xavier University
Antigonish, Nova Scotia B2G ICO
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, PartTime and Casual Employment.
Benefits in accordance with R.N.A.B.C.
contract .
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Supervisor - Operating
Room
Required to assume a leadership role in
an expanding Operating Room Suite
presently under construction with date of
completion September 1980.
The applicant must have demonstrated
leadership and administrative skills,
post-graduate education in O.R. nursing
and past experience as a Head Nurse or
Supervisor.
Must be eligible for B.C. registration.
Prince George Regional Hospital is a 340
bed acute Regional Referral Hospital
located in Central B.C.
Qualified applicants are invited to submit
their resumes to:
Assistant Executive Director,
Patient Services
Prince George Regional Hospital
2000 - I5th Avenue
Prince George, B.C. V2M 1S2
Nursing Co-Ordinator
Required by a 170-bed general
hospital. Incumbent will be
responsible for the development and
implementation of nursing programs
and systems; e.g. nursing histories,
care plans and audits. The position
reports to the Director of Nursing
Services.
Qualifications:
B.Sc.N. with current Ontario
Certificate of Competence and
having experience in Nursing
Education or Administration.
Resumes to:
Director of Personnel
St. Joseph s Hospital
519 King Street West
Chatham, Ontario N7M 1G8
62 Aprll1980
The Canadian Nurse
Now, an unusual
opportunity to
"bridge the gap"
New graduate. . .a nurse wanting to specialize
in pediatrics., .a pediatric nurse wanting to
specialize further? For all, Le Bonheur s new
clerkship program includes an array
of confidence-building classwork, I
clinical experience, preceptor guid
ance and formal recognition on completion.
And, you are paid while you learn! After the
basic program choose your pediatric specialty
. . . intensive care, emergency nursing, infant
care, surgical, medical or others. It will help you
bridge the gap between education and spe
cialized professional responsibilities. And it s at
one of North America s most modern and com
plete pediatric centers.
In addition, Le Bonheur is the principal teach
ing hospital of the Department of Pediatrics,
University of Tennessee. A $1 3 million expansion
provides the 225-bed facility with all new patient
care areas. One- third of the beds are devoted to
Le Bonheur
Children s
Medical
Center
such specialties as intensive care (18 beds),
special care (newborns to 1 2 months), hemodi-
alysis and neurological/neurosurgical. The
I hospital also has an ultra-modern
emergency department with full-time
^/ Medical Director and a full spectrum
pediatric ambulatory care service.
For those qualifying, Le Bonheur offers excep
tional opportunities: Specialized positions within
a personally rewarding environment. . . thorough
orientation program. . .fully paid advanced
education (tuition and books). . .personal rec
ognition incentives. ..competitive salaries and
benefits. . .all within an atmosphere of friendli
ness, professionalism, variety and challenge.
Our Nurse Recruiter would l.ike to hear from
the seriously interested and qualified. Call her
collect, (901 )-522-331 5. . . she will be visiting
Canada soon.
I
b
In the heart of the Sunbelt . _
One Children s Plaza/Dept. C./MemphisJennessee 38103 (901)-522-3315 An Equal Opportunity Employer
The Canadian Nurse
Registered Nurses
Applications from Registered Nurses are
now being accepted for ongoing
vacancies in a number of clinical areas.
This large active treatment hospital
offers challenge and an opportunity for
professional growth in a dynamic
atmosphere.
Candidates must be graduates of a
recognized school of nursing, and be
eligible for registration in Alberta. Post
basic training and/or experience in
specific clinical areas a definite asset.
Please apply in writing with details of
I education and experience to:
L,
Personnel Department
CALGARY GENERAL HOSPITAL
Registered Nurses
Planning your summer vacation?
Then by all means, include a visit to
beautiful Vancouver in your plans. And
while you re here, drop in and discuss
your nursing career opportunities at
Shaughnessy Hospital, an 1 100 bed
multi-level community teaching hospital.
We have full-time, part-time and float
positions available as well as a 2 week
orientation for RN s who wish to work
on a casual basis only .
When you re in Vancouver please call:
Jane Mann
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767
Exploring the Many
Faces of Opportunity
Opportunity wears many faces at
Santa Monica Hospital Medical Center in
Southern California It can be the excite
ment and challenge of working as part of
our Operating Room or Critical Care teams
It can also be in the achievement of your
goals as you begin to play a more active
role in management and/or supervision.
However, opportunities expand be
yond your professional life in Southern Cal-
ifornia. The total scope of the! active life is
virtually unlimited from wide, sunny beaches
to near-by winter slopes .the opportunities
are here
If you would like more information
about exploring the many opportunities now avail
able to you. please forward the below coupon.
Who knows, you may find a new definition
for "opportunity"
Santa Monica Hospital
Medical Center
1225 15th St., Santa Monica, CA 90404
(213) 451-1511 Eil 2537
Phone
An Equal Opportunity Employer M F
CN-4
Advertising
rates
For All
Classified Advertising
$20.00 for 6 lines or less
$3.00 for each additional line
Rates for display advertisements
on request.
Closing date for copy and
cancellation is 8 weeks prior to
1 st 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
K2P 1E2
Registered Nurses
Come to work in scenic Corner Brook !
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
West Coast of Newfoundland .
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January. 1979 $12,771.00 15,429.00
1 January, 1980 $13,410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
64 AorlUMO
The Canadian Nurse
IMPORTANT MEMO
To: Registered Nurse Applicants For Overseas Jobs
From: Hospital Corporation International
Subject: Some Advice On Seeking Employment In The Field Of
International Nursing.
Many organizations are offering overseas job opportunities in the health and hospital field these days. If you
are interested and seriously considering an overseas or international assignment, here are some important
points to consider and questions to ask before and at your interview:
Who is doing the interviewing
and recruiting? What is their
experience and background?
Make sure you are dealing with a
reputable organization that is a true
representative of your prospective
employer. Be sure they have first
hand knowledge of the location and
facilities where you d be living and
working.
Will I have to pay an
employment fee? If so,
for what and why?
Some independent agencies will
charge you a sizeable fee just to
send your resume somewhere else
and can make no commitment to
you. Other organizations do their
own recruiting or can make
commitments and they won t charge
you an employment fee.
What kind of organization or
company am I dealing with? What
is its primary business?
If it isn t the Health Care Business,
first and foremost, you may want to
investigate further: What are their
qualifications, experience,
standards, quality, etc?
How realistic is the
information and how much is offered
about the job, the working
conditions, culture, etc?
If it all sounds exciting, glamorous,
and positive, then the picture isn t
realistic, it s "rose-colored". It can
be adventurous and rewarding, but
there are day to day drawbacks,
frustrations, and difficulties to
consider before you decide to go.
And you should be told about all the
details don t accept
generalizations.
Will I be offered any
assistance in preparing for overseas
relocation, employment, and
adapting to the new environment?
Experienced, reputable
organizations will show concern for
you as an individual and for your
ultimate success by assisting you
with pre-departure processing
requirements and preparations and
by providing comprehensive
pre-departure and post-arrival
orientation programs.
Will I be offered any
assistance to relocate in another job
when my contract is finished?
Find out if the company can help
you "get back in touch" after being
away from home for two or more
years. It s an important point that
many individuals overlook and so
do many companies.
Hospital Corporation International, a member of the Hospital Corporation of America Group, is one of the most experienced and
professional organizations providing international recruitment and human resource services in the health care and hospital related field.
If you are thinking about an overseas assignment, we invite you to explore the possibilities by exploring Hospital Corporation
International. Ask us the questions: we ll give you the answers. You owe it to yourself .
If you are interested and would like more information, please send your resume to:
International Human Resource Management (7)
Hospital Corporation International
One Park Plaza
Nashville, Tennessee 37203
HOSPITAL
CORPORATION
An Equal Opportunity Employer
The University of Western Ontario
Graduate Program Coordinator
Applications are invited for the above position
coordinating an expanding graduate program
currently enrolling 35 students. Canada s first
M.Sc.N. program offers majors in Nursing
Education and Nursing Administration.
Duties involve overall program coordination,
delegated administrative functions, curriculum
development and teaching.
Qualifications include Ph.D., university teaching
experience, and demonstrated clinical competence.
Previous administrative experience is desirable.
Salary is commensurate with academic and
experiential background.
Send curriculum vitae and references to:
Dr. Beverlee Cox, Dean
Faculty of Nursing
The University of Western Ontario
London, Ontario, Canada
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 /Zip
Please complete appropriate category
a I hold active membership in provincial nurses assoc.
reg. no. /perm. cert. /lie. no.
n 1 am a personal subscriber
Mail to: The Canadian Nurse, 50 The Driveway, Ottawa
Ontario K.2P 1E2
Registered Nurses
1200 heel hospital adjacent to I niversity of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgerv
Burns and plastics
Neonatal intensive care
Renal dialysis
N euro-surgery
Planned Orientation and In-Service Education Programs.
PostGraduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Apph to:
Recruitment Officer Nursing
I niM-rsit) of Alberta Hospital
S440 1 1 2th Street
Kdmonton, Alberta
I6(, 2B7
University of
Alberta Hospital
Edmonton, Alberta
56 AprlM980
The Canadian Nurse
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
major 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 in many
areas such as:
Neonatology Nursing Intensive Care
(General & Neurosurgical)
Inservice Education Cardio-Thoracic Surgery
Coronary Care Unit Burn Unit
Hyperalimentation Paediatrics
Program
Renal Dialysis & Transplantation
If you are a Nurse considering a move please submit resume to:
Mrs. J. Macl hail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue Vancouver, B.C. V5Z 1M9
University of Western Ontario
Faculty of Nursing
Applications are invited for teaching positions in
undergraduate and graduate programs. Rank Open.
Master s or doctorate degree required. Preference will he
given to candidates with teaching experience and clinical
specialization. Candidates must be eligible for registration in
Ontario.
Salary commensurate with preparation and in accordance
with the University of Western Ontario policies.
Appointments are subject to availability of funds.
Send complete resume to:
Dr. Beverlee Cox, Dean
Faculty of Nursing
Health Sciences Addition
The I niversity of Western Ontario
Ix>ndon, Ontario. N6A 5C1
Winnipeg Municipal Hospital requires
Licensed Practical Nurses
Registered Nurses
Bachelor of Science in Nursing
Professionals wishing to become part of the team
approach toGerontological Patient Care.
To bridge the gap between education and practice, the
hospital maintains a comprehensive orientation program
followed by specific Nursing Unit orientation programs.
Continuing Education Inservice programs are carefully
planned to promote both quality patient care and job
satisfaction.
Specialty areas include Rehabilitation. Palliative Care,
Long Term Care and an expanding Respiratory Unit.
A 2 week hospital orientation will commence on March
3rd, 1980.
Salary negotiable - allowance for Academic Attainment.
Interested personnel please submit resume and names of
references to:
Mrs. June R. Roberts
Personnel Officer
Winnipeg Municipal Hospital
1 Morley Avenue
Winnipeg, Manitoba
R3L 2P4
OPPORTUNITY
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. andGeriatric Services.
Note: Transportation is available to and from Edmonton.
Accommodation is available in the Staff Residence.
Salary $ 1 ,229 S 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
Alberta Hospital, Edmonton
Box 307, Edmonton, Alberta
T5J2J7
Telephone: <403> 973-2213
The Canadian Nurse
April 1980 67
Wish
you were
here
...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
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 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 information on any, or all. of these career
opportunities, please contact the Medical Services
office nearest you or write to:
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1AOL3
Name
Address
City
I
Health and Welfare
Canada
Prov.
Sante et Bien-etre social
Canada
I
I
I
I
Are You a Nurse?
Here s an Opportunity To Be One.
Primary Nursing
at the New Regional Hospital means having direct
responsibility for the nursing care of your patient, his family,
and working with the doctor as a colleague.
Accountability
as a primary nurse means the outcome of your patient s
care is the measure of your effectiveness.
Satisfaction
results from your role as a professional and the significant
part you play in the care of your patient.
PUT IT TOGETHER with the new 300 bed Fort McMurray
Regional Hospital Opening in November, 1979.
Want to know more about your opportunities in our total
patient care facilities?
Call Penny Albers at (403) 743-3381
or
Write for an information package:
Personnel Department
Fort McMurray Regional Hospital
Fort McMurray, Alberta
T9H IP2
Royal Alexandra Hospital
This 932 bed active treatment hospital invites
applications from nurses across Canada.
We offer experience in all areas of patient care
including intensive care, neonatal intensive care
and obstetrical perinatology. The extended work
day and compressed work week is currently in
effect in the Intensive Care areas.
Applicants must be eligible for registration with the
Alberta Association of Registered Nurses.
Please direct inquiries to:
Personnel Officer
Nursing Recruitment
Royal Alexandra Hospital
10240- Kingsway Avenue
Edmonton, Alberta
TSH 3V9
88 April 1980
The Canadian Nurse
Index to
Advertisers
April 1980
Ames Division,
Miles Laboratories Limited
The Canadian Nurse s Cap Reg d
14
Designer s Choice. A Division of
White Sister Uniform Inc.
IFC
Equity Medical Supply Company
20
Health & Welfare Canada
54
Hollister Limited
J.B. Lippincott Company of Canada Limited 18. 19
Maple Leaf Laboratories Limited
15
McGraw-Hill Ryerson Limited
16
TheC.V. Mosby Company, Limited
12, 13
Nursing Abstracts Company Inc.
14
Pharmacia (Canada) Limited
70
Posey Company
45
The Procter & Gamble Company
52.53.IBC
W.B. Saunders Company
29
Simpsons-Sears Limited
OBC
Smith & Nephew Inc.
7,8,9
Upjohn HealthCare Services
17
Wellcome Medical Division,
Burroughs Wellcome Inc.
55
Whittaker International Services Company
56
Advertising Representatives Advertising Manager
Jean Malboeuf
601, Cote Vertu
St-Laurent, Quebec H4L 1X8
Telephone: (514) 748-6561
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P.O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215) 363-6063
Gerry Kavanaugh
The Canadian Nurse
50 The Drive way
Ottawa. Ontario K2P 1 E2
Telephone: (613) 237-2 133
Member of Canadian
Circulations Audit Board Inc.
Director, Extension Course in
Nursing Unit Administration
Applications are invited for the position of Director,
extension course in Nursing Unit Administration. The
incumbent will be responsible for the conduct of the
program and accountable to a Joint Committee composed
of representatives of the Canadian Nurses Association
and the Canadian Hospital Association.
Applicants should have advanced academic preparation,
a Master s degree or equivalent, relevant background of
experience in nursing administration and/or nursing
education and be bilingual.
The position should be filled in May, 1980.
Interested applicants are asked to submit their curriculum
vitae, in confidence, by 5 April 1980, to:
The Selection Committee
Nursing Unit Administration Course
410 Laurier Avenue West
Ottawa, Ontario
K1R7T3
Nursing Coordinator
OBS and GYN
The Nursing Coordinator is a senior staff position,
responsible for the Nursing Administrative and
Clinical Coordination of theOBS/GYN Units
including the Regional Perinatal Service. The OBS
Service has approximately 3 100 deliveries per year
Women s College Hospital is a 391 bed University
teaching hospital in downtown Toronto.
Qualifications:
B. ScN. or equivalent
Minimum of 5 years clinical experience in OBS
Administrative experience
Eligible for registration in Ontario
Please submit resume to:
Director of Nursing
Women s College Hospital
76 Grenville St.
Toronto, Ontario
M5S 1B2
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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
by relieving
pain and
odour fast
" 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
peared." 3
Day Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
Two. il exudation is very heavy.
After removing crust or Cover with a dressing,
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Debrisan cleans
decubitus ulcers fast.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dorval, Quebec
1. Lim LT, Michuda M, Bergan JJ, Angiology 29:9, Sepl 1978
2 Bewick M, Anderson A, Clin Trials J 15:4, 1978
3. Soul J. Brit J Clin Pract. 32:6, June 1978
4. DiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on file at Pharmacia (Canada) Ltd.
i INTRODUCING
wondrd
a new skin moisturizing lotion that merits
your consideration and recommendation
Promotes the natural
healing of dry skin
Healing help for dry skin
WONDRA works to help the skin restore
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skin and helping to eliminate roughness,
chapping, flaking, and scaling.
Clinically proven effectiveness
Three six-week, double-blind clinical studies
involving 574 men and women proved that
WONDRA was significantly effective in
alleviating dry skin problems.
Provides immediate relief
WONDRA quickly lubricates the skin to
provide immediate relief from rough, dry skin.
V
Long-term protection with regular use
By formingw occlusive film on the surface of
the skin, W<aNDRA helps the body retain its
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against the problems caused by dry skin.
Cosmeti
Patients wilt
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reciateWONDRA s
tic qualities: rapid rut
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ervices
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Sears
Sears uniforms...
as dedicated to comfort as you are.
Your situation often goes
from calm to critical in a
matter of minutes. That s
when the comfort of Sears
WHITE SISTER uniforms
really comes through. Our
Dacron* polyester knit pant
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treated for breathability
and absorbency. Robin Blue
or White. 5 to 13. $42.
Soft-looking dress is in
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Misses 10 to 20. $40.
Both machine wash-and-dry
Reg d. Can. T.M.
A fine selection of
uniforms is available
in our larger stores
and in our 1980 Spring/
Summer Catalogue.
Simpsons-Sears Limited
CNA s brief to Health Services
Review 79
Surgical tattooing: treatment of
port wine stains
An audit procedure that belongs
to nursing staff
Genetic guidance: the unanswered
questions
Living it up: how 14 Canadian
nurses promote healthier lifestyles
The
Can
Nurse
MAY 1980
^
&
&
J&*
CAREER DRESS
CANADA S MOST PRESTIGIOUS CAREER APPAREL
A Division of
ite Sister Unifor
Style No. 44717- Dress
Sizes: 3-15
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White, Lilac.
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ROYALE STRIPE SENSATIONC
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White, Yellow.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
Mathilde Bazinet.c/wirman. Health
Sciences Department. Canadore
College, North Bay. Ontario.
Dorothy Miller, public relations
officer. Registered Nurses Association
of Nova Scotia.
Jean Passmore.e</(/w, SRNA news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith, direct or of publications,
National Gallery of Canada.
FloritaVialle-Soubranne,ronju//artf,
professional inspection division. Order
of Nurses of Quebec.
The World of the Abnormal...
CNJ joins the Science Council
of Canada in a closer look at
some of the issues arising
from the increasing use of
genetic screening as an
integral part of preventive
medicine. Our cover photo of
an abnormal chromosome
multiplying is courtesy of
David Gillan, a technical
officer with the Division of
Biological Science of the
National Research Council.
The
Canadian
Nurse
May 1980 Volume 76, Number 5
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Nursing audit 33
I i
Health in the woikplace..38 Post-CV A 44
26
Surgical tattooing
May Chung and Julie McKenzie
42
The light still shines in Elora
Thelma R. May and Wendy J.
May
30
The need to know?
Science Council of Canada
44
Perceptual distortion
Geraldine Hart
33
Nursing audit
Shirley Sultan
48
Health around the world
Maureen Johnson
IQ A personal commitment to fitness
results in healthier clients
Judith Banning
50
YOU AND THE LAW
Hospitals and nurses: the evolution
of legal responsibility
Corinne Sklar
8
Input
20
CNA Brief to Health
Services Review 79
18
CNA Directors Approve
Nursing Ethics Code
22
News
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Single copies: $1.50 each. Make
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ISSN 0008-4581
Indexed in International Nursing Index, Cumulative
Index to Nursing Literature. Abstracts of Hospital
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Periodical Index. The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor, Michigan 48106.
Canadian Nurses Association. 1980.
MOVE INTO MAY WIT!
**** OUTSTANDINC
HARPER S HANDBOOK
OF THERAPEUTIC
PHARMACOLOGY 1980-1981
By R. Marilyn Schmidt; and Solomon
Margolin, Ph.D.
Following an introductory chapter on
the principles of therapeutic pharmaco
logy, the numerous drug references are
arranged primarily according to their
major effects on specific organ systems.
The information for each drug or group
of drugs is presented in a standardized
format:
4- THE PROCESS OF
HUMAN DEVELOPMENT:
A Holistic Approach
By Clara Shaw Schuster, R.N., B.S.N.,
M.Ed.; and Shirley Smith Ashburn,
R.N., B.S.N., M.S.
The Process of Human Development is a
fascinating exploration of the human
experience, and it is the perfect text for
your course in human growth and devel
opment. Clara S. Schuster, Shirley S.
Ashburn, and their contributing authors
provide a dynamic, comprehensive, multi-
disciplinary survey of the entire lifespan
from conception through senescence.
MATERNITY NURSING,
14th Edition
By Sharon R. Reeder, R.N., Ph.D.;
Luigi Mastroianni, Jr., M.D., F.A.C.S.
F.A.C.O.G.; and Leonids L. Martin,
R.N.,M.S.
New and expanded chapters deal with:
psychosocial aspects of normal preg
nancy; psychosocial aspects of the post-
partum; common concerns related to
sexuality; contraception; pregnancy ter
mination; infertility; genetic counseling;
nutrition in pregnancy; infant nutrition;
electronic fetal monitoring; and alterna
tives in childbearing.
TEXTBOOK OF MEDICAL-
SURGICAL NURSING,
4th Edition
By Lillian Sholtis Brunner, R.N., M.S.N.,
Sc.D.;and Doris Smith Suddarth, R.N.,
B.S.N.E., M.S.N.
Fully updated and expanded, the fourth
edition of this famous, best-selling text,
integrates concepts and clinical content
throughout, accenting assessment and
management in nursing practice.
The biophysical and psychosocial con
cepts underlying health and illness are
within each group of drugs, specific
therapeutic classifications are presen
ted
In response to health professionals in
creasing awareness of special dosage
variations and considerations in treating
patients of various age groups, dosage
information is included for pediatric
and geriatric populations when available
in addition to adult dosages and maxi
mal recommended daily dosages.
Harper & Row. Abt. 750 Pages.
April 1980. $17.50.
The focus is on all four domains
in human development biophysical,
cognitive, affective, and social. These
domains are segregated in the text
for discussion, yet integrated for
application.
The text is divided into 12 units, each
representing a separate phase of human
development. Each of these units reads
like an essay each tells its own story.
Together, they tell the story of human
growth and development.
Little, Brown. 960 Pages.
Illustrated. 1980. $23.95.
Updated material, based on current re
search and practice, covers such topics
as fetal development, parent education,
fetal diagnosis and treatment, antepar-
tal and postpartal care, normal and ab
normal pregnancy and delivery, pain
relief, and care of the normal infant and
the high risk neonate.
New illustrations throughout depict the
major anatomical and physiological fea
tures related to pregnancy, fetal develop
ment, labor, delivery and maternal and
infant care.
Lippincott. Abt. 623 Pages. Illustrated.
March 1980. Clothbound. $23.95.
explored in the opening units in chapters
dealing with:
the nursing process
patient education
homeostatic mechanisms
fluid and electrolyte balance
nutritional considerations in health
immunology and psychosocial needs
associated with stress and illness
Physiology and pathophysiology have
been expanded, offering an overview of
normal function and providing an under
standing of deviations from normal.
Lippincott. Abt. 1,500 Pages.
Illustrated. March 1980. $34.75.
M
#m
**
CHESE *******
SELECTIONS!
1 EDUCATION FOR
GERONTIC NURSING
By Laurie M. Gunter, R.N., Ph.D.; and
Carmen A. Estes, R.N., Ph.D.
An overview of current curricula, educa
tion, and research in gerontological nursing.
Includes curriculum guides and resources for
five levels of gerontic nursing care, a course
model for computer-based instruction, and a
sample of a short-term training program.
Springer. 224 Pages. 1979. $17.50.
2 BASIC PSYCHIATRIC
CONCEPTS IN NURSING,
4th Edition
By Joan J. Kyes, R.N., M.S.N.; and
Charles K. Hofling, M.D., F.A.C.P.
Extensive updating and revision make the
new fourth edition of this popular text
topical and timely as never before! Nursing
students will find it eminently useful in
general hospital and psychiatric settings.
Lippincott. Abt. 600 Pages.
March 1980. Abt. 818.00.
3 INTRAVENOUS
MEDICATIONS: A Guide to
Preparation, Administration and
Nursing Management
By Diane Proctor Sager, R.N., M.S.N.; and
Suzanne Kovarovic Bomar, R.N., M.S.N.
Here is a handy two part reference/text
designed to give the most complete coverage
of intravenous equipment, techniques, ma
nagement, and the drugs themselves. Part
One describes the theories and techniques
of the intravenous administration of drugs.
Part Two, the Drug Information section,
presents detailed information in column
form on all drugs currently approved for
intravenous use.
Lippincott. Abt. 500 Pages.
89 Illustrations. April 1980. $19.25.
4 NURSING MANAGEMENT
FOR THE ELDERLY
By Doris Carnevali, B.S., M.N.; and
Maxine L. Patrick, B.S.N., M.S.N., D.P.H.
\ definitive treatment of normal aging in
its many dimensions, this highly original
handbook focuses on nursing s territory in
assessment and diagnosis and on the nursing
management of specific high risk patho-
physiologic problem areas.
Lippincott. 570 Pages. 1979. $22.50.
5 CLINICAL ASSESSMENT OF
CHILDREN: A Comprehensive
Approach to Primary
Pediatric Care
By J. Deborah Lott Ferholt, M.D.
This book is a general introduction to the
clinical assessment of children. Its focus is
on primary health care, but the comprehen
sive approach offered here is also relevant to
pediatric subspecialties and to the care of
hospitalized children.
Lippincott. 331 Pages.
Illustrated. 1980. $17.95.
6 A MANUAL OF
LABORATORY DIAGNOSTIC
TESTS FOR NURSES
By Frances Fischbach, R.N., B.S.N., M.S.N.
This book is a quick -reference manual of
frequently ordered diagnostic tests, featur
ing normal values, concise descriptions of
each test, pertinent background informa
tion, clinical implications of increased or
decreased values, interfering factors, as well
as patient preparation and aftercare. A spe
cial feature, "Clinical Alert," is used exten
sively to highlight areas of nursing concern
that must be considered to assure patient
safety and well-being.
Lippincott. Abt. 300 Pages. Illustrated.
21 Tables. May 1980. Abt. $10.75.
7 COMMUNICATION IN
NURSING PRACTICE,
2nd Edition
By Eleanor C. Hein, R.N., Ed.D.
The ultimate goal of this book is to provide
patients, clients, and their families with
opportunities to reach their fullest poten
tial. We see persons with varying levels of
ability, functioning at varying levels of
health, but nevertheless all capable of
growth and change. The only tool we have
is an extraordinarily sensitive one our
selves. How we use ourselves in achieving
this goal is the heart of professional nursing
practice. This book begins that process.
Little, Brown. 960 Pages.
Illustrated. 1980. $23.95.
8 OPERATING ROOM
TECHNIQUES FOR THE
SURGICAL TEAM
Edited by Lois C. Crooks, R.N.
A comprehensive reference for practicing
operating room nurses, this book is designed
to prevent overviews of the major surgical
procedures, including relevant anatomy,
indications for each procedure, and the
related nursing obligations.
Little, Brown. 459 Pages. Illustrated.
1979. Paper, $15.50. Cloth, $21.50.
9 NURSING: Images and Ideals
Edited by Stuart F. Spicker, Ph.D.; and
Sally Gadow, R.N., Ph.D.
A collection of original essays on the philo
sophical foundations of the profession
and practice of nursing.
Springer. 224 Pages. 1979.
Paper, S15.50. Cloth, $25.25.
J. B. LIPPIXCOTT COMPANY OF CANADA LTD.
75 Horner Avenue, 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.
D Payment enclosed (postage and handling paid)
Please send me the following books for 15 days on approval :
D Textbook of Medical-Surgical Nursing, 4th Edition, $34.75.
D Harper s Handbook of Therapeutic Pharmacology, $17.50.
1234567
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D Maternity Nursing, 14th Edition, $23.95.
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"The settlement was overdue but it s still less than they owe us. They Ve corrected the discrepancy but RN s, on the whole,
will have to be better paid if the Feds hope to attract them to work in the penitentiary system. "
- Leona Mollis, the nurse at the federal correctional institution at Springhill, N.S., who filed the original complaint
leading to the recent precedent-setting pay settlement based on the principle of "equal pay for work of equal value. "
Gloria Blaker
SOME OF US ARE MORE EQUAL THAN OTHERS
"Sex discrimination in the
labor market generally results
in some combination of
unequal pay for equal work
and unequal employment
hiring and promotion oppor
tunities."* Although both
forms of discrimination are
inter-related, sex discrimina
tion in pay results from a
vicious, self-fulfilling circle
which is the result of
subjective beliefs. Females are
concentrated in jobs which
are logical extensions of
traditional housewife chores.
Because these jobs child
care, nutrition and nursing-
are so close to the unpaid
work that women normally
do in their homes, they are
not valued, rewarded and
respected as are the traditional
male tasks which have had a
dollar value on them ever
since currency began.
Females are erroneously
screened into low producti
vity, low-wage jobs and in this
fashion, an initially discrimi
natory subjective belief
becomes self-fulfilling and
male-female wage differentials
persist. Employers readily
accept subjective beliefs or
differential abilities because
this justifies their discrimi
natory behavior and,
therefore, wage differentials
persist even in the face of
competitive pressures.
Even though Treasury
Board has gone on the
record in support of the
elimination of sex discrimi
nation, the board s position
in bargaining has consistently
been that of paying salaries
comparable to those paid by
other employers in Canada,
thereby perpetuating this
self-fulfilling circle. At first
glance this bargaining position
appears to be an impartial or
non-discriminatory position.
On second glance, of course,
this particular position merely
serves to continue the existing
discrimination; therefore,
salary levels for occupations
primarily filled by women
will be consistently lower
than occupations primarily
filled by men which have
similar requirements for
professional training.
The Professional
Institute contends that the
federal government could and
should take the lead in
establishing more equitable
pay rates for predominantly
female occupational groups
and thereby take the lead in
eliminating sex discrimination
in pay practices.
It is a fact that the
Government still hires fewer
women than men, even though
more and more Canadian
women are working, regardless
of marital status.
The Government still
concentrates female public
servants in occupational
ghettos, particularly the
occupational and physical
therapy group, the home
economics group, composed
mostly of dietitians, and the
nursing group.
With the enactment of
the Canadian Human Rights
legislation and the subsequent
establishment of the
Commission, we thought that
at last an effective agency had
been provided with sufficient
clout to force an employer to
refrain from actions which
could be shown to be
discriminatory.
So, the Professional
Institute decided to lodge a
complaint on behalf of six of
its nurses employed in federal
penitentiaries at Springhill,
Nova Scotia and Dorchester,
New Brunswick. Not only did
these nurses carry out the
same functions as male
colleagues in the institution
who were classified as
Hospital Technicians, but in
fact, some five years
previously, the positions filled
by both sets of employees
had been upgraded to require
registered nurse training. In
spite of this, the six female
nurses were receiving salaries
nearly 9 per cent lower than
the male Hospital Technicians.
All efforts to redress
the situation at the bargaining
table over the past few years
had been rebuffed by the
Treasury Board. Now that a
complaint was lodged, it was
up to the commission to set
up its own investigation, and
as a result it was very soon
satisfied that there was in fact
a case of discrimination in
pay administration for the
nursing group.
At first the Treasury
Board persisted in its refusal
to acknowledge discrimina
tory practice in its pay
administration, but finally in
October 1979, after the
commission threatened to
appoint a tribunal which
would have the power to
impose a verdict, such an
admission was forthcoming.
All that remained was
to arrive at an agreement for
a settlement to redress the
situation cited at the
beginning of this article, a
step that took four months
and finally resulted in the
announcement by the Human
Rights Commission on
February 25, 1980.
It is interesting that the
federal government should be
the first employer found
guilty of contravening
legislation enacted by itself.
At the same time it is also
heartening to realize that
this legislation is not a mere
paper tiger as some of its
more cynical advocates had
feared. Even now there
remain reservations,
particularly in connection
with some of the procedures
adopted by the commission
but, in the wake of this first
decision, the outlook is
certainly optimistic.
The overall situation,
however, is still far from
settled. The case of the
penitentiary nurses might
well have been dealt with
under provincial legislation
which exists in some
provinces calling for "equal
pay for equal work". Perhaps
the most important feature of
the federal legislation under
which the nurses case was
heard, is the provision calling
for "equal pay for work of
equal value". This is a big
improvement over previous
legislation, but it still falls
far short of the programs and
enforced mandatory require
ments that characterize equal
pay and equal rate policies in
the United States.
The cost of implemen
ting equal pay for work of
equal value demands formal
solutions. It is unlikely that
there will be significant
progress in the direction of
equal pay for work of equal
value without strong govern
ment action, including
provision of adequate
resources at all levels of the
federal bureaucracy.
These costs are balanced
by benefits to the employer
for efficient use of human
resources and the higher
worker morale generated by
fair treatment. After all,
child labor which we now
regard as morally reprehen
sible, was also economically
beneficial to industry. We saw
that child labor was wrong
and the present problem is
just as obvious.
The Canadian Human
Rights Commission has
shown us the way. Now the
institute urges the federal
government to provide formal
solutions and to pay the cost
of implementing strong
programs which will result in
equal pay for work of equal
value.*
Gloria Blaker, BN, is
negotiator for the Professional
Institute of the Public Service
of Canada (Federal Nursing
Group).
*Morley Gunderson in
"Discrimination in Wage
Payments"
Getting to know you. ..The
password in the eighties is
"prevention" and, in keeping
with the times, more and
more nurses are taking that
big step from the clinical
area of an acute care hospital
to the often misunderstood
area of community health
nursing. We believe that
mutual understanding of each
other s work is the key to
continuous and conscientious
care-in the hospital or at
home. That s why we re
dedicating the January 1981
issue of the journal to the
nurse in the community.
CHN s across the country are
invited to submit original
manuscripts and photos,
including possible cover
photos, so that the editorial
staff can choose the best for
inclusion in our special issue.
Deadline for submissions is
September 15, 1980.
7TS EASY ID SEE WHY
PEOPLE GET SO ATTACHED
TO MY SHOES"
"If you examine the bottoms of your feet,
you ll discover they look exactly like the tops of
my soles.
Instead of the usual slab of curved leather,
my soles are anatomically sculptured. So they
faithfully match your soles, in every dimension.
Your feet mon t get pinched, slide around,
or have to strain for support.
Since they re honeycombed all through, my
soles are light,flexible, and cushion your entire
foot uj ith every step you take.
If your feet aren t quite compatible ujith the
shoes you re wearing, put them in a pair of
mine. You ll find they re FAMf)! APF
made for each other." MAI^UFEALJTTLE^^.
Some people need
to be cared for. Others
need a chance to care.
Upjohn HealthCare Services
brings them together.
f I
In any community, there are people
who need health care at home. There are
also people who want worth wh i le part-ti me
or full-time jobs.
We work to bring them together.
Upjohn HealthCare Services " 1 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 kind of job oppor
tunity. If you do, please pass this message
along. For additional information, com
plete the coupon below, or call our local
office listed in your telephone directory.
UPJOHN
HEALTHCARE
SERVICES 3 "
Please send me your free brochures (check one or both):
D "Nursing and Home Care"
D "Nursing Opportunities at Upjohn HealthCare Services"
Name
Address
Phone
City Province Postal Code
Mail to: Upjohn HeaithCare Services
Dept. B
716 Cordon Baker Road, Suite 203
Willowdale, Ontario M2H 3B4
HM 6410-C 1979 HealthCare Services Upjohn, Ltd.
input
A day to remember
March 4, 1980 is a date
to remember in the history of
nursing: on that day, in a
small amphitheatre in the
Government Conference
Centre in Ottawa, the sun
shone on the profession and
on its delegation when CNA
presented its brief to former
Supreme Court Justice
Emmett Hall.
CNA president Helen
Taylor provided an overview
of the brief by highlighting
the eight recommendations.
The association challenged
the commission to allow the
emergence of a health
insurance program that would
stimulate development of
primary health care services,
permit the introduction of
new entry points and promote
the appropriate utilization
of qualified health personnel.
Ginette Rodgers, CNA s
member-at-large for nursing
administration, elaborated on
community health care
facilities that would be
directed towards better
service at less cost.
Justice Hall explored
the possibility of using the
school as a community health
centre location. It seemed
that both the school and the
workplace might be appro
priate locations for a team of
health care workers.
The CNA recommenda
tion that "remuneration of all
health personnel be by salary"
carried with it the comment
that many physicians see no
clear avenue for reward for
high quality service. Many
situations do not require the
input of a physician but as
long as the physician is paid
a fee for service he is going to
be compromised by quantity
of service versus quality.
A recommendation for
better preventive, diagnostic
and ambulatory care programs
through various community-
based entry points was
presented and the question of
human resources available to
man new community-based
centers was explored. It was
pointed out that a variety of
health professionals would be
required to staff community
centers.
In a discussion of
nursing manpower, CNA
executive director, Dr. Helen
Mussallem noted that the
number of nurses entering
and leaving the profession
was cyclical. She stated that
the profession was
encouraging the development
of a number of refresher
courses, workshops and short
term courses. No rigorous
studies have been completed
assessing the degree of job
satisfaction perceived by
nurses but, generally speaking,
the higher the level of an
individual s education the
more likely they would be to
return to the profession.
President-elect Shirley
Stinson spoke to CNA s
recommendation that a
Health Science Research
Council be established to
focus on the study of health
services, the system of
delivery and its effective
ness. Dr. Stinson stated that
nurses have tried to initiate
research into the science of
the practice without great
success.
Two final recommen
dations encouraged govern
ments to re-institute the
National Health Survey and
to adopt, as a priority, better
and broader health education
programs to sensitize
consumers to the costs of
acute care services.
Throughout the
exchange, our delegation
appeared organized, poised,
thoroughly briefed and ready
to respond to any questions.
The efforts and frustrations
that preceeded the day of
presentation may have been
tremendous. The end result,
however, was a well polished,
well presented document that
generated the esteem of many
national health agencies and
demonstrated once again, for
all to see, the benefits that
can be attained by having a
national body speak on
behalf of the total profession.
That day, above any
other day for a long time, I
was extremely proud not
only of our national
representatives and their
work on our behalf, but also
of being a nurse.
Congratulations CNA
for a job well done.
Marjorie W. Hayes, RN,
BScN, MScN (edj, Director,
Health Computer Information
Bureau, Canadian Hospital
Association/Canadian Medical
Association I Canadian
Organization for Advance
ment of Computers In Health
Introducing the 1980
Nursing Blockbuster!
from Luckmann & Sorensen
MEDICAL-SURGICAL NURSING
A Psychophysiologic Approach 2nd Edition
As an essential part of the health care team, more is de
manded of today s nurse.. .so you demand more of your
text. Updated, revised and expanded the new Second
Edition of MEDICAL-SURGICAL NURSING: A Psycho-
physiologic Approach keeps pace with the needs of
today s nurse. . .to supply nurses with the knowledge and
confidence toundertakeever-increasing responsibilities.
Just a sample of the updated and expanded chapters:
74 new pages on psychosocial and physical assessment
I mportant new data coveri ng dependency on alcohol
and other abused substances
Enti rely new chapter on emergency and disaster nursi ng
To enhance all the new coverage, we ve improved on the
features that made Luckmann & Sorensen so practical
to use:
correlation of the nursing process with basic
human needs
holistic approach used in management of patient care
emphasis on social support systems
clearly organized
valuable study guides and objectives integrated
throughout
easy-to-read tables and charts
principles and rationale given for each nursing
procedure covered
Concise, yet comprehensive: MEDICAL-SURGICAL
NURSING can be used in conjunction with or indepen
dently from Sorensen & Luckmann s BASIC NURSING.
Content has been carefully divided between the two
texts, reducing unnecessary repetition . . . and therefore
eliminating wasted reader time and book space crucial
factors in a dynamic profession with a rapidly expanding
knowledge base. Plus important material on fluid-
electrolyte acid-base, pain, physical assessment and
emergency life support bridge both books. ..the funda
mentals in BASIC NURSING and the more advanced
principles in MEDICAL-SURGICAL NURSING.
By Joan Luckmann, RN, BS, MA, Formerly, Instructor of
Nursing, University of Washington, Highline College,
Seattle, Oakland City College, and Providence Hospital
College of Nursing, Oakland, CA; and Karen Creason
Sorensen, RN, BS, MN, Formerly, Lecturer in Nursing,
University of Washington; Formerly, Instructor of Nursing,
Highline College; Formerly, Nurse Clinical Specialist,
University Hospital and Firland Sanatorium, Seattle, WA.
2276 pp. 817 ill. $40.80. March 1980. Order #5806-7.
Also Available:
Sorensen & Luckmann
BASIC NURSING
A Psychophysiologic Approach
131 1 pp. 408 ill. $34.80. March 1979. Order #8498-X.
l\Y.B. Qaunders Company
^-^ 1 Goldthorne Ave., Toronto, Ontario M8Z 5T9, Canada
Send on no-risk 30-day approval:
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$30 Other
A comprehensive role
Author Mohamed
Rajabally (January) argues
that the comprehensive
examination for nurse
registration is in response to
changes in nursing education
and is inconsistent with the
practice of nursing.
I would argue that
nursing education is
responding to the needs of
nursing practice, the need for
practitioners who can
respond to the unique set of
nursing problems that
individual patients and their
families present.
Patients do not present
nice compartmentalized
problems labeled medical,
surgical, obstetrical and
pediatric nursing; patients do
present an individual mix of
nursing problems to which
the modern nurse must
respond. These demands
require the mobilization of a
wide range of nursing
knowledge and skill.
The Canadian Nurses
Association Testing Service
should be congratulated for
its response to changing
nursing needs and encouraged
to continue to examine the
problems which may result
from these changes.
Solutions can be found
to the problems presented by
failing candidates. How many
items do we really need for
a valid and reliable examina
tion? Is it possible to give a
sub-score report so that
failing candidates may know
their areas of weakness? We
must not abandon a forward
step because of some
problems which no doubt can
be resolved.
Canadian nurses should
be proud and support this
forward step.
-Patricia Stanojevic, RN,
Etobicoke, Ontario.
A managerial role
The statement by
Frances M. Tufts that, "When
nurse X has shown her
inability to function in any
other area, she is sent to OBS
unit", is very sweeping and
one I suspect not founded on
analyzed data. The
implication is that this
department is staffed by
numbers of incompetent
general staff and management
nurses. I personally have
more faith in the integrity of
nursing than to believe this.
Head Nurses should not
play the role of "hatchet
women"; rather, with a sound
performance appraisal system
in place, clearly define the
weakness of the individual
worker, set deadlines for
improvement and options if
expectations are not met. The
role of the head nurse as a
manager of staff is of
paramount importance but
have we in education and
senior management helped
him/her develop the
necessary skills? I do agree we
have to look to education and
inservice to develop
knowledge and skill.
OBS provides a
challenge, as do many other
services that are dynamic and
respond to the medical,
technical and social changes
inherent in our world of
today.
I am not in doubt that
the writer s intent was
sincere, but I am concerned
that the self-confidence and
integrity of some OBS nurses
may have been damaged by
such comments.
M. Gwen Hefferman,
Director of Nursing Staff
Education, Ottawa Civic
Hospital, Ottawa.
A busy spot
In response to Frances
Tufts letter (February), our
OBS department is not a
"dumping" ground for
incompetent or over-the-hill
nurses. No transfers are made
to any department to my
knowledge: vacancies are
filled by requested transfers
from other departments.
Our OBS-GYN ward is
one of the busiest in the
hospital. Nursing and other
staff must be able to cope
with the confusion resulting
from many admissions and
discharges, a wide range of
age groups, normal deliveries,
caesarean sections, prenatals
toxemia, hyperemesis,
bleeding, as well as
hysterectomies, vaginal
repairs, ectopics, other pelvic
and permeal surgery, D & C,
abortions just to mention
some of them.
Just like other floors,
we also have to treat the
medical aspects of our
patients depression,
diabetes, hypertension, drug
dependency and abuse; again,
just to mention some of
them.
The hospital inservice
keeps us abreast of medical
and nursing developments
and as well, our own area
has lectures and discussions
frequently. We also do a great
deal of teaching.
I think Frances Tufts
had better take another look!
Gloria Norwich, RN,
Oshawa, Ontario. *t
CNA
PROJECT REPORT
Development of a
Definition of Nursing Practice
and Standards
for Nursing Practice.
What do national standards for nursing practice mean to you? To help you
answer this important question we re giving you, on these four pages, draft
statements drawn from the work that began in July 1979 by the CNA Task
Group. It s a priority 1978-80 biennium project to be presented to the CNA
Board of Directors in Vancouver in June. What you read here is a substantial
basis for the presentation to be made - the work isn t over yet and that s why
we need your help now... It s important that you have the opportunity to
participate in the final development of a definition of nursing practice and
standards for nursing practice along with your national association.
Where it started...
One of the initial premises of the project was to utilize a
conceptual model approach to the development of a
definition of nursing practice and standards for nursing
practice.
There is a very real need for the nursing profession
as a vital member of the multidisciplinary health care
team, to identify and clarify nursing s unique
contribution to society to determine how it meets
societie s needs. What is the role of the nurse? Whatrfo
nurses do?
A conceptual model for nursing is a mental image, or
a way of looking at nursing, usually based on or derived
from theory and/or practice. It provides the direction and
specificity to make explicit nursing s unique independent
role.
Standards for nursing practice based on a conceptual
model approach provide the basis for measuring the
effectiveness of nursing actions.
Several conceptual models for nursing were studied
by the Task Group. Although each conceptual model has
merits and limitations, the decision made by the Task
Group and endorsed by the CNA board of directors, was
not to choose a specific model, but to adopt the principle
that a conceptual model be used to guide nursing practice
regardless of the setting in which that practice occurs.
This principle was built into the definition and the
standards.
The Task Group adopted these principles:
We recognize and endorse the use of a conceptual
model for nursing practice, education, research and
administration in any setting.
Respecting freedom of informed choice, we will not
impose upon others, our choice of any one of the
various conceptual models for nursing that exists.
This freedom of choice will allow for the utilization
of a number of conceptual models for nursing, their
eventual testing and further refinement as well as the
construction of new models.
We believe that the use of a conceptual model for
nursing will contribute to improved quality of
nursing practice, since it provides direction for
behavioural indicators required to evaluate that
practice.
PROJECT REPORT
As a result of the decision of the Task Group not to select a
specific conceptual model upon which to base standards for nursing
practice and because each conceptual model includes a distinct
conceptualization of nursing from which a definition of nursing
practice could be derived, the committee determined that it would
incongruous to develop a restrictive definition of nursing practice.
Philosophical Statement About Nursing
Nursing exists in response to a need of society, and holds ideals
related to man s health throughout his life span and includes the
promotion, maintenance and restoration of health, the prevention of
illness, the alleviation of suffering and the ensuring of a peaceful
death when life is no longer able to be sustained. Nurses value a
holistic view of man and regard him as a biophsychosocial* being
who has the capacity to set goals and make decisions and who has
the right and responsibility to make informed choices congruent with
his own beliefs and values. Nursing, a dynamic and supportive
profession, is rooted in caring, a concept evident throughout its four
fields of activity: practice, education, research and administration.
In assisting man to achieve and maintain optimal health, nurses
practice in a variety of settings and concurrently perform
independent, interdependent and dependent functions. Nursing s
unique independent contribution to health is made explicit through
any one of the various conceptual models for nursing, each of which
is a conception, or way of looking at nursing sufficiently precise as
to provide direction for practice, education, research and
administration. Interdependent functions are evident when nurses
collaborate with other health-directed and health-related workers,
whereas dependent functions are evident when nurses perform
activities under the direction of others such as carrying out
physicians orders. The three overlapping functions all contribute to
man s attainment of optimal health. Nurses value the on-going
discovery, acquistion and critical application of relevant knowledge,
attitudes and skills; these are prerequisites for the promotion of
excellence in nursing practice, education, research and
administration. In their search for excellence, nurses are committed
to the development and implementation of standards for their own
profession.
"The generally accepted term describing man as "biopsychosocial"
is meant here to include among others, spiritual, intellectual,
physical, cultural and environmental dimensions.
Toward a Definition of Nursing Practice
Nursing practice can be defined generally as a dynamic, caring,
helping relationship in which the nurse assists the client to achieve
and maintain optimal health. The nurse accomplishes this goal by
applying knowledge and skills from nursing and related fields using
the nursing process, the substance of which is determined by a
conceptual model for nursing.
A specific definition of nursing practice necessarily depends
upon the conception of nursing held.* There exist several
conceptual models for nursing and the selection of a particular
model is a matter of informed choice. It is therefore necessary that
nurses determine, according to the model chosen, what will be their
specific definition of nursing practice* in their setting. The definition
of nursing practice must influence and be consistent with legislation
governing or affecting the profession, with the code of nursing
ethics, and with policies, procedures and directives in a particular
setting.
*For example, if Roy s conception of nursing were selected, nursing
practice would be oriented to the promotion of man s adaptation in
his four adaptive modes, the nurse would assume the role of
facilitator; her intervention would consist of manipulating the focal,
contextual and residual stimuli that provoke the adaptive or
non-adaptive responses of man. On the other hand, if Henderson s
conception of nursing were selected, nursing practice would be
oriented to the independence of man in the satisfaction of his
fundamental needs, the nurse would assume a complementary-
supplementary role to supply strength, knowledge or will; her
intervention would consist of reinforcing and completing man s
capacities so that he would return to independence in the
satisfaction of his needs.
Beliefs About Standards for Nursing Practice
Standards for nursing practice must be developed by members of
the nursing profession.
Standards for nursing practice must express what is desirable
nursing practice in Canada.
Standards for nursing practice must be broad enough to apply to
any practice setting.
Standards for nursing practice are a prerequisite to the evaluation
of nursing practice, since they provide a baseline for
measurement.
Standards for nursing practice must include expectations about
the independent, interdependent and dependent functions of
nurses.
Standards for nursing practice must include expectations related
to a conceptual model for nursing, the nursing process, the
helping relationship, and professional responsibilities.
Standards for nursing practice must respect the freedom of
informed choice with regard to the selection of a conceptual
model to be used in a given setting.
Standards for nursing practice will influence and be influenced by
not only nursing practice, but also nursing education, research
and administration.
The adoption of standards for nursing practice will help clarify
nurses areas of accountability, since standards provide the health
agency and the client with a basis for evaluation of nursing practice.
Standards for nursing practice must be subjected to continuous
reevaluation.
The adoption of standards by nurses in practice will contribute to
the continued improvement of nursing practice.
How are Standards judged?
Here are some characteristics...
relevant to the domain under consideration
directed toward an ideal
realistic
acceptable
attainable
understandable
developed by experts in the domain
based on current knowledge
phrased in positive terms
indicative of acceptable performance
amenable to measurement
We have organized the standards into four groupings because
we believe that the nurse uses the nursing process as her method for
practice and the model as her conceptual base. The nature of her
interaction with the client is a helping one. Because she is a
professional and practices in a variety of settings, standards related
to professional responsibilities were developed.
It is important to remember that the four are necessarily
interrelated and occur together.
12 Mav1980
PROJECT REPORT
DRAFT
STANDARDS FOR NURSING PRACTICE
STANDARDS RELATED TO A CONCEPTUAL MODEL FOR NURSING
Criterion
Variable
Nursing Standards
Nursing Behaviours
The goal
of nursing
Nursing practice requires the nurse, in any
setting at any time, to have:
1. a clear conception of the distinct goal of
nursing
The Nurse:
1.1 expresses the specific goal of nursing which nursing seeks to attain
1 .2 communicates the goal of nursing to other members of the health team
1.3 states how the goal of nursing contributes to the overall goals of the health team
1.4 describes nursing actions which are consistent with the expressed goal of nursing
1 .5 performs nursing actions (cf. nursing process standards) which are consistent with the
expressed goal of nursing
The client
2. a clear conception of the client toward
whom nursing is directed
2.1 expresses her clear conception of the client
2.2 describes the kind of data to be collected according to her conception of the client
2.3 demonstrates her conception of the client by the kind of data she collects (cf. nursing
process 1.1)
The role of
the nurse
3. a clear conception of her role as a health
professional in response to health needs of
society
3.1 describes her specific role as a nurse
3.2 describes her conception of her role in relation to data analysis and intervention
3.3 demonstrates her conception of her role in data analysis and intervention (cf. nursing
process 2.1, 3.1)
The origin
of difficulty
4. a clear conception of the source of the
client s actual or potential difficulty
4.1 states the source of difficulty as defined by the conceptual model for nursing
4.2 describes how she will interpret data according to her conception of the type of client
problems that fall within the scope of her responsibility
4.3 demonstrates her conception of the source of client difficulty in her analysis of data
(cf. nursing process 2.1)
The focus and
modes of
intervention
5. a clear conception of the focus and modes
of nursing intervention
5.1 states her conception of the focus and modes of nursing intervention as defined by
the conceptual model for nursing
5.2 describes her intervention in relation to its focus and according to the means she has
at her disposal
5.3 demonstrates this conception in the actions she plans and carries out (cf. nursing
process)
The expected
results of
nursing
activities
6. a clear conception of the expected results
of nursing activities related to the goal
of nursing as expressed in the conceptual
model for nursing
6.1 describes expected results of her nursing activities as defined by the conceptual
model for nursing
6.2 demonstrates her conception of the expected results in the evaluation of her nursing
activities
STANDARDS RELATED TO THE NURSING PROCESS
Criterion
Variable
Nursing Standards
Nursing Behaviours
Collection
of Data
Nursing Practice requires the nurse to:
1. collect data in accord with her conception
of the client, and with her interdependent
and dependent functions
The Nurse:
1.1 systematically and continuously collects data that are relevant to her conception of the
client (cf. conceptual model 2.3)
1 .2 systematically and continuously collects data necessary for her to fulfill her interde
pendent and dependent functions
1.3 determines the client s expectations for care
1.4 uses all available sources for data collection including: client, family, relevant others,
records. the nurse s own knowledge and experience
1.5 employs various techniques in data collection including: interview, consultation,
physical examination, observation, measurement
1.6 treats data with regard for the confidentiality of those concerned
1.7 makes available relevant data to appropriate persons
Analysis
of Data
analyze data collected in accord with her
conception of the client s source of difficulty
and consistent with her interdependent
and dependent functions
2.1 examines and interprets the data
2.2 validates with the client and/or others when possible, her interpretation of the data
collected
2.3 identifies with the client actual and/or potential problems as suggested by the source
of difficulty
2.4 sets priorities for resolution of identified problems
2.5 communicates with appropriate others regarding identified problems
Planning
of the
intervention
plan her nursing actions based upon the
identified actual and potential client prob
lems and in accord with her conception of
the focus and modes of intervention as
well as nursing actions which arise from
her interdependent and dependent func
tions
3.1 identifies short and long term objectives of nursing actions in collaboration with the
client and relevant others (cf. conceptual model 5.3)
3.2 states the objectives in behavioural terms specifying the desired results
3.3 states a reasonable time period for achievement of these objectives
3.4 considers environmental conditions which could affect achievement of objectives
3.5 identifies requires resources
3.6 considers a number of nursing actions" in accord with the specified focus and modes
of intervention
PROJECT REPORT
DRAFT
STANDARDS FOR NURSING PRACTICE
STANDARDS RELATED TO THE NURSING PROCESS
Criterion
Variable
Nursing Standards
Nursing Behaviours
Planning
of the
Intervention
Nursing practice requires the nurse to:
3. plan her nursing actions based upon the
identified actual and potential client prob
lems and in accord with her conception of
the locus and modes ol intervention as
well as nursing actions which arise from
her interdependent and dependent func
tions
The Nurse:
3.7 selects nursing actions based on the highest probability of their effectiveness
3.8 plans nursing actions that derive from her independent, interdependent and dependent
functions
3.9 communicates with appropriate others regarding the planned interventions
Implementation
of the
Intervention
4- perform nursing actions which implement
the plan
4.1 encourages client participation whenever possible in carrying out nursing actions to
meet objectives (cf. helping relationship 1.9)
4.2 carries out nursing actions demonstrating required knowledge, attitudes and skills
4.3 utilizes appropriate resources
4.4 manipulates the environment to meet the objectives
4.5 communicates with appropriate others regarding nursing actions
Evaluation
5. evaluate all steps of the nursing process in
accord with her conceptual model for
nursing and consistent with her interdepen
dent and dependent functions
5.1 observes the results of her nursing actions
5.2 compares the results of nursing actions with those stated in the short and long term
objectives
5.3 judges, within the context of client participation the degree to which the objectives
have been met in accord with her conception of the expected results (cf, conceptual
model 6.2)
5.4 communicates with appropriate others regarding her evaluation
5.5 revises the objectives, priorities and nursing actions as indicated
5.6 implements the modified plan of action
5.7 continues in cyclical fashion the entire nursing process until the client-nurse relation
ship is terminated
* Nursing actions include teaching, supporting, counselling, informing, refering. providing care (comfort measures, maintenance, preventive, diagnostic, therapeutic). Canadian
Nurses Association A Blueprint for a Comprehensive Examination for Nurse Registration /Licensure (Ottawa: May 1977}, p. 4.
STANDARDS RELATED TO THE HELPING RELATIONSHIP
Criterion
Variable
Nursing Standards
Nursing Behaviours
Entry
Nursing Practice requires the nurse to:
T. initiate the helping relationship with the
client
The Nurse:
1 . 1 identifies herself and explains her role and responsibility to the client at her earliest
opportunity
1.2 ensures client understanding
1.3 ensures her communication is purposeful, appropriate and relevant
1.4 shows undivided attention through verbal and non-verbal behaviour
1.5 invites client participation in the helping relationship
1 .6 ascertains what the client expecls to give and to get from the relationship
1.7 establishes the duration of the relationship with the client in order for each to prepare
for eventual termination of the relationship
1.8 discusses confidentiality with the client indicating with whom any information will be
shared and why
1 .9 sets realistic nursing care objectives in collaboration with the client
1.10 makes explicit her availability and approach-ability with respect to client s needs
1.11 demonstrates congruency in verbal communication (words, touch, facial expression,
posture)
1.12 recognizes her own prejudices and handles them appropriately
Maintenance
2. assume responsibility for maintaining the
helping relationship
2.1 encourages the client to the express his beliefs, emotions and opinions
2.2 indicates her respect for the client s verbal expression or silence
2.3 refrains from making assumptions about the client s knowledge and values
2.4 initiates and stimulates in the mind of the client those insights that are important for
his own health
2.5 recognizes the client s thresholds of tolerance
2.6 recognizes and deals with unintentional threat to the client
2.7 recognizes her own limitations and admits error
2.8 discriminates nursing actions that should be for or with the client
Termination
3. assume responsibility for terminating the
helping relationship
3.1 reminds the client that the termination date is at hand
3.2 encourages the client s expression of emotion related to separation
3.3 recognizes and deals with her own emotions related to separation
3.4 reviews with the client accomplishment toward meeting mutual objectives
3.5 ensures that the termination of the relationship is complete and final
PROJECT REPORT
DRAFT
STANDARDS FOR NURSING PRACTICE
STANDARDS RELATED TO PROFESSIONAL RESPONSIBILITIES 1
Criterion
Variable
Nursing Standards
Nursing Behaviours
Legal
responsibility
Nursing practice requires the nurse to:
1. conform to statutes, policies, procedures
and directives relevant to the practice
setting
The Nurse:
1.1 knows relevant legislation governing or affecting the profession
1.2 practices within the recognized scope of nursing as defined by a conceptual model for
nursing and her interdependent and dependent functions
1.3 follows established legal procedures in the maintenance of records, obtaining con
sents, indentification of clients, use of control drugs
1 4 reports unsafe practice or professional misconduct of other nursing personnel to
appropriate authorities
1.5 knows the implications related to nurse registration/licensure
Ethical
responsibility
2. conform to the code ol ethics of her
profession
2.1 protects the rights of the individual such as confidentiality, privacy, beliefs, values (cf.
nursing process 1.6; helping relationship 1.8)
2.2 reports errors and omissions and takes appropriate action
2.3 recognizes own limitations and seeks appropriate resources
2.4 reports unsafe practices of other health care workers to appropriate persons
2.5 maintains an acceptable standard of nursing practice and professional behaviour as
determined by national and provincial nursing associations and own setting
Administrative
responsibility
3. comply with administrative practices and
procedures in a given setting
3.1 follows established administrative policies and procedures.
3.2 uses appropriate channels of communication
3.3 guides and supervises auxiliary nursing personnel in accord with her job description
and/or directives in her setting
3.4 recognizes health hazards in the work setting and takes appropriate action
1. Adapted from:
Canadian Nurses Association A Blueprint for a Comprehensive Examination for nurse Registration /Licensure (Ottawa: May. 1977). pp. 4-5
Tell us what you think about these draft statements
Philosophical statement about nursing
Toward a definition of nursing practice
Beliefs about national standards for nursing practice
Standards related to a conceptual model for nursing
Standards related to the nursing process
Standards related to the helping relationship
Standards related to professional responsibilities
Please write
your comments
and send to:
Patricia Wallace,
Project Director,
Canadian Nurses Association.
50 The Driveway,
Ottawa, Ontario K2P 1E2
Introducing New
they stay twice
Why It s Better
for Baby
Softer surface next to
baby s skin
D Embossed topsheet looks
and feels softer. . - reduces
skin contact and increases
separation of skin from
moisture in pad.
A drier, more
comfortable baby
D Polyester fibre topsheet is
more hydrophobic . . . does
not absorb fluids itself but
encourages passage
through into absorbent
padding below. . .resists
backflow.
D Stronger absorbent pad
with stronger tissue enve
lope... provides 225 percent
more wet strength for a
60 percent reduction in
tearing and shredding.
Proof Positive That Quilted Pampers
Stay Twice as Dry as Cloth
Equal amounts of
water are placed on
each diaper
A blotter is placed
over each wetted
A weight is placed on
each blotter
Quilted Pampers is
twice as dry as cloth
Quilted Pampers
as dry as doth
Pampers
used more often than cloth
in hospital nurseries
For further information write to
Pampers Professional Services
PO Box 355 Station "A"
Why
It s Better
for Nurse
and Better
for Mother
Saves time and
work
The superior contain
ment of New Quilted
Pampers versus cloth
benefits both nurses anc
mothers with:
D Fewer changes of
bed linen and
baby s clothing.
D More time for
other important
tasks for nurses,
more playtime
with baby for
mothers.
Easier than cloth to
fit and change
A one-piece system
more convenient than
cloth to change and clean
up easy to fit with tape,
not pins.
CNA Directors Approve Nursing Ethics Code,
1980 Budget and Health Services Brief
Approval of the first Canadian Code of Ethics for nurses a person-
oriented care ethic applicable to nursing service, education, adminis
tration and research was at the top of the list of accomplishments of
CNA directors at this year s Spring meeting.
The three-day, end of February meeting at CNA House in
Ottawa also saw directors:
officially endorse CNA s brief to the Health Services Review 79
dealing with ways of putting "health" into health care
approve a $3,275,093 budget for the national association for
1980
finalize plans for theassociation sannual meeting and convention
give the go-ahead to activities which will serve as preliminary
steps to an accreditation project, and
approve a position statement supporting the recommendation
of the Canadian Law Reform Commission concerning the definition
of death.
Numerous reports were received by directors during the course
of the meeting, including those from:
CNA s Nursing Research Committee
the director of the association s Development of a Definition
of Nursing Practice and Standards for Nursing Practice Project
CNA s member-at-large for nursing education, Margaret
McCrady, on the National Forum on Nursing Education in Ottawa last
Fall, and
Principal Nursing Officer Dr. Josephine Flaherty.
The Code of Ethics, a copy of which is contained in this issue of The
Canadian Nurse, will be presented to nurses attending the annual
meeting in Vancouver for endorsement by the association membership.
The Code, officially titled "CNA Code of Ethics: an
ethical basis for nursing in Canada", is the result of almost two years
of work by Sister Simone Roach of Antigonish, N.S. Sister Roach, who
is on a study leave from her job as chairman of the nursing department
of St. Francis Xavier University to act as project director, believes that:
"At this point in our history, our credibility as a profession may very
well depend on (1 ) the motivation and ability of individuals and the
profession to make a person-oriented care ethic operational in nursing
practice, education, administration and research and (2) the conviction
with which we express this person-oriented care ethic in our codes
of ethics."
The Code of Ethics grew out of a resolution approved by CNA
membership at the annual meeting in Toronto in 1978. Sister Roach
met with eminent specialists in bioethics, nursing and medicine at
conferences and seminars in Canada and the United States during the
period in which she was developing the Code.
The 1980 budget approved by directors puts CNA in the black again,
with a predicted excess of revenue over expenditures of $30,179.
Membership fees are expected to reach just over $2 million or
$2,039,215 in 1980, assuming the same level of membership as in the
previous year. Other revenue, including subscriptions and advertising
for The Canadian Nurse and L infirmiere canadienne, and GNATS
examination fees is estimated at $1 ,972,926. (For more information see
"Where does my money go?" and "Who pays what?"
The final draft of the report on the Development of a Definition of
Nursing Practice and Standards for Nursing Practice will be in the
hands of CNA directors on schedule in June, according to project
director Pat Wallace, who has been working with a task group on the
project. Directors also approved a second, "interpretation phase" of
the project to follow release of the final documents. (See also page 1 1
of this issue.)
Two CNA position statements were approved by directors during the
course of the meeting. The first, a re-affirmation of the association s
belief that "the delivery of nursing care is the social and professional
responsibility of nurses", states:
"Some hospital administrations have employed persons other than
nurses to direct nursing services. Although this situation occurs
infrequently, CNA has decided to take a position on the issue because
of the seriousness and the consequences of such a move.
The CNA affirms that:
1. Nursing services must be administered by a director who has the
responsibility to ensure the quality of nursing care and the provision of
it in a quantity sufficient to respond to the needs of clients.
2. The director must have educational preparation in nursing and in
administration.
3. The person occupying the position of director must report
directly to the executive director and must therefore be at the top
policy making, level of the organizational structure. "
The second CNA position statement approved by directors
reads as follows:
The Canadian Nurses Association supports the recommendations of the
Law Reform Commission to Parliament regarding proposed changes in
the legislation on the definition of death. The Canadian Nurses
Association believes that this legislation should be adopted as a
safeguard to the quality of health care in Canada. The Association
recognizes that difficulties arise in the clinical area as a result of
inadequacies in the present legislation. There is evidence that some
health professionals, for fear of legal consequences, are reluctant to
stop aggressive treatment for the person with irreversible cessation of
all brain function. The impact of continuing life-support measures in
such circumstances may be profound for family members, for persons
such as nurses who provide direct care to the patient, and for other
citizens with potentially reversible conditons who require the
sophisticated technology and health services being used for the brain
damaged person. The Canadian Nurses Association believes that this
current state of affairs is undesirable for both its members, and for
members of the public. The proposed legislation will facilitate clinical
decision making and thereby promote long term benefits both for
providers and consumers of health care.
WHO PAYS WHAT?
CNA membership
fee revenue.
1979
Total
Per capita
Prov./Terr.
Membership
paid
$
fee
f
RNABC
18,561
31 2,448
9
16.83
AARN
14,641
257,913
17.61
SRNA
7,656
132,183
17.26
MARN
7,748
133,839
17.27
RNAO
15,125
266,063
17.50
OIIQ
46,868
570,384
12.17
NBARN
5,151
87,093
16.90
RNANS
6,929
119,097
17.19
ANPEI
971
1 1 ,983
12.34
ARNN
3,884
64,287
16.55
NWTRNA
212
1,908
9.00
127,746
1,957,198
15.32
Late fees paid
198
Affiliate fees
150
Total
127,746
1,957,546
15.32
WHERE DOES MY MONEY GO?
CNA membership fee expenditure
and members equity, 1979
Total fees
% of total
Per member
Boards & committees
$ 172,253
8.80
$ 1.35
Special projects
169,642
8.67
1.33
Labour relations
139,401
7.12
1.09
Affiliation & sponsorship
282,280
14.42
2.21
Library
161,560
8.25
1.26
CNA Testing Service
108,537
5.54
.85
Public relations
84,871
4.34
.66
The Canadian Nurse
385,835
19.72
3.02
L infirmiere canadienne
374,133
19.11
2.93
House Expansion $50,000
Member Equity _ _ n .
Surplus 29,034
79,034
4.03
.62
Total
$ 1,957,546
100.00%
$ 15.32
Though the unit fee per individual CNA
member was $18.00 in 1979, the total fee revenue received from 127,746 CNA members at
December 31, 1979 (based on information provided January 1980) was $1,957,546 or a
per capita fee of
$15.32. Fees paid on behalf of
individual provincial members ranged from
$17.61 to $9.00.
CNA directors approve seven resolutions for presentation at annual meeting
Voting delegates attending the CNA annual meeting and
convention will be called upon to consider the following
resolutions approved by directors of the association at their
March meeting for presentation at the 1 980 meeting.
CERTIFICATION
1. Whereas, the American Nurses Association has developed
and adopted an ANA certification to recognize excellence in
the practice of nursing administration, and such certification
is available to qualified nurse administrators by means of
examinations;
Resolved, that the Canadian Nurses Association discuss
with the American Nurses Association the feasibility of making
this certificate examination available to Canadian nurse
administrators, or in lieu of this that the Canadian Nurses
Association investigate and develop a comparable tool for
Canadian nurses.
CONTINUING EDUCATION
2. Resolved, that the Board of Directors of the Canadian
Nurses Association study the issues inherent in continuing
education for nurses and produce a position paper on
continuing education for registered nurses in Canada during
the 1980-82 biennium.
INCOME TAX
3. Whereas, the person who works in the home may wish to
augment his/her skills by attending courses offered in publicly
funded institutions of learning;
Whereas, the competence of each spouse should be
maintained in a healthy, informed family life; and
Whereas, the Income Tax Act encourages one spouse to
improve his/her knowledge through provision of an income tax
deduction for course fees, while not providing the same
privilege for the other;
Resolved, that the Canadian Nurses Association support the
National Council of Women of Canada in their request to the
Government of Canada to amend the Income Tax Act to
provide income tax deduction to wage earners for monies
expended on such continuing education courses for their
non-earning spouses.
ADMINISTRATION
4. Resolved, that the Canadian Nurses Association publicly
re-affirm its belief that the executive responsible for the
Department of Nursing shall be an educationally qualified
registered nurse who shall be a member of the senior hospital
administrative staff, reporting directly to the chief executive
officer; and further be it
Resolved, that the Canadian Nurses Association request the
Canadian Council on Hospital Accreditation to enforce the
above standard which is stated in Standard Number Two under
Nursing Services section of the Guide to Hospital
Accreditation 1977, as a basis for accreditation of nursing
departments.
BACCALAUREATE DEGREE
5. Resolved, that the Canadian Nurses Association establish as
a priority for the next biennium, the development of a
statement concerning the baccalaureate degree in nursing as
the minimal educational requirement for the practice of
professional nursing in Canada.
SPECIALIZATION
6. Whereas, the practice of nursing has become greatly
diversified and the level of knowledge and skill required in
various specialty areas of nursing practice is increasing rapidly;
Whereas, it is improbable that students in nursing programs
will receive theoretical and clinical content in specialized
practice areas; and
Whereas, Canadian nurses are beginning to write the
examinations for certification in nursing specialties developed
by the American Nurses Association in increasing numbers;
Resolved, that the CNA Board of Directors study the
feasibility of developing examinations for certification in
major nursing specialties.
INDEPENDENT PRACTITIONERS
7. Whereas, professional nurses are becoming more involved in
independent health promotion activities and are providing care
to clients as independent practitioners in a variety of settings;
Resolved, that the CNA go on record as favoring the
concept that independent nursing services provided to clients
by professional nurses be eligible for compensatory coverage
in provincial health care plans.
Putting "health" into health
care,CNA brief promotes
more use of nurses
"A strategy to achieve the next level of wellness for Canadians,"
is the description CN A gives to the recommendations contained
in its brief to Health Services Review 79, presented to former
Supreme Court Justice Emmett Hall in Ottawa on March 4th.
Speaking on behalf of the nurses of Canada, association
spokesmen advocated the development of a health care system
that would allow the initiation of more programs promoting
primary health care, new points of entry into the system and
more efficient use of all qualified health personnel.
"Nurses, who comprise two thirds of the health occupations,
declare with confidence that they are capable of demonstrating
their abilities to make major contributions to the development
of the system in a variety of ways : store-front health counseling
clinics, nurse practitioners in medical clinics, increased public
health services and programs, community health centres,
clinical nurse specialists in hospitals to do special teaching,
follow-up programs in the home, through greater coordina
tion and care by nurses in home situations."
The eight recommendations contained in the brief are as
follows:
Recommendation 1
That the existing legislation underlying the hospital and
medical insurance programs be revised to allow the emergence
of a health insurance program which would stimulate the
development of primary health care services, permit the
introduction of new entry points and promote the appropriate
utilization of qualified health personnel.
The promotion of the appropriate utilization of qualified
health personnel will require other legislative revisions to
enable nurses and other prepared health personnel to undertake
activities which currently are legally defined as the exclusive
domain of medicine.
Recommendation 2
That provincial legislation be revised to enable qualified nurses
and other prepared health personnel to undertake activities
currently defined as medical acts.
The immediate corollary to the foregoing recommendations is
the need to institute a mechanism for remunerating all health
personnel by salary. This submission illustrates how the
fee-for-service payment scheme for physicians, together with
their guardian role of the gates of the system, cannot but
increase the use of costly acute care services, whether necessary
or not.
Recommendation 3
That remuneration of all health personnel be by salary.
Concrete examples are used to demonstrate the need to over
come the complexities and frustrations confronting the users
of the system. New points of entry, as recommended by CNA,
refer to the recognition of innovative uses of existing facilities
and organizations, rather than the building of costly new
structures.
Recommendation 4
That Health Services Review 79 strongly support the initiation
of better preventive, diagnostic and ambulatory care programs
through various community -based points of entry.
The basic principles of the Charter of Health are the uniting
force which transforms ten provincial systems of health care
into a national system. It is essential that criteria be developed
by the federal and provincial governments, in concert with
non-governmental organizations to ensure that these principles
are honored.
Recommendation 5
That the federal and provincial governments, together with
relevant non-governmental organizations, develop criteria to
ensure that the underlying principles of the Canadian health
insurance system are being upheld.
A basic requisite to the preceding recommended changes is the
need for health research and its fruit, data on the health status
of Canadians and the health care system.
Recommendation 6
That a health sciences research council be established to focus
on the study of health services, the system of delivery and its
effectiveness.
Recommendation 7
That the federal government be requested to reinstitute a
national health survey which would provide the necessary
information upon which to build and evaluate a health care
system to meet the needs of the people.
Canadian consumers are becoming increasingly knowledgeable
and articulate regarding their purchase of goods and services.
These consumers should be as knowledgeable about the types
of health professionals, the cost of the services and the sources
of care, as they are about the ingredients, cost and metric
containers of peanut butter.
Recommendation 8
That all governments and health profession organizations be
urged by Health Services Review 79 to adopt, as a priority,
better and broader health education programs to sensitize
consumers to the cost of acute care services. *
Given clinically documented eq ui potency 1 ?". .
Why complicate
simple analgesia?
ASA side effects
(at normal doses)
Adverse effects
...on hypersensitive
individuals 34
...on the
gastrointestinal tract 7
...during
pregnancy
...of concomitant
use with
other drugs 26
..on the blood 56
LENOL side effects
(at normal doses)
...resulting in
iron-deficiency
anemia 512
Hypersensitivity
in rare instances ;
13,14
References:
I . Botterman. R C , and Grossman, A J fed. ncc 14
316-317 (Mar ) 1955. 2. Goodman, IS , ono*G.lman. A .
eds : The Pharmacological Basis of Therapeutics, ed 5,
New York, The Macmitlan Company, 1975. (a) p 334,
(b) pp. 1350-1368 3. Yunginger. J W . O Conneil, E.W.,
and logon, GB J Ped.atr 82: 218 221 (Feb.) 1973 4.
Setupane. G A . Chalee, F H.. and Klein, D E.: J Allergy
Clm Immunol 53 20a204 (Apr ) 1974 5. Menguy, R
Am ) Clm Kes 2 17-26, 36-37 (Apr) 1971.6. Sprvack.
M.Med Times 99 129 133 (Jon ) 1971 7. Croft. D.N..
and Wood, P H.N Br Med.J. 1- 137-141 (Jan 21)
1967 8. Cooke, AR Am J Dig D.s 18 225-237
(Mot.) 1 973 9. Turner. G , and Collins. E : Lancer 2
338-339, 1975 10. Lewis. R B , and Schulmon, J D
Lancet 2 1 159-1161. 1973 11 . Bleye-, W A., and
B eckenndge. R T JAMA 21 3 2049-2053. 1970 12.
Summerskill, W.H.J.. and Alvarez, AS Lancet 2: 925-928
(Nov) 1958 13. Prescon. L.F S.de Effects of Drugs,
A logical first choice in
non-Rx analgesia
TYLENOL
acetaminophen
REGULAR STRENGTH /EXTRA- STRENGTH
325
g^n ^-Sto^. 00 mg
nuumra
GUELPH, ONTARIO N1H 7L4
news
Fun and fitness featured
at orthopedic nurses
meeting
"Canadians must be taught
what fitness is, how to get fit
and how to stay fit," says
former Olympic contender
Abby Hoffman, supervisor of
Sports Services with the
Ministry of Culture and
Recreation of Ontario.
Hoffman, who was guest
speaker at the recent third
annual conference of the
Canadian Orthopedic Nurses
Association, believes that
Canadians generally lead
inactive lives and that, to
date, our approach to
changing this has not been
effective.
Children attending
physical fitness classes,
Hoffman says, are taught
specialized skills, such as
shooting baskets, which they
will never be able to use
again. The aerobic aspect of
fitness is only just beginning
to be recognized: many of
our male population still feel
they are staying in shape if
they participate in short
season, non-aerobic sports
such as baseball, football and
hockey. Even elite athletes
sustain fewer injuries if they
maintain good basic fitness
levels.
Hoffman was one of 25
speakers featured at the 3-day
CONA conference which
took place in Toronto. A
total of more than 600 nurses
from across Canada and the
United States were in
attendance. In addition to
the papers and business
sessions, nurses were also
given the opportunity to tour
three large orthopedic
facilities in the Metro area.
Two Montreal nurses
were signalled out for special
recognition during the
meeting: Orthopedic Nurse of
the Year, an award sponsored
by Dillon Company, went to
Doreen Morin of St. Mary s
Hospital. Mary Flannery of
the Montreal Children s
Hospital received the Dupuis
Award for Continuing
Education for her
contribution to continuing
education in the orthopedic
nursing field.
The CONA journal,
now in its second year of
publication, with a
circulation of more than 800
CONA members, is currently
sponsoring a writing contest
to encourage members to
contribute to their journal.
For more information
on the Canadian Orthopedic
Nurses Association, contact:
CONA, 43 Wellesley Street
East, Toronto, Ont. M4Y 1H1.
Reminders for Vancouver!
A short list to help you plan for the best possible time:
Post convention tours:
Local A variety to choose from: Harbour Centre and
Gastown; city tour with dinner, Grouse Mountain tour
with dinner, etc. Register now or after arrival.
Distant Trips to Victoria, Seattle, San Francisco and
many other cities. Contact: Kanata Travel Consultants
307-837 West Hastings St.
Vancouver, B.C. V6C 1B6
Special Breakfasts each day; tickets at the hospitality
desk.
Luncheons June 22, 24 and 25; hosted by the
planning committee and RNABC; tickets at the
hospitality desk.
A bus to Stanley Park for early morning joggers; sign up
at tour desk.
CAUSN registration
over the 1 00 mark
Ann Hilton
Accountability in nursing
education was the theme of
the Western Region Canadian
Association of University
Schools of Nursing
conference. "We are
accountable to only two
groups: the public and the
profession of nursing, which
gives us a mandate and
invests in us its trust to
prepare those who will be the
nurses of tomorrow and
future leaders of nursing,"
Dr. Dorothy Kergin, director
of the University of Victoria
School of Nursing remarked
in her keynote address.
"We are not
accountable to students nor
to future employers but we
are responsible for providing
students with the
opportunity to develop the
skills and abilities to practice
competently as professional
nurses. These skills provide
them with the reasonable
expectation of employment
and we must describe the
abilities of the graduates so
that employers may decide
whether or not to employ
them."
Speakers taking part in
a panel discussion focused on
who really is accountable for
what. Dr. Bud Phillips from
the Vancouver School of
Theology explored differences
between responsibilityand
accountability; Maureen
Creed, a fourth-year student
at U.B.C., gave examples of
how we must be accountable
for our own actions from the
viewpoint of the practitioner.
"Hospitals must
provide the climate, facilities
and role models for
appropriate learning," said
Roselyn Smith, director of
nursing at Children s
Hospital. Ann Taylor,
director of nursing,
Metropolitan Health Services,
stressed outcome-oriented
management and emphasized
priority determination.
Dr. Marilyn Willman, director
of U.B.C. School of Nursing,
posed the question of nursing
educator s accountability.
Anne Wyness from U.B.C.
chaired the panel.
Sue Rothwell, director
of nursing at the Cancer
Control Agency with a dual
appointment at U.B.C.,
former president of RNABC,
chose the topic of "Political
Accountability in Nursing
Education", for her luncheon
address.
"The first step in our
responsibility is to shake off
our naive beliefs about health
care as an inalienable right,"
she said. "Health care is
alleged to be a right of
Canadians, but how it will
actually be provided is
determined more by a
politician s need for votes
than by rational process. The
political questions of
regulation of professionals
and, to a large extent, long
range policy planning are
overshadowed by the
economic considerations of
cost. The larger the cost, the
hotter the political interest
becomes.
"It is not enough that
we teach students the right
values and the proper way to
nurse, and then excuse our
colleagues in health agencies
for their poor performance.
For our political
accountability we need to be
in there beside our colleagues
and our students, changing
what is wrong. If we merely
excuse it, we perpetuate the
uncritical thinking and acting
that leads to divisiveness
among us."
Other speakers included:
Kay Arpin, University of
Toronto, "Joint Appoint
ments: Strengthening the
Clinical Practice Component
in Nursing Education
Program"; Omaima Mansi,
McGill University, "Our
Graduates will be
Accountable for Their
Nursing Practice: A Promise
Declared to Our Profession
and to the Public and a
Commitment Made to Our
Students"; Ann Murphy,
U.B.C., "Personal Accounta
bility as the Core of
Professional Accountability";
and Ina Watson, University of
Saskatchewan, "Socialization
of the Nursing Student in the
Professional Nursing
Education Program."
More than 1 00
registrants attended the
conference, the largest in the
association s history.
Nutritionists share findings
on diet and health
What kind of society dooms its children to
preventable illness such as coronary disease,
hyperlipedemia, hypertension and obesity?
Why are the dietary habits of our teenagers,
especially 16-17 year old females, inadequate
to ensure optimum health? These were some
of the questions raised at a two-day Kellogg
Salada Nutrition Symposium attended by
more than 300 nutritionists, medical
personnel, journalists and others in Toronto
in mid-March. The latest information on the
relationship between nutrition, lifestyle and
health included reports on:
a 1978 nutrient intake study of nearly
400 Ontario school children by Dr. Harvey
Anderson, University of Toronto and
Dr. Anthony Hargreaves, Harvard University
indicating that, as children grow older, more
non-traditional foods are included in their
diets and the total nutritional quality of most
frequently consumed foods decreases. In all
age groups, rural children drank less orange
juice and took fewer vitamin supplements
than their urban counterparts. Of greatest
concern were the dietary habits of teenagers,
particularly the 16-17 year old females, who
seem to need aggressive nutrition education
programs.
hospital malnutrition, assessed as
affecting between 40 and 50 per cent of
patients in one general city hospital.
Dr. G. Blackburn, Harvard Medical School,
reported that he has found low nutritional
status to be associated with anergy (a lack of
response to an injected allergen or antigen)
which is in turn associated with an increased
frequency of sepsis and mortality. If this
anergic state is due to malnutrition, it may be
reversed within three weeks if the nutritional
state is improved. Individuals must receive
protein every day as depletion occurs rapidly
if daily requirements are not met but, with
the availability of protein enriched glucose
solutions, it is no longer necessary to maintain
patients on plain glucose for days at a time.
On the other hand, when total parenteral
nutrition is used, only 2000-2500 calories
should be given, as more is not necessarily
better.
Studies have now been completed
showing nutrition as the major contributing
factor in complications leading to the use of
respiratory and intensive care units. Dr.
Blackburn feels that biometric assessments or
nutritional screening on an outpatient basis of
all individuals scheduled for surgery would
allow recognition of those at high risk for
protein-calorie malnutrition.
myths of diet and cancer and new areas
of concern. To date researchers have been
unable to demonstrate any increased risk of
bladder cancer with the use of artificial
sweeteners, while alcohol has been found to
effect an increased incidence of oral,
esophageal and laryngeal cancer when taken
in amounts comparable to seven shots of
whiskey daily.
"Cardiac disease and cancer are not
necessarily problems of old age" stated
Dr. Ernst Wynder, President, American
Health Foundation. "Most human cancers are
related to man s lifestyle, especially in terms
of what he smokes, eats and drinks." In fact,
one-half of all cancers experienced by women
relate to dietary factors as do one-third of all
cancers experienced by men. In North
America, one person in 15 can expect to
develop cancer of the colon during their
lifetime. While there seems to be no
relationship between this type of cancer and
constipation, there does seem to be a relation
ship to a high fat diet. Similarly, a high fat
diet, either saturated or unsaturated, seems to
be related to cancer of the breast which
affects one in 13 women. Obesity is no longer
considered to have any relationship to this
condition.
Dr. Wynder did have some positive
suggestions: no one should drink whole milk
(including infants after weaning from breast
milk), follow a prudent diet in which fat
intake does not exceed 35 per cent of total
calorie intake and cholesterol intake does not
exceed 300 mgm per day.
the effects of diet on atherosclerotic
heart disease. Dr. Kritchevsky of the Wistar
Institute of Anatomy and Biology,
Philadelphia, stated that everything in our
diet affects the serum cholesterol, not just our
cholesterol intake. However, it would seem
that high levels of serum high-density
lipoprotein (HDL) does decrease the tendency
to ASHD. Jogging and a moderate
consumption of alcohol have been shown to
raise these HDL levels which are normally
higher in women than men. Certain types of
fiber such as pectin have also been shown to
be effective in lowering cholesterol levels
while bran has not been shown to have any
effect on serum cholesterol levels.*
retelast
The first and last word
in all-purpose
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A plastic surgery technique offers a way for patients with port wine stains to alter their appearance.
-
Capillary hemangioma, port wine stain
or nevus flammeus are all terms which
are used to describe a condition of
over-vascularization of areas of skin.
Port wine stains are usually full-blown
when they appear at birth, and are often
seen on areas of the face and neck; they
may also affect mucous membranes,
such as the conjunctiva. The color, a
dusky red, is often intensified in
emotional upset or on exertion, or when
the patient is exposed to heat or cold.
Treatment in the past has involved
ionizing radiation, freezing and the use of
covering skin creams, all with limited
success.
There is one surgical procedure
which attempts to cover the port wine
stain, known as surgical tattooing.
Basically, the surgeon tries to place
enough skin-colored pigment in the
superficial dermis so that the stain is
Although stains may be found anywhere
on the body, the procedure is reserved
for facial areas for both technical and
psychological reasons. The tattooing
technique may be used also to tone
down hyperpigmented skin grafts, and
for vitiligo which is an absence of
pigment in the skin, but the results here
are not consistently good.
Several factors dictate that a perfect
color match can never be achieved in
tattooing: artificial material is being used
in living skin and the patient s skin
changes color with the seasons, with the
health of the patient and with his moods;
therefore, surgical tattooing attempts
only to give an average color which will
lessen the noticeability of the birthmark.
Pre-operative preparation
Surgeon Dr. Robert A. Newton of
Toronto is currently the only surgeon in
Canada who does this procedure.
Patients, after initial consultation with
the doctor, are sent to the Hospital for
Sick Children in Toronto, to the
Department of Visual Education for
pigment assessment. Several color
photos using a standard 35 mm camera
are taken, and a medical artist measures
the patient s normal skin pigmentation
with a densichron. A computer is then
used to give the proper mixture of
pigments to closely match the patient s
normal skin color. No tattooing or color
matching is done during the summer
months. Depending on how well the
pigment is retained after surgery, the
procedure may be repeated using the
specially-formulated pigment two or
three times at six month to one year
markedly reduced and that the tattooed May Chung Julie McKenzie intervals,
area blends into the surrounding skin.
Surgical
Tattooing
Operative procedure
The patient s skin is prepared as for
other types of surgery; we do not shave
but wash the area with chlorhexidine
gluconate 0.59c aqueous solution. The
size, location and time estimated to
cover the stain determine the type of
anesthetic to be given. However, even
when a general anesthetic is used.
Xylocaine* 1% with epinephrine is
injected locally to stimulate
vasoconstriction and to decrease
bleeding which would dilute the pigment.
The machine used in the tattooing
process is turbine-driven and injects
pigment into the skin with small sharp
pointed needles 0.05 mm in diameter at
20,000 penetrations per minute. The
needle penetration is 2 to 3 mm,
depending on the area being treated.
Most of the face is treated at 2 mm while
the eyelids are penetrated only to a depth
of 1 mm. While the doctor is using these
multiple sharp needles at ultra high
speed, the handpiece of the instrument
must be kept moving constantly to avoid
severely traumatizing the skin.
The pigment is kept at toothpaste
consistency, and particles are struck into
the skin at every stroke of the needles. A
needle tip cautery is used after the
tattooing to destroy those obvious blood
vessels close to the surface which cannot
be masked by the pigment layer.
Following the tattooing, the skin is
covered with more pigment, and
Polysporin* ointment. The operative site
is then covered with Telfa 8 gauze cut to
size and taped over the skin if the area is
small and the patient is an outpatient.
Inpatients skin remains undressed, and
they are removed from the O.R. to the
recovery room, and then to the plastic
surgery unit.
Crusting forms on the skin which
peels off in 5 to 7 days; the pigmented
area may look flat and stark in color but
within a few weeks post-op the tattooed
area begins to blend into the adjacent
normal-colored skin as the pigment
disappears both internally and
externally.
The recent introduction of the argon
laser in treatment of port wine stains
suggests that in the future, perhaps,
patients may be treated with a
combination of the laser cautery and the
surgical tattooing procedure.
CASE STUDY
A new face
In the early part of 1979, Mrs. C. entered
Toronto General Hospital s plastic
surgery unit to have elective cosmetic
surgery which would alter her facial
appearance. From birth, she had borne a
disfiguring burgundy-colored capillary
hemangioma, which covered the
majority of her face and part of her neck.
The 30-year-old married woman and
mother of one child had a job as a clerk
typist near her home in Mississauga,
Ontario; she told nurses that although
she had always been aware of her
"mark" it had never truly bothered her.
When she was quite young her
parents had wanted to have the
birthmark surgically removed but when
they were warned that significant
scarring was a possible side effect, they
decided against treatment at that time.
In her job as a secretary, Mrs. C.
met the public face to face each day, but
found her mark to be of little significance
in her personal life. She was actively
involved in community activities, and
was pursuing her Business
Administration degree at night school.
In 1978, Mrs. C. read a news item in
a magazine about Dr. Newton s
procedure and she thought about the
possibility of having her port wine stain
removed . The idea of surgery without
scarring appealed to her and she
contacted Dr. Newton for a consultation;
she decided to have the surgery.
Mrs. C. was admitted to hospital the
night before her surgery. Her past
medical history was uneventful: she had
had a tonsillectomy in 1958, an
appendectomy in 1969, and had given
birth to a child in 1970. She was a
non-smoker, and had no known allergies.
The usual admission blood work
was done (Hgb, Hct. and WBC), and
routine urine testing, and she was seen
by the anesthetist who ordered
pre-operative sedation to be given in the
morning. The nurse assigned to Mrs. C.
spent time with her patient to give
pre-operative instruction. Mrs. C. was
told that she would not be able to eat or
drink after midnight, and deep breathing
and coughing routines were
demonstrated to her along with the
explanation of the effect of a general
anesthetic on the respiratory system.
The most important aspect for
nurses in dealing with any patient who is
having surgical tattooing done is to
recognize the fact that although the
procedure is an elective one, any patient
experiences a fair amount of anxiety and
apprehension. Facial appearance and
resulting self-image will undergo a
change, and the nurses must understand
that patients having this type of plastic
surgery will have certain emotional
needs.
For this reason, then. Mrs. C. was
prepared for her post-operative
appearance. She was told that the
pigment would cake and that there would
be scab or crust formation over the
affected area of skin. No dressing would
be applied but she would have
Polysporin " ointment on her face to act
both as an antibiotic and a skin
moistener.
Mrs. C. returned tc the ward the
same day after her surgery from the
Recovery Room, with orders to have
sips of fluids progressing to diet as
tolerated and analgesia q4h p.r.n. The
head of her bed was to be elevated 30 to
45 degrees to minimize facial swelling.
Polysporin 5 ointment was to be
re-applied to the skin daily and Mrs. C. s
face was not to be washed with soap and
water for five to seven days. Because of
the possibility of infection, her hair was
kept tied back from her face.
It has been noted that a common
reaction post-operatively with this
procedure is disappointment. We had to
reassure Mrs. C. daily that the
unattractive scabby, oozing appearance
of her face was temporary, and that in 10
days to two weeks her face would have
healed enough for her to apply a light
cover of make-up if she felt it necessary .
Mrs. C. recovered well post-op and was
discharged five days after surgery, with
an appointment to return to Dr.
Newton s office.
In a follow-up nursing interview.
Mrs. C. was asked how she felt about the
results of her surgery. In spite of the fact
that before surgery she had said her mark
never bothered her much, her comment
was that she had increased
self-confidence and generally felt better
about herself than she had before. *
Bibliography
Newton, R.A. Surgical tattooing for port
wine stain. Canad.J .Otolar\ngol.
2:3:251-253, 1973.
May Chung, RN , is a graduate of the
Toronto General Hospital. She has
worked in the operating theaters of this
hospital since graduation and has
specialized in plastic surgery over the
past three years:
Julie A. McKenzie, RN , a graduate of
George Brown College, Toronto, was a
staff nurse working in plastic surgery,
burns and microvascular surgery at the
Toronto General Hospital at the time of
preparing this article. She has recently
taken up residence in London, Ontario.
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1. Winter, G.D.: Healing of Skin Wounds and the Influence
of Dressings on the Repair Process Surgical Dressings
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Reg.T.M.
Genetic Disorders and the Unborn
\
The need to know?
If a woman of 34 is refused
amniocentesis and subsequently bears a
child with Down s syndrome, can she
sue those who refused the diagnostic
procedure?
Is a doctor negligent if he or she does
not tell a patient about genetic
counselling services? What if such
counselling is indicated, but the patient
can t afford to travel to the nearest
clinic? How will this affect her peace of
mind?
Should amniocentesis be performed on
women who are not prepared to
consider abortion? How will she react to
the news that the baby she s carrying
has an untreatable and/or fatal genetic
disease?
Should prospective parents be told the
sex of their child? Should abortion be
permissible only if there is fear of a
sexlinked disease, but not just because
the parents want a child of a certain
sex?
Should widespread screening for carriers
of genetic diseases be done? What is the
psychological impact on those
diagnosed as carriers?
How should society weigh the various
costs associated with genetic disease
for example, the costs of amniocentesis
and abortion versus those of maintaining
children born with genetic defects?
As the technology necessary for genetic
screening and prenatal diagnosis moves
out of the research lab and into the
clinic, a welter of social, political, legal
and economic issues confront us -
difficult issues that involve balancing
the rights and responsibilities of society
(and its subgroups, such as doctors and
lawyers) against those of the individual.
The questions cut to the most
emotional level: how much reproductive
freedom can people have; what are the
limits of personal choice ; who bears the
costs of genetic disease; who makes the
value judgments?
As it becomes clearer what can
be done, the problem of what should be
done looms large. "It is distressing that
many of these questions are not simply
unanswered in Canada, but unasked,"
writes Bernard Dickens in the Canadian
Family Physician. Dickens teaches
medical jurisprudence at the University
of Toronto.
These and other questions were
raised at a workshop on social issues and
human genetics sponsored by the
Science Council as part of an on-going
study on Science and the Legal Process.
The meeting was attended by experts in
genetics, medicine, law and ethics, many
of them directly involved in genetic
counseling and screening programs.
There are 15 prenatal diagnosis
centres in Canada. Ontario has the
greatest number with five (Toronto,
Ottawa, Hamilton, London and
Kingston). Quebec, Alberta and British
Columbia have two each; and
Saskatchewan, Manitoba,
Newfoundland and Nova Scotia have
one each. The services and personnel
available vary from centre to centre.
(Canada has between one and two
trained geneticists per one million
population; the World Health
Organization recommends five per
million.)
All centres offer prenatal
diagnosis to mothers who have
previously borne a genetically abnormal
child. Most also offer the service to
those with a family history of certain
genetic diseases. Generally, women 35
or older are accepted at most of the
clinics (two set higher minimum ages
37 and 38) but the majority indicated
they are flexible on age and will take
somewhat younger women. Although
only about 10 per cent of pregnant
women are over 35, they bear more
than a quarter of Down s syndrome
babies. The risks rise sharply with age,
from less than 1 in 1000 births for
women under 30, to 1 in 500 at about
age 35, 1 in 100 at age 40, and 1 in 40
at 45 and over.
About three to five per cent of
infants born each year have congenital
malformations, abnormal chromosomes
or genetic disorders. Genetic diseases
account for about 20 per cent of infant
deaths in Canada, and about half of
spontaneous miscarriages are associated
with such conditions. The number of
disorders that can be detected through
prenatal diagnosis has increased steadily
in recent years (more than 60
biochemical abnormalities can be
detected by examining fetal cells),
but undergoing amniocentesis is no
guarantee that a normal child will be
born, because there are many disorders
for which there are no tests and only
indicated tests are made on any
amniotic fluid sample.
The ability to detect an increasing
number of genetic abnormalities raises a
number of philosophical and moral
questions, however. As one participant
at the Science Council workshop put
it: "Which defects are tolerable and
Reprinted from Agenda, the quarterly bulletin of the Science Council of Canada, Vol.2, No. 4.
which are unbearable?" Should abortion
be considered in the case of some
defects, while others are not serious
enough to merit publicly-funded
abortions? Who decides what is
tolerable or not tolerable?
In some cases, the alternatives are
more clear-cut, if not necessarily any
easier to accept, than in others. The
effects of Tay-Sachs disease or of spina
bifida, for example, are devastating and
in the case of the former invariably
fatal. But what of Down s syndrome,
which can result in severe mental
retardation? What about cleft lip or
cleft palate? Hemophilia?
What s to be done when the
amniocentesis turns up a case of
mosaicism (some normal cells, some
abnormal ones) or of abnormal sex
chromosomes. The XYY chromosome
pattern in males has received a
notorious reputation for being
associated with violent and anti-social
behavior but, according to a background
paper prepared for the workshop,
several studies indicate there is little, if
any, effect on physical and mental
development or on behavior. As Dickens
noted in his article: "The prediction of
tendencies to behavioral
maladjustment in the XYY male can
become a self-fulfilling prophesy when
parents, believing their growing child
has violent traits, respond abnormally
to his normally childish conduct.
The sex of the fetus can be
determined from amniocentesis and this
information has relevance when there is
fear of a sex-linked disease such as
hemophilia and Duchenne muscular
dystrophy, both of which affect only
males, although the mother is the
carrier. Writing in Science magazine, a
US doctor, Gilbert Omenn, noted:
"Often the mother has grown up caring
for a brother who succumbed to
hemophilia or muscular dystrophy. The
young woman presents a plaintive plea
that she would not risk a pregnancy, let
alone a delivery, if there were any
chance that her own son would have the
very same disease." Now she can have
amniocentesis with the intention of
carrying through the pregnancy only
if the fetus is female.
Geneticists are generally negative
to the idea of using prenatal diagnostic
techniques simply to allow parents to
choose the sex of their child ("just so
they know what color to paint the
room," as one participant at the
workshop put it.) According to
geneticist Tabitha Powledge, writing in
the New Scientist magazine, many US
diagnosticians "have been known to
indignantly refuse (sic) requests for
sex detection, although they have
sometimes been deceived into it by
couples pretending to be at risk for a
child with a sex-linked disease."
In the past, the argument has been
that sex detection alone did not warrant
the risk of the procedure, but since the
risks have been reduced, will this
argument hold sway with parents who
really want a child of a given sex? This
possibility raises the troubling issue of
abortion based on sex alone. According
to Powledge, this occurs in China where
"providing parents with a child of the
preferred sex is regarded as a way to
reduce family size, an urgent priority...
In the Chinese case, 29 out of the
detected 46 female fetuses were
aborted. Out of 53 detected males, only
one was aborted."
She asks: "Is this a morally
acceptable use of prenatal diagnosis?
For the Chinese, who view population
pressures as a matter of critical concern,
the answer is clearly yes. In the West,
where population pressures are
considerably less, we are not so sure."
In fact, the relationship of
abortion to prenatal diagnosis is one of
the most problematical aspects of the
issue. It would be different if the fetus
could be treated for the disease while
still in the womb; but, according to
Omenn, there has been only one notable
success in this field.* Although many
hope abortion will not prove to be the
only solution, experts are not predicting
any near-term alternatives. One such
expert, Carlo Valenti of the Downstate
Medical Center, New York, wrote in
Lancet that "the chances that useful
treatment will soon be at hand are
slim. For many conditions, irreversible
anatomical changes are probably present
so early in gestation that their
prevention or reversal (in the womb) by
drug or enzyme treatment seems highly
improbable. ..Although I would
welcome an alternative to the abortion
of a defective fetus, I reluctantly
conclude that abortion must remain the
solution to inheritable diseases."
If so, logically a number of
questions follow: Should a woman
whose moral convictions make abortion
unacceptable be offered amniocentesis
at public expense? Should women be
required to agree in advance to an
abortion, if indicated? A participant at
the workshop said there is at least one
case in Canada where this is done.
Another said that it is "my impression
that there is strong, if indirect, pressure
to agree in some form to abortion. The
attitude is that they don t like to go
*Large doses of oral Vitamin B 1 2
allowed normal development of a child
affected by a biochemical defect.
through the trouble unless the woman is
prepared to do something about it ."
However, the propriety of such an
attitude was questioned, since the
condition of the fetus is not legal
grounds for an abortion. Canadian law
allows termination of pregnancy only
when its continuation would or would
be likely to endanger the mother s
life or health. If the prospect of bearing
and caring for a genetically defective
child would endanger her mental health,
the pregnancy could be lawfully
terminated. But if she decides that she
will not abort the child regardless of the
outcome, should she be refused
amniocentesis?
Finally, who is to decide which
defects warrant abortion? As Powledge
notes: "Should one abort for Turner s
syndrome,. ..where the chief disability
appears to be sterility? The metabolic
disorder galactosaemia, which results in
cataracts and mental retardation, can be
diagnosed before birth, but it can also
be treated immediately after birth
relatively simply by eliminating milk
from the diet. Does the fact that
therapy is available mean that one
should not abort for such a disorder?"
Moreover, should anyone impose limits
on the point at which abortion is legal
and acceptable?
Participants at the workshop
suggested that there is a need for more
research into the psychological effects
of having to make decisions such as
these, and of having to live with the
consequences. What happens to the
woman who refuses amniocentesis
because she won t have an abortion,
then bears an affected child? Do women
feel pressured to agree to abortion -
and made to feel socially irresponsible if
they decide to bear defective children?
Do they fully understand what they re
getting into? As one workshop speaker
noted, when widespread screening
procedures become routine, "we run a
very serious risk of providing couples
with answers for which they had no
question. Couples having very strong
objections to abortion for any reason
may, in the fact of... a test they did not
request or fully understand in the first
place, submit to abortion and bear the
psychological consequences for as yet
unknown periods. Abortion of a normal
fetus as the result of a false positive
result is a disaster that needs no further
comment."
Diagnostic errors or testing
inadequacies of various sorts can
precipitate many such psychological
crises. One US study reported the cases
of two women who bore Down s
syndrome babies after the fetuses were
diagnosed as normal. Powledge painted
another hair-raising scenario arising out
of an inconclusive first amniocentesis:
"It seems almost inevitable that some
day soon a second (amniocentesis) will
result in a positive diagnosis, but that
the ensuing late abortion will lead to a
live delivery. Then, partly because of
the availability of neonatal intensive
care technology and partly because of
the crazy quilt of laws and abortion
attitudes in the US, the baby will be
kept alive. Who will take responsibility
for such an infant, aborted because of
an anomoly and further severely
compromised by the method and time
of delivery? Is the mother to be forced
to take the baby back? Or does the
baby become a ward of the state?"
Screening for disease after birth
can also cause families anguish. One
workshop participant cited the case of
screening newborn males for Duchenne
muscular dystrophy, for which there is
no treatment. "Of what possible use
could it be to hang the sword of
Damocles over some poor family and
make them watch each day for the
first sign of deterioration in their son?
And what if it were a false positive?
Perhaps one could make a case for early
diagnosis so that the parents know
they are at risk before they proceed to
have another child who might be
similarly affected. ..In my view, that
relatively small advantage hardly
justifies the potential anguish such a
screening program could create."
Screening for carriers of genetic
diseases could also have repercussions.
(Carriers are members of the population
who do not manifest the disease, but
have genes which, given appropriate
matings, may produce affected
children.) In one survey carried out in
conjunction with a Tay Sachs screening
program, a small percentage of those
diagnosed as carriers felt their self-image
was diminished (and an equal number of
non-carriers felt their image was
enhanced.) Half of the carriers felt
worried or depressed immediately after
the tests, but these feelings persisted for
some time in less than 2 per cent of the
cases.
Two other major issues relating to
prenatal diagnosis were discussed at the
workshop: the question of access to
diagnostic services and the question of
legal liability, especially of family
physicians.
It appears that only a very small
percentage of women who qualify for
amniocentesis receive it; and they are
mostly well-educated urban women who
have heard about the procedure through
the media and take the initiative in
seeking out a prenatal clinic. Several
reasons were cited for this situation:
attitudes toward abortion, fear of the
risks associated with the procedure,
ignorance about genetic risks in general,
inability to pay travel costs. But
resistance and negative attitudes on the
part of family physicians was described
as a major stumbling block; it was
reported that at the time of the
workshop only 2.3 per cent of the last
300 patients, in one Canadian centre,
receiving amniocentesis had been
referred by their own obstetricians.
But, in his article in the Canadian
Family Physician, Dickens warns that
doctors may leave themselves wide open
legally if they do not give adequate
genetic advice and guidance to their
patients. "Family physicians are
increasingly expected to identify
indications of genetic defects in children
and adults, to warn patients of genetic
risks to the children they may conceive,
A background paper prepared for the
workshop on human genetics outlines
some of the unexpected social hazards
that can occur if mass screening for a
genetic disease is initiated too hastily,
without adequate educational
precautions. The paper cites one such
case, in which there was "much
confusion on the part of both the
medical profession and the public as to
the medical significance of (the) trait
and many were stigmatized by the
mistaken belief that the (carrier) state is
a disease. Often, the results of the
screening program were communicated
to the individual by postcard, with little
or often unintelligible information.
Imaginary symptoms of fatigue, exercise
intolerance and headache have been
reported, and many thought they
should be on special diets with vitamin
supplements. Information was leaked to
insurance companies and employers,
and (carriers) were asked to pay higher
premiums, were excluded from jobs
and from some branches of the armed
forces. Airline stewardesses were fired
from their jobs in the mistaken belief
that they would be worse off than the
rest of us should an airplane cabin
depressurize at 30,000 feet. In a
screening program in Greece, young
females known to be carriers became
ineligible for marriage, and there have
been a number of occasions when the
tests results clearly indicated
non-paternity, resulting in break-up of
families."
and to advise specialized counselling
when it is appropriate. They must know
the genetic services in their communities
and, for more extreme conditions even
beyond their communities for
instance, in university-located medical
genetics centres. Their legal negligence
lies not in being incorrect in their
diagnosis or advice, but in exercising
their judgment on the basis of
inadequate (including outdated) genetic
and resource information,"
He noted that in the United States
negligent reproductive services,
including genetic advice causing the
birth of a damaged child, provide a
legal cause of action, and said that
Canadian courts could well move in this
direction.
A speaker at the workshop said
that successful suits have been brought
against US obstetricians who failed to
inform their patients of the increased
risk of Down s syndrome beyond the
age of 35. The issue of refusing
amniocentesis to women under 35
(usually because of the workload at the
clinic) was also raised; one participant
said: "I feel I have no legal protection
if I refuse."
Several speakers stressed the need
to increase educational programs, not
only of the public but of the family
physicians. In his article, Dickens
recommended immediate consideration
of promoting genetic counseling to "a
fully constituted speciality, with
appropriate licensing of practitioners,
accreditation of instruction, and
monitoring of standards."
As one speaker concluded, the
most important limiting factor on
making cautious and competent genetic
screening a part of preventive medicine
may be education of the public, of
health professionals, and of members
of the government. "The task will be
formidable, because of current levels
of unawareness and misunderstanding,
but comprehension of the general
principles of human biology and
realization that we ah 1 share the load of
deleterious genes may help diffuse
some of the touchy ethical and social
issues... ." *
How it s done
Basically, the nursing audit is
accomplished through periodic
assessment and evaluation using
previously developed outcome criteria.
The method of audit we use is called
"Intermittent Retrospective Patient
Outcome Review"; the name
emphasizes once again the fact that the
audit procedure is an examination not
of nursing activity but of the results of
nursing care.
The technique allows us to
accomplish three objectives:
to measure the level of patient
care in objective, quantified, patient
outcome terms
to communicate to the nursing
staff our survey findings
to conduct educational programs
to improve our standards of care for
patients and their families.
We study nursing care by first
selecting a specific patient population;
for example, we may decide to focus
on "long term patients" or patients who
have "diabetes as a secondary disease
entity". Audit criteria are then
developed and charts are reviewed to
determine whether or not the various
criteria are being met. Findings are
tabulated and the results are presented
to the nursing staff using various visual
aids, revealing strengths and weaknesses
in the care being given. Educational
programs are planned around our
findings.
The audit program does not work
in isolation it is integrated with the
work of other programs and committees
within the Department of Nursing, and
is thus one of several tools concurrently
being used in nursing s overall program
to improve patient care.
The Committee
The initial work of the nursing audit
program at MGH began several years ago
when a 13-member central audit
committee was formed, consisting of
representatives from nursing
administration, supervisors, teachers,
clinical nurse specialists and staff nurses.
The central committee continues to
function, but does not itself perform
the actual audit. The role of the
committee is to determine the
appropriate base from which to develop
criteria and to ensure that the program
as a whole is successfuly maintained and
ongoing. The committee reviews and
refines audit criteria as developed by
other nursing staff members, and it does
carry out trial audits.
In a nutshell
Developing the criteria has proven to be
one of the most valuable aspects of the
entire program. We believe this has to be
done on a team basis if the results of the
audit are to have any meaning or
credibility. In other words, the staff
nurses who are directly involved in
caring for patients and their families -
the clients for whom these criteria are
being written must be the people who
actually identify and develop the
relevant audit criteria.
Here s how it works in practice.
The head nurse, nurse clinician, and
staff nurses from various nursing units
(psychiatry, for example) meet on a
number of occasions with a member of
the central audit committee also in
attendance. This group of nurses
identifies the critical indicators of
nursing care and then writes the criteria
for their own area. Not all meetings are
attended by the same nurses: those who
are on duty and available at meeting
time write the criteria. In this way,
more nurses are able to take part in the
audit, and staff who are often on
evening or night duty get a chance to
participate.
We have learned that generally the
more nurses included in criteria
development, the more successful the
subsequent audit. The nurses who work
most closely with the patients come to a
consensus on what kind of care patients
should be getting, and their judgment
becomes the criteria upon which the
audit is based.
The central committee member
who attends these meetings acts as a
leader of the group and takes notes to
help keep all group members up to date.
The team approach gives audit results
more credibility and also ensures
that a set of criteria will be identical for
a specific group of patients regardless of
where in the hospital the patient stays.
For example, since a broad cross-section
of psychiatry unit staff are involved, a
common set of criteria for a chosen
patient population will apply to all
psychiatric units.
Audits are performed every two
weeks year round on a pre-arranged
audit day; currently we use the slogan
"Pay Day is Audit Day". A sample of
patients charts, typically about 30, is
drawn from Medical Records and
inspected to determine how well the
various criteria are being met; the audit
is done by staff nurses who are again
most closely involved with actual
patient care.
Because sample sizes are
determined as a percentage of the total
patient population the actual number of
charts reviewed in a single audit may
vary greatly; for example, the number
of charts used in an obstetrical audit
could be as high as 60, while a hip
pinning audit may require only 12. It
takes just 20 minutes for a nurse to
review a chart and thus it is relatively
easy to free a nurse from her unit for
this length of time.
Findings are tabulated and
submitted to members of the "Nursing
Standards and Evaluation Committee",
What s it all about?
Shirley Sultan
The nursing audit program at The
Montreal General Hospital is an
educational activity designed to improve
nursing care ; it is a program carried out
by nurses for nurses. Rather than
evaluating specific individuals or nursing
units, the goal of the nursing audit
program is simply to study nursing care
throughout the hospital.
Figure one
OUTCOME CRITERIA FOR PATIENT WITH HIP PINNING (60-80 years) DISCHARGED TO
CONVALESCENT HOME
See nursing history, nurses notes and standard care plan, intake and output sheet, med. sheet, nurses
discharge summary.
Developed by Orthopedic Nursing Staff - Staff Nurses, Head Nurses and Nurse Clinicians
Criteria
Pre-op
1 . Verbal or non verbal
expression of comfort
2. Patient s skin is intact
3. Patient s hydration
maintained
Post-op
4. Verbal or non verbal
expression of comfort
5. Patient s wound remains
clean
6. Patient breathing easily
7. Patient s skin is intact
8. Patient is free of
contractures
9. Patient is ambulatory with
walker and not weight
bearing on affected leg
Instructions to the Auditor
1. See nurses notes for quality, site and
degree of pain, also patient s response to
Medication and or nurses action, e.g.
(positioning and Buck s Extension)
(Chart once a shift)
2. Criteria not met if skin breakdown
occurs. Exception if patient admitted
with pressure area. (Chart once a shift)
3. Criteria not met if no documentation of
I.V. intake. (Chart once a shift)
4. Criteria not met if patient response to
analgesia and/or nursing measures not
indicated. (Chart once a shift for 48
hours).
5. Criteria not met if patient s dressing is
not changed when contaminated.
Exception if wound is infected at 1st
dressing change and M.D. notified.
(First dressing change usually P.O. day
10).
6. Criteria not met if respirations are
labored, sounds congested or abnormal
sputum. Exception patient with
underlying chest conditons. (Chart once a
shift for 48 hours).
7. Criteria not met if skin breakdown
occurs. Exception if patient admitted
with pressure area. (Chart once a shift for
48 hours then once a day until discharge).
8. Criteria met if patient demonstrates
active and passive ankle and foot
exercises on affected and unaffected leg.
Criteria not met if patient develops
contractures or foot drop. Exception
if patient admitted with contractures.
(Chart Q shift for 48 hours then once a
day until discharge).
9. Criteria not met if not walking by P.O.D.
5. Exception if patient was not
ambulatory on unaffected leg prior to
admission (2 or 3 x up with walking and
tolerated) (Chart once a day from day 5
until discharge).
Met
Not
Met
Exc.
Comments
I.
2.
3.
4.
5.
6.
7.
8.
9.
a nursing administration patient care
committee. Results are then circulated
to head nurses and in turn to staff
nurses on the individual nursing units.
Positive aspects and trends, as well as
deficiency areas, are highlighted.
Audits are repeated in each
patient area at approximately six-month
intervals according to a projected
schedule for the year. Operating in this
manner, the audit has evolved into an
established program involving many
of the nursing staff in the medical and
surgical areas, and several specialty
areas (see Figure one).
Positive results
The nursing audit is not a panacea it
is merely a tool to be used by nursing
managers to provide the best possible
nursing care. For example, it is an
effective data base development
instrument, providing statistics on
patient care throughout the hospital
which can in turn be used for the
definition and development of nursing
education programs. In this respect,
audit is readily integrated with overall
nursing department goals.
Our nursing audit provided useful
information, supported by hard figures,
that substantiated a feeling many
of our nurses already had - namely,
that we could and should be managing
our patients pain more effectively.
Opinions on the subject in the past were
always subjective and varied, and it was
always difficult to promote the need for
change simply on the basis of such
subjective individual opinions alone.
Now, that these views are supplemented
by a real data base, the audit has
facilitated discussions on the
management of pain.
The study of pain management in
the hospital is an excellent example of
how the audit process should work:
because the audit criteria for pain are
the same in many different audits
throughout the hospital, we were
able to study pain whenever an audit
was performed. The results showed that
we needed to improve nursing care
in this area and that further study and
action were called for. Pain management
became a priority within the Nursing
department and the nurse clinicians
arranged various educational activities.
Generally conferences were held on the
nursing units, using visual aids such as
slides and graphs; the hospital pain
center was involved too in that a nurse
was added to the team working in the
center, which is a consulting unit
dealing with the treatment and research
of chronic pain problems. Pain also
became one of the topics for Nursing
Grand Rounds, which have become a
popular event held every six weeks.
In short, the assessment of pain,
methods used and evaluation of these
methods were all given special attention,
and results over an 18-month period
show a definite and encouraging trend
toward improvement.
Education
The audit has pointed out the need to
improve our teaching skills as nurses:
nurses appear to have become more
aware of their own role as teachers for
patients and their families and the audit
has encouraged the preparation of
instructional material upon which to
base staff development. At the same
time it has acted as a stimulus for the
use of new teaching methods for the
nursing staff; for example, the chart
review is really an exercise in which the
nurse auditor learns "by doing".
As in pain management, where
deficiency areas have emerged, Inservice
Education has been able to develop
programs aimed at effecting
improvements. For example, workshops
and Nursing Grand Rounds have been
organized based on the results of the
audit on "Diabetes as a Secondary
Disease Entity". Criteria have been
developed to apply to any patient
hospitalized who has diabetes as a
secondary medical condition in other
words, not a newly diagnosed diabetic,
but a person hospitalized for other
medical or surgical reasons. Through
the audits, hospital nurses are given an
opportunity to assess how patients and
family are managing to control their
diabetes, which is a major health care
problem in the community. Nurses are
thus in a more advantageous position to
practice the principles of preventive
health care in their work by ensuring
that patients and family are indeed able
to care for themselves at home.
Communication has also been
improved through the audit. When a
group of nurses from various units with
different levels of experience,
knowledge and skills in nursing decide
to meet on a regular basis in order to
come to a consensus on what the
nursing care for their own patients
should be, positive communication
naturally results.
Everyone takes part in group
discussions, everyone is forced to think
through his or her personal standards
of nursing care and his or her own
approach to caring for a particular
group of patients; a free exchange of
viewpoints and opinions occurs; there is
a sharing of ideas, concerns and feelings.
We believe all this fosters a healthy
environment for communication which
leads to greater knowledge and
understanding.
The audit committee also served
as a structure within which
communication between staff nurses
and supervisors could be improved. For
example, it was noted that various
forms in the hospital were not always
used efficiently and nurses who were
not using the discharge summary sheet
in their areas saw the benefits and were
consequently more ready to adopt it.
Concurrently, the nursing audit
provides an opportunity to keep in
touch with nursing practices outside
one s own specialty area; on audit days
nurses from surgery may be auditing
obstetrical patients while OB nurses
may be looking at long term care
patients. This mingling of nursing
experience and outlook is particularly
beneficial in a large teaching hospital.
Nurses looking at nurses
The purpose of the nursing audit is to
allow nurses to see the results of nursing
care; audit is not peer review, and
it is in no way a threat to staff. The
process is a voluntary one, nurses have a
choice about getting involved, but
the opportunity for nurses to become
more directly involved in decisions
affecting patient care is obvious.
To this end, documentation is
important and must reflect the actual
quality of the care being given. The
results of the audit rely upon the
assumption that we communicate
results of nursing care accurately in our
nursing records.
Nursing records are not, of course,
always reliable, but we believe a
correlation exists between the
documentation and actual nursing
practices. As documentation improves,
so may the care we are giving, and
vice-versa. This is as yet an untested
theory but in time nurse researchers
may prove or disprove the hypothesis.
Another problem is that there are
undoubtedly many nursing practices
carried out which remain
undocumented; we are in the process of
designing techniques that will enable us
to measure and assess this phenomenon.
Clearly, accurate documentation
is going to become even more important
in the future; patients will acquire the
right to review their own records and as
more patients become aware of this
right, they will exercise it. At the same
time much has been written regarding
the legal liability inherent in the
accurate recording of events. Thus, what
we record today is vital, and the
incentives to improve that process are
growing. Accordingly, the documentary
aspect of the audit process can only be
strengthened.
What s it all about?
The audit belongs to the nursing staff. It
is designed to be a tool to be used in
improving patient care and to assess
patient results in a meaningful,
quantitative way. The nurses state what
patient care should be, they develop
criteria based on this appraisal, they do
actual chart review, and they take part
in the planning and the conducting of
the educational programs that result.
Naturally, the audit process is not
perfect, and the nursing staff is not
entirely satisfied, but we intend to
continue working within the same
framework and we can make
adjustments and improvements along
the way. We are beginning to meet with
people in other disciplines in our
hospital - dieticians, physiotherapists,
social workers and physicians - to
explain our objectives and approach in
the hope that we may one day have a
multidisciplinary approach to audit.
Looking to the future, nursing
audit encourages nursing study and
research. For the nurse researchers, an
abundance of useful factual material is
being collected. *
Shirley Sultan, a graduate of the
Vancouver General Hospital School of
Nursing, received her B. Sc. and M. Sc.
degrees from Boston University. With
experience in many areas of nursing in
both Canada and the United States, she
is currently a nurse clinician and
Chairman of the Nursing Audit Program
at the Montreal General Hospital.
Ponstari
(mefenamicacid)l
FOR PROMPT RELIEF
OF DYSMENORRHEA
# non-hormonal, non-narcotic therapy
(simple, short-term, non-addictive regimen
taken only when required)
* inhibits prostaglandin synthesis and
the action of prostaglandins on the uterine
smooth muscle 1 (reduces uterine
contractions and abdominal pain)
Ponstan Capsules 250 mg:
2 capsules at onset of dysmenorrhea
followed by 1 capsule every 6 hours for
the duration of symptoms
Rag. T M./M E Parka OlvK & Company
Ponstan
When it does its job, she can do hers
every day of the month.
PARKE-DAVIS
Parke-Davis Canada Inc., Scarborough, Ontario
IHEA
CNA
Code of Ethics:
an ethical basis
for nursing
in Canada
|;tive years in pain. Yet many of these women
1 with analgesics, or simply accepting their
liodic dysmenorrhea is unsatisfactory.
Icompetence, and the use of oral
cal picture
I: in causing the pain and other related problems.
Iprostaglandin levels (particularly levels of
Ismenorrhea.
lenorrhea .
Ithesis the enzyme system responsible for
pit the enzymes of the prostaglandin
lesics
|n the treatment of dysmenorrhea, affording
! caps of 32.5 mg/325 mg t.i.d.) and Ponstan
Ijesic combination on both clinically
l;s absenteeism in the group taking Ponstan. 4
Iptives
la more rational therapy than oral
[gents had not solved their dysmenorrhea
Lrbing the normal hormone balance of patients,
litrual pain becomes evident. For the rest of
nen
Tars, a patient takes two capsules stat, for fast
effects with short courses of treatment with
Canadian Nurses Association
50 The Driveway
Ottawa, Ontario
K2P 1E2
1980
$0.50
ISBN 0-91 91 08-50^
4. Anderson, A.8.M., Haynes, P J . el al: Lancet (1): 345-348. 1978
5, Consensus independent research, 1978 Data on File Parke-Davis Canada Inc
acetytsahcylic acid to cause gastrointestinal
bleeding
ADVERSE REACTIONS: In controlled clinical
investigation studies ot PONSTAN at analgesic
doses, up to 1 500 mg per day. associated side
effects were relatively mild and infrequent.
Complaints are dose-related, being more frequent
with higher doses
In 2.594 subjects given mefenamic acid over a
period of from 1 to 238 days, the most frequently
reported adverse effects were drowsiness (68
subjects), nervousness (28). nausea (20). dizziness
(36). gastrointestinal discomfort (10), diarrhea (11).
vomiting (5), and headache (2). There were single
reports of insomnia, urticaria and dyspnea and
facial edema, and 2 instances each of blurred
vision, gas and perspiration-
There have been a few reports of hematopoietic side
effects. A direct cause and effect relationship has
not been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg melenamic acid.
Bottles of 1 00 and 500 capsules
FULL PRESCRIBING INFORMATION ON
REQUEST
Ponstari
(mefenamicacid)l
FOR PRC
OF DYSIV
* non-hormonal, nor
(simple, short-ternr
taken only when re
# inhibits prostaglani
the action of prostc
smooth muscle 1 (re
contractions and a
Ponstan Capsules 25
2 capsules at onse
followed by 1 caps
the duration of synr
R<gT.M./M.EPtrk>.Davil& Company
PC
When it does
every (
PAR
I. Introduction
Nursing is a person-oriented health service. It is a service
called forth by the experience of human pain and suffering,
and directed to the promotion of health, the prevention and
alleviation of suffering, and the provision of a caring presence
for those for whom cure is not possible. The ethical norms
that guide this service evolve from a belief system that
perceives the human person to be of incalculable worth, and
human life to have a sacred, precious and even mysterious
character. Nursing is practiced in the context of human rela
tionships, the dominant ethical determinant of which is the
principle of respect for persons.
The concept which constitutes the unifying and
ethical focus for nursing practice, education, administration
and research is the concept caring. Caring, as a characteristic
descriptive of all authentic human action, is expressed within
the discipline of nursing through the following attributes.
1. compassion the human response through which nurses
participate in the pain and brokenness of humanity, by
entering into the experience of another s suffering, misfortune
or need in such a manner that the needs of that person are
the primary basis for the use of the nurse s personal and
professional skills.
2. competence the state of having the knowledge, skills,
energy and experience adequate to provide the required
service.
3. conscience the sense of what is right or wrong in one s
conduct, and the awareness of, and the will to apply relevant
ethical principles.
4. confidence the quality which fosters the development and
maintenance of trusting relationships.
5. commitment a pledge, based on free choice, to devote
oneself to meeting one s professional obligations.
In nursing, the human capacity to care is developed
and professionalized through the acquisition of those intellec
tual, affective and technical skills required to carry out the
responsibilities of specific nursing roles. The ethical obliga
tions arising from caring as required by these roles are met at
different levels of practice and within varying contexts. This
statement considers three categories of obligation, namely,
caring and the profession, caring and the healing community,
and caring and the individual nurse.
II. Caring and the profession
The nursing profession as a whole has ethical obligations to
society as well as to its own membership. The profession has
an obligation to examine its own goals and the service it
offers in the light of existing health problems, and to design
its programs in collaboration with other professions which
also provide health services within the society. Nursing, in
keeping with its mandate as a service profession, is bound to
see itself, not as an end to be promoted and served by society,
but as a professional body, constituted and legitimized by
society s approval, to offer a prescribed service required for
the improvement of the health status of people.
Parke-Davis Canada Inc., Scarborough, Ontario
i inn ATE rtM
HHEA
In meeting its obligations to society, nursing has
responsibility for monitoring the quantity and quality of
persons entering the profession, and for identifying and
implementing standards that promote the type and quality of
nursing service dictated by society s needs. Nursing has a
related responsibility to work for those conditions which
will enable its members to provide the quantity and quality
of service deemed necessary and desirable.
The nursing profession also has responsibilities to the
international community. Since health is a basic condition
for human development, and as no one nation or country can
develop its potential in isolation, the interests of the profession
transcend national boundaries. In fact, our credibility as a
profession is called into question if we do not collaborate on
an international level to promote the health of all peoples,
and to work toward the relief of human suffering wherever
it is experienced.
These broad obligations constitute the grounds for the
ethical responsibilities of nursing s organized professional
body, and include the following commitments:
1. In the context of existing health needs and problems, to
identify Canada s need for nursing activities and services.
2. To establish relevant and realistic goals for the profession
of nursing within Canadian society.
3. To foster collaboration with other health professions,
political bodies, and other agencies in responding to the
health needs of Canadians.
4. To collaborate with professional groups, institutions and
agencies in promoting the welfare of peoples in other
countries of the world.
5. To provide measures which will ensure that only those
with the potential, motivation and discipline required to
function as caring persons are accepted into, and endorsed by
the nursing profession.
6. To work for the realization of working conditions which
enable nurses to function as caring persons with the required
degree of autonomy.
7. To promote conditions for nurses which provide for
legitimate personal, professional and economic rewards.
8. To demonstrate, in its own transactions, accountability for
the use of internal and external resources.
ies
ctive years in pain. Yet many of these women
t with analgesics, or simply accepting their
modic dysmenorrhea is unsatisfactory,
ncompetence, and the use of oral
ical picture
d in causing the pain and other related problems.
I prostaglandin levels (particularly levels of
ysmenorrhea.
lenorrhea .
ithesis the enzyme system responsible for
ibit the enzymes of the prostaglandin
36SICS
in the treatment of dysmenorrhea, affording
2 caps of 32.5 mg/325 mg t.i.d.) and Ponstan
igesic combination on both clinically
ss absenteeism in the group taking Ponstan. 4
sptives
a more rational therapy than oral
agents had not solved their dysmenorrhea
turbing the normal hormone balance of patients,
strual pain becomes evident. For the rest of
III. Caring and the healing community
The attainment of health, in a holistic sense, requires services
from a variety of sources, professional and non-professional.
Health disciplines constitute one such source of service, and
nursing, as one of these disciplines, is directed by its own
unique focus and prescribed boundaries. The achievement of
personal and family health goals depends upon a sensitive,
deliberate fusion of the knowledge, skills and resources of all
involved in relevant helping services. In health care today, a
commitment to the collaboration essential for this process is
a fundamental ethical imperative for health professionals.
Where such collaboration is visible and operative, it consti
tutes an authentic sign of a caring, healing community.
ien
ears, a patient takes two capsules stat, for last
! effects with short courses of treatment with
ed
on
4 Anderson, ABM. , Haynes. P.J., el al: Lancet (1) 345-348.1978
5. Consensus independent research, 1978. Dala on File. Parke-Davis Canada Inc
acetylsalicylic acid lo cause gastrointestinal
bleeding
ADVERSE REACTIONS: In controlled clinical
investigation studies of PONSTAN at analgesic
doses, up to 1 500 mg per day, associated side
effects were relatively mild and infrequent.
Complaints are dose- related, being morelrequent
with higher doses
In 2.594 subjects given mefenamic acid over a
period of from 1 to 238 days, the most frequently
reported adverse effects were drowsiness (68
subjects), nervousness (28). nausea (20), dizziness
(36). gastrointestinal discomfort (10). diarrhea(11).
vomiting (5), and headache (2). There were single
reports of insomnia, urticana and dyspnea and
facial edema, and 2 instances each of blurred
vision, gas and perspiration.
There have been a few reports of hematopoietic side
effects. A direct cause and effect relationship has
not been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg mefenamic acid
Bottles of 100 and 500 capsules.
FULL PRESCRIBING INFORMATION ON
REQUEST
Ponstari
(mefenamicacid)l
FOR PRC
OF DYSI\i
* non-hormonal, nor
(simple, short-tern
taken only when re
# inhibits prostaglan
the action of prost<
smooth muscle 1 (r<
contractions and c
Ponstan Capsules 25
2 capsules at onse
followed by 1 caps
the duration of syn
Rg T.M./M E Pirke, 0vtt8t Company
PC
When it does
every
PAR
With the growing numbers and categories of people
providing services in an increasingly complex health care
system, the provision of a caring, healing community may be
considered a courageous undertaking. Present experience
leads some critics to conclude that the present health system
is anything but a caring, healing community. Based on the
observations of such critics, it would seem that each health
professional group is committed to its own various and
sundry goals teaching, practice, administration and research
with token recognition of needs of clients, and, in some cases,
operating in adversarial relationships with colleagues in other
disciplines.
Many, if not most, of the ethical problems experienced
by nurses today have their roots in conflict with other health
professionals over what constitutes appropriate care for their
clients. Such problems include, for example, confusion and
open disagreement about the nature, extent, and timing of
information required by patients and families; the initiation
and/or prolongation of specific treatment protocols; the use
of patients in teaching and research; disclosure of informa
tion and intrusions of privacy; threats to clients from known
or potential abusers; evidence of incompetency, incapacity
and negligence on the part of health care providers; and
limitations on the freedom of nurses themselves to provide
services for which they are prepared.
In the face of these issues, it is not sufficient that a
nurse maintain personal ethical behavior: responsibility
to clients demands a stance which promotes care, and
challenges actions which are contrary to acceptable health
care goals. When quality of care is jeopardized, merely to
live by one s own standards with the attitude that what
someone else does is none of my business , is to abdicate
one s ethical responsibility for promoting the welfare of
persons who require health services.
Other conflicts evolve from management relations and
working conditions which, from the perspective of the nurse s
legitimate needs and rights, may constitute grave violations
of justice. In the efforts made to resolve such injustice, there
is a serious responsibility to use only those methods which
are, in themselves, in accord with ethical principles.
The responsibility to care makes fundamental claims
on a person who chooses to enter the profession of nursing.
This responsibility is exercised in responding to the needs of
others, and the duty to provide needed services remains in
the face of conflicting demands which may effect the welfare
of the nurse in question. Thus, when a nurse is working under
conditions which violate justice, the withdrawal of needed
services to patients as a means of resolving such injustices, is
unethical. This is not to downplay the gravity or the unethical
character of the injustice itself, nor is it to imply that nurses
ought to do nothing.
The assurance of working conditions where nurses can
fulfill their caring obligations, and through which they can
receive just recompense, is a professional obligation which
ought not be delegated, and the resolution of conflicts arising
out of such working conditions calls for the wisdom and
dedication of the whole profession. From an ethical point of
view, neither the profession as a whole, nor the individual
nurse, may resort to strategies that would compromise the
health of clients.
Parke-Davis Canada Inc., Scarborough, Ontario
RHEA
1
In meeting the collaborative responsibilities inherent
in the caring, healing community, the individual nurse does
not relinquish the right nor the responsibility to adhere to
personal moral principles. The nurse as a moral person has
the ethical responsibility to refuse to participate in programs,
treatments or procedures, and to withdraw from situations
which are contrary to his or her informed moral conscience.
The design and on-going development of a caring,
healing community requires, on the part of all concerned, an
ethical sensitivity of the highest order. It presupposes, and is
built within, a climate of mutual trust and respect. Nursing
does not bear the burden of this responsibility alone, but
nursing does have the obligation to contribute its insights and
professional resources to bringing about the realization of
such a community. In fact, a commitment to work toward
the establishment of a truly caring, healing community may
be the most critical and fundamental ethical challenge to the
nursing profession at this particular time in its history. This
ethical challenge is addressed to nursing as a whole through
its professional bodies, and to nurses as individuals educators
practitioners, administrators and researchers.
No code of ethics can, nor ought it try, to delineate
the possible ways in which such a challenge may be met.
Such will be accomplished through the efforts of caring
nurses persons who are themselves compassionate, com
petent, conscionable, confident, and committed and who
have the resourcefulness and creativity to design suitable
models and select appropriate measures for implementation.
IV. Caring and the individual nurse
The final test of the credibility of ethical standards in nursing
lies in the behavior of the individual nurse educator, practi
tioner, administrator and researcher. Many of the responsibi
lities arising out of obligations of the profession as a whole,
and the ethical demands of the caring community itself, are
fulfilled only in the actions of the individual nurse. While the
profession has the obligation to identify, promote and
monitor ethical standards, the execution of such standards is
a personal responsibility, the final guarantee of which is in
the conscience and commitment of the individual nurse.
V. Guidelines
The following guidelines include general principles, with
statements of ethical responsibility which flow from these
principles. They are intended to provide a guide for reflection
and for the articulation of more specific ethical rules and
standards applicable to concrete experiences. With the
increasing complexity of ethical conflicts in nursing, and the
potential for greater ethical concerns in the future, ethical
discernment in nursing is an exciting challenge, requiring
knowledge, skill and great moral sensitivity. We have the
capacity to meet this challenge one which could be the
greatest in the history of our profession.
lies
uctive years in pain. Yet many of these women
at with analgesics, or simply accepting their
smodic dysmenorrhea is unsatisfactory,
incompetence, and the use of oral
lical picture
ed in causing the pain and other related problems,
al prostaglandin levels (particularly levels of
jysmenorrhea.
nenorrhea
/nthesis the enzyme system responsible for
hibit the enzymes of the prostaglandin
gesics
g in the treatment of dysmenorrhea, affording
(2 caps of 32.5 mg/325 mg t.i.d.) and Ponstan
algesic combination on both clinically
less absenteeism in the group taking Ponstan. 4
eptives
d a more rational therapy than oral
j agents had not solved their dysmenorrhea
sturbing the normal hormone balance of patients,
instrual pain becomes evident. For the rest of
nen
pears, a patient takes two capsules stat, for fast
ie effects with short courses of treatment with
3 Hulkktnen.M.O .Kaihola.HL . ActaUDstet tjynecoi Scant! 56 7"5- 75. 1977
4 Anderson. A.B M.. Haynes, P.J.. etal: Lancet (1): 345-348. 1978
5. Consensus independent research, 1978. Data on File ParKe-Davts Canada I
acetylsalicylic acid to cause gastrointestinal
bleeding.
ADVERSE REACTIONS: In controlled clinical
investigation studies of PONSTAN at analgesic
doses, up to 1 500 mg per day. associated side
- effects were relatively mild and infrequent
Complaints are dose-related, being more frequent
lered with higher doses
clion in 2.594 subjects given mefenamic acid over a
in at period of from 1 to 238 days, the most frequently
I " n 9 reported adverse effects were drowsiness {68
subjects), nervousness (28), nausea (20). dizziness
(36). gastrointestinal discomfort (10). diarrhea (1 1 ).
vomiting (5). and headache (2) There were single
reports of insomnia, urticaria and dyspnea and
facial edema, and 2 instances each of blurred
id vision, gas and perspiration
There have been a few reports of hematopoietic side
than effects. A direct cause and effect relationship has
not been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg mefenamic acid.
Bottles ot 100 and 500 capsules.
FULL PRESCRIBING INFORMATION ON
REQUEST
Ponstan
(mefenamicacid)l
FOR PRC
OF DYSH
# non-hormonal, nor
(simple, short-tern
taken only when re
* inhibits prostaglan
the action of prostc
smooth muscle 1 (n
contractions and e
Ponstan Capsules 2
2 capsules at onse
followed by 1 caps
the duration of syn
Reg. T M./M-E Prke, Dvll & Company
PC
When it does
every
PAR
General Principles
1. The human person, regardless of race, creed, color,
social class or health status, is of incalculable worth, and
commands reverence and respect.
2. Human life has a sacred and even mysterious character
and its worth is determined not merely by utilitarian
concerns.
3. Caring, the central and fundamental focus of nursing,
is the basis for nursing ethics. It is expressed in compassion,
competence, conscience, confidence and commitment. It
qualifies all the relationships in nursing practice, education,
administration and research including those between nurse-
client; nurse-nurse; nurse-other helping professionals;
educator-colleague; faculty -student; researcher-subject.
Statements of Ethical Responsibility
1. Caring demands the provision of helping services that
are appropriate to the needs of the client and significant
others.
2. Caring recognizes the client s membership in a family
and a community, and provides for the participation of
significant others in his or her care.
3. Caring acknowledges the reality of death in the life of
every person, and demands that appropriate support be
provided for the dying person and family to enable them to
prepare for, and to cope with death when it is inevitable.
4. Caring acknowledges that the human person has the
capacity to face up to health needs and problems in his or
her own unique way, and directs nursing action in a manner
that will assist the client to develop, maintain or gain personal
autonomy, self-respect and self-determination.
5. Caring, as a response to a health need, requires the
consent and the participation of the person who is exper
iencing that need.
6. Caring dictates that the client and significant others
have the knowledge and information adequate for free and
informed decisions concerning care requirements, alternatives
and preferences.
7. Caring demands that the needs of the client supersede
those of the nurse, and that the nurse must not compromise
the integrity of the client by personal behavior that is self-
serving.
8. Caring acknowledges the vulnerability of a client in
certain situations, and dictates restraint in actions which
might compromise the client s rights and privileges.
9. Caring, involving a relationship which is, in itself,
therapeutic, demands mutual respect and trust.
10. Caring acknowledges that information obtained in the
course of the nursing relationship is privileged, and that it
requires the full protection of confidentiality unless such
information provides evidence of serious impending harm to
the client or to a third party, or is legally required by the
courts.
11. Caring requires that the nurse represent the needs of
the client, and that the nurse take appropriate measures when
the fulfillment of these needs is jeopardized by the actions of
other persons.
Parke-Davis Canada Inc., Scarborough, Ontario
12. Caring acknowledges the dignity of all persons in the
practice or educational setting.
13. Caring acknowledges, respects and draws upon the
competencies of others.
14. Caring establishes the conditions for the harmonization
of efforts of different helping professionals in providing
required services to clients.
15. Caring seeks to establish and maintain a climate of
respect for the honest dialogue needed for effective colla
boration.
1 6. Cari ng establ ishes the legiti macy of respectful chal lenge
and/or confrontation when the service required by the client
is compromised by incompetency, incapacity or negligence,
or when the competencies of the nurse are not acknowledged
or appropriately utilized.
17. Caring demands the provision of working conditions
which enable nurses to carry out their legitimate responsi
bilities.
18. Caring demands resourcefulness and restraint
accountability for the use of time, resources, equipment, and
funds, and requires accountability to appropriate individuals
and/or bodies.
19. Caring requires that the nurse bring to the work
situation in education, practice, administration or research,
the knowledge, affective and technical skills required, and
that competency in these areas be maintained and updated.
20. Caring commands fidelity to oneself, and guards the
right and privilege of the nurse to act in keeping with an
informed moral conscience.
Prepared for
Canadian Nurses Association
by M. Sinione Roach, RN, PhD, csm
and
approved by
Board of Directors
February 1980
)ies
uctive years in pain. Yet many of these women
at with analgesics, or simply accepting their
smodic dysmenorrhea is unsatisfactory.
incompetence, and the use of oral
lical picture
ed in causing the pain and other related problems.
al prostaglandin levels (particularly levels of
dysmenorrhea.
nenorrhea
ynthesis the enzyme system responsible for
ihibit the enzymes of the prostaglandin
gesics
g in the treatment of dysmenorrhea, affording
; (2 caps of 32-5 mg/325 mg t.i.d.) and Ponstan
algesic combination on both clinically
less absenteeism in the group taking Ponstan. 4
eptives
id a more rational therapy than oral
3 agents had not solved their dysmenorrhea
isturbing the normal hormone balance of patients,
snstrual pain becomes evident. For the rest of
Tien
>pears, a patient takes two capsules stat, for fast
Je effects with short courses of treatment with
;tered
tction
tinal
Ting
TAN
4. Anderson, A B.M.. Haynes, P.J., et al: Lancet (1): 345-348, 1978
5. Consensus independent research. 1978 Data on File Parke-Davis Canada Inc.
acetylsalicyhc acid to cause gastrointestinal
bleeding.
ADVERSE REACTIONS: In controlled chmcal
investigation studies of PONSTAN at analgesic
doses, up to 1 500 mg per day, associated side
effects were relatively mild and infrequent.
Complaints are dose-related, being more frequent
with higher doses
In 2,594 subjects given mefenamic acid over a
period of from 1 to 238 days, the most frequently
reported adverse effects were drowsiness (68
subjects), nervousness (28). nausea (20). dizziness
(36), gastrointestinal discomfort (10), diarrhea (11),
vomiting (5), and headache (2) There were single
reports of insomnia, urticaria and dyspnea and
facial edema, ana 2 instances each of blurred
vision, gas and perspiration.
There have been a few reports of hematopoietic side
effects A direct cause and effect relationship has
not been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg mefenamic acid.
Bottles of 100 and 500 capsules.
FULL PRESCRIBING INFORMATION ON
REQUEST
Ponstari
(mefenamic acid) I
FOR PRC
OF DYSIV
* non-hormonal, not
(simple, short-terr
taken only when re
* inhibits prostaglar
the action of prost
smooth muscle 1 (r
contractions and c
Ponstan Capsules 2
2 capsules at ons(
followed by 1 cap;
the duration of syr
Reg. T M./M Pirke. Davis & Company
PC
When it does
every
PAF
Parke-Davis Canada Inc., Scarborough, Ontario
UPDATE ON DYSMENORRHEA
Shortcomings of traditional therapies
Surveys show that up to half of female patients may live a sixth of their reproductive years in pain. Yet many of these women
are reluctant or embarrassed to talk about their problem, preferring to self treat with analgesics, or simply accepting their
condition.
The Lancet, as recently as 1978, reported: "Current treatment of primary spasmodic dysmenorrhea is unsatisfactory.
Powerful analgesics may be habit forming, dilatation of the cervix may cause incompetence, and the use of oral
contraceptives seems unjustified unless contraception is required." 2
How prostaglandins fit into the clinical picture
In the 1940 s it was theorized that a menstrual toxin existed which was involved in causing the pain and other related problems.
Recent investigations have indicated that increased premenstrual endometrial prostaglandin levels (particularly levels of
prostaglandins E 2 and F 2 alpha) may play an important role in the etiology of dysmenorrhea.
How Ponstan assists in relieving dysmenorrhea
Most non-steroidal anti-inflammatory agents are inhibitors of prostaglandin synthesis the enzyme system responsible for
the formation of prostaglandin.
The fenamate group of anti-inflammatory drugs have a twofold action: they inhibit the enzymes of the prostaglandin
synthesis pathway and also antagonize prostaglandins at the receptor sites.
Ponstan versus conventional analgesics
Recent clinical trials have demonstrated that Ponstan is, indeed, a useful drug in the treatment of dysmenorrhea, affording
relief in some 89.3% of patients cycles. 3
In a double-blind comparison of dextropropoxyphene/paracetamol capsules (2 caps of 32.5 mg/325 mg t.i.d.) and Ponstan
(2 caps of 250 mg t.i.d.), Ponstan was significantly more effective than the analgesic combination on both clinically
determined and subjective patient preference assessments. There was also less absenteeism in the group taking Ponstan. 4
Alternative therapy to oral contraceptives
Ponstan provides prompt relief of dysmenorrhea, and may thus be considered a more rational therapy than oral
contraceptives.
In a recent survey, 55% of women taking oral contraceptives stated that these agents had not solved their dysmenorrhea
problems. 5 Ponstan has demonstrated a much higher success rate without disturbing the normal hormone balance of patients.
Unlike oral contraceptives, Ponstan is taken only when required, i.e. when menstrual pain becomes evident. For the rest of
the month the patient may be free of medication.
Ponstan: a simple short-term regimen
Patient acceptance of Ponstan is understandably enthusiastic. When pain appears, a patient takes two capsules stat, for fast
relief, followed by one capsule every 6 hours for the duration of symptoms.
In addition, Ponstan is well tolerated. Extensive data supports the fact that side effects with short courses of treatment with
Ponstan are restricted mostly to minor gastrointestinal disturbances.
Prescribing Information:
PONSTAN CAPSULES 250 mg
PONSTAN (mefenamic acid) is an analgesic
preparation with antipyretic, anti-inflammatory and
antiprostaglandin properties PONSTAN has been
shown to inhibit both the synthesis of prostaglandins
and their action on the cell receptor sites.
INDICATIONS: For the relief of pain in acute or
chronic conditions such as dysmenorrhea.
headaches and muscular aches and pains,
ordinarily not requiring the use of narcotics.
DOSAGE: Administration is by the oral route,
prelerably with food The recommended regimen for
adulls and children over 14 years of age is 500 mg
as an initial dose followed by 250 mg every 6 hours
as needed PONSTAN should not be given to
children under 1 4 years of age
CONTRAINDICATIONS: PONSTAN is
contramdicated in patients showing evidence
of intestinal ulceration. The drug \s also
contramdicated in patients known to be hyper
sensitive to mefenamic acid. If diarrhea occurs,
the drug should be promptly discontinued Safe
use in pregnancy has not been established.
PRECAUTIONS: PONSTAN should be administered
with caution to patients with abnormal renal function
and inflammatory conditions of the gastrointestinal
tract Caution should be exercised m administering
PONSTAN to patients on anticoagulant therapy
since it may prolong prothrombm times PONSTAN
should be used with caution in known asthmatics.
It rash occurs, the drug should be promptly
discontinued.
Mefenamic acid may prolong acetylsalicylic acid
induced gastrointestinal Weeding. However,
mefenamic acid itself appears to be less liable than
BIBLIOGRAPHY: 1 Smith, I D., Temple, D.M .etal: Prostaglandins 10: 41-57. 1975
2. Kapadia, L . Elder. M.G., Lancet (1): 348-350. 1978
3. Pulkkinen, M.O., Kaihola, H.L., ActaObstetGynecolScand 56.75- 76, 1977
4 Anderson, A B.M., Haynes, P.J., et al: Lancet (1) 345-348, 1978
5. Consensus independent research, 1978 Data on File Parke-Davis Canada Inc
acetylsalicylic acid to cause gastrointestinal
bleeding
ADVERSE REACTIONS: In controlled clinical
investigation studies of PONSTAN at analgesic
doses, up to 1500 mg per day, associated side
effects were relatively mtld and infrequent.
Complaints are dose-related, being more frequent
with higher doses
In 2,594 subjects given mefenamic acid over a
period of from 1 to 238 days, the most frequently
reported adverse effects were drowsiness (68
subjects), nervousness (28), nausea (20), dizziness
(36). gastrointestinal discomfort (10), diarrhea (1 1),
vomiting (5), and headache (2) There were single
reports of insomnia, urticaria and dyspnea and
facial edema, and 2 instances each of blurred
vision, gas and perspiration
There have been a few reports of hematopoietic side
effects. A direct cause and effect relationship has
no! been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg mefenamic acid.
Bottles of 100 and 500 capsules
FULL PRESCRIBING INFORMATION ON
REQUEST
"Thunder Bay is turned on to
fitness", reports Frances Welch,
BScN, M.Ed., Project Director of
Health Promotion with the
Thunder Bay Community Fitness
Campaign (CFC). The citizens of
the city demonstrated this when
in September, 1979, 22,000
individuals registered to walk,
run, bicycle or jog more
kilometers than their twin,
Brampton, Ontario, during a one
week kick-off to their
Community Fitness Campaign.
Thunder Bay s Community
Fitness Campaign is a two-year
project designed to encourage
citizens to become more active,
more frequently, more regularly
and, in doing so to accept
responsibility for their own health
through lifestyle management. As
a health promotion strategy, it
also attempts to provide an
environment which physically and
socially supports fitness. While
the project is very much based on
a community development model,
the focus has been placed on
several different target groups
including school-aged children,
women, employees, community
leaders, families, senior citizens
and the aged, through a series of
motivational, educational and
fitness events.
As a demonstration project
of the District Health Council,
the Community Fitness Campaign
has caused many elements within
the community and the health
care system to re-examine their
services and mandates. Traditional
fitness agencies, challenged by
this increase in non-traditional
fitness events which provide
participation for many and
spectatorship for few, are forced
to reassess their roles as
community agencies. Consumers
are beginning to demand
improved access to fitness; they
want the previous barriers of
high cost, limited availability and
rigid time scheduling eliminated.
Also as more people become
involved in fitness, clinically
oriented fitness professionals are
forced to reconsider the meaning
of fitness for these new clients.
The traditional roles of
existing community health
agencies, as well as those of
various health professionals are
also being challenged by the
presence of such a campaign.
Strategies for conflict
management have taken on new
significance at both the individual
and the planning level as issues
affecting the development of
fitness as a resource available for
positive lifestyle management are
delineated.
For nursing, CFC
represents a challenge as it
demands knowledgeable, feasible
and client-compatible planning
about how to market fitness,
how to manage a community-
wide nursing plan and how to
cope with the conflicts that are
bound to arise when any nursing
project attempts to facilitate
lifestyle change within or outside
of the existing health care system.
motivated after attending the
National Workshop on Fitness
and Lifestyle for Occupational
Eleanor Serviss, RN, is an
Occupational Health Nurse for
Weyerhaeuser Canada Ltd. at the
Kamloops Pulp Mill, British
Columbia. With 650 plant
employees and 200 administrative
employees situated five miles
from the town of Kamloops and
hospital facilities, Eleanor is kept
busy with the normal
occupational health nurse s duties
and coping with the job hazards
that are unique to a pulpmill,
such as inhalation of various
noxious chemicals and chemical
spills and splashes in eyes and on
skin. However, many hazards of
these highly automated mills can
be traced to the minimal physical
activity required.
Although Eleanor has been
promoting healthy lifestyles and
physical fitness over the years,
she was even more highly
Everyone agrees that fitness is fine. ..for the other guy. A
healthy lifestyle means a longer life. ..but what about right
now, today? Are Canadian nurses accepting the challenge of
integrating fitness and lifestyle teaching into their personal
lives and into their professional roles?
CNJ wondered about that and, in an effort to find out,
asked a sampling of occupational and community health
nurses across the country, many of whom had attended one of
the three national fitness workshops for nurses at Geneva
Park, to tell us what they are doing and how they are coping
with the realities of initiating change in this area.
Judith Banning
Photos courtesyof Weyerhaeuser Canada Ltd.
Health Nurses. She took a closer
look at her own lifestyle and in
response set up a personal fitness
schedule that included improving
her diet, swimming twice a week,
walking after work, using an
exercise bicycle, skipping and
doing specific exercises daily.
Now she feels much better
equipped to promote
individualized fitness programs
and does this daily through her
contact with employees.
Eleanor believes that if
individual counseling is done well,
people can be made to want to
keep fit and since it is then their
own idea, the chances that they
will be successful are greatly
increased. Presently, she is
holding two $100 cheques in
safekeeping for two employees
who are competing with each
other in a weight reduction
contest.
Management has needed
some convincing about their role
in the fitness of their employees,
but in the long run have been very
supportive. An acre of land has
been set aside for future
recreation uses, exercise breaks
have been initiated in many of the
office areas, hours of work have
become more flexible to allow
A personal commitment
to fitness results in
healthier clients
time for fitness classes at the local
YMCA at noon and the company
is sponsoring curling, hockey,
baseball and golf. Eleanor also
uses the Weyerhaeuser News,
the company newspaper which
circulates to employees in
British Columbia, Ontario and
Quebec, as a vehicle for her
fitness and lifestyle teaching.
The company employees
were not the only ones to benefit
from her workshop attendance.
Eleanor also met with the local
Occupational Health Nurses group
and shared her experiences and
updated knowledge. Once a cover
girl of the RNABC News, Eleanor
retired officially in March, 1980.
For the employees living
and working throughout rural
Saskatchewan, promotion of
fitness and lifestyle goes beyond
exercise and physical activity
which they often feel they have
accomplished through their active
jobs. Consequently, nutrition,
weight control and smoking are a
few of the topics that are
considered. Use of the employee
news publication, special annual
health bulletins on smoking,
availability of stop smoking kits,
buttons and posters and
correspondence with all new
employees are the teaching
methods used for these rural
employees.
Returning to her work area
from the excitement of the
Fitness and Lifestyle workshop,
Marilyn Reddy , RN, found she
had to redefine her enthusiasm in
the light of the realism of her own
work situation. Goals had to be
modified and accomplishments
seemed small at first but now
she s hoping that major changes
will soon be evident.
Marilyn is an Occupational
Health Nurse with the
Saskatchewan Wheat Pool, a
farmer-owned cooperative
employing approximately 4000.
As there are several different
operating divisions, there is a
great diversity in the working
environments of the employees.
Establishing a fitness or lifestyle
program either active or
promotional in a rural area is
difficult since personal contact by
the health nurse is infrequent and
in some widespread locations in
Saskatchewan, very impractical;
organized onsite exercise
programs are not feasible as the
number of employees are few and
facilities unavailable, even
community facilities in small
hamlets are usually non-existent.
The Wheat Pool in
Saskatoon includes the Western
Producer Publication, a printing
and publishing operation which
employs more than 200 persons
in a highly mechanized
environment. Assembly line jobs
become boring and although the
need may be there, production
usually cannot be interrupted for
mini-exercise breaks or fitness or
lifestyle programs. These
problems are further accentuated
by shift work, the lack of
available space for onsite facilities
and the location of the work site
in the industrial section of the
city far from existing community
facilities such as the YM-YWCA
or racquette clubs.
Marilyn visits the Western
Producer only one day a month
but has a good relationship with
management and employees
there. Besides the usual posters
and literature, she suggested that
a picnic site with tables be made
available for the many employees
who work all day on machines in
windowless environments. Now
there are tables, horseshoe games,
balls and frisbies. Unsweetened
juices, fresh fruit and cheddar
cheese are available through the
food service and Marilyn has
recommended to management
that a walk/jog trail with
exercise stations be developed
around the perimeter of the
building.
At the Head Office in
Regina, there are 550 more
employees. These sedentary office
workers working in one location
with little or no shift work, a
full hour lunch break and
community facilities close by,
make the probability of a
successful program quite feasible.
Fitness posters brighten the
coffee shop, YM-YWCA program
brochures are given a high profile,
an annual jog-a-thon is well
advertised, films are shown
regularly, articles on fitness and
nutrition are inserted in the
employees publication, onsite
Stop Smoking Clinics are held,
fresh fruit, bran muffins and
cheese are now available in the
coffee shop and sandwich and
soup machines have been installed
for those who do not bring a
lunch and previously had to
settle for chips, a chocolate bar
and a coke. A weekly weight club
has been initiated and at the
annual meeting, exercise breaks,
nutrition breaks and a ban on
smoking during sessions now
prevail.
In the future, Marilyn is
hoping for onsite lockers and
showers, an exercise room,
fitness testing facilities and an
employee fitness committee
which would promote various
inter-departmental activities and
more effectively represent the
employees suggestions to
management. If onsite facilities
are developed, Marilyn feels that
the employees should in some
way share in the cost with
management whether through
reasonable monthly memberships,
raffles or other fund-raising
projects.
After attending the
National Workshop on Fitness
and Lifestyle for Community
Health Nurses, Beth Truant, RN,
PHN, decided to integrate fitness
into her own professional nursing
role. A public health nurse with
the West Kootenay Health
District, Trail, British Columbia,
she began with an assessment
within her working area of the
benefits that might accrue from
improved fitness and the methods
that might be utilized. She
realized her first step was to
overcome her own lack of fitness
through improved nutrition,
keep-fit classes and generally
improving her own lifestyle.
Her nursing colleagues
were also concerned about their
personal fitness levels and the
problems of integrating fitness
into their community work. With
the support of management,
enthusiasm grew. Beth
coordinated the fitness and
lifestyle component of a Mother s
Parenting Group. Participants in
the program were given fitness
tests, counseled on their personal
levels of fitness and how to
improve these.
Soon Beth was distributing
resource tapes and materials to a
variety of groups, ranging from
schools within her district to care
facilities for the elderly. This
resource development put her in
touch with fitness cousultants and
she gained from their advice on
weight control and exercise.
Circuit training and exercise break
tapes were then made available
and Beth began noticing that
fitness and lifestyle teaching were
becoming part of all her duties
including prenatal teaching,
school duties and community
projects.
Although most
employment in the Trail area
requires a high degree of physical
activity in the lead, zinc and silver
smelters or in the pulp mills and
logging communities, these people
have not been immune to weight
gain. The West Kootenay Health
District is currently involved in a
promotional campaign called a
"Flab Fight" which is
encouraging people to reduce
their caloric input and to increase
their physical activity. Actively
promoted by local radio stations,
the campaign encourages people
to visit their local branch offices
of the West Kootenay Health
District to pick up a locally
designed "Fat Kat Fit Kit".
As community health
specialists, Beth believes that
public health nurses must guard
against overpowering clients with
the fact that fitness is the panacea
to all problems of western
society, but it is important to
understand that all aspects of life
and lifestyle are closely linked
and equal in their contribution to
the quality of life an individual
chooses.
Judy Proulx, RN, CHN,
coordinated a pilot project, "Fun
and Fitness", an obesity clinic in
Cochrane, Alberta for children
age six through fourteen. This
project, a joint effort of the
Mount View Health Unit and the
Alberta Children s Hospital,
Endocrine Clinic, utilized a team
consisting of a physician,
dietitian, physical education
teacher and community health
nurse.
Sixteen children were
involved in the eight-week
program which included a
complete physical assessment and
a three pronged approach to
initiate change through use of
diet, physical activity and
lifestyle of the child and the
family. The nutritionist met with
each parent and child individually
to discuss eating habits and ways
of cutting back calories, to
develop a personal diet according
to age and weight and to
emphasize family involvement
(one parent was usually
encouraged to join the child in
dieting).
The one and one-half hour
sessions began with a weigh-in
and discussion of personal
difficulties; during this time
warm-up exercises including disco
dancing and relay type exercises
were taking place in the gym.
Then specific sports activities
were organized, such as baseball,
hiking or swimming to give the
children new opportunities to
experience their bodies. After
cooling down, the children took
part in nutritional discussions.
Parent involvement was
encouraged in all aspects of the
program.
At the end of the eight-
week period, there was a total
loss of 106 pounds. Weekly
weigh-in at the health unit during
the summer was encouraged.
Eleanor Martin, RN, is an
occupational health nurse
working with Dominion Bridge
Company Limited in Winnipeg.
Not only does she treat injuries
which the steel plant workers may
receive, but she is also making a
concerted effort to improve
safety on and off the job site. She
describes some of the employee
and management feelings about
safety: "They think that is is dull
and boring. I have to convince
them that safety is just as
important as production. Every
day lost to an injury is not only
painful to the injured person: it is
expensive to the employer, and
costly to the community in the
sense that it is the taxpayer who
pays for medical and hospital
services if they are required.
Accidents can be prevented and
prevention starts with an
enlightened management."
Through the use of
personal accident prevention
meetings, with new employees,
films, first aid courses and a
regular safety newsletter sent to
the employees homes, safety on
the worksite and also in the home
is emphasized. Safety incentives
are also used, such as draws for
trips when specified numbers of
accident-free days are reached.
Alison Black, RN, B.N.Sc.,
works with the Ottawa
Centretown Community Resource
Centre, a community health
center with a difference. On staff
at the center are seven nurses who
function as independent,
community-based
practitioners, each of whom was
largely instrumental in developing
her own job description and
initiating her own program.
Alison works with a
"Lifestyles and Health Program"
which entered its pilot stage 18
months ago. The program has a
long term goal of helping
individuals adopt healthy habits
and lifestyles and maintain these
for a lifetime. By focusing on
lifestyle, personal responsibility
for health and on learning skills
for greater control over personal
health, the basic precepts of
nutrition, physical fitness and
the constructive management of
stress are taught.
During the initial 11-hour
block of lectures, the effects of
inadequate nutrition, physical
inactivity, inappropriate methods
of coping with stress (including
smoking and the excess use of
alcohol and drugs) and lack of
purpose and direction are
discussed. Health evaluations are
done to help the participant
assess and understand his own
current overall health level,
provide a baseline and motivate
him to initiate change. The
evaluations are not a search for
illness, although any pathology
indicated by abnormal results
would be followed up by an
appropriate referral to the
family physician.
These evaluations which
focus on health potentials, health
hazards, stress and physical fitness
levels, include a blend of measures
from blood tests, blood pressure
and pulse determination and
other biometric measurements to
a health hazard appraisal, life
change measurements, indexes of
well-being, cardiovascular risk
assessment and fitness tests.
The final two hours of the
initial block focuses on
implementing a program for
lifestyle change and health
improvement relevant to the
individual s situation and on
providing access to supportive
community resources.
Two subsequent sessions
are held at six months and 12
months, to provide ongoing
support, further information,
reassess health status and
reinforce and remotivate the
participant.
The participants, ranging
in age from 20 to 70 years, are
referred to the program as high
risk candidates by the Centre s
own medical staff, by community
physicians or agencies or come to
the program on their own
initiative having seen posters at
the center or heard of the
program from friends. Nurses and
doctors as well as
non-professionals make up this
group, some using the course as a
training session for their own
role in community education.
Generally, the participants
need help putting lifestyle
information into a workable
context. The most important
segment of the program seems to
be convincing these people that
lifestyle does relate to acute and
chronic diseases and explaining
why. Then through the
development of skills these
individuals are able to make an
informed decision about their
life and know they can influence
their health if they choose to. The
final step involves assisting these
individuals to develop realistic
goals and specific manageable
programs. This completes what
has become a highly successful
program.
"Occupational health
programs beyond the pill and
patch (first aid) concept are in
their relative infancy in Nova
Scotia," reports Jean Nickerson,
Occupational Nursing Consultant
with the Nova Scotia Department
of Health. When CNJ asked her to
share her experiences with our
readers she went one step further
and contacted occupational
health nurses across the province.
Gai Thomas, RN, BA,
MSC, of the Occupational Health
Department of the Victoria
General Hospital, Halifax,
responded by describing their
well-rounded lifestyle program
which includes:
"fit breaks", currently held
weekly or bi-weekly at all work
sites, with plans to increase these
to daily,
"fit walks", daily
purposeful walks for 15 minutes
in the immediate vicinity of the
hospital which include a short
exercise break along the way,
a "non-smoking"
committse which plans
educational programs with
highlights such as Weedless
Wednesday and Lungs for Life
slogans,
a new employee recreation
council which will organize and
develop programs and has already
designed T-shirts with the slogan
"Getting Fit For the V.G. and
Me" (the right to purchase these
shirts must be earned by
participants),
an accident program has
been developed in which the
Occupational Health Department
manages treatment of all day-time
accidents, advises the
Administration Department on
policy and procedure, investigates
all accidents, counsels all victims
and co-workers, recommends
repairs and improvement of
mechanical and environmental
contributors to accidents,
reports to Workman s
Compensation Board, etc.,
environmental concerns
addressed through a new program
of monitoring, investigation and
cooperative hazard appraisal, and
safety committees
restructured and expanded and a
new safety council formed in
hopes of raising the collective
safety consciousness of the
employees and administration.
Beverly LeBlanc, RN,
works with Devco health services
at one of their nursing stations
located at Prince Mine, Point
Aconi. Although the nursing
station operates on a 24-hour
basis and is readily accessible to
all workers, establishing a fitness
and lifestyle program has been
difficult because of the nature
and hours of the coal miners
work. In response to this the
nurses have established a special
program each month designed to
aid the workers in their daily
life. These programs focus on a
wide variety of themes such as
nutrition, blood pressure, vision
testing, weight control, blood
sugar testing, etc., and are
designed to educate as well as
diagnose. They also increase the
nurses contact with the men,
increasing their visibility on the
work site for other than injury or
illness consultation. Now the
miners drop in to pick up
information on healthy diets, to
have a blood pressure taken or for
a monthly weigh-in and their
anti-smoking teaching is
supplemented by the strict
no-smoking policy underground,
so eight hours of the miners day
is "smoke free".
About a year ago, Mary
MacNeil, RN, an Occupational
Health Nurse with the Point
Tupper Refinery, Port
Hawkesbury, a division of Gulf
Canada, sat down with the local
public health nutritionist to
discuss how they should go
about initiating a fitness and
lifestyle program. What resulted is
a program now well into its
operational phase.
A fitness testing team from
St. Francis Xavier University
visited the plant site and 92 of
the 138 employees participated in
the testing and health inventories
which made up the Lifestyle
Inventory and Fitness Evaluation
program. Individualized print-outs
featuring comparison with the
average Canadian and
recommendations for improving
the evaluations were given to all
participants.
Now a six-week nutritional
and physical fitness education
program is being prepared to
focus on three types of fitness
and lifestyle groups: first, those
who will retain their status quo,
second, those who will follow a
personal program
(self-maintenance) and thirdly,
those who will follow a controlled
program with an organized group.
A recheck and comparison of
data will be done at the end of
the six-week program.
Meg Macdonald, RN, is an
Occupational Health Nurse with a
self-sufficient, multi-faceted
electronics company made up of
approximately 600 employees.
While management seemed to
focus primarily on production in
the past, there now seems to be
a growing concern within
management for employee health.
For Meg, the major barrier to
establishment of a fitness program
has been the short 30-minute
lunch break and the lack of time
for fitness breaks during the day.
However, a group of women
employees do carry out
ten-minute stretch and bend
exercise sessions outside in the
warm weather and basketball
baskets and balls are to be
purchased for use this spring.
Otherwise teaching takes place
through the use of posters and
one to one counseling on
smoking, weight control,
nutrition and use of leisure time.
Soft ball, bowling and hockey
teams have also increased in
popularity.
Evelyn Bickerton, RN,
staff health nurse at the Sydney
City Hospital, reports that many
departments in her hospital have
become involved in fitness and
lifestyle teaching. Two afternoons
a week the hospital dietitian has
made herself available to all staff
with weight problems. Meal plans,
diet charts, individual interviews
and weekly weight checks are
used. An alcoholism committee
has been set up with
representatives from the local
Detox Centre and health service
available to all employees. Along
with confinement of smoking to
specific areas, the use of
audiovisual presentations on
smoking, nutrition, dieting and
alcoholism and the availability of
up-to-date literature, the
lifestyles of their employees will
hopefully be improved.
Even the student nurses are
benefiting, as a fitness program
including exercises, dancing,
outdoor jogging, swimming and
organized sports has been
incorporated ihto their nutrition
classes.
Norma Hooper, RN, is an
Occupational Health Nurse with
Maritime Telegraph & Telephone
Co., Ltd., a tele-communications
industry with an employee
population of approximately
3,500 people scattered
throughout Nova Scotia from
Sydney to Yarmouth and ranging
from craftsmen and operators to
clerical staff and professionals.
Initially, a nutrition/weight
control program organized in
Halifax, Sydney and Kentville
centers resulted in large numbers
of employees participating in
weekly weigh-in and nutritional
counseling. The enthusiasm
following setting up of this
program led to the establishment
of noon-time fitness programs
initially in the Halifax region and
now in some of the other centers.
More recently a supervisors
training program on alcohol and
drug abuse has been implemented
and more than 200 managers have
been involved in the 12 one-day
sessions held to date.
Promotion, awareness,
group education of employees on
a continuing basis, visibility and
self-example are all tools in the
continuing campaign to motivate
employees to take that last,
important step active
participation in an individual
fitness program. *
At the fork of the Irvine and
Grand Rivers in southwestern
Ontario, stands the small
village of Elora. Here, housed
in a rural Anglican church,
are the remnants of an almost
forgotten love story. This
story holds a special interest
for nurses because of the fact
that the woman involved was
none other than Florence
Nightingale.
"The Lady of the
Lamp", Florence Nightingale
and her first cousin, John
Smithurst, so the story goes,
fell in love in England when
both were very young. The
fact that they were cousins
made marriage out of the
question so they decided to
part, each taking up a new
vocation: Florence, of course,
became a nurse; John studied
for the ministry, was
ordained and, in 1839, left
for the lonely frontier of
Canada.
John Smithurst served
as pastor of St. John s
Anglican Church in Elora for
many years, until his retire
ment in 1857, but before that
happened, he was the
recipient of a unique and
lasting testimonial to his
relationship with "The Lady
of the Lamp". The gift was a
wes in 0/0/22
Thelma R. May
and Wendy J. May
beautiful silver English
communion set now on
display in a special vault in
the church. The inscription
engraved on one of the silver
pieces is in Latin. Translated
it reads:
"Acting as an agent for
someone, Ebenezer Hall
gave, as a gift, this set of
communion silver to
Reverend John Smithurst, a
very dear friend, in grateful
recognition of his many
kindnesses. A.D. 1852"
That "someone" was
Florence Nightingale.
John Smithurst died in
1867 at the age of 59 and was
buried in Elora Cemetery. His
cousin Florence was buried in
St. Paul s Cathedral in
London, England, some 43
years later.
In years gone by, a
special service for nurses was
held in St. John s on the
Sunday closest to the
anniversary of Florence
Nightingale s birth in May,
1820. Now, however, the
communion set is used by the
congregation only at
Christmas and Easter
although it is kept on display
and the little church is
always open to visitors.
Bibliography
1 Muir, Vera M.
Unpublished article, property
of the Wellington County
Historical Research Society,
Wellington County Museum,
Fergus, Ont.
2 -, "The Love Story of
Florence Nightingale and
John Smithurst"; pamphlet in
The Church of St. John the
Evangelist, Elora, Ont.*
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Perceptual
_*. -M "^Bi
tioteiG
You helped your post-CVA patient, Mrs. West, into the chair not twenty minutes ago; when you
return to her room, she is upset, saying she has been sitting there for "three hours" and has had to go
to the bathroom. Her callbell is still fastened to the left arm of her chair where you left it. Mrs. West
says she couldn t find it to ring for help. Is she confused, or are her perceptions distorted?
The nurse who does not understand or
recognize the problem of perceptual
distortion in a patient s behavior cannot
help but fail to ascertain the impact this
deficit may have on the patient s
progress. She may, mistakenly, attribute
his behavior to other causes perhaps
confusion or an uncooperative nature
which may lead to inappropriate nursing
interventions and feelings of
hopelessness and frustration on the part
of both patient and nurse.
Normal perception involves the
apprehension, reception and integration
of all sensory input by the human brain,
from within the body and without, such
as touch, vision, hearing or position
sense (proprioception); the result is that
the normal human has an ordered
understanding of the relationship of his
body to the outside environment, and the
parts of the body one to another.
Without this understanding, it is
impossible for an individual to
successfully accomplish the various
skilled motor activities that are part of
daily life.
Perceptual deficit may vary in both
type and degree following a C VA that
affects either side of the brain. In
general, however, patients with left
hemiplegia (right-sided brain damage)
have more problems with perception,
while those with right hemiplegia
(left-sided brain damage) have more
problems with language functions. Thus
the problems discussed in this article will
be most commonly found in stroke
patients with left hemiplegia and intact
language function.
While the absence of any difficulties
with language may allow the nurse and
patient to communicate and may ease the
nurse s assessment and management of
problems, it is still easy to underestimate
potential problems in rehabilitation.
Perceptual problems have a great effect
on the patient s level of independence.
The impact of some of the facets of
perceptual distortion are outlined below.
Lack of awareness
The post-CVA patient may actually be
unaware of the affected side of his body,
and he may subsequently neglect it. This
problem is due to a complex brain
dysfunction; if the patient is not aware of
one side of his body he will not use it,
and if preventive measures are not taken
he may develop further problems such as
weakness orcontractures, as severely as
if he had actual paralysis. Such a patient
when attempting to wash or dress
himself will believe he has finished when
he has washed only one side or put only
one arm into his hospital gown. A bizarre
but occasional example of unilateral
neglect of the body is the patient who
thinks another person or a dead body is
in bed with him because he sees or feels
arms or legs that he cannot recognize as
his own.
1A 1B
Figure one. Evidence of unilateral neglect in figure drawing.
Nursing assessment of this problem
can be based on observation of
spontaneous patient behavior as well as
the patient s response to requests to
touch various parts of his body. Another
way the nurse can assess a patient s
body awareness is to have him draw a
human figure, either from memory or by
copying a stick figure the nurse has
drawn. Figure one illustrates the impact
of unilateral neglect on figure drawing;
this patient shows almost complete lack
of awareness of the left side at 6 weeeks
(la) and partial return of awareness at 27
weeks after a stroke (Ib).
When doing any assessment that
involves asking the patient to perform
tasks that would have been simple before
his CVA, the nurse must take care not to
leave the patient with a feeling of
frustration and failure. She should
explain that the procedure will help her
understand what problems he has and
that she will help him cope with them.
While caring for a patient with body
awareness problems, the nurse should
take every opportunity to make the
patient aware of his neglected side. This
can be done when bathing or assisting
the patient with his bath by bringing the
neglected extremities to his unaffected
side and naming each part as it is
washed. Encouraging the patient to put
on his clothes by himself, even if he is
only wearing a hospital gown, is helpful
if the nurse gives consistent directions
and is ready to assist when the task
becomes too frustrating.
There is great value in frequent
repetition and consistency of approach
when practicing such basic skills; when
both are working with the patient, the
nurse and the occupational therapist
should consult so that they can establish
and follow a routine with the patient.
In addition to his perceptual
difficulty, the patient with left hemiplegia
may have loss of direct sensation in his
affected extremities, leaving him with no
sense of touch or position on that side of
his body which obviously makes
overcoming unilateral neglect more
difficult. The right hemiplegic patient,
who does not usually have perceptual
problems and thus remains aware that
the affected side of his body exists, may
have sensory loss alone. This means he
cannot feel the pressure of his foot on the
floor or of his arm on the mattress; he
cannot feel whether his knee is bent or
straight, or whether his arm is in front of
or behind him. All knowledge of the
affected limbs must come from touching
them with his unaffected side or by
looking to see where they are. Anyone
who has ever had a limb "go to sleep"
knows how awkward and useless this
can feel.
In contrast to the left hemiplegic
patient who may harm himself by
ignoring one side of his body , the right
hemiplegic patient tends to be overly
cautious and even afraid to move if he
has lack of sensation in his affected side.
This fear is often obvious in the
desperate grip the patient has on the bed
rail or nurse s arm when he is asked to
move; however he may have
accompanying language difficulties and
he may be unable to say why he is afraid.
The nurse can help overcome the
patient s fear with physical support and
frequent assurances that she will not let
him fall. This patient can benefit from
using a full length mirror to check the
position of his limbs as he is releaming
the activities of daily living.
Distortions of spatial awareness
While a stroke can cause distortion of a
person s perception of his body, it can
also cause distortion of his awareness of
space. Distortions of perception of space
can be divided into three main areas:
inattention to one side of space
distorted perception of distance and
vertical plane
distorted figure-ground perception.
Inattention to one side of space: With
stroke patients, problems of awareness
of the affected side of the body are
usually accompanied by inattention to
the same side of the environment.
However, in less extensive or resolving
strokes one deficit may be seen without
the other. When inattention to one side
of the environment is present, the patient
will eat the food from only one side of his
meal tray or ask why the orderly did not
return his urinal when it is hanging on the
side of the bed he neglects . I f he is
mobile, he may tend to bump into door
frames and furniture.
This neglect of one side of his
environment is sometimes but not
always accompanied by blindness in that
side of the patient s visual field
(homonymous hemianopsia). When
actual blindness is involved, the patient
will of course not see anything on his
affected side. However, the patient with
visual neglect only will often notice
objects on his affected side if they are
brought to his attention, or if the
competing stimuli on his unaffected side
are reduced, which can be done by
placing his bed so his unaffected side is
next to a wall. When blindness on the
affected side is a major factor in the
patient s inattention to one side of his
environment, frequent reminders to the
patient to turn his head in the direction of
his blindness are often enough to lead
him to the habit of constantly scanning
his environment, thus compensating for
his visual loss.
To ensure the patient s safety and to
minimize frustration if the neglect of one
side is severe, the nurse should place the
call bell, urinal, bedside table, etc. on the
patient s unaffected side. His bed should
not be positioned so that his unaffected
side is permanently against a blank wall
as this can lead to sensory deprivation
which often heightens any confusion
present. However, at later stages of
recovery and rehabilitation, the patient
usually benefits from having his
environment reorganized so that he is
encouraged to work across his affected
side. At this point, the objects he
commonly uses should be placed on his
affected side and his bed positioned so
that sources of his social stimulation, for
example, roommates and television, are
available mainly on his affected side.
To summarize, a judgement of the
most beneficial arrangement of the
patient s environment must always take
into consideration the need for safety
and to avoid the patient s frustration,
while at the same time encouraging him
to reintegrate the affected side of his
body into his daily activities.
Depth perception: Although they may be
aware of the existence of space on their
affected side, many stroke patients with
left hemiplegia cannot accurately
perceive distance or vertical plane.
Depth perception is dependent on
binocular vision, and in these patients
this is disturbed which means they
cannot tell how near or far objects are
from them or what is straight up and
down.
Distortions in distance perception
may result in patients bumping into
objects, or falling because they misjudge
the distance of a support for which they
are reaching. Inability to perceive
distance correctly may also cause
patients to drop and knock over small
articles they attempt to handle.
Distortion in perception of the vertical
plane leads to balance problems, in both
standing and sitting positions and can be
as much a cause of a patient consistently
slumping to one side in his wheelchair as
actual physical weakness; it can also
explain the difficulty a nurse may have in
getting a patient to stand up straight even
though she is bracing his knee. 2
Complicating both perceptual
deficits is the fact that the patient usually
seems to be unaware of these problems
and thus attempts activities he cannot
safely accomplish. Such a patient needs
close supervision until he can be taught,
through consistent reminders, to stop
and test correct balance and distance
before impetuously proceeding in any
activity. With vertical distortion, telling
the patient to lean to the opposite side
can be effective. Use of the terms left
and right will not be helpful if the patient
has difficulty distinguishing left from
right, another deficit that can result from
a stroke. Observing himself in a full
length mirror can also serve as a
reminder to the patient with problems in
sitting and standing balance caused by a
distorted perception of straight up and
down; when distance perception is
distorted, leaving furniture in the room
always in the same place may aid the
patient to relearn correct distance
judgement.
Distorted figure-ground perception:
Another perceptual problem is lack of
figure-ground discrimination; in other
words, the patient has difficulty sorting
out incoming visual stimuli and in
focusing on one thing in particular. This
means he may be unable to pick out a
specific object in his environment from
among others, and have special difficulty
in knowing what object is on top of or in
front of another. If there are many things
on his bedside table, for instance, he may
not be able to find the one item he wants,
or, if his slippers are on top of his plaid
bathrobe, he may not be able to pick
them out. This patient will be easily
distracted and have difficulty
concentrating on any one thing;
therefore, he will function better if his
environment is kept uncluttered and
objects are kept in the same place as
much as possible. For example, at meal
time he might manage better if food is put
on his tray one course at a time.
Apraxia
The inability to visualize internally and
to carry out the complex movements that
are part of daily activities is called
apraxia. Even with no attendant loss of
motor power or sensation, the apraxic
patient often cannot perform complex
motor tasks although he may show
understanding by describing the task.
Apraxia, which may result from strokes
in either side of the brain, is a complex
problem, the pathophysiology of which
is not yet completely understood/ What
is clear is that apraxia in its various
forms often results in rehabilitation
difficulties for the patient.
The apraxic patient typically is
unable to follow broad commands such
as "get out of bed now" or "put on your
dressing gown". He will often do much
better if asked to do one specific act at a
time, such as "roll over to me", "put
your legs over this side of the bed", etc.
Verbal instructions are not always
sufficient; however, the patient may be
able to perform the activity if the nurse
demonstrates it or physically guides him
through it one or more times while
repeating the instruction. Sometimes just
starting the sequence of movements,
such as putting one arm in his shirt
sleeve, will be enough to trigger the rest
of the sequence.
Time
A stroke can also cause distortions in
perception of time. Awareness of this
fact helps a nurse to understand that the
patient is not necessarily confused or
intentionally a trouble-maker when he
tells his wife, "I haven t eaten all day",
or "They left me in a wet bed all night."
Frequent verbal reminders of the time of
day can be helpful, as can a bedside
clock, if the patient has no problems with
visual perception that prevent him from
understanding it.
The family
If nurses have difficulty understanding
the impact of perceptual distortion on a
patient s behavior, it is easy to realize
that he and his family may be even more
confused and upset by the bizarre
behavior for which there is no apparent
cause. It is possible too that if the
patient s family is not aware of
disabilities such as vertical distortion or
problems judging distance, they will not
understand that there are situations in
which he could easily injure himself,
both in hospital and later at home.
Hopefully, the effort a nurse makes
to understand what is happening to her
patient, to learn how to help him cope
with his disabilities and to share her
knowledge with his family will have a
positive effect on the family s
understanding and commitment to have
him improve and return home. *
References
1 *Anderson, Elizabeth K. Sensory
impairments in hemiplegia.
Arch.Phys.Med.Rehabil. 52:7:296, Jul.
1971.
2 Halperin, E.J. Perceptual-motor
dysfunction: stumbling block to
rehabilitation, by E.J. Halperin and B.S.
Cohen. Md. State MedJ. 20:7: 140, Jul.
1971.
3 Siev, E. Perceptual dysfunction in
the adult stroke patient: a manual for
treatment, by E. Siev and B. Freishtat.
Thorofare.N.J., Charles B. Slack, 1976.
P .59.
Bibliography
1 Anderson, E. Parietal lobe
syndromes in hemiplegia, by E.
Anderson and E. Choy.
AmerJ.Occup.Ther. 24:1:13-18,
Jan. /Feb. 1970.
*Anderson, E.K. The significance
of the parietal lobes in hemiplegia.
Hawaii MedJ. 27:141-145, Nov. /Dec.
1967.
Burt, M.M. Perceptual deficits in
hemiplegia. A mer.J.Nurs.
70:5:1026-1029, May 1970.
4 Cohen, C. A. Perceptual problems
in hemiplegics. South MedJ.
67:1 1:1329-1332. Nov. 1974.
5 *Knapp,M.E. Problems in
rehabilitation of the hemiplegic patient.
JAMA 169:3:224-229. Jan. 17, 1959.
6 Weinstein, E.A.Hemi-inattention
and hemisphere specialization, ed. by
E.A. Weinstein and R.P. Friedland. New
York, Raven Press, 1977. (Advances in
Neurology Series, Vol.18).
"Unable to verify in CNA Library
Geraldine Hart is an assistant professor
at the Dalhousie University School of
Nursing where she teaches rehabilitation
nursing. She is a graduate of the Victoria
General Hospital School of Nursing in
Halifax and obtained her BN from
McGill University, followed by an MSN
at the University of British Columbia.
Most of her clinical nursing experience
has been in neurological and
neurosurgical nursing, and she spent
eight years working at the Montreal
Neurological Hospital.
Acknowledgement: The author wishes to
acknowledge the assistance of Janet
Millar who is a physiotherapist at the
Nova Scotia Rehabilitation Centre and
the Dartmouth Stroke Club
STROKE:
A Review
Jane Bock
Apoplexy. Stroke. Cerebral vascular accident or CVA. Whatever you or your
patients call it, stroke remains one of the leading causes of death in Canada. A
CVA can have a devastating effect on an individual s life of all CVA victims,
about 50 per cent recover with little or no deficit, but the other 50 per cent
require some form of continuous care for the rest of their lives.
Any individual case involves one of three causes of CVA:
cerebral hemorrhage
cerebral thrombosis
atherosclerosis of arteries in the head or neck.
Regardless of the specific cause, what happens is that the flow of blood to the
brain tissue is interrupted or reduced drastically, resulting in ischemia and the
destruction of brain cells which, in turn, results in certain neurological deficits.
A CVA resulting from cerebral thrombosis can occur in any vessel in the
brain but most often in the middle cerebral artery or one of its branches; the
infarction stimulates an inflammatory response which leads to cerebral edema
and the resulting occlusion of the artery.
Symptoms depend on the actual cause of the CVA, on the specific area of
the brain involved, and the size of the affected area. Hemiplegia is the most
common result; others are aphasia, memory loss and various neurological
symptoms.
There are several factors which are thought to influence the incidence of
CVA: high blood pressure, endocarditis or other cardiac disease,
atherosclerosis, and poor health habits such as heavy smoking or drinking.
The severity of signs of stroke varies from individual to individual, but
commonly seen are dizziness, headache, blurring of vision and black-out. The
CVA victim may complain of a severe headache which is then followed by loss
of muscular function and loss of consciousness. It has been noted that patients
who are in a deep coma when admitted to hospital, or who remain in a coma for
24 to 36 hours have a grave prognosis. One might also see convulsive
movements in the patient, or nausea and vomiting. Respirations may be slow,
or even Cheyne-Stokes; the pulse will be slow but bounding.
The short term goal in treating the CVA patient is to get him through the
initial or acute phase. This requires monitoring vital signs, and assessing the
extent of any damage. Tests that may be done include physical examination,
chest and skull x-rays, and other neurological tests such as brain scan, cerebral
angiogram, EEG or CT scan.
Patients are usually nursed in the semi-prone or lateral position, and,
depending on the degree of muscular deficit, may require total care such as
feeding, turning, bathing, etc. An important goal of nursing care, after assessing
the damage that has been done by the stroke, is to preserve existing function in
the patient and work toward rehabilitation.
Complications can obstruct the patient s road to rehabilitation and return to
his normal life: the post-CVA patient may have various deficits such as aphasia
(of which there are several types), dysphagia, loss of memory, poor
comprehension ability and various perceptual disorders. The most common
visual defect \shomonymous hemianopsia (loss of either the right or left field of
vision in each eye). A common misconception among both nurses and the
patients families is that patients suffering from aphasia are not able to
understand what is said to them: while both receptive and expressive capacities
may be affected, they may not be altered to the same degree.
Most post-CVA recovery occurs in the first six months, and care should
therefore be geared to returning the patient to normal function and self-care
during this period. Poor nursing care can result in thrombophlebitis, hypostatic
pneumonia, muscle atrophy, contractures, decubitii and sensory deprivation.
Bibliography
Keane, Claire Brackman, Essentials of Medical-surgical Nursing,
Toronto, Saunders, 1979.
Stillman. Margot J. Stroke! How to care for a recovering patient. RN Nov.
1979,42:11.
Watson, Jeanette M. Medical-surgical Nursing and Related Physiology,
Toronto, Saunders, 1979.
\\e M oarvwti tfo
world
Reality in the Third World
is... underweight (babies that
weigh less than 5.5 pounds at
birth). ..malnutrition that causes
blindness among
children... starvation that ends in
death for two-year-olds. This is
the kind of reality that only a
handful of North American nurses
will ever experience firsthand but
all of us have wondered about it.
We have worked with, grown up
with, gone to school with nurses
who have taken that big step
left their practice in Canada to
work among the underprivileged
people of the Third World.
Many , if not most of these
nurses, have found jobs through
CUSO (Canadian University
Services Overseas). This national,
nondenominational coordinating
agency presently has more than
600 volunteers working on
two-year contracts in health,
agriculture, technology, business
and education in Africa, Asia, the
South Pacific, the Caribbean and
Latin America.
What happens when you
become a CUSO volunteer? To
give you an idea, we present the
experience of two nurses who
served with CUSO in Sierra
Leone and in Columbia.
Debbie Grisdale grew up in a
comfortable, supportive Canadian
home. After graduation from
nursing school she worked in
pediatric nursing and then in
public health nursing in three
Edmonton public schools. Two
years ago she found herself thrust
into a totally different
environment an isolated
coastal town in Columbia, South
America, where children die of
malnutrition, diarrhea,
tuberculosis and other respiratory
diseases, where there is little
work available for the 90,000
inhabitants, where there is no
potable water and where
electricity is available only
spasmodically.
Maureen Johnson
After travelling in Europe for
three months and finding that she
enjoyed meeting people and
learning about their cultures,
Debbie had decided that she
wanted to experience a different
lifestyle more fully by actually
living in a different milieu; with
this in mind, she applied to
CUSO.
Debbie was assigned to
Tumaco, Columbia to work with
an agency which provides
sponsorship by individual
Canadians of needy children and
their families in developing
countries. CUSO paid her travel
costs, medical, dental and life
insurance coverage, and costs of
orientation and language training.
The employing agency paid her
salary at local rates and housing
was provided.
After a ten-week course in
Spanish, Debbie joined another
CUSO volunteer, a social worker,
in Tumaco. Both young women
had been warned that Tumaco
would not be an easy place to
work because of the extreme
poverty; and initially they found it
lonely as well. There were only
four expatriates in Tumaco, the
bulk of the population being of
African descent, brought over to
work as slaves in the gold mines in
Columbia s interior. Upon gaining
their freedom they gravitated to
the coast where they settled. The
remoteness of this coastal area (it
is 12 hours by dirt road from the
nearest major center, 300 km
away) had resulted in many years
of neglect by the central
government.
While most of the people in
Tumaco exist by fishing, much of
the fish is exported or sent to the
Columbian interior. "The people
live with fish on their doorstep yet
it is so very expensive" remarked
Debbie. "The majority of the time
the women are left alone with the
children. The birthrate is very
high and so is the deathrate. A
woman might have eight or nine
pregnancies but only four or five
children living. Conditions are
deplorable; people live in
crowded, wooden shacks; some
of them on stilts over the
mudflats, and the only sewage
system is the tide which carries
the sewage out with it. Nutrition
is poor because of the lack of
money and the lack of knowledge ;
the diet is mainly rice, plantain
and fish, when it is available. The
conditions provide amazing
potential for disease." Most
cooking is done over open fires,
candles are used for lighting as the
electricity supply is unreliable,
and during the two rainy seasons,
most of the roofs leak.
As 90 per cent of the children
in the town suffer from
malnutrition, a program was
organized in conjunction with the
Columbian government to provide
a daily lunch of salad, protein
(beans, lentils or fish), vegetables,
fruit and a glass of juice or
nutritious drink for each child.
Debbie worked with this program
and the 500 children involved,
who were checked monthly for
changes in height, weight and for
parasites intestinal worms and
amoebae are rampant because the
need to boil drinking water for 20
minutes is often ignored.
Debbie worked in the
agency s outpatient clinic which
was set up mainly to treat
sponsored children and their
families but also gives aid to local
needy people. On staff at the
clinic are three Columbian
doctors, two auxiliaries, eight
aides plus aCUSO nurse. Patients
pay five pesos (12 cents) per visit
and are given their drugs free of
charge. As well as curative
medicine, the clinic is involved in
preventive medicine; there is a
prenatal program, a well-child
clinic, vaccination and nutrition
projects and control programs for
tuberculosis and communicable
diseases. Laboratory services are
also provided.
Debbie was responsible for
starting the prenatal, well-child
andTB programs. "I also did
some primary care for a couple of
hours each day as the doctors
didn t have time to see
everybody," she recalls. "The
work was never dull, and was
quite different to the work I d
done in Edmonton where I found I
got bogged down with paperwork
and forms to fill in."
The most common problems
seen at the clinic were diarrhea,
respiratory diseases, pneumonia
and tuberculosis. Among the
malnourished children, diarrhea
often led to dehydration and death.
There was also an epidemic of red
measles in Tumaco during Debbie s
two years there. "We lost a lot of
kids," she remembers. "It s a
killerforthe malnourished child."
Tumaco, said Debbie, is hot,
dusty and dirty; the luxury she
missed most was a shower. But
she is anxious to go back. "It was
reminiscent of Africa. The people
used dug-out canoes and there
would be drumming at night when
a child died." Working in Tumaco
was a challenge both personally
and professionally. "It was
extremely frustrating... the way
people there have to live seems
very cruel at times. ..but I learned
so much and was given so much
more responsibility than I d had
before," says Debbie as she looks
back on her experiences. Nursing
in Columbia was a shock she
admits but it was an experience
she wouldn t have missed. She
returned to Canada in October
and is already planning to go back
to South America to work,
probably Ecuador.
Nancy Edwards, is another
CUSO volunteer. She grew up in
Montreal, studied for a nursing
degree at the University of
Windsor, was a staff nurse at
VancouverGeneral Hospital,
worked as a nurse educator in
Australia and then returned to
Canada to work at a
Newfoundland health center. Last
year she left for Sierra Leone to
work as a CUSO community
health nurse at a training hospital
for nursing students.
"It is a challenging and
exciting job with plenty of
opportunities for creativity," she
says. "Oyr students (most of
whom are males) are directly
involved in working with the
community health program which
is beginning to extend to all
sections of our chiefdom (similar
to a county in Canada) . . .The
community health program really
knows no limits here where the
infant mortality rate is greater
than 50 per cent , children die of
measles, tetanus and
malnutrition, polio victims are a
common sight, traditional
bone-setters, witch doctors and
herbalists provide a major portion
of health care, and taboos such
as mothers not feeding their
children fish because they believe
the children will get worms if they
do are common."
So far Nancy s work has
involved establishing a home
visiting program, supervising
mass immunization campaigns,
walking through three swamps to
reach a village only accessible by
bush path, organizing and
supervising under-five clinics and
supervising school health
education.
"It is surprising how quickly
one adjusts to so many situations
and changes all part of
adjusting to a new culture," she
says. "How can one describe the
experience of teaching five
traditional midwives in a small
village hut the principles of sterile
technique , of seeing an entire
school of primary school children
marching through a village
announcing an under-five clinic in
song, or of riding in the back of a
lorry (a small Mazda pick-up
truck) with 28 other people and
their possessions over roads that
make the vehicle respond like a
bucking bronco?"
"I feel very fortunate to be
here. It seems that public health is
the ideal job for getting to know
the culture and the people of any
area. As with health programs
anywhere in the world,
particularly community health,
progress is slow. However, it is
taking place and who can deny the
signs of development one sees
such as a mother learning to feed
her child nutritious foods and
passing that information to others,
or of a health committee building
17 latrines and numerous refuse
pits in a village which had none
before." *
Reference
Capeling, Sharon, Editorial,
CUSO Forum 1 :2:2, Autumn,
1979.
Maureen Johnson is an
information officer with CUSO
and associate editor of the CUSO
8 Forum.
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YOU AND THE LAW
Hospitals and nurses: the evolution of legal responsibility
Corinne Sklar
Previous columns have indicated that
hospitals are vicariously responsible in
law for the negligence of their
employees, servants and agents acting
within the scope of their employment.
This doctrine of "respondeat superior"
(let the master answer) is not limited to
hospitals: it applies generally to the
master-servant (employer-employee)
relationship wherever it may arise.
However, the application of this
doctrine with respect to the professional
employees of a hospital (physicians and
nurses) has until recently, had in the
past special and limiting treatment by
Courts. The trend in recent years has
become to expand the hospital s legal
responsibility for the conduct of
professional employees, as exemplified
by the recent decision of Mr. Justice
Holland in the Ontario case Yepremian
v Scarborough General Hospital. 1 That
decision and a consideration of the
hospital s legal responsibility for
physicians was discussed in February,
J980. 2
Is the hospital where you work legally
responsible for any negligence
committed in the performance of your
professional duties? Allocation of legal
responsibility is important for it
determines who will compensate the
patient for loss or harm. In general, the
doctrine of the master s legal
responsibility for the wrongful acts of
his employees arises because the
employee is considered to act on behalf
of the employer as part of the
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employer s enterprise. In addition,
because the employer "controls" the
conduct of the employee, he ought to
act to prevent his employee s
negligence. The employee acts upon the
instruction of the employer and for his
benefit. The employer is in a better
position financially to compensate an
injured party for his loss or damage. 3 The
viability of this approach in a
commercial or industrial situation is
clear, but its application in the hospital
context has been limited historically.
The patient had to seek financial redress
not from the hospital as the employer
but from the professional staff member
whose wrong had caused his loss or
damage.
The earliest hospitals were
charitable institutions (usually
denominational) where the
impoverished, the infirm and the
incompetent received medical and
nursing care. The nursing profession s
development was rooted in the delivery
of nursing care to patients on a
charitable basis. At the turn of the
twentieth century, hospitals were
charged with the legal responsibility of
providing facilities for patient care, as
well as obtaining competent
professional staff, both medical and
nursing. A hospital had sufficiently
discharged its legal responsibility to the
patient if due care was taken to select
and hire competent professionals to
deliver patient care.
Thus if the negligence of a
professional resulted in loss or injury to
the patient, the hospital, having taken
due care in selecting the professional,
was relieved of any legal responsibility
to compensate the patient for his loss or
damage. The professional, if sued and
found liable, had to compensate the
patient. Hospitals were legally
responsible for loss or damage resulting
from the negligent acts or omissions of
their non-professional employees such
as cleaning staff and kitchen personnel
under the master-servant doctrine as was
any employer. This position was
sustained as hospitals shed their
charitable image and became the
precursor of the complex health care
facility we know today.
The protection of a hospital from
legal liability to patients because of its
charitable status was not well developed
in Britain and Canada although the
doctrine of charitable immunity became
well entrenched in the United States
and as a result, the vicarious
responsibility of hospitals in American
law has taken a different course. Even in
the U.S., however, the thrust of modern
judicial interpretation today has eroded
this doctrine so that it is now rapidly
disappearing; modern concepts of legal
responsibility and the increasing use of
insurance have been instrumental in
reducing the applicability of the I
charitable immunity rule. Thus the rule
of respondeat superior applies
increasingly to both private and
charitable American health institutions.
The "Administrative-Professional"
Dichotomy
The famous 1909 English case, Hilly er v
St. Bartholomew s Hospital* influenced
the development of the law in this area.
The court held that a hospital s legal
responsibility was limited to the
selection of competent medical staff
and to furnishing proper facilities and
equipment. A hospital was vicariously
responsible only for negligent acts of
professionals in the exercise of
ministerial or administrative duties and
not for the negligent acts of
professionals if these acts occurred in
the exercise of their professional skills.
The reasoning was that hospitals could
not control a professional in the
exercise of professional duties. Where a
nurse s act was alleged to have caused
the harm, courts had to classify the
nurse s action as either "routine" or
"administrative" or as "professional" in
order to determine the hospital s
liability.
The Borrowed Servant Rule
The Borrowed Servant rule was that the
nurse passed out of the control of the
hospital authority when she moved
under the control, supervision and
authority of the physician. Once the
nurse passed out of the hospital s
control, it was not responsible in law for
For those who would like to develop
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in affiliation with
Northland Open University
offer two programs:
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Nurses, technicians, technologists and
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prior learning and experience .
Saturday tutorials or study at a distance
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1M5S 1V5
her wrongful acts. This rule was applied
most commonly in the operating iroom
where the surgeon was considered
"Captain of the Ship" and the members
of the O.K. nursing staff were; held
to be directly under his control and
supervision. This view was .also
expressed in the Hillyer case. Thus, the
case law considered both the
administrative vs professional
dichotomy and whether the- nurse was
exercising her duties under- the express
control of the physician. Tbese were the
important determinants ;in the
development of the law cyf hospital
responsibility. Today none of these
aspects applies however , to hospital
liability.
The Case Law
In Lavere v Smith s Falls Public
Hospital, 5 a. 1915 case, a hospital was
held responsible for the burns suffered
by the patient. The n urse was not sued
personally by the patient. The patient
had had surgery and while still under
the effects of the anesthetic, she
suffered a severe burn on her heel. The
nurse had placed an overheated brick
in the bed to warm it. The court found
that such action was a routine duty
performed by nurses. The nurse was
not acting under the supervision of the
surgeon but was carrying out her
routine duties as a hospital employee.
The court rejected the argument that as
a charitable institution the hospital was
immune from legal liability for this
negligence.
In Nybcrg v Provost Municipal
Hospital, 6 a 1926 case, the Supreme
Court of Canada found the hospital
liable for the negligence of a nurse who
caused the patient to be burned by
misapplying a hot water bottle
postoperatively. This decision reversed
the Alberta Court of Appeal s decision
which had absolved the hospital of
responsibility.
The Supreme Court found again
that the application of heat was a
routine duty performed by nurses
in their ward management. The hospital
was liable notwithstanding that the
nurse had applied the hot water bottle
in the presence of the O.R. surgeons.
The majority of the Court found that
here the nurse was. not under the
control of the physicians who had not
ordered the treatment.
In a 1937 Ontario case, 7 the
hospital was relieved of liability to the
patient who had been admitted with a
puerperal infection. The surgeon
ordered the application of heat by
means of a heat cradle which operated
with six light bulbs. The patient was
severely burned. The plaintiffs sued
only the hospital and were denied
recovery.
The Court found that the nurse
was performing a professional skill at
the orc?er of the physician and thereby
was under his direction and control.
Because she was carrying out the
express instruction of a physician, she
was exercising professional knowledge
and skill nd not performing a routine
responsibility. The nurse was acting
professionally in determining the
number of bulbs to be used in the
cradle. The hospital had "loaned" the
nurse to the doctor as a trained assistant
exercising professional skills as a nurse.
Thus the misapplication of a heat
apparatus seems to have forced the
Court to distinguish between heat as a
specific treatment and heat as a routine
nursing care matter. The appropriate
nursing care principles in applying heat
to a patient are the same for any heat
application.
One year later, in 1938, 8 the
Supreme Court of Canada found a
hospital liable for a nurse s negligence in
applying diathermy treatment to a
patient on the express order of the
physician. Again the patient was badly
burned. Here the physician simply
ordered the treatment with no detailed
instructions. The nurse was a hospital
employee who specifically acted as the
technician in administering this
treatment to the hospital s patients. The
Court did not engage in the
administrative vs professional
dichotomy. Significantly, the Court
focused on the basic relationship of
employment and found the nurse to be
the employee of the hospital and not
the assistant of the physician. Why was
the nurse not considered "a professional
exercising a professional skill?" It would
appear that nurses were not viewed as
independent professionals. Instead, they
were viewed as exercising professional
nursing skills only under the instruction
of physicians! This Supreme Court
decision heralded significant changes in .
the law that resulted from the following
English cases.
In 1942, the English Court of
Appeal in the case of Gold v Essex
County Council 9 dramatically altered its
position with respect to hospital
responsibility. The Court found that a
public hospital is liable for the
negligence of a physician employed by
it even though the physician is acting
professionally in the exercise of medical
skill and knowledge. In later cases (1951
and 1954) hospital responsibility for the
negligence of physicians paid by the
hospital, whether as full time employees
or not, was sustained and expanded. In
regard to nurses, two cases illustrate the
shift in judicial view.
In Winn v Alexander, [1940]
O.W.N. 238, a sponge left inside the
patient was discovered on subsequent
surgery. The hospital was not held
responsible because when a nurse enters
the operating room to assist the
surgeon, she passes out of the hospital s
control and is fully under the charge of
the surgeon.
In 1955, in Petite v MacLeod, the
Court took a different view. Here a
sponge again was found in the patient s
body after surgery. The patient had had
several abdominal operations previously.
The O.R. nurses of the defendant
hospital had found the sponge count to
be accurate in the surgery under
scrutiny. The Court looked at the
relationship between the nurses, the
doctor and the hospital. The Court s
finding was that hospitals are liable for
the negligenceJl^tnployees be they
professional
white polish
for professionals
Dura White 9 is not just another white shoe
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nally developed for the rigorous demands
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CONSIDER THESE OUTSTANDING
QUALITIES DELIVERED BY DURA
WHITE*
It defies water hazards, so thai rain, snow,
slush or dew cannot remove or streak it.
It can be cleaned with a damp cloth, even
using a mild cleaner if necessary
It is resistant to soiling and smudges, out
lasting ordinary white polishes and making
your shoes remain whiter longer fsavtng you
from frequent polishing),
It imparts an almost like new look to your
shoes.
It does not promote leather cracking as do
many white polishes
// gives consistent hiding power, with a pleas
ant shine, smooth appearance, and without
buffing.
As a nurse or other hospital or medical
professional in white leather footwear,
you recognize these outstanding Dura
White qualities as those you have sought
after in a white polish. When you use Dura
White 9 , you too will be impressed and
your professional appearance comple
mented.
HOW TO BUY
Ask for Dura White at your hospital s auxiliary
gift shop or if necessary use the form below for
ordering directly from our mailroom. Dura
White is sold in a 30 ml bottle with an applica
tor. Buy now and put an end to your white-shoe-
hassles. Look for it under the Dura trademark.
For direct mail orders, enclose your check or
money order for $3.00 for each bottle ordered.
B.C. residents please add 4% provincial sales tax.
Please send me bottles of Dura
White. I have enclosed $3. OOforeach bottle
ordered (B.C. residents include 4% Provin
cial Sales Tax).
Name.
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City .
Postal Zip Code .
Prov.
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cuts the cost of dccubittis care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
by relieving
pain and
odour fast
" 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
peared." 3
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided Day 28 Appearance on
decubitus ulcer infected with before Debrisan therapy and healing.
Pseudomonas and E.coli. after 7 days, infection
controlled.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
Two, H exudation is very heavy.
After removing crust or Cover with a dressing.
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Debrisan cleans
decubitus ulcers fast.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe [hem
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dorval, Quebec
References
1. Lim LT, Michuda M, Bergan JJ. Angiology 29:9, Sept 1978
2. Bewick M. Anderson A, Clin Trials J 15:4, 1978
3 Soul J, Brit J Clin Pract, 32:6. June 1978
4. DiMascio S RM, Decubitus Care A New Approach:
A Nursing Responsibility, on fileatPJiarrnacJalCanad^Lld.
nurses or physicians acting in the course
of their employment. The Court stated
that a nurse s employer is legally
responsible for the negligence of a
nurse in her execution of a physician s
order as part of her routine nursing
duties. The Court expressly found
that there was no difference between
professional and non-professional acts.
Modern hospital law is no longer
burdened with the artificial
considerations of the Borrowed Servant
rule and the professional vs
administrative dichotomy. The needs
and rights of the public to the delivery
of safe and competent nursing care in
hospital dictate that hospitals cannot .
discharge their legal responsibility solely
by hiring competent nursing staff.
Today, hospitals have a duty to control,
supervise and maintain nursing care at a
quality standard. Nurses have the legal
responsibility to -exercise their
professional knowledge and skill
according to the standard of care
required of professional nurses. If the
standard of care is not met and a patient
suffers loss or damage, a hospital is
vicariously liable for the negligence of
its staff nurses acting in the scope of
their employment and will have to
compensate the patient in accordance
with the determination of a Court.
We have come a long way from
the tortuous judicial route set out in
this area of law in the early 1900 s. That
the law can and does change to meet the
different and important needs of society
in changing times is clear. The law of
hospital responsibility illustrates both
how the law changes and how nursing
practice has been part of this growth.
References
*1 (1978), 20 O.R. (2d) 510. While
the appeal of this decision has been
heard by The Ontario Court of Appeal,
at this writing, the appellable Court s
decision has not yet been delivered.
2 Sklar, Corinne L. The extension of
hospital liability: a landmark decision in
the making. Canad. Nurse
76(2):8-ll,48; 1980 Feb.
3 Rozovsky, Lome Elkin. Canadian
hospital law: a practical guide. Toronto:
Canadian Hospital Association; 1974:
p.15.
*4
*5
1909
1915
1927
2K.B. 820.
35 O.L.R. 98 (C.A.).
S.C.R. 226.
*6
*7 [1937] O.R. 71 (C.A.).
*8 Sisters of St. Joseph of the Diocese
of London v Fleming, [l938] S.C.R. 172.
*9 [1942] 2 K.B. 293.
*10 [1955] 1 D.L.R. 147 (N.S.S.C.).
Unable to verify in CNA Library
"You and the law" is a regular column
that appears each month in The
Canadian Nurse and L infirmiere
canadienne. Author Corinne L. Sklar is
a recent graduate of the University of
Toronto Faculty of Law. Prior to
entering law school, she obtained her
BScN and MS degrees in nursing from
the University of Toronto and
University of Michigan.
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3rd Edition
Nutrition NUTRITION AND DIET THERAPY
By Sue Rodwell Williams, M.P.H., M.R.Ed., Ph.D.
The third edition of this widely-acclaimed text retains its
" person-centered" approach to basic nutrition. Divided into
four sections, this edition features:
clinical application of all scientific principles
increased emphasis on the role of nutrition in public
health, the basic health care specialties, and in the clinical
management of disease
expanded information on minerals in the body with
emphasis on the mineral zinc
an added section on the behavioral approaches to weight
control
plus a discussion on utilizing the problem-oriented
medical record for weight control
the companion title: NUTRITION AND DIET THERAPY:
A Learning Guide for Students, is also available
1977.741 pages, 134 illustrations. Price, >21.75.
2nd Edition
ESSENTIALS OF NUTRITION AND DIET
THERAPY
By Sue Rodwell Williams, R.D., M.R.Ed., M.P.H., Ph.D.
The second edition of this successful text helps health
care students understand the nutritional needs of people
from a variety of ethnic and religious backgrounds,
throughout their life cycles. Written by a noted authority in
the field, and updated throughout, it:
relates nutrition to human growth and development, and
incorporates discussions on pathophysiology
features a greatly revised chapter on the food
environment, which explores the ecology of human
nutrition, economic and political environment, poverty, and
government
adds new discussion to the chapter on diabetes, dietary
exchange groups and fad diets
introduces every chapter with a detailed outline, and
concludes all chapters with pertinent references
1978. 376 pages, 43 illustrations. Price, 51450.
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NUTRITION IN PREGNANCY AND
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By Bonnie S. Worthington, Ph.D.; Joyce Vermeersch,
Dr.P.H.; Sue Rodwell Williams, M.P.H., M.R.Ed, Ph.D.;
with 3 contributors.
The entirefocus of thisvolume isonAPPLYlMG concepts
of good nutrition inCUNICALSITGATIONS.Yourstudents
will appreciate important chapters on:
physiologic bases for nutritional needs in pregnancy
nutrient transfer through the placental barrier, additional
hormone action, increases in blood volume, changes in
renal function, and synthesis of new tissue
nutritional counseling assessing maternal nutritional
states, planning diets, etc.
nutritional therapies for pregnancies with special
conditions (anemia, toxemia, diabetes, etc.)
needs of the pregnant adolescent, including details on
emotional stress and increased energy needs
1977. 234 pages, 34 illustrations. Price, $10.75.
NUTRITION IN INFANCY AND
CHILDHOOD
By Peggy L. Pipes, R.D., M.P.H.
Blending theory with practical experience, this book first
reviews the role nutrition plays in growth and development
Subsequent chapters focus on such key topics as feeding
patterns and goals from infancy through adolescence,
childhood obesity, and development of individual feeding
behaviors in children.
discusses the use of behavior modification in pediatric
nutritional disorders
reviews current drug therapies for resolving nutritional
problems of developmentally delayed or hyperactive
children
presents the physiplogical and psychological
background of anorexia nervosa, along with management
strategies
1977. 218 pages, illustrated. Price, 10.75.
New 6th Edition!
MOWRVS BASIC NUTRITION AND DIET
THERAPY
By Sue Rodwell Williams, R.D., M.R.Ed., M.P.H., Ph.D.
This new edition continues to describe in a concise
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application of these principles to individual needs, and the
importance of nutrition in the treatment of disease.
Features include:
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new research material on solid foods and infant feeding
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updated material on anti-cancer drugs and nutrition
discussion of dietary treatment and hypertension
February, 1 980. 230 pages, 3 illustrations. Price, 510.75.
New 1 Oth Edition!
SELF-TEACHING TESTS IN
ARITHMETIC FOR NURSES
By Ruth W. McHenry, R.N., B.S.,
Pharmacology
Designed to help students remedy their deficiencies in
the use of basicarithmetic, this helpful guide servesas a self-
teaching tool for nurses seeking to better understand
arithmetic, and apply skills to more accurate dosage
calculations. Three sections cover the science of numbers,
metric measures and equivalent conversions, and the
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perforated and punched pages
achievement tests help determine proficiency
accompanying answer booklet allows for immediate
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metric system of weights and measures includes
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February, 1980. 194 pages, 27 illustrations. Price,
510.75.
New 2nd Edition!
HANDBOOK OF PRACTICAL
PHARMACOLOGY
By Sheila A. Ryan, R.N., MS.N. and Bruce D. Clayton,
B.S., Pharm.D.
Completely new chapters discuss thyroactive agents,
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skeletal muscle relaxants and biologic agents. Other
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pertinent information on monitoring and counseling
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precautions for usage of drugs during pregnancy or
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spiral binding allows the book to remain open and flatfor
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March, 1 980. 376 pages, 3 illustrations. Price, $1 3.25.
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WORKBOOK OF SOLUTIONS AND
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This new edition explainsfundamentalsof measurement
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of external, internal, parenteral and pediatric dosages. You
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chapters conclude with exercises providing
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focuses on calculation of drug dosages
includes a timely section on intravenous additive
mathematicsthat discusses millequivalentsandmillimoles
January, 1 980. 2 1 2 pages, 28 illustrations. Price, * 1 0.75.
14th Edition
PHARMACOLOGY IN NURSING
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Today s nurse has assumed an ever-increasing and
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1 979. 792 pages, 1 00 illustrations. Price, $22.75.
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SYSTEMATIC PATIENT MEDICATION
RECORD REVIEW: A Manual for Nurses
By Timothy H. Self, B.S.Ph., Pharm.D.; Quentin M. Smka,
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This new manual features a 10-step. self-instructional
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April, 1980. Approx. 128 pages, 48 illustrations. About
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British Columbia
Registered Nurses (4) required for full-time em
ployment in modern 30-bed hospital situated
90 miles north of Edmonton, Alberta. Require
three full-time nurses to replace part-time nur
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Residence accommodation available for ninety
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Registered Nurses required for a S60-bed acute
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be eligible for registration in Alberta. Current
salary rates under review. Apply to: Personnel
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Wanted R.N. s for 75-bed accredited hospi
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Registered Nurses. We invite you to join our
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A.A.R.N. Please contact: Human Resources,
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Registered Nurses requiredfor 75-bed, accredit
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Required - Full-time and part-time Registered
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British Columbia
Experienced General Duty Graduate Nurses re
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Apply in writing to: Director of Nursing, St.
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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 &
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General Duty Nurses Must be registered with
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registered. Must have experience in all O.R.
procedures. Salary: according to the RNABC
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General Hospital, 9636-IOOth Avenue, Fort
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located in southern B.C. s Boundary Area with
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Comfortable Nurse s home. Apply: Director of
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General Duty Registered Nurses required for
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Previous experience desirable. Salary as per
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For further information, please contact: Dir
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General duty nurses required for all clinical
areas and O.R. in a 360-bed acute care general
hospital. Salary and fringe benefits in accor
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The Director of Nursing, Nanaimo Regional
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General Duty R.N. Small hospital in scenic
West Kootenays of B.C. Apply: Slocan Comm
unity Hospital, Box 129, New Denver, British
Columbia VOG ISO.
Experienced Nurses (B.C. Registered) required
for a newly expanded 463-bed acute, teaching,
regional referral hospital located in the Fraser
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and within easy access of various recreational
facilities. Excellent orientation and continuing
education programmes. Salary 1979 rates
$1305.00-$1542.00 per month. Clinical areas
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Apply to: Employment Manager, Royal Colu-
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Westminster, British Columbia V3L 3W7.
Experienced Nurses (eligible for B.C. Registra
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ed just thirty minutes from downtown Van-
couverSalary and benefits accordingto RNABC
Contract Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to : Personnel Director, Queen s Park
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British Columbia V3L 5E8.
General Duty RN s or Graduate Nurses for 54-
bed Extended Care Unit located six miles from
Dawson Creek. Residence accommodation
available. Salary and personnel policies accord
ing to RNABC. Apply. Director of Nursing,
Pouce Coupe Community Hospital, Box 98,
Pouce Coupe, British Columbia or call collect
(604) 786-5791.
Registered Nurses required for permanent full-
time position at a 147-bed fully accredited reg
ional acute care hospital in B.C. Salary at 1979
RNABC rate plus northern living allowance.
One year experience preferred. Apply: Director
of Nursing, Prince Rupert Regional Hospital,
1305 Summit Avenue, Prince Rupert, British
Columbia V8J 2A6. Telephone (collect) 604-
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Experienced General Duty Nurses, preferably
eligible for B.C. Registration, required for 71-
bed accredited hospital on the Sunshine Coast
of British Columbia. Salaries and benefits
according to RNABC agreement. Residence
accommodation available. Apply in writing
to: Personnel Officer, St. Mary s Hospital,
Box 7777, Sechelt, B.C. VON 3AO.
Registered Nurses required immediately forper-
manent full time positions at 10-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 Col
umbia VOT 1WO. Telephone: (604) 636-2221
Collect.
General Duty Nurses required for an active,
103-bed hospital. Positions available for experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
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nue, Terrace, British Columbia V8G 2W7.
Manitoba
Challenging Career opportunities for registered
nurses in the growing town of Steinbach, Man
itoba with hospital of 65 acute, 60 personal, 12
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itoba ROA 2AO.
Registered nurses required for a fully accredi
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Must be eligible for registration in Manitoba.
Salary dependent on experience and education.
For further information contact: Mrs. Mona
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phone collect to: 1-204-623-6431, Ext. 179.
Challenging Career Opportunity for Registered
Nurses in Canada s North - A 100 bed acute
care hospital in Northern Manitoba which ser
vices Thompson and several small communities
in the surrounding area has immediate vacan
cies in Pediatrics, Medicine/Surgery, Obstetrics
and Critical Care. This opportunity will appeal
to nurses who want to increase their existing
skills or develop new skills through our com
prehensive inservice program. Many of our
nurses have become experienced in flight nur
sing. 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.
Northwest Territories
The Stanton Yellowknife Hospital, a 72-bed
accredited, acute care hospital requires register
ed nursestowork in medical, surgical, pediatric,
obstetrical or operating room areas. Excellent
orientation and inservice education. Some fur
nished accommodation available. Apply : Assist
ant Administrator-Nursing, Stanton Yellow-
knife Hospital, Box 10, Yellowknife, N.W.T.,
X1A 2N1.
Newfoundland
Ontario
United States
Director of Nursing - Applications are invited
for the Director of Nursing position at this 135-
bed general hospital. The position must be fill
ed by June 1 980. The incumbent will be a mem
ber of the senior management staff, will report
to the Administrator and will be responsible
for all activities related to the Nursing Depart
ment. The applicant should hold a Bachelor s
degree in nursing and have extensive experi
ence in managing a nursing department. Regis
tration, or eligibility for registration, in New
foundland is essential. Salary: $18,654 - $23,
807. Applications with resume outlining expe
rience and educational background should be
addressed to: The Administrator, Carbonear
General Hospital, P.O. Box 20, Carbonear,
Newfoundland AOA 1TO.
Ontario
Registered Nurses required for our ultra mod
ern 70-bed fully accredited general hospital in
a bilingual community of Northern Ontario.
Applicants should be registered or eligible for
registration with the College of Nurses of Ont
ario. Knowledge of both official languages and
experience in nursing are assets but not essen
tial. Salary is according to the O.M.A. schedule
and fringe benefits include one month of holi
days, OHIP, salary and life insurance and a
drug and dental plan. Assistance is also provid
ed in locating suitable living accommodations.
Forward your application to: Personnel Direc
tor, Notre Dame Hospital, P.O. Box 8000,
Hearst, Ontario POL 1NO. Telephone: (70S)
362-4291.
Registered Nurse required immediately most
ly day shift for Home for Mentally Retarded
Children. Apply to: Director of Nursing,
Lakewood Nursing Home Inc., Box 1830,
Huntsville, Ontario PDA 1KO.
Registered Nurses are required for permanent
full time positions in a 25-bed active treatment
hospital located in beautiful setting on the
northern shore of Lake Superior. Excellent sal
ary and benefits. Apply to: Mrs. P. McPhail,
Director of Nursing, Wilson Memorial General
Hospital, Marathon, Ontario POT 2EO. Tele
phone: (807) 229-1740.
Registered Nurses required. Hospitals located
on James Bay at Attawapiskat and Fort Albany.
Good salary scale plus Northern Allowance.
Accommodations provided. Enjoy a Northern
Experience. For further information, contact:
The Administrator, James Bay General Hosp
ital, P. O. Box 370, Moosonee, Ontario POL
1YO.
R.N. Grad or R.N.A., 5 6" or over and strong,
without dependents. Non-smoker for 180 Ib.
handicapped retired executive with stroke.
Able to transfer patient to wheelchair . Live-in
1/2 year in Toronto, 1/2 year in Miami. Wages
$250. 00 to $300. 00 weekly NET plus $100.00
weekly bonus on most weeks in Miami. Write:
M.D.C., 3532 Eglinton Avenue West, Toronto,
Ontario M6M 1V6.
Clinical Nurse Specialist with background in
Psychiatry required for an 1100-bed teaching
hospital affiliated with the University of Tor
onto. Qualifications include: Master s Degree
in Nursing, eligible for Ontario registration,
minimum 3 years nursing experience. Send
resumes to: Personnel Department, Sunny-
brook Medical Centre, 2075 Bayview Avenue,
Toronto, Ontario M4N 3M5.
Two R.N. s required for girls summer camp
located in eastern Ontario. Two months of
fresh air beside a lake commencing late June.
Further information write: Camp Oconto, 3
Pine Forest Rd., Toronto, Ontario M4N 3E6
orphone(416) 489-1032.
Childrenssummer camps in scenic areasofNorth-
ern Ontario require Camp Nurses for July and
August. Each has resident M.D. Contact: Harold
B. Nashman.CampServicesCo-op, 825 Eglinton
Avenue West, Suite 211, Toronto, Ontario
MSN 1E7. Phone: (416) 789-2181.
Registered nurse required for co-ed Jewish sum
mer camp near Gravenhurst, Ontario. Two hun
dred campers, aged 8-13 for the months of July
and August. Please contact: Camp Shalom, 788
Marlee Ave., Toronto, Ontario M6B 3K1 (416)
783-6744 Attention Tina Ornstein, Director.
Co-ed camp ages 14 & 15, Northern Ontario.
RN for 6 wks. attractive salary, private room &
bath, 90 campers, to Aug. 12; write or phone:
Camp Solelim, 788 Marlee Ave., Toronto, Ont.
M6B 3K1 (416) 781-5156 or 226-3285.
Quebec
Camp Nurses required for children s summer
camp in beautiful Quebec Laurentians. Mid-
June to end of August. Resident M.D. Contact:
Mr. Herb Finkelberg, Director of Camp B Nai
B Rith, 5151 Cote St. Catherine Rd., Suite203,
Montreal, Quebec H3W 1M6 or telephone
(514) 735-3669.
Saskatchewan
Director of Nursing required for a 10-bed
hospital in Dinsmore, Saskatchewan. Apply:
Secretary Treasurer, Dinsmore Union Hospital,
Dinsmore, Saskatchewan SOL OTO.
General Duty Registered or Graduate Nurses
required for 19-bed Active Hospital in Central
Saskatchewan. Salary and fringe benefits as in
effect with S.U.N. Contract (1980 under re
view). Residence accommodation available at
nominal costs. Please apply in confidence to:
Mrs. Doreen M. Smart, D.O.N., Maidstone Union
Hospital, Box 160, Maidstone, Saskatchewan
SOM 1MO.
United States
RN s California. Registered Nurses interested
in a career in California working in both acute
hospitals and skilled nursing facilities. Salary
comparable to Canadian wages. CGFNS certifi
cate and transportation expenses paid. Write
to: M. Cameron, c/o Ramona-Care Hospital,
485 West Johnston Ave., Hemet, California
92343; or call (7 14) 925-2645.
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 White is a 377-bed acute
care teaching medicalcenter with an open invita
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to 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. Callcollect or write: Ken Hoover,
Assistant Personnel Director, 1720 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92 503. Write or callcollect 7 14-688-22 11
Ext. 217. Betty Van Aernam, Director of
Nursing.
Appraise our Miami Hospital What can
Victoria Hospital offer you? We can give you
a modern 300-bed progressive, acute care hos
pital as a stimulating work environment. We
offer excellent salaries, benefits, CEU s, tuition
refunds and relocation assistance. For pleasure,
Miami has great beaches, boating, dining, dis
cos, tennis, golf, snorkeling, etc. Our Hospital
also has apartments available. Want to learn
more? Call Ms. McDonald, R.N., person-to-
person, colleci at (305)772-3682, or write
Nurse Recruiter, 800 N.W. 62nd St., Suite 510,
Ft. Lauderdale, Fla. 33309.
Fort Lauderdale Beach an extra benefit enjoy
ed by Nurses employed at Holy Cross Hospit
al. Our 596-bed health care complex will sp
onsor Work Visas for qualified R.N. s and new
Graduates interested in a challenging profess
ional opportunity. For details regarding licen-
sure, relocation and hospital-owned apartment
rentals, contact our Nurse Recruiter, 800 N.W.
62nd St., Suite 510, Ft. Lauderdale, Florida
33309 (305)772-3680.
R.N.s-Experienced nurses needed to staff
midwestern and eastern United States hosp
itals. Must be able to take and pass State
boards tests. Free housing while working in
United States. Full sponsorship available.
Wages begin at $7.00 per hour, Fulltime.
Send resume to: Bonnie Menees Smith, R.N.
Recruiter, JANNA Medical Systems, Inc.,
1810 Craig Road, St. Louis, Missouri 63141.
Nurses RNs Immediate openings in Califor
nia-Florida-Texas-Maryland-Virginia and many
other States if you are experienced or a re
cent Graduate Nurse we can offer you posi
tions with excellent salaries up to $16,000 per
year plus all benefits. Not only are there no
fees to you whatsoever for placing you, but we
also provide complete Visa and Licensure assis
tance 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 arrange for hospital interviews. You
can call us collect if you are an RN who is li
censed 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 23rd Year of World Wide Service"
Registered Nurses for interesting programs in
the Kingdom of Nepal. Must have had mini
mum two years practical experiences with
teaching responsibility. Stamina for prolonged
periods in remote area essential, plus ability to
improvise with available materials in develop
ing country. Basic contracts for 18 months,
with transportation, housing, food, and medi
cal insurance provided along with $250 US
monthly stipend. The Dooley Foundation/
INTERMED-USA, 420 Lexington Ave., No.
2428, New York, N.Y. 10017 (Ph.) 212-
687-3620.
The Best Location in the Nation - The world-
renowned Cleveland Clinic Hospital is a pro
gressive, 1030-bed acute care teaching facility
committed to excellence in patient care. Staff
Nurse positions are currently available in sever
al of our ICU s and 30 departmentalized medi
cal/surgical and specialty divisions. Starting
salary range is $14,789 to $17,056, plus
$1248/year ICU differential and premium shift
differential, comprehensive employee benefits
and an individualized 7 week orientation. We
will sponsor the appropriate employment visa
for qualified applicants. For further informa
tion contact: Director-Nurse Recruitment, The
Cleveland Clinic Hospital, 9500 Euclid Avenue,
Cleveland, Ohio 44106 (4 hours drive from
Buffalo, N.Y.); or call collect 216-444-5865.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the U.S.A.
B) Extensive information regarding
Hospital 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 1 133 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
United States
United States
RN S-Our Florida hospitals need you ! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 1211 N.
Westshore Blvd., Suite 205, Tampa, Florida
33607-(813) 872-0202.
Come to Texas- Baptist Hospital of Southeast
Texas is a 400-bed growth oriented organization
lookingforafewgood R.N. s.Wefeelthatwe can
offer you the challenge and opportunity to de
velop and continue your professional growth.
We are located in Beaumont, a city of 150,000
with a small town atmosphere but the conven
ience 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 pro
gress salary plan plus a liberal fringe package.
We will provide your immigration paperwork
cost plus airfare to relocate. For additional in
formation, contact: Personnel Administration,
Baptist Hospital of Southeast Texas, Inc., P.O.
Drawer 1591, Beaumont, Texas 77704. An
affirmative action employer.
Nurses RNs-A choice of locations with em
phasis 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 Or
call collect (713) 789-1550. Marilyn Blaker,
Medex, 5805 Richmond, Houston,Texas77057.
All fees employer paid.
Miscellaneous
Post-ICN Conference at UCSF School of Nurs
ing. The University of California, San Francisco,
School of Nursing, (only one-hour flight away
from ICN location) announces an internation
al conference focused on: Nursing s Influence
on the Health of Families; University of Calif
ornia, San Francisco, July 7, 1981 (CE credit
offered) For more information, contact:
Margretta M. Styles, Dean and Professor, School
of Nursing, N319Y, UCSF.San Francisco,
California 94143, USA.
MOUNT ROYAL COLLEGE
Post Basic Mental Health
Nursing Program for
Registered Nurses
A one-year clinical and academic pro
gram intended to prepare clinical practi
tioners in Mental Health Nursing will be
offered by Mount Royal College com
mencing September 1980. This program
has been designed to meet university
transfer requirements.
Enrollment is limited to 20 students. Ap
plications for the September class close
May 15, 1980
A limited number of bursaries ($315/mo)
plus tuition are available
Admission Requirements: Current Cana
dian Registration.
For further information write to:
Marlene Meyers, Director, Post-Basic
Mental Health Nursing Program, Allied
Health Department, Mount Royal
College, 4825 Richard Road S.W.,
Calgary, Alberta T3E 6K6
Adventure Holiday s: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For freecatalogue.apply to:Goway
Travel, 53 Yonge St., Suite 101, Toronto, Ont
ario MSB 1J3. Phone: 416-863-0799. Telex:
06-219621.
Electrolysis Successful Electrolysis Practice
for Sale. 6 months specialized included. Write
or phone: Margot Rivard, 1396 St. Catherine
Street West, Suite 221, Montreal, Quebec, H3G
1P9. Telephone: (514) 861-1952.
University of British Columbia
Health Sciences Centre
requires
Registered Nurses
Opportunities for nurses interested in working as
members of the interprofessional team in the new 240 bed
Acute Care Unit, of theH.S.C. ontheU.B.C. campus.
Positions available in:
Operating Room Suite
Intensive/Coronary Care
Medicine
Surgery
Emergency
Nurses must be registered or eligible for registration with
the RNABC.
Applicants should apply in writing with detailed resume
to:
Coordinator of Professional Employment
Health Sciences Centre
University of British Columbia
Vancouver, B.C.
V6T 1W5
Positions open to both female and male applicants.
Royal Alexandra Hospital
This 932 bed active treatment hospital invites
applications from nurses across Canada.
We offer experience in all areas of patient care
including intensive care, neonatal intensive care
and obstetrical perinatology. The extended work
day and compressed work week is currently in
effect in the Intensive Care areas.
Applicants must be eligible for registration with the
Alberta Association of Registered Nurses.
Please direct inquiries to:
Personnel Officer
Nursing Recruitment
Royal Alexandra Hospital
10240- Kingsway Avenue
Edmonton, Alberta
T5H 3V9
Interested in a Challenge?
Try International Nursing - in Saudi Arabia!
The King Faisal Specialist Hospital and
Research Centre, a 250 bed Acute Care Referral
facility in Riyadh, Saudi Arabia, has current
and/or periodic openings for experienced R.N. s.
Managed by the Hospital Corporation of
America Group, the hospital is staffed with
professionals from North America, Europe and
the Middle East.
The Nursing Areas currently available are:
NICU, L & D, PEDS, INSERVICE, CLINIC &
RADIATION THERAPY. Requirements include
three years current experience as an R.N. in an
Acute Care hospital with at least one year in the
specialty and a current R.N. license in one of the
provinces. Verbal and written fluency in English.
2- Year contract commitment. Positions are
single status.
Salaries are excellent and the exceptional
benefits include 30 days paid annual leave, free
transportation, furnished lodging, bonus pay and
leave and more.
If you are a dedicated professional with a desire
to make a contribution to experience the
unusual to travel to work side-by-side with
people from around the world then we d like
to hear from you.
Don t Let This Once In A Lifetime Opportunity
Pass You By
For further information please contact:
Kathleen Langan, R.N.
Hospital Corporation International, Ltd.
Two Robert Speck Parkway Ste. 750
Mississauga, Ontario L4Z 1H8
HOSPITAL
CORPORATION
An Equal Opportunity Employer
The heart of patient care.
If you re looking for the heart of patient care, you ll find it at the New York University Medical
Center, one ol the country s leading health care institutions, located in the heart of
New York City. You ll practice your professional career in a stimulating climate that in
cludes a school of medicine, a post graduate school of medicine, extensive research and
three patient care facilities: University Hospital, The Institute of Rehabilitation Medicine
and the new Cooperative Care Unit.
The nursing service department is an integral component of our medical
center s administrative and management programs. It employs the most
modern methods of nursing, offers three levels of nurse practice, and
provides extensive orientation and mservice programs. Excellent salary
and benefit plans including tuition remission through Masters and
Doctorate degrees.
And, our midtown, East side location offers you the stimulating
lifestyle of one of the world s most exciting cities. You ll find yourself
surrounded by legendary Broadway theatres, world famous museums,
parks, restaurants, and of course, our fabulous Manhattan nightlife.
If you want to be at the heart of patient care, in the heart of
New York City, please fill in coupon.
The heart of New York
CN 5/80
Personnel Department
New York University Medical Center
560 First Ave.. NewVtrt, NY. 10016
Ptease send me complete mtamalion on your nursing opportunities EXPERIENCED
BEGINNER
Name
Address
City
_State_
-Zip-
Telephone No._
an equal opponumty/atlionatrve action employer m/l
New York University Medical Center ... private imtibih on in Iht public servict
Offers R.N. s
|u.s. NURSE! An UNUSUAL OPPORTUNITY.
A.M.I. Will FURNISH One Way AIRLINE TICKET to Texas
and $500 Initial LIVING EXPENSES on a Loan Basis.
Alter One Year s Service. This Loan Will be Cancelled
American Medical International Inc.
HAS 50 HOSPITALS THROUGHOUT THE U.S.
* Now A.M.I. Is Recruiting R.N. s lor Hospitals In Teias.
Immediate Openings. Salary Range (11.000 to $16.500 per Year.
* You can enjoy nursing in General Medicine, Surgery. ICC,
CCU, Pediatrics and Obstetrics
A M.I provides an excellent orientation program.
in-service training.
U.S. Nurse Recruiter
P.O. Box 1 7778, Los Angeles, Calif. 9001 7
# Without obligation, please send me more
Information and an Application Form
NAME
ADDRESS
on ST ZIP
TELEPHONE ( )
LICENSES: .
SPECIALTY:
YEAR GRADUATED: _ _ STATE: _
OPPORTUNITY
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed, J.C.A.H. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differential
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 90% under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-5511
Good Samaritan Hospital
Flagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
Clinical Nurse Specialist -
Ponoka
You will serve as consultant on
patient care nursing diagnosis,
Health Care standards, improving
quality of care as it relates to human
relations, and by research,
developing and testing new concepts
and nursing theories.
Qualifications: Graduation from a
recognized School of Nursing plus
considerable related experience,
including consultive experience.
Must be eligible for registration in an
Alberta Association. Baccalaureate
or Master s Degree in Mental Health
and/or Behavioural Sciences
preferred. Equivalencies
considered.
Salary: $18,024 -$22,596
Competition #92 12-4 Open until
suitable candidate selected.
Apply to:
Personnel Director
Alberta Hospital
Box 1000
Ponoka, Alberta
TOC 2HO
Educational Opportunities
1. B.N. Degree Programmes
(a) Basic Students
(b)R.N. s
2. Degree or Diploma Program in
Outpost Nursing and
Nurse-Midwifery
3. Diploma Programmes
(a) Community Health Nursing
(b) Mental Health and
Psychiatric Nursing
Send applications to:
Mr. W. Brake
Admissions Committee
School of Nursing
Memorial University of
Newfoundland
St. John s, Newfoundland
A1C5S7
University of Jordan
Faculty of Nursing
Faculty Position: Positions available for
September 1980:
Medical-Surgical-Nursing
Pediatric Nursing
Obstetric Nursing
Community Nursing
Psychiatric Nursing
Nursing Administration, in
Baccalaureate Program.
Doctorate degree is preferable but
Master s degree with Clinical
specialization and teaching experience is
essential.
Salary and rank commensurate with
educational preparation and experience.
Apply to:
President
University of Jordan
Amman -Jordan
R.N. s Required
Applications are invited for full time nurses to
work rotating shifts in new 40 bed active
treatment hospital. High level of activity in
Emergency, Surgery and Obstetrics offers
challenge and the benefit of valuable
experience for conscientious nurses. Previous
experience an asset. Must be registered or
eligible for registration in Alberta.
AHA/AARN Policies in effect.
Hinton is a modern, progressive, industrial
town on the eastern slopes of the Rockies, 50
miles east of Jasper. Population 7,600.
Unlimited year round recreational facilities.
Apply with full resume including experience
and references to:
Director of Nursing
Hinton General Hospital
Box 40
Hinton, Alberta
TOE 1BO
Prince George
Regional Hospital
Positions available for experienced nurses or
nurses interested in developing their skills in
specialty nursing Operating Room,
1CU/CCU, Neonatology Nursing. Must be
eligible for B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and Obstetrical
Suite
lObedlCU/CCU
Prince George Regional Hospital is a 340 bed
acute regional referral hospital with a 75 bed
extended care unit and has a planned program
of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000 -15th Avenue
Prince George, British Columbia
V2M 1S2
Nursing
Our nurses
write better
ads than we
do!
Responsibility, pride,
and changing attitudes,
that s what Kaiser-
Permanente nursing is
all about. Our nurses
are vital members of
an expert medical care
team and have worked
hard in order to get
where they are today.
Kaiser-Permanente
recognizes that today s
nurse is a skilled pro
fessional and must be
treated as such. We re
seeing to it that our
nurses are given every
opportunity to explore
and utilize their pro
fessional talents. But
don t take our word for
it, take it from some
one who really knows...
our nurses. "The re
sponsibility is yours...
as a nurse, you are it!"
PERMANENTE
MEDICAL CENTERS
PULLING TOGETHER TO HELP PEOPLE
JanWuori, R.N. CAN
Regional RN
Program Recruiter
4747 Sunset Blvd.
Los Angeles, CA 90027
Toll Free
1(800)421-0086
Equal Opportunity
Employer M/F/H
"I might be tired when I go
home, but I know I did it all."
Norma Blancaflor, RN
Panorama City
"I ve gained a lot personally...
I have more insight because
Kaiser encourages you to be an
independent thinker."
Ruth Shaffer, RN
Mental Health Center
"There s going to be a lot of
change here, and I like that.
Change is the buzz word around
Kaiser."
Nancy McNeill, RN
West Los Angeles
Our nine southern California Medical Centers have openings
now for all levels of nursing. We invite you to join us and
accept the challenge of professional nursing. For more in
formation on any one of our 9 medical centers contact:
Intensive Care Nurses
300 bed Accredited general
hospital in Vancouver requires
full-time R.N .s for 4 bed I .C.U .
Candidates should be eligible for
registration with the RNABC.
Previous I. C.U. experience
required.
Please apply in writing to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C. VST 3N4
Supervisor - Operating
Room
Required to assume a leadership role in
an expanding Operating Room Suite
presently under construction with date of
completion September 1980.
The applicant must have demonstrated
leadership and administrative skills,
post-graduate education inO.R. nursing
and past experience as a Head Nurse or
Supervisor.
Must be eligible for B.C. registration.
Prince George Regional Hospital is a 340
bed acute Regional Referral Hospital
located in Central B.C.
Qualified applicants are invited to submit
their resumes to:
Assistant Executive Director,
Patient Services
Prince George Regional Hospital
2000 - 15th Avenue
Prince George, B.C. V2M 1S2
Summer Employment
Registered Nurses
Nursing opportunities will be available
for a 3 or 4 month period during the
months of May, June, July, August 1980.
Nurses will provide primary nursing
care, be able to exercise clinical
judgement and participate in a
patient-family oriented program in our
modern 300 bed teaching extended care
unit. Interested nurses, who are eligible
for registration in British Columbia
should write to:
Hospital Employment Officer
Health Sciences Centre Hospital
University of British Columbia
Vancouver, B.C.
V6T 1W5
Positions open to both female and male
applicants.
Royal Inland Hospital
Kam loops, B.C.
Registered Nurses
Applications are invited for staff
additions to Medical-Surgical Nursing.
Psychiatric, Intensive Care, Obstetrics,
Rehab Unit and Neuro Services.
400 bed accredited acute care referral
hospital.
active inservice programmes with
Clinical Instructors for staff
development.
1979 salary ($1305 - 1542 per month).
1980 being negotiated.
benefits as per R.N.A.B.C. contract.
extended and regular hour shift
rotations.
eligibility for B.C. registration
essential.
Apply to:
Personnel Director
Royal Inland Hospital
311 Columbia Street
Kamloops, B.C. V2C2T1
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, PartTime and Casual Employment.
Benefits in accordance with R.N.A.B.C.
contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
School of Nursing
Nursing Instructors
required for August, 1980
in a 2 year English language
Nursing Diploma program
Qualifications:
Bachelor of Nursing with experience in
Teaching and at least one ( 1 ) 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. MacMaster
School of Nursing
100 Arden St.
Moncton, N.B.
E1C4B7
Telephone: 506-854-7330
Post Graduate Training in
Operating Room Technique
and Management
Applications are now being
accepted. This programme will
begin in early September and has
a duration of twenty-six weeks.
For further information and
application forms please write
to:
Supervisor of Operating Room /
Recovery Room
Hotel Dieu Hospital
Kingston, Ontario
K7L 3H6
Canada
Supervisor in Public Health
Nursing
Supervisor in Public Health Nursing for the
Middlesex-London District Health Unit for
August-September 1980.
Challenging position in progressive agency
covering a rural and urban population of over
300,000.
Program administration responsibility as well
as staff supervision.
Qualifications:
B.Sc.N. degree currently registered in Ontario
with at least five years public health nursing
experience. Those with advanced degrees and
experience in supervision will be given
preference.
Excellent fringe benefits.
Salary Range: $20,432 to $23,710.
A curriculum vitae should be submitted to:
Mrs. Dorothy M. Mumby, B.Sc.N., M.A.
Director of Public Health Nursing
Middlesex-London District Health Unit
346 South Street
London, Ontario
N6B 1B9
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
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 Canadian 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 L8S4J9
RED DEER REGIONAL
HOSPITAL CENTRE REQUIRES
NURSES
With close proximity to the beautiful Rocky
Mountains, along with fine cultural and
excellent recreational facilities, we present to
you our City of Red Deer Midway between
Edmonton and Calgary thrives our City of
40.000.
Our Regional Hospital Centre is a rapidly
expanding multi-institutional hospital located
in Red Deer. The Centre will encompass 630
actiue treatment and Extended Care beds and
is projected to activate its new expanded
facilities by early fall of this year.
We require:
Head Nurses
Teaching Assistant Head Nurses
Staff Nurses
to complement our nursing staff for the centre Our Personnel
Department is presently accepting applications for these positions.
Applicants with general medical and surgical experience are
preferred. Also, a Bachelor of Science degree in Nursing uuould be
desirable.
// interested in these or any other hospital
related positions please call
Bob King, Personnel Co-ordinator
at (403) 343-4585 or write
"Nursing Opportunities", Personnel
Department, Red Deer Regional Hospital
Centre, 3942 - 50A Avenue,
Red Deer, Alberta, T4N 4E7
RD 1
RH,
OPPORTUNITY
Community Mental Health Nurse -
Red Deer
90 miles from Calgary/Edmonton
Functioning as a primary therapist, you will assess and
treat complex disorders of thought behaviour and
emotions; public education and community development.
Backed up by inter-disciplinary team resources, excellent
opportunities are provided for professional growth,
orientation and staff development.
Qualifications: B.Sc.N. preferred, butR.N. orR.P.N.
with experience will be considered. Must be eligible for
registration with approved Association(s) in Alberta.
NOTE: Automobile is required.
Salary: $14,748 -$17,340
Competition #9176-3 Open until suitable candidate
selected.
For detailed information, request Job Bulletins and apply
to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
MANITiBA
Director of Nursing Services
The Department of Health. Institutional Services,
Brandon Mental Health Centre, requires a person for this
senior administrative position wherein the incumbent is
responsible for planning and directing the delivery of
Nursing Services in a large Mental Health Centre.
Responsibilities include planning, directing and
evaluating patient care programs, staff recruitment and
development, and all related activities designed to ensure
high standards of nursing practice.
B.N. and significant related Psychiatric Nursing and
administrative experience at a senior level. Equivalent
combinations of training and experience may be
considered.
Salary Range: $20.876 - $25.569 per annum
Apply in writing immediately:
Civil Service Commission
904 - 155 Carlton Street
Winnipeg, Manitoba R3C 3H8
Competition No. CN/66
Director of
Professional Services
Applications are invited for the position of Director of
Professional Services. Canadian Nurses Association,
Ottawa, Ontario.
Candidates must be members of the Canadian Nurses
Association, have a master s degree or equivalent and
have had at least five years administrative experience. A
working knowledge of both official languages is required.
Interested applicants are asked to submit their curriculum
vitae, in confidence, to:
Executive Director
Canadian Nurses Association
50 The Driveway
Ottawa, Ontario
K2P 1E2
MANITiBA
DEPARTMENT OF COMMUNITY
SERVICES AND CORRECTIONS
Regional Co-Ordinator
Public Health Nursing - Winnipeg
A suitably qualified and experienced public health nurse
is required for the above position
Responsibilities include planning, co-ordinating and
evaluation of comprehensive public health nursing
programs for the Winnipeg Region.
Candidates should preferably possess a M.Sc.N.
supplemented by several years progressively responsible
related experience and be eligible for licensure with
M.A.R.N.
Salary range up to $29,480 per annum commensurate with
qualifications.
Apply immediately quoting Competition #1020 to:
Department of Community Services and Corrections
Personnel Management Services Branch
270 Osborne Street N.
Winnipeg, Manitoba
R3C OV8
OPPORTUNITY
Registered Nurses/Psychiatric Nurses
- Ponoka
The Alberta Hospital, a dynamic regional centre with a 3
year accreditation status, requires nursing staff for
general and psychiatric treatment duties. We offer a
nurses residence with attractive staff facilities, twelve
(12) paid holidays, three (3) weeks annual vacation (4
weeks after 10 years service), and a very attractive
benefit package; including uniforms, laundry and free
parking.
Qualifications: Graduation from an approved school of
Nursing. Must be eligible for registration with the
respective professional Alberta Association. NOTE: Shift
work involved.
Salary: $14,748 -$17, 340
Competition #9176-2 Open until suitable candidates
selected.
For detailed information, request Job Bulletins and apply
to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
G.F. Strong Rehabilitation Centre
Vancouver, British Columbia
Registered Nurses - Nursing
Supervisors
If you are interested in Primary Nursing in a modern rehab
setting, we will be opening a new 50-bed floor soon and have full
time vacancies for B.C. Registered Nurses and Shift
Supervisors.
We treat patients with severe disabilities, paraplegia,
quadraplegia from spinal cord injuries, arthritis, amputations,
head injuries, M.S. and other chronic neurological conditions.
Salary and benefits according to RNABC Agreement.
Please apply to:
Personnel
G.F. Strong Rehabilitation Centre
4255 Laurel Street
Vancouver, B C.
V5Z 2G9
734-1313
High Risk Obstetrics and Neonatal
Intensive Care Nurses
Chedoke-McMaster Hospital - McMaster Division 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-of-town nurses eligible
for Ontario registration if written requests are
accompanied by detailed resumes. Nurses with related
Critical Care backgrounds may be considered for training.
Please apply to:
Ms. N. Prosser, Personnel Interviewer
Chedoke-McMaster Hospital
McMaster Division
Box 2000, Station "A"
Hamilton, Ontario
L8N 4Z5
Director of Nursing
The Edmonton Health Department will require around August I ,
1980, a Director of Nursing to replace Miss Evelyn Crookshanks
who is retiring.
The Department serves a population of 500.000 with a
comprehensive range of public health services; staff in the
Nursing Division number 160 and there are seven program areas
for which the Director is currently responsible.
Formal qualifications should preferably include wide experience
in public health in field and administrative settings and a
Master s degree. Other qualities sought are the ability to think,
plan and communicate effectively, to provide dynamic
leadership, to assess critically yet objectively and to cooperate
harmoniously with other agencies.
Please write enclosing a full curriculum vitae to:
Dr. J. M. Howell
Medical Officer of Health
City of Edmonton Health Department
7th Floor CN Tower
Edmonton, Alberta
T5JOK1
Further details are available from Miss Crookshanks at (403)
428-3640.
Registered Nurses
Come to work in scenic Comer Brook .
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
West Coast of Newfoundland.
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
[January. 1979 $12.771.00 15,429.00
1 January. 1980 $13.410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
Open 10 both
men and women
DIRECTOR OF NURSING SERVICE
Salary: $18,554 - $21,732 (under revision)
Plus S1 ,000/yr Penitentiary Allowance
Ref. No: 80 PSC/CSC-OC-S227
Correctional Service of Canada, Regional Psychiatric Centre
Saskatoon, Saskatchewan
A Director of Nursing Service is required for a 106 bed
psychiatric hospital in Saskatoon, Saskatchewan responsible
for the treatment of psychiatrically disturbed inmates of
both provincial and federal institutions. This hospital is
affiliated with the University of Saskatchewan, in particular
the Departments of Psychiatry and Nursing. An active
research department is part of the establishment and it is
planned that the Centre will be used to train post-graduate
students of many health care disciplines.
We require a Director of Nursing Service with considerable
practical psychiatric nursing who is interested in accepting
challenge and responsibility.
Qualifications
This position carries with it a university appointment at the
University of Saskatchewan in the College of Nursing.
Candidates must possess as a minimum a Baccalaureate
degree in nursing and registration as a registered nurse in a
province or territory of Canada. Certification as a registered
nurse will be considered an asset. Candidates must also
possess acceptable psychiatric nursing experience and
demonstrated competence in nursing service management
and ability to provide expert professional advice in psychia
tric nursing.
Knowledge of English is essential.
Benefits
Excellent pension plan, good sick leave benefits; 1 1 statu
tory holidays: 3 weeks vacation to start: an excellent in-
service training programme; plus relocation expenses paid.
Hours of work: 37.5 hours per week.
"Additional job information is available by writing to the
address below;
Toute information relative a ce concours est disponible en
f ran fa is et peut etre obtenue en ecrivant a I adresse
suivante".
How to apply
Send your application form and/or resume to:
Keith A. Sinclair, District Director
Public Service Commission of Canada
111 - 1 867 Hamilton Street
Regina, Saskatchewan S4P 2C2
Please quote the applicable reference number at all times.
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:
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1 A OL3
Name
Address
Prov.
I
Health and Welfare
Canada
Same et Bien-elre social
Canada
I
I
Director of Nursing
A challenging career opportunity is available for a dynamic
innovative individual to direct and manage the department of
nursing. The hospital has 518 beds and is a teaching hospital
affiliated with Queen s University.
The successful applicant will possess B.Sc.N. with at least 5
years experience in a senior managerial position with
demonstrated administrative skills in terms of budgetary, clinical
and organizational concepts within the current health care
system.
Apply in confidence submitting complete resume, including
salary expectation to:
Director of Personnel
Kingston General Hospital
Stuart Street
Kingston, Ontario
K7L 2V7
Assistant Director of Nursing
Active Treatment
Required for a fully accredited 135 bed active care hospital.
The Position
As a member of the Nursing Administration Team, this nurse
needs innovative qualities and ability to organize, delegate and
direct the work of others. The applicant must have an enthusiasm
for initiating and following up new ideas, projects and quality
assurance programs.
Minimum Qualifications
Candidates must be currently registered in the Province of
Alberta, and possess a Baccalaureate Degree in Nursing, with
demonstrated competence and ability in a senior level nurse
management position.
The position becomes available August 18, 1980, upon the
retirement of the present incumbent.
Interested applicants may submit a comprehensive resume to:
Mr. Bruce Finkel, Director of Nursing
Wetaskiwin General Hospital
5505 - 50 Avenue
Wetaskiwin, Alberta
T9A OT4
A Completely
Modern Teaching Hospital
Requires
Registered Nurses
This 500 bed general hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered -
Critical Care, Medical, Surgical Coronary Care,
General Surgery, Urology, Gynecology,
Medicine, Nephrology, Clinical Teaching,
Neurosciences, Cardiology, Cardiovascular
Surgery, Orthopedics, Hemodialysis (kidney
transplants). Emergency and Out Patient
Services, active Rehabilitation Program (adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in Critical Care Nursing,
Neurosciences, Operating Room Nursing.
Located in St. John s. Newfoundland the
oldest city in North America with a population of
120,000, offering cultural and recreation
activities in a friendly atmosphere.
Fishing, hunting, boating available
approximately 10-14 miles outside the city.
For information regarding salary and relocation
expenses and other conditions of employment
write or call -
Miss Dorothy Mills
Staffing Officer - Nursing
The General Hospital
Prince Philip Drive
St. John s, Nfld.
A1B3V6
Telephone # (709) 737-6450
Centracare Saint John Inc.
Associate Director of Patient Care
(Nursing)
This 500-bed hospital is seeking applications from creative nurse
specialists seeking an opportunity to further their career.
Centracare is affiliated with the Dalhousie University School of
Medicine.
Qualifications:
Graduation from an approved School of Nursing with
considerable related experience, including supervisory or
consultative experience.
Must be eligible for registration in the New Brunswick
Association of Registered Nurses. Post -Graduate preparation,
preferrably to the Baccalaureate or Masters level. Competence
in English is essential.
Duties:
Acts as a Counsellor by assisting the Nursing team in Nursing
Diagnosis and new care approaches.
Acts as an Educator in order to bring Health Care Standards to
their optimal level.
Acts as a Change Agent to improve the quality of care by utilizing
Skills and Theories of Human Relations.
Acts as a Researcher by utilizing valid research, findings for
patient care and by contributing to Research activities in order to
develop and test concepts on Nursing Theories.
Performs other duties as required.
Responsible to the Director of Nursing.
Salary: Negotiable
Apply to:
Personnel Office
Centracare Saint John Inc.
P.O. Box 3220
Saint John, N.B.
E2M4H7 Competition NumberCSJ 80-11
OPPORTUNITY
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 will remain open until a suitable candidate has
been selected.
Qualified persons are invited to phone, write or submit
applications to:
Personnel Administrator
Alberta Hospital, Edmonton
Box 307, Edmonton, Alberta
T5J2J7
Telephone: (403) 973-2213
Metro-Calgary and Rural General
Hospital District #93
The Holy Cross Hospital, Rockyview Hos
pital and the Colonel Belcher Hospital invite
applications from R.N. s for positions in
all areas.
The Holy Cross Hospital is the Cardiac
Care Centre for southern Alberta. Twelve
hour shifts are available in I.C.U. and S.C.C.U.
The Rockyview Hospital is a 200 bed surgi
cal hospital which is to be expanding to a
550 bed general hospital. All shifts here
are 8 hours.
The Colonel Belcher Hospital is a 360 bed
federal hospital sold to the Provjnce of
Alberta and given into the jurisdiction of
District #93. The Department of Veteran
Affairs will retain priority use of 185 beds
while the rest will be for the general public.
Due to its location near the beautiful and
majestic Rocky Mountains, Calgary has
much to offer for leisure time activities.
Eligibility for registration in Alberta
required. Please apply to:
I Personnel Department
HOSPITAL DISTRICT #93
940 - 8th Avenue S.W.
Calgary, Alberta T2P1H8
is
Registered Nurses
Career Development Opportunities in
Vancouver.
If you are a Registered N urse in search of a change and a
challenge, look into nursing opportunities at Vancouver Genera]
Hospital. B.C. s major medical centre on Canada s
unconventional West Coast.
Positions For:
General Duty Nurses
Nurse Clinicians
Nurse Educators
at salaries ranging from $1231 - $1654, (1980 rates under
negotiation), plus educational premiums.
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 and Neurosurgical)
Inservice Education
Cardiothoracic Surgery
Coronary Unit
Burn Unit
Hyperalimentation Programme
Paediatrics
Renal Dialysis and Transplantation
Operating Room
If you are a Registered Nurse considering a move, please send
resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C.
V5Z1M9
Head Nurse
Ophthalmology Unit
Applications are invited for the above
position. The Unit serves as a tertiary
care referral centre for Ophthalmology
and offers a challenging career
opportunity for the initiative creative
nurse leader.
The successful candidate will be
responsible for the management of this
forty-two (42) bed unit as well as
providing leadership in the development
and evaluation of clinical practice, staff
development, consultation, and
demonstrating specialized nursing skills.
Applicants must be eligible for
registration in B.C., B.S.N. preferred,
post-graduate course and experience in
the clinical field. Please submit resume
to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C. V5Z 1M9
Registered Nurses
Planning your summer vacation?
Then by all means, include a visit to
beautiful Vancouver in your plans. And
while you re here, drop in and discuss
your nursing career opportunities at
Shaughnessy Hospital, an 1 100 bed
multi-level community teaching hospital.
We have full-time, part-time and float
positions available as well as a 2 week
orientation for RN s who wish to work
on a casual basis only .
When you re in Vancouver please call:
Jane Mann
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767
The Registered Nurses
Association of Nova Scotia
invites applications for
Nursing Consultant-
Education
Duties:
To provide assistance and consultation to
schools of nursing, as well as the organiza
tion and development of continuing
education programs for nurses.
To act as resource person to committees of
the Association.
To act as liaison with government, health
care and educational institutions and
other associations.
Qualifications
Applicant must be eligible for registration
in Nova Scotia. Preparation in education
at the Master s level preferred, with at
least ten years experience in nursing and
nursing education.
Salary negotiable.
Position Available August 1, 1980
Applications with complete resume of
qualifications, experience and the names
of three references should be submitted to:
Executive Secretary
Registered Nurses Association
of Nova Scotia
6035 Coburg Road
Halifax, Nova Scotia
B3H 1Y8
Assistant Professor
Concordia University
The Nursing Programme of Concordia University anticipates a
faculty position at the rank of Assistant Professor in the
non-tenured track. In addition to regular teaching duties, the
successful candidate will participate in the innovation and
implementation of a curriculum for graduate nurses.
Qualifications will include:
M.Sc.N. from recognized University School of Nursing;
Experience in hospital and community nursing;
Experience in University nursing education;
Interest in curriculum development;
Interest in further education of experienced graduate
nurses;
Innovative, creative approach to nursing education;
Bilingual in English and French an asset.
The appointment will be available from June 1 . 1980.
Applications, including curriculum vitae and names of at least
three referees, should be sent to:
Muriel Uprichard, Ph.D.
Professor and Director
Community Nursing
Concordia University
7270 Sherbrooke St. West
Montreal, Quebec
H4B 1R6
OPPORTUNITY
Director - Community Health Nursing
- Edmonton
This person will coordinate the planning, development and
promotion of province-wide community health nursing programs
and supervise a staff of specialists. You will actively participate
in the Branch management team and will represent the Alberta
Government or the Branch at various forums and on task forces
and committees.
Qualifications: R.N., M.Sc. in Nursing, and extensive
supervisory and administrative experience in public health. Must
be eligible for registration with A.A.R.N. and possess consulting
skills, initiative, leadership qualities and the ability to teach. A
current drivers license and freedom to travel are necessary. A
broad nursing background including some teaching experience is
desirable.
Salary: $22 ,680 -$29,9 16
Competition #M341-1 1 Open until suitable candidate selected
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education Programs.
Post Graduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Apply to:
Recruitment Officer Nursing
I Diversity of Alberta Hospital
8440 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
O
Foothills Hospital
Calgary, Alberta
Offers the
Following
Five Month Post
Graduate Courses
Advanced Neurological
& Neurosurgical Nursing
This course serves as an extension of basic knowledge of
neurological problems gained in an under graduate program.
Instruction proceeds from normal to abnormal. Opportunities are
provided to study and care for persons of all ages who have had
an interruption in neurological function.
Advanced Neonatal Nursing
This course allows the nurse to gain knowledge and expertise in
the Intensive Care Nursery setting. An overview of life as well as
experience in related settings are also included.
Applications must be completed three months prior to the
enrollment dates of March and September.
For information and application write to:
Educational Services
Department of Nursing
Foothills Hospital
1403 -29th St. N.W.
Calgary, Alberta
T2N 2T9
Toronto Western Hospital
"The Home Of Friendly Care and
Protection"
This 700 bed University Teaching Hospital has
employment opportunities for registered nurses, or
nurses eligible for Ontario Registration in such areas as:
Intensive Care
Renal Dialysis
Neuro Surgery
Cardio Vascular Surgery
Planned orientation and on-going education programme in
effect.
Apply to:
Miss H. Jones, Staffing Co-ordinator
Department Of Nursing
Toronto Western Hospital
399 Bathurst Street
Toronto, Ontario
M5T 2S8
Index to
Advertisers
May 1980
Canadian Hospital Association
10
The Canadian Nurse s Cap Reg d.
10
Canadian School of Management
50
Career Dress, A Division
of White Sister Uniform Inc.
IFC
Dow Chemical of Canada Limited
43
Equity Medical Supply Company
49
Famolare Inc.
Johnson & Johnson Limited
21
J.B. Lippincott Company of Canada Limited
4,5
Maple Leaf Laboratories
51
The C.V. Mosby Company Limited
54,55
Nordic Laboratories Inc.
23
Nursing Unit Administration Program
50
Parke, Davis & Company Limited
36,37,53
Pharmacia (Canada) Limited
52
Procter & Gamble
16, 17
Ross Laboratories, Division of
Abbott Laboratories Limited
24,25
W. B. Saunders Company
Smith & Nephew Inc.
28, 29.OBC
Upjohn HealthCare Services
Whittaker International Services Company
IBC
Advertising Represen tatives Advertising Manager
Gerry Kavanaugh
The Canadian Nurse
50 The Driveway
Ottawa, Ontario K2P 1E2
Telephone: (613) 237-2133
Jean Malboeuf
601, Cote Vertu
St-Laurent, Quebec H4L 1X8
Telephone: (514)748-6561
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (4 16) 297-2030
Richard P. Wilson Member of Canadian
P.O. Box 482 Circulations Audit Board Inc.
Ardmore, Pennsylvania 19003
Telephone: (215) 363-6063
A NURSE S STORY. IT COULD DEVOURS
I So many nurses I talk
to about my work in Saudi
simply can t understand
what it s like to get so much
satisfaction
RITA LAWRENCE, R.N.
CALL
REVERSING
THE CHARGES:
I ctcr Dow
(519)376-6809
W I l)ow& Assocs. Ltd.
(A Canadian Company)
3f>l 10th St. W.
( )wcn Sound,
Ontario N4K.W4
The Arabian Peninsula. Dif
ferent. Demanding. And most
decidedly gratifying.
"Like most nurses, I ve
always dreamt of my work
making the difference in peo
ple s lives. And not having it
taken for granted. But until
my job at Whittaker s Saudi
hospitals, I thought it would
never happen.
What made Saudi Arabia
different was the gratitude of
patients, families, government.
And the chance to work inde
pendently in a modern hospital.
Being in an exotic place,
coming home to free, air con
ditioned comfort that was
all part of it . Together with
excellent travel benefits, salary
and bonus provisions.
But when nurses ask why
Dedicated
I went back twice, I point to
job satisfaction. / really found
it. And they can too."
Rita Lawrence s reactions
are typical. And Whittaker, a
leader in international health
care, is now offering contracts
in either Saudi Arabia or Abu
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10539
Transcultural nursing: bridging
the gap
How to initiate a bladder protocol
that works
Portable ventilators, the breath
of life
HELP! A simulated disaster plan
for teachers and students
The
Nurse
)
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Separate origins, separate
destinies. This month CNJ
explores the sensitive area of
transcultural nursing, with a
feature story by Corinne
Hodgson that begins on
page 23 and comment on
page 5. Our cover photo is
courtesy of Health and
Welfare Canada.
The
Canadian
Nurse
June 1980
Volume 76, Number 6
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Editor
Anne Besharah.
Assistant Editors
Judith Banning
Jane Bock
Gail O Neill
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
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.
Jean Passmore. editor, SRN A news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith, director of publications,
National Gallery of Canada.
Florita Vialle-Soubranne, consultant,
professional inspection division. Order
of Nurses of Quebec.
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.
Canadian Nurses Association, 50 The
Driveway. Ottawa. Canada, K2P 1E2.
Lori Whittington 26
LMV..
..37
The Friesen system 45
18
YOU AND THE LAW
Was the patient informed?
Corinne Sklar
37
A second chance
Karen Dobson
Transcultural nursing:
the Canadian experience
Corinne Hodgson
Nursing in a university
health service
Florence Tracy
26
Bladder retraining
Lori Whittington
42
C.A.R.P. A new way to learn
Margaret E. Murray
30
Grading student nurses
Vivian Wood and Joanne Wladyka
45
CNJ talks to:
Gordon Friesen,
on the side of the angels
Anne Besharah
33
HELP! Simulated disaster game
Nelda Yantzie
7
Input
48
Names
50
Research
11
News
49
Audiovisual
52
Books
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
Indexed in International Nursing Index. Cumulative
Index to Nursing Literature, Abstracts of Hospital
Management Studies. Hospital Literature Index.
Hospital Abstracts, Index Medicus, Canadian
Periodical I ndex . The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor, Michigan 48106.
Canadian Nurses Association. 1980.
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perspective
Bridging the gap
"There are 240 nurses in Canada who are status
Indians. Of these, only 20 work in their own
communities." Numbers like this, coming from a
consultant with the medical services branch of
Health and Welfare Canada, make it almost
inevitable that right now and for at least the
forseeable future, Canada s native people are going
to continue to depend for their health needs on
the vagaries of professionals raised and educated
under a system that is completely foreign to the
recipients of this care.
More than 100 years ago, an Indian chief
from the Pacific Northwest commented: "We are
two distinct races with separate origins and
separate destinies. To us, the resting place of our
ancestors is hallowed. You wander far from the
graves of your ancestors, seemingly without
regret..." Obviously, the opportunities for
misunderstanding are both frequent and
fundamental.
Nurse Patricia Floyd, middle-aged, single
parent of three Indian children, writing in The
Canadian Nurse special issue on native health care
(October, 1978) didn t think the gap was closing.
"See the nurse," she wrote. "The nurse is going
into the crummy, crowded house. She is going to
teach health to the people there. ..She is going to
explain that sleeping four in a bed is a health
hazard. She is going to teach about nutrition. She
is going to explain that a diet of rice, macaroni,
bologna and tea is not good for growing children.
Explaining these things is a nursing task.
Explaining where they will get the space for more
beds or the money for better food is not a nursing
task.
"...Now the nurse is going home. She has
worked hard. She is a good nurse. She keeps her
hands clean. She does not meddle with the tasks of
other disciplines. She does not criticize other
government departments. She does not get
involved in politics.
"She does not have to live on the Indian
Reserve."
Cultural blindness, imposition, conflict. The
possibility is always there when people of different
origins, background and outlook are in day-to-day
contact, each dependent on the ability of the
other to see beyond and through the superficial
and obvious problem to the underlying human
need.
"It appears to be a perception problem,"
Canadian archeologist and northern researcher
George Wenzel notes. "Several Inuit people have
told me they won t go to the nursing station
because the nurses dislike Inuit and stay inside all
the time ."
Wenzel believes that "without an
appreciation of the fact that the Inuit and other
native northerners are not southern Canadians,
very little can be done to improve the nurse s
relationship with the population she serves."
Former Health and Welfare minister
David Crombie, speaking six months after his
department had announced a new federal Indian
health policy, summed up the problem this way:
"We must be prepared to break away from models
of health care delivery more suited to the urban
setting than to the needs of our native people."
If and when this happens and the needs and
concerns of Canada s original people are
recognized as being neither more nor less, but
different from general Canadian concerns, it will
be nurses who are at the heart of whatever delivery
system is set up.
Nurses are an integral and important part of
health care in the North just as they are in the
South. Transcultural nursing is not confined to
certain latitudes or people. Nurses in most of our
major Canadian centers in the South also
encounter problems of perception and
communication every day. How they handle them,
the contact they succeed in making with people
who are "different", will go a long way to shaping,
not only the future health status of people
everywhere, but also the wisdom, maturity and
"caring quality" of the nursing profession.
M.A.B.
The Canadian Nurse
June 1960 5
ILLUSTRATION FROM LUCKMANN & SORENSEN
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CRITICAL CARE NURSING OF THE
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follow-up, and includes case studies of multi-injured patients, a
complete bibliography, and discussion of psychological support
of the patient as well as physical care.
Edited by James K. Mann, RN, BSN, MN.Assoc Director of Nursing
Services, Harborview Medical Center, Seattle; Asst. Prof., Dept. of
Physiological Nursing, Univ. of Washington, Seattle; and Annalee R.
Oakes, RN, MA, CCRN, Assoc. Prof., Seattle Pacific Univ., Seattle,
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All entries based on latest available information.
Emphasizes vital information that can quickly be put to use in
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Listed in a columnar format for easy accessibility.
Organized according to categories of usage.
Includes a detailed index.
By H. Robert Patterson, BS, MS, Pharm D. Prof, of Microbiology and
Biology, San Jose State Univ., San Jose. CA.; Edward A. Gustafson,
BS, Pharm D, Pharmacist, Valley Medical Center, San Jose, CA., and
Eleanor Sheridan, RN. BSN, MSN, Asst. Prof., College of Nursing.
Arizona State Univ., Tempe. AZ 374 pp Soft Cover April 1980
$1315 Order#3572-5.
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING:
A PSYCHOPHYSIOLOGIC APPROACH
2nd Edition
Updated revised, and expanded the new Second Edition of
MEDICAL-SURGICAL NURSING: A Psychophysiologic
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By Joan Luckmann, RN, BS, MA, Formerly, Instructor of Nursing,
University of Washington, Highline College, Seattle, Oakland City
College, and Providence Hospital College of Nursing, Oakland. CA,
and Karen Creason Sorensen, RN, BS, MN, Formerly, Lecturer in
Nursing, University of Washington; Formerly. Instructor in Nursing,
Highline College; Formerly. Nurse Clinical Specialist, University
Hospital and Firland Sanatorium. Seattle. WA. 2276 pp 817 ill.
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Editor-in-Chief Sally Millar, RN, CCRN, Head Nurse, Respiratory/
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By Ara G. Tilkian, MD, FACC. Asst. Clinical Prof, of Medicine (Cardio
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By Jeannette E. Watson, RN. MScN, Prof. Emeritus, Faculty of
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CN 6/80
input
New opportunity in
nursing ed
I am delighted to
announce that the Nursing
Department of Ryerson
Polytechnical Institute will
implement a baccalaureate
program in nursing for
registered nurses in
September of this year.
We are planning to
enrol 45 full-time students
in the first year of the
program. We are discussing
opportunities for part-time
study, but as yet nothing
has been finalized.
The degree program
will require two years of
full-time study leading to a
Bachelor of Applied Arts in
Nursing. The unique feature
of this program is that it will
offer students an opportunity
to choose a clinical area in
which to develop their
knowledge and skills. Options
will be in Adult Medical
Surgical, Pediatric and
Psychiatric nursing. A
community health
component will prepare
graduates to function in the
community.
Further information
may be obtained from: The
Admissions Office, Ryerson
Polytechnical Institute, 50
Gould Street, Toronto,
Ontario MSB 1E8.
Gail Donner, chairperson
Nursing Department, Ryerson
Polytechnical Institute,
Headed out?
My thanks to Sylvia
Segal ("When experience
counts") for bringing to light
a very important point. All I
could feel was very sad. To
think that nursing today has
to hire volunteers to give
support, direction and tender
loving care to patients, and
the nurse, as ever, sits and
writes the notes.
I, for one, am sick of
sitting at the desk charting,
when all I want to do is be
with patients, giving them the
support they need. After all
that is why I chose nursing as
a profession in the first place.
What has happened to
the good old days when the
head nurse took care of paper
work, leaving her nurses to
give the necessary care?
Why is it that the paper
work has become all
important, leaving patients
(last in priority) to be cared
for by generous volunteers?
I think nursing should
take a good look at its role
and where it is heading. I, for
one, feel more inclined to
want to be one of the
volunteers, than the RN I am
today.
-Jean Ward. RN, SCM,
Surrey, B.C.
Helping skills
1 read with concern
Sylvia Segal s article (March)
regarding the use of
volunteers in the obstetrical
unit. While I agree that
volunteers provide an
invaluable service, I am
concerned re irresponsible
delegation of nursing duties.
The postpartum
mother s feeding of her baby
is one of the initial tasks in
the process of interactional
adaptation in the mother-
child relationship. Being with
the mother at this time, could
assist the mother in develop
mental tasks of mothering as
well as enhancing the
attachment process.
Essential interventions
at this time consist of inter
pretation of infant behaviors
to the mother, positive
reinforcement of maternal
behaviors and patient
teaching. To this nurse-client
interaction, the nurse brings
her knowledge of communi
cation skills, psychosocial
behaviors, physiology,
psychology and herself as a
therapeutic tool.
It seems inappropriate
to delegate such an important
intervention to volunteers
who operate on good
intentions, gut feelings and
limited personal experience.
Donna Roney, Nursing
Department, Vanier College,
St-Laurent, Quebec.
A losing battle
"A race against time:
caring for a patient with
radiation enteritis"
(February) was an excellent
account of caring for a
patient who is fighting a
losing battle.
As I read the article I
found myself identifying with
the nurses and experiencing
the frustrations they went
through.
Congratulations to
Roberta Ronayne for sharing
this caring with us. My hat s
off to the team cf nurses for
the physical as well as
psychosocial care given. The
author s sensitivity towards
both patient and the nurses
is very touching,
-Naomi Judah, Halifax, N.S.
Humanizing the birth
experience
It is encouraging to
read of the attempts of
hospitals to humanize birth
such as Ellen Rosen describes
in "The Birth Room",
(March).
I am distressed,
however, that Ms. Rosen and
some other health profess
ionals think that the addition
of sheer drapes to hide
obstetrical equipment and
soft colored wallpaper can
create a home-like
environment. The photograph
of the Birth Room with the
obvious presence of an
incubator and I.V. pole does
not look the least bit home
like, even though it is
undoubtably somewhat less
frightening to birthing
couples than the traditional
delivery room.
I was further
disappointed that the author
did not address the central
issue, that of the birthing
couple s involvement in
decision-making about their
birthing experience. She
focuses on issues of space,
equipment and selection
criterion.
I believe that the
re-education of staff is an
essential issue; without a
re-orientation of the role of
professionals in supporting
birthing couples the
cosmetics of the environment
are only a token gesture to
placate consumer demands.
-/. Alison Rice, RN, MS,
assistant professor, UBC,
Vancouver.
The author replies
In reply to Alison
Rice s letter (March)
commenting on my article
"The Birth Room", you note
that I neglected to address
the issue of staff education
and change, as an essential
component of the success of
humanization of the birth
experience.
I wrote this article in
response to many enquiries
from nurses in other agencies
who wanted specific
information on how to set up
such a room . These requests
came from nurses who have a
high commitment to parent
participation in the birth
experience, but were having
trouble convincing medical
staff to make the necessary
changes.
I did make reference to
the effects of the changes on
the staff and the importance
of parent participation, but
concentrated on describing
the physical changes
necessary and some of the
inherent problems. The
subject of staff education and
the trial and tribulations of
the attitude changes, was left
to another paper. This point
should have been clearly
defined, at the outset.
I appreciate your
comments. Thank you.
-Ellen Rosen, RN, MScN,
Clinical Nurse Specialist,
London, Ontario.
Not abandonned
The February editorial
commenting on the Guillain-
Barre Syndrome article in the
March issue did not reflect
the actual cooperative efforts
and effectiveness of the
medical and nursing staff and
the family in assisting in the
recovery of the patient with
Guillain-Barre Syndrome.
Sometimes, lay people
and health professionals who
should know better, need to
be reminded that, far from
abandoning or relinquishing
support, families tend to
over-extend themselves, often
depleting their physical,
economic, social and
emotional energies.
Sometimes this is to the
extent that they too may
become ill.
-Jill Watt, RN, Ann Colder,
Vancouver, B.C.
U of M reunion
Members of the class
of 1975 of the University of
Manitoba wishing to attend
their upcoming five-year
reunion should contact:
Sherry Wiebe
681 Patricia Avenue
Winnipeg, Man. R3T 3A8
-Patrice Yamada, Winnipeg,
Manitoba.
The Canadian Nurse
June 1980 7
Ponstari
(mefenamic acid) I
FOR PROMPT RELIEF
OF DYSMENORRHEA
* non-hormonal, non-narcotic therapy
(simple, short-term, non-addictive regimen
taken only when required)
* inhibits prostaglandin synthesis and
the action of prostaglandins on the uterine
smooth muscle 1 (reduces uterine
contractions and abdominal pain)
Ponstan Capsules 250 mg:
2 capsules at onset of dysmenorrhea
followed by 1 capsule every 6 hours for
the duration of symptoms
*Heg.TM/M.E Parkt, Davis & Company
Ponstan
When it does its job, she can do hers
every day of the month.
PARKE-DAVIS
Parke-Davis Canada Inc., Scarborough, Ontario
UPDATE ON DYSMENORRHEA
Shortcomings of traditional therapies
Surveys show that up to half of female patients may live a sixth of their reproductive years in pain. Yet many of these women
are reluctant or embarrassed to talk about their problem, preferring to self treat with analgesics, or simply accepting their
condition.
The Lancet, as recently as 1978, reported: "Current treatment of primary spasmodic dysmenorrhea is unsatisfactory
Powerful analgesics may be habit forming, dilatation of the cervix may cause incompetence, and the use of oral
contraceptives seems unjustified unless contraception is required." 2
How prostaglandins fit into the clinical picture
In the 1940 s it was theorized that a menstrual toxin existed which was involved in causing the pain and other related problems.
Recent investigations have indicated that increased premenstrual endometrial prostaglandin levels (particularly levels of
prostaglandins E 2 and F 2 alpha) may play an important role in the etiology of dysmenorrhea.
How Ponstan assists in relieving dysmenorrhea
Most non-steroidal anti-inflammatory agents are inhibitors of prostaglandin synthesis the enzyme system responsible for
the formation of prostaglandin.
The fenamate group of anti-inflammatory drugs have a twofold action: they inhibit the enzymes of the prostaglandin
synthesis pathway and also antagonize prostaglandins at the receptor sites. 1
Ponstan versus conventional analgesics
Recent clinical trials have demonstrated that Ponstan is, indeed, a useful drug in the treatment of dysmenorrhea, affording
relief in some 89.3% of patients cycles. 3
In a double-blind comparison of dextropropoxyphene/paracetamol capsules (2 caps of 32.5 mg/325 mg t.i.d.) and Ponstan
(2 caps of 250 mg t.i.d.), Ponstan was significantly more effective than the analgesic combination on both clinically
determined and subjective patient preference assessments. There was also less absenteeism in the group taking Ponstan. 4
Alternative therapy to oral contraceptives
Ponstan provides prompt relief of dysmenorrhea, and may thus be considered a more rational therapy than oral
contraceptives.
In a recent survey, 55% of women taking oral contraceptives stated that these agents had not solved their dysmenorrhea
problems. 5 Ponstan has demonstrated a much higher success rate without disturbing the normal hormone balance of patients.
Unlike oral contraceptives. Ponstan is taken only when required, i.e. when menstrual pain becomes evident. For the rest of
the month the patient may be free of medication.
Ponstan: a simple short-term regimen
Patient acceptance of Ponstan is understandably enthusiastic. When pain appears, a patient takes two capsules stat, for fast
relief, followed by one capsule every 6 hours for the duration of symptoms.
In addition, Ponstan is well tolerated. Extensive data supports the fact that side effects with short courses of treatment with
Ponstan are restricted mostly to minor gastrointestinal disturbances.
Prescribing Information:
PONSTAN CAPSULES 250 mg
PONSTAN (mefenamic acid) is an analgesic
preparation with antipyretic, anti-inflammatory and
antiprostaglandm properties PONSTAN has been
shown to inhibit both the synthesis of prostaglandins
and their action on the cell receptor sites.
INDICATIONS: For the relief of pain in acute or
chronic conditions such as dysmenorrhea.
headaches and muscular aches and pains,
ordinarily not requiring the use of narcotics.
DOSAGE: Administration is by the oral route,
preferably with food. The recommended regimen for
adults and children over 1 4 years of age is 500 mg
as an initial dose followed by 250 mg every 6 hours
as needed PONSTAN should not be given to
children under 1 4 years of age
CONTRAINDICATIONS: PONSTAN is
contramdicated in patients showing evidence
of intestinal ulceration The drug is also
contramd cated m patients known to be hyper
sensitive to mefenamic acid. If diarrhea occurs,
the drug should be promptly discontinued Safe
use in pregnancy has not been established
PRECAUTIONS: PONSTAN should be admmistered
with caution to patients with abnormal renal function
and inflammatory conditions of the gastrointestinal
tract. Caution should be exercised in administering
PONSTAN to patients on anticoagulant therapy
Since it may prolong prothrombm times PONSTAN
should be used with caution m known asthmatics.
If rash occurs, the drug should be promptly
discontinued.
Mefenamic acid may prolong acetylsahcyhc acid
induced gastrointestinal bleeding. However,
mefenamic acid itself appears to be less liable than
BIBLIOGRAPHY; 1 Smith. 1. 0., Temple, D.M.. et ai: Prostaglandins 10:41-57,1975
2. Kapadia, L, Elder, M.G.. Lancet (1): 348-350, 1978
3. Pulkkmen,M.O.,Kaihola, H.L, ActaObstetGynecolScand 56 75-76, 1977
4. Anderson, A B.M., Haynes, P.J , etal: Lancet (1): 345-348, 1978
5. Consensus independent research, 1978. Data on File. Parke-Davis Canada Inc.
acetyl salicylic acid to cause gastrointestinal
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ADVERSE REACTIONS: In controlled clinical
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Complaints are dose-related, being more frequent
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In 2,594 subjects given mefenamic acid over a
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reported adverse effects were drowsiness (68
subjects), nervousness (28). nausea (20). dizziness
(36), gastrointestinal discomfort (10), diarrhea (11).
vomiting (5), and headache (2) There were single
reports of insomnia, urticaria and dyspnea and
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There have been a few reports of hematopoietic side
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Within psychological
confines
I consider the purely
psychological approach that
Brian Cristall advocates in
"Do as I say!" (January)
inadequate for the care of the
young native girl, daughter of
a drunken mother, forsaken
by her father, sexually "taken
advantage of and beaten by
frustrated men."
He states, "There s
nothing that you can do to
change the economic and
social realities" but surely the
first thing that should be
done for a 14-year-old girl in
these circumstances, if unable
to change her immediate
environment, is to remove her
from it. She should have
shelter, security, education
and preparation for life, as
well as help in understanding
and resolving psychological
problems resulting from her
traumatic experience.
I do not believe the
present laws of Canada are
devoid of protection for a
14-year-old girl in such a
situation. If indeed there is
no protection in law, then
nurses should seek to resolve
this at the proper government
level.
While nursing is not
primarily concerned solely
with psychology or social
service, nursing cares for the
person as a whole and if that
person s well-being requires
extending oneself on her
behalf, through failure of
social service and psychiatry
and psychology, I am quite
sure nursing would not
tolerate such a situation
without seeking to better it.
-Margaret McLaughlin, RN,
Toronto, Ontario.
The Case of "Eve"
Corinne Sklar s You
and the Law (March) has
motivated me to write. As a
nurse (non-practising), wife,
mother and sterilized person
(tubal-ligation), I get so upset
when I read of cases such as
"Eve s". In my opinion, the
courts should not be deciding
on medical matters.
I wonder whether the people
involved have any under
standing of human sexuality.
Do they think that tubal-
ligation robs females of their
sexuality? Do they think that
the essence of being female
is limited to the baby-making
ability? I look forward to the
possibility that The Canadian
Nurse might have future
articles on this subject.
Name withheld on request.
ATTENTION GRADUATE NURSES!!
EDUCATIONAL OPPORTUNITIES AT RYERSON
POLYTECHNICAL INSTITUTE
A new two year degree program leading to a Bachelor of Applied
Arts in Nursing, commencing in the fall of 1980. This program
allows students to choose a clinical area of focus in Adult
Medical-Surgical, Psychiatric, or Pediatric Nursing, and is
designed to prepare nurses for the leadership role that
baccalaureate level graduates are expected to assume.
A well established 15 week Adult Intensive Care Certificate
Nursing Course offered annually in the Fall and Winter. This
program offers a rigorous and well-balanced course of studies in
the concepts, skills and knowledge required to work in the
rapidly developing areas of Intensive Care. Graduates of this
program may be eligible for credit towards the degree.
Both programs emphasize nursing assessment skills, pathology
and an integrated clinical experience.
For further information, contact:
Admissions Office
Ryerson Polytechnical Institute
50 Gould Street
Toronto, Ontario
MSB 1E8
Low status not us!
The opinions expressed
by P.M. Tufts in the
February issue of The
Canadian Nurse have alarmed
us: we do not consider
obstetrical nurses "low on the
totem pole" but rather equal
members of the health care
team. Nurses who are not
challenged by maternal-
newborn care should move on
to another facet of nursing of
their choosing.
Interest in OB nursing
can be generated in the basic
nursing curriculum and by
attaining government
recognition. In the province
of Nova Scotia maternity
nursing has been promoted
by programs such as the
Nova Scotia Reproductive
Care Program and the
Maternity and Neonatal
Courses offered by the Grace
Maternity Hospital.
The OB departments of
our hospitals therefore
continue to be staffed by
hospital administrators and
directors of nursing with an
equal interest and insight.
Nurses owe it to
themselves to educate
themselves, to develop
orientation and ongoing
educational programs that
result in highly skilled and
competent maternity nurses.
M. Johnson, R. Steele,
M. Power, Grace Maternity
Hospital, Halifax, Nova
Scotia, and S. St. Lewis,
Post RN Program, Dalhousie
University, School of Nursing
Partners in caring
I am a family physician
in a community health clinic
and I am disturbed to see
young interns and older
doctors treating nurses like
inferior beings. Why is this
still happening in a day and
age when we are striving
towards the "health care
team" approach?
Is the ego the
predominant force in
physicians or are they
covering a lack of
confidence? Do they not
realize that nurses are taught
substantially more than how
to take blood pressure and
pulse? Have they been taught
in medical school that nurses
are stupid and unable to
participate in rational
decisions about patient care?
As members of a health
care team we all have
something to contribute and
something to learn from each
other. Nurses are the first line
of contact for patients in
hospital, making their role
vital. In an office setting,
teamwork between physician
and nurse provides more
efficient, thorough health
care.
I hope nurses will be
accepted as colleagues by the
new generation of physicians;
this is the only way the
health care system will run
efficiently .
-Richard W. Swanson, B.Sc.,
MD, LMCC, MCFP,
Saskatoon Community Clinic,
Community Health Services
(Saskatoon) Association Ltd.
A "comforting role"
I found "Herpes:
scourge of the seventies",
(January) very interesting and
well-written but was
disappointed to note that the
role of the nurse was
described as one of
comforting and reassuring
patients.
I feel that everyone
including interns and
residents should consider
that their duty. Nurses also
have another important role
to play in connection with
sexually transmitted
diseases - that of prevention,
screening and education.
G.J. Croteau, BScN, PHN,
Montreal, Quebec.
Is your image slipping?
I wish to condemn the
sexist and condescending
caricature of nurses presented
on the television program
Trapper John M.D. . As a
professional who has both
studied and worked hard, I
deeply resent this portrayal
of the nurse offered for
public consumption.
At a time when nurses
are attempting to redefine
their role in the public eye,
such programs are incredibly
influential. Will we sit quietly
and take this? I have written
a personal note of protest to
the series. I d love my
association to do the same!
-S. Perry, RN, Edmonton,
Alberta.
Royal Jubilee
The Royal Jubilee
Hospital School of Nursing,
Victoria, B.C., is one of the
oldest schools of nursing in
Canada. The Alumnae
Association is planning a
reunion to celebrate its 90th
year to be held on June 4, 5
and 6th 1981. Former
graduates interested in
further information should
write to:
Mrs. R. Anderson
Apt. 104-2333 Beach Drive
Victoria, B.C., VSR 6K2 *
10 June 1980
The Canadian Nurse
news
Maria Zinck wins
3M scholarship
For the second time in ten
years, a Canadian nurse has
been awarded a $6,000 3M
(Minnesota Mining and
Manufacturing Co.)
International Council of
Nursing Fellowship for
nursing studies. Maria Dina
Zinck, of Antigonish,
Nova Scotia, hopes to
complete a doctorate in
nursing at the University of
Toronto. Her primary interest
lies in nursing education.
In 1973, Alice J.
Baumgart of Vancouver, B.C.,
won the award. Baumgart
studied health service
problems and planning of
health services at the
University of Toronto and
has since gone on to become
Dean of the School of
Nursing at Queen s
University in Kingston, Ont.
Zinck was chosen from
among 52 candidates by a
committee of the Interna
tional Council of Nurses in
Geneva, Switzerland. Other
nominees came from
countries such as France,
Ghana, Poland and Sri Lanka.
An assistant professor
at St. Francis Xavier
University in Nova Scotia,
Zinck holds a master s degree
in adult education and a
bachelor s degree in nursing
science. During the past 13
years of her nursing career,
she has held a wide range of
supervisory positions. As a
member of Canadian
University Students Overseas
(CUSO) she was in charge of
a rural hospital in Peru and
for two years was the
organization s Atlantic region
executive secretary.
Since 1966, Zinck has
recruited professional and
technical volunteers for
overseas assignments and has
trained students from more
than 60 countries in social
leadership. She has prompted
awareness of international
development through her
numerous lectures on
international health problems.
A second fellowship of
equal value was awarded to a
Jamaican nurse, Valerie J.
Hardware. Hardware will use
her scholarship to obtain a
bachelor s degree at the
Faculty of Medicine at the
University of the West Indies
in Kingston, Jamaica.
*
3M scholarship winner Maria Zinck of Antigonish, N.S.,
receives the award, along with a trophy symbolizing the flame
of life, from 3 M representative Gene Lewan. Also on hand for
the ceremony were RNANS executive director Joan Mills,
(far left), 3M sales manager Ted Williams and Phyllis
Manchester from the Higher Education Group, Ontario
Institute for Studies in Higher Education.
Four nurses - Sharon Ramstad ofCamrose, Alta.; Mary Myles of
Fredericton, N.B.; Barbara Rodney of Yarmouth, N.S.; and
Barbara Ann Me Williams of Vancouver - were among 21 Canadians
who received lifestyle awards at a ceremony in Ottawa this Spring.
The awards, for outstanding contributions to the development of
positive lifestyles in their communities, were first presented in 1977 as
part of Health and Welfare Canada s philosophy of encouraging
Canadians to assume greater responsibility for their own health and
well being.
Six nurse coordinators help international study
Does controlling high blood
pressure with treatment that
includes a beta-blocker (slow
oxprenolol) significantly
change the incidence of heart
attack and sudden death?
This is the question being
investigated through a major
research project sponsored by
Ciba-Geigy Pharmaceutical
Company. Currently, six
countries are involved in the
trial: Germany, Holland,
Great Britain, Israel, Italy
and Canada. Six centers in
Canada will be contributing
a total of 700 patients and by
1981 world-wide enrolment
will stand at 5,000.
Dr. Alexander Logan of
Toronto is Canadian Principal
Investigator, for this five year
International Prospective
Primary Prevention Study in
Hypertension (IPPPSH).
Day-to-day conduct of the
trial is carried out in each of
the six centers and
coordinated by the Medical
Department of Ciba-Geigy
Canada in Dorval, Quebec.
Each center has a medical
investigator and a nurse-
coordinator working on the
project:
Dr. Alexander Logan and
Barbara Milne, Mt. Sinai
Hospital, Toronto;
Dr. Victoria Bernstein and
Norma Kent, Vancouver;
Dr. Yves Lacourciere and
Jocelyn Garneau, Centre
Hospitalier de 1 Universite
Laval, Quebec; Dr. Carl
Abbot and Karen Mann,
Camp Hill Hospital, Halifax,
N.S.; Dr. Peter Fernandez
and Dr. George Fodor,
Shirley Granter and Jackie
McDonald, two centers in
Newfoundland connecting
with the St. John s General
Hospital. In addition there is
a national electrocardiogram
center directed by
Dr. P. Rautaharju at
Dalhousie University in
Halifax, N.S.
The responsibilities of
the nurse-coordinators for
this project include a variety
of functions: facilitation of
patients through the entry
procedures, long term
monitoring of blood pressure,
patient counseling and
documentation of data.
The control group
for this study will be patients
being treated for
hypertension according to
standard medical practice,
but not receiving a
beta-blocker drug.
The Canadian Nurse
June 1980 11
announcing The New
Twist-on cap just pour, cap,
and stack.
A clear plastic
chamber lets you
monitor the flow rate.
Hold it like a bottle and pour
Ensure in the large opening
and rigid neck make it easy.
The Flexitainer* holds a full
litre use it for intermittent
or continuous feeding.
The Ross Gavage Set fits any
nasogastric tube.
The CAIR* clamp gives you
precise control over delivery
The rigid neck and wide opening
make filling and handling easy.
The large graduated measurements
are easy to read, during filling and
during feeding.
Fill, cap, and stack in the refrigerator.
ENSURE Delivery System
the best
of the bottle
and the bag!
Together, the Flexiflo* Flexitainer* and the Ross
Gavage Feeding Set give you the first tube feeding system
that s really convenient and economical.
The Flexiflo Flexitainer is a bag and bottle in one!
Like a bag, it is light, shatterproof, and disposable.
Like a bottle, it has a rigid neck and wide opening, and
it s leakproof . You can stack it prefilled, more
easily and in less space than either bags or bottles.
The Ross Gavage Feeding Set ensures accurate delivery
control and helps maintain a constant rate of feeding.
The Ensure Delivery System. Developed to give
you better control over tube feeding.
I ROSS LABORATORIES
Division of Abbott Laboratories, Limited
I ROSS Montreal, Canada H4P 1 A5
Each Flexitainer has a self-adhesive
sticker, for instant patient
identification.
ThcCAIR" clamp allows fingertip
control of flow rate.
NEWS FEATURE
Locating Nursing Research Data Via Computer
A.C. Lynn Zelmer
Since 1977 nurse researchers across Canada have been able to
"telephone" the University of Alberta to obtain the information they
need on research already in progress. Using a suitable computer
terminal and a telephone coupler (modem), they can call for and
receive information on current thesis and non-thesis research at
Canadian nursing institutions.
The Faculty of Nursing at U of A
implemented CORN (Canadian
On-going Research in Nursing) in
1977; using information supplied
by about ten cooperating
institutions the faculty agreed to
maintain a computerized data
base on a trial basis. Datapac,
the computer access system which
uses special long distance
telephone lines, provided access
for users outside of Edmonton
and the Faculty of Library
Science prepared a search-
retrieval program to work with
the university s Amdahl
computer.
The data file contains the
proposed title of the thesis or
report; names of researchers,
supervisors and sponsoring
institutions; date of initiation of
the project; and keywords
describing the project.
Information may be entered and
searched in either French or
English. A thesaurus prepared by
the Canadian Nurses Association
allows those entering information
to list keywords in both
languages. The file allows
researchers to identify persons
working in similar fields and
should help prevent duplication
of effort in a field with limited
financial and research resources.
The data file has not
eliminated the need for
conventional publication of
research results, but it has
decreased the time required to
disseminate information about
research projects. Users of the
CORN system can write directly
to the individual researcher for
information while research is in
progress. Information on the file
is updated quarterly, with the
cooperating institutions and
individuals sending additions/
deletions and corrections through
the regular postal system.
The program is not
without its faults: data accuracy
is dependent upon the researchers
themselves, and how they
describe their research. Since
many of the researchers are not
bilingual they fail to include
keywords in both languages. The
standard lexicon also seems to be
inadequate for describing research
occurring in some of the newer
areas of nursing interest. This
results in the use of terms which
cannot be easily translated. Both
data input and search processes
suffer from the hazards of
computer "logic" which dictates
an absolute protocol of blank
spaces primes and format.
Forget even a single blank space
and the computer aborts the
search with the frustrating
message "Error, you probably
forgot..."
Nevertheless, use of the
CORN system is increasing and
Dr. Amy Zelmer, Dean of Nursing
and initiator of the service,
indicates that the problems are
being overcome. "CORN has
given us considerable information
about the needs of practitioners
who use data files. The current
program is oriented towards users
who understand computers.
Hopefully we can make the
necessary changes that will allow
better access by individuals who
don t want to understand
computers."
CORN is accessible by
anyone who has the use of a
suitable terminal. Once the user is
signed on to the computer
system, CORN prompts the user
(in both French and English) for
the search parameters. Signon
information and a user s manual
with more complete instructions
are available from the U of A
Faculty of Nursing.
Health and Welfare
issues warning
The Health Protection Branch
of Health and Welfare Canada
has informed CNA that they
have received a number of
reports of perianal
excoriation associated with
laxatives containing dioctyl
sodium sulfosuccinate. The
problem apparently occurs
when incontinent patients are
given this detergent stool
softener and the fecal matter
makes contact with their skin
for prolonged periods of
time. Marked scalding of the
buttocks and groin are often
seen within two to three days
of initiation of the
medication and a few patients
have had abdominal
discomfort. There have been
few or no problems in
patients who are not
incontinent.
Ian Henderson,
Director of the Bureau of
Drugs, states, "It seems
reasonable to recommend
that detergent products be
deemed not appropriate for
use in geriatric
non-ambulatory bed-ridden
patients who are at all
incontinent, when it cannot
be assured that the perianal
skin will stay dry and
feces-free."
Planners ready for
continuing ed meeting
Organizers of Canada s first
national continuing education in
nursing conference which is
scheduled to take place in
Vancouver June 26 and 27, have
announced the name of the major
resource person for the meeting.
She is Dorothy del Bueno,
associate dean of continuing
education at the University of
Pennsylvania and consultant in
in-service education at the
Hospital of the University of
Pennsylvania.
The conference theme is
"Continuing nursing education:
planning for the 80V. The
conference is intended to assist
individuals responsible for
continuing nursing education by
providing them with information
about strategies for cost effective
educational programs. It is
intended for nurses working in
health care agencies, educational
institutions, professipnal
associations and government
organizations. Registration is
limited to 150 persons.
Nurse administrators
conference
The administration of nursing
in the 80 s will be the theme
for the First National Nurse
Administrators Educational
Conference to be held in
Vancouver, B.C. on
June 25 and 26.
The plenary session
will focus on topics such as
management information
systems, maximizing the use
of staff, the impact of new
technology, coordinating care
internally and externally and
organizational models. Small
group sessions will follow
where participants will deal
with one of the above topics
in greater depth. The
challenges and stresses faced
by administrators will be
dealt with in two separate
plenary sessions.
The conference is
sponsored by the Canadian
College of Health Service
Executive in cooperation
with the Canadian Nurses
Association and the Nursing
Administrators Association of
British Columbia. The $95
fee includes lunch and
materials.
Did you know...
A new chapter of the
Canadian Orthopaedic Nurses
Association has been formed
in Nova Scotia with
approximately 70 members.
Monthly educational
meetings are held in the
Halifax area. If you are
interested please contact:
Carolyn Gesner, RN,
Chairman, Membership
Committee, Nova Scotia
Chapter, C.O.N.A.,
V6 West, Victoria General
Hospital, Halifax, N.S.
Health happenings
Fifty nurses working in
Canada s north have united to
set up their own professional
association which will stage
its first annual general
meeting in May of this year.
The Yukon Nurses Society
was officially incorporated
and registered early in 1980.
The fledgling association has
as its main objective the
provision of educational
programs and information for
its membership.*
14 June 1980
The Canadian Nurse
AYERST HAND CARE
to suit most hospital hand care needs
A new dimension in hand
hygiene. . .from the Ayerst
family of antiseptic products.
HIBITANE* Skin Cleanser
performs the dual function of
cleansing AND disinfecting.
HIBISOL* Hand Rub serves
as an adjunct to primary
hygiene practice. Rapid acting
disinfection WITH added
emollients to ensure cosmetic
acceptability. Simply apply
and rub dry.
HIBICARE* Lotion soothes
and softens hands PLUS it
maintains an antiseptic barrier.
Absorbs quickly.
For complete product information, please
contact your Ayerst representative,
or return this coupon.
TO: AYERST LABORATORIES
1025 Laurentian Blvd., Montreal, Quebec. H4R 1J6
I would like to receive information on the
AYERST ANTISEPTIC LINE.
Name
{Please print)
Address
No.
City
Province
M,B I AYERST LABORATORIES
Division of Ayerst, McKenna & Harrison Inc.
Montreal, Canada
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wild IMPERIAL CHEMICAL INDUSTRIES LIMITED
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Op-Site helps
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Day 0. Decubitus ulcer on the inner condylus
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A soothing synthetic second skin
Op-Site is a thin, waterproof, adhesive
polymer membrane that keeps the skin ven
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With Op-Site, pain is usually relieved imme
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Under Op-Site, the ulcer bathes in its own
Op-Site helps
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Reddened area before Op-Site.
Protects sensitive skin
Apply Op-Site to pressure areas at the first
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Op-Site stretches and fits snugly and
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Day 4. Conventional
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Day 5. Conventional Day 6. Conventional Day 7. Conventional
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Once you ve learned how, Op-Site is just as
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Op-Site can usually be left on for up to a
week and then removed painlessly, without
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A choice of sizes
Op-Site comes in several sizes which are
suitable for treatment and protection. Each
Op-Site dressing is sterilized and individu
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:iean and dry the area.
Apply Op-Site.
oothly over any part of the body and
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:ause Op-Site is waterproof.
i is you watch the redness
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I -Site is transparent. You can examine
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One dressing is usually enough
Erythema generally disappears within a few
days, provided that the patient is turned
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Op-Site for extra protection, as long as
there is risk of skin irritation.
1. Winter, G.D.-. Healing of Skin Wounds and the Influence
of Dressings on the Repair Process Surgical Dressings
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Reg.T.M.
YOU AND THE LAW
Canada s highest judicial authority, the Supreme Court, will rule this year on
two cases, Reibl v. Hughes and Lepp v. Hopp, dealing with the issue of what
constitutes informed consent to medical treatment, a question which has given
rise to more and more litigation recently. Some of the confusion which now
surrounds the issue appears to have been influenced by the U.S. situation
where a dichotomy in judicial approach has created controversy in the last few
years. In Canada this has exposed a noticeable lack of clarity and consistency in
trial and appellate decisions at the provincial level so that, until the results of
these two current appeals are announced, health professionals remain up in the
air about the standards that apply in this country.
Corinne Sklar
Was the patient informed?
The patient s consent to treatment is
required before those delivering health
care can lawfully minister to the
patient: failure to obtain this consent
abrogates the patient s basic legal right
to determine what shall be done with
his own body. 1 This right of
self-determination and control over
invasion of the individual s person is a
basic legal right which the law
scrupulously upholds: to touch another
without his consent, either express or
implied, constitutes the civil wrong of
battery. The individual s consent to the
touching validates the conduct. For
those delivering health care, there is
another "answer" to a complaint of
touching without consent, ie. the
emergency, in which a threat of danger
to life, health, limb or vital organ
provides lawful justification for such
touching. Our courts have upheld such
medical intervention when necessary to
safeguard the patient s life or health, 2
but not where the treatment has been
completed merely because it was, at
the time, medically convenient. 3
For consent to medical treatment
to be valid in law, four requisite
elements must be present:
capacity of the patient
voluntarily given
corresponding to the act
performed
informed to the degree required
by law.
It is the "informed" aspect that requires
clarification by the Supreme Court: for
the patient s consent to be valid, he
must understand the nature and purpose
of the contemplated treatment, the
risks of agreeing to it and the risks of
refusal to be so treated. In other words,
the patient must have all the facts
necessary in order to make a reasoned
decision as to whether or not he will
undergo the proposed treatment and in
order to do this, he must be given
sufficient information in language he
can understand.
How much information must the
physician disclose? Case law says that
physicians must disclose all material
facts to the patient but physicians must
also protect their patients from undue
alarm. What degree of disclosure will
suffice?
* The position taken by Canadian
courts has been to require that the
explanation be honest, reasonable and
fair so that the patient has enough
information to understand fully the
nature of the treatment and the reasons
it is necessary. Prior to Reibl and
Hughes, a Canadian physician had to
disclose risks that were material and
those his professional colleagues would
normally have disclosed. In addition the
physician had to subjectively assess the
patient and make the explanation
having regard to the intellectual and
emotional characteristics of the patient.
He also had to consider the degree of
dependency this patient had in the
physician-patient relationship.
"...the paramount consideration is the
welfare of the patient, and given good
faith on the part of the doctor, I think
the exercise of his discretion in the area
of advice must depend upon the
patient s overall needs. To be taken into
account should be the gravity of the
condition to be treated, the importance
of the benefits expected to flow from
the treatment or procedure, the need to
encourage him to accept it, the relative
significance of the inherent risks, the
intellectual and emotional capacity of
the patient to accept the information
without such distortion as to prevent
any rational decision at all, and the
extent to which the patient may seem
to have placed himself in his doctor s
hands with the invitation that the latter
accept on his behalf the responsibility
for intricate or technical decisions... >A
Physicians do not have to disclose
all of the risks which are usually
inseparable from any surgery such as the
dangers from undergoing anesthetic, the
risk of infection, etc. These are
considered to be generally known.
Some areas of the United States
however have adopted the
"full disclosure" standard which
demands that the physician disclose to
the patient all significant risks, whether
material or remote. The test is an
objective one, that of the
informational needs of the reasonable
and prudent person in the patient s
condition, armed with complete
knowledge of all of the facts, who
makes a reasoned decision as to
whether to accept or reject the
proposed treatment. This approach does
not consider the needs and
and characteristics of the actual patient.
Cases where the informed aspect
of the consent obtained has been
questionned raise the following points:
1. If the consent is not informed, was
the doctor only negligent or was there
no consent at all so that the wrong of
battery has also been committed?
(There are important legal differences in
the proof and presentation of the case,
depending on whether battery and/or
negligence is alleged.)
2. What degree of disclosure constitutes
an informed consent?
3. By what test is the patient to be
measured? Is it a subjective evaluation
of the intellectual and emotional
qualities of that particular patient or
is it an objective test of the reasonable
prudent patient in similar circumstances?
(This is important because the question
to be answered here is would the patient
[subjective or objective standard applied]
given the facts have undergone the
treatment?)
The stage for the current appeals
to the Supreme Court of Canada was set
in 1976 by the Ontario case of
Kelly v. Hazlett 3 . Before that, cases
alleging an absence of informed consent
were usually framed either in negligence
or battery, mostly the latter. In
Kelly v. Hazlett, Judge Morden (as he
then was) considered the American
situation and in his decision
differentiated between the battery and
negligence action. If the physician
failed to inform the patient of risks
material to or basic to the treatment,
then there was no consent and battery
had occurred. If, however, the
undisclosed risks were not basic to but
only collateral to the treatment, then
the physician had failed to live up to
the professional medical standard and
his conduct amounted to negligence.
This decision was not appealed but was
followed in Reibl v. Hughes 6 and referred
to in Lepp v. Hopp, the two cases now
on appeal to our Supreme Court.
18 June 1980
The Canadian Nurse
)UR JOB IS TO MAKE SURE HE LEAVES THE HOSPITAL
WITH THE SAME PERSON HE CAME IN WITH.
Infant mix-ups.
They may sound far-fetched and unthinkable. Yet every
well-run maternity section thinks of such things. And takes
precautions.
Such as putting into use the Hollister products displayed
on the right.
Ident-A-Band H Bracelets, a Hollister original, offer you the
safest, most time-tested means of on-patient identification in use
today.
Our Disposable FootPrinter is considered so effective it s
been hailed by major law enforcement agencies across the
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While our Newborn Identification Forms provide a quick,
accurate way of getting all the facts on paper (a nice, glossy
paper that retains even the delicate skin prints of an infant I.
The way Hollister sees it, every person should struggle to
find his own identity, at some point during his life.
But not on his first day.
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Case one: Reibl v. Hughes
In Reibl v. Hughes, the plaintiff was a
50-year-old married father of four who,
at the time of the onset of his
symptoms, was working on the Ford
assembly line in Oakville. In 1968-69,
he developed severe headaches. His
physician diagnosed hypertension and
prescribed medication. When the patient
failed to respond, he was admitted to
hospital for testing, the results of which
were inconclusive at that time except
for a finding of mild diabetes to be
controlled by medication and diet.
The headaches continued.
Investigation by the defendant
neurosurgeon revealed a left carotid
artery murmur indicating narrowing of
the vessel. Arteriography indicated
stenosis of 80 to 90 per cent. Although
the defendant determined that this
finding was not the cause of the
headaches, he was of the view that the
affected area should be removed to
reduce the risk to the patient of a
stroke. The defendant performed an
endarterectomy in March 1970 but,
either during or after the surgery, the
plaintiff suffered a massive stroke which
paralysed the right side of his body. He
will never work again.
The trial judge found that the
neurosurgeon "did not take sufficient
care to convey to the plaintiff and
assure that the plaintiff understood the
gravity, nature and extent of risks
specifically attendant on the
endarterectomy, in particular the risk
that as a result of the operation he
could die or suffer a stroke of varying
degrees of severity". 7 The trial judge
found that the defendant knew that the
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cumulative risks of death or
neurological damage were about
14 per cent yet he did not inform the
patient of this. The judge called this
degree of disclosure negligent and
described the duty of a surgeon as
"relating to the specific risks within the
surgeon s knowledge peculiar to the
contemplated treatment". 8 He stated
that, in his opinion, if the patient had
been fully informed of the risks, he
would not have consented to the
surgery. The trial judge held that
"the consent" obtained, being not
properly informed, was not legally valid
and therefore the civil wrong of battery
had been committed.
On appeal, the Ontario Court of
Appeal ordered a new trial. The
appellate court found that the trial
judge should not have injected the issue
of battery (no valid consent because not
informed) in a case where negligence
(failure to meet the required standard
of care in disclosure) alone was alleged.
In its view, the physician did not have
to give the patient statistical risks of
paralysis or death. The patient seemed
aware of the risks from the questions
he raised when the surgery was
discussed. The trial judge had imposed a
test of disclosure greater than the test
of disclosure required by law.
With respect to which test should
be applied to the patient, given the
effect of hindsight on any such
determination, the Court referred to the
usual application of the subjective test
in Canadian jurisprudence. The Court s
opinion was that safe practice would be
to test the patient s decision objectively
(ie. based on the reasonable prudent
patient) and only then consider it
subjectively (ie. based on the
characteristics of the actual patient).
Case two: Lepp v. Hopp
In Lepp v. Hopp, 9 the issue of informed
consent again was before the Court. In
this case, the question of the degree of
disclosure required in response to a
patient s questions was also considered.
Here the patient was a retired farmer,
66 years of age, who developed severe
pain in his left upper thigh, hip and
groin areas. The patient was diagnosed
as having a "slipped disc", with the
prolapse of disc material protruding in
the area of the third and fourth lumbar
vertebrae exerting pressure on the
spinal cord in that area.
After the patient had been
hospitalized, his family physician called
in the defendant, an orthopedic surgeon.
A myelogram confirmed the diagnosis
made by both physicians. After
discussion with the patient, and the
patient s consent to surgery having been
obtained, the defendant performed a
hemilaminectomy. However, the patient
did not continue to improve as expected
and a subsequent X-ray one month
later based on a residual amount of
contrast medium disclosed a complete
block at the same stage. This was in
contrast with the results of an X-ray
taken five days postoperatively which
showed that some of the contrast
medium had passed through the former
area of blockage.
20 June 1980
The Canadian Nurse
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A book that looks at what the
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Enjoyable reading about a problem
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Springer. 118 Pages. 1980. $13.25.
2 STATISTICS FOR NURSES:
An Introductory Text
By Frederick ]. Kviz, Ph.D.; and
Kathleen Astin Knafl, Ph.D.
Nursing students and graduate
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Little, Brown. 31 7 Pages.
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3 EDUCATION FOR
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Provides an overview of current
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Springer. 224 Pages. 1979. $1 7.50.
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Lippincott. Abt. 480 Pages.
Illustrated. May 1980.
5 INTRAVENOUS
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By Diane Proctor Sager, R.N., M.S.N.;
and Suzanne Kovarovic Bomar, R.N.,
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Here is a handy two part reference/
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The Canadian Nurse
June 1980 21
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The defendant referred the
patient to a neurologist in Calgary,
100 miles from the site of the first
surgery in Leth bridge. A further
myelogram confirmed the complete
blockage in the area of the third and
fourth lumbar vertebrae. On referral
to a Calgary neurosurgeon, an extensive
decompressive laminectomy was
performed. During this surgery a large
portion of extruded disc material was
removed from the space between
L3 and L4.
The plaintiff now suffers severe
weakness and loss of sensation in his
legs and is unable to walk without a
cane. He has severe disturbance of
bowel and bladder function. The
trial judge found these injuries to be
permanent and that their cause was due
to the pressure damage to the nerves
which resulted from the extruded disc
material.
The trial judge found no
negligence on the part of the defendant
orthopedic surgeon who performed the
first surgery. In his view, it was purely
speculative to determine whether the
additional disc material had become
extruded at the time of the first surgery
or thereafter. He found that the
defendant had found the spinal cord to
be freely moveable after his removal of
the offending disc material.
The trial judge also found that the
defendant had not failed in
obtaining an informed consent to the
procedure. At issue was the question
whether the surgeon had to disclose to
the patient that this was the first time
he would be performing this type of
surgery alone; the defendant had
performed this type of surgery many
times under supervision while
completing his residency in orthopedic
surgery. After a review of his
qualifications and experience, it was
held that there was no obligation to
inform the patient that this was the
first time he had performed this type of
surgery since obtaining his certification.
This issue was not raised on appeal.
The plaintiff had asked the
defendant, however, how serious the
operation was and whether it should be
done in Calgary, rather than in
Lethbridge. The response had been
that the operation was not serious and
that he, the defendant could do it as
well as any doctor in Calgary. Did this
response fulfill the requirements of an
informed consent?
The trial judge found that this was
sufficient and dismissed the plaintiff s
claim ; he was satisfied that the
Lethbridge facility was suitably
equipped to handle such surgery and
that no unreasonable risks were
involved.
This decision was overturned on
appeal. The Alberta Appeal Court
majority decision awarded the plaintiff
damages of $15,000. The Court here
held that specific questions directed to
the surgeon require a full and fair
disclosure in response. Once asked, it
was incumbent upon the defendant to
discuss with the patient the possible
risks and the convenience and expertise
involved in each alternative; to do less
was inadequate and, in the
circumstances, misleading. The Court
found the defendant liable in both
battery (no valid consent because not
informed) and negligence (failure to
meet the required standard of care in
disclosure).
The Appeal Court majority
accepted the traditional tests of
the medical professional standard for
the doctor and the subjective standard
of assessing the patient. The dissenting
opinion 10 in the Alberta Court of Appeal
held that the patient s general query
regarding the seriousness of the surgery
did not constitute a specific question
requiring the more full and frank
disclosure. In this view the defendant
was not negligent or in breach of any
duty to the patient in the disclosure
so made.
* The direction Canadian law will
take regarding the approach and degree
of disclosure required of physicians will
be determined by our Supreme Court.
It is to be hoped that the Court s
decisions in these cases will clarify the
law with respect to informed consent so
that physicians, lawyers, patients and all
those delivering health care will have a
clear appreciation of what the law
requires. *
"You and the law" is a regular column
that appears each month in The
Canadian Nurse and L infirmiere
canadienne. Author Corinne L. Sklar
is a recent graduate of the University
of Toronto Faculty of Law. Prior to
entering law school, she obtained her
BScN and MS degrees in nursing from
the University of Toronto and
University of Michigan.
References
1 Sklar, C.L. Legal consent and the
nurse. Canad. Nurse 74(3):34-37; 1978
Mar.
2 * Marshall v. Curry (1933),
3D.L.R. 268 (N.S.S.C.).
3 *Murray v. McMurchy, [1949],
2 D.L.R. 442 (B.C.S.C.).
4 Smith v. Aukland Hospital Board,
[1964] N.Z.L.R. 241. In: Picard, Ellen.
Legal liability of doctors and hospitals
in Canada. Toronto : Carswell Co. ;
1978: p. 80.
5 *(1976) 15O.R. 2d290(H.C.).
6 *(1978) 21 O.R. (2d) 14 (C.A.)
rev g 16 O.R. (2d) 306 (H.C.).
7 *16O.R. (2d)306,p.314.
8 *Ibid:p.312.
9 *(1977), 77 D.L.R. (3d) 321
(Alta. S.C.) rev d by (1979) 98 D.L.R.
(3d) 464 (Alta. C.A.).
10 *Note that there was also a
dissenting opinion in the Court of
Appeal in Reibl v. Hughes but this
dissent was not directed at the issue of
liability but rather at damages which
Haines J. at trial assessed at $225,000.
* Unable to verify in CNA Library
22 June 1980
The Canadian Nurse
We know that attitude plays a large part in how successful treatment will be. Separating culture from illness
is like trying to separate mind from body: the relationship between the two is so complex that division is
almost impossible.
Corinne Hodgson
In interethnic relations in city hospitals,
in outpost nursing and in many other
areas of practice, nurses are often called
upon to give care to people of another
culture. The field of study concerned
with this area of nursing has become
known as "Transcultural Nursing".
Madeleine Leininger, one of the first
nurses to study and write extensively
about this subject, considers cultural
factors an integral part of providing
total health care services to people:
"Nursing and health services cannot be
adequate, effective or comprehensive
unless cultural aspects of health and
illness are given full consideration." 1
Last Summer I spent time in the
Canadian North talking to nurses
practicing there. What has Leininger s
subdiscipline to offer outpost nurses?
Is transcultural nursing different from
nursing people of your own culture?
The
_ Canadian
Experience
In 1975, an Inuit Councillor
speaking at a northern health conference
made this statement:
"I don t know exactly how many beds
there are in the Nursing Station - some
have been added on but for whatever
reason it seems that the nurses don t
want to use the beds. Maybe they don t
want to get the beds dirty. Maybe they
consider Inuit too dirty to be in those
beds." 2
What happens when patient and
practitioner see things in fundamentally
different ways? Hazel Weidman suggests:
"One distressing outcome of unicultural
or unidirectional encounters may be
that the patient s concerns focus upon
an entirely different kind of problem
from that upon which the health
professional s attention is centered. The
latter could be responding to the same
set of symptoms as the patient, but his
efforts might be directed toward
treating the patient in ways that have no
meaning for him. Such instances begin
to border on an unintended but very
real intolerance and contempt for the
patient s cognitive system." 3
Are the concepts of transcultural
nursing applied in the Canadian North?
Occasionally, but mostly on individual
initiative. Neither the standard nursing
curriculum nor the orientation provided
by National Health and Welfare really
explains native Canadian culture to new
nurses. They pick up their knowledge
largely through trial and error, a slow
and costly way of learning. All goodwill
aside, under such conditions
misunderstandings are inevitable for
both sides.
The Canadian Nurse
June 1980 23
To understand what they might
want from health care, we must
consider the history of native Canadians.
Before the arrival of the Europeans, all
native groups were self-sufficient in this
area. In their world "health" was never
an isolated element of behavior, but an
integral part of cultural and social
life. Illness that would not respond to
home (usually herbal) remedies were
often interpreted as the result of social
or religious violations by the patient or
a member of his family. The healer was
called upon to restore the balance of
man, society and the supernatural; he
thus combined the roles of medical
practitioner, judge, policeman and
priest. A healing ceremony involved not
only the patient and healer, but also
the family and community of the sick
person. The medical rite thus contained
social, psychological, cultural and
religious elements.
Later, health care was provided
mostly by European missionaries.
Certain similarities existed between the
traditional "shaman" or healer and the
doctoring missionary. Both men
combined curing with religious duties
and both were concerned with the
structure and functioning of the society
as a whole; the shaman to maintain
social harmony and his own position,
the missionary to civilize, Christianize
and westernize. It is not surprising that
many Inuit remember the medical care
given by the missionaries with fond
nostalgia, even though the quantity and
quality of this care was very different
from today. The nursing missionary or
nun cared about your soul as well as
your broken arm, and generally lived in
close contact with the native poeple. It
is interesting to note that the modern
Inuit word for nurse is "nayanguak"
which translates as "fake nun".
What prompted the Inuit
Councillor s remarks about the nursing
station beds? Having talked to many of
the nurses in this area, I feel confident
in saying that the nurses aren t afraid to
use their inpatient facilities and don t
consider the Inuit "too dirty to be in
those beds". Rather, the nurses feel
that part of their job is to teach basic
home care and probably assume that
patients who don t require constant
nursing supervision would be happier at
home. To these nurses, the station is
not a hospital, but a clinic, and people
are kept as inpatients only if it is an
emergency. The Inuit, on the other
hand, tend to confuse nursing stations
and hospitals and to expect inpatient
care as given by the doctoring
missionaries. Not knowing that the Inuit
are used to total care from a healer, the
nurses probably assume that the Inuit
will understand why they are sending
the patient home and explain it only
briefly. The Inuit, expecting something
different, probably suspect that the
nurses explanation, if one is given, is an
excuse for her to duck out on her
responsibilities. Each side is acting in a
manner consistent with its culturally-
derived ideas of what constitutes health
care, without realizing that the other
side sees things very differently.
A similar problem is encountered
when northern nurses attempt to
establish regular clinic hours for remote
stations. Traditional Indian and Inuit
cultures possess the concept of time,
but not the precise, measured units used
by western society. Furthermore, the
early nursing missionaries probably saw
their work, including any after-hour
calls, as part of their Christian duty.
Modern day nurses, however, would
like to establish regular clinic hours so
they too can have some time to
themselves. Such a concept may be
difficult to introduce, and the nurses are
constantly teaching the community the
clinic hours, what constitutes an
emergency, and symptoms that can be
safely treated at home until the clinic
opens. Unfortunately, conflict is still
generated by this issue. Unnecessary
after-hour calls or a rush of stragglers
just before closing time can be very
annoying for the nurse and can cut
seriously into her free time. In remote
settlements it is often very difficult for
an outpost nurse to emotionally and
physically leave her work behind her,
especially if she is living at the station.
Many native people do not understand
why the nurses find these interruptions
so annoying. "After all, why shouldn t a
nurse want to nurse at any time? Isn t
that her job and her life? What s so
special about seven p.m. as opposed to
five p.m.? If hospitals provide around
the clock care, shouldn t that big station
with three nurses do the same?"
Problems like this, which seem
small on the surface, can aggravate basic
differences already existing between
native and white people in remote
settlements. The outpost nurse not only
works in these communities, but lives
there as well. In order to become part
of that community, she should make
friends with both her white and native
neighbors. Making friends involves not
only commitment, but an investment of
time and emotions. Often neither the
nurse nor the community member is
willing or able to make this
commitment. Most native poeple in the
north have experienced a long
succession of temporary nurses with
whom they have little, if anything, in
common. Although some nurses do
establish viable friendships with native
people, many nurses find it difficult to
overcome the linguistic, cultural and
educational barriers between themselves
and the majority of their native patients.
It must also be remembered that a nurse
may find it equally difficult to find
someone of similar tastes and interests
among the small white contingent of a
remote community. Although no one is
at "fault", a northern nurse may find
herself socially isolated, so that
interactions with the community are
limited to a "single strand" or
professional format. Needless to say,
this is not healthy for either the nurse
or the community. When native people
complain that nurses don t "like" them,
they are probably commenting on the
separation of medical care from culture
created by modern medicine. This
separation is greater when such care is
applied to northern communities.
Native people may find medical services
psychologically unsatisfying and socially
alienating unless they can establish ties
with the healer and vice versa. The
medical practitioner must not only cure
the disease but heal the patient as well.
Healing has been defined as "restoring
the sick to the world of the healthy". 4
It is a continuation of the curing process
rooted in a positive and personalistic
practitioner/patient relationship.
24 June 1 980
The Canadian Nurse
To establish such a relationship,
white nurses and native patients must
achieve cross-cultural communication.
This can be extremely difficult for new
nurses. Often the very young and very
old in the north, specifically those most
in need of reassurance when ill or
injured, do not speak English. Even
when a patient speaks English or an
interpreter is available, he/she may be
intimidated by the station and/or
unwilling to answer personal questions.
Furthermore, the body language and
communication patterns common to
many traditional Indian and Inuit
groups are different from those used by
Euro-Canadians. Eye contact, for
example, is avoided by many Indian
groups as a sign of respect or when one
is uncertain about a relationship or a
situation. Lack of eye contact and very
subtle facial expressions can make it
difficult for some Euro-Canadian nurses
to "read" native patients. Reading a
patient is essential, however, if a nurse is
to reassure someone who is frightened
or lonely. As an Indian councillor
recently pointed out:
"Most often the hospital is a foreign,
cold and unwelcome place for our
people. ..That doesn t mean that the
hospital staff are cold or prejudiced by
intent. Those are just the feelings our
people get." 5
Again, lack of cultural understanding is
probably the real villain.
In situations where communi
cation between different cultures is
necessary, "transcultural nursing"
studies could be a valuable aid: under
standing why people are behaving in a
manner different from our own, we
have a logical basis upon which to
interpret that behavior and plan our
response. Leininger argues that "caring
is the basis to curing effectiveness" 6 .,
and whether in the north or the south,
nurses are the source of this care. If
nurses cannot develop lines of
communication with their patients, this
care is patchy and prone to misunder
standings and breakdown.
Concepts of transcultural nursing
are as important in urban hospitals as in
the remote north. Any time a nurse
cares for a patient from another cultural
or ethnic group, problems in
communication can occur. As pointed
out by many authors, body language
alone varies widely throughout the
world. The cultural backgrounds of the
nurse and the patient can determine
both how the patient will react to his
illness (as well as how his family will
act), and how the nurse will interpret
this behavior.
CHECKING OUT YOUR OWN
"CULTURAL AWARENESS"
Gail O Neill
Are you conscious of the dominant
values of your own culture? Pervading
North American society and creating
a strong influence on behavior, we
have such cultural values as:
optimal health
democracy
individualism
achieving and doing
cleanliness
. time
automation
A distinction should be made between
two major categories of cultural
behavior: manifest culture refers to
patterns of actions, beliefs and feelings
which can readily be identified by
outsiders, in other words, what people
are actually doing; ideal culture refers to
those ways held desirable but not
always practiced.
Would you recognize common reaction
patterns that often occur in a
cross-cultural situation?
Ethnocentrism: the sense that
one s own beliefs, values and lifeways
are superior to and more desirable than
the lifestyles of others.
Cultural Blindness: the tendency
to avoid seeing those ways in another
culture that one finds unacceptable or
otherwise disturbing.
Culture Shock: being stunned by
what one sees in another culture.
Cultural Conflicts: conflicts
generated when the rules of one s own
culture are contradicted by the rules
of another.
Cultural Imposition: the tendency
to impose views and values of your own
culture upon persons or groups of
another culture with limited
consideration of their beliefs.
Bibliography
Leininger, Madeleine. Cultural diversities of
health and nursing care. Nurs. Clin. North
Amer. 12(11:5-18; 1977 Mar.
Leininger, Madeleine. Transcultural nursing:
concepts, theories & practices. Toronto:
Wiley; 1978.
Understanding the cultural
background of your patient has at
least three beneficial effects:
It makes it easier for the patient
to approach you ("the nurse will
understand")
It helps you understand what the
patient is saying and why, so actions
become more comprehensible and
predictable
It makes health care more
humanistic and personal, giving greater
satisfaction to both patient and nurse.
It is obvious that "awareness of
both the differences and similarities
among cultures can serve as an
important step toward enhanced sensiti
vity to patients and more effective
nursing care." 7 Achieving empathy in a
cross-cultural situation is not a simple
matter, but it is essential if we are to
give holistic health care. *
References
1 Leininger, Madeleine. Cultural
diversities of health and nursing care.
Nurs. Clin. North Amer. 12(1):5-18;
1977 Mar.
2 *Ittinuar, Ollie. Inuit health
concerns in Rankin Inlet. Univ. Man.
Med. J. 45(3): 142-143; 1975.
3 *Weidman, Hazel Hitson. The
transcultural view: prerequisite to
interethnic (intercultural)
communication in medicine. Soc. Sci.
Med. 13B(85-87); 1979.
4 Cassell, Eric J. The healer s art.
New York: Penguin Books; 1979.
5 Fines, Beatrice. Native child in
hospital. Dimens. Health Serv.
56(5):62-64; 1979 May.
6 *Leininger, Madeleine.
Transcultural nursing: a new subfield to
generate nursing and health care
knowledge. Annual lecture series,
School of Nursing, University of
Manitoba and VON, Winnipeg Branch,
Oct. 4, 1978.
7 Davitz, Lois J. (et al) Suffering as
viewed in six different cultures.
Amer. J. Nurs. 76(8):1296-1297;
1976 Aug.
*Unable to verify in CNA Library
Full bibliography available on request
from the Journal.
Corinne Hodgson, an MA student in the
Department of Anthropology , McMaster
University, Hamilton, Ontario, hopes to
complete her studies in June, 1980. In
the summer of 1979 she visited outpost
nurses in northern Manitoba and the
Northwest Territories as fieldwork for
her thesis on intercultural nursing.
The Canadian Nurse
June 1980 25
*;
Whittington
, SYMPATHETIC
TRUNK
KEY
SYMPATHETICS
PARASYMP.
SENSORY
SOMATIC
AORTIC
(INTER-
MESENTERIC)
PLEXUS
( SPASTIC
(CHRISTMAS
TREE)
BLADDER
WITH
SACCULATION
\
PELVIC
SPLANCHNIC
NERVES
(NERVI
ERIGENTES)
INFERIOR
HYPOGASTRIC
AND VESICAL
PLEXUSES
PUDENDAL NERVES
FLACCID, DISTENDED,
ATONIC BLADDER
WITH FINE
TRABECULATION
As nurses in the Rehabilitation Unit of
St. Joseph s Hospital, Hamilton, Ontario
we first met Mrs. Steen, a 55-year-old
widow when she was admitted to our
neurosurgical unit; she was worried and
very anxious about persistent pain in
her right hip, buttock and thigh and
queried an increasing right foot drop.
The cause of her distress was revealed
during a myelogram; an intraspinal
lesion was located at the spinal level
of I*
We prepared Mrs. Steen for
surgery as best we could but no one
could tell her what the exact outcome
would be. When a laminectomy of
L 2 and most ofL 3 resulted in the removal
of an intradural cyst, we were all
relieved. Now we just had to wait along
with Mrs. Steen to determine if recovery
would be complete; we knew that
frequently surgery in this area resulted
in a paraparesis due to the inevitable
damage of nerve fibers from L s to S 4 .
The first 48 hours after surgery
confirmed our fears: Mrs. Steen s
symptoms of urinary retention, bladder
distension and urine overflow were all
indicative of bladder paresis and
denervation of the external sphincter -
a lower motor neuron bladder. We
realized we must initiate a program of
bladder retraining immediately.
The Neurogenic Bladder
Neurogenic bladders may be divided
into three groups; the type can be
readily determined with knowledge of
the level of injury incurred. An
incomplete injury may produce variable
findings. A lesion of the cord less severe
than a complete interruption may be
only temporary and bladder function
may return partially or completely.
1. Upper Motor Neuron Bladder
An upper motor neuron bladder is
often referred to as an automatic or
spastic bladder as the pathways have
been interrupted above the micturition
center, that is, above S 2 , 3 , 4 of the
spinal column. With the sacral reflex arc
intact and the integrity of the pelvic and
internal pudendal nerves unimpaired,
the bladder will empty abruptly,
independent of the individual s wishes.
Bladder retraining and the technique of intermittent catheterization, now widely used in rehabilitation
centers throughout North America and around the world, has been shown to have an excellent success rate
in the treatment of neurogenic bladders. Early assessment of bladder function and implementation of a
routine is crucial, however, if permanent damage is to be avoided. Consequently, the responsibility lies in
the acute care setting where victims of accidents, post-operative complications or cerebrovascular accidents
receive their early medical and nursing care. Introduction of a bladder protocol in this setting is mandatory
so that, in the weeks ahead, in the rehabilitation setting, complications will be fewer and the chance of
success greater.
The amount of urine required to elicit
this reflex varies from person to person
and is usually related to previous
bladder management. Voiding becomes
completely involuntary unless the injury
is incomplete and then incontinence
will vary.
Frequency, urgency and
incontinence are the major symptoms
of the upper motor neuron bladder.
The bladder capacity is usually about
100-300 cc less than normal and since
often the bladder contractions are not
sustained long enough for complete
emptying to occur, residual urine may
be present at all times. Stimulation of
the areas innervated by the sacral
center, that is, the inner thighs, genitalia
and the abdomen, frequently will
stimulate the onset of micturition. The
individual may experience sensations of
bladder filling as mediated by the
autonomic nervous system; these
sensations all indicative of autonomic
hyperreflexia include abdominal
discomfort, sweating, restlessness,
headache, hypertension and
bradycardia.
Neurologic evaluation of the
individual with an upper motor neuron
bladder will reveal:
absence of voluntary initiation of
micturition
high residual urine, probably due
to spastic musculature or decreased
efficiency of returning motor neurons
vesical sensation or sensation of
bladder filling is rarely present. In low
thoracic lesions some sensory fibers may
enter the spinal cord above the level of
the lesion allowing minimal sensation
sensation in the saddle area
(perineal area) is absent
the ice water test is positive. This
test involves the introduction of 60 ml
of sterile ice water into the empty
urinary bladder, in the case of the upper
motor neuron lesion there is expulsion
of the water
uninhibited contractions are
present, and
bulbocavernous and anal reflexes
are active.
Early bladder management of this
condition is critical. If the bladder is
overly distended for long periods, it
will eventually require large volumes of
urine to stimulate micturition.
Conversely if the bladder is
continuously drained with an indwelling
catheter the muscle will contract
resulting in a low threshold for the
reflex. Bladder training should be
directed at making reflex emptying
more efficient.
2. Lower Motor Neuron Bladder
Destruction of the reflex arc at the
sacral levels, results in the lower motor
neuron bladder. While neurologic
connections to the brain remain intact,
control is lost as the bladder is
neurologically isolated from the spinal
cord. The reflex pattern via the
autonomic and somatic nerves is absent
breaking the reflex arc, thus eliminating
spontaneous voiding. Denervation of the
bladder muscle and the external
sphincter results in loss of bladder tone
and reflex emptying does not occur.
This bladder dysfunction is often
referred to as the autonomic or flaccid
bladder, as the walls are constantly
distended and therefore become flabby.
The bladder capacity increases and large
amounts of residual urine is common.
Complete lesions below T 12)
congenital lesions as in spina bifida ancl
myelomeningocele and more peripheral
lesions of the pelvic nerves all produce
this type of bladder dysfunction.
Neurologic evaluation reveals:
loss of voluntary micturition
vesical (bladder) sensation is
absent
uninhibited contractions are
absent
sensation in the saddle area is
absent
bulbocavernous and anal reflexes
are absent, and
the ice water test is negative.
Symptoms resulting from lower
motor neuron bladder are urinary
retention, distension and overflow.
Bladder training in this case is aimed at
developing methods of emptying the
bladder to prevent overdistension and
dribbling.
3. Mixed type of Neurogenic Bladder
The mixed type of neurogenic bladder
is found when the clinical picture
presents a combination of both the
lower motor neuron and upper motor
neuron bladders. Damage to the cerebral
cortex as in multiple sclerosis, tumors or
cerebrovascular disease and trauma to
the area between T n and L 2 result in
this type of bladder. As the cell fibers
implicated in bladder activity are in
close proximity, a variety of symptoms
can result and usually include partial
sensation and/or partial control.
Therapy would naturally depend on the
symptoms presented.
Cerebrovascular Accident and Bladder
Dysfunction
A hemispheric stroke results in an
incomplete upper motor neuron
bladder. The term incomplete is used
as the lesion is unilateral leaving the
patient with partial sensation and
control. Prognosis for such a condition
is usually good as the reflex arc remains
intact and the partial sensation
remaining maintains partial voluntary
control.
Brainstem strokes result in
bilateral damage to the neural pathways
and consequently an upper motor
neuron bladder with loss of all
facilitation and inhibition of
micturition.
For many CVA patients and those
suffering from a variety of spinal
lesions, a spastic urinary bladder may
dominate until after spinal shock is
over. Manifestations of this spinal shock
may last several weeks and in the case of
quadriplegia may persist anywhere from
a few weeks to a year or more.
If bladder care during the acute
stage is adequate, cord reflexes will
recover after spinal shock, making
reflex action possible. An indwelling
catheter resulting in contraction or
overdistension of the bladder for long
periods of time contribute to the
necessity of prolonged bladder
management. Impulses may return to
the bladder and prolonged repetitive
stimulation of synapses in the cord
increase reflex arc effectiveness.
Complications of the neurogenic
bladder
The fact that renal failure is the
principle cause of death following
The Canadian Nurse
June 1980 27
The Normal Bladder
Lying directly behind the symphysis pubis
and below the parietal peritoneum, is the
urinary bladder. With its walls consisting of
three layers of smooth muscle, commonly
referred to collectively as the detrusor muscle,
its internal rugae and its highly elastic lining,
the bladder is capable of considerable
distension for bladder filling. At the base of
the bladder, interlaced around the opening of
the urethra is the trigonal muscle or internal
sphincter, also an involuntary muscle. The
external sphincter or urogenital diaphragm, a
skeletal muscle, is located just a few
centimeters beyond the bladder and allows
the individual control over micturition.
Nervous control of the micturition
process is located in three distinct areas of
the nervous system. Arising from the second,
third and fourth sacral segments (S 2 S 4 )
is the pudendal nerve which controls the
voluntary external sphincter and supplies the
perineal muscles. Also arising from this area
are the pelvic nerves which carry the
parasympathetics made up of sensory and
motor nerve fibers which relay stretch
receptor information and cause contraction of
the detrusor muscle and some dilation of the
internal sphincter. The internal sphincter is
also innervated by sympathetic motor fibers
arising from the upper two lumbar segments
(Lj-L 2 ) and probably the lowest two thoracic
segments (T n T 12 ). Finally, micturition
centers are located in the upper pons and
hypothalamus. These centers exert ultimate
control over the micturition process. Only
when environmental factors are appropriate
and the intensity and frequency of stimuli of
sufficient intensity is the external sphincter
allowed to relax and the bladder to empty.
spinal cord injury illustrates the
potentially serious implications of
neurogenic bladder complications.
Prevention of urinary tract
infections is of primary importance.
Inflammation of the bladder increases
the activity of the detrusor muscle and
potentiates bladder dysfunction.
Avoidance of indwelling catheters which
provide an entry portal for bacteria
cannot be over-emphasized; if a catheter
is required it should be changed
frequently.
A second complication is the
increased tendency to stone formation
which can be caused by residual urine in
the bladder, decreased weight bearing
leading to bone demineralization or an
alkaline urine. By decreasing residual
urine in the bladder, encouraging
activity especially weight bearing to
prevent loss of calcium from the bones,
and increasing fluid intake to dilute the
urine, bladder calculi formation can be
reduced.
Vesiculouretral reflux is a
complication often caused by
overdistension of the detrusor muscle.
This back-up of urine into the uretors
and possibly the kidney pelvis can
result in pylonephritis and
hydronephrosis and eventually to
progressive renal failure. This problem
can be avoided or alleviated by avoiding
large residuals of urine or overdistension
of the bladder. If a drainage device is
employed, receptacles should be placed
below the level of the symphysis pubis.
Bladder management and retraining
Bladder retraining is utilized in an
attempt to establish a functional regular
voiding pattern, to eliminate the
necessity of catheters and to avoid such
urinary complications as infection,
retention and incontinence. Before any
retraining can be initiated, bladder
function must be assessed to determine
voiding patterns and the cause of the
incontinence. Certain individuals may
never become catheter free. Those with
sphincter damage, fistulas, high
quadriplegia, advanced multiple
sclerosis, multiple myeloma and severe
brain damage all present often
unsurmountable problems for a bladder
retraining program. As well as
physiological pathology, mental
confusion and urinary tract infection
may be causes of involuntary
micturition.
The current voiding pattern can
be determined by compiling a
twenty-four hour record of fluid intake
and output over a three to four day
period. The amount and time of fluid
intake will aid in estimating voiding
needs as the sensation for bladder
fullness begins at about 250-300 cc.
This relationship is verified by the time
and amount of voiding. If the patient
is incontinent, urine amounts can be
approximated, usually a nine inch stain
equals 50-75 cc, an 18 inch stain equals
150-175 cc and a 24 inch stain equals
200-300 cc.
Along with this intake and output
record, it is helpful to note any
awareness of spontaneous voiding or
bladder fullness, if there was a feeling
of urgency or pain, if straining was
necessary, what activities the individual
was involved in at the time, if any
transient illness was noted, if the
individual was under any emotional
stress and what position the individual
was in at the time (positioning often
plays an important role in awareness of
fullness and ability to void, in
particular the supine position often
inhibits micturition).
If urinary tract infection is
suspected, bacterial cultures and
sensitivity studies should be done.
Confirmation of suspicions warrants
appropriate antibiotic therapy and in
association with this high doses of
ascorbic acid may be helpful.
Once voiding patterns have been
carefully monitored, the support of
those who will help with implementing
the schedule must be assured. Family,
staff or whoever is to be involved must
be made aware of the importance of
uniform implementation of the
schedule.
A fluid intake schedule must be
established, pushing fluids during the
day and early evening and restricting
fluid intake after eight in the evening
until the early morning. A fluid intake
of 2000-3000 cc is recommended.
Offer the bedpan, urinal or take
the individual to the bathroom at
specific ritualized times on initiation of
the protocol. These times should be
approximately one half hour prior to
the voiding time noted on the initial
record of voiding patterns. Once a
pattern is established, it can be
modified somewhat by providing the
opportunity to void prior to the
anticipated time. Measures to
stimulate voiding may be used.
Evaluation and adjustment of the
program should be done regularly,
noting whether the individual was
incontinent and when.
The use of intermittent catheterization
Intermittent catheterization has proved
effective in the management of many
types of neurogenic bladders but is
especially beneficial in the case of the
lower motor neuron bladder. The filling
and emptying of the bladder allowed
with this type of catheterization
facilitates any existing spinal cord
reflexes and as well helps to maintain
external sphincter control. Introduction
of the catheter also stimulates both the
internal and external sphincters while an
indwelling catheter reduces splu ncter
tone by holding the sphincters open
continuously. The conscious attention
paid to the sensations associated with
bladder filling and emptying also
stimulates the higher brain centers.
Other benefits include the avoidance of
the complications of bladder
dysfunction, ease of sexual relations,
improved hygiene, decreased
hospitalizations for bladder
28 June 1980
The Canadian Nurse
How the bladder functions
During the period of bladder filling, the
sympathetic nervous system allows the
detrusor muscle to relax and simultaneously
causes the tone of the internal sphincter to
increase.
The micturition reflex is initiated when
the pressure of accumulating urine stimulates
sensory nerve endings in local stretch
receptors of the bladder, usually as the urine
approaches a volume of 250 cc. Afferent
pathways through the pelvic nerve conduct
these sensory impulses through
parasympathetic fibers from the bladder to
spinal segments S 2 -S 4 . Motor signals are then
transmitted by efferent pathways of the
pelvic nerve back to the bladder stimulating
the contraction of the detrusor muscle and
the relaxation of the internal sphincter
necessary for voiding.
These are known as micturition
contractions and are regenerative; that is, one
contraction of the bladder stimulates the
receptors and the stimulation process occurs
over again. However this micturition reflex
fatigues quickly and if bladder emptying is
not accomplished, the reflex will be inhibited
for several minutes to up to an hour before
another micturition reflex occurs. As the
bladder fills, the reflexes occur more
frequently and with greater intensity.
The cerebral centers, which exert
control over the external sphincter, determine
when micturition will take place. Cerebral
impulses to the motor neurons in the sacral
area of the spinal cord cause stimulation of
the efferent fibers of the pelvic nerve,
resulting in bladder contraction, while other
cerebral impulses inhibit stimulation of the
pudendal nerve, thus allowing the external
sphincter to relax.
Consequently voluntary control of
micturition is possible only if the nerves
supplying the bladder and urethra, the motor
area of the cerebrum and the projection
tracts of the cord and brain are intact.
Trauma, edema or injury may result in loss
of control or urinary incontinence.
complications and better patient
compliance.
Technique
1. The pH of the urine should be
acidic (about 5) to prevent proliferation
of bacteria. This can be facilitated with
high doses of ascorbic acid (500-1000
mgm Q.I.D.). Cranberry juice taken in
large quantities may help decrease the
pH in this way.
2. After approximately 300 cc of fluid
intake and a suitable period of time,
from one to two hours, have the patient
attempt to void. Use stimulation of the
inner thighs, genitalia and the abdomen
if necessary.
3. If micturition occurs, catheterization
for residual urine should be done to
ensure adequate emptying has taken
place. A residual of 75-100 cc is
considered acceptable. A higher residual
may produce complications such as
infection.
4. If the individual is unable to void,
catheterize using aseptic technique.
5. Record the amount and type of urine
obtained. Send urine specimens for
laboratory analysis periodically to
ensure that sterility has been
maintained.
6. Record whether Crede bladder
expression or perineal stimulation were
required. Crede bladder expression is a
technique used to promote expulsion of
urine from the bladder. With hands
flat and one on top of the other on the
abdomen, firmly stroke inward and
down from just below the umbilical
area to the bladder until no more urine
can be expressed.
Whet: we recognized that Mrs. Steen s
bladder dysfunction was of the lower
motor neuron type, it was apparent that
intermittent catheterization was the
treatment of choice.
Accurate daily 24-hour records
were kept to provide an ongoing
progress report and Mrs. Steen was
given one gram of ascorbic acid every
six hours to acidify her urine and help
to reduce the risk of infection.
For Mrs. Steen, bladder retraining
took place over a period of about one
month. Initially urine retention was
high with as much as 650 cc of urine
remaining in the bladder after
approximately 60 cc had been voided;
this initial amount of 60 cc was actually
overflow urine. Post-operatively it was
difficult to determine to what extent
pain, apprehension and positioning were
affecting Mrs. S teen s poor bladder
performance.
Once the amount of the residual
urine became less than 100 cc,
catheterizations were done only on a
daily basis to act as a check on effective
bladder emptying. When this was
assured, weekly checks were done and
finally the catheterizations were
discontinued altogether.
Naturally, all of this was a great
emotional strain for Mrs. Steen. The loss
of control was demoralizing and was a
great blow to her self-respect; she
became impatient with the slow and
erratic nature of the retraining method;
she wanted to get her bladder "back to
normal again". When her residuals
remained high or fluctuated drastically
she was easily discouraged and often
questioned if the treatment was actually
going to work for her. We reassured her
frequently and, when success was finally
attained and she was voiding
voluntarily, the excitement made the
whole process worthwhile. *
Bibliography
1 Assessment and reestablishment
of bowel and bladder function following
stroke. In: Total care of the stroke
patient. Boston: Little, Brown; 1978:
ch. 10.
2 Boroch, Rose Marie. Elements of
rehabilitation in nursing: an
introduction. St. Louis: Mosby; 1976.
3 Chusid, Joseph C. Co rrelative
neuroanatomy and functional neurology.
15th ed. Los Altos, CA: Lange; 1973.
4 Herr, Harry W. Intermittent
catheterization in neurogenic bladder
dysfunction. J.Urol. 113(l):477-479;
1975 Jan.
*Kendall, Richard A.;Karafin,
Lester. Classification of neurogenic
bladder disease. Symposium on
neurogenic bladder, n.d.
6 *Rossier, Alain }$. Neurogenic
bladder in spinal cord injury
management of patients in Geneva,
Switzerland and West Roxbury,
Massachusetts, n.d.
Wellington, F.L. Incontinence.
Pt. \.Nurs.Times 7 1(9): 340-341; 1975
Feb. 27; Pt. 2. Ibid. 71(10)378-381;
1975 Mar. 6; Pt. 3. Ibid.
71(1 1):422-423; 1975 Mar. 13;Pt.4.
Ibid. 71(12):464-467; 1975 Mar. 20;
Pt. 5. Ibid. 71(13):500-503; 1975
Mar. 27; Pt. 6. Ibid. 71(14):545-548;
1975 Apr. 3.
*Unable to verify in CNA Library
Lori Whittington, RN, a graduate of
Mohawk Community College, is a
full time student at McMaster University
and continues to work part time in the
Rehabilitation Unit of St. Joseph s
Hospital, Hamilton, Ontario.
Illustration - Copyright 1979 CIBA
Pharmaceutical Company, Division of
CIBA-GEIGY Corporation. Reprinted with
permission from The Ciba Collection of
Medical Illustrations by Frank H. Netter, MD.
All rights reserved.
The Canadian Nurse
June 1 980 29
Arriving at a grade which is mutually acceptable to both teacher and student has been a thorny
problem for many years. The authors review current literature and research on the subject of
grading to bring us up-do-date.
GRADING
STUDENT
NURSES
Grading students work is a difficult
task and every grading system used
today has its problems. 1 Nevertheless,
grading is an important and necessary
task for nurse educators. Whether
grading tests or clinical performance,
nursing instructors feel many conflicting
pressures and they are often frustrated
by the whole time-consuming process.
Grading clinical performance is a job
with its own peculiar characteristics and
difficulties which have made it a
traditional bone of contention among
instructors and students alike.
In recent years there have been
experiments with non-traditional
grading systems and attempts to reduce
some of the dysfunctional aspects of
grading such as tendencies to elitism. At
the same time social and cultural
changes have influenced grading
difficulties. What follows is a review of
some of these experiments and changes
in relation to the grading of clinical
performance.
An educational heritage
The grade is an abstract symbol that
represents an evaluation of student
performance. The many shortcomings
of the grade have been discussed often;
even so, some researchers concede that
the traditional methods of grading,
although problematic, have no
acceptable substitute. 2 Hiner, in his
article, "Grading as a Cultural
Function", has clearly outlined one of
the dilemmas. 3 He describes grading as a
cultural ritual and grades as
culturally-sanctioned symbols developed
to solve the problem of distributing
rewards. Thus a grading dilemma exists
30 June 1980
Vivian Wood
Joanne Wladyka
o
because North Americans profess
"allegiance to two mutually exclusive
criteria for distributing rewards." On
the one hand, we pursue individual
equality, on the other we value
individual achievement and excellence;
pursuit of one denies the other. Is there
no way out of this? The conflicting
allegiances, if not resolved, can whipsaw
educators and educational institutions
as the negative effects of neglecting one
value while upholding the other appear.
At the worst, grading systems end up
being ambivalent: over the school year
they pursue first one allegiance, then
the other, then back to the first, and so
on.
Hiner refers to grading as a ritual,
"...a type of behavior which is stylized
or formalized and made repetitive in
that form." He points out that while
there is nothing pathological in rituals,
they must pursue clearly-specified goals,
otherwise the means become the ends.
He also believes that grading will always
be with us because of societal demands,
and that the challenge therefore is
to make grading work, not to find ways
of living without it. To meet the
challenge many have experimented with
non-traditional grading.
Non-traditional grading
In 1971, a comprehensive study was
conducted by the American Association
of Collegiate Registrars and Admission
Officers which revealed that 41 per cent
of the responding colleges predicted a
shift toward less traditional grading
methods. It is significant to note that at
the time of this study, half of the
responding institutions were using
The Canadian Nurse
traditional grade scale measures, two per
cent were using non-traditional grading
methods exclusively, and 46 per cent
were using a combination of traditional
and non-traditional methods. Since
most nursing schools in Canada today
reside within community colleges or
universities, one would expect their
grading practices to be similar. A 1970
study conducted by Araneta and Miller
found that 44 per cent of the nursing
schools surveyed were utilizing the
non-traditional "satisfactory/
unsatisfactory" grading pattern for both
clinical and theoretical evaluation. 5 (The
sample size of this second study was
only 23 as compared to 1,301 in the
first study.) If we interpret the 44
per cent responses as not representing
exclusive use of non-traditional
methods, their results compare
reasonably with the NACRAO study
results. These results, while interesting,
serve to underline the need for
continuing research.
The shift to non-traditional
methods was brought about by pressure
to provide students of varying
capabilities with an equal opportunity
to learn; by eliminating pressures
created by grades that rank
achievement, students are free to
maximize individual learning. The
conflict with grading systems that
emphasize achievement is apparent.
Eventually however, the need for
recognition seems to prevail and systems
are still used which provide ranking. Is
the choice which objective do we pursue
or, how can we aim for excellence
without compromising equality?
Grading strategies
The changes from traditional to
non-traditional grading methods (and
vice-versa) reflect, to some extent,
changes in social values and student
expectations. Both individual choice in
constructing an educational program
and reduced "competition" in
evaluation schemes have been promoted
in many ways and consequently,
innovation and change in grading
methods have occurred. What are some
of the newer grading methods being
discussed? Several approaches have
been prominent including
criterion-referenced, blanket, and
credit/no credit grading.
Criterion-referenced grading
rewards achievement by comparing the
student s grades to "some standard
established by the teacher of the
school". 6 In norm-referenced grading or
grading on a curve, the student is
evaluated and rewarded in terms of
his/her performance relative to that of
other students. 7 "Grading on a curve"
tells the student he has achieved more
or less than some other students, and
encourages competitiveness. Supporters
of curve-grading state that marks
usually distribute themselves according
to the normal probability curve anyway
and its use reduces bias or distortion in
the distribution achieved; critics say it is
not equalitarian and from time to time
students have been vocal in objecting
to its use.
"Blanket grading" is another
approach: in this system all students
receive the same grade. A special case of
blanket grading ^no grade at all - is
utilized by some educators who
advocate the total abolition of grades.
Credit/no credit grading utilizes only
two grades "credit" or "no credit"
(pass/fail) either for the reason that
more precise grading is not possible or
that having more grade ranks interferes
with student learning.
The question of which method to
use, blanket grading, the traditional A B
C D E or credit/no credit, is drawing
considerable attention in clinical nursing
education. In Dodd s 1978 study, 76
per cent of nursing students and 74 per
cent of nursing teachers indicated that
they favored the non-traditional
"credit/no credit" method of grading
clinical performance. 8 Dodd compiled
lists of the advantages which the
students and teachers saw in this
method, including such examples as a
desire for greater intrinsic motivation,
less competition, less anxiety and
frustration and more creativity.
Following the initial survey, Dodd
implemented a "credit/no credit"
grading system in a sample group on a
trial basis; midway through the trial
period, students and teachers were
asked to specify again the advantages
and disadvantages which they perceived
with their new grading system. The
students did indeed note a decrease in
anxiety, frustration and
competitiveness, and they felt there was
an increase in the amount learned.
Interestingly however, 49 of the 163
(30 per cent) responding students
reported an actual decrease in
motivation.
Several studies have attempted to
explore the relationship between
student motivation and non-traditional
grading methods, but there is still no
consensus. In one such study, Vernon
and Ramseyer divided a class of second
semester freshmen enrolled in an
introductory psychology course into
three groups 9 for evaluation. The
traditional A to F scale was used to
evaluate the first group, the second
group was given a "pass/ fail" grade, and
the third group was given no evaluation
whatsoever. They found that in
comparison to the group marked on the
traditional A to F scale, the "pass/fail"
group studied only half as much and
achieved 89 per cent as many correct
answers on tests, while the
"non-evaluated" students studied only
13 per cent as much and achieved only
63 per cent as many correct answers.
These results contrast markedly
with those obtained in another study by
Gould in 1978. :0 The study was designed
to measure differences in motivation as
perceived by nursing students who had
been evaluated by both letter grades
and a "satisfactory/unsatisfactory"
system in their clinical practice. Gould
found that under the
"satisfactory/unsatisfactory" system, 63
per cent of the sample experienced
increased motivation while only 10 per
cent of the sample perceived a decrease
in motivation. In an article on the
subject, Kochman proposes that
credit/no credit grading is a solution to
the problems created by letter grading. 11
She maintains that this method permits
self-paced instruction for student nurses
without penalizing the slow learner who
brings prior experience to the learning
situation. Huckabay, in her study of
grading versus non-grading of nursing
student performances, demonstrated
that using grades to motivate is not
necessary for learning to take place and
in fact grading may inhibit learning. 12
The marked differences in results
obtained in the previous three studies
are typical of the inconsistencies that
exist among different authorities on the
effects on motivation of using
non-traditional grading systems in
nursing education. More equalitarian
grading methods have not succeeded in
resolving Miner s "dilemma"; we still
desire both achievement and equality
but they still tend to be mutually
exclusive goals. Thus, the use of
non-traditional grading methods as a
response to social change has achieved,
as might be expected, a qualified success
at best. Examining the problem in the
context of clinical teaching, the
problems are exaggerated when
evaluating clinical performance since
here many traditional measurement
techniques are appropriate.
Grading clinical performance
No matter which grading approach is
used in the clinical setting an important
focus of the student nurse s attention
is still as one would expect the
grade. In the classroom setting the
assignment of a grade can be
accomplished by the use of tests and
assignments but these alternatives are
not easily applied to clinical
performance and thus evaluation is
more complex. The data collected by
nursing instructors are largely
influenced by observational methods
and are difficult to rank, let alone
translate into values. 13 Consequently, the
frustrations voiced by both nursing
instructors and students are not
unexpected. The most frequently
expressed concern is the inability of the
instructor to give uniform learning
experiences to all the students in her
The Canadian Nurse
June 1980 31
clinical group: the changing variety and
mix of clinical clients, the many
different unit setups and the large
number of personnel to whom the
nursing student must adjust in any one
setting, form an intimidating list of
variables. Also, in the clinical setting the
nursing instructor is unable to observe
each student continuously. She may
have six to eight students to teach,
observe and evaluate in a four to six
week period. The observational data, at
best, are selective and subjective and
often there is no clear distinction made
between learning and evaluation.
Consequently, the student is being
evaluated while she is learning, a
situation both difficult and undesirable.
According to a study reported by
Hayter in 1973, marked discrepancies in
grading can be demonstrated among
clinical nurse educators. 14 In her study 31
nurse educators viewed a video tape in
which three nursing students gave
different levels of care to the same
patient. The teachers then submitted
letter grades for each student. Analysis
of these grades revealed an overall
agreement rate of only 44 per cent. The
teachers were then given a set of
objectives specific to the care required
by the patient in question, viewed the
video tape again, and subsequently
completed a checklist which stipulated
nursing actions relevant to the case. This
time an overall agreement rate of 76 per
cent was obtained.
Because of the frustrations
associated with the preceding
techniques, some clinical nurse
educators have been experimenting with
"contract grading". "Contract grading",
according to Rauen and Waring, utilizes
a written, signed agreement between
student nurse and instructor for a unit
of work to be completed in a set period
of time. 15 The agreement specifies the
educational objectives and the
conditions which the student must
fulfill to earn a specific course grade,
such as A, B, C, D, or E. Marriner states
that the contract helped the students to
define their goals and were thus
motivated to achieve them. 16 Delaney and
Schoolcraft also support use of the
clinical contract; 17 in their study, contract
grading was tried in a community
mental health clinic. The contract was
an agreement in writing between the
student and teacher as to what grade the
student was working to achieve.
Minimum expectations were cited for a
C grade, and additional activities were
required for grades B and A. Some
students favored the contract while
others did not. The authors state that
the contract method reduced the
student s anxiety about grades and
facilitated objectivity. However, several
concerns did arise. Both students and
faculty were concerned about the
"quantity" rather than "quality" of the
work, the rigidity and time parameters
in the contract caused concern and
students received a numerical grade
which was to be averaged with other
grades, a detail which had not been
mentioned in the contract.
The bottom line
None of the non-traditional grading
systems discussed provides a complete
solution to the problem of grading
clinical performance. This shortcoming
is, in part, because the problems exist in
the characteristics of the educational
experience and not in the grading
systems used. We can, however, look to
ways of reducing problems which do
arise from grading. The instructor must
be clear in her mind whether she is
evaluating performance or maximizing
educational experience. The
experimental results indicate that there
is no guaranteed way to obtain positive
motivation and maximum performance.
It would appear that the most flexibility
is achieved when precision requirements
are reduced. Teachers should remember
that overall success is obtained when
course design, teaching methods, and
testing and evaluation are integrated to
achieve specified objectives. Even
though clinical teaching encounters
difficulties in providing uniform
learning and evaluation, by utilizing all
the tools available for teaching success
the grading problem can be minimized.
The future will probably see an
increase in the pressures on the clinical
teacher. Student appeals, for instance,
are here to stay. Thus, implications exist
not only for the practicing teacher but
also for teacher preparation.*
References
1 Kramer, Mary Albert, Sister;
Cowles, John T. Weighting and
distributing course grades.
Nurs.Outlook. 22(3): 176-179; 1974
Mar.
2 Thorndike, Robert L.; Hagen,
Elizabeth P. Measurement and
evaluation in psychology and education.
4th ed. New York: Wiley; 1977:
p.588-605.
3 *Hiner, N. Roy. An American
ritual: grading as a cultural function.
The Clearing House, p.356-362; 1973
Feb.
4 *American Association of
Collegiate Registrators and Admission
Officers. The AACRAO survey of
grading policies in member institutions,
ERIC ED 055, 546, 1971: p.47.
Araneta, N.C.; Miller, C.L.
Philosophical systems of weighting
clinical performance in nursing. Int. J.
Nurs. Stud. 7:235-242; 1970 Nov.
6 Popham, W. James.
Criterion-referenced measurement: an
introduction. Englewood Cliffs, N.J.:
Educational Technology Publications;
1973;p.7-8.
Ibid.
8 Dodd, Marilyn J. A longtitudinal
study in the use of credit/no credit for
grading of clinical courses. /. Nurs.
Educ. 17(3): 14-21; 1978 Mar.
9 *Vernon, Walter M.; Ramseyer,
Gary C. Evaluated and non-evaluated
higher education. Normal Department
of Psychology, Illinois State University,
ERIC ED 065039; 1972: p.7.
10 Gould, Eleanor O Gara.
Satisfactory/unsatisfactory grading in
the evaluation of clinical performance in
nursing: its effect on student motivation
as perceived by nursing students. J.
Nurs. Educ. 17(8):3647; 1978 Oct.
11 Kochman, Arthur F. Are letter
grades and modularized nursing
programs compatible? /. Nurs. Educ.
15(3):25-27; 1976 May.
12 Huckaby, Loucine.
Cognitive-affective consequences of
grading versus nongrading of formative
evaluations. Nurs. Res. 28(3): 173-178
1979 May/Jun.
13 Wood, Vivian. Evaluation of
student nurse clinical performance: a
problem that won t go away./n? Nurs
Rev. 19(4): 336-343; 1972.
14 Hayter, Jean. An approach to
laboratory evaluation. J. Nurs. Educ
2(4): 17-22; 1973 Nov.
15 Rauen, Karen; Waring, Betty. The
teaching contract. Nurs. Outlook
20(9): 594-596; 1972 Sep.
16 Marriner, Ann. Student
self-evaluation and the contracted grade.
Nurs. Forum. 13(2): 130-1 35; 1974.
17 Delaney, Clare; Schoolcraft,
Victoria. Promoting autonomy: clinical
contracts./. Nurs. Educ. 16(9): 22-28;
1977 Nov.
*Unable to verify in CNA Library
Professor Vivian Wood has written
extensively in the areas of assessment
for student nurses and analysis of
student nurse problems for the
Canadian Nurse, Nursing Outlook,
Nursing Times, Nursing Papers and the
International Nursing Review. She is
well known to nurse educators in
diploma programs for her numerous
workshops on test construction, item
analysis, clinical evaluation, the
borderline student nurse and the adult
student. She is also the author of
"Casebook in Nursing Education" and
Teaching No tes .
Joanne Wladyka is a recent graduate of
the MScN teaching program at the
University of Western Ontario in
London, and became interested in the
topic of student grading during the
course of her studies. She is currently
employed in nursing education at the
Victoria Hospital Corporation in
London, and has several years
experience teaching med-surg nursing.
32 June 1980
The Canadian Nurse
Simulated Disaster Game
Nelda Yantzie
When the real thing happens, a disaster is no game! This nurse educator, however, finds that using a game
to interest and involve her students is the best way to teach them efficient delivery of health care in an
emergency situation.
CODE 99! CODE 99! This code could be
announced over the public address
system of any hospital in any city or
town, at any time. It means the
hospital s disaster plan has gone into
action. Does everyone on staff know
what to do? Will widespread panic
break out, or will incoming patients be
handled safely and efficiently? The
success of any disaster plan is directly
related to the health care workers
basic understanding of the plan s
purpose, principles and organization.
Ideally, before a student nurse
completes his or her education, he/she
should be instructed in the delivery of
health care in a mass disaster situation.
This is probably best done in a class
organized expressly for this purpose.
The principle objective of such a
class would be to communicate to
students the importance of a disaster
plan, and how to use its ideas to
organize emergency care. Other
objectives include helping the student
nurse to direct activities and assign
priorities while under a great deal of
pressure, trying to cope with a large
number of casualties at one time.
In order to make this learning
experience as effective as possible, I
felt that there was a need for the
students to become directly involved
and I developed the game HELP to be
used as an instructional device.
A class of students was divided
into small groups of four or five, with
no more than five groups playing the
game at once so I could manage to be
helpful to all as a resource person. Each
group was given the game and a hospital
disaster plan for reference.
The method seemed to be very
successful: the students became very
involved and used the opportunity to
develop their powers of judgment, to
use problem-solving and assigning
priority to needs, to absorb new
learning material, and to consider legal
implications.
All in all it was an active and
fun-filled class session despite the grave
subject matter.
HELP!
Directions for playing the game
There are two parts to the game:
Part I where injured people are put into
ambulances for transfer to hospital;
Part II, admission and treatment of the
casualties in the hospital.
The game begins by placing
buttons with names of the injured
people on the area marked disaster site.
The object of the game is to treat those
people most seriously injured first, and
to make sure that everyone needing help
gets it. This requires good judgment and
fast decisions. Relevant information is
given at the beginning of each part of
the game.
PARTI
TRIAGE AT ACCIDENT SITE
Information:
There has been an explosion at the local
cement factory. Three ambulances are
dispatched to the site of the accident.
The "external triage team" consists of
three ambulance drivers, three
attendants, one doctor and a nurse from
the emergency department. The injured
employees are transported to the
hospital in less than 1/2 hour following
the explosion.
Employees* with various degrees of
injury:
Gray, John age 32 suspected
multiple fractures, labored breathing
Elliott, Jim-age 45 - superficial
abrasions
Rudy, Clara-age 51 - hysterical
Austin, Grace-age 29 - lacerated
forehead, moderate bleeding, confusion
Godel, Ken age 54 president of
factory, history of M.I. two years ago;
in mild shock and complaining of
tightness in chest
Case, Frank-age 62 - amputation left
leg, shock severe, hemorrhage
Crane, Mike age 38 minor facial
lacerations, talking loudly and swearing
Moore, Otto age 45 -- increasing
cloudy state of consciousness, no other
injuries evident
Turner, John age 54 dead at site
O Riley, Mike-age 21 - deep scalp
wound, bleeding profusely
Hesson, Clark age 65 unconscious,
egg-sized swelling on side of head
Deane, Howard age 48 deep gash left
leg with bone protruding; looks grey
Hesse, Marg-age 41 - walking around
as if in a daze supporting her right arm
George, Rudy-age 18 - mild shock,
burns to arms and back
George, Rusty age 18 no apparent
injury other than irritation of his eyes
Claypole, Walter-age 43 - facial burns,
hair and eyebrows singed
*Names are fictitious: any resemblance
to persons living or dead is purely
coincidental.
The Canadian Nurse
June 1980 33
START HERE
Place all buttons containing
names of casualties and type
of injury here.
I I
Triage at Site of
Emergency
Entrance
Place the patients (possibly 2 in one ambulance) for the trip(s) to the hospi
U.
bulatc
B
Am
Car
)ry
Att
sntion
\ Coc
e99
(a lei
t for
)
Aorgu
L-
b
ib
/
S. M
(2
jdical
mpty
beds
41
Vest
O.
R.
N.S
jrgica
(0
Mr
Mr
;mpt\
Glov
;. Cro
beds
er
zier
I.C.I
Mr. [
Mrs.
. (1
Jorem
Leidk
empt
an, M
e, Mr
/bed
r. Cro
i. Elds
ss
rson
31*
1. Surgical
Caseman
5. Ehrodt
(0 empty t
Miss Unruc
Mr. Casselr
>eds)
Radi
alogy
Mr
nan
St
ares
2
N.M
;dical
(1a
mpty
bed)
E.R,
Minor Surgery
E.R.
h
Nursing
Office
x x
N >
/
/
Ma
n
[v
\
TR
AGE
ARE/
k
f
1
Lot
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1
1
\
H
oldins
area
for
/
N
4
E.R.
E.R.
Fracture Room
^
.
Asst
. exec
:tor
utive
E
(j
xecut
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ve
iiothe
rapy-
X
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-
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1 1
*
*
*
r
1 1
Resi
Jence
This area is designa
;ed for?
Move:
One player in the group acts as
scrutineer or challenger. The remaining
players will be the "external triage
team" and will select which of the
injured should be transferred first,
second, third, etc.
Note:
There are three ambulances at the site
and each ambulance can carry only two
injured at one time; each ambulance
makes three trips.
Close attention to Priority of Need is a
Critical Element
Time limit: 20 minutes
Following placement of injured in the
waiting ambulances pause for discussion
of rationale in choice.
PART II
MAKING ROOM IN THE HOSPITAL
FOR ADMISSION AND TREATMENT
OF THE INJURED
Information:
Within minutes following the disaster,
the police notified the hospital
switchboard operator of the accident
and in turn the executive director
declared that the hospital disaster plan
be put into effect.
The medical-surgical coordinator
and the discharge officer collected the
following information regarding the
hospital census:
The emergency department is filled
with outpatients for the orthopedic
clinic
-There are very few empty beds
anywhere in the hospital
-There are some patients who could be
discharged or moved to other areas.
Move:
Select one player to do the writing. The
remaining players in the group are the
head nurses and the admission and
discharge officer who are deciding
which of the following patients should
be moved or discharged. Show the
move by writing (using one color of pen
to distinguish the inpatients from the
injured) the name of the patient in the
area to which he/she was moved. Place
an X over the patient s name in the
area from which he/she was moved.
Patients:
I.C.U. 1 empty bed
Mrs. Leidke - 10 days Post M.I. -
condition stable
Mr. Boreman 3 days post
prostatectomy condition stable
Mr. Cross 2 days post M.I. -
condition appears stable
Mrs. Elderson - - 3 weeks post
septicemia temp, stable
3 North - no empty beds
Mr. Caseman 6 days post op,
cholecystectomy condition good
Mrs. Ehrodt - 10 days post cataract
removal, ambulatory - condition good
Miss Unruch - elective surgery -
bunionectomy
Mr. Casselman - diagnostic tests, gall
bladder series
4 South - 2 empty beds
4 North no empty beds
Mr. Glover elective surgery -
herniorrhaphy
J. Crozier appendectomy, 5 days post
op, elevated temp., incision sore to
touch
2 North - 1 empty bed
Note: Remember to use information
regarding patient census.
Time Limit: 20 minutes
Each player should pause briefly to
share with the total group reasons for
the various moves before proceeding.
INTERNAL TRIAGE IN THE
HOSPITAL
Information:
Three ambulances transporting the
injured leave the site of the accident -
each ambulance makes three trips to
the hospital. Mr. Frank Case (see
information, Part I) is dead on arrival at
hospital, Mr. Otto Moore has become
definitely more confused after a short
time in the Emergency Room, while
Mrs. Austin has become less confused.
Move:
Continue with the internal triage - the
players will receive the injured in the
emergency department where the
decision is made regarding which area
each injured person should be sent for
diagnosis, treatment or care.
Using a different colored pencil
write the names of the injured into the
area where they will be sent.
Time Limit: 15 minutes
Players conclude the game by sharing
with the total group their reasons for
placement of the injured including
probable diagnosis, treatment and care.
Teaching advantages
While the students may enjoy playing
this game as they learn, teachers can
enjoy the opportunity to evaluate
several aspects of their students
performance. Instructors who use HELP
have the opportunity to:
reinforce, challenge or correct
errors in judgment
evaluate the problem-solving
ability of their students as it relates
directly to judgment and priority of
needs
introduce new learning material
related to organization, operation and
principles of a hospital disaster plan
e.g. triage, communications and
directing activities and personnel
identify legal implications. *
Bibliography
1 Ellison, Dorothy. Education for
nursing care in disaster. Nurs.Clin.North
Amer. 2(2):299-307; 1967 Jun.
2 Giroux, Fern. Getting disasters
under control. Dimens.Health Serv.
54(8):53-54; 1977 Aug.
3 Landon, Betty. Stress: how you
and others can cope. Giving emergency
care competently. Edited by Marion Z.
Dover. Horsham,Pa.: Intermed
Communications; 1978:21-24, (Nursing
78 Skillbook Series).
4 . Triage: how to set priorities for
patient care. Giving emergency care
competently. Edited by Marion Z.
Dover. Horsham, Pa.: Intermed
Communications; 1978:15-20. (Nursing
78 Skillbook Series).
5 Montgomery, Chris. Post-mortem
on a disaster. Dimens.Health Serv.
53(12):31-33; 1976 Dec.
6 Strickler, Albert. The case for
disaster site medical teams. Dimens.
Health Serv. 53(2):30-32; 1976 Feb.
7 Weaver, Ouida J.; Robinson, Ruth
C. Nursing responsibility in mass
disaster planning. Nurs.Clin.North
Amer. 2(2):287-298; 1967 Jun.
Nelda Yantzie is a graduate of the
Victoria Hospital School of Nursing and
received her diploma in Nursing
Education from the University of
Western Ontario as well as a BA from
Wilfred Laurier University. She is
currently the program coordinator at
Conestoga College, Stratford Health
Sciences Division. In the past she has
worked as head nurse on a pediatrics
unit and as a clinical instructor in
medical, obstetrical, pediatric and
psychiatric nursing. During a summer
leave of absence she served as a staff
nurse with the International Grenfell
Association in St. Anthony s, Nfld.
36 June 1980
The Canadian Nurse
The development of small portable respirators has made a big difference for those with
life-threatening respiratory disorders. For Donna, it has meant a second chance, a chance to
live at home, to stay mobile and to pursue the goals of her choice.
Eighteen-year-old Donna was initially
admitted to the Health Sciences Centre
Intensive Care Unit following a
respiratory arrest. As a
child, Donna suffered many chest
infections serious enough
to demand hospital
treatment. Over time,
her exercise tolerance
had decreased and
her health deteriorated
to the point that she
required supplemental
oxygen at home. On
admission to our unit,
Donna s diagnosis
was bullous
emphysema of
unknown etiology.
Emphysema
is a form of chronic
obstructive
pulmonary disease
(COPD) in which
there is distention
of pulmonary alveoli
to the point of destruction.
Loss of alveolar elasticity
results in air trapping and increased
residual volume, the volume of air
remaining in the lungs at the end of a
maximal expiration. Progression of the
disease may lead to the formation of
bullae (air spaces resulting from
destruction of the pulmonary lobule).
As blood vessels surrounding the alveoli
become compressed, serious ventilation-
perfusion abnormalities may occur.
Emphysema may be caused by irritants
such as cigarette smoke and other
pollutants, or by such underlying
diseases as chronic bronchial asthma
and bronchitis. In Donna s case, the
specific cause of the disease process was
never identified.
Donna was admitted to Health
Sciences Centre late at night. She had
become so short of breath at home that
her parents had rushed her to
Emergency, where she collapsed.
Clinical and laboratory investigations
indicated that she was in hypoxic,
hypercapnic respiratory failure precipi
tated by staphylococcal pneumonia.
Several weeks of mechanical ventila
tion, antibiotics, bronchodilators and
intensive chest physiotherapy resulted
in considerable improvement in Donna s
health. In time, she was successfully
weaned from the ventilator, extubated
and transferred to the Respiratory
Centre of our hospital.
Second
^^P^MB^^H Karen Dob son
Chance
A few days after transfer however,
Donna s infection recurred, her
condition deteriorated significantly and
she was transferred back to intensive
care. Once again she required
mechanical ventilation. Her diseased
lungs were so badly fibrosed that even
brief periods without ventilation were
more than she could tolerate; she tired
quickly and her arterial pC0 2 levels
rose dangerously. Pulmonary function
studies and repeated arterial blood gas
results showed that Donna was unable
to cope with the abnormally high work
of breathing required to sustain her.
Routine medical treatments were
no longer adequate to maintain Donna s
health. It was evident that without
mechanical ventilation, she would die.
A tracheostomy was performed. It had
to be determined whether or not
long term mechanical ventilation was a
reasonable solution to Donna s problem.
Long term mechanical ventilation
It is often difficult to make a decision in
favor of long term mechanical ventilation
(LMV). The medical, moral and
economic implications of such a
decision give rise to considerable
thought and discussion.
It must be determined
whether long term
ventilation will improve
the patient s quality
of life or simply prolong
inevitable suffering.
Such a decision
involves the entire
health team, the
patient and his or her
family. In Donna s case,
the decision was positive
and so she began a
training program in
LMV to prepare her
to return home and
continue her schooling.
For the patient,
LMV used to involve
years of hospitalization on a
respirator or in an iron lung. If the
patient could live at home, he would be
restricted to a rocking bed or cuirass
(a respirator that covers the chest/
chest and abdomen and provides
artificial respiration by means of an
electric pump). With the development
of small portable respirators, however,
patients requiring long term ventilation
are able to enjoy a less restricted
lifestyle.
Portable respirators were first
used for victims of poliomyelitis. At the
Health Sciences Centre, we have used
them successfully in a number of cases:
several patients with polio, a young boy
with a high cervical spinal cord injury,
another with a form of muscular
dystrophy. Attempts are being made to
adapt the use of portable ventilators to
individuals like Donna who suffer
life-threatening hypoxia (inadequate
oxygenation) and/or hypercapnea
(excessive carbon dioxide retention)
and cannot maintain an abnormally high
work of breathing.
At the Health Sciences Centre, we
use several different ventilators for
long term mechanical ventilation. They
are small, compact machines that can
be mounted either on the back of a
wheelchair or, for ambulatory patients,
on a pushcart.
The Canadian Nurse
June 1980 37
CUFFED
TUBE"
INSPIRED AIR
- EXPIRED AIR
SCHEMATIC DIAGRAM OF LUNGS
Figure one Conventional respirator with cuffed tracheostomy
INSPIRATION WITH
CLOSED GLOTTIS
Figure two Portable ventilator
EXPIRATION WITH
OPEN GLOTTIS
The mechanics involved are quite
simple. These ventilators have a
motor-driven piston that can be set for
various volumes and rates of respiration.
They can operate for 1 2 hours on an
external 12-volt golf-cart battery, up to
one hour on their own internal
rechargeable battery and they may also
be plugged into any 1 10 AC outlet.
Alarms signal high pressure, caused by
coughing or excessive secretions; low
pressure, denoting disconnection of the
tubing; or low voltage, for AC and DC
power failure. In cases of AC power
failure, they automatically switch to DC
power. Some machines fit into a
portable carrying case resembling a
small suitcase and weigh about 1 1
kilograms or 24 pounds.
Learning to breathe
Portable ventilators are designed to
operate on room air. For this reason,
our training program aims first of all to
ventilate the patient on room air. If
supplemental oxygen is a must, it can be
added to the inspiratory tubing from a
portable oxygen tank. Although it is
difficult to determine how much
oxygen is in fact being delivered to the
patient, oxygen may help relieve a
certain amount of hypoxia. However,
the additional weight of an oxygen
cylinder reduces the portability of the
ventilator. Donna requires two to three
liters of oxygen for sitting or sleeping
and she turns the flow rate up to seven
or eight liters when she is walking.
Our second step is to help the
patient make the transition from a
cuffed to an uncuffed tracheostomy
tube. An uncuffed tracheostomy tube
allows the patient to talk, which is a
considerable advantage.
The cuffed tube, used with
conventional respirators, forms a seal in
the trachea (see Figure one). Air not
only flows in but also out of the lungs
via the tubing. Portable ventilators,
however, do not always require an
expiratory line and therefore the
tracheostomy tube must be uncuffed;
the patient exhales through his mouth
and nose (see Figure two).
This means that the patient must
learn glottic closure. Donna had to learn
to close her glottis as she began to take
a breath so that inspired air flowed into
her lungs and did not escape through
her mouth and nose. She describes this
skill as "swallowing before each breath".
During expiration, she must allow her
glottis to open in order to exhale
through her mouth and nose. These
techniques were among the most
difficult for Donna to perform,
especially while she was sleeping.
Practice soon makes glottic closure a
subconscious maneuver except in deep
sleep, when inadequate ventilation may
result.
Those who like Donna have an
obstructive lung disease have a more
difficult time adapting to a portable
ventilator than do individuals with
neuromuscular problems or normal
lungs. This is because COPD patients
have a variety of chronic pulmonary
problems which often contribute to an
increased resistance for the respirator to
overcome in delivering the prescribed
volume of air.
For example, patients with COPD
often have increased secretions. These
secretions not only increase resistance
to ventilation but also create hygiene
problems and potential risk of
infections. Glottic closure against high
pressure is another problem COPD
patients may encounter. In addition,
they often need a prolonged expiratory
time to deflate their lungs effectively
and may have difficulty adjusting to
the ventilator s 1/1 inspiratory-
expiratory (I/E) time ratio. The
simplicity of these ventilators,
necessitated by their portability, makes
it impossible to adjust the I/E ratio.
Donna stated that she sometimes felt
as if she was "blowing up" until the
rate was slowed, allowing her more time
for expiration.
At first, Donna practiced on a
conventional respirator set on the
control mode. Each day, the cuff on hei
tracheostomy tube was deflated while
she practiced glottic closure. She also
learned to eat and drink with the cuff
deflated and to speak on expiration as
air flowed out over her vocal cords.
Once she had learned these skills, an
uncuffed tube was inserted and Donna
made a permanent switch to the
portable ventilator.
An uncuffed tracheostomy tube
also allows the patient to take extra
breaths through his mouth and nose
between respirator breaths. It must be
stressed that the patient cannot assist
or trigger these ventilators; they are a
control mode only. If more than the
prescribed volume of air is needed, the
rate of the machine must be increased.
38 June 1980
The Canadian Nurse
A team approach
A variety of health care professionals is
involved in preparing a patient to go
home on a respirator. Of these, nursing
staff spend the greatest number of hours
teaching both patient and family.
Donna was taught to suction herself, to
do her own tracheostomy care and to
operate the respirator. Chest physio was
also taught in the program. Family
members were included in the teaching
sessions so they could manage
treatments if necessary. The amount of
work that the family is required to do
varies according to the abilities of the
individual patient. Donna, for example,
has no neuromuscular disorder and can
do a great deal for herself, whereas
many patients on LMV have little or no
use of their limbs and are totally
dependent upon others.
Physicians, physiotherapists and
respiratory technologists are very much
involved in the process of assessing,
teaching and preparing the patient for
discharge. Home visits must be made by
members of various departments to
ensure adequate preparation and to
assess the need for modifications in the
patient s home. Wheelchair ramps or
handrails may be necessary and alarm
systems are often installed. Suction
equipment is also essential.
Nursing staff and a respiratory
technologist usually accompany the
patient home on several occasions
before discharge. The patient and family
become very comfortable in the
protected environment of the hospital.
Without supervision and guidance, the
patient s discharge can shake the
family s confidence in its ability to deal
with situations as they arise. Home
visits can help family members with
real management problems and help
them make necessary changes.
The home care department plays a
large role in ordering supplies and
arranging for their pickup and delivery.
Respirator tubing and humidifiers must
be changed daily and returned to the
hospital for sterilization. Patients
themselves must return to the hospital
every seven to ten days for
tracheostomy tube changes until family
members are able to do this task. Home
visits by nurses are arranged as needed.
Financial assistance is adjusted
according to each family s medicare
coverage and other health insurance.
Home again
Donna s ventilator is mounted on a
four-wheeled cart along with a 1 2-volt
battery and oxygen cylinder; she wheels
this cart ahead of her as she walks.
Transportation out-of-doors can pose
another problem: for those confined to
a wheelchair, a van or bus is needed.
Donna s parents are able to use a truck
camper in the summer. In the winter,
they remove the back seat of their car
to allow room for the respirator cart.
Donna sits in the front seat, with her
respirator tubing running over the back
of the seat. A van transports her to and
from work.
o
m: f. V
The psychological impact of LMV
is tremendous. For a young teenager,
the change in body image alone can be
devastating. Donna states that one of
her biggest problems was the stares and
whispers behind her back. She says, "I
was worried about what my friends
would think. But they have been really
helpful. ..and now, I think they have
accepted me as I am."
Donna also expresses frustration
at her lack of independence. She is
unable to drive a car any more and so
must rely on someone else for
transportation. Donna now has
completed her Grade 12, and has a
part time secretarial job. She has her
own apartment, closely supervised by
her family. The weight of her ventilator
and cart makes it difficult for her to
move up and down stairs by herself,
thus limiting her mobility.
Often the patient s family finds it
difficult to accept all the changes that
have occurred and require a great deal
of support and guidance from hospital
staff. As for Donna s parents, they are
grateful that she does not need to be
institutionalized, that she has some
degree of independence. Although they
admit to becoming very tired, especially
during times when Donna is ill or
unable to sleep, they are coping well.
Donna is a very cheerful, friendly
girl. In spite of her disability, she
received an award from her school for
her contributions. She realizes that her
disease process is ongoing, and that her
predisposition to chest infections may
well determine her eventual prognosis.
Donna is determined to live her life to
the best of her ability and to cope
with problems as they arise.
It is evident that LMV is neither
a possibility nor a choice for every
patient with a life-threatening
respiratory disability. Certainly the
patient s age, general health, outlook
and support systems must be considered
carefully before undertaking such a
course. But for patients like Donna, the
portable ventilator has meant a second
chance, a chance to live at home, stay
mobile and pursue her goals. A few
years ago, such a choice would have
been impossible. *
Karen Dobson, RN, is a 1975 graduate
of the St. Boniface General Hospital
School of Nursing in Winnipeg. She
completed the Winnipeg Health Sciences
Centre post graduate course in intensive
care nursing in 1978 and is presently an
instructor in the same program. It was
in the ICU that she became involved
with Donna and the LMV program that
allowed Donna to return home.
The Canadian Nurse
June 1980 39
Nursing in a
university
health service
Florence Tracy
Working as a nurse in a university health
service, as I have for the past 12 years,
definitely places me on the "frontline"
of health care. It also offers some unique
challenges in understanding the
dynamics of human growth. Do students
really present problems that are unique
to this setting and population?
Most definitely. In our health
service, for example, almost all our
clients are adolescents and young adults.
In addition to any medical problems they
may have, most of them are also learning
how to cope with the pressure of their
studies, problems involved in
relationships with their peers, rebellion
against their parents and other authority
figures, and, often, their first taste of
living away from home. Sometimes they
find the university setting a threatening
place professors, advisors, the whole
bureaucratic system seems far removed
from their personal concerns and needs.
These are difficult years for them: their
inexperience, often coupled with
unrealistic parental expectations, makes
mistakes inevitable and the need for
counseling imperative.
At McGill, the University Health
Service is under the direction of the dean
of students and the staff includes two
internists, three general practitioners, a
gynecologist, a surgeon, a dermatologist,
two psychiatrists, two psychologists,
four nurses, an x-ray technician and a lab
technician. Students are encouraged to
visit the health service before minor
complaints escalate into something more
serious. A non-threatening, informal
atmosphere is established through an
open door policy, appointments are not
required and rarely does a student have
to wait longer than five to ten minutes to
see a nurse who assesses the problem
and makes the appropriate referral.
The University population is very
aware and present-oriented; they want
understanding, they want action and
they want reasons for why things are
happening. They are happier and more at
ease when they leave the service if I have
spent 15 minutes discussing with them
the treatment of the common cold, than
if I had simply handed them a patent
medication. They appreciate the helper
who goes the extra distance, who sees
beyond their immediate question or
symptoms, who shares some of the
responsibility with them and, quite
possibly, makes a return visit
40 June 1980
unnecessary. They are also extremely
up-to-date and easily influenced by
popular literature on fad diets, birth
control measures, etc. Long before this
product was marketed in Canada, I
received phone calls about the vaginal
suppository contraceptive, Encare
Ovals. The same day that an issue of
Time magazine printed an article on
non-gonococcal urethritis, I received a
call from a student asking the difference
between NSLJ and NGU and whether he
had been properly treated, because his
treatment was different from that
described in the article.
When a student visits us with a
problem, we try to capitalize on this visit
and help him in other areas. The young
man who comes in with a sprained ankle
and who also has a severe acne problem
is asked if he is seeing a doctor for his
skin problem and if he is not, we offer
him an appointment. In the same way,
we ask the girl we treat for monilial
vaginitis whether she is aware of birth
control information that we can give her
if she needs or wants it.
Although this age group appears on
the surface to be very sophisticated and
knowledgeable, this is usually not the
case: they know the words but have just
as much difficulty as their parents before
them in working out answers or asking
for help. Last year a young female
student in her early twenties came to see
me. She said that she and her fourth year
medical student boyfriend had developed
a very close long term relationship and
had decided that they were ready for
sexual involvement but neither had much
knowledge of birth control . As difficult
as it is for most of us to understand and
although the information is readily
available, many young people still have
difficulty translating this information into
their own lives.
Teaching self-responsibility for
health and the awareness that body and
mind must work together to maintain a
healthy equilibrium is how we attempt to
teach prevention. It has been my
personal experience that teaching on a
one to one basis is much more effective
on campus than attempting to organize
groups. We try to capitalize on the time
that students spend waiting for
appointments or waiting after allergy
injections. Most students do not realize
that stresses from school work or
personal relationships can be expressed
physically through headaches, a missed
period, eczema or, conversely, the
reason they are not doing well at school
may be due to a lack of good health.
They often fail to make the connection
between their woefully imbalanced diet
and their colds, infections, fatigue or
depression. We can teach students to
take care of themselves not through
formal lectures or through abstract
principles of nutrition but through
practical informed advice.
A student at the center for an allergy
shot, for example, joined in a discussion
on nutrition 1 was having with one of the
other students. As it developed, the
allergy student had had only one serving
of vegetables during the past week. Poor
diet is rarely caused by lack of money
although this is the excuse we most often
receive. More often, it is lack of
information, poor planning or just plain
bad eating habits. What we must do is
translate the principles into everyday
language to meet the specific needs of
the particular student we re talking to. It
is not that the students are cognitively
unable to do this, but at times they need
someone to do it for them first, to show
them the way. With this comes the
knowledge that someone really does care
about them.
Frequently the medical problem is
minor or non-existent, the student
doesn t know what is wrong, only that he
"just doesn t feel right". Recently, a
young man visiting the clinic for
treatment of venereal disease appeared
increasingly distressed and anxious on
each succeeding visit. He seemed unable
to discuss what was troubling him with
any of the staff, including the physician.
When I asked him directly why he was so
upset, he replied that he was worried
because he had V.D. I reassured him that
the antibiotics were going to clear that up
and that it really wasn t worth what he
was putting himself through. After much
discussion, he explained that he and his
girlfriend had been dating seriously for
two years but had not felt ready for a
sexual relationship. On a weekend with
some university friends, however, he
had been pressured by the group to join
in on group sexual activities. The result
had been the V.D. He recognized that
most of his friends were sexually active
and was now questioning whether there
was something wrong with him, since he
had sexual fantasies and dreams but still
felt no need for sex within his
relationships. I reassured him that young
men often have very strong sexual
desires and frequently fantasize these; he
and his girlfriend should enjoy their
relationship and, when they felt ready for
more physical involvement, they could
then approach it with maturity. When he
left much of his anxiety seemed to have
been relieved. A few days later when he
returned to see the physician, he poked
his head into my office and asked
"You re sure it s O.K. if I don t want
to?" I reassured him again and he was on
his way with a smile.
Over the 12 years that I have
worked at the health service, I have
noted a phenomenal increase in the
number of problems related to stress and
anxiety. Often it is difficult for a young
person to recognize what is happening or
to realize when he can no longer cope
and needs help. A very rational and
aware medical student that I had been
seeing regularly for allergy injections
came in one day, stating that he did not
know what was wrong or why he was
acting the way he was. "I did not know
where to start so I came to see vow" he
said. Because I was accessible, he had
someone to talk to and he received early
psychological assistance for an acute
anxiety reaction.
The role of the nurse as a supportive
figure in the student s life extends
beyond the health service. Attending a
play or a recital, reading and
remembering to comment on articles
written about or by the student, is I think
as important to the student s general
well-being as the other kinds of caring we
can provide. For some students,
weekends are particularly difficult
periods because the structure of
regularly scheduled classes is missing.
Just knowing that there is someone
available to talk to, even for a few
minutes on the phone, is important. As
one student wrote, in a note of
appreciation she sent to me following a
period when she needed help in
overcoming self-destructive behavior,
"For being there and being real,
thanks." v
Florence Tracy, RN , BA , a graduate of
the Queen Elizabeth Hospital School of
Nursing, Montreal and Concordia
University, Montreal, is currently
nursing coordinator at the McGill
University Student Health Service and
has recently been appointed Warden of
Royal Victoria College, McGill
University.
The Canadian Nurse
June 1980 41
ANewv
o Learn
Margaret E. Murray
Year after year, the staff at Toronto General Hospital had been plodding
through the same mandatory safety review, yet unsafe practices were still
evident all over the hospital. Last year, the staff development department
vowed they would make the annual review more interesting... and
successful.
CARP, or the Combined Annual Review
Program, was the child of a marriage
between basic principles of adult
education and a new concept of
presentation; it was born out of a desire
to relieve the monotony of yearly
reviews of accident prevention, fire
evacuation, electrical and medical gas
safety .
Part of the problem was that our
staff often felt the subjects of the annual
review were either self-evident or too
complicated a waste of time either
way. Since many had already "had it",
they didn t feel that they needed "it"
again. However, the continued use of
unsafe electrical equipment, unsecured
oxygen tanks on stretchers and
wheelchairs, plus an increased employee
accident rate indicated the contrary r
the staff definitely needed this
information, but how to make them
aware of their own need, and how to get
them to retain what they learned?
There is a story about a teenaged girl
who stood at a window repeating quiety
"Tom, Tom, Tom..."; when her mother
asked her what she was doing she
replied, "They told me at school that if I
used a word ten times it would be mine."
We in staff development had fallen into
that very trap, believing that
word-perfect recitation of information
from the staff meant real internal
comprehension. What we had been doing
in fact was presenting a given amount of
information to a passive audience
without realizing that much of it would
probably be forgotten. All that remained
for staff and teachers alike, was the
dubious satisfaction of having gotten
through it for another year. We began to
think there had to be a better way.
Principles of adult education tell us
that people learn best at their own pace,
according to their perception of the
importance of the material, and by
relating it to past experience. Because of
our wish for the staff to acquire a basic
core of content, we had organized a
single homogeneous presentation, but it
was unlikely that this was suitable for all.
Learning theories suggested too that
actual experience is ideal, but it seemed
slightly impractical to us to set fire to one
of our buildings merely to test our
efficiency at evacuating patients, or to
electrocute someone to emphasize the
importance of electrical safety. In some
areas at least, cognitive experience
would have to suffice.
But experience was the key word.
We had identified the first part of our
problem as the need to make staff aware
that their knowledge was inadequate.
While we could not involve them in a real
situation, we could ask questions which
would help them assess theirown
knowledge of content. We felt that the
use of short questions, combined with
visual displays and the availability of
teaching staff as resource people, would
lead to successful internalization.
Further, if this new method would
work for one subject area, why not for all
of them? We could condense previously
separate programs into a single entity;
three months of dreary repetitive classes
could be transformed into three weeks of
involved participative learning!
We anticipated stumbling blocks,
and we found them: "The idea is so
different, will anyone accept it?" "How
will we schedule it so everyone can
come?" "How can we staff it?" "How
will we know if anyone has learned
anything?"
Putting it together
First we devised the questions, which
were to be organized into a ten-page
booklet. We decided short answer,
multiple-choice and match type
questions would be the best and we
wanted the questions to draw on the
basic knowledge needed by a
safety-conscious bedside practitioner.
Questions ranged from generalities such
as "List five steps you would take if you
discovered a fire in the hospital," to
specifics such as "What are the two most
common causes of employee accidents in
this hospital?" Some questions were
complex such as "What is alternating
current, and what is direct current? Why
is AC more dangerous than DC?" While
the nurse is not expected to be a
handyman, she should be acquainted
with potential hazards and know safe
ways to deal with them until help arrives.
Once our booklet was organized, we
commissioned the most artistic member
of our teaching staff to design a cover
page using her imaginative goldfish
symbol: we then stunned the hospital
printing department with a request for
1500 copies!
Program presentation involved a
few more problems. We needed one
room large enough to house four
separate displays (one for each subject
area of the annual review) and to
accommodate the 30 to 40 people who
would be working in it at any one time.
Suddenly, realizing we had to work on
our visual displays as well, we felt like a
department store at Christmas with four
huge empty windows to fill. What could
we put in the displays that would be both
stimulating and educational?
42 June 1980
The Canadian Nurse
For Accident Prevention we
envisioned a series of posters dealing
with the causes of hospital accidents and
the resulting costs to both institution and
individual employee. Our statistics
indicated that back injuries and needle
pricks were responsible for the majority
of reported incidents in the Nursing
Department, so we concentrated on
body mechanics and the handling of
sharps. Although we felt the principles in
this case were well known, the prevailing
attitude among staff was. "it won t
happen to me." Basically, this would be
an exercise designed to increase
awareness of hazards and stress the need
for prevention. The Ontario Hospital
Association graciously supplied us with
safety buttons to carry the message
throughout the hospital, and excellent
pamphlets dealing with techniques for
moving patients without backstrain.
The posters for Medical Gas Safety
concentrated on a review of fire safety
with regard to oxygen administration and
particularly on the necessity for securing
all cylinders to prevent them from
falling. The number of people who were
unfamiliar with this latter danger was
very revealing; even those who knew of
it spoke vaguely of the hazard as an
"explosion". We used the analogy of
releasing an inflated balloon without
tying off the end to illustrate what can
happen to a highly pressurized cylinder
when it develops a leak. The image of a
highly erratic, five-foot-long, solid steel
projectile was, to say the least, sobering.
We obtained large and small oxygen
cylinders with appropriate stands and
transporting devices to demonstrate and
reinforce the correct way of handling this
equipment.
The Fire Evacuation display
required the greatest amount of physical
participation. We decorated the wall
with cartoon reminders of the principles
of fire safety, and displayed the
hospital s Fire Safety Manual as a
resource. We borrowed a film called
"Code 1001" which demonstrated the
most practical lifts and two beds for a
practice session held afterwards. Since
psychomotor skills become rusty with
disuse, we expected all able-bodied staff
members to practice. Inevitably they
were rather reluctant at first, but usually
became willingly involved with a little
encouragement. Besides giving us a
chance to reinforce body mechanics, it
introduced a needed physical component
into a mainly intellectual exercise, and
produced more than a little merriment.
Electrical Safety was the most
complicated and least understood area,
but also the area of our greatest
resources. Within the past five years, our
hospital, together with Ontario Hydro,
had developed a comprehensive series of
slide/tape programs dealing with
Electrical Safety in the general ward
setting, in the Operating Room and in the
Intensive Care Unit. These were too
extensive to be used in their entirety in
our review so we selected a portion of
the general ward program which dealt
with the basic minimum of electrical
theory needed to safely operate any
electrical equipment. What is voltage?
I
f f
What is current both alternating and
direct? How can you protect yourself
against the effects of electricity? What
should you do if you see someone being
electrocuted? These were only a few of
the questions addressed in this part of
the program, and the answers we^e
directly related to home or hospital
situations with which the staff are quite
familiar. Considering Canada s heavy
dependence on this form of energy and
the casual way in which most of us
handle it, it is either an inherent tribute
to the safety standards of the electrical
industry or a miracle that there are not
more accidents. We attempted to make
the staff realize that the familiar
household tabby is in fact a full-grown
tiger, to be used and handled with
respect.
We conducted two separate sessions
with the Operating Room staff to
illustrate the operation of the cautery
machine and to stress the cause and
prevention of cautery burns. An I.C.U.
program was offered as well to all I.C.U.
staff on a separate basis after CARP was
finished. Basically it was an extension of
the principles of the general program, but
it outlined why patients in I.C.U. s are
often more "electrically sensitive" than
other patients and hence why a working
knowledge of electrical hazards and
safety precautions is especially
important. Several posters and a few
visibly damaged electrical items rounded
out this display.
June 1980 43
Refining these concepts and putting
them to paper in imaginative form was
both the most difficult and the most
interesting part of planning CARP. In
addition to working on posters, which we
did for many hours, a flyer announcing
the program had to be prepared, and
arrangements made for classroom
facilities and audiovisual equipment.
One major concern was the head
nurses reaction to our proposal .
Although the Nursing Executive
Committee had accepted the idea, we
knew that only a brave inservice
instructor would ask a head nurse to
release her staff for one and a half hours
to attend the review. To our surprise,
when we presented our best arguments
at the administrative staff meeting, the
Staffing the review program was
relatively easy: we asked for a
moratorium on all other programs such
as orientation until CARP was finished,
and we divided the thirteen hour time
period in which CARP would be open
into three overlapping shifts, leaving a
fourth teacher free to continue with the
regular bi-weekly inservice classes.
One last question remained: how
could we know if anyone learned
anything? Unfortunately, there is no way
to objectively evaluate this, but we had
several indications that were highly
encouraging. First, the attendance
figures soared to an astonishing 75 per
cent of all staff (the usual was 50 per
cent), and the level of pre-class
participation was unexpectedly high.
Even without solid objective proof,
the presumptive evidence indicates that
something good happened with CARP:
the marked increase in attendance and
the lively participation were all
important.
For us in the staff development
department, CARP opened a door. It
was our first adventure in providing
self-acquired learning, while attempting
to replace monotonous repetition with
active participation. It was as much a
learning experience for us as for the rest
of the staff, and appears to have been
highly successful. CARP has left us with
a feeling of satisfaction, a host of new
ideas and a taste for more
experimentation in non-traditional
teaching methods: no small
accomplishment for a humble goldfish. *
, \Fety
UANPtf W
Resources
Electrical Safety in Hospitals, a
slide-tape program co-produced by
Ontario Hydro and Toronto General
Hospital.
Code 1001 , a film produced by Baltimore
County Fire Department, available in
Ontario from the Ontario Fire Marshall s
office. Toronto.
Pamphlets-Techniques for moving
patients
Basic Guide for safety
Your safetv in nursing
Accident prevention with
wheeled equipment
available in Ontario from
Ontario Hospital
Association, Don Mills, Ont.
Hospital Accident Prevention
Department.
head nurses seemed quite receptive . The
prospect of resolving three months
worth of programs in three weeks time
outweighed the negative aspect of losing
staff for 90 minutes at a time. A point in
our favor was the fact that we did not
assign specific class times; rather, we
held the program open from 0800 to 2100
hours for three days a week, thus
allowing staff to come at their
convenience, when it was safe for them
to leave their particular units. (If night
staff did not happen to rotate onto days
in this time, they were encouraged to
come on their own as they would be
given time off in lieu later. )The booklets
could be given out two weeks before the
program, and we emphasized that those
who answered whatever questions they
could in advance would complete the
review in less time.
Many staff nurses said they had
canvassed husbands or just friends in
general to get answers to the questions in
the booklet. Others had been involved in
group efforts during quiet periods on
their units.
During the program, staff displayed
a visible interest in checking the
correctness of their answers and in
finding the answers they hadn t known.
Often they worked in two s and three s,
helping each other and turning to us only
when they were really stuck.
Something good happened
After CARP was completed, we scanned
random booklets to determine the areas
which presented the most difficulty. As
anticipated, the Electrical Safety section
was still the subject of the most
confusion and misunderstanding. The
second time this program is run, we
should see an improvement if there has
in fact been any real increase in
knowledge.
Margaret Elizabeth Murray is a graduate
of the A tkinson School of Nursing,
Toronto Western Hospital, and has a
diploma in nursing education from the
University of Western Ontario as well as
a BScN . She has worked as a staff nurse
in both med-surg units and the operating
room in hospitals in Saskatchewan and
Alberta, as a surgical co-ordinator in
Saskatchewan, and for the past ten years
she has been a teacher at the Toronto
General Hospital. For three years she
taught nursing students at the TGH
School of Nursing, and for the last seven
she has been in Staff Development .
44 June 1981
The Canadian Nurse
CNJ
Talks
To...
Gordon I V ic%cn
\
--"
v
On the side of the angels
Anne Besharah
Why is the patient always the last one to
be consulted in any plans to improve
hospital services? Why is the nurse the
low man on the totem pole of providers
of health care? Why does she sometimes
spend as much as half of her eight or
twelve hour shift away from the bedside,
finding the supplies she needs to give
care? If Gordon Friesen had his way,
none of these situations would be
allowed to exist.
Gordon Friesen has been
preaching enhancement of the status of
professional nursing and a patient-
oriented approach to the delivery of
health care services for the past fifty
years. Now, as he enters his seventh
decade of life, he is beginning to see the
results of his long crusade: many new
hospitals around the world have been
built to his specifications, hundreds
more have been modified to embrace
the concept that "planning must
precede form and both must bow to
function".
Gordon Friesen is retired now,
after a long and sometimes
controversial career in hospital
administration that began when he
became business manager of the
300-bed Saskatoon City Hospital at the
age of 2 1 , and ended with the
establishment of his own independent
health care consulting firm, Gordon A.
Friesen Incorporated International in
Washington, D.C. Along the way, he has
received recognition at home and
abroad for his innovative approach to
health care administration and
construction; he has lectured at univer
sities in the U.S., West Germany,
Australia and Canada, given presenta
tions at the U.S. Naval School of
Hospital Administration and acted as
consultant to the Surgeon General of
the U.S. Navy, Army and Ail Force. In
1970, he received an Honorary Doctor
of Laws from George Washington
University in Washington, D.C., and
today he continues to receive requests
from universities and other groups to
lecture and take part in panel
discussions and conferences.
For nurses who come to work in
a "Friesen hospital", the first and most
obvious difference in design from
traditional structures, is the absence of
the familiar nurses station. The
administrative control center (ACC)
which replaces the nurses station is
staffed by a clerk who coordinates all
administrative fuctions thus permitting
the nurse to go from room to room
without returning to home base. The
nursing team (during the day shift
usually consists of Two Registered
Nurses, a Technician and an Aid)
remains in a twenty-bed zone of which
there are normally four on each floor.
Another key element of the
Friesen design, is the "Nurserver",
introduced simultaneously in the early
sixties in three institutions the
American-British-Cowdray Hospital in
Mexico City, St. John s Mercy Hospital,
St. Louis and Holy Cross Hospital in
San Fernando, California. The Nurserver
completely isolates clean from
contaminated supplies, it promotes
better patient care by reducing
unnecessary traffic in and out of patient
rooms (a primary Friesen concern later
approached through other innovative
corridor concepts); by assuring a daily
restocked supply of patient needs
including medications, it basically
eliminates requisitioning and
contributes to the Friesen goal of
permitting the nurse to devote the
maximum possible time to her primary
objective nursing the patient.
Friesen is convinced that the
professional nurse should be available
to the patient 100 per cent of the time,
which means that everything she needs
must be placed at her disposal. In order
to implement this philosophy, he has
eliminated the traditional nurses
station and made each patient s
bedroom, in effect, a nursing station
containing its own service area and all
other appurtenances required for daily
The Canadian Nurse
patient care. This cuts down nurses
"travel time", professionalizes the major
portion of their work and facilitates the
organization of the nursing staff into
teams a basic part of the implemen
tation of his plan.
By the year 2000 the acute
hospital as we know it today will have
disappeared. In its place we will have
Regional and Community Centres where
all health care will come under one
umbrella, including preventive medicine.
The larger health facilities of the future
will make better use of automation by
placing everything that the doctor or
nurse needs (except the patient) on the
production line. This concept is just as
applicable without automation in
smaller health centers where the
supplies are delivered manually. Food
should be available when the patient is
ready to eat, and by sending it to the
patient s floor in a frozen state and
preparing the tray in the galley for each
zone makes this concept possible and
logical.
And what does the future hold for
nurses? Gordon Friesen has a twinkle
in his eye when he replies, but there is
no doubt in his sincerity: "I love nurses.
They must be kept on the highest
professional level making sure they are
recognized as an important part of the
medical team. The role of the nurse is
to nurse, to treat the patient as a whole
respecting his or her dignity as a human
being. With such
qualifications and a
functional health
centre will come
improved quality of
care and efficient
organization. This is
the objective for the
year 2000."*
Photo of
Gordon Friesen by
Studio Impact,
Ottawa.
June 1980 45
Introducing New
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used more often than cloth
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For further information write to.
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Why
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A one-piece system
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names & faces
Dr. Amy Zelmer, currently
dean of the University of
Alberta s Faculty of Nursing,
has been appointed associate
vice-president (academic) of
the university, effective July
1 , 1 980. A graduate of the
Ottawa Civic Hospital School
of Nursing, Dalhousie
University, the University of
Michigan and Michigan State
University, she has worked in
public health in Nova Scotia
and Alberta. In 1975, Dr.
Zelmer worked with the
World Health Organization as
a health education specialist in
India, where she and her
colleagues were responsible
for providing support services
for educational activities in
ten Asian countries.
Marjorie W. Hayes, RN ,
BScN.MScN, has been
appointed Director of the
Health Computer Information
Bureau. Most recently, she
was Project Director of the
bilingual, multi-media home
health care program "There s
No Place Like Home For
HealthCare", which was
sponsored by St. John
Ambulance and the Canadian
Red Cross Society. HCIB
represents the first attempt
ever to establish a central
clearing house for
comprehensive information
about computer uses and
users in the health field.
Barbara A. Racine has been
appointed Administrator of
the In-Patient Division and
Di rector of N ursing of the
Alberta Children s Hospital in
Calgary. A graduate of the
Master of Health Services
Administration program of the
University of Alberta, she was
Assistant Administrator of
Nursing Services at Saint
John s Hospital, Santa
Monica, California, has held
senior nursing and
administrative positions in
Canada and the U.S.A., and
has served as Assistant
Professor at the University of
Alberta.
Students & Graduates
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Name
Address
City Postal Code
Your graduation school
Carolyn S. Roberts, a
Canadian scholar is the first
recipient of the Patricia
Christensen Memorial
Scholarship Award. The
award and fund was
established by friends of the
late Patricia Christensen, a
Canadian nursing scholar and
former chairman of the
maternity nursing department,
Texas Christian University.
Roberts who is currently
working on her Ph.D. at
Wayne State University,
Detroit is associate professor
of the University of Western
Ontario and a former teacher
at Belleville General Hospital,
Belleville, Ontario and St.
Mary s School of Nursing,
Sault Ste. Marie, Ontario.
Roberts received her
basic education at The Royal
Victoria Hospital, Montreal, a
B.Sc.N. at the University of
Western Ontario and a
Master s degree at Teacher s
College, Columbia
University. She has received a
number of awards and
scholarships and is an active
member of many professional
organizations.
Shirley L. Brandt has been
appointed director of
continuing education in
nursing at the School of
Nursing, University of British
Columbia, Vancouver
effective August 1, 1979. She
has held a number of positions
in nursing education and
service and has also served as
director of continuing
education in nursing
particularly in developing
programs in the areas of
infection control, emergency
care and primary care.
Brandt is a graduate of
the Lenox Hill Hospital
School of Nursing in New
York. She also holds a B.A.
and M.A. in education.
Margaret S. Neylan, RN,
BScN, MA, was admitted as a
Servicing Sister of the Most
Venerable Order of the
Hospital of St. John of
Jerusalem by Governor
General Edward Schreyer, in
a ceremony at Notre Dame
Basilica in Ottawa. Her
investiture recognized her
commitment and outstanding
efforts in the community,
particularly as head of the
Nursing Advisory Committee
for St. John Ambulance in
British Columbia for several
years. Currently, she is
involved with a Red Cross
project on health in the home,
as well as her full time
position with the British
Columbia Institute of
Technology as Head of the
Psychiatric Nursing
Department.
Rachel Bard, BScN,a
community health nurse in
Moncton.N.B., has been
awarded the Marjorie Hiscott
Keyes Medal for 1979 by the
Canadian Health Association.
The medal, named for one of
the pioneers of the Canadian
mental health movement, is
awarded annually to the nurse
who most nearly approaches
the ideal of psychiatric
nursing through
demonstration of interest,
understanding and warmth of
personality in daily contact
with the mentally ill. A
graduate of the Ecole des
Sciences Infirmieres in
Edmunston, N . B. and the
University of Moncton, Bard
is the senior mental health
nurse and acting coordinator
of the child psychiatry team at
the mental health clinic in
Moncton, N.B.
Una Ridley, formerly
principal of the Brockville
Campus of St. Lawrence
College, has been appointed
professor of nursing and dean
of the College of Nursing at
the University of
Saskatchewan. A past
president of the Council of
the College of Nurses in
Ontario, she has done much
research in the area of
nursing education.
Dr. Joanne Scholdra,
previously chairman of the
Lethbridge Community
College nursing program, has
been appointed director of
the newly established
University of Lethbridge
School of Nursing.
Dr. Scholdra has an extensive
background in general duty
nursing, administration and
education. *
48 June 1980
The Canadian Nurse
audiovisual
Medications. A series of five
self-instructional slide tape
programs written by Rhoda
Bowen and Joy Schermer of
Wayne State University.
Produced by Media Systems
Corporation, a Subsidiary of
Harcourt. Brace and
Janovich, Inc.. 757Third
Avenue. New York, NY
10017. Average length: 20
minutes.
Cost: $150.00 per program.
A newcomer to the health
field. Media Systems
Corporation has produced
several slide/tape programs on
nursing fundamentals. The
quality of their programs
reflects many years of
experience producing
self-instructional audiovisual
materials for business
education.
In 1977 a series of five
programs on medications was
released. The three most
useful are described here.
Math for Medications: relates
math to the preparation of
medications in tablet or
injectable form. It clearly
differentiates between generic
and trade names, available
and prescribed dose and
carefully reviews what
medication orders and labels
tell us. Metric, apothecary
and household systems of
measurement, with a table of
approximate equivalents, are
given. Many practice
exercises are included.
Administering Oral
Medications: safety and the
"5 rights" are emphasized.
Reviews both the unit dose
and traditional systems of
preparation and refers briefly
to various agency procedures
related to drug and narcotic
control. Gives common
abbreviations and
demonstrates the preparation
and administration of both
tablet and liquid medications.
What to record and how to
handle problems which may
arise, such as, dubious order,
client not being in his/her
room, or client refusing the
medication, are included.
Administering injections: tells
how and why intradermal,
subcutaneous and
intramuscular injections are
given, including syringe and
needle sizes. Excellent
graphic slides demonstrate
tissue involved, anatomy,
sites and injection angles. The
four intramuscular injection
sites are well demonstrated
with most emphasis on
dorsogluteal and ventrogluteal
sites. Ways of locating all sites
are clearly visualized.
The remaining two
programs in the series cover
topical medications and
preparing for injections.
A word about packaging:
carousel slide trays are used
and come in attractive, sturdy
boxes with snug foam inserts
for audiocassettes. Slides are
plastic mounted with slide
number and program name on
the mounting for easy
identification.
These are exceptional
programs for nursing students
and registered nurse refresher
courses.
Reviewed by Jovce Carver,
BN, M.Ed., Lecturer,
Dalhousie University School
of Nursing, Halifax, Nova
Scotia.
General
Nursing care
Spectrex announces the
availability of over 250 new
programs in nursing. The
programs cover such varied
subjects as the nursing
process, nursing procedures,
care of the diabetic patient,
nursing care in pediatrics and
geriatrics, as well as 33
additional programs for
nurses aides.
Each program consists of
a series of 35 mm color slides,
an audio cassette and a
printed handout. The
programs are designed for use
in hospital inservice education
departments, nursing homes
and health care institutions,
and to supplement teaching in
colleges and universities.
Spectrex also has 90 new
programs available on
nutrition and diet therapy.
For information, write:
Spectrex Limited, 701 Evans
Ave., Toronto, Ontario M9C
1A3.
Alcohol and Your Patient, by
Madelaine Coates, RN and
GailPaech.RN.MScN,
Toronto, Addiction Research
Foundation, 1979.
Approximate price: $1 .95.
In the introduction to this
handbook, the nurse is
described as "the ideal person
to identify the existence of an
alcohol problem which may
make diagnosis difficult
and/or treatment
unsatisfactory." Bearing the
nurse s special position in
mind, this handbook is written
to give the nurse a good
general understanding of
alcohol as a chemical
substance, how it affects
people both physically and
psychologically, and what
nurses can do to accurately
assess an alcoholic s problem
and design a blueprint for
action .
The authors accomplish
this by delivering a great deal
of information in a very
concise form: information is
presented in "point form", for
example . and diagrams are
used to advantage. Topics
include the effects of
alcoholism on family
structure, alcohol and women,
and up-to-date information on
the fetal alcohol syndrome. Of
interest as well is a list of
helping agencies for the
nurse s use in referring her
patients.
Acknowledged is the help
oftheRNAOinthe
production of the handbook.
For more information,
contact the Addiction
Research Foundation, 33
Russell Street. Toronto. *
MARY DOE R. N.
SUPERVISOR
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The Canadian Nurse
June 1980 49
research
Families
Familial Strain and the Development of Normal
and Handicapped Children in Single and Two
Parent families. Toronto, Ont., 1979. Thesis
(PhD), University of Toronto by Sharon
Ogden Burke.
The relationship of chronic familial strain and
developmental quotients in children was
studied in one and two parent families with
and without handicapped children. Sixty
families were studied, each having at least one
of the stressors of a handicapped child or a
single parent or both stressors.
High chronic familial strain was
significantly related to low developmental
quotients in normal children. Families with
high chronic strain levels were characterized
by a lack of short and long term plans and
strategies for dealing with day-to-day
changes. They were highly concerned with
the immediate family unit and unaware of
community and other outside influences.
Both the presence of a handicapped child and
a single parent were associated with lower
developmental quotients in normal children.
Maternal strain is related to, but conceptually
distinct, from chronic familial strain. High
maternal strain was related to higher
developmental quotients in handicapped
children and at the same time low
developmental quotients in the normal
siblings.
Gerontology
Problems of the Independent Elderly in Using
the Telephone to Seek Health Care. Toronto,
Ont., 1979. Thesis (MScN), University of
Toronto by Heather Caloren.
This exploratory -descriptive study involved
interviewing 72 persons sixty-five years of age
or older who spoke English and who lived
alone in the city of Toronto, to determine
problems experienced using the telephone to
contact health care services.
For those who would like to develop
further their professional potential and to
earn University credits while working
full-time
Canadian School of
Management
in affiliation with
Northland Open University
offer two programs:
Bachelor of Professional
Studies or
Bachelor of Management
Nurses, technicians, technologists and
all holders of Community College
diplomas may apply to the Upper Level
of the Program. Credits are given for
prior learning and experience .
Saturday tutorials or study at a distance
(for those who reside outside of Toronto)
available.
For more information please write to:
Canadian School of Management
S-425, 252 Bloor St. W.
Toronto, Ontario
M5S 1V5
Results revealed that an important
number of independent elderly persons
experience problems using the telephone to
contact services and there is a small number
who fail to contact services when they have
perceived needs. The organization of health
care services on the premise that those in
need will phone for them should be
reappraised. Those who experience contact
problems tend to neglect chronic and less
acute problems. Groups such as the visually
impaired and those who began telephone use
late in life may experience a greater number of
contact problems than others and men may
display more reticence than women about
using the telephone. Telephone recording
devices are a source of concern or difficulty
for some independent elderly persons.
By recognizing these findings, health care
providers in planning access for service
should adjust their practices to minimize these
problems.
Nursing Education
The Use of Written Simulations to Measure
Problem Solving Skills of Nursing Students.
Ann Arbor, Michigan, 1979. Thesis (PhD),
University of Michigan by Margaret Findlay
Munro.
This study was a pilot project in the
development and use of three written
simulations of community health nursing to
measure problem solving skills. A
convenience sample of 47 baccalaureate
students in nursing was randomly assigned to
three test groups which received the three
simulations in a fixed order at approximately
weekly intervals. Concurrent data were
gathered from evaluation rating reports
indicating the problem solving behavior of the
students and the primary medical and/or
nursing problems encountered with clinical
practice.
The study suggests that individual
problem solving competency and style can be
measured by means of written simulations.
Opportunities for decision-making, errors and
consequent progress were valid and reliable
within instrument and sample. Further use of
these and sequential problem situations is
recommended to test and teach problem
solving.
Retirement
Self-actualization in Retirement. Naples,
Florida, 1978. Thesis ( PhD), Walden
University by Rebecca P. Kingston.
This was an empirical study of the
self-actualization of the coping, older person,
retired from the labor force and living among a
general urban population. The findings
revealed that the overall level of
self-actualization of the retired person was
low-average, with the group having only
primary school education scoring lowest on
most scales. Satisfaction with environmental
variables in retirement was positively
correlated with self-actualization and
satisfaction with one s financial situation was
shown to be the most influential
environmental variable on self-actualization
in retirement.
Congenital Anomalies
Assimilative and Accommodative Responses of
Mothers to Their Newborn Infants With
Congenital Defects. Pittsburg, Pennsylvania,
1979. Thesis (PhD). University of Pittsburg by
June Kikuchi.
To determine the responses of mothers to
newborn infants who have congenital defects
which require hospitalization in a children s
hospital immediately following birth, five
mothers whose newborn babies were
hospitalized within two to eighteen hours after
birth were studied individually using
unstructured interviews.
Results showed the mothers to be reality
oriented and anxious to determine what kind
of infants they had produced and had to
mother. It appeared to take these mothers
longer than a month to become fully
acquainted with their infants. During the
initial few contacts with their infants, it
seemed to be especially important for the
mothers to have successful feeding
experiences and to see their infants awake and
active. Opportunities to prepare themselves
through the expression of both fearful and
wishful fantasies about their infants was
extremely important as was the freedom to
optimize and to protest about their infants
condition.
Cardiac Surgery
Knowledge of Prescribed Medical Regime,
Concerns and Unanswered Questions Reported
by Wives of Aortocoronary Bypass Patients in
Early Convalescence. Toronto, Ont. 1979.
Thesis (MScN), University of Toronto by
Joseline M. Sikorski.
The purpose of this study was to determine
the knowledge, concerns and unanswered
questions of wives of aortocoronary bypass
patients in early convalescence and ultimately
to determine information specific to the home
environment and early convalescence that
would assist wives to support their husbands
during this period.
A convenience sample of 30 wives of
aortocoronary bypass patients was
interviewed privately in their own homes the
second or third week after their husbands
discharge from hospital.
The majority of wives had excellent
knowledge of coronary risk factors, physical
discomforts and recommended activities: they
lacked adequate information on medications,
diet, weight, knowledge of the surgery and its
relationship to coronary artery disease and
angina, sexual activity resumption and
general activity levels.
The study concluded that
multi-disciplinary preoperative, postoperative
and convalescent information and support for
the spouse and patient should be improved
and early convalescent community nursing
visits for reinforcement and support are
needed.
Resumes are based on studies placed
by the authors in the CNA Library
Repository Collection of
Nursing Studies. *
50 June 1980
The Canadian Nurse
^MEDICAL CARE
EVALUATION
NURSES ... if you re a decision making management nurse concerned about high quality patient care, then PATIENT
CARE AUDIT CRITERIA is essential for you. PATIENT CARE AUDIT CRITERIA is a valuable resource to keep you up-to-
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The Canadian Nurse
June 1980 51
books
Case studies in neurological nursing
by S. Wehrmaker and J.
Wintermeute. Boston, Little, Brown
&Co., 1978.
Approximate price: $7.95.
The major purpose of this collection
of case studies is to provide nurses with
a "framework of practical knowledge in
the neurological sciences". This purpose
is achieved by beginning the book with a
review section, clearly and concisely
written, on neuroanatomy and
physiology and in the presentation of
case studies.
The emphasis is squarely on the
nurse s role in the care of patients with
neurological disorders. Items of interest
such as the screening evaluation of
motor strength which can be done
routinely by a nurse, cranial reviews
emphasizing those tested frequently by
nurses, bring to mind things that most
nurses do without realizing that they re
also evaluating neurological function.
Each chapter ends with short multiple
choice quizzes so that the nurse-reader
may evaluate her/his knowledge gained
retelast
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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- visual projector available for training programmes
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.
LABORATORIES IMC
2775 Bovel SI P O Box 403
Chomedey. Laval P O H7S 2A4
and the ability to apply that knowledge.
Each of the case studies follows a
question and answer format for the
particular disorder being discussed. The
information given in response to each
question follows loosely the ideas of the
Nursing Process, i.e. information needed
for assessment of the patient and care
planning, to various types of testing
methods, to the nursing management of
that patient.
Nurses who would benefit from
reading this book would be those
working on a neurological service, or in
an outpatient neurology clinic. Others
for whom certain conditions would be
relevant would be those working on a
general medical unit, where patients with
transient ischaemic attacks, or
cerebrovascular accidents are normally
admitted.
Reviewed by Phyllis Durnford, Teaching
Master, Algonquin College Nursing
Program, Pembroke, Ontario.
Pediatric cancer therapy by Carl
Pochedly, ed. 292 pages. Baltimore,
University Park Press, 1979.
Approximate price: $29.50.
This book presents current concepts
and technology in the treatment of the
various malignancies of childhood. It
includes the following: new diagnostic
techniques; detailed descriptions of
various recommended therapy regimens
(new drugs, new approaches);
management of infection in children with
cancer; supportive care; a sensitive
chapter on emotional care considerations
for the patient and his family; improved
prognostic data.
The book is a collaborative effort by
American authors who are experts in
their fields. It has been edited by one and
is meant to be a reference for
pediatricians and general practitioners
who assist in the care of pediatric cancer
patients. It is directed with the expressed
hope that these practitioners may
assume a more meaningful role on the
cancer management team.
The content is current; the book is
easy to read. Graphs and diagrams are
used appropriately and are easy to
understand. Photographic reproductions
of x-rays are used extensively and
effectively. Much less effective are black
and white photographs of living tissues,
tissue specimens and microscopic slides,
where color plates would have provided
much more visual information.
In short, this book is a worthwhile
reference for those to whom it is directed
and for nurses who are associated with
care of pediatric cancer patients and
their families.
Reviewed by June L. Blau, RN , Nursing
Inservice Instructor, Pediatrics, Regina
General Hospital, Regina, Sask.
52 June 1980
The Canadian Nurse
SPECIAL GROUP DISCOUNT OFFER FOR
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People,
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A guide for nurses toward
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Jennie Wilting
Jennie Wilting s insight and
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Soft cover $10.
Please send remittance with order.
University of Alberta Press
450 Athabasca Hall
Edmonton, Alberta
Canada T6G 2E8.
The Nursing Process - a Scientific
Approach to Nursing Care by Ann
Marriner. 276 pages. Saint Louis,
Mosby, 1979.
Approximate price: $12.00
This book is a compilation of
selected readings on various concepts
related to the four phases of nursing
process. Some of the concepts discussed
include problem oriented medical
records, nursing diagnosis and
communication and quality nursing care.
The book is divided into four
sections: the first presents an overview
of nursing process and subsequent
sections deal with the assessment,
planning, implementation and evaluation
phases. The methods, skills and
strategies for implementing each phase
are discussed in depth and case studies
are used in some of the readings to
effectively exemplify the proper use of
nursing process in enhancing nursing
care. The holistic approach used in this
book that is, looking at the whole
before the individual phases of process
makes the readings more meaningful,
and the comprehensive annotated
bibliography at the end of each chapter
supplements the content.
Reviewed by Shirley Wong, Assistant
Professor. School of Nursing, Dalhousie
University. Halifax. N.S.
Health Sciences Centre
Winnipeg, Manitoba
Post-Graduate Course in Emergency Nursing
September, 1980 - May, 1981
9 Month Duration
Applications are now being accepted for the 1980-81 Manitoba Emergency Nursing
Course conducted by the Health Sciences Centre.
The Course is a 9 month program incorporating both the theoretical and c linical
aspects of Emergency Nursing and is accredited by the Continuing Education
Appraisal Committee of the Manitoba Association of Registered Nurses.
Applicants must be registered or eligible for registration with the Manitoba
Association of Registered Nurses by September, 1980.
Candidates must have a minimum of one year s experience in Acute Care Medicine
or Surgery and previous experience in an Emergency Department is desirable.
This course is open to both males and females.
For further details write to:
Co-ordinator, Emergency Nursing Course
Department of Nursing
Health Sciences Centre
700 William Avenue
Winnipeg, Manitoba
R3E OZ3
Basic Concepts in Anatomy and
Physiology, A Programmed
Presentation by Catherine P.
Anthony and Gary A.Thibodeau,
Toronto, Mosby, 1980.
Approximate price: $10. 75.
This book is difficult to compare
with other texts of the same topic
because of the way in which the material
is presented. Certainly the book is
unique because it is a programmed
presentation, which might be an
interesting way in which to present
Anatomy and Physiology to students.
However, as a "basic" book of
Anatomy and Physiology, the concepts
as presented in the content material of
the book would be difficult for basic
students studying Anatomy and
Physiology to grasp. They most certainly
would require a guide, whether it be
another text, a manual, or an instructor,
to explain the format and terms.
Certainly, the illustrations and the panels
of information are a great help: these
items may be the best features to the
student reading this book.
Strangely enough, two of the most
important body systems have been
omitted "to keep the cost of the book
reasonable" muscular and skeletal
systems. The digestive system has also
been omitted from the contents. Because
of these omissions, the book appears to
be incomplete as a text for Anatomy and
Physiology.
On the other hand, the book has an
extremely good feature in that it can be
used as a study guide or review for
students who have already studied
Anatomy and Physiology; the
programmed presentation makes this
possible.
So, the book would be a good one to
recommend to students or other persons
who already have some Anatomy and
Physiology background, such as in
Nursing, Medicine or Physical
Education. I find this book to be a good
way of reviewing my understanding and
retention of the main concepts in those
areas of Anatomy and Physiology
covered in the book, but because it is
difficult to find needed information
quickly, I would prefer to use another
type of Anatomy and Physiology text.
Therefore, 1 would hesitate to purchase,
or recommend that someone purchase it,
unless it was used mainly as a study
guide or a review book.
Reviewed by Katharina A . Burns, PhD,
MD, Assistant Professor, School of
Nursing, Memorial University of
Newfoundland, St. John s, Nfld.
54 June 1980
The Canadian Nurse
Nurses handbook of fluid balance 3d
ed.,byN. Metheny and W.D.
Snively, Toronto, Lippincott, 1979.
I was initially introduced to this
book as a new graduate, when the first
edition was published in 1967. Now, as
then, I welcomed the straightforward
approach of the authors to the complex
subject of body fluid disturbances.
The third edition retains the basic
format of dividing the text into chapters
on the "fundamentals" of body fluids
and the related imbalances and also
chapters relating the knowledge to
practical application.
Although the authors have done a
thorough revision and expansion of the
original text, and have added
considerable material related to
increased knowledge and developing
technology, one of the major strengths is
the continuing focus on the nurse and her
role. Several current "nurse s
handbooks", and "programmed
learning" texts are, in my opinion,
lacking in this important area.
In summary, I would recommend
this book as an excellent handbook for
hospital and nursing unit libraries, for
individual graduate nurses, and certainly
recommend it highly as a reference for
students in hospital, college or university
nursing programs.
Reviewed by Dawn Patterson, RN ,
B.Sc., Instructor, Nursing Department,
Cariboo College, Kamloops, B.C.
Introductory maternity nursing by
Doris C. Bethea, Toronto,
Lippincott, 1979.
Doris C. Bethea has not succeeded
in her book in presenting the unique and
valuable contribution that today s nurses
make towards care of the new mother,
her infant and their significant other.
Rather than presenting a progressive
nursing perspective on the care of the
childbearing family, the author has taken
a predominantly medical orientation.
The author introduces each chapter
with a list of behavioral objectives and
presents material which enables the
reader to meet these objectives;
however, the content is not always
complete and up-to-date. Some
important topics such as how to assist
the mother to breastfeed successfully are
dealt with quite inadequately. In other
cases, the information given is not
current, for example the use of general
anesthetics in delivery or the
recommended weight gain during
pregnancy.
Reviewed by Antoinette LeBlanc,
BScN., Instructor, The Miss A . J.
MacM aster School of Nursing,
Moncton,N.B. *
GIRITY
TRIPAQUE SPONGES
designed for convenient,
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and micro-organism impermeable.
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INNOVATORS IN PATIENT CARE
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The Canadian Nurse
Jun19SO Si
A NURSE S STORY. IT COULD DEVOURS
1 So many nurses I talk
to about my work in Saudi
simply can t understand
what it s like to get so much
satisfaction
.^
a job.
RITA LAWRENCE. R.N.
The Arabian Peninsula. Dif
ferent. Demanding. And most
decidedly gratifying.
"Like most nurses, I ve
always dreamt of my work
making the difference in peo
ple s lives. And not having it
taken for granted. But until
my job at Whittaker s Saudi
hospitals, I thought it would
never happen.
What made Saudi Arabia
different was the gratitude of
patients, families, government.
And the chance to work inde-
ptndently in a modern hospital.
Being in an exotic place,
coming home to free, air con
ditioned comfort that was
all part of it. Together with
excellent travel benefits, salary
and bonus provisions.
But when nurses ask why
Dedicated
CALL
REVERSING
THE CHARGES:
Peter Dow
(519) 376-6809
W. P. Dow& Assocs. Ltd.
(A Canadian Company)
361 10th St. W.
Owen Sound,
Ontario N4K3R4
I went back twice, I point to
job satisfaction. / really found
it. And they can too."
Rita Lawrence s reactions
are typical. And Whittaker, a
leader in international health
care, isnow offering contracts
in either Saudi Arabia or Abu
Dhabi. If you are a Canadian
trained R .N . with two to three
years postgraduate experience,
call us today. (Single housing
available only.)
to a world of health
WhittakeR
Whittaker International Services Company
A Subsidiary of Whittaker Corporation
An Equal Opportunity Employer M/F
Classified
Advertisements
Alberta
British Columbia
Manitoba
R.N. s required. Registered nurses required for
new Brooks Health Centre, complex of 70 beds,
1 5 bassinettes, 75 nursing homebeds. Centrally
located in Southern Alberta between three
large cities. Salary as per Provincial Agreement.
Must be eligible for registration with AARN.
Apply in writing to: Director of Nursing,
Brooks Health Centre, Bag 300, Brooks, Al
berta TOJ OJO.
Registered Nurses required for a 560-bed acute
care hospital in Edmonton, Alberta. Positions
available in most clinical areas. Candidates must
be eligible for registration in Alberta. Current
salary rates under review. Apply to: Personnel
Department, EdmontonGeneralHospital4 1111
Jasper Avenue, Edmonton, Alberta T5K OL4.
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Registered Nurses required for75-bed, accredit
ed, active treatment hospital (including I.C.U.).
Situated in a lakeland resort area, 130 miles
northeast of Edmonton. Salary according to
AARN contract. Apply to: Director of Nursing,
St. Therese Hospital, Box 880, St. Paul,
Alberta TOA 3AO.
Required Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TOK 2GO.
British Columbia
Experienced General Duty Graduate Nurses re
quired for small hospital located N.E.Vancouver
Island. Maternity experience preferred. Person
nel policies according to RNABC contract. Res
idence accommodation available $30mpntnly.
Apply in writing to: Director of Nursing, St.
George s Hospital, Box 223, Alert Bay, British
Columbia VON 1AO.
General Duty Nurse for modern 35-bedhospital
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply: Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
Two Registered Nurses required for a 21 -bed
general hospital located in the beautiful
Robson Valley, 100 miles West of Jasper, Al
berta. Rotating shifts, full or part-time work
available. Accommodation available for single
person. Salary as per RNABC Collective Agree
ment. Apply immediately to: Director of Nurs
ing, McBride & District Hospital, Box 128,
McBride, British Columbia VOJ 2EO or tele
phone: 604-569-2662.
General duty nurses required for all clinical
areas and O.R. in a 360-bed acute care general
hospital. Salary and fringe benefits in accor
dance with RNABC contract terms. Apply to:
The Director of Nursing, Nanaimo Regional
General Hospital, Nanaimo, B.C. V9S 2B7.
General Duty R.N. Small hospital in scenic
West Kootenays of B.C. Apply: Slocan Comm
unity Hospital, Box 129, New Denver, British
Columbia VOG ISO.
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. Excellent orientation and continuing
education programmes. Salary 1979 rates
$1305.00-$1542.00 per month. Clinical areas
include: Operating Room, Recovery Room, In
tensive Care, Coronary Care, Neonatal Inten
sive Care, Hemodialysis, Acute Medicine, Surg
ery, Pediatrics, Rehabilitation and Emergency.
Apply to: Employment Manager, Royal Colu-
umbian Hospital, 330 E. Columbia St., New
Westminster, British Columbia V3L 3W7.
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van-
couver.Salary and benefitsaccordingto RNABC
Contract Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to: Personnel Director, Queen sPark
Hospital, 31 5 McBride Blvd., NewWestminster,
British Columbia V3L 5E8.
Experienced General Duty Nurses required for
130-bed accredited hospital. Salary in accord
ance with RNABC Contract. Residence acc
ommodation available. Apply in writing to:
Director of Nursing, Powell River General
Hospital, 5871 Arbutus Avenue, Powell River,
British Columbia V8A 4S3.
Registered Nurses required for permanent full-
time position at a 147-bed fully accredited reg
ional acute care hospital in B.C. Salary at 1979
RNABC rate plus northern living allowance.
One year experience preferred. Apply : Director
of Nursing, Prince Rupert Regional Hospital,
1305 Summit Avenue, Prince Rupert, British
Columbia V8J 2A6. Telephone (collect) 604-
624-2171 Local 227.
Experienced General Duty Nurses, preferably
eligible for B.C. Registration, required for 71-
bed accredited hospital on the Sunshine Coast
of British Columbia. Salaries and benefits
according to RNABC agreement. Residence
accommodation available. Apply in writing
to: Personnel Officer, St. Mary s Hospital,
Box 7777, Sechelt, B.C. VON 3AO.
Registered Nurses required immediately for per
manent full time positions atlO-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 Col
umbia VOT 1WO. Telephone: (604) 636-2221
Collect.
General Duty Nurses required for an active,
103-bed hospital. Positions available for experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
Registered nurses required for a fully accredi
ted 100-bed general hospital and a 72-bed per
sonal care home located in northen Manitoba.
Must be eligible for registration in Manitoba.
Salary dependent on experience and education.
For further information contact: Mrs. Mona
Seguin, Personnel Director, St. Anthony s
General Hospital, The Pas Health Complex Inc.,
P.O. Box 240, The Pas, Manitoba R9A lK4;or
phone collect to: 1-204-623-6431, Ext. 179.
Northwest Territories
The Stanton Yellowknife Hospital, a 72-bed
accredited, acute care hospital requires register
ed nursesto work in medical, surgical, pediatric,
obstetrical or operating room areas. Excellent
orientation and inservice education. Some fur
nished accommodation available. Apply : Assist
ant Administrator-Nursing, Stanton Yellow-
knife Hospital, Box 10, Yellowknife, N.W.T.,
X1A 2N1.
Ontario
Registered Nurses required for our ultra mod
ern 70-bed fully accredited general hospital in
a bilingual community of Northern Ontario.
Applicants should be registered or eligible for
registration with the College of Nurses of Ont
ario. Knowledge of both official languages and
experience in nursing are assets but not essen
tial. Salary is according to the O.M.A. schedule
and fringe benefits include one month of holi
days, OHIP, salary and life insurance and a
drug and dental plan. Assistance is also provid
ed in locating suitable living accommodations.
Forward your application to: Personnel Direc
tor, Notre Dame Hospital, P.O. Box 8000,
Hearst, Ontario POL 1NO. Telephone: (70S)
362-4291.
Registered Nurses for a 150-bed fully accredit
ed general hospital. Salaries in accordance with
association agreement. Apply to: Mr. C.F.
Dowling, Personnel Department, Lake of the
Woods District Hospital, 21 Sylvan Street West,
Kenora, Ontario P9N 3W7. Phone: 807-468-
9861.
Experienced registered nurses are required
immediately for our fully accredited thirty-two
bed complex and active treatment hospital loc-
cated in beautiful Northern Ontario. The hosp
ital pays 100 percent OHIP and Dental Plan
and many other excellent fringe benefits.
Apply to: The Director of Nursing, Hornepayne
Community Hospital, Hornepayne, Ontario
POM 1ZO.
Looking For A Temporary Change? Do you
want to keep your job but feel the need for
some renewing experience? International reg
istry for nurses interested in a temporary job
exchange under organization. Write: Nursing
Job Exchange, Box 1502, Kingston, Ontario
K7L 5C7.
R.N. Grad or R.N.A., 5 6" or over and strong,
without dependents. Non-smoker for 180 Ib.
handicapped retired executive with stroke.
Able to transfer patient to wheelchair . Live-in
1/2 year in Toronto, 1/2 year in Miami. Wages
$2 50. 00 to $300. 00 weekly NET plus $100.00
weekly bonus on most weeks in Miami. Write:
M.D.C., 3532 Eglinton Avenue West, Toronto,
Ontario M6M 1V6.
The Canadian Nurse
Jun19M 57
Ontario
Childrenssummercamps in scenic areasof North
ern Ontario require Camp Nurses for July and
August. Each has resident M.D. Contact : Harold
B. N ashman, CampServicesCo-op, 825 Eglinton
Avenue West, Suite 211, Toronto, Ontario
MSN 1E7. Phone: (416) 789-2181.
United States
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 White is a 377-bed acute
care teaching medical center with an open invita
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to develop
and continue your professional growth. We
will pay your one-way transportation.offerfree
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 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92503. Write or call collect 7 14-688-22 11
Ext. 217. Betty Van Aernam, Director of
Nursing.
Fort Lauderdale Beach an extra benefit enjoy
ed by Nurses employed at Holy Cross Hospit
al. Our 596-bed health care complex will sp
onsor Work Visas for qualified R.N. s and new
Graduates interested in a challenging profess
ional opportunity. For details regarding licen-
sure, relocation and hospital-owned apartment
rentals, contact our Nurse Recruiter, 800 N.W.
62nd St., Suite 510, Ft. Lauderdale, Florida
33309 (305)772-3680.
Appraise our Miami Hospital - What can
Victoria Hospital offer you? We can give you
a modern 300-bed progressive, acute care hos
pital as a stimulating work environment. We
offer excellent salaries, benefits, CEU s, tuition
refunds and relocation assistance. For pleasure,
Miami has great beaches, boating, dining, dis
cos, tennis, golf, snorkeling, etc. Our Hospital
also has apartments available. Want to learn
more? Call Ms. McDonald, R.N., person-to-
person, collect at (305)772-3682, or write
Nurse Recruiter, 800 N.W. 62nd St., Suite 510,
Ft. Lauderdale, Fla. 33309.
Nurses RNs Immediate openings in Califor
nia-Florida-Texas-Maryland-Virginia and many
other States if you are experienced or a re
cent Graduate Nurse we can offer you posi
tions with excellent salaries up to $16,000 per
year plus all benefits. Not only are there no
fees to you whatsoever for placing you, but we
also provide complete Visa and Licensure assis
tance 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 arrange for hospital interviews. You
can call us collect if you are an RN who is li
censed 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 23rd Year of World Wide Service"
R.N.s Experienced nurses needed to staff
midwestern and eastern United States hosp
itals. Must be able to take and pass State
boards tests. Free housing while working in
United Stater. Full sponsorship available.
Wages begin at $7.00 per hour. Fulltime.
Send resume to: Bonnie Menees Smith, R.N.
Recruiter, JANNA Medical Systems, Inc.,
1810 Craig Road, St. Louis, Missouri 63141.
Nursing in
the Sunny Palm Beaches
Picture yourself in the sunny Palm Beaches
working at the most prestigious hospital in
Florida. Good Samaritan Hospital has
maintained the tradition of being the first in the
latest hospital services and facilities. Our good
name and outstanding history attest to our
success.
A 326 bed, J.C.A.H. accredited hospital
offering attractive salaries and benefits
including:
Active in-service orientation
Continuing educational programs
37 1/2 hour week
5 day week
No shift rotation
Education and experience
differential
Fully paid Blue Cross/Blue Shield
Shift differential and other employee
benefits
Seasonal employment welcome
Patient-mix 90% under age 65
We will sponsor the appropriate employment
Visa for qualified applicants. Attractive
efficiency apartments available at far below
commercial rates, overlooking the beautiful
Lake Worth and located across the boulevard
from the hospital.
Write:
Director of Personnel (305) 655-5511
Good Samaritan Hospital
Flagler Drive at Palm Beach Lakes Blvd.
P.O. Box 3166
West Palm Beach, Fla. 33402
United States
Offers R.N. s
ufSKr An UNUSUAL OPPORTUNITY.
SERVICE
A.M.I. Will FURNISH One Way AIRLINE TICKET to Texas
and $500 Initial LIVING EXPENSES on a Loan Basis.
Alter One Year s Service, This Loan Will be Cancelled
American Medical International Inc.
HAS 50 HOSPITALS THROUGHOUT THE US
# Now A.M.I. Is Recruiting R.N. s lor Hospitals in Texas
Immediate Openings. Salary Range Si 1.000 to $16,500 per Year
* You can enjoy nursing in General Medicine. Surgery. ICC.
CCU, Pediatrics and Obstetrics
A.M.I, provides an excellent orientation program.
in-service training
U.S. Nurse Recruiter
P.O. Box 1 7778, Los Angeles, Calif. 900 1 7
# Without obligation, please send me more
Information and an Application Form.
NAME
ADDRESS
CITY ST ZIP
TELEPHONE ( )
LICENSES:
SPECIALTY:
YEAR GRADUATED: _ _ STATE: _
The Best Location in the Nation - The world-
renowned Cleveland Clinic Hospital is a pro
gressive, 1030-bed acute care teaching facility
committed to excellence in patient care. Staff
Nurse positions are currently available in sever
al of our ICU s and 30 departmentalized medi
cal/surgical and specialty divisions. Starting
salary range is $14,789 to $17,056, plus
$1248/year ICU differential and premium shift
differential, comprehensive employee benefits
and an individualized 7 week orientation. We
will sponsor the appropriate employment visa
for qualified applicants. For further informa
tion contact: Director-Nurse Recruitment, The
Cleveland Clinic Hospital, 9500 Euclid Avenue,
Cleveland, Ohio 44106 (4 hours drive from
Buffalo, N.Y.); or call collect 216-444-5865.
Nurses-RNs-Suite yourselves professionally,
personnally, financially and geographically. I
have clients throughout the U.S. needingnurses.
We provide full visa and licensure assistance.No
charges to you. Contact: Jack Grinovich &
Assoc., 7300 NW 23rd St., Bethany, Oklahoma
73008 (405) 789-4563.
Come to Texas- Baptist Hospital of Southeast
Texas is a 400-bed growth oriented organization
lookingforafewgoodR.N. s.Wefeelthatwecan
offer you the challenge and opportunity to de
velop and continue your professional growth.
We are located in Beaumont, a city of 150,000
with a small town atmosphere but the conven
ience 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 pro
gress salary plan plus a liberal fringe package.
We will provide your immigration paperwork
cost plus airfare to relocate. For additional in
formation, contact: Personnel Administration,
Baptist Hospital of Southeast Texas, Inc., P.O.
Drawer 1591, Beaumont, Texas 77704. An
affirmative action employer.
RN S Our Florida hospitals need you ! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the USA
B) Extensive information regarding
Hospital 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 1 133 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
58 June 1980
The Canadian Nurse
Immediate openings for qualified
RN s on all shifts, full time, part
time. 203 bed JCAH accredited
acute care hospital, adjacent to
Oregon Institute of Technology,
offering a 2 + 2 AD/BSN program.
We are located in Southern
Oregon. Excellent year round
outdoor activities. Family
oriented community. Excellent
working conditions and benefits.
Competitive salary with oppor
tunity for advancement. Contact
Personnel Department, MERLE
WEST MEDICAL CENTER, 2865
Daggett St., Klamath Falls, OR
97601, or call COLLECT (503)
882-631 1, Ext. 131. We are an
equal opportunity employer.
United States
Nurses RNs A choice of locations with em
phasis 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 Or
call collect (713) 789-1550. Marilyn Blaker,
Medex, 5 805 Richmond, Houston, Texas 7 70S 7.
All fees employer paid.
Miscellaneous
Electrolysis Successful Electrolysis Practice
for Sale. 6 months specialized included. Write
or phone: Margot Rivard, 1396 St. Catherine
Street West, Suite 22 I.Montreal, Quebec, H3G
1P9. Telephone: (5 14) 861-1952.
Adventure Holidays:Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario M5E
1J3. Phone: 4 16-863-0799. Telex: 06-219621.
R.N. s
Come to Texas
244 Bed Regional Medical Center
Located 75 miles north of Dallas on
the banks of Lake Texoma ( 1 2th
largest lake in the U.S.)
Progressive Nursing Administration
Professional growth opportunities
Excellent salary and benefits program
Openings in 1CU. Emergency,
Psychiatry. Renal Dialysis, and other
speciality areas
Contact:
Bonita Palmer, R.N.
Director of Nursing
Texoma Medical Center
P.O. Box 890
Denison, Texas, USA 75020
Choose a
Nursing
Career __
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H1V8
Telephone: 1 (902) 428-3484
The Registered Nurses
Association of Nova Scotia
invites applications for
Nursing Consultant-
Education
Duties:
To provide assistance and consultation to
schools of nursing, as well as the organiza
tion and development of continuing
education programs for nurses.
To act as resource person to committees of
the Association.
To act as liaison with government, health
care and educational institutions and
other associations.
Qualifications
Applicant must be eligible for registration
in Nova Scotia. Preparation in education
at the Master s level preferred, with at
least ten years experience in nursing and
nursing education.
Salary negotiable.
Position Available August 1, 1980
Applications with complete resume of
qualifications, experience and the names
of three references should be submitted to:
Executive Secretary
Registered Nurses Association
of Nova Scotia
6035 Coburg Road
Halifax, Nova Scotia
B3H 1Y8
Registered Nurses
Planning your summer vacation?
Then by all means, include a visit to
beautiful Vancouver in your plans. And
while you re here, drop in and discuss
your nursing career opportunities at
Shaughnessy Hospital, an 1 100 bed
multi-level community teaching hospital.
We have full-time, part-time and float
positions available as well as a 2 week
orientation for RN s who wish to work
on a casual basis only.
When you re in Vancouver please call:
Jane Mann
Employee Relations
Shaughnessv Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(604) 876-6767
The Canadian Nurse
June 1980 59
R.N. s Required
Applications are invited for full time nurses to
work rotating shifts in new 40 bed active
treatment hospital. High level of activity in
Emergency, Surgery and Obstetrics offers
challenge and the benefit of valuable
experience for conscientious nurses. Previous
experience an asset. Must be registered or
eligible for registration in Alberta.
AHA/AARN Policies in effect.
Hinton is a modern, progressive, industrial
town on the eastern slopes of the Rockies, 50
miles east of Jasper. Population 7,600.
Unlimited year round recreational facilities.
Apply with full resume including experience
and references to:
Director of Nursing
Hinton General Hospital
Box 40
Hinton, Alberta
TOE 1BO
Summer Employment
Registered Nurses
Nursing opportunities will be available
for a 3 or 4 month period during the
months of May, June, July, August 1980.
Nurses will provide primary nursing
care, be able to exercise clinical
judgement and participate in a
patient-family oriented program in our
modem 300 bed teaching extended care
unit. Interested nurses, who are eligible
for registration in British Columbia
should write to:
Hospital Employment Officer
Health Sciences Centre Hospital
University of British Columbia
Vancouver, B.C.
V6T 1W5
Positions open to both female and male
applicants.
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
1CU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
msj
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, Part Time and Casual Employment.
Benefits in accordance with R.N.A.B.C.
contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Head Nurse
Head Nurse required for Intensive Care
Unit (6 bed) in an expanding 258 bed
acute and extended care hospital in the
Okanagan Valley.
Must be eligible for registration in B.C.
Previous applicable clinical and
administrative experience required.
Advanced administrative education,
BScN, and post graduate education in
I.C.U. preferred.
To commence 1 August 1980.
Salary and benefits in accordance with
R.N.A.B.C. collective agreement.
Apply, with resume to:
Director of Personnel
Vernon Jubilee Hospital
Vernon, British Columbia
V1T 5L2
School of Nursing
Nursing Instructors
required for August, 1980
in a 2 year English language
Nursing Diploma program
Qualifications:
Bachelor of Nursing with experience 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
The Miss A.J. MacMaster
School of Nursing
100 Arden St.
Moncton, N.B.
E1C4B7
Telephone: 506-854-7330
International Grenrell Association
requires immediately
Assistant Director of Nursing
For accredited 160-bed general hospital in St.
Anthony. Newfoundland.
Duties include assisting the Director of
Nursing with the planning, organizing,
directing and evaluating of the nursing services
ofCharles S. Curtis Memorial Hospital.
Accommodation provided at reasonable rates.
Travel borne by the Association on minimum
of one year service. Group life health
insurance and pension plan offered. Other
fringe benefits.
Applicants must be eligible for registration
with ARNN . Post-basic preparation.
Preferably a baccalaureate degree in nursing or
other desirable combination of experience and
training.
Salary in accordance with Newfoundland
government scale.
Apply to:
Mr. Scott .Smith
Personnel Director
International Grenfdl Association
St. Anthony, Newfoundland
AOK4SO
Registered Nurses
Required immediately Registered
Nurses only for a 90 bed hospital in
Medicine, Surgery Paediatrics and
Special Care Units.
Salaries according to Provincial
Salary Guide.
Usual fringe benefits.
Apply to:
Director of Nursing
Digby General Hospital
Digby, Nova Scotia
BOV 1AO
Telephone: 245-2501
Ungava Hospital
Kuujjuaq (Fort-Chimo), Northern Quebec
Nurses:
for an 1 1 bed hospital at Kuujjuaq and for
Nursing Stations of Northern Quebec Inuit
villages.
Qualifications:
Minimum of one year of Nursing experience
Bilinguism essential
Ability to take responsibilities
Advantages:
Knowledge of a new culture
Functions different from regular hospital
routine
Supplementary benefits (isolation premium,
transportation, etc.)
Please send your Curriculum Vitae to:
Projet Nord
DSC, CHUL
2705, I .auric r Blvd
Ste-Foy, Quebec
G1V4G2 (418)656-8900
80 June 1980
The Canadian Nurse
The Aga Khan Hospital and
Medical College, Karachi
SCHOOL OF NURSING
Nursing Instructors
Applications are invited for 4 positions of nursing
instructors immediately and additional instructors
phased over 4 years.
The School is located in a modern facility which is due
to be completed in June. The first class of students of
a 3-year diploma program will be admitted late this
year. The medium of instruction will be English.
Initially, clinical experience will be provided in selected
Karachi hospitals until completion of the 721 -bed Aga
Khan Hospital in 1984.
Qualifications
Applicants must have a bachelor s degree in nursing or
nurse-teacher qualifications and must be eligible for
registration in Pakistan. Preference will be given to
applicants with three years of nursing practice and at
least 1 year of teaching experience. Teachers will
participate in classroom and clinical teaching.
Competitive salaries will be offered depending on
qualifications and experience. The initial contract
period is three years. Relocation assistance will be
provided.
Applications including a resume, recent photograph and
names of three references should be addressed to :
Ms. W. Warkentin
Director
School of Nursing Aga Khan Hospital
P. O. Box 3500 Karachi 5 Pakistan.
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?
We know where the best jobs are, how much they pay,
and where you ll fit in. R.R.N. can give you more than
just a job we can help you build a satisfying career.
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 that dotted line to-day, you should check with
Recruiting Registered Nurses Inc. We re the Canadian
Medical Placement Specialists throughout the United
States.
R.R.N. has immediate positions available in:
California Ohio Pennsylvania Michigan
Don t wait!!!! Call or write immediately for further
information.
"No Fee To Applicants"
RECRUITING REGISTERED NURSES INC.
JVW
1200 Lawrence Avenue East
Suite 301, Don Mills
Ontario M3A 1C 1
Telephone: (416) 449-5883
Cross flds
to
You ll find it an exciting experience on both
sides. America s favorite city, San Francisco,
hums with activity for all life styles on one side,
and a few miles down the road on the other side
you ll find the beautiful Stanford University
Campus, and one of the nation s most
progressive medical centers. The "Stanford
Experience" of a rich combination of learning
and doing. We re working with exciting new
concepts. ..developing new procedures...
generating opportunities for nursing
involvement at the heart of primary patient care.
Active inservice programs, specialty courses,
seminars, workshops and nursing research
offer a continuing education opportunity in
virtually every specialty. We d like to tell you
more about what you ll find on both sides of the
bridge. ..we call it the Stanford Experience.
Please submit a resume to or call COLLECT:
Nurse Recruiter, Stanford University Hospital,
Stanford, CA 94305, (415) 497-7330. An equal
opportunity/affirmative action employer
female/male/handicapped.
I would like to know more about Nursing
Opportunities at Stanford
Name
Stanford University
Medical Center
The Canadian Nurse
June 1 980 61
Director of Nursing
Applications are invited for the position of Director of Nursing
for the Centra] Peace General Hospital. The Hospital is a 50 bed,
active treatment facility located in the heart of the Peace River
Country at Spirit River, Alberta.
The applicants must be eligible for Registration with The Alberta
Association of Registered Nurses, preferably hold a B.Sc. degree
in Nursing and have at least five years experience in a
responsible nursing position.
Applicants should apply stating experience, education, salary
expected and date available for duty to:
Mr. J. V. Bjork
Administrator
Central Peace General Hospital
Spirit River, Alberta
TOH3GO
OPPORTUNITY
Team Leaders - Edmonton
The Eric Cormack Centre, provides residential
accommodation and developmental opportunities for 92
dependent multihandicapped children and young adults.
These persons will supervise and direct a team in
providing for the health maintenance needs of residents
living on a 24 bed unit.
Qualifications: Graduation from a recognized school of
nursing and current eligibility for registration in the
appropriate professional organization. Some exposure
and experience in the field of mental retardation, as well
as some supervisory experience would be an asset.
Salary: $14, 748 -$17, 340
Competition #9176-1 Open until suitable candidates
selected.
For detailed information, request Job Bulletins and apply
to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education Programs.
Post Graduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Appl> to:
Recruitment Officer Nursing
University of Alberta Hospital
8440 1 12th Street
Edmonton, Alberta
T6(, 2B7
University of
Alberta Hospital
Edmonton, Alberta
62 June 1980
The Canadian Nurse
Co-Ordinator
Surgical Nursing Services
This 1 100 bed community and teaching
hospital invites applications for the
position of Co-ordinator-Surgical
Nursing Services. The area components
are five nursing units plus a four bed
intensive care unit, totalling 146 beds.
This person will be responsible for the
overall delivery of quality patient care
and management of the surgical services
including budget control, staffing, staff
development and other administrative
duties.
Applicants must have an appropriate
degree and significant clinical
experience.
Please forward a resume detailing
experience and qualifications to:
Vjvian Walwyn
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C.
V6H 3N1
(6041 876-6767, local 271
MITCHELL COLLEGE OF ADVANCED EDUCATION
AUSTRALIA
Mitchell College is the largest country college of advanced education m Australia, situated at
BATHURST NSW. 210 Km west of Sydney. The College offers programs of study in Business and
Administrative Studies, Teacher Education, and Liberal and Applied Arts to an enrolment of 4000
students
Applications are invited for the position of
Lee tuner/Senior Lecturer
in \ursing Administration
The appointee will develop study material and teach Nursing Administration units within the Associate
Diploma in Health Administration which is a recognised professional qualification for nursing and
hospital administrators in New South Wales. As the course is formulated on an integrated approach to
health administration, the appointee will contribute additionally in those areas where his/her experience
or qualifications are appropriate.
This is the initial nursing appointment in the Department of Management Studies and Offers the
appointee the opportunity to provide personal and academic leadership to several hundred students.
Applicants should have recent experience in nursing administration at a senior level and hold a degree
in nursing or health administration or a good first degree with an emphasis towards management
oriented subjects
Further details of the position may be obtained from Dr R Garnett (063) 31 1022.
The successful applicant would be expected to take up the appointment in July/August, 1980.
SALARY and appointment level will depend on qualifications and experience -
Senior Lecturer 1 - SA24996 to SA26622 per annum
Senior Lecturer 11- SA22842 to SA24458 per annum
Lecturer 1 - $A1 9923 to SA22365 per annum
Lecturer 1 1 - $A1 7024 to $A1 9465 per annum
Lecturer 111 - SA14673 to SA16809 per annum
CONDITIONS of employment include an attractive superannuation scheme and a specially negotiated
bank finance arrangement for building or buying a home. Fares for the appointee and family to Bathurst
and reasonable removal expenses will be paid.
APPLICATIONS setting out personal data, telephone number, qualifictions and experience, accompanied
by the names and addresses of three (3) referees and a recent photograph of the applicant, should be
sent to:
The Registrar (Staff Appointments)
MITCHELL COLLEGE OF ADVANCED EDI
BATHURST NSW 2795
AUSTRALIA
EDUCATION
Applications close on Friday 20th June 1980
Registered Nurses
Applications are invited for full time and
part time employment at Oshawa
General Hospital, a 600 bed hospital. 48
kms. EastofToronto.
Successful candidates must be registered
in Ontario.
Services provided include:
Medicine
Surgery
Obstetrics
Emergency
Paediatrics
Intensive Care
Coronary Care
Out-Patients
Chronic/Rehabilitation
Salary Range: (Full time) $1,450.00 -
$1,676.00 (monthly)
Inquiries may be directed to:
Personnel Services
Oshawa General Hospital
24 Alma Street
Oshawa, Ontario
L1G2B9
Health Sciences Centre
Winnipeg, Manitoba
invite applications for the position of
Director
School of Nursing
A leadership position is available in a two-year diploma nursing school situated in a
large teaching hospital, with an enrolment of approximately 200 students and 30
faculty and support staff. The school has an established curriculum based on an
adaptation model. Responsibilities will include administrative and budgetary
functions, student counselling and recruitment, on-going review of curriculum and
policies, maintenance of a climate for teaching/learning and the overall maintenance
of standards.
Applicants must be registered or eligible for registration with the Manitoba
Association of Registered Nurses and have successful experience in both teaching
and administration. Preparation at a Master s level in nursing is preferred.
The position is available in July .198 1 .
This position is open to females and males. Interested persons should apply in writing
including a complete resume detailing education and experience to the:
Manager Employment & Training
Health Sciences Centre
700 William Avenue
Winnipeg, Manitoba
R3EOZ3
The Canadian Nurse
Jun*19M 63
Fishermen s Memorial Hospital
Director of Nursing
Applications are invited for the position of Director of Nursing
for this 60 bed, active treatment hospital located on the south
shore of Nova Scotia.
The successful applicant will report directly to the Administrator
and will be responsible for the planning, organization and
administration of the nursing services.
The applicant will have a successful background in nursing
administration and preferably will have had academic courses in
preparation for management.
Address all inquiries in writing, stating date available and salary
expected to:
Harley K. Frowd
Administrator
Fishermen s Memorial Hospital
Lunenburg, Nova Scotia
BOJ 2CO
Assistant Director of Nursing
Active Treatment
Required for a fully accredited 135 bed active care hospital.
The Position
Asa member of the Nursing Administration Team, this nurse
needs innovative qualities and ability to organize, delegate and
direct the work of others. The applicant must have an enthusiasm
for initiating and following up new ideas, projects and quality
assurance programs.
Minimum Qualifications
Candidates must be currently registered in the Province of
Alberta, and possess a Baccalaureate Degree in Nursing, with
demonstrated competence and ability in a senior level nurse
management position.
The position becomes available August 18, 1980. upon the
retirement of the present incumbent.
Interested applicants may submit a comprehensive resume to:
Mr. Bruce Finkel, Director of Nursing
Wetaskiwin General Hospital
5505 - 50 Avenue
Wetaskiwin, Alberta
T9A OT4
Registered Nurses
Come to work in scenic Comer Brook!
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
WestCoast of Newfoundland.
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January, 1979 $12,771.00 15,429.00
1 January, 1980 $13,410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
Required:
General Duty Nurses for an acute care Hospital
(37 beds)
27 -Adult
10 - Paediatric
10- Bassinettes
Clinical areas included:
Medicine - Surgery - Obstetrics
Paediatrics - Operating Room
Case Room and Delivery Room
Emergency and Out-Patient Departments
Applications must be eligible for registration in Nfld.
Personnel policies in accordance with the Nfld. Nurses Union
Agreement, 1980.
Salary Scale - Step I (at the present time) $14,228.00.
Shift and Charge Nurse differential.
To rotate all three shifts.
Accommodation available in Residence.
Apply to:
Director of Nursing
Channel Hospital
Port Aux Basques
Newfoundland
AOM ICO
64 June 1980
The Canadian Nurse
Open to both
men and women
NURSES
Solicitor General of Canada
Salary: Up to $23,367 (under review)
Ref. No: 80-NCRSO-NU-15
CLEARANCE NUMBER: 310-106-022
The Correctional Service of Canada will have positions
available at various locations across Canada over the next
12 months in Federal Correctional Institutions and special
psychiatric hospitals.
Salaries: Up to $23,367 (under review) - dependent on
qualifications, assignment, and location - plus
penological factor allowance of up to 31,000 per
annum, (under review)
Opportunities
Correctional health care and forensic psychiatry provide
new and expanding career opportunities for nursing
professionals. These unique, challenging areas demand men
and women with proficient nursing skills, special personal
qualities, and a pioneering spirit.
Responsibilities
In the Health Care Centres (HCCs), the nurses are the
inmates first contact with health care professionals. Each
nurse must be independent, resourceful and prepared to
operate in an expanded nursing role. In the Regional Psychia
tric Centres (RPCs), the treatment philosophy emphasizes
a multi-disciplinary approach encompassing all aspects of
psychiatry. The primary therapist in each of these
university-affiliated hospitals is frequently the nurse.
Duties
Assist in the development of medical and psychiatric
programmes for inmates in either health care centres or
regional psychiatric centres and provide nursing care to
patients on a 24 hour basis.
Benefits
Excellent pension plan; good sick leave benefits; evening,
night and weekend premiums; 1 1 statutory holidays; and a
minimum three weeks holiday; continuing education oppor
tunities and relocation expenses.
Qualifications
- Registered Nursing diploma for HCCs and RPCs
- Registered Psychiatric Nursing diploma for RPCs
- Registered/Certified/Licensed Nursing Assistant diploma
for RPCs
- Baccalaureat degree in Nursing an asset for HCCs and
RPCs
- Recent general nursing experience required for HCCs
- Recent psychiatric nursing experience required for RPCs
- Administrative and supervisory experience required for
managerial positions in HCCs and RPCs
Language Requirements
For some positions knowledge of both English and French
is essential. Because of the nature of these positions
bilingual capacity is required immediately. Other positions
require a knowledge of English, others a knowledge of
French while others require a knowledge of English and
French. Unilingual persons may apply for bilingual posi
tions but must indicate their willingness to become
bilingual. The Public Service Commission will assess the
likely aptitude of candidates to become bilingual. Language
training will be provided at public expense.
"Additional job information is available by writing to the
address below;
Toute information relative a ce concours est disponible en
franfais et peut etre obtenue en ecrivant a I adresse
suivante".
For further information call (collect) or write:
Director, Nursing Operations
340 Laurier Avenue West
Ottawa, Ontario K1 A OP9
Tel.: (613) 995-4971
How to apply
Send your application form and/or resume to:
Mrs. Joyce Bleakney
Public Service Commission of Canada
National Capital Region Staffing Office
L Esplanade Laurier, West Tower, 16th floor
Ottawa, Ontario K1AOM7
Closing Date: March 31, 1981
Please quote the applicable reference number at all times.
The Canadian Nurse
June 1980 65
Queensland Institute of Technology
Brisbane - Australia
Senior Lecturer in Nursing Studies
The Institute is a multi-disciplinary tertiary college with a student
population of 7,500 located in sub-tropical Brisbane, Australia.
The Department of Nursing Studies, in the School of Health Science,
currently offers Diploma of Applied Science courses in Nursing
Administration, Nursing Education and Nursing and Unit Management. A
Community Nursing course is planned for introduction in 1981 and abasic
nursing course is being developed. A new position is being created for a
senior lecturer who will assist in the administration of nursing programs,
and will exercise academic leadership in one or more special areas of
competence in the discipline of nursing.
Applications are invited from registered nurses, preferably with
experience in educational administration, who hold post-registration
degree or diploma level nursing qualifications. Higher academic and/or
professional qualifications are desirable, but other evidence of academic
achievement may be acceptable. Salary ranges: $A22,842 - $A24,461 ;
$A25,000-$A26,623p.a.
Conditions of service and general information may be obtained from the
Personnel Officer, Q.I.T., George Street, Brisbane 4000 Australia.
Applications quoting V. 32/80 together with full particulars, including
telephone number and the names and addresses of three (3) referees to
reach the Personnel Officer by April 30th, 1980.
Director of Nursing
Applications are invited for this position in a forty bed acute care hospital
located in beautiful Northern Saskatchewan.
We serve a population of 4,500 from a modern active community with all
services and excellent recreational facilities. Successful applicant will be
responsible for all nursing services including inservice education.
We have a nursing staff of 21 and a Medical Staff of three physicians
including a general surgeon.
Fringe benefits include four weeks paid vacation after one years service
increasing to five weeks after three years service; Group Insurance;
Pension Plan and Disability Income Plan. Air transportation paid on hiring
and for vacation. Private suite in modern residence available.
Salary is negotiable and will be commensurate with training and
experience.
Resumes and inquiries may be submitted to;
R. .1. King
Administrator
Municipal Hospital
Box 360
Uranium City, Saskatchewan
SOJ 2WO
or phone above person collect at 306-498-2412
Interested in a Challenge?
Try International Nursing - in Saudi Arabia!
The King Faisal Specialist Hospital and
Research Centre, a 250 bed Acute Care Referral
facility in Riyadh, Saudi Arabia, has current
and/or periodic openings for experienced R.N. s.
Managed by the Hospital Corporation of
AmericaGroup, the hospital is staffed with
professionals from North America, Europe and
the Middle East.
The Nursing Areas currently available are:
NICU, L & D, PEDS, INSERVICE, CLINIC &
RADIATION THERAPY. Requirements include
three years current experience as an R.N. in an
Acute Care hospital with at least one year in the
specialty and a current R.N. license in one of the
provinces. Verbal and written fluency in English.
2-Year contract commitment. Positions are
single status.
Salaries are excellent and the exceptional
benefits include 30 days paid annual leave, free
transportation, furnished lodging, bonus pay and
leave and more.
If you are a dedicated professional with a desire
to make a contribution to experience the
unusual to travel to work side-by-side with
people from around the world then we d like
to hear from you.
Don t Let This Once In A Lifetime Opportunity
Pass You By
For further information please contact:
Kathleen Langan, R.N.
Hospital Corporation International, Ltd.
Two Robert Speck Parkway Ste. 750
Mississauga, Ontario L4Z 1H8
HOSPITAL
CORPORATION
An Equal Opportunity Employer
The Canadian Nurse
Head Nurse in our Obstetrical
and Gynaecological Unit
The successful applicant will be responsible
for the administration of the 24 bed
Obstetric-Gynaecologic Unit, as well as the
Labour and Delivery area and Nursery.
Will work with a co-ordinator who has
additional responsibilities in the Paediatric
Department.
Must be eligible for Registration in the
Province of Ontario and should have
demonstrated Administrative ability.
Ours is a 300 bed, fully accredited General
Hospital serving a population of roughly
40.000 in this picturesque, culturally active,
semi-rural community. We have good
transportation links with the larger Southern
Ontario Cities.
Application, including resume should be sent
to:
Director of Personnel
Stratford General Hospital
Stratford, Ontario N5A 2Y6
Toronto East General Hospital
Required for 600 bed hospital with expanded
facilities. Minutes from downtown.
Registered Nurses:
Medical, Surgical
Operating Room
Critical Care Areas
Head Nurses:
Paediatric I nit
Special Neonatal Care Unit
Applicants must have clinical and management
experience in specialty and post basic
educational preparation
All applicants must be eligible for Ontario
registration.
Write to:
Miss H. Koski
Staffing Office, A 126
Toronto East General Hospital
825 Coxwell Avenue
Toronto, Ontario
M4C 3E7
Director of Nursing
Applications are inv ited for the challenging
position of Director of Nursing for Shouldice
Hospital an 89 bed active surgerv private
hospital located 1 I * miles north of Toronto.
The successful applicant will be a member of
the Management Team reporting to the
Administrator and will be responsible for
planning, organization and total administration
of the Nursing Serv ice.
The applicant should ideally have experience
in nursing administration and possess a
B.Sc.N. degree, but an equivalent
combination of formal education and
experience will be acceptable.
Applicants are requested to submit their
resume to:
John J. M.iiKai
Administrator
Shouldice Hospital
Box 370
I hurnhill. Ontario
L3T 4A3
ASSOCIATE
EXECUTIVE DIRECTOR -
NURSING
MOUNT SINAI HOSPITAL,
TORONTO, ONTARIO
Mount Sinai Hospital, a modern 510-bed fully accredited
active teaching hospital, affiliated with the University of
Toronto, requires an Associate Executive Director Nursing,
to provide continued leadership to an established Department
of Nursing. In addition to the medical/surgical services and
their sub-specialties, the Hospital has a short term, active
Rehabilitation In-Patient Unit, which serves as a regional area
of expertise, a Psychiatric Unit, and has recently been
recommended as a Regional Perinatal Unit.
This position will report to the Executive Director and the
individual will be responsible for planning, organizing, direct
ing and controlling the activities of the Department of Nursing.
Nursing education is provided to nursing students from the
University of Toronto and from the Community Colleges. The
Associate Executive Director Nursing plays an important
role in hospital programme formulation and in policy determi
nation, as a member of the senior management team of the
Hospital, and as a voting member of both the Medical
Advisory Council and its Executive Committee. A University
appointment is available for the appropriate candidate.
The suitable candidate will preferably have advanced prep
aration at the Master s Degree level and have a demonstrated
record of nursing experience, including 3-5 years in a senior
nursing position. The candidate must be able to work within
an academic environment and must be able to provide
leadership in furthering the patient care, teaching and re
search goals of the institution.
This position will become available November 1 , 1980, on the
retirement of the incumbent. Applications are now being
sought and resumes should be forwarded to:
Executive Director
MOUNT SINAI HOSPITAL
600 University Avenue
Toronto, Ontario,
M5G 1X5
The Canadian Nurse
June 1980 67
A Completely
Modern Teaching Hospital
Requires
Registered Nurses
This 500 bed general hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered -
Critical Care, Medical, Surgical Coronary Care,
General Surgery, Urology, Gynecology,
Medicine, Nephrology , Clinical Teaching,
Neurosciences, Cardiology, Cardiovascular
Surgery, Orthopedics, Hemodialysis (kidney
transplants), Emergency and Out Patient
Services, active Rehabilitation Program (adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in Critical Care Nursing,
Neurosciences, Operating Room Nursing.
Located in St. John s, Newfoundland the
oldest city in North America with a population of
120,000, offering cultural and recreation
activities in a friendly atmosphere.
Fishing, hunting, boating available
approximately 10-14 miles outside the city.
For information regarding salary and relocation
expenses and other conditions of employment
write or call -
Miss Dorothy Mills
Staffing Officer - Nursing
The General Hospital
Prince Philip Drive
St. John s, Nfld.
A1B 3V6
Telephone # (709) 737-6450
Head Nurse Intensive Care Unit
The Organization
University Hospital is a progressive 540 bed university teaching
hospital dedicated to providing exemplary standards of health
care. In 1979, a $40 million expansion project was completed,
including new intensive therapy facilities.
The Position
The successful applicant will report to the Director, Special
Services Nursing, and will be responsible for the administrative
and professional supervision and coordination of total patient
care in a 19-bed combined medical, surgical, respiratory,
coronary care and hemodialysis unit.
The Preferred Applicant
The preferred applicant will have previous clinical experience in
intensive care nursing, demonstrated teaching and administrative
ability and preferably a Baccalaureate Degree in Nursing.
Salary level will be according to Saskatchewan Union of Nurses
rates of pay and recognition for experience and qualifications.
Submit formal letter of application with resume to:
Employment Officer, Nursing
Personnel Department
University Hospital
Saskatoon, Saskatchewan
S7N 0X0
Head Nurse - Obstetrics
Applications are being accepted for this family centred unit
which consists of 21 obstetrical and 7 gynecological beds, plus
Nursery and Delivery suite. There are approximately 900 to 1000
births per year.
The successful candidate will be responsible for providing
innovative and creative leadership as well as for the quality of
nursing care and the administration of the unit.
Candidates should be currently registered with the College of
Nurses of Ontario and have post graduate obstetrics experience
(including fetal monitoring and Family Centred Care). Strong
leadership, management and communications skills are essential,
and graduates of the Nursing Unit Administration Course will be
given special consideration. The possession of a B.Sc.N. degree
would be a decided asset.
Please submit a resume, outlining qualifications and salary
expectations, to:
Staffing Co-ordinator
Greater Niagara General Hospital
5546 Portage Road
P.O. Box 1018
Niagara Falls, Ontario
L2E 6X2
6* JurwIMO
The Canadian Nurse
Index to
Advertisers
June 1980
Ames Division,
Miles Laboratories Limited
IBC
Ayerst Laboratories
15
The Badge Maker
49
The Canadian Nurse s Cap Reg d
48
Canadian School of Management
50
Jean Carroll Associates
51
The Clinic Shoemakers
Encyclopaedia Britannica Publications Limited
53
Equity Medical Supply Company
51
Health Sciences Centre
54
Hollister Limited
19
Kendall Canada
55
J.B. Lippincott Company of Canada Limited
21
Nordic Laboratories Inc.
52
Parke-Davis Canada Inc.
8,9
Pharmacia (Canada) Limited
70
Posey Company
22
Procter & Gamble
46,47
Ross Laboratories, Division of
Abbott Laboratories Limited
12,13
Ryerson Polytechnical Institute
10
W. B. Saunders Company
Smith & Nephew Inc.
16, 17.0BC
The University of Alberta Press
54
Upjohn HealthCare Services
20
White Sister Uniform Inc.
IFC
Whittaker International Services Company
56
Advertising Representatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
601, Cote Vertu The Canadian Nurse
St-Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone:(613)237-2133
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P. O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215) 363-6063
Member of Canadian
Circulations Audit Board Inc.
Wish
you were
here
...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
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 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 information on any, or all. of these career
opportunities, please contact the Medical Services
office nearest you or write to:
Medical Services Branch
Department of National Health and Welfare
Ottawa. Ontario K1AOL3
Name
Address
City
I
Health and Welfare
Canada
Prov
Sanle et Bien-etre social
Canada
I
I
I
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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
by relieving
pain and
odour fast
" 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
peared." 3
Day Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change 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 seeking." 4
"Two. if exudation is very heavy.
After removing crust or
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Cover with a dressing.
Debrisan cleans
decubitus ulcers fast.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
Pharmacia (Canada) Ltd.
Dorval, Quebec
References
1. Lim LT, Michuda M. Bergan JJ. Angiology 29:9, Sept 1978
2. Bewick M. Anderson A, Clin Trials J 15:4, 1978
3. Soul J, Brit J Clin Pract, 32:6, June 1978
4. DiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on file at Pharmacia (Canada) Ltd.
[%mes]
I
Today s Diabetics.
^^r
Through good control, they re enjoying better health
and a healthier outlook. And Ames is helping.
Todays diabetics have a healthier out
look on life. And it s all because they re in
control of their condition. They watch their
diet Get the exercise and therapy they
need. And keep a check on themselves with
daily urinalysis.
That s where Ames helps out
OurDiastix*orKeto-Diastix*tell them day
by day where they stand with their condition,
so there s less risk of complications than
ever before. And the cost is just a few
cents and a few seconds a day.
Our free Daily Diary
helps them keep a record of their
condition, so they can begin to see
Trademarks of Miles Laboratories. Inc Miles Laboratories, Ltd . authorized user
1979. Miles Laboratories Inc.
how, when and why it changes.
And our free Diabetic Digest offers lots
of useful information that may help them
understand their condition more clearly and
control it more effectively.
The only other thing they need is your
guidance and advice. With that, and a little
help from us, today s diabetics
can enjoy better health
and a healthier outlook.
Ames
Division
IX/IILI
Ames Division. Miles Laboratories. Ltd.,
Rexdale. Ontario M9W 1G6
We helped make urinalysis
the science it is today.
NEW Op-Site
I.V DRESSINGS
So eas so fast so
Applied in seconds
Op-Site
is comfortable
It fits like a second skin, and its
hypoallergenic adhesive
minimizes the risk of skin
irritation.
Just peel the pouch open.
Op-Site is sterile and ready to
apply.
Apply Op-Site on the clean, dry
i.v. site, right over the catheter.
Leave Op-Site undisturbed until
the catheter is changed!
Op-She secures
the catheter
firmly to the skin, to help pre-
vein irritation.
Op-Site
is transparent
It s the only dressing that allows
direct observation of the site
without being removed. Op-Site
lets you spot i.v. problems the
minute they occur!
Op-Site
is bacteria-proof
Under Op-Site, i.v. sites are pro
tected from contamination,
because no pathogens can
penetrate Op-Site. And Op-Site
is waterproof, too.
Simpler, safer catheter care
Op-Site is the only dressing that secures i.v.
catheters while helping to keep the site
sterile. It goes on in one easy step, and stays
on until the catheter needs to be changed !
Smith & Nephew Inc.
2100, 52 Avenue
Lachine, Que., Canada
H8T 2Y5
Op-Site is a skin-thin, transparent, adhesive
polymer membrane that seals out water and
bacteria, while letting air and moisture vapour
through to prevent skin maceration. Op-Site
is a comfortable, secure, hypoallergenic
dressing that protects without gauze, tape, or
ointments. And its low cost will surprise you!
Reg TM
Bu* En nombre
thtrd troisieme
class classe
10539
A self-help guide
to the aging process
Nutrition for seniors
Helping parents
of premature infants
Income tax
for the self-employed nurse
The
Can
Nurse
JULY/AUGUST 1980
SC/ENCES INFIRM/ERES
* 1980
NURSING LIBRARY
WONDERFEEL
YARN OF FORTREL" POLYESTER
FASHIONS FROM DESIGNER S CHOICE
FALL CLOSET
Style No. 5404 Dress
Sizes: 8-18
Wonderfeel*
100% Fortrel
Polyester, warp knit.
White, Blue.
Attitudes to aging are the
focus of this Summer issue of
CNJ... physiology, reality
orientation and nutrition are
all discussed in articles by
nurses and a dietitian. Plus,
an editorial comment from
one of this country s most
respected senior citizens,
Senator David A. Croll. Our
cover photo is courtesy of
Health and Welfare Canada.
The
Canadian
Nurse
July/ August 1980 Volume 76, Number 7
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Gail O Neill
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
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.
Jean Passmore.ecfoor, SRNA news
bulletin. Registered Nurses
Association of Saskatchewan.
Peter Smith . director of publications,
National Gallery of Canada.
Florita Vialle-Soubranne . cons ulia nt ,
professional inspection division. Order
of Nurses of Quebec.
Spotlight on aging 19
Preemie parents
44
14
YOU AND THE LAW
The responsibility of the patient
Corinne Sklar
35
Income tax and the
self-employed nurse
Maureen Garbutt
SPOTLIGHT ON AGING
- fi I. A self-help guide to the
38
Nerve palsies: the
preventable sort
26
28
30
aging process
Patricia Morden
, Reality orientation
Marion Walker, Rosalie Nepom
, Seniors: A target for
nutrition education
Doris Gillis
Self-help groups for parents of
premature infants
Nancy Shosenberg
Christine McNamee,
Bruce Maclean
44
Nurses, unions, professional
associations and YOU
Part one: Nurses take the union
route
Glenna Rowsell
5
Calendar
6
News
48
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ISSN 0008-4581
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Canadian Nurses Association, 1980.
perspective
A GERIATRIC CRISIS
Senator David A. Croll, Q.C.
Social welfare was born in Canada in 1909 when
the Annuity Act was made law. From its inception
it was popular and much used by the less fortunate
of this country.
During the Depression, many of the poor,
always fearful that their contract with the
government would be cancelled if they did not pay
the monthly amount due under the contract
it never was often sent in stamps and sometimes
nickels and dimes, so great was their desire to have
something to look forward to at the end of the
day.
In 1927 the government passed the Old Age
Security Act authorizing payment of $20.00 a
month to those 70 years and over who passed the
means test.
In 1952 a new blow was struck when the
Old Age Security Act was stripped of its means
test and applied on a universal basis. This was
meaningful progress.
Eventually, the minimum age was reduced to
65 and now those who receive the Old Age
pension are entitled to and receive about $185.00
a month, a figure now being indexed.
The next vital step was to proclaim Medicare
and make it available to all under all circumstances;
this was to be free medical service to all Canadians.
It has not turned out quite that way but corrective
steps are in the making.
This is one of our greatest achievements and
one which I believe we must guard with all our
strength. It is the cornerstone of our social welfare
system.
Then about fourteen years ago came the
Canada Pension Plan which since its inception has
also fallen short of our expectations. The recent
report of the Special Committee of the Senate on
Compulsory Retirement and Pensions indicates
that the pension reality in the country is uncertain
and unsatisfactory.
The report, "Retirement Without Tears",
has had wide acceptance and created an interest
in pensions that will soon be pursued by govern
ment. All political parties have indicated their
support for doing something effective with
pension legislation.
Old Age Security, Medicare and Canada
Pension Plan form the basis of our social security
system in Canada. I believe it is the responsibility
of the nursing profession to take an active and
prominent part in maintaining and preserving
these measures, particularly Medicare which is
so dependent on nursing and all that that
profession implies. An imaginative approach is
called for.
Our older people are now living 18 years
past 65 for women and 15 years past 65 for men.
This is a blessing; it is also an achievement and
should be treated as such.
We need these over 65 s in order to provide
a meaningful pension for themselves and to
contribute to a pension fund for as long as they
work so that the younger people will not be
paying too much for the pensions of older people.
The new situation is that there is a second or
third career after 65 which cannot be satisfied
by retirement.
Since this development involves older
people, it inevitably also involves nurses. The
geriatric crisis is now upon us. Here is an
opportunity for meaningful leadership to open
new avenues for preventive medicine, our weakest
aspect so far of Medicare.
The problems that will be involved are of
increasing concern and so an in-depth study of the
opportunities for service should be made at the
earliest date.
Nurses have a unique responsibility and
obligation to serve our older citizens and to help
solve the problems that will inevitably be brought
upon us by longer living. There must be a new
dimension to their contribution to the fastest
growing portion of our population.
The Hon. David A. Croll has served as chairman of
two major reports on the problems of aging in
Canada, The Senate Committee on Aging (1966)
and Retirement Age Policies (1977). He was also
chairman of the Special Senate Committee on
Poverty. Now 80 years of age himself, he remains
an active member of the Senate to which he was
appointed in 1955.
Notice to CNA members
Re: CODE of ETHICS
Directors of your association, at a June pre-convention board meeting in Vancouver,
approved a motion that the section of the CNA Code of Ethics containing references to
"the withdrawal of needed services" be deleted and a substitute section be developed by an
ad hoc committee appointed by the Board of Directors. This committee has been appointed
and further information will be available through The Canadian Nurse.
Dedicated to CARING)
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calendar
Contributions to CALENDAR are published
free of charge as space permits. For more than
one insertion or to ensure publication in a
specific issue, please consult our advertising
department.
The 16th annual conference of the
Association for the Care of Children in
Hospitals will be held May 10-14,
1981 at the Royal York Hotel, Toronto,
Ont. Papers, abstracts and workshop
proposals may be submitted until
August 31, 1980. Contact: ACCH 1981
Conference Office, The Hospital for
Sick Children, 555 University Ave.,
Toronto, Ont., M5G 1X8.
The University of Alberta will offer the
following nursing workshops in the fall
of 1980: Planning and Implementing
Staff Development, Sept. 8-9; Health
Assessment, Dealing with Neurotic
Behavior, Sept. 25-6; Dealing with
Anger, Oct. 17; Handling Patient
Discharge Effectively, Nov. 6-7; and
Instructional Skills for Nurses, Nov. 1 3-4.
Contact: Millie Pasemko, Faculty of
Extension, University of Alberta,
Corbett Hall, Edmonton, Alta.T6G 2G4.
"Meeting the Challenge" The rehabi
litation of the traumatic brain-injured
adult is the topic of a conference to be
held at the Holiday Inn, Toronto,
Sept. 18-9. Contact: Centennial College,
c/o Debby Banks, Ashtonbee
Conference Center, P.O. Box 631,
Station A, Scarborough, Ont.MlK 5E9.
The annual meeting of the Inter-Urban
Spinal Cord Association will be held
Sept. 25-6 in Ottawa, Ontario. Contact:
Mrs. Carol Anne Clarke, c/o The Royal
Ottawa Hospital, 1145 Carting Ave.,
Ottawa, Ont. K1Z 7K4.
"Respiratory Care for the Critically 111"
is the theme of the Conference of the
Toronto Chapter of the American
Association of Critical Care Nurses to be
held Sept. 29-30 at the Holiday Inn,
Toronto. Contact: Toronto Chapter
A.A.C.N., P.O. Box 37, Postal Station Z,
Toronto, Ont. M5N 2Z3.
The third international Seminar on
Terminal Care will be held Oct. 6-8
at the Queen Elizabeth Hotel, Montreal.
Contact: Post-Graduate Board, Royal
Victoria Hospital, 687 Pine Ave. W,,
Montreal, P.Q., H3A 1A1.
The Ontario Assembly of Emergency
Care will hold this year s conference at
the Skyline Hotel in Toronto, Oct.6-8.
Contact: Ontario Assembly of
Emergency Care, P.O. Box 550,
Vineland, Ont. LOR 2CO.
A three week course in Rehabilitation
Nursing will be held at the Wascana
Hospital, Regina, Sask., Oct. 14 to 31.
Contact: Shirlean Gear, Coordinator,
1980 Rehabilitation Nursing Course,
Wascana Hospital, 23rd Ave. & Ave. G,
Regina, Sask. S4S OA5.*
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It is resistant to soiling and smudges, out
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It imparts an almost like new look to your
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News Feature
Annual Meeting Roundup
BRITISH COLUMBIA
Almost five years to the day
after approving the creation
of an autonomous Labor
Relations Council that would
operate within the framework
of a restructured professional
association, BC nurses have
authorized directors of their
association to conduct an
examination of the legal
relationship between the two
bodies and "to take whatever
steps are necessary to resolve
this issue in the best interests
of the members of the
RNABC." Discussion of the
nature and extent of the
involvement between the two
bodies now and in the
future became an
unscheduled priority item on
the agenda of the 1980
three-day annual meeting in
Vancouver early in May and
resulted in a special evening
session.
The amended
resolution finally approved
by membership directed
elected officials to examine
the situation as quickly as
possible and "in their
examination to seek a
continuing involvement of
the Labor Relations Council."
Members also requested that
they be kept fully informed
of developments as they
occur.
Trouble on another
front was predicted by
RNABC president Stephany
Grasset in her report to
membership who described
nursing shortages in some
areas as "critical" and said
that too often nurses are not
able to give even minimal
care "the bare bones of
safety." Grasset, who said
that nurses are being driven
away by intolerable working
conditions and lack of
authority to do something
about it, pointed out that
"responsibility without
authority is a burden that
becomes intolerable after
awhile."
"Even money," she
said, "will not be enough to
bring these nurses (who have
1 left nursing) back." She
reminded her audience that
a shortage such as the current
one in BC had been forecast
several years ago by the
executive director of the
national association,
Dr. Helen K. Mussallem who
predicted that a decline
in status of the nursing
profession in that province
would result eventually in a
manpower shortage. BC
schools of nursing have
traditionally supplied less
than half of the number of
new nurses needed annually.
Last year only about one
third of new registrants were
BC graduates.
Preventing burnout
"Conflict can be a growing
experience" was the message
keynote speaker Dr. Frances
Storlie brought to her
audience. Dr. Storlie who is
associate professor of nursing
in the graduate program at
Orvis School of Nursing,
University of Nevada, Reno,
focused her remarks on the
coping behaviors available to
nurses in conflict and the
steps that they can take to
prevent professional
discouragement and
"burnout". Conflict takes
root at the crosspoint of
incompatible values," Dr.
Storlie said. "It is a natural
outcome when nurses with
differing values practice in
the same setting." She
described the nurse in
conflict as "one whose values
or ideals are at odds with her
surroundings" and pointed
out that, "when the solitary
nurse is cast against the
background of the group,
this conflict is poignant, raw
and very, very lonely."
Dr. Frances Storlie
The good news, Dr.
Storlie said, is that conflict
can have a positive outcome.
The nurse learns to recognize
shortcomings in herself
without being devastated by
that knowledge. "Her belief
in herself as a professional is
strengthened and she begins
to walk the road of
attainment again, this time
with increased understanding
of her goals, stronger after
the detour."
Five nurses
whose practice reflects
different aspects of nursing
took part in the panel
discussion on rewards in
nursing that followed Dr.
Storlie s presentation. The
five were: Lorna Janze of
Hazelton, head nurse in a
small hospital 750 miles
north of Vancouver; Diane
Porter, general duty nurse,
Mills Memorial Hospital in
Terrace; Mohamed
Rajabally, educator,
Okanagan College, Kelowna;
Georgina Dingwall, nurse
practitioner, Mayne Island;
and Lynn Woods, a nurse
with 1 2 years experience who
has left nursing "for awhile 01
for good" to return to school
Rewards in nursing,
according to the group,
include personal growth and
satisfaction from "hands on
care". Most agreed, however,
with panelist Mo Rajabally
who declared, "Whether we
like it or not, we re living in a
pressure cooker. It s a tough
life being a nurse."
Resolutions
Members approved upwards
of a dozen resolutions,
including one authorizing
directors to begin a search for
more adequate office space
and parking to house RNABC
staff and membership
facilities. The building now in
use was purchased when
membership was 10,528,
compared to the present
figure of almost 23,000.
Other resolutions
submitted by members and
approved by voting delegates
urged action in the following
areas:
1. Health education the
incorporation of health
education in teacher training,
extension courses in health
education for teachers and
students, and inclusion of
health education in school
curriculum planning.
2. Health services provision
of adequate and appropriate
long term psychiatric
facilities and services for
adolescents, increased
funding for child care and
better protection of the
public and environment from
the dangers involved in
transporting hazardous
products by road or rail.
3. Association policy and
member services
acceptance in principle of
making the office of
association president a full
time salaried position,
reimbursement of legal costs
incurred by members
appearing before the RNABC
discipline committee, board
of directors or provincial
courts who are subsequently
exonerated, a position
statement on affirmative
action and equal oppor
tunity for women, provision
for no-charge long distance
calls from members to the
association offices.
A number of
resolutions were defeated,
including proposals to
increase the yearly allotment
to chapters, to define the
responsibility of the nurse in
giving information to
children, to support in
principle a woman s right to
choose whether or not to
have an abortion, to provide
child care facilities at annual
meetings of the association,
to videotape proceedings of
these meetings for the general
membership, and to urge the
establishment of a central
health registry.
MANITOBA
"Nurses in the year 2000
need not be concerned with
preventible diseases in the
Third World, if, in the next
20 years, they can make a
legitimate impact on health
care." Dr. Helen Mussallem,
keynote speaker at the annual
meeting of the Manitoba
Association of Registered
Nurses was looking at the
goal of the World Health
Organization "Health for all
by the year 2000".
Speculating that nurses,
internationally, will be the
majic ingredient in reaching
this goal, Dr. Mussallem
predicted that "Canada and
other developed countries
will be faced with the
problems of af fluency, that is,
the diseases of choice, the
self-imposed diseases and that
these will be the major
problems for nurses who will
be on the front line of health
care."
But if nurses in the year
2000 are to realize their
potential, nurses now must
take giant strides. Dr.
Mussallem reminded her
audience "that currently,
over 80 per cent of registered
nurses in Canada are
employed in hospitals where
they do not have the
opportunity to alter the
course of events that bring
the patient to the hospital;
only nine per cent of our
registered nurses work in
settings where the primary
concern is not illness. Over
80 per cent of our nurse
manpower, more than
208,000 RN s, are located in
a setting that addresses itself
to about 1 5 per cent of the
actual health care problems
and, to compound this,
Canada continues to spend
about 95 cents of every dollar
on illness care."
Members of MARN
attending the two-day
meeting in Winnipeg, May 22
and 23 were also addressed
by Sister Simone Roach on
Research and Ethical Issues,
Roblin Tamblyn on
Specialization, Pat Wallace on
Standards of Nursing
Practice, and Dr. Shirley
Stinson, CN A president-elect
on Nursing Education and
Continuing Education.
Dr. Stinson predicted that, in
the future, many of our
questions involving nursing
education will remain the
same but our solutions will
be quite different as we
determine how we can best
use technology. "By the year
2000, nurses will receive a
substantial part of their basic
education via television
satellite and home-based
computers and they will
obtain their basic clinical
nursing experience in a wide
variety of health care settings,
including factories and
sea-based oil rigs."
Dr. Stinson did express
some concerns for the future
of nursing, "If nursing
administration teaching is not
strengthened, then by the
year 2000 health adminis
tration will have taken over
that role." She emphasized
the need for nursing to look
more closely at curricula and
especially to recognize the
present unacceptable reality
of a total lack of educational
facilities within Canada for
preparation of nurses at the
doctoral level.
Looking at local issues,
Louise Tod, executive
director of MARN, delineated
the realities of the increasing
shortage of registered nurses
within the province. "In the
fall of 1979 an acute shortage
of registered nurses was
apparent in Manitoba and
across Canada. A survey of
250 acute care and personal
care homes in Manitoba was
carried out. The 161 replies
revealed 262 full time and
part time vacancies as of
January 15, 1980." She
stated that a breakdown of
membership statistics
comparing 1979 to 1976
memberships revealed 265
fewer nurses returning to
nursing, 258 fewer new nurse
registrants from outside of
the province, and 91 fewer
Manitoba diploma graduates
in 1979.
In an attempt to
compensate for this shortage
and to deal with an increased
demand for nurses to return
to work, there has been a
renewed interest in refresher
programs. It is hoped that the
number of graduates from
these programs will increase
from 69 in 1979 to a total of
110 by December 1980.
The Manitoba Minister
of Health, the Honorable
L.R. Sherman sees the
potential shortage of nurses
as one of the major challenges
facing his department. He
said that meeting and
minimizing any shortage of
nurses and development of
recruitment programs for
nursing professionals has
become a priority item. He
then invited MARN to join
with the provincial
Department of Health "in
identifying the basic reasons
for the peaks and valleys in
nurse supply."
On the final day of
the meeting membership
voted on resolutions to direct
their board for the coming
year. First and most
controversial of the reso
lutions accepted by members
involved increasing MARN
fees to $ 1 00 annually for all
practicing registered nurses
and $40 annually for
non-practicing registered
nurses. Two other resolutions
reflected the current nursing
shortage: the board of
directors of MARN was
instructed to fund a career film
clip for television use directed
to the mature student and
suggesting nursing as a
career. The board will also
discuss with representatives
of Red River Community
College the feasibility of
developing a special
condensed and enriched
nursing education program
for out-of-country registered
nurses who have been unable
to meet the requirements for
registration within the
province of Manitoba.
President Marguerite Bicknell
Other resolutions
passed focused on:
occupational health
nursing: the development and
interpretation of guidelines
for OHN ; encouraging of the
Manitoba government to
employ a second OHN
consultant; asking the
Canadian Nurses Association
to request an OHN consultant
be hired at the federal level
and approaching the
provincial government to
change the Code of Practice
for Workplace Safety and
Health Committees to allow
the OHN to attend the Safety
and Health Committee in an
advisory capacity;
nursing administration:
MARN will support the
CNA s belief that the
executive responsible for the
department of nursing shall
be an educationally qualified
registered nurse who is a
member of the senior hospital
administrative staff, reporting
directly to the chief executive
officer. MARN will also
approach CNA to request the
Canadian Council on
Hospital Accreditation to
enforce this standard ;
specialization: an ad
hoc committee is to consider
the question of specialty
registries at either the
provincial or national level;
recognition of
excellence: the board is to
investigate the feasibility of
establishing an award to
recognize excellence in the
practice of nursing.
Plans are already
underway for next year s
meeting, September 30
through October 2, 1981.
Following suggestions from
membership, the MARN
annual meeting will now be
held annually in Winnipeg in
conjunction with the
Manitoba Association of
Nursing Students annual
conference. ^.
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SASKATCHEWAN
The Saskatchewan Registered
Nurses Association has
followed the lead of
Manitoba and Alberta in
agreeing to investigate
establishment of two levels of
nursing, one of which will be
designated as "professional"
and will require baccalaureate
level preparation. SRNA
members attending this
year s annual meeting also
approved, by a narrow
margin, a target date of 1 990
for implementation of this
requirement for those
entering practice for the first
time. The baccalaureate
requirement, if it is
implemented, will not
jeopardize the standing of
SRNA members already
practicing, but will apply
only to new graduates
registering for the first time
in Saskatchewan.
A total of 470 nurses
turned out for the
association s 63rd annual
meeting in Saskatoon in May.
One of their major
accomplishments during the
three-day meeting was
approval of 33
recommendations containing
directives for SRNA activities
over the next five to 15 years.
The recommendations are
contained in the report of a
task committee set up in
1977 to investigate the status
of nursing in the province and
presented to the annual
meeting.
The report identifies
the need for nursing research,
changes in nursing practice,
additional funding for the
continuing education of
nurses, and a strengthening of
the role of the nurse
administrator.
The report also notes
the "province-wide need for
additional university credit
courses for nurses and
supports the development of
a masters program at the
College of Nursing, University
of Saskatchewan, and the
establishment of a
baccalaureate program in
nursing at the University of
Regina. The association is
also urged to investigate
methods of transferring
course credits obtained in
diploma nursing programs to
degree programs for
registered nurses.
Action on the report s
recommendations as
approved by membership
will be determined by the
SRNA Council.
President s address
In her presidential address
Betty Hailstone warned
nurses of the possibility of
"a critical shortage of
manpower" and called on
them to demonstrate
flexibility and ingenuity in
meeting the challenges of
the coming decade. She cited
the Nightingale Nurse Group
who have established a group
private practice in Saskatoon
as "pioneers in alternate
methods of health care
delivery" and suggested that
refresher courses, day care
centers, new conservation
methods with regard to
supplies, equipment and
recycling of resources would
all have to be investigated.
"Nursing in Saskatchewan,"
Hailstone said, "has been
recognized as a humanitarian
service and we must ensure
that, with progress, the
humanitarian ethic which is
the basic component of our
profession is maintained and
strengthened."
Resolutions
Health promotion was the
focus of most of the 20
resolutions passed at the
meeting. Members directed
the SRNA to:
push for legislation
designating non-smoking
areas
encourage members to
become familiar with the
skill of breast
self-examination
encourage health
education programs on BSE
encourage nurses to
become certified in
cardiopulmonary resusci
tation at the Basic Rescuer
Level
request government
funding for programs leading
to the prevention of
substance abuse and the
treatment and rehabilitation
of alcohol and drug abusers
assume a more assertive
role in speaking out on health
issues and concerns.
Members also urged the
SRNA to "initiate action and
provide funding" for a
nursing research center in the
province.
The theme of the
meeting was "assertiveness
for nurses". Keynote speaker,
Dr. Carolyn Clark, told nurses
that the reason they often
had difficulty asserting
themselves was that they
were women who have been
socially conditioned to stifle
assertiveness in their homes,
in their nursing education
programs and in the work
place. Clark defined
assertiveness as the process of
setting goals, acting on those
goals and taking responsi
bility for the consequences.
She differentiated between
aggression and assertiveness
by saying that aggressive
behavior does not accept
responsibility for one s
actions and instead blames
others.
A new president-elect
and three members-at-large
were elected during the
meeting. They are: Catherine
Peters, Saskatoon, (president
elect) ; Eithne Reichert,
Saskatoon; Carole Skulski,
Saskatoon; and Phyllis Wise,
Regina.
SRNA life memberships
were awarded to Belle
Berenson of Regina, Anne
Graham of Moose Jaw and
Sister Agnes Schachtel of
Humboldt.
ONTARIO
President Jocelyn Hezekiah
"There is nothing
incompatible with being a
member of a union and a
member of one s professional
organization. Our
professional association is the
one body that cuts across
class and status lines and
through which collective
action can be taken on a
provincial scale. Our
divisiveness stems, not from
unionism but from our
attitudes towards each other
and our communication or
lack of it with others,
nurse managers, educators,
administrators, specialists or
whatever."
Jocelyn Hezekiah,
president of the Registered
Nurses Association of Ontario
in her address to the annual
meeting reminded members
that there will always be
tension between managerial
and non-managerial nurses
but this tension can and
should be used creatively
towards innovation of new
and improvement of existing
patient care systems and
methods of health promotion.
"It has been said that
possibly the greatest
stumbling block to unity is
our lack of a homogeneous
basic education program to
prepare individuals to
practice as registered nurses.
Today s nursing education
should really be preparing
tomorrow s nurses to meet
future health needs of
patients and clients," she said.
In the 80 s nurses must look
seriously at the need for
continuous learning to main
tain clinical competence,
even "...the majority of
nurses in managerial positions
are hot adequately prepared
to enter the executive jungle
possessing both the financial
and interpersonal skills
required for the role."
Hezekiah reflected that
nursing s ability to change, to
accept new roles and to
adapt to changing societal
needs promises a very
exciting future for our
profession.
This concept of the
fluidity of the nursing role
was also emphasized by
Dr. Mary Vachon, a research
scientist and psychiatric nurse
with the Clarke Institute of
Psychiatry, Toronto, who
presented the Laura Barr
lecture in honor of the
former executive director of
the RNAO. Barr is currently
assistant executive director,
Patient Services, Sunnybrook
Medical Centre.
Vachon feels that
nurses must face the
challenges of the future by
working to define their role,
which may be broad, working
to develop new roles and
accepting the patient as the
center of their prime
commitment to these new
roles. She proposed some
ways in which nurses could
make personal changes in
their lives, caring for
themselves, so that they can
then make changes as a
profession and eventually
change the systems in which
they operate.
In her speech entitled
"Care for the Caregivers"
Vachon looked at the areas in
our lives in which stress is
manifest and which we can
alter to decrease stress. She
identified danger signals of
the initial development of
stress and gave some
suggestions on how best to
cope. "As nurses look
towards the future, they must
reassess the concept of power
and see it from a more female
perspective, as a way of
promoting change. As a group
we must recognize that others
see us as competent and value
our opinions, as individuals
we must remember that if we
are confident and do not feel
like handmaidens then most
often we will not be treated
as one. As more nurses
develop an increased sense of
self-esteem and autonomy it
will be possible to make the
changes necessary to bring us
into the twenty-first century."
After a year of
functioning under the
completely revised set of
bylaws, the restructured
RNAO met from May 1
through May 3 in Toronto to
assess the results of these
changes and to set new
priorities. Executive director
Maureen Powers, in her
report to membership, cited
continuing problems in
membership numbers as a
major contributor to current
RNAO issues. "Our capacity
to act with collective strength,
wisdom and vision relates
directly to the numbers of
registered nurses the
association represents. The
future course of nursing may
well be determined by our
ability to maintain a vital,
assertive and responsive
organization. As individual
registered nurses, each one of
us is fully accountable for the
determination of that future"
she said.
Much of the direction
to be followed by the RNAO
in the coming year will result
from implementing
resolutions passed by
membership. Some of these
are intended to promote;
consideration and
discussion of the current
status of nursing services
provided to native Canadian
Indians in Ontario
liaison by the RNAO
with the Registered Nurses of
Canadian Indian Ancestry
encouragement of the
recruitment of native
Canadian Indians into nursing
programs
promotion of the use of
the awareness program
"Breast Feeding" (Health and
Welfare Canada) as a teaching
tool for registered nurses
urging of the Ontario
government to introduce
legislation to codify the
common law such that any
person, regardless of age, may
give a consent to health care
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if the person can understand
the nature and consequences
of the care, has been fully
informed of the care and
gives consent voluntarily
support of the
international boycott of
Nestle products to discourage
further provision of infant
formulas in third world
countries.
The final day of the
meeting included sessions on
topics ranging from
professionalism, bum out,
quality of work life and
the nurse in the courtroom,
to a look at the future and
the challenges and choices
available.
A lecture by Sheila
Kieran, deputy executive
director, Multiple Sclerosis
Society of Canada brought
the annual meeting to a close.
Kieran s topic of "Responsi
bility for others" focused on
the women s movement, its
past mistakes and potential
for a more positive future.
"Be aware that we have met
the enemy and they are us,"
Kieran said. She suggested
that we face the future with
an ever growing respect for
our individuality and
personal strengths and build
upon the idea "each
according to her ability, each
according to her need."
NEW BRUNSWICK
New Brunswick nurses
attending their association s
64th annual meeting in
Fredericton this year
approved major revisions to
the by-laws governing the
conduct of NBARN affairs.
Chief among the changes
resulting from the amend
ments are :
election of officers by
secret ballot at the annual
meeting each year instead of
mail ballots
clarification of the
procedure to be followed in
the handling of complaints
concerning the professional
conduct of registrants
a $ 1 increase in annual
membership fees, bringing the
1981 fee for practicing
members to $105
introduction of a
system of proxy voting which
will permit each practicing
member attending an annual
meeting to carry the votes of
up to four other practicing
members
use of the term Board
of Directors instead of
Council to refer to the 25
persons charged with
management of the
association affairs.
Changes in the handling
of disciplinary charges against
nurse members are designed
to formalize existing
procedures in such a way as
to ensure impartiality and
justice for the individual,
while continuing to protect
the public. Under the new
system, a Complaints
Committee will handle
preliminary investigations.
This body will have the
power to dismiss a complaint
or to recommend action by
the Board of Directors.
Complaints concerning
alleged health problems will
be referred to a Review
Committee. All other
complaints will be heard by a
Discipline Committee.
Nurse power
Keynote speaker Jenniece
Larsen, looking at "Nurse
power in the 80 s", described
nurses and nursing care as
"the glue that keeps the
health care system running."
"Without nurses," she
reminded her audience,
"hospitals do not run at all.
We have tremendous power if
we would just recognize it
and learn to use it."
Larsen, who is assistant
professor in the Faculty of
Nursing at the University of
Alberta, cited the provision
of adequate day care for
children of hospital
employees as one possible
change nurses could bring
about that would result in
better patient care and
happier nurses.
"It seems almost
obscene that one of the
richest nations in the world
should have totally
inadequate day care.
Hospitals in Alberta must
provide parking lots for cars
but not provision for the care
of the children of nurses.
Then when the nurse cannot
come to work because she
has no baby sitter, we all
shake our heads when some
male administrator says that
nurses are not committed
workers.
"Next time you are
without adequate day care,
do not stay home, come to
work and bring your child. I
suspect the hospital would
soon find a solution to the
day care problem if there
were kids hanging out of
hospital windows and running
in the hallways.
"This is an example of
how to use power and will
work most effectively in a
situation where there is a
shortage of nurses or where
nurses plan together as a
group."
Jenniece Larsen
Resolutions
President Anne Thorne noted
that the majority of resolu
tions to come before this
year s meeting related to the
quality of nursing care in
the province. "There are
signs," she noted, "that we
should be concerned also
with the quantity of care...
hopefully we can get a handle
on this issue."
Among the resolutions
approved by members were
several intended to facilitate
the process of obtaining a
post-RN degree for nurses
throughout the province.
Members also approved the
provision of mandatory
malpractice insurance for
NBARN members. A reso
lution expressing opposition
to statements contained in
the new CNA Code of Ethics
received almost unanimous
acceptance by members.
NOVA SCOTIA
"Change and technology have
made us more efficient in
health care, but have they
made us more effective?",
asked Milton Orris, director
of the health administration
program, Community Health
Division, University of
Toronto, who opened the
71st annual meeting of the
Registered Nurses Association
of Nova Scotia at Acadia
University. Orris said there
are three main reasons for
change change for the sake
of change, external forces
which change the
environment and over which
you have little or no
immediate control, and
internal forces which you as a
profession recognize and
carry out.
"The economy isn t
going to change much we
in the health industry will
continue to get more money
each year, more than any
other public sector but we are
always going to need more
than we get so we must
manage it better and begin to
make harder decisions," said
Orris.
The conference theme,
"Expectations of the nurse in
the eighties" was explored
from the point of view of the
consumer, the government
and the hospital
administrator, with repre
sentatives from each sector.
Hospital administrator,
Peter Mosher, executive
director of the Kentville
Hospital Association told the
nurses they should get their
act together and provide
some answers to help hospital
administrators by doing
research in nursing and by the
education of nurses to fit the
demands of the market.
Anita Dubinsky who
represented the consumer
said that she was worried
about the increasing numbers
of people over 65 who will
require care in the 80 s. As a
person involved in school
boards in Nova Scotia she has
become aware of decreasing
enrolment; she suggested
that empty school buildings
could be used as community
health centers where the
nurse could be the point of
entry into the health care
system.
Among the resolutions
passed was one on represen
tation from the RNANS on a
planning committee for a
regional hospital in Cape
Breton ; establishing a task
force to study mental health
facilities in the Cape Breton
area and another
recommending the use of
smoke detectors in all private
residences and public
buildings in Nova Scotia.
The Task Force on
Mandatory Continuing
Education as a requirement
for RNANS registration
presented their report with
the recommendation that
"continuing education should
not be mandatory but a
personal responsibility". This
resolution was accepted.
Life membership was
conferred on Sister Clare
Marie Lyons, RNANS
education consultant who has
spent 41 years in nursing
education in Nova Scotia, 3 1
as a teacher and the last ten
years with the RNANS. She
received many tributes and a
standing ovation. *
Canadian nurses to write CGFNS examinations
Legislation requiring all
foreign nurse graduates,
including Canadians, seeking
a non-immigrant occupational
preference visa that will
enable them to practice in
the US to pass the
Commission on Graduates of
Foreign Nursing Schools
(CGFNS) Qualifying
Examination became
effective May 16 this year.
Warning of the new
rule was contained in the
January issue of the
Canadian Nurse. The rule
affects all foreign nurse
graduates who have not
already obtained a full and
unrestricted licence to
practice professional
nursing in the state of
intended employment. Three
cities in Canada and five in
the US are among the 36 test
centers selected for the next
examination, October 1 ,
1980. The Canadian sites are
Montreal, Toronto and
Vancouver. Filing deadline
for the October exam was
July 14.
In addition, the US
Department of Labor (DOL)
has issued a proposed new
rule requiring FNGs to pass
the CGFNS examination if
they seek a labor certificate
in order to obtain a third or
sixth occupational preference
visa. In a step preceding the
DOL rule s enactment, this
proposal was published in the
Federal Register on
January 22, 1980. Final
publication and enactment of
this new rule is expected in
the near future.
Jessie Scott, newly-
elected President of CGFNS
Board of Trustees, points out
that the latest statistics show
CGFNS is achieving the pur
poses for which it was
established. Of those FNGs
who have taken and passed
the CGFNS exam, come to
the US and taken the state
licensing exam (SBTPE),
80 per cent have passed the
SBTPE and hold a license to
practice as a registered nurse.
This contrasts sharply with
the fact that in recent years,
only about 20 per cent of
foreign nurses passed the
state licensing exam.
"The CGFNS exami
nation, which determines the
nurses ability to pass the
state licensing examination
before they come to the
United States, helps protect
foreign nurses who are not
prepared for professional
practice in this country
against relocation costs,
personal disappointment, and
possible exploitation,"
according to president Scott,
"and at the same time, it
helps assure the American
health care consumer of
minimum safe practices."
CGFNS is sponsored by
the American Nurses
Association and the National
League for Nursing and is
presently operating under a
grant from the Kellogg
Foundation.
National OR meeting
draws 1 100 nurses
"We judge ourselves by our
intentions but we evaluate
our boss and she evaluates us
by our actions." Harvey
Silver, freelance management
consultant in Organizational
Psychology, spoke on the
topic of performance
appraisal (PA) at the sixth
national Operating Room
Nurses Conference in
Toronto, April 28-May 1 .
"A person is a process,
not a product; it is never
game over, he can change,
modify, grow and become in
a constant developing
process." With this in mind,
Dr. Silver suggested that
since it is behaviors and not
personalities which are being
evaluated in a performance
appraisal, the supervisor and
employee should attempt to
look at the appraised
behavior from a distance, as
an "it", so that vested
interests no longer play a
part. The PA should focus on
three items: what behaviors
should be continued, what
behaviors should be initiated
and what behaviors should be
stopped. By recognizing that
the goal of PA is not
perfectionism, but progress,
and that usually it is a
person s attitude rather than
her aptitude which
determines her success on the
job, then "inch by inch,
anything is a cinch".
More than 1100
registrants from across
Canada and the United States,
attended the conference
which was hosted by the
Operating Room Nurses of
Greater Toronto. The
conference theme was
"Changes, Challenges and
Choices of the 1980 s."
Speakers who addressed this
theme included Patricia
Leblanc, RN, Hamilton
General Hospital and Faye
Trouten, RN, BScN, Hospital
for Sick Children, Toronto
and Pat Williams, RN,
Women s College Hospital,
Toronto.
Working with invasive
pressure monitoring,
understanding how
transducers, amplifiers,
demodulators, peak detectors,
meters and oscilloscopes
function was the topic of a
presentation by Catherine
Boileau, RN, BScN, assistant
coordinator of educational
services, Humber Memorial
Hospital, Toronto. She
pointed out that since nurses
often have input into the
types of equipment that their
units purchase they should
make themselves
knowledgeable of what is on
the market and how it
functions, so that they can
ensure that they have the best
equipment to work with, will
know how to use it properly
and understand the meanings
of readings they obtain.
Plans are already
underway for the seventh
National Conference for
Operating Room Nurses to be
held two years from now in
Winnipeg, Manitoba. For
more information contact:
Fran Fenton, c/o Operating
Room, St. Boniface General
Hospital, Winnipeg, Manitoba.
Dalhousie launches
R & D campaign
A three-year campaign for
research and development
funds has been launched by
Dalhousie University School
of Nursing to stimulate and
support nursing research in
the Atlantic provinces.
A target of $150,000
has been set and the first
major contribution to the
fund, a $2,500 donation from
the Registered Nurses
Association of Nova Scotia,
has already been received.
Professor Margaret
Bradley, acting director of
the school of nursing,
commenting on the
campaign, said that "nursing
research is in its infancy in
this part of Canada, and
indeed elsewhere" and noted
that the idea for the
campaign originated with a
faculty member who
encountered difficulty in
obtaining funds to support
her research, v
Plans are underway for the seventh
national conference on nursing
research. The conference, to be held in
Halifax between October 22 and 24, is
a first for the Atlantic region. Above
from left are co-ordinators Barbara
Devine, Ruth MacKay, Evelyn Pollard
and Marion Allen.
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1. Winter, G.D.: Healing of Skin Wounds and the Influence
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YOU AND
THE LAW
The responsibility of the patient
Corinne Sklar
Recently some friends who are nurses
were discussing negligence and the
delivery of patient care. Mindful of their
legal responsibility to the patient they
asked: "What about the patient?
Doesn t the patient have some
responsibility in all of this? What about
the patient who fails to follow
instructions, refuses recommended
treatment or does not return for
follow-up?"
As a general rule, the patient
does have the right to refuse treatment.
This right of refusal can be exercised by
the patient at any point during the
course of treatment. The patient also
has the right to refuse to seek
treatment, to decide to change \/
physicians, to stop taking his
medication or to delay obtaining
further or any medical advice. Patients
often discharge themselves from
hospital AMA (against medical advice).
While this may be frustrating and
discouraging to health care providers,
nevertheless this remains the right of
the patient.
The right to determine what shall
be done to his body is a right of the
adult person of sound mind; it is the
cornerstone of the law regarding
consent to medical treatment since
the application of health care without
the consent of the patient results in the
commission of the legal wrong of
battery.
The patient s right to choose
includes the right to make decisions
about his own health that may be .
inconsistent with the view of those
providing health care. He may, for
example, make a choice that is not in
the "best interests" of his health. He
cannot be compelled to accede to the
viewpoint of physicians or nurses; the
final decision rests with him. 2
Ideally, refusal or rejection of
treatment by the patient should be as
informed a choice as any consent
obtained but this is not always the case.
Decisions are based on the internal and
external sources and resources of the
individual and medical input is only
part of this process. People make
lifestyle and other personal decisions
that directly or indirectly affect their
health every day. In general, the law
does not impose an affirmative duty
upon us to maintain and safeguard our
health. For example, vaccination is
strongly recommended as a health
measure but no law of Canada expressly
requires it of the general population,
although certain public health or other
requirements such as travel to other
countries or specific employment may
result in the imposition of such
treatments upon an individual in order
to safeguard the health of others. As a
TWO CAREERS
IN ONE.
Being a nurse and an officer in the Canadian Forces offers
many advantages. If you re a Canadian citizen and a graduate
nurse (female or male) of a school of nursing accredited by
a provincial nursing association and a registered member of a
provincial nurses association with two year s experience
why not combine two careers in one?
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general rule vaccination for one s own
protection, while prudent, is not
mandatory. Where there exists no
positive duty upon the individual to
seek or continue treatment for his own
benefit. there is no legal liability
imposed upon him for failure to do so:
The responsibility of a patient
arises from the law of negligence.
Legally, this responsibility may be
manifest when the patient complains
that those who owed him a duty of care
failed in this duty and that this breach
of duty resulted in harm (injury, loss,
damage) for which he now comes before
the Court requesting legal redress. Thus,
in defence of a claim by a patient of
malpractice against a physician, a nurse,
a hospital (individually or in any
combination), the issue may be raised of
the patient s having contributed to the
harm of which he complains.
For any complaint of negligence
to succeed in Court, the complainant
must prove that the defendant (the
person whose conduct is in issue) owed
him a duty in law (that is, a legal
responsibility of care) and that the
defendant breached that duty. The
plaintiff (ie. complainant) must show
that the harm he suffered was the result
of that inferior conduct and was
reasonably foreseeable. In addition, the
plaintiff must not have done anything
to have caused or aggravated the harm
he suffered. It is this area which may
provide a fruitful defence and which
gives rise to the patient s duty to
himself.
Conduct which contributes to the
harm of which the patient complains is
called "contributory negligence". In the
past, a finding by the Court that the
plaintiff had been contributorily
negligent resulted in loss of the entire
suit whether or not the defendant had
breached his duty and caused him harm.
Such a harsh result is not possible under
today s law.
If the defence proves to the Court
that the harm to the patient was not
caused by the defendant but was
caused solely by the patient s conduct,
then the plaintiff/patient will lose his
lawsuit. The harm of which the patient
complained must have resulted solely
from his own conduct; the patient was
the author of his own misfortune.
Where it can be proven that the
patient s conduct alone caused his
harm, then the defendant is absolved of
legal liability, notwithstanding the fact
that the defendant s conduct fell below
the standard of care required in the
circumstances. Before legal liability can
be imposed upon the defendant, the
plaintiff must convince the Court that
the defendant s conduct caused him
harm. If the harm is not the result of
the defendant s conduct even if it was
negligent, then the defendant is not
legally responsible for it. Such an
answer and finding can be considered a
total defence to the plaintiff s claim
against the defendant.
More often it can be established
that the defendant s conduct did result
in the harm of which the patient
complains. In this situation it may be
open to the defendant to attempt to
convince the Court in his defence that
his fault in the matter is diminished
because the patient contributed to his
injury through his own conduct and he
therefore was contributorily negligent.
The standard of care expected of
the physician or nurse is that of the
reasonable prudent practitioner (or
specialist, as the case may be) with
similar training and experience. The
standard of care by which the patient s
conduct is measured is that of a
reasonable, prudent patient in similar
circumstances. The standards applied
are objective standards. Conduct which
does not meet these objective yardsticks
is deemed to be negligent.
Once it is established that the
harm resulted from negligence on both
sides, then it falls to the Court to
determine in what degree each is
responsible. All of the provinces of
Canada have in force legislation which
permits a Court to apportion the
degree of fault or legal responsibility
between the parties. For example, the
trial judge may decide on the evidence
presented to the Court that the patient
was five, 20, 50 or 75 per cent to blame
for his own harm. The damages awarded
to the plaintiff will be reduced by the
degree of fault ascribed to him.
Therefore, if the trial judge finds that
the measure of damages for any injury is
$10,000 but believes that the patient
was 30 per cent and the physician was
70 per cent to blame, the patient will
recover only $7,000 from the
physician. The patient s recovery is-i
reduced by the percentage of fault
found against him.
In the U.S. many states retain the
requirement that the patient, in order to
recover damages, must be free of any
contributory negligence. There are a few
Canadian cases, however, in which a
claim against providers of health care
has raised the issue of contributory
negligence on the part of the patient.
The most recent Canadian case is
that of Grossman v. Stewart. 3 Mrs.
Grossman was referred to the defendant
dermatologist for treatment of a facial
skin disorder which he diagnosed as
discoid lupus erythematosis. He
prescribed Aralen (genetically,
chloroquine) tablets 250 mgm, one or
two tablets to be taken daily. The
dermatologist saw the patient for
consultation and treatment six times in
the six months between January 16 and
June 16, 1962; he gave her prescriptions
for the medication on all but one of
these visits. The patient obtained the
medication from a pharmacy and found
that it was effective. Between June
1962 and January 1963 the patient did
not see the defendant but continued to
take the drug which she obtained
without a prescription from a drug
salesman who sold drugs to the physician
for whom the patient worked as a
medical receptionist. The Court found
that the defendant was not aware of nor
did he approve of this method of
obtaining the drug. 4
In December 1962 the defendant
attended a medical convention where he
learned that some patients, as a result
of prolonged use of the drug, had
suffered irreversible damage to the
retina causing blindness. Already aware
that there were risks associated with
long term use of the drug, and alerted
now to this specific danger, he called in
all of his patients who had been so
treated and arranged for them to have
their eyes examined by an
ophthalmologist. Mrs. Grossman was
called in on January 28, 1963. The
specialist s report, 5 dated February 14,
1963, indicated that while there was no
evidence of retinopathy, there were
some corneal changes suggestive of a
sequelae of chloroquine therapy. The
report stated that Mrs. Grossman gave
a history of having had the medication
for the past 13-14 months. Mrs.
Grossman was not warned at any time
of the dangers of prolonged use of the
drug. The defendant was never informed
that the patient continued to use the
drug.
Although the patient was seen by
the defendant several times in early
1963, no more medication was
prescribed. From March 1963 to March
1965, the patient did not see the
defendant but continued to take the
drug, again obtaining her supply from
the drug salesman. This supply route
terminated in the summer of 1 964 when
the salesman retired.
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In March 1965, the defendant was
again consulted by Mrs. Grossman and
he again prescribed Aralen therapy
which continued until the fall of 1965.
The last prescription was dated
September, 1965.
In April of 1966, signs of retinal
damage were found and it was
determined that permanent irreversible
retinal damage had occurred. By 1971,
Mrs. Grossman s vision was so impaired
that she could no longer work. At the
date of trial she was "near" blind.
Mrs. Grossman can see large objects
within a few feet of her but she cannot
read or sew. To go out, she requires
someone to guide her. She does her
housework and cooking by a sense of
touch. 6
The trial judge found liability on
the part of the physician and fault on
the part of the patient. He found that
the physician had breached the required
standard of care when he failed to
discover the consumption of the drug
by the patient over a prolonged period;
a careful review of the specialist s report
in February 1963 would have disclosed
this. The trial judge specifically stated
that a higher standard of care must be
met where the drug being used may
cause permanent substantial damage. In
addition, a careful review of the report
would have alerted the defendant to the
patient s ingestion of the drug long
after he had last prescribed it because of
the corneal changes reported by the
specialist. Corneal changes are reversible
upon cessation of the drug therapy;
retinal changes demonstrate permanent
damage.
The trial judge found that Mrs.
Grossman was two thirds responsible.
He said: 7
"...While a reasonable patient is not
required to possess special knowledge
related to the specific risks involved in
using "prescription" drugs, it seems to
me that ordinary commonsense would
dictate that it is foolhardy in the
extreme to do the following things:
(a) to obtain "prescription" drugs from
an unorthodox source.
(b) to continue to use drugs on a
prolonged basis without obtaining
"prescription" renewals.
(c) to continue to use drugs on a
prolonged basis without consulting the
"prescribing" physician (in this case
almost two years).
Surely the "reasonable patient"
knows fully well that a pharmacist will
not renew a prescription without
obtaining at least a "telephone"
authorization from the prescribing
physician. Surely he knows that the
reason for such cautious behavior on the
part of pharmacists is because of the
real dangers involved in the use of
"prescription" drugs in an unauthorized
manner."
In the view of the trial judge, if
the patient had acted with any
reasonable degree of prudence,
permanent eye damage would have been
averted. He assessed damages at
$80,000, apportioning fault one third to
the defendant and two thirds to the
patient. Mrs. Grossman recovered only
one third of the total $80,000 damages.
Remember that the patient has
the responsibility of acting reasonably
in the circumstances: he cannot cast
blame on those delivering health care
without assuming some responsibility
for his own conduct. While duties of
affirmative action have not been
specifically imposed, ^ome writers are of
the/view that a finding of contributory
negligence could result where the
patient fails
to return for treatment
to seek treatment
to cooperate during treatment or
to follow instructions. 8
Further, a failure to disclose personal
information in response to the health
provider s questions might also result in
such a finding. Future cases will
determine such results.
Health care providers continue to
have a legal responsibility to meet the
required standard of care. In order to
protect themselves and/or the health
care facility, appropriate
communication with the patient and
recording of instructions is prudent. In
the Grossman case, the detailed notes
made by the defendant helped him to
substantiate his evidence regarding his
practice and his recollection of the facts.
Nurses should record specific
warnings given to patients, for example,
not to get out of bed, not to eat or
drink anything or specific foods. Where
incidents occur as a result of the
patient s failure to follow instructions
(for example, the patient fell when she
failed to call for assistance in getting out
of bed), nurses should record the salient
facts at that time. If a patient is to
return for follow-up treatment, it is
important to communicate this clearly
to him, explaining why and recording
the communication.
The law does not demand
perfection from doctors, nurses and
hospitals, nor from patients: what is
required is reasonable and prudent
conduct in the circumstances. Meeting
this standard will help to avoid findings
of direct or contributory negligence. *
References
1 Sklar, C.L. Legal consent and the
nurse. Canad.Nurse. 74(3):34-37; 1978 Mar.
2 -. Was the patient informed? Canad.
Nurse. 76(6): 18-22, passim; 1980 Jun. The
right of the adult patient of sound mind is
considered here. Other considerations come
into play when the patient is a minor or
suffers from mental incapacity. These special
circumstances are beyond the scope of this
column.
3 (1978) 82 D.L.R. (3d) 677 (B.C.S.C)
4 *lbid: p.679.
5 *Ibid:p.681.
6 Ibid: p.687.
"Ibid: p. 686.
8 Picard, Ellen I. Liability of doctors and
hospitals. Toronto: Carswell; 1978: p. 188.
*Not verified
"You and the law" is a regular column
that appears each month in The
Canadian Nurse and L infirmiere
canadienne. Author Corinne L. Sklar
is a recent graduate of the University
of Toronto Faculty of Law. Prior to
entering law school, she obtained her
BScN and MS degrees in nursing from
the University of Toronto and
University of Michigan.
SPOTLIGHT ON AGING
"In nursing school, I was taught that disorientation was a result of poor nursing care. So when I took care of
patients, I did not document how disoriented they were, but how clear they were. To do otherwise would
have been to show my teacher the poor quality of my nursing care. With this expectation I discovered it was
possible to talk to patients clearly even when they were disoriented, and that there were meaningful thoughts
behind their disorientation." (Loretta Nowakowski "Oisorientation-signal or diagnosis", Journ.Geron.IMsg.
Vol. 5, No. 4, April 1980) As nurses, are our attitudes towards aging based on reality, or are they largely
determined by negative stereotypes and false or misleading information? Isn t aging a normal part of human
development? Will you live out your negative fantasies, even if there is a way out?
PART ONE
A self-help guide
to the aging process^
Patrir.ia Mnrdf>n *
To use the chart
This chart has been prepared so that it may be used as either a learning
tool or an information package for groups or individuals.
If you decide to use it as a learning package, all you have to do
is, first, read through the sections on normal physiological changes and
some of the accompanying pathophysiological occurrences and circum
stantial factors, that may accentuate the aging process, then cover the
right hand column and see how many nursing measures or observations
you can think of to alleviate existing or potential problems.
As a learning resource, the chart can be displayed on a handy
bulletin board or filed for review, with the option always of adding
your own ideas to the suggestions it contains.
Either way, we hope it provokes personal and professional
thought and discussion, since it is only by continual review of what we
are doing and why that we can continue to plan for and provide
responsive, caring health services for the over-65 s in our midst.
nt
MENTAL STATUS
While no age-related changes in verbal ability have been recognized, the following may be noted:
general decline in psychomotor skills (general CNS as well as special senses),
increasing susceptibility to interference in problem solving,
more time is required to process information,
amount and accuracy of sensory input is decreased.
Mental confusion may be due to a change in
environment, decreased sensory stimulation,
medications, fear or anxiety, decreased 2l
electrolyte imbalances, poor nutrition, psychotic
illness, sub-dural hematoma, depression or disease
states such as hypo/hyperthyroidism,
hypo/hyperglycemia, myocardial infarction or
infection which often presents as confusion before
the temperature is elevated.
Many potential// curable conditions present with
symptoms that are easily mistaken for confusion.
Determination of your patient s mental status
requires careful assessment. Where should you begin?
1. Modern tests of intelligence and mental ability may
disadvantage the elderly person in many ways as their
education, values and interests may be quite different from
those tested. Give the individual time to think and answer
questions. Many tests are time limited and do not allow for
accurate assessment of the mental status.
2. There is a need for assessment and re-assessment of
treatment modalities such as reality orientation,
re-socialization etc. More consideration must be given to
psychotnerapeutic modalities for elderly persons.
3. We must begin by examining our own attitudes and values
re: aging, the aged person and how this affects our
interaction with them.
4.
5.
VISION
With the normal aging process the following changes may occur:
presbyopia, the crystalline lens loses the ability to adapt its shape and results in a decrease in
peripheral vision and some degree of myopia,
atrophy and rigidity of the iris causing a decrease in pupil size, leading to decreasing ability to adapt
to changes in light,
arcus senilus, a clouded ring may form around the cornea,
retinal atrophy causing a decreased capacity to distinguish color and brightness, (especially in the
blue-green range),
reaction time may increase, especially with a rapid series of visual stimuli.
Two common conditions that frequently occur in this
age group are glaucoma and senile cataracts.
Knowing this, how many nursing measures or
observations can you suggest to ease the visual
problems encountered by the aging person?
1. Ensure preventive screening tests for glaucoma and
cataracts are done.
2. Ensure each individual wears and has access to his glasses
as required.
3. Remember, focusing on close objects, including a face that
may be too close, may be difficult.
4. Elderly persons sitting in rows may be unaware of anyone
beside them because of decreased peripheral vision.
5. Leave a light on in hallways and bathrooms at night.
6. Decrease of color vision may affect clothing choices and
the effect of the environment on the person s mood.
7. Contrasting strips of color on steps, around doorways and
on toilet seats make them easier to distinguish from their
surroundings.
8. Be aware of the confusing effect of glare on vision, e.g.
shiny floors.
9. Consider nametags with yellow backgrounds and black
block letters as yellow is better visually than white.
10. Use large print on prescription bottles and instruction
sheets.
11.
12.
HEARING
Loss of hearing may be related to previous middle ear disease, vascular disease or exposure to noise.
Presbycusis, degenerative changes in the middle and inner ear, may be associated with such functional
abnormalities as:
impaired sensitivity due to tissue atrophy, decrease in the number of hairs in the ear and a decrease in
nervous conduction especially at the upper end of the auditory scale, e.g. sounds such as s, sh, and ch,
difficulty in sound localization,
decline in sound discrimination, especially speech.
These functional abnormalities may be exaggerated
by a build-up of wax in the ears, ossification of the
bones of the middle ear and decreased stimulation
especially when institutionalized.
How can you help an elderly person to cope with
these problems?
1. Lower the pitch of your voice when speaking to someone
with high frequency loss, possibly also increase the volume
(sometimes when you increase the volume, the pitch will also
increase, thus making it even harder for someone to hear).
2. Speak directly to the person, use their name.
3. Speak slowly and clearly.
4. Remember that people who are hard of hearing may
withdraw socially as the effort of maintaining involvement in
a conversation may be too much work.
5. Be sure that hearing aid batteries are fresh and the hearing
aid is positioned correctly.
6. Be aware that persons who do not hear normally may hear
some distorted sounds or words and this may cause them to
appear confused or even paranoid.
7. Remember that there may not be enough background
noise in an institution to keep the hearing sense stimulated.
Research on sensory deprivation has shown that in this
situation, a person may create his own stimulation and
hallucinate.
8.
9.
OLFACTION AND TASTE
As an individual grows older, the following changes may occur:
the number of nasal hairs decreases,
receptors atrophy,
taste buds atrophy and decrease in number,
oral secretions decrease.
These common effects of aging may be further
aggravated by:
loss of teeth due to poor hygiene
long term smoking which may cause a decrease in
taste sensation
loose or ill-fitting dentures which may cause
problems in mastication and
the long term effects of institutionalization which
may cause decreased stimulation of both taste and
smell.
Can you suggest some measures to alleviate these
problems?
1. Focus on prevention throughout life, through good
nutrition, hygiene, mouth and denture care.
2. Teach the use of spices in food preparation, especially for
those on sodium-restricted diets.
3. Consider safety carefully - could this elderly person smell
smoke if there was a fire?
4. Are there some normal stimuli that you could provide in
your work setting, such as brewing coffee?
5.
6.
(U/ TOUCH
Receptor sensitivity decreases with age.
The sensation of touch may also be reduced as a
result of:
peripheral neuropathies due to COPD, chronic
nutritional deficiencies, anemia, ASHD, etc.
-decreased stimulation due to long term
institutionalization and hypothermia.
How does one determine if tactile sense is reduced
and how can you stimulate this sensation?
1. Assess for chronic medical conditions and peripheral
problems.
2. Assess ability to feel hot and cold.
3. Stimulate the tactile sense through finger foods,
handicrafts, etc.
5.
SKIN INTEGUMENT
With the normal aging process, there is:
a decrease in natural moisture and elasticity,
a decrease in collagen,
a loss of sub-cutaneous fat in the periphery,
shrinkage of the epithelial layer of skin,
a decreased number of sweat glands,
decreased melanocytes (pigment),
a decrease in total body hair,
graying of hair due to loss or malfunction of pigment cells and
increased facial hair in women due to changes in androgen/estrogen ratio.
A common condition that frequently occurs in this
age group is lent/go senilus (liverspots), caused by
excessive exposure to the sun.
How do these changes affect nursing care of the
elderly?
1. Decreased sub-cutaneous fat and decreased sensory
perception combined with immobility increase the need for
nursing intervention. Observe for signs of rubbing of
prosthetic devices and encourage or help an individual to
change his position in bed and when sitting.
2. Maintain adequate fluid intake. Use super-fatted soaps.
3. The elderly may have more difficulty regulating body
temperature due to loss of sweat glands.
4. Preventive sun protection throughout life can help prevent
some wrinkles.
5. All these changes can lead to body image problems which
can be minimized with good hygiene, make-up, etc.
6.
7.
ENDOCRINE SYSTEM
With the aging process, there is:
a generalized decrease in the ability to adapt to stress,
a decrease in the metabolic rate and
a decrease in the functional ability of the thyroid.
Two common conditions that frequently occur in this
age group are maturity onset diabetes and hypo or
hyperthyroidism.
What implications does this system alteration have for
nurses?
1. Thyroid function tests should be included as part of any
screening for causes of decreased mental status.
2. Observe for signs of diabetes and through teaching help
the elderly person to cope with this condition if it is
diagnosed.
3.
4.
GENITOURINARY SYSTEM
(i) Urinary Tract:
This system may undergo the following changes:
generalized neurological loss leading to less conscious inhibition of micturition and thus allowing the
spinal reflex to predominate,
decreased bladder capacity due to muscle atrophy,
less time between urge to void and need to void; research has shown that the maximum distance that
many people can travel without an accident is 40 feet,
decreased urine concentrating ability of the kidney,
decrease in activity and changes in the cardio-vascular status may also affect this system.
/
"\
Two complications that may arise are drug toxicity as
the kidneys are functioning less efficiently and
incontinence, the passing of urine in the wrong place
at the wrong time, due to:
increased pressure on the bladder arising from
constipation, a prolapsed uterus or prostatic
hypertrophy
decreased fluid intake which may reduce
stimulation of the bladder for voiding reflex
decreased fluid intake which may cause a decrease
in the circulating blood volume and blood pressure
which may lead to some confusion and weakness and
then incontinence
medications, specifically those which sedate or
increase urgency or urine volume
restraining, with restraints, drugs or even furniture
that is difficult to get out of
change in environment
immobility
illness
retention which may lead to overflow
-dribbling
urinary tract infection
psychological problems
decreased mental functioning, and
lack of privacy or other environmental issues.
Remember that continence is a conditioned response,
one thing that keeps us continent is our clothing.
It is very easy for incontinence to become the
conditioned response.
What problems should you be aware of and how can
nurses best cope with incontinence?
1. Assess carefully the causes of incontinence.
2. Take a detailed and complete incontinence history.
3. Remember restlessness in a patient who has difficulty
communicating may indicate a need to void.
4. Reducing fluid intake may increase the problem of
incontinence rather than solve it.
5. Blood flow to the kidneys may increase at night due to the
recumbent position, thus increasing the production of urine.
6. Remember to leave lights on in bathrooms and provide a
safe, easy access.
7. Incontinence may be a conditioned response to the
preference of remaining in the comfortable privacy of bed
rather than attempting to urinate in a room with other
people or while someone waits in the bathroom with him.
8. Wearing street clothes with underwear may be a strong
social stimulus for continence.
9. Mark toilets well, ensure that persons who need assistance
have a call bell at all times, even when sitting in the corridor
or in the sunroom.
10. Pelvic floor exercises may be useful to prevent and stop
problems with dribbling in both men and women.
11. Be aware of drugs metabolized in the kidney and
recognize signs of their toxicity.
12. Be aware of new products and make manufacturers aware
of your needs.
13. As there are often many incontinent patients on one
floor and it will take much initial effort to re-train some
people, it is important to choose only one or two at a time so
that you can give the time and effort necessary for success.
14.
15.
GENITOURINARY SYSTEM (Continued)
(ii) Sexuality:
With aging, males experience:
an increased need for stimulation, both direct penile stimulation and psychological stimulation,
an increased refractory period between erections,
a decreased ejaculatory force.
Women will note the following changes:
decreased vaginal lubrication,
decreased orgasmic intensity,
increased libido with hormonal changes post-menopause, or difficulties with sexual response due to
lack of or infrequent sexual intercourse.
Sexuality may be also influenced by social norms and
attitudes: "people over 60 shouldn t"; the increased
response time may cause some men to give up in
frustration; widowhood may lead to difficulties in
finding partners, and sexuality may decrease as a
result of a negative response or poor psychological
adjustment to changes in body image and sexual
response.
How can nurses best help the elderly to cope with
their sexuality?
1. Counseling often helps this group to understand
age-related changes in sexual responsiveness and determine
how they can best meet their personal needs. Counselors
must be careful not to suggest their own values if the elderly
person is satisfied with his/her situation.
2. Provide privacy in institutions.
3.
4.
CARDIOVASCULAR SYSTEM
Changes in this system usually result in changes in the respiratory system, and vice versa. Basically, changes
in the heart and vessels that are related to aging are functional changes which reduce the heart s ability to
adapt to excessive stress. The changes normally attributed to aging include:
atherosclerosis, which is usually present after the second decade of an individual s life,
decreased collagen, leading to decreased elasticity of arteries,
changes in heart size,
decreased heart rate with irregular beats due to loss of some resiliency of the heart muscle,
a decreased resting cardiac output which decreases as much as 30-40 per cent between ages 25 and 65,
thickened valves due to sclerosis and fibrosis,
increased blood pressure which is necessary for physiological functioning due to the decreased
elasticity of the vessels and the increased lability of vaso-pressor control.
Conditions which may further aggravate these effects
of aging include myocardial infarction, congestive
heart failure, cardiovascular accident, angina
hypertension, murmurs due to malfunctioning valves,
and hypotension due to dehydration, medications,
postural changes, inactivity and peripheral pooling of
body fluids.
What nursing measures should be considered in caring
for patients who may be suffering from any of these
functional changes or complications?
1 . Assess the need for medications carefully - consider the
ranges of blood pressure to determine what is functional and
what is pathological.
2. Confusion may be a result of low cardiac output.
3. Lack of exercise, excessive food and alcohol intake, and
smoking may all cause problems.
4. Management of heart disease must include consideration of
all other systems, e.g. a decreased glomerular filtration rate
may lead to drug toxicity at "normal" dosages.
5. Preventive counseling on nutrition, exercise, smoking, etc.
should take place throughout life.
6. Assess medications being taken, compliance and the
patient s understanding of drug.
7. Positional changes and exercise are necessary to decrease
peripheral pooling, hypotension, etc.
8.
9.
RESPIRATORY SYSTEM
As an individual ages these changes take place:
decreased collagen leads to decreased elasticity of the lungs, decreased efficiency of the smaller
bronchioles and a decrease in chest wall compliancy,
decreased perfusion due to atherosclerosis,
decreased gas transfer due to a loss of lung capillaries with age,
decreased ciliary action due to decrease in epithelial layer and moisture.
Smoking, emphysema, congestive heart failure and
the immobility often promoted with bed rest
aggravate the above effects of aging.
What factors are important in coping with these
changes?
1. Respiratory infections can become increasingly more
dangerous as lung and chest resiliency decreases.
2. Optimal positioning must be ensured for best lung
perfusion.
3. Confusion may be caused by lack of 2 . Respiratory
infections may be indicated by confusion rather than
elevated temperatures.
4. Environmental pollution must be considered in promoting
respiratory health and in its effect on an already
compromised system.
5.
6.
GASTRO-INTESTINAL SYSTEM AND NUTRITION
(i) Intake may be affected by:
changes in taste and smell,
decreased caloric requirements due to decreased activity and a decreased metabolic rate,
digestion problems resulting from atrophic changes in the gastric mucosa causing decreased gastric
secretions,
impaired intestinal absorption due to mucosal atrophy and changes,
decreased fat absorption, including fat soluble vitamins due to ptosis of the gall bladder as a result of
a decreased elasticity of the walls.
Common contributing factors to nutritional problems
include:
loss of teeth or ill-fitting dentures
loneliness, eating alone may decrease the appetite
decreased power of mastication due to teeth loss,
dentures and generalized muscle atrophy
obesity as intake remains constant but activity
decreases or losses in life may be dealt with by
increasing intake
chronic illness may decrease the appetite and/or
hamper the ability to prepare or shop for food.
What positive steps can you take to make sure older
individuals are eating properly?
(ii) Output changes are usually related to:
a decrease in tone of the abdominal muscles due
a decrease in sensitivity of the nervous system to
These effects of aging may be further affected by.
decreased dietary bulk due to decreased intake,
difficulty with mastication, or restrictive diets
chronic constipation due to decreased food and/or
fluid intake, chronic laxative abuse, medications for
other medical conditions, lack of physical activity,
diverticular disease, hiatus hernia, cancer of the
colon, or depression
dehydration from many causes such as lack of
availability or reducing fluid intake due to fear of
urinary incontinence.
What can you do to reduce these bowel problems?
1. Offer guidance in coping with cooking restrictions, i.e.
add spices to low salt diet. A dangerous lack of nutrition and
a reduced psychological satisfaction are frequently associated
with diet changes.
2. Consider giving budget and nutrition counseling.
3. Assess for chronic vitamin deficiency.
4.
5.
to atrophy,
stimulation.
1. Increase bulk in the diet through the use of bran, whole
wheat bread, etc.
2. Assess present diet and fluid intake, include past
defecation patterns and laxative use in history.
3. Provide privacy and comfort for defecation.
4. Monitor urine and stools for signs of malabsorption or
metabolic deficiencies (mineral oil used as a laxative may
cause Vitamin A, D and E deficiencies).
5. If constipation is present, assess for type, then treat the
cause and symptoms (some people report lack of a regular
bowel movement as constipation, others define it when
stools are hard and difficult to pass).
6.
7.
MUSCULO-SKELETAL SYSTEM
With increasing age:
muscle fibers are replaced with scar (fibrous) tissue,
elastic fibers are mineralized, e.g. ligaments calcify,
cartilaginous joint surfaces are eroded and ossification follows,
soft tissue in joints degenerates,
ligaments of vertebrae calcify and ossif icate,
intervertebral discs atrophy, and
osteoporosis is generalized.
The most common condition associated with this
group is arthritis.
How can you protect and prolong the mobility of
your aging patient?
1. Bones are generally less able to withstand stress, for
example, there are changes in the angle of the neck of the
femur and the shaft.
2. Joint mobility can be maintained through exercise.
3. Chairs with arms make it easier for these individuals
to be mobile.
4. Rehabilitation time is increased.
5.
6.
Resources for the Older Canadian
a) "Don t Take it Easy" is a motivational 40-page
booklet designed to give those over the age of 55,
some practical information about physical activity
and its relationship to health, aging and well-being.
"Take It Easy. ..But Take /f the companion
booklet, is an illustrated home exercise program
designed to be safe and effective for the mobile
senior adult.
Single copies of both booklets are available
free of charge upon request; sets of up to 40 copies
may be obtained by health and fitness professionals,
leaders of group fitness classes or pre-retirement
courses.
b) Health and Fitness is a 60-page comprehensive
booklet of fitness.
c) General information, pamphlets and posters on
fitness.
Write to: Fitness Canada, Journal Building,
365 Laurier Ave. W., 11th Floor, Ottawa, Ontario
K1A OM5.
dj The Fit Kit contains the Canadian Home Fitness
Test, a Fitness Progress Chart and Fit-Tip Exercises
(Cost $7.95).
Write to: Fit-Kit, P.O. Box 5100, Thornhill, Ontario
L3T4S5.
e) Canada food guide, information, pamphlets or
posters on nutrition, alcohol, drugs or tobacco.
Write to: Health Promotion Directorate, Health
Services and Promotion Branch, Department of
National Health and Welfare, Ottawa, Ontario
K1A 1B4.
f) Funding is available for community-based projects
in Fitness and Recreation for retired adults.
Write to: National Office, New Horizon Programs,
Health and Welfare Canada, Ottawa, Ontario
K1A 1B5.
Bibliography
1 Brocklehurst, J.C., ed. Textbook of geriatric
medicine and gerontology. New York: Churchill
Livingstone; 1973.
2 Brocklehurst, John C.; Hanley, Thomas.
Geriatric medicine for students. New York: Churchill
Livingstone; 1976.
Jennings, M. et al. Physiologic functioning in
the elderly. Nurs.Clin. North Amer. 7(2):237-252;
1972 Jun.
4 Kaplan, Helen S. New sex therapy: treatment
of sexual dysfunctions. New York: Brunner-Mazel;
1974.
5 * Rubin, I. The sexless older years a socially
harmful stereotype. In: Sexual development and
behavior: selected readings. Jennings, A.M., ed.
Illinois: Dorsey Press; 1973.
6 Science Council of Canada. Study on
population and technology. Perceptions 2:
Implications of the changing age structure of the
Canadian population. Ottawa: Minister of Supply and
Services; 1976.
7 *Willington, F.L., ed. Incontinence in the
elderly.
8 Zarit, Steven J. et al. Brain function,
intellectual impairment and education in the aged.
J. Amer.Geriatr.Soc. 26(2): 58-67; 1978 Feb.
Unable to verify in CNA Library
Pat Morden, a graduate of the School of Nursing,
McMaster University, is currently completing her
M.Ed, degree at the Ontario Institute for Studies in
Education while lecturing part time at the School of
Nursing, McMaster University. Her previous
experience includes working as a nurse clinician in a
chronic hospital.
PART TWO
Reality
Orientation:
Establishing a
climate of trust
in geriatric care
Marion Walker Rosalie Nepom
Mrs. Turner is 84 years old. Every
afternoon as the sun sinks lower in the
sky and dusk approaches, the nurses
who have been with her all day gather
their things and prepare to leave. New
faces, rested and fresh, appear off the
elevator and slowly, the fear builds as
old anxieties stir inside Mrs. Turner. In
days gone by this was the time when
she awaited the return of her husband
from work, this was the time to worry
about the little ones getting safely back
from school and it was the time to start
dinner for her family, which she forgets
has now grown and established lives of
their own. Every afternoon when she
becomes afraid, she paces and wrings
her hands and starts to cry; her look is
one of utmost worry and suffering.
But every afternoon a wonderful
thing happens for Mrs. Turner. The
nurses aide assigned to her that day
always finds her, takes her hand, looks
into her sorrowful face and says, "It s
OK Mrs. Turner, you will be safe with
us here in your home for the night; we
will cook your dinner and show you
where the dining room is when it s time
to eat, and we will help you to your
room when it s time to go to bed. Here
is your evening nurse. I am going home
now but she will be with you for the
whole evening. Goodbye, 111 see you
tomorrow. " Then the evening nurses
aide takes her hand and says, "I am
here to take care of you. Come let s go
down to the lounge and sit together for
a few minutes. "
Every day the worried look begins
to fade as Mrs. Turner realizes that she
is still with people she can trust and that
for at least one more day everything will
be alright.
What we have just described is the
miracle which we observe every day at
the Jewish Home for the Aged,
Baycrest Centre in Toronto, where our
residents reflect the kindness, concern
and consistency of the reality
orientation program that is now a well
established part of their care. For
Mrs. Turner, now into her fifth year as a
resident of our Special Care Section,
reality orientation has helped her to
cope with her organic brain disease, a
disease which has caused her to lose her
ability to remember recent events and
left her not knowing what time it is,
where she is or, sometimes, even who
she is.
Organic Brain Disease
Approximately ten per cent of the
population over 65 years of age suffer
from some type of brain failure, usually
termed organic brain syndrome, senile
dementia or, more commonly, senility.
Mental confusion, disorientation to
time, place and person, emotional
lability and apathy may all be signs of
this deterioration.
Organic brain syndrome is an
organic disorder of the brain tissue in
which brain cells are actually damaged
or lost. It is not a mental illness which is
a functional disorder without brain
damage. This syndrome which has no
known cause also has no known medical
treatment. Dr. Roy Fisher of
Sunnybrook Hospital, Toronto, states
"Where drugs can be used to relieve
some of the agitation associated with
this disease, drugs to improve dementia
have not as yet been shown to be
effective." He refers to reality
orientation as one of the only methods
of treatment at this time.
What is reality orientation?
Reality orientation is a tool for aiding
the elderly, a therapy for the mentally
impaired. To accommodate for the loss
of memory, the confusion and the break
with reality which mental impairment
causes, reality orientation is used to
provide a helping environment, a
climate of trust and a 24 hour supply of
needed information. By surrounding the
affected individual, not haphazardly,
but 24 hours a day with simple
information such as names, time and
weather conditions, this stimulation and
constant reminder can rebuild
confidence, lessen agitation and
sometimes even stimulate thought
processes back into use.
A person who has suffered
memory and orientation loss needs
someone in the environment to tell him
where he is, what time it is and what he
should expect next. For example, when
waking in the night, he should be
reminded that it is two o clock in the
morning, that he is in bed, that
everyone else is sleeping and that you
will wake him in time for breakfast.
Besides discussing current information,
these elderly individuals should be
encouraged to socialize, to give their
opinions and to verbalize about their
past. Interpersonal relationships can be
encouraged by emphasizing what
another person has said or reinforcing
what two individuals have in common.
Although this may seem to be a
simple, common sense approach to
nursing care which can be learned
quickly, it is, on the contrary,
extremely difficult for nurses aides who
have been primarily trained to give
physical care to add this new kind of
repetitive verbal encouragement to their
role. However, just knowing that there
is something that they can do to help
these people who have previously been
classified as beyond help, and then
actually seeing an improvement in their
elderly patients status can serve as
excellent motivation for continuing this
approach. Staff can be trained to use
the attitudes and concepts needed by
the mentally impaired but consistency
depends on ongoing supervision and
solid nursing administrative support.
Sharing the experience
In 1978, after working together in
geriatrics for ten years, the authors felt
that the Special Care approach at
Baycrest was something that we wanted
to share with other nurses working in
similar settings. This feeling was based
on two premises: first, this method of
dealing with the mentally impaired,
which had been developed by the charge
nurse of the Special Care Section,
really worked, and secondly, we both
felt that we had absorbed enough of the
philosophy and techniques of reality
orientation to teach it effectively to
others. Also even though we were two
very different types of people, we liked
each other and felt that as a team,
teaching would be fun.
Initially, after organizing our
thoughts and putting together a
proposal, we contacted one of the local
community colleges and were invited to
present our ideas to the head of the
Workshop Division. To our surprise, he
was very skeptical despite our
enthusiasm and positive feelings about
the potential success of the project. He
said that he had never heard of reality
orientation and didn t know if this kind
of a workshop would sell. When we
insisted that there was a great need for
teaching in the area of the mentally
impaired aged, he reluctantly agreed to
prepare a brochure and see what the
response to a one day workshop on
reality orientation would be.
In late August, 1978, the
brochure was circulated. We received
over 1 00 applications for a class
capacity of 20. As a result of only one
mailing we were able to fill four
workshops in that teaching year; in fact,
we had to teach classes of 25-27 people
when we were actually prepared to
work with 20. Now that we knew that
the need was as great as we had
anticipated, the challenge of presenting
our topic was before us. Could we help
our students understand the reality of
mental impairment and recognize the
benefits of reality orientation?
A learning experience
We have found that the most
important factor in teaching reality
orientation is to demonstrate what it
feels like to be old and so we start our
workshop with exercises which
simulate the losses of aging. This
sensitivity training has proved to be a
most effective and dramatic teaching
tool. One exercise asks participants to
write with the hand they don t normally
write with. We give our instructions
quickly, without repetition and we limit
their time and ask them to hurry. Later,
during discussion, a multitude of
feelings are expressed, feelings of
anger, frustration, futility and
helplessness. When this is followed by
asking the students what kind of help
would have made them feel better, they
discover for themselves how a nurse
should react in order to be most
helpful. The whole experience is then
translated from the aged resident
experiencing anger and frustration due
to loss, to the nurse relating to the
resident in the most helpful and
welcome way.
During the initial workshops we
allocated very little time for discussion
or sharing of problems and ideas as we
felt that we had much information to
give and we could not afford time for
discussion. Through trial and error, we
found that small discussion task groups
with feedback from each group were
beneficial, if not essential as each
workshop participant came with a
different background and differing
individual needs. With more open
discussion time, fewer questions were
left unanswered and more ideas were
examined.
Along with a kit, which includes a
bibliography as well as selected reprints
concerning the evolution and
application of reality orientation as a
treatment technique, we send our
students away with some tips on
implementing reality orientation in their
work setting. We emphasize the
importance of presenting the concept of
reality orientation to administration,
of obtaining their interest and support
before considering instituting this
program, as the major change in staff
attitudes required by reality
orientation cannot be realized without
this administrative support.*
Reading list
1 *Folsom, James C. Reality
orientation for the elderly mental
patient. /. Geriatric Psychiat.
1(2); 1968 Spring.
2 Hahn, A. It s tough to be old.
Amer.J.Nurs. 70(8):1698-1699;
1970 Aug.
3 *Leading the elderly back to
reality. In-Service Training and
Education 1973 Oct.
4 Moe, Mildred I. For patient s
sake. Minneapolis, Mn.: Geriatric Care;
1971.
5 *Nursing Service, Tuscaloosa VA
Hospital. Guide to reality orientation.
Tuscaloosa, Feb. 1970. (Mimeographed)
6 Oberleder, Muriel. Emotional
breakdowns in elderly people. Hasp.
Commun. Psychiat. 20(7): 191-196;
1969 Jul.
7 Stone, Virginia. Give the older
person time. Amer.J.Nurs.
69(10):2124-2127; 1969 Oct.
8 *To live with dignity (Film).
New York: American Journal of
Nursing Co., Educational Services
Division; 1970.
*Unable to verify in CNA Library
Marion Walker, RN, BScN, a graduate of
the Atkinson School of Nursing,
Toronto Western Hospital and the
University of Toronto, was director of
nursing of the Jewish Home for the
Aged, Baycrest Centre for seven years
and has taught several reality
orientation workshops. Currently, she is
director of nursing at the Willows
Estate Nursing Home in Aurora.
Rosalie Nepom, BScN, a graduate of the
University of Toronto School of
Nursing, has been coordinator of
education at both Baycrest Hospital and
the Jewish Home for the Aged and has
taught adult education courses in
supervisory techniques and reality
orientation. She is currently senior
nursing supervisor at the Jewish Home
for the Aged, Toronto.
Reality orientation therapy was
developed by Dr. James C. Folsom
of Topeka, Kansas in the late
fifties and was first put into
practice in 1962 in Mount Pleasant,
Iowa.
It seems like yesterday that Mrs. D s kitchen smelled of homemade soup and fresh baked bread. The big
dining room table was always noisy and food was plentiful. But things are different now. Cooking only for
herself, she s less fussy. Tea and toast will do for dinner. Besides, her dentures hurt when she bites into
anything hard and the arthritis in her hands has made cutting meat painful. Carrying groceries three blocks
from the store has become too much for her and the prices are too high anyway.
Seniors: A target for nutrition education
PART THREE
Doris Gillis
As people get older, many who have eaten well all their lives
slip into careless eating habits. Because the nutrition concerns
of the aged are complex and closely interrelated with other
medical and social problems, senior citizens are not an easy
target for nutrition education. But the potential for improving
the nutritional health of the elderly through nutrition
education does exist and is gaining recognition.
During the early life of most seniors, diet consisted of
simple but nutritious foods, without the highly refined
carbohydrate and fat-laden foods popular today. As well,
"three-meals-a-day" was everyday fare with breakfast often
given a strong emphasis. These food habits are consistent with
good nutrition and therefore provide a good background for
the elderly to draw upon.
Seniors also have a headstart in nutrition education in
that their concern for health generally increases as biological
changes of aging appear. They are the most frequent users of
health care facilities and are exposed to the expertise of health
professionals. Their awareness of the subject is more likely to
be increased.
Although much has been written about the nutritional
concerns of the elderly, more research into their nutritional
requirements is needed. 1 Nutrition problems vary considerably
among individuals and are, for the most part, secondary to
other physical and social disabilities. Malnutrition, like aging,
is progressive and reflects the accumulation of a lifetime of
experience (See figure one).
The major nutrition problem of ambulatory, non-
institutionalizecr senior citizens is obesity. Nutrition Canada s
national nutrition survey tells us that women run a greater risk
of becoming obese and that more than one-third of those over
65 years are actually classified as such. 2
However, energy intakes of seniors surveyed were not
excessive; the median intake for women was 1530 kilocalories
and for men 2056 kilocalories. 3 This is close to the Canadian
Dietary Standard s recommended daily energy intake of 1500
kilocalories for women over 65 years and 2000 kilocalories for
senior men. 4 Despite the fact that energy requirements decrease
with advancing age due to a decline in both basal metabolism
and physical activity, the need for nutrients does not. It was
not surprising therefore, to find intakes of protein, iron,
vitamin A and calcium of elderly subjects surveyed to be close
to or below the acceptable range.
The obvious conclusion therefore is that careful food
/^choice is a must if the senior is to meet nutrient requirements
and still maintain energy balance. However, oftentimes
physical, social and personal problems can interfere with his
diet. Health professionals involved in nutrition education
should be aware of such problems in order to effectively deal
with each situation (See figure two).
A common physical problem to watch out for is sensory
iosSj.A decline in taste and olfactory sensitivity can result in
diminished interest in food or in excessive use of salt and
sugar to compensate for lack of taste. Hearing and sight
impairments can make food shopping difficult, social eating
occasions uncomfortable and communication with health
professionals limited.
Medical factors such as diabetes, hypertension or
cardiovascular disease can limit a person s diet. Although
adherence to a special diet can prevent the worsening of such
conditions, sometimes several dietary restrictions are
recommended without discussing with the senior what he can
eat. Indigestion and constipation can cause a senior to avoid
fruits, vegetables or whole grain products, and poor fitting
dentures can curtail the intake of fibre-rich foods, resulting
in increased constipation.
Adaptation to change is difficult in the senior years.
Retirement or loss of spouse may necessitate a redefinition in
roles of provider, purchaser or preparer of food. To the senior
on his own, social isolation may pose the greatest obstacle to
sensible eating.
Figure one: The vicious cycle of malnutrition and disease in the aged
(Adapted from "Problems of Nutrition in the aged" by D.B. Rao in
Journal of the American Geriatric Society 21 :8, page 362, 1973.)
aging process
chronic disease
retirement
poor nutritional health
T
poor food habits
*
lack of nutrition
awareness
lowered income
poor housing
social isolation
At a time when emotional needs are great, food may be
used to excess as a comforting agent, or on the contrary, have
limited effectiveness in meeting these needs. Foods which were
once a source of pleasure may cause distress in the aged, to the
point that dietary restrictions and intolerances become a
reminder of the senior s vulnerability to disease and disability.
Lower economic status has been shown to have a more
adverse effect on the nutritional status of elderly men than
women. 5 One might postulate that fewer men than women
have the skills and resourcefulness to select nutritious foods
on a limited budget, especially if kitchen facilities are minimal
or transportation to competitive food stores inconvenient.
The melange of food and non-food products from which
to choose may confuse the older consumer, so much so that
he neither obtains the product he wants nor makes the most
economical and nutritious choice. Distrust of the food supply
is not uncommon among seniors.
The senior may not recognize the relationship of sensible
eating to good health and feeling good. After all,
he may not have a strong appetite, he is no longer growing
and he is not as active as in younger days. There may
Figure two: Role of health professionals in attainment and
maintenance of senior s nutritional health
MINIMIZE
proven good food
habits by fact
of survival
interest in health
Factors For
Factors Against
sensory loss
medical conditions
changes in lifestyle
emotional needs
limited income
lack of nutrition
awareness
confusion in the
marketplace
MAXIMIZE
be a feeling of fatalism in that he does not want to provide
nourishment to an aging body. Or, the senior may simply not
view nutrition as important. After all, public interest in
nutrition is a relatively recent phenomenon. (Most vitamins
. were not even discovered until after today s seniors had
finished their formal schooling!)
Nutrition education programs must be designed to equip
seniors with the knowledge and skills necessary to eat sensibly
while encouraging them to assume responsibility for their
own health. Opportunities to reach senior citizens through
nutrition education should be sought and exploited by nurses,
as well as other health professions.
In the summer of 1979, a federal government survey 6
of nutrition education programs directed at well Canadian
seniors revealed that a variety of approaches have been
implemented. Techniques ranged from mass media to
individual counseling and from formal lectures to small group
discussions. Although further evaluation is needed to identify
the most effective means of reaching senior citizens, small
group discussions have an obvious advantage in that they
provide seniors, themselves, the opportunity to offer each
other practical solutions to their problems. The role of the
health professional becomes that of facilitating the exchange
of a wealth of experiences and skills available within the
group, rather than that of providing all the answers.
In attempting to reach seniors with nutrition education,
nurses and other health professionals should consider some of
the following points:
1 . Give seniors the opportunity to define what they want
to learn. Needs for nutrition education vary considerably
among all individuals, but especially in the senior years, and
should be identified before planning the program.
2. Encourage voluntary participation. Adults learn better
when willing, and seniors in particular may have short
attention spans.
3. Relate nutrition to the senior s life by integrating it
with relevant topics (eg. fitness control of medical conditions,
personal hygiene) or events (group meals, social functions
involving foods, fitness classes).
4. Provide practical information to help seniors deal with
the realities of sensible eating. Topics which are frequently
identified as concerns by seniors are food budgeting, buying
and cooking for one, selecting convenience foods, weight
control.
5. Help seniors understand the emotional and social
motives for their food selection and eating practices in order
to better enable them to make rational food decisions.
6. Respect existing food practices and positively reinforce
acceptable food habits. Changing food habits is difficult but
not impossible, especially if minor adaptation rather than-
complete modification is recommended.
7. Emphasize health and "feeling good" as benefits of
sensible eating. Good nutrition can enhance quality of life in
the senior years.
8. Provide opportunities for the sharing of experiences
and knowledge among seniors. Special attention to the
dynamics of small group discussion can facilitate exchange of
ideas. Visual aids can be particularly effective in stimulating
while guiding discussion as well as in holding the senior s
attention.
9. Be alert to possible entries into the topic of prevention,
both as it relates to senior s food habits as well as the practices
of younger family members.
10. Project a positive attitude toward both the process of
aging and the senior years. Prevention is hard to sell if the
goal is not appealing.
The concern for nutrition education has only recently
spilled over into senior years. However, as the older segment of
our population expands, it will invariably demand greater
attention. By the year 2,000, about 12 per cent of the
Canadian population will be over 65 years of age. 7 As the
nutrition problems of Canadians tend to become more severe
with advancing age, health professionals must direct their
attention not only to prevention in early life, but also to
prevention throughout later life. *
References
1 Exton-Smith, A.N. Nutrition problems of elderly
populations. In: Nutrition of the aged. Proceedings of a
symposium presented by the Nutrition Society of Canada.
Hawkins, W.W. ed. Calgary, Alta.; 1977 Jun.20: p.1-20.
2 Canada. Nutrition Canada. Report. Ottawa: Bureau of
Nutritional Sciences, Department of National Health and
Welfare; 1975.
3 Canada. Nutrition Canada. Food consumption patterns
report. Ottawa: Bureau of Nutritional Sciences, Department of
National Health and Welfare; 1977.
4 Canada. Health and Welfare Canada. Health Protection
Branch. Dietary Standard for Canada. Ottawa: Information
Canada; 1975.
5 Canada. Nutrition Canada. Report on the relationship
between income and nutrition. Ottawa: Bureau of Nutritional
Sciences, Department of National Health and Welfare; 1975.
6 *Health Promotion Directorate. Nutrition education of
the well elderly. An annotated list of resource materials and
Canadian programs. A report to the Health Promotion
Directorates Summer Resource Fund. Dumochel, D., comp.
1979.
7 Schwenger, C.W. Non-nutritional factors affecting the
nutritional status of the aged. In: Nutrition of the aged.
Proceedings of a symposium presented by the Nutrition
Society of Canada. Hawkins, W.W., ed. Calgary, Alta.; 1977
Jun.20: p.37-43.
*Unable to verify in CNA Library
Doris Gillis, B.H.Sc., M.Sc., R.P.Dt., is a graduate of the
University ofGuelph, Ontario and is currently a nutritionist
with the Ottawa-Carleton Health Unit. She acts as a
consultant to public health nurses, other health professionals
and the community. This article stemmed from Doris work
with public health nurses and their community contact with
the elderly.
L.,m.*t loan ->o
Self-help groups have increased
tremendously in the past 20 years;
they are used to supplement and,
sometimes, to provide an alternative to
traditional professional care. All such
groups are based on the "veteran
concept": those who have successfully
weathered the specific crisis are
available to help those new to the
situation. Some groups include a role
for the professional, others completely
reject it; some meet only for the
duration of the crisis, others see the
group as a possible life-long support.
Staff in neonatal intensive care
units (N.I.C.U.) are becoming more
concerned with the needs of parents and
ways to promote solid parent-infant
relationships. Although parents are seen
as members of the team caring for the
infant, they require special support
during this crucial time. This is
particularly so if the stress and physical
separation produced by having a
hospitalized infant is complicated by
illness of both mother and baby.
At the Hospital for Sick Children a
multi-disciplinary research team
conducted a two year project to
evaluate self-help groups for parents of
premature infants. The project team was
made up of N. Shosenberg, RN, BScN;
K. Minde, MD FRCP(C); P. Marton,
PhD; B. Hines, B.Sc.; J. Shanoff, BA
and D. Manning, B.Sc. Coordination of
the parent groups was under the
direction of a nurse. Professionals were
involved in both planning and
functioning of the groups; this was
considered necessary due to the nature
of the crisis and to evaluate
effectiveness of the project.
Project guidelines and objectives
Research criteria for inclusion of the
infant and parents in the project were
met if the infant weighed less than 1500
grams, was a singleton birth, had no
congenital abnormalities, and at 72
hours of age had not suffered any major
complications, e.g. intra-cranial
hemorrhage, convulsions. Over the two
years of the project, 28 English-speaking
families living within 15 miles of the
hospital met this criteria and were
willing to participate in the groups. In
addition, 17 families who did not meet
all the criteria were invited to attend the
groups; this helped to fill out small
groups when insufficient numbers of
infants were born in close enough
succession. The control group for the
project consisted of 29 families who
met the same criteria as the project
group. Permission to include an infant
in the project was given by the
neonatologist and family pediatrician
and the families were contacted by
phone and invited to join the group
when the infant was three days old.
Before determining research
results the families in the two groups
were matched for marital status, parity,
previous abortions and socio-economic
class. The majority of mothers were
married (75 per cent approx.) and
obstetrical histories showed a high
incidence of previous obstetrical
problems in both groups. The infants
had mean birth weights of 1 142 grams
(S.D.= 215) and 1144 grams (S.D.= 249)
in the experimental and control families
respectively. There was an
approximately equal distribution of
male and female babies in the two
groups.
The objectives for the project
were the following:
that parents have an opportunity
to share and to learn to cope with the
stress of having a premature infant
that parents become acquainted
with their baby in hospital, share in
Y groups i
for parents
of premature infants
Nancy Shosenberg
30 July/Auantl9flfl_
Tho fonf Hlan I
meeting his present needs, and prepare
to meet his future needs
that parents be provided with
general information about the
characteristics and growth and
development of premature infants
that parents become familiar with
the resources in the hospital and the
community.
Preparation phase
The major initial task of the coordinator
was to plan for the groups; this took
approximately six weeks and included
a variety of tasks:
Resources: A search for audiovisual and
written resources was fruitless; as a
result the following aids were developed:
a slide presentation describing the
neonatal intensive care unit at Sick
Childrens
a videotape entitled "Good things
come in small packages" describing the
characteristics of premature infants, the
equipment used in N.I.C.U., and
methods of feeding
a kit containing the small
equipment used in N.I.C.U. so that
parents could handle these items that
are sometimes frightening to the
uninitiated
a second videotape on
prematurity entitled "A crisis for
families". This video previously filmed
by the research team and originally
intended for professionals, was edited
and adapted for parents.
Other films for new parents on
general subjects such as bathing,
breastfeeding, etc. were available for use
if this type of specific information was
requested.
A special note: discovering the lack of
appropriate literature on prematurity,
at the end of the project, the nurse
coordinator produced a 60-page booklet
with photographs entitled, "The
premature infant: a handbook for
parents" (see insert).
Information gathering: To become more
familiar with the functioning and styles
of other community self-help groups the
coordinator met with some of these;
this also prepared us for some of the
problems that could arise within the
groups.
Consult with veteran parents: A number
of parents met with the research team
to offer suggestions and to pilot
evaluation tools. (A pilot group session
had been held the year before and so we
did not repeat this important
preparatory measure.)
Choosing veteran mothers for groups:
This was a most important task; all
veteran mothers were chosen for their
role because of their interest in the
project, their expressed desire to help
other parents and their ability to
discuss their feelings openly and
objectively. Some veteran fathers were
also willing to participate and so some
groups had this additional benefit.
Staff preparation: The staff nurses in
N.I.C.U. met with the coordinator on a
number of occasions to discuss the
purpose and method of the project. The
principal investigator interpreted the
program to the medical community. All
staff had an opportunity to preview any
material that might be used in the group
sessions.
Arranging a meeting place: It is difficult
for parents to relax and discuss their
concerns when they are in or near the
busy I.C.U., so an office in the research
department one floor away was chosen.
With the addition of plants, brightly
colored furniture, pictures and
equipment for serving refreshments, it
was transformed into a suitable meeting
room.
Project phase
Once preparation for the project was
complete, we were ready to start the
group sessions. At this point the
nurse-coordinator took on the duties of
main organizer and facilitator of the
groups. She was responsible for
screening admissions, inviting parents to
take part, arranging meeting times,
providing A-V aids and scheduling
participation of resource professionals
in the groups.
The nurse-coordinator was also
responsible for an initial individual
meeting with parents to orient them to
the program. This was usually arranged
to coincide with their first visit to the
N.I.C.U. At this time they were
introduced to their baby and the nurse
caring for him, given a brief tour of the
unit, and also introduced to members of
the research team. At the conclusion of
this visit the coordinator provided time
for them to discuss their concerns about
the baby.
Throughout the entire project the
coordinator and the principal
investigator attended rounds in the
N.I.C.U. and the post N.I.C.U. This
allowed them to act as a liaison between
the ward staff and the research team
members; it also provided a time to
share the problems and progress of
families with staff as necessary.
The whole research team met
weekly throughout the project. These
meetings were a time of evaluating the
progress of the groups and a means of
support for the coordinator. Between
groups time was allowed for follow-up
of the past group and preparation for
the next one.
The group setting
Each group consisted of three to seven
families and met weekly for
approximately 10 weeks (range 6-14);
each session was 1 1/2 to 2 hours long.
The coordinator attended all sessions
and veteran mothers were present for
about half of the sessions; five of the
eight groups had veteran fathers also
attending. During the sessions the
coordinator and veteran parents acted in
team fashion; the coordinator took
responsibility whenever special
information or clarification was
required.
Every group was different and
therefore required a different approach;
nevertheless, there were topics common
to all of the groups. The initial three or
four meetings focused mainly on the
emotions of the parents, and coming to
terms with the reality of having a
premature baby. The next meetings
were centered around parents concern
with their role of caretaking in the
hospital and their infants progress.
Final meetings were oriented to the
many aspects of care at home.
Conversations recorded during the
meetings are included here to help give
the flavor of the group sessions and to
indicate how objectives were met in the
self-help setting.
Most parents were trying to
understand why their baby had been
born early. Mothers had tremendous
feelings of guilt that they had caused
the prematurity; often they blamed the
early birth on a drive over a bumpy
road, a fall on the ice, or having
intercourse. Despite good medical and
self care during pregnancy, they still
felt this way. Some parents knew the
The Canadian Nurse
Jylv/Auau8t1980 ..31
medical reason for their early labor and
this inevitably sparked a conversation
of the causes of prematurity and
recognition of high risk pregnancies.
The group setting usually
provided the first opportunity to share
delivery experiences with others
without "feeling like a failure".
Obstetrical complications are common
to this group and so they readily under
stand each others difficulties and
frustrations.
Mrs. B : They found out that my
placenta was in the way when
they did the ultrasound.
Mr. M : My wife had one of those
ultrasounds done too. I d
never heard of them before.
Mrs. B : I m glad they have them
because from that I knew
that bleeding was an
emergency and we didn t
waste any time getting to the
hospital when it happened.
Mr. B: Eight minutes from our place
to the hospital.
Mrs. B: They did a caesarean right
away because the bleeding
kept on.
Mrs. M : Oh, I had a caesarean too,
but it wasn t for bleeding. I
was in bed in the hospital
four weeks before Anna was
bom. They were worried that
I was getting toxemia because
my blood pressure kept going
up.
Women normally feel vulnerable
to danger in their third trimester; they
are protective of their unborn child and
are unwilling to give him up yet. When
premature labor occurs and
interventions from medical and nursing
staff are necessary, women feel even
more vulnerable, less able to protect
their child and unable to control events.
Mothers talked at length about these
feelings of vulnerability and failure.
"/ knew something was wrong but I
couldn t get anyone to believe me. It
was the most terrible feeling - I knew
the baby was coming but no one else
seemed to. The nurse gave me some pills
but I felt the same and rang for her
again. I knew that I must seem
unreasonable but I knew something
was wrong and had to tell someone. She
said I was too impatient. I phoned my
husband and he believed me and told
me to call the nurse again and ask her to
stay with me. I was sure that both the
baby and I would die. It was a real
surprise when the baby was born and I
heard him cry. "
Mothers who deliver early miss
many, if not most, of the traditional
social customs that accompany
childbearing. This adds to their
unfamiliarity with their role and their
alienation from friends and family who
are also acutely aware of what makes up
a normal childbearing experience.
Mothers in the group shared a feeling of
being cheated of one of the most
dramatic events of a woman s life.
"/ couldn t believe I was in labor. I
spotted all day before I realized what it
might be. I hadn t even been to prenatal
classes yet! My sister was having a
shower for me in a month. It would
have been next Monday. It s cancelled
now. Everyone s too jumpy. When the
baby was bom they put me out. I
missed the whole thing. Me! The girl
who was going to have a natural
childbirth. The whole thing s a flop. I
didn t even get flowers in the hospital.
Our family says to wait with the birth
announcements - just in case. "
Mothers of premature infants go
through a grieving process for the
fantasy baby of their pregnancy as well
as anticipatory grieving for the baby
who may die. They perceive their
symptoms of grief (inability to think
about or concentrate on anything but
the baby, crying, feelings of guilt,
upset sleeping and eating patterns,
irritability with others as
depression, or inability to cope, as
"going crazy", or as "serious
postpartum blues".
Veteran The depression was the worst
mother: part of the experience for me.
I can t say how long it
lasted - it seemed like
forever then. I got better
gradually and then much
faster when Andrew came
home.
Mrs . A : At first I was okay and didn t
see why anyone would want
to come to a group. I
understood everything about
the baby and felt okay myself.
But my next visit, I really
collapsed and cried and cried
when I saw the baby. It just
hit me suddenly and hasn t
left since. Now I can hardly
wait until our next talk.
When I m home I m sure I
must be going crazy.
The reaction of relatives and
friends to the baby s birth and to the
parents feelings were often an
additional stress. Although one story of
"I know a 170 Ib man who was only
2 Ib when he was born" may be
reassuring, most parents find these
anecdotes inappropriate because they
bear little resemblance to the complex
b fe of their tiny infant. Friends and
family in their search to find some
comforting aspect to the situation
often receive a sharp rebuttal from
parents.
Mrs. S: My best girl friend came to
the hospital to see me. I was
glad to see her and told her
about the delivery. She
started to kid around and
said I d cheated because I
didn t have to push the way
she did to deliver her 8 Ib
baby. Imagine! My best
friend said that!
Veteran Most people don t know that
mother: it s usually harder work to
have a premature baby than a
full-term one because of the
complications, never mind
how you feel about it. If
they only knew you d push
anything anywhere if it
would help.
Mrs. S: My best friend though! Well
she sure isn t my best friend
anymore.
Parents shared many other
concerns which professionals are often
unaware of. These included the special
role of fathers in this situation, the
difficulties in providing a preemie with
breast milk, the stress associated with
the transfer of baby back to the
community hospital with a change in
rules and staff, the economic strain of
having a child in hospital despite
medical insurance, the inflexibility of
regulations for maternity leave and
unemployment insurance benefits when
a baby is born early, and the worry of
finding a suitable babysitter for this
special baby.
Parents took advantage then of
the meetings to share with each other
their reactions to having a baby
prematurely. Being with others in a
similar stressful crisis helped them to
find a normal range of coping behaviors
to events that are not part of the
everyday world.
Problem sharing
The group sessions usually began with
parents giving an update of their
32 July /Augutt 1980
The Canadian Nurse
infant s condition. Parents learned
about prematurity, the equipment, and
the complications of prematurity in
these first weeks. This sharing, the
slides, videotapes and veterans
experiences prompted a realization from
the group that preemies have common
characteristics and problems. Parents
came to the group with questions to
clarify their understanding of new
terms. For example, a father had
observed a notation on the Kardex
which read "observe for bradycardia".
The doctors hadn t mentioned this
problem yet and he hoped that it
wasn t a serious one. A mother had
known about her baby s R.D.S. but
when a new doctor referred to the
baby s "lung disease" she was
shattered. "Another problem with his
lungs?" This mother stopped her
daily visiting for one week. When she
found that the two terms meant the
same thing her fear lessened and visiting
the baby resumed.
Parents shared both progress and
problems. A decrease in the baby s
oxygen requirements or an increase in
the number of cc s of milk being
consumed brought cheers from the
group. Apnea, patent ductus
arteriosus or a return to ventilation
brought sympathy. When a baby
became ill the parents regressed in their
hope and re-experienced grief
symptoms.
Mrs. R: Apnea! That s been the most
terrible experience yet.
Mr. L: What did you do when it
happened?
Mrs. R: / went to pieces. I ran from
the room and yelled for a
doctor to help me. I was
crying and saying "Please
help me my baby s not
breathing". The nurse said it
was okay and that he was
going to be all right. I went
back in and he was okay. I
was so embarrassed and
apologized to the nurse for
acting like that. I was so
scared it would be a bad one
like before. I m afraid to
leave the hospital in case
he has another one.
Veteran / was always afraid to be
mother: there when Sarah had one. I
just wanted to leave and have
nothing to do with it. It was
the same when they took
blood. I just couldn t stay
there. Id go home and cry.
Then I d feel so bad because
I d left her. What kind of a
mother was I anyway - I
couldn t even stay there when
she had her worst times. It
was a big day for both of us
when I could stay and hold
her hand while they took the
blood from her heel.
Professional input
As parents became more involved in the
daily care of their baby, they asked for
information on parenting in the hospital
setting and at home.
The veteran parents were helpful
in putting relationships with staff into
perspective.
Mrs. D:
Veteran
mother:
Mrs. D:
Veteran
mother:
Mrs. D:
TJiese nurses think he s their
baby and he s not!
I used to think that too.
When I was here yesterday
the nurse kept doing things to
Sacha when I could hardly
wait to get in there and hold
him. I was so mad - it was
like she was doing it on
purpose.
Probably she was doing it on
purpose so you could have
Sacha to yourself after every
thing was finished with no
interruptions.
Do you think so? That s
what she said too, but I
didn t believe her. I guess
you re right. I m so upset - I
react to everything.
Three professionals had regular
input with each group. A neonatologist
from the N.I.C.U. came midway in
group meetings to answer medically-
oriented questions and to discuss taking
the premature baby home. He also told
the group about current trends in
perinatal care; many parents had not
heard such terms as "high-risk
pregnancy" and were unaware of new
facilities and philosophies in care.
The occupational therapist from
the N.I.C.U. came to a session to
discuss the abilities of infants (many
Figure one
Number of Hospital Visits by Mother
Control
Mothers
3.1
Group
Mothers
4.5
Weeks
parents are surprised that preemies can
hear and see) and the developmental
tasks to be achieved in hospital and at
home. She also stressed the valuable
input parents can have during their
baby s hospitalization.
The nurse from the follow-up
clinic attended to familiarize parents
with the function of this clinic and to
discuss common concerns parents have
when taking their baby home. In
addition she reviewed the important
concept of age correction used to assess
premature babies in the first few years.
Sometimes discussions that
developed showed a need for further
interpretation of professional roles; for
example, the parents in one group
interpreted the "public health nurse"
visit as a sign that the hospital knew the
mother wasn t coping well and was
sending someone to check up on her.
A P.H.N. was invited to the group to
clarify.
A nutritionist was also available to
the group whenever her expertise was
required.
Research results
Each family was interviewed by the
team psychologist at the time of the
infant s discharge from N.I.C.U. This
interview was designed to determine the
parents feelings on seven separate
issues:
satisfaction with medical care
satisfaction with nursing care
satisfaction with information
understanding of the infant s
ondition
interaction with other parents
comfort with ability to care for
baby at home
knowledge of community
resources.
Each of these was scored from 1 to 5,
most unsatisfactory to most
satisfactory, so that a total score could
range from 7 to 35. Each category had a
clear definition that allowed for
objective scoring. Scoring on all seven
issues was significantly different when
the groups were compared; the project
group demonstrated higher scores in
every case (total mean scores:
project: 28.7, control 22.1).
Attendance rates for the group
sessions were also studied; the mean
attendance was 65 per cent. The
mothers whose attendance was below
50 per cent were all from families with
special individual problems; this group,
experiencing multiple crises, seemed
unable to focus consistently on the
infant.
The mothers in the project group
visited their infants in N.I.C.U.
significantly more often than mothers in
the control group {See figure one).
This outcome strongly suggests that
participation in the self-help groups
encouraged mothers to visit more often.
The Canadian Nurse
When parents visit frequently staff
have a better opportunity to promote
solid parent-infant relationships. The
mean stay for all 57 infants in N.I.C.U.
was 55 days; they returned to their
community hospital when their weight
was approximately 1800 grams and
their medical status was stable.
In the comparison of statistics
on length of separation for mother and
infant (birth to first visit) a difference
was noted again between the two
groups: project mothers had a shorter
separation time. This could have
resulted from the early call to the
mother inviting her to join the group,
however, as illness of the mother after
birth would also increase separation
time, this cannot be accepted as the
only interpretation.
Conclusions
The entire course of pregnancy and
childbirth is often very different for
these parents: they have probably
missed prenatal classes, been separated
by hospitalization before birth,
estranged from the baby soon after
delivery, and required to adjust their
version of a "normal" newborn. They
are also subjected to a greater
diversity of professionals and
technology. By setting up these group
sessions the research team hoped to
offset the negative effects of all these
differences, and capitalize on the
strength of other parents with similar
past experiences. Also this was a way
for professionals to fulfill their respon
sibility to give information and support
to these parents, and to do this in an
innovative manner.
Group support is beneficial to
many but it may not be appropriate for
everyone. One of the project s problem
areas was encountered when attempting
to meet the needs of families with
special problems, e.g. no housing,
marital problems, psychiatric illness,
unemployment, etc. Recognition of
and provision for these families became
a responsibility of the coordinator;
support from other professionals was
essential for helping these families
cope.
The results of this study strongly
suggest that the objectives of the
self-help program were attained. Sharing
common problems helped parents
recognize and accept their crisis reaction
as normal. It showed also that parents
can care for their infant in hospital
when they are ready and accepted; it
demonstrated that they are eager to
learn about prematurity and the special
needs of their baby.
The Premature Infant
by Nancy Shosenberg, RN, BScN
This 60-page booklet on prematurity,
subtitled "A handbook for parents", has
been prepared as a self-help aid. It covers all
aspects of infant care in excellent detail
using language appropriate for parents
unfamiliar with the characteristics of a
premature baby and the technology of care.
Numerous photographs add visual reality to
the text and convey a sense of warmth and
support. This booklet is a bonus for worried
parents needing information and an A-1 aid
for staff to use in their "patient educator"
role.
The booklet is available from the
following addresses:
In Ontario order from:
Health Resources Centre
Communications Branch
Ministry of Health
Hepburn Block, 9th Floor
Queen s Park, Toronto M7A JS2
Other provinces:
The Hospital for Sick Children
Room 1218
555 University A venue
Toronto, Ont. M5G 1X8
Cost: In Ontario the booklet is available free
to families with a premature infant.
Other provinces: single copies-$3.00 each
50-99 copies-$2.50 each
100 or more-$2.00 each
Difficulties for the coordinator
included meeting the wide range of
needs in the different groups, and the
flexibility required to handle each group
in an individual way. A positive
outcome was the development of an
educational role for the nurse
coordinator. Staff in N.I.C.U. and
parent-oriented groups asked for
dialogue, inservice sessions, workshops
and conferences. These groups wanted
to learn about the role of the caregivers
and the experiences and needs of the
family with a premature infant.
Undoubtedly the single most
obvious indication of the program s
success has been the subsequent
formation of the Toronto Perinatal
Association; this organization of
parents continues to make self-help
groups available for families coping with
prematurity at the Hospital for Sick
Children.*
Bibliography
1 Dilmont, M.P. Self-help treatment
programs. Amer.J. Psychiatry
131:631-635; 1974 Jun.
Klaus, Marshall; Kennell, John.
Maternal infant bonding: the impact of
early separation or loss on family
development. St. Louis: Mosby; 1976.
Powell, T.J. The use of self-help
groups as supportive reference
communities. Amer.J. Orthopsychiatry
45(5):756-764; 1975 Oct.
4 Rubin, Reva. Maternal tasks in
pregnancy. Matern.Child Nurs.J.
4(3): 143-153; 1975 Fall.
5 *Taylor, Paul M.; Hall, Barbara
Lee. Parent-infant bonding: problems
and opportunities in a perinatal centre.
Seminars in Perinatology 3(l):73-84;
1979.
*Unable to verify in CNA Library
Acknowledgement: This project could
not have been done without the
continuing assistance of the following
staff members of The Hospital for Sick
Children: Dr. P.R. Swyer, chief,
Division of Perinatal Medicine; Dr. G.
Chance, formerly assistant chief,
Division of Perinatal Medicine;
Mrs. S. Blacha, supervisor of
Occupational Therapy, Department of
Rehabilitative Medicine, and Mrs. M.
Bracht, nurse coordinator, Follow-up
Clinic, Department of Perinatal
Medicine.
The study was supported by
Grant No. 606-1 360-44 Al from Health
and Welfare Canada and the Laidlaw
Foundation
Nancy Shosenberg was nurse
coordinator for the project described
in this article. She is a graduate of the
Nightingale School of Nursing, Toronto,
has a diploma in neonatal nursing from
The Hospital for Sick Children and a
BScN from Queens University,
Kingston, Ontario. She is employed by
the Department of Psychiatric Research
at The Hospital for Sick Children,
Toronto.
! -
Income Tax
and the
Self-
Employed
Nurse
In Ontario alone, at least one
nurse in 60 is in private
practice. That province s
licencing body, The College of
Nurses, estimates that last year
close to 1000 nurses out of a
total of 59,875 employed
RN s were self-employed.
Maureen Garbutt
Do you dream of becoming your own
boss? Or maybe you already enjoy the
freedom of choosing your own hours
and working conditions? Being self-
employed can be very satisfying but it
requires a business-like attitude to
some things you once took for granted:
it s important, for example, that you
fully understand the tax implications of
your decision. One of the first things to
consider is whether or not you really
are self-employed for tax purposes. This
is important because it determines the
deductions you may claim.
Employee or self employed?
How is your employment status
determined? Basically by the amount of
control the contracting client or
company has over your work. This is
usually made clear at the onset by the
terms and conditions under which your
nursing services are to be performed.
If you exercise control over the hours of
work, the premises and equipment used
and the manner in which you perform
your nursing duties, you will probably
be considered self-employed.
If, on the other hand, the
hospital, clinic, nursing home or
doctor s office pays you a salary, has
the right to discharge you, and has
established definite working hours, you
will be considered an employee. If you
have any doubts, you can obtain a
specific ruling from your District
Taxation Office.
Once you ve determined your
employment status, how do you report
your earnings? Remember that as a
self-employed nurse in Canada you
won t have the help of that handy
T4 Supplementary that employers send
to their employees each year to provide
a record of their annual earnings and
deductions. You ll have to keep track of
these yourself. In addition, tax won t be
deducted at source on your
self-employed income. It will be up to
you to calculate the amount you owe
and send it to Revenue Canada,
Taxation.
You are required to pay tax by
instalment if the tax on your earnings
will amount to more than $400 for the
year or the immediately preceding year.
Unless three-quarters of your income
(both self-employed or other income) is
taxed at source, you are expected to
pay tax by instalment.
Tax is due on income as it s
earned. You re required to pay the tax
on your self-employed income in four
equal instalments March 3 1 , June 30,
September 30 and December 31. It s
to your benefit to make your payments
regularly to avoid being faced with an
unmanageable tax bill and penalties at
the end of the year. When you file your
annual tax return, on or before
April 30, you pay the difference
between the amount you ve already
paid by instalment and the amount of
tax due. If you have overpaid, you will
receive a refund of the overpayment.
Interest is charged on late or
insufficient payments.
Instalment payments may be
made where you usually bank or you
can send them to the Taxation Centre
serving your region. When making your
first instalment payment, however, mail
it to the Ottawa Taxation Centre,
Ottawa, Ontario, K1A 1B1. Identify the
payment as a quarterly instalment.
Include your name, address, date of
birth and social insurance number on
the face of your cheque or money
order, which should be made payable
to the Receiver General for Canada. Do
not send cash through the mail.
Revenue Canada, Taxation will send
you a combination receipt (for your
records) and remittance form (for
making your next payment).
Canada Pension Plan and UIC
Like most working Canadians between
18 and 70, you are required to
contribute to the Canada Pension Plan
unless you live in Quebec where the
Quebec Pension Plan is in effect. Your
CPP contribution is paid by instalment
at the same time as your income tax.
Your contribution is based on
maximum earnings of $13,100. You
would not contribute any amount for
earnings above that level. In doing the
actual calculation, however, there is a
basic exemption of $1,300 which you
subtract from your income.
If your income happened to be
$13,100, you would subtract the
basic exemption of $1,300 and
calculate your CPP contribution as
3. 6 per cent of $11,800.
If you earned more than
$13,100 (for example $16,000) you
would subtract the $1,300 basic
exemption, which leaves $14,700, an
amount greater than the $1 1,800
maximum contribution. In that case
you would pay 3.6 per cent of $1 1,800
which is $424.80 (or $106.20 each
instalment).
If you earned less than $13,100,
for example $5,000, and as this amount
is less than the $1 1,800 maximum
contribution, you would pay 3.6
per cent of $3,700 ($5,000 minus the
$1,300 basic exemption) or $133.20
($33.30 per instalment).
If you ve already contributed to
the Canada Pension Plan as an
employee, then the salary or wages on
which you made a contribution are
taken into account. For instance, if
you ve made the maximum contribu
tion for a year as an employee, no
contribution is required on your
self-employed earnings for that year.
As a self-employed nurse, you are
not required to pay Unemployment
Insurance premiums.
It s wise to keep records
It s not hard to see that good records
can work to your advantage.
Remember, you ll need detailed
information on your self-employed
earnings and related expenses in order
to estimate your tax due and calculate
your Canada or Quebec Pension Plan
contributions. At the end of the year
you ll need all these details to complete
your tax return accurately. Well-kept
records can save you tax, as they can
remind you of the deductible expenses
available to you.
One method of maintaining
records is a two-file system an active
file and a dead storage file. Your active
file should hold unpaid bills, paid bill
receipts, current bank statements,
cancelled cheques and income tax
working papers. These should be
arranged in envelopes which have been
clearly labelled as to contents and
filed by year. Keep records up-to-date
by cleaning your active file annually and
moving older records to the dead
storage file. You can use anything from
a metal filing cabinet to manila folder.
The essential thing is to know where
everything is.
One handy record is a diary of
your expenses. At the end of each day,
simply write down all of the amounts
you have spent in order to earn income,
pay telephones, parking fees, gas and oil
purchases, etc. Where possible, ask for
receipts which you can keep on file to
substantiate your expenses. You ll
probably be surprised at the amounts
you spend that are deductible for tax
purposes. Maintain a written record of
those expenses for which you have no
receipt, noting names, amounts, dates
and places. This information will help
justify your claim for expenses.
You are required by law to keep
your records and supporting documents
from year to year until you request and
obtain written permission from the
District Taxation Office for their
disposal.
Your fiscal year
Except for farmers and fishermen,
virtually all self-employed taxpayers
must follow the accrual approach to
accounting. This means that income is
reported in the year in which it is
earned, regardless of when payment is
received. Allowable expenses are
deductible in the year they are incurred
whether paid or not.
As a professional nurse, you are
allowed to use a modified accrual
method. Income is treated as being
earned when accounts are sent,
providing there is no undue delay in
delivering them.
For example, suppose you had
billed a client for nursing services but
had not been paid when it came time to
determine your income for the year.
That unpaid amount would still have to
be included in your income but you
would not have to report it for that
year if you had not yet billed your
client.
Individuals are taxed on a
calendar year basis. However, as a
self-employed nurse, you can determine
the dates of your own tax year. This
fiscal period may coincide with the
calendar year but must not be longer
than 12 months. If you don t pick a
year-end to report your self-employed
income, you ll automatically be given
the normal calendar year-end. By
choosing a year-end other than
December 3 1 , you might be able to
maximize certain allowances.
Your fiscal period is established
when you file your first income tax
return. Once you have selected a
business year, though, you are not
allowed to change it without first
obtaining permission from your District
Taxation Office. A change will not be
permitted if your main reason is to
minimize taxes.
Suppose you choose January 31
as your year-end. What you earned as a
self-employed duty nurse between
February 1, 1979 and January 31, 1980
would not have to be reported until you
filled out your 1980 tax return - and
you don t do that until early 1981. So
although you earned your self-employed
income during 11 months of 1979,
because your year ends in 1980, you
don t have to report any of that income
until 1981.
If you had other income as well,
for instance employment or investment
income, you would report it on the
same tax return but it must cover the
taxation year running from January 1 to
December 31, 1979. That s why it s
usually easier for taxpayers with both
kinds of income to use the regular
taxation year as their business year as
well.
Reporting your self-employed earnings
You will be reporting your
self-employed income on the line for
"Business income" on the first page of
your tax return. You are required to
report both gross and net income.
Gross income is your total
earnings as a self-employed nurse. Net
income is what you end up with when
you subtract the allowable expenses you
incurred to make those earnings.
To support the net income figure
you arrive at, you are required to file a
statement of income and expenses and a
balance sheet with your tax return.
Form T2032 (available from your
District Taxation Office) is a useful
checklist for expenses you may have
forgotten to claim.
Generally if you incur an expense
to earn income, the expense is
deductible for tax purposes. These
expenses must be reasonable and must
relate to the year in which you are
deducting them. You should keep all
the receipts, cancelled cheques, etc.
necessary to support your claim for
expenses in case Revenue Canada should
question them. If you re asked to prove
you made an expenditure and you do
not have supporting evidence, your
claim could be disallowed. Complete
documentation also enables you to
prepare your tax return more quickly
and accurately and can remind you of
deductible expenses which you might
otherwise overlook.
These individual expenses may
not seem like much, but over a year
they add up. Items most commonly
claimed by self-employed nurses relate
to automobile and transportation
expenses, office upkeep including
telephone costs, nurses uniforms and
shoes, and professional conventions and
courses. Here s an alphabetical list of
the expenses you should be aware of.
Remember though, that these
deductible expenses apply only to
income earned from self-employment:
Accounting and legal expenses:
Accounting fees for the preparation of
your income tax return are deductible.
Any legal expenses incurred to collect
unpaid earnings owing to you can also
be claimed.
Advertising expenses: You may deduct
the cost of running an advertisement in
a Canadian publication to tell of your
availability to perform nursing services.
Business cards may also be claimed as an
expense.
Automobile expenses: If you own an
automobile that you use in the course
of your work, you may claim
automobile expenses. If you use your
automobile partly for business and
partly for personal use, you claim only
that portion of the total operating
expenses that relate to your working
use. Thus, if your business mileage is
12,000, your total mileage 20,000, and
the operating expenses for the year
amount to $1,500, your deduction
would be l_2,0_qp x $1,500, or $900.
20,000
.!/. ... 10
Driving back and forth between your
home and the place where you work is
not considered business use and cannot
be included in your business mileage.
If you own and use two
automobiles, you are not allowed to
claim total expenses for both; you must
allocate expenses for each.
Operating expenses include
automobile licence and insurance fees as
well as washing, gas, oil and routine
maintenance and repairs. You can also
claim capital cost allowance on your
automobile, interest on a loan made to
buy it, or rental costs if you are using a
leased automobile. Remember that you
claim only the amount related to your
business use of the car.
To claim these expenses, you will
need to keep receipts for all operating
costs. You will also need a record of
your total mileage and business mileage.
If you change automobiles during the
year, record the mileage for each one
when you start or stop using it. To
claim capital cost allowance, you must
have the original bill of sale for your
car, or if you have an older car, record
its value when you first begin to use it
for business purposes.
Bank charges: If you have a special
chequing account for your
self-employed earnings, you can claim
cheque, money order and similar
charges.
Books and magazines: You may deduct
the cost of single issues of magazines
and library fees for books necessary to
keep your nursing skills up-to-date. You
can also deduct fees paid for nursing
library privileges.
Canada and Quebec Pension Plan
contributions: Contributions you make
to either plan are deductible.
Capital cost allowance: The cost of
acquiring a capital asset (an automobile,
typewriter, etc.) is one outlay not
deductible in full for the year it s
incurred. As this kind of asset is
expected to have a useful life of more
than one year and to be of long-term
benefit, it is deductible over a period of
years rather than the year of purchase.
This is called "capital cost allowance"
or depreciation.
This deduction is available to all
self-employed taxpayers and covers
many types of assets, such as vans,
office furniture and equipment. Not all
capital assets qualify for capital cost
allowance, however. To qualify, a
capital asset must be included in a class
specified by law. Rates for these classes
may be obtained from your District
Taxation Office.
Automobiles are in Class 10,
where the rate is 30 per cent. Thus, if
the undepreciated capital cost of your
automobile was $8,000 at the end of
last year, your capital cost allowance
rate is 30 per cent of that, or $2,400.
This amount is subtracted from the
undepreciated capital cost of your
automobile, and next year s claim
would be based on $5,600 ($8,000
minus $2,400).
If you use your automobile for
both business and personal use, you
may claim only that portion of the
depreciation that relates to your
business use. Thus, if your business use
is 35 per cent of your total use, you can
claim only 35 per cent of $2,400 01
$840. If your business use was 50
per cent, you could claim $1,200, and
so on. Note, however, that your capital
cost for the following year would still
be $5,600, no matter what the ratio of
your business use.
If you sell your automobile for
more than the undepreciated capital
cost, you must include in your income
the difference as a "recapture" of the
capital cost allowance you have claimed
in previous years. "Recapture" applies
only to capital cost allowance you have
previously claimed, not to any profit
you might have made when you sold the
car. If you sell your car for less than the
undepreciated cost, you may also be
entitled to claim a terminal loss on the
difference.
Convention expenses: You may claim
only two conventions a year and they
must relate to earning your income. In
addition, they must take place within
the territorial scope of your business.
You don t need to be a member of the
association holding the convention but
your attendance must have a direct
bearing on your way of earning income.
Entertainment: Expenses you incur to
entertain clients are deductible provided
they are for business purposes. Expenses
must be reasonable under the
circumstances and supported by
appropriate receipts and records.
Undated restaurant stubs are not
acceptable as receipts.
Losses: Business losses are generally
deductible. For example, if your
expenses for a year should exceed your
earnings, then you may claim a business
loss.
Memberships: Annual dues to maintain
memberships in trade, professional or
commercial associations are deductible
only if they are necessary to earn
income. Lump sum life memberships are
deductible if they substitute for annual
membership fees. These may be
deducted for the year in which they are
paid. Admission or initiation fees are
not deductible.
Office expenses: To claim a deduction
for an office in your home, you must
have a room set aside for the sole
purpose of earning income. It cannot
also serve another purpose, for example,
a sewing room or workshop. You must
establish clearly that your office is
separate from your living quarters and
that a substantial amount of your
business is conducted there.
If that is the case, you may
deduct a reasonable portion of your
home expenses. These include such,
items as electricity, heating, taxes,
home insurance, general maintenance
and repairs, etc. The expenses must be
apportioned between the business and
non-business use of your home. This is
done by dividing the square feet or
number of rooms for your business by
the total square feet or number of
rooms of the entire house. You may
also claim a deduction for capital cost
allowance or mortgage interest provided
you own the home. Remember,
however, that if you claim these
deductions you might affect the
"principal residence" status of your
home. If your office is in a rented
house or an apartment in which you
live, you may deduct the portion of
your rent that can be attributed to
your business use.
Supplies: Any supplies that you use in
the ongoing performance of your work
are deductible. This might include
street maps, stationery, stamps, medical
equipment, etc.
Telephone bills: You may not deduct
telephone charges unless the telephone
was installed specifically for business
use. The cost of long distance calls are
deductible if you can show they were
incurred for earning your
self-employed income.
Travel expenses: Travel expenses are
generally considered personal living
expenses and are not deductible (except
for attending conventions as discussed
earlier). However, taxi charges, bus
fares and parking fees incurred in
carrying out your nursing duties are
deductible if you have to travel away
from your normal place of business.
Tuition fees: Tuition fees for taking a
course or seminar related to nursing are
deductible. However, you cannot
deduct travel expenses if the course or
seminar is out of town.*
Resources
For more information on specific topics
ask your District Taxation Office for:
1 . Instalment Guide for Individuals,
Form T7B.
2 The Canada Pension Plan -
Information for the Self-Employed.
3. Income Tax and the Small Business.
4. Automobile Expenses Claimed by
Self-Employed Individuals,
Interpretation Bulletin IT-180.
5. Convention Expenses, Interpretation
Bulletin IT-131.
6. Principal Residence, Interpretation
Bulletin IT-120R.
About the author: Maureen Garbutt is
on the staff of the Information Services
Branch of Revenue Canada Taxation.
Nerve Palsies:
the preventable sort
Christine McNamee Bruce Maclean
Larry, a twelve-year-old boy, has
undergone elective surgery for repair of
a nasal septal defect. Shortly after his
return to the ward from the
post-anesthetic recovery room, he
complains of numbness and tingling in
his left hand. Upon investigation you
find that Larry has a markedly
weakened grip. Larry is a victim of
ulnar nerve palsy, a complication
which can occur during the operative or
post-operative period, due to lack of
knowledge or vigilance on the part of
nursing staff.
Mrs. S., a 78-year-old woman with
diabetes, has her right foot amputated
for gangrene. During her recovery from
surgery she has a metal cradle on her
bed to relieve the pressure of bed
clothes. Her left leg has diminished
sensation: she does not feel it pressing
on the edge of the metal cradle. When
you help her up for the first time you
notice that she has foot drop. She too
is a victim of a preventable nerve palsy.
Peripheral nerves are readily damaged,
particularly at certain sites along their
course where they are relatively
superficial and unprotected. The
damaging assault to these nerves is
usually excessive pressure or stretching,
or a combination of both these forces.
Less often, nerves are directly damaged
by injections; either the needle itself or
an irritating substance injected into or
surrounding the nerve being the cause
of injury. The risk of injury to
peripheral nerves is greatly increased in
patients with conditions making them
susceptible to neuritis, e.g. diabetes,
alcoholism. Hypothermia is also another
predisposing factor, whether due to
exposure or induced as an operative
adjunct.
What nerves are prone to injury?
Where are the vulnerable sites? What are
the sources of this pressure and stretch
that could result in nerve damage? What
signs and symptoms indicate a nerve
palsy? The following discussion of six
individual nerves and one plexus should
help answer these important questions.
I The most vulnerable of the
peripheral nerves is probably the
ULNAR NERVE which surfaces
directly behind the medial epicondyle
of the humerus. The nerve lies beneath a
sharp-edged aponeurosis, and is other
wise subcutaneous at this point. Thus
pressure can be exerted on it in a
number of ways. For instance, an arm,
unattended during surgery, can drop
over the side of the table and rest on the
metal railing, or press on the hard table
top if the mattress has shifted slightly.
Similar hazards exist in a bed with side
rails or on a stretcher with a hard
rubber bumper. Hyperflexion of the
arm pulls the nerve tightly across the
condyle; prolonged stress of this sort
can damage the nerve as well.
Compression is more likely to occur if
the arm is pronated than if supinated.
Other sources of compression include
blood pressure cuffs, pneumatic
tourniquets and stethoscopes strapped
to the arm for long periods.
The ulnar nerve controls the
muscles of the flexor side of the
forearm and the ulnar border of the
hand, the small muscles of the hand and
the flexor muscles of the fourth and
fifth fingers. Similarly, the sensory
distribution covers the ulnar border of
the forearm, continuing along the fifth
finger and the lateral half of the fourth
finger. From this pattern of innervation
it is easy to see that damage to the ulnar
nerve is no small matter. If an injury has
occurred the patient will usually
complain of numbness and tingling
along the ulnar border of the hand,
especially in the fifth finger. In an
advanced case, there will be some small
muscle wasting and weakness in the
ulnar half of the hand, with clawing of
the fourth and fifth fingers.
Perioperative palsies have not
been frequently reported upon, but the
prognosis has usually been considered
good. A more recent detailed study by
Miller and Camp suggests otherwise.
Recovery may be slow, and permanent
dysfunction has been reported. In the
meantime it is essential that the nerve
be protected from further insult, and
that the fingers and affected hand be
exercised regularly. If necessary, the
fingers and hand should be splinted to
maintain normal positioning.
II The RADIAL NERVE, is not as
commonly involved as the ulnar, but it
must also be considered at risk. Leaving
the brachial plexus, it winds around the
back of the humerus and becomes
vulnerable at the mid-point of the
humerus. It is particularly susceptible to
pressure, especially when the patient is
in the lateral position with additional
weight of the head resting on the arm. A
call bell or bed rail left lying beneath
the arm can create pressure points, thus
increasing the possibility of nerve
damage. An unconscious patient
requires careful observation because he
can easily fling an arm out over the side
of a bed or a stretcher in such a way
that pressure is exerted on the nerve by
the bed s edge. Armboards carelessly
applied can also serve as a source of
damaging stress to this nerve.
The radial nerve serves the flexors
and extensors along the radial border of
the hand, and provides some sensory
function to the back of the hand and
the thumb. The results of radial nerve
palsy are variable. Frequently the
patient develops a wrist drop because of
the loss of function of the extensor
muscles; there may or may not be any
significant sensory loss in the hand. The
prognosis is good, but a wrist splint will
be needed to maintain proper
positioning, and regular physiotherapy
will be required to regain function.
III The MEDIAN NERVE is at risk in
the peri-operative period from
injections. A needle placed in the
ante-cubital vein or in the brachial
artery may slip off to the side, or the
injection may be aberrant; in either
case, damage to the median nerve is
possible. The median nerve carries
motor impulses to many of the small
muscles of the hand, and sensory
impulses from the central portion of the
palm. Thus patients with median nerve
damage will likely have muscle wasting
and weakness of the hand, as well as
sensory loss in the palm and fingers.
Peri-operative damage of the median
nerve is not frequently encountered;
symptoms of this palsy are fairly often
seen in people with Carpal Tunnel
Syndrome.
IV The LATERAL PERONEAL
NERVE is a superficial nerve which can
be readily damaged. It winds around the
head of the fibula on the outer aspect of
the leg and serves the muscle groups on
the frontal aspect of the tibia which are
responsible for elevating the foot. This
nerve also carries sensory impulses for
the dorsum of the foot. It can be
damaged when a patient is placed in
unpadded stirrups, or when the legs are
improperly positioned. There is also
great risk of injury to this nerve when
an unconscious patient is left in the
lateral position with insufficient
padding or excessive weight on the legs.
Tensor bandages applied too tightly can
also be responsible for this palsy;
diabetics or older individuals with
arteriosclerotic disease are the most
likely candidates. Foot drop is the most
dramatic symptom of lateral peroneal
nerve damage. Splinting and regular
physiotherapy will be essential to
correct this serious problem. Recovery
can be expected to take considerable
time.
V The BRACHIAL PLEXUS is a
complex of nerves arising from a band
of spinal nerve roots from C4 or 5 down
to T2 or 3. These combine, divide and
recombine in intricate patterns along
their course. The main pathway they
follow travels over the first rib and
below the clavicle. This point, called the
thoracic outlet, is the vulnerable area.
The causes of stress can vary: some
people have an additional cervical rib
which adds extra stress; others have a
tight scalene muscle, which tends to
pull the first rib up closer to the
clavicle, or there may be abnormal
vessels or fibrous bands present in the
area. All these conditions can keep the
nerves of the brachial plexus in a
continual state of stretch and any
additional stretch or pressure will
usually suffice to produce a palsy.
There are several surgical or
physical stresses that can be exerted on
the nerves arising from the brachial
plexus. Placing a patient in steep
Trendelenburg position, for example,
requires the use of shoulder braces;
if these are applied too far medially,
the pressure between the clavicle and
the first rib can be increased.
Positioning the arm of an unconscious
patient beyond a 90 angle from the
body (which can occur accidentally if
the arm falls backward without
support), results in excessive
stretching of these nerve fibres,
particularly if the situation is
aggravated by rotation of the arm. The
rather marked relaxation techniques
sometimes used in the process of
surgery can produce such lack of
resistance in the shoulder girdle, that
any additional pressure is passed
straight through to the small thoracic
outlet. Since the nerve trunks arising
from the brachial plexus continue on to
become the ulnar, the radial and the
median nerves, any of the symptoms
previously mentioned can result from
pressure on or stretching of these
nerves. The most common would likely
be ulnar discomfort, i.e. pain,
numbness, tingling and eventual wasting
of the small muscles in the hand in
instances of prolonged insult.
VI The SCIATIC NERVE is not
likely to be affected directly by
positioning. It is primarily at risk from
injections. This nerve is sufficiently
superficial in some people that it can be
directly damaged with a needle. Chronic
back problems, with lumbar disc
degeneration, old injuries and
spondylolisthesis, however, cause a
certain amount of continuous stretch of
the nerve fibres. If the nurse can
provide a degree of flexion either at
the back or behind the knees, this
stretching is relieved, and pre-existing
sciatic pain or disease is less likely to be
aggravated.
The prognosis with sciatic nerve
palsy is good, although it may take from
many months to more than a year for
complete return of function. The
treatment is usually supportive.
Splinting is required when there is some
loss of motor tone and abnormal
positioning. Physiotherapy will maintain
circulation and restore muscle strength.
Analgesics should be given as necessary
to relieve the accompanying discomfort.
VII The FACIAL NERVE, although
rarely involved, is at risk in the
peri-operative period as well. A branch
of this nerve surfaces immediately
anterior to the parotid gland. Undue
pressure on the face, such as that
produced by a tight head harness, can
produce facial nerve palsy. Since this
nerve serves the orbicularis muscle, the
result could be weakening of the
affected side of the face such as that
seen in Bell s Palsy.
Nursing implications
Prevention of nerve palsies is simple and
basic nursing care. To be competent in
this area, the nurse requires
fundamental knowledge of the
following:
vulnerable nerve sites
a sound sense of proper
positioning
awareness of environmental
hazards.
More specific suggestions for nursing
care include :
use of foam padding for elbows in
the operating room
avoidance of all inflexible surfaces
constant alertness to positioning
of the unconcious or unaware patient
generally keeping limbs slightly
flexed
special precautions with
armboards, stirrups, braces, harnesses,
bandages, etc.
correct and cautious injection
technique
extra vigilance with predisposed
individuals, e.g. those with diabetes,
alcoholism, or hypothermia.
Through quality nursing aimed at
preventing palsies, nurses can protect
their patients from needless suffering
and the prolonged treatment necessary
to regain healthy nerve tissue and
functioning. *
Bibliography
1 Bannister, Roger, ed. Brain s
clinical neurology. 3rd ed. London:
Oxford University Press; 1969.
2 *Churchill-Davidson, H.C. A
practice of anaesthesia. 4th ed. London:
Lloyd-Luke (Medical Books) Ltd.;
1978.
3 Grant, John Charles Boileau.
An atlas of anatomy. 6th ed. Baltimore:
Williams & Wilkins Co.; 1972.
4. Miller, R.G.; Camp, P.E.
Postoperative ulnar neuropathy. JAMA
242(15):1636-1639; 1979 Oct.
*Unable to verify in CNA Library
Christine McNamee, RN, BScN, is
currently administrative supervisor,
Inservice Education, at Nanaimo
Regional General Hospital on
Vancouver Island.
R. Bruce Maclean, MD, has been an
anesthetist at this same hospital since
1962. The idea for this article came
from a lecture on the subject that he
gave recently to the hospital nursing
staff.
Enhance Your Clinical Expertise
and Professional Growth
through Lippincott
1 QUALITY ASSURANCE:
Guidelines for Nursing Care
By the Duke University Hospital
Nursing Services.
Written to ensure that nurses
will be explicit about and accountable
for the quality of care they provide,
this much-needed new book gives a
simple and straightforward strategy
designed to improve patient care,
strengthen nursing management, and
enhance the total patient care program
of a health care facility.
Lippincott. Abt. 480 Pages.
Illustrated. May 1980. 19.00
oooooooo
2 A MANUAL OF
LABORATORY
DIAGNOSTIC TESTS
By Frances Fischbach, R.N., B.S.N.,
M.S.N.
A Manual of Laboratory Diagnos
tic Tests is a quick-reference handbook
of frequently ordered diagnostic tests,
featuring normal values, concise des
criptions of each test, pertinent back
ground information, clinical implica
tions of increased or decreased values,
interfering factors, as well as patient
preparation and aftercare. A special
feature, "Clinical Alert," is used exten
sively to highlight areas of nursing
concern that must be considered to
assure patient safety and well-being.
Lippincott. Abt. 800 Pages.
13 Illustrations. May 1980. $15.50
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3 Bowes and Church s FOOD
VALUES OF PORTIONS
COMMONLY USED,
13th Edition
By Jean A. T. Pennington, Ph.D.,
R. D. ; and Helen Nichols Church, B.S.
The new thirteenth edition of this
widely used reference provides a selec
tive cross-sampling of foods commonly
consumed in the U.S. and includes
some specialty items and foreign
foods. Several new food categories
have been added, and many new
foods, especially those from industry,
are included.
Lippincott. Abt. 175 Pages.
May 1980. $13.75
4 INTRAVENOUS
MEDICATIONS: A Guide to
Preparation, Administration
and Nursing Management
By Diane Proctor Sager, R.N., M.S.N.;
and Suzanne K. Bomar, R.N., M.S.N.
Here is a handy two part reference
text designed to give the most com
plete coverage of intravenous equip
ment, techniques, management, and
the drugs themselves. Part One des
cribes the theories and techniques of
the intravenous administration of
drugs. Part Two, the Drug Informa
tion section, presents detailed informa
tion in column form on all drugs
currently approved for intravenous
use.
Lippincott. Abt. 500 Pages.
89 Illustrations. April 1980. 19.25.
OOOOOOOO
5 THE PROCESS OF
HUMAN DEVELOPMENT:
A Holistic Approach
By Clara Shaw Schuster, R.N., M.Ed.;
and Shirley Smith Asburn, R.N., M.S.
This comprehensive new text of
human growth and development cov
ers the entire life span, from concep
tion to senescence. The book is divi
ded into twelve parts, each represent
ing a separate phase of development.
The four major domains biophysical,
cognitive, affective, and social are
covered separately within each unit.
Little, Brown. Abt. 900 Pages.
453 Illustrations. 1980. 23.95
6 DEVELOPMENT OF
THERAPEUTIC SKILLS
Edited by Mary Jo Trapp Bulbrook,
R.N., Ph.D.
For all trainers and trainees in the
psychotherapies, the process and con
tent of personal self-development as a
therapist are discussed in terms of the
incorporation and integration of phi
losophy, theory, methods, and tech
niques. Dr. Bulbrook and the contri
buting authors, who range from clini
cian to consumer, explore personal
philosophical viewpoints on therapist
training, present condensed and exten
sively referenced explanations of the
various psychotherapeutic theories,
and guide the reader in a personal
analysis of beliefs and growth.
Little, Brown. Abt. 380 Pages.
Illustrated. Spring 1980. 15.50
OOOOOOOO
7 NURSING: Images and
Ideals: Opening Dialogue
with the Humanities
By Stuart F. Spicker, Ph.D.; and
Sally Gadow, R.N., Ph.D.
A collection of essays on the
philosophical foundations of the pro
fession and practice of nursing. These
essays, are a thoughtful contribution
to the subject of nursing ethics and
an exciting introduction to the philo
sophical issues underlying the day-to
day problems of nursing practice.
Springer. 224 Pages. 1980.
Paper, 15.50. Cloth, 25.25.
J. B. LIPPINCOTT COMPANY OF CANADA LTD.
75 Homer Avenue, Toronto, Ontario M8Z 4X7
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CN-7/8-80
announcing The New
Twist-on cap just pour, cap,
and stack.
Hold it like a bottle and pour
Ensure in the large opening
and rigid neck make it easy.
TheFlexitainer* holds a full
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A clear plastic
chamber lets you ^
monitor the flow rate.
The Ross Gavage Set fits any
nasogastric tube.
TheCAIR* clamp gives you
precise control over delivery.
The rigid neck and wide opening
make filling and handling easy.
The large graduated measurements
are easy to read, during filling and
Fill, cap, and stack in the refrigerator.
ENSURE Delivery System
the best
of the bottle
and the bag!
Together, the Flexiflo* Flexitainer* and the Ross
Gavage Feeding Set give you the first tube feeding system
that s really convenient and economical.
The Flexiflo Flexitainer is a bag and bottle in one!
Like a bag, it is light, shatterproof, and disposable.
Like a bottle, it has a rigid neck and wide opening, and
it s leakproof. You can stack it prefilled, more
easily and in less space than either bags or bottles.
The Ross Gavage Feeding Set ensures accurate delivery
control and helps maintain a constant rate of feeding.
The Ensure Delivery System. Developed to give
you better control over tube feeding.
I ROSS LABORATORIES
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Each Flexitainer has a self-adhesive
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The CAIR* clamp allows fingertip
control of flow rate.
Nurses unions, professional associations and YOU
Part 1*
Nurses
take the
union route
Glenna Rowsell
"Nurses have always fantasized that
they don t have a union. I don t know
why, because a union we got. "
(Stephany Grasset, president, Registered
Nurses Association of British Columbia,
addressing delegates to the 1980 annual
meeting.)
Canadian nurses have recognized the
need for collective action to protect
their socio-economic welfare for more
than half a century. The first nurses
union in this country was formed in the
Quebec City area in 1928 and became
known as the Catholic Nurse Union.
Sixteen years later, in 1944, the
national body representing nurses across
the country, the Canadian Nurses
Association went on record as approving
the principle of collective bargaining for
v its members and publicly stated its
belief that the bargaining authority for
nurses should be vested in the
professional association in each
province. The result was that, in most
provinces, it was the professional
association which worked to establish
the structure and constitution of the
precursors of today s unions. It was the
professional association, too, which in
most instances pressed for changes in
*Nurses unions, professional
associations and YOU" is a two-part
special feature in the July/ August and
September issues of CNJ. The series is
based on a chapter prepared by author
Glenna Rowsell for a new textbook for
nurse managers, "Nursing Unit
Administration, first edition", released
in June and available from the Nursing
Unit Administration Program, 410
Laurier Avenue West, Suite 800, Ottawa,
Ontario, KIR 7T6.
the nurses acts and by-laws of each
province that would permit these
associations to bargain collectively and,
it was hoped, to act as bargaining agents
for their members.
In 1946, the Registered Nurses
Association of British Columbia became
the first provincial association in Canada
to apply for certification for all
registered nurses in that province under
the Labor Relations Act of BC .
Certification was granted and the
RNABC thus became the first
professional association to achieve the
status of bargaining agent.
The remaining nine provincial
associations continued to assume
responsibility for the social and
economic welfare of their members,
including the publication annually of
recommended personnel policies and
distribution of these to both nurses and
their employers. The main objective in
doing this was to provide nurses with
employment standards and
recommended salaries that they could
use to support negotiations for better
working conditions and salaries.
Ultimately, however, both sides
came to realize how ineffective this
tactic was: employers for the most part
regarded the personnel policies as
merely "suggestions" and ignored them.
The result was that little change
occurred in the employment situation
and nurses grew to realize that, if
change was to be effected, there must
be a revolution in their approach to
employment relations. Professional
associations, reacting to pressure from
their members, began in the sixties to
develop collective bargaining structures
and to prepare for more formal
negotiations with employers. The nurses
themselves began to organize local staff
associations which closely resembled
local union or bargaining units in
industry.
In most cases, the professional
association in each province could not
achieve certification as the appropriate
bargaining agent for its members
because of conflict with existing labor
legislation.** In Canada, laws governing
collective bargaining are under the
jurisdiction of both the provincial/
territorial and federal governments.
These acts are administered by the
Labor Relations Board in each province
which also determines the level of
employees eligible to become members
of the bargaining unit. In determining
the appropriate unit, each board must
comply with the definition of
"employee" described in its provincial
act. Nursing classifications included in
provincial bargaining units therefore
differ from province to province. The
fact that some of their members were
classified as "management", meant that
professional associations, for the most
part, could not qualify under the Labor
Act to serve as bargaining agents. To
bargain without the protection of the
Labor Act was unthinkable since
employers, faced with such a situation,
could simply refuse to negotiate. Thus,
nurses found themselves coming under
the definition of a trade union as
determined by existing labor
legislation.
**The exception was Prince Edward
Island which does have collective
bargaining rights under the Nurses Act
of PEL
And thus, the decision to create
a separate entity that would protect and
provide for the social and economic
welfare of the "labor", as opposed to
"management" side of nursing was
forced upon the organized profession.
Today, the vast majority of registered
nurses in these unions are also members
of their provincial/territorial
associations. Nurses unions and
professional associations continue to
communicate with each other and, in
most provinces, liaison committees have
been established to ensure cooperation
between the two agencies in the best
interests of all nurses.
A fraternity of trained professionals
The problem of deciding at what level a
nurse becomes management (within the
meaning of the labor acts) has plagued
employers and provincial labor boards
and has resulted in a variety of decisions
across Canada. British Columbia, New
Brunswick and Prince Edward Island
include all positions except director and
assistant director of nursing; Alberta,
Saskatchewan, Manitoba, Nova Scotia
and Newfoundland include head nurses
in their bargaining units. Quebec has
two separate units, one including
general staff nurses and assistant head
nurses, and a second including head
nurses and supervisors. In Ontario
panels of the Labor Board have handed
down awards that include supervisors
in a few units, head nurses in others,
with the majority including assistant
head nurses and general staff nurses
only.
Registered nurses may belong to
both the union and professional
association. They each function under
separate legislation and are autonomous
in their own right. With exception of the
Registered Nurses Association of
Ontario, each registered nurses
association has the legal right to
discipline its own members. If a nurse is
dismissed or suspended for disciplinary
reasons she may be reported to her
professional association and if just cause
is found her registration/license can be
revoked or suspended. The nurse who is
also a union member has the right to
grieve her dismissal or suspension
through to arbitration, and the union
under the labor laws must process her
grievance. If the arbitration board
re-instates the nurse and the
professional association revokes her
registration, a problem obviously arises,
since both the award of the arbitration
board and the action of the disciplinary
committee are binding under law. In a
situation such as this, it is, important
that the management-nurse have full
knowledge of the relevant legislation
and understand fully her role in labor
relations.*
Glenna Rowsell is director of Labor
Relations Services for the Canadian
Nurses Association. She was formerly
employment relations officer for
New Brunswick s Provincial Collective
Bargaining Council and consultant in
social and economic welfare for the
New Brunswick Association of
Registered Nurses.
NURSES UNIONS have now assumed the major responsibility for advancing
the socio-economic welfare of the members they represent approximately
85,000 across Canada. The prime responsibility of these unions is to regulate
relations between the employees and employers through:
negotiating collective agreements providing particularly for improvements
in salaries, hours of work, medical welfare benefits and working conditions
promoting and understanding of administration of collective agreements
processing grievances including grievance arbitration
educating members in the area of labor relations and labor legislation
assisting members with problems arising in a work setting related to the
practice of the nurse s profession
communicating with its members, professional associations, government
and general public
promoting and maintaining professional standards of care as developed by
the professional nurses associations
striving to improve practice settings to allow for the achievements of these
standards
ensuring fair representation of all the employees under the jurisdictions of
the unions
protecting the health and safety of nurses in their working environments.
Most registered nurses who belong to a union are also members of their
provincial/territorial professional association. Not all union members are
registered nurses, however, since under the terms of their certification some
unions are required to represent graduate nurses.
One of the major roles of THE PROFESSIONAL ASSOCIATION is the
improvement of practice through standards of selection, preparation and
performance of practitioners. It is usually the licensing authority with the right
to discipline members who do not meet acceptable standards of practice. It
meets the needs of the public and its members by:
providing and influencing continuing education programs for nurses
ensuring competency to practice
presenting an informed voice to effect change
acting as spokesman for the nursing profession with government and other
organizations and groups
protecting the safety of the public
seeking desirable changes in legislation
promoting research and studies in nursing
communicating with members through meetings, conferences, newsletters
nd the media
collaborating with other health organizations engaged in health care
developing social and economic welfare programs for its members
developing a code of ethics to maintain standards of performance
encouraging its members to develop new and improved skills to retain and
improve their knowledge and practice.
All provincial/territorial nurses associations are members of the Canadian Nurses
Association and the International Council of Nurses; each level of organization
supplements the other by extending its sphere of influence.
NEXT MONTH: "The single most
important interpersonal relationship in
a hospital staff is between the nurse and
nurse-manager. The institution reflects
its lifestyle in the general attitude of
management towards employee
grievances. " Read how the
nurse-manager can achieve a real voice
in the system, in Part two of "Nurses,
unions, professional associations and
YOU, The role of the nurse-manager
in labor relations ", in the September
issue ofCNJ.
Intensive Care Nursing Program
This Post Basic Nursing Program is offered jointly by
Winnipeg s two largest teaching hospitals, The Health
Sciences Centre and the St. Boniface General Hospital.
The 1 1 month program integrates advanced academic and
clinical aspects of Intensive Care Nursing.
Candidates must have a minimum of one year experience in
acute medical or surgical nursing. Applicants must be
eligible for registration with the M.A.R.N.
Applications are currently being accepted for the
September 1980 and February 1981 classes.
The program is open to both males and females. For
further information please write to:
Course Coordinator
Health Sciences Centre
GH601-700 William Avenue
Winnipeg, Manitoba
R3E OZ3
Course Co-ordinator
St. Boniface General Hospital
OR E4003-409 Tache Avenue
Winnipeg, Manitoba
R2H 2A6
ASSISTANT DIRECTOR
OF NURSING
Rockyview Hospital, a 200 bed fully accredited
active treatment hospital, will soon be expand
ing to a 543 bed community general hospital.
We invite applications from individuals who can
meet the challenge of this growth as part of the
Senior Nursing Administration Staff.
The Assistant Director of Nursing will be re
sponsible for the total Nursing Program in des
ignated areas. The successful candidate must
have a baccalaureate degree (a masters degree
would be an asset) and possess strong leader
ship and interpersonal skills. Considerable
nursing experience and responsibility at a
supervisory level are required.
This position offers obvious potential for ad
vancement. If you are interested please direct
your resumes or inquiries to:
Debra L. Tomas
Personnel Department
HOSPITAL DISTRICT #93
940 - 8th Avenue S.W.
Calgary, Alberta T2P1H8
SPHYGMOMANOMETERS
diaphragm for high sensitivity No 5079A$l895ea
ECONOMY MODEL STETHOSCOPES. Similar to above
but not TVCOS brand Same 2 year guarantee. Complete
with spare diaphram and eartips*:oiours as above
SlngU-Head No lOO$!395ea
Dual-HeadNo Il0$l785ea
No 698.3V,"
No. 699. 4V 2 "
No. 700, 5v,"
No. 702, 7V,"
$585
$585
S669
$1198
HAEMOSTATIC
FORCEPS (Kelly)
Ideal for clamping
off tubing, etc.
Dozens of uses
Stainless steel,
locktng type, 5 /;_"
P420 straight $6 98
P422 curved $698
duly Velcro cult and -=
inflation system
$69 92 each
ANEROID TYPE
Rugged and dependable. 10
year guarantee of accuracy t
3 m m. No stop-pin to hide
errors Handsome zippered c
to tit vour pocket
$32.60 complete
NURSES PENLIGHT, Powerful beam lor examination o
throat, etc Durable stainless-steel case with pocket
chp Made in U.S. A No 28 $5 98 complete with
batteries.
NURSES WHITE CAP CLIPS. Wade in Canada for
Canadian nurses Strong steel bobby pins with nylon
lips. 3" size $1 29 cafdol 15. 2" size $1 00 /card
o 12. (Minimum 3 cards]
NURSES 4 COLOUR PEN for recording temperature,
blood pressure, etc One-hand operation selects red,
black, blue or green NO 32 52 97 each
Kill
DELUXE POCKET SAVER
No
nore annoying ink
s or frayed edges
: : compartments tor pens,
[Scissors, etc.. plus change
pocket and key chain.
can Plastahide.
505 $195 each.
MEASURING TAPE
In strong plastic case
Push button for spi
return Made of din
linen Measures tc
on one side. 200 cr
reverse $5 95 each.
NOTE: WE SERVICE AND
STOCK SPARE PARTS FOR
ALL ITEMS.
CAP STRIPES
Self-adhesive type, removable and
(e-usabie No 522 RED, No. 520 BLACK,
No 521 BLUE. No 523 GREY. All 15Vi"
long except red (14"). 12 siripes per card
$4.69 /card
NURSES EARRINGS. For pierced
ears Dainty Caduceus in gold plate
with gold filled posts. Beautifully
gift boxed No. 325 $1i49/pr
> 502 Practical Nun*
503 Nurse s Aid*
All $8 59 each
CADUCEUS PIN GUARD
Chained to your professional letters Heavily
MEMO-TIMER.
lamps, park me
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Lightwe --
OTOSCOPE SET C
powerful magnifying It
standard size specula. S
batteries included Metal i
ing case lined with soft c
No 309. $79 95 e
n plastic pouch $65.9!
ENGRAVED NAME-PINS IN 4 SMART STYLES -SIX DIFFERENT COLOURS...
TO ORDER NAME PINS
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oratat
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SOLID PLEXIGLASS. ..Molded from solid Plexiglas
Smoothly rounded edges and corners Letters deeply
engraved and filled with laquer colour of your choice.
Mothei
of
Pearl
1 line
, red
2 line
letters
$457
$729
PLASTIC LAMINATE, ..Lightweight but strong Will
contrasting colour core Bevelled edges match
letters. Satin finish Excellent value al this price.
White
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Blue ""^
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letters
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letters
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Add 50 handling f less than $10. . .
METAL FRAMED... Similar to above but mounted in
FRAME
letters
$326
$4 24
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$
polished metal frame with rounded edges and
Gold wmie
black x
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fc ; White
SOLID METAL... Extremely strong and durable but
lightweight Letters deeply engraved for absolute
permanence and filled with your choice of laquer
colour Corners and edges smoothly rounded Satin
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Gold
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$639
ASK ABOUT C
CLASS GIFTS
UR GENEROUS QUANTITY DISCOUNTS FOR
GROUP PURCHASES. FUND RAISING ETC
Nursing
Blockbusters
from
Saunders
AACN
CRITICAL CARE NURSING OF CHILDREN
AND ADOLESCENTS
Aimed at critical care nurses who take care of children, this new
AACN book provides concise, easy-to-read information written
by the most eminent names in the field. Of particular value are
the sections on growth and development which describe critical
care problems related to developmental stages. Additional
special sections include: care of the poisoned child, care of the
burned child, and care of the abused child. Two case studies
demonstrate care of the multi-injured child and more! In short,
this important new work puts the information you need most at
your fingertips. It s also an excellent reference for pediatric
nurses. Order your copy now on 30-day, no-risk approval.
By The American Association of Critical Care Nurses. Editor Annalee R. Oakes, RN
MA, CCRN. Assoc. Prof, and Instructor. Emergency/Critical Care Nursing. Seattle
Pacific Univ., Seattle. WA. About 385 pp. Illustrated. Ready soon. $17.95.
Order #1003-X.
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING:
A PSYCHOPHYSIOLOGIC APPROACH
2nd Edition
Updated, revised, and expanded the new Second Edition of
MEDICAL-SURGICAL NURSING: A Psychophysiologic
Approach keeps pace with the needs of today s nurse ... to
supply nurses with the knowledge and confidence to undertake
ever-increasing responsibilities. Concise, yet comprehensive;
MEDICAL-SURGICAL NURSING can be used in conjunction
with or independently from Sorensen & Luckmann s BASIC
NURSING.
By Joan Luckmann, RN, BS, MA; and Karen Creason Sorensen, RN BS, MN. March
1980. 2276 pp. 817 ill. S40.80. Order #5806-7.
AACN
METHODS IN CRITICAL CARE:
The AACN Manual
Illustrated with more than 140 superb drawings and photographs,
this exciting new book provides guidelines for performances of
about 100 advanced procedures at the heart of critical care
nursing today. You ll find top-quality coverage of intra-aortic
balloon pump management, use of Swan-Ganz catheter and
much more.
Editor-in-Chief Sally Millar, RN. CCRN. Head Nurse, Respiratory Surgical Intensive Care
Unit, Massachusetts General Hospital. Boston. Associate Editors: Leslie K. Sampson, RN.
CCRN; Sister Maurita Soukup, RSM. RN. MSN; and Sylvan Lee Weinberg, MD. May
1980. 484 pp. 148 ill. Hard cover. $21.55. Order #1006-4.
AACN
CRITICAL CARE NURSING OF THE
MULTI-INJURED PATIENT
Written in a unique outline format, this important new work gives
you up-to-the-minute coverage of initial evaluation of the
multi-injured patient, stabilization, and systems disruptions with
behavioral objectives. It describes the post trauma phase of
follow-up, and includes case studies of multi-injured patients, a
complete bibliography, and discussion of psychological support
of the patient as well as physical care.
Edited by James K. Mann, RN. BSN. MN. Assoc. Director of Nursing Services.
Harborview Medical Center, Seattle; Asst. Prof., Dept. of Physiological Nursing. Univ.
of Washington, Seattle; Clinical Instructor. Seattle Pacific University; and Annalee R.
Oakes, RN. MA. CCRN. Assoc. Prof.. Seattle Pacific Univ., Seattle. Washington. Ready
May 1980. 168 pp. Illustd. Soft cover. S13.95 Order #1002-1.
Tilkian & Conover
UNDERSTANDING HEART
SOUNDS AND MURMURS
Here s an exciting package that provides a basic familiarity with
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. Tilkian, MD. FACC. and Mary Boudreau Conover, RN, BSN, Ed. Book only:
122 pp. Illustd. Soft cover, $12.00. April 1979. Order #8869-1. Package: $22.75. Order
#8878-0.
Braunwald
HEART DISEASE
A Textbook of Cardiovascular Medicine
Edited by a leading authority in cardiology, this landmark volume
provides the most outstanding coverage of cardiovascular
medicine available today. Dr. Eugene Braunwald has personally
written or co-authored 27 of the 55 chapters. Contributors
include 44 of the most eminent names in the field. Over 1 ,000
figures, 285 tables and 12,700 bibliographic references are
provided in this 2,100-page volume. HEART DISEASE now
the definitive work.
Edited and with contributions by Eugene Braunwald, MD. Mersey Professor of Theory
and Practice of Medicine and Head. Department of Medicine at the Peter Bent Brigham
Hospital, Harvard Medical School; Physician-in-Chief. Affiliated Hospitals Center.
Boston. 1943 pp 1194111. May 1980. Single Vol.: $78.00. Order #1923-1. 2-Vol. Set:
$90.00 Order #1924-X.
Phillips & Feeney
THE CARDIAC RHYTHMS:
A Systematic Approach to Interpretation
2nd Edition
This thoroughly updated revision logically classifies and explains
all common arrhythmias. Many EKG s are taken directly from the
cardiac monitor to familiarize the reader with their actual
appearance. The workbook format and sequence of topics
(which follow the same order as the cardiac impulse through the
heart s chambers) make it easy to read, easy to use.
By Raymond E. Phillips, MD. FACP. Senior Attending Physician, Phelps Memorial
Hospital. North Tarrytown, New York: Clinical Asst. Prof, of Medicine, New York Medical
College. Valhalla, New York; and Mary K. Feeney, RN. MN, CCRN. Critical Care Clinical
Specialist St Joseph s Hospital. Instructor, ICU/CCU. Columbia Hospital School of
Nursing. Milwaukee. WS. About 420 pp. 745 ill. $20.34 Ready soon. Order #7221-3.
r
W.B. Saunders Company
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Send on no-risk. 30-day approval:
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n Luckmann 5806-7
AACN Manual 1006-4
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audiovisual
Shopping for audiovisuals:
how to know when the price is right
Joyce Carver
Nurses, whether they are in service or
education, are heavy users of
audiovisual materials. That s why it
pays to know as much as possible.
Shopping wisely is important: these are
expensive materials and costs must be
justified. Also, few users are aware that
it is always cheaper to buy than to
produce your own assuming of course
that you can find what you want. And
finding what you want means shopping
around.
How to shop
Previewing is time consuming and
costly, so it is wise to narrow your
choice before you reach that stage.
Start with the reviews and ask your
librarian for assistance, if necessary ;
avoid producer catalogues.
Good review sources:
computer search: this can be
done through AVLINE (Audiovisuals-
on-line), a service of the U.S. National
Library of Medicine on the same
network as MEDLINE. The materials
have been reviewed by experts and the
printout will give content description
and an evaluation. If you do not have
access to this service, these reviews are
published in the National Library of
Medicine Audiovisual Catalog.
Two indexes, the Media Review
Digest and the International Index to
Multi Media Information also provide
evaluations and cite the original
reviewing source.
Two periodicals, Hospital/Health
Care Training Media Profiles and Health
Media Reviews give extensive coverage
to reviews.
Having gone through the reviews
and made a choice of suitable A/V
materials, you are now ready to preview
them. The following checklist should
help you in this process:
Content quality: is the content
accurate, comprehensive, impartial and
current? is the context and level suited
to the intended audience? does it deal in
specific facts and procedures or
principles and broad concepts? can it be
adapted for use in various settings?
Instructional quality: are the objectives
stated? does it meet them? is an
instructor s guide or student manual
included? does it observe basic
principles of learning, i.e. provide an
overview and summary, use simple-to-
complex presentation, reinforce
important points, and involve the
learner by questions and practice
exercises?
Technical quality: is narration clear and
concise? is the sound easy to listen to
and understand? is the pacing right for
the material? is the photography well
composed and varied? are colors bright
with good contrast? are titles and
graphics easy to read and understand?
are slides and filmstrips numbered with
manual advance control for reviewing
specific parts of the program?
Cost effectiveness: can it be used with
different levels of learners? will it be
useful for individual learning and group
presentation? will it become outdated
quickly? is the equipment available to
use this A/V form? how often will it
be used and by how many learners?
what is rental vs. purchase cost?
Answering these questions should help
you make a good decision based on
quality and cost. And don t forget,
keep a record of your evaluations on
file.
Recommended reading
1 Koch, Harriett. Production and
technical standards. Nursing Outlook
23:5:287; 1975 May.
2 Lange, Crystal M. Availability and
cost of media. Nursing Outlook
25:3:164; 1977 Mar.
3 Sparks, Susan M. AVLINE for
nursing education and research
Nursing Outlook 27:11:733-737; 1979
Nov.
Joyce Carver, RN (P.E.I. Hospital},
BN (Dalhousie) received a Master s
Degree in Educational Media and
Technology from Boston University in
1979. She is an assistant professor at
Dalhousie University School of Nursing
in Halifax, where she has been involved
with A/V affairs since 1975. Previous
experience includes work as a
community health nurse in P.E.I, and
Vancouver.
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
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 Canadian Regist
ration. Preceptorship from a medical
practitioner. At least one year of work
experience, preferably in primary care.
For further information write to:
Director
Educational Program for Nurses
in Primary Care
Faculty of Health Sciences
McMaster University
Hamilton, Ontario L8S 4J9
The Ups and Downs of Blood
Sugar
A color poster entitled "The Ups and
Downs of Blood Sugar" has been
developed by the Canadian Diabetes
Association. The 19 x 24 inch poster
depicts the causes of high and low blood
sugar by using seven color illustrations.
Each illustration includes cartoon
figures personifying insulin, exercise and
food. The figures are strategically placed
on a see-saw that moves up and down to
demonstrate changes in blood sugar
level caused by changes in the amount
of insulin, exercise and food.
This teaching tool is intended for
use with both children and adults. The
poster sells for $3.50 and is available
from:
The Canadian Diabetic Association
123 Edward Street, Suite 601
Toronto, Ontario M5G 1E2
Immediate openings for qualified
RN s on all shifts, full time, part
time. 203 bed JCAH accredited
acute care hospital, adjacent to
Oregon Institute of Technology,
offering a 2 + 2 AD/BSN program.
We are located in Southern
Oregon. Excellent year round
outdoor activities. Family
oriented community. Excellent
working conditions and benefits.
Competitive salary with oppor
tunity for advancement. Contact
Personnel Department, MERLE
WEST MEDICAL CENTER, 2865
Daggett St., Klamath Falls, OR
97601, or call COLLECT (503)
882-631 1, Ext. 131. We are an
equal opportunity employer.
Classified
Advertisements
Alberta
British Columbia
British Columbia
R.N. s required. Registered nurses required for
new Brooks Health Centre, complex of 70 beds,
1 5 bassinettes, 75 nursing home beds. Centrally
located in Southern Alberta between three
large cities. Salary as per Provincial Agreement.
Must be eligible for registration with AARN.
Apply in writing to: Director of Nursing,
Brooks Health Centre, Bag 300, Brooks, Al
berta TOJ OJO.
Registered Nurses required for a 560-bed acute
care hospital in Edmonton, Alberta. Positions
available in most clinical areas. Candidates must
be eligible for registration in Alberta. Current
salary rates under review. Apply to: Personnel
Department, EdmontonGeneralHospital ,111 1 1
Jasper Avenue, Edmonton, Alberta T5K OL4.
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Required-Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TOK 2 GO.
British Columbia
Experienced General Duty Graduate Nurses re
quired for small hospital located N.E.Vancouver
Island. Maternity experience preferred. Person
nel policies according to RNABC contract. Res
idence accommodation available $30 monthly.
Apply in writing to: Director of Nursing, St.
George s Hospital, Box 223, Alert Bay, British
Columbia VON 1AO.
General Duty Nurses required for 30 bed ac
credited hospital. Salary according to RNABC
Contract. Apply: Administrator, Chetwynd
General Hospital, Box 507, Chetwynd, British
Columbia VOC 1JO. (604) 788-2236/2568.
General Duty Nurses for modern 41-bed hosp
ital located on the Alaska Highway. Salary and
personnel policies in accordance with RNABC.
Accommodation available in residence. Apply:
Director of Nursing, Fort Nelson General
Hospital, P.O. Box 60, Fort Nelson, British
Columbia VOC 1RO.
General Duty Nurse for modern 35 -bed hospital
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply: Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
General Duty Registered Nurses required for
108-bed accredited hospital in northwest B.C
Previous experience desirable. Salary as per
RNABC Contract with northern allowance.
For further information, please contact: Dir
ector of Nursing, Kitimat General Hospital,
899 Lahakas Blvd. N., Kitimat, B.C. V8C 1E7.
Registered and Graduate Nurses required for
34 bed acute care hospital located 240 miles
North of Vancouver. Accommodation avail
able. Apply to: Director of Nursing, Lillooet
District Hospital, Box 249, Lillooet, British
Columbia VOK 1VO.
Two Registered Nurses required for a 21 -bed
general hospital located in the beautiful
Robson Valley, 100 miles West of Jasper, Al
berta. Rotating shifts, full or part-time work
available. Accommodation available for single
person. Salary as per RNABC Collective Agree
ment. Apply immediately to : Director of Nurs
ing, McBride & District Hospital, Box 128,
McBride, British Columbia VOJ 2EO or tele
phone: 604-569-2662.
General Duty R.N. -Small hospital in scenic
West Kootenays of B.C. Apply: Slocan Comm
unity Hospital, Box 129, New Denver, British
Columbia VOG ISO.
Experienced Nurses (B.C. Registered) required
for a newly expanded 463-bed acute, teaching,
regional referral hospital located in the Eraser
Valley, 20 minutes by freeway from Vancouver,
and within easy access of various recreational
facilities. Excellent orientation and continuing
education programmes. Salary 1979 rates
$1305.00-51542.00 per month. Clinical areas
include : Operating Room, Recovery Room, In
tensive Care, Coronary Care, Neonatal Inten
sive Care, Hemodialysis, Acute Medicine, Surg
ery, Pediatrics, Rehabilitation and Emergency.
Apply to: Employment Manager, Royal Colu-
umbian Hospital, 330 E. Columbia St., New
Westminster, British Columbia V3L 3W7.
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van-
couver^alary and benefitsaccordingto RNABC
Contract-Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to : Personnel Director, Queen s Park
Hospital, 315 McBride Blvd., NewWestminster,
British Columbia V3L 5E8.
Experienced General Duty Nurses required for
130-bed accredited hospital. Salary in accord
ance with RNABC Contract. Residence acc
ommodation available. Apply in writing to:
Director of Nursing, Powell River General
Hospital, 5871 Arbutus Avenue, Powell River,
British Columbia V8A 4S3.
Registered Nurses required for permanent full-
time position at a 147-bed fully accredited reg
ional acute care hospital in B.C. Salary at 1979
RNABC rate plus northern living allowance.
One year experience preferred. Apply: Director
of Nursing, Prince Rupert Regional Hospital,
1305 Summit Avenue, Prince Rupert, British
Columbia V8J 2A6. Telephone (collect) 604-
624-2171 Local 227.
Registered Nurses requiredimmediately forper-
manent full time positions at 10-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 Col
umbia VOT 1WO. Telephone: (604) 636-2221
Collect.
O.R. Head Nurse required for an active 103-
bed acute care hospital. Must be eligible for
B.C. Registration. Post graduate training &
experience necessary. R.N. A. B.C. Contract in
effect. Accommodation available. Apply to:
Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British
Columbia V8G 2W7.
General Duty Nurses required for an active,
103-bed hospital. Positions availablefor experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
Registered Nurses Full-time and casual relief
positions are available at the University of
British Columbia, Health Sciences Centre, Ex
tended Care Unit. The 12 hour shift, the pro
blem oriented record charting system, an em
phasis on maintaining a normal and reality bas
ed clinical environment and an interprofession
al approach to management are some of the
features offered by the Extended Care Unit.
Interested applicants may enquire by calling
228-7025 or 228-7000. Positions are open to
both male and female applicants.
Manitoba
Registered nurses required for a fully accredi
ted 100-bed general hospital and a 72-bed per- j
sonal care home located in northen Manitoba.)
Must be eligible for registration in Manitoba. f
Salary dependent on experience and education.
For further information contact: Mrs. Mona
Seguin, Personnel Director, St. Anthony s
General Hospital, The Pas Health Complex Inc.,
P.O. Box 240, The Pas, Manitoba R9A !K4;or
phone collect to: 1-204-623-6431, Ext. 179.
Northwest Territories
The Stanton Yellowknife Hospital, a 72-bed
accredited, acute care hospital requires register
ed nursesto work in medical, surgical, pediatric,
obstetrical or operating room areas. Excellent
orientation and inservice education. Some fur
nished accommodation available. Apply : Assist
ant Administrator-Nursing, Stanton Yellow-
knife Hospital, Box 10, Yellowknife, N.W.T.,
X1A 2N1.
Ontario
Looking For A Temporary Change? Do you
want to keep your job but feel the need for
some renewing experience? International reg
istry for nurses interested in a temporary job
exchange under organization. Write: Nursing
Job Exchange, Box 1502, Kingston, Ontario
K7L 5C7.
United States
United States
Ontario
Nurses-RNs-Immediate openings in Califor
nia-Florida-Texas-Maryland-Virginia and many
other States if you are experienced or a re
cent Graduate Nurse we can offer you posi
tions with excellent salaries up to $20,000 per
year plus all benefits. Not only are there no
fees to you whatsoever for placing you. but we
also provide complete Visa and Licensure assis
tance 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 arrange for hospital interviews. You
can call us collect if you are an RN who is li
censed 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 23rd Year of World Wide Service"
The Best Location in the Nation - The world-
renowned Cleveland Clinic Hospital is a pro
gressive, 1030-bed acute care teaching facility
committed to excellence in patient care. Staff
Nurse positions are currently available in sever
al of our ICU s and 30 departmentalized medi
cal/surgical and specialty divisions. Starting
salary range is $14,789 to $17,056, plus
$l,248/year ICU differential andpremiumshift
differential, comprehensive employee benefits
and an individualized 7 week orientation. We
will sponsor the appropriate employment visa
for qualified applicants. For further informa
tion contact: Director-Nurse Recruitment, The
Cleveland Clinic Hospital, 9500 Euclid Avenue,
Cleveland, Ohio 44106 (4 hours drive from
Buffalo, N.Y.); or call collect 216-444-5865.
Choose a
Nursing
Career
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
Halifax is an attractive place to work and play. It is the capital city of a Province
offering a quality of life which is a careful blend of scenic lifestyle and modern
development boasting cultural, recreational and educational facilities second
to none.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H 1V8
Telephone: 1 (902) 428-3484
Registered Nurses required for our ultra mod
ern 70-bed fully accredited general hospital in
a bilingual community of Northern Ontario.
Applicants should be registered or eligible for
registration with the College of Nurses of Ont
ario. Knowledge of both official languages and
experience in nursing are assets but not essen
tial. Salary is according to the O.M.A. schedule
and fringe benefits include one month of holi
days, OHIP, salary and life insurance and a
drug and dental plan. Assistance is also provid
ed in locating suitable living accommodations.
Forward your application to: Personnel Direc
tor, Notre Dame Hospital, P.O. Box 8000,
Hearst, Ontario POL 1NO. Telephone: (705)
362-4291.
Experienced registered nurses are required
immediately for our fully accredited thirty-two
bed complex and active treatment hospital loc-
cated in beautiful Northern Ontario. The hosp
ital pays 100 percent OHIP and Dental Plan
and many other excellent fringe benefits.
Apply to : The Director of Nursing, Hornepayne
Community Hospital, Hornepayne, Ontario
POM 1ZO.
Registered Nurses required. Hospitals located
on James Bay at Attawapiskatand Fort Albany.
Good salary scale plus Northern Allowance.
Accommodations provided. Enjoy a Northern
Experience. For further information, contact:
The Administrator, James Bay General Hosp
ital, P. O. Box 370, Moosonee, Ontario POL
1YO.
R.N. Grad or R.N.A., 5 6" or over and strong,
without dependents. Non-smoker for 180 Ib.
handicapped retired executive with stroke.
Able to transfer patient to wheelchair. Live-in
1/2 year in Toronto, 1/2 year in Miami. Wages
$250.00 to $300.00 weekly NET plus $100.00
weekly bonus on most weeks in Miami. Write:
M.D.C., 3532 Eglinton Avenue West, Toronto,
Ontario M6M 1V6.
Saskatchewan
Director of Nursing for St. Joseph s Union
Hospital, a 22-bed acute care facility. Position
available June 30, 1980. Applications are invit
ed from those with appropriate experience
and education. Apply with complete resume to
the: Administrator, St. Joseph s Union Hosp
ital, Lestock, Saskatchewan SOA 2GO.
Applications are invited for the position of
General Duty Nurse in a new 22 bed hospital
which will be opening in June, located in the
beautiful rural north-western Saskatchewan.
Salaries, fringe benefits, etc. as per S.U.N.
Agreement. Apply or phone :MargareteLathan,
Director of Nursing, Paradise Hill Union Hosp
ital, Box 179, Paradise Hill, Saskatchewan
SOM 2GO. (306) 344-2255.
University of Saskatchewan-College of Nursing
Invites applications for the position of Princip
al Nurse Researcher with faculty status. This
position is available immediately. The major
responsibility of the appointee is to develop
and direct a Nursing Research Unit based at
the University of Saskatchewan and supported
by the Saskatchewan Registered Nurses Assoc
iation. The purpose of this new Research Unit
is to facilitate the growth of nursing research;
develop nurse researchers and provide for con
tinuity and coordination of nursing research
projects to influence the delivery of nursing
care in the province. Involvement in this new
joint project is a unique opportunity for a
nurse researcher seeking a challenge. Qualific
ations: Doctoral preparation preferred ;Masters
degree essential. Eligible for registration with
the S.R.N.A. Experience in carrying out appli
ed research related to complex issues in the
nursing component of the health care system.
Salary: In accordance with university policy
and the rank for which the candidate is qualif
ied. Applications and inquiries: Address all in
quiries to: The Dean, College of Nursing, Univ
ersity of Saskatchewan, Saskatoon, Saskatch-
wan, Canada S7N OWO.
United States
Australia
RN/Staff & Management Positions-- Kaiser-Per-
manente, the country s largest Health Mainten
ance Organization, currently has excellent
opportunities available in our 583-bed Los
Angeles Medical Center. Located 7 miles from
downtown Los Angeles, close to many of Calif
ornia s finest Universities, this teaching hosp
ital offers RN s a unique chance to further
their careers in such areas as: OR, Med/Surg,
Maternal Child Health & Critical Care. Manage
ment positions are also available . Kaiser offers
an attractive array of fringe benefits including
relocation assistance, full medical, dental &
health coverage, continuing education advanc
ed training available in the Nurse Practitioner
& CRNA Programs, individualized orientation,
tuition reimbursement, and no rotating shifts.
New graduates are always welcome and encour
aged to inquire. For more information, please
write or call collect: Ann Marcus, RN, Kaiser
Hospital/Sunset, 4867 Sunset Blvd., L.A.,
California 90027. (213) 667-8374.
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 White is a 377-bed acute
care teaching medical center with an open invita
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to develop
and continue your professional growth. We
will pay your one-way transportation, offerfree
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 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
R.N.s-Experienced nurses needed to staff
midwestern and eastern United States hosp
itals. Must be able to take and pass State
boards tests. Free housing while working in
United States. Full sponsorship available.
Wages begin at $7.00 per hour. Fulltime.
Send resume to: Bonnie Menees Smith, R.N.
Recruiter, JANNA Medical Systems, Inc.,
1810 Craig Road, St. Louis, Missouri 63141.
Registered nurses to work in Texas. Qualifi
cations: Nursing registration since 1970. No
exams necessary for Texas. Experience in OR,
Emergency, Pediatrics, Neurology or other
areas desired. Available in 1-2 months. No cost
to candidates. We handle everything. For infor
mation: VISA CONSULTANTof Americalnc.,
1 Place Ville Marie, Suite 3235, Montreal,
Quebec, Canada H3B 3M7. Telephone: (514)
467-1209.
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario MSE
1J3. Phone: 416-863-0799. Telex: 06-219621.
Faculty Positions available in undergraduate
instruction in Medical-Surgical Nursing and in
a Baccalaureate program designed for Register
ed Nurses in the area of Nursing Administrat
ion. Both are dynamic programs. The School
of Nursing has a student enrolment of over
300. Salary commensurate with qualifications
and experience:Lecturerll-A$ 17,024-19,645
per annum; Lecturer 1-AS 19, 923-22,362 oer
annum. Preference: Master s degree; teaching
and clinical experience; knowledge of curricul
um development. The Institute has allowance
schemes covering re-location expenses, immed
iate superannuation, insurance cover and ass
istance with accommodation. Closing date for
applications: three weeks after publication of
this advertisement. Appointees are expected to
take up duties as soon as possible. Curriculum
vitae and transcripts of tertiary work to:Lydia
Hebestreit, R.N., Head: School of Nursing,
Preston Institute of Technology, Bundoora/
Melbourne, 3083, Australia.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
It* U.S.A.
B) Extensive information regarding
Hospital 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 1 1 33 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
BRITISH COLUMBIA
INSTITUTE OF TECHNOLOGY
DEAN
HEALTH DIVISION
BCIT is a major post-secondary institution, located in Burnaby, with a mandate to
serve the entire province of British Columbia in two-year diploma programs in the
areas of health, business and engineering. The nine diploma programs which the
health division comprises of are: Biomedical Electronics, Environmental Health,
Medical Laboratory, Medical Radiography, Nuclear Medicine, Health Data, General
Nursing, Psychiatric Nursing and Prosthetics and Orthotics. There are 85 instructors,
7 department heads and a student enrolment of about 900. The total full-time student
enrolment at BCIT is 4,000.
The dean will be accountable to the vice principal of education, for the provision of
responsive and effective educational programs in the health field and for the person
nel, financial and operational control of the division. Considerable interaction and
consultation with advisory committees, accreditation bodies, professional organiza
tions and the provincial government will be required.
The successful candidate
with o solid backgrounc
must have a proven abilit
and health care organize
<l possess wide experience in the health care field
strong administrative capabilities. Also the candidate
carry out a liaison role with senior levels of government
s.
doting date for applications: July 1, 1980
Submit resume in strict confidence to Personnel/Labor Relations Office
British Columbia Institute of Technology
3700 Willlngdon Avenue, Burnaby, B.C.
V5G 3H2, Phone (604) 434-5734
Prince George
Regional Hospital
Positions available for experienced nurses or
nurses interested in developing their skills in
specialty nursing Operating Room,
ICU/CCU, Neonatology Nursing. Must be
eligible for B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and Obstetrical
Suite
10 bed ICU/CCU
Prince George Regional Hospital is a 340 bed
acute regional referral hospital with a 75 bed
extended care unit and has a planned program
of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000 -15th A venue
Prince George, British Columbia
V2M 1S2
The Izaak Walton Killam
Hospital for Children
Assistant Head Nurse
Neo-Natal
The I.W.K. Hospital for Children requires
an Assistant Head Nurse for our Neo-
Natal Unit, which is a 32-bed referral
centre providing intensive, intermediate
and convalescent care.
Applicants must be a graduate of an
accredited School of Nursing and eligible
for registration in Nova Scotia. Degree or
Diploma in Nursing Service Administrat
ion is preferred. Must have a good know
ledge of Neo-Natal nursing principles and
techniques.
Inquiries and applications should be
directed to:
Karen Lyle, Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Registered Nurses are required for an 87
bed accredited Hospital in Northern
Ontario.
Applicants must be eligible for
Registration with the College of Nurses
ofOntario.
Bilingualism is an asset.
Salary and Fringe Benefits in accordance
with O.N. A. Contract.
Temporary residence accommodation is
available.
Please apply in writing to:
Director of Nursing
Sensenbrenner Hospital
10 Drury Street
Kapuskasing, Ontario
PSN 1K9
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Registered
Nurses or those eligible for B.C. Registration
with recent nursing experience.
Positions are available in all services of this
950 bed accredited hospital which includes
Acute and Specialty Care, Obstetrics and
Paediatrics, Psychiatry and Extended Care for
Full Time, Part Time and Casual Employment.
Benefits in accordance with R.N.A.B.C,
contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
V8R 1J8
OPPORTUNITY
Psychiatric Nurses
required
For regional hospital. Primary duties to
include provision of nursing service in
"day hospital", mental health centre and
the community.
Applicants should have (or be eligible for)
current registration in Province. Post
graduate training in psychiatric nursing
preferred but equivalent combination of
training and experience will be consider
ed.
Applications to:
Personnel Office
Highland View Regional Hospital
110 East Pleasant Street
Amherst, Nova Scotia
B4H 1N6
Camp Hill Hospital
a fully accredited 350 bed active care teaching
facility in beautiful Halifax, N.S., is currently
inviting applications for the position of:
Head Nurse, Operating Room
If you are eligible for registration in the
province of Nova Scotia, have previous
experience in an Operating Room with
demonstrated skills in leadership and
interpersonal relationships, and post-graduate
Operating Room Training, then we are looking
for you.
Our hospital, centrally located in Canada s
Ocean Playground, provides progressive care
in medical, surgical, psychiatric, and extended
care areas.
Salary range:
presently - $15, 300 to $17,200
eff. II 10/80 - $16,000 to $17,900
plus additional educational premiums
If you are interested in joiningour staff, please
apply in writing to:
Stafflng Officer
Camp Hill Hospital
1 763 Robie Street
Halifax, Nova Scotia
B3H JG2
Senior Community
Mental Health Nurse -
Fort McMurray
We require an experienced nurse for
a multi-disciplinary treatment team.
You will supervise community
psychiatric nurses, consult and act
as educator to other therapists
caseloads, assume a limited
caseload, evaluate staff
performance, and consult with the
clinic director on effective service
objectives.
QualificationsrGraduation from a
recognized school of nursing,
considerable related experience and
eligibility for registration with the
appropriate nursing association.
Salary: $16,608 - $20,604 plus
Northern Allowance.
Competition #9186-4
Community Mental
Health Nurses -
Athabasca/Slave Lake
Area & Edmonton
We require nurses to provide
assessment, treatment and
follow-up as primary therapists of a
multi-disciplinary team. Other
duties include provision of services
to community and liaison and
consultation with agencies.
Qualifications: Graduate of a
recognized school of nursing and
eligible for nursing registration in
Alberta and some related
experience. NOTE: Must own
transportation and a valid Alberta
drivers license.
Salary: $14, 748 -$17, 340
Competition #9 184-5 Open until
suitable candidates selected. Please
indicate location preference on
application form.
For detailed information, request
Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
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?
We know where the best jobs are, how much they pay,
and where you ll fit in. R.R.N. can give you more than
just a job we can help you build a satisfying career.
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 that dotted line to-day, you should check with
Recruiting Registered Nurses Inc. We re the Canadian
Medical Placement Specialists throughout the United
States.
R.R.N. has immediate positions available in:
California Ohio Pennsylvania Michigan
Don t wait!!!! Call or write immediately for further
information.
"No Fee To Applicants"
RECRUITING REGISTERED NURSES INC.
J9W
1200 Lawrence Avenue East
Suite 301, Don Mills
Ontario M3A 1C1
Telephone: (416) 449-5883
Ministry of Health
Community Nurses
Competition H80: 1 150-98 $18,768 - $22,176
Applications are invited from qualified persons to form an
Eligibility List (valid for six months) of community nurses from
which vacancies occurring at various locations in British
Columbia will be filled.
Duties include provision of general public nursing, counselling
and crisis intervention services in the area concerned; liaison
with health professionals and others providing care, and
encouragement of appropriate use of available facilities.
Qualifications - University degree in nursing, including public
health training, or equivalent combination of education and
experience; preferably some general nursing experience,
including directly related duties: registered, or able to obtain
registration, in the Registered Nurses and/or Registered
Psychiatric Nurses Association of British Columbia. May use
own or government car on expenses.
Return applications immediately.
Positions
are open to both
men and women.
Obtain applications from,
and return to. address below.
544 Michigan Street. Victoria, B.C., V8V 1S3
New
Dimensions
In Nursing
You can practice "tomorrow s" nursing
today at Stanford University Medical
Center. Automated systems and non-
clinical personnel handle many of the
administrative and support procedures
so that you can concentrate on
progressive nursing. You ll take part in
the application of new techniques,
participate in research projects and
work with leading authorities in nearly
every medical specialty.
We d like you to know more about pur
on-going inservice instruction which
includes an excellent orientation
program. We offer an outstanding
salary and benefits package which
includes tuition reimbursement for
continuing education. For additional
information, write Dept. V/3, Nurse
Recruiter, Personnel Department,
Stanford University Hospital,
Stanford, CA 94305. Or call collect to:
(415) 497-7330. For immediate
consideration, send your resume and
salary requirements. We are an
affirmative action, equal opportunity
employer male & female.
Foothills Hospital
( alum > . Alberta
Olferv [he
Following
Five Month Posl
Graduate Courses
Advanced Neurological
& Neurosurgical Nursing
This course serves as an extension of basic
knowledge of neurological problems gained in
an undergraduate program. Instruction
proceeds from normal to abnormal.
Opportunities are provided to study and care
for persons of all ages who have had an
interruption in neurological function.
Advanced Neonatal Nursing
This course allows the nurse to gain knowledge
and expertise in the Intensive Care Nursery
setting. An overview of life as well as
experience in related settings are also
included.
prior to the enrollment dates of Mai
September
Educational Services
Department ofNursmg
Foothills Hospital
1403 -29th St. N. W.
Cal(-ar>. Alberta T2* 2T9
Drumheller Health Unit
requires
Community Health Nurse
Position available approximately Sept
ember 30, 1980.
Qualifications:
Registered Nurse with Diploma in Public
Health or a B.Sc. degree. Experience in
Community Health is desirable. Appli
cant must have valid driver s license, and
be eligible for registration in Alberta.
Salary:
Commensurate with qualifications and
experience (presently under review) and
excellent fringe benefits.
Applications with curriculum vitae to:
Dr. A.E. O Neil
Medical Officer of Health
Drumheller Health Unit
P.O. Box 1780
Drumheller, Alberta
TOJ OYO
Registered Nurses
Cross Cancer Institute
Edmonton
Our Institute has immediate openings for Staff
Nurses who are interested in progressive
nursing as members of a dynamic
multi-disciplinary health care team. We offer
challenging and rewarding nursing, job
security, continuing education, and excellent
fringe benefits.
For additional information and details, please
call collect or write:
Mary James
Nursing Co-ordinator
11560 University Avenue
Edmonton, Alberta
T5G 1Z2
Phone (403) 432-8771
R.N. s Required
Applications are invited for full time nurses to
work rotating shifts in new 40 bed active
treatment hospital. High level of activity in
Emergency, Surgery and Obstetrics offers
challenge and the benefit of valuable
experience for conscientious nurses. Previous
experience an asset. Must be registered or
eligible for registration in Alberta.
AHA/AARN Policies in effect.
Hinton is a modern, progressive, industrial
town on the eastern slopes of the Rockies, 50
miles east of Jasper. Population 7,600.
Unlimited year round recreational facilities.
Apply with full resume including experience
and references to:
Director of Nursing
Hinton General Hospital
Box 40
Hinton, Alberta
TOE 1BO
Selkirk College
Castlegar, B.C. requires an
Instructor Allied Health
(Nursing)
Duties:
Classroom instruction and clinical teaching of
nursing to students in a diploma nursing
program.
Qualifications:
Baccalaureate degree, including courses in
nursing and education. Practicing registration
or eligibility for registration as a nurse (R.N.I
in B.C. is desirable; appropriate clinical
experience (2 year s minimum). Master s
degree preferred.
Starting Date: Application Closing Date:
July 1,1980 May 30, 1980
Salary:
Commensurate with qualifications and
experience with the faculty agreement.
Submit Applications and References To:
Personnel Manager
Selkirk College
Box 1200
Castlegar, B.C.
V1N3J1
Head Nurse
Royal Inland Hospital, a 400-bed acute
care regional referral hospital, invites
applications for:
Head Nurse in the Emergency and
Out Patients Department. This is a
14 stretcher 2 crib Emergency De
partment.
Qualifications: preferably a nursing de
gree and 3-5 years experience with
demonstrated administration skills and
clinical expertise or NUA course with
relevant experience. Must be eligible
for B.C. registration. Rate per R.N.A.B.C.
contract.
Please send resume to:
Personnel Office
Royal Inland Hospital
311 Columbia Street
Kamloops, British Columbia
V2C 2T1
R.N. s
Come to Texas
244 Bed Regional Medical Center
Located 75 miles north of Dallas on
the banks of Lake Texoma ( 1 2th
largest lake in the U.S.)
Progressive Nursing Administration
Professional growth opportunities
Excellent salary and benefits program
Openings in ICU, Emergency,
Psychiatry, Renal Dialysis, and other
speciality areas
Contact:
Bonita Palmer, R.N.
Director of Nursing
Texoma Medical Center
P.O. Box 890
Denison, Texas, USA 75020
Head Nurse Paediatrics
The Prince George Regional Hospital, a
340 bed acute care and 75 bed extended
care hospital, requires a Head Nurse for
a 30 bed Paediatric Surgical Unit.
Requirements:
Demonstrable leadership and
administrative skills.
Clinical preparation and previous
experience in the care of the Paediatric
surgical patient.
Must be eligible for registration in
B.C.
Salary Range: In accordance with the
R.N.A.B.C. Contract.
Interested applicants are invited to
submit applications to the:
Personnel Department
Prince George Regional Hospital
2000 15th Avenue
Prince George, British Columbia
V2M 1S2
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
ICU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
msj
Association of Registered Nurses of Newfoundland
Executive Secretary Director
The Association of Registered Nurses of Newfoundland
invites applications for the position of Executive
Secretary Director.
The applicant must have a comprehensive knowledge of
the nursing profession and its role in the health care
system, a wide experience in the practice of nursing
administration.
Applicants must have had experience in the practice of
nursing and administration, have demonstrated leadership
ability, ability to initiate and maintain relationships with
governments, allied professionals, the members and the
public, and be eligible for registration with the
Association of Registered Nurses of Newfoundland. A
Baccalaureate Degree in Nursing required, a Master s
Degree preferred.
Send curriculum vitae by August 31, 1980 to:
Chairman, Selections Committee
Association of Registered Nurses of Newfoundland
P.O. Box 4185
St. John s, Newfoundland
A1C6A1
OPPORTUNITY
Senior Community Mental Health Nurse
Fort McMurray
We require an experienced nurse for a multi-disciplinary
treatment team. Responsibilities include supervision of
community psychiatric nurses, consultant and educator
to other therapists caseloads, assuming a limited case
load, evaluating staff performance, and consulting with
the clinic director on effective service objectives.
Qualifications: Graduation from a recognized school of
nursing, considerable related experience and eligibility
for registration with the appropriate nursing association.
Salary: $16,608-520,604 plus Northern Allowance
(currently under review).
Competition No. 9 186-6 Open until suitable candidate
selected. Alberta Social Services and Community Health.
For detailed information, request Job Bulletins and
apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
A
Good
To work... A Great
At Santa Clara Valley Medical Center, we recognize the importance of an
environment that offers meaningful work and intellectual challenge. We also
offer you a great place to live in Northern California s unique Santa Clara
Valley, where you ll find a variety of cultural and geographical attractions.
Santa Clara Valley
Medical Center
Caring is our Specialty
To Live.
We are a tully accredited, acute care, general teaching hospital which includes
government designated rehabilitation center specidlizmg in head trauma and
spinal cord injuries. We are offering opportunities for experienced and
graduating nurses in the following areas:
Critical Care Unit
Neonatal
Intensive Care Unit
Burn Unit
Head Injury Unit
Medical/ Surgical
Spinal Cord Injury Unit
Emergency Room
OB/CYN
To find out more about our excellent benefits, salaries and educational
opportunities, fill out and send us the coupon below, or call Eleanore Abeytu d
(406) 279-5232. We are an equal opportunity employer m/f/h.
Address
City
Phone
Graduate of:
Year Area of lnterest_
_ State _
-Zip-
. DIP_
Mail to: Eleanore Abeytia, Personnel Depariment,
751 S. Bascom, Bg H-6. San Jose, CA 95128. An equal
opportunity employer m/f/h.
University of British Columbia
Health Sciences Centre Hospital
Extended Care Unit
requires
Clinical Nursing Consultant Education
Reporting to the Director of Nursing, plans and
implements orientation and on-going in-service programs
for nursing and other staff members, coordinates pre
admission assessment activities, provides direct patient
care to selected patients as arranged, facilitates clinical
nursing research, participates in School of Nursing
activities in the unit as requested, represents E.C.U. in
Nursing Education areas and maintains an effective
working relationship with nursing and other health
professionals. Requires Master s degree in Nursing or
Nursing Education, registration with the RNABC,
evidence of clinical competence in the care of elderly/
disabled patients demonstrated skills in program planning,
implementation and evaluation and successful work
experience in clinical nursing and nursing education.
Salary and benefits according to RNABC collective
agreement.
Applicants should submit detailed resume to :
Coordinator of Hospital Employment
Health Sciences Centre Hospital
University of British Columbia
Vancouver, British Columbia
V6T 1W5
Position open to both male and female applicants.
International Grenfell Association
requires
Registered Nurses, Public Health Nurses and
Nurse Midwives (R.N.)
For Northern Newfoundland and Labrador
The International Grenfell Association provides medical services
in northern Newfoundland and Labrador. It staffs four hospitals,
seventeen nursing stations and many public health units. Our main
hospital is a 150 bed accredited hospital situated in scenic
St. Anthony, Newfoundland. Active treatment is carried on in
surgery, psychiatry, medicine, pediatrics, obs/gyn, and intensive
care. Orientation and active inservice program provided for staff.
Salary based on government scales, 37-1/2 hrs. per week. Rotating
shifts. Excellent personnel benefits include liberal vacation and
sick leave. Accommodation available. Return travel expenses
paid to Winnipeg and east of Winnipeg on completion of one year
service, and west of Winnipeg on completion of two years service.
Apply to:
Mr. Scott Smith
Personnel Director
International Grenfell Association
St. Anthony, Newfoundland
AOK 4SO
Home
is where
the
heart is
Sometimes you have to go a long way to find home. But when
you arrive at White Memorial you ll know your heart is in the right
place.
Canadian Nurses DO NOT have to take the screening examination
offered by the commission on graduates of foreign nursing
schools. Your California license will be issued upon completion
of application for license.
White Memorial is a 377-bed acute care teaching medical
center offering diversity and challenge for skilled RNs. Addi
tionally, The White will pay your one-way transportation, offer
free meals for one month and all lodging forthree months in our
nurses residence and provide your work visa. We provide an
excellent salary, outstanding benefits and the opportunity to
participate in our exceptional continuing education program.
Call collect or write:
Ken Hoover
Assistant Personnel Director
(213) 268-5000 ext. 1680
UJHIT6 MMORini M6DICRL CNTR
1 720 Brooklyn Avenue / Los Angeles, California 90033
An Equal Opportunity Employer M/F
VON
VON FOR CANADA
Applications are invited for
positions across Canada
Registered Nurses
with at least one year s experience
Nurses with BScN or
Master s Degree
experience in supervision and/or
administration preferred
Salary commensurate with education
and experience
Apply to:
National Director
VON for Canada
5 Blackburn Avenue
Ottawa, Ontario
KIN 8A2
Clinical Instructor -
Operating Room
Required for a 340 bed acute care
hospital and 75 bed Extended Care Unit.
Expanding Operating Room suite
presently under construction with date of
completion September 1980.
Will be responsible to design and
implement an education-orientation
program for new employees and to
provide programs for inservice and
continuing education forO.R. personnel.
Salary as per R.N. A. B.C. Contract.
Diploma in Teaching and Supervision
required plus minimum of three years
progressive experience in Operating
Room nursing.
Apply to:
Personnel Department
Prince George Regional Hospital
200<V-l5ih Avenue
Prince George. British Columbia
VJM 1S2
The Izaak Walton Killam
Hospital For Children
Staff Nurses
The I.W.K. Hospital for Children has
vacancies for Staff Nurses on various
units throughout the Hospital. Must be a
graduate from an accredited School of
Nursing and be eligible for registration in
Nova Scotia. Previous pediatric exper
ience would be an asset.
Inquiries and applications should be
directed to:
Karen Lyle
Personnel Officer
The I.VV.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Applications are invited for full time and
part time employment at Oshawa
General Hospital, a 600 bed hospital, 48
kms. East ofToronto.
Successful candidates must be registered
in Ontario.
Services provided include:
Medicine
Surgery
Obstetrics
Emergency
Paediatrics
Intensive Care
Coronary Care
Out-Patients
Chronic/Rehabilitation
Salary Range: (Full time) $1,450. 00-
$1,676.00 (monthly)
Inquiries may be directed to:
Personnel Services
Oshawa General Hospital
24 Alma Street
Oshawa, Ontario
L1G2B9
f OPPORTUNITY
Community Mental Health
Nurse -
Peace River Mental Health
Clinic
Working as a primary therapist
within a multi-disciplinary team,
you will provide treatment services
to people of all ages, co-operate
with other related agencies, and
participate in programs promoting
mental health.
Qualifications: Graduation from an
approved school of nursing plus
some related experience in
psychiatric or community nursing.
Eligibility for registration in the
appropriate nursing association.
NOTE: Own transportation.
Salary: $14,748 - $17,340 (currently
under review)
Competition #91 84-4 Open until
suitable candidate selected.
Alberta Social Services and
Community Health
For detailed information, request
Job Bulletins and apply to:
Alberta Government Employment
Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Health Sciences Centre
Winnipeg, Manitoba
invite applications for the position of
Teacher Post-Basic Course in
Pediatric Critical Care Nursing
The Children s Hospital of the Health Sciences Centre is a 202 bed
accredited referral and tertiary care teaching and research facility for
children, which serves Manitoba and surrounding areas.
Individuals must be registered or eligible for registration with the
Manitoba Association of Registered Nurses and have post-basic
preparation and demonstrated expertise in critical care nursing.
Applicants must have experience in pediatric and/or neonatal nursing
and have experience in teaching. A Baccalaureate degree in nursing is
preferred.
The successful applicant will be responsible for the implementation and
coordination of this new course. The course is designed to provide
advanced preparation for nurses in the care of the critically ill neonate
and child. The duties will include student selection, classroom and
clinical teaching within the Critical Care Units of the Children s
Hospital.
This position is open to females and males.
Interested persons should submit a resume detailing education and
experience to the:
Manager Employment & Training
Health Sciences Centre
700 William Avenue
Winnipeg, Manitoba
R3E OZ3
Interested In
Paediatric Nursing ?
Toronto, Canada
The Hospital For Sick Children invites applications for all
units from experienced nurses interested in working in a
paediatric tertiary care setting.
We are a fully accredited 700 bed paediatric teaching
hospital affiliated with the University of Toronto located in the
thriving environment of downtown TORONTO. A thorough
orientation and a variety of continuing education programs is
provided. The majority of units operate on a 1 2 hour shift
basis, which normally allows every other weekend off. A
comprehensive employee benefit package, including a
Dental Plan is offered.
Our philosophy is Family Centred Care.
Qualifications:
Current registration with the Ontario College of Nurses
or eligibility for registration.
Recent related experience in an active treatment
setting preferred.
Paediatric experience would be considered a definite
asset.
Applicants are invited to contact.
Dorothy Franchi.
Personnel Coordinator,
The Hospital for Sick Children,
555 University Avenue,
Toronto, Ontario, Canada M5G 1X8,
(416) 597-1500 ext. 1675.
The Hospital
for Sick Chik
OPPORTUNITY
Nurse - Edmonton
Rosecrest Home, cares for physically and/or mentally
handicapped infants from birth to 4 years of age. You will
examine and admit children, check case histories and arrange for
any special care or diet required, prepare and maintain reports
and progress charts on the children, supervise nursing aides, and
assist with the routine daily child care. Shift work involved.
Qualifications: Graduation from an approved school of nursing;
experience in professional nursing work, pediatrics preferred.
Eligible for registration with the appropriate Nursing Association
in Alberta.
Salary: Up to $18,840 (rates to be revised)
Competition #9185-4 Open until suitable candidate selected.
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Churchill Health Centre a community -governed comprehensive health and social
service facility serving Churchill, the surrounding area of Manitoba and acting as a
referral centre for the Keewatin District of the Northwest Territories has an
opening for a
Public Health Nurse
The successful candidate will provide Nursing services and promote the health of individuals and
families in the community through program development, teaching, counselling and appropriate
rehabilitative methods.
In addition to regular duties as a Public Health Nurse, the successful candidate will be a member of
a multi-disciplinary team and must be willing to work flexible hours. A willingness to engage in
non-traditional nursing areas and a desire to work with Native people will be an asset. Community
Health Workers work alongside the Public Health Nurse as well as workers from Child Welfare,
Probation and Alcohol Counselling.
The successful candidate should possess a Baccalaureate Degree in nursing or a Public Health
Diploma. The successful candidate also must have a current license to practise as a Registered
Nurse in Manitoba.
Salary: commensurate with qualifications and experience.
Fringe Benefits: Northern Living Allowance, 20 days paid annual vacation with removal
assistance, inward and outward removal assistance, group life and pension available, and fully
modern furnished subsidized housing.
Interested persons should send a detailed resume to:
Ms. Florence Flynn
Director of Outreach
Churchill Health Centre
Churchill, Manitoba
ROB OEO
Phone: 204-675-8881, ext. 152
Open to both
men and women
NURSES
Solicitor General of Canada
Salary: Up to $23,367 (under review)
Ref. No: 80-NCRSO-NU-15
CLEARANCE NUMBER: 310-106-022
The Correctional Service of Canada will have positions
available at various locations across Canada over the next
12 months in Federal Correctional Institutions and special
psychiatric hospitals.
Salaries: Up to $23,367 (under review) - dependent on
qualifications, assignment, and location - plus
penological factor allowance of up to $1,000 per
annum, (under review)
Opportunities
Correctional health care and forensic psychiatry provide
new and expanding career opportunities for nursing
professionals. These unique, challenging areas demand men
and women with proficient nursing skills, special personal
qualities, and a pioneering spirit.
Responsibilities
In the Health Care Centres (HCCs), the nurses are the
inmates first contact with health care professionals. Each
nurse must be independent, resourceful and prepared to
operate in an expanded nursing role. In the Regional Psychia
tric Centres (RPCs), the treatment philosophy emphasizes
a multi-disciplinary approach encompassing all aspects of
psychiatry. The primary therapist in each of these
university-affiliated hospitals is frequently the nurse.
Duties
Assist in the development of medical and psychiatric
programmes for inmates in either health care centres or
regional psychiatric centres and provide nursing care to
patients on a 24 hour basis.
Benefits
Excellent pension plan; good sick leave benefits; evening,
night and weekend premiums; 11 statutory holidays; and a
minimum three weeks holiday; continuing education oppor
tunities and relocation expenses.
Qualifications
- Registered Nursing diploma for HCCs and RPCs
- Registered Psychiatric Nursing diploma for RPCs
- Registered/Certified/Licensed Nursing Assistant diploma
for RPCs
- Baccalaureat degree in Nursing an asset for HCCs and
RPCs
- Recent general nursing experience required for HCCs
Recent psychiatric nursing experience required for RPCs
Administrative and supervisory experience required for
managerial positions in HCCs and RPCs
Language Requirements
For some positions knowledge of both English and French
is essential. Because of the nature of these positions
bilingual capacity is required immediately. Other positions
require a knowledge of English, others a knowledge of
French while others require a knowledge of English and
French. Unilingual persons may apply for bilingual posi
tions but must indicate their willingness to become
bilingual. The Public Service Commission will assess the
likely aptitude of candidates to become bilingual. Language
training will be provided at public expense.
"Additional job information is available by writing to the
address below,-
Toute information relative a ce concours est disponible en
franfais et peut etre obtenue en ecrivant a I adresse
suivante".
For further information call (collect) or write:
Director, Nursing Operations
340 Laurier Avenue West
Ottawa, Ontario K1 A OP9
Tel.: (613) 995-4971
How to apply
Send your application form and/or resume to:
Mrs. Joyce Bleakney
Public Service Commission of Canada
National Capital Region Staffing Office
L Esplanade Laurier, West Tower, 16th floor
Ottawa, Ontario K1AOM7
Closing Date: March 31, 1981
Please quote the applicable reference number at a/1 times.
HOSPITAL
CORPORATION
Interested in a Challenge?
Try International Nursing - In
Saudia Arabia
If you are looking for a change, a chance to
travel, some hard work and adventurous living,
then you might consider international nursing.
You will have not only the opportunity to give -
to share your nursing expertise but the
opportunity to receive as well to learn by
living in a completely different culture. Truly, a
chance for personal and professional growth.
Available positions include both administrative
and staff level nursing. Requirements depend on
the position at staff level a minimum 2-3 years
current experience in an acute care hospital or
clinic setting. Current R.N. license in one of the
Provinces. Single status contracts are offered for
18 or 24 month periods.
Attractive salaries with excellent benefits
including air transportation, furnished lodging,
generous vacation, bonus pay and bonus leave.
Interested in this once in a lifetime opportunity?
For more details, please send professional
resume to:
Kathleen Langan
Hospital Corporation International, Ltd.
Two Robert Speck Parkway, Ste. 750
Mississauga, Ontario L4Z 1H8
An Equal Opportunity Employer
Director of Nursing
Acute Care
Shaughnessy Hospital requires a Director of Nursing for
450 adult acute care beds situated within an 1,100 bed
community and teaching facility. Affiliated with the
University of British Columbia, we offer medical,
surgical and specialty care services.
Reporting to the Director of Patient Services (Nursing)
the incumbent will be responsible for the management
of acute services.
The successful candidate will possess 5-10 years exper
ience in nursing management and varied clinical exper
ience in acute care. A Master s in Nursing Administrat
ion is preferred.
Salary will be commensurate with qualifications and
experience.
Please submit resume to :
Vivian L. Walwyn
Employment Manager
Shaughnessy Hospital
4500 Oak Street
Vancouver, British Columbia
V6H 3N1
Regina General Hospital
Requires
Clinical Coordinator
Under the supervision of the Director, Nursing Services, is
responsible for the supervision, coordination and administration
of all nursing services in the Operating Room Department.
Position requires successful completion of aDiplomaNursing
course and registration with the S.R.N.A.
Three years of O.R. Nursing experience with Post-Basic
Operating Room training. Preparation in nursing administration
with related experience.
A regeneration program which is in progress includes plans for
new facilities for surgical suite covering a wide range of services
to be completed in 1983. This challenging position will allow the
successful applicant to become involved in all aspects of
planning.
Please apply to:
Personnel Services
Regina General Hospital
Regina, Saskatchewan
S4POW5
The University
Off Lethbridge
invites applications for
ASSISTANT OR
ASSOCIATE PROFESSOR
School of Nursing
QUALIFICATIONS Current Canadian Registration. Post-
Masters or Masters degree and experience in nursing educa
tion and curriculum development at the university level.
Preference will be given to candidates with Community Health
or Maternal and Child Health background.
RESPONSIBILITIES Teaching in the Bachelor of Nursing
(Post-RN) degree program. Responsibility for planning,
organizing and directing field experiences in community
health agencies in Southern Alberta
SALARY Appointment possible at Assistant or Associate
Professor rank, depending upon qualifications.
1979*0 Range: Assistant $20,446 to $28,616
Associate $26,180 to $37,280
APPOINTMENT Effective as soon as possible, not later than
January 1, 1981.
APPLICATIONS Including a curriculum vitae and names of
three references should be forwarded to:
Director of Nursing
University of Lethbridge
4401 University Drive
LETHBRIDGE, Alberta T1K3M4
Registered Nurses
Come to work in scenic Corner Brook!
Registered nurses are needed for this 350 bed Regional General
Hospital, with detached 60 bed Special Care Unit, serving the
West Coast of Newfoundland .
The hospital offers good fringe benefits such as four weeks
annual vacation and eight statutory holidays plus birthday
holiday. In addition there is a hospital pension plan and a group
insurance plan for all permanent employees.
Accommodation and assistance with transportation is available.
Negotiated Salary Scale:
1 January, 1979 $12,771.00 15,429.00
1 January, 1980 $13.410.00 16,199.00
(Contract not yet signed)
Service Credits recognized.
Interested applicants apply to:
Mrs. Shirley M. Dunphy
Director of Personnel
Western Memorial Regional Hospital
P.O. Box 2005
Corner Brook, Newfoundland
A2H 6J7
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:
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1 A OL3
Name
Address
City
Prov.
Health and Wellate
Canada
Sante et Bien-etre social
Canada
I
I
Toronto Western Hospital
The Home Of Friendly Care and
Protection"
This 700 bed University Teaching Hospital has
employment opportunities for registered nurses, or
nurses eligible for Ontario Registration in such areas as:
Intensive Care
Renal Dialysis
Neuro Surgery
Cardio Vascular Surgery
Planned orientation and on-going education programme in
effect.
Apply to:
Miss H. Jones, Staffing Co-ordinator
Department Of Nursing
Toronto Western Hospital
399 Bathurst Street
Toronto, Ontario
MST 2S8
Nurse Clinician Pediatrics
This position represents a challenging opportunity for a
baccalaureate prepared nurse with experience in teaching
and pediatric nursing.
The successful applicant will provide nursing care to a
specified group of patients having complex needs and
will carry out staff development activities for pediatric
nursing staff.
Applicants should be prepared to develop, the Nurse
Clinician role in a pilot project over a period of 18
months.
If you re a nurse who enjoys the challenge of patient
care and teaching....
Please send resume to :
Mrs. L. Rivers
Manpower-Nurse Interviewer
St. Boniface General Hospital
409 Tache Avenue
Winnipeg, Manitoba
R2H 2A6
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics,
orthopaedics, obstetrics, psychiatry,
rehabilitation and extended care including:
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education Programs.
Post Graduate Clinical Courses in Cardiovascular
Intensive Care Nursing and Operating Room Nursing.
Apply to:
Recruitment Officer Nursing
University of Alberta Hospital
8440 11 2th Street
Edmonton, Alberta
T6(; 2B7
University of
Alberta Hospital
Edmonton, Alberta
Registered Nurses
Are You Looking
for a challenge in your career?
Would You Enjoy
living in Vancouver?
a salary range of $ 1 ,624.00 - 1 ,784.00 per month?
4 weeks vacation, and 100 percent medical-dental
premiums?
1 week orientation or longer for specialty areas?
If So Read On!....
Shaughnessy Hospital is a major community and
teaching facility treating the adult patient in an acute
and long term care setting.
We have full-time, part-time and on-call general
duty positions available in Medicine, Surgery and
Spinal Cord Injury Unit.
Experienced Critical Care Nurses are required for
our Surgical and Medical Intensive Care Units
and the Critical Care Nursing Pool.
Why Not Make Your Move Before That Long, Cold
Winter Sets In!!
Administrative Supervisor
An opening is available for a Registered Nurse who
has the initiative to seek advancement in his/her career.
This position offers a challenge: --the opportunity to
be responsible for all activities pertaining to patient
care delivery during the night shift.
A good clinical background in critical care nursing
and effective leadership skills is essential.
Preference will be given to applicants with recent
administrative experience and/or BSN.
Applicants must be eligible for registration in British
Columbia. Salary: $2,030.00 - 2,230.00 per month.
Phone or write, detailing your qualifications and
experience to:
Jane M. Mann
Nursing Recruiter
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C. V6H3N1
(604) 876-6767, local 431
SHAUGHNESSY HOSPITAL
4500 Oak Street
Vancouver, B.C. V6H 3N1
OPPORTUNITY
Team Leaders - Edmonton
The Eric Cormack Centre requires Team Leaders to direct the
work activities of a 20-24 bed unit housing dependent
handicapped children and young adults. You will be responsible
forthe maintenance of health and safety of the residents, and for
the nursing standards and quality control of treatment activities
on the unit. Supervision of a team of Institutional Aides is
involved. Afternoon and relief shift are available.
Qualifications: Graduation from a recognized school of nursing
(R.N., R.P.N., R.M.D.N. ). Must be eligible for registration in
appropriate professional organization (A.A.R.N., P.N.A.,
A.M.D.N.A.). Experience in the field of mental retardation
would be an asset.
Salary: To $17,340 (under review)
Competition #9184-1 Open until suitable candidate selected.
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Regina General Hospital
Requires
Administrator Patient Care
Excellent opportunity for an individual who possesses a blend of
management ability, human relations skills and a clinical
knowledge. This position reports directly to the Executive
Director, is responsible for nursing service and several other
related departments in a fully-accredited professionally-oriented
500 bed acute care facility. The ReginaGeneral Hospital strives
for excellence in the delivery of patient care. In addition to the
normal medical and surgical services, we offer specialty care in
high risk obstetrics, neonatology, pediatrics, hemodialysis and
burn care. The successful candidate must possess the ability to
interface effectively with all levels of hospital personnel and
medical staff. The candidate must possess as a minimum, a
Bachelor sDegree in Nursing with preference given to those
with a Master s Degree. We require at least five years clinical
nursing experience with three years in a nursing management
position indicating a history of increasing responsibility.
We offer an excellent compensation and benefit program.
Interested candidates are invited to submit their curriculum
vitae, which must include salary history and expectations to:
Personnel Services
Regina General Hospital
1440-I4th Avenue
Regina, Saskatchewan
S4P OW5
University of British Columbia
Health Sciences Centre
requires
Registered Nurses
Opportunities for nurses interested in working as
members of the interprofessional team in the new 240 bed
Acute Care Unit, of the H.S.C. on the U. B.C. campus.
Positions available in:
Operating Room Suite
Intensive/Coronary Care
Medicine
Surgery
Emergency
Nurses must be registered or eligible for registration with
the RNABC.
Applicants should apply in writing with detailed resume
to:
Coordinator of Professional Employment
Health Sciences Centre
University of British Columbia
Vancouver, B.C.
\6T 1W5
Positions open to both female and male applicants.
Registered Nurses
Career Development Opportunities in
Vancouver.
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 major medical centre on Canada s
unconventional West Coast.
Positions For:
General Duty Nurses
Nurse Clinicians
Nurse Educators
at salaries? 1980 rates under negotiation.
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 and Neurosurgical)
Inservice Education
Cardiothoracic Surgery
Coronary Unit
Burn Unit
Hyperalimentation Programme
Paediatrics
Renal Dialysis and Transplantation
Operating Room
If you are a Registered Nurse considering a move, please
send resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C.
V5Z 1M9
Index to
Advertisers
July -August 1980
The Apothecary Service
Ayerst Laboratories, Division of
Ayerst, McKenna & Harrison Inc.
The Canadian Armed Forces
The Canadian Nurse s Cap Reg d.
The Clinic Shoemakers
Designer s Choice, A Division of
White Sister Uniform Inc.
Dow Chemical of Canada Limited
Equity Medical Supply Company
Health Sciences Centre
Hospital District No. 93
Kendall Canada
J. B. Lippincott Company of Canada Limited
Maple Leaf Laboratories Limited
McMaster University
Merle West Medical Center
Nordic Laboratories Inc.
Posey Company
R.N.S. Limited
Ross Laboratories, Division of
Abbott Laboratories Limited
W.B. Saunders Company
Smith & Nephew Inc.
Upjohn HealthCare Services
Whittaker International Services Company
16
OBC
15
IFC
46
46
46
5, 14
41
48
48
17
18
16
42,43
47
12, 13
8
IBC
Advertising Representatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
601 , C6te Vertu The Canadian Nurse
St-Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone: (6 13) 23 7-21 33
Gordon Tiffin
1 90 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P.O. Box 482
Ardmore, Pennsylvania 1 9003
Telephone: (215)363-6063
Member of Canadian
Circulations Audit Board Inc.
A NURSE S STORY. IT COULD DEVOURS
} So many nurses I talk
to about my work in Saudi
simply can t understand
what it s like to get so much
satisfaction \
RITA LAWRENCE, R.N,
V
CALL
REVERSING
THE CHARGES:
(f>02) 258-8554
ORWRITETO:
RO. Box 5653
Phoenix, Ariz. 85010
The Arabian Peninsula. Dif
ferent. Demanding. And most
deridedly gratifying.
"Like most nurses, I ve
always dreamt of my work
making the difference in peo
ple s lives. And not having it
taken for granted. But until
my job at Whittaker s Saudi
hospitals, I thought it would
never happen.
What made Saudi Arabia
different was the gratitude of
patients, families, government.
And the chance to work inde
pendently in a modern hospital.
Being in an exotic place,
coming home to free, air con
ditioned comfort that was
all part of it . Together with
excellent travel benefits, salary
and bonus provisions.
But when nurses ask why
Dedicated
I went back twice, I point to
job satisfaction . / really found
it. And they can too."
We are happy to report
that Rita Lawrence s reactions
are typical. And Whittaker, a
leader in international health
care, is now offering contracts
in either Saudi Arabia or Abu
Dhabi. If you are a Canadian
trained R.N. with two to three
years postgraduate experience,
call us today.
to a world of health
WhittakeR
Whittaker International Services Company
A Subsidiary of Whittaker Corporation
An Equal Opportunity Employer M/F
AYERST HAND CARE
to suit most hospital hand care needs
H I bl SOl Hand Rub chlorhexidine gluconate 0.5% w/v in 70
w/w isopropyl alcohol and emollients. A disinfectant for clean
hands and intact skin.
A new dimension in hand
hygiene. . .from the Ayerst
family of antiseptic products.
HIBITANE* Skin Cleanser
performs the dual function of
cleansing AND disinfecting.
HIBISOL* Hand Rub serves
as an adjunct to primary
hygiene practice. Rapid acting
disinfection WITH added
emollients to ensure cosmetic
acceptability. Simply apply
and rub dry.
HIBICARE* Lotion soothes
and softens hands PLUS it
maintains an antiseptic barrier.
Absorbs quickly.
For complete product information, please
contact your Ayerst representative,
or return this coupon.
TO: AYERST LABORATORIES
1025 Laurentian Blvd., Montreal, Quebec. H4R 1J6
I would like to receive information on the
AYERST ANTISEPTIC LINE.
Name
(Please print)
Address
No.
Street
City
Province
AYERST LABORATORIES
Division of Ayerst, McKenna & Harrison Inc. I
Montreal, Canada
Quality has
no substitut
Reg dTM
2648
Made in Canada by arrangement
With IMPERIAL CHEMICAL INDUSTRIES LIMITED
Bulk En nombre
third troisieme
class classe
10539
CNA convention highlights
Malignant hyperthermia: the facts
Living with dying
Oncology nursing, an
administrative approach
Nurse-managers: establishing a
healthy relationship with staff
The
Can
Nurse
SEPTEMBER 1980
NURSING LIBRARY
I
NEW AND EXCLUSIVELY OURS OF COURSE
ROYALE SEERSUCKER
A luxurious 100% DACRON Polyester in a delicate, light-weight
SEERSUCKER design, which maintains a supple yet fresh look.
r
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Today s Diabetics.
Through good control, they re enjoying better health
and a healthier outlook. And Ames is helping.
Today s diabetics have a healthier out
look on life. And it s all because they re in
control of their condition. They watch their
diet Get the exercise and therapy they
need. And keep a check on themselves with
daily urinalysis.
That s where Ames helps out.
Our Diastix*or Keto-Diastix*tell them day
by day where they stand with their condition,
so there s less risk of complications than
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cents and a few seconds a day.
Our free Daily Diary
helps them keep a record of their
condition, so they can begin to see
Trademarks of Miles Laboratories. Inc. Miles Laboratories, Ltd.. authorized user.
1979. Miles Laboratories Inc.
how, when and why it changes.
And our free Diabetic Digest offers lots
of useful information that may help them
understand their condition more clearly and
control it more effectively.
The only other thing they need is your
guidance and advice. With that, and a little
help from us, today s diabetics
can enjoy better health
and a healthier outlook.
Ames
Division
IX/IILI
Ames Division, Miles Laboratories, Ltd.,
Rexdale, Ontario M9W 1G6
We helped make urinalysis
the science it is today.
When the coll light is on
and time is counted in seconds
the lost thing you think
about is your shoes.
*****
MADE IN
USR
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THE
Your shoes they re the first
thing we think about
CLINIC
THE CLINIC SHOEMAKERS Dept. CIM-9, 7912 Bonhomme Ave. St. Louis, Mo. 63105
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Gail O Neill
Production Assistant
GitaDean
Editorial Assistant
Cathy Squires
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
George Bergeron,
communications officer, New
Brunswick Association of
Registered Nurses.
Kate Fulton, RN, Addiction
Research Foundation, Toronto.
Jerry Miller, communications
coordinator, Labor Relations
Division, Registered Nurses
Association of British Columbia.
Beverley Pittfield.ftJV,
Gravelbourg, Saskatchewan.
Peter Smith, director of
publications, National Gallery of
Canada.
Florita Vialle-Soubranne,
consultant, professional
inspection division, Order of
Nurses of Quebec.
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.
Canadian Nurses Association, 50 The
Driveway, Ottawa, Canada, K2P 1E2.
The chain of office passes out
of the hands of retiring CNA
president Helen Taylor and
into those of incoming
president Shirley Stinson. Our
coverage begins on page 18.
Cover and inside photos by
B.C. Jennings, Vancouver.
The
Canadian
Nurse
September 1980 Volume 76, Number 8
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Malignant hyperthermia.33 Donelda Ellis 42
Fire
30
Nurses unions, professional
associations and YOU
Part two: The role of the
nurse-manager in labor relations
Glenna Rowsell
42
FRANKLY SPEAKING
Whatever happened to the
spiritual dimension?
Donelda Ellis
33
Malignant hyperthennia need
not be lethal
Elizabeth Noble
43
Denial
Gisele Fontaine Kermer
38
A time to be born, a time to die
Vera Mclver
44
A developing framework for
oncology nursing
Barbara Price and Diana Law
41
The House of Respect
Barbara Devine
49
Fire
Cathy Squires
10
Input
18
CONVENTION
REPORT
Vancouver 1980
15
Calendar
14
News
52
Here s
How
The Canadian N itrse 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
\ nr\e. A biographical statement and return address
should accompany all manuscripls.
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
Indexed in International Nursing Index. Cumulative
Index to Nursing Literature. Abstracts of Hospital
Management Studies, Hospital Literature Index.
Hospital Abstracts, Index Medicus. Canadian
Periodical \nAe\. The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor. Michigan 48106.
Canadian Nurses Association. 1980.
perspective
A PRACTICAL GOAL FOR THE 80 s
Nursing research. Is it relevant? Is it necessary?
Strange questions to ask in 1980 when the answer is
so obviously yes? Does it follow that research is a
part of all nursing practice? If so, must all nurses
be research-minded?
In seeking answers to these questions we find
ourselves posing further queries relating to research
and nursing service.
Can nurses provide effective and logical nursing
interventions for the patients they are preparing for
surgery without knowledge of nursing research on
presurgery fasting?
Can nurses provide relevant care for the dying
person and his family if they are not aware of nursing
research findings that help them to understand their
feelings and those of their patient?
Can they provide optimum nursing care for the
patient in pain if they are not aware of research on
pain control?
Can they develop their independent role as
nurses if they do not know the research findings on
wellness? Are they sensitive to the latest findings
about the strengths and limitations of tools such as
health indicators?
We believe the answer to these questions is NO;
we believe that nurses cannot practice effectively
unless they have some awareness of such research
findings, however limited such findings may be at this
point in time. To know about our gaps in knowledge
we must know our achievements.
It would be unrealistic to expect all nurses to
become involved in conducting research. Nevertheless,
all nurses do need to know the results of research and
how to apply these findings to their specific area of
nursing. Until every nurse asks the question, "What
research has been done to help me with this nursing
care problem (or nursing education problem or
nursing administration problem)?", we will continue
to fly by the seat of our pants in providing nursing
care and fail to build a body of knowledge specific to
nursing.
The progress of nursing research has been slow:
almost nothing until the 1900 s (although Miss
Nightingale gave us a beginning) and even since the
1900 s much of the research on nursing has been
done by non-nurses. Nursing researchers, that is,
researchers educated as nurses, have really only been
available in the last 20 years. It is only in the last
ten years that the term research has become a
legitimate part of the vocabulary in an undergraduate
nursing curriculum.
Could this scarcity of nursing research in
Canada and an increasing awareness of the need for
it be one of the reasons for the enthusiastic response
to the six national conferences on nursing research
that have taken place during the past nine years?
The 300 Canadian nurses who attended the first
national conference in 1971 blazed a trail for those to
follow. This first conference was made possible by
Department of National Health and Welfare funds
awarded to the University of British Columbia School
of Nursing. It was organized by members of that
faculty but held in Ottawa. The focus was on a review
of nursing research and on generating interest. That
this was a milestone in the development of research in
Canadian nursing, is evidenced by the five
conferences that followed. The national sharing of
funding and hosting of these conferences by
provincial education and service groups is further
evidence of a growing nursing research consciousness.
National conferences in nursing research are
now part of the pattern; nurses need to meet to
identify research areas, to find solutions to common
problems and to further develop their research skills.
Taken together, these conferences contribute to a
broader base of research-mindedness in the
community. The seventh national conference, which
takes place this year in Halifax from October 22 to
24, moves us close to a decade of sharing nursing
research on a national basis. The topic is fitting: a
research basis for nursing in the 80 s.
Yes, nursing research is relevant and necessary.
Nursing cannot achieve full professional status
without it. How can nursing care be improved unless
it is through the demands of all nurses for more and
better research into all aspects of nursing?
Marion Allen
assistant professor, and
Myrna Slater
associate professor.
School of Nursing,
Dalhousie University.
AYERST HAND CARE
to suit most hospital hand care needs
HibiSOl* Hand Rub chlorhexidine gluconate 0.5% w/v in 70
w/w isopropyl alcohol and emollients. A disinfectant for clean
hands and intact skin.
A new dimension in hand
hygiene. . .from the Ayerst
family of antiseptic products.
HIBITANE* Skin Cleanser
performs the dual function of
cleansing AND disinfecting.
HIBISOL* Hand Rub serves
as an adjunct to primary
hygiene practice. Rapid acting
disinfection WITH added
emollients to ensure cosmetic
acceptability. Simply apply
and rub dry.
HIBICARE* Lotion soothes
and softens hands PLUS it
maintains an antiseptic barrier.
Absorbs quickly.
For complete product information, please
contact your Ayerst representative,
or return this coupon.
TO: AYERST LABORATORIES
1025 Laurentian Blvd., Montreal, Quebec. H4R 1J6
I would like to receive information on the
AYERST ANTISEPTIC LINE.
Name (Please print)
Address
No.
Street
City
Province
Ayerst
AYERST LABORATORIES
Division of Ayerst, McKenna & Harrison Inc.
Montreal, Canada
Reg d TM Made in Canada by arrangement
2648 with IMPERIAL CHEMICAL INDUSTRIES LIMITED
Ponstari
(mefenamic acid) I
FOR PROMPT RELIEF
OF DYSMENORRHEA
# non-hormonal, non-narcotic therapy
(simple, short-term, non-addictive regimen
taken only when required)
* inhibits prostaglandin synthesis and
the action of prostaglandins on the uterine
smooth muscle 1 (reduces uterine
contractions and abdominal pain)
Ponstan Capsules 250 mg:
2 capsules at onset of dysmenorrhea
followed by 1 capsule every 6 hours for
the duration of symptoms
Reg T M /M.E. Parke, Davis & Company
Ponstan
When it does its job, she can do hers
every day of the month.
PARKE-DAVIS
Parke-Davis Canada Inc., Scarborough, Ontario
UPDATE ON DYSMENORRHEA
Shortcomings of traditional therapies
Surveys show that up to half of female patients may live a sixth of their reproductive years in pain. Yet many of these women
are reluctant or embarrassed to talk about their problem, preferring to self treat with analgesics, or simply accepting their
condition.
The Lancet, as recently as 1978, reported: "Current treatment of primary spasmodic dysmenorrhea is unsatisfactory.
Powerful analgesics may be habit forming, dilatation of the cervix may cause incompetence, and the use of oral
contraceptives seems unjustified unless contraception is required." 2
How prostaglandins fit into the clinical picture
In the 1940 s it was theorized that a menstrual toxin existed which was involved in causing the pain and other related problems.
Recent investigations have indicated that increased premenstrual endometrial prostaglandin levels (particularly levels of
prostaglandins E 2 and F 2 alpha) may play an important role in the etiology of dysmenorrhea.
How Ponstan assists in relieving dysmenorrhea
Most non-steroidal anti-inflammatory agents are inhibitors of prostaglandin synthesis the enzyme system responsible for
the formation of prostaglandin.
The fenamate group of anti-inflammatory drugs have a twofold action: they inhibit the enzymes of the prostaglandin
synthesis pathway and also antagonize prostaglandins at the receptor sites. 1
Ponstan versus conventional analgesics
Recent clinical trials have demonstrated that Ponstan is, indeed, a useful drug in the treatment of dysmenorrhea, affording
relief in some 89.3% of patients cycles. 3
In a double-blind comparison of dextropropoxyphene/paracetamol capsules (2 caps of 32.5 mg/325 mg t.i.d.) and Ponstan
(2 caps of 250 mg t.i.d.), Ponstan was significantly more effective than the analgesic combination on both clinically
determined and subjective patient preference assessments. There was also less absenteeism in the group taking Ponstan. 4
Alternative therapy to oral contraceptives
Ponstan provides prompt relief of dysmenorrhea, and may thus be considered a more rational therapy than oral
contraceptives.
In a recent survey, 55% of women taking oral contraceptives stated that these agents had not solved their dysmenorrhea
problems. 5 Ponstan has demonstrated a much higher success rate without disturbing the normal hormone balance of patients.
Unlike oral contraceptives, Ponstan is taken only when required, i.e. when menstrual pain becomes evident. For the rest of
the month the patient may be free of medication.
Ponstan: a simple short-term regimen
Patient acceptance of Ponstan is understandably enthusiastic. When pain appears, a patient takes two capsules stat, for fast
relief, followed by one capsule every 6 hours for the duration of symptoms.
In addition. Ponstan is well tolerated- Extensive data supports the fact that side effects with short courses of treatment with
Ponstan are restricted mostly to minor gastrointestinal disturbances.
Prescribing Information:
PONSTAN CAPSULES 250 mg
PONSTAN (mefenamic acid} is an analgesic
preparation with antipyretic, anti-inflammatory and
antiprostaglandm properties PONSTAN has been
shown to inhibit both the synthesis of prostagtandins
and their action on the cell receptor sites.
INDICATIONS: For the relief of pam in acute or
chrome conditions such as dysmenorrhea,
headaches and muscular aches and pains,
ordinarily not requiring the use of narcotics.
DOSAGE: Administration is by the oral route.
preferably with food. The recommended regimen for
adults and children over 14 years of age is 500 mg
as an initial dose followed by 250 mg every 6 hours
as needed. PONSTAN should not be given to
children under 14 years of age.
CONTRAINDICATIONS: PONSTAN is
contramdicated in patients showing evidence
of intestinal ulceration. The drug is also
contramdicated tn patients known to be hyper
sensitive to mefenamic acid. If diarrhea occurs,
the drug should be promptly discontinued. Safe
use in pregnancy has not been established.
PRECAUTIONS: PONSTAN should be administered
with caution to patients with abnormal renal function
and inflammatory conditions of the gastrointestinal
tract Caution should be exercised in administering
PONSTAN to patients on anticoagulant therapy
since it may prolong prolhtomtitn times PONSTAN
should be used with caution in known asthmatics
If rash occurs, the drug should be promptly
discontinued
Mefenamic acid may prolong acetylsaiicyfic acid
induced gastrointestinal bleeding. However,
mefenamic acid itself appears to be less liable than
BIBLIOGRAPHY: 1. Smith, I D., Temple, D.M .etal: Prostaglandins 10: 41-57, 1975
2. Kapadia, L, Elder, M.G., Lancet (1): 348-350. 1978
3. Pulkkmen, MO., Kaihola. H.L., Acta Obstet Gynecol Scand 56:75-76. 1977
4 Anderson, A.B.M., Haynes, P. J., etal: Lancet (1)- 345-348, 1978
5. Consensus independent research, 1978 Data on File. Parke-Davis Canada Inc.
acetylsaticyhc acid to cause gastrointestinal
bleeding
ADVERSE REACTIONS: In controlled clinical
investigation studies of PONSTAN at analgesic
doses, up to 1 500 mg per day, associated side
effects were relatively mild and infrequent.
Complaints are dose-related, being more frequent
with higher doses
In 2,594 subjects gtven mefenamic acid over a
period of from 1 to 238 days, the most frequently
reported adverse effects were drowsiness (68
subjects), nervousness (28), nausea (20), dizziness
(36), gastrointestinal discomfort (10), diarrhea (11),
vomiting (5), and headache (2). There were single
reports of insomnia, urticaria and dyspnea and
facial edema, and 2 instances each of blurred
vision, gas and perspiration.
There have been a few reports of hematopotetic side
effects. A direct cause and effect relationship has
not been established
SUPPLY: Each ivory capsule with aqua blue cap
contains 250 mg mefenamic acid.
Bottles of 1 00 and 500 capsules.
FULL PRESCRIBING INFORMATION ON
REQUEST.
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Continuous urinary output
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Transparent meter scale affords clear
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input
The code interpreted
In response to the issues raised
and comments by members at the
recent biennial meeting in Vancouver,
I would like to remind nurses that:
From the initiation of the project
it seemed clear that whatever model was
to be developed for a code of ethics for
nurses in Canada, such a model could
not address itself to specific issues: the
complexity of ethical issues faced by
nurses in the 80 s does not lend itself to
a simple black and white categorization.
As project director, on the basis
of the problems submitted by nurses
across the country, I came up with more
general categories of ethical obligation,
all grounded in nursing s mandate to
respond to health needs of people and
to provide appropriate helping services.
The code articulated this mandate by
expressing the ethical responsibilities of
nursing through the fundamental and
unifying characteristic of nursing
caring.
The code is structured around
guidelines, including 20 statements of
ethical responsibility, preceded by a
commentary. It is not a list of do s and
don t s but a statement designed to
provide a basis for reflection and
study. The fundamental responsibility
of the nurse to care, to respond to
health needs with trust and respect,
contain the ethical principles needed to
guide nursing action.
It is important that any statement
in the code be interpreted in the
context of the whole, for example, the
following statements provoked a
reaction of concern from members who
perceived them to be in conflict with
union commitments:
Thus, when a nurse is working
under conditions which violate justice,
the withdrawal of needed services to
patients as a means of resolving such
injustice, is unethical.
From an ethical point of view,
neither the profession as a whole, nor
the individual nurse, may resort to
strategies that would compromise the
health of clients.
The commentary does not
mention collective bargaining, nor does
it refer to strike action by nurses. It
does, however, emphasize the
profession s responsibility to promote
conditions which enable nurses to carry
out their caring functions.
This could mean that the
profession supports legitimate collective
bargaining activities of nurses as a way
of ensuring appropriate working
conditions. The code commentary
acknowledges the reality of injustice in
working conditions of nurses, but also
indicates that there are ethical
constraints on the nature and extent of
actions taken to resolve such injustice.
Where strike action by nurses is
contemplated, important distinctions
need to be made. There is a difference,
for example, between total strike
where patients may be held "hostage"
to an economic dispute, and strike
action which takes into account levels
of care requirements and provides for
care needs which are of an essential
nature. Or, in a situation where staffing
conditions are poor and resources
inadequate for safe care, nurses would
be compromising the health of clients
by staying in the situation.
Ethical issues are complex. A code
of ethics will not make our problems
less complex or less ambiguous. The
purpose of a code is to sensitize us to
the ethical components of the issues we
face on a daily basis, and to assist us in
responsible discernment based on facts,
principles and personal integrity. A code
of ethics is not a guarantee against
mistakes: hopefully, it will enable us to
make fewer mistakes and ultimately to
avoid tragic ones.
-Sister M. Simone Roach, St. Francis
Xavier University, Antigonish, N.S.
Holes in our caring
By chance I read "HELP" by
Nelda Yantzie (June). I thought it was
an excellent game plan, but there was
one glaring oversight.
Along with the 14 living patients,
there were six who had symptoms that
could be described as psychiatric
one described as hysterical, one "talking
loudly and swearing", one "walking as if
in a daze", and one "in mild shock".
Two other patients were described
as confused. This means that
approximately 40 per cent of the
patients exhibited some emotional
distress. Yet, nowhere in the plan after
triage was arrangement made for any
sort of psychiatric or psychological
support.
I realize that this plan is for a
small hospital where only one doctor is
available, but I do think it is important
that some area in the hospital should be
made available for a person with some
expertise in helping emotionally
disturbed people, such as a nurse or a
social worker, to be available to help
these patients deal with their emotional
reactions.
-J.B. O Regan, MD, FRCP (C),
Associate Professor of Psychiatry,
University of Saskatchewan, Chief of
Psychiatry, Saskatoon City Hospital.
Northern training
The "Bridging the Gap"
perspective regarding transcultural
nursing (June 1980) was excellent. But
what s the next step?
We need a native northern nursing
program. The Brandon University
Hospital Program is too long and is
southern-based. Dalhousie s is post-RN.
Models in western United States
are proof that quality training for work
in isolation is possible.
Lionel Orlikon, Winnipeg, Manitoba.
ER nurses unite
There has been some preliminary
discussion among emergency nursing
representatives from Ontario, British
Columbia and Alberta about the need
for emergency nurses in Canada to have
national affiliation.
There will be another meeting at
the Ontario Assembly of Emergency
Care, October 5-8, 1980, at the Skyline
Hotel, Toronto. We hope to hear then
from other emergency nurses from the
remaining provinces who would be
interested in developing a national
association.
Interested persons may write to
the following address: ENAO, Box 100-
217, 2 Bloor St. W., Toronto, Ontario,
M4W 3E2. As far as we know, Ontario,
British Columbia and Nova Scotia have
formalized provincial membership ;
Alberta has a less formalized structure
but very similar objectives. Provincial
membership is not a pre-requisite for
demonstrating interest in national
affiliation.
-Pat McGuire, president, Emergency
Nurses Group of British Columbia.
-Sandra Boston, president, Emergency
Nurses Association of Ontario.
Overseas mail
I write to acknowledge receipt of
your journals. I really appreciate your
faithfulness and would say I have been
finding it very useful.
The April issue with the articles
on exercises and the test project draft
have been very useful to me.
Hoping to read more.
-A. A. E. Olaogun, University of Ibadan,
Ibadan - Nigeria. (Continued on page 54)
"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.
ill
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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."
HM6402-C 1979 Healthcare Services Uppohn. lid
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716 Cordon Baker Road
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calendar
September
The Psychiatric Nurses
Association of Canada will
hold its 1 980 annual meeting
Sept. 22-26 at the Devonshire
Hotel, Vancouver. Contact :
Psychiatric Nurses Association
of Canada, 871 Notre Dame
Ave., Winnipeg, Manitoba
R3E OM4.
October
The Association of British
Columbia Enterostomal
Therapists will hold their
annual teaching seminar for
health professionals Oct. 2-3
at the Public Health Centre,
Nanaimo, B.C. Contact:
Aileen E. Barer, Enterostomal
Therapy Center, Royal
Jubilee Hospital, 1900 Fort
St., Victoria, B.C. VSR 1J8.
A two-day workshop on pain
will be held at the University
of Manitoba Oct. 9-10,
featuring author Margo
McCaffery. Contact: Prof.
Erna Schilder, School of
Nursing, University of
Manitoba, Winnipeg, Man.
R3T2N2.
The first annual meeting and
workshop of the Canadian
Association of Quality Care
Coordinators will be held in
North Bay, Ont., Oct.2-3.
Contact: Brian Rogers, St.
Joseph s General Hospital,
720 McLaren Ave., North
Bay, Ontario.
"The Nurse as a Community
Activist Leadership and
Personal Influence" is the
theme of the annual
workshop of the Community
Mental Health Nurses
Association of Ontario to be
held Oct. 3 at the Ramada
Inn Airport West, Mississauga,
Ont. Contact: Lynda Hessey,
York Community Services,
1651 Keele St., Toronto,
Ontario M6M 3W2.
"Continuing Professional
Education: Moving into the
80 s" will be presented by the
University of Calgary,
October 22-24. Contact: The
Faculty of Continuing
Education, The University of
Calgary, Calgary, Alberta,
T2N 1N4.
Students & Graduates
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Name
Address
City Postal Code
Your graduation school
A national conference on
Smoking Prevention for the
Young, sponsored by the
Manitoba Interagency
Council on Smoking and
Health will be held in
Winnipeg, Oct. 17-19.
Contact: Manitoba Heart
Foundation, 301-352 Donald
St., Winnipeg, Man. R3B 2H8.
Queen s University School of
Nursing Alumnae of all years
are invited to a special dinner
in conjunction with the
Queen s Reunion Weekend,
Oct. 17- 19. Contact: R,
Maloney, Queen s University,
School of Nursing,
Summerhill, Kingston,
Ontario K7L 3N6.
The Canadian Association on
Gerontology will hold its
annual scientific and
educational meeting, October
16- 19 at the Hotel
Bessborough, Saskatoon,
Sask. Contact: Dr. Duncan
Robertson, Program
Chairman CAG 80, Box
7997, Saskatoon, Sask.
S7K 4R6.
The Ontario Occupational
Health Nurses 9th annual
conference will be held at the
Holiday Inn, Ottawa, October
20-24. Contact: Mrs. S. Smith,
Registration, Room 600, Bell
Canada, P.O. Box 8239,
Ottawa, Ont. K1G 3J4.
The Greater Vancouver
Mental Health Service
presents "The Community
Approach Mental Health or
Mental Illness?" on Oct.30-3 1 .
Contact: G.V. M.H.S.
Conference Committee, 201-
828 West 8th Ave.,
Vancouver, B.C. V5Z 1E2.
The Amsco Seminar on
Sterilization in O.R. and
C.S.R. will be held Oct.27-29
at the Place Dupuis Holiday
Inn, Montreal. Contact:
Victoire Audet, 1275 Cote
Vertu, Ville St. Laurent,
Quebec, H4L 4 V2.
The annual seminar of the
Manitoba Operating Room
Nurses Study Group will be
held on Oct. 30 in
conjunction with the
Manitoba Health Organization
Conference. Contact: Judy
Cameron, Operating Room,
Health Sciences Centre-
General, 700 William Ave.,
Winnipeg, Man. R3E OZ3.
The fourth annual Nursing
Lecture Series co-sponsored
by the University of
Manitoba School of Nursing
and the Victorian Order of
Nurses, Winnipeg Branch
featuring Dr. Jacqueline
Chapman, will be held Oct. 9.
Contact: June Bradley,
Acting Director, School of
Nursing, The University of
Manitoba, Winnipeg, Man.
R3T2N2.
The York-Toronto
Respiratory Care Society
annual respiratory update will
be held Oct. 23 at the Royal
York Hotel. Contact:
York-Toronto Lung
Association, 157 Willowdale
Avenue, Willowdale, Ontario,
M2N4Y7.
November
Depression in the 80 s: the
most common mental
disorder is a two-day
symposium being held Nov.
3-4 at the Sheraton Caswell
Inn, 1696 Regent Street
South, Sudbury, Ontario.
Contact: Alice Shaw, Staff
Development Department,
Sudbury Algoma Sanatorium,
680 Kirkwood Dr., Sudbury,
Ontario P3E 1X3.
An Update on Peritoneal
Dialysis is the subject of a
workshop to be presented by
the Toronto Western Hospital
for nurses and other
paramedical personnel, Nov. 8.
Contact: Sharron Izatt,
Program Coordinator, c/o
Peritoneal Dialysis Unit,
Toronto Western Hospital,
399 Bathurst St., Toronto,
Ontario, M5T 2S8.
The Canadian Intravenous
Nurses Association will hold
its 5th annual convention at
the Inn on the Park, Toronto,
Nov. 13-14. Contact: C.I.N.A.
4433 Sheppard Ave. E.,
Suite 200, Agincourt,
Ontario, MIS 1V3.
"Ethical Issues In Psychiatric
Nursing", a workshop
designed for RPN s and RN s
employed in psychiatric
settings, will be held Nov.
14-15. Contact: Roy Morris,
Health Continuing Education,
B.C.I.T., 3700 Willingdon
Ave.,Burnaby,B.C. V5G 3H2.
Contributions to CALENDAR are
published free of charge as space
permits. For more than one
insertion or to ensure publication
in a specific issue, please consult
our advertising department. V
news
Nurse heads CPHA
For the second time in the
71 -year history of the
Canadian Public Health
Association, a nurse has been
elected president. Marie des
Anges Loyer, director of
nursing and associate dean of
health sciences at the
University of Ottawa,
assumed office during the
annual CPHA conference in
June 1980.
Loyer told The
Canadian Nurse that, as
president, she hopes to work
closely with provincial
nursing and public health
associations to put pressure
on their respective
governments for increased
financial support. "This is a
significant mandate for nurses
in public health," she said.
Ten years ago, Geneva
Lewis, then director of public
health nursing for the
Ottawa-Carleton region,
was elected president.
Three other nurses were
also named to the CPHA
board of directors: Jill
Christensen from the
Northwest Territories branch,
Karen Mills from the Alberta
Public Health Association and
Ann Harling from the New
Brunswick/Prince Edward
Island branch.
The conference, held in
Ottawa, was attended by
more than 650 delegates and
centered on the theme
"public health in the 80 s
opportunity or demise".
Maureen Law, MD,
assistant deputy minister of
the national department of
Health and Welfare and
keynote speaker, was
optimistic about the future.
"I most certainly see the 80 s
as a decade of great
opportunity for public
health," she said.
Dr. Law foresaw
prevention programs, health
promotion and public health
manpower as instrumental to
the achievement of the
federal goal of "health for all
by the year 2000". She told
members this goal could only
be attained through their
"concentrated effort" and
that public health
practitioners should not "go
on to administrative or
academic careers" because of
the shortage of manpower.
Ottawa Mayor Marion
Dewar, who is also a nurse,
challenged delegates to a
more specific public health
opportunity: that of aiding in
the resettlement of
Vietnamese refugees.
CPHA s 1981
conference will be held in
Saskatoon next June.
Nurse administrators hold
first national conference
"Lab-coated, harried and
absolutely demystified,
coping in ways most suited to
her personal style, comfort
and sanity level," that s how
nurse administrator Roberta
Coutts of Ottawa sees her
fellow DON s. "The nurse
administrator of today has a
calculator on her desk, a
ministry report in her drawer
and a grievance in her IN
basket," Coutts told close to
200 registrants attending the
first national Nurse
Administrators Conference in
Vancouver last June 25 and
26.
Coutts, director of
nursing of the Ottawa
General Health Sciences
Centre, who delivered the
keynote address, "Functional
aspects of administering
nursing in the 80 s",
suggested that what nurse
administrators need are not
more courses in caring but,
instead, "the wiles and guiles
of a hungry cheetah!"
"Why has the question
arisen of whether or not a
director of nursing must be a
nurse," Coutts wondered.
"Is it because there are nurse
administrators who cannot
effectively run interference
for nursing, or choose not to?
Is it because they themselves
are intimidated or have
accepted the power and
status dictated by others?"
The conference, which
was sponsored by the
Canadian College of Health
Service Executives in
cooperation with the
Canadian Nurses Association
and the Nursing Adminis
trators Association of British
Columbia, featured an
impressive list of speakers.
Proceedings of the
meeting will be compiled and
available from the Canadian
College of Health Service
Executives, British Columbia
Education Services,
440 Gamble St., Vancouver,
B.C. V6B 2N5, at a cost of
$10.50 (including mailing
charges).
Continuing ed challenge
topic for national meet
What nurses in this country
need, according to an expert
on the American scene, is a
statement by their
professional organization on
the meaning of continuing
education for the nurse as a
professional and for the nurse
as a worker, with a
distinction made between the
two.
Dr. Dorothy del Bueno
who is associate dean in the
Continuing Education
Faculty at University of
Pennsylvania and consultant
in inservice education at the
Hospital of the University of
Pennsylvania, made the
comment in her keynote
address to nurses attending
the second national
Continuing Education
Conference in Vancouver
June 26 and 27.
"There is some
overlap," del Bueno noted,
"between the nurse as a
professional and the nurse as
a worker, but there is also a
big difference and it is this
difference which determines
who provides the continuing
education and who pays. If
the CNA made such a
statement, I could almost
guarantee that the amount of
continuing education
available to Canadian nurses
would increase."
Addressing the need for
strategies for cost effective
educational programs,
del Bueno presented her own
formula for determining the
cost effectiveness of
individual programs. By
considering the learner from
three perspectives, as a
person, as a professional and
as a worker, it is easier to
examine the issue.
"The criterion for
determining who does what,
must be an economic
criterion, based on return on
investment," she said. "The
group that will receive the
greatest return for the
investment should pay for
it." She also reminded her
audience that the greatest
cost involved in continuing
education is that of the time
of the learner; it is very
effective if the agency can
contract the program out so
that the individual will take
the course on her own time.
More than 1 25 nurses
from across the country
attended this second national
conference with the theme of
"Continuing Nursing
Education: Planning for the
80 s." The first such
conference took place in
Winnipeg in April, 1979.
Copies of the proceedings of
the first conference are still
available at a cost of $8.40
(includes postage) and may
be obtained by writing to
Dr. Helen Niskala, 310-
6055 Vine St., Vancouver,
B.C. V6M 4 A3. Proceedings
of the 1980 meeting are to be
published at a later date. *
ICN SETS CONGRESS FEES
Registration fees for ICN s 17th Quadrennial Congress in
Los Angeles June 28-July 3, 1981 have been set by ICN
directors. The fee schedule is as follows:
Registration
Early (until February 28, 1981)
Late (until April 30, 1981)
Advance (per day)
Nurses Students
US$90.00 US$45.00
110.00
30.00
55.00
15.00
Registration takes place through ICN s 89 member
associations. Any nurse belonging to an ICN member
association (such as CNA) is eligible to attend the congress.
A preliminary program is now available from CNA;
included in this program are registration and hotel
accommodation forms.
September! 98Q 15
I Id ill (insulin. Lilly) Diabetes Mellitus Therapy
Product Information
Description: Insulin is a protein hormone secreted by the beta cells
of the pancreatic islets of Langerhans. Chemically, it is a protein con
taining 51 ammo acids arranged in 2 chains connected lor bridged by
2 disulphide linkages and having a molecular weight ot approximately
6.00C
The administration of suitable doses of insulin to patients with
diabetes mellitus. along with controlled diet and exercise, tempo
rarily restores their ability to metabolize carbohydrates fats and pro
teins: to store glycogen in the liver: and to convert glucose to fat.
When given in suitable doses at regular intervals to a patient with
diabetes mellitus. the blood sugar is maintained within a reasonable
range, the urine remains relatively free of sugar and ketone bodies,
and diabetic acidosis and coma are prevented
Insulin preparations differ in onset, peak and duration of action.
The addition of protamine to insulin, in the presence of zinc produces
a stable complex with less intense and more prolonged action, due to
its slow solubility. The onset and duration of action is also modified by
reprecipitation in the presence of sodium acetate and zinc. This
modified action depends on tbe structure of the resulting precipitate
Regular and Semilente insulins are rapid-acting: NPH and Lente
are intermediate-acting: Protamine Zinc IPZH and Ultralente are long-
acting. Regular insulin is a clear solution, while the others are cloudy,
white suspensions. Unless otherwise specified, lletin is of mixed beef-
pork origin. Additional information is available on request from Eli Lilly
and Company (Canada) Limited.
Indications: Replacement therapy in the treatment ot diabetes mellitus
which cannot be controlled satisfactorily by dietary regulation alone
Insulin is indicated in tbe treatment of juvenile-onset diabetes or
brittle diabetes The drug may also be indicated in maturity-onset
diabetes which cannot be controlled by diet alone In addition, insulin
must often be substituted for oral hypoglycemic therapy in patients
with maturity-onset diabetes complicated by acidosis. ketosis. diabetic
coma, major surgery, fever, severe trauma, infections, serious impair
ment of renal or hepatic functions, thyroid or other endocrine dys
functions, acute cardiac accidents, gangrene or Raynaud s disease,
and in pregnant women Combinations of insulin and oral hypoglycemic
drugs may be used when a patient is being transferred from insulin
to therapy with oral hypoglycemics Long term use combining insulin
and oral hypoglycemic therapy is seldom warranted,
May be used to improve appetite and increase weight in selected
cases of nondiabetic malnutrition
Insulin has been used as a test for the completeness of vagotomy
because of its stimulant effect on gastric secretion
Precautions and Adverse Effects: Every diabetic patient taking in
sulin should carry an identification card containing pertinent medical
information.
Any change of insulin should be made cautiously and only under
medical supervision. Changes in strength, purity, brand {manufacturer),
type iLente. NPH, Regular, etc.), and/or source of species [beet, pork,
or beef-pork) may result in the need for a change in dosage. It is not
possible to identify which patients will require a change in dose
Adjustment may be needed with the first dose or occur over a period
ot several weeks Be aware ot the possibility ot symptoms ot either
hypoglycemia or hyperglycemia
Tbe number and size of daily doses and the time of administra
tion, as well as diet and exercise, are problems that require direct
and continuous medical supervision Usually, tbe most satisfactory
injection time is before breakfast.
Prompt recognition and appropriate management of the com
plications ot insulin therapy are essential for the sate and effective
control of diabetes mellitus
Hypoglycemia may occur in any patient receiving insulin and
is most commonly manifested by hunger, nervousness, warmth and
sweating, and palpitations Patients also may experience headache,
confusion, drowsiness, fatigue, anxiety, blurred vision, diplopia, or
numbness of the lips. nose, or fingers Tbe clinical manifestations
of hypoglycemia can be masked by the concomitant administration
of propranolol or other beta adrenergic blockers.
Symptoms are likely to appear anytime when tbe blood sugar
concentration falls below 40 rug 100 m but may occur with a
sudden drop in blood glucose even when the value remains above
40 mg/100 ml.
If a patient is unable to take soluble carbohydrate or fruit juice
orally, hypoglycemia is treated with 10 to 20 g of dextrose in sterile
solution administered intravenously If glucose is unavailable. 1 mg
of glucagon may be given subcutaneously or intramuscularly every
20 minutes for 2 or 3 doses
Local and allergic reactions are commonly seen in patients
receiving insulin for the first time or when therapy is reinstituted
Local inflammatory responses also result from improper cleansing
of tbe skin, contamination of tbe injection site with alcohol, use of
an antiseptic containing impurities or accidental intracutaneous rather
than s.c. injection Local reactions that result from skin-sensitivity
phenomena usually subside spontaneously. Allergic urticaria, an-
gioedema. and anaphylactic reactions occur infrequently and may
sometimes be avoided by changing the species source of insulin.
Rarely, an intradermal or s.c. byposensitization procedure may be
required see standard texts for details).
It has been observed that areas of fat atrophy llipodystrophy)
resulting from previous administration ot older insulin preparations
are frequently restored to normal or near normal appearance by
repeated injection of current insulin preparations into, or adjacent
to, the areas of fat atrophy.
Visual disturbances in uncontrolled diabetes due to refractive
changes are reversed during the early phase of effective management.
However, since alteration in osmotic equilibrium between tbe lens and
ocular fluids may not stabilize for a few weeks after initiating therapy,
it is wise to postpone prescribing new corrective lenses tor 3 to
6 weeks
Hormones that tend to counteract the hypoglycemic effects of
insulin include growth hormone, corticotropin, gluco-corticoids. thyroid
hormone, and glucagon. Epinephrine not only inhibits tbe secretion of
insulin, but also stimulates glycogen breakdown to glucose. Thus, the
presence of such diseases as acromegaly. Gushing s syndrome,
hyperthyroidism and pheochromocytoma complicate the control of
diabetes.
The hypoglycemic action of insulin may also be antagonized by
diphenylhydantoin. Insulin s hypoglycemic action can be increased
in some patients by concomitant administration of anabolic steroids.
MAO inhibitors, guanethidine. alcohol, propranolol (masking effect),
or other drugs affecting beta adrenergic receptors, or by daily doses
of 1.5 to 6 g of salicylates
Insulin requirements can be increased, decreased, or unchanged
in patients receiving diuretics. Concomitant administration of oral
contraceptives can cause a decrease in glucose tolerance in diabetic
women possibly resulting in increased daily insulin requirements
Supplied: Each 10 cc multidose vial of Regular. PZI. NPH. Lente.
Semilente. or Ultralente contains: 100 units cc of the slated insulin
preparation, prepared from a mixture of insulin crystals extracted
from beef and pork pancreas.
Insulin should be stored in a cool place, preferably a refrigerator
Exposure to either freezing or high temperature should be avoided
No vial should be used in which tbe precipitate has become clumped
or granular in appearance or has formed a deposit of solid particles
on the wall of the vial. Vials in use should be kept cold and protected
from strong light and their contents used as continuously as practic
able. A partially empty vial should be discarded it it has not been
used for several weeks
Full product information available on request.
Eli Lilly and Company ICanada) Limited
Toronto. Ontario
SPHYGMOMANOMETERS
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stripe (irmly in place Nor
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with Caduceus or No 30
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ENGRAVED NAME-PINS IN 4 SMART STYLES -SIX DIFFERENT COLOURS..
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SEND TO eQUITY MEDICAL SUPPLY CO ALL ORDERS SHIPPED
P BOX 726-S. BROCKVILLE, ONT K6V 5V8 WITHIN 24 HOURS
Be sure to enclose your name and address
Mother
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letters
2 lines
letters
$248
S3 22
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i707
SORRY
C.OD & hiinr
for mstitutio
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Add 50* handling it *ess man SlO.
Total enclose!
Now available
for the Canadian diabetic
i
Dec DIN
N
S-ZINC
J
> CP-110
ILETIN
ZINC
INSULIN lY
100 UNIT* 1 "
x"H .. ^^^
Itj "" SHAKE CA*** 1 ^
<1^5TES
^
J
Insulin of
"Improved Single
purity*
it
cc DIN*
J I
Regular* Lente* NPH Semilente
Protamine Zinc Ultraiente
Differs from single peak insulin in that it has undergone additional steps of chromatographic purification, resulting in reduction of noninsulin substances
Eli Litiy and Company (Canada) Limited.
Toronto. Ontario
PUBLIC SAFTEY, PROFESSIONAL EXCELLENCE
CNA moves into the eighties,
politically active, professionally challenged
Opening ceremonies
"I declare this 1980 meeting of the
Canadian Nurses Association officially
open." President Helen Taylor s words
touched off an enthusiastic round of
welcoming speeches, telegrams of
congratulations and greetings from
representatives of various health-related
disciplines.
British Columbia s new (seven
months) Minister of Health, Rafe Mair,
congratulated RN s "individually and
collectively" on the representations
made to his government by nurses in his
province and on the proposals for
alternate forms of health care set out in
CNA s brief to the Hall Commission.
"The question of salaries for all health
care personnel will almost certainly
become a matter of debate in BC," he
predicted.
Canadian Verna Splane, second
vice-president of the International
Council of Nurses, brought greetings
from the ICN of which Canada has been
a member for 70 years.
American Nurses Association
president Barbara Nichols expressed her
happiness at being able to represent the
185,000-member sister association of
CNA and reminded Canadian nurses of
their shared roots in the Nurses
Associated Alumnae of the United
States and Canada, forerunner of CNA.
The president of the BC nurses
association, Stephany Grasset,
welcomed the more than 1000 nurses
attending the convention to
"Vancouver, Renaissance City, and a
fitting site for the renaissance of
nursing".
Kellogg Lecture
"Primary care: nursing" was the topic
chosen by Kellogg Lecturer Dr. Lea
Zwanger for her presentation on current
and emerging problems in health care.
To illustrate her points Dr. Zwanger
used the example of primary care units
"pivoted by a nurse" serving a kibbutz
in Israel.
"The health services of a
kibbutz," Dr. Zwanger pointed out,
"have all the essential attributes that
characterize primary care, ie.
accessibility, comprehensiveness,
coordination, continuity and
accountability."
Although practical problems a
kibbutz nurse faces are not necessarily
different from those encountered by
nurses in other primary care units,
Dr. Zwanger said, the dual role of
member of the kibbutz and nurse
imposes an emotional burden on these
primary care providers. "She must
resolve these ethical and practical
dilemmas alone."
18 Sot<tmhisr 10
CNA president Helen Taylor (left) with B.C. Minister of Health, Rafe Mair and Stephany Grasset,
RNABC president, welcomed CNA members and visitors to the 1980 meeting.
Dr. Zwanger touched briefly on
the nursing education situation in her
home country, describing current
efforts to put more emphasis on
"neglected population care". She said
that to date "we have failed to fit our
graduates with nursing abilities to care
for future patients needs or demands.
We know that a larger number of elderly
with multiple pathology and greater
dependence on nursing will need our
graduates. We know that complexities
of life will result in increasing anxiety
conditions and psychiatric illnesses. But,
so far, a drastic adaptation of nursing
education programs has not occurred."
"In our changing world we are
exposed to problems and challenges
unforeseen by our ancestors. We must
therefore develop, within ourselves, the
ability to adapt to scientific advances,
to changing trends in health care and to
a changing social order."
Dr. Lea Zwanger
Lorine Besel
Keynote address
"It is time to go back to our roots, to
enact, adhere to and derive our sense of
direction for practice, teaching and
research from caring," keynote speaker
Lorine Besel told a packed audience on
the opening morning of the convention.
Besel, who is director of nursing at the
Royal Victoria Hospital in Montreal and
a former member of the CNA Board of
Directors, explored the question of
"who will shape nursing in the
eighties?".
Her advice to nurses: "Forget the
mini-doctor kick . Let s establish our
own power base and bring forward our
own special contribution to patient/
client care."
"Decision-making that counts,"
according to Besel, "depends on
fostering the growth of an informed and
educated leadership power base that
will:
compete as peers on the
interdisciplinary health team
analyze health care delivery
problems and prepare recommendations
for change with objective supporting
data and
research the health care needs of
the communities and individuals we
Besel called on nurses to make
more use of their professional
associations in their efforts to obtain
monetary recognition of nursing s real
contribution to the health care
situation. "Professional nurses should
be paid more," she said. "In my view we
ought to be the highest salaried of all
health professionals - including
doctors. The rest are the true ancillary
services."
In the eighties, Besel warned, the
impact of current fiscal constraints
could result in violence becoming an
area of major health concern. "Wherever
and whenever you underpay, underrate,
undersupport, undervalue the persons
who are designated to care, you create a
situation where some humans may
abuse other humans." Battering
professional "care-takers" in the
hospital setting could, in time, become
as common as the battering
"care-takers" we already know about in
the community... mothers who take care
of children, even children who take care
of aged parents.
Robyn Tamblyn
SgrtmnberlMq 19
Monday luncheon speaker
Adaptation of the nurse practitioner
role to allow the nurse to live up to her
potential was the theme of mystery
luncheon speaker , Robyn Tamblyn.
Speaking from the vantage point of her
experience in the areas of nursing
research, education and practice,
Tamblyn addressed the problem of
specialization within the profession.
"Cost and confusion" are included in
the toll exacted from the patient who is
subjected to increasing layers of
specialization, she declared.
Tamblyn, whose specialty is
neurological and neurosurgical nursing,
has worked as neurological nurse in
team practice at McMaster University,
Hamilton, Ontario, where she is
currently a clinical lecturer.
It has been shown that the less
clearly nurses perceive nursing practice,
the more difficult it is for them to join
or participate in a professional
association and also the more negative
perceptions nurses hold of their
colleagues, the less they will want to
take part in their professional
association. If professional associations
accept these difficulties, Professor
Foucher suggests they must reassess what
they have to offer their membership.
To encourage nurses to join the
association or to consolidate
compulsory membership, members must
feel that they have some influence on
the direction of the association, they
themselves must be allowed to develop,
the association must provide advantages
that nurses currently value and the
Ginette Rodger chaired panel on labor relations and professional associations.
Labor movement vis-a-vis the
professional association
"Is dual allegiance to nursing union and
professional nursing association still
possible?" was the question Professor
Roland Foucher, labor analyst and
industrial psychologist, posed in his
address to CNA convention delegates.
"During the last decade we have been
witness to the separation of professional
associations and unions of nurses across
Canada for several reasons, many of
which are legal in nature and dependent
upon changes in values." Professor
Foucher feels that nursing unions are
somewhat unique due to their strongly
female membership, the values held
typically by women and the values
typically attributed to women and as
well by the initial reluctance and
frequent refusal of nurses to use the
strike approach (in a recent study of
Quebec nurses, 70 per cent of the
respondents considered devotion to
duty an essential feature of nursing).
Similarly professional nursing
associations differ from the norm as
human relationships are more highly
valued by members than success or
rewards.
professional association must be viewed
by its members as having some power to
improve the profession.
Aline Michaud, presidente, Federation
des syndicats professionels d infirmieres
et d infirmiers du Quebec:
"Can we say that the nursing union
movement is healthy? I believe that
currently our nursing unions are
choosing the road towards health, both
for themselves and for society . In the
future, the influence of the unionization
of nurses on the profession of nursing
will be dependent upon the orientation
and ideologies which develop. "
Louise Lemieux-Charles, project
coordinator, College of Nurses of
Ontario:
"Conflict is certain to arise when more
than one organization not only
represents the member s interests, but is
also required to ensure the public s
interests. A co-operative role must
therefore characterize our relationships
and we must not only identify through
discussion our areas of conflict but also
decide how we want to deal with them. "
The Great Debate
Continuing education:
mandatory vs. voluntary
Kathie Clark, education coordinator,
Registered Nurses Association of
Ontario, Toronto:
"Maintenance of competence is a
complex problem requiring a complex
solution. Mandatory continuing
education is a simplistic approach. Use
of this theory will drain our education
systems of vital resources to be used for
approval mechanisms and cumbersome
recording, a false sense of security will
be created among nurses and will
actually sidetrack the real issue of
competence. "
Norma Fulton, associate professor and
director, Continuing Nursing Education,
College of Nursing, University of
Saskatchewan:
"We cannot leave it to individuals to
choose whether they will involve
themselves in continuing education.
What about the nurse who doesn t
perceive a need? How can we be sure
that the individual nurse will select an
appropriate educational resource?
Mandatory continuing education allows
for accountability, the very essence of
professionalism. "
Rita Lussier, conseiller en formation
professionnelle Ordre des infirmieres
et infirmiers du Quebec, Montreal:
"The learning experience occurs within
an individual independent of outside
forces. Motivation requires one s own
consciousness and determination.
Mandatory continuing education ignores
the main components of freedom of
choice and liberty. "
Margaret Steed, professor and associate
dean, Faculty of Nursing, University of
Alberta, Edmonton:
"The real issue and thrust of nursing
practice is based on continuing
education, the assurance of
competency. With gallopping
technology, specialized aspects of
practice and care delivery, mandatory
continuing education has been shown to
be the only effective method of ensuring
safety to practice. This shouldn t be
called the Great Debate , it should be
known as the Dumb Argument . "
20 September 1980
The Canadian
CXL
o
o
u
UJ
0-
The health care system and Canadian
public policy
"We are currently experiencing and
witnessing the deterioration of what we
thought was one of the best health care
systems in the world," Dr. Malcolm
Taylor, professor of public policy,
Faculty of Administrative Services,
York University, Toronto, told
delegates to CNA s annual meeting. In
his presentation "The health care
system and Canadian public policy",
Dr. Taylor noted that "what is
happening in the health care system
seems also to be happening in the
hat our
e explained
sible realities
turn are an
ital
ently, as our
uj policies.
J are out of
^ d and policy
Z cause of the
1/1
ovinces,
aps,
nore
aylor
;am shoulders
sating new
with their
their goals.
urses will
eady
>ing others.
l/l
C
UJ
Q
Reaction panel
Judy Eraser, occupational health nurse,
Winnipeg, Manitoba:
"I feel that there remains one major
flaw in the health care system, as the
largest portion of health care dollars are
still being spent on the treatment of the
ill and injured, neglecting the area of
prevention, with the most neglected
area for the maintenance and promotion
of health being in the workplace. "
Jessica Ryan, head nurse, pediatric
service, Chaleur General Hospital,
Bathurst, N.B.:
"There are too many people in the
institutions we call hospitals; there are
too few personalized regional and
community health care centers in our
nation and far too many
depersonalized and dehumanized
buildings.
"I believe that too many children
enter hospital; too many children stay
in hospital too long and are thus
traumatized by this experience, and too
many children are admitted over and
over again for conditions which could
and should be cared for by mothers at
home.
"People have to be taught,
starting in kindergarten, how to look
after their bodies. If everybody in
Canada washed their hands nine or
ten times a day, had a bath every day
and washed their hair once a week I am
convinced our health costs would be
cut way down. "
Shelley Kremer, general duty nurse,
B.C. Cancer Control Clinic,
Vancouver, B.C.:
"/ think that the health care system is
a little like Christopher Columbus
who set out not knowing where he was
going, arrived net knowing where he
was, returned not knowing where he
had been and all on someone else s
money.
"Although demands by the public
and health care workers may seem
excessive, are they really? It is really
only acute care that is out of bounds.
Why didn t our architects of health
insurance realize that as the population
aged, so would acute care demands
increase. This is an epidemiological
principle today just as it was in 1958. "
Phyllis Barrett, executive secretary,
Association of Registered Nurses of
Newfoundland:
"We know where we want to go.
Nurses have declared for change and
reform. We have declared with
confidence (in our brief to the Hall
Commission) that we are capable of
putting health into health care. We
need change. We need reform and we,
the nurses of Canada, can do this. "
September 1980 21
Monday luncheon speaker
Adaptation of the nurse practitioner
role to allow the nurse to live up to her
potential was the theme of mystery
luncheon speaker , Robyn Tamblyn.
Speaking from the vantage point of her
experience in the areas of nursing
research, education and practice,
Tamblyn addressed the problem of
specialization within the profession.
"Cost and confusion" are included in
the toll exacted from the patient who is
subjected to increasing layers of
specialization, she declared.
Tamblyn, whose specialty is
neurological and neurosurgical nursing,
has worked as neurological nurse in
team practice at McMaster University,
Hamilton, Ontario, where she is
currently a clinical lecturer.
It has been shown that the less
clearly nurses perceive nursing practice,
the more difficult it is for them to join
or participate in a professional
association and also the more negative
perceptions nurses hold of their
colleagues, the less they will want to
take part in their professional
association. If professional associations
accept these difficulties, Professor
Foucher suggests they must reassess what
they have to offer their membership.
To encourage nurses to join the
association or to consolidate
compulsory membership, members must
feel that they have some influence on
the direction of the association, they
themselves must be allowed to develop,
the association must provide advantages
that nurses currently value and the
Ginette Rodger chaired panel on labor relations and professional associations.
Labor movement vis-a-vis the
professional association
"Is dual allegiance to nursing union and
professional nursing association still
possible?" was the question Professor
Roland Foucher, labor analyst and
industrial psychologist, posed in his
address to CNA convention delegates.
"During the last decade we have been
witness to the separation of professional
associations and unions of nurses across
Canada for several reasons, many of
which are legal in nature and dependent
upon changes in values." Professor
Foucher feels that nursing unions are
somewhat unique due to their strongly
female membership, the values held
typically by women and the values
typically attributed to women and as
well by the initial reluctance and
frequent refusal of nurses to use the
strike approach (in a recent study of
Quebec nurses, 70 per cent of the
respondents considered devotion to
duty an essential feature of nursing).
Similarly professional nursing
associations differ from the norm as
human relationships are more highly
valued by members than success or
rewards.
professional association must be viewed
by its members as having some power to
improve the profession.
Aline Michaud, presidente, Federation
des syndicats professionels d infirmieres
et d infirmiers du Quebec:
"Can we say that the nursing union
movement is healthy? I believe that
currently our nursing unions are
choosing the road towards health, both
for themselves and for society. In the
future, the influence of the unionization
of nurses on the profession of nursing
will be dependent upon the orientation
and ideologies which develop. "
Louise Lemieux-Charles, project
coordinator, College of Nurses of
Ontario:
"Conflict is certain to arise when more
than one organization not only
represents the member s interests, but is
also required to ensure the public s
interests. A co-operative role must
therefore characterize our relationships
and we must not only identify through
discussion our areas of conflict but also
decide how we want to deal with them. "
The Great Debate
Continuing education:
mandatory vs. voluntary
Kathie Clark, education coordinator,
Registered Nurses Association of
Ontario, Toronto:
"Maintenance of competence is a
complex problem requiring a complex
solution. Mandatory continuing
education is a simplistic approach. Use
of this theory will drain our education
systems of vital resources to be used for
approval mechanisms and cumbersome
recording, a false sense of security will
be created among nurses and will
actually sidetrack the real issue of
competence. "
Norma Fulton, associate professor and
director, Cor i:
College of N
Saskatchewa
"We cannot ,
choose whet,
themselves ir
What about i
perceive a ne
that the indi. f^
appropriate t ^.
Mandatory c ~Z_
for accounta 50 ^
professionali, CP
-a
m
O
m
73
m
O
70
Rita Lussier,
professionne
et infirmiers
"The learnin,
an individual
forces. Motiv
consciousnes
Mandatory c<
the main con
choice and li
Margaret Ste- , ,
dean, Faculty of Nursing, University of
Alberta, Edmonton:
"The real issue and thrust of nursing
practice is based on continuing
education, the assurance of
competency. With gallopping
technology, specialized aspects of
practice and care delivery, mandatory
continuing education has been shown to
be the only effective method of ensuring
safety to practice. This shouldn t be
called the Great Debate , it should be
known as the Dumb Argument . "
20 Sp(mbei 1980
The Canadian NurA
The health care system and Canadian
public policy
"We are currently experiencing and
witnessing the deterioration of what we
thought was one of the best health care
systems in the world," Dr. Malcolm
Taylor, professor of public policy,
Faculty of Administrative Services,
York University, Toronto, told
delegates to CNA s annual meeting. In
his presentation "The health care
system and Canadian public policy",
Dr. Taylor noted that "what is
happening in the health care system
seems also to be happening in the
education and welfare systems, all of
the humanitarian systems that our
society has undertaken." He explained
that public programs are visible realities
of public policies which in turn are an
expression of our fundamental
underlying values. Consequently, as our
values change, so must our policies.
Just now, "the times are out of
joint, the mood has changed and policy
making is more difficult because of the
increasing powers of the provinces,
more powerful interest groups,
budgetary constraints and more
prevalent sexualism." Dr. Taylor
suggested that the health team shoulders
a major responsibility in creating new
policies by inspiring others with their
idealism and dedication to their goals.
Specifically, he feels that nurses will
respond since they have already
dedicated their lives to helping others.
Reaction panel
Judy Eraser, occupational health nurse,
Winnipeg, Manitoba:
"I feel that there remains one major
flaw in the health care system, as the
largest portion of health care dollars are
still being spent on the treatment of the
ill and injured, neglecting the area of
prevention, with the most neglected
area for the maintenance and promotion
of health being in the workplace. "
Jessica Ryan, head nurse, pediatric
service, Chaleur General Hospital,
Bathurst, N.B.:
"There are too many people in the
institutions we call hospitals: there are
too few personalized regional and
community health care centers in our
nation and far too many
depersonalized and dehumanized
buildings.
"I believe that too many children
enter hospital; too many children stay
in hospital too long and are thus
traumatized by this experience, and too
many children are admitted over and
over again for conditions which could
and should be cared for by mothers at
home.
"People have to be taught,
starting in kindergarten, how to look
after their bodies. If everybody in
Canada washed their hands nine or
ten times a day, had a bath every day
and washed their hair once a week I am
convinced our health costs would be
cut wav down. "
Shelley Kremer, general duty nurse,
B.C. Cancer Control Clinic,
Vancouver, B.C.:
"/ think that the health care system is
a little like Christopher Columbus
who set out not knowing where he was
going, arrived not knowing where he
was, returned not knowing where he
had been and all on someone else s
money.
"Although demands by the public
and health care workers may seem
excessive, are they really? It is really
only acute care that is out of bounds.
Why didn t our architects of health
insurance realize that as the population
aged, so would acute care demands
increase. This is an epidemiological
principle today just as it was in 1958. "
Phyllis Barrett, executive secretary,
Association of Registered Nurses of
Newfoundland:
"We know where we want to go.
Nurses have declared for change and
reform. We have declared with
confidence (in our brief to the Hall
Commission) that we are capable of
putting health into health care. We
need change. We need reform and we,
the nurses of Canada, can do this. "
September 1980 21
Shirley Stinson
Sue Rothwell
Jessica Ryan
22 Seotmbr 1980
\
Meet your new executive!
A new slate of officers is at the helm of
your professional association following
voting at the 1980 annual convention in
Vancouver. In charge is president
Shirley M. Stinson, professor in the
Faculty of Nursing and Division of
Health Services Administration at the
University of Alberta, assisted by
president elect Helen Glass, coordinator
of the Graduate Program in Nursing at
the University of Manitoba School of
Nursing.
Three familiar faces from the
previous biennium are those of second
vice president Myrtle E. Crawford,
assistant dean, College of Nursing,
University of Saskatchewan ;
member-at-large for nursing research,
Odile Larose, director of the Nursing
Sector of 1 Ordre des infirmieres et
infirmiers du Quebec; and
member-at-large for nursing practice,
Jessica Ryan, head nurse, Chaleur
General Hospital, Bathurst, N.B. All are
serving their second term in these
offices.
Other officers are: first vice
president Sue Rothwell, director of
nursing and assistant professor at the
Cancer Control Agency of British
Columbia; member-at-large for nursing
administration, Mary Murphy,
vice president, Nursing, Vancouver
General Hospital; member-at-large
for nursing education, Patricia
Stanojevic, staff development officer,
George Brown College, Toronto; and
member-at-large for social and economic
welfare, Winnifred E. Kettleson,
employment relations officer, Nova
Scotia Nurses Union, Halifax.
Odile Larose
TJmCanaillan Nurse
Helen Glass
Myrtle Crawford
Patricia Stanojevic
Winnifred Kettleson
In a warm and sincere tribute to all of
those she worked with both nurses
and non-nurses - during her 1 7-year
career as executive director of Canada s
national nursing organization,
Helen K. Mussallem acknowledged the
help and assistance of:
all of the staff at CNA House
her family who taught her "what
dedication is all about"
her teachers and her students who
"taught me more than I ever taught
them"
colleagues who directed her
attention to overseas assignments and
co-workers in other disciplines,
including those who "disputed the
passage".
She paid tribute, too, to "my
many friends from Cape Race to
Nootka Sound", the nurses who
through their provincial association are
members of CNA, and recalled
humorous incidents that had occurred
in each of these provinces during her
visits there.
"There are many problems, many
responsibilities still before you," she
said, pointing out that "we can no
longer enjoy the luxury of delay."
" Decisions are not forever,
however. What is forever is intellectual
honesty, the courage of your
convictions and the results and
satisfaction you obtain from your
labors."
President Helen Taylor, who
presented Dr. Mussallem with CNA s
"Nurse of Honor" award, reserved for
nurses who have made an outstanding
contribution to nursing, reminded the
audience of some of the many other
awards already bestowed on
Helen Mussallem. These include:
Officer of the Order of Canada
The Canadian Red Cross Citation
award for Distinguished
Achievement in Research and
Scholarship, Columbia University
Commander, Order of St. John
Honorary Fellow, Royal College
of Nursing (U.K.)
Queen s Silver Jubilee Medal,
1977
Medal for Distinguished Service,
Teacher s College, Columbia University.
She quoted also from the citation
Dr. Mussallem received last year from
the Royal College of Nurses that
described her as "Canada s most
distinguished nurse in her generation."
Other notable achievements during this
time include: establishment of the CNA
library and archives, publication of
national nursing statistics, construction
of CNA House, appointment of two
full-time editors for the CNA journals,
and admittance of the Northwest
Territories Registered Nurses
Association.
THE END OF AN ERA AT CNA
Tribute to Helen K. Mussallem
Helen K. Mussallem is awarded the Medal of Service of the Order of Canada with
actor Lome Greene in October 1969.
Dr. Mussallem was the first nurse and the first Canadian to receive a Medal for
Distinguished Service from Teacher s College, Columbia University, in New York
City. Dr. Mussallem, who received her PhD in education from Columbia Lf, was
presented with the award by university president Lawrence Cremin in May, 1979.
With Her Royal Highness, Princess Margaret and Sir Michael Coleman last April
at Leeds Castle in Kent, England. "I had the gorgeous Walnut Bedroom with a
four poster bed, slept in by many queens, "Mussallem reminisces. She was a
participant in the United Kingdom Seminar for Fellows of the Royal College of
Nursing.
ThA r jnc*iA Nur
CNA directors finish 1978 1980
business, prepare for newbiennium
The last meeting of CNA directors elected for the 1978-80 biennium
took place in Vancouver immediately preceeding opening of the
association s annual meeting and convention. Although some agenda
items will be carried over for action during the coming biennium, one
major 1978-80 project, "A definition of nursing practice and
standards for nursing practice", was completed on schedule and
accepted by directors as "an official document of national
significance to be utilized by the various jurisdictions as they see fit."
An implementation and interpretation phase will begin immediately.
Action on several items was postponed
or deferred by directors until after
election of the new slate of officers for
the coming biennium. Among the
questions this board will deal with are:
further study of a proposed
multiple-step fee increase
editing and revision prior to
re-issuing the association s official
statements on nursing and health-related
issues
a decision on an application for
affiliate membership in CNA by the
Canadian Association of Practical
and Nursing Assistants.
In response to concerns expressed
by members, directors voted to
re-examine one section of the recently
released CNA Code of Ethics - the
section containing reference to "the
withdrawal of services", dealing with
"Caring and the healing community".
As a result, a committee consisting of
five nurses, headed by former CNA
member-at-large for social and economic
welfare, Linda Gosselin, was constituted
to develop a substitute section. The
committee will present its findings to
the Spring meeting of the board of
directors. Committee members, in
addition to the chairman, are: Judith
Lougheed, president, Association of
Nurses of Prince Edward Island;
Stephany Grasset, president, Registered
Nurses Association of British Columbia;
Mary Ann Lamb, RN, of the University
of Alberta and Sunny Arrojado,
president, Manitoba Organization of
Nursing Associations (MONA).
Directors approved the report of
two selection committees, one naming
the next executive director of CNA
(see page 24), the other naming
members of an editorial advisory
committee which will, under its terms
of reference, "provide a systematic and
ongoing review of the association s
publications, The Canadian Nurse and
L infirmiere canadienne. Committee
members are: Jerry Miller,
communications officer, Labor
Relations Division, RNABC
(British Columbia and Northwest
Territories); Beverley Pitfield, RN,
Gravelbourg, Sask. (Western Provinces);
Kate Fulton, RN, (Ontario); Florita
Vialle-Soubranne, Consultant,
professional inspection division, Order
of Nurses of Quebec (Quebec) ; and
George Bergeron, communications
officer, NBARN, (Atlantic Region).
Directors also approved a list of
convention sites for biennial meetings
over the next decade. Places and dates
are as follows: St. John s, Nfld., 1982;
Quebec City, 1984;Regina, 1986;
Charlottetown, 1988 and Banff,
Alberta, 1990.
Directors also heard a progress
report on "Operation Bootstrap", a
$5.2 million, multi- faceted, long term
project intended to support and foster
the development of doctoral
preparation of nursing in Canada
(see The Canadian Nurse, January,
1979). President-elect Shirley Stinson,
in her role of liaison person between the
CNA Board of Directors and Operation
Bootstrap Steering Committee, reported
on progress in the committee s
continuing efforts to obtain funding for
the project from the W.K. Kellogg
Foundation. A final decision is expected
shortly.
Outgoing president
Standards, quality of nursing practice,
accreditation of nursing education
programs and development of a code of
ethics for Canadian nurses were
signalled out by retiring president
Helen Taylor as the most significant
of the priorities under review by CNA
during the past biennium.
Taylor, who is director of
nursing at the Montreal General
Hospital, was addressing delegates at the
conclusion of her two-year term of
office. "Nurses of tomorrow must be
steeped in the visions of the future...
prepared for a burgeoning work world
of science and technology. We will need
to learn how to assess the need for
specific services that directly affect
health and we will require the necessary
skills to influence community and
national leaders with the aim of
promoting healthy environments."
Taylor noted that quality of care
in practice settings should be our
greatest concern both today and
tomorrow. She reminded nurses in the
audience that adoption of standards
does not guarantee that high quality
care is, in fact, being provided. "The
individual nurse must assume the
greatest proportion of responsibility
in adopting and applying these nursing
standards in her daily practice."
The CNA Code of Ethics, Taylor
observed, "speaks to the relationship of
nurses to both clients and the
community. It goes beyond what the
law states nurses must do to help us
identify what we should do. It
highlights areas of accountability that
we choose to accept because of
personal integrity."
Standards for nursing education
and practice, a program of
accreditation for nursing education
programs, development of resources and
facilities enabling nurses to be prepared
at the doctorate level, as well as the
code of ethics, and a proposed national
plan for continuing education, Taylor
said, are all issues with a common
purpose. "These are tools to enable us
to provide the highest possible quality
of nursing to our patients in an already
complex and rapidly changing society."
Incoming president
"More and more, I believe that
collective professional excellence is
needed in order to effect necessary
changes within the health care system,
as presently the system is being shaped
by forces which themselves are of a
collective nature, forces which reach
well beyond the grasp of any of us as
individuals." Dr. Shirley Stinson, newly
elected president of the Canadian
Nurses Association in her inaugural
address to membership, cited the need
for strong, relevant professional
organization at the international,
national, district and local levels. "I
believe CNA can play a vital role at the
national level and a vital role in
strengthening professional organization
at all of the other levels."
Dr. Stinson feels that the
questions facing CNA today are
essentially the same as they were 72
years ago when CNA was founded.
However, the answers have changed
radically. Whereas in earlier days, CNA
focused on developing a collective
nursing identity, evolving standards for
nursing education, and acting as a
clearing house for ideas, the timing and
ways in which CNA speaks for nursing
have changed. "CNA now responds
more quickly to issues rather than
waiting for a general consensus. Where
CNA s role was primarily reactive in the
past, it is now becoming proactive,
putting forth new ideas, being in the
vanguard rather than the rear guard,"
Dr. Stinson says, pointing out the ever
increasing need for CNA to be strong
and relevant.
"Over the next two years CNA
must make many informed choices
about some very vital questions. No
matter how thorny the questions
may be, CNA cannot and should not try
to be all things to all people. We should
use CNA only for those things that are
of common interest to all member
associations and that are of true
significance to the betterment of the
public interest and the development of
the profession as a whole."
Dr. Stinson, who is a professor in
the Faculty of Nursing and Division of
Health Services Administration at the
University of Alberta, was president
elect of CNA during the last biennium
and, before that, first vice-president
(1976-78) and member-at-large for
nursing education (1974-76). She is a
graduate of the University of Alberta
(BScN), University of Minnesota (MNA)
and Columbia University (EdD). She
was project director for the Kellogg
National Seminar on Doctoral
Preparation for Canadian Nurses (1978)
and since then has directed plans for
Operation Bootstrap, a program
intended to support and foster doctoral
preparation for nurses in Canada.
Penny Stiver and Alice Girard, both founding members of CNF, attended the
annual meeting. Behind them is the Virginia Star quilt raffled by CNF.
has increased over the past three years,
it currently stands at only 535 as
compared to 1441 in 1970 (or 1311 in
1969).
The Virginia Lindabury fellowship
is now a reality and will be offered in
perpetuity as donations already have
surpassed the $30,000 mark. The first
of the yearly scholarships will be
awarded next year. Contributions to the
fund have come from both individuals
and associations from across the
country. At the time of the meeting,
Jocelyn Hezekiah, on behalf of the
Registered Nurses Association of
Ontario presented CNF with a cheque
from the RNAO, along with a
photograph of the former editor of
The Canadian Nurse.
A new board of directors was
elected to serve the upcoming two-year
term of office. Fabienne Fortin,
Diane Pechuilis, Margaret McLean,
Marvelle McPherson and Margaret
Arklie will determine the executive
structure at their first meeting.
A year-long search for the next chief
officer of this country s national nursing
organization ended in June when CNA
directors approved the appointment of
Ginette Rodger to the position of
executive director. Rodger, who has
been director of nursing at Notre Dame
Hospital in Montreal for the past seven
years, served as member-at-large for
nursing administration on the 1978-80
CNA board of directors. She has a
baccalaureate degree in nursing from the
University of Ottawa and a master s
degree in nursing administration from
the University of Montreal, as well as
wide experience in nursing in a variety
of hospital settings. She is active on
professional associations at both the
national and provincial level. Rodger
will assume her duties on February 1 ,
1981.
Canadian Nurses Foundation
At this year s meeting of the Canadian
Nurses Foundation, president Louise
Tod issued a challenge to membership, a
challenge of increasing the General
Trust Fund to one million dollars by
1982. "The interest accrued from such a
sum would support an administrative
structure and a healthy and stable
scholarship program," Tod said.
However, to achieve this goal CNF will
have to continue to increase Canadian
nurses awareness of and commitment
to the foundation. While membership
From sea to shining sea, St. John s,
Nfld. in 1982! Marg McLean, retiring
ARNN president, invited CNA members
to their next biennium.
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
RESOLUTIONS
Nursing administration
Resolved that the CNA publicly
reaffirm its belief that the executive
responsible for the department of
nursing shall be an educationally
qualified registered nurse who shall be a
member of the senior hospital
administrative staff, reporting directly
to the chief executive officer.
Resolved that the CNA request the
Canadian Council on Hospital
Accreditation to emphasize the above
standard which is stated in Standard
Number Two under Nursing Services
section of the Guide to Hospital
Accreditation 1 977, as a basis for rating
nursing departments.
Resolved that CNA hold a national
forum for nurse administrators on
powers and responsibilities related to
nursing management during the 1980-82
biennium.
Resolved that CNA study the issues
inherent in the education of nurses for
nursing administration.
Entry to practice
Resolved that the CNA establish as a
priority for the next biennium the
development of a statement concerning
the minimal educational requirement
for entry into the practice of nursing in
Canada.
Continuing education
Resolved that the board of directors of
the 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 1980-82 biennium.
Certification of specialists
Resolved that the CNA study the
feasibility of developing examinations
for certification in major nursing
specialties.
Spirited debate and informed participation marked many of the
sessions of this year s CNA convention. At no time was this interest
more pronounced than during discussion of the resolutions. Fifteen
resolutions, plus two motions, were voted on; all but two were
approved. Judging by the content of these resolutions, a short list
of contemporary nursing concerns in Canada would begin with the
following five topics:
nursing administration
entry to practice
continuing education
certification of specialists
independent practice.
The resolutions dealing with these concerns, like all resolutions
approved by the voting delegates, will be taken under advisement by
CNA s newly elected executive committee and directors of the
association. Their action in implementing the resolutions will form
the basis for association programs, projects and priorities over the
next biennium. The resolutions are as follows:
Independent practice
Resolved that the CNA go on record as
favoring the concept that independent
nursing services provided to clients by
professional nurses be eligible for
compensatory coverage in provincial
health care plans.
Other resolutions
Members also directed the association to:
sponsor a second national forum
on nursing education with a focus on
clinical aspects of nursing education
express the concern of its
members over infant formula promotion
practices in the Third World by
supporting a boycott of these products
promote use of the Health and
Welfare Canada awareness kit,
"Breastfeeding", as a teaching tool for
RN s
promote efforts to establish an
Occupational Health Nurse consultant
service at the federal level
lobby to have dangerous
household chemicals packaged in
child-resistant containers
support the National Council of
Women of Canada in their efforts to
have the Income Tax Act amended to
allow wage earners to deduct from their
taxable income money spent on
continuing education courses for
non-earning spouses.
Fee structure
A motion that the association set
up a working party to "study and
develop a plan with regard to the issues
of equitable representation and the
annual unit fee of member associations
in CNA" was also approved. The motion
followed discussion of a resolution
urging that the "ceiling" on fees paid by
any one provincial/territorial association
member be revised downward from the
current maximum of one third of CNA
fee income for the previous year, to a
maximum of one fifth of that total.
The resolution, which originated
with 1 Ordre des infirmieres et infirmiers
du Quebec, pointed out that the annual
OIIQ contribution to the national
association budget has reached the
present ceiling three times in the past
five years and requested that "its
financial contributions be more
proportionate to its true representation
within CNA." Membership in the OIIQ
now stands at close to 48,000; total
CNA membership is approximately
127,700.*
All convention photos by B.C. Jennings,
Vancouver.
Books for a new
decade of nursing.
Tilkian & Conover
UNDERSTANDING HEART
SOUNDS AND MURMURS
Here s an exciting package that provides a basic familiarity with
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. Tilkian, MD. FACC. Asst Clinical Prof of Medicine (Cardio
logy). Univ of California School of Medicine, Los Angeles; and Mary
Boudreau Conover, RN. BSN. Ed Instructor of Critical Care Nursing
and Advanced Arrhythmia Workshops, West Hills Hospital and West
Park Hospital, Canoga Park. CA. Book only: 122pp. Illustd. Soft cover
S120O April 1979 Order #8869-1. Package: $22 75 Order #8878-0.
Grant
HANDBOOK OF TOTAL PARENTERAL NUTRITION
A manual of safe and effective administration of total parenteral
nutrition, Grant provides easy reading by not going into exces
sive detail with basic research and laboratory investigational
material. Coverage spans from initial patient evaluation to
recognition and avoidance of metabolic and technical compli
cations. Every major advance is included.
By John P. Grant, MD. Director. Nutritional Support Service. Asst.
Prof, of Surgery. Duke Univ Medical Center, Durham, NC. 197 pp
Illustd. $21.00. Jan. 1980 Order #4210-1.
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING:
A PSYCHOPHYSIOLOGIC APPROACH
2nd Edition
Updated, revised, and expanded the new Second Edition of
MEDICAL-SURGICAL NURSING: A Psychophysiologic
Approach keeps pace with the needs of today s nurse ... to supply
nurses with the knowledge and confidence to undertake ever-
increasing responsibilities. Concise, yet comprehensive;
MEDICAL-SURGICAL NURSING can be used in conjunction
with or independently from Sorensen & Luckmann s BASIC
NURSING. For the fundamentals, turn to, BASIC NURSING; for
more advanced principles MEDICAL-SURGICAL NURSING.
ByJoan Luckmann. RN, BS. MA, Formerly. Instructor of Nursing,
University of Washington. Highiine College. Seattle. Oakland City
College, and Providence Hospital College of Nursing. Oakland, CA;
and Karen Creason Sorensen. RN. BS, MN, Formerly. Lecturer in
Nursing. University of Washington; Formerly, Instructor of Nursing.
Highiine College; Formerly. Nurse Clinical Specialist, University
Hospital and Firland Sanatorium, Seattle, WA. 2276 pp 81 7 ill.
$4080 Order #5806-7.
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 com
ments 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. Prof of Pediatrics, Case Western Reserve
University School of Medicine and University Hospitals (Rainbow
Babies and Children s Hospital). Cleveland. OH; and Avroy A.
Fanarotf, MB(RAND). MRCPE. Assoc Prof, of Pediatrics, Case
Western Reserve University School of Medicine; Director of the
Neonatal Nurseries. University Hospital (Rainbow Babies and
Children s Hospital). Cleveland. OH 437 pp. Illustd. $26 40 July 1979.
Order #5478-9.
Patterson, Gustafson & Sheridan
FALCONER S CURRENT DRUG HANDBOOK
1980-1982
Up-to-date, quick reference to more than 1500 common drugs.
Emphasizes drug interactions and nursing implications.
Also lists generic and major trade names, sources, dosages,
major and minor uses, action and fate, toxicity, and contra
indications.
All entries based on latest available information.
Emphasizes vital information that can quickly be put to use
inaclinical situation.
Listed in a columnar format for easy accessibility.
Organized according to categories of usage.
Includes a detailed index.
By H. Robert Patterson. BS. MS. Pharm D. Prof of Microbiology and
Biology. San Jose State Univ . San Jose, CA; Edward A. Gustafson, BS.
Pharm D. Pharmacist, Valley Medical Center, San Jose. CA, and
Eleanor Sheridan, RN, BSN. MSN! Asst Prof.. College of Nursing.
Arizona State Univ., Tempe, AZ. 374 pp. Soft cover. $1 3.1 5 April 1 980.
Order #3522-5.
Phillips & Feeney
THE CARDIAC RHYTHMS
Second Edition
For clear-cut instruction in the precise interpretation of cardiac
rhythms this up-to-date revision is the book to turn to. The
authors discuss basic anatomic and physiologic aspects, as well
as more advanced topics such as action potentials and bundle
branch blocks. You ll find the text s workbook format and periodic
self-evaluation tests ideal for self-instruction. Over 700 illustra
tionsmany of them EKGs taken directly from the cardiac
monitor help clarify fine points of interpretation.
By Raymond E. Phillips. MD. FACP. Senior Attending Physician.
Phelps Memorial Hospital. North Tarrytown. NY; Clinical Asst. Prof
of Medicine. New York Medical College, Valhalla, NY; Consultant in
Cardiovascular Medicine, Veterans Administration Medical Center.
Castle Point. NY; Exercise Cardiologist. Cardiac Rehabilitation Center.
Montefiore Hospital and Medical Center. The Bronx, NY; and Mary
Kay Feeney. RN, MN. CCRN. Critical Care Specialist, St. Joseph s
Hospital; formerly Clinical Instructor. ICU/CCU, Columbia Hospital
School of Nursing, Milwaukee, Wisconsin 419 pp. 744 ill. Soft cover.
62035 Order #7221-3. ^^
W.B. Sounders Company
1 Goldthorne Ave., Toronto, Ontario M8Z 5T9, Canada
Send on no-risk. 30-day approval
~ Tilkian pkg. 8878-0
Z book only 8869-1
Z Grant 4210-2
Z Luckmann 5806-7
= KI3US5478-9
Z Patterson =3572-5
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.r,.rfl. U. ....
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Op-Site for extra protection, as long as
there is risk of skin irritation.
1. Winter, G.D.: Healing of Skin Wounds and the Influence
of Dressings on the Repair Process Surgical Dressings
and Wound Healing, Harkiss. K.J. (Ed.), Bradford University
Press. 1971.
It s easy to learn the Op-Site decubitus care
technique. For a free colour brochure, just fill
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The single most important interpersonal relationship within a hospital staff is between the nurse and the nurse-
manager. Management nurses who establish a healthy relationship with their staff can resolve many problems
before they reach the formal grievance stage and in turn increase productivity.
Who are these nurse-managers and what is their role? This is the focus of part two of "Nurses unions,
professional associations and YOU".
Nurses unions, professional associations and YOU
Part 2
The role of the nurse-manager in labor relations
The level or group of nurses who are to
be considered nurse-managers is
established at the time of certification
of the bargaining unit. During the
certification process, the labor relations
board determines who is not eligible for
Inclusion in the bargaining unit, based
on their managerial or confidential
functions. Although specific criteria
may differ from province to province as
well as within each province, all labor
relations boards consider the employee
in light of his or her authority to
employ, suspend or discharge other
employees in the unit, either directly or
by effective recommendations, his or
her authority to discipline employees
and his or her position as it relates to
confidentiality in the labor relations
process and involvement in the
grievance procedure.
Although employers often try to
have as many nurses as possible
excluded from the bargaining unit on
the basis that their roles are managerial
in function, the majority of nurses fight
to remain part of the unit, since once
they are excluded, they lose the legal
protection and job security of the
collective agreement.
Nurse-managers are the
implementors of the collective
agreement within the work-setting.
However, with the exception of the
director of nursing, few nurse-managers
ever participate in the negotiation
process. As it is at the bargaining table
that the intent and implementation
of the contract clauses are discussed and
agreed upon, the members of the
negotiating committee must provide a
complete interpretation of the contract
to the nurse-managers. This additional
knowledge allows for more efficient and
trouble-free application of the contract.
Working within a contract
Knowledge of discussions at the
bargaining table must be accompanied
by a thorough knowledge of the
contract if day to day problems are to
be resolved quickly. This also includes
encouraging staff to become familiar
with the contract and its contents. For
the nurse-manager who is feeling
uncomfortable with her role in coping
Glenna Rowsell
with a contract and a bargaining unit,
seminars and workshops on labor
relations may help in alleviating her
problems and assist her in becoming
more skillful in her role.
The nurse-manager plays a major
role in handling day-to-day grievances.
This involves developing an
understanding of the employees as well
as of the collective agreement under
which they work. A genuine interest in
the employees allows the nurse-manager
to understand their needs more clearly
and enables her to more readily identify
the root of their problems.
Grievance management
Grievances must be presented in the
manner outlined in the collective
agreement. The specific grievance
procedure involves a number of steps
and a stipulated time frame. Grievances
may fall in one of three categories:
failure to carry out the terms of the
agreement, a discipline grievance, or a
general application grievance which has
an impact on more than one employee.
Since a more harmonious
union-management relationship can be
anticipated when grievances are resolved
in the early stages of the grievance
procedure, management nurses must not
be reluctant to become involved in
resolving the problem. 1 Although there
is no specific method for eliminating
grievances, there are many basic
guidelines which can minimize.their
number, frequency and magnitude.
Some stumbling blocks to
grievance handling include: 2
no plan of action - intuition has
no place in grievance handling, lack of
an identified plan of action may cause
more difficulties than already exist.
less than complete knowledge of
the agreement nurse-managers who
are not fully aware of the contents of
the union contract or what constitutes
hospital policy should not pretend to
be experts; rather than give the wrong
interpretation, check the facts.
failure to investigate - analyzing
the grievance requires investigation of
the situation; deciding without
investigation is a disastrous route.
failure to interpret facts correctly
subjective interpretations are counter
productive, analysis of a specific
grievance with unique characteristics
requires the nurse-manager to have an
open mind.
reliance on pat solutions
stereotyped handling of grievances can
be disastrous as yesterday s solutions
may not adequately solve today s
problems. Effective managers check
precedents but do not allow previous
solutions to interfere in a unique
situation requiring a unique solution.
failure to sell a decision -
explaining the reason behind the
decision is just as important as the
decision-making. A sympathetic "no"
can be more productive than a harsh
"yes".
procrastination festering
grievances are one of the chief causes of
confrontation; employees have long
memories about injustices, real or
imagined.
failure to anticipate problems
effective nurse-managers anticipate
resistance and concerns and mitigate
against such reactions with appropriate
communication and behavior.
Management nurses who establish
a healthy relationship with their staff
can resolve many grievances before they
reach the formal grievance stage and in
turn increase productivity. A little bit of
attention initially when problems are
small and frequently easily resolved,
goes further than a great deal of hurried,
stressful and pressured attention later
on. Most complaints can be
satisfactorily resolved by management
before they become formal grievances.
If a grievance is not settled at
the final stage of the grievance
procedure, it goes to rights arbitration
or adjudication, where a neutral party
decides the facts of the case. The
arbitrator or arbitration board s award
is final and binding on both parties. If
the grievance is an alleged violation of
the agreement by the employer, it is
the responsibility of the union to prove
that the employer violated a section(s)
of the contract. Similarly in the case of
suspension or dismissal of an employee,
the employer must prove that the
employee was dismissed or suspended
for just cause. If the termination
occurred during the probationary
period, the employee does not usually
have recourse to the grievance procedure.
Documentation
Since in the case of suspension or
dismissal of an employee the employer
must prove just cause before the
arbitration board, the responsibility of
documentation usually falls upon the
nurse-manager. The arbitration board
will not accept second hand information
of what management "thought"
happened as evidence. Incidents of
unsafe nursing care, insubordination,
and so on, must be documented by the
supervisor, discussed with the nurse in
question and filed.
Once an employee has been
warned of an impending dismissal, the
nurse-manager must make sure she
knows the following:
who is involved, the employee s
full name, the department, branch or
division, the employee s position, title
and job classification, as well as any
witnesses concerned in the case or
anyone else involved,
what happened, including all of
the incidents that occurred from the
time a problem was suspected,
when the act or omissions took
place, including times, dates, frequency
and over what period of time,
where the incident took place, the
exact locations (the diversity of areas
may be important),
why the problem exists, whether
the employer violated the Labour
Relations Act, a department regulation
or a personal right; the employer must
be prepared to justify the "why", and
finally,
what you want to accomplish, if
it is suspension, the length must be
determined and justified.
Remember, cases can be lost if
management does not document the
facts, fails to warn an employee that
she is not meeting the standards or if
regular written evaluations are not
completed, signed by the employee and
filed in her personal file.
Achieving a voice in the system
While the nurse-manager s ability to
achieve a voice in the system reflects
the responsibility delegated by
administration, it is also dependent
upon her ability to accept responsibility
and authority. Delegation of
responsibility without authority to act
can place the nurse-manager in a very
difficult position and every effort
should be made to have the job
description re-evaluated. On the other
hand, nurse-managers may not assume
the authority they are given, tending
not to want to perform unpleasant
tasks or make unpopular decisions but
leave these to more senior adminis-
THE COLLECTIVE BARGAINING PROCESS
Certification
Labor acts in the provinces and federal jurisdictions are administered by labor relations
boards which are responsible for the certification of bargaining agents. These boards have
exclusive powers to determine matters such as:
who is an employer and employee
who is a member in good standing
what constitutes a unit of employees appropriate for collective bargaining, and
if the bargaining requirements of the statutes have been met.
In the majority of provinces, legislation dictates that an employer may not
unilaterally alter wages, hours and conditions of employment of employees from the date
when an application for certification is filed until the date when a decision is rendered by
the labor relations board. All acts set forth limitations on employers and on employees or
their unions regarding interference in each other s rights: violation of these rights is termed
an unfair labor practice or simply, an unfair practice.
Negotiations
Once a union has been certified as a bargaining agent, legislated obligations are placed on the
parties concerned, the employer and the union, to bargain collectively in order to conclude
a written agreement covering salaries and other conditions of employment. In all labor
relations acts ground rules are laid down for newly certified bargaining agents. Legal
requirements for negotiations include:
a notice to bargain,
time limits in which the parties are to meet,
representatives of the parties,
circumstances which may interrupt or suspend bargaining,
procedures to follow when one of the parties to bargaining changes,
restrictions on employers during bargaining, and
enforcement of the bargaining requirements.
One of the basic principles underlying negotiations is that the parties sit at the
bargaining table as equals. Strategies are prepared by both parties before collective
bargaining begins with their demands representing the bargaining objectives of their
members (this applies equally to the employers team if more than one institution or agency
is being represented).
"Bargaining in good faith" is a basic and essential element of collective bargaining
and occurs when both parties make every reasonable effort to effect a collective agreement.
Communications is another important element as both parties must be able to present their
views and in turn listen to those of their opponent. There must also be a willingness to
compromise: each party to the agreement must be willing to give something up during the
negotiation process.
If a contract is negotiated and accepted by the employer and the union, it is signed
by both parties and is binding until the expiration of the agreement. However if negotiations
break down, there are various degrees of government intervention outlined in the labor acts
before a legal work stoppage may take place.
Mediation/Conciliation
Mediation and conciliation are regarded as equivalent terms referring to essentially the same
kind of third party intervention used to promote the voluntary settlement of disputes, a
process of peace-making.
A conciliation officer, appointed by the local labor relations board, meets with the
parties and attempts to assist them in settling their stalement within th , negotiating process.
The parties may also ask for a conciliation board made up of a neutral chairman, and one
employer and one employee representative, this is sometimes called second stage
conciliation. The award of the conciliation officer or board is not binding on either party. If
both parties agree then a contract is signed, but if the parties reject the award and fail to
reach an agreement, the next step is either strike or arbitration.
Arbitration/Strikes/Lockouts
Two types of arbitration exist for use in the collective bargaining process. Interest
arbitration is used when negotiations break down and the conciliation process fails to bring
the parties together. Rights arbitration is used to deal with grievances which have not been
settled during the grievance procedure. With the exception of Ontario, all labor acts do not
provide for arbitration. Consequently, if this avenue is not open a strike vote and a possible
strike follow.
All civil or public servants who are covered by public service labor acts have the right
to choose the arbitration or strike route. If the strike route is chosen, the majority of these
employees are covered by essential service legislation which gives the employer the right to
negotiate the number of employees who will have to remain at work if a strike is called. A
strike vote must precede a legal strike and if a majority vote is received, a notice of intent to
strike must be given. The period of time required between the vote and the actual strike is
stipulated by the appropriate labor act which also provides for a continuity of employee
status during the strike.
A lockout of employees requires a vote where more than one employer is involved in
the same negotiations or a vote of the board where only a single employer is involved.
Although the majority of statutes prohibit work stoppages including lockouts during the
term of an agreement, it is common to negotiate a clause in the collective agreement which
prohibits the employee to strike and the employer to lock out during the life of the
collective agreement.
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trative officers, effectively minimizing
their impact and input into the system.
The nurse-manager can have a
voice in the system if she is prepared to
accept her responsibilities, keep
up-to-date in all aspects of her work
and present a positive approach to all
decisions. She must accept the authority
she is given and use it in the
improvement of her services.
The nurse-manager as a non-unionized
employee
Quebec is the only province with a
management nurses union, and nurses
in this province have succeeded in
negotiating individual contracts.
Management nurses who do not have
the protection of a contract have no
recourse to grievance and arbitration
procedures and depend solely on a good
employer to provide fair and equitable
benefits. Although all employers must
meet minimum standards set out by
provincial Employment Standards
Acts, the majority of employers provide
greater benefits than are legislated.
Management nurses who are
non-unionized workers, may find
themselves behind the unionized nurses
in benefits and salaries. Since they are
not in a negotiating position, they must
depend on administrations decisions to
increase salaries and benefits in an
attempt to maintain a realistic
relationship with those who work under
their supervision. Recently, however,
several cases have been reported where
staff nurses are earning more than
management nurses, including directors
of nursing working in the same small
institution. As a result, in some areas,
management nurses have organized in
groups to discuss problems of mutual
concern. Others are seeking voluntary
recognition with their employers in an
attempt to negotiate changes in salaries
and working conditions. *
*References
1 Turner, James T.; Robinson,
James W. A pilot study of the validity
of grievance settlement rates as a
prediction of union-management
relationships. J. Industrial Relations.
1972 Sept. p. 3 14-322.
2 Black, James Menzies; Black,
Virginia Todd. The front-line manager s
problem solver. New York:
McGraw-Hill; 1963: p. 242-244.
*Not verified
Nurses unions, professional
associations and YOU" is a two-part
special feature in the July/ August and
September issues of CNJ. The series is
based on a chapter prepared by author
Glenna Rowsell for a new textbook for
nurse managers, "Nursing Unit
Administration, first edition", released
in June and available from the Nursing
Unit Administration Program, 410
Laurier Avenue West, Suite 800, Ottawa,
Ontario, KIR 7T6.
Malignant
Hunertlierinia
MAftt-t^
need
not be
lethal
Elizabeth Noble
Malignant hyperthermia, with its
propensity for killing healthy, muscular
athletes, is a relatively new disease in
the medical world. Identified only 17
years ago, malignant hyperthermia (MH)
remains frequently unrecognized and
difficult to treat with a fatality rate
still exceeding 50 per cent. Although
this genetically determined condition is
often considered to be a hazard only
under the conditions of a general
anesthetic in a large operating room, it
should also be anticipated during local
anesthesia in the dentist s chair, after
conduction anesthesia for childbirth and
on the playing field during an athletic
event.
Susceptibility seems to be related
to muscle bulk, strength and activity
and consequently definite age and sex
differences have been noted in victims.
Males are more commonly affected than
females, particularly between puberty
and 30 years of age ; MH is rare in adults
over 50 and in infants under the age of
two.
Although not diagnostic of MH, a
number of clinical musculoskeletal
abnormalities are more common in
malignant hyperthermia susceptible
(MHS) individuals than in normal
persons. These MHS individuals tend to
be emotionally tense and hyperactive,
they may have been dyslexic in
childhood, their muscles are strong at
the beginning of exercise but they
fatigue rapidly and they may exhibit
mild localized weaknesses such as:
strabismus, ptosis, lumbar lordosis and
club foot. Some may also present with
hernias (slipped discs, inguinal,
umbilical or liiatal hernias), joint
hypermobility with frequent joint
dislocations (spontaneous or with
minimal trauma), ecchymosis (bruising),
prolonged bleeding after injury and
frequent and severe epistaxis and poor
dental enamel with many caries.
A pharmocogenetic disease
MH is a true pharmocogenetic disease,
as triggering drugs and/or stresses, as
well as MH genes, are necessary for the
development of an anesthetic crisis
(see figure one).
During anesthesia, MH reactions
may be precipitated by the following
drugs:
potent inhalational agents
including halothane (Fluothane),
methoxyflurane (Penthrane), enflurane
(Ethrane), diethyl ether (Ether),
isoflurane, cyclopropane,
trichloroethylene, fluoroxene and
ethylene;
skeletal muscle relaxants such as
succinylcholine (Anectine, Scoline and
Quelicin), decamthonium, gallamine and
d-Tubocuarine, and
amide local anesthetics such as
lidocaine (Lignocaine, Xylocaine),
mepivacaine (Carbocaine), bupivacaine
(Marcaine) and prolocaine (Citanest).
Thft Canadian
Figure one
FACTORS CAPABLE OF PRECIPITATING
AN MH REACTION
Within the operating theatre
1. Potent Inhalations! Agents
Methoxyflurane
Halothane
Enflurane
Isoflurane
Trichloroethylene
Fluoroxene
Diethyl ether
Ethylene
Cyclopropane
2. Skeletal Muscle Relaxants
Succinylcholine
Decamethonium
Gallamine
d-Tubocurarine
3. Local Anesthetics
Lidocaine
Mepivacaine
Bupivacaine
Prilocaine
Outside the operating theatre
Extreme emotional excitement
High environmental temperature
Mild infections
Muscle injury and/or exercise
Aggravating factors
Sympathomimetics
Parasympatholytics
Cardiac Glycosides
Quinidine analogues
Calcium salts
Caffeine and Theophylline
Ethyl Alcohol
Anesthetic induced MH reactions
may be aggravated by stressful
situations including pain and
apprehension immediately prior to or
after anesthesia, hypoxia, hypercapnia,
metabolic acidosis, hypotension and
tracheal irritation.
MH reactions may be further
aggravated by such groups of drugs as:
Sympathomimetics, adrenergics
such as epinephrine or Levophed,
parasympatholytics, cholinergic
blocking agents such as atropine
sulphate, propantheline bromide
(Pro-banthine) or belladonna leaf,
cardiac glycosides such as
digitalis,
quinidine analogues,
calcium salts,
theophylline derivatives such as
aminophylline,
ethyl alcohol and caffeine.
Malignant hyperthermic reactions
may also be precipitated by stressful
situations which cause a release of
endogenous catecholamines such as
epinephrine and norepinephrine.
Extreme emotional excitement, high
environmental temperatures, mild
infections, muscle injury and exercise
are all capable of this.
The nature of the biochemical defect
The immediate cause of a malignant
hyperthermia crisis is a sudden increase
in the concentration of calcium in the
muscle myoplasm (cytoplasm). This
increase is induced by the direct or
indirect action of triggering agents on
the sarcoplasmic reticulum (SR) which
are calcium storing organelles (sacs)
lying within the muscle myoplasm.
Their function is to take up calcium
from the myoplasm during muscle
contraction. Agents that trigger MH
may activate a previously latent defect
in the SR thereby rendering them
incapable of taking up calcium from the
myoplasm during relaxation and
increasing the rate of release of calcium
to the myoplasm during contraction.
The net result is a marked increase in
the concentration of calcium of the
myoplasm.
This elevated myoplasmic calcium
causes an increase of catabolic heat
production in the muscle cell, an
increase in the intensity and duration of
muscle contraction and a decrease of
the duration and completeness of
muscle relaxation. For instance, a small
rise in the concentration of myoplasmic
calcium induces activation of the
enzyme phosphorylase kinase which
increases the rate of catabolism of
glycogen to lactic acid, carbon dioxide
and heat as well as increase the rate of
consumption of oxygen in the
mitochondria. Consequently a mild MH
crisis leads to respiratory and metabolic
acidosis, fever and hypoxia but no
muscle contracture.
A greater rise in the concentration
of myoplasmic calcium has two
additional effects both of which
increase and prolong muscle
contraction. First, calcium activates the
enzyme ATPase which causes hydrolysis
of ATP to ADP and phosphorus and
produces free heat and energy. This
energy is utilized for muscle
contraction, for the sliding of myosin (a
myofibril which is a short, thick rod)
over actin (a second myofibril which is
a thin coiled spring) to form short and
rigid actomyosin. Secondly, calcium
inhibits troponin, a third myofibril
which is a long strand lying within the
helices of actin. Troponin on
combination with calcium becomes
broken up into a series of short
segments between which are open gaps.
Through these gaps, cross bridges on the
heads of myosin reach out to join
receptors on the actin. These cross
bridges move from one receptor to the
next in a ratchet-like fashion, enabling
myosin to slide over actin to form
actomyosin in which myosin and actin,
instead of lying end on end (as in the
relaxed state) now lie side by side.
In normal individuals, alternation
between muscle contraction and
relaxation is cyclical. Relaxation follows
contraction with the aid of ATP (but
not its hydrolysis) when myoplasmic
calcium falls below a critical threshold
level, usually 5 x lO^M, and contraction
recurs with the aid of ATP hydrolysis
when myoplasmic calcium again rises
above this threshold level. During an
MH reaction, however, the myoplasmic
calcium concentration remains
permanently above the threshold level
and so relaxation cannot occur.
As calcium rises to really toxic
heights in the myoplasm during
prolonged, untreated MH reactions,
some of the excess calcium seeps into
the by now leaky mitochondria. Here it
uncouples oxidative phosphorylation
from electron transport in such a way as
to accelerate oxygen consumption and
heat, lactic acid, carbon dioxide and
water production but to inhibit ATP
formation. ATP is the cells refined fuel
and is vitally essential for all cell work,
not only muscle contraction and
relaxation but also transport of ions
across cell membranes. The result,
therefore of inhibition of ATP
formation and acceleration of ATP
hydrolysis (utilization) is a fall in the
concentration of ATP in the muscle
cell. Consequently, there is a further
decrease in the ability of the muscle to
relax and a diminuition in the rate of
active pumping of ions across cell
membranes. Instead, ions simply
follow their natural concentration
gradients. For instance, uptake of
calcium into the SR, an active
process against a concentration
gradient, is further inhibited, while
calcium release from the SR, a passive
process with a concentration gradient,
is to an even greater extent increased.
Figure two
EFFECTS OF CAFFEINE AND HALOTHANE ON NORMAL, MHS AND MH MUSCLE
Normal muscle
Nonrigid MHS muscle
Type I rigid
MH muscle
Type II rigid
MH muscle
Type III rigid
MH muscle
Caffeine alone added
1 .0 gm increase in tension
is seen with 4.1 mm of caffeine
no increase in tension
even at highest dose
greater than normal
increase in tension
greater than normal
increase in tension
no increase
Halothane alone added
no increase in tension
no increase
greater than normal
increase in tension
no increase
no increase
Caffeine plus Halothane
increase in muscle tension
with 1.2 mm of caffeine
no increase
greater than normal
increase in tension
greater than normal
increase in tension
greater than normal
increase in tension
Similarly ions which are normally in
higher concentration inside than
outside the muscle cell, i.e. potassium,
magnesium and phosphorus, leak from
the interior of the muscle cell to the
extracellular fluid. Conversely, sodium
and calcium, ions whose concentration
gradients are in the opposite direction,
leak inward. This inward leakage of
calcium, further aggravates the already
pre-existing biochemical dearrangements
within the muscle cell. Somewhat later
large molecules such as myoglobin and
muscle enzymes including creatine
kinase and glutamic oxalic transaminase,
escape across the by now incompetent
sarcolemmal membrane.
As platelets are really floating
muscle cells with many components
similar, if not identical, to those of
skeletal muscle cells, it is not surprising
that these problems are reflected in
their functioning as well. Once the
normal functioning of platelets
becomes disordered during an MH
reaction, clotting ceases and the patient
dies from hemorrhage.
Preanesthetic diagnosis of MH
A skeletal muscle biopsy is necessary to
diagnose the MH trait. As an anesthetic
technique that is both safe for MHS
individuals and that does not alter the
muscle must be used, a mixture of
Innovar (droperiodol plus fentanyl),
diazepam and nitrous oxide is
commonly used. Muscle is removed
from the vastus lateralis, a muscle lying
on the front of the thigh.
In the laboratory, the muscle
sample is carefully divided into small
strips or fascicles. These are
isometrically mounted between a
plastic frame and a force transducer in
baths of Kreb s Ringer solution which
are maintained at 31C. The transducer
is attached to a Grass polygraph on
which is recorded the tensions
(contractures) exhibited by the muscle
fascicles. Six muscle strips are examined.
To the bathing solutions surrounding
the first two are added incremental doses
of caffeine, to the second two, 1 .0 vol%
halothane and to the third pair,
1.0 vol% halothane plus incremental
doses of caffeine. Caffeine is used as it is
known to cause release of calcium from
the SR and as well inhibit uptake of
calcium into the SR. Halothane is
employed as it is a drug known to
trigger MH reactions.
Depending on the tension
responses of the muscle the patients are
classified as normal, as non rigid or as
rigid. Three subgroupings of rigid MH
may also be discerned and categorized
as types I, II and III, ranging from the
most to the least severe (see Figure two).
Clinical signs of an MH reaction
An MH crisis can occur at any time
during anesthesia from induction until
several days post operatively. The first
evidence of a reaction is usually a
tachycardia or other rapid, multifocal
ventricular arrhythmia, the blood
pressure then becomes unstable and
respirations increase in rate and depth.
The anesthetic tubing becomes
extremely hot and the soda lime
exhibits excessive discoloration and
heat. The skin may at first turn bright
red and then mottled blue. Rigidity of
the jaw muscles may occur initially and
later generalized skeletal muscle
stiffness ensues although a few patients
(called non rigid) never manifest any
increase in muscle tone. Because the
heart is a muscle it may also display
stiffness and eventually fail. The urine
may turn a reddish brown due to the
presence of muscle myoglobin. Fever
develops as a result, not as a cause, of
the reaction and is therefore a relatively
late event. The patient s temperature
may rise l^C per minute and attain
values of up to 46"^ or more. While
death has occurred when maximum
temperature elevations have been
fairly low, survival has occurred after
a fever of 44C.
Roy Healey, a previously healthy 32-year-old male was admitted to hospital for
a lung biopsy. In the operating room, induction was commenced with
thiopentothal, succinylcholine drip and pavulon. Approximately 15 minutes
after induction his blood pressure increased, his heart rate increased in
rate and his skin felt hot. At this time his temperature was 39C rectally. At 20
minutes, ventricular tachycardia was noted and treated with a bolus of Lidocaine
2/o50 mg. Mr. Healey was packed in ice and the operation was continued.
Despite the ice packing his temperature rose to 41.4C over the next twenty
minutes and remained at that reading for the following thirty minutes. The
operation was concluded in two hours at which time the temperature remained
at 41.4C and the heart rate continued to increase.
Five minutes after the anaesthetic had been discontinued and the
operation completed, Mr. Healey suffered a cardiac arrest and had increased
bleeding noted in his thoracic secretions as well as bleeding from his other body
orifices. Closed cardiac massage resulted in a reasonable heart rate. He was
treated with heparin, protamine, cardiac glucosides and sodium bicarbonate.
In another 25 minutes Mr. Healey suffered a second cardiac arrest with
complete asystolic and an isoelectric electrocardiogram. At this time he was put
on a cardiopulmonary bypass. As he continued to hemorrhage, his chest was
surgically opened and sutures were used to ligate the hemorrhaging vessels and
chest tubes were inserted. A tracheostomy was performed and he was connected
to a respirator. We estimated that he had lost two to three liters of blood.
During this reaction, Mr. Healey s LDH isoenzymes increased three to
five times, causing skeletal muscle damage. After one hour his temperature began
to decrease and fell rapidly to 30.4C, at which point he had to be warmed.
For two weeks Mr. Healey was comatose and his pupils were fixed and
dilated, but he began to regain consciousness slowly. He was weaned off the
respirator gradually and was found to have severe cerebral deficits including a
partial paralysis of his left side, difficulty with speech and loss of memory.
When malignant hyperthermia was investigated, the muscle biopsy at
37C revealed: a one gram tension level in the muscle with 0.23mM of caffeine
(normal is 4.1-1 7.5mM) and a one gram increase in muscle tension was noted
with l.lmM of caffeine plus halothane (normal is Ll-2.1rnM); positive for rigid
malignant hyperthermia.
Greg Brand, a healthy 43-year-old male, was competing in a six mile road race
with his local running club on a sunny May morning. He felt relaxed and well
during the early part of the race, but remembers nothing between then and the
time he awoke in hospital a few days later. What Greg doesn t recall is that he
collapsed during the race in a very cyanotic and febrile state. Wrapped in ice
water soaked towels, he was rushed to hospital by ambulance.
On arrival at the Emergency Room, Greg was in an agitated comatose
state with a temperature of 42.2C. The diagnosis given was heat stroke. Blood
tests revealed markedly elevated LDH and GOT levels and a CPK of 1 0,000 units
(normal male level is 30-160 units). Within two days, his kidney functioning had
deteriorated to the point where renal failure was a reality. Initially, hemodialysis
was used but when the problem was not corrected immediately, a program of
peritoneal dialysis was established and was necessary for a period of two weeks.
During the days after admission, Greg s consciousness levels improved; he
complained of severe muscle soreness and weakness. In total, he was hospitalized
for seven weeks, losing 30 pounds over this period but on discharge his prognosis
was excellent.
Over the years, Greg had undergone several uneventful operations and
anaesthetics. This was the only occasion which indicated a potential for
malignant hyperthermia. This was confirmed when a muscle biopsy at 37C
revealed a one gram tension level in the muscle with 4.4mM of caffeine (normal
is 4.1-1 7.5mM) but with caffeine plus halothane, a one gram increase in muscle
tension was noted with 0.57mM (normal is 1.1 to 2.1mM). Rigid malignant
hyperthermia was diagnosed.
Early laboratory findings include
a combined respiratory and metabolic
acidosis due to elevated lactic acid and
carbon dioxide production in the
muscles; arterial pH therefore falls to a
very low level. Increases in serum
creatinine and myoglobin develop
several hours after the onset of the
reaction and finally massive elevations
of muscle enzymes (CK and GOT)
develop in the serum.
A prolonged and fulminant MH
reaction may lead to:
acute renal failure secondary
to myoglobinuria,
acute pulmonary edema and
ventricular fibrillation secondary to
rigor of the heart muscle,
generalized bleeding from body
orifices, wound and needle sites
secondary to depletion of platelets,
fibrinogen and other clotting factors
and
cerebral dysfunction with
associated cerebral edema.
Treatment of acute reactions
Recognition of an MH reaction is the
single most important factor in ensuring
the patient s survival. The time to
recognize a reaction is during the
first few minutes for within this
precious time, awareness and speed may
be lifesaving. All vital signs, including
temperature, pulse rate, blood pressure,
respirations and electrocardiogram,
therefore should be monitored during
and after every anesthetic. If the
temperature rises by more than IT
a diagnosis of MH should be
entertained.
Once a reaction is suspected ALL
triggering anesthetic agents must be
discontinued immediately and the
surgery terminated as soon as
practicable. The rubber tubing and bags
and soda lime should be changed for
new and unused equipment to ensure
total removal of lipid soluble
anesthetic vapors from the gas machine.
To return blood oxygen and carbon
dioxide tensions to normal the patient
must be hyperventilated with a gas
mixture containing 50 to 70 per cent
oxygen. Enough sodium bicarbonate
should be infused to about half
correct the metabolic acidosis. Vigorous
cooling measures may be necessary to
achieve significant temperature
reductions. Thus, in addition to
external cooling with cooling blankets
and ice water baths, internal cooling
with cold intravenous solutions and
irrigation of body cavities (stomach,
GENETIC TRANSMISSION OF MALIGNANT HYPERTHERMIA
Malignant hyperthermia (MH) is a hereditary trait as transmission is due
to one pair of autosomal dominant genes, sometimes in combination
with one or more pairs of weak recessive genes. When one or both
parents possess both dominant and recessive genes, the probabilities of
MH inheritance become complex, with nine different possible gene
combinations, including one normal, one carrier (someone who appears
normal but who can pass the trait on to his or her offspring if the
spouse also possesses a similar MH gene) and seven others with varying
degrees of clinical MH abnormalities.
Even with normal parents, a new mutation may occur. This is
often due to harmful exposure of the mother to radiation, drugs or
viral infections such as the German measles during the first few weeks
of pregnancy.
one parent
both parents
One dominant
MH gene
Two dominant MH
genes (one pair)
One recessive gene
Two recessive genes
(one pair)
50% of offspring
are MHS*
100% of offspring
are MHS
25% of offspring
are MH carriers
100% of offspring
are MH carriers
25% of offspring
are severely MHS
50% of offspring
are less severely
MHS
25% of offspring
are normal
100% of offspring
are MHS
25% of offspring
are MHS
100% of offspring
are MHS
*MHS Malignant Hyperthermia susceptible
rectum and abdomen) with sterile iced
solutions may be necessary.
Medications effective in the
treatment of an MH reaction include:
chloropromazine (Largactil), a
useful adjunct in lowering body
temperature as it decreases heat
production by inhibiting both
shivering and non-shivering
thermogenesis and increases heat loss
by inducing peripheral vasodilation,
propranolol (Inderal), verapamil,
procainamide (Pronestyl) and
diltiazem, effective in the treatment of
cardiac arrhythmias as they prevent the
release of calcium from the cardiac SR
to the cardiac myoplasm and/or inhibit
influx of extracellular fluid calcium
across the cardiac sarcolemma into the
myoplasm,
dantrolene sodium (Dantrium)
which decreases the temperature and
relaxes the skeletal muscles by
preventing release of calcium from
skeletal (but not cardiac) muscle SR,
regular insulin in 50 per cent
glucose, effective in lowering serum
potassium early during the reaction,
potassium chloride infusions may
be substituted for the insulin therapy
later when hypokalemia supervenes over
hyperkalemia,
furosemide (Lasix) which
facilitates removal of myoglobin from
the renal tubules and corrects the
sodium overload that is generally
induced by the sodium bicarbonate
therapy,
mannitol, a free water diuretic,
is also useful in overcoming the
myoglobinuria as well as attenuating
cerebral edema,
hydrocortisone (Solu Cortef)
which may be of some value in
stabilizing muscle cell membranes and
in reducing cerebral edema, and
heparin infusions, to retard the
development of acute consumption
coagulopathy, a therapy that is still
not yet well proved.
A brighter future
Research continues to be conducted
into the cause of MH, in particular the
nature of the SR defect. With more
accurate causal theories, methods of
diagnosis and treatment will become
more refined. Already more accurate
and less invasive diagnostic tests are
being developed, tests that require only
one single muscle cell. In the future,
tests of platelet dysfunction may
entirely obviate the need for any type
of muscle biopsy. *
Bibliography
1 Britt, Beverly A. Etiology and
pathophysiology of malignant
hyperthermia. Fed.Proc. 38(l):44-48;
1979 Jan.
2 *Britt, Beverly A. Malignant
hyperthermia. Clin.Dig. 31(6):511-516;
1976 Jun.
3 * Britt, Beverly A. A guide to
malignant hvperthermia. Malignant
Hyperthermia Association, 1979.
4 Britt, B.A. Malignant
hyperthermia. Br.J.Anaesth.
45:269-275; 1973 Mar.
5 Brown ,L.L.; Britt, B.A. Malignant
hyperthermia. South.Med.J.
67(7):799-804;1974 Jul.: p.799.
6 Kalow, W. et al. The caffeine test
of isolated human muscle in relation to
malignant hyperthermia.
Canad.Anaesth.Soc.J. 24(6):678-694;
1977 Nov.
7 Relton, J.E.S. et al. Malignant
hyperexia. Br.J.Anaesth. 45:269-275;
1973 Mar.
8 *Stephen, C.R. Fulminant
hyperthermia during anaesthia and
surgery. JAMA 202; 1967 Oct.
*Not verified
Elizabeth Noble, a graduate of the
Oshawa General Hospital School of
Nursing, is a staff nurse in the Clinical
Investigation Unit of the Toronto
General Hospital, where most of the
malignant hyperthermia investigation
takes place. Elizabeth is presently
enrolled in the Faculty of Nursing
Program at University of Toronto.
My father, at 94, was dying. He was so far gone that he did not enjoy his food; his intake was practically
nil. It was a hot summer day when I visited and I thought perhaps a glass of cold beer might tempt him to
drink something. So I went out and bought some beer. When I brought it back to his room, it was taken
from me: hospital policy did not permit liquor on the premises. Probably my father wouldn t have enjoyed
that drink anyway but I ll never know.
For years, our institutions, the people
who administer them, the doctors and
nurses who work in them; have
conspired to rob dying patients of their
individuality. Now the growing credi
bility of the hospice movement offers
new hope of providing care that will
"personalize" death, recognizing it as
part of the individual s total experience
of growth and development.
We see the hospice as providing a
haven for the dying, a place where
distressing symptoms and pain will be
relieved. The hospice strives to
recognize individuality in planning for
care and death, whether the patient
remains at home or enters the facility.
Care is holistic, with particular
attention to the mind and spirit as well
as the body. "Intensive caring instead of
intensive care" Ms the central concept
on which planning is based. Energies are
directed to improving or at least main
taining quality of life, rather than
prolonging survival through heroic
measures. Care is provided in the setting
of a homelike, congenial and protective
community comprised of family
members, staff, volunteers and members
of the broader community. Personnel
recognize the patient/family unit as
being at the center of this service.
During their bereavement, family
members continue to receive this
support.
Observation convinces me that
there is general agreement on the
desirability of these objectives; most of
us realize that the best interests of the
patient are not well served by existing
methods of pain management and
confrontation with death in the hospital
setting. Why then have the objectives
and assumptions of the hospice
movement not become general practice
long before now? Why are our dying,
even today, often neglected? Perhaps we
can benefit from our errors and
omissions in the past if we look at them
realistically and then use this evaluation
as a stepping stone to implementing a
new approach.
time
time
Vera Mclver
The acute care model
For years, professional disciplines in
the health field have addressed them
selves to curing; all our skills and
concerns were channelled towards
defying and defeating disease. Rewards
were task-oriented. Care was given in an
efficient, dispassionate and detached
manner because we were taught that, as
professionals, personal involvement and
self-disclosure were in poor taste. Nurses
actually experienced guilt and
embarrassment if they were "caught"
sitting in conversation with a patient.
Personalities were kept concealed and
the patient s problems buried so as not
to create problems for the staff and the
organization.
Naturally, attitudes such as these
had definite and strong implications
that were reflected in the kind of care
that was provided. This was especially
the case when the patient was one who
confronted death in a hospital setting.
When he was brought to hospital, even
if he was still mobile, he was given a
gown and put to bed. All his belongings
were checked and removed from his
room. Then he was expected to get on
with the business of dying and, what s
more, to go about it in a cooperative
manner.
For the most part he was kept in
ignorance; many uncomfortable, painful
and sometimes unnecessary treatments
were performed without explanation or
permission. When death approached, he
was continually disturbed to check for
vital signs; nurses in those days certainly
were well aware that the temperature
reached 107rectally and the patient s
blood pressure dropped just before he
died.
The nurse abetted the doctor in
keeping the patient in the dark about
his condition: naturally she couldn t
divulge medical secrets. The physician
was the person in charge and he would
do the telling. Well, maybe not all, just
enough to save the day. Families were
not well informed either; they kept a
stiff upper lip during their visits and
tried to avoid discussing his illness with
the patient. The patient saw through
these maneuvers, of course, but
respected the unwritten rules of the
institution and, not wishing to be
considered out-of-line or a troublemaker,
conformed with the non-verbal request
that he keep quiet. At the same time, he
bottled up the panic, fear, guilt and
other emotions arising from his
situation. At a time when he should
have been working openly towards a
peaceful death, he was surrounded by
evasion and denial.
Pain was not well handled.
Medications were limited and controls
were rigid. Morphine 15mgm, q4h,
p.r.n. was the order of the day, even
though this was often grossly and
patently inadequate. You made the
patient hold out "until it really hurts"
because, after all, you didn t want to
make a dope fiend out of him or cause
his condition to deteriorate. As a
consequence, the patient was constantly
on the bell since he was preoccupied
with his severe pain and his need for the
next needle. This pain kept him
immobilized in bed, totally dependent
on your care and a nuisance to all the
staff.
To ensure that a patient s spiritual
needs were met you checked his kardex
and, if he happened to be of the Roman
Catholic faith, sent for a priest. The
priest came alone, carrying the
necessary items, and performed the last
rites behind drawn curtains. Clergy
looked in briefly on other patients and
left just as quickly so that they
wouldn t upset them by causing them to
believe that the end was approaching.
Families were considered a
bother: their visiting hours were
generally limited. It was difficult for
nurses to assume the role of Florence
Nightingale succoring to the
dying in front of the whole
family. You felt inadequate.
It was also difficult
to deal with the
emotions of family
members; small
talk was a struggle
and, besides,
it kept you at
the bedside when
you had so much
other work to do.
Accommodation
for visiting
family members
was often limited
to two chairs;
even husbands or
wives were forbidden
to sit on their dying
spouse s bed. Recently,
when my own husband was
ill, the nurse who was caring for
him asked me to get off the bed.
Finally, the person slipped quietly
away, hopefully on someone else s shift,
and you experienced a feeling of great
relief if the family preferred not to be
present or did not get there in time.
Mourners were asked to sign the
necessary forms and then they left. The
body was hastily prepared for the
morgue and smuggled out of the room
and down the hall after all the doors
were closed. Closing the doors in itself
told the story but if someone enquired
you always denied that there had been a
death on the floor. Death was not
always so dispassionately treated, but
often it was. Those who fared better
had families who took the initiative. In
recent years, I have had personal
experience with some of these old rules
and regulations: in each case, the heavy
hand of bureaucracy came down when
an act of human kindness should have
been in evidence.
Old habits die hard and, as
recently as 1976, a study carried out at
the Royal Victoria Hospital in Montreal,
showed that, even though educators
began talking about "psychosocial care"
in the forties, dehumanizing behavior is
more often than not still the order of
the day on busy surgical wards.
R.W. Buckingham HI was the participant
observer in this study of the treatment,
attitudes and interactions of hospital
staff, terminally ill patients and their
families. 2 During his hospitalization,
he was frustrated by the lack of
meaningful relationships he
experienced: staff/patient contacts were
mostly technical and brief. Interviews
were rushed and restrictive: lengthy
responses by patients were "tolerated"
and, if the evidence was not strictly
related to staff concerns, impatience
on the part of the
questioner was evident.
Frequently staff, including doctors,
entered or left the room without
recognizing by word or look, the people
in it. Monotony and loneliness on the
part of the patients was the rule rather
than the exception. This behavior is not
an isolated experience; it occurs
throughout America.
Custodial vs. therapeutic care
Whatever their age or personality type,
whether they are in an acute or chronic
care setting, persons subjected to
impersonal, even rude behavior do not
fare well. Their integrity suffers, they
lose their identity and their spirit fails
because they are not allowed to
integrate with their environment.
We know the effects of this
"hospital-type", custodial care on the
elders allowed to languish in long term
care facilities. Acute care attitudes,
philosophies, rules, regulations and
rituals, transposed to a long term
setting, just don t work. The fact that
the term "vegetable" was coined is
poignant testimony to this fact.
Noted gcrontologist, Dr. Herbert
Shore, is one who advocates the
introduction of a psychosocial model of
care for long term patients. His
fundamental premise is that present
long term institutional care is
experiencing problems primarily
because it is modeled after a hospital,
measured by a criterion which is not
only inappropriate, grossly inefficient
and costly, but harmful as well. 3 A
psychosocial model of care would not
only provide excellent physical
care, but would develop an holistic
approach that views the person s
psychological, social and spiritual
needs as being of equal importance.
The needs of elders in their final phase
of life accompanied by chronic
diseases for which there are no cures
have much in common with the
needs of the dying at any
age, that is, that the quality
of life remaining meets
the individual s needs.
Both long term
care facilities and
hospices, in the home or
in an institution, should
provide care adapted
to the functional
abilities, personal
and emotional states,
economic background,
social status, religious
persuasion, culture, past
experiences and environ
mental exposures of the
individual. Support is provided
to assist the person to reach self-
actualization. The client and his
or her family is kept informed so
that they can participate in decisions
about care, preferences and intentions.
Diversional recreational and
occupational activities are provided to
overcome monotony and provide the
person with the opportunity of
participating in useful endeavors.
Religious services are provided to meet
the needs of those who wish to parti
cipate. In both levels of care the clients
will die but, in the hospice, death is
imminent.
The hospice movement attempts
to take us one step further: it shows us
how to provide a more personal death
by introducing specialized components.
Incorporation of these will enhance the
psychosocial model of care and can be
applied in any facility because to a great
degree they are attitudinal and
philosophical concepts.
A "good death"
How and when did our impersonal
Th Canadian Nurse
R*ntmhr 1OAH
attitudes towards death and the dying
patient develop? I believe it was because
the dying process was taken out of the
hands of the families and away from
their support systems. Years ago, a
person died at home surrounded by
family, neighbors and clergy. When the
dying were taken to the hospitals family
support suffered because of the rules
and regulations of the hospitals. Visiting
hours were limited. Children were not
allowed. I have seen a mother waving
her last goodbyes through a window to
her children on the street below. Care
was taken out of the hands of family.
The custom of holding wakes at home
gradually stopped as the undertaker
took over. The undertaker became more
and more expert in easing the pain of
the mourners, even to the point of
camoflaging the earth. Gradually,
mourners were pushed further and
further away from the reality of death.
Death was taken out of the hands of
families and placed in the hands of
strangers, albeit "professional"
strangers. Cultural influences also came
into play and these professionals
contributed to the creation of certain
myths, including the myth that the
patient does not want to be told he is
terminally ill.
Researchers have found up to
89 per cent of those surveyed report
wanting to be told in the event that
they become terminally ill. 4 s Less
than ten per cent indicate that they
would resent this frankness. 6 A poll
of physicians revealed that the
overwhelming majority would want to
be informed in the event that they had
an incurable disease. 7 But our doctors
are also caught up in cultural
apprehensions concerning death: more
than half of these doctors were not in
favor of telling a patient he was dying.
Vernon and Payne write: "When
we refuse to recognize that the person is
dying, or let him know we are aware of
his dying behavior we impose an
isolation on him; such agreed upon
silence may increase the patient s fears
and despair while at the same time
cutting him off from the opportunity to
reduce those anxieties through
sympathetic discussions or some type of
therapy. Some patients suffer more
from emotional isolation and unwitting
rejection than from the illness per se.
Can we deduce from this that the
patient wishes to be told? And, if we
are going to inform him, how will we do
it? Sensitivity must be used. Each
patient reacts to this news in his own
way. Some patients may not wish to be
told; this denial must be respected. Most
people at first experience an emotional
storm denial, grief, fear, bargaining,
depression and acceptance. The patient
experiences each of these in turn, with
varying degrees of intensity, until
hopefully acceptance occurs and he
becomes resigned to his own death.
While I was still at school, my
previously healthy 25-year-old brother
was brought in dying of a ruptured
appendix. Surgery was performed, to no
avail. My sister, a nun, and a nurse, told
him so and he said, "God can t do this
to me," but within five days he achieved
resignation and died peacefully. The
last thing he said was, "I am happy now."
The doctor needs to give the team
freedom to discuss the patient s
condition frankly with that patient, so
as to erase hesitations which could be
construed in a negative way. Nurses
must also have the right to adjust
medications to need so that they do not
unwillingly contribute to pain and
anxiety. The patient should also have
the privilege of going home for visits
without the need for continuous orders.
Being free of pain greatly assists the
patient in dealing with death
realistically and narcotics should
therefore be given freely when required.
Doctors and nurses may need to revise
their opinions on this subject, and come
to grips with the fact that drug
dependency is not a problem so long as
pain is not allowed to reach intense
proportions. Nurses, who generally do
not give large doses of narcotics, may
fear that by doing so they may hasten
death. One should think of the intent in
this regard: medication is given for
comfort. The required dose may be given
conscientiously at prescribed intervals
so that the patient can relax, knowing
that intense pain will not be allowed to
occur.
Along with good pain
management the nurse gives excellent
Barbara Devine
A home for senior citizens where
residents participate eagerly in their
own maintenance assisting with
meals, feeding chickens, gardening,
growing flowers and helping to care
for their fellow residents who are
less able? A home where other
members of the community come
and go freely and frequently -
visiting, reading, playing chess with
the residents?
A home that really is
"homelike" with bright, cheerful
surroundings, shady areas outside
set up with tables for chess and
checkers and a reading room inside
equipped with books, newspapers,
TV, and, usually, a staff member to
help out with reading sessions?
Sounds too good to be true?
Not really because these were some
of my observations during a brief
visit to a senior citizens home in the
People s Commune in Nanhuan,
outside Peking, last year. This
particular House of Respect is
"home" for 100 residents. The staff
of 18, all members of the commune,
include an administrator, three
cooks and a barefoot doctor whose
duties include the provision of
meals, laundry services, working in
the tailor s room where all clothing
for the residents is manufactured
and, generally, assisting in the care
of the elderly residents. Rooms are
set up for married couples, or for
three or four residents. Sometimes,
if requested, meals are served in
rooms, but, more often, they are
shared in the common dining area.
Medical attention at the primary
level is provided by the barefoot
doctor who has had two years of
medical training. Seriously ill
residents are referred to the
hospital. Food, clothing, medical
care and all other expenses are
shared by members of the
commune.
In China, where 85 per cent
of the people live in rural areas, the
three-generation extended family
continues to assume most of the
responsibility for caring for older
persons. Homes for the elderly such
as the one I visited usually house
only people who do not have
children. Older people who are able
and wish to continue living in their
own homes are free to do so.
Members of the commune provide
support systems to these elderly
who wish to remain in their own
village.
In a country which is
attempting to build a new society,
the elderly are made to feel they
are an integral part of that society.
Barbara Devine, RN, MA, is an
assistant professor at the School of
Nursing at Dalhousie University in
Halifax. "House of Respect" is
excerpted from data collected
during a visit to the People s
Republic of China in August, 1977,
when Barbara served as official
nurse for the group she was with. A
more complete account of her
observations may be found in the
June, 1980, issue of the Journal of
Gerontological Nursing.
40 Seotember 1 980
The Canadian Nurse
basic care and treats each symptom as it
appears so as to provide comfort.
Freedom from pain and discomfort
encourages mobility, participation in
activities and often permits the patient
to remain at home much longer than he
otherwise would. It also allows him to
work through his grief process and helps
him get his "books" in order.
Living experiences must be
offered at this time so that the person
can experience quality of life suited to
his needs for as long as he can enjoy this
participation.
Robert Kastenbaum gives
direction to the team on how to plan
for death; he advocates a final care plan
which makes death a "legitimate"
outcome rather than an event which
violates the norm. 9 The plan includes
not only what should be done during
the last days, but also the scene
immediately after death - where it
should be, who should be there, what
should be done, all in the context of the
person s cultural and religious beliefs,
lifestyle and individual wishes. If the
person wishes to make final
arrangements regarding pallbearers and
the funeral, you should not hesitate,
but participate by assisting in their
plans. Just remember, there is no one
good death! Besides fearing the
unknown, patients who are facing death
fear abandonment by those close to
them. Patients need to know that they
will not be left alone and to feel secure
in this knowledge. Relatives and close
friends must always be made welcome;
an area should be set aside for their rest
and refreshment and should be pointed
out to them. These mourners are going
through a difficult time; their situation
demands our kindness, consideration
and counsel.
Often, people are uncomfortable
because they do not know what to say
in the presence of death. All of us have
confronted this problem at one time or
another. Sometimes, listening will
provide the key. Remember, it isn t
what is said that counts but how it is
said. Often just being there is enough.
Don t forget also, the importance of the
outstretched hand. ..for touching,
caressing and holding.
Clergy and church volunteers can
provide valuable support and counsel.
Readings from the Bible and prayer,
religious rites and rituals, carried out at
the patient s request, can also provide
comfort to the patient. Always try to
respect the wishes of the family
members who want to remain involved
to the end or wish to be left alone with
the body after death occurs. In some
hospices, death is not hidden: there are
viewing rooms where the bodies remain
for awhile so that families, staff and
other patients can pay their respects.
Memorial services can be held on the
premises. Hospice personnel should be
encouraged to attend funeral services if
possible.
Nor does caring stop with death:
family members need support and
counselling in both the early stages of
their bereavement and later on. Three
and twelve months are thought to be
particularly difficult anniversaries.
The hospice concept
To sum up, there exists today a real
need for an imaginative and innovative
approach to new concepts in caring
for the terminally ill patient. This is
particularly true at the management
level but it affects all nurses. We need
fresh air if we are going to succeed in
providing a living environment for the
dying at a price we can afford. We need
personnel who can create a
people-oriented, patient and
family-centered atmosphere in whatever
agency they work. Because they are
attitudinal and philosophical in nature,
many hospice concepts can be
introduced in any agency where death
occurs. Some of the principles to
remember include the following:
Hospices should function
independently from other institutions to
prevent the carryover of traditional
attitudes, policies and practices.
Regional teams whose members
are experienced in the area should be
available to provide education,
inservice and consultation on:
1 . psychosocial models of care
2. confronting death
3. supporting the family during the
dying process and bereavement
4. good basic nursing care with pain
control and symptomatic management
5. a holistic approach to care.
Personnel must come to grips with
the fact that they are no longer
concerned with saving a life; the priority
is now on providing a good death
without needless monitoring and
procedures.
Compassionate and intensive
caring is crucial. This care must be
available 24 hours a day, seven days a
week, and must be supported by a
network of resources that will permit
needs to be met when they become
evident since postponement can be
pain wracking or emotionally
devastating.
Above all, there must be good
pain management by a team of health
care professionals that really is
knowledgeable in this area.*
References
1 Corbett, Terry L.;Hai, Dorothy M.
Searching for euthanatos: the hospice
alternative. Hosp.Prog. 60(3):38-41, 76;
1979 Mar.: p.38.
2. Buckingham, R.W. et al. Living
with the dying: use of the technique of
participant observation. Canad.Med.
Ass.J. 115(12): 121 1-1215; 1976 Dec.18.
3 Shore, Herbert. Psychosocial
approach for long term care. Hosp.Prog.
57(10):70-73; 1976 Oct.
4 Feifel, Herman. Attitudes toward
death. In: Feifel, Herman, ed. The
meaning of death. New York: McGraw-
Hill; 1959: p.i25.
5 Kasper, August M. The doctor and
death. In: Feifel, Herman, ed. The
meaning of death. New York: McGraw-
Hill; 1959: p. 125.
6 *Hinton, J.M. The physical and
mental distress of the dying. Q.J.Med.
72-73;1963 Jan.
*Vernon, Glen M.; Payne, W.D.
Myth conceptions about death.
J. Religion Health. 19; 1973 Jan.
8 Ibid.
9 Kastenbaum, Robert. Death,
society and human behavior. St. Louis:
Mosby;1977.
*Not verified
Vera Mclver, RN, has received
international acclaim for her work in
long term care for the elderly. When she
became director of health services at
four Juan de Fuca Society Hospitals in
Victoria, B.C. in 1967, she established
the Priory Method of helping the
elderly, a method aimed at treating
seniors as normal people rather than as
sick patients. Now retired, she has
given numerous lectures and published
many articles on the method. Vera
participated in the Canadian Council on
Hospital Accreditation s "Appraisal of
Long Term Excellence of Care Project
for Development of Care Appraisal
Manual" workshop in March 1979;
she has also given workshops at the
University of British Columbia on
"The Priory Method - Implemen
tation of a Psychosocial Model" and to
the Pacific Gerontology Association on
"Creating a Living Environment for the
Dying". Other recent workshops on
"The Implementation of a
Psychosocial Model" have taken her
across the country from the
University of Calgary - Alberta
Hospital to Summerside, Prince Edward
Island, where she spoke to the
Department of Health and Social
Services. On the international scene,
she presented "A New Organizational
Model for Long Term Care " last May in
Buffalo, New York. Currently Vera is
a surveyor with the Canadian Council
and a member of the Capital Regional
Hospital and Health Planning
Commission of Victoria.
55
Th Canadian Nurse
September 1980 41
Frankly speaking
Over the last 90 years,
religion and sex seem
to have reversed their
positions. During the
Victorian era spiritual
matters were freely
discussed in print
and in speech, while
sexuality was hardly
recognized, let alone
verbalized. However,
in the last quarter of the 20th
century we are experiencing quite
a different situation, especially in the
field of nursing. Sexuality has become
a very common, if not prominent, area
of content and concern for nurses while
spirituality is at best treated with
embarrassment or, even worse, ignored.
Why the embarrassment? Why the
lack of recognition of such a pervasive,
prevalent aspect of human life? Did not
nursing historically develop in a
religious milieu in which love of God
and mankind was expressed through
care, compassion and charity to the
sick, the poor, the orphans and the
outcasts? Have we become so
secularized that we cannot even
recognize that our patients needs might
be affected by spiritual beliefs? The
Code of Ethics of the International
Council of Nurses states: "The nurse, in
providing care, promotes an
environment in which the values,
customs and spiritual beliefs of the
individual are respected." 1
Undoubtedly this statement
implies more than the ascertainment of
a patient s religious preference during
admission procedures or the initial
assessment; it means respecting his
expression of his spiritual beliefs. I
have heard nurses say the following:
"You don t have to answer this,
but, what is your religious preference?"
"What relevance has religion to
patient care?"
"Religion has a devastating effect
on sexuality."
"I think it s terrible the way some
sects brainwash their children!"
Such statements suggest not only
discomfort with the topic of religion
but a lack of understanding of the
significance of religion in the lives of
many people, gross generalization, and
bias with regard to different spiritual
beliefs and religious practices.
Census figures show that, in 1971 ,
95.69 per cent of Canadians who were
asked "What is your religion?", named a
religious preference. The
Judeo-Christian religious denominations
constituted 94.25 per cent of the total
population, while 1 .44 per cent was
comprised of Buddhism, Confuscianism
and "others". 2 it must be noted that
the above figures deal with nominal, not
practiced religion since it is likely that
individuals chose to name a religion
rather than say "no religion".
Whatever
to the
Dimension?
Giving meaning to life
Spiritual beliefs do abound and are a
very vital component of the lives of
many of our patients. When we limit
our nursing assessment to the
identification of the patient s religious
affiliation we severely hamper our
ability to provide the best care
concerning the spiritual dimension.
Since spiritual factors may profoundly
affect a person s response to health,
illness, crisis or death, it is the
responsibility of the nurse in her
assessment to determine what meaning a
patient s spiritual beliefs have for him.
For many, illness is a time for
reflection. "Patients have time to
consider their past, their future and
their values." 3 Where illness poses a
threat to life, one may turn to his
religion for spiritual support. As Gordon
Allport notes, "...under conditions of
fear, illness, bereavement, guilt,
deprivation, insecurity, the restoration
of values through religion is commonly
sought." 4
It is clear, therefore, that
spirituality is not limited to such
religious practices as adherence to
dietary laws, communion, baptism,
circumcision and the last rites, but is
experienced as a relationship with God
that "integrates one s life, vocation and
relationships and gives them meaning." 5
Religion is defined as an organized
system of worship which is
characterized by the possession of
beliefs which the person professes,
norms of morality which regulate the
conduct of the members of the system
of religion and the rites and practices
utilized in the system of worship.
Spirituality, on the other hand, can be
defined as the quality of having a
dynamic and personal relationship with
God. Although the most common forms
of spiritual beliefs are founded in
theology one cannot ignore the fact that
religion can be atheistic. Jourard states
that "Whatever a person takes to be the
highest value in life can be regarded as
his god, the focus and purpose of his
time and life." 6 Every man needs a
purpose in order to give his life
meaning, and that meaning is a
personally perceived phenomenon,
whether it is related to a personal
relationship with God, or a non theistic
activating force.
Man also strives to find the
meaning in his suffering and as Viktor
Donelda Ellis Frankl, who survived
the horrors of the
World War II
concentration camps
states, "man s main
concern is not to
gain pleasure or to
avoid pain but rather
to see a meaning in
his life." 7 Frankl
also sees the
majority of patients as considering
themselves accountable to
God. "They represent those who do not
interpret their own lives merely in terms
of a task assigned to them but also in
terms of the taskmaster who has
assigned it to them." 8
The relationship to this "highest
value" and its associated beliefs provide
a unifying and integrating force in the
life of an individual and, therefore,
cannot be ignored by the nurse who
purports to be concerned with the
whole person. The nurse must be
prepared to assess the spiritual
dimension and provide (for) spiritual
help, which Piepgras states "may be
regarded as distinct from either physical
care or emotional support. Although it
leads into new directions it is no less
real and needs to be examined openly
and discussed intellectually." 9
Assessment and approach
The spiritual dimension is not a separate
department of an individual s life but an
integrated and integrating force of the
total person. The nurse can assess the
individual s perception of how his
spiritual beliefs influence the ways in
which he attempts to satisfy basic
human needs. To assess this area some
guidelines are necessary; the following
are suggested for your consideration.
the assessment should be
integrated with other forms of history/
information methods
the approach must be sensitive
and based on a relationship of trust
between the patient and nurse
respect for silence or objection is
essential
questions require (1) an
appropriate format as with other
psychosocial areas and (2) language
suitable and comfortable for both nurse
and patient.
The assessment interview can elicit
information about how the individual s
spiritual beliefs affect his needs:
1 for achievement and purpose in life,
e.g. how these beliefs determine use of
time, money and talents
2 for love, a sense of belonging and
dependence, e.g. source of solace in
times of desolation
3 for feelings of self worth, e.g.
factors that increase or decrease feelings
of self esteem or the esteem of others
including God
42 Sntmhftr 1Qft(l
4 for feelings of safety, security,
wholeness or integrity, e.g. source of
help when feeling insecure, anxious or
threatened
5 for sensory stimulation and
satisfaction, e.g. degree of enjoyment of
religious practices such as music,
ceremonies, prayers, reading etc. 10
Most questions could
appropriately be posed while the nurse
is giving physical care such as bathing or
helping with a meal. Insensitive and
poorly timed questions will lead to
difficulties. Information can also be
gathered through the observation of cues:
a Star of David about the neck,
religious literature or a rosary at the
beside
spontaneous questions such as,
"Why does God let this happen to me?"
or statements suchas Tm afraid of dying."
facial expressions indicating
depression, fear, doubt or despair
"The casual, and even amusing
mention of God or religion to test out
the nurse s reaction" 11 ...possibly
indicating a cry for help.
The manner of the nurse is a
significant influence on the quantity
and quality of information obtained.
Even though the nurse might not have a
particular concern for spiritual life, this
does not exclude her from the
obligation to be aware of the patient s
needs in this area. She needs to
demonstrate empathy and
non-judgmental understanding while
assessing and carrying out nursing care,
whether she intervenes directly or
arranges for a lay person or a member of
the clergy to provide spiritual support.
If the general goal of nursing is
"holistic" care for individuals then we
cannot deny the spiritual/religious
dimension of the person. We must
recognize the potential healing force of
all aspects of the person s life. What sort
of assistance can the nurse offer?
Because of the variety of beliefs and
practices it is difficult to be specific,
however a few concrete examples are
possible:
1 . helping to arrange for solitude or
privacy if necessary for prayer,
meditation or other practices
2. being open to cues that indicate a
desire to discuss spiritual concerns
3. arranging schedules of care to allow
for visits of chaplain, rabbi or others
4. providing the necessary assistance for
the patient to attend services.
Piepgras states: "Spiritual help is
different from emotional support.
Whereas the latter concerns itself with a
relationship of a person to himself and
his environment, the former concerns a
person s relationship to a higher being.
This relationship is personal and even
though its concepts and the specific
supporting philosophy may be shared
by others, it is still an T-You or
God-Man relationship ." 12
Conclusion
We give lip service to offering care to
the total person, while consistently
avoiding discussion of spiritual/religious
matters. My contention is that we must
become active in this domain. Our
approach must be more intellectual,
beginning with an attempt to
understand the reasons for the present
situation of neglect. From there we
must incorporate methods of assessment
and care into both our theory and
practice. This must become a visible
area of study and activity in nursing. *
References
1 Du Gas, Beverly Witter.
Introduction to patient care: a
comprehensive approach to nursing.
3d ed. Toronto. Saunders; 1977: p. 108.
2 Canada. Statistics Canada.
Population: general characteristics.
Vol.1, Pt.3. Religious denominations.
Ottawa, 1971. (Catalogue no.92-724).
3 Simsen, B. Spiritual dimension
NZNurs.J. 69(1): 12-14; 1976 Jan..
p.12.
4 Allport, Gordon W. The individual
and his religion. New York. Macmillan;
1962: p.l.
5 Stoll, Ruth I. Guidelines for
spiritual assessment. Amer.J.Nurs.
79(9): 1574-1577; 1979 Sep.. p. 1574.
6 Jourard, Sidney M. Healthy
personality: an approach from the
viewpoint of humanistic psychology.
New York: Macmillan; 1974: p.307.
Frank], Viktor. Alan s search for
meaning. Boston: Beacon Press; 1962:
p.115.
Ibid., p. 112.
9 Piepgras, Ruth. The other
dimension: spiritual help Amer.J.Nurs.
68(12). 2610-2613; 1968 Dec.: p. 2612.
10 Campbell, M.A. et al. "A model
for nursing. University of British
Columbia School of Nursing. Nurs.Pap.
8(2): 5-9; 1976 Summer.
11 Simsen, op.cit.:p. 13.
12 Piepgras, op.cit.
Donelda Ellis, RN, BScN, MSN, is a
graduate of Toronto Western Hospital
School of Nursing, the University of
Western Ontario and the University of
British Columbia. She has held teaching
and administrative positions at the
University of Alberta Hospital and
Wusasa Hospital, Nigeria and has been a
CHN with the Vancouver Health
Department. Donelda is currently an
instructor in the University of British
Columbia School of Nursing.
DENIAL
Gisele Fontaine Kermer
He said it would be our last
Christmas together.
I thought it was because I was
moving away.
He sent my sister all the family
slides to divide between us.
It struck me as a rather strange
thing to do. I mean, why now?
He spent more time at home,
thinking about the past and
updatingthe family history.
I didn t get letters about hockey
games at the arena or dinners
with friends, anymore.
He got the flu the flu! They put
him in hospital. He needed rest,
that s all. He d gotten well before
and he would again.
I knew that! After all, I was
the nurse. ..wasn t I?
The summer would be a better
time to visit anyway.
I d tell him about my writing
projects then something I rarely
shared with anyone.
There was time. Lots of time.
Summer never came. ..death did.
My Dad!
Gisele Fontaine Kermer, RN, author of
"Denial", works as a lab demonstrator
in the Nursing Diploma Program at
Langara College in Vancouver. From
time to time she also teaches Basic
Cardiac Life Support at the Royal
Columbian Hospital/Douglas College
Education Center. Writing, she says, is
her way of sorting out her thoughts;
"Denial" was written following the
death of her father last Spring. "I
wrote it for him," Gisele comments,
"but perhaps other nurses can identify
with it. "
C
< are for cancer patients has changed in
many ways over the past five to 10
years. Some of these changes are the
direct result of rapidly changing
methods of treatment ; others are the
result of changing philosophies and
administration of care. Specialization in
"oncology " has also become a reality
for both medicine and nursing and,
particularly in the larger medical
centers, this directly affects the
organization of patient services. Acute
care oncology units, outpatient cancer
clinics, palliative care units or hospices
(with or without home care programs),
community nursing programs for home
care... all of these services are active or
developing at the present time in various
parts of the country.
As nurses working with cancer
patients in this time of rapid change, we
are concerned with the quality of
patient services and the role of nursing
in these services. We want to share with
you our philosophy and objectives for
"oncology " nursing, and outline our
thoughts on administration of an acute
care oncology unit. We hope that
putting our thoughts on paper will
help you if you are in a similar
situation; we hope too that it will
facilitate discussion of some of the
larger issues involved, those we cannot
deal with in this paper, for example,
patient advocacy, pros and cons of
specialization, continuity of patient
care between services, postgraduate
programs for oncology nursing, etc.
Diana Law and Barbara Price
Philosophy of oncology nursing
We list here the major beliefs in our
philosophy of oncology nursing so that
you may consider them in devising
your own. We believe:
cancer is increasingly a chronic
illness with intermittent acute episodes,
rather than an acute illness with early
death
nursing care of patients diagnosed
with cancer is a distinct nursing
specialty
oncology nursing is an integral
part of a multidisciplinary, coordinated
approach to patient care
the main focus of care should
always be on the optimal functioning
of the patient and family at any stage of
the illness
the nurse should act as the patient
advocate when necessary
the patient has a right to know
the disease, prognosis and plan of
treatment and should be included in the
decision-making
it is important to do nursing
research and to assist and support our
colleagues in their research efforts.
Our objectives are:
to deliver comprehensive quality
health care to each patient and family
by establishing policies, procedures and
standards of care
to develop an awareness and
understanding of the patient with
cancer and to realize the impact of the
illness on the family
to provide patient and family
education as a consistent part of care
to provide for outpatient care so
the patient can remain an active family
member
to monitor standards of
professional performance through
constant evaluation and to provide for
staff counseling as necessary
to provide and encourage an
atmosphere of learning and staff
development through orientation and
continuing education programs
to support the nursing profession
by exemplifying quality care to nursing
students
to maintain relationships with
other departments
to provide job descriptions which
define the role of oncology nursing and
clarify functions of each level of nursing
practice
to participate in research to
improve patient care.
We believe it is important to have
our objectives clearly defined and
adopted by all nursing staff. These
objectives evolved from daily
experiences on the unit, especially those
surrounding difficult issues such as
cure vs. care, staff and personal
conflicts, family participation, etc. We
use every opportunity that arises to
further develop our goals: sharing
experiences, concerns and ideas in unit
meetings, at coffee break, and during
incidental problem solving situations.
We attempt to realize our objectives on
a daily basis through head nurse -
primary nurse rounds and conferences
with other team members (social
worker, dietician, etc.) as necessary to
plan patient care.
Staffing
Patients on an acute care oncology care
unit are generally in the midst of
aggressive treatment for their
malignancy. Although the available
treatments hold out hope of cure or
longer remission periods for many
patients, these new protocols often
place the patient in a position of
physical and emotional jeopardy. Toxic
side effects of therapy include alopecia,
nausea, vomiting, neurotoxicity,
immunosuppression, stomatitis, bone
marrow depression, carditoxicity,
hemorrhagic cystitis and renal and/or
liver failure. From admission to
discharge the patient will require
intensive nursing observation and
intervention and this is a major factor in
the staffing requirements affecting both
quantity and quality. We have based our
personnel requirements (see Figure one)
on a 38-bed-unit.
There are few formally trained
oncology nurses due to the lack of
training programs in Canada; the nurse
seeking such training must go to either
the United States or Britain. We have
learned, however, that training and
experience need not be top priority
considerations in the hiring of staff; the
important qualifications are much
broader in scope. Many explicit
questions should be asked by nursing
management when considering the
"type" of nurse qualified to work on
an oncology unit:
What is it about this kind of nursing
position that made you apply?
What do you feel you would need to
know before you could do this job?
What are some of vour goals for this
fob?
How will you accomplish these goals?
How would you describe your
leadership style? Why?
What about yourself could be improved
or strengthened?
What do you enjoy most about nursing?
What kind of people do you work best
with?
The initial interview is critical in
selection of staff for an oncology unit.
The head nurse must have a large part
in the decision to hire ; we consider this
a joint responsibility of the coordinator
and head nurse.
There should be a pool of
permanent part time staff for this unit
that allows for staff replacements by
experienced nurses during sick leave,
vacations, etc.
iJhifts
The question of the numbers of hours
nurses should work in a shift (eight or
1 2) on an oncology unit is always an
issue of debate. Some concerns that
have been raised in other institutions
are:
Can nurses endure 12 hours of
active duty considering the intensity of
nursing required or does having several
days off in a row provide a needed
break?
Does the 1 2 hour shift provide
greater continuity of care? per day?
per week?
Will the 1 2 hour shift be routine
for full and part time staff? If not,
what problems will this create?
D.
"elivery of nursing service
Discussion of the general organization
must be considered in two ways:
the functioning of the multi-
disciplinary care team and
the delivery of nursing care to
patients.
The traditional hierarchy no
longer provides an efficient system for
coordinating care because of increasing
technology, more specialized
professionals and the need for rapid,
complex decision making. A "matrix
organization" system is a better
approach for functioning of a multi-
disciplinary care team. This form of
organization embraces both hierarchical
(vertical) and lateral (horizontal)
communication and coordination. Two
methods of facilitating communication
and enhancing the reality of matrix
organization are: (1) to physically
design or arrange the unit so that staff
are more likely to mix and exchange
ideas and concerns about patient care
and (2) to have rounds for all staff that
are organized and timed so that as many
as possible can attend. We want nurses
to participate more in decision making
and to enhance their education; the
lateral communication within the
matrix organizational form offers more
opportunities for individual initiative
and participation. The quality and
effectiveness of such organization
naturally depends on moving these
concepts from discussion to use.
For delivery of nursing care to
patients we advocate primary nursing
rather than team nursing. Because of
their illness, patients will be involved
with nurses, doctors and other health
professionals, their relationships with
family and friends will be affected and
many personal changes will occur. A
system like primary nursing with a
one-to-one, nurse-patient relationship
Acute Care Oncology Unit: - Projected Nursing Complement and Mix
Research Nurse - I HN - I Clinical Nurse Specialist
33 Beds
Extra Care Unit - 4 Beds
1 AHN
35. 5 SN
3 RNA
2 U.C.
1.9 Unit Aide
This will yield 6.5
nursing hours per
patient per 24 hours.
I AHN
15.8 SN
I U.C.
This will yield 16
nursing hours per
patient per 24 hours.
Fig.
The Canadian Nurse
September 1980 45
Matrix Organization
JNCTIONAL
Medical Director of
Staff Nursing
Social
Work
Dietary
Home
Care
Pharmacy
Volunteers
Etc.
i
Onoci
Nurs
Coord
)logy
ng
inator
U-
B
h-
ct
t
CO
oo
O
Ci.
LO
LU
Of
"Clinical
id
"Research
Nurse
Specialist
He<
Nu
Nurse
rse
5
Q
< > Prirt
iary
Nurse
i
THE PATIENT CARE TEAM
"The positions of clinical nurse specialist and research nurse may evolve as the global needs
of our oncology unit become more clearly defined and operational.
Fig. 2
is necessary so the nurse can act as a
mediator and facilitator.
The central principles of primary
nursing are :
24 hour-a-day accountability for
the nurse realized through written and
verbal planning and communication
a case method of assignment in
which care planner is care giver; the
nurse gives total patient care : initial
assessment, planning, implementing and
evaluating that care.
We are now in our third year of
"modified" primary nursing and we
continue to strive towards full
implementation of the concept. The
process of change from team to primary
nursing has brought considerable
anxiety, frustration, joy and
satisfaction. The two greatest hurdles
have been the psychological aspects of
change and the mechanics of patient
staff assignments; we have tried to meet
these challenges through unit meetings
and combined, planning efforts.
In comparing team and primary
nursing after our three year experience
we have concluded that primary
nursing:
offers more holistic, patient
centered care (as opposed to fragmented
task oriented care)
makes communication less
complex because the primary nurse is
central and a direct patient link
increases autonomous functioning
of the nurse, thus furthering self-
development
encourages constant learning
makes the staff nurse role less
managerial and more clinically oriented
allows the matching of patient-
nurse needs and abilities.
Jtaff development
Ours is a "four point" program for staff
development that covers the following
areas:
orientation program
continuing education program
staff exchange program
staff stress-reduction program.
Orientation program
Oncology nurses must become
knowledgeable in the fields of
hematology, infectious disease,
immunology, radiation therapy,
chemotherapy of neoplastic disease and
psychology. Developing expertise in
physical and emotional assessment of
patients with cancer is another required
skill. An adequate orientation program
must offer the new staff nurse both
information and time to gain practical
experience. Methods for achieving a
good program are many and varied, but
it is essential to have objectives clearly
defined first. Staff nurses should be
involved in the development of the
program.
Suggestions for specific program
content include:
I General information about the organi
zation of the hospital and unit; the
philosophy and objectives of oncology
nursing; clinical information: pathology
of neoplasms, detection and treatment
procedures, pain control, theories of
chronic illness and rehabilitation,
community resources, death and dying,
etc.
II Practical experience in new technical
skills, e.g. starting IV s, preparation and
administration of antineoplastic drugs,
etc.; physical and emotional assessment
of patients; experience in nursing
patients with specific symptoms of
cancer or suffering side effects of
therapy; and participating in rounds,
patient care conferences, etc.
At the end of the orientation
period the head nurse and new
employees should meet for an
evaluation session. This should be a
time to exchange perceptions and to
determine plans for further
development.
Continuing education
Some plan for continuing education for
staff is an administrative must ; one very
good reason for this is the continual
change in medical treatment modalities
which directly affects nursing care. It
will be necessary then to consider this in
planning staff schedules; if education is
46 September 1980
to be effective it must become a part of
the philosophy and functioning of the
unit. Whether programs are formal or
informal, conducted on the unit or off,
organized by hospital inservice or unit
personnel, is not the significant factor:
any arrangement that suits the
institution and works for staff is a
positive option. The crucial factor is
administrative and staff commitment to
an educational program as one method
of improving patient care.
Staff exchange program
Another method for staff development
we have found invaluable is to have an
exchange of staff with an outpatient
treatment clinic. This exchange of staff
between different types of treatment
facilities should help meet the following
objectives:
to provide oncology nurses with
the chance to appreciate the total
course of illness and treatment initial
diagnosis, treatment on an in or
outpatient basis, partial or complete
remissions, and/or terminal care
to help nurses working in
palliative care maintain a positive
attitude toward treatment of malignant
disease
to help foster a realistic attitude
toward malignant disease so that
appropriate recognition and treatment
will ensue if the patient reaches a
terminal phase.
We hope to designate an "extra care"
unit within our larger unit, using a core
of specially trained nurses. Should this
become a reality, we will develop a
schedule to rotate all nursing staff
through this area to broaden their
experience.
Stress-reduction program
The stress of continually nursing
patients with cancer must be taken into
administrative consideration. As with
the educational areas probably the most
important thing is to be serious about
this need and to have some action plan.
Group sessions might be useful for this
purpose; other hospital staff could act
as resource persons for these groups,
for example, other nurses, chaplains,
social workers, etc. Staff could develop
methods of helping each other or a list
of staff able and willing to offer
individual help could be made available;
the variety of possibilities is great.
Perhaps the arrangements made for
helping staff might also be a useful
adjunct in helping patients and their
families.
Conclusion
We continue to work towards our
goals; some of our present activities
are:
working on a design for the unit
that will help us meet our objectives
completing an outline for a
THE PATIENT CARE TEAM
Head
Nurse
Social
Service
Physicians
Home
Care
Family .
certification course for oncology
nursing
having a pastoral care resident
work with patients, families and staff
to offer support and leadership
exploring concepts for future use
in a patient-family education program.
It is not easy to plan and
implement any new program; that s why
we have chosen to share our ideas and
experiences with you. *
*Bibliography
Neuhauser, Duncan. The hospital as a
matrix organization. Hospital adminis
tration; Fall, 1972.
*Not verified
Acknowledgement : Information
gathered from the following institutions
is gratefully acknowledged: Cross
Cancer Institute, Edmonton, Alberta;
Cardiovascular Unit, Holy Cross
Hospital, Calgary, Alberta; St. Jude
Children s Research Hospital, Memphis,
Tennessee; Southern Alberta Pediatric
Oncology Program; University of
Minnesota Hospitals, Minneapolis,
Minnesota.
We would like to acknowledge the
support and encouragement of other
members of Foothills Hospital staff:
Mrs. Marg Harris, Director of Nursing;
Brian Wright, Coordinator of
Educational Services; Ben Ruether, MD,
Division Chief - Hematology: Jim
Russell, MD - Medical Oncologist; and
also Martin Jerry, MD - Director of the
Southern Alberta Cancer Centre.
Diana C. Law, RN, BScN, is a graduate
of the Toronto General Hospital School
of Nursing and has completed a
postgraduate course in psychiatric
nursing. She is working at the Foothills
Hospital in Calgary as medical nursing
coordinator. She is also the author of an
article in the February issue of The
Canadian Nurse on chemotherapy.
Barbara J. Price, RN, is a graduate of
St. Michael s School of Nursing in
Lethbridge, Alberta and has completed
a postgraduate course in pediatric
oncology. She has held various
positions at the Foothills Hospital in
Calgary where she is presently working
as an instructor. Her article on caring
for the child with cancer appeared in
the December, 1979 issue of The
Canadian Nurse.
Volunteers
Fig. 3
ThA rannrlln NnrftA
September 1980 47
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Finally, you get to decide when
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When the code words "Matron
Please Call" were announced at St.
Joseph s Hospital in Hamilton, Ontario, nurses
the eight-story Surgical Tower thought
was a routine fire alarm. Little did they ^
now that in just over an hour more than
00 patients would be evacuated as^fresult
a boiler room fire. What s it like when the
real thing happens?
^
I
f
Cathy Squires
On the morning of Thursday, May 1 ,
1980, general medicine staff nurse,
Georgia Schmiedeberg was clearing up
the breakfast trays of her 16 chronic
care patients when thick, acrid smoke
poured into the corridors.
Four floors up, cardio respiratory
head nurse, Thelma Blair, also noticed a
faint smell of smoke. Convinced it was
coming from the garbage shoot, she
ordered all patients into their rooms and
the nurses to seal the doors with wet
towels but, seconds later, the
eye-stinging smoke began spewing out
of the vents in each room. She quickly
had all patients moved out into the hall.
Meanwhile in orthopedics, head
nurse Sarah Fleming sensed trouble and
began handing out masks and wet face
cloths to her patients. When the order
to evacuate came at 9:50 a.m., she
quickly began a production line to have
them moved down four flights of stairs.
The traction on one patient was
removed; another patient with a spinal
fusion had to be loaded onto a
stretcher.
By the time many of the staff at
St. Joseph s realized the alarm was for
real, evacuation procedures were well
under way. Production lines to move
bedridden patients down the two
remaining stairwells had been formed
automatically. Housekeepers, volunteers
and maintenance men carried patients
out into the parking lot while those who
were ambulatory linked arms and made
their own way outside.
Nurses on their day off suddenly
appeared on the scene - some clad in
jeans. Those without their pins were not
allowed to enter the building but
instead acted as taxis, driving patients
home.
Sue Spence, a general medicine
staff nurse, had just arrived home from
working the evening shift when she
heard the news. Reaching for her
uniform, she raced out the door and ran
September 1980 49
the two blocks back to the hospital.
Weaving her way through the crowd, she
arrived at the main entrance and
immediately pitched in no questions
asked.
By 10:30 a.m. the parking lot at
St. Joseph s was jammed with patients
on stretchers, wheelchairs and
mattresses. All were bundled in blankets
and many were accompanied by nurses
holding IV bottles. Within moments 38
ambulances, 8 city buses, 1 1 fire trucks
and even a postal truck arrived on the
scene to transport them to waiting
hospitals.
Evacuation
The electrical fire was the second test of
emergency procedures for the staff at
St. Joseph s. Five months before,
patients evacuated from Mississauga
hospitals exposed to chlorine gas during
a train derailment were brought to
Hamilton.
Director of nursing, Margaret
Peart describes the procedure on the
day of the fire as quiet and without any
signs of panic. "I m really proud of the
way the nurses acted," she says. "They
kept their cool and used good
judgement." Peart says the nurses put
themselves at personal risk and
conducted themselves in a professional,
caring manner.
Pediatrics on the third floor was
the first to be evacuated. Staff nurse
Sheila Maggio recollects that the
children were carried out on a
one-to-one basis. "The mothers listened
and did what we told them to do," she
says. "But if we hadn t been there, I m
sure they would have taken their babies
and run."
Pediatrics head nurse Donna
Danecker never thought the ward would
have to be evacuated, but when a little
girl ran past her saying "she wasn t
going to stay to burn," she began to
think about the possibility. One of her
main concerns was a teenager with brain
damage. "I knew she would be difficult
to move," says Danecker. Eventually
the teenager was put on a stretcher and
brought out along with the rest of the
patients. Firemen smashed more than a
dozen windows in the pediatric ward.
The only people left in the
building after the evacuation were the
surgical teams for two operations in
progress. Eight operations had been
scheduled that morning but only two
had begun. OR head nurse Phyllis
Morelli remembers that nurses in the
operating theatres felt "very closed in".
"They all had an uneasy feeling about
what was going on outside," she says.
"They didn t know how bad the fire
actually was."
Although the OR nurses stuffed
et towels around the doors, smoke
wasn t a problem: each theatre has its
own air supply. When the operations
finished more than two hours after the
evacuation had begun, the patients were
sent to McMaster University Hospital to
recover. Morelli says the nurses in OR
were prepared if necessary to pack the
wounds with sterile dressings and get
out quickly.
St. Joseph s patients were sent to
other local hospitals such as Chedoke,
McMaster, Henderson and Hamilton
General Hospital; several nearby nursing
homes also took in patients.
Associate director of nursing at
McMaster, Sonia Franklin says the
hospital s disaster plan was put into
effect the moment the call for help
came. Two closed wards were opened
up immediately and as many patients as
possible were discharged to make way
for the incoming patients from St.
Joseph s. The busier tilings got, the
smoother they ran; more than 60
pediatric and surgical patients were
triaged and settled into the 35-bed
wards at McMaster within two hours.
Franklin describes the transfer as
smooth and commendable. "Everyone
rose to the initial disaster," she says.
"People came in on their day off and
heads of departments were cleaning
beds." After awhile, however, Franklin
says, the continual pace began to tell on
her staff. "Everyone s adrenalin was up
for the first day but eventually my
nurses felt the strain."
Aftermath
Although nurses from St. Jo s were used
to staff the new wards at McMaster, the
fact that there was one less hospital
operating in town created temporary
pressures on the remaining facilities. For
example, while St. Joseph s was closed,
Franklin noticed a definite increase in
labor and delivery patients.
She realized that there were
problems for the nurses from St.
Joseph s as well. "Little things made the
adjustment difficult," she said. "Each
hospital has its own way of doing
things like charting."
Margaret Peart agrees that minor
details caused a bit of friction. "I went
over to check on my nurses and none of
them were wearing their caps," she
smiled. "At St. Jo s we always wear
caps. My nurses told me McMaster
nurses didn t wear caps and that they d
feel too out of place wearing them.
What could I do?"
Although the nurses involved in
the evacuation came through with flying
colors, their director of nursing worries
there are still some emotional scars
they ll have to deal with. Orthopedics
nurse Fleming, for example, admits she
shook for more than an hour when she
got home that night and didn t sleep for
three days thinking how lucky they
were. The lounge set up for the nurses
following the disaster provided a place
to talk and come to terms with their
initial feelings. "But it s going to be a
long while before these nurses feel
comfortable again," Peart comments.
On one tiling though, every nurse
agrees: the episode brought them closer
together and reassured them that they
could deal with such a situation if it
ever happened again.*
50 September 1980
Timely concepts and
current techniques...
> KHJPOAH
ii IR MEDICAt
Lippincott
1 THE NURSE PERSON:
Developing Perspectives for
Contemporary Nursing
By Lillian M. Simms, R.N., Ph.D.; and
Janice B. Lindberg, R.N., M.A.
*Reviewed by Susan W. Talbott,
R.N., M.A., M.B.A.-The American
Journal of Nursing.
"It is refreshing to find a nursing
text that asks more questions than it
answers. The authors address the
nursing student as a unique human
being who wants to become a hu
manistic, realistic, and competent
nurse. The student is encouraged to
consider her own strengths, weak
nesses, and philosophical outlook.
. . . The focus on nursing as a
profession, with distinct and unique
services to offer society, plus a real
istic and questioning review of such
contemporary issues as patients need
for individualized care, nurses needs
for decision-making and communica
tion skills, role conflicts faced by
nurses, the status of women, and
concern for health economics make
this text a strong link between the
classroom and the real world. It can
be put to good use in baccalaureate
refresher programs."
Harper & Row. 243 Pages. 1979.
$13.25.
2 ESSENTIALS OF NURSING
RESEARCH, 2nd Edition
By Lucille E. Notter, R.N., Ed.D.
*Reviewed by Dolores Brown, Ph.D.
Nursing Outlook.
"The general format is well orga
nized and easy to follow, with the
content presented in an uncomplica
ted style. The glossary of selected
research terms enhances comprehen
sion of subject matter discussed
throughout the book. The author
achieves her stated purpose: intro
ducing the reader to the research
process and discussing specific know
ledge and skills essential for conduc
ting scientific inquiries.
This is an excellent reference for
students in baccalaureate programs
who need to develop an appreciation
for research and acquire fundamen
tals to be used at the entry level of
practice. To all nurses in current
practice who have not had the bene
fit of formal exposure to the research
process but have the desire to con
duct clinical investigations, this refer
ence is an invaluable tool."
Springer. 178 Pages. 1978.
Paper, $10.25. Cloth, $16.75.
3 CASE STUDIES IN
NEUROLOGICAL
NURSING
B. S. Wehremaker, R.N., B.A.; and
J. Wintermute, R.N., M.A.
*Reviewed by Phyllis Durnford in the
Canadian Nurse.
"The major purpose of this collec
tion of case studies is to provide nurses
with a "framework of practical know
ledge in the neurological sciences".
This purpose is achieved by beginning
the book with a review section, clearly
and concisely written, on neuroana-
tomy and physiology and in the pre
sentation of case studies. . .
Each of the case studies follows a
question and answer format for the
particular disorder being discussed.
The information given in response to
each question follows loosely the
ideas of the Nursing Process, i.e. infor
mation needed for assessment of the
patient and care planning, to various
types of testing methods, to the nurs
ing management of that patient.
Nurses who would benefit from
reading this book would be those
working on a neurological service, or
in an outpatient neurology clinic.
Others for whom certain conditions
would be relevant would be those
working on a general medical unit,
where patients with transient ischae-
mic attacks, or cerebrovascular acci
dents are normally admitted."
Little, Brown. 304 Pages. 1978.
$10.75.
4 A GUIDE TO PHYSICAL
EXAMINATION,
2nd Edition
By Barbara Bates, M.D.
*Reviewed by Molly C. Billingsley,
R.N., Ed.D. -Nursing Outlook.
"This is the second edition of
the highly popular 1974 textbook,
which has been widely used and is
appropriate for undergraduate, gra
duate, and continuing education stu
dents in nursing as well as other
ancillary health personnel. The orga
nization of this edition is similar to
that of the first and is essentially
based on the medical model. Fol
lowing new content on interviewing
and classically recording as assess
ment, the next 15 chapters address
the systems of the body via discus
sion of anatomy and physiology,
techniques of examination, and com
mon abnormalities. In combination
with a well-taught didactic course
and supervised practicum, the book
offers a cogent, readable approach to
learning physical assessment. It is
also useful as a first-line reference for
validating identification of anomalies
commonly encountered in nursing
practice ... It continues to be the
classic of its kind."
Lippincott. 440 Pages. 1979. $29.75
J. B. LIPPINCOTT COMPANY OF CANADA LTD., 75 Horner Avenue, Toronto, Ontario M8Z 4X7
D Payment enclosed (postage and handling paid) D Bill me (plus postage and handling)
Please send me the following books for 15 days on approval : 1 2-P 2-C1 3 4
Name Department
Address Apt.
City /Town
Prices subject to change without notice.
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P. C.
CN-9-80
The Canadian Nurse
September 1980 51
KGRLIX*
here s how
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INNOVATORS IN PATIENT CARE
Kendall Canada/6 Curity Avenue
Toronto, Ontario M4B 1X2
Registered Trademark
To prevent retaking blood samples
Once a patient has had blood drawn for
"group and screen" place an orange
self-adhesive dot with the date on the
patient identification armband; add a
red dot when a cross match is done.
This system allows for a quick check on
what has been done and prevents
unnecessary discomfort for the patient.
-Kathy Trip, RN, IV Team, Toronto
East General and Orthopedic Hospital
Hospitals are O.K.
At the Stanton Yellowknife Hospital
the pediatric staff have designed a
"Travelling Trunk" program to orient
schoolchildren to the hospital. Many
ideas came from the successful
"travelling suitcase" program of the
child life department, Isaac Walton
Killam Hospital in Halifax. Our program
is meant for children in the Indian
settlements near Yellowknife and the
Inuit communities of the MacKenzie
Zone. The program is for use in the
classroom and it is hoped that the
teachers will ask local health personnel
to act as resource people.
Each trunk includes:
an instruction manual
the puppet "Tony Tonsillectomy"
with removable tonsils, an
appendectomy scar and a strip of
detachable hair
pieces of hospital equipment:
stethoscopes, caps, gowns and masks,
etc.
a slide presentation on a child s
admission to Stanton Hospital; two
tapes, one in English, the second in the
common native language
a film entitled "A Hospital Visit
with Clipper"
a coloring book to keep.
The trunk is on loan for about a
month and is then sent back to the
hospital for replenishing and forwarding
to the next stop. An evaluation form is
included for feedback on the program.
We hope this program will help
children agree with Tony Tonsillectomy
that "hospitals are O.K."
Pat Zehr, Chesley, Ontario. .
Did you know...
Patients who use Medisets, containers
which hold a seven day supply of a
multiple drug regimen, are more likely
to comply with drug routine than
patients who use safety-cap prescription
vials. Research reported in the Journal
of Hospital Pharmacy 37:379-84
reported that patients like this container
because pills are easily removed from it
and it helps them and family members
keep track of what has been taken and
what needs to be taken. The only
negative comment made was on the
bulkiness of the container. Since the
container is not childproof it should not
be used in homes where there are small
children.*
52 September 1980
The Canadian Nurse
I lie i^MiiduiH
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KGRLIX
here s how
DISPOSABLE LAP SPONGES
Lint free, prewe
read}
To prevent retaking blood samples
Once a patient has had blood drawn for
"group and screen" place an orange
self-adhesive dot with the date on the
patient identification armband; add a
red dot when a cross match is done.
This system allows for a quick check on
what has been done and prevents
unnecessary discomfort for the patient.
-Kathy Trip, RN, IV Team, Toronto
East General and Orthopedic Hospital
Hospitals are O.K.
At the Stanton Yellowknife Hospital
the pediatric staff have designed a
"Travelling Trunk" program to orient
schoolchildren to the hospital. Many
ideas came from the successful
"travelling suitcase" program of the
child life department, Isaac Walton
Killam Hospital in Halifax. Our program
is meant for children in the Indian
settlements near Yellowknife and the
Inuit communities of the MacKenzie
Zone. The program is for use in the
classroom and it is hoped that the
teachers will ask local health personnel
to act as resource people.
Each trunk includes:
an instruction manual
THE new ENCYCLOPAEDIA BRITANNICA
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No more unsightly, stained
sponges, or inspection and repair of
reusable sponges.
INNOVATORS IN PATIENT CARE
Kendall Canada/6 Curity Avenue
Toronto, Ontario M4B 1X2
Registered Trademark
to comply witn drug routine than
patients who use safety-cap prescription
vials. Research reported in the Journal
of Hospital Pharmacy 37:379-84
reported that patients like this container
because pills are easily removed from it
and it helps them and family members
keep track of what has been taken and
what needs to be taken. The only
negative comment made was on the
bulkiness of the container. Since the
container is not childproof it should not
be used in homes where there are small
children.*
52 September 1980
_- - _,i. ... -,. . _w
The Canadian Nurse
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Input (continued from page 1 1 )
Our "well-being"
The April issue was undoubtedly
one of the best that I have ever enjoyed.
Having worked in "prevention" (from
the dental health end) for the past seven
years I am particularly pleased to see
the continuing emergence of the nurse
as a key person in optimal health
promotion.
Being fit and well is the best gift
we could ever share with our fellow
humans; and as driving forces in the
health field it is very much our
responsibility to do whatever we can.
-Linda Anaka, RN, Revelstoke, B.C.
The voice of the student
Nursing students from the
University of Saskatchewan were among
those who presented briefs to Health
Services Review 79. As members of this
group we would like to highlight some
of our recommendations, particularly
those related to education, research and
the expanded role of the nursing
component in the health care system :
nurses are working to define new roles;
improvements in educational programs
have led to the development of nursing
expertise and the legitimate right to
practice as autonomous professionals.
We see nursing research as a
necessary framework for the
development of new concepts in health
care, as well as the improvement of
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present clinical skills. We recognize the
inadequacy of funds for nursing
research as a problem needing attention.
One solution may be in the realm of
research centers, and the provision of
ongoing funding for research studies.
Findings presented to the Kellogg
National Seminar (December, 1978)
indicate that only 51 of Canada s
180,000 nurses are prepared at the
doctoral level and only six of these have
doctoral degrees in nursing. Canadian
nurses, including educators, are in dire
need of doctoral programs in nursing.
We recommend, therefore, that these
programs be established in Canada s
four main regions and that masters
degree programs in nursing be
established in each Canadian province.
The reluctance of health care
professionals to see collaboration as a
means of filling gaps in the health care
system has resulted in increased health
costs and dissatisfaction among
consumers. The effective utilization of
nursing professionals in expanded roles
can improve the accessibility and
quality of health care delivered to the
public. A mutual recognition of
professional capabilities would enhance
joint practice in which the overlap of
services could virtually be eliminated.
We feel that serious consideration
and implementation of the above will
ultimately have definite positive effects
on our future health care system.
Heather Conway, Meagan Griffin,
Pam Reilly, College of Nursing,
University of Saskatchewan.^
Decubitus Ulcers
An audio-visual
presentation available
on loan, free of charge
This presentation describes treat
ment and dressing techniques for both
simple cutaneous and deep decubitus
ulcers, using BenOxyl 20% (benzoyl
peroxide) Lotion.
The taped narrative, by W.E. Pace,
M.D., M.Sc., F.R.C.P.(C) and Heather
Hanson, R.N., runs for approximately
30 minutes and is supported by a series
of before-and-after illustrative colour
slides.
To complement the slide-tape pre
sentation a folder illustrating the dress
ing techniques is available in quantity.
For any of the above material,
including a complete script, please
write to:
Scientific Services Dept.
Stiefel Laboratories
(Canada) Ltd.
6635 Henri-Bourassa Blvd. W.
Montreal, Quebec H4R 1E1.
From Mosby
to the
Canadian
nurse . . .
Lj-LTl]
TIMES MIRROR
THE C V. MOSBY COMPANY
1 1830 WESTLINE INDUSTRIAL DRIVE
ST LOUIS. MISSOURI 63141
New 2nd Edition!
PATIENT CARE
STANDARDS
By Susan Martin Tucker, R.N., B.S.N., P.H.N.;
Mary Anne Breeding, R.N., B.S.; Mary M.
Canobbio, R.N., M.N.; Eleanor Vargo
Paquette, R.N., B.S.; Marjorie E. Wells, R.N.,
B.S.; and Mary E. Willmann, R.N.
The new edition of this highly-acclaimed
book can help you improve the quality of
patient care and meet JCAH standards.
Organized according to body systems, it
presents standards for medical conditions,
surgical interventions, diagnostic proce
dures, chemotherapeutic agents, and
related supportive mechanical equipment.
Highlights include:
32 new standards
new assessment tools for physical, nu
tritional, psychosocial, pain, spiritual and
aging assessment
expanded patient teaching sections
additional sections on obstetrics and pe
diatrics
definition and laboratory values for each
condition
April, 1980. 576 pages, 168 illustrations. Price,
$20.50.
2nd Edition
CLINICAL IMPLICATIONS OF
LABORATORY TESTS 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. This concise
guide focuses on the clinical
significance of laboratory
tests. Highlights:
step-by-step approach em
phasizes physiological
implications, variations and
interrelations of laboratory
values
new chapters describe tests
for rheumatoid and infec
tious diseases
features special sections on
patient preparation and
care
1979. 334 pages, 45 illustra
tions. Price, $12.00.
A New Book!
CLINICAL MANUAL OF HEALTH
ASSESSMENT. By June M.
Thompson, R.N., M.S. and Arden
C. Bowers, R.N., M.S. This com
prehensive manual guides you
through the mechanics and
analysis of findings to health
assessment:
each chapter covers cogni
tive objectives, clinical objec
tives, related health history,
clinical guidelines, strategies,
plus sample recordings, vo
cabulary, and cognitive self-
assessment
explores assessment of pedi-
atric and geriatric clients
March, 1980. 486 pages, 487
illustrations. Price, $19.25.
New 3rd Edition!
UNDERSTANDING ELECTRO-
CARDIOGRAPHY: Physiologi
cal and Interpretive Concepts.
By Mary Boudreau Conover,
R.N., B.S.N.Ed.; with one contrib
utor. In this new edition, you ll
find:
the latest material on Wolff-
Parkinson-White syndrome
as a cause of paroxysmal
supraventricular tachy-
chardia, atrial fibrilla
tion, and primary ventri
cular fibrillation
a rewritten discussion of
pacemakers
a new, detailed and well-
illustrated discussion of 12-
lead ECG s
a new glossary
May, 1980. 302 pages, 411 illus
trations. Price, $1 3.25.
A New Book!
STANDARDS FOR CRITICAL
CARE. By Brenda Crispell
Johanson, R.N., MA, Ed.M.,
CCRN et al; with 7 contributors.
This new reference provides
more than 60 standards for
conditions and procedures
you encounter in everyday
practice. Each standard:
defines the condition
outlines assessment
discusses behaviorally-
oriented goals for therapy
presents potential problems,
along with criteria for
expected outcome, nursing
orders and patient teaching
November, 1980. Approx. 432
pages, illustrated. About$1 5. 75.
New 2nd Edition!
TECHNIQUES IN BEDSIDE
HEMODYNAMIC MONITOR
ING. By Elaine Kiess Daily, R.N.,
R.C.V.T. and John Speer
Schroeder, M.D.; with 2 contrib
utors. The new edition of this
popular manual presents a
comprehensive "how-to"
guide to bedside hemody-
namic monitoring. Highlights:
thorough explanation of
cardiovascular physiology
and its effects on hemody-
namics
updated material on use of
equipment for obtaining
hemodynamic pressures
physiologic basis for current
use of pharmacologic
agents and their effects on
hemodynamic pressures
August, 1980. Approx. 224
pages, 128 illustrations. About
$13.25.
New 2nd Edition!
HANDBOOK OF PRACTICAL
PHARMACOLOGY. By Sheila A.
Ryan, R.N., M.S.N. and Bruce D.
Clayton, B.S., Pharm. D. This new
edition offers readily accessible
information for the safe admin
istration and monitoring of
commonly used drugs. High
lights:
more than 250 drugs are
indexed
summary charts on adminis
trations, dosage, adjustments
and monitoring included in
the appendices
convenient spiral binding
March, 1980. 376 pages, illui
trated. Price, $1 3.25.
lT
implications of
laboratory tests
Understanding .
ELECTROCARDIOGRAPHY ;
Physiological and interpretive ^
HART BOUDREAU CONOVER
Clinical manual of
Health
assessment
|UNE M.THOMPSON
ARDEN C. BOWERS
PRACTICAL
PHARMACOLOGY
BASIC PATHOPHYSIOLOGY: A
Conceptual Approach. By
Maureen E. Groer, R.N., Ph.D.
and Maureen E. Shekleton, R.N.,
B.S.N., M.S.N. In this useful text,
the vast field of pathophysiol-
ogy is organized into major
conceptual areas. Noteworthy
discussions investigate:
immunopathology
aging as a genetic process
atherosclerosis
diabetes and obesity
immune viral origins of hu
man cancer
1979. 534 pages, 423 illustra
tions. Price, $19.25.
New 2nd Edition!
CLINICAL LABORATORY TESTS:
A Manual for Nurses. By Mar-
cella M. Strand, B.S.N., R.N. and
Lucille A. Elmer, B.S. in M.T.,
M.T.(A.S.C.P.). Designed for
quick reference, this handy
guide will help you transcribe
physicians orders, explain tests
to patients, and collect labora
tory specimens. Highlights:
includes normal adult
ranges along with possible
interferences
lists laboratory abbreviations
in color for added conven
ience
provides guidelines for nurs
ing responsibilities
March, 1980. 168 pages. Price,
$8.50.
All prices subject to change.
Add sales tax if applicable.
AMS21 3
New 5th Editon!
TOTAL PATIENT CARE: Founda
tions and Practice. By Gail H.
Hood, R.N., B.S., M.S. and Judith
R. Dincher, R.N., B.S.N., M.S.Ed.
This new 5th edition features:
new chapters on fluid/
electrolyte imbalance and
community acquired infec
tions
rewritten chapters on the geri
atric patient and preopera-
tive/ postoperative care
more than 200 new illustra
tions
April, 1980. 924 pages, 277 illus
trations. Price, $1 9.25.
A New Book!
LIVING WITH STRESS AND
PROMOTING WELL-BEING: A
Handbook for Nurses. Edited
by Karen E. Claus, Ph.D. and
June T. Bailey, R.N., Ed.D.,
F.A.A.N.; with 9 contributors. This
practical handbook will help
you manage job-related stress.
Highlights:
a section on insight con
cerning stress by Dr. Hans
Selye, "father of the stress
concept"
discussion on the "burnout
syndrome" focusing on the
intensive care unit
a unit of 15 independent
stress-reduction training
modules for nurses
perceptions of stress gath
ered from 1800 nurses
June, 1980. 188 pages, illus
trated. Price, $12.00.
New 2nd Edition!
MOSBY S COMPREHENSIVE
REVIEW OF CRITICAL CARE. By
Donna A. Zschoche, R.N., MA;
with 63 contributors. Using a
question/answer format, this
new edition features:
current information on criti
cal care
1 7 new chapters
33 new contributors
August, 1980. Approx. 1,024
pages, 336 illustrations. About
$30.00.
A New Book!
EMERGENCY NURSING: Princi
ples and Practice. By Susan A.
Budassi, R.N., M.S.N., MICN and
Janet M. Barber, R.N., M.S.N. This
outstanding new volume was
written by emergency nurses
and follows the curriculum for
mat of the ANA Standards of
Emergency Nursing Practice.
Four units examine:
"Introduction to emergency
nursing"
"Basic concepts of emer
gency nursing"
"Medical and surgical emer
gencies"
"Environmental emergen
cies"
September, 1980. Approx. 832
pages, 418 illustrations. About
$22.75.
TIMES MIRROR
THE C V MOSBY COMPANY
11830 WESTLINE INDUSTRIAL DRIVE
ST LOUIS MISSOURI 63141
Fifth edition
Classified
Advertisements
Alberta
British Columbia
British Columbia
R.N. s required. Registered nurses required for
new Brooks Health Centre, complex of 70 beds,
IS bassinettes, 75 nursing home beds. Centrally
located in Southern Alberta between three
large cities. Salary as per Provincial Agreement.
Must be eligible for registration with AARN.
Apply in writing to: Director of Nursing,
Brooks Health Centre, Bag 300, Brooks, Al
berta TOJ OJO.
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Nurses - The Grande Prairie General Hospital,
located in the commercial and industrial heart
of Canada s Peace River Country, invites regis
tered nurses to join their progressive hospital.
This 230-bed hospital complex, currently un
dergoing expansion to match the rapid devel
opment of Grande Prairie, has vacancies in a
number of areas. Assistance in finding employ
ment for spouses is offered to nurses who are
willing to relocate. Apply to: Personnel Direc
tor, Grande Prairie General Hospital, 10409-
98 Street, Grande Prairie, Alberta T8V 2E8
Phone: (403) 532-7711 Ext. 78.
Registered Nurses required in a 68-bed active
treatment hospital in Northeastern Alberta.
Applicants will be required to assume respon
sibility of a given unit Pediatrics, Emergency,
Obstetrics or Medicine and must be willing to
rotate all shifts. Accommodation for tempor
ary or permanent residence is available in the
Nurse s Residence. Salary and benefits in ac
cordance to the newly negotiated provincial
agreement. Apply in writing to: Director of
Nursing, Lac La Biche General Hospital, Box
507, Lac La Biche, Alberta TOA 2CO.
Director of Nursing required for a 30-bed
active treatment hospital in southern Alberta.
The Director of Nursing is responsible for
planning and directing the nursing department,
as well as being directly involved in patient
care. This position will be open September 1,
1980. Milk River is 45 miles south of Leth-
bridge on Highway No. 4, 10 miles from the
U.S. border. Please send resume to:W. Sholdice,
Administrator, Border Counties General Hosp
ital, Box 90, Milk River, Alberta TOK 1MO.
Graduate & Registered Nurses required imme
diately. Opportunity to acquire experience in
all clinical areas of a 75 bed accredited hospital
(located 130 milesN.E. of Edmonton, Alberta).
(Time off in lieu of vacation negotiable). Sal
ary and fringe benefits in agreement with
U.N.A. ($1465-$ 1867). Contact: Director of
Nursing, St. Therese Hospital, Box 880, St.
Paul, Alberta TOA SAO (Phone)403-645-3331.
Required-Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TOK 2GO.
Experienced General Duty Graduate Nurses re
quired forsmall hospital located N.E. Vancouver
Island. Maternity experience preferred. Person
nel policies according to RNABC contract. Res
idence accommodation available $30 monthly.
Apply in writing to: Director of Nursing, St.
George s Hospital, Box 223, Alert Bay, British
Columbia VON 1AO.
Registered Nurses for 41-bed acute care hosp
ital, 200 miles North of Vancouver, 60 miles
from Kamloops. Limited furnished accommo
dation available. Apply: Director of Nursing,
Ashcroft & District Hospital, P. O. Box 488,
Ashcroft, British Columbia VOK 1AO.
Two Registered General Duty Nurses, 1 full-
time, 1 permanent 1/2 time required for 21-
bed hospital. 12 hour rotating shifts, salary as
per RNABC contract, residence available. Apply
to : Rosalie Bitterlich , D.O.N ., Queen Charlotte
Islands General Hospital, P.O. Box 9, Queen
Charlotte City, British Columbia VOT ISO.
General Duty Nurses required for 30 bed ac
credited hospital. Salary according to RNABC
Contract. Apply: Administrator, Chetwynd
General Hospital, Box 507, Chetwynd, British
Columbia VOC 1JO. (604) 788-2236/2568.
General Duty Nurses for modern 41-bed hosp
ital located on the Alaska Highway. Salary and
personnel policies in accordance with RNABC.
Accommodation available in residence. Apply:
Director of Nursing, Fort Nelson General
Hospital, P.O. Box 60, Fort Nelson, British
Columbia VOC 1RO.
General Duty Nurse for modern 35-bedhospitaI
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply: Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
Registered and Graduate Nurses required for
34 bed acute care hospital located 240 miles
North of Vancouver. Accommodation avail
able. Apply to: Director of Nursing, Lillooet
District Hospital, Box 249, Lillooet, British
Columbia VOK 1VO.
Roy al Columbian Hospital -Experienced Nurses
(B.C. Registered) required for this 500-bed
progressive regional referral and teaching hospi
tal located in the Fraser Valley, 20 minutes by
freeway from Vancouver and within easy ac
cess of various recreational facilities. Excellent
orientation and continuing education pro
grammes. Salary - 1980 rates - $1624.00 -
$1889.00 per month. Clinical areas include:
Operating Room, Recovery Room, Intensive
Care, Coronary Care, Neonatal Intensive Care,
Labour and Delivery, Family centred Obstetrics,
Emergency, Renal Dialysis, Psychiatry, Acute
Medicine, Palliative Care, Surgery, Pediatrics,
Rehabilitation and Extended Care. Pleaseapply
in writing to: Employment Manager, 330 East
Columbia Street, New Westminster, British
Columbia V3L 3W7.
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van-
couver.Salary and benefitsaccordingto RNABC
Contract-Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to : Personnel Director, Queen s Park
Hospital, 3 1 5 McBride Blvd., New Westminster,
British Columbia V3L 5E8.
Experienced operating room and P.A.R. nurses
required for 230-bed acute hospital in the
Okanagan Valley. Apply in writing to the:
Director of Nursing, Penticton Regional Hosp
ital, Penticton, British Columbia V2A 3G6.
Experienced General Duty Nurses required for
1 30-bed accredited hospital. Salary in accord
ance with RNABC Contract. Residence acc
ommodation available. Apply in writing to:
Director of Nursing, Powell River General
Hospital, 5871 Arbutus Avenue, Powell River,
British Columbia V8A 4S3.
General Duty Nurses required by an active 80-
bed acute care and 40-bed extended care hosp
ital located in the Cariboo region of B.C. s
central interior. Year round recreational activ
ities in this fast growing community. Appli
cants eligible for B.C. registration preferred.
Apply in writing to: The Director of Nursing,
G.R. Baker Memorial Hospital, 543 Front
Street, Quesnel, British Columbia V2J 2K7.
Registered Nurses required immediately for per
manent full time positions at 10-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 Col
umbia VOT 1WO. Telephone: (604) 636-2221
Collect.
O.R. Head Nurse required for an active 103-
bed acute care hospital. Must be eligible for
B.C. Registration. Post graduate training &
experience necessary. R.N.A.B.C. Contract in
effect. Accommodation available. Apply to:
Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British
Columbia V8G 2W7.
General Duty Nurses required for an active,
103-bed hospital. Positions availablefor experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
Registered Nurses- Full-time and casual relief
positions are available at the University of
British Columbia, Health Sciences Centre, Ex
tended Care Unit. The 12 hour shift, the pro
blem oriented record charting system, an em
phasis on maintaining a normal and reality bas
ed clinical environment and an interprofession
al approach to management are some of the
features offered by the Extended Care Unit.
Interested applicants may enquire by calling
228-7025 or 228-7000. Positions are open to
both male and female applicants.
Manitoba
Registered nurses required for a fully accredi
ted 100-bed general hospital and a 72-bed per
sonal care home located in northen Manitoba.
Must be eligible for registration in Manitoba.
Salary dependent on experience and education.
For further information contact: Mrs. Mona
Seguin, Personnel Director, St. Anthony s
General Hospital, The Pas Health Complex Inc.,
P.O. Box 240, The Pas, Manitoba R9A lK4;or
phone collect to: 1-204-623-6431, Ext. 179.
Northwest Territories
United States
United States
The Stanton Yellowknife Hospital, a 72-bed
accredited, acute care hospital requires register
ed nurses to work in medical, surgical, pediatric,
obstetrical or operating room areas. Excellent
orientation and inservice education. Some fur
nished accommodation available. Apply : Assist
ant Administrator-Nursing, Stanton Yellow-
knife Hospital, Box 10, Yellowknife, N.W.T.,
X1A 2N1.
Ontario
Experienced registered nurses are required
immediately for our fully accredited thirty-two
bed complex and active treatment hospital loc-
cated in beautiful Northern Ontario. The hosp
ital pays 100 percent OHIP and Dental Plan
and many other excellent fringe benefits.
Apply to : The Director of Nursing, Hornepayne
Community Hospital, Hornepayne, Ontario
POM 1ZO.
Toronto Western Hospital, Department of
Nursing presents An Update on Peritoneal
Dialysis for Nurses and other Paramedical Per
sonnel. Saturday November 8, 1980. Enroll
ment Limited to: 100. For information, con
tact: Miss Sharron Izatt, R.N., Programme Co
ordinator, c/o Peritoneal Dialysis Unit, Toronto
Western Hospital, 399 Bathurst Street,
Toronto, Ontario M5T 2S8.
Respiratory Ambulatory Care Program. Saint
Joseph s Health Centre is an acute and chronic
care hospital servicing the community health
needs of West Toronto. We are seeking a Reg
istered Nurse for an expanding hospital based
home visitation programme. A challenging and
rewarding position focusing on patients with
chronic lung disease. Candidates must be cur
rently registered in Ontario, preferrably expe
rienced in Respiratory Nursing and Adult
Education, possess a car and a valid driving
license. Salary commensurate with experience
together with excellent employee benefits.
Apply with resume in confidence to: Nellie
Iglar, Personnel Department, St. Joseph s
Health Centre, 30 The Queensway, Toronto,
Ontario M6R IBS (416) 534-9531, Ext. 543.
Saskatchewan
General Duty R.N. s required immediately
for a 20 bed Rural Hospital located near pro
vincial park. New hospital, modern equipment,
all areas of nursing done, surgery, obstetrics,
pediatrics, emergency and general medicine.
Modern community, bus services, paved streets,
etc. Wages and fringe benefits as per 1980
S.U.N. provincial agreement. For further infor
mation please contact: Administrator, Porcu-
pine-Carragana Union Hospital, Box 70,
Porcupine Plain, Saskatchewan SOE 1 HO. Phone
(Bus) 278-2233 or 278-2211 (Res) 278-2450.
United States
RN S Our Florida hospitals need y ou ! J oin the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun , and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario M5E
1J3. Phone: 416-863-0799. Telex: 06-219621.
RN/Staff & Management Positions-Kaiser-Per-
manente, the country s largest Health Mainten
ance Organization, currently has excellent
opportunities available in our 583-bed Los
Angeles Medical Center. Located 7 miles from
downtown Los Angeles, close to many of Calif
ornia s finest Universities, this teaching hosp
ital offers RN s a unique chance to further
their careers in such areas as: OR, Med/Surg,
Maternal Child Health & Critical Care. Manage
ment positions are also available. Kaiser offers
an attractive array of fringe benefits including
relocation assistance, full medical, dental &
health coverage, continuing education advanc
ed training available in the Nurse Practitioner
& CRNA Programs, individualized orientation,
tuition reimbursement, and no rotating shifts.
New graduates are always welcome and encour
aged to inquire. For more information, please
write or call collect: Ann Marcus, RN, Kaiser
Hospital/Sunset, 4867 Sunset Blvd., L.A.,
California 90027. (213) 667-8374.
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 White is a 377-bed acute
care teaching medicalcenterwithanopeninvita-
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to develop
and continue your professional growth. We
will pay your one-way transportation, offerfree
meals for one month and all lodging for three
months in our nurses residence and provide
y our work visa. Callcollect or write: Ken Hoover,
Assistant Personnel Director, 1720 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92503. Write or call collect 7 14-688-22 1 1
Extension 217. Betty Van Aernam, Director
of Nursing.
NURSING
OPPORTUNITIES
CALGARY, ALBERTA
As Calgary s population increases, our hospitals are expanding to meet
the growing demand for high quality medical care. We require skilled
Nurses who are interested in the challenge and excitement of working in
a progressive environment and earning a better than average salary.
The recent nursing settlement has resulted in significantly revised
salaries for Alberta Registered Nurses.
Present salary range is from $1 ,455.00 to $1 ,717.00 per month.
October 1 , 1 980 range will be $1 ,581 .00 to $1 ,867.00 per month. March 1 ,
1 981 range will be $1 ,701 .00 to $1 ,987.00 per month.
In addition we offer excellent benefit packages which will include a den
tal plan by December 1, 1980. The Calgary General, Colonel Belcher,
Foothills, Holy Cross and Rockyview Hospitals have Staff Nurse
positions available in most clinical areas.
For further information or applications, you may contact:
Calgary General Foothills
841 Centre Avenue E. 1403 - 29 Street N.W.
Calgary, Alberta Calgary, Alberta
T2E OA1 T2N 2T9
Ph.:(403)261-3800 Ph.:(403)270-1411
District #93
940 - 8 Avenue S.W.
Calgary, Alberta
T2P1H8
Ph.: (403) 264-9880
L
J
R.N. s
Would you like to nurse in:
California, with Beverly Hospital, a
212 bed acute carehospital in Montebello
just minutes from Los Angeles.
Ohio, with the Jewish Hospital of
Cincinnati, a 604 bed teaching hospital.
Florida, with American Hospital, growing
to 400 beds in a very livable part of
Miami.
All of our client hospitals encourage pre-
employment visits by paying all or part
of visit costs. Our services are free to
nurses.
Wherever you would like to move, we
can help you get there.
Wood, Watson Professional Search
12 Sheppard Street
Toronto, Ontario
M5H 3A1
Phone: (416)261-6825
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
theUS.A.
B) Extensive information regarding
Hospital 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 1 133 Great Neck, N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
R.N. s
Come to Texas
244 Bed Regional Medical Center
Located 75 miles north of Dallas on
the bank s of Lake Texoma ( 1 2th
largest lake in the U.S.)
Progressive Nursing Administration
Professional growth opportunities
Excellent salary and benefits program
Openings in ICU, Emergency,
Psychiatry, Renal Dialysis, and other
speciality areas
Contact:
Bonita Palmer, R.N.
Director of Nursing
Texoma Medical Center
P.O. Box 890
Denison, Texas, USA 75020
WHY
WOULD A
CANADIAN
NURSE -
SELECT
ONE!
UCLA Center for the
Health Sciences will be
conducting interviews for
AI JB A RNs in the following areas:
117 Halifax, Ottawa, Toronto
and Sault ste. Marie.
Two of our outstanding Head
Nurses (who incidentally are Cana-
dian) will be interviewing registered
nurses and making job offers in the
following areas: Peds & Peds ICU,
General Medicine, General Surgery,
Intensive Care, Neuro Surg., OR,
Maternal Child, Female Surg., Psych.
We offer many other obbortunities,
watch your local newspapers for
dates and locations.
If you re not located in any of
these areas, call us collect, and we ll
attempt to meet with you if at all
possible. Call our Nurse Recruiting
Office at (213) 825-8141. We re
an edual opportunity employer.
ucLA
Medical
Center
r
HOSPITAL
CORPORATION
Interested in a Challenge?
Try International Nursing - In
Saudia Arabia
If you are looking for a change, a chance to
travel, some hard work and adventurous living,
then you might consider international nursing.
You will have not only the opportunity to give -
to share your nursing expertise but the
opportunity to receive as well to learn by
living in a completely different culture. Truly, a
chance for personal and professional growth.
Available positions include both administrative
and staff level nursing. Requirements depend on
the position at staff level a minimum 2-3 years
current experience in an acute care hospital or
clinic setting. Current R.N. license in one of the
Provinces. Single status contracts are offered for
18 or 24 month periods.
Attractive salaries with excellent benefits
including air transportation, furnished lodging,
generous vacation, bonus pay and bonus leave.
Interested in this once in a lifetime opportunity?
For more details, please send professional
resume to:
Kathleen Langan
Hospital Corporation International, Ltd.
Two Robert Speck Parkway, Ste. 750
Mississauga, Ontario L4Z 1H8
An Equal Opportunity Employer
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?
We know where the best jobs are. how much they pay,
and where you ll fit in. R.R.N. can give you more than
just a job we can help you build a satisfying career.
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 that dotted line to-day, you should check with
Recruiting Registered Nurses Inc. We re the Canadian
Medical Placement Specialists throughout the United
States.
R.R.N. has immediate positions available in:
California Ohio Pennsylvania Michigan
Don t wait!!!! Call or write immediately for further
information.
"No Fee To Applicants"
RECRUITING REGISTERED NURSES INC.
1200 Lawrence Avenue East
Suite 301, Don Mills
Ontario M3A 1C1
Telephone: (416) 449-5883
Interested In
Paediatric Nursing ?
Toronto, Canada
The Hospital For Sick Children invites applications for all
units from experienced nurses interested in working in a
paediatric tertiary care setting.
We are a fully accredited 700 bed paediatric teaching
hospital affiliated with the University of Toronto located in the
thriving environment of downtown TORONTO A thorough
orientation and a variety of continuing education programs is
provided. The majority of units operate on a 12 hour shift
basis, which normally allows every other weekend off A
comprehensive empbyee benefit package, including a
Dental Ran is offered.
Our philosophy is Family Centred Care.
Qualifications:
Current registration with the Ontario College of Nurses
or eligibility for registration.
Recent related experience in an active treatment
setting preferred.
Paediatric experience would be considered a definite
asset.
Applicants are invited to contact:
Dorothy Franchi,
Personnel Coordinator,
The Hospital for Sick Children,
555 University Avenue,
Toronto, Ontario, Canada M5G 1X8,
(416) 597-1500 ext. 1675.
The Hospital
for Sick Children
Immediate openings for qualified
RN s on all shifts, full time, part
time. 203 bed JCAH accredited
acute care hospital, adjacent to
Oregon Institute of Technology,
offering a 2 + 2 AD/BSN program.
We are located in Southern
Oregon. Excellent year round
outdoor activities. Family
oriented community. Excellent
working conditions and benefits.
Competitive salary with oppor
tunity for advancement. Contact
Personnel Department, MERLE
WEST MEDICAL CENTER, 2865
Daggett St., Klamath Falls, OR
97601, or call COLLECT (503)
882-63 1 1 , Ext. 1 3 1 . We are an
equal opportunity employer.
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
ICU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
HIS]
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Register
ed Nurses or those eligible for B.C.
Registration with recent nursing ex
perience.
Positions are available in all services
of this 950 bed accredited hospital
which includes Acute and Specialty
Care, Obstetrics and Paediatrics,
Psychiatry and Extended Care for
Full Time, Part Time and Casual
Employment.
Benefits in accordance with
R.N.A.B.C. contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Victoria Hospital Corporation
London, Ontario
Registered Nurse Positions
Available Early 1981
Full-Time/Part-Time
Medical - Surgical
Obstetrics - Gynecology
Paediatrics
Critical Care
This large teaching hospital, affiliated
with The University of Western Ontario,
presently undergoing complete redevel-
opments
Offers:
Good fringe benefits
Active orientation and educational
programmes
8 hour and 12 hour rotating tours
Fitness programme
Employee Health Service
Recreational facilities
For information and application contact:
Employment Division
Human Resources Department
Victoria Hospital Corporation
375 South Street
London, Ontario
N6A 4G5
Director of Nursing
St. Joseph s General Hospital, Comox,
B.C. invites applications for the position
of Director of Nursing.
St. Joseph s General Hospital is a fully
accredited 190 bed hospital (45 E.C.U.)
expanding to 220 beds (75 E.C.U.) in
1981.
The Director of Nursing will report to
the Executive Director and will be
responsible for the administrative and
professional activities of the Nursing
Department as well as the quality assur
ance of nursing practice throughout the
hospital.
The applicant must have a BScN (mini
mum), a recognized course in health adm
inistration and be eligible for B.C. regis
tration.
A minimum of three years in a senior
management position is required.
Send complete resume to:
Sister Christine
St. Joseph s General Hospital
2137 Comox Avenue
Comox, British Columbia
V9N4B1
The Izaak Walton Killam
Hospital For Children
Staff Nurses
The I.W.K. Hospital for Children has
vacancies for Staff Nurses on our
Intensive Care Unit and Neo-Natal Unit.
Must be a graduate from an accredited
School of Nursing and be eligible for
registration in Nova Scotia. Previous
pediatric experience would be an asset.
Inquiries and applications should be
directed to:
Karen Lyle
Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Registered Nurses are required for an 87
bed accredited Hospital in Northern
Ontario.
Applicants must be eligible for
Registration with the College of Nurses
ofOntario.
Bilingualism is an asset.
Salary and Fringe Benefits in accordance
withO.N.A. Contract.
Temporary residence accommodation is
available.
Please apply in writing to:
Director of Nursing
Sensenbrenner Hospital
10 Drury Street
Kapuskasing, Ontario
P5N 1K9
Assistant Supervisor of Nurses
Peace River Health Unit
An Assistant Supervisor is required in
the main office of the Health Unit.
Peace River is located 500 km.
northwest of Edmonton.
Duties:
Assist in planning, organizing, co
ordinating and evaluating community
health nursing programs. A limited
caseload will be assigned.
Qualifications:
B.Sc. in Nursing preferable.
Community Health Nursing experience
essential.
Salary:
Negotiable and dependent upon
qualifications and experience.
Please apply to:
Supervisor of Nurses
Peace River Health Unit No. 21
P.O. Box 69
Peace River, Alberta
TOH 2X0
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 major medical centre on Canada s
unconventional West Coast.
Recent graduates and experienced professionals alike
will find a wide variety of positions available which
could provide the opportunity you ve been looking for.
Applications are invited for the following positions:
General Duty
($1624-$ 1889 per month 1980 rates)
Head Nurse
Nurse Clinician
Nurse Educator
Supervisor
For those with an interest in specialization, challenges
await in many areas such as:
Neonatology Nursing Intensive Care
(General & Neurosurgical)
Inservice Education Cardio Thoracic Surgery
Coronary Care Unit Burn Unit
Renal Dialysis &
Transplantation
Pediatrics
Psychiatry
Extended Care
If you are a nurse considering a move please submit
resume to.
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, British Columbia
V5Z 1M9
OPPORTUNITY
Night Duty Nurse-Edmonton
The Eric Cormack Centre requires a Nurse to direct the work
activities of a 20-24 bed unit housing dependent children and
young adults. You will be responsible for the maintenance of
health and safety of the residents, and for the nursing standards
and quality control of treatment activities on the unit. Super
vision of a team of Institutional Aides is involved.
Qualifications:
Graduation from a recognized school of Nursing (R.N., R.P.N.,
R.M.D.N.). Must be eligible for registration in appropriate pro
fessional organization (A.A.R.N., P.N.A., A.M.D.N.A.). Expe
rience in the field of mental retardation would be an asset. Note:
Night shift work is required of this position.
Salary:
$14,748 to $17,340 (currently under review)
Competition No. 9184-1 Open until suitable candidate selected.
Alberta Social Services & Community Health.
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
r
Registered Nurses
required immediately
Applications are now being accepted for qualified
Registered Nurses to fill on-going vacancies in the
following areas:
Psychiatry
Neurosurgery
Orthopedics
Rehabilitation Medicine
Candidates must be eligible for registration in Alberta
and should have at least one year of experience in the
designated area of interest.
These are permanent positions in a large active treatment
environment providing considerable scope for profession
al development. Salaries range from $1455-$ 171 7 per
month, depending on experience ($1581-$1867 per
month-October 1, 1980) with a full range of employee
benefits.
Interested applicants are asked to reply to:
Personnel Department
CALGARY GENERAL HOSPITAL
841 Centre Avenue E.
Calgary, Alberta T2E OA1
MIDWIFERY TUTOR NIGERIA
NURSING INSTRUCTORS COLOMBIA
& PAPUA NEW GUINEA
PROFESSOR OF NURSING PERU
PUBLIC HEALTH NURSES W EST
AFRICA & PAPUA NEW GUINEA
CUSO. Canada s largest non-government inter
national development agency, is seeking
qualified and experienced nurses for the above
positions
Qualifications: Positions require appropriate
degree (diploma for midwifery position) plus
relevant experience.
Contract: Two years
Salary: At local rates with fringe benefits
For more information, write:
CUSO Health D1 Program
151 Slater Street
Ottawa, Ontario
K1P 5H5
Nursing Coordinator
Nursing Coordinator required to
assume leadership role in an O.R./
P.A.R. and expanding Emergency/
Day Care suite presently under
construction.
The applicant must have demon
strated leadership and administrative
skills, post grad in O.R. and past
experience as a Head Nurse or
Supervisor. Must be eligible for B.C.
Registration.
Cranbrook and District Hospital is
a 130-bed hospital in the East
Kootenays with many winter and
summer recreational facilities.
Qualified applicants apply in
writing to:
Mrs. P.N. Janzen
Director of Patient Care
Cranbrook and District Hospital
13-24th Ave. N.
Cranbrook, British Columbia
VIC 3H9
Canadian Red Cross Society
Blood Transfusion Service
Pheresis Nurse
An administrative position is available
at the National Office to co-ordinate the
pheresis programme of the Canadian Red
Cross Blood Transfusion Service.
Based in Toronto but travel involved to
seventeen Blood Transfusion Centres
across Canada. Will work actively with
Centre Medical Directors and Pheresis
Nurses regarding local operations, and
with Director of Medical Services and
Director of Nursing at the National level.
Applicants must have two years practical
experience in automated cell and plasma
pheresis and be eligible for Ontario
Registration.
Applicants are requested to submit
curriculum vitae to:
Mrs. Marjorie Ferguson
Director of Nursing
Canadian Red Cross Society
95 Wellesley Street East
Toronto, Ontario
M4Y 1HS
Hotel Dieu Hospital
St. Catharines, Ontario
Requires a
Head Nurse-Urological
Operating Room
The Position:
Reports to the Surgical Co-Ordinator,
and is responsible for the on-going plan
ning, organizing, evaluating and directing
of nursing care for a Urological O.R. The
O.R. consists of two Endoscopy Rooms
and one major Operating Room serving
approximately 2,500 patients per year.
Qualifications:
The successful applicant will be a Regist
ered Nurse with a current Ontario Certifi
cate of Competence who has recent ex
perience and up-to-date knowledge of
Urological procedures and who has
demonstrated sound management and
communication skills during their
recent employment.
This is an ideal career opportunity for
a management oriented individual who
is interested in advancement within
Urology.
Please apply by resume, in confidence,
stating your experience, qualifications
and salary requirements to:
Director, Personnel/Staff Development
Hotel Dieu Hospital
155 Ontario Street
St. Catharines, Ontario
L2R5K3
Registered Nurses
Applications are invited for full time and
part time employment at Oshawa
General Hospital, a 600 bed hospital, 48
kms. East ofToronto.
Successful candidates must be registered
in Ontario.
Services provided include:
Medicine
Surgery
Obstetrics
Emergency
Paediatrics
Intensive Care
Coronary Care
Out-Patients
Chronic/Rehabilitation
Salary Range: (Full time)$l,450.00-
$1,676. 00 (monthly)
Inquiries may be directed to:
Personnel Services
Oshawa General Hospital
24 Alma Street
Oshawa, Ontario
L1G2B9
Choose a
Nursing
Career _
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H 1V8
Telephone: 1 (902) 428-3484
Join the Team providing leadership in Provincial
Public Health Nursing Programs.
Meet the professional challenges of developing,
promoting and evaluating programs; conducting
program research, staff development and providing
consultation in a program specialty.
Three Positions:
Consultant to Northern Regions with a specialty
in Primary Care Nursing
Consultant in Maternal & Child Health Programs
Consultant in Staff Development Programs
Qualifications:
Master s degree in Community Health Nursing with
appropriate specialty and directly related experience,
demonstrated leadership skills and knowledge in research
methodology. Positions located in Winnipeg, frequent
travel throughout province required.
Salary up to a maximum of $32,280, commensurate
with qualifications.
Competition No. CN-3013. Closing Date: Immediately.
Apply to:
Department of Health
Personnel Management Services
270 Osborne St. North
Winnipeg, Manitoba
R3C OV8
MANITOBA
OPPORTUNITY
Community Mental Health Nurse Lacombe
Lacombe is a thriving community of 5,000 with excellent access
to Red Deer and Edmonton. Supported by interdisciplinary
team resources, you will function as a primary therapist, respon
sible for comprehensive assessment and treatment of complex
emotional and behavioural disorders. You will also be involved
in public education and community development.
Qualifications:
B.Sc.N. preferred, but R.N. or R.P.N. with experience will be
considered. Must be eligible for registration with approved
association(s) in Alberta. A valid Alberta driver s license and
automobile are required. Mileage will be paid.
Salary:
Up to $17,340 (currently under review)
Competition No. 9184-9 Open until suitable candidate selected.
Alberta Social Services and Community Health.
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
DIRECTOR OF EDUCATION
is required by
THE CANADIAN ASSOCIATION OF MEDICAL RADIATION TECHNOLOGISTS
RESPONSIBILITIES:
The primary function of this position is to research, identify, and develop the appropriate educational experience
directed towards both under-graduate and post-graduate levels; and to organize and ensure the appropriate
access by the membership to educational resources involving current, continuing, and developing programs at
these levels. The Director of Education as a senior member of the Associations administrative staff will be
responsible to the Executive Director. This position will be based at the Associations head office in Ottawa. The
position will require extensive travel throughout Canada.
QUALIFICATIONS:
The applicant must have an interest in education relative to professional development; preferably should have
prior experience in adult education, and a technical background in medical radiation technology, or similar
experience within other health professions. A command of both the English and French languages would be an
asset.
OPPORTUNITY:
This challenging career is open to a self-motivating person with a demonstrated ability to function at an
administrative level, and whose major interest lies in the educational process.
BENEFITS:
Standard CAMRT employee package.
SALARY:
Commensurate with experience and qualifications.
Applications must be submitted in writing including a curriculum vitae, a minimum of three references who can be
contacted if necessary and a brief expression of personal views on continuing education as related to Allied Health
Disciplines, to the Executive Director, C.A.M.R.T., Suite 410, 280 Metcalfe Street, Ottawa K2P 1R7 Canada
postmarked not later than November 15, 1980. All applications will be treated in confidence.
Royal Inland Hospital
Kamloops, B.C.
Registered Nurses
Applications are invited for staff additions to Medical-Surgical
Nursing, Psychiatric, Intensive Care, Neuro Services, Obstetrics
and Rehabilitation Unit.
400 Bed Accredited Acute Care Referral Hospital.
Active Inservice Programmes with Clinical Instructors For Staff
Development.
1980 Salary- $1624-$ 1889 per month.
Benefits-As Per R.N.A.B.C. Contract.
Eligibility For Registration in British Columbia Essential.
Kamloops, a rapidly expanding industrial area with population
of 65,000 known as the Sunny Sportsman Paradise-Hub City of
British Columbia is served by the Trans Canada Highway, both
major Railways and Airline Services. Kamloops offers a large
variety of winter and summer activities including excellent skiing,
golfing, boating, fishing, camping, horseback riding, flying,
drama, concerts, and active adult education programmes. It is
the site of Cariboo College, one of the Regional Colleges, its
nursing programme is affiliated with the Royal Inland Hospital.
Apply to:
Personnel Director
Royal Inland Hospital
Kamloops, British Columbia
V2C 2T1
Assistant Director Nursing Education
Opportunity to become part of the nursing management team
in a progressive 616-bed, fully accredited, acute care facility
located in southwestern Ontario.
Kitchener-Waterloo Hospital invites applications for the position
of Assistant Director Nursing Education.
The successful applicant would report directly to the Director of
Nursing and would be responsible for co-ordination of all phases
of nursing education, including orientation, in-service, and con
tinuing education.
Qualifications
Master of Science Degree in Nursing preferred.
Bachelor of Science Degree in Nursing with previous
inservice education experience would be considered.
Minimum of five years experience in the health care
delivery system.
Knowledge and demonstrated skills in adult learning,
human relations and management.
Eligible for registration in the Province of Ontario.
Position vacant September 1, 1980.
Please submit resume to:
Director of Nursing
Kitchener-Waterloo Hospital
835 King Street West
Kitchener, Ontario
N2G 1G3
Operating Room
Clinical Coordinator
Applications are being accepted for the above position.
The incumbent will provide leadership in the develop
ment and implementation of current clinical practice
for the area, and be responsible for its administration.
Qualifications
Registered Nurse
Demonstrated highly successful work performance
within the specified field
Demonstrated skills in leadership and inter
personal relations
Demonstrated managerial ability
Bilingualism an asset
Please apply in writing or telephone:
Director of Personnel
Laurentian Hospital
41 Ramsey Lake Road
Sudbury, Ontario
P3E5J1
522-2200, ext. 307
Head Nurse
Medical Nursing
Vancouver General Hospital
Applications are invited for the above position. The successful
applicant will be responsible for providing innovative and creative
leadership in the development of clinical practice within the unit
by teaching, consulting and demonstrating specialized nursing
skills. She/he is responsible for the quality of nursing care and
the nursing administration of the unit.
The incumbent must be eligible for registration in B.C. and
have experience in the specific clinical field, hold a BSN or
equivalent post basic education. This person must demonstrate
skill in leadership and interpersonal relations. Salary and benefits
in accordance with the RNABC contract.
Please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, British Columbia
V5Z 1M9
University of British Columbia
Health Sciences Centre Hospital
Extended Care Unit
requires
Clinical Nursing Consultant -Education
Reporting to the Director of Nursing, plans and
implements orientation and on-going in-service programs
for nursing and other staff members, coordinates pre
admission assessment activities, provides direct patient
care to selected patients as arranged, facilitates clinical
nursing research, participates in School of Nursing
activities in the unit as requested, represents E.C.U. in
Nursing Education areas and maintains an effective
working relationship with nursing and other health
professionals. Requires Master s degree in Nursing or
Nursing Education, registration with the RNABC,
evidence of clinical competence in the care of elderly/
disabled patients demonstrated skills in program planning,
implementation and evaluation and successful work
experience in clinical nursing and nursing education.
Salary and benefits according to RNABC collective
agreement.
Applicants should submit detailed resume to:
Coordinator of Hospital Employment
Health Sciences Centre Hospital
University of British Columbia
Vancouver, British Columbia
V6T 1W5
Position open to both male and female applicants.
Assistant Nursing Supervisor
Medical Nursing
Vancouver General Hospital
Applications are invited from Registered Nurses for the above
regular and temporary vacancy. The Assistant Supervisor provides
innovative and creative leadership in the development and
implementation of current clinical practice for the Nursing
Division.
Duties include, evaluating and maintaining established standards
of nursing care, planning and organizing inservice and continuing
education programs, performance evaluation, budget controls,
recommendations regarding staff selection. The position involves
working evenings and night shift as well as rotating days off.
Applicants must be eligible for registration in B.C. and have a
BSN or equivalent plus demonstrated successful work experience
within the Medical Nursing field. Demonstrated skills in leader
ship, interpersonal relations and managerial ability essential.
Please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, British Columbia
V5Z 1M9
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics, orthopaedics,
obstetrics, psychiatry, rehabilitation and
extended care including.
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education
Programs. Post Graduate Clinical Courses in
Cardiovascular Intensive Care Nursing and
Operating Room Nursing.
Apply to.
Recruitment Officer Nursing
University of Alberta Hospital
8440- 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
o
The Canadian Nurse
SDtembr19ao 67
General Hospital
St. John s, Newfoundland
A completely modern teaching hospital requires
an Operating Room Manager.
This 500-bed General Hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered:
Critical Care (Medical-Surgical), Coronary Care,
General Surgery, Urology, Gynecology,
Psychiatry, Medicine, Nephrology, Clinical
Teaching, Neurosciences, Cardiology, Cardio
vascular Surgery, Orthopedics, Hemodialysis
(Kidney Transplants), Emergency and Out-
Patient Services, Active Rehabilitation
Program (Adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in-Critical Care Nursing, Neurosciences,
Operating Room Nursing.
Located in St. John s, Newfoundland - the oldest
city in North America with a population of
1 20,000, offering cultural and recreation activities
in a friendly atmosphere.
Fishing, hunting, boating available approximately
10-14 miles outside the city.
For information regarding salary and other
conditions of employment write or call:
Director of Nursing
General Hospital
Prince Philip Drive
St. John s, Newfoundland
A1B 3V6
Telephone No.: (709) 737-6307
Director of Nursing
The University of British Columbia
Health Sciences Centre Hospital
Extended Care Unit
Applications are invited for the position of Director of Nursing
for the 300-bed Extended Care Unit, Health Sciences Centre
Hospital, University of British Columbia. This long term care
unit is part of the 600-bed university health sciences centre
complex. An appointment in the School of Nursing accompanies
the position.
Qualifications:
Candidates should have a Master s Degree in Nursing with con
siderable administrative and clinical experience in long term care
settings. Candidates must be eligible for registration with the
Registered Nurse s Association of British Columbia. Salary will
be commensurate with qualifications and experience.
Please apply to:
Sheila Stanton
Chairman, Search Committee
c/o Hospital Employee Relations
Health Sciences Centre Hospital
University of British Columbia
Vancouver, British Columbia
V6T 1W5
ASSISTANT DIRECTOR
NURSING SERVICE
The Calgary General Hospital invites appli
cations for the position of Assistant Director
responsible for the Division of Medicine in the
Department of Nursing Service. This Division
consists of six Nursing Units, plus Cardiac
Rehabilitation Unit, G.I. Investigative Unit, Dia
betic Day Care Unit, and has a total of 190 beds.
The successful applicant will be a registered
nurse with an advanced preparation and consid
erable experience at the supervisory or man
agement level.
This is a permanent nursing management posi
tion offering a competitive salary and full em
ployee benefits.
Interested applicants are asked to reply in writing
with details of education and experience to:
Personnel Department
CALGARY GENERAL HOSPITAL
841 Centre Avenue E.
Calgary, Alberta T2E OA1
Index to
Advertisers
September 1980
Ames Division,
Miles Laboratories Limited
Ayerst Laboratories, Division of
Ayerst, McKenna & Harrison Inc.
The Canadian Nurse s Cap Reg d.
14
The Clinic Shoemakers
Encyclopaedia Britannica Publications Limited
53
Equity Medical Supply Company
16
Hollister Limited
OBC
Kendall Canada
10,52
Eli Lilly & Co. (Canada) Limited
16, 17
J. B. Lippincott Company of Canada Limited
51
The C.V. Mosby Company
55,56,57
Nordic Laboratories Inc.
54
Parke-Davis Canada Inc.
8,9,32
Personnel Pool of America, Inc.
Medical Division
48
Pharmacia (Canada) Limited
70
Ross Laboratories, Division of
Abbott Laboratories Limited
12, 13
W. B. Saunders Company
27
Smith & Nephew Inc.
28, 29,IBC
Stiefel Laboratories (Canada) Limited
54
Upjohn HealthCare Services
11
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IFC
Advertising Representatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
60 1 , Cote Vertu The Canadian Nurse
St-Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone: (613)237-21 33
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416)297-2030
Richard P. Wilson
P.O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215) 363-6063
Member of Canadian
Circulations Audit Board Inc.
NURSES
You are a Canadian nurse - interested in serving
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to build your nursing career - and see Canada
while doing it.
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health care to the peoples of Canada s north
country. We d like to have you on our team.
If you qualify you will begin your career at
one of our outpost nursing stations, an important
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able to use your self-reliance, good judgment and
sense of responsibility, supported by experienced
senior nursing and medical personnel, both
"on call" and on "routine visits".
There will be opportunities for promotion -
for moving to other locations across Canada in
our hospitals, outpost nursing stations, health
centres, major clinics, occupational health units
and in other health areas.
Salaries are supplemented by special allowances,
overtime compensation and pension benefits, in
addition to holidays and an opportunity for travel.
For further information, mail the coupon below.
Nursing Advisor
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Canada
cuts the cost of decubitus care
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infection fast
Debrisan sucks bacteria and tox
ins out of decubitus ulcers. The
ulcer is quickly cleansed, healthy
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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 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
by relieving
pain and
odour fast
" 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
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following day, the smell had disap
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decubitus ulcer on knee. granulation base.
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Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change a day* ^HfeJ^ ^
is needed. Debrisan therapy can ^StlT
be stopped as soon as all signs of
Only one Debrisan change a day*
is needed. Debrisan therapy can
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infection have gone and the ulcer
is clean and granulated.
1 Debrisan appears to be, in my
opinion, just what we as nurses
are seeking." 4
Two, if exudation is very heavy.
After removing crust or
necrotic tissue, pour a thick
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the ulcer.
Cover with a dressing.
Debrisan cleans
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When the beads are
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Pharmacia (Canada) Ltd.
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References
1 . Lim LT, Michuda M, Bergan J J. Angiology 29:9, Sept 1978
2. Bewick M. Anderson A, Clin Trials J 15:4, 1978
3. Soul J, Brit J Clin Pract. 32:6, June 1978
4. DiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on file at Pharmacia (Canada) Ltd.
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Burnout, a look
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Six steps to better bonding
Shock lung, how it happens,
how to treat it
Danger! ICP rising
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OCTOBER 1980
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POSITIVE PATIENT
IDENTIFICATION.
<L>
NON-ELASTIC
MATERIAL.
Won t stretch or break.
CLIP SEAL
Secure. e;isv to close.
COMFORTABLE
VINYL
Band won t chafe skin.
TAMPERPROOF.
Impossible to open or
remove without detection.
Hollister will never leave a patient s side, no matter how long the hospital stay.
Because our Ident-A-Band* bracelet is the most secure system of patient identi
fication on the market today.
The system is specialized. It meets all the requirements of Adults, Pediatric,
Emergency, and Outpatient procedures.
But its also very versatile. Pertinent patient information fits easily on insert cards
of 2-line, 3-line, and 4-line widths.
And we make carbonless insert cards for cleaner, clearer imprints. And Color-
Alert " cards that warn staff of any specialized care required.
We even include pens with waterproof ink.
All the features that let patients and hospitals rest easy. Because our Ident-A-Band w
bracelet can make a big difference in situations ^>
where there is no such thing as a small mix-up. *]? Hoi 1 i StPT
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A healthy harvest good
to look at, good to eat and
good for you! Our cover
photo this month comes
to you courtesy of Health
and Welfare Canada.
The
Canadian
Nurse
October 1980 Volume 76, Number 9
The official journal of the Canadian Nurses Association
published in French and English editions eleven times per
year.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Gail O Neill
Production Assistant
GitaDean
Editorial Assistant
Cathy Squires
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
George Bergeron,
communications officer. New
Brunswick Association of
Registered Nurses.
Kate Fulton, RN, Addiction
Research Foundation, Toronto.
Jerry Miller, communications
coordinator, Labor Relations
Division, Registered Nurses
Association of British Columbia.
Beverley Pittfield, RN,
Gravelbourg, Saskatchewan.
Peter Smith, director of
publications, National Gallery of
Canada.
Florita Vialle-Soubranne,
consultant, professional
inspection division, Order of
Nurses of Quebec.
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.
Canadian Nurses Association. 50 The
Driveway, Ottawa, Canada. K2P 1E2.
Care for the caregiver 28 ICP rising
..34 OB special 38
7
YOU AND THE LAW
Student nurses and the law
Corinne Sklar
42
New baby in the family
Joy Bliss
28
Care for the caregiver
Mary L.S. Vachon
44
Nursing mothers then and now
Anne Wallace
~~ Stressed? Or Burnt Out?
J\J Marvel Miller Sanders
34
Increased intracranial pressure:
when assessment counts
Angela Ladyshewsky
Six steps to better bonding
Margaret Rhone
Input
48
Are your students positive
about their experience in
the clinical area?
Frances Ban
I Adult respiratory
3 A distress syndrome
Frances Bourbonnais
NEWS FEATURES
14 Perinatal nursing
22 - Health hotline
25 - CNF scholars
23
Audiovisual
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
Indexed in International Nursing Index, Cumulative
Index to Nursing Literature, Abstracts of Hospital
Management Studies. Hospital Literature Index.
Hospital Abstracts. Index Medicus, Canadian
Periodical I ndex.TVip Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor, Michigan 48106.
Canadian Nurses Association, 1980.
To help
keep the
busy nurse
current.
-^ m. ~*
nursing
abstracts
Covering 48 nursing journals.
Written by RN s for RH s.
Aids the student and teacher.
A valuable tool for the researcher.
For subscription information:
NURSING ABSTRACTS CO., INC.
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Name
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Address
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Your graduation school
input
Patient privacy
One of the most sensi
tive, intimate areas of person
ality is privacy. Loss of it
debases a person; one loses
self-respect, dignity and the
feeling of worth.
As an MS victim, I need
assistance in washing and
dressing. After a shower, I am
dressed not ten feet from a
door that may open unexpec
tedly, and I cringe waiting to
be dressed. Though I have no
objection to being bathed by
a nurse, I do object to others
coming and going while this is
occurring. Unlike you, I can
not quickly run to another
room or pull on a housecoat.
A disabled person has
difficulty maintaining an ac
ceptable level of privacy.
Nurses who recognize and pro
vide for a patient s need for
privacy can only add to the
stature of the profession.
B. Francis, (pseudonym),
Cambridge, Ontario.
Reducing bladder
infection risk
I enjoyed very much
Lori Whittington s article
"Bladder Retraining" (June
1980). It outlined bladder
function and nursing care very
clearly, but I would like to
comment on the suggestions
related to infection control.
I agree that an indwell
ing catheter is a portal of
entry for bacteria, but fre
quent changing of the cathe
ter only places the patient at
greater risk.
The experience of my
colleagues and myself with
catheterized extended care
patients has shown that the
bladder of any patient with
an indwelling catheter will be
come colonized with bacteria
within a few days of cathe-
terization.
Colonization is the pre
sence of poly bacteria in the
urine in numbers greater than
100,000 per ml. of urine in
the asymptomatic patient. No
amount of catheter change
will prevent this.
However, the trauma of
catheterization or catheter
manipulation can result in a
break in the normally pro
tective mucous membrane,
allowing colonizing bacteria
to escape into the blood
stream. This leads to bacter-
emia, septic shock and even
death. Reducing the numbers
of catheter changes reduces
the risk of trauma and subse
quent infection.
As long as the cathe
terized patient is asymptoma
tic of infection, he should not
be treated with antibiotics as
the organisms will recur and
will become resistant. How
ever, if the patient becomes
symptomatic, treatment
should begin immediately.
High doses of ascorbic
acid will not prevent coloni
zation. Instead of colonizing
with bacteria which like more
alkaline environments, the pa
tient will colonize with acid-
loving bugs. Also it takes a
very large amount of cran
berry juice and/or acid-
forming fluids to significantly
alter the pH of urine. The
best solution is to provide the
large amounts of fluid sugges
ted : 2000 - 3000 cc daily. This
keeps the urine dilute and ir
rigates the urinary system
"by mouth".
An excellent reference
on this subject is "Detection,
Prevention and Management
of Urinary Tract Infections"
3rd Edition, by Calvin M.
Kunin, Lea and Febiger,
Philadelphia, 1979.
-Roberta Clark, staff educa
tion department, Saint John
Regional Hospital, Saint John,
N.B.
(continued on page 68)
We were wrong.
A photo caption on page 25 of the
September issue of CIMJ incorrect
ly identifies Lillian E. Pettigrew as
Pearl (Penny) Stiver, executive
director of CNA from 1952 to
1963 and also a founding member
of the Canadian Nurses Founda
tion. Lillian Pettigrew, pictured
with a third founding member of
the CNF, Alice Girard, was asso
ciate executive director of CNA
from 1964 to 1972. Our apologies
to both.
DON T FORGET
The Association of Registered
Nurses of Newfoundland will hold
its 1980 annual meeting at the
Holiday Inn, St. John s, New
foundland, November 3 to 5 and
the annual meeting of L ordre des
infirmieres et infirmiers du
Quebec will be held November 24
to 26 at the Bonaventure Hotel,
Montreal, Quebec.
October 1980
The Canadian Nurse
YOU AND THE LAW
Student
nurses
and the law
Corinne L. Sklar
Student nurses are, by definition, less
experienced and less knowledgeable
than registered nurses. But are they
equal in the eyes of the law? Is the jf
standard of care required by law the
same for both?
Nursing care is judged by the
standard reasonably expected of an
ordinary, reasonable and prudent
professional nurse of similar training
and experience. This legal standard is an-
objective comparison, the yardstick by
which all nursing conduct is measured.
. A nurse who delivers patient care that
falls below this standard is considered
negligent in the performance of her
professional duties, negligence which
might result in the imposition of legal
liability by a court against her or the
hospital employer if a lawsuit is brought
by the patient who suffered harm as a
result of this conduct. Such substandard
nursing care could also result in a
finding of professional misconduct or
incompetence by that nurse s
professional regulatory body.
Y . The student nurse, as is any
individual, is personally responsible in
law for his or her own negligent acts or
wrongs. When student nurses cany out
their nursing responsibilities during the
course of their clinical experience, they
must perform their duties with the same
degree of competence that would be
required of a registered nurse/This
higher standard is necessary to protect
the patient: to do otherwise would be
to subject the patient to a lower
standard of care merely because he is
receiving care from a nursing student.
The patient is entitled to receive a
professional standard of care regardless
of the educational status of the person
delivering it. This is true of all personnel
delivering patient care or treatment -
physicians, physical or occupational
therapists, dietitians, technologists,
dentists, psychologists and social
workers.
The public expects nurses to have
special skills and competence, acquired
by virtue of their special training and
experience. Thus they must deliver care
that measures up to the degree of
proficiency expected of a member of
the profession. While the law does not
demand perfection of nurses, and a
Court always considers all of the
circumstances of the case, nevertheless,
a nurse must use reasonable care and
proficiciency in exercising her
professional responsibilities. This
applies also to st jdent nurses.
CURITY*
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INNOVATORS IN PATIENT CARE
Kendall Canada/6 Curity Avenue
Toronto, Ontario M4B 1X2
Registered Trademark
The Canadian Nurse
October 1980 7
41m
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The kidnapping
was solved
because the baby
left prints at the
scene of the crime.
You could only describe it as a hellish nightmare.
A three-day-old 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
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only record. Many experts believe footprints are
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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 million 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.
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INNOVATORS IN PATIENT CARE
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In general, the requirements of
our modern society dictate a need for
encouragement of beginners in all
fields of endeavor. Counterbalancing
this, however, is the obvious necessity
of protecting society from the errors
and omissions of these beginners, as well
as compensating the victim for any loss
suffered. A student driver, for example,
is held to the standard of the reasonable
and prudent motorist ; to require less
would subject pedestrians and motorists
alike to unreasonable risk of harm on
the nation s streets and highways But
the law does not leave the studen ; to
fend for himself: in order to protectjhe
interests of both the student and the
public, a legal responsibility to provide
students with supervision and guidance
during the learning process is imposed
upon the employer, school or other
responsible individuals such as clinical
instructors. 1
The student s clinical instructor is
responsible for the student s
assignments; student supervision must
meet the standard reasonably expected
of a prudent clinical instructor of
similar experience and training. If an
instructor failed to meet this standard
and if there were a finding that her
student s conduct was negligent and
caused harm to a patient, that instructor
could be held legally liable for the
negligence of the student nurse. The
clinical instructor, like registered nurses
and student nurses, also has an objective
standard of care by which her
supervision of students is gauged ; if this
supervision falls below the standard of
the reasonable and prudent clinical
instructor, then that instructor is
negligent.
It is important to recognize that
instructor negligence and student^nurse
negligence are not inextricably lifted:
student negligence does not
automatically impose legal liability
upon the clinical instructor. If a student
nurse is negligent but the supervision
that student received met the legal
standard of care for such supervision,
then a Court finding of liability would
be directed against the student. The
instructor would not be liable for the
negligence of the student.
Creighton refers to a U.S. case
involving a first year student
administering medication I.M. to a
patient with Buerger s disease whose
right sciatic nerve was severely injured.
The patient recovered a substanfial
judgment against the hospital because,
although first year students were
permitted to give injections under
supervision, in this instance adequate
supervision had not been given.
In another American case,
Walker v. Graham et. al., 3 an
inexperienced orderly successfully sued
the hospital after contracting hepatitis;
the illness occurred after his skin was
pierced by needles protruding through a
bag of garbage he was carrying to
disposal. The court found that the
hospital had failed in its duty to teach
inexperienced employees how o avoid
dangers connected to their employment.
10 October 1980
The Canad an Nurse
Obviously, hospitals can have
liability to as well as liability for
students. The hospital may incur
liability as a result of student nurse
negligence because it has a duty to the
patient to provide competent and
qualified personnel to deliver care. If
the hospital provides a student nurse
who is negligent, it has breached this
duty to the patient. Hospitals are also
vicariously liable for the negligence of
employees acting within the scope of
their employment; 4 if the student
nurse is a hospital employee, then the
hospital s vicarious liability follows. In
such a case, it is the relationship
between employer and employee, not
the status of "being a student", that
dictates the vicarious liability of the
hospital employer. 5
If a nursing school is directly
connected to a hospital that
supervises, controls and perhaps pays
(or otherwise benefits) its student
nurses, then the employment
relationship is clear: the hospital
generally provides room and board,
training and supervision etc. in
exchange for the student s services on
the hospital s ward units for the benefit
of that hospital. In such hospital
training programs, the vicarious liability
of the hospital for the negligence of
employees including student nurses is
clear.
In Harkies v. Lord Dufferin
Hospital, 6 a student nurse with nine
months experience was caring for an
infant ill with pneumonia. The infant
was placed in a steam crib and steam
inhalation was achieved by means of a
hose connected to a kettle. The other
end of the hose was placed in the crib
under a canopy. The infant suffered
severe scalding of his back and legs
which left him with a permanent limp.
No one, including the student nurse,
could explain how the injuries had
occurred.
The trial judge noted that if the
child had tampered with the hose, the
scalding would have occurred on the
upper part of the child s body. He
stated that, on the evidence received, he
accepted that the equipment was safe if
it was used correctly and that the
student nurse had been instructed in its
proper use. He held the hospital liable
for the injuries because, in the absence
of any other explanation, they must
have resulted from negligent use of the
equipment by the nursing student.
Most nursing students today are
not hospital employees since schools of
nursing are usually separate from the
hospital in which the student may have
all or part of her/his clinical experience.
These students pay tuition fees as well
as their room and board and
maintenance. The nursing service
provided by these students is considered
educational in nature rather than a
return for maintenance provided by the
hospital. Here, the question of a
hospital s vicarious responsibility for
the negligence of a student nurse would
depend upon a finding that the student
is a hospital employee. The ag re - in*
between the school of nursing and the
hospital providing clinical experience
would be another important factor in
this determination.
In some provinces, legislation
exists which provides that students,
including student nurses, are hospital
employees. For example, in Ontario,
s. 6 1 of Regulation 729 under The Public
Hospitals /lc/ 7 includes student nurses
in the definition of hospital employees.
The thrust of that section of the
Regulation which governs hospital
management, deals with the regulation
and supervision of the personal health
of hospital employees in order to
safeguard the health of all those in the
hospital be they employees, patients or
visitors. Because other sections of The
Act and the regulations thereunder also
refer to students, it might be argued that
student nurses can be considered
hospital employees even though the
services they provide are educational in
nature rather than in exchange for the
maintenance benefits that hospitals
used to provide.
The hospital s duty to provide
competent and qualified nursing staff to
deliver care to patients is met, in part,
by the head nurse who is responsible
for the work assignments and the
nursing care delivered to the patients on
the unit. It is the head nurse who
supervises those delivering care on the
unit and she therefore also has a role in
the observation and supervision of the
care delivered by students on the unit.
Where a head nurse finds that a
student nurse is not delivering care that
meets the required standard, this must
be corrected. The clinical instructor
should be informed and the student
given additional instruction and/or
supervision. Other nurses working on
the unit should also bring to the
attention of those in charge
circumstances of student nursing care
which they observe to be wanting, for
example, failure to hand wash or breaks
in sterile technique. Failure to deal with
problems like these creates an
unreasonable risk of harm to the
patients and leaves the hospital open to
legal liability for the negligence of its
employees and for lack of proper
supervision of beginners. The protection
of the interests of the patient must be
paramount.
Where student nurses are
delivering care, the nursing staff on the
unit should be aware of and have some
guidelines as to the scope of activities
the students are permitted to undertake.
Students should be specifically
instructed not to undertake to perform
nursing care for which they have not
received instruction. Students, like
RN s, should be instructed to ask for
assistance if they are uncertain about
the performance of any procedure,
treatment or care generally. The ward
staff should encourage the students to
request assistance when necessary ;
even though this may be perceived as an
additional burden on staff already
over-burdened, the primary goal of
"ecting the patient s safety, health
and well-being cannot be overlooked.
On graduation, students become
colleagues in delivering patient care and
time spent assisting the competence of
a student today means a competent
professional nurse later on. In addition,
student nurses as well as registered
nurses should always advise those
making the order of situations in which
they feel they are not competent to act.
As Creighton so aptly states: 8
"The inherent responsibility of
the nurse who supervises others
whether it is nursing students, registered
professional nurses, practical nurses,
aides, orderlies, or attendants is to
determine which of the patients needs
can be safely entrusted to a particular
person and whether or not the person to
whom the duty is delegated or assigned
is competent only if personally
supervised." (emphasis added)
The health, safety and well-being
of the patient are at stake; the required
standard of nursing care must be met to
protect the patient. Staff nurses, clinical
instructors and student nurses must
work together to deliver competent and
quality nursing care to the patients in
their trust.
References
1 *Fleming, J.L. The law of torts.
5th ed. Toronto: Carswell Co.; 1978:
p.110.
Creighton, Helen L. Law every
nurse should know. 3d ed. Toronto:
Saunders; 1975: p. 108.
3 * Walker v. Graham et al.
343 So. 2d 1171 (La 1977). In: Hosp.
Infection Control. 1978 Nov.: p. 174.
4 Sklar, C.L. The extension of
hospital liability : a landmark decision in
the making. Canad.Nurse 76(2):8-ll,
48; 1980 Feb.
Sklar, C.L. Hospitals and nurses:
the evolution of legal responsibility.
Canad.Nurse 76(5):50-53; 1980 May.
6 *[1931] 2DLR441 (Ont.).
*R.S.O. 1970 c. 378 as amended.
Creighton, op. cit.
*Not verified
Author Corinne L. Sklar is a lawyer and
practices law in Toronto, Ontario. She is
legal counsel with The Imperial Life
Assurance Company of Canada. Prior to
her law studies, she obtained her BScN
and MS degrees in nursing from the
University of Toronto and the
University of Michigan respectively.
ideniiftcdt
The Canadian Nurse
October 1980 11
announcing The New
Twist-on cap just pour, cap,
and stack.
Hold it like a bottle and pour
Ensure in the large opening
and rigid neck make it easy.
The Flexitainer* holds a full
litre use it for intermittent
or continuous feeding.
\
A clear plastic
chamber lets you r ^
monitor the flow rate.
The Ross Gavage Set fits any
nasogastric tube.
The CA1R* clamp gives you
precise control over delivery
The rigid neck and wide opening
make filling and handling easy.
The large graduated measurements
are easy to read, during filling and
during feeding.
i tib o-dnammrrtutwr
cap, and stack in the refrigerator.
ENSURE Delivery System
the best
of the bottle
and the bag!
Together, the Flexiflo* Flexitainer* and the Ross
Gavage Feeding Set give you the first tube feeding system
that s really convenient and economical.
The Flexiflo Flexitainer is a bag and bottle in one!
Like a bag, it is light, shatterproof, and disposable.
Like a bottle, it has a rigid neck and wide opening, and
it s leakproof. You can stack it prefilled, more
easily and in less space than either bags or bottles.
The Ross Gavage Feeding Set ensures accurate delivery
control and helps maintain a constant rate of feeding.
The Ensure Delivery System. Developed to give
you better control over tube feeding.
I ROSS LABORATORIES
Division of Abbotl Laboratories. Limited
I ROSS | Montreal. Canada H4P 1A5
J
Each Flexitainer has a self-adhesive
sticker, for instant patient
identification.
TheCAIR* clamp allows fingertip
control of flow rate.
TYLENOL
Acetaminophen
A LOGICAL FIRST CHOICE IN
NON-Rx ANALGESIA
ACTIONS:
Acetaminophen is an analgesic and antipyretic.
INDICATIONS:
TYLENOL" Acetaminophen is indicated for the
relief of pain. Also as an analgesic-antipyretic in
the symptomatic treatment of colds.
CONTRAINDICATIONS:
Hypersensitivity to acetaminophen.
ADVERSE EFFECTS:
In contrast to salicylates, gastrointestinal
irritation rarely occurs with acetaminophen. If a
rare hypersensitivity reaction occurs, discontinue
the drug. Hypersensitivity is manifested by rash
or urticaria. Regular use of acetaminophen has
shown to produce a slight increase in
prothrombin time in patients receiving oral
anticoagulants, but the clinical significance of
this effect is not clear.
PRECAUTIONS AND TREATMENT OF
OVERDOSE:
The majority of patients who have ingested an
overdose large enough to cause hepatotoxicity
have early symptoms. However, since there are
exceptions, in cases of suspected acetamino
phen overdose, begin specific antidotal therapy
as soon as possible. Maintain supportive
treatment throughout management of overdose
as indicated by the results of acetaminophen
plasma levels, liver function tests and other
clinical laboratory tests.
N-acetylcysteine as an antidote in
acetaminophen overdose is recommended.
However, its use at present is considered
experimental. More detailed information on the
treatment of acetaminophen overdose, including
the availability of N-acetylcysteine, the
preparation of N-acetylcysteine for
administration as an antidote, recommended
dosage regimen and acetaminophen assay
methods is available from JOHNSON &
JOHNSON Limited/Limitee, 890Woodlawn Road
West,,Guelph, Ontario N1H 7L4, or contact your
nearest Poison Control/Information Centre.
DOSAGE:
TYLENOL Drops:
Children 10-14 years: 1.5 mL 3 times daily
5 9 years: 0.6 mL 4 times daily
2 - 4 years: 0.3 mL 4 to 5 times daily
Children under 2 years: As directed by physician
Adults: 3 mL 3 times daily or as directed by
physician
TYLENOL Elixir:
Administer 4 times daily
Children 10-14 years: 1 teaspoonful
5- 9 years. Vz teaspoonful
2- 4 years: /> teaspoonful
Children under 2 years: As directed by physician
Adults: 2 teaspoonfuls or as directed by physician
TYLENOL Tablets 325 mg:
Adults: 1 or 2 tablets 3 to 4 times daily
Children 10-14: Vi or 1 tablet 3 to 4 times daily
TYLENOL- Tablets 500 mg:
Adults: 1 or 2 tablets 3 to 4 times daily
Children: As directed by physician
TYLENOL- Capsules 500 mg:
Adults: 1 or 2 capsules 3 to 4 times daily
Children: As directed by physician
SUPPLIED:
TYLENOL- Drops: Each 0.6 mL contains 60 mg
acetaminophen in a deep red liquid vehicle with a
slightly bitter, cherry-flavoured taste. Available in
amber bottles containing 15 mL and a calibrated
dropper.
TYLENOL" Elixir: Each 5 mL contains 120 mg
acetaminophen in cherry-flavoured red vehicle.
Available in amber bottles containing 100 mL and
455 mL.
TYLENOL Tablets 325 mg: Each round, white
tablet, scored on one side and engraved
"TYLENOL" other side; contains 325 mg
acetaminophen. Available in amber bottles of 24,
100 and 500 tablets.
TYLENOL" Tablets 500 mg: Each round white
tablet, engraved "TYLENOL" one side and "500"
other side; contains 500 mg acetaminophen.
Available in amber bottles of 30 and 100 tablets
TYLENOL" Capsules 500 mg: Each red and white
capsule, printed "TYLENOL 500 mg" cap and
body, contains 500 mg acetaminophen. Available
in amber bottles of 24 and 50 capsules.
Complete prescribing information available on
request A fl
(k?wvrovt
GUELPH, ONTARIO N1H 7L4
"Trademark of Johnson & Johnson.
US, Canadian nurses attend perinatal symposium
Special Report
by
Sandra LeFort
Obstetrical, pediatric and neonatal nurses
from across the US and Canada came to
gether at the National Symposium of
Perinatal Nursing held in Montreal,
August 7-10. Three hundred American
nurses came from as far away as Califor
nia and Texas, with a large representation
from the mid-west and from New York
state. Sixty Canadian nurses primarily
from the Maritimes and central Canada
also attended this gathering of specialty
nurses.
The four-day meeting provided a
forum for discussion of advances in per
inatal nursing and current clinical man
agement. In all, 25 lectures and 32 work
shop sessions were presented on a wide
variety of topics including:
genetic screening and prenatal
diagnosis of intrauterine growth retarda
tion
care of the pregnant diabetic and
her infant
neonatal infections
fetal heart rate monitoring
pregnancy after 35
pros and cons of circumcision
the high risk pregnancy
necrotizing enterocolitis.
Lectures were presented in the morning
followed by a question period and then
by workshop sessions in the afternoon.
Meeting highlights
All speakers were experts in their field;
many had conducted recent research into
their particular specialty area of peri
natal care. The lectures were primarily
a review of current literature and research
on the subjects along with the clinical
management and protocols used in spe
cific hospitals.
Dr. William On, professor of ped
iatrics and obstetrics, Brown University
in Rhode Island discussed patent ductus
arteriosus (PDA) in the low-birth-weight
infant. He stated that babies over 1500
gm, treated with Indomethicin had clo
sure of the ductus in 70-80 per cent of
cases. Smaller babies often did not res
pond satisfactorily to the prostaglandin
synthetic compound.
Recent studies also strongly re
commend conservative fluid intake if
PDA is suspected. Babies given liberal
amounts of fluid (160 ml/kg/day or
more) had a high risk of developing or
worsening their left to right shunt. The
message to nurses was "watch the fluid".
Frank Boehm, MD, director of
fetal intensive care and associate profes
sor of obstetrics and gynecology at Van-
The Canadian Nurse
derbilt University in Tennessee, spoke
on the controversy surrounding fetal
heart rate monitoring in labor. A strong
advocate of fetal monitoring, Boehm re
viewed the past 10 years stating that fe
tal monitoring had decreased the ante-
partum death rate to about five per
thousand deliveries, as opposed to seven
to eight per thousand where fetal moni
toring is not used. He stated that the
alarming rise in Caesarean sections in the
US and Canada over the last decade was
due to poor interpretation of the moni
tor data by physicians and nurses. Now,
with greater expertise in the use of mon
itors, the C-section rate is going down
and many babies in fetal distress due to
cord compression, utero-placental in
sufficiency or infection, are being saved.
Prolonged apnea and sudden infant
death syndrome (SIDS) was discussed
by William Kanto, associate professor,
department of pediatrics at Emory Uni
versity in Atlanta, Georgia. He gave a
chronological history of the progress in
knowledge related to SIDS. Of special
interest was one retrospective study
which tried to see whether these babies
really had been "normal" prior to their
death.
In comparing SIDS victims to their
living siblings, mothers reported that the
SIDS infant:
had been less active than her other
children
was less responsive to stimuli
was easily exhausted especially
with feedings
possessed a different and less varied
cry.
In another collaborative study
done in the United States, 60,000 preg
nancies were followed with 125 babies
developing SIDS. The results indicated
that there was an increased incidence in
babies of young, smoking mothers; that
the SI DS victims had a low Apgar at birth
and many required resuscitation; and
that some had subtle neurological signs.
In discussing possible treatment
for high risk SIDS victims, Kanto sugges
ted that Theophylline should be given
to the preterm infant who has respira
tory problems, home monitoring with
electronic devices could be initiated and
in all cases strong family support was
needed.
Canadian content
A number of nurses and health profess
ionals from the Montreal area presented
excellent lectures and seminars to the
group, among them:
Given clinically documented equipotency 1 ?. .
Why complicate
simple analgesia?
ASA side effects
(at normal doses)
Adverse effects
...on hypersensitive
individuals 3 -!
...on the
gastrointestinal tract
...during
pregnancy 911
...of concomitant
use with
other drugs 2 ^
...on the blood
...resulting in
iron-deficiency
anemia 512
TYLENOL
acetaminophen
(at normal doses)
Hypersensitivity
in rare instances 1 . 3 - 14
side effects
1 . Bottermon. R C , and Grossman. A.J Fed
3 16-3 17 (Mar) 1955 2. Goodman. IS, andGilman. A.
eds The Pharmacological Basis of Therapeutics, ed. 5,
New York, The Macmillan Company. 1 975, (a) p 334.
(b)pp 1350-1366 3. Yung.nger, J W . O Connell. E.W..
and logon, GB J Pediotr. 82: 218-221 (Feb.) 1973 4.
Selnpone, G A . Chafee. F H , and Klein. D E-: J Allergy
Oin Immunol 53 200-2O4 (Apr ) 1974 5. Menguy. R :
Am J Clm Res 2 17-26. 36-37 (Apr) 1971.6. Sprvock
M.:Med T im es99 129-133 (Jon.) 1971 7. Croli. D.N..
and Wood. P H.N Br Med J 1 137-141 (Jon. 21)
1967 8. Cooke. A R Am. J Dig Dis 18:225-237
(Mot ) 1 973 9. Turner, G . and Collins. E. lancet 2
338-339. 1975 10. lewis, R B , and Schulmon, JO
lancet 2 1159-1 161. 1973 11. Bleyer. W A . and
Breckenndge, R T JAMA 213 20492053. 1970 12.
SummersWI. W.H.J.. ond Alvarez, AS: lancet 2 925-928
(Nov.) 1958 13. Prescott. LF Side EKects ol Drugs,
e. Williams ordWilkms, 1968. pp 101-139 14.
A logical first choice in
non-Rx analgesia
TYLENOL
acetaminophen
REGULAR STRENGTH /EXTRA-STRENGTH
325 mg
500 mg
pmtfron
GUELPH, ONTARIO N1H 7L4
Judith Collinge, nurse researcher,
neonatal intensive care unit, Montreal
Children s Hospital who discussed nur
sing management of hyperbilirubinemia;
Valmai Elkins, director of the ob
stetrical program, School of Physio and
Occupational Therapy, McGill University
who spoke on pain control methods in
labor;
Frances McLean, information offi
cer, perinatology at Royal Victoria Hos
pital who discussed physical and gesta-
tional age assessment of the newborn;
Anne Kiss, instructor of family
structure and community health nursing.
Concordia University who presented the
challenges of teenage pregnancy;
Joula Hatherall, coordinator of the
Childbirth Education Program in Mon
treal who discussed childbirth education.
Of special interest was a seminar
presentation by a team from Montreal s
Royal Victoria Hospital. Marion Copp,
nurse clinician teacher, Nancy Fuller,
director of social services and psychia
trist Catherine La Roche presented re
cent findings on reactions to stillbirth
and neonatal death.
They explained that until two
years ago, health care personnel offered
Ovol Drops
relieve
infant colic.
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.
Shhh. Ovol Drops.
Also available m tablet form for adults
no special support to parents of stillborn
infants. Parents requests to see and
touch their dead baby or to have a
photograph of their infant were viewed
as morbid and were discouraged. Feed
back to nursing staff from several par
ents about how difficult it was to cope
with stillbirth led to the formation of a
team approach to deal with the crisis of
stillbirth and neonatal death.
The importance of parents seeing
and touching their infant, taking photo
graphs, the meaning of a ritual such as a
funeral and the importance of empa-
thetic health care personnel were high
lighted.
Symposia Medicus
The Symposium was sponsored by Sym
posia Medicus, a private, non-profit asso
ciation that organizes programs to meet
the continuing education requirements
of physicians and nurses in specialty
areas. Speaking on behalf of Symposia
Medicus, Dwight Stump, vice-president,
stated that "a private corporation such
as ours can do a good job in the area of
continuing medical and nursing educa
tion because we can use expertise from
across the country". The Perinatal Sym
posium took over a year of planning.
Stump explained that surveys are con
ducted across the US to identify the to
pics of current interest.
Ovol 8O
Tablets
Ovol4O mg
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 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.
HORDER
Montreal. Canada
Full information available on request.
16 October 1980
The Canadian Nurse
Saneen. Because incontinent patients
have feelings, too.
ith the Saneen
two-part incontinence
system, even ambulatory
patients need never
feel embarrassed again.
The Saneen two-part
incontinence system satisfies an important
psychological need, as well as an obvious physical
one. Because it s less bulky than similar products,
it s a lot less obvious when worn.
Psychologically, this makes it
easier for your patients to
be more active.
The Saneen system is in
use in many major Canadian
institutions. It consists of .
an absorbent, soft, fibre-filled
pad and separate stretchable,
snug-fitting brief. One
washable size fits all. Patients who ve tried it, quite
naturally prefer it. When you stop and think
about all the problems
they have, we think you ll
prefer it, too.
For additional inform
ation, complete and mail the
coupon below. Your patients
mental and physical well-
being will both be better served if you do.
Jfff Mail to:
Facelle Co. Ltd.,
Saneen BSOjane Street,
Toronto, Ontario M6M 4Y4
Please send me more information on the Saneen two-part incontinence system.
Product only available in Eastern Canada.
NAME
TITLE
NAME OF INSTITUTION
ADDRESS
CITY
PROV.
POSTAL CODE
PHONE
aneen
"Saneen" Reg d T.M. Facelle Company Limited
Made in Canada for Facelle Company Limited
Subsidiary of Canadian International Paper Company
CURITY*
Urine Meter
and Streamline Drain Set
Two systems in one.
Hourly urine measurement designed
into a closed urinary drainage system.
Closed system
Accurate
measurement
Transparent
meter scale
Convenient
specimen collection
Urine transfer tube allows transfer from
urine meter to drainage bag without
breaking the closed system.
Continuous urinary output
measurements may be taken at any
desired time interval. Measurement
procedure is convenient and aseptic.
Transparent meter scale affords clear
view measures in increments of 1 ml
from to 34 ml, and in increments of 5
ml from 35 to 200ml.
Push-pull valve permits collection of
fresh urine for specimen.
INNOVATORS IN PATIENT CARE
Kendall Canada/6 Curity Avenue
Toronto, Ontario M4B 1X2
Registered Trademark
CNA CONVENTION
Presentations available on cassette
Presentation Quantity
CNA A & B
Helen K. Mussallem Roast
(two cassettes)
CNA 1
Lea Zwanger Primary Care
CNA 2
Lorine Besel Who shapes
nursing in the 80 s?
CNA 3
Robyn Tamblyn
Specialization in nursing
CNA 4
Malcolm Taylor Health care
system and public policy
CNA 5
Reaction panel Health care
system and public policy
CNA 6
Helen Taylor President s address
CNA 7
Roland Foucber Labor movement
vis a vis the professional
CNA 8
Aline Michaud and Louise
Lemieux-Charles Labor movement
vis a vis the professional
A.
B.,
CNA9A&9B A .
Continuing education: mandatory
or volun tary (two cassettes) B.
Mail Order Form
1. Indicate number of each cassette desired in
"Quantity" column above.
2. Price $7.00 plus $0.50 handling per cassette.
3. Payment by (check one only):
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International Simultaneous Translation
Services
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St. Laurent, Quebec, H4R 1 E6
Books for a new
decade of nursing.
Tilkian & Conover
UNDERSTANDING HEART
SOUNDS AND MURMURS
Here s an exciting package that provides a basic familiarity with
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. Tilkian, MD. FACC. Asst. Clinical Prof, of Medicine (Cardio
logy). Univ of California School of Medicine. Los Angeles, and Mary
Boudreau Conover, RN. BSN. Ed Instructor of Critical Care Nursing
and Advanced Arrhythmia Workshops, West Hills Hospital and West
Park Hospital. Canoga Park. CA. Book only: 122 pp. Illustd. Soft cover
$12 OO. April 1979 Order #8869-1. Package: $22 75 Order #8878-0.
Grant
HANDBOOK OF TOTAL PARENTERAL NUTRITION
A manual of safe and effective administration of total parenteral
nutrition. Grant provides easy reading by not going into exces
sive detail with basic research and laboratory investigational
material. Coverage spans from initial patient evaluation to
recognition and avoidance of metabolic and technical compli
cations. Every major advance is included.
By John P, Grant, MD. Director. Nutritional Support Service. Asst
Prof, of Surgery. Duke Univ Medical Center. Durham, NC. 197pp
Illustd. $21 OO. Jan. 1980. Order #4210-1 .
Luckmann & Sorensen
MEDICAL-SURGICAL NURSING:
A PSYCHOPHYSIOLOGIC APPROACH
2nd Edition
Updated, revised, and expanded the new Second Edition of
MEDICAL-SURGICAL NURSING: A Psychophysiologic
Approach keeps pace with the needs of today s nurse ... to supply
nurses with the knowledge and confidence to undertake ever-
increasing responsibilities. Concise, yet comprehensive;
MEDICAL-SURGICAL NURSING can be used in conjunction
with or independently from Sorensen & Luckmann s BASIC
NURSING. For the fundamentals, turn to. BASIC NURSING; for
more advanced principles. MEDICAL-SURGICAL NURSING.
ByJoan Luckmann, RN. BS. MA. Formerly, Instructor of Nursing,
University of Washington. Highline College. Seattle. Oakland City
College, and Providence Hospital College of Nursing, Oakland. CA:
and Karen Creason Sorensen, RN. BS. MN, Formerly, Lecturer in
Nursing. University of Washington; Formerly. Instructor of Nursing,
Highline College, Formerly, Nurse Clinical Specialist. University
Hospital and Firland Sanatorium. Seattle. WA. 2276 pp 81 7 ill.
$4080 Order #5806-7.
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 com
ments 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, Prof, of Pediatrics, Case Western Reserve
University School of Medicine and University Hospitals (Rainbow
Babies and Children s Hospital). Cleveland, OH; and Avroy A.
Fanaroff, MB(RAND). MRCPE. Assoc Prof, of Pediatrics. Case
Western Reserve University School of Medicine; Director of the
Neonatal Nurseries, University Hospital (Rainbow Babies and
Children s Hospital). Cleveland. OH. 437 pp Illustd $26 40 July 1979
Order #5478-9.
Patterson, Gustafson & Sheridan
FALCONER S CURRENT DRUG HANDBOOK
1980-1982
Up-to-date, quick reference to more than 1500 common drugs.
Emphasizes drug interactions and nursing implications.
Also lists generic and major trade names, sources, dosages,
major and minor uses, action and fate, toxicity, and contra
indications.
All entries based on latest available information.
Emphasizes vital information that can quickly be put to use
in a clinical situation,
Listed in a columnar format for easy accessibility.
Organized according to categories of usage.
Includes a detailed index.
By H. Robert Patterson, BS. MS, Pharm D. Prof, of Microbiology and
Biology. San Jose State Univ.. San Jose, CA ; Edward A. Gustafson, BS.
Pharm D, Pharmacist. Valley Medical Center, San Jose. CA; and
Eleanor Sheridan, RN, BSN, MSN. Asst Prof . College of Nursing.
Arizona State Univ, Tempe.AZ 374 pp Soft cover $13. 15. April 1980
Order #3522-5.
Phillips &Feeney
THE CARDIAC RHYTHMS
Second Edition
For clear-cut instruction in the precise interpretation of cardiac
rhythms this up-to-date revision is the book to turn to. The
authors discuss basic anatomic and physiologic aspects, as well
as more advanced topics such as action potentials and bundle
branch blocks. You ll find the text s workbook format and periodic
self-evaluation tests ideal for self-instruction. Over 700 illustra
tions many of them EKGs taken directly from the cardiac
monitor help clarify fine points of interpretation.
By Raymond E. Phillips, MD. FACP. Senior Attending Physician,
Phelps Memorial Hospital, North Tarrytown, NY; Clinical Asst. Prof,
of Medicine, New York Medical College. Valhalla. NY; Consultant in
Cardiovascular Medicine, Veterans Administration Medical Center,
Castle Point. NY; Exercise Cardiologist, Cardiac Rehabilitation Center.
Montefiore Hospital and Medical Center, The Bronx, NY; and Mary
Kay Feeney, RN. MN. CCRN. Critical Care Specialist, St. Joseph s
Hospital; formerly Clinical Instructor, ICU/CCU. Columbia Hospital
School of Nursing, Milwaukee. Wisconsin. 419 pp 744 ill. Soft cover
S20.35 Order #7221-3. ^^
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CAR-288
Health hotline makes house calls in Halifax
Help your patients cover up with the
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prints in nylon jersey material. Waist strap
helps keep them sitting comfortably in
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Health
Dimensions Ltd
2222 S. Sheridan Way
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Tel.: 416/823-9290
Mary -Lou Ellerton
Health information at the turn of a radio
dial. That s what Haligonians get when
Dalhousie University s School of Nursing
and a local radio station join forces.
Hotline to the health team, a two-
hour, call-in show aired once a month in
the Halifax-Dartmouth area, is designed
to help the public learn more about
community services. Each program is co-
hosted by a faculty member of the
school of nursing and radio station
CJCH s Dave Wright. A different faculty
member every month gives each program
a different focus.
The show opens with a 20-minute
discussion of some aspect of physical
and emotional health, usually the faculty
member s area of special interest. So far,
topics have ranged from food and fitness
to human sexuality, from parenting to
stress. The phone lines are then opened
and listeners are invited to call in ques
tions about their health.
Most of the calls come from wom
en working in the home and for the most
part, tend to reflect the difficulties of
coping with life crises such as parent
hood, menopause, retirement and family
sickness.
The success of the hotline comes
from the anonymity it provides people;
many would be reluctant to ask a health
professional the same question in an
office setting. One caller confided her
distress at her husband s lack of interest
in sex after a heart attack and others
have expressed concern about their body
image and sexuality. All were relieved to
find that their concerns were normal.
If the co-host feels that a caller
deserves more individual attention, she
asks him to call back after the program
for further discussion and possible refer
ral.
Co-host Deni Sommerfeld with Dave Wright
Besides requests for advice, the
program has elicited many calls for in
formation on, or clarification of specific
diseases, treatments and drug usage; cur
rent public interest in nutrition has also
been reflected in the number of calls
about vegetarianism and natural foods.
Health professionals, including a
physician, nutritionist and a pharmacist,
are available by phone hook-up to handle
requests for specialized information.
So far, audience response has been
enthusiastic. The switchboard usually
gets about 12 to 15 calls per show and
listeners who don t get through, can mail
their questions to the station. The half
dozen letters received are answered on
the next program.
Moving into its second year, Hot
line to the health team hopes to intro
duce more topics related to health and
lifestyles such as:
health for women cancer, meno
pause, careers and mothering
health for the elderly nutrition,
social contact, home care
health and fitness exercise, nu
trition for athletes, the heart.
Hotline to the health team is one
of a series of four shows on community
service professions. Its sister programs
deal with law, consumerism and police
protection.
Mary-Lou Ellerton is a lecturer in Medical-
Surgical Nursing at Dalhousie University and
chairman of the Public Relations Committee
which coordinates Hotline To The Health
Team.
22 October 1980
The Canadian Nurse
audiovisual
Award Winning Films
The John Muir Film Festival
(California) is the only festival in the
world to exclusively honor films
produced for the continuing education
of doctors, nurses, paramedics and
community health education. This year
almost 200 films were entered in 22
different categories and Canadian films
took three awards:
There s No Place Like Home For Health
Care, a series of 12 films produced as a
joint project of Saint John Ambulance
and the Red Cross, won honorable
mention in the rehabilitation category.
Peter Cock directed the films and they
were produced by Crawley Films Ltd.
of Ottawa. The series is designed to
teach basic home skills to the public and
thus reduce the need for hospitalization.
It is part of a package that includes
handbooks and classroom instruction,
and is now being distributed across
Canada; for further information contact
St. John Ambulance or Red Cross.
Four Women: Breast Cancer, produced
by the Canadian Broadcasting
Corporation and directed by John
Kastner, won the festival s oncology
award. This film explores the personal
experiences of four women having a
mastectomy; they, and three husbands
speak candidly about their fears,
uncertainties and adjustments.
One of Our Own, produced by Bill
Gough and directed by William Fruet,
received honorable mention in the
mental retardation category. The story
is that of an 1 8-year-old boy with
Down s Syndrome adjusting to a move
from a small town to a big city. The
film deals with the family s difficulties
in coming to grips with the future of
this boy. The lead role is played by an
actor with Down s Syndrome. The film
is available through the Canadian
Broadcasting Company.
A catalogue of audiovisual resources in
the field of psychiatric-mental health
nursing has been developed as a special
project of the faculties of Continuing
Education and Nursing at the
University of Calgary. Compiled by
Janice Bell and Sylvia Teare, two nurse
educators, the catalogue contains titles
and descriptions of audiovisual
resources, many of which have been
evaluated by them. Names and addresses
of distributors are also included. Cost
per copy is $5.00; order from:
Mary Hammond
Faculty of Continuing Edu cation
University of Calgary
2500 University Drive N. W.
Calgary, Alberta T2N 1N4.
Can I Take This If I m Pregnant is a
brochure published by the Addiction
Research Foundation. It is intended as
an expectant mother s guide to the use
of social and non-prescription drugs.
Alcohol, tobacco, caffeine and
marijuana are among those discussed;
most drugs are discussed under group
headings such as analgesics,
tranquilizers, etc. Cost of the brochure
is 25 cents. It is available from:
Addiction Research Foundation
33 Russell Street
Toronto, Ontario
M5S 2S1
Health and Welfare Canada and the
Canadian Pediatric Society have
produced an awareness program on
breast feeding. This packet of materials
contains scientific articles on the
uniqueness of human milk and the
practical management of breast feeding,
lists of resource persons, as well as an
attractive wall poster.
Copies of the kit are available
from:
Nutrition Education Unit
Health and Welfare Canada
Ottawa, Ontario
K1A 1B4
The Canadian Institute of Child Health
has published three reports:
1. Care of Children in Health Care
Settings: A Resource and
Self-Evaluation Guide
2. Care of Children in Health Care
Settings: Play and Play Programs
3. Care of Children in Health Care
Settings: Preparation for Hospitalization.
The Resource and Self-Evaluation
Guide is a manual for use by doctors,
nurses, administrators or consumers to
assess care on a pediatric unit with more
than 20 beds. The question and answer
format covers such topics as policy and
procedure manuals, maintaining a safe
environment, facilities and equipment.
It is available in French or English at a
cost of $8.00 per copy.
The Play and Play Programs is an
information kit for use in setting up a
play program or implementing changes
in an existing one. It is available in
English for $5.00.
The Preparation for
Hospitalization resource kit is designed
to help parents, teachers, health care
professionals and others in
implementing a hospital orientation
program for children. It is available in
English for $5.00.
All publications can be ordered
from:
The Canadian Institute of
Child Health
Suite 803
410 Laurier Avenue West
Ottawa, Ontario KIR 7T3.
Choose a
Nursing
Career __
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H 1V8
Telephone: 1 (902) 428-3484
The Canadian Nurse
October 1990 23
TWO CAREERS
IN ONE.
Being a nurse and an officer in the Canadian Forces offers
many advantages. If you re a Canadian citizen and a graduate
nurse (female or male) of a school of nursing accredited by
a provincial nursing association and a registered member of a
provincial nurses association with two year s experience
why not combine two careers in one?
For more details, contact your nearest Canadian Forces
Recruiting Centre in the Yellow Pages under "Recruiting"
or return the coupon.
ASK US
ABOUT YOU
THE CANADIAN
ARMED FORCES
Director of Recruiting and Selection
National Defence Headquarters
Ottawa, Ontario, K1A OK2
Name
Address
City
Prov.
Postal Code
Telephone Number
N-CN-2/80
Ten Canadian Nurses
Receive Scholarships
This year, ten Canadian nurses have
been awarded scholarships totaling
$38,000 from the Canadian Nurses
Foundation. Half of the nurses will use
their fellowships for doctoral studies,
while others will commence or continue
studies at the master s level.
The Canadian Nurses Foundation,
established in 1962, receives funds and
administers fellowships for the
preparation of nurses for leadership
positions. A total of 2 1 5 scholarships
have been awarded since its inception.
CNF funding is voluntary and depends
upon gifts, donations and bequests from
individuals and organizations.
The five nurses who will pursue
doctoral studies are:
Janet Beaton of Winnipeg,
Manitoba. Beaton, who holds a Bachelor
of Nursing from the University of
Manitoba and a Master of Arts in
maternal-infant health from the
University of Washington, plans to
study at the University of Texas. After
graduation, she will return to teaching
graduate and possibly undergraduate
courses at the University of Manitoba,
School of Nursing.
Lillian Bramwell of Belmont,
Ontario. Bramwell earned her B.Sc. and
MScN in health education and nursing
education from the University of
Western Ontario. She received her RN
diploma at the University of Alberta
Hospital in Edmonton. Bramwell plans
to return to the Faculty of Nursing at
the University of Western Ontario, from
which she presently has leave of absence
to attend Wayne State University in
Detroit.
Heather Clarke of Victoria, British
Columbia. Clarke will study at the
University of Washington in Seattle. She
received her diploma in nursing at
Wellesley Hospital in Toronto, a B.N.Sc.
in public health nursing from Queen s
University and a Masters of Nursing in
maternal/child health from the
University of Washington. When she
finishes her PhD, Clarke plans to resume
her teaching responsibilities at the
University of Victoria as an assistant
professor.
Elizabeth Davies of Edmonton,
Alberta. Winner of the Katherine E.
MacLaggan fellowship, Davies is
presently enrolled in the postmaster s
program at the University of
Washington in Seattle where she plans
to continue her studies. Davies earned
her BScN from the University of
Alberta and her MS in nursing from the
University of Arizona.
Lesley Degner of Winnipeg,
Manitoba. Degner will attend the
University of Michigan School of
Nursing. She holds a BN from the
University of Manitoba and a Master of
Arts in physiological nursing and
philosophy from the University of
Washington. Upon completion of her
PhD, she plans to return to her teaching
position at the University of Manitoba.
Of the five nurses who will pursue
studies at the master s level, four
received CNF scholarships. They are:
Susan Abbott of Toronto,
Ontario. Abbott holds a BScN from the
University of Toronto and is currently a
teaching assistant at Boston University.
She will continue her studies there.
Linda Cooper also of Toronto,
intends to study at Boston University.
She holds a BScN from the University
of Windsor.
Margaret Earle of St. John s,
Newfoundland, has been awarded a
CNF fellowship of $2,000 and the
Agnes Campbell Neill Memorial award
of $ 1 ,000 to pursue graduate studies at
the University of Toronto. She received
a BN from Memorial University.
Yvette Fliesser of Ilderton,
Ontario. Fliesser will use her scholarship
to complete her MScN at the University
of Western Ontario where she is
currently enrolled in part-time studies.
She holds a BScN from UWO.
The winner of the Helen
McArthur Canadian Red Cross Society
Fellowship valued at $3,500 is:
Beverley Robson of Melfort,
Saskatchewan. Robson, who holds a
BScN from the University of
Saskatchewan, plans to continue
working on her master s degree at Case
Western Reserve University in
Cleveland, Ohio. She will specialize in
community health and education.
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For full details and training supplies, contact your Nordic representative or
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LABORATORIES INC
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The Canadian Nurse
October 1980 25
Books of Interest for the
NEW FOR 1980! O NEW FOR 198O! O NEW FOR 198O! O
1 A MANUAL OF
LABORATORY DIAGNOSTIC
TESTS
By Frances Talaska Fischbach, R.N.,
B.S.N., M.S.N.
"A Manual of Laboratory Diagnostic
Tests is intended to be a quick reference
for practitioners and a teaching-learning
tool for students in a variety of health
care areas: nursing, physical therapy,
inhalation therapy, x-ray technology,
medical technology, and others. The
need for a book of this type became
evident to me while working with nursing
students, practicing nurses, and educators
who were looking for a reliable, up-to-
date resource in one volume." F. T. F.
The purpose of this book is twofold,
first, to present current information on
commonly ordered laboratory diagnostic
tests; second, to organize the data in a
form that is orderly and easy to use and
understand.
Lippincott. 828 Pages. 1980. $15.50
NEW FOR 1980 ! O
2 QUALITY ASSURANCE:
Guidelines for Nursing Care
By the Duke University Hospital Nursing
Services, Durham, North Carolina.
Quality Assurance is written for
nurses who intend to be explicit about
and accountable for the quality of care
they provide. Quality assurance pro
grams provide the means by which groups
of nurses and their employers can rea
sonably assure the public that the services
rendered in their institution are equiva
lent to agreed upon standards of care for
similar patients in other locations.
This manual is written by practicing
nurses for other practicing nurses, nursing
students, nurse educators, and nurse
managers.
Lippincott. 459 Pages. 1980. $19.00
NEW FOR 198O! O
3 LIPPINCOTT S GUIDE TO
NURSING LITERATURE
By Jane L. Binger, R.N., M.S.; and
Lydia M. Jensen, R.N., M.S.
Here at last is a helping hand for
every nurse who has ever wanted to con
tribute to the nursing literature! Lippin-
cott s Guide to the Nursing Literature
answers all your questions about re
searching and preparing an article or a
book for publication. A unique and
remarkable text that tells you how-to-
do-it step-by-step!
Lippincott. 303 Pages.
10 Illustrations. 1980. $13.25
OPHTHALMOLOGIC
NURSING
By Joan F. Smith, Ph.D., R.N.; and
Delbert P. Nachazel, Jr., M.D.
A thorough, systematic look at the
eye: its component parts, its potential
disorders, and the nurse s role in every
situation of its care. The book begins
with separate chapters on each anato
mical sector of the eye region that
scrutinize anatomy, histology, and phy
siology, introduce the related special
diagnostic instruments and tests, and
describe all the possible pathological
conditions in terms of their treatment
and nursing care. The authors then dis
cuss such special topics as nursing care of
the blind patient, physical assessment of
the patient with eye disorders, and spe
cific ophthalmologic nursing procedures.
Little, Brown. 302 Pages.
Illustrated. 1980. $18.00
NEW FOR 198O! O
5 BASIC PSYCHIATRIC
CONCEPTS IN NURSING,
4th Edition
Joan J. Kyes, R.N., M.S.N.; and Charles
K. Ho fling, M.D., F.A.C.P.
Extensive updating and revision
make the new fourth edition of this
popular text topical and timely as never
before! Case studies elaborate upon the
dynamic concepts presented. Chapter
summaries (for every chapter) capture
the salient points for the student s
review. And, as with the previous edi
tion, general psychiatric theory is inte
grated throughout the text.
Lippincott. 736 Pages.
Illustrated. 1980. $18.95
NEW FOR 198O! O
6 FUNDAMENTAL SKILLS IN
PATIENT CARE, 2nd Edition
By LuVerne Wolff Lewis, R.N., M.A.
The purpose of this leading intro
ductory text is to present basic nursing
skills that all nurses need to know, re
gardless of the type of educational pro
gram in which they are enrolled prac
tical, associate degree, diploma or bacca
laureate. New material includes: a
brief description of the nursing process
and problem-oriented records; a patient s
bill of rights; sensory deprivation; prepa
ration of the patient for common diag
nostic procedures; urinary diversion;
basic cast care; cardiopulmonary resusci
tation; introduction of a nasogastric
tube; the living will; and hospice care.
Lippincott. 408 Pages.
Illustrated. 1980. $16.50
7 TEXTBOOK OF MEDICAL-
SURGICAL NURSING,
4th Edition
By Lillian S. Brunner, R.N., M.S.N.,
Sc.D., F.A.A.N.; and Doris S. Suddarth,
R.N., B.S.N.E., M.S.N.
Fully updated and expanded, the
fourth edition integrates concepts and
clinical content throughout, accenting
assessment and management in nursing
practice.
Physiology and pathophysiology
have been expanded, offering an over
view of normal function and providing
an understanding of deviations from
normal.
Lippincott. 1500 Pages.
Illustrated. 1980. $34.75
NEW FOR 1980! O
8 INTRAVENOUS
MEDICATIONS: A Guide to
Preparation, Administration
and Nursing Management
By Diane Proctor Sager, R.N., M.S.N.;
and Suzanne K. Bomar, R.N., M.S.N.
Here is a handy two part reference
designed to give the most complete cover
age of intravenous equipment, tech
niques, management, and the drugs them
selves. Part One describes the theories
and techniques of the intravenous admini
stration of drugs. Among the topics
discussed are: helping the patient cope
with stress; the correct technique for the
insertion of the intravenous cannula;
maintaining a patient intravenous line
and regulating the flow rate of fluids
and drugs; major complications of intra
venous drug therapy; and three modes of
intravenous administration. Part Two,
the Drug Information section, presents
detailed information in column form on
all drugs currently approved for intra
venous use.
Lippincott. 560 Pages.
Illustrated. 1980. $19.25
NEW FOR 198O! O
9 WORKBOOK FOR
FUNDAMENTAL SKILLS IN
PATIENT CARE
By LuVerne Wolff Lewis, R.N., M.A.
Follows the textbook chapter-by-
chapter but can be used separately as a
self-evaluation manual in basic care skills.
Lippincott. 257 Pages.
Illustrated. 1980. $9.50
Dedicated Nurse ZTx
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FREE CATALOGUE!
HARPER/LIPPINCOTT
NURSING and
ALLIED HEALTH
1980 CATALOGUE
J. B. LIPPINCOTT COMPANY OF CANADA LTD
75 Homer Avenue, Toronto, Ontario M8Z 4X7
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CN-10-80
Care for.the
caregiver
You entered nursing because it
was a good opportunity to use
your natural nurturing skills; it
would be a preparation for
motherhood you thought. You
could serve people in a worthwhile
career that wouldn t cost too
much initially, would allow some
freedom, enough money to travel
and perhaps a chance to pursue a
career with leadership options.
For some, there was the fantasy
of catching and marrying a doctor,
while others naively saw attending
nursing school as a way of
avoiding the working world and
the rigors of university. But it
didn t work out that way. It s
a tough life being a nurse. Your
professional and personal life has
become so stressful, you find it
hard to cope. Now the caregiver
needs care.
Nurses are prime candidates for role
stress. Current nursing trends have
attracted a new breed of students and
educated them to expect to function
in a greatly expanded role. However,
much of the profession still functions
with the belief that "a nurse is a nurse is
a nurse". The broader educational
background of today s nurse has forced
her to view the world in a different
Mary L.S. Vachon
context, and therefore has left her role
full of uncertainties. In order to cope
with the stress brought on by such
confusion, nurses must make personal
changes as individuals, caring for
themselves, so that the profession can
then change and alter the systems
within which nurses operate.
28 October 1980
Basically, there are four areas of
our lives in which stress is manifest and
which can be altered to decrease stress.
They are the psyche, soma, family and
social life and our occupational life.
They can also be looked at under the
subtitles of getting to know yourself;
taking care of yourself; getting to know
others and putting it all to work. In
dealing with each of these areas, you
should know the danger signals that the
stress of life is really beginning to get to
you and how you can cope.
The Canadian Nurse
The psyche getting to know yourself
When one s psychological health
becomes somewhat impaired, the body
will react and physical signs will appear.
Some of the signs that you may be
under stress are:
Sleep Disorders such as insomnia
or its converse, the desire to sleep all
the time. Either pattern may be
accompanied by frequent conflict-
ridden dreams reflective of anxiety
about professional or personal issues.
Depression which can be
displayed in behavior patterns such as
apathy, isolation and withdrawal and
low self-esteem; lack of interest in work
and other people; a sense of anger
towards others in the environment;
feelings of powerlessness, hopelessness
and worthlessness; and clear-cut
depression with its signs of early
morning wakening, constipation,
changes in eating patterns, feelings that
life isn t worth living
Anxiety which can be expressed
by restlessness, inability to make
decisions and a fear of taking on
responsibility
The use of drugs such as sedatives,
antidepressants, tranquilizers,
stimulants.
The best way to deal with these
psychological disturbances is to avoid
their occurrence. This can be done in a
number of ways. For instance, some
experts have suggested that a good way
of reducing stress in one s life is to take
one hour a day to pursue something
that really interests you. This is your
time to read, walk, bird watch, meditate,
garden, engage in physical activity , listen
to music whatever gives you pleasure.
People are often skeptical of the
effectiveness of such a measure but this
can have particular value for nurses
because as a group, we often suffer from
low self-esteem. Taking the time to take
care of yourself for at least one hour a
day, acknowledges that you do indeed
have value you are worthwhile you
are worth the expenditure of your time.
Nurses tend to have little difficulty
acknowledging that patients and
families deserve time but often feel that
they aren t really worth the effort. To
give themselves pleasure is somehow
wrong, hedonistic and selfish and this
can lead to guilt.
Depression is closely related to
the problem of low self-esteem. As the
need to nurture is often socialized into
the female, many nurses come into the
profession with a strong need to
nurture. Women are especially prone to
depression because they have not been
socialized to think of themselves as
primary people; their identity evolves
only through caring for others.
Therefore, when a woman wishes to get
out of the nurturing role, others are
threatened and often rebel. This
threatens the woman s attempt to stand
on her own two feet. She feels she has
stepped out of her role and made others
unhappy. For their sake, she must
resume her passive, nurturing role,
which she does, but often with a fair
amount of depression and a resentment
of this role.
This type of behavior is evident in
the young nurse who comes into her
first job full of new ideas. As she
develops confidence she shares these
ideas and gets put down with comments
such as "you get paid to work not to
think", "if you don t like the way
things are then leave, remember the
door swings both ways." Gradually the
new nurse s self-esteem is eroded, she
stops making suggestions, thinks less of
herself for doing so and glumly goes
about her tasks with a pervasive,
low-lying sense of depression. The
feeling that you are playing an
important role in life both personally
and professionally is one of the best
ways of enhancing self-esteem and
avoiding depression. At least once a day
try to praise one of your colleagues who
has done a good job. Take a moment to
think of one good thing you did each
day rather than constantly berating
yourself for your inadequacies.
Another aspect of depression has
to do with the unmet dependency needs
some nurses might have had while
growing up. We may have come into
nursing wanting to care for others, in
part because we never really felt cared
for ourselves. That may be why nurses
can be such demanding patients : we have
a desire to get paid back for all we have
given while at the same time, an
inability to relax in the dependency role
because of a basic fear that no one can
really be trusted to care for us.
Problems of low self-esteem and
dependency needs can be seen in all
levels of nursing, including those at the
very top. Some of the hardest working
and best nurses are motivated by this
sense of low self-esteem and
dependency needs which means that
they function taking care of others with
a fairly high level of depression in
themselves. Recognize that the need to
care for others and be needed for this
role can cause considerable difficulty. It
can lead to making patients and
colleagues dependent and cause you to
be resentful of this dependency but to
interfere when they try to become
independent.
Depression may also result from a
-sense of powerlessness, but as nurse,
you are actually far from it. You can
decrease some of this sense of
powerlessness by making yes/no
decisions such as "Yes, I ll take that job
that I know will really challenge me"
or "No, I won t float to a unit where
I m a hazard". Recognize that you have
needs and assume some control over
your personal life. If you live alone,
schedule yourself to go out a certain
number of times per week. It is too easy
to come home at the end of a long shift,
fall asleep and not do anything with
your time. You feel fatigued all the time
but unless there is something wrong
physically, the problem is probably
depression, which can be lifted or
decreased by assuming some control
over your life. If depression is really bad
or persistent than it s time to seek
outside help; remember nurses have
needs too.
Dealing with anxiety and the
inability to make decisions or think
straight may also be related to a low
sense of self-esteem and fear of failure
or sometimes even, the fear of success.
If you are having a lot of anxiety, sit
down and try to figure out exactly what
is happening. List the symptoms you are
experiencing. Try to identify what
causes the anxiety - is it that you fear
being yelled at by a doctor, are you
afraid you ll give the wrong drug, won t
know how to do a procedure, may be in
a position of telling a doctor what to do
and being put down? Is your fear logical
or illogical? If it is logical, such as being
insecure working with a certain
machine, then take the time to have it
explained to you. Don t allow yourself
to be put into a position where you are
accountable for things you really don t
understand - it s an issue of assuming
power and responsibility again. If your
fear is illogical, then try to figure out
why it might have come about - is this
a situation reminiscent of your child
hood when your father consistently r
yelled at you? Are you afraid of
confronting physicians with what might
be superior knowledge fearing that they
will think you are a castrating female?
Talk to other nurses and find out how
they handle these situations. Figure out
how you can make valid suggestions in
appropriate ways without playing the
traditional doctor-nurse game.
The use of drugs to handle the
stress of personal and professional life is
an area of particular concern. The
availability and liberal use of drugs in a
hospital setting has resulted in a high
addiction rate for nurses and doctors.
Orinh*r 1QAO
Using drugs to alleviate stress should be
a last resort: explore other options such
as a stress-management program, an
assertiveness training workshop,
changing your lifestyle to allow for
more pleasure in your personal life and
even changing jobs. When you use
drugs, it should be under a doctor s
order - that doesn t mean getting a
prescription from your friendly
resident. If problems persist, see a
psychiatrist or other mental health
professional for help in understanding
the root of the problem rather than
using chemicals to block it out
indefinitely.
The soma taking care of yourself
The signs and symptoms of physical
problems which may or may not be
related to psychological problems
include:
chronic fatigue
headache, stomach pains
frequent colds and flu
frequent somatic complaints of
other types
increased use of sick days.
If you are having a lot of physical
problems then it is time to get a good
physical examination from a competent
physician who will take the time to
really explore what is going on. Nurses
seem to have a rather ambivalent
relationship with the medical care
system and tend to either over-doctor,
going with each ache or pain or to
under-doctor, believing that only
"patients" have problems. If you are
having numerous physical symptoms
and are frequently at the doctor s
office, it is time to ask yourself
whether you are actually physically ill,
whether you are .under too much stress
or whether constant exposure to various
diseases has made you afraid you are
developing cancer or heart disease. A
well-balanced diet with an effective
program of weight maintenance or
reduction should be part of each nurse s
self care. Regularly scheduled meals
eaten in an unhurried fashion with the
controlled use of xanthenes, cholesterol
and unnecessary carbohydrates gives the
energy necessary for work and play.
Avoiding regular physical exercise
can be a reflection of a lack of interest
in yourself. Taking care of everyone else
at the expense of yourself is
self-destructive. The minimal exercise
you get often leads to overweight and a
generalized sense of lethargy. Talking
with people who successfully maintain a
stress reduction program one finds that
they schedule time for walking, running,
swimming, squash or some sort of
regular exercise.
Jogging, swimming or dancing
A sure sign of an increasing stress
level is frequently spending the night
dreaming about your job or having
dreams of powerlessness and anxiety.
Shift work predisposes one to sleeping
problems. Allow time for proper sleep
and if you establish a chronic sleep
deficit on night duty remember that it
will stay with you for quite awhile
before you get caught up.
Family and social life : getting to
know others
Research has shown that social support
is important in mediating the impact of
a variety of life stressors; people need
people. Overextending yourself with
work oriented activities so there is no
time to nurture the relationships at
home is a common nursing problem.
When you are at this point, you may
find yourself in real trouble and you
should sit down and assess your
Stressed? Or Burnt Out?
Marvel Miller Sanders
Every day you arrive home exhausted, but you can t sleep. You
resent your work, but it s always on your mind. You feel bitter.
You re stagnating. Are you just under stress? or are you burnt out?
The point at which stress becomes "burnout" is cloudy: in fact
leading nursing researchers aren t even sure how to identify the
condition. However, on two things they are agreed: burnout is stress
gone out of control and all nurses are susceptible hosts. Read how
the experts view the problem.
Nursing literature first began to comment on "burnout" in the early 1970 s but
it is only recently that much has been written on the issue. Herbert
Freudenberger, a mental health co-ordinator at a New York clinic, coined the
term "burnout" in the late 1960 s when he recognized symptoms of exhaustion
and fatigue in his dedicated staff of social workers. He noted weight loss,
insomnia, depression, shortness of breath and physical deterioration among them
and, in addition, they appeared bored, resentful, disenchanted, discouraged and
confused.
Noting the same physical symptoms in nurses, Seymour Shubin, one of
the first male nursing leaders to write about burnout, outlined some specific
ways nurses manifest burnout. He observed that they were:
spending as little time as possible with patients
referring to them by symptoms
going strictly "by the book" in administering treatment
joking excessively about the patient or his ills.
Shubin believes that sometimes the converse can occur. Some nurses
become too closely involved with patients, cannot turn off thoughts about their
work after hours and begin to find excuses to stay on duty long after they have
completed a shift. He says these behaviors can change a nurse s personality and
she may begin to treat her relatives and family the same way she treats her
patients and colleagues. Since nursing is emotionally taxing and demands
optimum physical well being, the nurse who suffers the initial stages of
exhaustion, psychosomatic illnesses such as colds and headaches, cannot survive
the rigors of a full day in an active treatment setting. She will likely move
30 Octobw198G
The Canadian Nurse
priorities. Look at what your real values
in life are. For example, if your role as a
wife and mother is primary, then you
will have to get your work situation
under control. This involves assessing
why you are working so hard. Are you
trying to be all tilings to all people -
never saying no to anyone but seething
and resenting things inside? Do you
have a very strong need for praise?
(Patients are often much more grateful
for services rendered than are families
who have a way of expecting that you
have an obligation to care for them.) Do
you have a great need to be needed?
You may be giving far more than is
necessary, constantly trying to prove
that you really are a good nurse, hence
a good person. Having nothing left to
give at home can then set up a situation
in which you feel guilty, thus making
you feel that you are not very good
after all. Are you creating completely
unrealistic demands on your family?
A good way of preserving family
relationships is to get rid of job tension
before you arrive home. A short walk or
just time to yourself can help defuse
some of the tension you feel. Dividing
I give at the office!
quickly to the stages of guilt, dislike of self, and then on to what Shubin calls
the stage "where there is total disgust, a sour attitude towards humanity and
self, resulting in terminal burnout".
Dr. Frances Storlie, one of the most recent nursing leaders to write on the
topic, describes burnout as an "insidious process with an etiology which is
difficult to trace". She believes that the most susceptible host is a highly
idealistic young nurse. The process may begin while she is still a student, when
learned ideals conflict with the real world of health care. This conflict can lead a
nurse to a state of frenzied activity wherein she may become aggressive, charged
with energy, taking on new tasks or working long overtime hours. "At the same
time the nurse may become sensitive to the slightest criticism, perceiving non
existent depreciation in light or tangential remarks" says Storlie. "At some point
in the frenzied search for reality, the nurse gives way to self doubts and self
re-evaluation this is the crucial point. ..the nurse either begins to recover or
goes on to burnout."
Dr. Marlene Kramer, author of "Reality Shock", spent eight years
researching the problem and came up with similar notes on burnout and its
causes. She points out that in many young nurses, the discrepancy between what
they learn in school and what is actually practiced in the work setting, results in
"professional-bureaucratic work conflict". She says this conflict results in
"reality shock", wherein the new graduate may experience rejection of her new
surroundings or exhibit regression manifested by a pre-occupation with the past.
Occasionally, there is a total rejection of the school-taught values, and the
neophyte becomes a "super efficient bureaucratic technician". Other common
reactions are feelings of failure, rejection of their formal professional education,
withdrawal and moral outrage against the school which "failed to prepare them"
for the job situation. These feelings of anger, hostility and frustration lead to
fatigue and illness. The new graduate often does not recognize the problem and
deludes herself into thinking that things will get better, or that somewhere there
is a perfect job or work situation. This unfulfilled hope only generates continued
frustration and despair, which escalates until burnout occurs.
Nurse educator Bernard Shapiro, claims overstated altruism is to blame for
burnout suffered by nurses. While he believes altruism is a desirable character
istic in nurses, he says it is not sufficient to carry them through what he terms an
"unbelievably difficult" career. Shapiro upholds that many nurses who leave the
profession, do so because the altruism which started them on their career was
not sufficient and that those "disenchanted nurses who remain assume an icy
detachment, machine-like efficiency, or arrogant, patronizing airs."
In the view of nurse educator Estella Robinson, one could substitute the
word "burnout" for "anxiety". Robinson labels the condition "patient-nurse
alienation". She states that nurses are affected by society s alienating milieu
up family roles can also relieve you of
the need to prove that you are
"supermom, wife and nurse": share
cooking, cleaning and child care
responsibilities and schedule time for
relaxing together. A casual dinner with a
bottle of wine on a Friday night is a
nice way to end a busy week.
Learn to listen to your family and
get support from them. If they
complain that there is not enough time
for them, look carefully at what is going
on. Are they afraid work is becoming
too important to you or are they just
asking you to be around a bit more?
You should also realize that children
can be proud of your career so let them
know what you do and bring them to
see where you work. When they
understand what you do, they will be
more accepting when you come home
tired.
Friends can play a very influential
role in your life as well. Building a good
social support system and developing
new relationships can lend a whole new
richness to your life. It is important to
note that social relationships can form
an open or closed network. In a closed
network, everyone knows each other.
While helpful in daily activities, this
kind of system can be restrictive. For
example, research on bereavement has
shown that women from closed social
networks are assisted in adjusting to
widowhood in the early days and
months but if they want to branch out,
make new friends and form a new
identity, it is difficult because others are
threatened when they begin to change.
In an open network everyone doesn t
know everyone else and an individual
may be able to get different types of
help from different people. If you do
not have any openness within your own
social network, try to branch out a bit
and develop relationships with people
outside of your usual family and
professional sphere. Talking to other
women can be a good experience
because it makes you realize that what
you are going through is not unique to
you but is more likely part of a larger
societal issue, one with which other
women are grappling. An effective way
of dealing with a stressful job can be
having lots of friends who are not
nurses. Such relationships are enriching
and give you the potential to bring new
energy and insights into your personal
and professional life.
The Canadian Nurse
October 1980 31
Occupational life putting it all to work
As nurses, we often fail to see ourselves
as autonomous beings, rather we see
ourselves as helpless victims, victims of
our socialization as women, of our
education as nurses, of the
bureaucracy of the health care system
and of power-plays by physicians. To
operate from the position of helpless
victim negates the strength we have
when we decide to become assertive and
unite, as witness the recent Alberta
nurses strike. To be a helpless victim is
in fact a power play, the power of the
powerless may be somewhat subtle but
it is there. It comes from our fear of
accepting responsibility, of standing
out, of daring to take risks. Look what
happens to nurses who dare to be
different, they often get put down, or
put "back in their place" by other
nurses who subtly or not too subtly
give the message, "What makes you
think you re competent to be doing or
saying that?" "What makes you think
you re better than I am?" The message
is "you only succeed at my expense.
Your success threatens my
powerlessness."
Nurses are often ambivalent about
learning from other nurses because we
have a low sense of self-esteem as i
women and as members of a female
profession, we tend to project our
feelings of incompetence onto other
nurses and figure that only male
physicians can really teach us very much.
In a recent evaluation of the instructors
of a nursing program, students said, "we
learned a lot from the doctors but you
girls didn t teach us anything we didn t
already know."
There are many put-downs we
give to one another. Take for example
what feminists call the "queen bee
syndrome": that is, women who get
ahead and then deny their roots and set
themselves apart as being above other
women. At a recent gathering of
professionals from varied disciplines,
two attractive professional women were
present. The moderator introduced
them as both having PhD degrees and
sharing a similar background which
they had forbidden him to mention.
The two women were nurses. However
the fact that they were attractive, held
advanced degrees and had good careers-
all qualities highly valued in the male-
dominated system gave them
sufficient status to repudiate their
original profession. The fact that each
was in a position of evaluating health
care facilities made their nursing
knowledge very valuable, but they chose
to take what they wanted from nursing
and leave. One woman said she refused
to see herself as a nurse because as a
nurse she felt put-down and powerless.
It s a tough life, being a nurse.
Nursing is losing good people to
other careers because of the feeling of
powerlessness they experience. The
whole concept of power needs to be
reassessed. Power should not be seen in
terms of the male-oriented dominance/
submission, controller/controlled model
but rather from a more female
perspective as a process of effecting
change. Be aware of the ways in which
you respond to the power of others who
attempt to control you: remember you
cannot be governed by another unless
you choose to follow or be controlled
by that person. Take for example the
case of Alberta nurses who refused to
accept the government s pay offer. The
nurses found that the government was
shocked that these nice, caring people
would not accept the salary the
omnipotent male-dominated
government had decided was
appropriate. However, they united and
succeeded in getting improved wages.
Nurses do need to unite to effect the
changes that are necessary. Think
through what you try to change and be
careful of what you ask for you
might get it.
especially because of increased technology and are often ill-prepared emotion
ally to cope with this alienation. She believes alienation results in stereotyped
and rigid interpersonal behavior on the part of the nurse and this in turn
produces self-alienation. Robinson concludes that alienation involves treating a
patient in a mechanical manner and is used to protect the nurse from anxiety.
Although men in the health professions appear to suffer from burnout,
there is a possibility that many nurses are experiencing symptoms mainly
because they are women. Sexual discrimination and women s present complex
role in our turbulent society places additional stress on them. In addition to the
caring, giving and altruistic attitude towards clients, many nurses must also
extend these same feelings to their husbands, children and perhaps aging parents
and in-laws. According to Elaine Brody, this is especially true of the middle-aged
nurse who is subject to a whole host of new expectations as well as the tradi
tional filial responsibility of care of the elderly.
Rogers, a psychiatric nurse educator, claims that because nurses are
predominately female, they are caught up in stereotyped role relationships with
men, involving the issue of power and control. Sex roles in nursing have not yet
changed to any extent since Rogers declared: "the status or position of the male
in the health care hierarchy is usually higher than that of the female." This
places an additional burden on nurses who may tend (perhaps unconsciously)
to court the favor of these males in order to gain access to power. They are
condoned and encouraged in this behavior by male physicians and administra
tors and the game of sexual politics continues.
Alice Baumgart, a leading Canadian nurse educator, feels that sexist
attitudes are hampering the struggle for professionalism. She states "The
interest, the knowledge, the academic aspiration of women have been devalued
when measured against those of men. The same ability, the same expertise, the
same performance has been more highly valued in men than in women."
These sexist attitudes may well extend beyond the nurse s professional
life. Her social life and home atmosphere may also place her in positions where
she must continue to exhibit passive-aggressive behavior. The giving, caring nurse
may well find this behavior only adds to her disillusionment and bitterness and
that it precipitates or aggravates burnout.
Burnout is almost impossible to define and its etiology is obscure. Whether
nurses exhibit symptoms because they are too idealistic, too dedicated, too
altruistic, or conversely because they may lack career commitment is difficult to
determine. Perhaps the major factors are the working conditions combined with
heavy home responsibilities and sometimes academic pressures as well. Regard
less of cause, burnout results in unprofessional behavior, dehumanization of
patients, and an exit of women from nursing.
32 October 1980
The Canadian Nurse
To effect greater change, nursing
needs an organized system to create
leadership roles and to encourage other
nurses to move ahead. In the past,
nursing leaders picked out those
neophyte nurses they thought had
strong potential and provided
encouragement, role-modelling and
introductions to other nursing leaders.
However such a system no longer exists
and many nurses are finding themselves
in dead-end roles. Nurses need to give
praise to one another and help each
other to feel tall. A new nurse on an
intensive care unit was thrilled when she
handled a difficult situation and two of
her peers looked at teach other and said,
"She did a good job. She belongs."
As nurses, we obviously have
difficulty coping with our own inter
personal difficulties but what about our
relationships with other disciplines?
A sense of self-esteem is essential. If you
are competent and do not consider
yourself to be a handmaiden, then you
will not be treated as such. Often
put-downs are interpreted from others
when they do not necessarily exist.
Some nurses are seeing themselves
as very competent and are assuming
expanded roles quietly in the
background. When others, such as
doctors, social workers or psychologists,
.
Member of the team/
Many factors contribute to burnout among nurses and, as yet, only a few
solutions are being applied. Nursing leaders must realistically examine the
"burnout phenomenon" as a possible source of a poor quality of patient care
and a very probable influence on increased costs of health care in our country.
Researchers could develop a tool such as a questionnaire or rating scale which
would detect and measure burnout in nurses. Is there a correlation between our
universal health care system and burnout? Can burnout be predicted? If so,
should "high risk nurses" be assigned to intensive care units, terminal care areas,
burn units? Ethical issues need to be examined too. If a co-worker exhibits or
confesses to symptoms of burnout, yet refuses to rectify the situation, how
should this be handled?
Burnout must not become a casual "wastebasket" term for every and any
difficulty a nurse may be experiencing, the "status illness" of our profession.
But, at the same time, we cannot afford to allow the burnout syndrome to
flourish unchecked. We owe it to ourselves and our colleagues to recognize and
deal with this issue.
Bibliography
1 Baumgart, Alice. Sexist attitudes hamper struggle toward professionalism.
RNABCNews. 11 (3 & 4): 32-33; 1979 Apr./May/Jun.
2 Brody, Elaine. Women in the middle. HospitA/ta. 19(3): 14-15; 1980 Mar.
3 Freudenberger, Herbert J. The staff burnout syndrome in alternative
institutions. Psychotherapy: Theory, Research and Practice. 12(1):73-82; 1975
Spring.
4 Kramer, Marlene. Reality shock. St. Louis: C.V. Mosby; 1974.
Canadian Nurses Association. Code of ethics [prepared by Sister M.
Simone Roach] Ottawa: CNA; 1980.
6 Robinson, Estella C. Factors contribution to patient-nurse alienation
Imprint. 21 (4):26-27, 32-33; 1974 Dec.
7 Shapiro, Bernard. The dead end of altruism: a note to nurses. Nurs. Forum
15(4):384-389; 1976.
8 Shubin, Seymour. Burnout: the professional hazard you face in nursing
Nursing 78. 8(7):22-27; 1978 Jul.
9 Storlie, Frances J. Burnout: the elaboration of a concept. Am.J.Nurs.
79(121:2108-2111; 1979 Dec.
Marvel Sanders, RN, is a full-time staff member at the Foothills Hospital School
of Nursing and a part-time student in the Post Basic RN program at the Universi
ty of Calgary. A graduate of the Ottawa Civic Hospital School of Nursing, she
a/so has a diploma in Nursing Education from the University of Western Ontario.
eventually realize how competent the
nurse is they can be very threatened and
seek to eliminate the expanded role she
has assumed. They attempt to clearly
delineate roles and prevent role-blurring.
But we have gone too far for this.
Nurses are going to have some rough
roads ahead as we struggle for expanded
roles. Belonging to multidisciplinary
groups such as a palliative care work
group and/or attending multidisciplinary
meetings where the focus is on the
broader subject rather than on turf
fights about Mrs. Jones can be a useful
way to deal with such problems.
Sometimes when you establish
credibility by working together with
people outside of the immediate
patient care setting, the good will which
evolves is carried back to the clinical
setting and facilitates day-to-day
communication.
Our history as women has
functioned to make us feel fairly
powerless within the health care system.
Much of the powerlessness is a myth. As
more nurses develop an increased sense
of self-esteem and autonomy, it will be
possible to make the changes necessary
to bring us into the twenty-first century.
These changes must start with one s
self. Coping with the stress of life
through improved attention to your
physical and psychological health,
building outside support systems and
strengthening relationships within the
profession can help you meet the
challenge of the changes of the future. *
Bibliography available on request.
Mary L.S. Vachon, RN, PhD, is a
research scientist at the Clarke Institute
of Psychiatry in Toronto, Ontario, and
assistant professor, Department of
Psychiatry, University of Toronto as
well as a consultant in psychiatric
nursing at The Princess Margaret
Hospital, Toronto. She received her RN
at Massachusetts General Hospital in
Boston, her MA in sociology from the
University of Toronto, and completed
her doctoral studies last year at York
University. She has had several articles
published on bereavement, cancer and
staff stress.
The Canadian Nurse
October 19SO 33
HOSP.TAL.ZED AFTER COUUS.ON
MOTOR CYCLIST
SIX-YEAR-OLD SUFFERS HEAD INJURIES IN FALL FROM BALCONY
WINDOW WASHER SUFFERS CONCUSSION WHEN LADDER BREAKS
What do you know about assessing possible increased intracranial pressure? Could you give comprehensive
care to these accident victims? Here s a guide that may help.
Increased intracranial pressure:
when assessment counts
Why does it happen?
The causes of increased intracranial
pressure are numerous and relate to an
increase in one of the three basic cranial
components within the rigid, unyielding
structure of the skull. The space required
by these three components brain tissue,
blood and cerebrospinal fluid is depen
dent upon some of the following
conditions:
Brain tissue may increase in volume
because of: an increase in cell growth as
in tumor formation; hypoxia, as inade
quate brain perfusion results in sodium
remaining within the cell and drawing
extra fluid in to increase cell size
eventually leading to cell rupture, closed
head injuries (contusions) with
generalized cerebral edema; and intrusion
by foreign objects.
The volume required by the blood
component may increase with vaso-
dilation. This occurs with hypoxia as
increasing levels of carbon dioxide
(C0 2 ) and hydrogen cause the veins to
dilate, especially those in cerebral
tissue. 1 As well, damaged cells excrete
histamines, bradykinins and potassium
which are all powerful vasodilators.
Arterial/venous malformations such as
aneurysms or hemorrhages within the
cranium also increase space demands.
The cerebrospinal fluid (CSF)
component may increase for one of
three reasons. First there may be an
increased production of CSF due to rare
choroid plexus papillomas. Normally
50 per cent of the CSF is formed in the
choroid plexus, a highly vascularized
structure located in the walls of the
lateral and third and fourth ventricles. 2
Secondly, there may be a decrease in
the rate of absorption of CSF by the
arachnoid villi, small venous identations
of the arachnoid membrane. This may
be due to blockage of the arachnoid
villi by blood from birth trauma or a
spontaneous subarachnoid hemorrhage.
Angela Ladyshewsky
Finally, there may be interference with
the circulation of CSF due -to tumors,
adhesions, congenital malformations of
CSF pathways, arterial/venous malfor
mations, hemorrhages or infection.
If ICP increases to a point where
there is no more room for expansion
within the skull, the cranial contents are
pushed downwards in a process known
as "coning". The end result is transten-
torial herniation, that is, the brainstem
and part of the cerebral hemispheres are
pushed down through the tentorium
(See figure one). Compression of this
vital center, the brainstem, accounts for
decreased levels of consciousness, pupil
changes and changes in pulse and res
piratory rate.
Observations for suspected increased ICP
1) Upon admission after establishing
that ventilation and circulation are
adequate, obtain enough information to
establish a baseline of data. This would
include the normal information accumu
lated in the admission nursing history as
well as details on the type of accident or
precipitating conditions, of any loss of
consciousness, of any previous consump
tion of alcohol or medications (this will
affect consciousness levels and pupillary
response) and any previous neurologic
deficits, such as paresis, speech disorders,
deafness, etc.
Early signs of rising ICP may be
noted at this time and include: rest
lessness, irritability, confusion, dis-
orientation or a decreasing level of
consciousness due to cerebral hypoxia,
headaches, either constant or increasing
in intensity, which are aggravated by
coughing, sneezing, straining, etc. and
nausea and/or vomiting due to pressure
on the vomiting center in the medulla
oblongata.
2) Determine the level of consciousness.
Is the patient alert? If so, is he oriented
to time, place and person? What is his
attention span? Is he drowsy or lethar
gic? Does he respond to painful stimuli
in a purposeful way, that is, does he
push the pain source away?
The most important indicator of
cerebral functioning, that is, conscious
ness, is controlled by the reticular
activating system in the frontal lobe.
Levels of consciousness include:
alert: responds appropriately to
auditory, tactile and visual stimuli, is
oriented to time, place and person,
lethargic: sleeping much of the
time but is easily aroused and is
oriented,
obtunded: is difficult to arouse
from sleep, responds appropriately when
awake, but returns to sleeping state
quickly when stimulation isdiscontinued.
stuporous: arousal only by painful
stimuli, response to stimuli is purposeful
but the individual is actually never fully
wakened (painful stimuli may be applied
by pressing your fingernail into the
patient s nailbed, applying a sternal rub
or pinching over the Achilles tendon).
semicomatose: painful stimuli
elicits reflex movement, decorticate pos
turing or decerebrate posturing and
corneal and gag reflexes are present. The
corneal reflex, with its nuclei situated in
the pons, may be checked by touching
the cornea with a piece of cotton. An
immediate blink indicates an intact
reflex. The gag or pharyngeal reflex
with its nuclei in the medulla, is tested
by holding the tongue down with a
depressor and touching the pharynx
with a cotton tipped applicator. Presence
of a gag indicates an intact reflex.
comatose: no response to painful
stimuli, reflexes are absent and there is
no muscle tone in the extremities.
Remember, that description of the level
of consciousness is more helpful than a
label used inaccurately.
3) Once the patient is as alert as possible,
34 October 1980
The Canadian Nurse
motor r esponses, muscle strength and
function controlled by the pyramidal
tracts, should be assessed. Does the
patient move his extremities to
command? Is there, any weakness and if
so to what degree, for example, is one
limb slightly weaker or noticeably
weaker than the other? Don t always
rely on testing the patient s hand grips
for strength: check for arm drift. Ask
the individual to lift both arms in the
air and close his eyes. Watch for drifting
downwards of either arm, thus indicating
weakness.
located in the midbrain. Are the pupils
equal in size or do they differ? What is
their size, that is, are they constricted,
normal or dilated? What is their reaction
to light, do they react sluggishly, briskly,
normally or is there no reaction at all?
Under optimal conditions, pupils
should be examined in a darkened
room. Cover the eye not to be examined
and pass the light source over the eye
from the outside to the inside. Remem
ber that miotic and mydriatic medi
cations affect pupillary reaction to
light.
pressure is indicated on the midbrain
and upper pons where the nuclei for the
third, fourth and sixth cranial nerves
are located.
5) Vital signs should be checked at
regular intervals from every 15 minutes
to four times daily, depending on the
patient s condition. Observe for any
fluctuations or changes. While a
quickening pulse and a dropping blood
pressure are signs of hemorrhage, the
very opposite is indicative of increased
ICP. The medulla responds to increased
pressure on the brainstem or decreasing
Figure one: Stages of Transtentorial Herniation
1. As ICP increases, as from an expanding hematoma, there is a midline shift of the
falx. The lateral ventricles are pushed over and compressed. Fluid from the ventricles is
squeezed out into the intracellular spaces.
2. As the ICP continues to rise, the brain content is pushed downward, the only escape
being through the tentorium. The uncus, the hooked edge of the temporal lobe, herniates.
3. As the pressure continues to increase, the cranial contents are further displaced
downward. The only direction being toward the foramen magnum. The medulla brain-
stem become compressed.
There are two other types of herniations. They are:
A. Supratentorial (above the tentorium)
B. Subtentorial (below the tentorium)
NB. The tentorium and falx are folds of meningeal dura. The falx is attached above the
tentorium and forms a roof over it.
Falx Cerebri
Skull
2: Uncus of
-Temporal Lobe
T"j Cerebral
V s **\ Aqueduct
4th Ventricle
Brainstem
-Foramen Magnum
If the patient is ambulatory, have
him walk, observing his gait, an
unsteady, ataxic gait may indicate
cerebellar dysfunction. Movement of
arms, fingers and toes should also be
assessed.
If the patient is unable to follow
verbal instructions, voluntary move
ments must be noted whenever they
occur. When even voluntary movement
is absent, purposeful movement with
stimulation must be assessed. Check the
Babinski reflex by moving an object up
the lateral side of the foot. A negative
Babinski, plantar flexion of the great
toe, is a normal reaction.
Stimulation may elicit decorticate
or decerebrate posturing. Decorticate
posturing, which indicates damage to
the internal capsule and corticospinal
tracts above the brain stem, is recog
nizable as fingers, wrists and shoulders
are flexed and adducted while the feet
and legs are extended and internally
rotated, all extremities are rigid.
Decerebrate posturing, indicating mid-
brain damage, includes extension,
adduction and internal rotation of the
arms, extension of the legs with feet in
plantar flexion and arching of the back,
with all extremities again being rigid.
4) Observe pupil size. Reaction to light
and extraocular movements are impor
tant indicators of increased ICP as the
third and fourth cranial nerves are
To check for consensual light
reflex, both eyes are held open wide, a
light is shone in one eye and the
reaction in the other is noted. If consen
sual reaction is present, the opposite
pupil will constrict and indicates that
optic fibers which diverge in the mid-
brain are intact. Pressure on these fibers
which form the oculomotor nerve can
be identified by unilateral pupil dilation,
ptosis and decreased eye movement.
Interruption of sympathetic pathways
from the pons causes the pupils to be
constricted and non-reactive.
Next, check eye movement by
having the individual follow your finger
without moving his head. Movement up,
down and to both sides should be
assessed as well as conjugate eye move
ment (eyes move in the same direction
at the same time), doll s eye maneuver
and clarity of vision, including blurring
and diplopia. The doll s eye or oculo-
cephalic reflex, a normal reflex that can
be controlled by the conscious indivi
dual may be tested on an unconscious
patient. While holding both eyes open,
move the head from side to side and
check the eye movement. Normally
both eyes will turn in the opposite
direction of the head movement, that
is, if the head is turned to the right the
eyes should turn to the left. If the eyes
remain fixed in the midline position,
or movement is disconjugate, then
circulation to the cerebral tissue by
causing the pulse to decrease and the
blood pressure to increase. However
these are both late signs of the problem,
indicating sustained pressure peaks of
ICP.
The patient s respiratory status
should be assessed with consideration to
both rhythm and depth of respiration,
both of which are controlled from
various positions within the brainstem.
Look for snoring and irregular breathing,
both signs of pressure and resulting
anoxia of the respiratory center in the
medulla. Some typical respiratory
patterns which may be identified
include:
apneustic breathing which
indicates brainstem damage and is
identified by a typical abnormal rhythm
of holding a breath for a long period
and then letting it out at a regular rate.
Cheyne-Stokes respirations, consi
dered a late sign, are recognizable
by their long, hyperpneic phase
followed by a shorter phase of apnea.
This type of respiration indicates
pressure on or an interruption of the
descending motor tracts at the mid-
brain level and occurs as a result of an
increased sensitivity to C0 2 causing
the period of rapid deep breathing to rid
the system of C0 2 . When this is
accomplished and the CO 2 stimulus is
no longer present, respirations are
discontinued until another build-up of
C0 2 stimulates respirations again.
central neurogenic hyperventi-
lation, continuous, regular, rapid and
deep hyperpnea is caused by anoxia of
the midbrain and pons. If the pneutaxic
center in the pons which controls the
rhythmicity of respiration is affected,
respirations may become irregular with
several deep gasps followed by an apneic
period and repeated as in Cheyne-Stokes.
clusters of breaths followed by
apnea may result from damage or
pressure on the upper medulla oblongata
which contains the respiratory center.
When observing any of these types
of respirations it is of utmost importance
to identify if respirations are regular. If
not, record the duration of the inspira-
tory phase, of apneic periods and of the
expiratory phase and, as well, if the
pattern is consistent or intermittent. As
it is often difficult to label the type of
respiration accurately a description is
usually preferable.
Regular temperature checks
should not be overlooked as an elevation
can be indicative of increasing ICP.
Treatment
Treatment of increased ICP is dependent
upon the severity of the condition and
may include one or several of the
following.
1) Osmotic diuretics, such as Mannitol,
are only a short term treatment. Given
intravenously, as a drip or a bolus,
Mannitol acts by increasing the osmo-
lality of the blood to create an osmotic
gradient and thereby draw fluid from
the brain cells into the vascular system.
Effective for only three to ten hours, be
aware that a rebound effect may occur
if this type of medication is used over a
prolonged period. Mannitol can enter
the cerebral tissue and cause a fluid
shift into the brain tissue creating a
further increase in ICP. The usual adult
dosage is 100 g daily, never exceed
200 g/24 hour period. In bolus form
40-50 g may be administered.
Prior to administering this type of
medication, a foley catheter should be
inserted so that urinary output may be
closely monitored. After administra
tion, observe carefully for any signs of
vascular or cardiac overload such as
pulmonary edema, or congestive heart
failure; electrolyte imbalance, especially
a depletion of sodium or potassium, and
dehydration.
2) Steroids, most commonly Dexa-
methasone (Decadron), is used to act
as an anti-inflammatory agent and as a
diuretic. The initial dose of dexametha-
sone is 10 mg followed by 4 mg every
6 hours, usually intravenously.
Maximum effect is normally noted after
12 hours, but the drug may be used on a
long term basis for a period of weeks.
Side effects include all those common
to steroid administration, ie. gastro
intestinal bleeding, suppression of
infection, retention of sodium, aggra
vation of diabetes, etc.
3) Fluid restriction is commonly
practiced to avoid contributing to cere
bral edema although it is of little value
in reducing ICP. A daily maximum of
1500 cc either intravenously or orally
is a realistic level.
4) Hyperventilation may be used to
decrease C0 2 levels as the volume of
cerebral blood flow is directly pro
portional to the plasma C0 2 level.
Intubation with an endotracheal tube
and use of mechanical ventilation can
produce a cerebral decompression
rapidly but blood gases must be eva
luated frequently to ensure stabilization
of arterial C0 2 levels.
5) Barbiturates, such as thiopental or
pentobarbital, may be used along with
ICP monitoring and hypothermia to
treat increased ICP when the cause is
known not to be a hemorrhage or
post-operatively if a repair has been
done. Barbiturates are thought to
decrease the demands of the cerebral
tissue for oxygen, thus decreasing the
blood flow to the brain, or to have some
specific action on the vascular tone of
the cerebral vessels, causing them to
constrict thereby reducing blood flow
to an already edematous brain. 3
Usually barbiturates are adminis
tered on an hourly basis to maintain a
blood level of 3 mg/100 ml of blood.
ICP is monitored through the use of a
screw or bolt inserted into the sub-
arachnoid space through a burr hole and
connected to a transducer which tran
scribes pressure changes to a graph.
6) Surgery, including removal of a
localized hematoma or tumor, insertion
of a ventric drain into one of the
lateral ventricles, or removal of a bone
flap to allow for expansion may be
utilized. The opportunity for severe
herniation of the brain tissue through
the surgical opening may make this a
risky procedure.
Nursing priorities
There are many things that you can do
to ensure that your patient will not
succumb to the effects of increased
ICP.
First, be aware of the importance
of a clear airway. Since increased C0 2
concentrations cause cerebral vasodila-
tion, any factor that may cause your
patient to hypoventilate must be elimi
nated. Work to prevent chest conditions
such as pneumonia or atelectasis from
developing. Listen to chest sounds
regularly. Use narcotics cautiously as
they depress respirations. Position
patients on their sides if consciousness
is decreased to prevent aspiration.
Encourage those who are alert to deep
breathe and encourage positioning
which is conducive to maximum venti
lation. Coughing and sneezing must be
prevented as much as possible.
Second, keep an accurate record
of intake and output. Restrict fluids as
necessary and monitor all intravenous
infusions closely. Patients on Mannitol
should have a fluid intake of 2500 cc
daily to prevent dehydration. Observe
for electrolyte imbalances, indicated by
serum values, changes in behavior,
decrease of urine specific gravity below
1.010, muscle weakness and diminished
reflexes.
Third, elevate the head of the
patient s bed to 30 degrees to promote
increased cerebral venous drainage
through use of gravity. Avoid neck
flexion and having the head higher than
30 as a negative pressure may be
created and force intracranial contents
downwards towards the foramen
magnum.
Fourth, reduce straining by your
patient through the use of stool softeners
and mild laxatives to prevent consti
pation and straining at stools (never
give an enema). Administer antiemetics
to reduce vomiting and nausea as
necessary. Instruct your patient not to
use the Valsalva Maneuver which occurs
when the patient strains while defecating
or trying to move himself up in bed,
using his upper trunk muscles. As the
patient holds his breath, the upper
thorax becomes fixed, the breath is
forced up against the glottis and the
thoracic pressure as well as the intra
cranial pressure is increased. When
moving up in bed, instruct your patient
to exhale. Do not restrain your patient
unless absolutely necessary as fighting
with restraints increases physical
activity and need for oxygen. If your
patient requires suctioning for increased
secretions, do so for 15 second periods
only, and hyperventilate with oxygen
first.
Fifth, be aware of the importance
of rising temperature. Patients may
experience an increase in temperature
due to interference with heat regulating
centers in the thalamus. "For each one
degree centigrade rise in body tempera
ture the body tissues oxygen require
ments increase by approximately
13 per cent." 4 If the temperature is
elevated, remove excess blankets, give
tepid sponge baths, use fans, reduce the
room temperature and give antipyretics
as ordered.
Finally, observe for seizures which
may occur as a result of cerebral irrita
tion. Naturally establishing an airway is
of prime importance, but observation
of all aspects of the seizure including
muscle groups involved is necessary for
identifying the focus of the problem.
If an individual is seizuring with his
mouth clamped tightly shut, no attempt
should be made to force it open as this
will only result in damage to oral tissues
and teeth. Instead, simply position the
individual on his side to facilitate
36 October 1 980
The Canadian Nurse
drainage of secretions. Remember that
any seizure lasting longer than four to
five minutes is a medical emergency
(status epilepticus) which can lead to
severe cerebral hypoxia and respiratory
arrest.
All individuals suspected of having
a head injury are candidates for seizures.
Keep an airway at the bedside, use a
night light, use only rectal thermo
meters, keep side rails in place, have a
suction machine available and give
anticonvulsant medications on time.*
References
1 Ganong, William F. Review of
medical physiology. 9th ed. Los Altos,
CA: Lange; 1979: p.457.
Ibid.: p.469.
3 Marshall, L.F. et al. The outcome
with aggressive treatment in severe head
injuries. Pt.2. Acute and chronic barbi
turate administration in the manage
ment of head injury. J.Neurosurg.
50(1):26-30; 1979 Jan.: p.29.
4 Luckman, Joan, Sorensen, Karen
Creason. Medical-surgical nursing; a
psychophysiologic approach. Toronto:
Saunders; 1974: p.433.
Bibliography
1 American Association of Neuro-
surgical Nurses. Core curriculum for
neurosurgical nursing. Baltimore:
AANN Publications; 1977.
Bergersen, Betty S. Pharmacology
in nursing. 12th ed. St. Louis: Mosby;
1973.
3 Coping with neurologic problems
proficiently. Horsham, Pa: Intermed
Communications; 1979.
4 DeCoursey, Russell Myles. The
human organism. 4th ed. New York:
McGraw-Hill; 1974.
5 Ganong, William F. Review of
medical physiology. 9th ed. Los Altos,
CA: Lange; 1979.
6 Luckman, Joan: Sorensen, Karen
Creason. Medical-surgical nursing; a
psychophysiologic approach. Toronto:
Saunders; 1974.
7 Marshall, L.F. et al. The outcome
with aggressive treatment in severe head
injuries. J.Neurosurg. 50(1}:20-30, 1979
Jan.
8 Mitchell, Pamela H, Mauss, Nancy.
Intracranial pressure: fact and fancy.
Nursing 76 6(6):53-57; 1976 Jun.
*Not verified
Angela Ladyshewsky, a graduate of the
St. Boniface School of Nursing, is
currently working in the Neuroscience
Unit at the St. Boniface General Hospi
tal in Winnipeg. She is an active member
of the Canadian Association of Neuro
logical and Neurosurgical Nurses.
Previously published work includes an
article in the June, 1978 issue of CNJ
entitled "I hope he gets transferred
soon. "
TYPES OF CEREBRAL HEMORRHAGE
1. Epidural hemorrhages occur most
commonly as the result of a laceration
of the middle meningeal artery in the
temporal lobe. The temporal portion of
the skull is thin and thus very fragile,
consequently blows to this area are
dangerous and frequently constitute
a surgical emergency. Although the
rapid escape of blood between the dura
and the skull causes intracranial pressure
to rise quickly, the prognosis is usually
good if treatment is initiated early.
Rupture of the middle meningeal artery
results in an inward pressure on the
temporal lobe with ipsilateral pupil
dilation resulting from compression of
parasympathetic fibers of the oculo
motor nerve, unconsciousness due to
compression of the reticular activating
system and weakness or paralysis due to
compression of cerebral peduncles.
When this type of hemorrhage
occurs in the posterior fossa, it is fre
quently fatal as the lack of local signs
coupled with depression of the cardio
vascular center and reticular activation
system make detection early enough for
treatment almost impossible.
In the subfrontal area, an epidural
hematoma may be indicated by head
ache, bilateral retro-orbital pain, inter
mittent disorientation, poor recent
memory recall and papilloedema.
Treatment involves a craniotomy
to facilitate removal of the clot for
mation as early as possible.
Skull
Dura
Arachnoid
Membrane
2. Subdural hemorrhages occur when
bleeding takes place into the potential
space between the dura and arachnoid
membrane layers of the brain. Pressure
is generalized over a whole hemisphere
as movement of blood is limited only by
the falx and tentorium. Symptoms of
headache, loss of consciousness, pupil
changes, personality changes and mental
deterioration may be intermittent,
depending on the type of hemorrhage:
acute, symptoms occur within 24
hours, there is rapid intracranial com
pression, prognosis is poor.
subacute, with a mortality rate of
25 per cent, symptoms occur up to one
to two weeks after injury and is often
due to laceration of cerebral surfaces
and sinuses or both.
chronic, the least dangerous, may
not be detected for weeks to months
after the injury.
Treatment consists of surgical
removal of the clot. A chronic CSF leak,
an infection or brain abscess may ensue
if the dura is not securely sutured to
ensure that it is watertight.
Skull
Dura
Arachnoid
Membrane
3. Intracerebral hemorrhages occur
when there is bleeding deep into the
brain tissue itself. Petechial type
hemorrhages are common and are often
related to blood dyscrasias or super
ficial contusions of the brain.
Symptoms are similar to those of a
subdural hematoma but as yet surgical
results are poor due to irreversible
brain damage caused by the hematoma.
Skull
Dura
Arachnoid
Membrane
Maternal-infant bonding is as old
as mother love! In fact, that is
precisely what it is and promoting
a healthy maternal-infant bond
should come naturally. At the
Royal Jubilee Hospital in Victoria,
BC, nurses have been instrumental
in shifting the focus of maternity
and nursing care away from
hospital routines which were, for
the most part, cold and
intimidating to the more personal
rhythms of mother and baby.
Margaret Rhone
The concept
Maternal-infant bonding begins as early
as the first fetal movement ; it is an
unfolding relationship in which the
mother falls in love with her baby. The
process is not, however, one-sided: both
mother and infant play an active part in
the bonding process. The mother s
behavior, derived from her own
complex history of interpersonal
relationships, her experience during
pregnancy, labor and delivery, as well as
her recollections from childhood, is
dictated largely by her own self-concept
and the positive or negative feelings she
has about herself. The infant s role in
attachment is based on his response to
the mother, the response he elicits from
her (determined partly by his own
appearance), his sensory and motor
ability and his sucking behavior.
Bonding is a fragile and protracted
process: while it is taking place it can be
disturbed or even broken and it may
take weeks, months or even years for
the union to solidify.
Assessment
As nurses, we can use the tool of
assessment to define the mother-infant
relationship as either normal or
maladaptive and then attempt to either
enhance a healthy relationship or to
intervene in a maladaptive relationship
that could lead to later child abuse,
infantile autism or other psycho-social
problems in the growing child. 1 In
assessing this interaction between
mother and infant, the nurse looks at
four stages in the mother s development.
/. Preconception. A medical and social
history of the prospective mother
plays a major role in this area of the
assessment. How is the mother s general
health? Does she have any physical
incapabilities, such as deafness or
chronic illness, with which she must
cope? How does she do this? Does she
have anyone who is a significant
mother-model, perhaps a favorite aunt?
What can she tell you about the model s
parenting style? Was her mother warm
and loving or was she herself a victim of
child abuse? What type of relationship
does she have with her mate?
The answers to these and other
questions may point to trouble ahead
for the mother. Emotional and physical
energy reserves are necessary for the
development of a healthy mother-child
relationship. Past experience with other
mothers parenting styles and the
woman s own experiences as a child are
often reflected in her parenting
attitudes and activities; research has
shown that victims of child abuse are at
high risk for abusing their own children.
Also a recent loss in the form of a
divorce or death may drain a mother s
emotions leaving her without the energy
to form a new relationship with her new
baby. She will also be especially
susceptible to postpartum depression
and its inherent bonding problems. A
stressful family relocation to a new city
or a change in employment status are
just two of a number of other factors
which affect a woman s attitudes
towards pregnancy and motherhood.
2. Present Pregnancy. The pregnant
woman is in the process of great change;
things will never be quite the same for
her. During this dynamic period her old
role will be mourned and the expectant
mother will accept and prepare herself
for her new role, both internally, by
becoming ready to accept change, and
externally, by way of support systems.
She will seek out other pregnant
women, attend prenatal classes and
obtain information on parenting
through reading, discussing with friends
and experts and observing her
mother-model.
Activities such as changing her
habits of eating and sleeping, seeing her
physician, buying maternity clothes,
seeking out other pregnant women and
expressing joy over the kicking
movements of her unborn child indicate
that she is validating her pregnancy and
feeling positive about it. When the child
is unwanted (this is not synonymous
with unplanned), the mother does not
prepare for his arrival, may not seek
antenatal care, often will not choose a
name and may even view the unborn
infant s movements as threatening. One
mother, abused as a child, felt that the
baby was bruising her.
3. Parturition. The bonding process may
be dramatically affected by the actual
labor and delivery. If the labor is short,
that is, less than five hours, the mother
may have some difficulty in realizing
that the baby is here and is hers. If the
labor is long and difficult, the mother
feels only exhaustion when the baby is
born. Her lack of enthusiasm over her
newborn baby should not be assessed as
abnormal.
If the mother s expectations of
this period were exceptionally high
during pregnancy, that is, if she were
keen on natural childbirth without
medication or assistance, she may feel
bitterly disappointed if medical or
surgical intervention is necessary. She
may perceive herself as having failed and
thus being a bad mother, leading to
feelings of guilt and consequent
interference with the bonding process.
Analgesics and barbiturates which pass
the placental barrier also affect bonding.
The mother who receives these drugs
during the first stage of labor will have a
baby who is sleepy for the first 48 hours
of his life and she also will be groggy
and perhaps even too tired to hold the
baby immediately after birth.
4. Early child-bearing stage. Bonding
during this stage can be initially assessed
during the fourth stage of labor
beginning with the birth of the baby.
Immediate acceptance or rejection of
the baby by the mother may depend on
her preconceived ideas of what he will
look like; there is the "fantasy" child
and here is the "real" child. The normal
mother stares at her baby in order to
dispel her fantasy whereas the
vulnerable child will have a mother who
detaches herself from him, one who
refuses to accept this "real" child. Illness,
deformity or prematurity often result in
this stepping back or detachment by the
mother and less than adequate bonding
may be anticipated for any infant who
requires extensive hospitalization after
birth.
As the dream child gives way to
the real child, the mother strives to
discover what the baby is like. His
behavior transmits a message to his
mother, so that she will think "he s
rejecting me I m not a good mother"
or "he s okay, so I m doing okay". The
baby is an active partner in mother-
infant bonding but not every baby is
born wide awake, cuddly and content.
The baby may be sleepy because of
sedation received by the mother during
a long labor or he may be irritable or
jittery from a low blood sugar, jaundice
or application of forceps.
How does the mother respond to
the baby s cry? Is she able to distinguish
the cry of hunger from the cry of pain,
fatigue or boredom? Can she offer the
appropriate response? A mother
sensitive to her baby s cues will offer
him the breast, reduce distractions,
stimulate him with a toy or a song or
provide another appropriate response.
An insensitive mother will be angered,
ignore the baby completely or perhaps
even strike him.
Each baby, because he is an
individual, has his own sensitivity
threshold. A baby with a low sensory
threshold is easily disturbed by loud
noises and bright lights. He needs and
responds best to soft sounds and lights,
gentle handling and cuddling; he needs
to be protected from too much
stimulation. In contrast, a baby with a
high sensory threshold is very sleepy.
Because he initiates little interaction, he
may receive a minimum of stimulation
as he simply does not demand to be
noticed and runs the risk of being
ignored. He needs stimulation or he will
not meet his potential. Parents of
autistic children often describe them, in
retrospect, as good babies.
The Canadian Nurse
The Canadian Muraa
October 1980 39
Oetnhar 1 OAn 41
Enhancing the mother-infant
relationship
Ideally, pregnancy is a time of personal
growth, readying the woman to provide
loving care to her infant. The symbiotic
relationship the mother has with her
baby is momentarily broken at birth
and must be re-established and
maintained. At this time, some mothers
need assistance in learning to gratify
their infants so that they both can feel
pleasure.
A healthy baby should be
delivered straight into his mother s
arms where he can be caressed and
cooed at the breast. The parents and the
new baby should then be left alone for
the first hour, so that mother and father
can get to know their baby on their
own. Now the fantasy-child image is
dispelled and the real baby takes his
place. The baby during this first hour
after birth is in a state of quiet
ASSESSMENT OF MOTHER-INFANT INTERACTION
DURING FOURTH STAGE OF LABOUR
Client s Name:- .
A. Immediately after birth
-2
Displays body movements
in an effort to gain visual
contact with baby. Asks
about baby s condition,
sex, appearance.
-1-
No visual contact
attempted. Asks doctor,
husband or nurse about
baby.
-0-
Verbalizes concern for
self. Seeks support for self.
No questions about baby.
B. Few minutes later
Calls baby by name,
affectionate terms or
by appropriate sex.
Calls baby "it" or by
opposite sex.
Does not speak to baby.
Expresses joy and/or
satisfaction with the
outcome of labour.
Expresses no feelings
about outcome of labour.
Expresses dissatisfaction
or anger at outcome of
labour.
Holds by "en face"
position and makes
eye-to-eye contact.
Holds baby, no eye-to-eye
contact.
Refuses to hold baby.
Reaches out to baby with
fingers and looks at baby.
Glances at baby without
reaching out or touching.
Does not touch or look
towards baby.
Total Score ,
Time afterbirth.
mm. .
hrs.
Score of 7-10 requires usual nursing support.
5-7 requires extra nursing support.
0-5 requires intensive nursing support.
Other observations of mother/baby that may affect above score:
Stressful labour?
Analgesics?
Caesarian section? etc. .
(Source: Adapted from Grace Hospital, Calgary, "Parent-Infant Interact/on
Study," 1978. Mimeo.j
wakefulness;he then falls into a deep and
peaceful sleep which usually lasts for
three to four hours. Mothers who have
been separated from their babies at
birth have said, when reunited, that
they didn t feel the baby was totally
theirs. In leaving the baby alone with his
parents for the first hour after birth,
the unspoken message to the parents is
"You are the important ones."
The early days after birth should
be a time of mutual acquaintance for
parents and baby. This is the time
mother learns about baby s rhythms and
needs and baby learns about how his
mother will respond to him. Rooming
in facilitates tkis process. Studies have
shown that arotheyi who have
experienced rooming in feel more
confident and competent in caring for
their babies than mothers separated
from their babies in traditional hospital
practice. 2
As the new mother may feel sad
and worried when separated from her
children at home and this may be a
source of emotional fatigue, all
members of the family should be
permitted to visit often.
Intervention in maladaptive relationships
In order to promote a healthy
relationship between mother and infant
it is essential to assist each mother in
realizing that each infant is different.
This focus on individuality is essential.
The nurse plays an important role
in helping the mother identify the
unique traits of her infant, beginning
with an understanding of his sensory
level. With this knowledge the mother
can then learn how she can best
stimulate him in his emotional and
cognitive development. Just as each
baby has his own biorhythms and
sensitivity level, each mother has her
own personality characteristics: if the
mother is impulsive, she may not
consider the emotional needs of her
infant, if she has a low capacity for
empathy she may be emotionally
isolated from her baby, or an
independent woman may not be able to
accept the role of being depended upon.
40 October 1980
The Canadian Nurse
The primary concern of any
obstetrical nurse must be this reuniting
of mother and baby in a healthy
symbiotic relationship. Interventions in
maladaptive relationships must come
between the mother and the difficulty
she is experiencing, freeing her from a
defeating pattern so that she may love
her baby.
Six types of interventions 3 have
worked for us at the Royal Jubilee
Hospital. These may be grouped into
two categories enabling or directive as
follows:
Enabling
1. support: words and actions which
affirm the value of the person and show
respect form the basis for all other
interventions.
Comment: We accept each mother
for what she is, with her own
personality, feelings and needs.
2. clarification: words and actions
which promote exploration and
clarification of ideas, feelings and
situations.
Comment: We try to help the
mother see her strengths and her fears
and thereby herself.
3. catharsis: words and actions
which enable a person to discharge or
gain release from painful emotions.
Comment: We can help a mother
free herself from restrictive emotions or
feelings. Perhaps she has lost self-control
during labor and delivery and now feels
extremely embarrassed or guilty; this
restrictive emotion may prevent her
from loving her baby. The helper
repeats the key words identifying the
emotion.
Directive
4. instruction, giving information,
new knowledge or teaching "how to"
do something, for example, teaching a
person to relax.
Comment: The nurse should keep
in mind that there are many ways of
doing the same thing, for example,
putting a diaper on a baby. The mother
folds them her own way - this is not
wrong. Show mother only if she asks
you, or is having difficulty with a
procedure, then let her practice doing it.
5. prescription: giving opinions or
advice; directing a person what to do or
not to do; stating rules.
Comment: Mother is free to
accept or refect advice. Do not "take
over" for her.
6. confrontation, giving direct
feedback; challenging the behavior/
belief/attitude of the person.
Comment: This is probably a
very rare intervention. An example
could be a mother rejecting her baby
because he looks like her mother-in-law.
The nurse s confrontation could be
"You have trouble loving the baby
because he looks like someone you do
not like. "
Conclusion
The practice on maternity units of
separating mother from baby at birth
except during hospital-designated
feeding times did not reflect what we
know now about bonding. The mother
was made to feel helpless and
inadequate, she was discharged with a
baby she hardly knew. Some mothers in
this situation never fell in love with
their babies.
Now, our primary concern in
hospital is to "reunite" mother and
baby in a healthy symbiotic relationship.
The purpose of our interaction is to
free the mother to love her baby so that
they both will grow to their emotional
potential. Our nursing goal is to enhance
the mother and infant attachment so
that the needs of both are defined and
met and, in this way, the infant has the
opportunity to develop as a healthy
human being. *
References
1 Funke-Furber, Jeanette.
Reliability and validity testing of
maternal adaptive behavior. Edmonton:
University of Alberta, Faculty of
Nursing; 1978.
2 Clark, A.L. Recognizing discord
between mother and child and changing
it to harmony. MCN Amer.J.Matem.
Child Nurs. 1(2): 100-106; 1976
Mar./ Apr., p. 102.
3 Peavy. R.V. Mutual aid
counselling: a model for adult peer
counselling. Paper presented to 19th
International Congress of Applied
Psychology, July 30 - Aug. 5, 1978,
Munich, Germany: p.16.
Bibliography
1 British Columbia. Child abuse/
neglect policy handbook, compiled by
Ministry of Education, Science and
Technology, Ministry of Health,
Ministry of Human Resources, Ministry
of the Attorney -General, edited by Jay
Rogers. Victoria, B.C.: Ministry of
Human Resources; 1979.
2 Clark, A.L.; Affonso, D.D.
Mother-child relationships. Infant
behavior and maternal attachment:
two sides to the coin. MCNAmer.J.
Matern.Child Nurs. l(2):94-99; 1976
Mar./ Apr.
3 Dunn, J. Distress and comfort.
Cambridge, MA: Harvard University
Press; 1977.
4 Eckes, S. The significance of early
contact between mother and newborn
infant. JOGNNurs. 3(4):4244; 1974
Jul./Aug.
5 Jolly, H. The importance of
bonding for newborn baby, mother...
and father. Nurs.Mirror. 147(9): 19-21;
1978 Aug. 31.
6 Klaus, Marshall H.; Kennell, John
H. Maternal-infant bonding; the impact
of early separation or loss on family
development. St. Louis. Mosby; 1976.
Lipkin, G. Parent-child nursing:
psychosocial aspects. 2d ed. St. Louis:
Mosby; 1978.
8 Montagu, Ashley. Touching: the
human significance of the skin. New
York: Columbia University Press; 1971.
9 Penfold, K.N. Supporting mother
love. Amer.J.Nurs. 74(3):464-467;
1974 Mar.
1 Young, D. Bonding: how parents
become attached to their baby.
Rochester, N.Y.: International
Childbirth Education Association; 1978.
Margaret Rhone, a graduate of St. Paul s
Hospital School of Nursing in
Vancouver and a mother of five
children, is currently completing her
baccalaureate at the School of Nursing,
University of Victoria, B.C.
The Canadian Nurse
October 1980 41
A nursing role in the preparation of children for the arrival of siblings
Joy Bliss
When a birth occurs in a family,
many children are not
psychologically prepared to move
over and share the spotlight with a
stranger; the process can be
traumatic, resulting in behavior
patterns such as temper tantrums
and regression to infantile
activities. To help keep little noses
from going out of joint when they
find they must share parental
attention, the postpartum unit at
Calgary General Hospital has
developed a unique program called
sibling classes.
Held on the unit, the classes are
designed to prepare children for the
arrival of a new baby; the main
objective of these classes is to promote
family bonding and to decrease anxiety
reactions in children who feel
threatened by the new baby. Sibling
classes benefit the entire family by:
providing guidance and support
developing mutual trust between
parents and medical staff
decreasing sibling fears by
increasing awareness of the hospital
setting and birthing process
enhancing sibling bonding and
acceptance of the new baby
helping siblings to feel "as
important" as the new baby, and an
active rather than passive member of the
expectant family.
Stage one
Class sessions, each of which provides
two hours of instruction, are planned
for children aged three to nine years
whose parents are expecting a baby. A
maximum of 10 children participate in
each class and the fee for the series is
ten dollars. Classes include a tour of the
labor and delivery corridor, the post
delivery unit, the intensive care nursery
and the normal nursery. We make sure
that, before going on the tour, the child
is in excellent health, having had the
proper immunizations and not having
been recently exposed to mumps,
chicken pox, measles, strep throat or
scarlet fever.
The Canadian Nurse
After the tour, the children return
to a small, informal classroom. Each
child is connected to a fetal monitor to
listen to his own heartbeat; he learns
that this is the way staff watch and
listen to the new baby before the birth
takes place.
Later, the children gather around
the instructor to listen to a story about
how it feels to have a new baby in the
family. Open cribs with large dolls are
used to demonstrate holding, feeding
and diapering the baby. At this stage,
there is plenty of time for discussion
and practice and for positive
re-enforcement on how well each child
performs. Often, mothers who have new
infants and are breastfeeding join the
group to demonstrate this art to the
children in the class. The children are
also reminded that some mothers
bottle-feed their babies. Once, a
physician visited the class to
demonstrate an examination of the
baby to the children, and each child was
given the opportunity to listen to the
baby s heartbeat through the
stethoscope.
Parents are excluded from this
first half of the class; we have found
that being on their own encourages the
children to participate more freely in
discussion. It also helps them to prepare
for the subsequent separation from their
mother when the baby is actually born.
When the parents rejoin the class, an
hour later, the entire group watches a
film on childbirth featuring animated
cartoons dealing with the common
misconceptions children have about
where babies come from. At this time
we try to answer any questions the
children may have about the impending
arrival of the sibling. Often, parents
have difficulty in discussing sex and
reproduction with their growing
children. This film provides them with
an opportunity to open up new
channels of communication on birth
and related subjects.
Before he leaves, each child
receives a specially designed coloring
book that reminds him of the material
covered in the class. Each "graduate"
also receives a certificate stating that he
or she has successfully completed the
Big Brother/Sister Course.
Stage two
After the arrival of the sibling, and
while the mother and babe are still in
hospital, a party is held for each child
taking the classes. At the party, we serve
cupcakes and present the child with a
T shirt featuring the message: "New
babies are fun! We ve got one!"
During the party, the child may
hold his new brother or sister for the
first time; our aim at this early stage is
to encourage the start of a warm and
loving relationship. Before he leaves,
the child whose party it is, receives a
Hero Badge stating that he has a new
baby sister or brother.
Stage three
After the baby leaves the hospital, the
new brother or sister receives a
congratulatory letter and a balloon in
his own home. In the letter, we suggest
that he may call the class instructor if
he has any questions or problems.
Evaluation
We started this program in 1979, as
part of our commemoration of the
International Year of the Child. Our
evaluation is carried out by means of
questionnaires completed by the
parents, one after their child has
completed the sibling classes, another
two weeks after the birth of the baby.
Response to date has been very positive:
parents agree that the classes help the
child to understand the development
and birth of a new baby, reduce anxiety
connected with the hospitalization of
the mother and help the child to feel
more involved in the pregnancy and
subsequent arrival of the sibling.
We are convinced that the classes
not only benefit the children, helping
them to adjust to a change in lifestyle,
but also foster and facilitate improved
relations within the family during the
birthing and early bonding process.*
Joy Bliss is the nurse in charge of the
sibling classes of Calgary General
Hospital. A graduate of Foothills
School of Nursing, Joy has worked in
renal transplant, ICU, 1C N and northern
isolation posts. She is currently Clinical
Development Nurse Instructor in
Obstetrics at Calgary General and, in
addition to the sibling classes, teaches
prenatal classes for unwed mothers.
Author Joy Bliss
helps student
in sibling classes.
Learning how staff watch
and listen to their new baby
"while he s still in mommy ".
The Canadian Nurse
Anne Wallace
Introduction
As head nurse on our maternity ward, I
wanted to demonstrate that hospital
nurses could gather the information
they need to improve their practice and,
at the same time, help the mothers and
infants they care for. As a result, five
years ago at the Burnaby General
Hospital in BC where I work, we
initiated a breast feeding survey. Four
years later, in 1979, we repeated the
survey with the intention of comparing
results obtained in the two
investigations.
The specific reasons we identified
for carrying out this survey were:
to find out how long mothers
nurse their infants after discharge from
the hospital
to discover why mothers stop
nursing their infants
to determine when the majority
of mothers introduce solids to the
infant s diet
to uncover teaching problems in
our individual counseling and breast
feeding classes.
Our first survey was carried out over
10 months, September, 1975 to
June, 1976, with 200 mothers; the
repeat version covered two months,
January and February, 1979, and
involved 50 mothers.
Method
During the survey months all mothers
choosing to breast feed were asked if
they were willing to participate. As we
intended to do our post-discharge
follow-up by telephone, we had to
eliminate those mothers who did not
have a phone, or those who lived in a
long distance charge area.
The head nurse in the nursery was
responsible for devising the information
sheets, collecting the information, and
writing up the results. Information
sheets were divided into two parts,
hospital and follow-up data. A
description of the type of information
recorded follows:
Part I Hospital data
personal information: name, age,
phone, parity, delivery data, type of
delivery, previous nursing time
baby: birth weight, sex, discharge
weight
problems with previous nursing
experience, e.g. cracked nipples,
premature baby, sibling jealousy, etc.
general hospital course of mother
and baby
specific information on nursing in
hospital, e.g. schedule, supplementary
feedings, etc.
discharge notes.
Per cent
100
1975 Survey
1979 Survey
90
80
70
60
50
40
30
20
10
1 2 3 4 6 8 10 12 16 20 24
Weeks
Figure one: Mothers still nursing at specific times
Part II Follow-up data
routine questions: are you still
nursing? are you using supplementary
feedings? if so, how often? are you still
nursing at night? what is the feeding
schedule? do you follow demand
feeding? have you added solids? is your
breast milk supply adequate?
specific nursing problems of
mother or baby
advice given.
The information for Part II was
collected by phone on a regular basis:
1st call 1 week after discharge
2nd call 2 weeks after discharge
3rd call infant age 8 weeks
4th call infant age 3 months
5th call infant age 6 months.
If no contact was made on the first call,
the mother was phoned twice more in a
one to two day period, and if still
unable to contact the form was filed
until the next stage. If no contact was
made on this next call, the mother was
dropped from the survey.
Results
1. Mothers still nursing at specific times
Figure one summarizes our findings
concerning the time at which mothers
stopped nursing during the two study
periods. In 1975 there was a gradual but
steady decline throughout the six
month period in the number of mothers
continuing to nurse their babies, with a
"levelling-off stage becoming apparent
at about four months (16 weeks). All
of the mothers who were nursing at
20 weeks were still nursing one month
later when their baby was six months of
age. Between one and two weeks and
again at four to six weeks, the number
of nursing mothers dropped sharply
(by ten per cent). This was followed by
a 12 per cent drop at three months
(12 weeks) and another 10 per cent
drop between three and four months.
The gradual decline noted on the
first survey can also be seen in the 1979
survey ; here the significant drop
between one to two weeks is still ten
per cent, however the decline between
four and six weeks is only six per cent
this time, a decrease of four per cent
from 1975. Another 12 per cent drop
was recorded between eight and ten
weeks, while a ten per cent drop
occurred between five and six months.
This ten per cent of mothers who
stopped nursing at five months
(20 weeks) was not found in the first
survey.
2. Reasons for discontinuing nursing
This data was very difficult to assess
accurately because of the subjective
nature of replies. Often when closely
questioned mothers had in fact several
reasons for stopping at the time they
did. In figure two the reasons for
discontinuing nursing are correlated
with the percentages of mothers who
stopped at a given time.
In the first survey, 46 per cent
of the mothers stopped nursing because
they felt they had insufficient milk
to satisfy their infants. The mothers
who gave the same reason at the three
month check, on closer questioning also
said they felt they had nursed long
enough. In the second survey 28.9
per cent gave insufficient milk as their
reason for discontinuing nursing; only
one mother felt that her milk "was not
strong enough for the baby".
In 1975, 14.8 per cent of mothers
stopped nursing due to sickness of
either their baby or themselves; in 1979,
sickness accounted for 10.5 per cent
including two cases of hospitalization. A
third mother successfully nursed her
infant while he was hospitalized.
Returning to work meant 4.7
per cent of mothers changed to formula
feeding in 1975 ; this increased to 7.9
per cent in 1979. In this latter survey,
however, several mothers returned to
work and successfully continued
nursing
Mothers who stopped because
they felt they had nursed long enough
made up 17.2 per cent in the 1975
group; 47.8 per cent of these mothers
stopped at five months. Although this
reason was given as early as six weeks in
the first survey it did not show up
until four months in the second; 37.5
per cent of mothers discontinued
nursing for this reason at both four and
five months with a total of 21 .1
per cent for this category.
The Canadian Nurse
OoMMMMO 45
Figure two: Reasons for discontinuing nursing
*1975 (top row) *1979 (bottom row)
Insufficient
Milk
Sickness
Return
to
Work
Nursed
Long
Enough
Social
Reasons
No
Reason
Sore
Nipples
Infant
Refused
Breast
%
%
%
%
%
%
%
%
1 Week
*6.7
**9.1
21.0
25.0
33.3
20.0
66.7
50.0
2 Weeks
16.9
18.2
26.3
25.0
7.7
33.3
50.0
33.3
3 Weeks
6.7
25.0
7.7
4 Weeks
11.8
18.2
5.3
7.7
16.7
50.0
6 Weeks
20.3
18.2
10.5
16.6
4.5
15.4
20.0
8 Weeks
8.4
5.3
16.6
7.7
10 Weeks
3.3
36.4
5.3
33.3
8.7
23.1
16.7
40.0
3 Months
13.5
15.7
33.3
33.3
13.0
15.4
20.0
50.0
4 Months
8.4
5.3
16.6
26.1
37.5
7.7
16.7
5 Months
3.3
5.3
16.6
47.8
37.5
7.7
33.3
6 Months
25.0
33.3
25.0
33.3
TOTAL
46.0
28.9
14.8
10.5
4.7
7.9
17.2
21.1
10.3
15.8
3.9
7.9
1.2
1.6
7.9
In 1975 a total of 10.2 per cent of
mothers discontinued nursing for
social reasons; the distribution was
evenly spread over the six months.
Explanations given included such things
as nursing was too time consuming,
interfered with social life, and that
friends and relatives pressured the
mother to stop nursing. It should be
noted that this survey period included
the holiday period of Christmas and
New Year. In 1979 social reasons
accounted for 15.8 per cent of
mothers changing to formula feeding;
the highest incidence occurred at
one week, 33 per cent, with other
drops at four weeks, ten weeks and
four months. Explanations given this
time were sibling jealousy, interfering
with sibling activities such as sports,
feeling awkward when nursing, too
much company and stress.
In both surveys, some mothers
offered no reason for discontinuing
nursing; when questioned further some
responded that they "just didn t like
nursing". The high percentage of
mothers giving up nursing in weeks one
and two of the 1979 survey fall in this
category. Of those offering no reason
total percentages were not high at
3.9 for 1975 and 7.9 for 1979.
Sore nipples accounted for
1 .2 per cent of mothers discontinuing
nursing in the first survey; no mothers
gave this reason in the second survey.
Only 1 .6 per cent of mothers in
the 1975 survey said that the infant
refused to nurse; 7.9 per cent gave this
reason in the 1979 survey. Those
mothers offering this reason at five to
six months (66.6 per cent, 1979) said
they felt the infant had lost interest and
was ready to try something different.
3. Age at which the infant started solids
This information was gathered to see if
solids were being added to the infants
diets as recommended by nutritionists
around four to six months (see figure
three). In the first survey solids were
started earlier than in the second;
30 per cent at eight weeks in 1975 and
32.3 per cent at twelve weeks in 1979
were peak times. Although still starting
solids early, mothers do appear to be
delaying longer than a few years ago
when soft cereals and fruits were
started at two weeks.
4. Supplementary feedings
The data showed that 16 per cent of
the infants were still on supplementary
feedings when leaving the hospital in the
1975 survey and 13.3 per cent in the
1979 survey. Further data on how long
these supplementary feedings continued
could not be calculated as not all the
infants stayed in the study.
Supplementary feedings are not given if
the mother indicates she prefers not to
have them given.
46 October 1980
The Canadian Nurse
Per cent
30
25
20
15
10
1975 Survey
1979 Survey
1 2 3 4 6 8 10 12 16 20 24
Weeks
Figure three: Percentage of infants starting solids at specific times
Discussion
We wanted first of all to establish some
facts: how long mothers nursed, why
they stopped, and when they added
solids to the infant s diet. The
description of the survey results shows
we achieved this purpose. Meeting our
fourth objective was not quite so easy;
the results must be interpreted to make
them relevant to our nursing practice.
The central concern of this discussion
will be how we viewed the results, and
the action we took.
Some specific implications
A large number of mothers gave up
nursing in the early weeks giving
insufficient milk as their reason; this
clearly indicated to us that our
message "lactation is not established
for six to eight weeks" - was not
understood by these mothers.
Convinced of this teaching problem, we
do think we improved between 1975
and 1979: the percentage of mothers
giving insufficient milk as a reason to
discontinue nursing dropped from
46 to 28.9.
As mentioned above, mothers
often gave more than one reason making
clear cut interpretation difficult. They
sometimes added other factors such as
pressure from family and friends. We
took this to mean that perhaps we did
not offer mothers the long term support
they needed to clarify their own
feelings. Maybe we did not convey to
them that the community health nurse
was available or that they could call
the unit nurses if they had problems in
the evenings or on weekend.
General interpretation and teaching
program changes
Because only 20 per cent of the (1975)
mothers who chose to nurse continued
until six months, we felt we could
improve both our individual counseling
and our breast feeding classes. Some
steps we took after the 1975 survey:
we made up special care plans for
mothers with particular problems such
as sore or inverted nipples
we urged all mothers to ask for
individual help from their assigned nurse
when they had problems with feedings
we distributed pamphlets to all
mothers: first, an introductory one for
in-hospital use, and later, one for home
reference
we continued our twice weekly
classes and tried to improve content and
teaching from what we learned in the
survey
we introduced a film for mothers
on the first three months of an infant s
life, reassuring them that a crying or
fussy baby is not always a sign of
parental mistakes
we encouraged sharing of
experiences in class discussions;
experienced mothers are often very
good at reassuring new mothers
we had the community liaison
nurse visit all mothers in hospital, and
made referrals for early home visits for
mothers having problems.
We think some of our 1979
results indicate progress. One difference
we noted was that mothers seemed
better able to discuss their reasons for
discontinuing nursing; we believe this is
important because while we wish to be
positive and encouraging about breast
feeding, we do not want to make any
mother feel guilty if she chooses to do
otherwise.
Since the 1979 survey we have
started monthly postnatal classes at the
hospital; these are informal drop-in
sessions to which parents can bring their
babies. Common problems and concerns
are shared and solutions are exchanged
between parents; a nutritionist and a
nurse are on hand for teaching and
assistance as necessary. We continue to
try and improve our program in keeping
with our findings; this last is our most
recent venture. .
Acknowledgement: The author would
like to acknowledge the cooperation
and assistance of the nurses of the
Burnaby General Hospital maternity
unit and all the parents who
participated in the surveys. Special
thanks for the help and support of
June Nakamoto during the 1975 survey
and Maureen Oliver during the 1979
survey, both of whom were
coordinators of the maternal /child
health department.
Anne Wallace is a graduate of St. Mary s
Hospital in Portsmouth, England where
she received her SRN and SCM. She has
worked in the Vancouver area since
2964, and is presently assistant director
of nursing of the maternal-child
department at the Burnaby General
Hospital.
The Canadian Nurse
October 1980 47
Are your
students
positive
about
their
experience
in the
clinical
^^^WMMMM^^^^^^^^^M
area?
Frances Ban
Nurse educators are constantly
asked to look within themselves
for answers to the discrepancy
between the clinical competence
of their graduates and the service
demands of the beginning work
role. They know that the time
their students spend in the clinical
area must be as meaningful and
productive as possible. What
follows are some practical
suggestions for making sure that
students find the work setting
comfortable and conducive to
learning.
The clinical area
An examination of the clinical area, the
environment, the people and their roles,
is necessary before considering the
practical aspects of setting the learning
climate.
Consider the patients first since
they are central to the learning
experience: it is their nursing needs that
make up the content of the student s
experience. Before patient assignments
are made the teacher must consider the
ethics of the situation: patient needs
must not be compromised by the
learning needs of the students. This
issue has been debated by Corcoran who
claims "to be acceptable, the situation
must promote growth and must protect
the rights of all persons involved". 1
Patient selection is crucial to
student learning; assignments must be
made to provide experiences that are
challenging and relevant to the student s
current learning. Does the assignment
encourage transfer of classroom theory
into practical application? Will patient
care allow for some risk-taking and
decision-making on the part of the
student? Will she be stimulated towards
further inquiry and investigation? All
of these activities are necessary for
learning so the potential for them must
exist in the patient assignment.
The type and number of patients
available for student experience is also
very important. Fluctuations in the
ward population are beyond the control
of the teacher, so we must be sure to
choose areas where the possibilities for
learning are reasonably constant and
varied. A surgeon s vacation may be
enough to radically change the
experience available on some surgical
units.
Careful preplanning is essential in
providing good student experience, but
The Canadian Nurse
a certain flexibility must be maintained
as unexpected changes are always a
possibility on any ward or with any
patient.
There is always the possibility
that the patient might be better served
by having a student caring for him.
Not functioning under the same work
load as staff, the student may have more
time and energy to devote to the patient
and this added time may balance the
disadvantages of being cared for by a
beginner.
Staff nurses and other members of
the health team giving patient care in
the clinical area are the next group to
consider. A degree of conflict with this
group is inherent in the differing goals
of education and service. If the two are
to work successfully, it is essential that
the validity of this conflict be
recognized and dealt with.
Concentrating on the mutual benefits to
be derived from the situation and
learning to respect the differing
expertise of both positions will help.
Staff members, in particular, often
benefit from the enthusiasm and
excitement of students who serve as a
morale booster for experienced
personnel. Students can also serve as an
inspiration, encouraging high standards
of care in the role models adopted by
staff.
Sexton lists eight benefits to the
service organization that she feels result
from having students in the clinical area:
1 an immediate source of temporary
manpower
2 screening and recruitment of future
employees
3 access to skills and knowledge of
academic institutions
4 opportunities to supervisors and
others to learn ways to manage and
learn for themselves
5 opportunities to examine the
teaching and learning dimensions of
their own organization
6 access to thoughts and attitudes of
the young
7 invigoration of permanent staff
through the presence of students
8 fostering credible witnesses (students
and faculty) to the nature and worth
of the organization in promoting public
interest. 2
Nursing personnel in the clinical
area play a vital role in the students
learning experience. They are the
primary role models whose attitudes,
positive or negative, and techniques are
quickly observed and sometimes
imitated by students. The degree to
which the staff support the educational
program and welcome the student and
teacher has a profound effect on the
learning climate. Janetta MacPhail says:
"Quality nursing practice must exist in a
clinical setting, whether that be
hospital, nursing home, public health
agency, doctor s office or other setting,
to provide an exemplary learning
climate for students and staff. Although
one can learn from a poor role model
what not to do, negative learning is
expensive of time and is difficult. A
spirit of inquiry and a positive attitude
toward learners must exist to permit
learners to question and test out new
ideas, and to promote learning." 3
Many other members of the
health team also play a role in the
students education, including doctors,
dietitians, physiotherapists, clinical
pharmacists, social workers and a
variety of technicians. It is important
that students learn to interact early with
these other professionals, who are
involved in patient care ; it is the best
way to become aware of the variety of
contributions and methods of team
cooperation. Students should also be
helped to realize something of the
emotional and physical pressure of
health care roles and the effects this
pressure might have on staff
relationships.
The physical setting is another
important factor when considering the
clinical area for educational purposes.
Students are generally assigned to wards
in groups of about eight with one
teacher. A prime consideration is
whether or not the ward can
accommodate the influx of a group of
this size, both in terms of physical
space and actual experience. The whole
issue of physical space and nurses has
been discussed by Besel under the
heading "proxemics" :
" We reach the conclusion that, among
all health professionals only nurses have
so little control over intrusion into
personal space. Medical staff,
physiotherapists, or occupational
therapists who must touch the body,
and thus intrude into the patient s
personal space, manage to do so on an
appointment basis, thereby achieving
some modicum of control in this
anxiety-provoking situation." 4
The constant intrusion we must
make into the personal space of others
and the many intrusions of others into
ours is a stress-producing fact of life on
a nursing unit. Nurses must often work
through difficult decisions in an
atmosphere akin to an aquarium.
Private office space is generally not
available; "the majority of nurses share
a stall as a group, for instance, the
nursing station. They frequently exert
little control over those who will enter
that stall, at what time, or for what
purpose." 5 Students in the clinical area
are affected by this lack of personal
space and their presence contributes
further to the existing problem. It is
very important that the teacher make
arrangements to minimize this problem
because of the negative effect on
learning. Booking classroom space for
student use during clinical hours may
help; however, busy clinical facilities
are often short of such space or it is
reserved for use of staff.
Another dimension of the
physical setting that warrants concern is
whether or not there is adequate
equipment for patient care. If beginning
students must constantly adapt or
"make do" bad habits may be the
result; an attitude of "that s okay in the
classroom but it doesn t work in real
life" is easily adopted by students if
they are constantly frustrated in their
attempts to do things correctly.
The teacher s role in the clinical
setting is very much that of a catalyst
and she is involved in many
interactions with staff, patients,
students - all with different
responsibilities attached. The level of
her expertise as a practitioner and her
ability as a teacher will determine the
measure of control she can exert over
the learning climate. Teachers are also in
a position to benefit from the clinical
teaching experience: it offers a chance
to keep skills and information current.
The student in the clinical area is
often the real unknown; although she
comes with a defined classroom
background, this is theoretical and
untested knowledge. Age, maturity
levels and other personal factors greatly
influence performance, learning styles
and communication abilities, a fact
that leads us directly to the idea of
evaluation of the student in the clincal
setting. This area is a source of very real
anxiety both for the teacher and the
student and therefore must always be
considered as influencing the learning
climate. The idea of mistakes must be
replaced with the notion of clinical
choices. Nursing has suffered too long
from the need for infallibility ; real
growth in learning is impossible without
the right to fail. This in no way implies
that caution can be thrown to the winds
but it does mean that we should start
being more realistic about our
expectations, while still not
compromising patient safety.
A positive learning climate
If the learning climate is positive,
students will feel good about being
there, what they are doing and learning
and the input and control they have
over their experience : in essence they
will feel challenged by and able to meet
the challenges of the clinical setting.
Preplanning
The teacher gives herself a good start if
she does a thorough investigation of the
clinical area she will be using. Simple
but basic things like having a place to
meet on the first day are important to
an atmosphere of security necessary to
The Canadian Nurse
October 1980 49
offset the anxiety of a new experience.
The information that the students
require from the teacher will vary with
their familiarity with the facility in use,
but the teacher should be sufficiently
familiar with her students to know what
information is essential, and find an
adequate route for getting it to them.
Although these may seem to be minor
concerns they influence the tone of the
teacher-student relationship, an
important part of the climate for
learning.
Communication with staff
The head nurse and staff must be
included in the planning of student
learning experiences. Before they can do
this they will need to know the
philosophy of the educational program
and the aims of this particular
experience. How the teacher initiates
and maintains communication in this
area will depend on her style and the
particular needs of the staff in question.
One method that has proven useful is to
post weekly objectives for the
experience prior to the week and to
supplement these with daily objectives
written on the assignment sheet for easy
reference. Consultation with staff about
choice of patients for student
assignment provides a time for
cooperation and leads to greater
involvement of staff in the student s
experience.
Making sure that students and
staff are introduced to each other is a
simple matter but if overlooked will
interfere with the communication
process vital to relationships for
learning. Also the teacher must
constantly remember that staff cannot
become involved in and support learning
experiences if they do not understand
them or see their relevance.
Orientation
Students require a basic introduction to
the physical layout of the ward, the
personnel and type of patients, and any
routines that are specific to a
particular area. This should be done
early using whatever methods are
suitable to the group and the ward. This
can also be part of the process of
teacher and student getting to know
each other if this is their first experience
together. It is very important for the
teacher to clarify early her expectations
about assignments and participation in
group activities and conferences. At the
same time students should be
encouraged to discuss their personal
learning objectives for this experience;
these may help the teacher to make
assignments that would enhance
personal motivation.
Patient assignment
Patient assignment must be made soon
enough to allow the student necessary
preparation time ; if an assignment is a
worthy learning experience for the
student it will require some forethought
and planning. The teacher must be
readily available to the student, and the
student needs to be aware of the other
resources available for her use in the
clinical area. Different methods are
useful for "being there" for students.
I personally prefer the informal
approach of walking rounds; a way to
see both the patient and student
together at the beginning of the
experience. Knowing that the student
has back-up support gives a certain
security to the patient.
Conclusion
To work toward the creation of a
positive learning climate in the clinical
area the teacher must be skilled in both
interpersonal relationships and as a
nurse practitioner. She is the one who
must act as the primary link between
ward staff and the nursing school. She
must work at being accepted as a
member of the ward team if staff are to
become committed to the educational
program she represents, and must be
prepared to remain in the same clinical
area for a reasonable period of time to
develop constructive relationships with
staff.
Before they can respect and care
for others, teachers must first respect
and care for themselves. "When teachers
have essentially favorable attitudes
toward themselves, they are in a much
better position to build positive and
realistic self concepts in their students." 6
In the end, it is the teacher s belief in
the student s desire and ability to learn
that gives the student the freedom to
function more independently.*
References
1 Corcoran, Sheila. Should a service
setting be used as a learning laboratory?
An ethical question. Nurs.Outlook.
25(12):771-776; 1977 Dec.: p.775.
2 *Sexton, Robert; Ungerer,
Richard. Rationales for experiential
education. Washington; 1975: p.34.
3 MacPhail, Janetta. Promoting
collaboration between education and
service. Canad. Nurse. 71(5):32-34;
1975 May: p.32.
4 Besel, Lorine. The private and
professional self. Canad.Nurse.
70(1 1):21-23; 1974 Nov.: p.22.
5 Ibid.
6 Purkey, William Watson. Self
concept and school achievement.
Englewood Cliffs, N.J.: Prentice-Hall;
1970: p.46.
*Not verified
Frances Barr, RN, BScN, M.Ed., is a
graduate of the Oshawa General
Hospital, the University of Western
Ontario and the Ontario Institute for
Studies in Education. She has worked in
a variety of clinical nursing areas and is
presently employed as a teacher in the
nursing division of George Brown
College, Toronto. Barr is a past
president of Cathedral Chapter of the
Registered Nurses Association of
Ontario and a regular contributor to the
Journal of the Canadian Orthopedic
Nurses Association.
AUDIOVISUAL
Nursing process
For those interested in planning and
conducting workshops on the nursing
process, the RNAO has developed a
resource package as a teaching aid. The
package includes background
information, workshop materials and
guidelines for use, and information on
valuable resources.
The package is available for $30
from RNAO Publications, 33 Price
Street, Toronto, Ontario, M4W 1Z2.
Auto Safety For Children
To provide complete factual
information on auto safety for children,
the Transportation Agency of
Saskatchewan has designed a multi-media
resource kit. Included in the package is
Transport Canada s Secure Your Child s
Future, and a Canadian Institute of
Child Health production, available on
both videotape and film. Other
resources are a slide tape, overhead
transparencies, Transport Canada
posters and various brochures. The kit
represents an attempt to improve public
understanding of the risk factor for
unrestrained children in cars, as well as
the importance of child safety seats and
seat belt use for pregnant women and
small children.
Public health nurses are a key
group in the safety campaign, having
direct contact with the ideal audience
for this kit young parents and
teenagers who will one day be parents ;
OB nurses, prenatal instructors and
teachers are also important.
For more information contact:
Harry Gow, Program Coordinator,
Canadian Institute of Child Health,
Suite 803, 410 Laurier Avenue West,
Ottawa, Ontario, KIR 7T3.
50 October 1980
The Canadian Nurse
Adult
Respiratory
D
Syndrome
Shock lung, stiff lung or wet lung, whatever the term, nurses who work in an acute care setting are aware
that the body s reaction to shock, and it s aggressive treatment may result in this acute respiratory
condition. Why does adult respiratory distress syndrome occur? How is it treated? What can be done to
prevent it?
The Canadian Nurse
October 1980 51
Adult Respiratory Distress Syndrome,
sometimes called "shock lung" or
"post-traumatic pulmonary
insufficiency", refers to a clinical
syndrome of acute respiratory failure
occurring in critically ill patients. Seen
in a diverse group of conditions
including multiple trauma, sepsis and
shock, adult respiratory distress
syndrome (ARDS) is characterized by a
severe impairment of gas exchange at
the alveolar-capillary membrane in a
patient with previously healthy lungs. 1
Within 48-72 hours of the critical insult,
it becomes apparent that the patient is
experiencing increasing respiratory
distress as evidenced by apprehension,
dyspnea, tachycardia and a falling
arterial oxygen level (P0 2 ). Despite
high concentrations of oxygen, the
P0 2 continues to fall (see figure one).
Typically, the patient is admitted
to hospital with severe trauma and is in
both a hypoxic and shock state. Despite
a successful resuscitation from this
shock state, ARDS develops in
approximately three days.
Regardless of the cause of ARDS,
there appears to be a common
pathology in the lungs, that of damage
to the pulmonary capillary membrane
leading to leakage of fluid into the
alveoli and interstitial spaces of the
lungs (see figure two). In shock, for
example, the lung is underperfused, as
blood is being directed to the heart and
brain. Lack of perfusion of the lung
tissue is accompanied by lack of
oxygen. This hypoperfusion and
hypoxia create increased pulmonary
capillary permeability leading to
interstitial edema which causes the lungs
to become very stiff and the compliance
of the lungs decreases. This stiffness of
the lungs increases the mechanical work
of breathing. 3
In ARDS, surfactant production is
also decreased. Surfactant, a lipoprotein
produced by Type II alveolar cells in the
lungs, helps prevent collapse of the
alveoli. Therefore, a reduction in
surfactant leads to atelectasis. Also in
ARDS, thromboemboli are found in the
small pulmonary blood vessels. 4
The net is that of
arterio-venous shunting. Arterio-venous
shunting creates a low arterial oxygen
level as oxygen is not transported across
the alveolar-capillary membrane because
of edema and atelectasis. However as
carbon dioxide diffuses more readily
than oxygen, it crosses the membrane to
a greater extent. In ARDS, a "right to
left" shunt exists whereby the alveoli
are not ventilated and the blood
bypasses the alveoli without receiving
oxygen. Therefore, a low P0 2 results
despite higher concentrations of oxygen
being delivered to the patient. 5
insult to body (ie. massive trauma, gram negative sepsis)
I
decreased
surfactant
causing atelectasis
thrombo-emboli
in small
pulmonary
blood vessels
I
decreased gas exchange
across alveolar-capillary
membrane
I
damage to pulmonary
capillary membrane
causing serous fluid
in alveoli and
interstitial spaces
decreased lung
compliance
(stiff lung)
right to left
shunting
I
marked
respiratory
distress
decreased oxygen
in arterial
blood (PO 2 )
Figure one: Adult Respiratory Distress Syndrome
Etiology of ARDS
The development of ARDS involves a
multitude of factors, one or several of
which may be present in the patient
who develops this syndrome.
1. Fluid overload. Excessive use of
crystalloid fluids in the resuscitation of
the shock patient can lead to ARDS.
Crystalloid fluids, such as normal saline,
contain no protein and thus dilution of
the colloid osmotic pressure occurs. The
resulting loss of fluid into the interstitial
spaces, particularly the lung, creates a
stiff lung with little compliance. The
effect created is that of increased effort
of respiration and decreased diffusion of
oxygen into the capillaries because of
fluid in the interstitial spaces and
eventually fluid in the alveoli.
Therefore, the amount of crystalloid
fluid given to patients in shock must be
closely monitored.
2. Sepsis can cause the release of toxic
agents such as endotoxins which can
result in the leakage of fluid through the
alveolar capillary membrane leading to
alveolar collapse. It is important to
remember that patients with severe
shock and tissue trauma are more
susceptible to broncho-pneumonia and
the possible release of toxic agents.
Also, the increasing atelectasis and
alveolar fluid seen in the patient with
ARDS are an excellent medium for
bacterial growth.
3. Oxygen toxicity occurs when patients
are exposed to high concentrations of
oxygen (greater than 60 per cent) for
prolonged periods of time. The lungs,
eyes and central nervous system can all
be affected. Pulmonary damage due to
high concentrations of oxygen over
prolonged periods cause damage to
the alveolar Type II cells which produce
surfactant resulting in atelectasis.
Within 30 hours of 100 per cent oxygen
administration, a decrease in pulmonary
function can be seen. Therefore, the
nurse must closely monitor blood gas
results and the oxygen concentration
delivered to the patient.
4. a) Emboli. Patients who are exposed
to multiple blood transfusions because
of hemorrhagic shock, for example, may
develop small pulmonary emboli.
Banked blood contains degenerated
platelets and fibrin strands which can
lead to pulmonary emboli if the patient
does not receive the blood through a
special microfilter. These microthrombi
are also thought to increase the capillary
permeability leading to a stiff lung. In
addition the shock state itself produces
stasis of blood in the capillaries leading
to microthrombi.
b) Fat Emboli. High levels of free
fatty acids may be seen in patients with
fractures of long bones. These free fatty
acids can inactivate the production of
surfactant and may also have a toxic
effect on the alveolar-capillary
52 October 1980
The Canadian Nurse
Normal
capillary
Figure two: Perfusion and Ventilation
Right to left
shunting
atelectic alveolus
capillary not receiving oxygen
from alveolus due to atelectasis
membrane causing production of
exudate in the small airways. Early
immobilization of fractures is vital to
help prevent the development of these
fat emboli.
c] Disseminated Intravascular
Coagulation. This disorder may be seen
in the patient with shock and is a
paradox of simultaneous clotting and
bleeding, producing microthrombi in
the lung.
Phases of ARDS 7
Injury and Resuscitation. In this phase
the patient has been resuscitated from a
shock state. Arterial blood gases reveal
that the patient s P0 2 level is starting
to decrease, but with supplemental
oxygen it remains at a satisfactory level.
The patient in this stage tends to
hyperventilate resulting in an increased
respiratory rate and a decreasing arterial
carbon dioxide level (PC0 2 ). At this
stage of ARDS, the patient may recover
with no permanent lung damage.
Circulatory Stabilization. Tissue
perfusion has been restored in the
patient and the cardiac output is good.
The patient is lucid and oriented but
may show signs and symptoms of early
respiratory difficulty such as tachypnea.
In this stage, supplemental oxygen does
not return the P0 2 to a normal level.
This indicates that arterio-venous
shunting is occurring. However, with
treatment, the patient will recover.
Progressive Pulmonary Insufficiency
At this stage, the patient displays
marked dyspnea. Despite higher and
higher concentrations of oxygen
therapy, the P0 2 continues to fall.
In addition, the PC0 2 level may begin
to rise above normal levels. Both these
factors indicate a marked decrease in
the diffusion of gases at the
alveolar-capillary membrane. To
maintain adequate oxygenation of
tissues, support with a mechanical
ventilator is required. It is still possible
for the patient to recover at this phase
with treatment.
Terminal Hypoxia and Increased PCO 2 .
During this phase which usually lasts
only a few hours, the hypoxia is so
severe that the patient may have a
cardiac arrest from the lethal cardiac
arrhythmias that are prone to develop.
The PC0 2 continues to rise and
because of the very low P0 2 and
lactic acid buildup, the patient develops
metabolic acidosis. The patient
deteriorates into a deepening coma and
finally cardiac standstill occurs. The
patient usually succumbs regardless of
treatment. Chest x-rays during this
period reveal a diffuse white-out of lung
tissue similar to pulmonary edema. On
autopsy, the patient s lungs resemble
liver tissue. They are inflated and
saturated with fluid which makes them
heavy and stiff.
Arterial PO 2 and PCO 2 in ARDS
(before treatment with ventilator and PEEP)
PO 2 : 40-50 mmHg with 100% inspired
oxygen (normal is 85-100 mmHg)
PCO 2 : initially less than 35 mmHg, in
phase IV greater than 50 mmHg
(normal is 35-45 mmHg)
Treatment
The increasingly stiff lungs of the
patient with ARDS make it difficult for
the patient to breathe on his own.
Therefore, treatment usually involves
maintenance of the patient on a
ventilator to decrease the work of
breathing and to ensure adequate
oxygenation of tissues. The use of
positive end expiratory pressure (PEEP)
with a ventilator is the recommended
treatment. PEEP maintains a positive
pressure in the alveoli during expiration
thus preventing atelectasis, by
preventing collapse of the alveoli. By
improving diffusion of gases, the
patient s P0 2 level increases and lower
concentrations of inspired oxygen are
required. PEEP also helps to prevent the
migration of fluid into the alveoli, the
net effect of which is to improve
diffusion of gases. While the patient is
on the ventilator, the nurse must apply
good suctioning technique and
tracheotomy care, in order to minimize
the possibility of pulmonary infection.
Steroids may be used in the
treatment of ARDS although the exact
mechanism of their action with this
syndrome is not clearly understood.
However, it is believed that steroids
prevent platelet clumping, increase
surfactant production, block the effect
of endotoxins and maintain cell
integrity. The nurse must observe the
patient carefully for the many side
effects such as gastric ulceration which
complicate steroid therapy. 8
Since excessive administration of
fluids potentiates the development of
ARDS, diuretics may be used to help
control fluid volume, particularly
pulmonary fluid volume. However, with
the shock patient, care must be taken
that the diuretics do not deplete the
intravascular volume and lead to
another severe episode of shock. Close
monitoring of intake and output and
the patient s response to diuretics is
essential.
At the earliest signs and
symptoms of infection, antibiotic use
is considered. Appropriate smears
and cultures should be obtained
regularly and any indications of
infection reported. 9
Nursing measures
The treatment of ARDS begins with
prevention which falls largely within
the responsibility of the nurse.
Resusciation of the shock patient
and maintenance of adequate tissue
perfusion is essential in preventing the
development of ARDS. Without
correction of poor tissue perfusion,
circulatory stasis increases and
thromboemboli result. While fluid
replacement is essential in the shock
state, careful monitoring of the patient s
intake is necessary to prevent fluid
overload. The nurse must be cognizant
of the patient s response to fluid
therapy as indicated by blood pressure,
pulse rate, urine output, skin perfusion,
central venous pressure and by
auscultation of the lungs for detection
of fluid (rales).
As fluid therapy for the patient
in shock usually involves blood
transfusions, the nurse should ensure
that filters are used for all such
infusions. The filters should be fine
enough to prevent particulate matter
in the blood transfusion from entering
the circulation and forming emboli in
the lungs.
Pulmonary function is also
compromised by pain which can result
in decreased respiratory effort and
increased pulmonary secretions. While
analgesic administration is important to
reduce these reactions, it is essential to
beware of oversedation which depresses
respiratory function.
Patients in shock have decreased
resistance to infection for several
reasons. For example, the
reticulo-endothelial system may be
depressed because of poor perfusion and
the mucosal barrier in the intestine may
become increasingly permeable to
bacteria leading to the release of toxins.
The Canadian Nurse
October 1980 S3
Careful observation by the nurse of any
signs of developing infections can
minimize further lung damage from
occurring.
Oxygen should be administered to
the patient in shock as the resulting
decreased cardiac output may lead to
inadequate tissue oxygenation. Careful
monitoring of blood gases, the response
to oxygen therapy and the levels of
inspired oxygen are vital to help prevent
oxygen toxicity.
The nurse should be particularly
cognizant of naso-gastric tube
placement and its patency because a
malfunctioning naso-gastric tube can
lead to aspiration of gastric contents
resulting in infection and pneumonia.
In addition, a blocked naso-gastric tube
can lead to gastric distention which
contributes to shallow breathing and the
subsequent development of atelectasis. 10
Finally, the basic nursing
measures of regular turning, encouraging
coughing and deep breathing and chest
physiotherapy on a 24-hour basis may
be the most important ingredients in
preventing the development of
atelectasis and pneumonia which
further compromise your patient s
chances in dealing successfully with
ARDS. *
References
1 Meltzer, Lawrence E. et al., eds.
Concepts and practices of intensive care
for nurse specialists. 2d ed. Bowie, Md.:
Charles Press; 1976: p.424.
Shatney, C.H.; Lillehei, R.C.
Pathophysiology and treatment of
circulatory shock. In: Zschoche, Donna
A., ed. Mosby s comprehensive review
of critical care. St. Louis: Mosby;
1976:p.484-512.
3 Cook, W.A. Shock lung: etiology,
prevention, and treatment. Heart Lung.
3(6):933-938; 1974 Nov./Dec.
4 Wade, Jacqueline F. Respiratory
nursing care: physiology and techniques.
2d ed. St. Louis: Mosby; 1977: p.6.
5 Meltzer, op. cit.: p.428-429.
6 Rosen, A.J. Shock lung: fact or
fancy? Surg.Clin.North Amer.
55(3)613-626; 1975 Jun.
*Moore, Francis D. et al.
Post-traumatic pulmonary insufficiency.
Toronto: Saunders; 1969: p.99-124.
8 *Wilson, Robert F., ed. Critical
care medicine: principles and techniques
of critical care. Upjohn; 1976: p. 1-36.
9 Weil, Max H.;DaLuz,P.L., eds.
Manual of critical care medicine. Berlin:
Springer- Verlag; 1978: p.40-41.
10 Gracey, D.R. Adult respiratory
distress syndrome. Heart Lung.
4(2):280-283; 1975 Mar ./Apr.
*Not verified
Frances Bourbonnais, RN, BScN, MN,
is a graduate of the Montreal General
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experience includes several years in
Intensive Care settings.
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CACOLECMA.
54 October 1980
The Canadian Nurse
with your profession. . .
New 2nd Edition!
Patient Care
Standards
By Susan Martin Tucker, R.N.,
B.S.N., P.H.N.; Mary Anne Breeding,
M.N., R.N., B.S.; Mary M. Canobbio,
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"The authors of this book are to be
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Nursing Digest
review of the first
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Each standard in this in-depth
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outlines signs, symptoms, and po
tential complications
covers acute or immediate post
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explains and differentiates between
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reviews patient teaching and
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April, 1980. 576 pages, 168 illustra
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Clinical Manual of
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Obtaining a complete health history
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effective patient care. This
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Highlights:
each chapter covers cognitive objec
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each chapter explores assessment of
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generous illustrations detail
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March, 1980. 486 pages, 487 illustra
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New 3rd Edition!
Understanding
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Almost every chapter in the new
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May, 1980. 302 pages, 411 illustra
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New 5th Edition!
Total Tatient Care:
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behavioral objectives and key words
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April, 1980. 924 pages, 277 illustra
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March, 1980. 168 pages. Price, $8.50.
2nd Edition
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Classified
Advertisements
Alberta
British Columbia
British Columbia
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Registered Nurses required in a 68-bed active
treatment hospital in Northeastern Alberta.
Applicants will be required to assume respon
sibility of a given unit Pediatrics, Emergency,
Obstetrics or Medicine and must be willing to
rotate all shifts. Accommodation for tempor
ary or permanent residence is available in the
Nurse s Residence, Salary and benefits in ac
cordance to the newly negotiated provincial
agreement. Apply in writing to: Director of
Nursing, Lac La Biche General Hospital, Box
507, Lac La Biche, Alberta TOA 2CO.
Graduate & Registered Nurses required imme
diately. Opportunity to acquire experience in
all clinical areas of a 75 bed accredited hospital
(located 130 milesN.E. of Edmonton, Alberta).
(Time off in lieu of vacation negotiable). Sal
ary and fringe benefits in agreement with
U.N.A. ($146S-$1867). Contact: Director of
Nursing, St. Therese Hospital, Box 880, St.
Paul, Alberta TOA 3AO(Phone)403-645-3331.
Required-Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TDK 2GO.
British Columbia
Experienced General Duty Graduate Nurses re-
qulredforsmallhospitallocated N.E. Vancouver
Island. Maternity experience preferred. Person
nel policies according to RNABC contract. Res
idence accommodation available $30 monthly.
Apply in writing to: Director of Nursing, St.
George s Hospital, Box 223, Alert Bay, British
Columbia VON 1AO.
Director of Nursing Ashcroft and District
General Hospital, Ashcroft, British Columbia,
27 acute, 8 extended and 6 long term care
beds invites applications for the position of
Director of Nursing. Must be eligible for re
gistration within the province of British Colum
bia. Advanced education and clinical adminis
tration experience preferred. Hospital is fully
accredited. Please apply with resume and re
ferences to G.P. Holgate, Administrator, Ash
croft and District General Hospital, P.O. Box
488, Ashcroft, British Columbia VOK 1AO.
Telephone (604)453-2211.
General Duty Nurses required for 30 bed ac
credited hospital. Salary according to RNABC
Contract. Apply: Administrator, Chetwynd
General Hospital, Box 507, Chetwynd, British
Columbia VOC 1JO. (604) 788-2236/2568.
General Duty Nurses for modern 41-bed hosp
ital located on the Alaska Highway. Salary and
personnel policies in accordance with RNABC.
Accommodation available in residence. Apply:
Director of Nursing, Fort Nelson General
Hospital, P.O. Box 60, Fort Nelson, British
Columbia VOC IRQ.
General Duty Nurse for modern 3S-bed hospital
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply. Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
General Duty Registered Nurses required for
108-bed accredited hospital in northwest B.C
Previous experience desirable. Salary as per
RNABC Contract with northern allowance.
For further information, please contact: Dir
ector of Nursing, Kitimat General Hospital,
899 LahakasBlvd. N., Kitimat, B.C. V8C 1E7.
Small hospital located in West Kootenay area
of B.C. requires experienced RN for maternity
relief. Begins December 1, 1980-may lead to
permanent position. Apply to Slocan Comm
unity Hospital, Box 129, New Denver, British
Columbia VOG ISO.
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van
couver .Salary and benefitsaccordingto RNABC
Contract-Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to: Personnel Director, Queen sPark
Hospital, 315 McBride Blvd., New Westminster,
British Columbia V3L 5E8.
Royal Columbian Hospital Experienced Nurses
(B.C. Registered) required for this 500-bed
progressive regional referral and teaching hospi
tal located in the Eraser Valley, 20 minutes by
freeway from Vancouver and within easy ac
cess of various recreational facilities. Excellent
orientation and continuing education pro
grammes. Salary - 1980 rates - $1624.00 -
$1889.00 per month. Clinical areas include:
Operating Room, Recovery Room, Intensive
Care, Coronary Care, Neonatal Intensive Care,
Labour and Delivery, Family centred Obstetrics,
Emergency, Renal Dialysis, Psychiatry, Acute
Medicine, Palliative Care, Surgery, Pediatrics,
Rehabilitation and Extended Care. Please apply
in writing to: Employment Manager, 330 East
Columbia Street, New Westminster, British
Columbia V3L 3W7.
Experienced nurse (eligible for B.C. Regist
ration) required for full time position in our
lovely cottage hospital on northern Vancouver
Island. Apply to the: Port McNeill and District
Hospital, P.O. Box 790, Port McNeill, British
Columbia VON 2RO.
General Duty Nurses required by an active 80-
bed acute care and 40-bed extended care hosp
ital located in the Cariboo region of B.C. s
central interior. Year round recreational activ
ities in this fast growing community. Appli
cants eligible for B.C. registration preferred.
Apply in writing to: The Director of Nursing,
G.R. Baker Memorial Hospital, 543 Front
Street, Quesnel, British Columbia V2J 2K7.
General Duty Nurses required immediately for
a ten-bed acute and ambulatory care hospital
located in Stewart, B.C. Stewart has a popula
tion of 2000 and is Canada s northernmost ice-
free port with transportation, mining and con
struction as its primary industries. There are
excellent school facilities. A few of the many
sports offered are boating, fishing and, in the
modern community pool, swimming. Stewart
General Hospital is affiliated with the Prince
Rupert Regional Hospital and nurses are en
couraged to take part in the inservice educa
tion programmes at both hospitals. Salary
rates are according to the RNABC contract
and for a general duty RN the ranges are: May 1,
1980-$1624-$1889 plus $26.87 northern al
lowance. Jan. 1, 1981-$1700-$1965 plus
$28.12 northern allowance. Fringe benefits
include: 20 days paid annual vacation; 5 days
marriage leave; annual educational leave, in
addition to the other usual health care insur
ance and monetary benefits. We are eager to
help you relocate. For further information
please call COLLECT: (604) 624-2171, ask for
Mrs. L. Bremner, Director of Nursing.
General Duty Nurses required for an active,
103-bed hospital. Positions available for experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
O.R. Head Nurse required for an active 103-
bed acute care hospital. Must be eligible for
B.C. Registration. Post graduate training &
experience necessary. R.N.A.B.C. Contract in
effect. Accommodation available. Apply to:
Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British
Columbia V8G 2W7.
The Cancer Control Agency of British Colum
bia is seeking two Chemotherapy Nurse Clini
cians. Master s Degree preparation in nursing is
preferred. Successful applicants for these posi
tions will have demonstrated abilities to carry
a patient case load, work on an interdiscipli
nary oncology team, and teach nurses about
the care of oncology patients and their fami
lies. Teaching responsibilities are in the A.
Maxwell Evans Clinic in Vancouver and
throughout the Province of British Columbia.
These two positions will provide a challenging
opportunity for the advanced practice of nur
sing, as well as experience in teaching and the
implementation of oncology nursing standards.
Interested applicants should phone or write:
Sue Rothwell, Director of Nursing, Cancer
Control Agency of British Columbia, 2656
Heather Street, Vancouver, B.C. V5Z 3J3.
Phone: 604-873-4221.
The Canadian Nurse
October 1980 59
British Columbia
Saskatchewan
United States
Registered Nurses Full-time and casual relief
positions are available at the University of
British Columbia, Health Sciences Centre, Ex
tended Care Unit. The 12 hour shift, the pro
blem oriented record charting system, an em
phasis on maintaining a normal and reality bas
ed clinical environment and an interprofession
al approach to management are some of the
features offered by the Extended Care Unit.
Interested applicants may enquire by calling
228-7025 or 228-7000. Positions are open to
both male and female applicants.
Manitoba
Registered nurses required for a fully accredi
ted 100-bed general hospital and a 72-bed per
sonal care home located in northen Manitoba.
Must be eligible for registration in Manitoba.
Salary dependent on experience and education.
For further information contact: Mrs. Mona
Seguin, Personnel Director, St. Anthony s
General Hospital, The Pas Health Complex Inc.,
P.O. Box 240, The Pas, Manitoba R9A lK4;or
phone collect to: 1-204-623-6431, Ext. 179.
Northwest Territories
The Stanton Yellowknife Hospital, a 72-bed
accredited, acute care hospital requires register
ed nursestowork in medical, surgical, pediatric,
obstetrical or operating room areas. Excellent
orientation and inservice education. Some fur
nished accommodation available. Apply: Assist
ant Administrator-Nursing, Stanton Yellow-
knife Hospital, Box 10, Yellowknife, N.W.T.,
X1A2N1.
Ontario
Psychiatric Nurses Saskatchewan Health, Psy
chiatric Services Branch, Psychiatric Centre in
Prince Albert, and the Saskatchewan Hospital
North Battleford, in North Battleford, require
graduates from approved School of Psychiatric
or General Nursing. Both centres are adjacent
to Saskatchewan s finest outdoor recreational
areas. Excellent benefits and an opportunity to
experience career and personal growth through
in-service education and on-the-job training
exist. Incumbents will provide specialized psy
chiatric nursingcare, procedures and treatment,
and have supervisory responsibility over junior
staff and aides. Applicants must be eligible for
registration as Nurses in Saskatchewan. Loca
tion preference should be specified. Salary:
$17,088-$19,644 (Nurse 1), $ 17,664-$20,352
(Senior Nurse 1). Salaries commensurate with
experience and qualifications. Competition:
604100-0-745 (Prince Albert) 3 positions.
Competition: 604111-0-783 (North Battle-
ford) 18 positions. Closing: As soon as possi
ble. Forward your application forms and/or
resumes to the Saskatchewan Public Service
Commission, 3211 Albert Street, Regina,
S4S 5W6, quoting position, department and
competition number.
United States
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 White is a 377-bed acute
care teaching medical centerwith an openinvita-
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to develop
and continue your professional growth. We
will pay your one-way transportation, offerfree
meals for one month and all lodging for three
months in our nurses residence and provide
your work visa. Callcollect or write : Ken Hoover,
Assistant Personnel Director, 1720 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
RN S-Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
Registered Nurses Virginia, USA-The Medical
College of VA Hospitals is a 1058 bed, full ser
vice, referral, and research University hospital
comprised of 50 specialty units within the nur
sing department; including Oncology, Medi
cine, Surgery, OB/GYN, Pediatrics, Critical
Care, OR/RR and Outpatients. You may spe
cialize in nursing and continue education
through in-service workshops or pursue B.S.N.
or M.S.N. (100 percent tuition reimbursement
for 12 credits/year) in our school of nursing.
We offer competitive salaries and fringe bene
fits. Personal interviews will be arranged. To
learn more call collect 804-786-0918 or write
to Wanda Barth, MCV Hospitals, Box 7, Rich
mond, VA 23298. An Equal Opportunity
Employer.
Catholic Relief Services seeks medical person
nel for Health Center in Hodeidah, Yemen
Arab Republic. Openings include specialized
nurse clinicians: Dir/Nursing, administration,
supply, ER, supervision, Peds, OB-GYN, ENT,
Med-Surg, burns, outpatient; also midwife,
medical records, educator, accounting/book
keeping, secretarial, office manager, language
teacher. Support includes housing, neg. living
stipend, generous leave. All positions volun
teer. Contact: CRS-Region I, 1011 1st Ave.,
NYC 10022, 212/838-4700.
Miscellaneous
Looking For A Temporary Change? Do you
want to keep your job but feel the need for
some renewing experience . International reg
istry for nurses interested in a temporary job
exchange under organization. Write: Nursing
Job Exchange, Box 1502, Kingston, Ontario
K7L 5C7.
Registered Nurses required. Hospitals located
on James Bay at Attawapiskat and Fort Albany.
Good salary scale plus Northern Allowance.
Accommodations provided. Enjoy a Northern
Experience. For further information, contact:
The Administrator, James Bay General Hosp
ital, P. O. Box 370, Moosonee, Ontario POL
1YO.
RN or RNA 5 6" or over and strong, without
dependents. Non-smoker for 180 Ib. handi
capped retired executive with stroke. Able to
transfer patient to wheelchair. Live in 1/2 year
in Toronto, 1/2 year in Miami. Wages $250.00
to $325.00 weekly net plus $100.00 weekly
bonus on most weeks in Miami. Free room and
board. Write M.D.C. 3532 Eglinton Ave. West,
Toronto, Ontario M6M 1V6.
Saskatchewan
General Duty R.N. s required immediately
for a 20 bed Rural Hospital located near pro
vincial park. New hospital, modern equipment,
all areas of nursing done, surgery, obstetrics,
pediatrics, emergency and general medicine.
Modern community, bus services, paved streets,
etc. Wages and fringe benefits as per 1980
S.U.N. provincial agreement. For further infor
mation please contact: Administrator, Porcu-
pine-Carragana Union Hospital, Box 70,
Porcupine Plain, Saskatchewan SOE 1HO. Phone
(Bus) 278-2233 or 278-2211 (Res) 278-2450.
RN/Staff &. Management Positions-Kaiser-Per-
manente, the country s largest Health Mainten
ance Organization, currently has excellent
opportunities available in our 583-bed Los
Angeles Medical Center. Located 7 miles from
downtown Los Angeles, close to many of Calif
ornia s finest Universities, this teaching hosp
ital offers RN s a unique chance to further
their careers in such areas as: OR, Med/Surg,
Maternal Child Health & Critical Care. Manage
ment positions are also available. Kaiser offers
an attractive array of fringe benefits including
relocation assistance, full medical, dental &
health coverage, continuing education advanc
ed training available in the Nurse Practitioner
& CRNA Programs, individualized orientation,
tuition reimbursement, and no rotating shifts.
New graduates are always welcome and encour
aged to inquire. For more information, please
write or call collect: Ann Marcus, RN, Kaiser
Hospital/Sunset, 4867 Sunset Blvd., L.A.,
California 90027. (213) 667-8374.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92503. Write or call collect 714-688-2211
Extension 217. Betty Van Aernam, Director
of Nursing.
Enterostomal therapy education program.
Eight-week program for registered nurses off
ered several times annually. Specialized care
of adults and children with abdominal stomas,
with draining wounds, related skin problems,
and decubitus ulcers. Contact: Program Direc
tor, Enterostomal Therapy Education, The
University of Kansas School of Nursing, 39th
and Rainbow Boulevard, Kansas City, Kansas
66103.
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario M5E
U3. Phone: 416-863-0799. Telex: 06-219621.
Aloe-Vera Positions now available for per
sons interested in skin care who wish to retail
natural aloe skin care products. Contact Ms. C.
Crowe-Sturino, 15 Stonehouse Cres., Toronto
or call (416) 534-2925.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the US A.
B) Extensive information regarding
Hospital 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 1 133 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
60 October 1980
The Canadian Nurse
General Hospital
St. John s, Newfoundland
A completely modern teaching hospital requires
an Operating Room Manager.
This 500-bed General Hospital is the major
teaching facility for the Medical School of
Memorial University of Newfoundland.
Services offered:
Critical Care (Medical-Surgical), Coronary Care,
General Surgery, Urology, Gynecology,
Psychiatry, Medicine, Nephrology, Clinical
Teaching, Neurosciences, Cardiology, Cardio
vascular Surgery, Orthopedics, Hemodialysis
(Kidney Transplants), Emergency and Out-
Patient Services, Active Rehabilitation
Program (Adult).
The Staff Development and Training Department
offers ongoing lectures and demonstrations in
addition to a 6 month diploma course (twice
yearly) in-Critical Care Nursing, Neurosciences,
Operating Room Nursing.
Located in St. John s, Newfoundland - the oldest
city in North America with a population of
120,000, offering cultural and recreation activities
in a friendly atmosphere.
Fishing, hunting, boating available approximately
10-14 miles outside the city.
For information regarding salary and other
conditions of employment write or call:
Director of Nursing
General Hospital
Prince Philip Drive
St. John s, Newfoundland
A1B3V6
Telephone No.: (709) 737-6307
, v *^-^ii^^^*
with Canada^ Medical Services
When you, as a qualified nurse, join Canada s
Medical Services, the door opens to unique oppor
tunities for a nursing career.
Our job is to provide health care to the native people
in the provinces and territories of Canada. We
operate hospitals, outpost nursing stations, health
centres, major clinics, occupational health units
and other stations of various types from coast to
coast. In the course of your career with us you can
move through many of these nursing posts and
advance from staff to senior positions, as you attain
the required qualifications and demonstrate your
ability.
You may sometimes be located in remote areas
where self-reliance and good judgment are needed
with the nearest physician atelephonecall away.
But you always have the support of senior nursing
and medical personnel, both "on call" and on
"routine visits".
In addition to yoursalary, therearespecial allow
ances and benefits such as travel expenses,
overtime compensation, isolation post allowances,
superannuation and holidays, plus the opportunity
to see distant parts of Canada.
When you join ourteamyoucan be sure that you will
be providing a very important professional service
that fills a vital need for those you help. If you
would like further information, mail coupon below.
Nursing Advisor
Human Resource Planning
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1AOL3
NAME.
ADDRESS
CITY
PROV .
._CODE_
Health and Welfare Sante et Bien-etre social
Canada Canada
Canad a
The Canadian Nurse
October 1980 61
Immediate openings for qualified
RN s on all shifts, full time, part
time. 203 bed JCAH accredited
acute care hospital, adjacent to
Oregon Institute of Technology,
offering a 2 + 2 AD/BSN program.
We are located in Southern
Oregon. Excellent year round
outdoor activities. Family
oriented community. Excellent
working conditions and benefits.
Competitive salary with oppor
tunity for advancement. Contact
Personnel Department, MERLE
WEST MEDICAL CENTER, 2865
Daggett St., Klamath Falls, OR
97601, or call COLLECT (503)
882-631 1, Ext. 131. We are an
equal opportunity employer.
The Izaak Walton Killam
Hospital For Children
Staff Nurses
The I.W.K. Hospital for Children has
vacancies for Staff Nurses on our
Intensive Care Unit and Neo-Natal Unit.
Must be a graduate from an accredited
School of Nursing and be eligible for
registration in Nova Scotia. Previous
pediatric experience would be an asset.
Inquiries and applications should be
directed to:
Karen Lyle
Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Registered Nurses are required for an 87
bed accredited Hospital in Northern
Ontario.
Applicants must be eligible for
Registration with the College of Nurses
ofOntario.
Bilingualism is an asset.
Salary and Fringe Benefits in accordance
withO.N.A. Contract.
Temporary residence accommodation is
available.
Please apply in writing to:
Director of Nursing
Sensenbrenner Hospital
10 Drury Street
Kapuskasing, Ontario
P5N1K9
I unihilK Hospital
C algari . AlhiTta
OtTeri the
I i\i Month Post
f ,, .iiin.iM Courses
Advanced Neurological
& Neurosurgicai Nursing
This course serves as an extension of basic
knowledge of neurological problems gained in
an under graduate program. Instruction
proceeds from normal to abnormal.
Opportunities are provided to study and care
for persons of all ages who have had an
interruption in neurological function.
Advanced Neonatal Nursing
This course allows the nurse to gain knowledge
and expertise in the Intensive Care Nursery
setting. An overview of life as well as
experience in related settings are also
included.
Applications must he completed three months
prior to the enrollment date*, of March and
September.
Kducational Services
Depart ment of Nursini;
Koflthills Hospital
140. - 29th SI. V \\.
(algarv. Alberta I2N21<>
Obstetrical Supervisor
400 bed District Hospital in beautiful
Georgian Bay area invites applicants
from experienced Registered Nurses,
with specialization in Obstetrics, for
challenging opportunity in a referral
District Hospital having approximately
650 deliveries per year.
Present hospital is now in the planning
stages for a totally new facility by 1985.
Obstetrical Department includes a Neo-
Natal Intensive Care Unit.
Qualifications: Eligible for current
Ontario Registration, post RN Obstetrical
preparation and experience, BScN or
equivalent an asset, leadership skills, an
interest in a challenging opportunity.
All inquiries are welcome. Contact:
Executive Director of Nursing
Owen Sound General & Marine Hospital
1201 6th Avenue West
Owen Sound, Ontario N4K 5H3
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
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 Canadian Regist
ration. Preceptorship from a medical
practioner. At least one year of work
experience, preferably in primary care.
For further information write to:
Joan Eagle, Director
Educational Program for Nurses
in Primary Care
Faculty of Health Sciences
McMaster University
Hamilton, Ontario L8S 4J9
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
ICU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
ittSj
Prince George
Regional Hospital
Positions available for experienced nurses
or nurses interested in developing their
skills in specialty nursing Operating
Room, ICU/CCU, Neonatology Nursing.
Must be eligible for B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and
Obstetrical Suite
10 bed ICU/CCU
Prince George Regional Hospital is a
340 bed acute regional referral hospital
with a 75 bed extended care unit and has
a planned program of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000- 15th Avenue
Prince George, British Columbia
V2M 1S2
Director of Nursing
Southern Alberta Cancer Centre
Calgary, Alberta
The Southern Alberta Cancer Centre
invites applications for this new Senior
Management position for its expanding
Cancer Control Programs. The Centre
is affiliated with the University of
Calgary and will be relocating to new
facilities adjacent to a major Calgary
teaching hospital in mid 1981.
Candidates will have senior nursing
management experience, effective
leadership and communication abilities
and experience in the field on oncology
nursing. A Bachelors Degree in Nursing
is required and a Masters Degree
preferred.
Please direct resumes in confidence to:
Director
Southern Alberta Cancer Centre
2104 - 2nd Street S.W.
Calgary, Alberta T2S 1S5
Oetnh*r1!Mfl
The Canadian Nurse
Registered Nurses
Are you looking
for a challenge in your career?
Would you enjoy
living in Vancouver?
a salary range of $1,624.00-1,784.00 per month?
4 weeks vacation, and 1007o medical-dental
premiums?
1 week orientation or longer for specialty areas?
If so read on!...
Shaughnessy Hospital is a major community and
teaching facility treating the adult patient in an
acute and long term care setting.
We have full-time, part-time and on-call general
duty positions available in Medicine, Surgery
and Spinal Cord Injury Unit.
- Experienced Critical Care Nurses are required
for our Surgical and Medical Intensive Care
Units and the Critical Care Nursing Pool.
Head Nurse
We are seeking a Head Nurse for our Medical
Intensive Care Unit and Cardiac/Respirology Ward.
This position offers a challenge .... the opportunity
to be responsible for the management of this 32
bed area.
Clinical expertise in medical and critical care
nursing plus previous administrative experience is
essential.
Applicants must be eligible for registration in
British Columbia.
Salary: $1,868.00- $2,052.00 per month.
Please phone or write, detailing your qualifications
and experience to:
Jane Mann
Nursing Recruiter
Employee Relations
Shaughnessy Hospital
4500 Oak Street
Vancouver, B.C. V6H 3N1
(604) 876 - 6767, local 430
SHAUGHNESSY HOSPITAL
4500 Oak Street
Vancouver, B.C. V6H 3N1
OPPORTUNITY
Community Mental Health Nurse -
Athabasca/Slave Lake Area
Athabasca and Slave Lake are thriving farming communities
located 100 to 150 miles north of Edmonton. We require a nurse
to provide assessment, treatment and followup as a primary
therapist to these communities. Other duties include provision of
services to the communities, liaison and consultation with
agencies.
Qualifications: Graduation from an approved school of nursing,
eligible for nursing registration in Alberta and some related
experience. Must have valid Alberta Driver s license and own
transportation. Mileage costs will be reimbursed.
Salary: $14,748 to $17,340 (currently under review).
Competition No. 9184-5 Open until suitable candidate selected.
Alberta Social Services & Community Health
For detailed information, request Job Bulletins and apply to:
Alberta Government Employment Office
5th Floor, Melton Building
10310 Jasper Avenue
Edmonton, Alberta
T5J 2W4
Newfoundland
Public Service
Regional Public Health Nursing Director
(Public Health Nursing Supervisor II).
Western Regional Public Health Services Division, Department of
Health, Corner Brook.
Duties: Directs a comprehensive public health nursing
programme for the western region of the province; recruits, and
evaluates nursing and supervisory staff; provides public health
education services to the general public and participates in the
implementation of regional health programmes.
Qualifications: Considerable experience in public health nursing
including some supervisory and administrative experience;
graduation from university with a Bachelor of Nursing
supplemented by post graduate courses in nursing administration;
or any equivalent combination of experience and training.
Competition number: H.PHNSII.14
Applications may be submitted in confidence to:
Public Service Commission
16 Forest Road
St. John s, Newfoundland
A1C 2B9
This competition is open to both men and women.
The Canadian Nurse
October 1980 63
The International Grenfell Association
requires
Regional Nurses
on permanent or short-term basis to
work in community health centres and
nursing stations.
Beginning salary $ 15 , 1 24 .00 per annum ,
with steps for education and experience.
Room and board $126.00 per month.
Travel arranged and paid for by Grenfell
Association in return for one year s
service. Apply to:
Mr. Scott Smith
Personnel Director
International Grenfell Association
St. Anthony, Newfoundland
AOK 4SO
Royal Jubilee Hospital
Victoria, B.C.
Applicationsareinvited from Register
ed Nurses or those eligible for B.C.
Registration with recent nursing ex
perience.
Positions are available in all services
of this 950 bed accredited hospital
which includes Acute and Specialty
Care, Obstetrics and Paediatrics,
Psychiatry and Extended Care for
Full Time, Part Time and Casual
Employment.
Benefits in accordance with
R.N.A.B.C. contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Nursing Coordinator
Nursing Coordinator required to
assume leadership role in an O.R./
P.A.R. and expanding Emergency/
Day Care suite presently under
construction.
The applicant must have demon
strated leadership and administrative
skills, post grad in O.R. and past
experience as a Head Nurse or
Supervisor. Must be eligible for B.C.
Registration.
Cranbrook and District Hospital is
a 130-bed hospital in the East
Kootenays with many winter and
summer recreational facilities.
Qualified applicants apply in
writing to:
Mrs. P.N. Janzen
Director of Patient Care
Cranbrook and District Hospital
13-24th Ave. N.
Cranbrook, British Columbia
VIC 3H9
Vancouver General Hospital
Nurse Clinician Orthopaedics
The primary responsibilities of the above
position would be to assist the
orientation program for new employees
and to participate in the on-going
education of nursing staff on the
Orthopaedic Division. Under the
direction of the Clinical Director, the
incumbent is responsible for the review,
development, and maintenance of
nursing practice and standard of care.
Applicants must be a registered nurse
with a BSN or equivalent preparation,
extensive experience in the particular
field of nursing plus demonstrated skill
in leadership and interpersonal relation.
Please submit resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 W. 12th Avenue
Vancouver, B.C.
V5Z 1M9
Canadian Association of
University Schools of Nursing
Applications are invited for a part-
time appointment as Executive-
Secretary, Canadian Association of
University Schools of Nursing, with
headquarters in Ottawa.
Appointment: October 1, 1980.
Master s degree, working knowledge
of English and French and
knowledge of university nursing
education are essential qualifica
tions; experience with a national
organization is desirable.
Interested applicants may apply,
with a resume and names of 3 - 4
references, to:
Dr. Dorothy J. Kergin, R.N., Ph.D.
President
Canadian Association of
University Schools of Nursing
c/o School of Nursing
University of Victoria
P.O.Box 1700
Victoria, British Columbia
V8W 2Y2
Registered Nurses
Applications are invited for full time and
part time employment at Oshawa
General Hospital, a 600 bed hospital, 48
kms. East ofToronto.
Successful candidates must be registered
in Ontario.
Services provided include:
Medicine Paediatrics
Surgery Intensive Care
Obstetrics Coronary Care
Emergency Out-Patients
Chronic/Rehabilitation
Salary Range: (Full time) $1,450.00-
$1,676. 00 (monthly)
Inquiries may be directed to:
Personnel Services
Oshawa General Hospital
24 Alma Street
Oshawa, Ontario
L1G2B9
Advertising
rates
For All
Classified Advertising
$20.00 for 6 lines or less
$3.00 for each additional line
Rates for display advertisements
on request.
Closing date for copy and
cancellation is 8 weeks prior to
1 st day of publication month .
The Canadian N urses
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
K2P 1E2
C4 October 19*0
The Canadian Nurse
Open to both
men and women
NURSES
Solicitor General of Canada
Salary: Up to $23,367 (under review)
Ref. No: 80-NCRSO-NU-15
CLEARANCE NUMBER: 310-106-022
The Correctional Service of Canada will have positions
available at various locations across Canada over the next
12 months in Federal Correctional Institutions and special
psychiatric hospitals.
Salaries: Up to $23,367 (under review) - dependent on
qualifications, assignment, and location - plus
penological factor allowance of up to $1 ,000 per
annum, (under review)
Opportunities
Correctional health care and forensic psychiatry provide
new and expanding career opportunities for nursing
professionals. These unique, challenging areas demand men
and women with proficient nursing skills, special personal
qualities, and a pioneering spirit.
Responsibilities
In the Health Care Centres (HCCs), the nurses are the
inmates first contact with health care professionals. Each
nurse must be independent, resourceful and prepared to
operate in an expanded nursing role. In the Regional Psychia
tric Centres (RPCs), the treatment philosophy emphasizes
a multi-disciplinary approach encompassing all aspects of
psychiatry. The primary therapist in each of these
university-affiliated hospitals is frequently the nurse.
Duties
Assist in the development of medical and psychiatric
programmes for inmates in either health care centres or
regional psychiatric centres and provide nursing care to
patients on a 24 hour basis.
Benefits
Excellent pension plan; good sick leave benefits; evening,
night and weekend premiums; 1 1 statutory holidays; and a
minimum three weeks holiday ; continuing education oppor
tunities and relocation expenses.
Qualifications
- Registered Nursing diploma for HCCs and RPCs
- Registered Psychiatric Nursing diploma for RPCs
- Registered/Certified/Licensed Nursing Assistant diploma
for RPCs
- Baccalaureat degree in Nursing an asset for HCCs and
RPCs
- Recent general nursing experience required for HCCs
- Recent psychiatric nursing experience required for RPCs
- Administrative and supervisory experience required for
managerial positions in HCCs and RPCs
Language Requirements
For some positions knowledge of both English and French
is essential. Because of the nature of these positions
bilingual capacity is required immediately. Other positions
require a knowledge of English, others a knowledge of
French while others require a knowledge of English and
French. Unilingual persons may apply for bilingual posi
tions but must indicate their willingness to become
bilingual. The Public Service Commission will assess the
likely aptitude of candidates to become bilingual. Language
training will be provided at public expense.
"Additional job information is available by writing to the
address below;
Toute information relative a ce concours est disponible en
franfais et peut etre obtenue en ecrivant a I adresse
suivante".
For further information call (collect) or write:
Director, Nursing Operations
340 Laurier Avenue West
Ottawa, Ontario K1 A OP9
Tel.: (613) 995-4971
How to apply
Send your application form and/or resume to:
Mrs. Joyce Bleakney
Public Service Commission of Canada
National Capital Region Staffing Office
L Esplanade Laurier, West Tower, 16th floor
Ottawa, Ontario K1AOM7
Closing Date: March 31, 1981
Please quote the applicable reference number at all times.
The Canadian Nurse
October 1980 65
Registered Nurses
Opportunities exist in the following areas of a large
teaching hospital:
Specialty Intensive Care
General Care Areas
Labour and Delivery
Operating Room
Successful candidates must be eligible for registration in
Ontario and have had recent related clinical experience
If interested, please write:
Personnel Department
Toronto General Hospital
101 College Street
Toronto, Ontario
M5G 1L7
1829-1979
TORONTO
GENERAL
HOSPITAL
Registered Nurses
Career Development Opportunities in
Vancouver.
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 major medical centre on Canada s
unconventional West Coast.
Positions For:
General Duty Nurses
Nurse Clinicians
Nurse Educators
at salaries? 1980 rates under negotiation.
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 and Neurosurgical)
Inservice Education
Cardiothoracic Surgery
Coronary Unit
Burn Unit
Hyperalimentation Programme
Paediatrics
Renal Dialysis and Transplantation
Operating Room
If you are a Registered Nurse considering a move, please
send resume to:
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, B.C.
V5Z 1M9
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics, orthopaedics,
obstetrics, psychiatry, rehabilitation and
extended care including.
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education
Programs. Post Graduate Clinical Courses in
Cardiovascular-Intensive Care Nursing and
Operating Room Nursing.
Apply to.
Recruitment Officer - Nursing
University of Alberta Hospital
8440- 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
o
66 October 19*0
The Canadian Nurse
The Battlefords Indian Health Centre is run by and for Indian
people in the North Battleford District. It provides a wide range
of primary care and preventive programs. We are seeking
applications for the following positions.
1 . Community Health Nurse
Duties: To assist the Indian people in the development of
operation of a combined primary care and community health
program.
Candidates should be eligible for registration in Saskatchewan
and have some experience or special training in Community
Health.
Previous working experience with Indian people is desirable.
2. Health Careers Coordinator
Duties: To conduct research into different health professions,
educational background required for these professions, and to
develop training programs in conjunction with recognized
educational institutions; To act as liaison with funding agencies,
Band Councils, and to provide career counselling to potential
students. Qualifications: Completion of grade XII. Previous
experience in working with Indian people is desirable. Ability to
initiate and maintain working relationships with funding agencies
and with training institutions.
3. Dental Nurse
Duties: To assist in providing a comprehensive dental treatment
program for the Indian people in the surrounding reserves. To
assist in the planning, development, and presentation of
preventive programs.
Candidates should be graduates of a recognized Dental Nursing
or Dental Therapy Program. Ability to work independently and
as a team member. Previous experience in working with Indian
people is desirable. Must have a valid drivers license.
Apply in writing to:
The Executive Director
Battlefords Indian Health Centre, Inc.
Box 250
North Battleford, Saskatchewan
S9A2Y1
Reactions to Living/Responses to Dying
"Cancer as a Model"
Calgary Convention Centre
Calgary, Alberta, Canada
January 28, 29.30, 1981
A three day symposium focusing on the psychosocial impact of
Cancer on patients, families and care givers.
Share With
Mr. Roy Bonnisteel of CBC TV s "Man Alive"
Dr. Gail Hongladarom, Seattle, Washington
Dr. Neil MacDonald, Montreal, Quebec
Dr. Melvin Krant, Worchester, Massachusetts
Dr. William Lamers, Marin County, California
Dr. Mary Vachon, Toronto, Ontario
the topics of:
Survivorship, Care For The Care Givers,
Impact Of Threatened Loss Of Family,
Selection Of Care Givers And Models Of Care.
Registration Fee:
$175 prior to Dec. 1, 1980
$200 thereafter
For information write:
Symposium 81
Foothills Hospital
1403 - 29th Street N.W.
Calgary, Alberta, Canada
T2N 2T9
(403)270-1642
Interested In
Paediatric Nursing ?
Toronto, Canada
The Hospital For Sick Children invites applications for all
units from experienced nurses interested in working in a
paediatric tertiary care setting.
We are a fully accredited 700 bed paediatric teaching
hospital affiliated with the University of Toronto located in the
thriving environment of downtown TORONTO. A thorough
orientation and a variety of continuing education programs is
provided. The majority of units operate on a 1 2 hour shift
basis, which normally allows every other weekend off A
comprehensive employee benefit package, including a
Dental Ran is offered.
Our philosophy is Family Centred Care.
Qualifications:
Current registration with the Ontario College of Nurses
or eligibility for registration.
Recent related experience in an active treatment
setting preferred.
Paediatric experience would be considered a definite
asset.
Applicants are invited to contact.
Dorothy Franchi,
Personnel Co-ordinator,
The Hospital for Sick Children,
555 University Avenue,
Toronto, Ontario, Canada M5G 1X8,
(416) 597-1500 ext. 1675.
The Hospital
for Sick Chik
ildren
Th Canadian Nurse
October 1980 67
Input (continued from page 6)
Nursing s lifeline?
"I m bored. I m not
stimulated. If only there was
something else I could do."
These are some of the com
ments and complaints that
I ve heard and thought so
many times. But recently
they ve become more frequent
and nurses are now leaving
the profession to enter other
fields.
Why? What is happening
in nursing today that is causing
members so much discontent?
Shift work, increasing work
loads, increasing demands of
administration and doctors
and supply shortages are
common complaints. How
ever, a larger issue has sur
faced: continuing education.
The lack of opportunity to
pursue continuing education
and the lack of employers
who encourage or support
those who desire to continue
their nursing education, are
posing a genuine threat to the
growth of the profession.
At present, inservice
education is not functioning
properly. If such a program is
available in a hospital, it is
often scheduled during the
busiest day or hour on the
nursing unit. After-work
classes, impromptu classes or
nursing rounds during quiet
times would be more appro
priate.
Better use should be
made of workshops and con
ferences. Often staff nurses
requests for professional con
ference leave are either refused
or granted without pay, and
expenses come from the
nurses own pocket.
University or college
courses are not actively en
couraged. For the most part,
the hospital employer offers
little or no financial assis
tance and makes no provision
in a work rotation for interes
ted nurses to attend courses.
Then, after a nurse has paid
to take a course and juggled
her rotation in order to attend
classes, she is not given a sal
ary increment or encouraged
to relate information to her
peers.
School of nursing alum
nae associations should offer
scholarships or other financial
assistance to members wishing
to further their education.
Increasing technology
in the hospital setting and
advances in care and treatment
make continuing education a
must for nurses to adequately
care for their patients. They
need accessible, ongoing in-
service programs, workshops,
conferences and courses to
maintain their level of compe
tence. If these needs are not
met, will nursing become a
profession of bored, frustra
ted people?
-Tena McLellan, RN, Ottawa,
Ontario.
Time to play our
trump card
Lately I am becoming
more and more aware of
nursing apathy. Needless to
say, it appalls me! I pride my
self in my profession and feel
we should and can as nurses,
evolve to greater professional
heights.
When I graduated from
nurses training, I was really
keen. I wanted to get out there
and "practice". Sifting
through all my experiences, I
began to form my concept of
nursing but I became disillu
sioned, disappointed and most
of all discouraged.
Where is nursing head
ing? Many health professions
are clammering to put defini
tions to their craft and conse
quently new disciplines are
emerging. Nursing, a profes
sion that has been around for
centuries, is experiencing
"the squeeze". For example,
nurses used to be responsible
for pre-op and/or post-op
care, including respiratory
functions. Then a specialty
emerged - inhalation thera
py. While this provided opti
mal care, nurses lost the role.
Physicians are also suddenly
discovering "new" techniques
and philosophies which nurses
have been using for years.
They are talking about and
teaching nursing!
We nurses are suppress
ed. Nursing schools are
pushing and promoting new
nursing strengths. Nursing
philosophy is advocating the
expanded role. Soon we are
going to be backed into a
corner. Unfortunately, physi
cians hold the power the
trump card and we are going
to lose.
Why? Perhaps because
we are not a totally together
group. We do not have a defi
nition of role. Do we really
participate in our nursing or
ganizations? Maybe because
we are primarily females we
expect to be passive and play
a back seat role. Or are we
downright lazy? Do we care?
-Lesley Aiton Spevack, RN,
N.D.G., Quebec.
Index to
Advertisers
October 1980
Ayerst Laboratories
The Canada Starch Company Limited
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The Canadian Nurse s Cap Reg d
Career Dress, A Division of
White Sister Uniform Inc.
IFC
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IBC
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54
Facelle Company Limited
17
Hollister Limited
4,8,9
Frank W. Horner Limited
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Johnson & Johnson Limited
14, 15
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J.B. Lippincott Company of Canada Limited
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The C.V. Mosby Company Limited
55,56,57
Nordic Laboratories Inc.
25
Nursing Abstracts Company Inc.
Posey Company
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Procter & Gamble
20, 21
Ross Laboratories, Division of
Abbott Laboratories Limited
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W.B. Saunders Company
19
G.D. Searle & Co. Canada Limited
Victoria General Hospital
58
23
Wellcome Medical Division
Burroughs Wellcome Inc.
70
Advertising Representatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
601, Cote Vertu The Canadian Nurse
St-Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone: (6 13) 237-2 133
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P. O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (2 15) 363-6063
Member of Canadian
Circulations Audit Board Inc.
M October 1980
The Canadian Nurse
You can get
any job you want.
But you don t want just any job.
Freedom.
As an MPPsm nurse, you ll enjoy
more of it than you ve ever
known before.
To begin with, you can choose the
city you work in. Big ones like Toronto.
Or smaller ones like Burlington.
Because MEDICAL PERSONNEL
POOL has offices throughout
the U.S. and Canada. Over 165 of
them. And we re continuing to
expand rapidly.
With MPR you can also choose
the job setting you ll work in. A hos
pital. Nursing home. Private duty.
Home care.
And there s still more freedom.
Freedom to select your assign
ment. A choice of whether you ll
work in 1CCJ, CCCJ, Med/Surg. Obstet
rics, Orthopedics. Wherever
you re qualified.
Finally, you get to decide when
you re going to work. The days, the
hours. From one day to as long as
you like. And all this will give you plenty
of time to devote to the "other you"
who may want to continue with an
education. Or for travel, leisure
or family.
So why take any job you can get
when MPP offers you any job you want?
CN 10
Medical
Personnel
PooL
An International Nursing Service
208 Bloor Street West #304
Toronto, Ontario M5SITB
MEDICAL PERSONNEL POOL
208 Bloor Street West #304, Toronto, Ontario M5SITB
I m interested in MEDICAL PERSONNEL POOL. Please give
me more information about working with you.
Name-
Address-
City
Telephone (Area Code)-
- Province -
. Postal Code-
Please check if you are an: D RN D RNA D Other
Type of work preferred (Hospital, Inhome, Nursing Home, etc.):
Copyright 1980 Personnel Pool of America. Inc.
Registered (IS. Trademark Office
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The kind of advice
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/
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For the obese and/or hypertensive patient, the risk
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when serum cholesterol levels are elevated.
Sensible eating as part of a cholesterol control
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Mazola corn oil is a good start toward sensible
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To order your
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A programmed learning package
on the addictions
Dealing with the disruptive patient
Physiological consequences
of alcohol abuse
The AWS patient in hospital
The
Canadian
Nurse
NOVEMBER 1980
BIBLIOTHEQUE
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DEC ; mo
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The kind of advice
your patient will eat up
For the obese and/or hypertensive patient, the risk
of developing coronary heart disease is increased
when serum cholesterol levels are elevated.
Sensible eating as part of a cholesterol control
programme could be an important factor in the
prevention of coronary heart disease.
Mazola corn oil is a good start toward sensible
eating. 100% pure corn oil contains no cholesterol
Name
and is high in polyunsaturated fats (54%) and
low in saturated fats (14%). Mazola will help /
you help your patients with a booklet /
called HEART SENSE. They will find /
it a valuable source of information /
on how to control cholesterol /
through sensible cooking and x Address-
eating habits. /
City :
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To order your
copies, write to:
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Box 1 29, Station "A"
Montreal, Quebec H3C 1C5
-
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Todays Diabetics.
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Through good control, they re enjoying better health
and a healthier outlook. And Ames is helping.
Today s diabetics have a healthier out
look on life. And it s all because they re in
control of their condition. They watch their
diet Get the exercise and therapy they
need. And keep a check on themselves with
daily urinalysis.
That s where Ames helps out.
Our Diastix*orKeto-Diastix*tell them day
by day where they stand with their condition,
so there s less risk of complications than
ever before. And the cost is just a few
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Our free Daily Diary
helps them keep a record of their
condition, so they can begin to see
"Trademarks of Miles Laboratories, inc. Miles Laboratories, Ltd , authorized user
1979, Miles Laboratories Inc.
how, when and why it changes.
And our free Diabetic Digest offers lots
of useful information that may help them
understand their condition more clearly and
control it more effectively.
The only other thing they need is your
guidance and advice. With that, and a little
help from us, today s diabetics
can enjoy better health
and a healthier outlook.
635362*
Ames
Division
IVIILI
Ames Division, Miles Laboratories, Ltd.,
Rexdale, Ontario M9W 1G6.
We helped make urinalysis
the science it is today.
Editor
Anne Besharah
Assistant Editors
Judith Banning
Jane Bock
Gail O Neill
Production Assistant
GitaDean
Circulation Manager
Pierrette Hotte
Advertising Manager
Gerry Kavanaugh
CNA Executive Director
Helen K. Mussallem
Editorial Advisors
George Bergeron,
communications officer. New
Brunswick Association of
Registered Nurses.
Kate Fulton, RN, Addiction
Research Foundation, Toronto.
Jerry Miller, communications
coordinator, Labor Relations
Division, Registered Nurses
Association of British Columbia.
Beverley Pittfield, RN,
Gravelbourg, Saskatchewan.
Peter Smith, director of
publications, National Gallery of
Canada.
Florita Vialle-Soubranne,
consultant, professional
inspection division, Order of
Nurses of Quebec.
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.
Canadian Nurses Association, 50 The
Driveway, Ottawa. Canada, K2P 1E2.
Drugs and people.. .a
combination as old as
recorded history. It can be
therapeutic. What happens
when it isn t? In this issue, a
look at drug abuse from the
nurse s point of view. Cover
illustration by Gerry Sevier,
courtesy of the Addiction
Research Foundation.
The
Canadian
Nurse
November 1980 Volume 76, Number 10
The official journal of the Canadian Nurses Association ,
published in French and English editions eleven times per
year.
It could happen to you 20
e disruptive patient 26 Alcohol and the body 46
10
YOU AND THE LAW
"Nurse, you did this to me!"
Corinne Sklar
22
A learning program
in the addictions
Arlee D. McGee
14
About the authors
20
It could happen to you!
Gregory Kolesar
23
Dangerous equations
Kathy Chater
26
Dealing with the disruptive patient
Kathy Chater
A Gasoline inhalation:
.Z4 a community challenge
Marie Daubert and Carol MacAdam
Understanding the physiology
of alcohol abuse
Marylou Gaerlan
29
Primary nursing in the addictions
Eileen Fitzpatrick
30
Breaking the cycle of abuse
Gwen Casselman
Names
35
A programmed learning package:
Living and working with drugs
Marylou Gaerlan
AWS: recognition
49 ar) d rehabilitation
Gregory Kolesar Joanne M. Shaw
-jo The drug abusing patient in the E R
Kathy Chater
Addictions Reading List
PERSPECTIVE
18 A health-oriented approach
Gail Paech
19 Use? Or Abuse?
Ian W.D. Henderson, MD
56 Research
69 Input
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
Indexed in International Nursing Index, Cumulative
Index to Nursing Literature, Abstracts of Hospital
Management Studies, Hospital Literature Index,
Hospital Abstracts, Index Medicus, Canadian
Periodical I ndex . The Canadian Nurse is available in
microform from Xerox University Microfilms, Ann
Arbor. Michigan 48106.
Canadian Nurses Association. 1980.
names
Susan French, RN, BN,
M.Sc., P.Ed., has been
appointed associate dean,
Health Sciences (Nursing)
McMaster University.
Formerly a CNF scholar and
recipient of the Dr. Katharine
E. MacLaggan Fellowship,
Professor French has been a
coordinator of the Master of
Health Sciences Programme
at the university and has
helped to review grant
applications for Health and
Welfare Canada.
Margaret Steed, BN Admin.,
MA, has recently been
appointed associate dean of
the Faculty of Nursing,
University of Alberta.
Professor Steed who is also
director, Continuing
Education with the university,
has been active in many areas
of nursing education,
including consultation
services, curriculum, testing
and research.
Dr. Margaret C. Cahoon, a
professor in the faculties of
nursing and medicine at the
University of Toronto, has
been appointed Rosenstadt
Professor in Health Research
in the Faculty of Nursing.
Concurrent with this award is
the establishment of the
Sunnybrook-University of
Toronto Nursing Project,
based at Sunnybrook Medical
Centre, the purpose of which
is to examine and test new
and/or different methods of
nursing through research in
nursing practice.
Karen Mills, RN, BScN,
MHSA, has been appointed
director of nursing of the
Edmonton Local Board of
Health to succeed the retiring
Evelyn Crookshanks. Mills,
previously associate director
of nursing with the board, is
currently president of the
Alberta Public Health
Association, a member of the
board of directors of the
Canadian Public Health
Association, a member of the
Universities Coordinating
Council Committee on
Nursing Education and was a
member of the Canadian
Nurses Association Task
Group on developing
standards for nursing practice.
Students & Graduates
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N. Patricia Barry, RN, BN,
MA, has been appointed
Director of Nursing of the
Hamilton Psychiatric Hospital
in Hamilton, Ont. A graduate
of the Saint John General
Hospital School of Nursing,
Saint John, N.B., McGill
University, Montreal and New
York University, she was a
clinical specialist in mental
health nursing and Assistant
Director of Nursing at
Hamilton Psychiatric Hospital
prior to this appointment.
Ginette Rodger, BScN, MM,
has been elected vice president
of the Board of Directors of
the Canadian Council on
Hospital Accreditation for
the year 1980-81. Presently
Director of Nursing at
1 Hopital Notre-Dame in
Montreal, she will be assuming
the position of executive
director of the CNA,
February 1, 1981.
Lorea A. Ytterberg, RN, BN,
M.Sc., a graduate of St. Paul s
Hospital School of Nursing,
Saskatoon, Sask., McGill
University and the University
of British Columbia, has been
appointed vice-president
(Nursing) for the University
of Alberta Hospitals.
Formerly director of medical
nursing at the Vancouver
General Hospital, she has also
been active as a nursing
instructor and hospital
planner.
The names of this year s
winners of the Judy Hill
Memorial Fund scholarships
have been announced.
Heather Blundell, a graduate
of the British Columbia
Institute of Technology
School of Nursing, has worked
as a staff nurse in Vancouver
hospitals and spent one
summer nursing in Resolute
Bay, NWT. She is currently
enrolled in the Advanced
Practical Obstetrics program,
University of Alberta. Patricia
Gaye Hanson, a graduate of
the University of
Saskatchewan, has worked as
a public health nurse in
northern Saskatchewan. Early
in 1981, she hopes to begin a
midwifery course in Scotland
or Australia and will then be
posted to a northern nursing
station.
Eleven Judy Hill
Memorial Fund scholarships
have now been awarded.
Recipients of the award
include: Teresa Landry from
New Brunswick, studied
midwifery in the UK,
returned to Pangnirtung,
Baffin Island as nurse-in-
charge, then transferred to
Spence Bay, but is now
returning to Pangnirtung.
Beverley Ann Robson of
Melfort, Sask., studied
midwifery at the Simpson
Memorial Hospital in
Edinburgh, returned to work
in Cambridge Bay, NWT and
is presently nursing in
northern Ontario. Jean
Livingstone of Antigonish,
NS, also studied midwifery at
the Simpson Memorial
Hospital, then worked in
Rankin Inlet as charge nurse.
Angela Kucinskas, studied
nursing at St. Bartholomew s
Hospital in London and
midwifery at the Royal
Berkshire Hospital in Reading,
UK, then nursed in Fort
Resolution, NWT. Gail
Maclntyre, of New
Westminster, BC, studied at
the Simpson Memorial
Maternity Pavillion before
returning to nurse at Igloolik
on Baffin Island. She is
presently nursing at the Baker
Lake Nursing Station. Arlene
Drysdale has now completed
a nursing program at
Greenwich and Bexley Health
Authority, England and plans
to begin nursing in the NWT
later this year. Diana Fenwick,
an Australian nurse, studied
midwifery in Sydney, then
nursed with the Flying
Doctor Service in northern
Australia before taking up a
position with Health and
Welfare Canada as a nurse in
Inuvik. She will be moving to
Baffin Island later this year.
Eleanor Nolan, who has had
previous nursing experience
in Ireland, Port Hope,
Simpson and Goose Bay,
Labrador, as well as with the
Flying Doctor Service in
Australia and Frobisher Bay,
NWT, is completing her
midwifery and outpost
nursing studies at Memorial
University in Newfoundland
and then expects to be posted
to a northern nursing station.
Elizabeth Cochrane who studied
midwifery at the Aberdeen
Maternity Hospital in Scotland,
hopes to complete her studies in
community health nursing at
Memorial University before
finalizing her plans for outpost
nursing.
R Mr 1980
The Canadian
You can get
any job you want.
But you don t want just any job.
Freedom.
As an MPPim nurse, you II enjoy
more of it than you ve ever
known before.
To begin with, you can choose the
city you work in. Big ones like Toronto.
Or smaller ones like Burlington.
Because MEDICAL PERSONNEL
POOL S has offices throughout
the U.S. and Canada. Over 165 of
them. And we re continuing to
expand rapidly.
With MPP you can also choose
the job setting you ll work in. A hos
pital. Nursing home. Private duty.
Home care.
And there s still more freedom.
Freedom to select your assign
ment. A choice of whether you ll
work in ICC1, OCtl, Med/Surg. Obstet
rics, Orthopedics. Wherever
you re qualified.
Finally, you get to decide when
you re going to work. The days, the
hours. From one day to as long as
you like. And all this will give you plenty
of time to devote to the "other you"
who may want to continue with an
education. Or for travel, leisure
or family.
So why take any job you can get
when MPP offers you any job you want?
CM-ll
Medical
Personnel
PooL
An Internationa] Nursing Service
208 Bloor Street West #304
Toronto, Ontario M5S 1T8
MEDICAL PERSONNEL POOL
208 Bloor Street West #304, Toronto. Ontario M5S ITS
I m interested in MEDICAL PERSONNEL POOL S , Please give
me more information about working with you.
Name
Address -
City
Telephone (Area Code)-
- Province -
-Postal Code -
Please check if you are an: D RN D RNA D Other
Type of work preferred (Hospital, Inhome, Nursing Home, etc.):
Preferred Specialty (for which you are qualified):
i; Copyright 1980 Personnel Pool of America. Inc.
Registered U.S. Trademark Office
Serving the Health Professions in Canada Since 1897 Serving the Health Professions in Canada Since 1897 Serving the Health Professions in Canada Since It
1980
1 THE PROCESS OF HUMAN
DEVELOPMENT: A Holistic
Approach
By Clara Shaw Schuster, R.N., M.Ed.; and
Shirley Smith Ashburn, R.N., M.S.
This comprehensive new text of
human growth and development covers
the entire life span, from conception to
senescence. The book is divided into
twelve parts, each representing a separate
phase of development. The four major
domains - biophysical, cognitive, affec
tive, and social are covered separately
within each unit. Specific situational
and maturational crises such as language
development, discipline, sexuality, and
death receive in-depth consideration at
the most critical developmental phase. A
separate unit on the family and thorough
treatment of normal physical develop
ment throughout the life cycle differen
tiate this book from the traditional hu
man development texts and enhance its
applicability to today s nursing curri
culum.
Little, Brown. 960 Pages.
Illustrated. 1980. $23.95
1980
2 NURSES RESPONSES TO
PATIENTS SUFFERING
By Joel R. Davitz, Ph.D.; and Lois A.
Davitz, Ph.D.
This is the concise, easily readable
version of the authors comprehensive
research report, focusing on the factors
that influence the varied reactions of
nurses to the pain and psychological
distress of different patients. The authors
clearly show how nurses are affected by
their patients age, sex, socioeconomic
class, ethnic and religious backgrounds
and also by their own background charac
teristics. Many examples illustrate how
nurses perceptions and beliefs affect
their behavior with patients.
Springer. 160 Pages. 1980. $15.50
Timely concepts
Dependable texts and references
Keep up to date with books ******
on current practice
1980
3 MATERNITY NURSING,
14th Edition
By Sharon R. Reeder, R.N., Ph.D.; et. al.
Featuring expanded coverage of the
numerous facets of maternity, neonatal
and perinatal nursing care with emphasis
on assessment and management through
out the antepartal, intrapartal and post-
partal periods the new 14th edition of
this highly regarded text begins with a
philosophy of family centered care and
an exploration of culture, society, mater
nal care and the family in a changing
world. It then progresses through units
on the biophysical aspects of human
reproduction, reproduction control and
sexuality, antepartal, intrapartal and post-
partal assessment and management, ma
ternal disorders related to pregnancy and
labor, and problems of the high risk
neonate.
Lippincott. 775 Pages.
Illustrated. 1980. $23.95
O 1980
4 OPHTHALMOLOGIC
NURSING
By Joan F. Smith, R.N., Ph.D.; and
Delbert P. Nachazel, Jr., M.D.
A thorough, systematic look at the
eye: its component parts, its potential
disorders, and the nurse s role in every
situation of its care. The book begins
with separate chapters on each anatomi
cal sector of the eye region that scruti
nize anatomy, histology, and physio
logy, introduce the related special diag
nostic instruments and tests, and describe
all the possible pathological conditions
in terms of their treatment and nursing
care. The authors then discuss such
special topics as nursing care of the blind
patient, physical assessment of the
patient with eye disorders, and specific
ophthalmologic nursing procedures.
Little, Brown. 302 Pages.
Illustrated. 1980. $18.00
1980
5 INTRAVENOUS
MEDICATIONS: A Guide to
Preparation, Administration
and Nursing Management
By Diane Proctor Sager, R.N., M.S.N.;
and Suzanne Kovarovic Bo mar, R.N.,
M.S.N.
Here is a handy two part reference
designed to give the most complete cover
age of intravenous equipment, techni
ques, management, and the drugs them
selves. Part One describes the theories
and techniques of the intravenous admin
istration of drugs. Among the topics
discussed are: helping the patient cope
with stress; the correct technique for
the insertion of the intravenous cannula;
maintaining a patient intravenous line
and regulating the flow rate of fluids and
drugs; major complications of intravenous
administration. Part Two, the Drug
Information section, presents detailed
information in column form on all drugs
currently approved for intravenous use.
Lippincott. 560 Pages.
Illustrated. 1980. $19.25
1980
6 BASIC PHYSIOLOGY AND
ANATOMY, 4th Edition
By Ellen E. Chaffee, R.N., M.N., AT.Litt.,
and Ivan M. Lytle, Ph.D.
Extensively revised, updated, and ex
panded, this new fourth edition of z
leading text contains three entirely new
chapters on the basic concepts of immu
nity, nutrition, and aging. The centra!
concept of homeostasis has been reinfor
ced throughout the entire book. Revi
sions include material on the physiology
of muscle tissue, the central nervou-
system, and vascular and respiratory phy
siology.
Lippincott. 628 Pages.
Illustrated. 1980. $23.95
ing the Health Professions in Canada Since 1897 Serving the Health Professions in Canada Since 1897 Serving the Health Professions in Canada Since1897
and current techniques...
that constitute a basis for superior performance
*************************************************
1980
O 1980
7 CLINICAL ASSESSMENT OF
CHILDREN: A Comprehensive
Approach to Primary Pediatric
Care
By J. Deborah Ferholt, M.D.
For clinicians who care for pediatric
patients from birth through adolescence,
this unique pediatric assessment text
teaches the student how to systematically
gather, organize, and utilize a large data
base covering the child s physical health,
psychological development, and interac
tion with his parents. It differs from
other texts by emphasizing the clinical
approach to physical assessment, making
it ideally suited to accompany a "how-
to" text on physical diagnosis, such as
Bates A Guide to Physical Examination .
Lippincott. 331 Pages.
Illustrated. 1980. $21.00
9 NURSES, PATIENTS, AND
FAMILIES
By Carolyn J. Rosenthal; et. al.
Provides sociological perspectives on
four major problem areas: behavioral
components of care, decision-making
within the health care team, participation
by patients and families in medical care,
and sex role stereotyping. How patients
are labelled and typified by nurses and
how control is exercised by the institu
tional and personnel structure of the hos
pital are some of the themes discussed.
Springer. 168 Pages. 1980. $16.25
1980
10
1980
8
PHYSIOTHERAPY
ASSESSMENT
By Anne Parry.
The basics of patient assessment for
physiotherapists. Provides concise guide
lines and principles of history-taking,
objective examination, interpretation and
presentation of findings.
Springer. 97 Pages. 1980. $8.50
ORTHOPEDIC NURSING
PROCEDURES Part I:
Initial and Emergency Care,
3rd Edition
By Avice Kerr, R.N.
Expanded, updated handbook for
nurses in emergency functions, with
guidelines for establishing priorities, a-
voiding mistakes and initiating treatment.
Invaluable procedural reference for nurses
in all wards, including cast and traction
rooms.
Springer. 144 Pages.
Illustrated. 1980. $13.25
1 1 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, emphasizing
palliative pain relief 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 clinical settings!
Significantly, the second edition
not only emphasizes the nurse s role in
the effective use of medications for pain
relief; it also stresses the nurse-patient
relationship and patient teaching. Cover
age of non-invasive pain relief methods is
truly extensive, with separate chapters
devoted to distraction, relaxation, cutane
ous stimulation, and imagery. Much of
the content in these chapters has never
before appeared in print!
Lippincott. 340 Pages. 1979. $22.25
Lippincott/Harper 1980 Nursing Catalogue
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LIPPINCOTT
YOU AND THE LAW
"Nurse, you did this to me! It s your fault!
Corinne Sklar
"I work on an oncology unit and must
administer medication to patients whose
skin, muscles and veins may be in poor
condition because of the course of their
illness and, sometimes, the side effects
of chemotherapy. Although I try to be
as gentle and as skilled as possible,
sometimes post-injection there may be
some discoloration, bruising or swelling
in the site area. This is distressing for
patients and sometimes they become
very angry and blame me saying,
Nurse, look what you did to me!
The patient does not remember that
before beginning the course of
treatment we discussed the possibility
of such occurrences. Needless to say,
this is also most distressing to me. Can
the patient sue me? Would I be at fault?
This nurse is concerned that she could
find herself the defendant in a lawsuit
brought by such a patient even though
she believes that she carried out her
professional responsibilities to the
patient with due diligence and care.
Would a Court find her legally
responsible for causing such injuries?
While not specifically raised by this
nurse as part of her question, the fact
that many of the medications used in
the treatment of oncology patients are
potentially highly toxic and irritating
to tissue if improperly administered
should not be forgotten. As well, the
side effects of these drugs can be
severely debilitating and devastating to
the patient both physically and
psychologically. This is the harsh side
of the therapeutic effort to combat,
arrest and slow the ravages of the
disease process.
Can the nurse be sued? Put
baldly, the answer to this question is
yes: where any person believes another
person s negligence has caused him
injury or damage, then that person has
the right to bring a lawsuit against the
person he alleges caused him that harm.
The decision to sue or not to sue and
who to sue is made by the plaintiff (the
complainant), generally in consultation
with his solicitor. It would be usual in
such circumstance for a patient who
decides to commence such a lawsuit to
name the hospital and the nurse as
defendants.
Some major factors in deciding
whether or not to commence such a
lawsuit are the facts themselves and the
likelihood of success in Court. Given the
foregoing facts, would a Court find that
the nurse had negligently performed her
professional duties thereby causing the
harm of which the patient complains?
And, because such injuries could
result in a lawsuit being initiated, would
the patient succeed, given the foregoing
facts?*
As in any lawsuit, the facts of the
case are most important and will be a
major influence in the ultimate
outcome. Here the facts are sketchy;
our consideration of them must be in
very broad and general terms.
For a plaintiff to succeed in a suit
alleging negligence, he must show that
the defendant owed to him a legal duty
of care. That such a legal duty exists in
this nurse-patient relationship is
unquestioned; nurses owe such a duty
of care to their patients. However, the
plaintiff must also show that the nurse
failed to fulfill this legal duty and that
this failure was the direct cause of the
harm of which he now complains. In
our example, the patient will have to
persuade the Court that the nurse
administered the medication negligently
and as a direct^esultofthaTnegigeTice
the injuries at the site occurred. The
nurse s professional performance will
be measured against the yardstick of the
performance of the reasonable and
prudent nurse of like training and
experience. 1 In other words, nursing
expert evidence will be presented to
the Court describing the techniques and
methods which the ordinary, reasonable
and prudent nurse of similar training
and experience functioning on an
oncology unit would have employed in
such circumstances. In this way, the
standard of care is established.
If the care given falls below this
standard and there are no mitigating
circumstances (for example, the patient
failed to follow instructions and hence
was contributorily negligent because he
assisted in his own misfortune) 2 then
the nurse would be found to have been
negligent in the administration of the
medication. If the evidence presented
by the nurse in her defence indicates
that the nursing care given meets the
*Whether the suit will be successful in
Court is highly relevant because in our
system of justice, the costs of a lawsuit
are generally awarded to the successful
party. Therefore, if the plaintiff loses he
might have to bear the costs of the
defendant as well as his own. In the
case that follows, costs were awarded
to the successful defendant.
professional standard of care established
by the nursing expert evidence, then the
nurse will not be found by the Court to
have breached her duty to the patient.
Her conduct will not be found to have
been negligent and legal liability will not
follow; the patient s suit against the
nurse, given these facts, would not be
successful.
A case in point 3
The plaintiff was a 44-year-old married
woman suffering from cancer who had
had a mastectomy and bilateral
ovariectomy. The disease process
continued and chemotherapy was
instituted, in this case, Adriamycin
and vincristine sulfate, both of which
are administered intravenously. The
plaintiff suffered skin burns requiring
plastic surgery to her hand following an
injection. She later brought suit against
her physician, alleging that the injection
he administered on a certain date caused
this burn.
The trial judge noted both the
courage of the plaintiff and the high
degree of care and concern
demonstrated by the physician. He was
unable to find, on the facts before him,
that the plaintiff s injury was a direct
consequence of any professional
negligence on the part of the physician.
Both the medications involved can
cause damage to tissue if there is any
extravasation on administration but, in
this case, vincristine sulfate was not at
issue. At the time, Adriamycin was not
widely used; the trial judge noted that it
was a "somewhat novel" form of
treatment and it was this medication
that the plaintiff alleged to have been
negligently administered and to have
caused the damage. Adriamycin is an
antineoplastic agent which can result in
cardiac toxicity, bone marrow
depression and hepatic impairment. The
patient must be well-monitored. As
well, extravasation on injection can
cause severe irritation and tissue
necrosis. In addition, the side effect of
complete alopecia almost always occurs
as well as nausea, vomiting and
mucositis. The medication is usually
administered into the tubing of a freely
running I.V. saline solution to reduce
the possibility of extravasation on
injection.
The judgment described fully the
procedure used by the defendant
physician. The patient s arm was soaked
in warm water for 5-10 minutes to raise
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her veins as she was fairly obese. This
would increase I.V. starting facility and
be more comfortable for the patient.
The blood pressure cuff was inflated
again to swell the vein on the back of
her hand which was being used as the
injection site. Then, once the I.V. saline
solution was running well, Ihe
Adriamycin was injected into the
Y-joint of the tubing. The physician was
present constantly throughout and
observed his patient, her facial
expression, the site, the I.V. flow and
the color of the fluid. He could recall
nothing unusual occurring during that
treatment. When the treatment was
over, the physician applied manual
pressure to the site to halt any blood
flow and prevent tissue bruising.
Evidence given by the medical
experts established that the physician
met the standard of care applicable to a
physician of similar training and
experience. The trial judge stated that
the highly toxic nature of the
medication imposed an even higher duty
upon the physician to take care, a duty
the doctor met. He noted that the
doctor was excessively conscious of the
dangerous nature of the drug he was
administering and that he took all
reasonable precautions.
The trial judge dismissed the
plaintiff s action. He stated that he was
not satisfied that the injury was a direct
consequence of any professional
negligence on the part of the physician
but observed that, given the novelty and
toxicity of the medication, the
plaintiffs action in bringing suit was a
perfectly proper exercise of her legal
rights.
The patient does have the right to
sue the health professionals delivering
care to him in circumstances such as
these. Whether or not he succeeds
depends on the facts. Is defensive
nursing necessary? If the nursing care
you deliver is truly professional,
sensitive and caring , the answer is
most probably "no".*
References
1 Sklar, C.L. Nursing negligence in
the administration of medication...
Could it happen to you? Canad. Nurse.
75(7):51-53; 1979 Jul./Aug.
2 Sklar, C.L. The responsibility of
the patient. Canad.Nurse. 76(7):14-17;
1980 Jul./Aug.
3 *Neufeld v. McQuitty ( 1 979)
18. A.R. 271 (Alta. S.C.)
4 Ibid.: p.279.
5 Law, Diana. Successful
chemotherapy: quality care for the
cancer patient. Canad.Nurse. 76(2):
19-22; 1980 Feb.
*Not verified
Author Corinne L. Sklar is a lawyer and
practices law in Toronto, Ontario. She is
legal counsel with The Imperial Life
Assurance Company of Canada. Prior to
her law studies, she obtained her BScN
and MS degrees in nursing from the
University of Toronto and the
University of Michigan respectively.
CURITY*
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Transparent
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Urine transfer tube allows transfer from
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breaking the closed system.
Continuous urinary output
measurements may be taken at any
desired time interval. Measurement
procedure is convenient and aseptic.
Transparent meter scale affords clear
view measures in increments of 1 ml
from to 34 ml, and in increments of 5
ml from 35 to 200 ml.
Push-pull valve permits collection of
fresh urine for specimen.
INNOVATORS IN PATIENT CARE
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Registered Trademark
TYLENOL
Acetaminophen
A LOGICAL FIRST CHOICE IN
NON-Rx AN ALGESIA
ACTIONS:
Acetaminophen is an analgesic and antipyretic.
INDICATIONS:
TYLENOL* Acetaminophen is indicated for the
relief of pain. Also as an analgesic-antipyretic in
the symptomatic treatment of colds.
CONTRAINDICATIONS:
Hypersensitivity to acetaminophen.
ADVERSE EFFECTS:
In contrast to salicylates, gastrointestinal
irritation rarely occurs with acetaminophen. If a
rare hypersensitivity reaction occurs, discontinue
the drug. Hypersensitivity is manifested by rash
or urticaria. Regular use of acetaminophen has
shown to produce a slight increase in
prothrombin time in patients receiving oral
anticoagulants, but the clinical significance of
this effect Is not clear.
PRECAUTIONS AND TREATMENT OF
OVERDOSE:
The majority of patients who have ingested an
overdose large enough to cause hepatotoxicity
have early symptoms. However, since there are
exceptions, in cases of suspected acetamino
phen overdose, begin specific antidotal therapy
as soon as possible. Maintain supportive
treatment throughout management of overdose
as indicated by the results of acetaminophen
plasma levels, liver function tests and other
clinical laboratory tests.
N-acetylcysteine as an antidote in
acetaminophen overdose is recommended.
However, its use at present is considered
experimental. More detailed information on the
treatment of acetaminophen overdose, including
the availability of N-acetylcysteine, the
preparation of N-acetylcysteine for
administration as an antidote, recommended
dosage regimen and acetaminophen assay
methods is available from JOHNSON &
JOHNSON Limited/Limitee,890Woodlawn Road
West, Guelph, Ontario N1H7L4, or contact your
nearest Poison Control/Information Centre.
DOSAGE:
TYLENOL Drops:
Children 10 -14 years: 1.5 mL 3 times daily
5 9 years: 0.6 mL 4 times daily
2 - 4 years: 0.3 mL 4 to 5 times daily
Children under 2 years: As directed by physician
Adults: 3 mL 3 times daily or as directed by
physician
TYLENOL Elixir:
Administer 4 times daily
Children 10-14 years: 1 teaspoonful
5- 9 years: Vi teaspoonful
2- 4 years: v 4 teaspoonful
Children under 2 years: As directed by physician
Adults: 2 teaspoonfuls or as directed by physician
TYLENOL Tablets 325 mg:
Adults: 1 or 2 tablets 3 to 4 times daily
Children 10 -14: Vi or 1 tablet 3 to 4 times daily
TYLENOL Tablets 500 mg:
Adults: 1 or 2 tablets 3 to 4 times daily
Children: As directed by physician
TYLENOL 1 Capsules 500 mg:
Adults: 1 or 2 capsules 3 to 4 times daily
Children: As directed by physician
SUPPLIED:
TYLENOL Drops: Each 0.6 mL contains 60 mg
acetaminophen in a deep red liquid vehicle with a
slightly bitter, cherry-flavoured taste. Available in
amber bottles containing 15 mL and a calibrated
dropper.
TYLENOL Elixir: Each 5 mL contains 120 mg
acetaminophen in cherry-flavoured red vehicle.
Available in amber bottles containing 100 mL and
455 mL.
TYLENOL Tablets 325 mg: Each round, white
tablet, scored on one side and engraved
"TYLENOL" other side: contains 325 mg
acetaminophen. Available in amber bottles of 24,
100 and 500 tablets.
TYLENOL Tablets 500 mg: Each round white
tablet, engraved "TYLENOL" one side and "500"
other side; contains 500 mg acetaminophen.
Available in amber bottles of 30 and 100 tablets.
TYLENOL* Capsules 500 mg: Each red and white
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Complete prescribing information available on
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SPECIAL REPORT ; DRUG ABUSE
Drugs work in subtle ways, changing the way we look at the world around us,
how we relate to our friends and family and sometimes even the decisions we
make. Prepackaged solutions to everyday problems, drug misuse or abuse can
threaten our parents, our children and even ourselves. This month CNJ takes
a closer look at the problem of drug abuse and the possibilities for prevention.
Most of the contributions to this issue have come from nurses on the
staff of the Clinical Institute of the Alcoholism and Drug Addiction Research
Foundation, an agency of the provincial government of Ontario. Affiliated
with the University of Toronto, the Clinical Institute, the Foundation s major
resource for clinical research, treatment and education in the field of alcohol
and drug dependence, is a 63-bed hospital with a multi-disciplinary staff
representing medicine, nursing, occupational therapy, physiotherapy,
pharmacy, psychiatry, psychology and social work. Facilities for assessment,
outpatients, inpatients and emergency treatment allow for the provision of
research-based treatment programs for persons suffering from physical, social
and psychological problems associated with the use of alcohol and
psychoactive drugs. Similar foundations, commissions or government
departments are present in all provinces. They re there to help you!
\
Joanne M. Shaw, RN
(Saint John General
Hospital School of Nur
sing) BN (University of
New Brunswick), was
unit coordinator of the
Clinical Research Unit,
Addiction Research
Foundation when this
research was conduct
ed. When she wrote this
article she was coordi
nator of nursing services
Clinical Institute, Ad
diction Research Foun
dation, a position she
still holds.
Gregory Kolesar com
pleted his BA degree in
psychology at Temple
University in Philadel
phia and received his
RN training at George
Brown College in Tor
onto. When the article
was written, he was
working as project man
ager on the Clinical
Research Unit of the
Addiction Research
Foundation.
Mary Lourdes S.V.
Gaerlan, RN, BScN, is a
graduate of the Univer
sity of St. Thomas in
Manila, has a certificate
in Nursing Education
from the University of
Toronto and is a candi
date for a Master s
Degree in Counselling
Psychology at the Al
fred Adler Institute in
Chicago.
Eileen Fitzpatrick is a
graduate of St. Mich
ael s School of Nursing.
For the past two years,
she has been employed
as a staff nurse on 4
South at the Addiction
Research Foundation.
Gwen Casselman, RN,
has specialized in the
field of drug dependen
cy for the past ten
years and is currently
the nursing coordinator
of a clinical research
program for younger
drug users at the Addic
tion Research Founda
tion.
Kathy Chater, RN, has
worked for the Addic
tion Research Founda
tion for the past thir
teen years. She is pre
sently nursing coordi
nator in the Emergency
Department. Kathy is a
graduate of Toronto
Western Hospital.
GUELPH. ONTARIO N1 H 7L4
Given clinically documented equipotency 1 *? . .
Why complicate
simple/analgesia?
ASA side effects
(at normal doses)
Adverse effects
...on hypersensitive
individuals 3 "
...on the
gastrointestinal tract
...during
pregnancy
...of concomitant
use with
other drugs 2b
..on the blood
...resulting in
iron-deficiency
anemia 512
YLENOL side effects
(at normal doses)
Hypersensitivity
in rare instances 1 . 3 -"
1 . Borterman, R C . and Grossman, A J.: Fe
316-317(Mor) 1955 2. Goodman. LS..
eds The Pharmacological Boys of Therapeutics, ed 5.
New York, The Macmillan Company, 1 975. (a) p 334,
(b) pp 1 350- 1 368 3. Y u ng,nger. J W., O Connell, E.W..
ondlogon.GB 1 Pedioir, 82, 218-221 (Feb.) 1973 4.
Setlipone, G A , Chalee, F.H./and Klein. D E.: J Allergy
Clin Immunol 53 200-204 (Apr ) 1 974 5. Mnguy. R .
Am J.Om Res 2 17-26. 36-37 (Apr) 1971.6. Spivock.
M.Med Times 99 129-133 (Jon) 1971 7. Cfofl, D.N ,
andWood.PHN Br Med J I 137-141 (Jan 21)
1967 8. Cooke. AR Am J Dig Dis 18 225-237
(Mar ) 1973 9. Turner. G . and Collins. E , lancei 2
338-339, 1975 10. Lewis, R.B . and Schulman. J.D.:
Loncei2 1159-1 161, 1973 U . Bleyer. W.A., and
Bteckenndge. RT JAMA2I3 2049-2053.1970 12.
Summetskill. W.H.J.. and Alvarez, AS Lancet 2 925-928
A logical first choice in
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with baby for
mothers.
Easier than cloth to
fit and change
A one-piece system
more convenient than
cloth to change and clean
up easy to fit with tape,
not pins.
Pampers
used more often than cloth
in hospital nurseries
For further information write to
Pampers Professional Services
R^y. TRK Qt^H^r, "A"
perspective
A HEALTH-ORIENTED APPROACH
Gail Paech
What can we, as health professionals, do to increase
society s ability to help alcohol and drug-hurt people?
Our first concern, of course, is with our clients.
We must ensure that the care we provide to them is
humane, effective and based on appropriate and
up-to-date research findings. Since the "typical
alcoholic or dug abuser" does not exist, this care
must also be client-centered.
It is up to us to ensure that each one of our
clients understands that the use of drugs carries with
it the potential for misuse, that responsible use means
controlled use, at levels which keep the benefits as
high and the risks as low as possible.
To do this, we need to mount vigorous
education programs that encourage each individual to
choose behavior alternatives resulting in the healthiest
possible lifestyle, a life that is as close as possible to
being problem-free. It is important also for us to add
positive reinforcement to decisions our clients may
have already made about adopting a healthier
lifestyle. At the same time, we must try to make sure
that each individual receives scientific, factual
information he can understand and which will help
him to understand and support relevant changes in
social policy.
This November issue of The Canadian Nurse
marks a special effort to sensitize nurses to the
problems associated with substance abuse, problems
that affect an estimated 15-20 percent of the
patients we care for. With numbers like this, obviously
we can no longer leave it up to others to find the
solution. Nurses have a unique responsibility and
obligation to learn to identify and assist anyone who
is experiencing problems related to substance abuse
and, at the same time, to promote prevention
strategies that will help these clients to adopt
healthier lifestyles.
Many substances are addictive tobacco,
heroin, flurazepam (Dalmane), cocaine, diazepam,
(Valium), codeine, among others but the majority
of drug problems that nurses encounter relate to the
use of alcohol.
In the 13-year period between 1960 and 1973,
the industrialized countries of the world experienced
a more than 43 percent increase in the amount of
alcohol consumed by the general population. Why do
we drink more today than our grandparents drank
yesterday? Several reasons come to mind:
increased availability, including more drinking
facilities, more retail outlets
more liberal legislation, including lowered
drinking age
a decline in the real price of alcohol and
disappearance of the counteracting effect of
temperance laws.
With increased consoumption has come an
increase in alcohol-related problems, both social and
medical, including damage to physical and
psychological health, poor work performance,
disruptions to family life, financial crises and
difficulties with the law.
What can nurses do to to help? In the past,
attention has focused on the idea that the trouble lay
with the victim . The moralistic concept of the
alcoholic (victim) as sinner has given way to the
illness-oriented concept of the alcoholic (victim) as a
sick person suffering from a specific disease, one
symptom of which relates to alcohol use. The patient
requires empathy, support, treatment possibly
hospitalization.
Both of these victim concepts reinforce the
idea that the drug alcohol per se has little to do with
the problem. BUT excessive use of alcohol and the
problems that this misuse and abuse create are clearly
health issues. As health professionals, we must
develop programs designed to prevent alcohol abuse
that are effective and meet with public support.
Recently, there has been a revival of interest in
control policy as potentially important preventive
strategy. Controls tend to focus on society-at-large,
rather than on individuals, a focus consistent with the
research finding that relates levels of alcohol
consumption in the general public to the overall
health of the population. Some people argue that
such controls constitute a curtailment of individual
freedom but relaxing controls on alcohol as has been
done in recent years indicates to many people that
drinking alcohol in increasing quantities \snot
harmful, an assumption that those of us who work
with alcoholic patients and their families recognize as
false.
Investigation indicates that two of the most
important factors in determining how much alcohol a
person consumes are first, cost and second, availability.
It would seem reasonable then to assume that, in the
interests of health, there should be no further
liberalization of control measures and that the price
of alcohol should bear a reasonably constant
relationship to the consumer price index. No control
policy by itself is going to provide all the answers.
What we need is a health-oriented, integrated approach
that combines an effective control policy with
preventive education and knowledgeable methods of
treatment. Nurses cannot resolve the problems of
drug dependence alone but, without their
commitment and involvement in the promotion of
healthier lifestyles, society will continue to pay the
high costs associated with the abuse of these chemicals.
USE? OR ABUSE?
Ian W.D. Henderson
The term substance abuse implies not only a
philosophical stance, but also a concept of the
problem of drug use that relates to dependence on a
variety of chemical entities social lubricants such
as caffeine, tobacco and alcohol, as well as numerous
forms of licit and illicit drugs.
To label the problem as abuse signifies of
course that we regard a harmful pattern of personal
use of any mood-altering agent as a phenomenon that
must be strongly if not righteously discouraged. Such
a stance is understandable: who can deny in the face
of very substantial knowledge that overuse of caffeine
ultimately is a cause of frazzled nerves and
embarassing mood changes as well as some adverse
cardiovascular effects. Similarly, few would argue
that in terms of a risk: benefit ratio, anything good
can be said for tobacco. And very few of us could
ever contend that excessive alcohol consumption is
not a serious health and social problem in Canada.
Nevertheless, most of us would probably still say that
moderate use of caffeine is an entirely acceptable
custom, that occasional use of tobacco is not
particularly harmful, and that ready access to
alcoholic beverages by adults is almost a fundamental
right in our society. Wise personal use is not
reprehensible but harmful use is to be frowned upon.
When we turn to drugs, however, we are not
nearly so sure of ourselves. We have developed a kind
of double standard of acceptability even for legal
drugs. The use of barbiturates, often in combination
with analgesics, to assuage tension headache is an
acceptable practice but the same barbiturates used to
soften the harsh realities of a rough spot in our life is
also a form of abuse . We regard the use of cannabis
to control severe nausea and vomiting associated with
cancer chemotherapy as laudatory, but still consider
even the occasional non-medical use of the same
drug to produce a sense of relaxation and euphoria as
a form of abuse .
In recent years many of us have been concerned
about the widespread use of prescribed mood-altering
drugs. About twice as many of these are prescribed
for women as for men and this seems to be predicated
by the belief of many (male) physicians that the
presenting symptoms of women patients commonly
have their origin in an emotional disorder. The
prescribing of minor tranquilizers in Canada however
is only about 60 percent as high as in the U.S.A., and
the overall consumption of these drugs has decreased
by about 15 percent over the past three years. Still,
inappropriate use remains a widespread problem.
Self-medication with tranquilizers is not only unwise,
but differs little from other similar forms of drug
abuse. Continued use of minor tranquilizers over a
long period can and does result in some physical and
psychological dependence which makes withdrawal
both difficult and stressful. What is equally important
is the fact that oftentimes the continual use of
mood-altering and tranquilizing agents, of sleeping
pills, or conversely of stimulants, masks either a
medical or a social problem, or both. When this
happens, these problems must be recognized and
dealt with in a more realistic manner.*
Gail Paech, RN, MScN, is director of nursing. Clinical
Institute, Addiction Research Foundation and
assistant professor. University of Toronto, Faculty of
Nursing. Gail received her baccalaureate of nursing
from the University of Ottawa and her MScN from
the University of Toronto. She is presently a director
of the Registered Nurses Association of Ontario.
Ian W.D. Henderson, MD, FRCS (C), is Director of
the Bureau of Drugs in the Health Protection Branch,
Health and Welfare Canada. He is also a senior lecturer
in the Faculty of Health Sciences at the University of
Ottawa.
It could
happen to you
Gregory Kolesar
Nurses, physicians and pharmacists
are at greater risk for substance
abuse than are members of the
general population. Yet, in spite
of our profession s unique training
and knowledge, nurse abusers
often fail to recognize and
confront their own problems of
drug and alcohol dependence.
The intent of this article is to increase
your knowledge about nurses as
substance abusers. To do this, it may
help to organize information under the
"five P s": the Problem, a Profile of
nurses who become substance abusers,
Patterns of abuse, Politics in the
workplace which contribute, and a look
at the Prognosis for abusers to get some
help.
First of all, there is definitely a
problem of drug abuse among nurses;
American statistics have revealed several
significant facts.
in one study group of drug
abusers, 15 percent were either nurses
or pharmacists.
there are approximately 40,000
known alcoholic nurses in the U.S.
in one treatment center, 50
percent of the meperidine (Demerol)
abusers were RNs and doctors. 1 2 3
Canadian statistics are less readily
available, but using Ontario as an
example the College of Nurses of
Ontario heard 100 cases involving
nursing "incapacity" between 1976 and
1979. These cases were a mix of
alcoholism, drug abuse, and/or
psychiatric illness. One hundred cases
among more than 94,000 registrants
might not seem like a large number, but
CNO registrar Betty Secord cautions
that this is "just the tip of the iceberg" ;
these hearings represent only the nurses
who have been reported. 4
A profile
While one cannot precisely define a
personality profile for alcohol-abusing
nurses, Dr. LeClair Bissell, Chief of the
Smithers Alcoholism Treatment and
Training Center in New York, has noted
some common traits. The nurses were in
the upper third of their class and many
had attained advanced degrees. These
ambitious nurses tended to be
achievement-oriented and functioned
with great competence in demanding,
responsible positions; more than
one-third of these alcohol abusers were
drug abusers as well. 5
A profile for the drug-abusing
nurse may be gleaned from an in-depth
study conducted by Levine, Preston and
Lipscomb at the National Institute of
Mental Health Clinical Research Center
in Lexington, Kentucky. The
researchers found the average age to be
40 years, and the mean period of abuse
five years. One half of the nurses abused
alcohol before drugs, and 75 percent
smoked cigarettes. All had undergone
surgery once, and the group had an
average of 6.1 surgical procedures/
nurse/lifetime. During developmental
years, the average number of hospital
admissions was eighteen/ nurse/lifetime.
The authors postulate that the 90
nurses who were studied experienced a
strong medical dependence in
adolescence which temporarily was
resolved with their choice of
occupation. They suggest that these
nurses sustained an unresolved
dependency struggle which was the basis
for their later substance abuse in adult
life. 6
Another study by William Lyle
found that nurses "did not use drugs for
kicks, but to alleviate pain or escape
from reality". By reality , he does not
mean the generalized reality of life,
but rather three specific realities of
physical illness, great emotional
pressure, or over-demanding physical
and work pressure. Thus, the profile of
the nurse drug abuser is different from
other drug abusers who take drugs for
pleasure, to express rebellion, out of
curiosity, or to be one of the crowd".
Another difference is the method of
obtaining drugs; an "addict" (also
typically much younger), uses black
market and street drugs while the nurse
more likely obtains his or hers through
doctors, by forging prescriptions on
stolen prescription pads, or by outright
stealing from the medicine cupboard.
The nurse s abuse is solitary, while
other abusers usually participate in a
group.
Nurses also abuse alcohol
concurrently with drugs more than
other drug abusers. In fact the Levine
study reveals that 50 percent of their
90 drug-abusing nurses had abused
alcohol first. Ironically, many nurses
feel the switch from alcohol to drugs is
an improvement: alcohol has a skid-row
connotation, but drugs are medicine .
Misuse of drugs by nurses is viewed as
self-administration of a therapeutic
agent.
A definitive substance abuse
profile hasn t been described here
although certain traits do appear
consistently in the population
examined; not all nurses involved with
substance abuse have these traits, and
many with no problems do.
Patterns of abuse
Nurses often continue to work for
years after the onset of substance
abuse. They are probably too
conscientious to take drugs (including
alcohol) on the job at this point, but
"work shrinkage" can occur. The nurse
does only what is absolutely necessary
and no longer welcomes challenging
assignments or extra work. 7
Isler has identified a pattern 8
which has been substantiated by several
nursing administrators. As the substance
abuse causes increasing problems, the
nurse cannot cope with a busy active
treatment area, so she switches to a
slower paced unit. A switch to night
duty where supervision is minimal or to
a nursing home often follows. A writer
in RN magazine hints at this pattern:
"It s more likely that you ll face this
situation on the night shift than the day
shift," the author stated when writing
about substance-abusing superiors. 9
The next step is to per diem service,
perhaps with a supplementary agency,
because this kind of service lends itself
to pilferage (a regular pattern isn t
obvious) and to being absent from work
without too many questions being
asked. Of course, simply because a
nurse works in one of the above
situations, does not mean he or she is on
the downward spiral of substance
abuse. The variety of work situations
available is one of the attractions of
nursing, and a nurse who has found the
workplace best suited to his or her
lifestyle is ahead of the game. However,
this flexibility does allow the substance
abuser more time to "hide out" and to
postpone the ultimate confrontation
between himself and the abuse problem.
Politics in the workplace
Even though the nurse with a substance
abuse problem says nothing and tries to
hide everything, colleagues are usually
aware of a problem. Co-workers notice
increased absences, increased lateness,
disappearances for short periods while
on duty, and "work shrinkage".
Personality changes including
withdrawal and irritability, which are
usually inconsistent with the abuser s
previous affect, may appear. 10 The
nurse doesn t always recognize that he
or she has a substance abuse problem,
much less what course of action to
pursue and co-workers may not have
much knowledge about addictions
themselves, preferring to watch and
wait in the hope that the addicted nurse
will leave and take the problem else
where. They may cover up the abuser s
unexplained absences or many
colleagues may even give the substance-
abusing nurse non-prescribed minor
tranquillizers for shakiness.
Because of the staffs and
supervisor s inability to face the
problem and to take positive action,
the connection between decreased
work performance and substance abuse
is avoided. Evaluation of job
performance is, in fact, the only tool
available to help the substance abuser
in the workplace. Accusations about
drinking or taking drugs will only
increase denial, and the substance
abuser may feel hostile. If these charges
are delivered from a moralistic point of
view, damage may be done to the
abuser s perception of self.
Undocumented charges of substance
abuse could also be libelous, especially
if other things are happening in the
employee s life that are unknown to
you. Avoid value judgments and
generalizations; for example, if someone
is late, he or she is "fifteen minutes
late on such and such a day", not
"always late because of a hangover".
Action on poor job performance should
come from a responsible person at
least one rank above the abuser and
above the reporting nurse, 11 however
special allowances should not be made
for substance-abusing nurses, especially
at the expense of co-worker s feelings. If
the troubled nurse has fallen asleep in
the lounge, and others had to do her
work, say so without rampaging or
passing innuendo. The statement, "I
am angry because I had to answer your
lights while you were napping", is as
effective as any in helping the substance
abuser to realize that her abuse is
affecting her professional life. 12
The Canadian Nurse
November 1980 21
To help the substance abuser in
the workplace, document, report and
confront poor job performance;
accusing, ignoring, preaching, and
over-support all contribute to blocking
the substance abuser from the
realization that he or she has a problem.
Ill-informed attempts at "counseling"
by inexperienced persons will certainly
not help the substance abuser. 13
Prognosis for abusers
Once a nurse realizes his or her
decreased work performance or changed
personal life is the result of substance
abuse, help is available. Many nurses
have their own counselors or family
physicians but if the nurse is working
for a larger institution, the employee
health service can arrange for an
appropriate referral. If he or she has
joined a registry or has stopped
working, there are the usual community
supports. Many nurses do have family,
friends and even strong personal
resources to help them through this
crisis. The most difficult task for the
nurse selecting his or her own
therapeutic milieu is to find an
understanding therapist who is
experienced in the field of substance
abuse; otherwise, time will be wasted
skirting around the real issues, and the
nurse could merely end up with a
prescription for a minor tranquillizer
which will not help and could lead to
cross-tolerance.
The most helpful means of
treatment and support which is
emerging to help all substance abusers in
the workplace is the Employee
Assistance Program. Such a program is
meant to assist by allowing the person
to seek out confidential help and by
encouraging managers to identify
performance problems and invite
employees to seek that help. Ironically,
these programs are spreading more
slowly in the health care field than in
industry. For example, out of more
than 70 hospitals in the Toronto area,
only three have EAPs. However, nursing
leadership is aware of the situation and
several provincial nursing associations,
among them the RNAO and MARN, are
looking into making employee
assistance programs available to nurses.
An area of particular concern to
the substance-abusing nurse is his or her
licence to practice nursing. Licencing
agencies exist to protect the public, but
they are also there to help nurses. For
instance, the College of Nurses of
Ontario is typical of many licencing
agencies in its efforts to help the
substance abuser; if the nurse-patient
maintains treatment, the licence will be
suspended until treatment is finished or
if the nurse is attending a treatment
program, the licence may not even be
suspended, but have conditions
attached. By way of comparison,
statistics from the Colorado State Board
of Nursing in 1975 show that out of 10
actions on drug abuse, only two nurses
had licences revoked. There were four
suspensions, and three continued
nursing under active mental health
care. This example serves as an
illustration of the support that seems to
be available from nurse-licencing
organizations.
There is a problem of substance
abuse among nurses. Although there is
no strictly accurate description of the
typical abuser s personality indeed,
there is no typical abuser one can
use observations of work habits and
personality changes to help identify the
nurse with a substance abuse problem.
Just as important as identifying the
problem is the realization that help is
available. If the problem is yours, get
help now; if you work with someone
who has a substance abuse problem,
help them to find help.
Anyone, at any time, has the
potential to become a substance abuser.
References
1 Canfield, Thomas M. Drug
addiction of health professionals.
AORNJ. 24(4):665-671; 1976 Oct.:
p.667.
2 Isler, Charlotte. The alcoholic
nurse. What we try to deny. RN
41(7):48-55; 1978 Jul.: p.48.
3 Peirce, Sadie. When the addict is
anwse.AORNJ. 24(4):655-664;
1976 Oct.: p.658.
4 Secord, Betty. Personal
communication.
5. Isler. Op. Cit.: p.49-50.
6 Perice. Op. cit.
7 Isler. Op. Cit.: p. 49.
Ibid.: p.51.
9 When a colleague s drinking
becomes your headache. Leadership at
work.^V41(7):31-34; 1978 Jul.:
p.32.
10- Ibid.: p.33.
11 Canfield. Op. Cit. : p.670.
12 When a colleague s... op. cit.:
p.34.
13 Blose, Irvin L. Confronting the
alcoholic employee AORNJ.
25(6):1159-1160;1977May:p.ll60.
14 Peirce. Op. Cit.. p.656.
A
Learning
Program
in the
Addictions
Arlee D. McGee
Six years ago in New Brunswick, the
federal-provincial Working Group on
Alcohol Problems set up a task force
which in turn developed a series of
information documents, Core
Knowledge in the Addictions Field. The
12 training booklets function both as a
publication and as a learning program,
presenting up-to-date information and
research on addiction.
The program is currently being
offered to all workers in the alcohol and
drug field in the Atlantic Provinces; in
New Brunswick, for example, 1 5 out of
25 nurses working in this field are
taking the course. A certificate of
achievement is awarded on completion
of the program along with 1 continuing
education units from St. Francis Xavier
University in Antigonish, Nova Scotia.
The course includes discussion on
the history of alcohol and drugs in
Canada, federal and provincial
legislation, economics the supply and
demand of alcohol and drugs, prevention
and developing programs for prevention
of abuse, etiology and symptomatology,
and treatment, including pharmacology,
ethics and research evaluation.
The program provides an excellent
basis of knowledge for work in this
specialized field, and familiarizes the
care provider with the major issues and
concepts of substance abuse and
addiction.
Universities and community
colleges across Canada offer courses for
workers in the health care field on
addiction, either within their regular
sessions or as day workshops. Contact
the college near you for further
information.
Arlee McGee, RN, BN, is a member of
the Alcoholism and Drug Dependency
Commission of New Brunswick. A
member of the New Brunswick
Association of Registered Nurses, Arlee
is presently pursuing a career as
independent patient advocate,
consultant in addiction counseling, and
freelance writer. She is also a member of
the board of the Canadian Addiction
Foundation, CAP representative for
the Atlantic region.
22 November 1980
The Canadian Nurse
Dangerous
Equations
Drugs and carelessness add up to danger
Kathy Chafer
Every drug, whether prescription or an
over-the-counter preparation, has been
formulated to act a certain way in your
body. When several drugs are taken to
gether or with alcohol, they may alter
each other s effects and result in a
serious drug interaction.
Sometimes a drug interaction may
be intentional; the use of ascorbic acid
and Mandelamine is a common exam
ple as the ascorbic acid increases the
acidity of urine and potentiates the
effect of the antibacterial agent. A doc
tor may prescribe two drugs to be taken
in combination because he knows they
will react in a positive way to benefit
the patient.
However, unplanned drug inter
actions, caused by taking certain drugs
together or with alcohol can result in
unpleasant or even dangerous conse
quences. For example, if a patient who
is taking an anticoagulant on a regular
basis happens to take a dose of ASA as
a pain reliever, the ASA and anticoagu
lant may work together and cause gastric
bleeding.
Anyone can mix drugs uninten
tionally and become the victim of a
dangerous equation . Check the table of
common drug and alcohol interactions
to make sure you or your patients are
not accidentally mixing substances
dangerously.
There are many more categories
of drugs which have the potential for
dangerous side effects diuretics and
antihypertensives, for instance. Every
nurse should have some knowledge of
the signs and symptoms of drug inter
actions to increase effective nursing
intervention.
In the interest of prevention,
there are a number of simple rules we
can remember and pass on to health
care consumers:
Never take drugs that have been
prescribed or recommended for someone
else.
Before taking any drug, read the
label carefully for directions.
Whenever your doctor prescribes a
drug for you, be certain to tell him of
any other drugs you are taking.
Before taking any drug, prescrip
tion or OTC, ask your doctor or phar
macist about the effects of the drug and
alcohol.
Any drugs which produce drowsi
ness, uncoordination or dizziness, should
never be taken if you are going to drive
or operate machinery of any kind.
DANGEROUS EQUATIONS*
Alcohol
+ Antidepressants
may
Increased alcohol effects
Alcohol
+ Antihistamines
may
= Increased alcohol effects, depression
and dizziness
Alcohol
+ Pain relievers
may
Bleeding in the stomach or intestines
Alcohol
+ Sedatives
may
= Increased sedative effects, depression
Alcohol
+ Sleeping pills
may
Dangerously depressed respiration,
possible death
Alcohol
+ Tranquilizers
may
= Increased sedative effects, depression
and dizziness
Antibiotics
+ Antacids
may
= Decreased antibiotic effects
Antibiotics
+ Sedatives
may
= Increased sedative effects
Antidepressants
+ Antihistamines
may
= Increased antihistamine effects,
dizziness
Antidepressants
+ Cold remedies
may
= Drastically increased blood pressure
Antidepressants
+ Sedatives
may
= Increased sedative effects
Pain relievers
+ Sleeping pills
may
= Dangerously increased drowsiness
Sedatives
+ Antihistamines
may
= Increased sedative effects, decreased
antihistamine effects
Sedatives
+ Tranquilizers
may
Dangerously increased sedative effects
*From Health and
Welfare Canada
The Canadian Nurse
November 1980 23
Gasoline
Inhalation:
A community challenge
Marie Daub en
Carol MacAdam
Two community health nurses
help a small northern settlement
to face the problem of gasoline
inhalation among its children.
Two young boys died in 1976 in a small
settlement in northern Manitoba from
lead encephalopathy attributed to
chronic gasoline inhalation. This tragedy
woke the community to the realization
that gasoline inhalation was a serious
problem among the Cree Indian youth
and children, and caused the federal
government to begin an investigation.
The Medical Services branch of
Health and Welfare Canada undertook
to test the serum lead levels in a group
of children between the ages of five and
18. In all, 156 children were tested and
of these two-thirds admitted to sniffing
gas regularly they were found to have
blood lead levels in the toxic range. 1
Many of the remaining children said
they sniffed gas at least occasionally.
Thirty-five children were evacuated to
a Winnipeg hospital for immediate
treatment; the rest who did not require
treatment were monitored closely.
It was unfortunate that it took a
tragedy such as this to initiate action,
but the community and the government
decided steps should be taken to
discourage gasoline abuse among the
town young people.
Gasoline inhalation has two major
implications for the future health of
children: the first is the physical effect
that gasoline has on the body and the
second, and perhaps most difficult to
deal with, is the social disruption this
form of drug abuse causes for the child,
his family and the community.
The components of gasoline
which pose the greatest problems for
physical health are tetraethyl lead
(TEL) and, to a lesser extent,
hydrocarbons, whose long term effects
are still unknown.
The hydrocarbons produce the
immediate effects that inhaling gasoline
give the user, including the initial high
which simulates that of alcohol
intoxication, appearing within five
minutes of beginning inhalation. Other
effects that users have described are:
euphoria, confusion, auditory and visual
hallucinations, impaired judgment, and
aggressive behavior. Eventually, if
sniffing continues, drowsiness and coma
may ensue. The goal of the user is to
maintain the high just short of
unconsciousness. As soon as inhalation
ceases, the effects will usually wear off
within an hour, although a hangover
effect may persist for one or two days.
Some manifestations of this hangover
are tremor, headache, nausea, vomiting,
mild abdominal pain, anorexia and
fatigue. Increased nasal secretions and
red, watery eyes have also been noted,
probably as a tissue response to the
chemical irritation of the fumes.
The long term toxic effects are
thought to be due mainly to the TEL
component of the gasoline. TEL
poisoning has been shown to cause
damage to virtually every organ system
within the body, occurring insidiously
with repeated frequent use of gasoline
over a long period of time. The extent
of damage varies with the individual.
The symptoms of lead poisoning first
appear in the nervous system as
manifested in changes in orientation,
exaggerated deep tendon reflexes,
postural tremor, and cerebellar
dysfunction (ataxia, incoordination and
intention tremor). If left untreated and
inhalation persists, these symptoms may
progress to cause coma, convulsions and
death.
Lead is deposited in the long
bones of the body, and can impair the
growth process in a child; research is
being done on the possible relationship
24 November 1900
The Canadian Nurse
between TEL poisoning and in increased
incidence of spontaneous abortion and
congenital abnormalities after chronic
exposure.
Some generalized symptoms
which may also be seen are anemia,
weight loss, fatigue, anorexia and
lethargy. The psychological effects that
have been described include
hyperactivity, behavioral problems and
a possible connection to later
development of psychotic disorders.
Working from the inside out
As is the case with any form of drug or
substance abuse, gasoline inhalation
poses a threat to the user s emotional
health and future social relations; when
a group of people are abusing gasoline,
their behavior is a major social problem.
Factors apparently predisposing
an individual to a drug problem include:
low socio-economic status
member of a minority group
prevalence of anxiety and
c epression
family disorganization
lack of harmony in parental
relationships
social disorganization within a
community
an environment that provides few
alternatives to drug abuse.
All these factors were evident to
some degree in our community,
probably partially because the
settlement was very isolated; there were
also problems of unemployment,
alcohol abuse, violence and a lack of
recreation facilities. Reasons given by
the children when asked why they
abused gasoline were boredom, sadness
and depression. The high made them
feel good, at least for awhile.
The community leaders felt that
if the larger social problems could be
worked on then probably the gas
sniffing would decrease. A Drop-In
community center was designed and
implemented through a cooperative
effort between the people of the
community and representatives of the
federal government.
The overall objective of the
program was, generally, to promote a
healthier lifestyle which could be
accomplished in part through the
provision of recreational facilities and
activities for both the children and
their families. The program also
included lifestyle counseling in such
areas as alcohol and drug abuse, and
effective parenting - general child
care, supervision and discipline. The
program was to be supervised by outside
professionals only at the outset; the goal
was to have members of the community
train to take over management.
Our role as the community nurses
entailed two objectives, monitoring and
support. Our chief responsibility was to
monitor and assess the physical
condition of the children known to be
sniffing gas, and to make the
appropriate medical referrals for
medical treatment of lead poisoning to a
hospital in Winnipeg. We took monthly
and bi-monthly blood sample for lead
levels in children considered to be high
risk because of continued abuse, and we
did neurological screening as well.
We tried to provide support for
the community s efforts by becoming
involved in community activities,
thereby providing role models, and by
assisting with the counseling activities
for the children and their families at
the Center.
After the program had been in
operation for a period of three years,
many positive changes could be
perceived in the town. There was a
dramatic decrease in the number of
children who sniffed gasoline, in alcohol
abuse and resultant violence, and an
increase in parental supervision of the
children. The management of the center
is currently being carried out by local
people and is functioning well.
The lesson learned within this
community is that substance abuse
when practiced on such a large scale is
the result of basic social problems, and
when behavior is influenced to focus
on health, both physical and emotional,
changes can be made.*
Reference
1 Johnson, C. Shamattawa: a model
for influencing lifestyle change. Health
and Welfare Canada, Medical Services
Branch, 1979 Mar.
Bibliography
1 *Boekx, R.L. Gasoline abuse:
some comments regarding implied risk.
Winnipeg: Dept. of National Health and
Welfare, Medical Services; 1977.
2 Brenner, Joseph et al. Drugs and
youth: medical, psychiatric and legal
facts. New York: Liveright; 1970.
3 *Canada. Dept. of National
Health and Welfare. Medical Services.
Gasoline inhalation: Shamattawa
1 9 74-1 9 77; Winnipeg; 1977.
4 Harms, E. Drugs and youth: the
challenge of today. New York :
Pergamon Press; 1973.
5 Hemsing, Esther, ed. Children and
drugs. Washington: Association for
Childhood Education International;
1972.
6 *Johnson, C . Shamattawa: a
model for influencing lifestyle change.
Winnipeg: Dept. of National Health
and Welfare, Medical Services; March
1979.
*Seisha, S.S. et al. The
neurological manifestations of chronic
inhalation of leaded gasoline.
Developmental medicine and child
neurology. 20:323-334.
Sharp, Charles W.; Carroll, L.
Thomas. Voluntary inhalation of
industrial solvents. Rockville, Md.:
U.S. Dept. of Health, Education and
Welfare. Public Health Service, Alcohol,
Drug Abuse, and Mental Health
Administration, National Institute on
Drug Abuse; 1978.
9 Solvents, adhesives and aerosols:
proceedings of a seminar held in
Toronto in May 1977 by the Ontario
Ministry of Industry and Tourism in
cooperation with the Addiction
Research Foundation of Ontario; 1979.
10 Waldron, H.A.; Stofen, D. Sub-
clinical lead poisoning. New York:
Academic Press; 1974.
1 1 Zinberg, Norman E. et al.
Teaching social change: a group
approach. Baltimore, Md.: Johns
Hopkins University Press; 1976.
*Not verified
Carol MacAdam, a graduate of Humber
Community College in Toronto, worked
as a lifestyles counselor at the Drop-In
community center. She is now enrolled
in the outpost nursing program at
Dalhousie University.
Marie Daubert, who also worked at the
center, is a graduate of Holy Cross
Hospital School of Nursing, Calgary.
She too is studying in the outpost
nursing program at Dalhousie University.
Currently both Marie and Carol are
gaining clinical experience in Frobisher
Bay, NWT.
SOMETHING NEW!
Now available from the Addiction
Research Foundation is an Education
Material Catalogue which lists and
describes all material offered by the
A.R.F. From pamphlets to books, from
video-tapes to T-shirts, there is
information on every aspect of addiction
and abuse. What s different about being
a female alcoholic? The pamphlet
entitled The Female Alcoholic (16 pages,
40$ ) deals with society s perception of
the woman alcohol abuser, her specific
guilt and stress. For teachers there are
the Alcohol Education lesson plans,
formulated for various age groups.
Occupational health nurses will be
interested in the audiotape on Employee
Assistance Programs, available for $9.00.
To obtain the Catalogue, contact
Marketing Services, Addiction Research
Foundation, 33 Russell Street, Toronto,
Ontario, M5S 2S1, or telephone collect
416-595-6260.
Dealing with the /
disruptive patient *
Kathy Chater
If you are an ER nurse, more than
likely you can remember occasions
when you ve felt hurt,
embarrassed, angry, disgusted,
disappointed and/or frustrated as
the result of a confrontation with
a patient showing the signs of
alcohol or drug intoxication.
Maybe you have been the target of
physical violence. How can
situations like this be avoided?
Here s how these nurses deal with
the problem.
Physical environment is important as a
therapeutic milieu. At the ARF, we
have found it advantageous to
physically separate medically ill patients
from those manifesting behavioral
effects of drug abuse. In order to give
adequate nursing care to both, we have
retained the standard medically
equipped examination rooms and have
transformed a treatment room into a
quiet room where we can talk down
our patients. By removing all furniture,
carpeting the walls and floor and
installing adjustable lighting, we have
created an atmosphere with minimal
external stimuli.
Patients who are paranoid feel
much safer in this environment and
staff are able to relate more effectively
than in a conventional hospital room
setting. A patient who is extremely
disturbed from ingesting a drug such as
phencyclidine would not be left
unattended in this room but patients
who do not require constant supervision-
can be monitored via a two-way
intercom system connected to the
nursing station.
In dealing with the disruptive
patient, empathy and confidence are
crucial. The nurse always introduces
herself and tells the patient what she is
going to do. She understands what is
happening to the patient and knows
that this is a temporary state induced by
the drug.
Contingency plans
Our team approach fosters pre-planned
contingency management. If the staff
on duty in a department cannot manage
a patient, they call a Code 33. Male staff
from other units, the duty doctor and
security all respond to the emergency,
enabling the doctor in charge to inform
them of the situation and receive their
assistance in carrying out the necessary
procedure.
If the patient is armed, the
contingency plan is reversed: staff leave
the area and police are called in and
advised of the situation. We have found
it beneficial to maintain patient care
plans on patients we know present
frequently with the same problematic
behavior. This allows staff to be
consistent in treatment and eliminates
manipulation of new or relief staff.
These plans are updated to match
changes in the patient s status.
If a staff member is assaulted,
police are informed and, if the patient is
judged sane, charges are laid. Similarly,
patients who vent their hostilities by
damaging the furniture or breaking
windows are also charged, thus holding
them responsible for their own actions
and not reinforcing this type of
behavior by implicitly condoning it.
Having an appropriate
combination of specially trained staff
on each shift makes adequate control of
difficult patients easier. One very
important concept is the idea that each
member of the team knows he or she
can request help from another member
if the need arises. For example, a staff
member may become aware that he
cannot relate therapeutically to a
particular patient, he may have had
several ineffectual discussions with this
patient already and feel that this is
happening again, or he may feel
antagonistic toward a patient because of
a personal problem that is bothering
him, or perhaps he simply needs a
coffee break. By explaining how he feels
to another team member and requesting
that he take over, he is exercising good
judgment. The other team member will
respect this and be willing to help out.
In this way, the best interests of the
patient are served.
Another situation which can
create upsets is in the area of
prescription demands. Patients are
aware that physicians are the only
people to prescribe medications. In
some instances, patients demand drugs
as part of their treatment. Even though
the nurse might be well aware that drug
therapy is not warranted and a medical
assessment not necessary, it is wise to
make the referral to the doctor anyhow.
As the doctor is in a position of
authority, most clients will accept the
physician s reinforcement of the nurse s
assessment (drugs are not required).
Drug knowledge
Familiarity with drugs - knowing
which ones are most likely to be
ingested, understanding dependency,
the factors contributing to misuse, how
drugs alter sensation, mood, conscious
ness or other behavioral functions,
cumulative effects, tolerance, symptoms
of intoxication, overdose and
withdrawal is essential for nurses
working in this area. Persons who abuse
drugs often fail to provide a reliable,
complete or accurate history and staff
must therefore watch for and learn to
spot the physiological and psychological
effects of the various drugs and be alert
for possible complications.
Awareness of individual drug
idiosyncrasies allows the nurse to give
appropriate care. The patient who
presents while nursing staff are quite
busy, volunteering the information that
he has "just had a couple of beers and
would like to talk to someone", may
well be asked to take a seat for a few
minutes until someone is free to talk to
him. If the receiving staff member does
not notice that this patient is in a much
more intoxicated state than that
produced by a couple of beers, that he
has pinpoint pupils and is having
difficulty standing or walking, she may
find it necessary to call a cardiac arrest
to revive the patient who actually
ingested a large amount of barbiturates
or narcotics, as well as the beer, prior
to presenting.
Behavior modification
Training in behavior modification is
also important in controlling disruptive
behavior; staff members must
understand the basic concepts of
behavior analysis, why such behavior is
happening, and what they can do about
it. They must know how to reinforce
good behavior and how to decelerate
undesirable behavior, thus preventing
possible violence.
When a verbally abusive patient is
confronted and aggravated by an
inexperienced staff member, or perhaps
ignored by a staff member who feels
inadequate, he feels he is not achieving
his likely goal of receiving sympathetic
attention; in order to achieve it, he must
accelerate his abusiveness or perhaps
become physically violent. Staff
members should recognize that verbal
abuse is often a prelude to more
aggressive behavior. The most effective
way to deal with this behavior is to
inform the patient, using a modulated
tone of voice and maintaining eye
contact, that he must stop his abuse
(probably swearing) if he wants
someone to discuss his problem. If his
abusive behavior continues, nursing
personnel retire to the adjacent
observation room with a one-way
window, through which they can
continue to observe the patient, while
at the same time withdrawing all
obvious attention. Usually this process
will modify his behavior and he will
either stop the behavior in order to talk
with someone, or leave. When he stops
it is most important that staff respond
positively as a means of encouraging this
more acceptable behavior. Disruptive
behaviors that nurses may encounter in
the Emergency Department include:
manipulation
physical violence, either
threatened or real, and
self-destruction.
Manipulation can be frustrating
for staff to manage and difficult to
discern through assessment, depending
on the degree of sophistication the
patient has developed in the use of this
type of behavior. If manipulation is not
recognized early in the assessment and
responded to sensitively but firmly,
the situation may deteriorate rapidly
and violence may result from not
meeting the patient s demands. A staff
member, faced with an intoxicated
patient demanding an admission which
is not appropriate after medical
assessment, is in a good position to avert
possible danger. If the nurse is aware
that this particular patient s anxieties
stem from an earlier difficult
withdrawal, she can present a calm
explanation of an alternative plan
(probably sending the patient to a
detoxification center with prescribed
medication to alleviate withdrawal
symptoms) that will be acceptable to
the patient.
Threats of physical violence must
be taken seriously. Although a
one-to-one interaction is usually
preferable since the nurse is attempting
to help the patient with his problem,
team effort is necessary to prevent
physical harm occurring to one of its
members. All new staff members should
be alerted to the possibility of physical
violence should the nurse be unable to
defuse the situation. An observation
room with a one-way window that
allows other team members to observe
what is happening in the reception and
treatment areas is also valuable.
In conducting an interview with a
patient who has threatened physical
violence, the nurse should maintain
some distance between herself and the
patient, remaining behind the desk in
the reception area and not taking the
patient to the examination room until
she has had the opportunity to assess for
herself the seriousness of his threats.
Usually, behavior of this nature is
modified when the patient receives
assurance that he will be given help
after he calms down enough to discuss
the problem. If this does not happen
and the patient does attempt to harm
the nurse, the alternative of calling a
code is clearly indicated.
Sometimes, patients threaten to
harm themselves if their demands are
not met. This acting-out may be an
attention-seeking gesture or they may
actually be suicidal or psychotic.
Patients have been known to slash their
wrists, mutilate their arms or swallow a
bottle of pills before anyone could
intervene. If we are physically unable
to manage such a patient with the
number of staff on duty, we call a
Code 33 for assistance. The first doctor
to respond takes charge of the
treatment plan. He can order restraints
if necessary, 01 medication. A drug
screening is always done to determine
what drugs are present. Once the
situation is under control, a psychiatric
consultation is carried out to determine
appropriate disposition, for example
transfer to a psychiatric facility or
admission to our medical unit.
Maintaining a safe environment and
constant observation of such patients is
essential since they may decide to leave
the hospital once they are feeling better.
In order to provide an effective
treatment service for disruptive patients
as well as others who present, we have
had to work through many conceptual
changes using a trial and error process.
Through clinical experience, self-
examination of attitudes and feeling,
training in inter-personal skills, behavior
analysis and modification and updating
our program policies, we have succeeded
in improving the effectiveness of our
intervention.*
NEED HELP?
Advice and assistance are close at hand:
ALBERTA - Alberta Alcoholism and Drug
Abuse Commission, 5th Floor, Professional
Centre, 10050-112St., Edmonton, T5K1L9.
BRITISH COLUMBIA - Alcohol and Drug
Commission of B.C., Ministry of Health, Box
21, 805 West Broadway Avenue, Vancouver,
V5Z1K1.
MANITOBA - Alcoholism Foundation of
Manitoba, 1580 Dublin Avenue, Winnipeg,
R3EOL4.
NEW BRUNSWICK - N.B. Alcoholism and
Drug Dependency Commission, 103 Church
St., P.O. Box 6000, Fredericton, E3B 5H1.
NEWFOUNDLAND - Department of Social
Services, Confederation Building, St. John s
District Office, Harvey Road, Box 4040,
St. John s, A1C5Y6.
NORTH WESTTERRITORIES- Department
of Social Development, Yellowknife,XOE1 HO.
NOVA SCOTIA - Nova Scotia Commission on
Drug Dependency, 5668 South Street, 4th
Floor, Halifax, B3J 1A6.
ONTARIO -Addiction Research Foundation,
33 Russell Street, Toronto, M5S 2S1.
PRINCE EDWARD ISLAND -Addiction
Foundation of P.E.I., P.O. Box 37, University
Avenue, Charlottetown, C1A 7K2.
QUEBEC - Health Promotion Directorate,
450 St. Joseph Blvd. E., Montreal H2J 1J7.
SASKATCHEWAN -Alcoholism Commission
of Saskatchewan, T.C. Douglas Bldg., 3475
Albert Street, Regina, S4S 6X6.
YUKON -Department of Health, Welfare and
Rehabilitation, Box 2703, Whitehorse,
Y1A2C6.
The drug abusing
patient in ER
Kathy Chafer
Not all nurses receive specific instruction during their education on the short-term management of patients who present in
the Emergency Room with symptoms of drug abuse or withdrawal. Here, in chart form is a quick review of the basics of
nursing management for such patients: for more detail on exact clinical signs and symptoms, see/4 programmed learning
package by Marylou Gaerlan (page 35).
Abused Drug
Principle Symptoms
Nursing Actions
AMPHETAMINES
hyperactivity
general debilitation
- administer drugs as ordered,
usually diazepam
- allow patient to rest
give fluids to maintain hydration,
- monitor liver function tests
- approach with calm, empathetic
attitude
HALLUCINOGENS
behavioral such as
general euphoria or
psychosis
(symptoms vary with
specific drugs)
employ "talk down" intervention
through one-to-one interaction
promote relaxation and give
reassurance
monitor results of drug screening
tests
observe
BARBITURATES
difficult to assess since
abuse is often in tandem
with alcohol. Most
noticeable clinical sign
is drowsiness, disorientation
which may progress to
state of coma
gastric lavage on doctor s order
observe closely for signs of
respiratory depression
observe for withdrawal-patient
may have seizures if he is a
chronic abuser
OPIATES
of use: alternating
wakefulnessand
drowsiness, look of
intoxication
Heavy dose or overdose:
general depressed functions
withdrawal: cramps in
stomach and leg, nausea,
vomiting, irritability
like a severe case of flu
- observe closely
establish airway, position patient
on his side, suction and bag
until doctor arrives
be prepared for cardiac arrest
prepare injection of nalaxone
(narcotic antagonist)
treat symptomatically; symptoms
usually abate within 48-72 hours
Primary Nursing
Treatment that works for the
hospitalized drug dependent client
Eileen Fitz pat rick
Nancy G. (not her real name) is one of
six full-time nurses on 4S, the 15-bed
in-patient drug unit of the ARF s Clini
cal Institute. Her fellow workers include
three small-group therapists, four atten
dants, a nursing coordinator and a pro
gram director. Two physiotherapists, an
occupational therapist and a recreational
therapist are assigned to the unit part-
time. Medical coverage is provided by
the Out-Patient Department and, if
necessary, Emergency.
Nursing on 4S is structured on the
primary care model. This includes res
ponsibility and accountability on a
24-hour basis, planning, implementing
and evaluating patient care, giving direct
patient care and information sharing.
For Nancy, this means acting as
primary nurse for anywhere from one
to five patients, each of whom may stay
up to six weeks on the unit. When she
goes on shift, she also acts as associate
nurse for up to 15 clients. The drug users
and alcoholics on the unit range in age
from 15 to 30. Their backgrounds and
experience differ widely: Mark N. is a
15-year-old high school student in
trouble with his teachers and parents
because of cannabis use. John F. is 27, a
multiple drug user referred for treatment
by the courts.
The 4S program is based on a
social learning theory of behavior modi
fication; it incorporates a multiple disci
plinary approach consisting of small
group sessions, relaxation training, occu
pational therapy, leisure skills training
and a physical fitness program. Nancy s
role is three-fold: (1) to facilitate her
client s entry into this particular aspect
of the health care system; (2) to do an
in-depth medical and psychosocial assess
ment; and (3) to provide supportive
nursing care for the duration of his stay.
Case study
Robert S. is one of Nancy s clients. He
is a 29-year-old divorced male who has
been taking 500 mg of Demerola day
for the past two years. When he is ad
mitted, Nancy sees that he is quiet, with
drawn and visibly anxious in this new
environment. She begins therefore, in
conjunction with the admitting atten
dant, to familiarize him with the unit
and to let him know what will be expect
ed of him for the first few days. She ex
plains the ward rules, including a des
cription of the behaviors which will mean
automatic discharge from the unit.
Robert discovers that he is charged with
responsibility for his own behavior and
that participation in the program is also
up to him.
Within 24 hours, Nancy has com
pleted a nursing medical history and,
with Robert s help, drawn up the necess
ary care plans. Like most clients on the
unit, Robert is physically fit and able to
participate in all aspects of the program.
His physical complaints are minor -
toothache, colds, headaches, etc.
Assessment phase
In assessing the medical complaints of
the drug-dependent client, Nancy tries
to remember that these patients have
probably over-learned the use of medi
cation to deal with physical and emo
tional discomfort: 4S philosophy is based
on the belief that drug use is a learned
behavior. Many clients display a con
vincing set of somatic complaints in
order to obtain medication. Staff do not
respond to such requests with drugs, but
instead assist clients to develop a reper
toire of alternative responses to physical
complaints learned from understanding
the relationship between stress, tension
and physical discomfort.
Thus, when Robert says: "/ have
a terrible headache. I m getting a mi
graine. I can t go to the gym," Nancy
responds: "I noticed you just got off
the phone. Was the conversation up
setting?" She learns that Robert is upset:
"/ just found out I won t be able to see
my children for two years" and the two
of them attempt to generate ways of
dealing with his tension. As a result,
Robert feels his complaint is recognized.
He generates possible solutions and
meets Nancy s expectation of attending
the gym program, deciding that by att
ending gym he could decrease his tension
and relieve his headache.
The Canadian Nurse
November 1980 29
Psychosocial assessment occurs
over a four- to seven-day period, during
which the team tries:
to engage the client in a treatment
process by establishing a therapeutic
relationship.
to examine the drug history, iden
tifying patterns of drug use.
to examine lifestyles, identifying
behavior patterns directly or indirectly
related to drug use.
to identify reinforcing conse
quences of drug use.
to clarify the purpose of admission
by determining the clients goals with
respect to drug use and lifestyle.
to identify areas of potential treat
ment focus (both medical and socio-
behavioral).
Brief legal, sexual, marital and/or
family histories are obtained and incor
porated into the assessment if both the
primary nurse and client consider them
relevant. This information is obtained
through interviews and written assign
ments.
During this time, Nancy and
Robert work very closely together. The
information that she obtains and the
goals they set become the basis for
Robert s treatment. In the assessment,
the client is given full responsibility for
setting his own treatment goals. The
nurse simply provides him with the
necessary tools, a crucial step in foster
ing independence and self-determination.
Naturally, the degree of success varies
with the client. However, to be truly
therapeutic the nurse strives to provide
encouragement, support and guidance,
never to be autocratic at the expense of
her client s right to self-determination.
On-going care
The assessment completed, Robert is
invited to attend its presentation to the
4S team. He is then randomly assigned
to a small group and a small-group
therapist begins to work closely with
him developing strategies to meet the
goals defined in his assessment.
As long as he stays on 4S, Robert
will remain involved with small-group
therapy. He chooses the goals he wants
to work on each week and the therapist
assesses how well he is achieving his
goals, according to clearly defined cri
teria. Points are awarded for achieving
goals, participation in group and assign
ments. When Robert receives a certain
number of points, he is allowed privi
leges such as the right to remain in the
program and passes to leave the unit.
Although Nancy continues to
assume responsibility for Robert s medi
cal management, her contact is greatly
decreased, partly because of his increased
physical well-being but also because in
dependence, self-responsibility and self-
determination are measures of his suc
cess in the program.
Typically, the success of nursing
care is measured by the tasks the nurse
performs for her clients. On 4S, the
success of nursing care is measured by
the tasks that clients learn to perform
for themselves. Decreased contact with
clients indicates increased effectiveness
of care.*
Near the end of Robert s stay,
Nancy asks: "How are things going,
Robert?" and he replies: "Well, I have
a pass tomorrow to see a lawyer and
I m working towards re-establishing
contact with my parents and children."
Nancy: "I m very pleased to hear that.
How are your headaches?"
Robert: "/ haven t had one for a few
days and when I get one I usually work
out in the gym or use an ice pack. See
you later. "
Breaking the
cycle of abuse
Gwen Casselman
Taking drugs is a type
of learned behavior. If
the nurse-therapist can
help the client to analyze
his behavior, then to
gether they can establish
a treatment plan to
which the client is com
mitted.
30 November 1980
The Canadian Nuraa
Planning
The client s position on the
illness-to-health continuum is an
important variable to consider in
planning and implementing nursing
strategies. Clients with drug and/or
alcohol problems generally present in
one of the following four stages:
a) Physical crisis: the client is acutely ill
or physically injured as a consequence
of drug and/or alcohol misuse. Problems
might include drug/alcohol intoxication,
overdose, physical withdrawal, hepatitis,
gastritis, uncontrolled diabetes or
injuries from falls or fights. There may
be other problems not directly
associated with drug/ alcohol use, such
as pregnancy, tuberculosis, epilepsy, a
heart defect, asthma, and so on.
bj Emotional crisis: clients present for
treatment when they can no longer cope
with their fears, unpleasant memories,
guilt or stress. Acute anxiety and
depression are common. The request for
help is often precipitated by a
psychosocial crisis such as being without
a place to live, arrest, deterioration of
social relationships, loss of employment
or death of a loved one. Often these
clients choose to act in such a way (arm
cutting, overdose, overwhelming
physical or emotional complaints) as to
guarantee help without having to
overtly ask for it.
c) Decision making: the client thinks
that he would like to change the way he
uses drugs and/or alcohol because it is
simply creating too many other
problems for him. Many may indeed be
coerced by others to seek help for
their drug and alcohol taking behavior.
At this point, the idea of controlling
drug/ alcohol intake is just that an
idea! The client may be motivated but
he is not necessarily committed to
change.
d) Rehabilitative: The client decides to
do something about his drug and/or
alcohol use and seeks a specific program
of treatment.
The stage or combination of
stages in which the client presents often
dictates the type of treatment required;
as he moves through the various stages,
the focus of treatment will shift from
physical to emotional to psychosocial
needs, to the acquisition of knowledge
and skills and to the application of these
in real life situations. Generally
speaking, these needs are arranged on a
hierarchy and one set of needs must be
met before the next set can be
addressed. We see the progression of
planning nursing intervention according
to needs in the following case history.
Scenario
Mary Jane is an 1 8-year-old girl who
abuses oxycodone compound
(Percodan). She presents at hospital
in a tearful state, disheveled in
appearance, and complains of light
headedness, dizziness, nausea, vomiting
and constipation. During the initial
interview, the nurse learns that Mary
Jane has been asked to leave her family
home by her father. She does not know
where to go and feels very lost and
alone.
The physician says that Mary Jane
needs some blood tests and some x-rays;
the psychiatrist says she needs firm
support and an antidepressant; the
psychologist says that she needs to get
rid of the unconscious desire to punish
herself; the social worker says Mary
Jane needs to improve her self-esteem.
Mary Jane s mother accompanied her
to the hospital and says what Mary Jane
needs is a good spanking and a bath!
No one has yet asked Mary Jane
what she wants or, more specifically,
why she has come to the hospital.
In the admission interview, the
nurse observes the manner in which
Mary Jane and her mother interact.
The mother frequently interrupts Mary
Jane to confront her and to give her
unsolicited advice ; Mary Jane says little
and keeps her fists tightly clenched. The
physical examination reveals that Mary
Jane is a nail biter and has muscle
rigidity, especially in the neck and
shoulder area. Her pulse rate and
respirations are rapid but decrease to
within normal limits as soon as her
mother leaves the room. The nurse
notes that stress is a potential problem
area for Mary Jane and she identifies
confrontation, advice and interaction
with her mother as triggers to stress
behavior. Her basic care plan stipulates
that confrontation and direct advice-
giving are to be avoided while Mary
Jane learns alternate coping strategies.
Mary Jane s physical and
emotional complaints are known
manifestations of stress as well as
adverse effects of oxycodone
compound. The nurse shares this
opinion with Mary Jane and proceeds
to demonstrate a simple deep breathing
exercise. Mary Jane tries it and
experiences a sense of slowing down:
she feels relaxed after a few breaths.
The fact that Mary Jane has cooperated
with this request is encouraging; it
means she will probably comply with
future treatment strategies, and because
she has had some success, she is more
likely to be committed to working on
her problem. Next, the nurse assists
Mary Jane to take a warm bath which
further relaxes her; when she looks at
herself in the mirror at the end of the
admission procedure, she feels good and
is ready to rest.
The first nursing action now that
Mary Jane is hospitalized, is to prepare
for potential physical and psychological
withdrawal from oxycodone compound.
The nurse keeps Mary Jane as
comfortable and quiet as possible,
eliminating unnecessary noise which
might disrupt her rest. Mary Jane is
visited regularly but not aroused which
serves to reassure her of the nurse s
availability while affording opportunity
for observation of her physical and
mental state.
The Canadian Nurse
November 1980 31
ANTECEDENTS
BEHAVIOR
CONSEQUENCES
Isolation of self
from peers
Loneliness
Boredom
Fear of being
disliked by peers
Complains of
headache every
evening between
21:00- 01 :00hrs.
Talks to nurses for
longtime periods,
thus reducing loneliness
and boredom
Avoids attempting to
joio others in T.V.
lounge. "You can t
watch T.V. when your
head is pounding."
Forgets headache while
talking to nurses about
more pleasant things such
as music, travel, reading,
etc.
The next day Mary Jane seems
more relaxed ; she smiles more and
interacts pleasantly with staff, and there
is a dramatic decrease in physical
complaints. This positive behavior is
reinforced, thus promoting a sense of
achievement towards the goal of
improved health.
Evaluation
The nurse begins to identify possible
clues to Mary Jane s drug-taking
behavior. Assessment could include a
lack of assertive ness, inadequate coping
mechanisms, pain, stress, frustration,
fear, unpleasant memories, negative
feelings about self and others or a
general feeling of hopelessness.
Given that oxycodone compound
is an analgesic, the manner in which
Mary Jane experiences and deals with
pain in hospital will provide clues as to
how she misuses the drug. Nursing
staff monitor any request for
medication or complaint of pain,
keeping in mind certain factors such as
her facial expression at the time of a
complaint is it compatible with
physical discomfort? Does the
discomfort get better or get worse with
time? Do others sympathize with her?
The monitoring process is
explained to Mary Jane and she is
encouraged to keep her own daily
record of antecedents and consequences
of complaint and request behavior.
She is asked to note situations, events,
feeling states and social activities which
lead to a reduction or increase in pain
behavior including the taking of
medication. Baseline patterns are then
determined, facilitating easy
recognition of any changes as Mary Jane
progresses through the decision-making
stage.
By studying her daily record,
Mary Jane can identify a relationship
between pain and stress, as well as
between stress and requests for
medication. She notes that stress, pain
and request for medication increase
before visits with her mother; in general
Mary Jane s reports are congruent with
staff observations of her behavior in a
variety of situations.
Mary Jane has entered boredom
and feeling of loneliness on her daily
report sheets as antecedents to
complaints of severe headache during
the hours of 2 1 :00 and 1 :00. The
nurse and Mary Jane discuss the pattern
as follows:
Because Mary Jane has been
practicing application of behavior
analysis to common, everyday behaviors
(such as putting on a sweater when she
feels cold, turning up the air
conditioning when she feels hot) she is
able to transfer the method of analysis
to her behavior in more stressful
situations. She does not know how
much her head really hurts when she
complains but she knows that
sometimes it hurts more than others.
What is clear to her at this point is
that such things as boredom, loneliness
and fear that others won t like her serve
as cues to complain to the nurse about
headache in this situation.
The talks with the nurse do make
her feel better and serve as a substitute
for being with the other clients;
however, Mary Jane would like to watch
T.V. and sometimes she would like to
be with the other clients. Obviously,
there is a gap between Mary Jane s
present situation and where she would
like to be.
Effective use of relaxation
exercises, conscious thought control and
assertiveness training could fill this gap.
With the nurse, Mary Jane practices
relaxation and imagines how she would
like to present herself as she enters the
T.V. lounge. She makes a list of
different things she could say and
practices a variety of ways to enter the
room and take a seat with the nurse
providing feedback. Mary Jane applies
this practice the next afternoon when
the T.V. lounge is less crowded; once
she feels comfortable with the
afternoon situation, she plans to try it
during the evening hours.
MARY JANE S PRESENT SITUATION BLOCKING AGENTS
Alone in room or talking to nurses
between the hours of 21 :00 and 01 :00
1. Feels anxious when she anticipates
walking into the crowded room
2. Worries that others won t accept her
3. Does not know where to sit or what
to say
WHERE MARY JANE WANTS TO BE
Sitting in T.V. room with other clients
watching movies and the Johnny Carson
Show
32 November 1 MO
The Canadian Nurse
Behavior analysis of drug use
ANTECEDENTS
REINFORCING CONSEQUENCES
Within 1/2 hr. of
awakening each day
thinks, "If I don t
take the pills, I m
going to get a lot
of pain."
Takes Percodan
2 tabs.
regularly
every 3 - 5 hours
throughout
the day
Avoids/reduces pain and physical
discomfort
Feels relaxed
Spends hours alone fantasizing
about a better way of life
Other people leave her alone and
don t expect too much from her
because she is sick .
Feels anxious,
pressured during
waking hours
Terminates situation by getting
sick .
Before leaving house
When others advise her
When confronted
If involved in an
argument, when
others yell, argue
When feeling hurt,
rejected by others
Increases use
of oxycodone
compound, up to
a total of 25
tabs, per day
Too sick to work, go out, to be
around others.
As Mary Jane starts making
decisions and taking action to reduce
her immediate problems, she is ready to
consider her future drug use. She
notices that she "looks good and is
thinking more clearly". Relaxation
strategies are being used successfully,
not only to reduce pain but also to
prevent stress in unpleasant situations -
all of these factors are positive
incentives to change.
Analysis of behavior
Mary Jane completes a behavior analysis
of her oxycodone compound abuse and
the nurse adds to the analysis by
providing information from her
observations. Then the nurse and Mary
Jane meet with her mother; it is Mary
Jane who explains her plans to, and
shares the behavior analysis with her
mother and her mother in turn adds to
the analysis. She is obviously pleased
with Mary Jane s progress so far.
We now have a fairly clear pattern
of how Mary Jane was abusing
oxycodone compound prior to
admission.
This analysis demonstrates how
Mary Jane was locked into a cycle of
taking Percodan, not just to relieve
pain, but to avoid pain, physical
discomfort and generally stressful
situations: she learned to use drugs as
an avoidance-coping mechanism. Others
expected less of her, consequently she
did less and the entire pattern
reinforced her negative feelings about
herself.
The pattern created other
problems for Mary Jane such as
decreased mental functioning,
deterioration of personal relationships,
unemployment and depression, but
experience has shown that awareness of
these problems associated with drug
abuse is not enough to bring about a
change in the abuser s behavior. They
can, however, serve as incentives to
change. The question to be answered
then is "what fills the gap between using
drugs to reduce and avoid stress and
living a drug-free life without excessive
stress?" As long as Mary Jane keeps
telling herself that she can t cope, she
won t. She will continue to use drugs
and hope for a miracle a man,
winning a lottery, any chance to start
over again. The more choices Mary Jane
perceives she has in a given situation,
the less likely she will be to resort to
drug use. To have more choices, she has
to broaden her repertoire of daily living
skills. As she moves into the
rehabilitation stage she defines learning
to live independently of others as her
general goal. This is broken down into
smaller steps:
learning self-control strategies
abstinence from psychotropic
medication
controlled use of alcohol and
over-the-counter medications
further development and use of
relaxation techniques
social skills training (assertiveness)
further development of problem
solving skills
learning to use leisure time
constructively
improving physical fitness.
Eventually, Mary Jane chooses a
live-in program for younger drug users
based on social learning principles and
focused specifically on skill
development. The program has a policy
restricting the use of psychotropic
medication which appeals to Mary Jane
because she will have the opportunity to
develop other ways of dealing with
physical and emotional complaints in a
setting where the temptation to use
drugs is minimal. Gradually, she will
learn other ways of responding to the
cues to use drugs. The pay-offs of her
drug use were negative incentives in
that she was able to avoid unpleasant
situations but as she develops life skills,
the need to avoid such situations will
be reduced as she feels increasingly
confident. Eventually, she will learn
to enjoy social activities and
relationships.
Long term goals for Mary Jane
include improving her relationship with
her parents, setting up housekeeping
in her own apartment and finding
suitable employment. The in-patient
phase should be completed within six
weeks, but the rehabilitation stage will
continue beyond discharge.*
Bibliography
1 Bandura, A. Social learning
theory. Englewood Cliffs, N.J.: Prentice
Hall; 1977.
2 Berni, Rosemarian; Fordyce,
Wilbert. Behavior modification and the
nursing process. St. Louis: Mosby; 1977.
3 Fuller, Sarah S. Holistic man and
the science and practice of nursing.
Nurs.Outlook. 26(11): 700-704; 1978
Nov.
4 Goldfriend, M.;Davison, Gerald C.
Clinical behavior therapy. New York:
Holt, Rinehart, Winston; 1976.
Kendall, Philip C.; Hollon, Steven
D. Cognitive behavioral interventions:
theory, research and procedures. New
York: Academic Press; 1979.
6 Miller, Judith Fitzgerald. The
dynamic focus of nursing: a challenge to
nursing administration. J.Nurs. Admin.
10(1): 13-18; 1980 Jan.
7 Thoresen, Carl E. Behavioral self
control. Toronto: Holt, Rinehart,
Winston; 1974.
The Canadian Nurse
November 1980 33
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NAME,
INSTITUTION (IF APPLICABLE)
ADDRESS
PROVINCE
POSTAL CODE
Living and
working with drugs
Marylou Gaerlan
Do you know what "angel dust" is? The symptoms of morphine withdrawal? How "cross tolerance
affects drug consumption? A working knowledge of frequently used and abused drugs, the effect of
short term or chronic use on the individual, is essential for today s nurse as chemical dependency
becomes increasingly common. To help you brush up, here is a programmed learning package that will
test your assessment skills. First, read through the information section provided for each drug, then
with your hand covering the answers in the right hand column, read the questions and try to answer
them. When you re finished, you may want to take advantage of the tearout format and save the
package for future reference or pass it along to some of your co-workers.
I DEFINITIONS
A DRUG is any substance which when taken into the body may alter one or more of its functions. Contrary to popular
belief, drugs do not refer only to prescription drugs, over the counter drugs or street drugs but also social drugs.
Anyone who smokes cigarettes; drinks coffee, alcohol, tea, cocoa or cola; eats chocolates or takes laxatives, antibiotics
or tranquilizers has ingested a drug.
DRUG USE means consumption of a drug; a "drug user" therefore is just about everyone.
DRUG MISUSE refers to the occasional inappropriate use of either a social or a prescription drug. Having too
much to drink at a party is something we condone; however, from a nursing and medical viewpoint this is unhealthy
behavior and would be seen as drug misuse. Illegal drug taking is also drug misuse by virtue of its inappropriateness.
DRUG ABUSE is the use of any drug to the point where it interferes with an individual s physical and mental
health or with his or her economic and social adjustment.
A drug is anything that modifies one or more functions of the body. Name three socially acceptable
drugs used for recreation.
Mrs. Brown drinks 10 cups of coffee, smokes a pack of cigarettes a day, drinks wine at dinner,
occasionally becomes intoxicated when she is worried and takes Valium mgm prn for anxiety, but
never more than prescribed. She is a:
drug misuser ( )
drug abuser ( )
caffeine
nicotine
alcohol
(X)
( )
The Canadian Nurse
November 1980 35
DRUG DEPENDENCE is a psychic and sometimes physical state which results from the interaction between a living
organism and a drug. It is characterized by several behavioral and physical responses which include a compulsion to take
the drug on a continuous or a periodic basis in order to experience its effects and often to avoid the discomfort of its
absence. Many hypotheses based on the notion of an underlying character disorder that amplifies immediate gratification
despite long term ill effects have been formulated in an attempt to explain the cause of drug dependency. Other
circumstances that may contribute to an individual s dependence on drugs include:
delinquent deviant behavior
an attempt at self-medication to relieve psychic or physical distress
a desire to enhance human faculties
drug use as a means of achieving social acceptance
a manifestation of a drug induced lesion
rebellion against conventional social values
acquired behavior, or
socio-cultural pressures.
PSYCHOACTIVE DRUGS are those that alter sensation, mood, consciousness or other behavioral functions. All
psychoactive drugs have multiple effects which depend on the dosage, one s past experience with drugs, expectations
of what the drug will do, the environment in which the drug is taken, the user s age, sex, state of health, body weight,
genetic complement and the presence of other drugs.
Mr. Klein is a 46-year-old man of German origin who weighs 88 kilos. Drinking a 12 pack of
beer does not intoxicate him but Violet, a 22-year-old girl half his weight becomes dizzy and
drowsy after drinking two glasses of wine and consuming two cold pills. What are some reasons
for the different reactions of Mr. Klein and Violet?
presence of other drugs
genetic difference
age
sex
state of health
body weight
DRUG EFFECTS vary with time and the amount of the drug consumed. CUMULATIVE EFFECTS are produced when
repeated dosages of the same drug result in an increase in the normal or expected response. ADDITIVE EFFECTS or
compounding drug effects refer to the result of administering or consuming different drugs that combine to act on the
same system.
TOLERANCE develops when the response to the same dose of a drug decreases with repeated use. Metabolic
tolerance which refers to the body s increased ability to break the drug down and deactivate its constituents more
rapidly and cell or tissue tolerance which is the adaptation of CNS cells to a substance, are the two primary types of
tolerance. Other forms include: acute tolerance, seen in individuals who are frequently under the influence of alcohol
or morphine and perform better as the blood levels are falling rather than rising; behavioral tolerance, a phenomenon in
which frequent users of a particular drug act in a way not possible for a novice user; and cross tolerance, when an
individual who is tolerant to one drug shows tolerance to another.
Alcohol compounds the effects of barbiturates.
True ( )
False ( )
Mrs. Gray has to take more and more Seconals so that she can sleep. She has developed
The first time 18-year-old Susan drank a cocktail, she became dizzy. Six months later she could drink
two or three without getting dizzy; she had developed Mr. White is a heavy drinker.
When he had surgery, the anesthetist had difficulty putting him to sleep. He had developed:
acute tolerance ( )
cross tolerance ( )
tissue tolerance
metabolic tolerance
( )
(X)
The Canadian Nurs*
WITHDRAWAL is the rebound image of dependence experienced when drug levels in the blood drop after a drug is
withdrawn and compensatory mechanisms cause a temporary overactivity of the cells. Symptoms of withdrawal can be
prevented or relieved by giving a drug which is pharmacologically equivalent to the drug from which the individual is
withdrawn. This is referred to as CROSS DEPENDENCE.
Mr. Black comes to the emergency department anxious, trembling, nauseated, flushed and
tachycardia. He is a known alcoholic but has run out of wine, as this is election night and all the bars
and liquor stores are closed. He is suffering from
An alcoholic who takes barbiturates and becomes addicted to them is said to be
to the barbiturates.
withdrawal,
cross dependent
II DRUGS AND THEIR "EFFECTS"
A. Narcotic Depressants
MORPHINE, an opiate, is used clinically as an analgesic. Acute intoxication is manifested by a decrease in
consciousness, respiratory depression, cyanosis, hypotension, pin point pupils, hypothermia and flaccid muscles. With
prolonged use, a marked physical and psychological dependence develops rapidly. Tolerance to respiratory depression
and analgesic and euphoric effects ensues and constipation becomes a problem. A cross tolerance to all other narcotics
and analgesics also develops but will largely disappear after withdrawal.
Symptoms of withdrawal can be described within a time frame: eight to 12 hours after the last dose, lacrimation,
rhinorrhea and yawning are evident; from 12 to 14 hours, a restless sleep or yen may be noted; and from 48 to 72
hours following the last dose, pupils may be dilated, the individual restless, irritable and anorexic and
goosef lesh skin may be evident. Generally, withdrawal from morphine results in complaining and even begging behavior,
insomnia, nausea, vomiting, cramps, diarrhea, tachycardia, hypertension, weakness, hot and cold flashes, muscle spasms
and kicking behavior. These symptoms usually disappear in seven to 10 days.
Mr. Gray, who has had several back operations, has taken narcotics and analgesics for pain for the last
two years. During his most recent admission, the pain was so severe that he was given Morphine 15
mgm every three to four hours. When he began to ask for the injection more frequently and was told
to wait, he became quite abusive. Mr. Gray may have developed and .
dependence, cross-tolerance
HEROIN (Diacetyl Morphine), a popular street narcotic, is seldom seen clinically in North America. Acute and chronic
intoxication and dependence are similar to the clinical manifestations of morphine.
LAUDANUM and PAREGORIC are opium derivatives used clinically for diarrhea and dysentery. While the.
manifestations of intoxication, dependence and withdrawal are similar to those of morphine, they are much slower in
progression and milder in nature.
DILAUDID (Dihydromorphone, Hydromorphone) which has been largely replaced by newer drugs is still used for
severe pain because of its morphine-like qualities. Clinical manifestations of intoxication and withdrawal are similar to
those of morphine.
PERCODAN (Oxycodone), a widely prescribed oral analgesic, also has symptoms of intoxication and withdrawal
similar to those of morphine.
LEVODROMORAN (levophanol tartrate) a narcotic synthetic used as an analgesic, closely resembles morphine
but has a greater potency and longer duration of action.
Sally has been taking medication for pain, mostly narcotic analgesics, for about six months.
One evening the pain is so severe that she takes Percodan in combination with gin. When her
husband returns home and finds her unconscious, he checks her medication and determines that
she must have taken 16 tablets within an eight-hour period. In addition he suspects she has
also taken Aspirin and Bufferin.
What signs do you look for on admission?
., and
alteration in consciousness,
respiratory depression,
cyanosis, hypotension,
pin point pupils, hypothermia,
flaccid muscles
The Canadian Nurse
November 1980 37
METHADONE which is used as treatment for narcotic abstinence syndromes and in maintainance therapy of opiate
addicts, has symptoms of intoxication and dependence similar to those of morphine. However, tolerance develops more
slowly and there is less constipating effect. Withdrawal is also like that of morphine but less intense and more
prolonged, beginning on the third day, peaking on the sixth and minimal between day 10 and 16. Lethargy and
anorexia may exist.
CODEINE is a mild analgesic and antitusive drug which is usually combined with ASA. Opiate dependent persons
use codeine containing preparations because of their availability. Symptoms of acute intoxication are milder than those
of morphine, as is withdrawal. Chronic use is manifested by tolerance, dependence and constipation.
DARVON (propoxyphene hydrochloride), a mild analgesic is very similar to codeine but is not under the narcotic
control act. Its abuse commonly begins through prescriptions, occupational contact or the illicit market.
TALWIN (pentazocine lactate or hydrochloride) an analgesic used widely in clinical areas, is usually abused
through liberal prescriptions and underestimation of its abuse potential. Acute intoxication causes sedation, sweating,
dizziness and nausea; overdose is manifested by respiratory depression, hypertension and tachycardia. Chronic use
results in dependence and tolerance, although tolerance develops more slowly than with most other analgesics and
creates no cross tolerance with opiates. Withdrawal symptoms include abdominal cramps, chills, hyperthermia,
vomiting, lacrimatioh and craving.
Mr. White took Talwin 50 mgm every four hours prior to and following orthopedic surgery a year ago.
Now when he insists that he needs an analgesic, his doctor prescribes a placebo instead. What signs
may occur as he withdraws from the drug?
abdominal cramps, chills, fever,
vomiting, tearing, craving.
( )
( )
(X)
Sudden abstinence from methadone causes withdrawal symptoms in:
12-24 hours ( )
24-72 hours ( )
72- 144 hours ( )
DEMEROL (meperidine hydrochloride), NISENTI L (alphaprodine hydrochloride) and LERITINE (anileridine), are
very effective short -acting oral analgesics commonly used in the clinical area and consequently abuse of these drugs
usually occurs among health professionals. Respiratory depression is a sign of acute intoxication, while chronic users
may anticipate tremors, twitches, dilated pupils, hyperactive reflexes and convulsions. Physical and psychological
dependence develops like that of morphine but tolerance develops more slowly. Withdrawal, similar to that of
morphine, but shorter, begins in three hours, peaks at eight to 12 hours and ends in three to four days, with little
nausea, vomiting or diarrhea. However, muscle twitching, restlessness and anxiety are all worse than with morphine
withdrawal.
You notice that meperidine is ordered much more frequently than any other drug in your supply
cupboard. One day you notice that one of your colleagues is extremely anxious and restless and some
of her facial muscles are twitching. What would you suspect? and
meperidine addiction, withdrawal
38 November 1980
The Canadian Nurse
B. Hallucinogens
MARIJUANA, HASHISH and CANNABIS (tetrahydracannabinol) have been used clinically to reduce intraocular
pressure and more recently to reduce nausea and pain in terminal malignant conditions. Acute intoxication is mild with
no fatal result; tachycardia, corneal congestion, dryness of the mouth, dizziness, nausea, craving for sweets,
disconnected and free flowing ideas, disturbances in time perception, hallucinations, feelings of exultation, excitement
and joyousness, uncontrolled laughter, sometimes panic states with delusions and distortion of reality may all result.
Dependence is manifested psychosocially rather than physically and tolerance is moderate. Withdrawal occurs on the
third day of abstinence and is manifested by restlessness, insomnia and dysphagia.
LSD (lysergic acid diethylamide), once used in psychiatric settings, is now most commonly seen clinically in
research areas. A drug that has been abused in the streets, symptoms of acute intoxication of LSD include illusions,
hallucinations, delusions and other altered states of consciousness with feelings of euphoria or dysphoria, dilated
pupils, hypertension, tachycardia, tremors, nausea, piloerection, hyperthermia and muscle weakness. Chronic use results
in memory impairment with extreme passivity and loss of aggression and flashbacks. Tolerance levels increase rapidly
with repeated daily doses but return to normal after a period of abstinence.
MESCALINE (peyote cactus), PSILOCY BIN (sacred mushroom), ISOLYSERGIC ACIDAMIDE (mexican
morning glory), DIMETHEL TREPTAMINE (DMT), and DIETHYLTRYPTIME (DET) are all much like LSD but their
effects are much less potent.
MDA-34 (methylenedioxyamphetamine) combines some of the characteristics of mescaline and amphetamines.
Symptoms of acute intoxication with low doses include dilated pupils, hypertension and tachycardia, while higher
doses produce hyperthermia, diaphoresis and muscular rigidity. A sense of well being and increased tactile sensation are
also common with low doses, with higher doses resulting in illusions and hallucinations.
DOM or STP (215 dimethoxy-4-methyl-amphetamine) is used in research and is found in the illicit market. Acute
intoxication produces mild euphoria and enhancement of self awareness without perceptual distortion or hallucination.
PCP (Sernyl) an animal tranquilizer used in veterinary medicine has become a street drug known as "angel dust",
"peace pill", "hog" or "horse tranquilizer". Acute intoxication with this drug varies in severity according to the dose
consumed and the individual reaction. Resembling the toxic effects of stimulants, narcotics, general depressants and
hallucinogens in any combination, PCP frequently produces toxic psychosis which can culminate in convulsions, coma
or death. Chronic use results in anxiety, depression and flashbacks.
Since your teenage brother has come home this evening he has been laughing a lot, has eaten all of
the cookies in the cookie jar, keeps rattling from subject to subject and is just not his usual
coordinated self. What would you suspect he has taken?
marijuana
C. Stimulants
TOBACCO (nicotine) has no known clinical use but its abuse is world wide. Personal, social and economic factors all
influence its sustained use. Mild and temporary dizziness, nausea and weakness are considered signs of acute toxicity
while chronic effects are linked to cardiovascular, pulmonary and neoplastic disease. Severe physical, psychological and
social dependence usually develops, tolerance is moderate and withdrawal symptoms include craving, irritability,
hyperphagia, lassitude, agitated depression and mild confusion.
COCAINE, mainly used as a local anesthetic in the past is now increasingly abused outside the clinical setting,
with its use being sustained by personal and peer group pressure. Acute effects include excitement, anxiety, confusion,
headache, hypernausea, vomiting and convulsions and chronic use is marked by toxic psychosis with hallucinations,
delusions and paranoia. While dependence is mainly psychological, withdrawal consists of lassitude, headache and
fatigue.
The Canadian Nurse November 1 980 39
THEOPHYLLINE, CAFFEINE, THEOBROMINE (tea, coffee, cola drinks, cocoa) are the most popular, widely
used and most socially tolerated of all drugs. Clinically the active ingredients are used as cardiac stimulants, respiratory
stimulants and diuretics. Acute toxic effects consist of tension, restlessness and insomnia and chronic effects include
cardiac arrhythmias, palpitation, tachycardia, diarrhea (coffee) and constipation (tea). Dependence is predominantly
psychological, tolerance is moderate and withdrawal consists of headache and fatigue.
AMPHETAMINES (Ritalin, Benezidrine, Dexedrine, Methedrine) are used clinically for the treatment of
narcolepsy and hyperkinetic children and are commonly known on the street as "speed". Acute intoxication is
demonstrated by restlessness, dizziness, tremors, irritability, insomnia, euphoria, confusion, aggression, delirium,
hallucinations, panic, headache, tachycardia, sweating, nausea, vomiting, diarrhea and psychotic symptoms. Chronic use
predisposes toxic psychosis with hallucinations, delusions and paranoia plus weight loss and dermatitis. Both physical
and psychosocial dependence are common, tolerance is very high and withdrawal symptoms come in the form of severe
fatigue, lassitude, hyperphagia, prolonged sleep and depression.
Recently your mother has been complaining about being restless and unable to sleep. These
complaints along with problems of constipation and occasional "racing heart", lead you to
r|iipstjnn her ahniit hf>r rnnsiimptinn nf ( nr
tea/coffee/cocoa
If you advise her to cut down her intake or abstain altogether, you should tell her to expect
, and
lassitude headache and fatigue
Four-year-old Jimmy is hyperkinetic and has been on Ritalin 10 mgm T.I.D. In order to
encourage Jimmy to take his pills his mother has always told him that it was candy and "good
for Jimmy". One day while his mother was busy in the kitchen, Jimmy busied himself in the
medicine cabinet and swallowed six Ritalin tablets. A few hours later when you receive
Jimmy anri hi<! mother in thp fimergpnry department y n " shnnlrl (ihjervp foi"
tremors irritability confusion
, , , and
aggression delirium, hallucinations,
tachycardia sweating nausea, vomiting
After Jimmy has been detoxified what behavior would you expect?
or diarrhea.
anri
lassitude, hyperphagia, prolonged sleep,
depression.
D. General depressants
ETHYL ALCOHOL (beer, wine, liquor) is the most widely used and most abused depressant throughout recorded
history. It has a wide range of clinical uses including as a solvent for other drugs and as a skin disinfectant. Acute
intoxication is exhibited by a disturbance of learned behavioral controls with loss of control of mood and emotion,
impaired judgment, concentration coordination, balance, speech, vision, reaction time, pain sensation and consciousness.
Chronic use leads to physical and psychosocial dependency and a wide range of progressive problems including damage
of the central nervous system, gastrointestinal tract and cardiovascular system. Cross tolerance with other general
depressants is common. Withdrawal symptoms consist of tremulousness, nausea, weakness, anxiety, perspiration,
cramps, vivid dreams, visual hallucinations, weakness, confusion, agitation, disorientation, grand mal seizures and
delirium tremens.
Mr. O Keefe, a 50-year-old man is admitted to the medical ward with a diagnosis of G 1 bleeding
and a possible gastric ulcer. You overhear his wife saying to him "I ve been telling you all these
years what drink would lead to, now look what s happened". Upon further questioning you
find that he has been on a 10-day-binge and had his last drink 12 hours ago. What can you
pxppot in thp next 17-48 hnurs?
tremulousness, nausea, weakness,
anxiety, cramps, perspiration, vivid
dreams, visual hallucinations, weakness,
confusion, agitation, disorientation,
possibly grand mal seizures or delirium
tremens.
anri
40 November 1900
The Canadian Nurse
BROMIDES (Bromoseltzer, Nytol, Sominex) have been used clinically as anticonvulsant sedatives since 1857.
Now available over the counter, acute intoxication is very rare but habitual users may experience impaired thoughts and
memory, drowsiness, dizziness, irritability, neurological effects such as tremor and uncoordinated thick speech, an
acne-like rash, anorexia, halitosis and constipation. In severe cases there may be delirium, delusions, hallucinations,
mania, lethargy and coma. Psychological dependence and moderate tolerance may develop and withdrawal symptoms
are similar to the chronic toxic effects.
CHLORAL HYDRATE, an hypnotic, gained fame outside the clinical arena, as the drug to be combined with
alcohol to produce the "Mickey Finn". Acute intoxication mimics barbiturate intoxication; chronic use produces
tolerance, dependence, gastritis, dermatitis and renal damage and withdrawal symptoms are similar to those of alcohol.
BARBITURATES (Veronal, Luminal, Mebaral, Amytal, Butisol, Nembutal, Seconal, Pentothal)
are used as hypnotics, sedatives, anti-convulsants and in the case of Pentothal, as an intravenous anesthetic. Acute
intoxication mimics that of alcohol in its early stages, however, severe intoxication leads to coma, respiratory
depression, hypotension, cyanosis, weak and rapid pulse and cold and clammy skin. Respiratory and renal
complications and death may result from a cardiopulmonary arrest. Thick speech, nystagmus, diplopia, strabismus,
ataxia, positive romberg, skin rashes, dependence and tolerance are all signs of chronic use. Withdrawal symptoms
which are like those of alcohol with a somewhat greater chance of convulsions, peak on the second to third day for
short acting barbiturates and on the seventh or eighth day for the longer acting drugs.
What signs would you observe for in someone who had been on prolonged barbiturate use?
thick speech, nystagmus, ataxia, positive
romberg, skin rashes, diplopia and
strabismus.
, and
SEDATIVE HYPNOTICS, such as Doriden (glutethimide) and Noludar (methyprylon), are frequently used
clinically. Acute intoxication mimics that of short acting barbiturates with less respiratory depression but more
hypotension and danger of circulatory collapse and physical dependence. Withdrawal symptoms are also like those of
barbiturates except that there is a greater tendency towards convulsions. Withdrawal-like symptoms may also occur in
individuals taking only moderate doses when dosages are reduced.
TRANQUILIZERS, such as Miltown, Equanil (Meprobamate) are used clinically as tranquilizers and create
effects similar to barbiturates. Benzodiazepines (Librium, Chlordiazepine), Valium (Diazepam), Serax (Oxazepam),
Dalmane (Flurazepam) are minor tranquilizers and are the most widely prescribed of all depressant drugs. As sedatives,
anti-convulsants and sedative hypnotics, they are used in the clinical management of a wide variety of conditions
including alcohol withdrawal and labor. Acute toxicity is less than with other depressants but additive effects occur
when these medications are used with other depressants. Elderly people are most susceptible with drowsiness and
lethargy as the most common effects. Chronic use leads to tolerance, dependence, stimulation of appetite, skin rash,
impaired sexual function, vertigo and menstrual irregularities. Withdrawal symptoms mimic those of long acting
barbiturates.
Mrs. Barnes, the mother of a five-year-old girl and two boys, three and one, was prescribed
Diazepam 5 mgm T.I.D. and 10 mgm hs, after complaining to her physician of vague aches, pains
and insomnia. After taking the medication for 10 months, she returns to the clinic with the same
complaints as well as dizziness, irregular periods and weight gain. She wants her prescription
renewed and increased. Mrs. Barnes is suffering from: withdrawal ( )
dependence { )
tolerance ( )
chronic toxicity ( )
acute intoxication ( )
Mrs. Smith, a 78-year-old lady, was becoming quite unmanageable on the geriatric ward.
Since her physician prescribed Valium 5 mgm Q.I.D., she has become quiet and sleeps most of the
time, even falling asleep during mealtime. She is suffering from: withdrawal ( )
dependence ( )
tolerance ( )
chronic toxicity ( )
acute intoxication ( )
(X)
(X)
(X)
The Canadian Nurse
NotrwntwrlMO 41
VOLATI LE SUBSTANCES (aerosols, commercial solvents, anesthetics) initially cause slurring of speech, loss of
coordination, lessening of inhibitions, dizziness, ataxia, diplopia and tinnitus. Hallucinations, hazy euphoria, muscle
spasms, marked behavioral changes and impaired perception and judgment are sometimes also experienced. As the
effects wear off, the individual usually feels drowsy and nauseated and there may be alterations in consciousness from
stupor to coma. Chronic use leads to tolerance, dependence, weight loss and damage to organ systems (lungs, bone
marrow, liver and kidneys). Most effects, however, are reversible upon cessation of use unless the drugs abused were
cleaning fluids or aerosol spray.
When emaciated 14-year-old Michael was found unconscious in the school yard, a plastic bag
was found in his pocket. He regained consciousness soon after but behaved in a bizarre manner,
even hitting the school nurse. The nurse suspects solvent abuse. What are the possible
physiological consequences for Michael? , ,
, and .
damage to lung tissue, liver, kidney
tissue and bone marrow.
Ill PSYCHO-SOCIAL PROBLEMS ASSOCIATED WITH DRUG ABUSE
1 . Avoidance mechanisms are commonly used by drug abusers in order to maintain their drug taking behaviors;
deception and denial are common among middle class "hidden" drug abusers. Frequently, counseling is made
particularly difficult when the addict develops the skill of manipulation, "gaming" others or "conning" them, forming
an almost impenetrable wall against counseling. "Rounding", the verbal ability to avoid unpleasant subjects, especially
when confronted, is another skill developed by many addicts.
2. Criminal activity, such as theft, prostitution and breaking and entering have long been associated with heroin
addiction and more recently physical violence has become linked to the problem. However, there are still large numbers
of addicts who do not engage in these activities.
3. Suicide is usually accidental, resulting from confusion or a semi-conscious state where the individual forgets how
much of the drug he has consumed. It may also occur as a result of contamination, where the drug has been mixed with
other drugs or toxic substances or may follow hallucinations and loss of judgment from "bad trips" and intoxication.
4. Child abuse is the result of an addict s inability to alter his lifestyle to accommodate children. He fails to make
responsible decisions concerning the child s needs and is incapable of meeting the child s needs if it means denying his
own. Consequently, the child is alternately pampered and neglected.
5. Chronic unemployment due to tardiness, constant absences and inability to perform a job occur because of
intoxication and apathy while under the influence of drugs. The addicted population have a higher incidence of
unemployment than the general population.
6. Family breakdown is inevitable due to the inability of the addict to maintain a close relationship by altering his own
lifestyle to accommodate someone else.
A mastery quiz is available from the author.
42 November 1980
The Canadian Nurse
Saneen. Because incontinent patients
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ith the Saneen
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The Saneen two-part
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Psychologically, this makes it
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The Saneen system is in
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! they have, we think you ll
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For additional inform
ation, complete and mail the
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^7 Mail to:
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^anBGn USOjane Street,
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Please send me more information on the Saneen two-part incontinence system.
Product only available in Eastern Canada.
NAME
TITLE
NAME OF INSTITUTION
ADDRESS
CITY
PROV.
POSTAL CODE
PHONE
aneen
"Saneen" Reg d T.M. Facelle Company Limited
Made in Canada for Facelle Company Limited
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\
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Understanding
the physiology
of alcohol abuse
Marylou Gaerlan
Four-year-old Johnny doesn t seem to
be growing as fast as his friends, he is
mentally slow, and although he is not a
downright ugly child, his face just
doesn t look right.
Mr. Peters, a 52-year-old man
comes to the emergency department
with frank hematemesis, his vomit
smells of alcohol.
Three days post-op, Mrs. Fox
spikes a temperature of38.8C. She
complains that her skin feels crawly
and that she is having nightmares.
Mr. Long, a 48-year-old man,
admitted to the medical unit with a
diagnosis of hepatitis, is described by his
admitting nurse as having wiry
telangiectasia, spider nevii and cigarette
burns on his skin.
What do these individuals have in
common? All four have medical
problems stemming from the
physiological consequences of alcohol
abuse.
Can you recognize an alcohol
problem and understand its occurrence?
Alcohol, the drug
Alcohol or, more specifically, ethyl
alcohol is directly absorbed into the
bloodstream from the G.I. tract. It is
rapidly absorbed from an empty
stomach but the rate of absorption in
this organ varies, depending on the
volume, character and dilution of the
beverage, the presence of food and the
time taken for absorption. In the small
intestine, absorption is extremely rapid
and independent of the above factors. It
is evenly distributed throughout the
body according to the water content of
the tissues involved, but more
specifically in organs where there is a
large blood supply, such as the brain.
Since increased fatty acid esterification
in vivo occurs with ethanol, its
molecules become small enough to pass
through the blood-brain barrier, making-
the central nervous sytem a veritable
target.
CLINICAL DISORDERS ASSOCIATED WITH ALCOHOLISM
CENTRAL NERVOUS SYSTEM
1. Acute Intoxication
2. Withdrawal
3. Chronic Alcohol Brain
Syndrome (Dementia)
4. Cerebellar Degeneration
5. Sleep Disorders
LUNG
1. P. Tuberculosis
2. Cold
3. Pneumonia
LIVER
1. Fatty Liver
2. Alcoholic Hepatitis
3. Laennec s Cirrhosis
Fetal Alcohol Syndrome
Impotence (Usually
Psychogenic)
DIETARY
Wit. Bj B 6 B 12
+ Fat Soluble Vitamins
+ Folic Acid, Amino Acids
Calcium and Magnesium
PSYCHIATRIC
1. Personality Disorders
a) Sociopathic
b) Passive-Aggressive
2. Alcoholic Paranoia
3. Alcoholic Hallucinations
4. Depression
5. Suicide
6. Other Drug Abuse
(sedatives, hypnotism,
tranquilizers, tobacco,
caffeine)
HEART
1. Alcohol CardiopathyV
2. Arrhythmias
Splenomegaly
Reflux Esophagus
STOMACH
1. Alcoholic Gastritis
Gastric Ulcer
Pancreatitis
Intestines
1. Drinker s Diarrhea
2. Folate Malabsorption
BONES AND JOINTS
1. Trauma (fractures)
2. Gout
Muscles
Myopathology
Peripheral Neuropathology
Adapted from Geoffrey Robinson, MD
Addiction Research Foundation
Approximately two percent of
alcohol ingested is eliminated in the
breath and urine, the remainder is
metabolized in the liver where the
following phenomenon occurs. Alcohol
dehydrogenase catalyzes a breakdown
of alcohol into acetaldehyde and
nicotineamide dinucleotide (NAD).
Acetaldehyde is further metabolized
into acetate. With the help of coenzyme
A , acetate enters the Krebs cycle. It
is eventually excreted by the lungs as
C0 2 and the kidneys as H 2 (See
figure one).
The liver is capable of
metabolizing one ounce of absolute
alcohol per hour without affecting the
nervous system, however, a daily
consumption of more than ten
centilitres of absolute alcohol, that is,
six bottles of beer, six 1 1/2 ounce shots
of liquor or 26 ounces of wine a day
increases the probability of physiological
damage.
1 . The Nervous System
Because of the vascularity of the brain
and alcohol s ability to cross the
blood-brain barrier, the central nervous
system is especially susceptible to
alcohol effects.
Alcohol exerts a depressant action
on the polysynaptic structures of the
reticular activating system and certain
areas of the cortex, particularly those
parts that control integration. Therefore,
taking large amounts of alcohol results
in a progression of perceptual,
functional and behavioral changes
known as acute intoxication.
When the blood alcohol level
(BAL) of an individual reaches
1000 mg/1, he tends to talk very loudly
and his social inhibitions are reduced.
With increasing BAL levels, his speech
becomes progressively slurred, he begins
to have mood swings and a decreased
attention span, his fine motor ability
Figure one: Metabolism of CjHjOH
Alcohol Acetaldehyde
(ethyl
alcohol) Dehydrogenase NAD
FIRST MOLECULE
Acetaldehyde
SECOND MOLECULE
coenzyme CO2 Lungs
Acetate >(Krebs Cycle) <^
A H 2 Kidneys
is depressed, his memory becomes
impaired and he assumes an unsteady
gait. On physical examination, you will
find a full, bounding pulse, dilated
pupils and a fine nystagmus at lateral
gaze.
When the BAL reaches 2000 to
3000 mg/1, the individual will exhibit
tremors, ataxia, stupor, irritability and
eventually unconsciousness. Death has
been known to occur at a BAL of
between 4000 to 7000 mg/1, depending
on the tolerance level. Acutely
intoxicated chronic alcoholics may also
suffer from alcohol amnesia or
blackouts , a short term memory loss
lasting for about three to five minutes.
When an individual drinks 150 to
250 grams (approximately 10 drinks) of
absolute alcohol daily for at least ten
consecutive days and then stops, a
period of hyperexcitability follows. This
rebound phenomenon of previously
depressed nervous tissue, is known as
withdrawal or abstinence syndrome and
is considered indicative of alcohol
dependence.
There are three stages to
withdrawal. The early symptoms peak
24-36 hours after the last drink leaving
the individual anxious, mildly
disoriented, easily startled and irritable
and complaining of anorexia, insomnia,
tremors and internal shaking . The
second stage, 48 hours until up to two
weeks after the last drink, is sometimes
marked by grand mal seizures. Finally,
the third stage brings the possibility of
delirium tremens. This stage which
tends to peak three days after the last
drink, lasts for about three days and
ends abruptly. The classical symptoms
include irrationality, visual and tactile
hallucinations, agitation, disorientation,
hyperpyrexia, tachypnea, hypercapnea,
diaphoresis and vomiting.
Acute brain syndrome may occur
as acute intoxication, delirium tremens
or alcohol hallucinosis. Chronic brain
syndrome, sometimes referred to as
dementia, on the other hand, has a slow
insidious onset, a progressive course and
is relatively irreversible because of
anatomical changes in the brain. Both
acute and chronic brain syndrome
present general symptoms such as
alterations in memory, impaired
judgment, lability, shallowness of affect
and alterations in intellectual functions,
including calculation, comprehension
and new learning.
Chronic brain syndrome, however,
is also associated with a diffuse loss of
functioning brain tissue manifesting
itself in behavioral symptoms. Early
symptoms are fatigue, listlessness, loss
of interest, depression, anxiety and
personality changes such as irritability,
social withdrawal, lack of consideration
for others, petulance or moral laxity.
These signs may be present for years
and the individual may be aware that
something is wrong but be unable to
identify it. In the later stages there
may be confusion, loss of memory for
recent events and general forgetfulness
with generally poor judgment. The
individual may be oversensitive, exhibit
psychotic symptoms like paranoia or
delusions of grandeur or use other
defence mechanisms such as
perserveration, denial, avoidance,
diversionary tactics and confabulation
to avoid anxiety over functional deficits.
In the terminal stage, the patient
exhibits mono-syllabic speech and loss
of motor and sphincter control. Death
occurs from intercurrent infection.
Peripheral neuropathy which is
commonly seen in the clinical setting is
probably due to nutritional deficiencies,
in particular those of the B vitamins.
Initial damage is seen in the Schwann s
cells which make up the neurilemma of
the most peripheral nerves. As the
neuropathy progresses, the conduction
velocity of the involved nerve will
decrease and eventually the neuron
located in the spinal cord will be
affected by the degenerative process.
The onset of peripheral neuropathy is
slow, taking from weeks to months.
The involvement is bilateral and
symmetrical, starting peripherally and
gradually progressing centrally. Initially
there may be pain in the calf muscles or
the feet, which may be associated with
numbness, burning, tingling or pricking
sensations of the lower extremities.
Later these symptoms occur in the
hands and arms, sometimes numbness of
the stocking/ glove type occurs. As the
neuropathy progresses there is muscle
weakness and wasting, paralysis of the
extremities, diminishing deep tendon
reflexes and a wide-based foot drop
gait. Speed of recovery which is based
on a treatment program of abstinence
from alcohol, a nutritious diet and
supplementary B vitamins, is rapid in
less severe cases and decreases according
to the severity of the neuropathy.
The type of cerebellar
degeneration seen with alcoholism is
unique. While no one factor has been
pinpointed as a cause, it has been
suggested that nutritional deficiencies as
well as the effect of the high levels of
acetaldehyde (the first byproduct of
alcohol metabolism) on the highly
sensitive cerebellum may play a role.
The condition may progress rapidly, and
become stabilized for years or may
begin slowly at first and deteriorate
rapidly during a period of stress. The
clinical manifestations consist of a
broad unsteady gait and stance with
movement severely impaired in the dark
when there are no visual cues; mild
tremor of the outstretched hand,
impaired coordination of fine finger
movements such as writing and slow,
slurred speech.
Sleep disturbances are a common
complaint of most alcoholics, whether
due to the biochemical effects of the
alcohol itself or the psychological
depression that frequently accompanies
the condition. Basically, alcohol tends to
suppress rapid eye movement (REM)
sleep. The problem is reversed when the
BAL drops as REM rebound occurs,
causing the periods of REM sleep,
dreaming sleep, to be extended.
Clinically the picture presented is one of
frequent wakening, restless sleep,
insomnia and night terrors.
2. Respiratory System
Chronic alcoholics are susceptible to
respiratory diseases as alcohol depresses
the central nervous system, thus
suppressing the cough reflex and
allowing the pooling of secretions.
Alcohol also impedes phagocytosis and
the immune response. Since many
alcoholics are also heavy smokers, these
problems are magnified. Commonly
occurring respiratory conditions include
chronic obstructive lung disease,
pneumonia, pleurisy, bronchitis,
emphysema and pulmonary tuberculosis.
3. Cardiovascular and Hematological
Systems
Alcoholic cardiomyopathy is manifested
primarily in the heart with little effect
on the remainder of the cardiovascular
system. Myocardial cells lose their
integrity and leak potassium,
phosphates, creatinine, creatine
phosphokinase (CPK), glutamic-
oxalacetic transminase (GOT), glutamic-
pyruvic transaminase (GPT) and lactic
dehydrogenase (LDH). The result is
depressed myocardial functioning which
is usually manifested as congestive heart
failure and/or arrhythmias. Earlier signs
include decreased exercise tolerance,
tachycardia, dyspnea or orthopnea,
edema and palpitations.
4. Skeletomuscular Systems
Excess alcohol produces potassium and
phosphate deficiencies thus inhibiting
the use of carbohydrates by muscle
cells. It also inhibits the active transport
of sodium, potassium and adenosine
triphosphatase. These effects may
produce alcohol myopathy in the
proximal muscles of the extremities, the
pelvis and shoulder girdles and the
muscles of the thoracic cage. In the
acute stage, there is muscle pain,
tenderness and edema, while in chronic
cases there is no history of pain, muscle
weakness progresses slowly and the
individual has difficulty climbing stairs
or getting up from a sitting position.
5. Gastrointestinal System
Digestive problems are common among
alcoholics; the following areas are
affected:
Esophagus. Reflux esophagitis
occurs as a result of local irritation to
the esophageal mucosa by alcohol
and hydrochloric acid following
vomiting or regurgitation. The
individual with an alcohol problem is
also predisposed to epidermoid
carcinoma of the esophagus and
esophageal varices can occur in
conjunction with liver disease.
Stomach. Erosive gastritis is an
inflammation of the gastric mucosa
resulting from alcohol ingestion as
alcohol reduces the mucosal barrier
leaving the stomach wall susceptible to
the erosive effects of increased levels of
acid. The individual displays symptoms
such as epigastric distress, nausea,
vomiting, distension and sometimes
episodes of upper GI ulceration and
bleeding.
Small intestine. Malabsorption
of substances including fat, xylose,
folk acid and Vitamin B 12 are the
main problems occurring in the small
intestine. These conditions arise because
of poor food intake, liver disease leading
to a decreased storage of folic acid, a
decrease in pancreatic enzyme and
direct inhibition of tissue utilization
of folate by alcohol.
Pancreas. Pancreatitis, an
inflammation of the pancreas, may be
acute or chronic. Acute pancreatitis
syndrome is clinically manifested by
upper abdominal pain, nausea, vomiting,
hypotension and an elevated serum
amylase and lipase concentration.
Although the exact cause of the
inflammation has not been determined,
some theorists speculate that: alcohol
causes an increase in pancreatic
secretion, spasm of the sphincter of
Oddi results in an increase in pancreatic
intraductal pressure, relaxation of the
sphincter of Oddi allows duodenal
contents to enter the pancreatic duct or
a change in the chemistry of the
pancreatic juices leads to calcification
and calculus formation.
Chronic pancreatitis may result
from the cumulative effects of the
above or perhaps the direct toxic
effects of alcohol on the pancreas. The
development of chronic pancreatitis is
insidious, sometimes without clearcut
attacks of pain, although patients may
complain of chronic pain which may
lead to analgesic or narcotic abuse.
Signs of exocrine insufficiencies include
weight loss, malnutrition and foul
smelling bulky stools, often with
diarrhea. Endocrine insufficiency can
result in diabetes. Pancreatic
calcification on x-ray and abnormal
pancreatic secretion tests are classic of
chronic pancreatitis. Pain is decreased
with alcohol abstinence but because
of its chronicity the condition is
usually irreversible.
Liver. As alcohol metabolism
takes place almost exclusively in the
liver, this organ suffers the largest
portion of abuse. Alcohol flooding in
the liver causes reduced glycogen
formation, increased production and
decreased oxidation of lipids, and
changes in the structure of the liver
cell. Some resultant conditions include:
a) fatty liver, due to the increased
amount of fat in the liver parenchyma.
This causes liver enlargement, mild
derangement of biological chemical
changes (liver function tests), some
nausea and abdominal pain. Frank
jaundice is unusual. Alcohol abstinence
completely reverses the condition both
structurally and physiologically.
b) alcoholic hepatitis is an active,
inflammatory necrotizing process which
involves loss of liver tissue and results
in scarring and fibrosis. It may be slow
and insidious in onset or acute, leading
to the development of cirrhosis or death
over a matter of a few weeks. Clinically,
alcoholic hepatitis is manifested by
hepatomegaly, jaundice, pain in the
right upper quadrant, elevated
temperature (102F), marked
leukocytosis and ascites. When ascites
is present, the abdomen is distended
with fluid, the intestines distended with
air and the umbilicus is everted. Veins
and white striae are visible on the
abdominal wall and the renal system
responds with a decrease in urine
volume and an increase in urine specific
gravity.
c) alcoholic cirrhosis, also known as
Laennec s cirrhosis, is seen in
approximately 40 percent of alcoholics
in North America. Other countries
report less (England, eight percent) and
others report more (France, 47.6
percent). It is marked by a disruption in
the normal structure and formation of
liver lobules and is irreversible as a result
of the scarring process. Clinical
manifestations are similar to those of
hepatitis but also include signs of portal
hypertension such as shunting of portal
blood around the liver and esophageal
varices. Hepatic encephalopathy
characterized by progressively
deteriorating mental alertness, hand
flapping, elevated temperature,
anorexia, increased jaundice, ascites and
fetor hepaticus (peculiar, sweetish odor)
may become a sequela of cirrhosis.
Nutritional Deficiencies. Alcohol
provides calories but has no nutritional
value. This, combined with the
corrosive action of the chemical on the
gastric mucosa and the fact that alcohol
inhibits absorption of thiamine, folic
acid, amino acids, Vitamin B 6 ,
Vitamin B 12 , fat soluble vitamins,
calcium and magnesium leads to
malnutrition. Signs and symptoms vary
depending on what nutrients are missing
but may include hyperventilation,
tremor, convulsions, bizarre movements,
confusion, disorientation, vivid auditory
and visual hallucinations, delusions,
stupor, and of course, heartburn,
nausea, vomiting, diarrhea and
constipation.
6. The Skin
Dermatological problems encountered
by the alcoholic generally result from
liver damage, peripheral neuropathy
and less than adequate nutrition.
Premature aging, dryness and itchiness
of the skin, wiry telangeictasia
(prominent capillaries), palmar
erythema (liver palms), spider
angiomata on trunk and face, breast
enlargement in men, Dupuytren s
contractures (contraction of palmar
facia causing the little finger to bend
towards the palm) and bleeding gums
are all typical problems of the chronic
alcoholic. In some instances, a lifestyle
of chronic neglect may result in
pediculosis, scabies, burns, bruises and
frostbite.
7. Reproductive System
While prolonged alcohol ingestion may
be a factor in secondary impotence,
Fetal Alcohol Syndrome is now the
major topic of concern in this area.
Fetal Alcohol Syndrome is caused
by alcohol crossing the placental barrier
from mother to fetus and may result in
gross growth deficiency in the infant.
Once thought to only be found in
babies born to chronic alcoholic women
it has more recently been determined
that moderate alcohol consumption can
also predispose the fetus to this
syndrome and as yet no safe level of
alcohol consumption during pregnancy
has been identified. The infant suffering
from this condition usually has a
birthweight somewhat less than would
be expected for his gestational age and
subsequent growth is approximately
two-thirds that of the normal rate. The
infant s head may be small in
proportion to his body, his eyes may be
undersized with shortened palpebral
fissures (micropthalmus), there may be
intraocular defects and ptosis of the
eyelids. In the extreme case, he may
have a small mid-face giving a flat
lateral facial contour, there may be a
cardiac septal defect and a cleft palate.
The crease pattern of his hands may be
altered and there may be minor joint
abnormalities, pectus excavatum
(pigeon-chest) and small nails.
Behavioral and coordination problems
are common. The child may remain
chronically physically handicapped and
his I.Q. may not improve with age. With
these problems the child may be
considered at risk for child abuse.
8. Trauma and Injury
The alcoholic is prone to accidents due
to intoxication. These vary from
slipping on the stairs at home and
fracturing ribs to cutting a hand at work
or in the kitchen; from spraining an
ankle to sustaining a head injury during
a fight.
Putting your knowledge to work
Recognizing the undiagnosed alcoholic
individual requires astute assessment
skills and a thorough knowledge of the
disease. Yet bringing the problem out in
the open is only half of the battle. The
chronicity of the disease of alcoholism
probably means that your patient will
keep coming back. Your knowledge and
understanding of what is happening to
him can make his hospital stays shorter
and hopefully his visits less frequent.
Bibliography
1 Burkhalter, Pamela. Nursing care
of the alcoholic and drug abuser.
Toronto: McGraw-Hill; 1975.
2 Estes, N.;Heineman,M.E., eds.
Alcoholism: development, consequences
and interventions. St. Louis: Mosby;
1977.
3 *Holt, Stephen. Biomedical
factors in identification of alcohol
abuse. (Unpublished paper).
4 *Johnson and Luckas. Medical
complications of alcohol abuse.
Committee of Alcoholism and Drug
Dependency, AMA 1973. (Young, A.W.
Cutaneous stigmata of alcoholism)
5 Phillips, Lome et al., eds. Core
knowledge in the drug field: a basic
manual for trainers. Ottawa: National
Planning Committee on Training,
Federal/Provincial Working Group on
Alcohol Problems; 1978.
6 *Zimmerman, MA. The nurse and
the alcoholic patient. Alcoholism Rev.
10(4); 1971 Aug./Oct.
*Not verified
AWS:
recognition and
rehabilitation
10
*/
Gregory S. Kolesar
Joanne M. Shaw
Mr. Smith, a 45-year-old male is
admitted to your unit for an elective
hernia repair. He works as an office
manager in a large manufacturing
company. On admission you think you
smell alcohol on his breath but when
you ask about his drinking habits, he
states he is a social drinker. At this time,
Mr. Smith is mildly anxious. He has
never been hospitalized before, and you
attribute this anxiety to the fear of
hospitalization and surgery. He has an
uneventful evening and night. In the
morning, you go to administer his
preoperative diazepam (Valium) as
ordered by the anesthetist. At this time,
he is moderately anxious, tremulous,
agitated and perspiring profusely. His
pulse is 110, his blood pressure is
140/100. What is happening to
Mr. Smith? What can you, as his nurse,
do?
The Canadian Nurse
November 1980 49
The exact frequency of alcohol
withdrawal experienced within a general
hospital population is unknown, but
recent statistics indicate that 30 percent
of patients can be expected to be
affected by some type of complications
of alcohol abuse. 1 In any case, alcohol
withdrawal is common and probably
under-diagnosed. Many patients are
treated for symptoms like those of
Mr. Smith s without recognition that
these symptoms are components of an
alcohol withdrawal syndrome (AWS).
The patient s major problem of alcohol
abuse is often not recognized and
appropriate rehabilitation steps are not
considered.
An abstinence or alcohol
withdrawal syndrome occurs when
alcohol is eliminated or the amount
normally consumed is decreased in
individuals who consume large amounts
over an extended period of time. The
syndrome occurs because of the
rebound excitability of the central
nervous system effects as alcohol, a CNS
depressant, is eliminated from the body.
Occurrence of this abstinence syndrome
indicates physical dependence on the
drug.
AWS is classified into minor and
major syndromes. The minor syndrome
occurs a few hours after cessation of
alcohol intake and lasts as long as 48
hours. The symptoms include tremor,
sleeplessness and irritability. Grand mal
seizures usually occur in the first sixty
hours after cessation of drinking and
typically are not the result of epilepsy.
The major syndrome, delirium tremens,
occurs 48-70 hours after cessation of
alcohol intake. The symptoms include
anxiety, agitation, disorientation,
diaphoresis and hallucinosis. The
traditional method of treating patients
with AWS has been pharmacotherapy.
In a study of patients with AWS
conducted at the Clinical Institute of
the Addiction Research Foundation of
Ontario, 67 percent of the patients
studied suffering from moderate to
severe alcohol withdrawal were treated
successfully with supportive nursing
care. 2 Other researchers have also
produced similar results in treating
patients in mild AWS. 3
To give appropriate supportive
care, nurses must recognize which
patients are at risk, which symptoms
comprise the total syndrome and which
nursing measures alleviate the symptoms.
Assessment at admission
In addition to obtaining current medical
and psycho-social histories upon
admission of an individual to hospital,
nurses must also assess alcohol
consumption (See figure one). The
statement that a patient is a social
drinker should not be accepted at face
value, rather the nurse should explore
the amount, frequency and pattern of
Figure one: Guidelines for Alcohol
Consumption History and Risk Factors
for AWS
1. Alcohol consumption in last week?
2. Alcohol consumption in last 24 hours?
3. Average daily consumption?
At risk for AWS if daily
consumption 9 oz spirits or
26 02 wine or
21 oz fortified wine or
6-12 oz bottles of beer
4. Continuous days of consumption at risk
levels in number 3.
At risk for AWS if greater than 7 days
5. Time since last drink.
-At risk for AWS 0-60 hours after
last drink if greater than risk levels
in number 3 and greater tharv
7 days continous drinking.
6. Any previous withdrawals, shakes, DT s?
(if at risk from questions 3, 4, 5.)
7. Any previous seizures?
(if at risk from questions 3, 4, 5)
alcohol use; Mr. Smith should have
been asked the questions in figure one
to determine his risk of developing
AWS. However, the nurse must
remember that alcohol dependent
patients do not generally give reliable
histories. Consequently, in addition to
taking the patient history, the nurse
must use his/her observational skills
and clinical judgment in assessing total
risk. If possible, blood alcohol or
breath alcohol concentrations should be
determined. If the readings are above
1000 mg/1 the patient would be
considered at risk for AWS. 4
Symptoms of AWS
In the study of AWS at the Clinical
Institute, 39 patients were studied and
their symptoms documented (See
figure two). The symptoms of tremor,
clouding of sensorium, agitation, quality
of communication, thought
disturbances, flushing of face and
seizures were assessed by clinical
observation. The symptoms of
headache, shakiness inside, and patient
feelings were assessed by patient report.
All other symptoms were assessed using
both patient report and clinical
observation.
All symptoms, except seizures,
were then rated on a continuum from
none, or mild, through moderate to
severe. Visual, tactile and auditory
disturbances, for example, were rated as:
not present
mild sensitivity to sensory stimuli
severe sensitivity to sensory
stimuli, or
severe hallucinations with
gradations between these ratings.
Anxiety accounted for the major
portion of the symptomatology, 63
percent. Tactile disturbances accounted
for 11 percent; tremor, eight percent;
visual disturbances, six percent; nausea
and vomiting, four percent; and a
clouding of sensorium, three percent.
The remaining symptoms were not seen
frequently, however the presence of
Figure two: Alcohol Withdrawal Symptoms, Percent
Method of Observation
of Total
Symptoms, and
Symptom
Percent of
Total Symptoms
Clinical
Patient report Observations
Anxiety
63%
X
X
Tactile Disturbances
11
X
X
Tremor
8
X
Visual Disturbances
6
X
X
Nausea and Vomiting
4
X
X
Clouding of Sensorium
3
X
Agitation
X
Temperature ( in AWS)
X
Pulse ( in AWS)
X
Respiratory Rate ( in AWS)
X
Blood Pressure ( in AWS)
X
Sweating
X
Auditory Disturbances
X
X
Hallucinations
5
X
X
Quality of Communication
X
Thought Disturbances
X
Headache
X
Flushing of Face
X
Seizures
X
Are you shaky inside?
X
How do you feel now?
X
50 November 1980
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PREFACE; FORWARD; INTRODUCTION
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9. Adopting a Conceptual Model:
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1 0. Clinical Examples
BIBLIOGRAPHY: GLOSSARY
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The Canadian Nurse
November 1980 51
Figure three: Supportive Nursing Care
systematized
^^- standardized
occurring at regular intervals
report to physician for
j^^- pharmacotherapy and
medical management
assessments
control of sensory stimuli
food and fluid intake
physical comfort
maintenance of normal body temperature
sleep and rest
elimination
rehabilitative _
seizures
fused hallucinations
hallucinations patient is acting on
arrhythmias
temperature 38.5C
medical complications
these often indicate a greater probability
of a need for pharmacotherapy.
Your observations of Mr. Smith
indicate that he has anxiety, tremor
and agitation which are three of the
most frequent symptoms of A WS. In
addition, he has an elevated heart rate
and blood pressure, and is perspiring,
three of the less frequent symptoms. If
his alcohol consumption history
indicates he is at risk, then you can
probably assess his condition as A WS.
Supportive nursing care
The ideal drug for the treatment of
AWS should not interact with alcohol,
should not have any addictive properties,
should be effective in the treatment of
target symptoms and should prevent
delirium tremens. Supportive nursing
care is not a drug, but it does meet the
first three criteria. In fact, current
literature and research, indicate that
supportive nursing care can help arrest
the development of delirium tremens.
Assessment of the symptoms,
outlined in figure two is part of the
supportive care because the process
provides a focus for interaction
between patient and nurse at regular
intervals. This nurse/patient
communication reassures the patient
about his present condition and serves
as a reorientation to time, place and
person.
Supportive care also includes
control of sensory stimuli by providing
a care area that is as private as possible.
This involves a reduction in light and
noise levels, and in the number of staff
members in contact with the patient.
Fluids such as milk and juice and soft
foods are given. Tea and coffee intake is
discouraged since the stimulant effects
may increase the severity of the AWS
symptoms. Methods of insuring physical
comfort, sleep, rest, elimination and
maintenance of normal body
temperature are implemented. Very
often during the supportive care, a
patient will say, "Once I get through
this, I ll never drink again." This is the
ideal time to introduce treatment plans
for his/her addictive disease.
52 November 1980
Research Foundation; 1979.
2 *Shaw, Joanne et al. Development
of optimal treatment tactics for alcohol
withdrawal: effectiveness of supportive
nursing care and pharmacotherapy.
1980. (In preparation for publication)
3 Whitfield,C.L. etal.
Detoxification of 1 ,024 alcoholic
patients without psychoactive drugs.
JAMA. 239(14): 1409-1410; 1978 Apr.3.
4 Morse, Robert; Hurt, Richard D.
Screening for alcoholism. JAMA.
242(24):2688-2690; 1979 Dec. 14.
*Not verified
Formulation of long term rehabilitation
plans is highly effective when plans aie
made in this controlled and stable
atmosphere. Of the 39 patients in the
study, all were referred for long term
rehabilitation; 21 have continued in
treatment after discharge.
In the study of AWS patients at
the Clinical Institute, assessments and
supportive care were given every half
hour up to every four hours. Other
studies are being planned to evaluate the
efficacy of supportive measures being
applied hourly. The nurse in the general
hospital should apply the care at regulai
intervals as the patient s condition
dictates. The importance of this care is
that it is systematized and standardized,
and reassuring to the patient who can
anticipate the care at predictable
intervals.
The special problems of severe
hallucinations, seizures, hyperthermia
and arrhythmias usually require
pharmacotherapy and must be reported
to the physician for management
(See figure three. )
Assuming that Mr. Smith is in
alcohol withdrawal, the nurse should
advise the physician of the patient s
condition and then decide with the
physician whether to treat the patient
with supportive care alone or with
supportive care in conjunction with
pharmacotherapy. The frequent
assessments which follow allow the
nurse to closely monitor the clinical
course of the syndrome and to detect an
improved, stable or deteriorating
condition.
Early and appropriate treatment
for target symptoms benefits the
patient. The nurse who can identify
AWS identifies physical dependency on
alcohol and can then initiate long tenn
rehabilitation. This supportive care is
only good nursing care but it is nursii.g s
unique and independent contribution to
Mr. Smith and other patients with AWS,*
References
1 Coates, Madelaine ; Paech, Gail.
Alcohol and your patient; a nurse s
handbook. Toronto: Addiction
The Canadian Nurse
WANT TO READ MORE?
Books
1 Burkhalter, P. Nursing the
alcoholic and the drug abuser. New
York: McGraw-Hill; 1975.
2 Canada. Health and Welfare
Canada. Drug crisis treatment: a guide
to medical management of acute drug
toxicity. Ottawa; 1976.
3 Estes, N.; Heineman, M.E.
Alcoholism: development, consequences
and interventions. St. Louis: Mosby;
1977.
4 Oakley, S.R. Drugs, society and
human behavior. 2d ed. St. Louis:
Mosby; 1978.
Papers, Pamphlets and Manuals
1 *Addiction Research Foundation.
Can I take this if I m pregnant?
Toronto: Pharmacy Service.
2 * . Cannabis: adverse effects on
health. Toronto; 1980.
3 . Coffee, tea and me. Rev. ed.
Toronto. 1978.
4 Coates, Madelaine; Paech, Gail.
Alcohol and your patient: a nurse s
handbook. Toronto: Addiction
Research Foundation. 1979.
5 *Cork, M.R. Alcoholism and the
family. Toronto: Addiction Research
Foundation.
6 *Cox, A. Behavioural
management of intoxicated and
disruptive clients: workbook. Toronto:
Addiction Research Foundation; 1979.
7 Cox, Anne. The management of
intoxicated and disruptive patients:
emergency department training manual.
Toronto: Addiction Research
Foundation; 1979.
8 Dobbie, J. Substance abuse amohg
the elderly. Toronto: Addiction
Research Foundation; 1978.
(Continued on page 58)
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research
The Development of Health Sciences
Education Programs in Metropolitan
Toronto Region Colleges of Applied
Arts and Technology, 1967-1977; A
Study of Selected Factors Influencing
This Development. Toronto, Ont.,
1979. Thesis (D.Ed.), University of
Toronto by Lucille Peszat. This study
which traces the development of health
sciences education at non-degree levels
recommends that more regional
cooperation and sharing of educational
and human resources be undertaken by
the Toronto colleges and that a
consortium approach involving all
educational institutions and other
agencies in the region which offer health
sciences programs be considered for the
future.
An Empirical Investigation of the
Relationship between Nurse s Level of
Self-actualization and Ability to
Develop Positive Helping Relationships
with Hospitalized Patients. Ottawa,
Ont., 1980 by Marion Logan, University
of Ottawa. This study involving 7 1
nurses and one to five patients of each
of these nurses, concluded that the
nurse s level of self-actualization does
not directly influence the quality of the
helping relationship and questions the
appropriateness of the Barrett-Lennard
Relationship Inventory for use in
evaluating nurse-patient relationships.
The Relation of Constraint and
Situational Theory to Diploma Nursing
Program Leadership. Detroit, Michigan,
1980. Thesis (PhD), Wayne State
University by Dolly Goldenberg.
Participating in the study were 35 heads
of diploma nursing programs and 1 06
senior faculty members. The study
substantiates the belief that nursing
administrators view their leadership role
as being primarily a supportive one;
suggested a causal relationship between
the phenomenon of follower-maturity
and leader behavior; identified the need
to further investigate environmental
variables that impinge upon and affect
leadership styles and identified that
other personality or psychosociocultural
variables have a probable effect on
leader behavior.
Commitment to the Nursing Profession:
An Exploration of Factors Which May
Explain its Variability. Vancouver, B.C.
Thesis (MScN). University of British
Columbia by Suzanne Flannery. A five
part questionnaire mailed to a stratified
random sample of 400 nurses reveals
that certain personal and work-related
variables, i.e. professional orientation,
marital status, basic education and work
satisfaction, account for 23 percent of
the variability to work commitment,
leaving a large portion of the variability
unexplained.
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TELEPHONE NO.
POSTAL CODE
Sales Rep. Tom Moore OA-1-386-80
Authorized Ontario Representative For General Development Corporation,
1000 Finch Avenue West, Suite 700, Downsview, Ontario M3J 2V5.
Telephone: (416) 661-1625 Call Collect. Licensed salesmen s inquiries invited.
(416) 689-8559 residence-evenings.
ASK FOR AND READ CAREFULLY THE PROSPECTUS RELATING TO THIS OFFERING.
Factors Influencing Dietary Adherence
as Perceived by Patients on Long-term
Peritoneal Dialysis, Toronto, Ont.,
1980. Thesis (MScN), University of
Toronto by Margaret Hume. Descriptive
study, sample of 25 men and women,
28 to 79 years of age having been
dialysed for periods ranging from three
months to four years. More positive
than negative influences are reported,
with health-related beliefs and values
accounting for the majority of positive
factors and situational factors relating
to most of the negative factors.
Child Rearing Concerns of First Time
Mothers. Kingston, Ontario, 1 980 by
Faye Brooks and Lynn Kirkwood. This
feasibility study undertook to identify,
on a longitudinal basis, the child rearing
concerns of 56 first-time mothers; when
they emerged and how they changed.
The most common concerns involved
infant care; it was identified prenatally
and little change was noted throughout
the course of the study. No effective
tool was developed for eliciting
mothering and family relationship
concerns.
Development and Validation of
Information Needs Inventory (MI
Patient), Edmonton, Alberta, 1 980 by
Marianne Lamb, Louise Payne, and
Karran Thorpe. This study was designed
to develop and validate an instrument to
measure the degree of importance of an
item of knowledge for individuals who
have experienced a myocardial
infarction. A 75 item questionnaire
(Information Needs Inventory) was
developed and tested with 100
individuals. Some evidences of validity
were established and recommendations
are made for further development of the
INI.
H.E.L.P. (Health Evaluation and
Lifestyle Promotion). Calgary, Alta.,
1979 by Maryann Yeo, University of
Calgary. Descriptive study, sample of
250 individuals were given the Health
Hazard Appraisal in industrial and
physician s office settings with varying
degrees of follow-up. The value of the
Health Hazard Appraisal appears to be
that of an awareness tool only, its
usefulness as a measure of behavior
change is questionable.
The Effects of Two Types of Fetal
Monitoring on Ability to Maintain
Control During Labour. Toronto, Ont.,
1980. Thesis (MScN), University of
Toronto by Ellen Hodnett. A two phase
investigation of 1 00 postpartum women
and 30 laboring primipaiae revealed that
the Labour Agentry Scale is a useful
tool for measuring experienced control
in labour and that the type of fetal
monitoring used influences experienced
control.
Resumes are based on studies placed
by the authors in the CNA Library
Repository Collection
of Nursing Studies.*
The problem: flatulence.
Although flatulence is normal to a
certain degree, some conditions
tend to produce, or exacerbate it. In particular, when
patients are supine for lengthy periods, gas may be
unable to escape through the oesophago-gastric
junction. The result isdistention, bloating, discomfort,
borborygmi, and pain.
A solution: Ovol 80 mg.
Ovol 80 mg contains simethicone, a proven
antiflatulent compound. It is an inert silicone agent that
rapidly lowers surface tension and causes small
"bubbles" in the stomach to coalesce, thereby
releasing "trapped" gas. Ovol 80 mg is supplied as
white, chewable tablets pleasantly flavoured with mint.
Recommended dosage is 1 tablet
after meals as required.
FAST,
EFFECTIVE RELIEF
OF GAS.
fiiiditili
Prescribing information on page 58.
SPHYGMOMANOMETERS
MERCURY TYPE. The ultimate m
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tips 3 sued 29 caraat is. 2 sue $1 00 card
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NURSES 4 COLOUR PEN lor recording temperature.
biood pressure. etc One-hand operation selects red.
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(Continued from page 52)
9 - ; Bill, P. Fetal alcohol syndrome.
Toronto: Addiction Research
Foundation; 1978.
10 Eraser, J. The female alcoholic.
Rev. ed. Toronto: Addiction Research
Foundation; 1976.
1 1 Richter, R. Medical aspects of
alcohol abuse. New York: Harper Row;
1975.
12 Schmidt, Wolfgang; Popham,
Robert. Alcohol problems and their
prevention: a public health perspective.
Toronto: Addiction Research
Foundation; 1978.
13 *Wilkinson, P. A. Control of drug
use and other pro-social and anti-social
behaviour by means of group contingent
reinforcement. Toronto: Addiction
Research Foundation; 1977.
Articles
1 Alcohol: a hidden factor in
physical illness. RN 37(7):31-34;
1974Jul.
2 Heinemann, Edith ; Estes, Nada.
Assessing alcoholic patients. Amer. J.
Nurs. 76(5):785-789; 1976 May.
3 * Jacob, M.; Sellers, E. Emergency
management of alcohol withdrawal.
Drug Therapy. 1977 Apr.
4 Luke, Barbara. Maternal
alcoholism and the fetal alcohol
syndrome. Amer.J.Nurs. 77(12):1924-
1926; 1977 Dec.
5 Mueller, J.F. et al. The role of
the nurse in counselling the alcoholic.
J.Psychiatr.Nurs. 12:26-32; 1974
Mar./ Apr.
*For further information and a price list
for ARE publications, readers should
contact:
Marketing Services
Dept. CO
Addiction Research Foundation
Central Office
33 Russell Street
Toronto, Ontario M5S 2S1
Did you know...
The Manitoba Association of Registered
Nurses is preparing a list of all agencies treating
alcohol and drug related problems. This
information on community resources is to be
made available to all member nurses. After
studying the Physicians at Risk referral
program established by the Manitoba Medical
Association, MARN decided to look at their
own membership needs. Executive director of
MARN, Louise Tod, commented, "Volunteers
amongst the members who are specialists in
alcohol and drug related problems will be
sought to be available to assist fellow nurses
who are identified as requiring assistance. No
formal program will be established by the
MARN at the present time."
Ovol Drops
relieve
infant colic.
OVOl 8Omg
Tablets
Ovol4Om g
Tablets
ovor
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 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.
HORHER
Montreal, Canada
Full information available on request.
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.
Shhh. Ovol Drops.
Also available in tablet form for adults
cuts the cost of decubitus care
by controlling
infection fast
Debrisan sucks bacteria and tox
ins out of decubitus 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 Infected, heavily Day 2 Exudate diminished. Day 14 Clear, healthy
exudating decubitus ulcer on Erythema and edema granulation base; grafted
left hip. reduced. successfully.
by relieving
pain and
odour fast
" 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
peared." 3
Day Infected exudating Day 4 Clear, healthy
decubitus ulcer on knee. granulation base.
Day 14 Ulcer healing after
Debrisan discontinued.
Day Undermined sacral Day 7 Surgically debrided
decubitus ulcer infected with before Debrisan therapy and
Pseudomonas and E.coli. after 7 days, infection
controlled.
Day 28 Appearance on
healing.
by saving valuable nursing time
Only one Debrisan change a day*
is needed. Debrisan therapy can
be stopped as soon as all signs of
jnfection have gone and the ulcer
is clean and granulated.
Debrisan appears to be, in my
opinion, just what we as nurses
are seeking." 4
Two, if exudation is very heavy.
After removing crust or Cover with a dressing,
necrotic tissue, pour a thick
(4 mm) layer of Debrisan on
the ulcer.
Debrisan cleans
decubitus ulcers fast.
Pharmacia (Canada) Ltd.
Dorval, Quebec
References
1. Lim LT, Michuda M. Bergan JJ. Angiology 29:9. Sept 1978
2. Bewick M. Anderson A. Clin Trials J 15:4. 1978
3. Soul J. Brit J Clin Pract. 32:6, June 1978
4. DiMascio S RN, Decubitus Care A New Approach:
A Nursing Responsibility, on tile at Pharmacia (Canada) Ltd.
When the beads are
saturated (12 to 24 hours
later) rinse and wipe them
away. Apply a fresh layer of
Debrisan.
A NURSE S STORY. IT COULD BE YOURS
> So many nurses I talk
to about my work in Saudi
simply can t understand
what it s like to get so much
satisfaction
RITA LAWRENCE, R.N.
\
-
CALL
REVERSING
THE CHARGES:
(602) 957-1777
OR WRITE TO:
P.O. Box 5653
Phoenix, Ariz. 85010
The Arabian Peninsula. Dif
ferent . Demanding. And most
decidedly gratifying.
"Like most nurses, I ve
always dreamt of my work
making the difference in peo
ple s lives. And not having it
taken for granted. But until
my job at Whittaker s Saudi
hospitals, I thought it would
never happen.
What made Saudi Arabia
different was the gratitude of
patients, families, government.
And the chance to work inde
pendently in a modern hospital.
Being in an exotic place,
coming home to free, air con
ditioned comfort that was
all part of it . Together with
excellent travel benefits, salary
and bonus provisions .
But when nurses ask why
Dedicated
I went back lu iVe, I point to
job satisfaction . / really found
it. And they can too."
We are happy to report
that Rita Lawrence s reactions
are typical. And Whittaker, a
leader in international health
care, is now offering contracts
in either Saudi Arabia or Abu
Dhabi. If you are a Canadian
trained R.N. with two to three
years postgraduate experience,
call us today.
to a world of health
WhittakeR
Whittaker International Services Company
A Subsidiary of Whittaker Corporation
An Equal Opportunity Employer M/F
Classified
Advertisements
Alberta
British Columbia
British Columbia
Registered Nurses required for the Drumheller
General Hospital a seventy bed acute care Gen
eral Hospital. Drumheller is situated ninety (90)
miles from Calgary on the Red Deer River. It
ranks third amongst Alberta s tourist attrac
tions. Send your resume to: Heather McKee,
D.O.N., Drumheller General Hospital, Box
4500, Drumheller, Alberta TOJ OYO or call
collect to 1-403-823-6500.
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Nurses - The Grande Prairie General Hospital,
located in the commercial and industrial heart
of Canada s Peace River Country, invites regis
tered nurses to join their progressive hospital.
This 230-bed hospital complex, currently un
dergoing expansion to match the rapid devel
opment of Grande Prairie, has vacancies in a
number of areas. Assistance in finding employ
ment for spouses is offered to nurses who are
willing to relocate. Apply to: Personnel Direc
tor, Grande Prairie General Hospital, 10409
98 Street, Grande Prairie, Alberta T8V 2E8
Phone: (403) 532-7711 Ext. 78.
Registered Nurses required in a 68-bed active
treatment hospital in Northeastern. Alberta.
Applicants will be required to assume respon
sibility of a given unit Pediatrics, Emergency,
Obstetrics or Medicine and must be willing to
"rotate all shifts. Accommodation for tempor
ary or permanent residence is available in the
Nurse s Residence. Salary and benefits in ac
cordance to the nev/ly negotiated provincial
agreement. Apply in writing to: Director of
Nursing, Lac La Biche General Hospital, Box
507, Lac La Biche, Alberta TOA 2CO.
Registered Nurses required for a 20-bed Ex
tended Care hospital which includes an Emer
gency and Out-Patient Department. Located
50 miles north-east of Edmonton. Accommo
dation available. Salary and benefits in accor
dance with the negotiated provincial agree
ment. Apply in writing to: Administrator,
Radway Health Care Centre, Box 70, Radway,
Alberta TOA 2VO.
Graduate & Registered Nurses required imme
diately. Opportunity to acquire experience in
all clinical areas of a 75 bed accredited hospital
(located 130 milesN.E. of Edmonton, Alberta).
(Time off in lieu of vacation negotiable). Sal
ary and fringe benefits in agreement with
U.N.A. ($1465-$1867). Contact: Director of
Nursing, St. Therese Hospital, Box 880, St.
Paul, Alberta TOA 3AO (Phone)403-645-3331.
Required Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TOK 2GO.
British Columbia
General Duty Nurses required for 30 bed ac
credited hospital. Salary according to RNABC
Contract. Apply: Administrator, Chetwynd
General Hospital, Box 507, Chetwynd, British
Columbia VOC 1JO. (604) 788-2236/2568.
Experienced General Duty Graduate Nurses re
quired for small hospital located N.E.Vancouver
Island. Maternity experience preferred. Person
nel policies according to RNABC contract. Res
idence accommodation available $30 monthly.
Apply in writing to: Director of Nursing, St.
George s Hospital, Box 223, Alert Bay, British
Columbia VON 1AO.
General Duty Nurses for modern 41-bed hosp
ital located on the Alaska Highway . Salary and
personnel policies in accordance with RNABC.
Accommodation available in residence. Apply:
Director of Nursing, Fort Nelson General
Hospital, P.O. Box 60, Fort Nelson, British
Columbia VOC IRQ.
General Duty Nurse for modern 35-bedhospital
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply : Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
Roy al Columbian Hospital -Experienced Nurses
(B.C. Registered) required for this SOO-bed
progressive regional referral and teaching hospi
tal located in the Fraser Valley, 20 minutes by
freeway from Vancouver and within easy ac
cess of various recreational facilities. Excellent
orientation and continuing education pro
grammes. Salary - 1980 rates - $1624.00 -
$1889.00 per month. Clinical areas include:
Operating Room, Recovery Room, Intensive
Care, Coronary Care, Neonatal Intensive Care,
Labourand Delivery, Family centred Obstetrics,
Emergency, Renal Dialysis, Psychiatry, Acute
Medicine, Palliative Care, Surgery, Pediatrics,
Rehabilitation and Extended Care. Please apply
in writing to: Employment Manager, 330 East
Columbia Street, New Westminster, British
Columbia V3L 3W7.
Experienced nurse (eligible for B.C. Regist
ration) required for full time position in our
lovely cottage hospital on northern Vancouver
Island. Apply to the: Port McNeill and District
Hospital, P.O. Box 790, Port McNeill, British
Columbia VON 2RO.
WE FULFILL A NEED!
Thousands of people die needlessly each year simply because they may live alone, and
under a medical or other emergency, can not make it to the phone to call for help.
IF YOU KNOW OF A LOVED ONE WITH
MEDICAL PROBLEMS PERSONAL & PROPERTY SECl RITY
STROKE
DIABETIC
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If you are serious about making lots of money, are sincere about helping other
people, and have $1,275 (secured by inventory), your future looks great! First
come first served.
PHONE: (416) 749-HELP or write:
3625 WESTON RD., I NIT 9. WESTON, ONTARIO, CANADA M9I. 1V9
British Columbia
Ontario
United States
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van-
couverSalary and benefitsaccordingto RNABC
Contract-Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to: Personnel Director, Queen s Park
Hospital, 315 McBride Blvd., New Westminster,
British Columbia V3L 5E8.
General Duty Nurses required by an active 80-
bed acute care and 40-bed extended care hosp
ital located in the Cariboo region of B.C. s
central interior. Year round recreational activ
ities in this fast growing community. Appli
cants eligible for B.C. registration preferred.
Apply in writing to: The Director of Nursing,
G.R. Baker Memorial Hospital, 543 Front
Street, Quesnel, British Columbia V2J 2K7.
General Duty Nurses required immediately for
a ten-bed acute and ambulatory care hospital
located in Stewart, B.C. Stewart has a popula
tion of 2000 and is Canada s northernmost ice-
free port with transportation, mining and con
struction as its primary industries. There are
excellent school facilities. A few of the many
sports offered are boating, fishing and, in the
modern community pool, swimming. Stewart
General Hospital is affiliated with the Prince
Rupert Regional Hospital and nurses are en
couraged to take part in the inservice educa
tion programmes at both hospitals. Salary
rates are according to the RNABC contract
and for a general duty RN the ranges are : May 1 ,
1980-$ 1624-$ 1889 plus $26.87 northern al
lowance. Jan. 1, 1981-$1700-$1965 plus
$28.12 northern allowance. Fringe benefits
include: 20 days paid annual vacation; 5 days
marriage leave; annual educational leave, in
addition to the other usual health care insur
ance and monetary benefits. We are eager to
help you relocate. For further information
please call COLLECT: (604) 624-2171, ask for
Mrs. L. Bremner, Director of Nursing.
O.R. Head Nurse required for an active 103-
bed acute care hospital. Must be eligible for
B.C. Registration. Post graduate training &
experience necessary. R.N.A.B.C. Contract in
effect. Accommodation available. Apply to:
Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British
Columbia V8G 2W7.
General Duty Nurses required for an active,
1 03-bed hospital. Positions available for experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
New Brunswick
Registered Nurses-The Moncton Hospital a
539-bed fully accredited General Hospital is
accepting applications for full time positions
from General Staff Nurses. Rates and benefits
in accordance with the Provincial Agreement.
Replies and inquiries should be addressed to:
Personnel Office, The Moncton Hospital, 135
MacBeath Avenue, Moncton, New Brunswick
E1C 6Z8.
Northwest Territories
The Stanton Yellowknife Hospital, a 72-bed
accredited acute care facility requires register
ed nurses to work in medical, surgical, paediat-
ric, obstetrical or operating room areas. For
further details concerning salary and benefits
contact: Lynette McLeod, Personnel Officer,
Box 10, Yellowknife, N.W.T. X1A 2N1. (403)
873-3444 (Collect).
R.N. or R.N.A.,5 6" or over and strong with
out dependents. Non-smoker for 1 80 Ib. handi
capped retired executive with stroke. Able to
transfer patient to wheelchair. Live in 1/2 year
in Toronto 1/2 year in Miami. 4 day work
week most of year. Wages $275.00 to $350.00
weekly NET plus $100.00 weekly bonus on
most weeks in Miami. Free room and board.
Write: M.D.C., 3532 Eglinton Avenue West,
Toronto, Ontario M6M 1V6.
Quebec
Registered Nurses: Full-time and part-time
positions for modern 50 bed Nursing Home
located in small community setting in Western
Quebec 50 miles from Ottawa. Excellent sal
ary and benefits. Applicants should write
giving full particulars to: Director of Nursing,
Pontiac Reception Centre, Shawville 2001,
Quebec JOX 2YO.
Saskatchewan
Registered Nurses and Registered Psychiatric
Nurses (eligible for Saskatchewan registration)
required for 340 fully accredited extended
care facility. For further information contact:
Personnel Department, Souris Valley Extended
Care Hospital, Box 2001, Weyburn, Saskatch
ewan, S4H 2L7.
United States
RN/Staff & Management Positions-- Kaiser-Per-
manente, the country s largest Health Mainten
ance Organization, currently has excellent
opportunities available in our 583-bed Los
Angeles Medical Center. Located 7 miles from
downtown Los Angeles, close to many of Calif
ornia s finest Universities, this teaching hosp
ital offers RN s a unique chance to further
their careers in such areas as: OR, Med/Surg,
Maternal Child Health & Critical Care. Manage
ment positions are also available. Kaiser offers
an attractive array of fringe benefits including
relocation assistance, full medical, dental &
health coverage, continuing education advanc
ed training available in the Nurse Practitioner
& CRNA Programs, individualized orientation,
tuition reimbursement, and no rotating shifts.
New graduates are always welcome and encour
aged to inquire. For more information, please
write or call collect: Ann Marcus, RN, Kaiser
Hospital/Sunset, 4867 Sunset Blvd., L.A.,
California 90027. (213) 667-8374.
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 White is a 377-bed acute
care teaching medical center with an open invita
tion to dedicated RN s. Well challenge your
mind and offer you the opportunity to 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 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92503. Write or call collect 7 14-688-22 1 1
Extension 217. Betty Van Aernam, Director
of Nursing.
RN S Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
Registered Nurses Virginia, USA-The Medical
College of VA Hospitals is a 1058 bed, full ser
vice, referral, and research University hospital
comprised of 50 specialty units within the nur
sing department; including Oncology, Medi
cine, Surgery, OB/GYN, Pediatrics, Critical
Care, OR/RR and Outpatients. You may spe
cialize in nursing and continue education
through in-service workshops or pursue B.S.N.
or M.S.N. (100 per cent tuition reimbursement
for 12 credits/year) in our school of nursing.
We offer competitive salaries and fringe bene
fits. Personal interviews will be arranged. To
learn more call collect 804-786-0918 or write
to Wanda Barth, MCV Hospitals, Box 7, Rich
mond, VA 23298. An Equal Opportunity
Employer.
Miscellaneous
Adventure Holidays: Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario M5E
1J3. Phone: 416-863-0799. Telex: 06-219621.
Looking For A Temporary Change? Do you
want to keep your job but feel the need for
some renewing experience? International reg
istry for nurses interested in a temporary job
exchange under organization. Write: Nursing
Job Exchange, Box 1502, Kingston, Ontario
K7L SC7.
NEW ADVERTISING RATES
EFFECTIVE JANUARY 1, 1981
FOR ALL
CLASSIFIED ADVERTISING
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
theUS.A.
B) Extensive information regarding
Hospital 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. Boi 11 33 Great Neck. N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
HOSPITAL
CORPORATION
Interested in a Challenge?
Try International Nursing - In
Saudia Arabia
If you are looking for a change, a chance to
travel, some hard work and adventurous living,
then you might consider international nursing.
You will have not only the opportunity to give -
to share your nursing expertise but the
opportunity to receive as well to learn by
living in a completely different culture. Truly, a
chance for personal and professional growth.
Available positions include both administrative
and staff level nursing. Requirements depend on
the position at staff level a minimum 2-3 years
current experience in an acute care hospital or
clinic setting. Current R.N. license in one of the
Provinces. Single status contracts are offered for
18 or 24 month periods.
Attractive salaries with excellent benefits
including air transportation, furnished lodging,
generous vacation, bonus pay and bonus leave.
Interested in this once in a lifetime opportunity?
For more details, please send professional
resume to:
Kathleen Langan
Hospital Corporation International, Ltd.
Two Robert Speck Parkway, Ste. 750
Mississauga, Ontario L4Z 1H8
An Equal Opportunity Employer
Pediatric & Orthopedic Nurses
Jazz up your career at
JoEllen Smith/
F. Edward Hebert Hospitals
in New Orleans
Most hospitals sing the same song . . .
good salary, good benefits, good
facilities. We go beyond that. We
encourage each nurse to grow as an
individual.
Leadership training to help you
move up. Unlimited opportunities
to learn as we open new services and
pioneer new techniques. Plus a
professional atmosphere where your
special talents are appreciated.
"^F^
Call collect (512/824-7478) or write:
J. Philip Knight-Sheen
1635 N.E. Loop 410
Suite 501
San Antonio, Texas 78209
Clinical Nurse Specialist
Haematology/Oncology
DUTIES: The successful applicant will be required to work
with other health care professionals in the in-patient and
out-patient areas served by the Haematology Oncology
Department. Contact will be primarily with children who
have malignant illnesses, and their families. Attention is
concentrated on families at crisis time, such as
diagnosis, relapse, terminal phase, and death of the
child. Staff education and research activities are
additional responsibilities of this position.
QUALIFICATIONS:
Current registration in Ontario or eligibility for registration
is essential.
Masters Degree in Paediatric Nursing essential
Recent related nursing experience preferred
Demonstrated ability to work harmoniously with patients.
families and staff.
Please apply to:
Dorothy Franchi
Personnel Co-ordinator
The Hospital for Sick Children
555 University Ave.
Toronto, Ontario M5G 1X8
(416) 597-1500 Ext. 1528. 1677
PROVINCE OF NOVA SCOTIA
CARE IROPPORTUNf ES
Supervisor, Community Health Nursing
The Nova Scotia Department of Health invites applications for
the position of Supervisor, Community Health Nursing for the
Cobequid Health Unit based in Truro, Nova Scotia. This position
offers the opportunity to contribute to the provincial community
health services system, as well as the responsibility of managing
the nursing program of this Health Unit.
The incumbent of this position reports to the Health Unit
Director and is responsible for a number of delegated managerial
functions. The supervisor also provides the professional super
vision of approximately 22 community health nursing personnel
in consultation with the Director of Community Health Nursing.
The successful applicant will have current registration as an
R.N. in Nova Scotia, along with a Master s Degree in community
nursing and nursing administration or equivalent. A minimum of
five consecutive years nursing is desirable.
Salary Range:
$19,713.72 - 22,020.96.
Full Civil Service Benefits.
Competition is open to both men and women.
Please quote Competition Number 80-337.
Closing Date: November 14, 1980.
Application forms may be obtained and should be returned to
the Nova Scotia Civil Service Commission, P.O. Box 943, Halifax,
Nova Scotia, B3J 2V9, and from the Provincial Building, Sydney,
Nova Scotia, B1P5L1.
Head Nurse - Psychiatry
A 289 bed accredited hospital, located in Chilliwack,
B. C., requires a Head Nurse for its Psychiatric Unit.
The successful applicant will be responsible for the
organizing, teaching and supervision of the nursing staff.
A post graduate course in Psychiatry, demonstrated
leadership abilities, and effective management skills are
essential with a B.Sc.N. preferred.
Must be eligible for current R.N.A.B.C. registration
and have three years psychiatric experience - one of
which must have been at the supervisory level.
Salary and benefits as per R.N.A.B.C. Collective
Agreement.
Please submit resume, in confidence to:
Personnel Director
Chilliwack General Hospital
45550 Hodgins Avenue
Chilliwack British Columbia
V2P 1P7
Toronto Western Hospital
"The Home of Friendly Care and Protection"
This 700 bed University Teaching Hospital has
employment opportunities for registered nurses, or
nurses eligible for Ontario Registration in such areas
as:
Medical/Surgical Units
I.C.U./C.C.U.
Operating Rooms
Planned orientation and on-going education programme
in effect.
Apply to:
Miss H. Jones
Staffing Co-ordinator
Department of Nursing
Toronto Western Hospital
399 Bathurst Street
Toronto, Ontario
M5T 2S8
flnterestedln
I Paediatric Nursing 7
unr
Toronto, Canada
The Hospital For Sick Children invites applications for all
units from experienced nurses interested in working in a
paediatric tertiary care setting.
We are a fully accredited 700 bed paediatric teaching
hospital affiliated with the University of Toronto located in the
thriving environment of downtown TORONTO. A thorough
orientation and a variety of continuing education programs is
provided. The majority of units operate on a 12 hour shift
basis, which normally allows every other weekend off. A
comprehensive employee benefit package, including a
Dental Plan is offered.
Our philosophy is Family Centred Care.
Qualifications:
Current registration with the Ontario College of Nurses
or eligibility for registration.
Recent related experience in an active treatment
setting preferred.
Paediatric experience would be considered a definite
asset.
Applicants are invited to contact:
Dorothy Franchi,
Personnel Co-ordinator,
The Hospital for Sick Children,
555 University Avenue,
Toronto, Ontario, Canada M5G 1X8,
(416) 597-1500 ext. 1675.
The Hospital
for Sick Children
Royal
Alexandra
Hospital
This 938 bed active treatment hospital invites
applications from nurses across Canada.
We offer experience in all areas of patient care
including intensive care, neonatal intensive care
and obstetrical perinatology. The extended work
day and compressed work week is currently in
effect in the Intensive Care areas and Emergency.
Applicants must be eligible for registration with
the Alberta Association of Registered Nurses.
Please direct inquiries to:
Mrs. D. Kivell
Personnel Officer
Nursing Recruitment
Royal Alexandra Hospital
Room 1108
10204 Kingsway
Edmonton, Alberta
TSH 3V9
Assistant Director Clinical Nursing
(General Surgery, Thoracic Surgery,
and Gastroenterology) NEW POSITION
Assistant Director Clinical Nursing
(Internal Medicine) NEW POSITION
Assistant Director Clinical Nursing
(Orthopedics and Outpatient Surgery)
Hospital:
The Plains Health Centre, a division of the South
Saskatchewan Hospital Centre, is a 300 bed fully
accredited teaching hospital.
Position:
In a decentralized nursing structure that separates clinical and
administrative functions, the incumbents will be responsible
for the quality of nursing care developed and provided to 36
patients.
Qualifications:
A baccalaureate or post-basic degree. Evidence of progress
towards attainment of a degree will be considered. Teaching
experience an asset. Applicants with three or more years
experience in the clinical areas specified will be given preference.
Full range of fringe benefits, salary currently under review.
Reply to:
Personnel Department
South Saskatchewan Hospital Centre
Plains Health Centre Division
4500 Wascana Parkway
Regina, Saskatchewan
S4S 5W9
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment jn
medicine, surgery, pediatrics, orthopaedics,
obstetrics, psychiatry, rehabilitation and
extended care including.
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro-surgery
Planned Orientation and In-Service Education
Programs. Post Graduate Clinical Courses in
Cardiovascular Intensive Care Nursing and
Operating Room Nursing.
Apply to.
Recruitment Officer Nursing
University of Alberta Hospital
8440- 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
o
The Canadian Nure
November 1980 65
Choose a
Nursing
Career
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.-N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H 1V8
Telephone: 1 (902) 428-3484
Cancer Control Agency of
British Columbia
Oncology Nursing
The Cancer Control Agency of
British Columbia, a provincial
cancer diagnosis and treatment
center located in Vancouver, has
general and senior administrative
openings for oncology nurses
beginning immediately and running
through November 30, 1980. The
positions include responsibilities
in both inpatient and ambulatory
care settings.
Applicants should send a resume to :
Sue Rothwell
Director of Nursing
Cancer Control Agency of B.C.
2656 Heather Street
Vancouver, British Columbia
V5Z 3J3
Phone No: (604)873-4221,
Local 37
Saint John Regional Hospital^
Attention
Registered Nurses
The Saint John Regional Hospital has
Full Time, Part Time, and Casual
positions available for Registered Nurses,
to participate in the planning and giving
of total nursing care in Medical, Surgical,
and Geriatric Units.
Hours of Work:
37-1/2 hour work week (Twelve or
Eight hour shifts).
Qualifications:
Graduate of an approved School of
Nursing.
Must be eligible for registration in the
province of New Brunswick.
Salary:
Contract presently under negotiations.
Excellent fringe benefits include three
weeks vacation after one year s service,
paid sick leave, annual increments,
group life insurance, and hospital
pension plan.
Interested persons please apply in
writing to:
Employment Manager
Saint John Regional Hospital
P. 0. Box 2100
Saint John, New Brunswick
E2L 4L2
MIDWIFERY TUTOR NIGERIA
NURSING INSTRUCTORS COLOMBIA
& PAPUA NEW GUINEA
PROFESSOR OF NURSING PERU
PUBLIC HEALTH NURSES WEST
AFRICA & PAPUA NEW GUINEA
CUSO. Canada s largest non-government inter
national development agency, is seeking
qualified and experienced nurses for the above
positions
Qualifications: Positions require appropriate
degree (diploma for midwifery position) plus
relevant experience
Contract: Two years
Salary: At local rates with fringe benefits
For more information, write:
CUSO Health D1 Program
1 51 Slater Street
Ottawa. Ontario
K1P 5H5
The Izaak Walton Killam
Hospital for Children
Assistant Head Nurse
Neo-Natal
The I.W.K. Hospital for Children requires
an Assistant Head Nurse for our Neo-
Natal Unit, which is a 32-bed referral
centre providing intensive, intermediate
and convalescent care.
Applicants must be a graduate of an
accredited School of Nursing and eligible
for registration in Nova Scotia. Degree or
Diploma in Nursing Service Administrat
ion is preferred. Must have a good know
ledge of Neo-Natal nursing principles and
techniques.
Inquiries and applications should be
directed to:
Karen Lyle, Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Nursing Education
Co-Ordinator
$
required by
Fort McMurray Regional Hospital
Effective: Immediately
Responsibilities :
Responsible for nursing orientation,
staff development and monitoring of
primary nursing in a new active treat
ment hospital (150 beds expanding to
300 beds).
Responsible to the Vice-President of
Patient Services.
Qualifications:
B.ScN. with teaching experience or
equivalency.
Applications with curriculum vitae to
be submitted to:
Personnel Department
Fort McMurray Regional Hospital
No. 7 - Hospital Street
Fort McMurray, Alberta
T9H 1P2
(403) 791-6031
Afi Nnumi *.r 1 Qftn
h PwnaHlan I
CARE ER OPPORTUNmES
Registered Nurses
An Opportunity To Use Your Knowledge and Skills
The Hospital:
The Nova Scotia Hospital is a 400 bed, fully accredited,
active treatment facility for the care and treatment of
psychiatric patients. It is a teaching hospital and is
affiliated with Dalhousie University. Being the major
psychiatric referral hospital for the Province of Nova
Scotia, it offers a full range of services for children,
adolescents, geriatrics, mental retardation, and adults,
as well as forensic services and a Community Clinic. A
Day Hospital will be opening early in the Fall.
Its Location:
The Hospital is located in the City of Dartmouth on the
shores of Halifax Harbour, with direct access to cultural
and recreational facilities. It is just minutes from the
City of Halifax, Nova Scotia s Provincial Capital.
The Job:
Using a team approach, we focus on short term, active
treatment for the majority of patients. We also have
ongoing and innovative programs for the small number
of long term patients. Due to an increase in our staff
quota, we require Registered Nurses for all inpatient
services.
Educational Opportunities:
The Nova Scotia Hospital offers:
a two week orientation program;
clinical supervision and instruction for all staff;
an inservice program in psychiatry and psychiatric
nursing for new R.N. s;
seminars, workshops and ongoing continuing education
programs for all staff.
A six month post graduate course in psychiatric nursing
is available at the Nova Scotia Hospital School of Nursing.
Please quote Competition Number 80-335.
Full Civil Service Benefits.
Competition is open to both men and women.
For further information and/or application forms please
contact:
Ms. Geraldine Webber
Director of Nursing
Drawer 1004
Dartmouth, Nova Scotia
B2Y 3Z9
Telephone: (902)469-7500
urse
a very special person
to a very special people
An important responsibility of the federal govern
ment is to provide health care for the more than
295,000 registered Indians located throughout
Canada.
Here a nurse may have to make decisions about the
probable cause of illness and the appropriate care
until help arrives or the patient can be moved to
hospital. Self-reliance and judgment are essential,
but you are never alone carrying total responsibility
because you are supported by senior nursing
and medical personnel, both "on call" and on
"routine visits".
As a member of our Medical Services team, you are
an important member of the community you serve.
There are opportunities for promotion and travel,
and to further your education at university. As
well as your salary, there are special allowances and
benefits such as travel expenses, overtime compen
sation, isolation post allowances, superannuation
and holidays, plus the opportunity to see
distant parts of Canada.
To the Indian people you serve, you are a very
special person.
For further information, mail coupon below.
Nursing Advisor
Human Resource Planning
Medical Services Branch
I
I
I
I
Health and Welfare Sante et Bien-etre social
_ Canada Canada
Department of National Health and Welfare
Ottawa, Ontario K1AOL3
NAME.
ADDRESS.
CITY.
PROV .
_.CODE_
Canada
The Canadian Nurse
November 1980 67
Clinical Specialist of
Medicine/Psychiatry
required by
Fort McMurray Regional Hospital
Effective: Immediately
Responsibilities :
1. Responsible for the management of
a Medical/Psychiatric unit.
2. Utilizing Primary Nursing in a new
active treatment hospital (150
beds expanding to 300 beds).
3. Responsible to the Vice-President
of Patient Services.
Qualifications:
B.ScN. with management experience or
equivalency.
Applications with curriculum vitae to
be submitted to:
Personnel Department
Fort McMurray Regional Hospital
No. 7 - Hospital Street
Fort McMurray, Alberta
T9H 1P2
(403) 791-6031
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
ICU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
Fanshawe College
London, Ontario
Invites applications for the following
position:
Teaching Master
Health Sciences
(Continuing Education)
Duties: To teach the Post Diploma
Registered Nurse Neurological Nursing
Programme. This is a sessional appoint
ment for the period January 5, 1981
to May 29, 1981.
Qualifications: B.Sc.N or equivalent
University degree with a post diploma
programme in Neurological Nursing
and related clinical and teaching
experience.
Please submit applications to:
Personnel Services, Fanshawe College,
P.O. Box 4005, London, Ontario
NSW SHI.
Closing date for applications
December 1, 1980.
The College encourages applications
from both men and women.
The Izaak Walton Killam
Hospital For Children
Staff Nurses
The I.W.K. Hospital for Children has
vacancies for Staff Nurses on our
Intensive Care Unit and Neo-Natal Unit.
Must be a graduate from an accredited
School of Nursing and be eligible for
registration in Nova Scotia. Previous
pediatric experience would be an asset.
Inquiries and applications should be
directed to:
Karen Lyle
Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Sacred Heart Hospital
McLennan, Alberta
General Duty
Nurses Required
For sixty-three (63) bed active treatment
hospital. Must be registered or eligible
for registration with the A.A.R.N.
Salaries and benefits per U.N.A. and
A.H.A. contracts.
Address all enquiries and applications
to:
Director of Nursing
Sacred Heart Hospital
P. O. Box 390
McLennan, Alberta
TOH 2LO
(403)324-3730
Royal Jubilee Hospital
Victoria, B.C.
Applicationsare invited from Register
ed Nurses or those eligible for B.C.
Registration with recent nursing ex
perience.
Positions are available in all services
of this 950 bed accredited hospital
which includes Acute and Specialty
Care, Obstetrics and Paediatrics,
Psychiatry and Extended Care for
Full Time, Part Time and Casual
Employment.
Benefits in accordance with
R.N.A.B.C. contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Ryerson Polytechnical Institute
Nursing Department
Toronto, Ontario
Applications are invited for
Faculty Positions in the
Following Areas of the
Baccalaureate Program
Psychiatric nursing and Community
Health Nursing
Qualifications:
Preference will be given to applicants
with Master s preparation in the areas
noted and to applicants with current
clinical and teaching experience.
Salary and benefits determined by
relevant collective agreement.
For information contact:
Gail Donner
Chairperson
Nursing Department
Ryerson Polytechnical Institute
50 Gould Street
Toronto, Ontario MSB 1E8
Public Health Nurse
Applications are invited for the position
of Public Health Nurse for the Stoney
Health Centre, Morley, Alberta.
Program Administration responsibility
as well as supervision of staff, also able
to assist in operation of clinic when
required.
Qualifications:
Public Health Diploma or Bachelor
of Nursing.
Current A.A.R.N. Registration or
qualification thereto.
Five years experience in General Nursing.
Ability to establish and maintain good
relationship and deal effectively with
patients, staff and public.
Ability to use independent judgement,
initiative and discretion.
Must possess a high Degree of Maturity.
Experience working with Native peoples
an asset.
Apply and submit resume to:
The Administrator
Stoney Health Centre
P. O. Box 8
Morley, Alberta
TOL 1NO
Registered Nurses
required
Applications are invited from Registered
Nurses interested in full-time employ
ment in a fully-accredited, 65-bed
personal care home in Notre Dame de
Lourdes, Manitoba, 90 miles Southwest
of Winnipeg.
Excellent personnel benefits as well as
rotations of Days/Evenings with every
other weekend off are offered. Salary
range is in accordance with current
contract.
Qualified individuals are directed to
forward their applications to the
attention of:
Jacqueline Theroux
Director of Nursing
Foyer Notre Dame Incorporated
Notre Dame de Lourdes, Manitoba
ROG 1MO
Telephone: (204) 248-2092
Index to
Advertisers
November 1980
Ames Division, Miles Laboratories Limited
Ayerst Laboratories, Division of
Ayerst, McKenna & Harrison Inc.
11
Becton Dickinson Canada
34
Can- Am Real Estate Limited
56
The Canada Starch Company Limited
The Canadian Nurse s Cap Reg d.
Encyclopaedia Britannica Publications Limited
53
Equity Medical Supply Company
57
Facelle Company Limited
43
Ford Motor Company of Canada
OBC
Hollister Limited
44,45,70
Frank W. Homer Limited
57,58
Insta-Help
61
Johnson & Johnson Limited
14, 15
Kendall Canada
13
J.B. Lippincott Company of Canada Limited
Medical Personnel Pool
Pharmacia (Canada) Limited
59
Procter & Gamble
16,17
Ross Laboratories, Division of
Abbott Laboratories Limited
54,55
W.B. Saunders Company
Smith & Nephew Inc.
51
12
Standard Brands Limited
White Sister Uniform Inc.
Whittaker International Services Company
IBC
IFC
60
A dvertising R epresen tatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
601 , Cote Vertu The Canadian Nurse
St- Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone:(613)237-2133
Gordon Tiffin
1 90 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P. O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215)363-6063
Member of Canadian
Circulations Audit Board Inc.
input
An easier death
I was thoroughly an
noyed by the opening sen
tence of Vera Mclver s article
on dying in hospital (A time to
be born, a time to die, Sep
tember, 1980) which read,
"for years, our institutions,
the people who administer
them, the doctors and nurses
who work in them, have con
spired to rob the dying pa
tients of their individuality."
I think that like most nurses
I am well-intentioned and wish
to give good care to my pa
tients. I do not always suc
ceed but there are reasons for
that which do not come from
malevolent intent.
First, what does the
work situation contribute?
Mclver praises the hospice
setting. I quite agree but it is
totally geared for the dying
rather than the "curing" pa
tient. The pace is slower and
the staff as well as the patients
are nourished and supported.
Nurses have more time to give
nursing care, the ethic is one
of encouraging family ties and
personal relationships, and
there is peer support for the
nurse whose feelings are tem
porarily a little off-balance
because of her response to
her patients. A pressured,
worried mother gives short
shrift to the emotional idio
syncrasies of her children -
she attends to their obvious
needs and that is all she can
manage. A nurse is no differ
ent if overwhelmed by the
physical needs and anxieties
of too many patients she will
become curt.
Second, nurses are still
given little expert teaching
concerning listening skills.
They come to difficult, emo
tionally-loaded situations
with less training about how
to handle them than they have
had in giving enemas. There
are conferences and classes
for students about patients
emotional needs but not much
high-level supervision of their
emotional interactions with
patients by nurses very skilled
themselves in that aspect of
care. Scolding nurses for not
giving empathic nursing care
is unempathic in itself; teach
ing them how to do so as I
suspect most want to is
more profitable.
Mclver ignores the var
iable of the patient. Some
people are easier to support
then others; they have the
knack of drawing our interest
rather than alienating it when
they are upset. These people
will be cared for better no
matter what the setting or the
nurse s training. This doesn t
mean that the less sympathe
tic individual deserves less
care, but the path to his death
will be harder for him and his
caretakers.
I have no wish to ab
solve nurses of responsibility
for their part in not demand
ing better conditions for their
dying patients or for going
along with abuses rather than
fighting for change. But al
though I have met a very very
few nurses who seem to enjoy
their power over patients,
most, if they have blunted
their sensibilities, have done
so because of the stress they
feel in the situation and herein
lies the problem. To put this
letter into one sentence I
object to once more being a
villain.
-Susanna Jack, RN, M.Ed.,
Montreal, Quebec.
Feedback
Your interesting maga
zine is occasionally read by
members of my family in ad
dition to my wife (RN - gra
duate of the Quo Vadis
School of Nursing, Toronto).
The article in this month s
issue, "A time to be born, a
time to die", by Vera Mclver
proved helpful to my daughter
in a school project.
In the same issue, I felt
the article "Whatever hap
pened to the spiritual dimen
sion", by Donelda Ellis was
excellent. Congratulations on
a thoughtful, well-written and
timely article.
-T.Stevens, P. Eng., Winnipeg,
Manitoba.
Many, many thanks for
Donelda Ellis September
1980 article, "Whatever hap
pened to the spiritual dimen
sion?" As a Christian nurse, I
have been wondering if you
would have just such an arti
cle. Thank you and may there
be more.
- Barbara Cope, RN, Otter-
ville, Ontario.
Did you know...
Copies of the 1978 National Con
ference on Nursing Research,
"Methodology in Nursing Care Re
search, Issues, Innovation, Prob
lems", are available from the Col
lege of Nursing, University of
Saskatchewan, Saskatoon, Sask.,
S7N OWO. Cost: $9.00.
The idea germinated from an earlier Hollister product, our sterile
Karaya blanket.
Today, we re out front again, with a brand new concept, sterile Holli
Hesive skin barrier.
It gives you all the advantages of our regular skin blanket durability,
comfort, exceptional moldability yet it s alot more versatile.
For one thing, sterile HolliHesive skin barrier goes where no product
of its type has ever been before. Namely, into an operating theatre.
Use it to aid in the management of draining wounds, fistulae, decubitus
ulcers almost any kind of skin problem requiring a sterile environment.
It also gives you immediacy since it s no longer necessary to prepare a
sterile field. That s because each sterile HolliHesive blanket comes
individually packaged in its own plastic tray.
Leave it to Hollister to not only bring you a fresh product idea, but
then to serve it up to you on a platter. .fr*.
Hollister
HolliHesive" is a Irademark at Hollisler Incorporaicd Hollister Incorporaied 2ll East ChicaRo Av<
Wnwiwnh*, 1 MOT
l Disirihuied in Canada by Hollisler Limited. 322 Coi
K Road. Willowdale. Ontario M2J I P8 1980 Hollister Incorporated.
en you feel a patient should cut
down on saturated fats and watch his
cholesterol intake, you probably recommend
Fleischmann s 100% Corn Oil Margarine -
and perhaps Egg Beaters, too.
You may also suggest more fresh air and
exercise as part of a general fitness program.
Fleischmann s margarine, salted or
unsalted, contains no cholesterol. Its high
liquid corn oil content gives it an excellent
polyunsaturated/saturated fats ratio. The
natural ability of corn oil to inhibit serum
cholesterol makes Fleischmann s margarine
well worth recommending.
What about compliance? Are your
patients taking your advice?
Yes. Canadians are getting out and
exercising like never before. And they re
becoming much more diet conscious. As a
result, health concerned Canadians have
made Fleischmann s their No. 1 margarine.
And here s a fact that bears thinking
about: the overall CV death rate for people
under 65 is down by 27% since 1953. *
Whatever Canadians are doing, they are
doing something right. So it makes sense to
continue with the same good advice and
recommendations.
Fleischmaiiris
Your patients are
making it part of their life.
*"Heart Facts & Figures", Canadian Heart Foundation.
100% Corn Oil Margarine and Egg Beaters
THE NEW WORLD CHR
FORD ESCORT
FORD ESCORT
Front wheel drive. Four wheel independent suspension.
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Engineering teams from North
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forces to create a new car with
better ideas from around the
world.
Top engineers drawn from
the worldwide resources of Ford
Motor Company teamed up to
create Escort. They pooled their
expertise... tested, evaluated,
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better ideas. Ideas so much
better, at least 27 patents are
issued or pending approvals.
The result: An aerodynam-
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built in North America for Amer
ican and Canadian drivers-with
other models built and sold
overseas.
42 MPG
*Transport Canada Fuel Guide
ratings
for standard power train.
Your actual results may vary.
S.7L/100km
Escort takes on the world in
mileage ratings. An impressive
54 mpg. on the highway. And a
very satisfying 42 mpg.
combined city/hwy.
One of the most power-effi
cient engines built in North
America.
Escort s new-design
compound valve hemispherical
head (CVH) engine gives you
high mileage plus power to take
highway driving in its stride.
Standard transmission is manual
with fuel-efficient fourth gear
overdrive, (automatic available,
too.)
Front-wheel drive and four-
wheel independent
suspension.
To match the performance of
the new engine, Escort comes
not only with front-wheel drive,
but four-wheel fully independent
suspension for smooth road
holding. ..precise rack-and-
pinion steering. ..front stabilizer
bar.. .new all season steel-belted
radials for sure footed traction,
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Drive a world car.
Ford Escort... 3-door Hatch
back, 4-door Liftgate with fold-
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cubic ft (867 L) of storage.. .and
there s even a Squire wagon
option. Whether you buy or
lease, see your Ford Dealer now.
BUILT IN NORTH AMERICA TO TAKE ON THE WORLD.
UK M/i,,.m> .- IfittV
Hemostasis and hemophilia
Risk factors in breast disease
Realistic care for the
post-partum patient
Nurse vs microbe
The
SV6 MM
DRIVING VMVil
911 I3SSIHDW qHVUQ JO A I hJ
Old
Nurse
r .np
DECEMBER 1980
SCIENCES INFIHMiERES
DEC 181980
NURSING LIBRARY
*
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A Division of
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m
cross Canada
You can get
any job you want.
But you don t want just any job.
Freedom.
As an MPPsm nurse, you ll enjoy
more of it than you ve ever
known before.
To begin with, you can choose the
city you work in. Big ones like Toronto.
Or smaller ones like Burlington.
Because MEDICAL PERSONNEL
POOL* has offices throughout
the U.S. and Canada. Over 165 of
them. And we re continuing to
expand rapidly.
With MPR you can also choose
the job setting you ll work in. A hos
pital. Nursing home. Private duty.
Home care.
And there s still more freedom.
Freedom to select your assign
ment. A choice of whether you ll
work in 1CU, CCCJ, Med/Surg. Obstet
rics, Orthopedics. Wherever
you re qualified.
Finally, you get to decide when
you re going to work. The days, the
hours. From one day to as long as
you like. And all this will give you plenty
of time to devote to the "other you"
who may want to continue with an
education. Or for travel, leisure
or family.
So why take any job you can get
when MPP offers you any job you want?
Medical
Personnel
PooL
An International Nursing Service
208 Bloor Street West #304
Toronto, Ontario M5S 1X8
MEDICAL PERSONNEL POOL
208 Bloor Street West #304,Toronto, Ontario M5S 1T8
I m interested in MEDICAL PERSONNEL POOL.. Please give
me more information about working with you.
Name
CN-12
Address _
City
Telephone (Area Code)_
_ Province -
-Postal Code.
Pleasecheckifyouarean: D RN D RNA n Other
Type of work preferred (Hospital, Inhome, Nursing Home, etc.):
Copyright 1980 Personnel Pool of America. Inc
Registered (J.S.Trademark Office
Preferred Specialty (for which you are qualified):
iust
uniforms...
another alternative
is
...the selection in your area
limited or non-existant?
...the time spent shopping
for uniforms better spent
elsewhere?
...buying uniforms becoming
just too costly?
THEN
...why don t you just write
our head office.. .we will
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as well as update your
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with new styles, colors,
and fabrics... please read
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the most competitive in
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with today s continuous
efforts to fight inflation.
just uniforms
480 Lawrence Ave. West.
Ste. 102
Toronto, Ontario
M5M 1C5
Phone: 781-9666
Occupational health nurses urged to take aggressive stand
Blow your own horn, and
maybe make it an airhorn!
That s the message 480 OHN s
got at the Ontario Occupa
tional Health Nurses confer
ence in Ottawa last October.
The theme of the meeting was
Excellence in the Eighties ,
and the nurses learned from a
variety of speakers how they
could both improve and eva
luate their programs in the
workplace, and how they
could sell management on the
job they re doing.
The keynote address was
given by RNAO president
Jocelyn Hezekiah, who point
ed out that excellence in occu
pational health nursing was
difficult to assess because
"preventing illness is harder
to measure than curing ill
ness." She mentioned that
with the acceleration of con
flict and stress in society to
day, the OHN s work was
becoming more difficult but
that through management of
stress (both the worker s and
the nurse s), continuing edu
cation, and working with one s
professional association, the
nurse working in industry
could achieve excellence by
doing the best she can in any
situation.
Josephine Flaherty, Prin
cipal Nursing Officer, Health
and Welfare Canada, said that
nurses may have to put aside
the traditional methods of
health care and decide that
whatever works is what they
should be using. She said that
it s difficult to get people in
terested in health promotion
programs, even the ones that
are for their own benefit:
"one of the best ways to get
people interested in immuni
zation is a handy little
epidemic or two!"
Wayne Cornell, who is an
advisor with Health and Wel
fare on Employee Assistance
Programs, spoke on the rela
tive success of Occupational
Health Nurses in contacting
people who have alcohol
problems. He noted that
management often tended to
view the health professional
with suspicion, saying look
at the bottom line! It s up to
nurses, he said, to tell manage
ment that you re both talking
about the same thing, but in
different ways. There is a
move toward industrial hy
giene and to counseling health
in the workplace he said and
he emphasized that nurses
should take great care not to
simply be caught up in this
wave, but to place themselves
"in the vanguard". "You re
the people with the know-
how," he said, adding that
nurses tended not to "blow
their own horns" enough and
that they should learn how to
sell their programs to manage
ment.
Diane Hobbs, RN, BA,
who is with the Addiction
Research Foundation of Ont
ario, spoke on assisting the
employee with an alcohol
problem through personal
contact or through organized
programs. She stressed the
importance of a sound know
ledge base and the necessity
for informed referrals. "Don t
just send your people to a
place: how would you like to
be referred to something
called The 28-day Program?
Would you go?" She said there
was no need for nurses to fear
getting in over their heads if
they made use of the various
community resources avail
able to them.
Next year OOHNA holds
its tenth annual conference in
London, Ontario. Executive
elected at the 1980 conference
are: Madeleine Wenman, pres
ident; Sue Arnold, 1st vice-
president ; Marilyn Fischer,
2nd vice-president ; Sylvia
Matchett, treasurer and certi
fication coordinator; Gail
Maginnis, membership chair
man.
Health happenings
The high intensity light of the
argon laser has revolutionized
treatment of the port wine
stain or hemangioma (see
Surgical Tattooing CNJ May
80). The blue-green light of
the laser beam is finely focus
ed upon the skin of the pa
tient and absorbed selectively
by the red pigment of the cells
in the walls of the extra blood
vessels in the skin. As the
burned skin heals, the red
color disappears and is re
placed by normal skin color.
"Care for the caregiver",
(October, CNJ) by Mary L.S.
Vachon was based on The
Laura Ban Lecture delivered
by the author to the annual
meeting of the Registered
Nurses Association of Ontario
in Toronto last spring. Credit
for the original address, deli
vered in honor of the former
RNAO executive director,
was inadvertently omitted
from the information on the
author that appeared with the
article.
12 ttecwnbr1980
The Canadian Nurse
Photo by Zwicker, Content Magazine
TWO NURSES, CNJ COLUMNIST CORINNE SKLAR (left)
and guest editorial writer Shirley Wheatley (right) were both
winners in the Media Club of Canada s 1979 Memorial Awards
competition. Above, they chat with national president Esther
Crandall at the presentation ceremony in Toronto in October.
Shirley Wheatley, who is president-elect of the Registered
Nurses Association of Ontario, was awarded first prize in the
newspaper column or editorial category for her guest editorial
on birth control in the teen years which appeared in the
November, 1979 issue of CNJ.
Lawyer and former nurse Corinne Sklar received an
honorable mention for her You and the Law column, "Sinners
or Saints" in the November and December 1979 issues of CNJ.
CNJ Editor A nne Besharah also received an honorable
mention for her editorial, "Who took the nurse out of nursing",
that appeared in February, 1979.
Help is as close as the phone
The Hospital for Sick Child
ren in Toronto has recently
expanded its Medical Infor
mation Service to allow for
24-hour coverage. Staffed by
eight RN s and four clerks, the
service is a three-part opera
tion that includes Poison
Control, Emergency triage
and child-care information.
Parents can call in for child-
care information and answers
to questions that range from
"Should I bring my baby
to hospital" to "What s nor
mal growth and develop
ment?"
According to head nurse
Judith Nielsen, most of the
calls, which averaged 158 a
day, are from parents whose
children are acutely ill and
who want to know what to
do, or who need reassurance.
"We re careful not to step over
the boundary and give medi
cal information," she says,
pointing out that nurses do
not recommend specific me
dication over the telephone,
rather, they inform the par
ents of home care measures.
The caller s name and
information necessary for as
sessment is recorded on a
profile sheet and parents who
call about a child s illness are
called back in a few hours to
check on the child s pro
gress. Most of the calls come
in the evening hours when
parents can t get in touch
with their doctors or are
afraid to bother them.
"You d be surprised at the
number of mothers who
really have no one to talk
to," said Mrs. Nielsen.
Affiliated with Medical
Information at HSC is the
Family Information Service, a
drop-in center in the hospital
where parents can pick up
pamphlets on any aspect of
child care, read books on
parenting or watch one of 50
videotapes. The focus is on
preventing health problems
says Ruth McCamus, RN,
who presides in the center
five days a week.
(continued on page 61)
Students & Graduates
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To receive a free sample of our "needs no starch" cloth ,
and more information, please clip this coupon and mail
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The Canadian Nurse
Dcmbr1MO 13
audiovisual
Help for special services
Health and Welfare Canada has prepared
a series of handbooks, Guidelines for
Establishing Standards for Special
Services in Hospitals. The booklets,
which cover a number of services such
as Total Parenteral Nutrition, Intensive
Care Units, geriatric day hospitals and
ultrasound facilities among many
others, have set out guidelines for the
establishment of such services. Included
are recommendations for patient load,
staff coverage, staff training and
necessary equipment. For more
information, or copies of the guidelines,
contact New Technology and
Guidelines, Health Services Directorate,
Health Services and Promotion Branch,
Health and Welfare Canada, Ottawa,
Ontario K1A 1B4.
A special place
Bloorview Children s Hospital is a very
special place for children in Ontario
who are chronically ill or handicapped.
Bloorview promotes the team approach
to care of these children, who suffer
from cerebral palsy, muscular dystrophy,
spina bifida and other crippling diseases
or injuries, and under the hospital s
administration the large professional
staff provides incentives to motivate
each child to develop to his or her full
potential. A film "Bloorview A Very
Special Place" has been commissioned
to tell the hospital s story and is available
without charge. Contact the distributor,
Modern Talking Pictures, 143 Sparks
Street, Willowdale, Ontario, M2H 2S5,
or telephone 416-498-7290.
A series of 1 5 minute videocassettes on
patient education topics have been
produced by Robert Abelson of Ottawa.
The film work was done on contract by
CBC or the National Film Board;
content was prepared in consultation
with specialists in the specific fields.
The series has three different
programs, each made up of 1 3 separate
cassettes:
1. Dentistry Today
2. Woman Talk (on obstetrics and
gynecology)
3. Cardiology: You and Your Heart.
These videocassettes are available
for sale at a cost of $200.00 per
program, or to lease at $99.00 per
month. For further information contact:
Take HI Video Education
Robert Abelson Company Inc.
46 Elgin Street
Ottawa, Ontario
Health Sciences Centre
Winnipeg, Manitoba
Intensive Care Nursing Program
This eleven month post-basic program integrates advanced academic and clinical
aspects of Intensive Care Nursing. Challenging experiences are offered in a variety
of critical care settings in a University affiliated hospital.
Approved by the Manitoba Association of Registered Nurses.
Candidates must have acute medical or surgical nursing experience of at least one
year and be registered in their province of current practice.
Program entry dates are in February and September. Applications must be
completed three months prior to starting date.
This program is open to females and males.
For information and applications write to:
Program Co-ordinator
Intensive Care Nursing Program
Health Sciences Centre
Room GH601
700 William Avenue
Winnipeg, Manitoba
R3EOZ3
The 1980 Health Computer
Applications in Canada contains over
250 pages of information valuable to
any health facility. Its four sections
give users the latest "who s who" in
health computing, details of the
hardware and software packages now
in use, and describes over 350 accounts
of individuals across the country getting
maximum use out of their computers.
This sixth edition reference guide
is available from :
The Health Computer
Information Bureau
41 Laurier A venue West
Suite 800
Ottawa, Ontario
KIR 7T6
Cost: $5 0.00 in Canada
$65.00 outside Canada.
The Computer Bureau is sponsored by
the Canadian Hospital Association,
Canadian Medical Association and the
Canadian Organization for the
Advancement of Computers in Health.
Maternity Care Checklist
The latest publication from the
Canadian Institute of Child Health is
Family Centred Maternity and Newborn
Care: A Resource and Self-Evaluation
Guide. Designed as an evaluation tool
for units with more than 20 obstetrical
beds, the guide is an aid to assessment
of the quality of care being offered. In
question and answer format, the
guidebook can be used by nurses,
physicians, hospital administrators or
consumers.
A French edition will be released
in the fall of 1980.
Copies are available from CICH,
Suite 803, Laurier Avenue West,
Ottawa, Ont. KIR 7T3, for $10.00 each.
Periodic health examination
Does preventive medicine really prevent
disease and reduce the toll of disability
and untimely deaths? This is the central
question facing all health professionals,
the public and all levels of government.
A recent publication from the Canadian
Task Force on the Periodic Health
Examination provides an authoritative
and reasoned review, and summary of
published evidence. The price is
$18.50.
Other current publications are
Diagnosis and Treatment of Sexually
Transmitted Diseases ($2.25) and
Health Protection and Drug Laws
($2.95).
Orders should be accompanied by
a cheque or money order made out to
the Receiver General of Canada and sent
to Canadian Government Publishing
Centre, Hull, Quebec, K1A OS9. *
14 December 1 980
The Canadian Nurrc
Although most of our knowledge about the blood clotting mechanism has been acquired since the 18th
century, the phenomenon of liquid blood being converted to a solid gel must have been familiar to
primitive man. Some of the earliest recorded observations were left by Aristotle who made extensive study
of the subject. His observations, recorded in Historia Animalium, show he recognized that the clotting
process was dependent upon the watery portion of blood which he called serum. He was also aware of
marked differences in the blood clotting ability of various species and in diseased and healthy human
beings. These observations and deductions, remarkable for his time, were later substantiated by
investigators with more sophisticated equipment such as a microscope.
Henjostasis
atjd the nature of its defect
in henjophilia
Anne Hedlin
Cuts and bruises are common
occurrences in our daily lives and we
pay little attention to them because
experience has shown us the bleeding
will stop with little or no treatment.
Obviously we possess some efficient
mechanisms capable of preventing blood
loss which are lapidly activated in
response to blood vessel injury.
Hemostasis, the process concerned with
the prevention of blood loss, involves
the combined activities of blood vessels,
platelets and the coagulation
mechanism. Each of these makes a
unique contribution, the extent of
which depends on the severity of the
injury and the number and size of the
blood vessels involved.
Vascular response
When a blood vessel is injured, such as
by a blow or a cut, it immediately
constricts; that is, it undergoes
vasospasm. This response helps to
reduce blood loss by decreasing the flow
of blood to the area. Vasospasm makes
an important contribution to hemostasis
as it can occur in all types of vessels and
may be of sufficient intensity to
completely occlude the vessel. This
constriction is prolonged by substances
released by those platelets which react
to the vessel injury.
Platelet action
Platelets, non-nucleated cell fragments,
are formed in bone marrow from
megakaryocytes, which extrude a
portion of their cytoplasm into a blood
vessel where it becomes pinched off.
They are usually discoid in shape but
can form pseudopodia (finger-like
processes) which are contractile (see
figure one).
Platelets are normally present in a
concentration of about 250,000 per
cubic millimeter of blood. If their
number falls to below 20,000 per cubic
millimeter, a serious bleeding tendency
develops. This bleeding may take the
er.8
Figure one: Platelets lose their discoid
shape and form pseudopodia
when activated.
form of petechiae (tiny hemorrhages in
the skin) and oozing from intact
mucosal surfaces.
Platelets do not normally adhere
to the smooth intact endothelium of
blood vessels; when the vessel wall is
damaged, however, they are exposed to
underlying connective tissue containing
collagen to which they do adhere.
This adhesion of platelets to collagen
triggers the release of platelet adenosine
diphosphate (ADP) which promotes
adhesion of platelets to each other.
Collagen and ADP induced adhesion
together result in the formation of a
platelet plug; in tiny vessels this plug
will seal the opening and prevent
bleeding. Adhesive platelets also release
chemical vasoconstrictors, such as
serotonin, which prolong the
constriction initiated by the vasospasm ;
this assists in the formation of the
platelet plug. The combined effect of
the vascular response and platelet plug
formation will halt the flow of blood
from vessels temporarily, but if a fibrin
clot does not form to hold the platelets
in place, they will be washed away when
the vessel relaxes.
The coagulation mechanism
Most of the substances necessary for
clot formation are present in the blood,
The Canadian Nurse
DmmtarltM 15
but because these factors are in an
inactive form, blood does not normally
clot in the vessels. These clotting factors
will be activated when blood comes in
contact with a "foreign" surface such as
a rough vessel lining, other damaged
tissues, or an object like a syringe, needle
or glass tube. The process is called
intrinsic clotting if it uses only the
substances found in the blood; when it
involves the contribution of substances
found in surrounding tissues it is called
extrinsic. Bleeding from a severed vessel
initiates both intrinsic and extrinsic
clotting mechanisms (see figure two).
Intrinsic coagulation
When blood comes in contact with a
foreign surface, Factor XII is activated
to Factor XHa. This activated factor
sets off a cascade of reactions when in
turn it acts on Factor XI. Factor XI
then causes Factor IX s activation and
together with Factor VIII, calcium ions,
and a phospholipid contributed by
platelets, brings about activation of
Factor X.
Activated Factor X then enlists
the assistance of Factor V, calcium ions
and platelet phospholipid to convert the
plasma globulin prothrombin to an
active proteolytic enzyme, thrombin.
Finally, thrombin acts on another plasma
protein fibrinogen;it attacks certain
bonds in the fibrinogen molecule,
producing fragments known as fibrin
monomers. These monomers attach
end-to-end, forming long tangled chains
in which red blood cells are trapped.
Figure two: The activation of blood coagulation factors which results in conversion of blood
from a liquid to a gel.
The resulting mass of fibrin and cells
assumes the appearance of a gel. The
liquid portion of the clotted blood,
known as serum, is squeezed out of the
gel during clot retraction.
Extrinsic coagulation
When blood escapes into the
surrounding tissues, a substance called
tissue thromboplastin or tissue factor
forms a complex with Factor VII. This
complex in the presence of calcium
ions, activates Factor X and from this
point the action proceeds as for
intrinsic clotting. Because this process
requires the action of a substance found
outside the blood it is called extrinsic
clotting.
CONVERTED
TO
ACTS UPON
Fibrinogen
V
Fibrin
y Ca-H-
Insoluble
Fibrin
Thrombin
FXIIIg
I
!*
M FXII I
Prevention of clot formation
Obviously, this clotting mechanism is
potentially harmful; if clots form within
the blood vessel and obstruct blood
flow in a vital area such as the heart or
brain, the individual s life is endangered.
Fortunately, in addition to the fact
that the clotting factors are in an
inactive form there are both natural and
artificial methods of preventing blood
coagulation. Normally, the smooth
endothelial lining and a layer of
negatively-charged protein on the inner
surface of the vessel reduce the
possibility of clotting through contact
activation. Also, the blood contains
inhibitors to the active factors, which,
if activation does occur can sometimes
prevent coagulation by their interaction,
e.g. antithrombin interacting with
thrombin.
To maintain the liquid form
of the blood in vitro, anticoagulants
may be added, or one of the essential
clotting factors can be eliminated,
neutralized or inhibited. To preserve
blood for transfusions or for
hematological purposes an anticoagulant
such as sodium citrate is added to it.
The citrate combines with calcium ions,
thereby preventing them from
contributing to the clotting process.
(Calcium must be in the ionized form to
promote clotting.) Once sufficient
sodium citrate has been added blood
will remain liquid indefinitely, unless
calcium ions are added again to restore
clotting ability.
Procedures involving
extracorporal circulation require the use
of artificial anticoagulants. In open
heart surgery or the use of the artificial
kidney when the patient s blood must
circulate through a network of tubing
outside the body, these artificial vessels
provide a "foreign" surface contact. If
an anticoagulant, in this case heparin,
were not added the blood would clot.
Heparin prevents clotting by
interfering with the action of several
blood factors; it is ideal for these
treatments since its anticoagulant effect
is immediate in the artificial system and
it is subsequently rapidly inactivated in
the patient s circulation.
Fibrinolytic mechanism
A clot once formed is still susceptible
for a short period, to dissolution by the
action of plasmin, a proteolytic enzyme.
Plasmin is formed from plasminogen by
the action of specific activators in the
blood and tissues. It attacks the fibrin
molecules of the clot breaking it into
small fragments thereby dissolving or
lysing the blood clot.
Bleeding disorders
Blood coagulation is in part the result
of a chain reaction; a weak link in this
16 December 1980
The Canadian Nurse
chain can cause a serious delay in clot
formation. Perhaps the best known
bleeding disorder is hemophilia, the
commonest form of which is classical
hemophilia resulting from a deficiency
of Factor VIII. The term hemophilia is
also used for deficiencies of Factors
IX and XI which occur less frequently.
Classical hemophilia is
characterized by a sex-linked recessive
inheritance of a hemorrhagic tendency
which affects males almost exclusively.
The defect is transmitted to the
affected sons by the X-chromosome of
the carrier mother. The carrier usually is
symptom-free, but may bleed
abnormally following childbirth or
surgery. Although hemophilia is limited
almost exclusively to males, symptoms
of the disease have been known to occur
in the female child of a hemophiliac
father and carrier mother (see figure
three). Female hemophiliacs, however,
are rare.
The earliest manifestations of
this condition occur in early childhood,
not necessarily as might be expected, in
the neonatal period. Even severely
hemophilic babies may appear to be
normal for the first six to nine months
of life except for excessive bruising. It is
suggested that during this time the
combined effect of Factor VIII derived
from the mother, and the typically
protected life of the infant reduce the
possibility of bleeding. Once the child
begins to crawl and walk, however, the
inevitable falls and blows cause bleeding
into tissues.
Hemophilic blood clots slowly.
Whole blood clotting time for a
hemophiliac may be several hours as
compared to the normal time of
5-8 minutes. Because of this delayed
clotting time the large hematoma
characteristic of hemophilia may form
as a result of a minor injury. Without
effective treatment bleeding can
continue for days or weeks from slight
injuries. If extensive bleeding occurs
repeatedly into muscles and joints the
results will be not only pain and
swelling but also muscle contracture and
joint deformity.
Hemophilic individuals do not
normally bleed excessively from
superficial cuts because the normal
forces of their hemostatic system,
namely vessels, platelets and extrinsic
clotting, may be sufficient to seal the
wound and stop blood loss. For
example, the hemophiliac s bleeding
time test is usually normal. However,
when bleeding is sufficient to
overwhelm these components of the
hemostatic system, the delayed intrinsic
clotting of the hemophiliac places him
in danger of uncontrolled hemorrhage.
Figure three: The heredity pattern of hemophilia. The defect is carried by the X
chromosome. The offspring of a female carrier and normal male may be normal, a female
carrier or hemophilic male. Mating of two individuals who each possess the defect may, in
the extreme case of a hemophilic male and hemophilic female, result in exclusively
hemophilic offspring (Generation (4)).
1)
XY XX
2) *
XY XX XY XX
XX-
-XY
XX XY
I I I I
XY XY XX XX
TT 1 I I
XY XY XX XX XY
4)
XY
XY
XX
XX
Uncontrolled hemorrhage into
tissues in the hemophiliac suggests the
presence of a defect in extrinsic
coagulation. However, even in the
normal system extrinsic coagulation is
not capable of controlling blood loss
from vessels but requires the assistance
of the intrinsic. The delayed intrinsic
clotting allows large volumes of blood
to escape.
Methods used to halt bleeding in
the individual with normal clotting
time are ineffective in the hemophiliac
who requires administration of the
defective clotting factor, e.g. Factor
VIII. If treatment is instituted
promptly, not only can the bleeding be
controlled but deformity can be greatly
reduced or prevented.
Factor VIII deficiency hemophilia
is perhaps the best known bleeding
disorder, but there are others. The
Factor VIII defect in von Willebrand s
Disease, defects of Factors IX, XI and
fibrinogen, a deficiency of platelets,
and excessive activity of plasmin
(causing fibrinolysis) all contribute to
bleeding disorders.
It is easy for the one who is
blessed with normal hemostatic
function to take for granted that minor
injuries will not result in a serious
hemorrhage. Those who suffer from a
defect in hemostasis are acutely aware
of the importance of normal hemostatic
activity as they live from one crisis to
the next.*
Bibliography
1 Aristotle. Historia animalium.
Translated by A.L. Peck. London:
Heinemann; 1965: Vol. 1.
2 Biggs, Rosemary. The treatment
of hemophilia A and B and Von
Willebrand s disease. New York:
Lippincott;1978.
3 Guyton, Arthur Clifton.
Textbook of medical physiology.
5th ed. Philadelphia: Saundersf 1976.
4 Rapaport, Samuel I. Introduction
to hematology. New York: Harper and
Row; 1971.
5 Wintrobe, Maxwell M. Clinical
hematology. 6th ed. Philadelphia:
Lea and Febiger. 1967.
Anne M. Hedlin (BScN, University of
Saskatchewan; M.Sc., University of
Saskatchewan; PhD, Physiology,
University of Toronto) is a research
associate in the department of
physiology and a lecturer in the faculty
of nursing at University of Toronto. She
has had experience in general duty
nursing, public health nursing and
nursing education. Hedlin has published
numerous articles on blood coagulation
and blood fibrinolysis, her main area of
research.
The Canadian Nurse
December 1980 17
A Special
Hemophilia Program
Gail O Neill
Hemophilia is a rare disease; less than 2000 persons in Canada
are affected. It remains incurable but treatment has improved
greatly in the past 15 years. The necessary ingredients for
comprehensive care are a knowledgeable, cooperative patient
and family combined with good clinical and laboratory services.
In 1970 the Montreal Children s Hospital Home Care
Department organized a special hemophilia program. The
program has grown considerably in the last ten years and now
provides comprehensive care for approximately 160 patients
of all ages. Delia Kermack was one of the first nurse coordi
nators and she continues to work with the program. CNJ talks
to Delia to find out more about the present treatment of
hemophilia and the nurse s role in a center of this type.
CNJ: Could you explain the origin of the program?
Delia: The Montreal Children s Hospital started a home care
program for chronically ill children in 1964 with a staff of one
nurse and one doctor. In 1970, a decision was made to expand
the program to include children with hemophilia who were
frequently admitted to the hospital. At this time, we had
40 to 50 children with this disease.
CNJ: Were there changes in treatment around this time?
Delia: Up until 1965, patients were treated with plasma
infusions. In the late 1960 s it became possible to replace the
missing clotting factor in classical hemophilia with cryopre-
cipitate, a plasma derivative rich in Factor VIII. This was made
available through the Red Cross and it was a major break
through in treatment.
CNJ: Is cryoprecipitate the only new treatment product?
Delia: No; to discuss treatment further we must distinguish the
types of hemophilia. The two major forms are hemophilia A
(factor VIII deficiency or classical hemophilia) and hemophilia
B (factor IX deficiency or Christmas Disease). The basic treat
ment for both A and B is to replace the missing factor. Fresh
frozen plasma contains both of these factors, but there are
many side effects such as frequent allergic reactions and
hypervolemia. Commercially prepared freeze dried concentrates
of both factor VIII and IX became available in the 1970 s. The
freeze dried concentrate is reliable, easy to use and store in
homes, schools or offices and convenient for transport by the
traveller.
CNJ: How is the choice made between cryoprecipitate and the
dry concentrate for those with factor VIII deficiency?
Delia: It is possible that either one is used under different
circumstances. For example, cryoprecipitate is a single donor
infusion and it is recommended for mild bleeders and young
children because of the reduced risk of hepatitis. The concen
trates are much more effective though, and ideal for home
infusion.
CNJ: What are the problems and side effects of these treat
ments?
Delia: The problems are those normally encountered in intra
venous infusions and the use of blood products. The long term
effects are unknown. We are now concerned about the growing
number of patients with abnormal liver function tests and this
may be one of the side effects.
CNJ: What are the major dangers for the person with
hemophilia?
Delia: The vascularity of the tissue and the body cavity or area
determine the dangers of the hemorrhage. Bleeding into the
central nervous system, into the neck, chest cavity or the
abdomen require immediate treatment and hospitalization.
These incidents are uncommon in most individuals but when
they occur a knowledgeable patient and family is very
important. On the other hand, frequent hemorrhages into
muscles and joints without good treatment leads to progressive
hemophilia arthropathy and crippling.
CNJ: What does comprehensive care for the person with
hemophilia involve?
Delia: It is equivalent to the care of any person with a chronic
illness: they require services and support that will allow them
to live as normally as possible with their disability. Specifi
cally this means prompt treatment of acute bleeding episodes
and follow-up care. Continuous patient education and good
coordination with other services is mandatory if all health care
needs are to be met adequately.
CNJ: How does this program provide for comprehensive care
of chronically ill patients?
Delia: We are a multi-disciplinary team consisting of physicians,
nurses, physiotherapists, social workers, occupational thera
pists and secretaries. We provide 24-hour on-call coverage. Our
consultant staff include hematologists, orthopedic surgeons,
internists, dentists, geneticists and psychiatrists.
Francois, born in 1949, was the second of three children in a
family with no history of hemophilia. When he was circumcized
one week after his birth he bled excessively and as a result
remained in hospital for a month. A year later he was diagnosed
as having severe classical hemophilia but he did not have any
serious problems until he was two. From two until his early
teens he was hospitalized on an average of 15 times a year.
Hemarthroses, his major problem, was treated at that time
with whole blood, fresh frozen plasma, joint aspirations, casts,
traction, physiotherapy, and codeine or aspirin for pain. At
five a cerebral hemorrhage put him in a coma for three days
but he made a good recovery in time. An appendectomy at
seven was complicated by an evisceration requiring more
surgery; during his recovery Francois remembers being tied to
the bed with IV s running in both arms, sometimes whole
blood and other times plasma. At 11, the year he had cobalt
radiation for his tonsils, he was sent to a school for the
handicapped where he stayed for seven years. From 16 to 18
he was treated in the emergency department two or three
times a week for various hemarthroses and required hospitali
zation four to six times a year on an average. Most of his
admissions were short stays of three to six days, but in 1976
he spent 300 days in hospital because of poor response to
treatment. Dental work was only done once in ten years.
Most of Francois s bleeding episodes caused extreme and
prolonged periods of pain. He believes that this chronic pain
was not treated adequately because of fear of addiction and
that this may have contributed to some of his problems such
as anxiety, depression, obesity, headaches and a duodenal ulcer.
In 1977 at the age of 28 he was admitted to the Home
Care Program and taught the self-infusion procedure so that he
could treat his bleeds immediately. He a I so underwent extensive
dental work at this time using local anesthesia and factor VIII
coverage. The frequency of his bleeding episodes remains high
but control is good. Pain is still very much a problem but it is
modified by mild analgesics. Hospitalizations have almost
become a thing of the past.
18
December 1980
Nni/ornl -r 1 Ql
The Canadian Nurse
CNJ: What is the nurse s role in this program?
Delia: The nurse assesses and treats acute bleeding episodes
and coordinates the acute and chronic care for these patients:
she really provides primary care. She is responsible for patient
and family education including the disease, treatment, IV
infusion techniques and genetic counseling. She also acts as a
liaison with schools and employers. Education of other hospital
staff, including the emergency department, is another
important function. The nurse participates as well in any
hemophilia research the centre may be involved in.
CNJ: What other resources exist for the person with hemophilia?
Delia: The Canadian Hemophilia Society, a voluntary non
profit consumer organization, has been in existence since 1953
and now has a chapter in every province. The society works
toward solving the problems of this disease by helping patients
and families, ensuring the effective use of national blood
resources and striving for the eventual cure and elimination of
the condition. The society is a charter member of the World
Federation of Hemophilia. At Montreal Children s Hospital, as
at other special Canadian treatment centers across the country,
it is the nurse coordinator who acts as a liaison person between
the clinic and the Hemophilia Society. Nurses who wish to ob
tain more information about the work the society is doing
should write to:
The Canadian Hemophilia Society
Chedoke Centre Patterson Building
P.O. Box 2085
Hamilton, Ontario L8N 3R5
Executive Director: Edwin Gurney *
John, a ten-year-old boy from a family with a history of
hemophilia, was diagnosed at eight months of age after a
hemorrhage into his hand. He was immediately referred to the
Home Care Program and the nurse made frequent home visits
to teach the family about the disease and its management.
Being an active toddler he bled frequently into muscles and
joints and these episodes were treated at home by the home
care nurse. On weekends and after hours his mother would
contact home care and arrangements would be made to have
his treatment ready for his arrival at the emergency room. As
soon as his veins were more easily accessible, his mother was
taught intravenous infusion technique, so from age three she
treated him for all minor bleeding episodes. The family was
supported by telephone contact during the early days of home
infusion and they quickly achieved independence in day-to-day
management. Time was no longer lost in travel and this
immediate treatment shortened the duration of the hemorr
hages.
John was hospitalized six times between the ages of two
and six; four times for minor head injuries, once for a tongue
laceration, and once for a synovectomy of his left ankle. When
he started school the home care nurse met with school
personnel to discuss hemophilia and its management. Since the
age of six he has averaged about 35 bleeding episodes a year
each requiring a day or two of treatment; he receives factor
VIII concentrate and occasionally must wear a splint for joint
immobilization. His primary care is under a pediatrician and he
sees an orthopedic surgeon for his chronic left ankle problem.
Dental examination and care is routine at least twice a year
and he has a total evaluation yearly at the home care
assessment clinic.
John leads a relatively normal life and is now in grade
five of a French immersion program; he rarely misses school.
He is an excellent swimmer and enjoys his guitar lessons.
Special Canadian Treatment Centres for Hemophiliacs
British Columbia
Hemophilia Assessment Clinic
The Arthritis Centre
Vancouver, B.C.
Nurse Coordinator: Lois Lindner
Alberta
Comprehensive Assessment Clinic and
Home Care Program for Hemophiliacs
Alberta Children s Hospital
Calgary, Alberta
Nurse Coordinator: Cathy Bennett
Comprehensive Hemophilia Centre
University of Alberta Hospital
Edmonton, Alberta
Nurse Coordinator: Carol Zittlau
Saskatchewan
Hemophilia Treatment Centre
Elliss Hall Patient Education Centre
University Hospital
Saskatoon, Saskatchewan
Nurse Coordinator: Caryl Bell
Manitoba
Hemophilia Program
Health Sciences Centre
Winnipeg, Manitoba
Nurse Coordinator: Myrna Deagon
Ontario
Hamilton Regional Hemophilia Program
McMaster University Medical Centre
Hamilton, Ontario
Nurse Coordinator: Brenda Blair
Southwestern Ontario Hemophilia Centre
St. Joseph s Hospital
London, Ontario
Nurse Coordinators: Matthew Maynard, Alison Currie
Hematology Clinic
Hospital for Sick Children
Toronto, Ontario
Nurse Coordinator: Clair Smith
Ottawa General Hospital
d/o Dr. Smiley Office
Ottawa, Ontario
Nurse Coordinator: Claire Brodeur
Toronto Auxiliary Children s Hospital
Toronto, Ontario
Nurse Coordinator: Sylvia Simpson
Quebec
Home Care Program
Montreal Children s Hospital
Montreal, Quebec
Nurse Coordinators: Delia Kermack, Ann Lynch, Gisele
Belanger, Dona Johnston, Margaret Hall
Hemophilia Program
Hopital Ste-Justine
Montreal, Quebec
Nurse Coordinator: Muriel Girard
Centre Hospitalier Universitaire
Departement d Hematologie
Sherbrooke, Quebec
Nurse Coordinator: Lucie Biron
Hopital St-Sacrement de Quebec
Centre d Hematologie
Quebec, P.Q.
Nurse Coordinator: Evangeline Morin
Newfoundland
Hemophilia Program
Dr. Charles Janeway Child Health Centre
Saint John s, Newfoundland
Nurse Coordinator: Irene Walshe.
The Canadian Nurse
December 1980 19
_
pursing
Do patients I ike it
Are nurses satisfied
Does it cost more
Laverne E. Roberts
The concept of "primary nursing" was
developed in the late 1960 s as a result
of general dissatisfaction among nurses
with fragmentation of patient care and
lack of a professional level of nursing
practice within hospital settings. Since
then, it has spread widely across the
U.S. and Canada and has been the
object of numerous research studies.
The nursing department of the Victoria
General Hospital in Winnipeg
implemented the concept of primary
nursing on one unit as a pilot project to
compare its effectiveness to the system
of "team nursing" used throughout the
institution.
Formulation of the study
Our search of the literature revealed
that usually, when primary nursing is
implemented, quality of care increases.
Most of the available information
though is based on studies conducted in
the United States, the majority of them
focused on the underlying objectives of
primary nursing. What we sought to do
was to replicate these positive findings
in a Canadian setting, using the
following variables as a measure of
effectiveness:
continuity of care
individualization of care
patient satisfaction
staff nurse satisfaction, and
operating costs.
The established system on most
nursing units in the 254-bed Victoria
General Hospital is team nursing (also
called total care nursing) in which a
group of nurses (RN s and LPN s)
function under the direction and
coordination of a team leader. Each
nurse is individually assigned to a
BMP
i
. Ibi -Cnnflrtini-Ni u
number of patients for that particular
shift during which she gives total
"hands on" nursing care. Assessment,
planning and evaluation of the care of
those patients is the responsibility of
the team leader who share" these
responsibilities at her discretion with
the other nurses on her team. The
team leader coordinates the patient
care and communicates with other
members of the health team.
Primary nursing, on the other
hand, is defined as "a system of
delivering nursing care in which each
patient is assigned to the care of a
primary nurse (registered nurse). This
nurse, in collaboration with the patient,
family and other members of the
health team, plans, implements and
evaluates the patient s nursing care
from admission to discharge. " Each
primary nurse is responsible for a
caseload of four to five patients and
is accountable for their nursing care on
a 24-hour basis. The associate nurse
(another RN or LPN) provides care in
the primary nurse s absence, following
her directions. The primary leader (the
equivalent of a head nurse) provides
quality control for the care given to all
patients on the unit and acts as a
resource person for the primary nurse.
We adopted the elements of
primary nursing as developed by the
University of Minnesota Hospitals to
further define the concept:
a basic one-to-one patient
relationship
decentralization of decision-
making for patient care to the individual
nurse
clear allocation of responsibility
and authority for nursing decisions
24-hour total nursing care
planning by the primary nurse for
assigned patients
direct communication between
primary nurse, associate nurses and
other disciplines caring for the patient
inclusion of the patient and
family in planning care.
Methodology
In order to implement primary nursing
within a research design, in February,
1978 we divided our acute care medical
unit into one 24-bed experimental unit
and one 24-bed control unit. The
control unit continued to utilize team
nursing, while the experimental unit
implemented primary nursing.
Three instruments were used in
the study to determine effectiveness of
nursing care on each unit:
1. a patient questionnaire, which
contained 20 items, looked at the
patient s perception of the continuity of
his care, how individual he thought it
was and his degree of satisfaction with
this care.
2. a job satisfaction inventory, designed
to be especially sensitive to differences
in nursing care delivery systems.
Developed by Peterman and
Shauwecker as part of the Western
Interstate Commission for Higher
Education nursing research project, the
questionnaire contained 48 items which
measure certain factors contributing to
job satisfaction.
3. a patient record audit, developed by
the author specifically for this study,
which examined the directions given by
the care planner on the nursing care
plan and measured how closely those
directions were followed by other care
givers.
Operating costs were studied in
relation to baseline staffing, differences
in sick time, and in unscheduled over
time. Since both the primary and the
team nursing unit functioned financially
as one entire unit on one approved
budget, other statistics were almost
impossible to identify. The statistics
used were obtained from records kept
by the unit director for a period when
both primary and team nurses were on
identical rotation schedules.
Findings
Our findings were interesting:
First, the patient records
demonstrated that there was slightly
more continuity of care on the primary
nursing unit. Responses to the patient
questionnaire also indicated that there
was more continuity of care on the
primary unit, and that this care was
more individualized, but patients from
both units were equally satisfied
generally with the care they received.
Primary nurses on the other hand
were more satisfied with their job than
were the team nurses, except in
relationships with physicians.
Finally, no increase in costs was
incurred as a result of dividing the unit
into team and primary nursing sections;
both functioned at an equal cost in
relation to baseline staffing,
unscheduled overtime and sick time.
Discussion
Recording that nursing care has been
implemented as directed on the nursing
care plan is probably a good indicator of
continuity of care, and the study results
showed that the nursing care plan was
followed more often on the primary
unit: 57.7 percent of nursing orders
were recorded as implemented, as
opposed to 39.6 percent on the team
unit.
The primary nurse has the
responsibility of both planning and
directing the patient s care, and of
ensuring that care is carried out in a
consistent manner by her associate
nurses, chiefly through use of the
nursing care plan. If the care is not
given as directed, the primary nurse has
the authority to investigate the reasons.
This authority and accountability
among peers may well explain why the
nursing staff followed the care plans
more often on the primary unit.
Another factor that may have
influenced the difference in results
between the two units was that the
primary nurses had been oriented to the
nursing process which involves a
systematic approach to nursing care
planning. This approach emphasizes
specificity; the more specific the nursing
care plan, the less open it is to
individual interpretation, and the more
easily it can be followed.
These two factors, the authority/
accountability of the primary nurse and
the use of the nursing process are
highly interdependent. The primary
nurse needs to use an approach to
patient care that will clearly identify her
personal accountability; however, as
Carlson states, "many graduate nurses
are unable to utilize the theory (of
nursing process) due to the fact that we
are still using mass production
techniques, rather than a primary
nursing concept in our delivery of
nursing care.
The Canadian Nurse
December 1 980 21
It is interesting to note that both
units rated lower in following nursing
orders than might be expected
neither 57.7 percent nor 39.6 percent is
a high percentage. Either nurses were
not recording what they were doing or
they were not following the nursing
care plan. One can only speculate on an
explanation: the hospital s guidelines
for documenting nursing care were
unclear and open to misinterpretation
so that methods of recording may have
been inconsistent, or, as the literature
on nursing process often comments,
many nurses feel that nursing care plans
are useless or unimportant and as a
result, do not use them. (Do nurses
feel that way due to a poor self-image,
reflecting a history of subservience and
their current difficulty in adjusting to
independent practice?)
The fact that the primary nurse
herself cares for her patients each time
she is on duty also contributes to
continuity of care. She informs her
patients of her schedule and of the
associate nurses who will be caring for
them in her absence. The responses on
the patient questionnaire indicated that
the patients on the primary unit were
more often able to identify which nurse
would be looking after them from one
shift to the next and felt the nurses
were more aware of what happened on
previous shifts. When the patients were
asked how often something was omitted
from their care that they had expected
the nurse to do, the primary patients
identified fewer omissions than the
team patients.
When patients were queried
regarding their perception of
individualization of nursing care, the
primary patients more often felt the
information they shared was being used
by the nurse to help her care for them.
The continuity of the nurse-patient
relationship in primary nursing likely
contributes to this feeling. It is also
interesting that primary patients
perceived that the nurses talked to their
families about their care more often
than did team patients; this is one of
the basic elements of primary nursing
the inclusion of patient and family in
planning care.
Figure one: Variations in
job satisfaction, primary and team
nurses
Primary Nurses
Team Nurses
(N = 5)
(N = 4)
Mean Score
Mean Score
Accomplishment
2.8
23
Workload
2.8
2.6
Head Nurse
3.0
3.0
Physician
2.5
2.8*
Administration
2.9
2.8
Decision-making
3.3
3.1
Recognition
3.2
2.8*
Utilization of knowledge and skills
3.2
2.9*
Significant differences
Despite all the positive results
received from the primary patients
versus the team patients, when we asked
how satisfied they were with nursing
care, there was little difference in their
responses. Obviously, not all the
variables that influence patient
satisfaction were tested in this study.
Why do patients answer items
negatively in relation to what nurses
would consider quality care and then
turn around and say they are satisfied
with that care? What are the public s
expectations of nursing? It was hoped
that the two open-ended questions that
asked what patients liked best and least
about their nursing care would shed
some light on this mystery, but while
almost all patients answered the "liked
best" question, very few of them
responded to the "liked least" question.
What they liked best about the nursing
care was similar on both units, ie.
characteristics of the nurse such as
pleasantness, concern, friendliness,
etc., described by both groups.
Another variable that we
examined was job satisfaction. As
discussed earlier, one of the reasons for
developing the primary nursing system
was a lack of professionalism in hospital
nursing. Primary nursing attempts to
give the staff nurse a high degree of
autonomy, authority and accountability
in practice; nurses on the primary unit
indicated on the job satisfaction
inventory that they had more
opportunity for using their knowledge
and skills (See figure one). Throughout
their education, nurses learn to assess,
plan, implement and evaluate the
nursing care of the patient but often,
when they begin working in a hospital
setting, they are not given the
opportunity to use the full range of
these skills. Primary nursing supports
independent decision-making; the care
giver is the care-planner.
Another significant finding of
the inventory was that the primary
nurses felt they received recognition
of their work not only from immediate
supervisors, but from patients, peers and
other members of the total health care
team. Of course, this may have been due
to the fact that these nurses were
spotlighted by the study, but some
consideration must be given to the
rewards of primary nursing.
By contrast, the scores on items
asking nurses about their relationship
with the physicians were higher for the
team unit than the primary unit. We had
predicted the opposite because the
primary nurses have one-to-one contact
with the physicians on a daily basis,
whereas the team nurses have only
sporadic contact with physicians, and
because during their orientation and
throughout the development of primary
nursing, the nurse-physician colleague
relationship had been emphasized a
great deal. Perhaps the primary nurses
expected immediate changes in those
relationships and when only the amount
of contact rather than the nature of the
relationship changed they became
discouraged. The traditional
handmaiden image is difficult to discard
and the desire for change may seem to
be one-sided.
22 December 1980
The Canadian Nurse
The cost of primary nursing is of
great concern to administrators; it is
commonly thought that primary nursing
costs more. However, neither current
literature nor our study support this.
The change to primary nursing need not
cost more providing that staffing is
already adequate. As Ciske reminds us,
"If requests must be made for more and
higher quality staff to ensure quality
care, then the request is valid, no
matter what organization is chosen." 3
No increase in costs was incurred as a
result of dividing the unit into team
and primary nursing. The total number
of equivalent full-time positions (EFT s)
before dividing the unit equalled 28.8;
when primary nursing was introduced,
this figure increased to 30.5 EFT s. At
the time, the increase seemed
unavoidable as working with two
smaller rotation schedules usually costs
more, but with some streamlining, that
figure was reduced to 27.4 and again to
27.1, finally stabilizing at 27.2 EFT s.
Unscheduled overtime for the entire
unit (primary and team) was negligible
and sick time during the two-month
period when both primary and team
staff were on identical rotation shedules
was equal.
Our conclusion that primary
nursing is at least as effective as team
nursing and, in fact, more effective in
terms of continuity, individualization of
nursing care and staff satisfaction,
suggests that the primary nursing
concept is a justifiable alternative to the
team system in the described clinical
setting. Other studies in the U.S. have
supported the effectiveness of primary
nursing in a variety of settings but
consideration must be given to the fact
that differences in the health care
system between that country and
Canada make it difficult to project
these findings to any individual
Canadian institution. Further study is
needed to replicate these findings in
other settings. *
The author wishes to express
appreciation to the Members of the
Board -Research and Services Fund for
sponsoring the study and to the
administration of the Victoria General
Hospital, Winnipeg, for its support.
Also acknowledged is the help from the
unit director, team leaders, and staff
nurses on Unit 5, and Dr. L. W. Roberts,
who gave helpful advice and assistance.
References
1 *Sangster, L.E. A comparison of
the effectiveness of primary nursing and
team nursing as organizational systems.
Winnipeg: Victoria General Hospital;
1979: p.9. (Unpublished research
report).
2 Carlson, S. A practical approach
to the nursing process. Amer.J.Nurs.
72(9): 1589-1591; 1972 Sep.: p.1589.
3 Ciske, K. Misconceptions about
staffing and patient assignment in
primary nursing. Nurs.Admin.Q.
1(2): 61-68; 1977 Winter: p.62.
Bibliography
1 Ciske, K. Primary nursing: an
organization that promotes professional
practice. J.Nurs.Admin. 4(1):28-31 ;
1974 Jan./Feb.
2 Corpuz, T. Primary nursing meets
needs, expectations of patients and
staff. Hospitals. 51(11): 95-100, passim;
1977 Jun. 1.
3 Felton, G. Increasing the quality
of nursing care by introducing the
concept of primary nursing: a model
project. Nurs.Res. 24(1): 27-32; 1975
Jan./Feb.
4 Marram, G. et al. Primary nursing:
a model for individualized care. 2d ed.
Toronto: Mosby; 1979.
5 -. Cost-effectiveness of primary
and team nursing. Wakefield, Ma.:
Contemporary; 1976.
*Not verified
Laverne E. Roberts, BN, is a graduate of
the University of Manitoba School of
Nursing, and who is currently teaching
at the Red River Community College. In
the past she has held a variety of
positions ranging from general duty
staff nurse to clinical instructor and
coordinator at the Health Sciences
Centre School of Nursing. At the time
this article was written she was project
leader of the primary nursing program
at the Victoria General Hospital,
Winnipeg.
Did you know... <j
Between 1972 and 1978 there has been
an 822 percent increase in Ontario
Workmen s Compensation Board claims
as a direct consequence of noise.
Noise-induced hearing loss, which is 1 00
percent preventable and 100 percent
incurable, results in permanent nerve
damage to the ear and also contributes
to high blood pressure, tension,
nervousness, headaches and even ulcers.
Dr. David Naiberg, Chief of
Otolaryngology at Scarborough General
Hospital, cites an effective hearing
conservation program as a way to
reduce these claims but says that one of
the biggest obstacles is employee
education. Correct use of protective
measures, such as ear muffs must be
stressed; ventilating them with holes or
just hanging them around one s neck are
common practices. Naiberg claims that
employee absenteeism is reduced and
workers efficiency increased when
noise pollution is decreased.
Did you know...
In the first 41 weeks of 1979, 21,726
cases of measles were reported in
Canada, i.e. 250 per 100,000 persons
under 20 years of age, an increase of
460 per cent over the comparable
period in 1978. However, in the United
States, where legislation requiring
measles immunization before or at the
time of school entry has been passed in
50 states, only 12,353 cases or 18.5
cases per 100,000 persons under the age
of 18 years were reported in the same
period. This is 50 per cent lower than
their figures in the corresponding period
in 1978 and 75 per cent lower than the
1977 figure.
While measles is often considered
to be a viral disease of little importance,
statistics show that one in 15 sufferers
have complications of pneumonia or
otitis media, about one in every 1000
develops encephalitis and about one in
every 10,000 dies.
Did you know...
Dentists warn mothers of infants against
the Nursing Bottle Decay pattern of
tooth decay, which may occur in
children between the ages of one and
four years. The chief cause is leaving a
bottle in bed with a child: the constant
washing of sweet fluid (and this can be
juice, soft drinks, or even milk) over the
teeth and gums results in a build-up of
acid which weakens tooth enamel,
exposing it to decay.
The Canadian Nurw
Dcembr1980 23
THE
PERIOD
What is reality*?
Constance Becker
Nurses who provide care to the maternity patient are aware of the move to more comprehensive patient-
centered care; some changes have occurred, but does current management and patient teaching match the
hard reality of the patient s own experience?
Part of the reality of the postpartum
experience is that clients and health
professionals alike have made several
assumptions about it. They are:
the puerperium is a healthy not
unhealthy or diseased state.
the transition for both parents
from expectant to actual parenthood is
smooth and natural.
the postpartum period lasts six
weeks.
The first assumption is based on
the broad experience that most women
have a good outcome from pregnancy
and a medically uncomplicated puer
perium. From a medical point of view
this may be realistic, but if one s defi
nition of health encompasses more than
physiological function to include emo
tional and social function, then the
assumption is not accurate. Neither is it
accurate to assume that the transition to
parenthood is uncomplicated the real
ity is that for many new parents prob
lems and stress result. Thirdly, while a
woman s body may have assumed its
pre-pregnant state on the whole, her
emotional and social functioning cannot
have adapted in such a short time. Is the
concept of the fourth trimester merely
a concept or is it an actuality in patient
care?
If, as one researcher has said,
childbearing is a multidimensional ex
perience, then it requires a multi
dimensional approach, one that deals
with the reality of the postpartum ex
perience as it is for most new parents,
and which dispels those myths to which
many patients and health professionals
subscribe.
Learning the role
Why is learning the new mother and new
parent role so problematic? Four factors
which affect the transition are:
1. the lack of a cultural option to reject
parenthood,
2. the fact that marriage no longer con
stitutes a major transition point in a
woman s life,
3. the abruptness of the change, and
4. the lack of realistic guidelines for
successful parenthood. 2
An individual who is learning a
new role in life generally learns some
thing about that new role before she or
he has to assume it: as student nurses,
for instance, we learned something of
our role functions before we became
graduate nurses. The less role clarifica
tion one needs after assuming the role,
the less difficulty one encounters in
making the transition and in functioning
effectively. Bearing these thoughts in
mind, we may ask ourselves do women
and new parents learn enough about
their new role beforehand? Do they re
ceive adequate clarification? What can
nurses do to help?
The role of new parent can be
learned and clarified in several ways;
people may observe their own parents
or peers functioning, but often they be
lieve they will operate differently -
"I ll never do that the way my parents
did with me."
24 December 1980
The Canadian Nurse
They learn from the media too
but the style of parenting presented on
TV or in the movies is unattainable and
unreal for most viewers. More often
than not the new mother is given the
picture of a supermom who presides
over an immaculate home, looks like a
fashion model, whose children are well-
behaved and never fight, and who has
lots of spare time to spend in leisure
activities with her spouse and offspring.
Magazine or newspaper articles or pam
phlets may provide conflicting informa
tion, thus confusing parents. Worse, the
information given by health professionals
may contradict that presented in the
media.
A new mother may also gain infor
mation on her role function through
clarification with her mate but this too
can be problematic for several reasons.
First, men generally expect women to
know how to care for an infant and as
they see the function to be inherently
female they may provide no real feed
back. The reality here is that the so-called
maternal instinct may be a comfortable
male myth; believing in it, a man can ab
dicate all responsibility for infant care
to the woman. But belief in the myth is
not exclusive to males: women believe
it too. How often is the new mother told
in answer to a question, "Just relax and
do what comes naturally." Some well-
meaning people may tell her to have her
husband take on some of the infant care
or home-making activities without realiz
ing that there are those who feel uncom
fortable taking on activities generally
associated with the opposite sex. A man
may feel uncomfortable doing domestic
chores and a woman may feel she has
failed if she requires assistance.
A woman may learn about her role
function from her role complement -
the infant. As in any role, an individual
is dependent on feedback to determine
the effectiveness of his or her behavior;
thus the new mother looks to her infant s
responses to her to evaluate her perfor
mance as a mother. For example, if she
is capable of soothing a fretful infant
she sees herself as competent; if she can
not and then someone else can, she may
perceive herself to be inadequate.
Hard work
Certain developmental tasks have been
identified for the postpartum woman. 3
She must accomplish the task of physical
restoration, she must learn to meet the
physical needs of her infant which in
volves a host of new skills, and she must
establish an emotionally healthy mother-
infant relationship.
It has been said that the woman s
need to mother is relative while the in
fant s need to be mothered is absolute. 4
In order to meet these absolute needs
the new mother must perceive her rela
tionship with her baby as satisfying to
each, but this may take several weeks to
accomplish.
With the addition of a new baby,
whether a first or subsequent infant, all
the family relationships must change. In
many families the responsibility for this
integrative process falls on the mother;
it is she who helps other family members
relate to the baby and establish mean
ingful relationships. It is important to
remember that the addition of one new
family member does not increase the
number of role relationships within the
family group by one, rather it multiplies
the number. For example, in the family
of a newborn there are three functioning
Do new
parents learn
beforehand?
o
Z
X
3
relationships -- mother-infant, father-
infant, and spouse-spouse. Prior to the
baby s birth, there was just one, spouse-
spouse.
Another developmental task with
which the postpartum woman must deal
is the sense of loss. This may seem rather
odd since with the birth there has been
an addition rather than a loss but the
disappearance of the state of pregnancy
may be distressing. Some women take
pride in the obvious physical changes,
and they enjoy the special activities and
the attention they receive. After delivery
the special status of pregnancy is lost
and suddenly the woman is a mother
rather than a mother-to-be. There are
significant changes in body image to con
tend with too: getting "back to normal"
takes time and effort. The postpartum
woman is best described as appearing
five months pregnant, which may seem
to be neither pregnant nor unpregnant.
Further, the woman who chooses
to be a full-time mother loses the social
definition she had prior to the birth of
her child; depending on how she per
ceives the mother role she may have a
sense of being devalued.
The reality of these developmental
tasks is that they take time to accom
plish, and many parents and nurses are
unaware of both the specific tasks and
of ways in which their accomplishment
may be helped or hindered.
Behavior postpartum
An important part of the postpartum
experience that must be understood is
the fact that certain behaviors appear in
the new mother, whether she is multi-
parous or primiparous. There are three
phases which may be designated as the
taking-in phase, the taking-on or
taking-hold phase, and the bursting
out . 5 6
The taking-in phase occurs in the
first few days of the puerperium and is
the woman s response to the expenditure
of energy during labor and delivery. In
short it is a period of hunger: hunger for
sleep, for food, for bodily comfort, and
for talking about the experience. The
woman is concerned about regaining
control of her bodily functions, such as
voiding. She is concerned too that she
performed well during labor, that she
was a "good patient". In effect, the new
mother in this phase herself needs moth
ering. She seeks reassurance from her
significant others, family and friends,
that they will accept the new infant into
their social systems, thereby validating
her ability to produce a new member
who is valuable.
Do we as care-givers, mother the
mother? Do we respond to her needs,
especially the need to talk about the
experience? Do we assist her in physical
restoration? Do we assume the imme
diate caretaking responsibilities for the
new infant? Do we facilitate acceptance
of the new infant by her family? How?
The second phase of tne post
partum period has been called the
taking-on phase and it is signalled by the
woman s feeling of comfort dealing with
her own body and by her interest in
learning to care for the baby. Now she
needs positive reinforcement that she is
performing capably, and she needs feed
back from both nurses and her infant.
This last is an important point for the
nurse to remember as often we are
tempted to take over some activities from
the mother, especially when she is not
adept; it seems quicker and easier to do
things ourselves rather than to take the
time assisting the mother. I experienced
a vivid example of this a few years ago:
a woman had had her second baby after
an interval of ten years. She had been
unsuccessful in breastfeeding with the
first but she very much wanted to
breastfeed this infant even though she
was unsure of her ability. The infant
was brought to her to nurse but was
sleepy and did not feed well. A well-
meaning nurse came into the room and
after hearing the mother s apology that
she hadn t been able to get the baby to
wake up to nurse, the nurse said, "Oh,
he ll wake up for me - give him to me,"
and she took the baby back to the nur
sery. The mother began to cry, and de
cided not to continue breastfeeding.
Although the mother is gaining
more control at this time, the taking on
phase is characterized by the familiar
postpartum depression or "baby blues".
Traditionally this has been ascribed to
the massive physiological changes which
occur after delivery but we now recog
nize another major factor involved, that
of the mother s sudden awareness of the
enormous responsibility of motherhood,
the reality that for 24 hours a day, seven
days a week, for the next many weeks
and years to come she will have the re
sponsibility of this infant. Contributing
to these feelings of depression is her per
ception of the shift of attention from
her to the baby; often the new mother
is greeted with questions about the in
fant s well-being rather than hers, and
visitors may rush off to the nursery to
see the infant.
In view of the move to early dis
charge of the postpartum patient, under
standing these two phases is especially
important, for the mother going home
after one or two days may be still in the
taking on phase when she is sent home
and told to rest and enjoy her baby -
hollow words to the mother for whom
reality is an unhealed episiotomy, sore
breasts, unestablished lactation, and
whose baby has an erratic feeding pat
tern and an unhealed circumcision. She
is going home without too much in the
way of realistic knowledge or support
from community services.
The third phase of the postpartum
period has been identified as that of the
"bursting out-binding in" phase and has
been found to occur a few weeks after
delivery. In this stage, after the woman
has recovered physiologically and psy
chologically from the delivery, she ex
periences a healthy revolt against the
feeling of depression, isolation and lack
of self-identity. She may go out with a
friend, or have an extravagant evening
with her spouse, but in any case she
"bursts out" from under the demands
of infant care. The important thing is
that she feels comfortable leaving the
baby in the care of another person; how
ever, she does experience a slight degree
of guilt but this concern for the baby
serves only to reinforce her maternal
feelings.
Health care services-what s the reality?
One recent study 7 identified the major
concerns of new mothers following dis
charge from hospital: the women had
concerns about infant feeding, their
own physiological state re: diet, exercise
and regaining their figure, and they had
problems with fatigue, emotional ten
sion, feelings of isolation, family rela
tionships with siblings of the infant, and
with their spouses. It was found that the
peak period for concerns was in the first
few weeks postpartum when the women
sought support and advice primarily from
spouses. None of the women identified
the nurse as a potential source of sup
port, counseling and advice.
Patients are
not getting
the care they
really need
The implications are quite clear:
patients are not getting the care they
really need. Postpartum teaching in hos
pital needs improvement to incorporate
more anticipatory teaching and realistic
counseling for the needs of the new
mother after discharge. More informa
tion must be provided about the re
sources available, and more services must
be developed, implemented and eva
luated.
Another study looking at patterns
of nurse-patient interaction on a post
partum unit made several interesting
discoveries: 8 mothers tended to obtain
more information from other mothers,
either by talking to them or by observ
ing, than they did from the nursing staff.
Information from nurses was generally
time and task-specific - "Have you had
your Sitz bath yet this morning? You
need to have it twice a day, you know,"
and was often repeated by other nurses
without anyone ascertaining the wo
man s real need for information. Most
nurse-patient interaction was on a
one-to-one basis, rather than in a small
group. Again, the implication is clear:
advantage is not being taken of the
opportunity to teach a small group of
mothers informally where each could
benefit from the others experience.
Special cases
There are certain instances wherein the
postpartum woman deserves special
attention, the first of which is the woman
who has undergone a delivery by Cae-
sarean section. Too often the focus of
nursing care in this case is on the patient
as being post-operative rather than on
the patient who is both post-operative
and postpartum. The reality is that she,
as a result of the surgical procedure,
may move more slowly through the var
ious adaptation phases than will other
women. Nurses must realize too that
while they may not place any sort of
negative connotation on the Caesarean,
the patient herself might. The following
excerpt from a recent study reveals one
patient s feelings about her Caesarean:
Other mothers express outright pity,
and subtle and outright implications of
abnormality. You feel left out, as well.
You have to learn to respond to this and
it can be difficult to do. If you let it,
it can get you down. One woman was so
condescending to me she said "Couldn t
take it, I guess." The operating room
recurred in my dreams regularly for two
months.. The dreams brought back the
fears and feelings of that night, and re
living of the immediate time before, and
the actual emergency treatment. Perhaps
they reminded me of my own mortality.
The dreams come less often as time
passes. They are just not as frightening;
I am not left with the same internal
shaky feeling. I feel guilty about my ini
tial reaction to my son. It was so oppo
site from the reaction I expected. I
looked at him and felt almost nothing. I
had a hard time feeling he was even mine.
I remember telling my husband, "How
do I know that s my baby?" 9
The second special situation is the
woman who has a multiple birth; while
the arrival of twins or triplets is now sel
dom a surprise, the new mother still has
special information needs postpartum.
She needs to know about feeding sche
dules and methods of feeding can a
woman with twins breastfeed? how
to organize her time in order to meet
the needs of each baby, how much and
what kind of infant equipment is needed,
and how to manage "twinness". 10 Do
nurses really meet these needs or do we
overlook them and cheerfully remark on
the amount of "fun" the woman is going
to have when she gets home?
Multiparous patients are a third
special group and yet they are often ne
glected since, as Mercer says succinctly.
26 DcmbM980
The Canadian Nurse
we assume they "know the ropes". 11
Often at the change of shift, staff report
that a particular patient is "a multip and
okay". Sound familiar? It is true that
the multiparous woman knows the ropes
having experienced firsthand the diffi
culties of motherhood but it is also true
that she will receive less attention this
time from family and friends, and she
has as many, if different, concerns. Al
though the love a mother feels for her
children is not drawn from a finite reser
voir, she might worry about the amount
of time she will have to spend with her
other childrenwill this detract from
her mother-child relationships? Do we
ask the multiparous mother about this,
or do we send her home to work this out
without suggestions, advice or support?
Other special situations which are
beyond the scope of this article need to
be mentioned at least - the woman who
has had an unexpected outcome to preg
nancy such as a baby who is ill or who
has an anomaly, or the woman who has
a stillbirth. The adolescent mother, too,
has special needs because of the imposi
tion of developmental tasks of adoles
cence over those of the postpartum
period. 12
One might say then that all post
partum patients are special cases and
that is exactly the point. Postpartum care
cannot ever be routine if it is to really
meet the needs of the new mother.
The new father too requires some
attention from nurses; although more
and more commonly men attend the pre
natal classes and participate in the labor
and delivery, we in the hospital do not
regularly involve them in the postpartum
experience.
New fathers undergo a response
that has been termed engrossment ,
which is simply that they are engrossed
with their new baby, seeing it as physi
cally attractive and desiring to hold and
touch it. Many describe a sense of elation
and increased self-esteem. 13 The new
mother should know about this to allay
her sense of no longer being the center
of attention. Providing mother with some
informal or formal teaching in infant
care is accepted practice but do we make
an attempt to involve the fathers as well?
If not, we are reinforcing the myth that
infant care is chiefly a feminine role.
Recommendations
It has been established that what is
needed during the postpartum period is
better patient teaching; the wise nurse,
in her assessment of her patient, decides
which stage of the postpartum period
that patient is in so that teaching may
be directed to the special needs of that
particular phase. For example, the taking
in phase when a woman is primarily in
terested in regaining control of her bod
ily functions is not the time to inundate
her with the myriad aspects of infant
care; she will learn better later on, when
she is interested in learning.
Other recommendations for more
complete postpartum care include:
inclusion of the father in infant
care teaching sessions. Are classes given
at times other than the traditional mor
ning class so that men who work during
the day can attend?
utilize small groups of women for
informal teaching. Patients learn from
each other as well as from nurses and we
should capitalize on this.
patients should be provided with
printed information as to what to expect
at home, and with lists of names and
One might
say that all
postpartum
patients are
special cases
telephone numbers for community re
source persons and services.
obstetrical units should not be
understaffed. For administrators to do
so is to assume that the puerperium is
routine and normal for all patients and
requires a minimum of care.
to facilitate teaching, perhaps
guides could be kept either at the bedside
or on the charts to avoid redundant
teaching and gaps in information.
the use of a telephone follow-up
service, either by hospital nurses or by
the public health nurse may be of great
value. 14 15
A century of care
Comprehensive, multidimensional care
to the postpartum woman and family
can be provided but it requires that
nurses have a full understanding and
appreciation of the components and
complexities of the postpartum and that
they have a commitment to provide the
necessary care. The gap between the
reality and unreality of the postpartum
experience must be bridged. The com
bined life prognosis of the newly formed
postpartum family is approximately a
hundred plus years.. .surely we can in
vest in that family the comprehensive
care that they need. *
References
1 Rubin, R. Maternal tasks in preg
nancy. Matern. Child Nurs. J. 4(3): 143-
153; 1975 Fall.
2 *Rossi, A. Transition to parent
hood. J. Marriage and the Family.
30(2):26-39;1968.
3 Gruis, M. Beyond maternity: post
partum concerns of mothersMCN Amer.
J. Matern. Child Nurs. 2(3): 182-1 88;
1977 May/Jun.
4 *Benedek, T. Parenthood as a
developmental phase. J. of the Amer.
Psycho/analytic Ass. 7(8):389-41 7;1959.
5 Rubin, R. Basic maternal behavior.
Nurs. Outlook. 9(1 1):683-686; 1961
Nov.
6 Rubin, R. Binding-in in the post
partum period. Matern. Child Nurs. J.
6(2) :67-75; 1977 Summer.
7 Gruis, Op. cit.
8 Saunders, P.; Tissington, C. Post-
partal interaction. Nurs. Pap. 2(2):6-14;
1970 Nov.
9 Marut, J.; Mercer, R. Comparison
of primiparas perceptions of vaginal and
cesarean births. Nurs. Res. 28(5) :260-
266;1979Sep./Oct.
10 Foley, K. Caring for the parents
of newborn twins. MCN Amer.J. Matern.
Child Nurs. 4(4):221-226; 1979
Jul./Aug.
11 Mercer, R. Having another child:
she s a multip she knows the ropes .
MCN Amer. J. Matern. Child Nurs.
4(5) :30 1-304; 1979 Sep./Oct.
12 Mercer, Ramona T. Nursing care
for parents at risk. Thorofare, N.J.:
Charles B. Slack; 1977.
13 Greenberg, M.; Morris, N. Engross
ment: the newborn s impact upon the
father. Amer. J. Pathol. 44:520-531;
1974 Jul.
14 Donaldson, N.E. Fourth trimester
follow-up. Amer. J. Nurs. 77(71:1176-
1178; 1977 Jul.
15 Freeman, K.N. A postpartum pro
gram that really works. Canad. Nurse
76(3) :40-42; 1980 Mar.
*Not verified
Constance Becker, RN, BN, MScN, is
assistant professor and team coordinator
at the School of Nursing, University of
Manitoba. Since graduating from the St.
Elizabeth Hospital School of Nursing in
Elizabeth, New Jersey, she has had a
varied career, working as general duty
staff nurse, in public health and cancer
chemotherapy research. Her area of spe
cial interest is maternal child nursing.
The Canadian Nurse
December 190 27
I ini MM 11^ IWnHnHiUei In. ..i|.,i.,l,-,l All I n hls
Ho/lister
soothe* and moisturizes
.j in tain healthy skin
skin
Helps protect
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H
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:t sonsitivj^
SOMETIMES IT TAKES MORE TH A
<ec* S ensi, ive sk
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ORDS TO SOOTHE AN OSTOM ATE,
Man versus
microbe:
a case for
the infection
control nurse
Infectious processes are not new to
mankind; in fact, early hospital
populations were made up primarily of
persons suffering from infections of one
type or another. Sometimes up to 25
per cent of all hospital admissions died
of causes related to a hospital-acquired
infection, making hospitals an unsafe
environment for both patient and
attendant.
The history of nosocomial
(hospital-acquired) infections can be
organized into three eras. First, from
the earliest hospitals to the 1940 s,
a time during which there was no
specific therapy for any type of infection
and essentially no preventive techniques.
It was in this era that aseptic technique
was developed. The period between
1940 and the late 50 s was the era of
antibiotic therapy, marked also by the
development of antibiotic resistant
staphylococci. There was a remarkable
reduction in streptococcal infections, but
unfortunately there also developed a
feeling of security which led to the
relaxation of the aseptic techniques
developed earlier.
Finally, since the 1950 s, the
importance of gram negative organisms
has been recognized with the
introduction of broad-spectrum
antibiotics. There has been an
emergence of organisms previously
thought to be non-pathogenic as well as
antibiotic-resistant fungi and viruses.
The problem today
Present day populations of hospitals are
becoming ever more susceptible to
invasion by microorganisms, fungi and
viruses for a variety of reasons.
30 December 1980
KK Hnwmr>r 1 QHf>
Ann Beaufoy M. Bernadet Ratsoy
1. Diagnostic and treatment
techniques frequently disturb or disrupt
the body s physiologic resistance to
invading organisms. Invasive techniques
are ever more dramatic, some, such as
urinary catheterization, intravenous
therapy and anesthesia, have become
commonplace procedures. Others, such
as various pressure monitoring systems
and cardiovascular assessments are
increasing in frequency and
instrumentation has become accepted as
a frequent antecedent to infection.
Complex and extensive surgical
techniques causing increased trauma
over longer periods of operating time
occur more and more frequently.
2. As the geriatric proportion of the
general hospital s population increases,
the percentage of debilitated patients
in the hospital increases as well. These
patients who are usually older and
sicker than were their counterparts in
previous years, are correspondingly
more susceptible to infection. And, as
would be expected, as techniques
improve, they are more commonly
being applied to the older patient.
3. Since host defences are impaired
in the individual with burns, diabetes
mellitus, malnutrition, renal and
hepatic insufficiency and those receiving
immuno-suppressive therapy, many
hospitalized patients are already in a
compromised position.
4. The hospital environment may
expose the patient to a residue of
resistant bacteria spawned by broad
antibiotic usage and to which he may
not have had the opportunity to
establish resistance.
5. Because of increasing
specialization and the expansion of
_ The Canadian Nurse
services available for diagnosis and
treatment, more and more hospital
employees and physicians come in
contact with each patient, thereby
increasing the individual s exposure to
infection.
6. Maintenance of basic techniques
during care may be compromised
because of staffing difficulties and
inadequate physical facilities, thus
contributing to the spread of organisms.
7. A complacent attitude, the feeling
that infections can be easily controlled
with antibiotic therapy has allowed the
breakdown of basic techniques,
especially in aseptic technique.
8. The ever-increasing mobility of
the population allows for the import of
previously uncommon infectious
processes in to the area.
It now seems obvious that new
and better antibiotics will not provide a
satisfactory solution to the problem.
What then is the solution?
Could it be prevention and control?
Indeed that is exactly the answer.
Infection control programs have become
the most important means of prevention
and control of nosocomial infections.
In 1959, when the need for
specific surveillance of infection
incidence was recognized at Torbay
Hospital, England, the first Infection
Control Nurse was appointed. Then
early in the 1960 s in the USA, Bertha
Yanis Litsky proposed the establishment
of a position at the level of assistant
administrator responsible for what she
called Hospital Sanitation, to counteract
the lack of safety from infection for the
hospitalized person.
Today accreditation of a hospital
requires the formation of an Infection
Control Committee responsible for an
Infection Control Program. The
Canadian Council on Hospital
Accreditation recommends that
membership of such a committee be
made up of representatives from diverse
clinical areas, other hospital
infection control to their colleagues
the control program will become more
effective more rapidly. Similarly, the
success of an Infection Control Nurse is
largely dependent on the recognition,
acceptance and support of hospital
administration and employees.
Photo courtesy St. Paul s Hospital, Vancouver
departments when there is a concern
regarding infection control and the
Infection Control Nurse. The size of the
committee should be restricted to allow
for effective functioning.
Obviously existence of the
committee tells one nothing of the
activities this committee actually does
or does not undertake. For example, a
committee which meets once a year is
window-dressing, a committee which
meets monthly is much more likely to
be a working group of individuals
interested in problem-solving.
The Infection Control committee
may be responsible to hospital
administration or to the medical staff
organization of the hospital.
Recommendations from the committee
will be submitted either directly to
hospital administration or through the
medical staff organization and then to
administration. However, depending on
the nature of the recommendation, it
may not be necessary for everyone to
follow the complete route. Most of the
concerns raised and most of the control
program decisions are made by those
charged with carrying out the program
with these decisions being made within
the policy framework established by the
committee.
If the medical members of the
committee can sell the concept of
The Infection Control Nurse
Since the Infection Control Program
often is personified by the Infection
Control Officer, nurse or nurse
epidemiologist or whatever other title
she/he may carry, selection of this
individual is important. Leadership
qualities, positive interpersonal skills,
expertise in aseptic and antiseptic
techniques, expertise in patient care and
educational skills are all desirable
characteristics. A registered nurse,
preferably with a university background,
would be appropriately prepared for
this role. Useful preparation should
probably include additional background
in microbiology, knowledge of hospital
epidemiology to assist in surveillance
programs, an orientation of three to
four weeks with an experienced
Infection Control Nurse and an on-going
education through conferences,
workshops, seminars and Infection
Control interest groups. To date in
Canada, there are no preparatory
courses for Infection Control Nurses as
there are in the United States.
Duties and responsibilities
I. To establish and maintain a simple
system of data collection, tabulation,
analyses, interpretation and
dissemination.
Questions which should be answered
regarding this responsibility include
"What kind of information should be
collected?" "How can it be collected
most easily with the greatest degree of
accuracy?" and "What will be done with
the collected data?"
2. To carry out surveillance through
regular contact with all hospital
departments, particularly those
providing patient care.
Means to accomplish this responsibility
include daily rounds to the nursing
units, regular visits to other hospital
departments, evaluation of equipment
and defining procedures to be used for
prevention of infections. It is very
important that all hospital employees
have some understanding of the
functions of the Infection Control
Nurse.
3. To carry out investigations of
particular problems.
The specifics of such investigations will
depend upon the services, such as
technician time, and facilities available
to any particular Infection Control
Nurse. The nurse s deductive reasoning
is tested in tracking down the source of
an organism, such as in the case of an
outbreak of Salmonella.
4. To perform an educational function
for all persons using the hospital
facilities.
Group teaching in orientation programs,
such as new employee orientation
including new interns and residents or
ward inservice programs, are always
appropriate and productive to some
degree. We believe that individual
teaching which is usually carried out in
the course of problem-solving with the
individual nurse is much more
productive of results. The Infection
Control Nurse as role model to
demonstrate such things as personal
hygiene and appropriate dress is also an
important function. The program can be
kept at the forefront by holding
"Infection Control Days" or week,
circulating articles related to a specific
infectious process and by using the
hospital paper.
5. To carry out environmental and
personnel monitoring when appropriate.
This responsibility includes collection of
specimens from high risk areas, or
personnel, follow-up of contacts and
carriers and monitoring of suspicious
equipment and products.
6. To act as resource person to all
persons working in the hospital.
It is imperative that all hospital
personnel are aware that the Infection
Control Nurse is always available but
also that there are written resources
The Canadian Nurse
December 1980 31
available. Every nursing unit and
hospital department should have a
procedure manual which contains
Infection Control policies, both general
and specific in nature.
7. To maintain the credibility of a
control program.
8. To maintain liaison with various
community agencies, such as the City
Health Department, Tuberculosis
Control Centre and Home Care.
9. To institute new or revised policies
and procedures for Infection Control
through membership on the Procedure
Manual Committee and by participating
in development of standards as part of
the Quality Assurance Program.
The Infection Control Nurse must be
knowledgeable and consistent, using
problem-solving techniques so that all
are aware of the logical approach used
to resolve questions. The nurse must be
prepared to defend the program against
hostility, negativism and to accept not
only ideas for improvement, but also
criticism. She must not only support the
nursing staff who are carrying out
accepted procedures but also be willing
to point out errors.
It is easy to see from this
description that the job of the Infection
Control Nurse is a full time position.
Recommended coverage is one
Infection Control Nurse for every 250
patient beds (U.S.A. standard).
Principles of Effective Functioning
Unfortunately infection control is an
emotionally charged area of function.
Many persons resent the inconveniences
involved with control techniques. A
nurse may say she wished she had never
sent the specimen to the Laboratory,
or some physicians may regard an
infection as a black mark on their
reputations or resent what they see as
interference in their plan of therapy.
Emphasis must be placed on the
improvement of performance and not
on the assignment of blame. Every
Infection Control Nurse s function is
based upon sound knowledge of policies
set by the Infection Control Committee
and upon a set of principles. Following
are the principles which we have found
most useful:
1 . Because of the difficult situations in
which she will become involved, the
Infection Control Nurse must know she
has administrative backing and medical
consultation when necessary.
2. The Infection Control Nurse in turn
must be supportive of nursing staff who
carry out control procedures particularly
in the face of antagonism.
3. Nurses have the authority and
responsibility to submit specimens to
the Laboratory if infection is suspected.
4. Isolation of patients is an
administrative action designed to
protect staff and other patients. It is not
medical treatment.
5 . Nurses have the authority and
responsibility to initiate control
techniques on the basis of laboratory
and clinical evidence.
6. Failure to apply knowledge already
possessed regarding infection control
underlies a large proportion of
nosocomial infection.
7. An infection control program is only
as good as the desire of all hospital
personnel to prevent infections.
8. Establishing the importance of
infection control results in more
accurate and complete record keeping,
more consistent attempts at maintaining
basic technique and quicker responses
to the need for institution of control
procedures such as isolation.
9. Always use a reasonable and practical
approach. No procedure is without
loopholes but that is no reason not to
undertake control measures. These
measures occasionally require
adaptation related to the individual
patient care needs.
10. Never expect anyone to remember a
procedure. Provide complete, easily
interpreted instructions in writing for
every department and nursing unit.
1 1 . Infection control methods must be
easily implemented to encourage
compliance.
12. Constant repetition of well-known
principles of control is necessary. Every
encounter is an educative opportunity
to apply problem-solving to an infection
control problem.
13. Concentrate on the single most
important control procedure
handwashing.
14. Constant, gentle surveillance
promotes willing cooperation among
staff members.
15. The Infection Control Nurse must
be available for reinforcement, for
information, etc. Frequent rounds will
demonstrate availability and establish
credibility.
16. Even the best program loses
momentum over the years. Sometimes a
change is indicated simply because the
old program no longer has appeal and
no longer stimulates the necessary
interest.*
Bibliography
Books
1 Altemeier, Burke, et al., eds.
Manual on control of infection in
surgical patients. Toronto: Lippincott;
1976.
2 American Hospital Association.
Infection control in the hospitals. 3d ed.
Chicago; 1974.
3 Barrett-Connor, E., et al, eds.
Epidemiology for the infection control
nurse. St. Louis: Mosby, 1978.
4 Bartlett, R.C. Control of hospital
associated infections. Reprint. Atlanta:
U.S. Dept. of Health, Education and
Welfare, Center for Disease Control;
1974.
5 Benenson, Abram S. Control of
communicable disease in man. 12th ed.
Washington, D.C.: American Public
Health Association, 1975.
6 Burdon, K.L.; Williams, A.B.
Microbiology. 6th ed. New York:
Macmillan; 1968.
7 Center for Disease Control.
Isolation techniques for use in hospitals.
2d ed. Atlanta: U.S. Dept. of Health,
Education and Welfare, Public Health
Service, Center for Disease Control;
1975.
8 Litsky, Bertha Y. Hospital
sanitation; an administrative program.
Chicago: Clissold; 1966.
9 Mallison, G.F.^ hospital
program for control of nosocomial
infections. Reprint. Atlanta: U.S.
Dept. of Health, Education and Welfare,
Center for Disease Control; 1974.
10 Parisi, J.T. Personnel education
for infection control. Reprint. Atlanta:
U.S. Dept. of Health, Education and
Welfare, Center for Disease Control; n.d.
Articles
1 *Association of Practitioners in
Infection Control. Position paper.
APIC. 6(1), 1978 Mar.
2 Cragg, C.E. Cross infection: a new
approach to an old problem. Canad.
Nurse. 75(2):40-45, 1978 Feb.
3 Infection control
recommendations. Ho -sp. Admin. Can.
17(9):45-46; 1975 Sep.
4 Katz, Elizabeth. Keeping up with
infection control. Dimens.Health Serv.
55(4).21-22; 1978 Apr.
*Not verified
Ann Beaufoy, currently the Infection
Control Nurse at St. Paul s Hospital, is a
graduate of the Queen Elizabeth
Hospital, Montreal.
M. Bernadet Ratsoy , formerly the
Infection Control Nurse and now the
Director of Nursing at St. Paul s
Hospital, Vancouver, is a graduate of
the Edmonton General Hospital School
of Nursing and the University of
British Columbia.
/
32 December 1980
The Canadian Nurse
Hepatitis B
an
occupational
risk
J.W., a 25-year-old male, was first
seen in the Employee Health
Department at the time of his
pre-employment medical assessment.
The only significant finding in his
medical history was a contact with
hepatitis B two months earlier at
another hospital. He had no medical
complaints and no abnormalities were
noted on physical examination. Routine
blood work including HBsAg
(Australian antigen), HBsAb (Australian
antigen antibody) and SCOT were
taken. The results revealed serum
positive for HBsAg, negative for HBsAb
and an SCOT of 78 IU/1 (normal
8-30 IU/1). His serum had been negative
for HBsAg and HbsAb in 1975 and
1977.
When these abnormal results were
discovered he was seen by the Employee
Health physician and instructed to rest
at home and return in one week.
Following a week s rest at home he
reported fatigue and intermittent dark
brown urine which had, in fact, been
present for three weeks. He had no
fever or malaise, no light colored stools,
no jaundice and appeared well. On
examination there was no hepatomegaly.
At this time his total bilirubin was
0.4 mg/dl (normal < LOO), direct
bilirubin 0.1 mg/dl (normal < 0.5),
alkaline phosphatase 15 7 IU/1 (normal is
56.0-244), SCOT 184 IU/1, SGPT291
IU/1 (normal is 6-30) and GGPT 74 IU/1
(normal is 11-51 ).
He continued to rest at home for
a period of 4 weeks returning weekly
for assessment and repeat liver function
tests. During this time his liver function
tests showed gradual improvement and
it was decided that he could return to
work. His direct bilirubin at this time
was 0. 1 mg/dl, alkaline phosphatase
137IU/1, SCOT 107 IU/1, SGPT 200
IU/1, and GGTP 76.5 IU/1. His serum
remained positive for HBsAg.
Jean Keck and Peggy Swerhun
At this time he was seen by the
Employee Health physician and nurse.
Instructions were given to him by the
Infection Control Nurse on
precautionary measures to be taken
while on duty. He was restricted from
serving meals to patients and performing
vena puncture and other treatments.
Liver function tests were repeated
weekly for several weeks but remained
abnormal and showed little
improvement, his serum remained
positive for HBsAg. He seemed tired but
was able to carry out his duties.
Despite the restrictions he had
been given on his return to work, J. W.
attended a Cardiopulmonary
Rescusitation Course (C.P.R.) which
involved practicing mouth-to-mouth
rescusitation on a plastic manikin.
significant contact with Hepatitis B in
the previous three months. Fortunately
all baseline and three month blood
samples were negative.
Hepatitis B
Hepatitis B is a systemic viral infection
which predominantly affects the liver.
Transmitted by direct contact with
blood products, this infection is known
more commonly as "serum hepatitis".
Other types of viral hepatitis include:
hepatitis A, formerly known as
"infectious hepatitis", a comparatively
brief illness without a tendency to
chronicity; and another form of
hepatitis currently called "non-A,
non-B hepatitis" which is probably
transmitted by blood products and may
cause chronic disease. However no
specific virus has yet been identified.
Figure one:
Viral particle
found in hepatitis 6
infected serum
Although the manikin was cleansed with
70 percent isopropyl alcohol in between
each practice session, it was impossible
to cleanse it during instruction with the
two man rescue procedure. Thus, nine
other staff members taking the same
course had direct contact with J. W. s
saliva. When a sample of his saliva was
obtained and sent for HBsAg
determination, the report returned
positive for HBsAg. The Employee
Health Nurse drew up a contact list of
the staff involved, interviewed them and
obtained baseline blood samples for
HBsAg and HBsAb. The results revealed
that none of these staff had had any
The Canadian Nurse
Diagnosis
Diagnosis of hepatitis B became easier
when a specific serum antigen associated
with the infection was discovered.
Dr. B.S. Blumberg identified this
antigen in an Australian aborigine in
1965 and in 1976 received the Nobel
Prize in medicine for this discovery.
Later it was shown that the antigen
initially called the "Australia Antigen"
was associated with hepatitis B, and
now it is called the hepatitis B surface
antigen (HBsAg).
When serum from patients with
hepatitis B is studied with an electron
microscope, viral particles can be seen.
December 1980 33
Figure two: Acute viral hepatitis type B
Clinical
Hepatitis
HBsAg in
Blood -
f + +
Anti-HBs
1
Exposure
6 7
Months
48
One particle, the Dane particle, is now
thought to be the hepatitis B virus. It
has an inner core surrounded by an
envelope. The core is associated with
the hepatitis B core antigen (HBcAg)
and the outer coat contains HBsAg.
Small spherical particles and tubular
particles are also present: these are
considered to be excess coat protein
(See figure one).
The incubation period of hepatitis
B may extend from six weeks to three
months. Some individuals, possibly the
majority of persons infected, never
develop clinical illness. HBsAg may be
found in the blood for a period of time
following the acute stage of illness; if
it is detectable for more than four
months following the acute state of the
disease, chronic hepatitis B should be
considered. In most cases following
acute infection, antibodies known as
anti-HBs or HBsAb, can be detected.
These antibodies may remain for several
years thus providing complete or partial
immunity to subsequent hepatitis B
infection. An antibody (HBcAb) to the
core antigen also develops. It appears
early in the clinical phase of illness
whereas anti-HBs does not become
apparent until later, during the
convalescent stage. Sometimes HBcAb
is the only clue to hepatitis B infection
(See figure two).
The symptoms of hepatitis B
vary with the individual. Nausea,
vomiting, fatigue, malaise, skin rash, loss
of weight and headaches may precede
the onset of jaundice by one to two
weeks. Clay colored stools and dark
amber urine may be noticed one to five
days before jaundice appears. With the
onset of jaundice, some of the
constitutional symptoms will diminish.
There will then be a mild weight loss of
two to five kilograms which may
continue throughout the entire icteric
34
Ml
December 1980
phase, the liver may become enlarged
and tender, the individual may
experience upper right quadrant pain,
and splenomegaly may be present in
10 to 20 percent of individuals. The
duration of the post icteric phase is
variable ranging from two to 12 weeks.
In three quarters of the uncomplicated
cases, complete clinical and biochemical
recovery can be expected three to four
months after the onset of jaundice.
Diagnosis begins with a thorough
medical history including a drug history
as some drugs produce a picture similar
to that of acute hepatitis. Acute
hepatitis B may also be confused with
cholecystitis, common duct stones or
ascending cholangitis, because of their
symptoms of nausea, vomiting, right
upper quadrant pain and fever. In the
elderly it may be confused with cancer
of the pancreas or obstructive jaundice
due to stones in the common bile duct.
Laboratory tests are necessary for
making a diagnosis and should include
HBsAg, HBsAb and liver function tests.
SCOT and SGPT levels increase during
the acute viral stage and preceed the rise
in bilirubin level. Liver function tests
should be checked every one to four
weeks until normal and HBsAg and
HBsAb in four to 12 months after the
acute stage has subsided. Viral diseases
such as infectious mononucleosis,
herpes simplex and toxoplasmosis all
share certain clinical features with viral
hepatitis, that is, they cause an
elevation in serum SCOT and SGPT.
Transmission
Material from both carriers and
individuals with acute hepatitis has been
subject to intense scrutiny as to its
ability to transmit the virus. The
following levels of HBsAg have been
found:
blood high concentrations.
urine may be present in minute
amounts in the urine in the acute phase
The Canadian Nurse
and in carriers with normal renal
functions.
feces early serological tests on
fecal extracts from individuals with
acute hepatitis gave false-positive results.
saliva often detected in the
saliva of patients with acute diseases. It
is only of academic importance to
discuss whether the antigen is acutally
secreted by the parotid gland or arises
from contamination of the specimen
with blood in the mouth, since it is
known that hepatitis B is transmissible
by a bite from a carrier.
menstrual blood - contains
concentrations comparable to those in
the circulation.
semen- has been detected in
semen of patients with acute illness.
milk has been found in both
colostrum and milk.
sweat has been found to be
present in sweat of carriers.
cerebrospinal fluid - absent.
Sporadic outbreaks of acute viral
hepatitis B have been reported in blood
bank employees, nurses, lab technicians,
doctors and dentists. Exposure to this
vims may result from contact with
blood or other body fluids, when
starting or maintaining intravenous
cannulas, drawing blood, changing
surgical dressings, caring for catheters,
handling surgical instruments or using
defective gloves during surgical
procedures. In some instances contact
with heavily contaminated articles is
sufficient. Hepatitis B is definitely an
occupational hazard amongst health
workers with laboratory workers,
general surgeons, dentists and staff in
renal units seeming to be most at risk.
Carriers
HBsAg is carried in the serum of a
percentage of the general population.
Many of these carriers may be
completely asymptomatic and in
excellent health while others may suffer
from significant liver disease. For some
unknown reason, the carrier rate is
higher among men than among women.
One theory on the development
of carriers is that these individuals have
a persistent infection following a
subclinical illness of hepatitis B.
Environmental factors may also play a
role in determining whether or not a
person becomes a carrier. Repeated
exposure to hepatitis B increases the
risk of becoming a carrier, whether
through transfusions or through
occupational, household or sexual
contacts. A high incidence of hepatitis
B has also been observed in the male
homosexual population, patients with a
past history of hepatitis, multiple
transfusions and parenteral drug abuse.
Approximately 10 percent of
individuals with acute hepatitis B
became chronic carriers of HBsAg. One
theory or possible cause of this is an
inadequate production of Anti-HBs to
terminate the infection. Therapeutic
immunosuppression and certain diseases
such as chronic liver disease, chronic
renal failure, leukemia, Hodgkin s
Disease, Down s Syndrome and leprosy
may also increase chance of carriage
with the duration varying.
Isolation procedure
All patients with positive HBsAg serum
must be placed on enteric isolation. The
importance of hand washing in
prevention of the transmission of
hepatitis must be stressed, not only for
hospital personnel, but also for the
patient and all contacts. This isolation
procedure involves the following steps.
1. Explain the procedure to the patient.
2. A single room must be used with
separate washroom facilities.
3. Gowns must be worn by persons
having direct contact with the patient.
4. Masks are generally not necessary,
but must be worn by the patient when
using the telephone.
5. Disposable dishes must be used.
6. Disposable gloves must be worn
when performing veni-punctures; a
vacutainer holder and tourniquet should
be kept in the patient s room.
7. Patients should be instructed to
wash their hands thoroughly before and
after meals, after using the washroom
and before leaving the room.
8. All linen and garbage must be
double-bagged and removed
immediately.
9. Special precautions must be taken
with the following:
Needles must be inserted into
their original plastic sheath before
discarding (special disposal
container must be provided).
Extra care must be taken to avoid
needle pricks.
Disposable syringes must be
discarded into special containers.
10. Laboratory Specimens urine,
sputum, stool and blood must be
obtained in the patient s room.
Containers must have a tight fitting lid.
All samples must be double-bagged and
labelled ISOLATION: HEPATITIS.
1 1 . Instruct and caution medical and
nursing personnel to take special
precautions to prevent spread of
infection when patients undergo surgical
or obstetrical procedures.
Inservice education programs should
provide necessary information and
training techniques for all personnel
working in high risk areas. Written
procedures should be available for the
following personnel: nursing,
physicians, laboratory, housekeeping
and non-medical personnel.
Instructions on discharge from hospital
1 . Instruct the patient and provide the
patient s family with written information
on precautionary measures to be
followed.
2. Inform the patient that he must not
donate blood.
3. Advise the patient to report positive
test levels of HBsAg to his dentist so
that appropriate precautions can be
taken when he is being treated.
4. Instruct the patient on the
importance of medical follow-up.
Immunization
The use of gammaglobulin in the
prevention of hepatitis B is controversial.
Immune serum globulin has been found
to be effective in providing protection
against hepatitis A but this has not
proven to be the case with hepatitis B.
Specific immune globulin called
hyper-immune-globulin (HIG)
containing a high titre of anti-HBg has
been used experimentally in preventing
hepatitis B, but is not in general use in
Canada at this time and some people
fear that a high proportion of carriers
might arise from widespread use of this
serum. Active immunization for
hepatitis B is being developed but has
not been approved for use at this time.
Recommendations for C.P.R. training
1. All staff must have blood taken for
HBsAg and HBsAb within a 3-month
period prior to taking a C.P.R. course.
The results must be obtained before the
staff member can participate in the
course.
2. A history should be taken by the
Employee Health Nurse to determine
the presence of any physical, acute or
chronic medical conditions.
3. Staff may not participate in C.P.R. if
they are found to have any of the
following infectious conditions:
blood positive for HBsAg
upper respiratory infection
Herpes Simplex (cold sore)
dermatologic lesions.
4. A plastic face protector should be
used on the manikin to prevent cross
infection.
5. The manikin must be washed
thoroughly after each session and course
instructors made responsible for proper
cleaning and maintenance of manikins.
The manikin head should be
disassembled and washed with soap and
water plus 0.5 percent sodium
hypochloride (Hygeol) solution (0.5
percent sodium hypochloride to nine
parts water). Note: Isopropyl alcohol
70 percent is not effective against
hepatitis B virus.
6. Manikins should be inspected
routinely for signs of physical
deterioration, such as cracks or tears in
plastic surfaces.
7. Inservice education for course
instructors is essential in preventing
cross infection. *
Bibliography
1 Aach, RJ). Viral hepatitis A to E.
Med.Clin.North Amer. 62(1):59-70;
1978 Jan.
2 Alter, H.J. et al. Health care
workers positive for hepatitis B surface
antigen. Are their contacts at risk?
New Eng.J.Med. 292(9):454457;
1975 Feb. 27.
3 Cossart, Yvonne E. Virus hepatitis
and its control. London: Bailliere
Tindall; 1977.
4 Dienstag, J.L. et al. Hepatitis A
virus infection: new insights from
seroepidemiologic studies. J. Infect. Dis.
137(3):328-340; 1978 Mar.
5 Krugman, S. et al. Viral hepatitis
type B. Studies on natural history and
prevention re-examined. New Eng.J.Med.
300(11): 101-106; 1979 Jan. 18.
6 MMWR. Morbidity and mortality
weekly report. 27(29); 1978 Jul. 21.
Atlanta: U.S. Dept. of Health,
Education, and Welfare, Public Health
Service, Centre for Disease Control;
1978.
7 Popper, H. Clinical pathological
correlation in viral hepatitis. The effect
of the virus on the liver. Amer.J.Pathol.
81(3):609-628; 1975 Dec.
8 Regamey, R.H. et al., acting eds.
International Symposium on Viral
Hepatitis, Milan, 1974. Proceedings of
the 44th symposium. Organized by the
International Association of Biological
Standardization and held at the
Congress Hall, Via Corridoni, Milan,
Italy, 16 - 19 Dec. 1974. New York:
Karger; 1975.
9 Vyas, G.N. et al., eds. Viral
hepatitis: etiology, epidemiology,
pathogenesis and prevention.
Philadelphia: Franklin Institute Press;
1978.
10 Wands, J.R.etal. The pathogenesis
of arthritis associated with acute
hepatitis B surface antigen-positive
hepatitis. Complement activation and
characterization of circulating immune
complexes. J.Clin.Invest. 55(5):930-936;
1975 May.
Jean Keck is head nurse of Infection Con
trol for the Clinical Institute of the Ad
diction Research Foundation. A graduate
of the Beckett Hospital School of Nurs
ing, she has had several years experience
in the field of research staff education
and Infection Control.
Peggy Swerhun, a graduate of the St.
Thomas Elgin General Hospital School of
Nursing, is head nurse of the Medical Out
Patient Clinic and Employee Health De
partment at the Clinical Institute of the
Addiction Research Foundation.
Acknowledgement: The writers would
like to thank Dr. Eve A. Roberts for her
assistance in reviewing this paper.
The Canadian Nurse
DccwntwrlMO 35
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Breast cancer is currently the most common type of cancer (apart from skin cancer) found in women.* Each year, close to
8,000 women in Canada are diagnosed as suffering from this disease. Breast lumps, therefore, though common, are a source of
much stress. The majority of breast lumps, however, are not cancerous but represent benign breast disease (BBD). The
participants in this study, nursing students at Vancouver General Hospital at the time of the original interview and physical
examination, were contacted up to 34 years later and asked to identify breast problems and factors that might be related to
these problems. Using this information, the authors assess the frequency of BBD and identify some of the factors that may
predispose or tend to prevent its occurrence.
Breast disease in nurses, a 30-year study
J. Mark El wood, M.D. T.G. His/op, M.D.
The study
In 1945, and from 1947 to 1956, all
second year nursing students at the Van
couver General Hospital were informed
of this study: a total of 1,374 of them
participated. At entry each participant
had a physical examination and complet
ed a questionnaire covering her personal
and family history. While many nurses
kept in contact with the study group,
no deliberate follow-up effort was made
until 1979 when, using nursing registries,
class secretaries, notices in nursing jour
nals, and radio messages, we attempted
to contact the original participants and
succeeded in identifying 787 of them.
We sent each one a questionnaire asking
about breast problems and factors that
might be related to such problems and
received 726 replies, 94 percent of loca
ted nurses, an extremely high response
rate. The questionnaires were generally
completed with considerable care, and
many nurses provided us with further
information, or took the trouble to check
back to their physician or other family
members in order to give the correct
response to some questions. We were able
to compare the nurses whom we had lo
cated with those whom we had failed to
locate in terms of their original quest
ionnaires and physical examination re
sults at study entry, and there were no
important differences between the two
groups. We believe, therefore, that the
women we did contact are representa
tive of the entire group.
Our study examined both sympto
matic and biopsied BBD. Symptomatic
BBD includes a history of breast lumps
or cysts, whether or not biopsied;
biopsied BBD includes diagnoses of
fibrocystic disease, fibroadenoma and
intraductal papilloma.
Incidence of breast disease
Two percent ( 1 7) of the 726 respondents
reported having had breast cancer; thirty
percent (215) reported a history of
symptomatic BBD. One-half (107) of
*The number of cases of lung cancer is rising
rapidly and may soon overtake that of breast
cancer.
these women with symptomatic disease
had biopsy confirmed BBD. As we ex
pected, the proportion of women who
had developed symptomatic BBD rose
with age, increasing from three percent
at age 20 years to over 30 percent by
age 50 years (See table one).
Likewise, the probability of having
had a biopsy for BBD increased from
less than one percent at age 20 years to
17 percent by age 50 years. However,
the rise with age was not regular: the
chance of developing either symptomatic
or biopsied BBD at a particular age (the
age specific incidence rate) showed a
distinct peak at age 20 to 24 years fol
lowed by a decline and then a rise to age
50 years. This suggests that at least two
distinct types of BBD exist that can be
separated, at least in part, by age. A re
view of available pathology reports
showed that fibrocystic disease and
fibroadenoma were both frequently
diagnosed before age 30 years, whereas
only fibrocystic disease was frequently
diagnosed after that age.
Risk factors (characteristics associa
ted with the development of BBD) were
analysed separately for symptomatic
BBD and biopsied BBD; in general, the
trends in risk were similar. Because of
the bimodal age pattern in BBD inci
dence, we assessed these factors for
biopsied BBD before and after age 30
years separately. These findings are now
discussed as they relate to recognized
risk factors for breast cancer as reviewed
by Kelsey 6 (See table two).
BBD and breast cancer similarities
and differences
A higher incidence of biopsied BBD was
found in women who:
had not had children
had had an abortion
had a sister with breast cancer
had reported frequent premenstrual
breast engorgement and pain, or
had irregular menstrual cycles.
Nulliparity and a family history of
breast cancer are both recognized as re
lated to a higher risk of breast cancer.
Premenstrual breast engorgement or
pain, and irregular menstrual cycles have
been associated with an increased risk of
breast cancer in several studies, but the
association is not, as yet, conclusive.
Many studies have now shown conclu
sively that when age at first delivery is
taken into account women who have
breast fed have the same risk of breast
cancer as those who have not. 6 Similarly,
breast feeding did not change the risk of
BBD in our study group.
We found that women who had used
oral contraceptives, who had a heavier
body build as assessed by a weight to
height ratio, and who had larger breasts
as assessed by physician examination or
brassiere size, reported biopsied BBD
less frequently than women without
these characteristics. In contrast, breast
cancer is known to be more common in
relatively obese women, whereas no
association has been reported with oral
contraceptive usage or breast size. We
found no association between the occur-
ence of BBD and age at first delivery,
ages at menarche and menopause or type
of menopause, all of which are known to
alter the incidence of breast cancer.
Women who had had abortions reported
BBD more frequently; no such associa
tion has been confirmed for breast can
cer. We could not distinguish the type
of abortions; most would have been
spontaneous.
Discussion
Very few studies have attempted to
measure the incidence of BBD but our
finding that it had affected at least 30
percent of the nurses in our study by
the time they were 50-years-old is con
sistent with other investigations. 7 " 9 BBD
is a very common disease but, in addition
to its prevalence, it is also important
because of its association with breast
cancer. Women with fibrocystic disease
are two to four times more likely to de
velop breast cancer, 1 ~ s a risk that persists
for at least 30 years after diagnosis of
fibrocystic disease. The association of
fibroadenoma with breast cancer is less
clear. 2 5 Recent pathological studies
suggest that the increased risk is only re
lated to certain types of benign disease,
with other types carrying no breast
cancer risk. 4 5
38 December 1980
The Canadian Nurse
TABLE ONE: FREQUENCY OF BENIGN BREAST DISEASE BY AGE
Percentage ot nurses in the study who, by the age shown
Age
had had a biopsy
for benign disease
had had symptomatic
BBD without a biopsy
had not reported
any BBD
18 (study entry) 1
20 1
25 4
30 5
35 7
40 10
45 14
50 (end of follow-up) 17
1
2
3
5
6
8
11
14
98
97
93
90
87
82
75
69
Note: The percentages shown are cumulative, e.g. of nurses aged 30, 5 percent had had a
biopsy. The percentage of women with new findings is given by subtraction - e.g. between
age 30 and age 35, 2 percent of nurses (7 percent - 5 percent) underwent their first biopsy.
Most women who develop BBD will
not develop breast cancer even though
BBD and breast cancer are, to some
extent, related. Our study, like some
others, 7 10 11 has shown that, while a
few factors seem to be related to an in
creased incidence of both benign disease
and breast cancer, other factors appear
to have differing effects for the two
diseases, reflecting a difference in causa
tive factors.
Our study findings are consistent
with the hypothesis that BBD is due to
a relative excess of estrogen resulting
from an endocrine imbalance. (Estrogen
stimulates proliferation of epithelial cells
and ductal growth in the breast, while
progesterone promotes the development
of acini.) The major risk factors we have
identified, such as premenstrual breast
discomfort and irregular menstrual cycles
are known to be related to relative es
trogen excess, while nulliparity and the
occurrence of spontaneous abortions
could also be related to such a mechan
ism. The factors of age at first delivery,
age at menarche, and age at menopause
are also thought to depend for their re
lationship with breast cancer occurrence
on a hormonal mechanism, but the me
chanism must be different from that
involved in the causation of BBD, as
these factors are not related to BBD risk.
One of the most intriguing contrasts
is the increased incidence of breast can
cer relative to weight (higher in more
obese women) compared to the decreas
ed incidence of BBD. It has been sugges
ted that the lower risk of BBD might
relate only to greater difficulty in diag
nosing a breast lump in a woman with a
larger breast, but our study shows that
the relationship with general body build
persists even within women of similar
breast size. These and other issues in
this study are discussed more fully
elsewhere. 12
One question yet to be answered is
why only approximately half of all
women who develop symptomatic BBD
undergo a biopsy, and what are the
determining factors leading to a biopsy.
Our study did not show any marked
difference in terms of personal charac
teristics and past medical history be
tween those who were biopsied and
those who were not.
The wholehearted enthusiasm of
nurses involved in this study has encour
aged us to look further at this question,
and we are undertaking a second study
looking more particularly at the way
lumps are recognized, and the response
made to them by the woman and by her
physician. With their specialized training
and interest in health matters, nurses
provide an ideal group for such a study.*
Acknowledgement: We wish to thank all
the nurses who participated in this study
over the years and Dr. D.A. Boyes and
the other members of the staff at the
Cancer Control Agency of British
Columbia for their interest, helpful
comments and participation. We are
grateful to the Canadian Cancer Society,
British Columbia and Yukon Division,
for encouragement and financial sup
port; to Karen Anderson for typing and
to Candace Elwood, RN, for reviewing
the manuscript.
Breast disease in nurses, a 30-year study
is based on a more extensive report,
"Risk factors for benign breast disease:
a 30-year cohort study", scheduled to
appear in the February 1, 1981 issue of
the Canadian Medical Association
Journal, (for references see page 41)
TABLE TWO: CHARACTERISTICS PREDISPOSING TO BENIGN BREAST DISEASE AND TO BREAST CANCER
Effect on
Characteristic Effect on BBD risk breast cancer risk
Nulliparity
Breast cancer in sister
Premenstrual breast engorgement
Premenstrual breast pain
Irregular menstrual cycles
Previous abortion
increase, after age 30
increase, after age 30
increase, before age 30
increase, all ages
increase, before age 30
increase, before age 30
increase*
increase**
uncertain
uncertain
uncertain
no effect
Use of oral contraceptives
Heavier body build
Larger breast size
decrease, after age 30
decrease, after age 30
decrease, before age 30
no effect
increase
uncertain
Late age at first delivery
Early age at menarche
Late age at menopause
Artificial menopause
Breast feeding
no effect
no effect
no effect
no effect
no effect
increase*
increase
increase
decrease
no effect
*Breast cancer risk rises with later age at first delivery, and at first delivery after age 30 appears to confer
nulliparous women. An increase is also seen with breast cancer in mothers and other close relatives.
a higher risk than is seen in
Th Canadian NurM
Dacambaf 1MO 39
Home Care, a provincially administered and financed program, combines the services of a range of
community health care professionals to form a team working toward the common goals of the patient.
Patients can receive needed rehabilitative or palliative care in a familiar environment. For the nurse, Home
Care can also be a rewarding and gratifying experience.
Shirley , a success story
Noreen McNaim
Shirley Sims was diagnosed as having
Parkinson s Disease at the age of 27,
but, for the next nineteen years, she
seldom sought medical supervision.
During this time, she gave birth to six
children - all girls. Now, at forty-eight,
she was walking with a walker and was
both unwilling and unable to do much
for herself or her family. Separated nine
years earlier, she was living in a small
downtown apartment with her youngest
daughter, aged thirteen.
It was on a June morning three
years ago that Shirley slowly shuffled
into Dr. Foster s office, her hair
dishevelled, rumpled dress loose on her
wasted frame, shoes untied and no
stockings. Eyes fixed on the floor, she
answered his medical queries in a weak
whisper. Dr. Foster realized that she was
in need of both emotional and physical
support if she was to remain at home
but even he couldn t possibly have
foreseen the amount of frustration and
team effort on the part of health
professionals, homemakers and family
that would ensue over the coming year.
The next day, Shirley was referred
to our Home Care program. As
coordinator, I began to assemble her
file. Although her somewhat unusual
and scant history made it difficult to
establish a data base, I went to work on
her case. After discussions with Dr.
Foster, I began to delineate Shirley s
needs and the personnel that would be
necessary to assist her. Our goal was to
help her attain a maximum level of
functional independence within the
limitations of her disease.
Initially, I asked the VON to send
a nurse to help with general care and to
assess the need for other services such as
meals-on-wheels or homemaking.
Monitoring nutrition, medications, vital
signs and the family situation would
give us a better idea of how her care
plan would evolve. However, when I
heard the VON report the next day, I
knew we needed additional help. The
nurse had found the apartment in an
incredible state of disarray and neither
mother nor daughter was capable of
caring for herself. I immediately asked
the Visiting Homemakers Association for
help. They could take care of the initial
tidying up of the apartment and then
work with Shirley and her daughter to
increase their motivation to do more for
themselves.
As time went on, it was obvious
that working with the Sims family was
by no means an easy task. Their
youngest daughter, Donna, had never
been given any responsibility for either
herself or for the household. As a result,
she had accepted her older sisters label
of a "lazy, useless teenager". She isolated
herself both physically and emotionally
from any decision-making or
cooperative activities. Forcing a
confrontation would be unwise, so we
alternated homemakers to minimize the
frustration to any one individual.
Shopping and laundry were done by
the older daughter who lived in an
adjoining apartment so the homemaker
made meals, washed dishes and did the
vacuuming hardly a rewarding
situation from her point of view.
For two months, the nursing care
plan covered the bare necessities.
Shirley showed little motivation to take
care of her own personal hygiene, so
the nurses helped her bathe, shampooed
her unruly hair and encouraged a more
balanced diet. Despite her attitude,
Shirley wanted to stay at home and
Home Care was willing to support her
even though staff frustrations were
mounting.
By the end of August, Shirley s
physical condition had worsened. She
was admitted to hospital suffering from
levo-dopa toxicity. The prescribed
levo-dopa, used to overcome the
depletion of dopamine that occurs in
Parkinson s Disease, was replaced by
bromocryptine. The results were
encouraging and Shirley could return
home again.
When we met to discuss her plan
of care, it was obvious that Shirley had
become more receptive to suggestion.
The occupational therapist assigned to
the case developed an intensive
education program in activities of daily
living.
A later meeting indicated that
Shirley was responding well to this
more demanding treatment plan. One
specific homemaker, working with the
occupational therapist and Shirley, had
succeeded in having her assume a more
active part in personal and household
management. What had been a totally
frustrating situation was gradually
becoming a rewarding process of
rehabilitation. The nurse was now only
giving guidance in bathing since Shirley
had mastered safe transfer techniques
and, thanks to the occupational
therapist, Shirley began to enjoy
carrying out simple household tasks.
The homemaker found herself assisting
with household duties rather than
waiting on an unmotivated patient.
After a few weeks, it became
obvious that the time was right for a
conference involving Shirley, Donna,
two other married daughters, the VON
nurse, the homemaking supervisor,
occupational therapist, the family
doctor and myself. This would allow
us to assess and redefine the goals
originally established for and with
Shirley. We met in Dr. Foster s office on
November 17. Shirley was no longer the
shy little mouse with the rumpled
clothes who had come into this office
six months before. She spoke out
as
The Canadian Nurse
clearly and audibly, in marked contrast
to the almost unintelligible whispered
tones she had used before. It was clear
that a lack of confidence rather than the
debility of her disease had been
responsible for eroding her vocal
abilities.
During the meeting, family
conflicts and concerns were aired
without antagonism but rather with
relief. The opportunity to voice them
was long overdue. The older sisters
admitted that they had, without
realizing it, been downgrading Donna
for most of her life. They had regarded
her as an unresponsive child rather than
as an adolescent entering adulthood
with virtually no family support.
Everyone agreed that communication
between them was improving and even
admitted that they were beginning to
feel like a family again. Donna had
begun to cooperate with her mother in
doing dishes and making her bed and
they both took more pride in their
personal appearance. It was an effective
beginning that no one had envisioned
so soon.
In January, 18 months after our
first contact, a follow-up meeting
revealed that Donna and her mother
were definitely caring for and about
each other. Donna s school grades had
improved significantly and mother and
daughter appeared much happier and
more open in their conversation.
Occupational therapy had been
discontinued several months earlier but
the homemaker was still providing
assistance. Shirley did not choose to
attend a day care center that had been
suggested. She did however accept
weekly visits from a volunteer visitor,
arranged by the VON who encouraged
conversation and involved her a little
more in the world outside the
apartment door.
Shirley and Donna have since
moved to western Canada to join other
members of the family. Although we
may never meet again, none of those
who were caught up in the maelstrom of
confusion and frustration that
envelopped the Sims family will ever
forget the ultimate satisfaction that
was ours when we succeeded in opening
the door of independence for someone
imprisonned by her physical, emotional
and social situation.*
Noreen McNairn, PHN, BScN, is the
assistant administrator of the
Hamilton-Wentworth Home Care
Program. In addition to her work with
the VON, she has been involved in
teaching programs for health
professionals and for homemakers.
Noreen has had several articles
published on Home Care and has also
given lectures on Home Care, lung
disease and skin ulcers.
Breast disease in nurses
(continued from page 39)
References
1 Monson, R.R., et al. Chronic masti
tis and carcinoma of the breast. Lancet.
2(7979):224-226; 1976 Jul. 31.
2 Donnelly, P.K., et al. Benign breast
lesions and subsequent breast carcinoma
in Rochester, Minnesota. Mayo Clin. Proc.
SO(ll):650-656; 1975 Nov.
3 Haagensen, C.D. The relationship of
gross cystic disease of the breast and carcino
ma (editorial). Ann. Surg. 185(3):375-376;
1977 Mar.
4 Black, M.M., et al. Association of atypi
cal characteristics of benign breast lesions
with subsequent risk of breast cancer. Cancer.
29:338-343; 1972 Feb.
5 Kodlin, D., et al. Chronic mastopathy and
breast cancer. A follow-up study. Cancer.
39(6):2603-2607; 1977 Jun.
6 *Kelsey, J.L. A review of the epi
demiology of human breast cancer. Epidemio-
logic Rev. 1:74-109; 1979.
7 Cole, P., et al. Incidence rates and risk
factors of benign breast neoplasms. Amer. J.
Epidemiol 108(2): 1 12-120; 1978 Aug.
8 Vessey, M., et al. A long-term follow-up
study of women using different methods of
contraception an interim report. J. Biosoc.
Sci. 8(4):373-427; 1976 Oct.
9 Royal College of General Practitioners.
Oral Contraceptives Study. Oral contracep
tives and health: an interim report. New
York: Pitman; 1974.
10 *Soini, I., Hakama, M. Inverse associa
tion between risk factors for benign and mal
ignant breast lesions. Scand. J. Soc. Med.
7:79-85; 1979.
11 Sartwell, P.E., et al. Benign and malig
nant breast tumours: epidemiological similari
ties. Int. J. Epidemiol. 7(3) :2 1 7-22 1 ; 1978 Sep.
12 *Hislop, T.G.; Elwood, J.M. Risk factors
for benign breast disease; a 30 year cohort
study. Canad. Med. Ass. J. (In press).
Not verified
A sabbatical year
in international development
\ INTERNATIONAL
i DEVELOPMENT
/ RESEARCH CENTRE
CANADA
The IDRC offers eight awards for training, personal study or investi
gation in international development to Canadian professionals in
1981-82.
Candidates
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 pro
fessional experience.
Programme
to be developed by the candidate. May be any form of training
work/study or personal investigation provided:
a) the programme has direct relevance to the problems of
developing countries.
b) it provides increased professional competence as well as a
greater familianty with developing country problems.
Field or discipline
any field pertaining to international development.
Length of award
Minimum 6 months maximum one year.
Value
Stipend up to $25,000, field travel and research costs up to
$4,500, plus international travel costs and training fees.
Application*
Available from:
Professional Development Award Canada
International Development Research Centre
P.O. Box 8500
Ottawa, Canada
K1G 3H9
Deadline for applications
February 1 , 1981
Awards announced
May 15, 1981
The International Development Research Centre is a corporation
established by an Act of the Canadian Parliament, May 1 3, 1 970.
FRANKLY SPEAKING
Wanted !
A new interface between administration, nursing and medical staff
Gabrielle Monaghan
The symptoms are there for anyone to
see.
One of this country s leading
nurse educators, at the recent Combined
Canadian American Hospital Conference
in Montreal, called on administrators in
the audience to become more
"democratic" in their relationships
with nurses on their staff. 1
One quarter of the nurse
respondents in a survey conducted by
RN Magazine cited "poor
communication between nurses, doctors
and administrators" as one of the
reasons they are leaving the profession. 2
More than half (55.6 percent) of
the nurses taking part in an earlier
survey on job satisfaction by the same
magazine recognized "no input in
matters concerning you" as a crucial
problem. 3
Three of the 15 resolutions
approved by voting delegates at last
spring s annual meeting of the CNA
were aimed at increasing the education
and power base of the nurse managers
who direct nursing staff and speak for
nursing on an administrative level.
Only an ostrich would try to deny
that the relationship between the chief
executive officers of many if not most
Canadian hospitals and, to a lesser
degree, other health care institutions
and the nursing staff who work in them
is a troubled and troubling one.
Reorganizing the nursing
department may not solve the problem.
Nor is organization theory helpful: it s
quite possible to have a nursing
department structured on an impeccable
model but, like a Ferrari with an empty
gas tank, it simply does not run.
What then is the answer? I believe
that, first of all, we must come to grips
with the fact that many administrators
lack conceptual knowledge of the work
environment in which nurses operate.
What this boils down to is that, most of
the time, when administrators talk
about nursing and what nurses do, they
are not dealing with the realities of
practice in today s work setting.
Medical staff and management are
supposed to get this information from
the director of nursing but all too often,
given the busy schedules of hospitals,
the opportunity for this exchange of
ideas simply does not occur. Somehow,
administrators must be made to realize
that nursing really is different, that
nurses and other health care workers
simply cannot be lumped together as
"staff", employees of the institution
they direct.
The uniqueness of nursing, both
in terms of the work content and the
workforce, cannot be over-emphasized.
Alone among health care workers,
nurses have responsibility for
continuous twenty-four-hour care for
patients. As the acuity of illness and the
dependency level of patients in acute
care hospitals have increased, so have
the physical demands on nurses.
On-the-job emotional and intellectual
demands have also increased. A larger
proportion of the nursing work force,
relative to other health workers, is
composed of staff who have the dual
responsibility of being both homemaker
and professional.
The interdependence of medicine
and nursing has made for a great deal of
tension between the two professions
and the tendency of physicians to
regard themselves, rather than the
patient, as the consumer of the nursing
service has also increased the pressure
on nurses who are attempting to
develop for themselves, a more
independent role.
Another singular strain on the
nursing staff is the small group milieu
in which the work is carried out, making
it necessary for the members of this
group to continually confront each
other in order to resolve conflicts
related to their work, the needs of the
group and the personalities of its
members. 4
As I see it, though, the greatest
barrier to understanding between
administrators, medical staff and nurses
is not the result of any of these factors
but, rather, the fact that the former are
predominantly male and the latter
predominantly female.
One hundred years ago, John
Stuart Mill reminded his readers that
"men are men before they are lawyers,
or physicians, or manufacturers". I
believe the same holds true today and
the first step in developing a better
understanding between administration
and departments of nursing must be
recognition of the truth of this
observation and application of the
fruits of tlu s knowledge.
Nurses must realize and take into
account the fact that, in all likelihood,
the perspective of male administrators
and physicians has been distorted by
the predominantly masculine
environment of medical schools and
management programs, that, as a result,
the perceptions of these individuals are
probably different from their own, and
that it is this conditioning which lies
at the heart of the mistrust between
nurses, administration and medical
staff.
Unlike male health care workers
who have been conditioned, either in
the military or sports competition, to
accept this type of structure 5 , nurses
are uncomfortable in the hierarchic
structure of most health care
institutions.
Now that they can expect to
spend a lifetime in the workforce, many
nurses are attempting to restructure tlu s
environment. This explains the current
interest in primary nursing, unit
assignment, total care systems,
modalities of nursing care which allow
nurses greater autonomy.
I see this restructuring as a
positive approach to our common
problem. I believe the response to the
current antipathy between nurses,
administration and medical staff should
be:
1 . to recognize that its roots lie deep in
the passive and dependent role
traditionally assigned to nursing,
2. to develop better means of
communicating the realities of the
situation, and
3. to adopt methods of organizing
nursing care which will permit nurses to
escape this role.*
References
1 *Baumgart, A. Combined
Canadian American Hospital
Association Conference. Montreal, Que,
28, 29, July, 1980.
2 Hallas, Gail Ghigna. Why nurses
are giving it up. RN. 43(7): 17-21 ; 1980
Jul.
3 Donovan, Lynn. What nurses want
(and what they re getting). RN.
43(4):22-30; 1980 Apr.
4 Coffey, Robert E., et al. Behavior
in organizations: a multidimensional
view. 2d ed. Englewood Cliffs, N.J.:
Prentice-Hall; 1975.
5 Henning, Margaret; Jardim, Ann.
The managerial woman. New York:
Pocket Books, Inc.; 1978: Chapter 4.
*Not verified
Gabrielle Monaghan, RN, BA, DHA, is
director of nursing service at McKellar
General Hospital in Thunder Bay,
Ontario. She is a graduate of the
University of Toronto hospital
administration program and of
Richmond School of Nursing in Dublin,
Ireland and Laurentian University in
Sudbury, Ontario.
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Made in Canada by arrangement
with IMPERIAL CHEMICAL INDUSTRIES LIMITED
Community mental health
nursing: an ecological perspective
by Jeanette Lancaster. Toronto,
Mosby, 1980.
Approximate price: $10.95.
The underlying concept of this
book is that "man s health status is the
result of the dynamic interaction
between his internal environment and
the multiple external environments in
which he exists". The editor, however,
failed to convince this reader. The
accompanying articles from her
colleagues are very disparate both in
content and point of view, and do not
further her purpose.
The book has five parts each
containing several chapters by different
authors. The quality of articles is
uneven ; some are excellent with new
material and fresh suggestions while
others are stilted and even superficial
in their approach. Although most are
written by nursing specialists, little
attention is paid to the way in which
other nurses might integrate the
information into their own practice.
Statements like "The nurse. ..must
consider the demands of society," or
"must develop strategies that aim
towards alleviating the disastrous effects
of being poor in an affluent society"
leave me overwhelmed. Where do I
start? The specific role of nurses in
community mental health what they
can realistically do and not do given
their position on the health care team-
is largely ignored. Grandiose generali
zations occasionally overshadow the
good material flowing directly from the
authors work, experience, and thought
which provokes the reader to go further
on his own.
There is information here for a
wide audience ; clear organization and
an index help the reader to discover
what will be of interest to her. Nursing
students and beginning practitioners
will find chapters which orient them to
community mental health problems
rape, child abuse, maturational crises.
A look at
BOOKS
Nurses more experienced in the field
may find in the ideas and alternate
frameworks presented new possibilities
for their intellectual exploration.
Reviewed by Susanna Jack, RN, M.Ed.,
Psychiatry - Outpatient Dept.,
Montreal General Hospital.
Patient and family education:
tools, techniques and theory by
Rose-Marie Duda McCormick and
Tamar Gilson-Parkevick. New
York, John Wiley, 1979.
This book is an enlightening and
useful manual for all nurses, especially
those in pediatrics. The introductory
poem "They heard but did not
remember", is eloquent evidence of the
patient/family need for comprehensive,
take-home instructions.
The unique aspect of this book is
the collection of 79 model instruction
packages called "Helping Hands", an
outgrowth of H.E.L.P. or Homegoing
Education and Literature Program.
These model teaching tools are
presented in laymen s language with
realistically simple, delightful illus
trations. These illustrations, while
concise, have been executed with a
sensitivity that is stress-reducing.
The text offers a detailed
description of how to produce your
own "Helping Hands" package. An
excellent teaching blueprint is also
included ; it will be appreciated by those
helping others learn to teach.
I commend the authors for
releasing copyrights on the "Helping
Hands"; these instructions may be used
as they are, or modified to suit your
agency s policies. This manual would be
an invaluable addition to any health
services library.
Reviewed by M. Kathleen Cowan, RN,
BScN, Inservice Educator, Nursing
Education, The Hospital for Sick
Children, Toronto.
Health Counseling by Lawrence
Litwack, Janice M. Litwack and
Mary B. Ballou. New York,
Appleton-Century-Crofts, 1980.
Approximate price: $13.50.
The three authors of this text, one
of whom is a nurse, are involved in
counseling and have written the book
for students and professionals whose
work is not in counseling per se. They
suggest that teachers, community nurses
and health educators are among those
who will find it useful.
Different forms of counseling are
examined and the process of counseling
is differentiated from other helping
relationships such as teaching and
advising. An overview is provided of
normal growth and development,
current issues in personal health (e.g.
physical fitness) and crisis intervention,
but the treatment of these is too
superficial to be of use. Most nurses
know more about both health and
counseling than the authors realize.
Possibly the best chapter deals
with legal and ethical considerations.
Although specifics refer to the U.S.,
the principles and guidelines have a
general application.
Probably the authors have tried to
cover too much ground. For example,
there is a chapter on group approaches
which includes a discussion of
leadership as well as group dynamics.
Both of these topics are sketchily
treated and their comments about
leadership are out of date. The reading
list provided is so meagre that it might
have been better to leave this chapter
out altogether.
Although well written and
organized, the style is somewhat
pedantic in places. This text is too
simplistic and deals with its subject too
superficially to be of use to nurses.
Reviewed by Kirsten Weber, RN, MSN,
associate professor, School of Nursing,
University of British Columbia.
Handbook of infectious disease
management by Cornells Kolff
and Ramon Sanchez. Don Mills,
Addison-Wesley Publishing, 1979.
Approximate price: $11.95.
The stated purpose of this book is
to "present clinically useful information
on infectious diseases in a manner that
is both convenient for quick reference
and graphic for instruction." This
handbook is intended for the use of
physicians, nurses and students
practicing in the hospital or community
setting. While the multidisciplined,
global approach seems like a formidable
task, it is nevertheless achieved in a
compact 280 pages.
Discussion includes disease
entities, initial management,
antimicrobial theory, laboratory tests
and techniques, and immunization and
other control measures. The general
format allows for easy access to
information, and the diagramatic
approach to diagnosis provides a
framework for problem solving. This
book does not look at rationales; it is an
outline, a map, and as such would be a
valuable addition to community,
hospital and school libraries. It would
be a useful addition to the personal
library of a public health nurse, a
physician, or any other professional
concerned with the control and
management of infectious diseases.
Reviewed by Elfriede Home, RN, BSN,
Head Nurse, Infectious Disease Ward,
Vancouver General Hospital.
The Canadian patient s book of
rights by Lome Elkin Rozovsky,
Toronto, Doubleday, 1980.
Approximate price: $8.95.
Rozovsky clarifies the purpose of
his book by stating that it deals with
laws affecting consumers of health care
but that it in no way replaces a lawyer
for advice on particular questions.
The author writes for consumers
and succeeds in making clear legal
principles often expressed elsewhere in
terms not easily understood by persons
lacking a background in law. Included
among the topics are health insurance
and medicare, the right to the doctor of
one s choice, consent to treatment,
standard of care and confidentiality.
Each is treated in a clear manner.
The author makes an important
distinction between rights and standards
of care. "The danger of a bill of rights is
that instead of health personnel
exercising their professional judgment
and acting in a humane manner, they
will treat the patient according to the
rules and only according to the rules."
Although the book is intended as
a guide for consumers, it could well
serve students of a variety of occupations
within the health service field in Canada.
Reviewed by Anne D. Thome, RN,
M.Ed., director, Saint John School of
Nursing, Saint John, N.B.
OVOlSOmg
Tablets
QvoUOmg
Tablets
over
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 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.
HORR6R
Montreal Canada
Full information available on request.
Ovol Drops
relieve
infant colic.
I
0HORHER
^W Mcrv.eal C*HOS
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.
Shhh. Ovol Drops.
Also available in tablet form for adults
,
Any wound
is too serious
to deserve
less than
iu^
i* I** 1
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Mi
best.
W
ma
ofra-IUIIe
Tested and proven for
over 19 years... that means
quality performance.
Sofra-Tulle is a quality surgical dressing
that goes on treating the wound long after
application. Bactericidal against Gram
positive and Gram negative infections,
Sofra-Tulle remains active in the presence of
blood, pus and serum. 1
Sofra-Tulle is soft and pliable with minimal
adherence, easy to cut and contour to fit
the lesion. Sofra-Tulle avoids maceration,
helps drain exudate, and provides a sterile
healing environment.
Sofra-Uille
Leadership in wound repair
from Roussel
1, Data on File Roussel Canada Inc.
ROUSSEL^.
Montreal. Quebec ^BTm
Obstetric nursing by Olds,
London, Ladewig and Davidson.
Don Mills, Addison-Wesley
Publishing Co., 1980.
Approximate price: $25.00.
The authors have dealt
comprehensively with the childbearing
process and provided a valuable text
for nurses responsible for the care of
patients and their families during the
reproductive cycle. The concise yet
detailed writing style of the authors is a
recognized strength. Along with the
physiological and psychological aspects
of childbearing, this text emphasizes
family dynamics, crisis theory and
intervention and the nursing process,
information important for nursing
practice; physiology is another
positive feature. Topics related but less
significant to the childbearing phase
(ie. climacteric) are included, and
although described briefly, enhance the
understanding of the life cycle.
The text stresses the nursing
role in the well-being of the family.
The diagrams, photographs, tables, and
nursing care plans all add to the
effectiveness of the material. However,
discussion of the teaching and
counseling related to family planning
and/or birth control is limited.
Considerable explanation of male
orgasm is included, but little attention
is given to female orgasm. Despite these
limitations no significant topic is
omitted. The text would be an
appropriate choice for baccalaureate
nursing programs, health science
libraries, maternity units, public health
agencies and the personal library of any
nurse interested in quality maternal-
child health care.
Reviewed by Shirley MacLeod,
associate professor, Faculty of Nursing,
University of New Brunswick,
Fredericton, N.B.
Maternal and child nursing by
S. Joy Ingalls and M. Constance
Salerno. 4th edition. St. Louis,
Mosby, 1979.
The fourth edition of this book
claims to reflect recent efforts in
maternal and child health services "to
prevent illness and promote a high level
of wellness and also treat disease";
regretably, the aspects of disease
prevention and health promotion
receive only token attention.
Like the earlier editions, this
text focuses primarily on hospital
treatment. However, a considerable
amount of material on hospital care of
the mother, infant and child is covered
in a well organized, clear fashion. Charts
and illustrations are numerous and
excellent. A phonetic glossary is
included and each chapter explains
vocabulary.
In keeping with "rising consumer
expectations", the obstetrical section
has been updated; new material is
presented on bonding, breathing
exercises and activity during labor, and
alternative childbirth arrangements.
Subtle but meaningful word substi
tutions have occurred, for example, the
chapter entitled "Labour and Delivery"
is now "Labour and Birth". The
pediatric section has been expanded
with more discussion of diseases.
Despite the comprehensive title,
the nurse interested in health promotion
strategies will find little of relevance ;
this text does not extend beyond
hospital walls and is appropriately
dedicated to "the bedside nurse". The
contribution of the nurse researcher is
unrepresented even in the chapter-end
bibliographies, and the role of the
community nurse is omitted. The book
follows the medical model and does not
have any conceptual or philosophical
framework other than that ; family-
centered concepts, psychosocial and
cultural aspects of care are addressed
only superficially. A good example of
this superficial treatment is seen in the
chapter on the contribution of the male
parent; the discussion is confined to a
description of anatomy and physiology.
The book is not without value as
a compact and practical reference for
beginning students, especially since the
hospital is still the setting,
unfortunately, of much student
experience. The practitioner and senior
student would doubtless prefer
reference material of greater scope and
depth. This book contains little of value
to either the educator or practitioner
wanting to explore new approaches to
care of the childbearing family.
Reviewed by Janet B. Harris, MScN,
Clinical Teacher, Maternal-Infant
Nursing, Faculty of Nursing,
University of Toronto.
Cardiac rehabilitation: a
comprehensive nursing approach
by P. Comoss, E. Burke and S.
Swails, 334 pages. Toronto,
Lippincott, 1979.
Cardiac rehabilitation nursing
theories are translated into practical
applications in this book using
myocardial infarction as a model.
Theories and principles are developed
for one patient from his admission into
the coronary care unit up to and
including his discharge one year later
from the outpatient section of the
program.
The four phases of cardiac
rehabilitation divide this book into an
easy to read and quick reference text.
The case method and use of one patient
maintain continuity.
Although it does not provide a
comprehensive clinical reference for
other cardiac diseases, the book is a
valuable guide for a nurse beginning a
cardiac rehabilitation program. It would
also serve as an excellent model for the
student, the generalist nurse or the
established cardiac rehabilitation nurse
specialist.
Reviewed by Lorea Ytterberg, clinical
director, Medical Nursing, Vancouver
General Hospital, Vancouver, B.C.
Decubitus Ulcers
An audio-visual
presentation available
on loan, free of charge
This presentation describes treat
ment and dressing techniques for both
simple cutaneous and deep decubitus
ulcers, using BenOxyl 20% (benzoyl
peroxide) Lotion.
The taped narrative, by W.E. Pace,
M.D., M.Sc., F.R.C.P.(C) and Heather
Hanson, R.N., runs for approximately
30 minutes and is supported by a series
of before-and-after illustrative colour
slides.
To complement the slide-tape pre
sentation a folder illustrating the dress
ing techniques is available in quantity.
For any of the above material,
including a complete script, please
write to:
Scientific Services Dept.
Stiefel Laboratories
(Canada) Ltd.
6635 Henri-Bourassa Blvd. VV.
Montreal, Quebec H4R 1E1.
Sofra -Tulle
Framycetin Sulphate
ROUSSEL
ANTIBIOTIC
Indications: Treatment of infected or potentially
infected burns, crush injuries, lacerations. Also vari
cose ulcers, bedsores and ulcerated wounds.
Contraindications: Known allergy to lanolin or fra-
mycetin. Cross-sensitization may occur among the
group of streptomyces-derived antibiotics (neomycin,
paromomycin. kanamycin) of which framycetin is a
member, but this is not invariable.
Precautions: In most cases absorption of the anti
biotic is so slight that it can be discounted. Where
very large body areas are involved (e.g. 30% or more
body burn], the possibility of ototoxicity being even
tually produced should be considered. Prolonged use
of antibiotics may result in the overgrowth of non-
susceptible organisms, induding fungi. Appropriate
measures should be taken if this occurs.
Dosage: A single layer to be applied directly to the
wound and covered with an appropriate dressing. If
exudative.dressings should be changed at least daily.
In case of leg ulcers cut dressing accurately to size
of ulcer.
Supplied: A lightweight, paraffin gauze dressing
impregnated with 1% framycetin sulphate B.P.
Sofra-Tulle also contains anhydrous lanolin 9.95%.
Available in 2 sizes: 10 cm by 10 cm sterile single
units, cartons of 10 and 50; 10 cm by 30 cm sterile
single units, cartons of 10. Store at controlled room
temperature.
Th Canadian Nurse
Manual of orthopedics by Nancy
Hilt and Shirley Cogburn, 846
pages. St. Louis, Mosby, 1980.
Approximate price: $41.50.
This book is the most compre
hensive and definitive work available in
its field. It is a reference book with a
multi-disciplinary approach to the care
of orthopedic patients.
Each chapter is well organized and
clearly illustrated with hundreds of
drawings, color and black-and-white
photographs and x-rays. Laboratory
data and specific forms are also
incorporated. The inclusion of an
extensive glossary and a bibliography
at the end of each chapter further adds
to the effectiveness of this text as a
resource.
The manual fills a crucial need for
all nurses involved with orthopedic
patients: it meets the needs of persons
new to the field and those already
practicing orthopedic nursing,
physiotherapy and occupational
therapy. As well, it can be used as a
learning text for students and a tool
for nursing instructors.
I recommend "Manual of
Orthopedics". It is difficult, if not
impossible, to fault either the content
or format of this manual. Although it
is not directed specifically towards
orthopedic nursing, the book is a
valuable reference for allied health
disciplines.
Reviewed by Marilyn D. Edgren, head
nurse - Orthopedics, Halifax Infirmary,
Halifax, N.S.
Current practice in critical care
Toronto, Mosby, 1979.
As a reflection of critical care
nurses concern that nursing practice be
based on total patient needs, the authors
of this book have presented articles
dealing with current perspectives of
critical care. As the preface clearly
indicates, this book is not a textbook,
nor does it seek to provide a consistent
approach. The authors are critical care
practitioners of various health centers in
the United States, who together offer
"...alternatives for practice and food for
thought".
Committed to continued learning
and the importance of appropriate
nursing intervention in effective
rehabilitation of the whole person,
critical care nurses should find the
selection of topics in this book pertinent
and fundamental in many respects to
their adult critical care settings and the
expanded role of the critical care
practitioner.
This book brings together a selected
cross section of perspectives of interest
to the new and more experienced critical
care nurse, the clinical specialist and the
educator. It offers brief historical
viewpoints of evolution in critical care.
The first two chapters discuss
educational methods and approaches in
preparation of practitioners and
continuing education. Administration
and management is the focus of a brief
essay. Pertinent to all critical care
settings, physical assessment of the
cardiovascular and respiratory systems
is developed and nursing application
described.
The larger portion of this book is
devoted to articles dealing with selected
multisystem critical illness, describing
pathophysiology, medical, surgical
principles and management approaches
to treatment, nursing assessment and
care . These are interwoven with
discussion of pharmacological
management, with some overlapping
evident, describing agents, their actions
and current nursing observations. The
final two chapters deal with patients
behavioral responses to critical illness
and the environment.
The articles vary in approach and
style but the information is clearly
presented with a detailed list of content
of each article in the table of contents .
The material is well researched and
referenced and illustrations and tables
are clear and pertinent.
The book achieves a formidable task
of touching on perspectives of education
to management and theory to current
scientific research. Although many
readers may be familiar with the content,
there is considerable merit to having a
book which brings it all together. This
book offers practical and theoretical
approaches on issues fundamental to
comprehensive and quality critical care
nursing.
Reviewed by Margaret Eades, RN, BN,
Head Nurse, M1CU, Montreal General
Hospital.
Conceptual models for nursing
practice by Joan P. Riehl and
Callista Roy. 2d ed. New York,
Appleton-Century-Crofts, 1980.
The second edition of this book
contains discussion of many more
nursing models than did the first
edition and includes explanations and
descriptions of implementation of the
models by individual nurses. However,
the models are not critiqued, which
leaves the impression that no problems
were encountered in the implementa
tion.
The book was difficult to read in
places but might be useful as a reference
for researchers or graduate students who
are considering using one of the models
discussed because some models appear
not to be published elsewhere.
Reviewed by Nancy Grant, RN, BScN,
PhD, School of Nursing, Dalhousie
University, Halifax, N.S.
Total patient care - foundations
and practice, 5th ed., by G. Hood
and J. Dincher, Toronto, Mosby,
1980.
Approximate price: $19.25.
This book is presented as a
"textbook of medical-surgical nursing
designed for students preparing for first
entry level into nursing practice and as a
reference for practicing nurses". It
could well fill these roles but if used for
students would require, in several
sections, additional guidance through
the instructor and/or another text, as
the seemingly straightforward
explanations require good background
knowledge of some topics. On the other
hand, this type of presentation does
serve as good concise review of basic
material for the practicing nurse.
One drawback is the lack of
description or diagrams during
discussion of certain nursing care
responsibilities, eg. percussion in chest
physio when caring for patients with
respiratory problems, or insertion of
nasogastric tubes. Such procedures are
not generally included in nursing
fundamentals texts and are taught along
with the content of a medical-surgical
text. In addition, much of the
information regarding community and
agency organizational patterns,
immunization schedules and statistics is
American with no Canadian references.
The brevity of explanations makes
for quick and easy reading but could
prove a detriment to student use of this
text unless further explanation in some
areas and emphasis on important
specific details were offered from some
other source.
Reviewed by Elizabeth Hobden,
teaching master, Algonquin College
Nursing Program, Pembroke Centre.
Orthopedic traction manual by
Andrew Brooker, MD and
Gerhard Schmeisser Jr., MD,
Baltimore, Williams & Wilkins,
1980.
Approximate price: $14.95.
Basically this manual intends to
teach what to do and how to do it. The
authors deal briefly with mechanical
aspects of traction such as beds, frames
and knots, and apply their knowledge
and skills to the types of traction most
commonly utilized.
The presentation is clear and
precise, with good drawings clearly
illustrating the principles of traction.
Excellent anatomical drawings are also
included.
The manual is recommended as an
excellent resource for all medical and
para-medical personnel in the day-to-day
management of patients in traction.
Reviewed by Simon Kam, RN, B.Sc.,
MS (Ed), teaching master, Mohawk
College and Richard Blake, RN,
McMaster University Medical Centre,
Hamilton, Ontario.
The Canadian Nurse
SAUNDERS
NURSING
TITLES...
Keep you aware of new ideas, new theories, new techniques and methods
luckmann & Sorensen
MEDICAL-SURGICAL NURSING: A
PSYCHIC-PHYSIOLOGIC APPROACH
2nd Edition
Updated, revised, and expanded, the new Second
Edition keeps pace with your needs today,
supplying you with the knowledge and confidence
to undertake ever-increasing responsibilities.
MEDICAL-SURGICAL NURSING can be used in
conjunction with or independently from Sorensen
& Luckmann s BASIC NURSING.
By 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; and Karen Creason Sorensen,
RN, BS, MN, Formerly Lecturer in Nursing, Univ. of Washington; formerly
Instructor of Nursing, Highline College; formerly Nurse-Clinical Specialist,
Univ. Hospital and Firland Sanatorium. Seattle, WA. 2,276 pp . 817 illus
1980 $40.80.
Gillies & Alyn
SAUNDERS TESTS FOR SELF-EVALUATION OF
NURSING COMPETENCE
3rd Edition Revised Reprint
Following the same patterns as nursing licensure exams this book
serves as a perfect means for you to refresh your knowledge of clinical
nursing matters. It is divided into four specialty areas. Maternity and
Gynecologic, Pediatric, Medical-Surgical, and Psychiatric and Mental
Health Nursing. Ten new sections have been added to this edition,
including amniocentesis, hyperbilirubinemia. and failure to thrive.
By Dee Ann Gillies, RN, BA, MA, MAT, EdD, Divisional Nursing Director.
Surgical Nursing, Cook County Hospital, Chicago, and Irene Barrett Alyn,
RN, BA.MSN, PhD. Prof, of Nursing, Univ. of Illinois. Chicago. 745 pp
Nov.. 1980 About $17.95.
INEWIN1981J Asperheim
PHARMACOLOGY: An Introductory Text,
5th Edition
The fifth edition of this handy reference contains clear, up-to-date
discussions of pharmacologic practice and information on new
drugs. Case studies, review questions and chapter objectives have
been added to facilitate learning. Designed as a basic introduction to
drug therapy, the text includes relevant material on anatomy and
physiology, as well as a thorough math review focused on dose calcula
tion. Drugs are discussed in relation to their major classifications, with
nursing implications integrated throughout.
By Mary K. Asperheim (Favaro). BS. MS, MD. Private Practice Pediatrics
Assis. Prof, of Pediatrics, Medical Univ. of South Carolina, Charleston SC
About 272 pp. Illustd. Ready Feb. 1981 . About $12.60.
|NEWIN1981| Asperheim & Eisenhauer
THE PHARMACOLOGIC BASIS OF PATIENT CARE
4th Edition
Now revised and expanded, this easy-to-use text provides complete
information on basic pharmacology. Organized by system and drug
categories, this edition includes material on action, toxicity, food and
drug interactions, and adult and pediatric dosages. Nursing implications
have been added or revised, and the text also contains introductory
chapters on drug laws and the nurse s legal responsibilities
By Mary K Asperheim (Favaro). BS, MS, MD, Private Practice Pediatrics
Assis. Prof, of Pediatrics, Medical Univ. of South Carolina. Charleston, SC
and Laurel A. Eisenhauer, RN, BS, MSN, PhD. Assoc Prof, of Nursing
Boston College School of Nursing, Chesnut Hill MA About 624 pp Illustd
Ready March 1981 About $23.40.
CUP AND MAIL THIS NO-RISK COUPON TODAY
Jackson
THE WHOLE NURSE CATALOG
This handy reference/sourcebook enables you to
quickly locate the right answers to all types of
health care-related questions from patients rights
to taking a health history, to where to find patient
teaching materials, to lists of nursing organiza
tions. There is much clinical material, and the
appendix contains information on film sources,
publishers, state boards of nursing, major poison
control centers, normal weights and heights,
metric conversions.
By Jane Clark Jackson, RN, B$N, MSN, CNM, formerly Nurse-Midwife,
Brooklyn-Cumberland Medical Center, and Maternity and Infant Care
Projects of the City of New York, Brooklyn. 743 pp. Illustd. 1980 $23.95.
Creighton
LAW EVERY NURSE SHOULD KNOW,
4th Edition
The most up-to-date, comprehensive manual of law for nurses is now
in a_new fourth edition! Dr, Creighton explains those parts of the law
applicable to nursing practice and what the nurse s responsibilities are
under those laws Updated and expanded, the fourth edition includes
recent court decisions and many of the references cited are from
1978-1 980. This new edition is the one single source on law that should
be required reading for every nursing student and on the reference
shelf of every practicing nurse.
By Helen Creighton, RN, BSN, JD, DLitt, Distinguished Prof, of Nursing,
Univ. of Wisconsin-Milwaukee. About 480 pp. Ready Jan 1981
About $18.00.
Kron
THE MANAGEMENT OF PATIENT CARE:
Putting Leadership Skills to Work
5th Edition
This new edition has been strengthened by the addition of new material,
including: expanded coverage of the role of communication in
management; an entire section by Ellen Durbin, comparing team
nursing, primary care and individual nursing; new chapter on the legal
implications of nursing practice; full discussion of "burn out". You ll
examine the changing role of nursing in the 80 s as well as new
methods of health care planning and management.
By Thora Kron, RN, BS, Member, Ozark Foothills Home Health Agency
Advisory Group; with contributions by Ellen Durbin, RN, MEd, MBA.
Consultant for Management and Nursing, San Francisco, CA. formerly Asst.
Administrator for Patient Care Services. Barnert Memorial Hospital Center,
Paterson, NJ. About 238 pp Illustd. Ready Jan 1981 About $11.95.
W. B. Saunders
1 Goldthorne Ave., Toronto, Ontario M8Z 5T9
Yes! Send me on no-risk 30-day approval:
Bai?ieT ann D Jackson
D Asperheim 5 Creighton
D Asperheim/Eisenhauer
D Kron
D I HAVE ENCLOSED A CHECK (SAUNDERS PAYS POSTAGE
AND HANDLING)
D BILL ME (PLUS POSTAGE & HANDLING)
Full Name.
Address
City
_ Prov.
-Postal Code-
Prices are subject to change.
CN 12/80
Helping the retarded child in the
elementary school years by John
B. Fotheringham and Joan Morris.
Toronto, University of Toronto,
1979.
Approximate price: $5.95.
This text on assisting the mentally
retarded child is unique: it is directed
towards both families and professionals.
It offers little new to those f amiliar with
the hand -; pped. but it is suitable for
those having limited experience with
retarded youngsters. It provides current
information on some of the many issues
that families and helpers must contend
with.
The classification of mental
retardation is clarified, and considerable
attention is given to the problems and
benefits of labelling. Assessment of
children, program planning and school
arrangements are dealt with in some
detail. This information would be of
value to the nurse involved in hospital
or community care of handicapped
children. The text is sometimes rather
confusing; the benefits of integration
and modelling are outlined early on, but
later the author states "special schools
are probably more appropriate for
T.M.R. children." This seems to reflect
the confusion experienced by both
professionals and families as they
attempt to "normalize" care for these
children.
The section on counseling and
community services will be of particular
interest to nurses as these are the areas
in which we often become involved.
This book would probably be
most useful to nurses unfamiliar with
the problems of the retarded child and
family.
Reviewed by Sheila Cameron, Assistant
Professor, School of Nursing, University
of Windsor.
People, patients and nurses: a
guide for nurses toward improved
interpersonal relationships by
Jennie Wilting. 130 pages.
Edmonton, University of Alberta
Press, 1980.
Approximate price: $10.00
The area of communication and
interpersonal relations has been one of
great concern for many nurses. Often,
an accumulation of minor emotional
happenings can bring on feelings of
frustration and helplessness. People,
patients and nurses, a unique and timely
paperback, is an excellent guide to help
nurses look at such problems in a
systematic way. The book lists and
discusses each problem under three
logical headings: problems arising from
relationships with self, patients and
co-workers.
The section on problems arising
from the relationship with self, offers a
good explanation of the concept of
accepting oneself. To accept yourself,
you must know yourself in terms of
your characteristics: are you ambitious?
kind? intelligent? In determining your
own character, you must be honest and
non-judgmental. Learning to accept
your true feelings is essential before you
can decide how you will respond to
the problem.
The same principles are applied in
the second section on problems arising
from relationships with patients. Several
excellent examples are drawn from the
author s 25-year experience in the
mental health field.
Problems arising from relation
ships with co-workers are cited as the
cause of more unhappiness and
discontent than any other situation.
Some guidelines for dealing with minor
problems are discussed, again using the
principles outlined in the preceding
chapters.
While the information in this
book is not new, I recommend it to all
nurses. The examples could be used in
classroom or clinical discussion groups
to emphasize interpersonal relationships
and communication, and the role they
play in problem prevention and solution.
The title of the book "People,
patients and nurses", seems rather
ambiguous I would hope patients and
nurses are people too. This readable
book would be of interest to anyone
interested in guidelines for personal
improvement and more satisfactory
interpersonal relationships.
Reviewed by Eileen French, assistant
professor, School of Nursing,
University of Ottawa, Ottawa, Ontario.
Review of hemodialysis for nurses
and dialysis personnel by C.F.
Gutch and Martha H. Stoner. 3d
edition. Mosby s Comprehensive
Review Series, Toronto, Mosby,
1979.
Approximate price: $1 7.00.
As the title suggests, this third
edition provides a concise, easy to read
review of the basic principles of
hemodialysis, renal physiology and
chemistry, available dialysis equipment,
and the common problems and
complications associated with acute and
maintenance hemodialysis.
As in the two previous editions
the authors have retained their unique
question and answer format, making the
book easy to read and digest in parts.
Thanks to the extensive index, the book
also serves as an excellent quick
reference when problems or questions
arise in the dialysis unit. A list of
basic reference texts that are
recommended for a small ward library is
also included.
There is a short discussion of
home care, peritoneal dialysis and some
consideration of the implications of
long term dialysis for the patient,
family and society ; almost all important
subject areas are mentioned. This book
is an excellent reference to have on any
dialysis unit.
Reviewed by Marcia Wiltse, RN, Staff
Nurse, Regina General Hospital,
Hemodialysis Unit, Regina, Sask.
Teaching tomorrow s nurse: a
nurse educator reader by Susan
Kooperstein Minn, 1st ed.
Wakefield, Massachusetts Nursing
Resources Inc., 1980.
Approximate price: $10.95.
This is an anthology of 24 articles
submitted to the Nurse Educator and
divided into seven major areas:
preparing students for contemporary
practice, clinical teaching, the use of
nursing theory, the RN student, the
adult learner, helping students succeed
and faculty development.
The author suggests the articles
are practical, readable and based on
sound theoretical foundations. While
many of them do whet your appetite,
several do not provide the reader with
sufficient information and/or detail to
replicate the authors instructional
design or strategy.
Educators are continually
expressing a need for information on
clinical teaching, preparing students
for expanded practice and the adult
learner. However, of the three articles
devoted to clinical teaching, one deals
with clinical conferences, one with
anecdotal records and one with a
student experience with well adults. The
section on preparing students for
expanded practice runs the gamut of
health assessment to discharge planning.
The area of the adult learner addresses a
competency based nursing program,
individualized instruction and an
andragological experience with graduate
students.
The articles are well written and
the book is of general interest to
educators, but it certainly would never
be called an essential text.
Reviewed by M. Kaye Fawdry, assistant
professor, School of Nursing, University
of Windsor, Windsor, Ontario.
Research in nursing practice by
Donna Diers. New York, J.B.
Lippincott Co., 1979.
This publication should be a
welcome addition to the bookshelf of
anyone interested in finding answers to
clinical nursing problems. The
importance of rigor in research is
tempered with realism ; the author gives
credit to practitioners hunches and
stresses choosing tools that will help
tell something important about nursing
practice. The mystique that research
requires knowledge and skill only
obtainable by a few is counteracted by a
positive assumption that all nurses can
and should do research.
The reader is introduced early to
the idea that research begins with a
problem that must be translated into a
question answerable through research.
The four chapters on study design, the
most valuable section of the book, are
ordered progressively starting with
naming theory and ending with
prescriptive theory. Each design is
considered within the framework of the
nursing process. These chapters would
serve as a good reference while research
is in progress.
SXS&Oisr 13S8
The Canadian Nurse
The examples used in this text all
deal with research on nursing problems.
The notes at the end of each chapter are
very helpful, providing other sources for
more specific information and offering
further clarification of chapter content.
One unique feature is the
description of a study by the author
using information gathered while she
was a participant observer in a research
class; a personal and practical
demonstration of research in action.
This book is a very useful text for
those concerned with the systematic
study of nursing practice.
Reviewed by Sheila Stanton, associate
professor, University of British
Columbia, School of Nursing,
Vancouver, B.C.
Geriatric clinical protocols by L.J.
Pearson and M.E. Kotthoff.
Philadelphia, Lippincott, 1979.
Approximate price: $19.00.
This book provides clear, factual
information for nursing care of the
geriatric patient. Set in the format of
clinical protocols, it is one of the few
comprehensive books available for
specific reference in caring for the
elderly.
The book is divided into two
segments: unit one discussing protocols
for presenting complaints in the elderly
and unit two protocols for chronic
conditions common to the elderly. The
units on urinary incontinence and
depression, two common problems in
the elderly, requiring much nursing
input, are rarely addressed in adequate
detail in alternate texts.
Each of the 13 protocols begins
with an overview of the physipj.ofbie). Sal-
pathology, effects of the acJgreement with
and any psychosocial fac: tact ; Dir ?" OI c of
the issue being presentpA P one)403 645 3331
for assessment and p.
presented followed and part-time Registered
for ea~n segment three shifts in Active Treat-
ratior ; ale to fo~P ital - A Pply to: Director of
, , -r General Hospital, Box 939,
and iomple^a TOK 2G0 .
pro ided.
nurse prr^uty Nurses required for a SO-bed
esc-Tlt el * aux arv hospital 55 miles east of
.nton, Alberta. Genuine interest in geriat-
pr ;VI nursing necessary. Salary according to
ISSARN contract. Applicants may telephone
(jj+03) 632-2871 to arrange for an interview,
r write giving resume to: Director of Nursing,
~1inburn Auxiliary Hospital and Nursing Home
ilDistrict No. 22, Box 959, Vegreville, Alberta
f a OB 4LO.
British Columbia
pivpplications are invited for registered nurses
pfor a 62 bed acute care hospital located in
_jOuth-eastern British Columbia. Applicants
" Mist be registered or eligible for registration in
in te Province of British Columbia. Salary:
skL543.00/month (unregistered) or $1624.00 -
asse 889 00 / mon th (registered). Benefits in ac-
, dance with R. N. A. B.C. plus planned orient-
ana r>n, regular inservice programs, master ro-
ion, 8 hour shifts, staff rotate between med-
yl/pediatrics and surgical/obstetrics unit every
Sch nontns - Residence accommodation within
Iking distance, ski resort within 3 miles of
nan. city. Apply in writing to: Director of Nurs-
Service, Fernie District Hospital, Box 670,
nie, British Columbia VOB 1MO.
A guide to physical examination
by Barbara Bates. Second edition.
Toronto, J.B. Lippincott, 1979.
This second edition is markedly
improved by the addition of an
excellent introductory chapter on
interviewing and the healthy physical.
More explanatory diagrams, photos and
descriptions are used to aid the student
in the examination procedure and in
identifying abnormalities. This book
also provides a good sample method for
recording a complete history and
physical in a continuous smooth flow;
the drawback of this method is that it is
lengthy and makes limited use of
abbreviated terms.
The design of the book is helpful
in that the sequence of chapters follows
the same order used in carrying out a
physical exam. The chapters on eyes,
ears, nose and throat seem to scatter
information making them difficult to
follow.
The many pictures used surpass
pages of explanation in guiding a
student through the physical examina
tion procedure. The addition of color
plates of an eardrum, normal and
abnormal fundi and skin lesions and
rashes would enhance the otherwise
good illustrations.
The book does not discuss
problem-oriented history taking and
recording, a serious gap in a book of
this sort. Hopefully the third edition
will remedy this problem.
Reviewed by Lissa w fie Proulx, Nurse
Practitioner, currinati employed as a
nurse practitio>S, Kiy Health Centre of
General Pr -* M - N -
General Duty R.N. i
position. 10-bed acute- nursmg: a
Kootenay region of B.C , wni r>
RNABC Contract. Send b Y tloise R.
Community Hospital, Box SaunderS
British Columbia VOG ISO.
Experienced Nurses (eligibltSl 3.15.
tion) required for full-time
modern 300-bed Extended Ca
ed just thirty minutes from ver text-
couver.Salary and benefitsacccted
ContractApplicants may teteppioeiams
to arrange for an interview, or ^ fj.
particulars to : Personnel Direc . , *~
Hospital, 315 McBride Blvd., Nlcluding
British Columbia V3L 5E8. J freeing
urs more
Royal Columbian Hospital ExpshipS
(B.C. Registered) required fo ori
progressive regional referral and !
tal located in the Fraser Valley, "
freeway from Vancouver and wHlUSt
cess of various recreational facility to
orientation and continuing ed
grammes. Salary 1980 rates ,
$1889.00 per month. Clinical abOOk
Operating Room, Recovery Roc in
Care, Coronary Care, Neonatal In a
Labourand Delivery, Family centn
Emergency, Renal Dialysis, Psyc
Medicine, Palliative Care, Surgei
Rehabilitation and Extended Cart;,
in writing to: Employment Mana; _
Columbia Street, New WettmHT*
Columbia V3L 3W7.
Experienced nurse (eligible for
ration) required for full time po
lovely cottage hospital on northe*
Island. Apply to the: Port McNeil
Hospital, P.O. Box 790, Port M
Columbia VON 2RO.
POSEY SOFT BELT
Comfortably prevents patients from slid
ing in wheelchairs or geriatric chairs. Soft
polyurethane cushion is so soft your pa
tient will hardly know it s there. Wash
able. Sm., med., Ig.
No. 4125
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 stabilizes foot.
No. 6412
POSEY PATIENT RESTRAINER
Get the added plus of shoulder loops and
straps Comfortable vest criss-crosses in
front or rear and waist belt ties to bed
spring frame. Excellent in wheelchairs too.
Sm., med , Ig
No. 3111
Health
Dimensions Ltd.
2222 S. Sheridan Way
Mississauga, Ontario
Canada L5J 2M4
Phone: 416/823-9290
Open to both
men and women
NURSES
Solicitor General of Canada
Salary: Up to $28,342
Ref. No: 80-NCRSO-NU-15
mma*mma**aam*
CLEARANCE NUMBER: 310-289-001
The Correctional Service of Canada will have positions
available at various locations across Canada over the next
12 months in Federal Correctional Institutions and special
psychiatric hospitals.
Salaries: Up to $28,342 - dependent on qualifications,
assignment, and location - plus penological factor
allowance of up to $1,000 per annum.
Opportunities
Correctional health care and forensic psychiatry provide
new and expanding career opportunities for nursing
professionals. These unique, challenging areas demand men
and women with proficient nursing skills, special personal
qualities, and a pioneering spirit.
Responsibilities
In the Health Care Centres (HCCs), the nurses are the
inmates first contact with health care professionals. Each
nurse must be independent, resourceful and prepared to
operate in an expanded nursing role. In the Regional Psych
trie Centres (RPCs), the treatment philosophy emphasizes
a multi-disciplinary approach encompassing all aspects of
psychiatry. The primary therapist in each of these
university-affiliated hospitals is frequently the nurse.
Duties
Assist in the development of medical and psychiatric
programmes for inmates in either health care centres or
regional psychiatric centres and provide nursing care to
patients on a 24 hour basis.
Qualifications
- Registered Nursing diploma for HCCs and RPCs
- Registered Psychiatric Nursing diploma for RPCs
- Registered/Certified/Licensed Nursing Assistant diploma
for RPCs
- Baccalaureat degree in Nursing an asset for HCCs and
RPCs
- Recent general nursing experience required for HCCs
- Recent psychiatric nursing experience required for RPCs
- Administrative and supervisory experience required for
managerial positions in HCCs and RPCs
Language Requirements
For some positions knowledge of both English and French
is essential. Because of the nature of these positions
bilingual capacity is required immediately. Other positions
requ^T a knowledge of English, others a knowledge of
rsc
Fre , while others require a knowledge of English and
Fre > s o :yiingual persons may apply for bilingual posi-
t Toronto indicate their willingness to become
"ommission will assess the
./?ev; ewfeah, Jingual. Language
professor, Sch^
of Windsor, Winu,
bil
li . price: $17.00.
> suggests, this third
j a concise, easy to read
>asic principles of
renal physiology and
ailable dialysis equipment,
non problems and
s associated with acute and
hemodialysis.
tie two previous editions
lave retained their unique
I answer format, making the
j read and digest in parts,
le extensive index, the book
is an excellent quick
rhen problems or questions
dialysis unit. A list of
mce texts that are
ded for a small ward library is
tod.
e is a short discussion of
peritoneal dialysis and some
tumties and relocation expenses.
Benefits
Excellent pension plan; good sick leave benefits; evening,
night and weekend premiums; 1 1 statutory holidays; and a. n of the implications of
minimum three weeks holiday ; continuing education OppoT^X 8 ^ ** the patient,
society ; almost all important
as are mentioned . This book
.ent reference to have on any
it.
<y Marcia Wiltse, RN, Staff
[na General Hospital,
is Unit, Regina, Sask.
Research in nun the
Donna Diers. Ne\
Lippincott Co., lt, n
This publication should
welcome addition to the books
anyone interested in finding an
clinical nursing problems. The
importance of rigor in research is
tempered with realism; the author gives
credit to practitioners hunches and
stresses choosing tools that will help
tell something important about nursing
practice. The mystique that research
requires knowledge and skill only
obtainable by a few is counteracted by <
positive assumption that all nurses can
and should do research.
The reader is introduced early to
the idea that research begins with a
problem that must be translated into a
question answerable through research.
The four chapters on study design, the
most valuable section of the book, are
ordered progressively starting with
naming theory and ending with
prescriptive theory. Each design is
considered within the framework of tl
nursing process. These chapters would
serve as a good reference while researc
is in progress.
The Canadian Nurse
Classified
Advertisements
Alberta
British Columbia
British Columbia
Registered Nurses are required for a 560-bed
acute care Teaching Hospital in downtown
Edmonton. The Hospital offers a planned
orientation and Inservice Program. Good em
ployee benefits, including a Dental Care Plan.
Successful candidates must be eligible for reg
istration in Alberta. Present salary is between
$1,5 8 1.00 and $1,867.00 per month. On March
1st, 1981, the salary will be increased to be
tween $1,701.00 and $1,987.00 per month
(salary is based on experience). Apply: Re
cruitment Officer Nursing, Personnel Depart
ment, Edmonton General Hospital, 11111
Jasper Avenue, Edmonton, Alberta T5K OL4.
Phone: (403)482-8111.
pled
challenging career. Currently we have
full and part time R.N. positions available in
our 32 bed active treatment hospital located
in a beautiful and historic southern Alberta
tourist community, 30 miles from the Univer
sity city of Lethbridge. A future 72 bed facility
means that we need you! Please forward a
resume to: Mrs. Lois St. Germain, Director of
Nursing, Macleod Municipal Hospital, Fort
Macleod, Alberta TOL OZO or phone: (403)
553-4025.
Slow Down! Enjoy the easy paced life coupl
with a challenging career. Currently we ha
Registered Nurses. We invite you to join our
Health Care Team at the Fort McMurray Reg
ional Hospital which is expanding from a 75-
bed hospital to a 300-bed hospital. We will
provide you with a challenging professional
opportunity as a primary nurse involved in
our high level patient care programs. Good
employee benefits, salary as per the Collect
ive Agreement and registration as per the
A.A.R.N. Please contact: Human Resources,
Fort McMurray Regional Hospital, 7 Hospit
al Street, Fort McMurray, Alberta T9H 1P2,
(403) 743-3381, ext. 19.
Graduate & Registered Nurses required imme
diately. Opportunity to acquire experience in
all clinical areas of a 75 bed accredited hospital
(located 130 milesN.E. of Edmonton, Alberta).
(Time off in lieu of vacation negotiable). Sal
ary and fringe benefits in agreement with
U.N.A. ($1465-51867). Contact: Director of
Nursing, St. The.-ese Hospital, Box 880, St.
Paul, Alberta TOA SAO (Phone)403-645-3331.
Required Full-time and part-time Registered
Nurses to rotate all three shifts in Active Treat
ment 66-bed hospital. Apply to: Director of
Nursing, Taber General Hospital, Box 939,
Taber, Alberta TOK 2GO.
General Duty Nurses required for a 50-bed
accredited auxiliary hospital 55 miles east of
Edmonton, Alberta. Genuine interest in geriat
ric nursing necessary. Salary according to
AARN contract. Applicants may telephone
(403) 632-2871 to arrange for an interview,
or write giving resume to: Director of Nursing,
Minburn Auxiliary Hospital and Nursing Home
District No. 22, Box 959, Vegreville, Alberta
TOB4LO.
British Columbia
Applications are invited for registered nurses
for a 62 bed acute care hospital located in
south-eastern British Columbia. Applicants
must be registered or eligible for registration in
the Province of British Columbia. Salary:
$1543.00/month (unregistered) or $1624.00 -
$1889.00/month (registered). Benefits in ac
cordance with R.N.A.B.C. plus planned orient
ation, regular inservice programs, master ro
tation, 8 hour shifts, staff rotate between med
ical/pediatrics and surgical/obstetrics unit every
3 months. Residence accommodation within
walking distance, ski resort within 3 miles of
the city. Apply in writing to : Director of Nurs
ing Service, Fernie District Hospital, Box 670,
Fernie, British Columbia VOB 1MO.
General Duty Nurses for 39-bed Acute and Ex
tended Care Hospital in an Island Community
of 1,800, off N.E. Vancouver Island. Maternity
experience preferred. RNABC Contract. Res
idence accommodation $30.00 monthly. Rec
reational facilities, badminton, bowling, tennis
and fishing. Frequent ferry to Vancouver Is
land for curling, skating and swimming. Apply
to: Director of Nursing, St. George s Hospital,
Alert Bay, British Columbia VON 1AO or call
collect (604)974-5232 for further information.
General Duty Nurses required for 30 bed ac
credited hospital. Salary according to RNABC
Contract. Apply: Administrator, Chetwynd
General Hospital, Box 507, Chetwynd, British
Columbia VOC 1JO. (604) 788-2236/2568.
General Duty Nurses for modern 41 -bed hosp
ital located on the Alaska Highway. Salary and
personnel policies in accordance with RNABC.
Accommodation available in residence. Apply:
Director of Nursing, Fort Nelson General
Hospital, P.O. Box 60, Fort Nelson, British
Columbia VOC 1RO.
General Duty Nurse for modern 35-bed hospital
located in southern B.C. s Boundary Area with
excellent recreation facilities. Salary and per
sonnel policies in accordance with RNABC.
Comfortable Nurse s home. Apply: Director of
Nursing, Boundary Hospital, Grand Forks,
British Columbia VOH 1HO.
General Duty Registered Nurses required for
108-bed accredited hospital in northwest B.C
Previous experience desirable. Salary as per
RNABC Contract with northern allowance.
For further information, please contact: Dir
ector of Nursing, Kitimat General Hospital,
899 LahakasBlvd. N., Kitimat, B.C. V8C 1E7.
General Duty R.N. required for full time
position. 10-bed acute care hospital in West
Kootenay region of B.C. Salary, benefits per
RNABC Contract. Send resume to: Slocan
Community Hospital, Box 129, New Denver,
British Columbia VOG ISO.
Experienced Nurses (eligible for B.C. Registra
tion) required for full-time positions in our
modern 300-bed Extended Care Hospital locat
ed just thirty minutes from downtown Van-
couver.Salary and benefitsaccordingto RNABC
Contract Applicants may telephone 525-0911
to arrange for an interview, or write giving full
particulars to : Personnel Director, Queen "s Park
Hospital, 315 McBride Blvd., New Westminster,
British Columbia V3L 5E8.
Royal Columbian Hospital-Experienced Nurses
(B.C. Registered) required for this 500-bed
progressive regional referral and teaching hospi
tal located in the Fraser Valley, 20 minutes by
freeway from Vancouver and within easy ac
cess of various recreational facilities. Excellent
orientation and continuing education pro
grammes. Salary - 1980 rates - $1624.00 -
S1889.00 per month. Clinical areas include:
Operating Room, Recovery Room, Intensive
Care, Coronary Care, Neonatal Intensive Care,
Labour and Delivery, Family centred Obstetrics,
Emergency, Renal Dialysis, Psychiatry, Acute
Medicine, Palliative Care, Surgery, Pediatrics,
Rehabilitation and Extended Care. Please apply
in writing to: Employment Manager, 330 East
Columbia Street, New Westminster, British
Columbia V3L 3W7.
Experienced nurse (eligible for B.C. Regist
ration) required for full time position in our
lovely cottage hospital on northern Vancouver
Island. Apply to the: Port McNeill and District
Hospital, P.O. Box 790, Port McNeill, British
Columbia VON 2RO.
Experienced General Duty Nurses, preferably
eligible for B.C. Registration, required for 71-
bed accredited hospital on the Sunshine Coast
of British Columbia. Salaries and benefits
according to RNABC agreement. Residence
accommodation available. Apply in writing
to: Personnel Officer, St. Mary s Hospital,
Box 7777, Sechelt, B.C. VON 3AO.
General Duty Nurses required immediately for
a ten-bed acute and ambulatory care hospital
located in Stewart, B.C. Stewart has a popula
tion of 2000 and is Canada s northernmost ice-
free port with transportation, mining and con
struction as its primary industries. There are
excellent school facilities. A few of the many
sports offered are boating, fishing and, in the
modern community pool, swimming. Stewart
General Hospital is affiliated with the Prince
Rupert Regional Hospital and nurses are en
couraged to take part in the inservice educa
tion programmes at both hospitals. Salary
rates are according to the RNABC contract
and for a general duty RN the ranges are: May 1,
1980-$1624-$1889 plus $26.87 northern al
lowance. Jan. 1, 1981-$1700-$196S plus
$28.12 northern allowance. Fringe benefits
include: 20 days paid annual vacation; 5 days
marriage leave; annual educational leave, in
addition to the other usual health care insur
ance and monetary benefits. We are eager to
help you relocate. For further information
please call COLLECT: (604)624-2171,ask for
Mrs. L. Bremner, Director of Nursing.
O.R. Head Nurse required for an active 103-
bed acute care hospital. Must be eligible for
B.C. Registration. Post graduate training &
experience necessary. R.N.A.B.C. Contract in
effect. Accommodation available. Apply to:
Director of Nursing, Mills Memorial Hospital,
4720 Haugland Avenue, Terrace, British
Columbia V8G 2W7.
General Duty Nurses required for an active,
103-bed hospital. Positions availablefor experi
enced R.N. s and recent Graduates in a variety
of areas. RNABC Contract in effect. Accommo
dation available. Apply to: Director of Nursing,
Mills Memorial Hospital, 4720 Haugland Ave
nue, Terrace, British Columbia V8G 2W7.
St. Paul s Hospital invites applications from
(B.C. Registered) R.N. s for a 550 bed teaching
hospital located in downtown Vancouver, B.C.
Easy access of recreational facilities and good
living accommodations. Salary 1981 rates-
$1700.00-$1965.00 per month. Full-time and
Vacation Relief positions available in all clini
cal areas. (No Pediatrics) .Please apply in writ
ing to: Mrs. S. Howie, Nursing Administrative
Assistant, Personnel Department, 1081 Burrard
Street, Vancouver, British Columbia V6Z 1Y6.
Newfoundland
Faculty position available in Degree/Diploma
Program in Outpost Nursing and Nurse-Mid
wifery. Knowledge and experience in Commun
ity Health and Primary Care Nursing in North
ern and Rural Areas. Apply to: Margaret D.
McLean, Director & Professor, School of Nurs
ing, Memorial University of Newfoundland,
St. John s, Newfoundland A1C 5S7. Phone
(709) 737-6695.
Northwest Territories
Quebec
United States
The Stanton Yellowknife Hospital, a 72-bed
accredited acute care facility requires register
ed nurses to work in medical, surgical, paediat-
ric, obstetrical or operating room areas. For
further details concerning salary and benefits
contact: Lynette McLeod, Personnel Officer,
Box 10, Yellowknife, N.W.T. X1A 2N1. (403)
873-3444 (Collect).
Ontario
Urgently Needed Registered Nurses-general
hospital in small community. Applicants pro
ficient in both official languages preferred.
Apply to: Mrs. P. Vehkalahti, Director of
Nursing, Bingham Memorial Hospital, Box 70,
Matheson, Ontario POK 1NO (70S) 273-2424.
Registered Nurses required. Hospitals located
on James Bay at Attawapiskat and Fort Albany.
Good salary scale plus Northern Allowance.
Accommodations provided. Enjoy a Northern
Experience. For further information, contact:
The Administrator, James Bay General Hosp
ital, P. O. Box 370, Moosonee, Ontario POL
1YO.
Registered Nurses-Full-time and part-time Reg
istered Nurses currently registered in Ontario
required for a new 136 bed community hospi
tal. Recent medical, surgical, special care unit
and/or obstetrical experience would be an as
set. Qualified applicants are invited to submit
their resumes outlining qualifications and ex
perience to: Mrs. G. Saxton, Director of Per
sonnel, Temiskaming Hospital, New Liskeard,
Ontario POJ IPO.
St. Joseph s Health Centre is a West Toronto
Acute and Chronic Care Hospital. We require:
Registered Nurses, Full & Part Time, I.C.U./
C.C.U. This is a new intensive coronary care
unit which contains the most modern techno
logical equipment available. Nurses are also
needed in: Emergency Department. Nurses
will find our location in West Toronto, on the
Queensway, overlooking Lake Ontario, ideal
for commuting. We offer excellent benefits and
competitive salary. Weekdays, Telephone
534-9531 Ext. 543, Week-ends & After Hours
Ext. 303. St. Joseph s Health Centre, 30 The
Queensway, Toronto, Ontario M6R IBS.
Saskatchewan
Diploma Nursing Instructor (Psychiatric Nurs
ing) Saskatchewan Continuing Education,
Wascana Institute of Applied Arts and Sciences,
Regina requires an Instructor who will be a
member of a team teaching Psychiatric nursing
to second year diploma nursing students during
eight week clinical rotations. Primary respon
sibilities include classroom instruction, plan
ning and supervising clinical experience in a
psychiatric setting and related community
agencies; evaluating students and providing
guidance to assist them to meet program
objectives; assisting in the on-going up-date
and revision of curriculum. Applicants will
have a Bachelor s degree in Nursing, be
eligible to register as a nurse in Saskatchewan,
and have two years clinical experience in a
psychiatric setting. Supervisory or teaching
experience or preparation preferred. Salary:
$21,168 - $28,248 (with B.Sc.N.);$23,040 -
$30, 132 (with M.Sc.N.). (Instructor, Technical
Institute). Competition No.: 501010-0-4660;
Closing: As soon as possible. Forward your
application forms and/or resumes to the
Saskatchewan Public Service Commission,
3211 Albert Street, Regina S4S 5W6, quoting
position, department and competition number.
Concordia University-Department of Nursing
Science* requires a Director/Professor for the
newly reorganized Nursing Department. Com
mencing date: June 1, 1981 or as soon as pos
sible. Requirements-Educational: M.Sc.N. es
sential; Doctorate degree preferred (Ph.D.,
D.Sc.N. or D.Ed.); French/English bilingualism
an asset. Experience: University teaching and
administrative experience essential. Salary &
Prerequisites: Salary negotiable within present
North American scales. Concordia offers ex
cellent fringe benefits. Candidates should apply
sending complete curriculum vitae, with the
names, addresses and phone numbers of 3
referees to: Dr. Maurice Cohen, Dean, Division
III, Arts and Science, Concordia University,
1455 de Maisonneuve Blvd. West, Montreal,
Quebec H3G IMS. * Opening Fall, 1981,
subject to government approval.
Concordia University-Department of Nursing
Science* requires faculty at all ranks for a
newly organized Nursing Department. Edu
cational Qualifications: M.Sc.N. (minimum);
Doctorate an advantage; Bilingual (French/
English) an advantage. Experience: 2 years
clinical; 2 years teaching; university teaching
experience an advantage. Salary & Prerequi
sites: Commensurate with education, experi
ence. Concordiaoffers excellent fringe benefits.
Candidates should send their curriculum vitae
together with the names, addresses and phone
numbers of three referees to: Professor Muriel
Uprichard, Ph.D., Health Education/Commu
nity Nursing, 7141 Sherbrooke Street West,
Montreal, Quebec H4B 1R6. * Opening Fall,
1981, subject to government approval.
Saskatchewan
Two Registered Nurses are needed for a 12-bed-
acute care facility, 430 miles northwest of
Saskatoon. Wages and benefits as per SUN
Contract. Living accommodations available.
Apply to: Director of Nursing, St. Martin s
Hospital, LaLoche, Saskatchewan SOM lGO,or
call collect (306) 822-2011.
One General Duty Registered Nurse required.
11 bed hospital. Duties to commence as soon
as possible. Salary accordingtoS.U.N. Contract.
Residence accommodation available. Please
contact: Margaret Friesen, D.O.N., Neilburg
and District Union Hospital, Neilburg, Sask
atchewan SOM 2CO. Phone: (306) 823-4262;
823-4703.
Registered Nurses and Registered Psychiatric
Nurses (eligible for Saskatchewan registration)
required for 340 fully accredited extended
care facility. For further information contact:
Personnel Department, Souris Valley Extended
Care Hospital, Box 2001, Weyburn, Saskatch
ewan, S4H 2L7.
United States
RN/Staff & Management Positions-Kaiser-Per-
manente, the country s largest Health Mainten
ance Organization, currently has excellent
opportunities available in our 583-bed Los
Angeles Medical Center. Located 7 miles from
downtown Los Angeles, close to many of Calif
ornia s finest Universities, this teaching hosp
ital offers RN s a unique chance to further
their careers in such areas as: OR, Med/Surg,
Maternal Child Health & Critical Care. Manage
ment positions are also available. Kaiser offers
an attractive array of fringe benefits including
relocation assistance, full medical, dental &
health coverage, continuing education advanc
ed training available in the Nurse Practitioner
& CRNA Programs, individualized orientation,
tuition reimbursement, and no rotating shifts.
New graduates are always welcome and encour
aged to inquire. For more information, please
write or call collect: Ann Marcus, RN, Kaiser
Hospital/Sunset, 4867 Sunset Blvd., L.A.,
California 90027. (213) 667-8374.
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 White is a 377-bed acute
care teaching medical center with an open invita
tion to dedicated RN s. We ll challenge your
mind and offer you the opportunity to develop
and continue your professional growth. We
will pay your one-way transportation, offerfree
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 Brooklyn
Avenue, Los Angeles, California 90033 (213)
268-5000, Ext. 1680.
Total patient care with all licensed personnel is
our goal! Staff RNs currently interviewing for
part-time and full-time positions. Full service,
except psych, progressive 156-bed accredited
acute general hospital. Located within 60 min
utes from LA, the ocean, mtns., and the desert.
Orientation and staff development programs.
CEUs provider number. Parkview Community
Hospital, 3865 Jackson Street, Riverside, Calif
ornia 92503. Write or call collect 7 14-6 88-22 1 1
Extension 217. Betty Van Aernam, Director
of Nursing.
RN S-Our Florida hospitals need you! Join the
many Canadian RN s who are currently enjoy
ing Florida s Gulf Coast beaches, sun, and excit
ing recreational activities. We will provide work
visas, help you locate a position, find housing,
and arrange your relocation. No Fees! Call or
write: Medical Recruiters of America, 3421
West Cypress St., Tampa, Florida 33607
(813) 872-0202.
Miscellaneous
To all alumni members of the Edmonton Gen
eral Hospital School of Nursing wishing to no
tify us of their change of address, include your
name, year of graduation, and please forward
to: Station F, Box 8124, Edmonton, Alberta,
Canada T6H 4N9.
Adventure Holidays:Camping Safaris, Overland
Expeditions and Fun Experiences. We offer
trips from one week to 3 months in: Canada,
USA, Europe, Africa, Asia, South and Central
America, Australia, New Zealand and the
Caribbean. For FREE catalogue, contact your
travel agent, or apply to: Goway Travel, 53
Yonge St., Suite 101, Toronto, Ontario M5E
1J3. Phone: 4 16-863-0799. Telex: 06-219621.
Before accepting any
position in the U.S.A.
PLEASE CALL US
COLLECT
We Can Offer You:
A) Selection of hospitals throughout
the US A.
B) Extensive information regarding
Hospital 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 1 133 Great Neck, N.Y. 11023
(516)487-2818
Our 23rd Year of World Wide Service
Pediatric & Orthopedic Nurses
Jazz up your career at
JoEllen Smith/
E Edward Hebert Hospitals
in New Orleans
Most hospitals sing the same song . . .
good salary, good benefits, good
facilities. We go beyond that. We
encourage each nurse to grow as an
individual.
Leadership training to help you
move up. Unlimited opportunities
to learn as we open new services and
pioneer new techniques. Plus a
professional atmosphere where your
special talents are appreciated.
Call collect (512/824-7478) or write:
J. Philip Knight-Sheen
1635 N.E. Loop 410
Suite 501
San Antonio, Texas 78209
NURSING
EXECUTIVE
Modern 300+ bed community hospital
seeks a highly qualified nursing adminis
trator. The position reports to the chief
executive officer. The hospital is a
regional center providing sophisticated
medical and nursing care.
Ideal candidates will have a record of
success at the assistant or director level.
A minimum of a bachelor s degree is
required. Starting salary is $35,000 to
$42.000.
Submit resume and salary history in
confidence to:
John E. Quigley
Witt
I ASSOCIATES INC
1415 WEST 22ND STREET OAK BROOK. ILLINOIS 60521
(312) 325-5070
RNs: you won t find
anything better
than this!
The Hospital
We re the newest hospital in the Twin Cities, and the 16th largest
private hospital in the nation Our competitive 600-plus bed city
hospital system is designed to provide the most current
professional health care available You ll work in an atmosphere of
warmth with a multitude of bright colors throughout the cheerful
ecology-oriented building We re opening several new units by
Christmas
The Care System
A primary care setting.
The Working Area
Circular and triangular nursing stations with no long corridors
means fewer steps for you and security for your patients. You will
find systems that free you for patients care such as HBO
Computerized Data Systems and Unit Dose Medication System
Specialize in such areas as Coronary Care, Oncology, Open
Heart, Intensive Care and light risk perinatal center
Education
Last year, alone, we held 392 development classes designed to
build on previously acquired knowledge and skills And 60
inservice classes were held for continued learning necessary to
follow through with hospital job expectations We now offer a 6
month OR course and a 6 week critical care course We also pay
75% tuition and books toward an advanced nursing degree,
St. Paul, Minnesota
The Twin Cities of Minneapolis/St Paul are only 280 miles from
the Canadian border Cultural and entertainment happenings are
big-city exciting and the people are small-town friendly. There s a
quality of life that s hard to describe, why not come down and we ll
show you.
If you are eligible for a Minnesota State License and are looking
for that "Something Better" to put real meaning into your nursing
career, CALL BARB BLAND COLLECT AT 612-296-8114 or write
UNITED and CHILDREN S HOSPITALS
333 N Smith
St. Paul, MN 55102
An Equal Opportunity Employer M/F
HOSPITAL
CORPORATION
Interested in a Challenge?
Try International Nursing - In
Saudia Arabia
If you are looking for a change, a chance to
travel, some hard work and adventurous living,
then you might consider international nursing.
You will have not only the opportunity to give -
to share your nursing expertise but the
opportunity to receive as well to learn by
living in a completely different culture. Truly, a
chance for personal and professional growth.
Available positions include both administrative
and staff level nursing. Requirements depend on
the position at staff level a minimum 2-3 years
current experience in an acute care hospital or
clinic setting. Current R.N. license in one of the
Provinces. Single status contracts are offered for
18 or 24 month periods.
Attractive salaries with excellent benefits
including air transportation, furnished lodging,
generous vacation, bonus pay and bonus leave.
Interested in this once in a lifetime opportunity?
For more details, please send professional
resume to:
Kathleen Langan
Hospital Corporation International, Ltd.
Two Robert Speck Parkway, Ste. 750
Mississauga, Ontario L4Z 1H8
An Equal Opportunity Employer
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 major medical centre on Canada s unconven
tional West Coast.
Recent graduates and experienced professionals alike will find a
wide variety of positions available which could provide the
opportunity you ve been looking for. Applications are invited
for the following positions:
General Duty (S1624 - $1889 per month 1980 rates)
Head Nurse
Nurse Clinician
Nurse Educator
Supervisor
For those with an interest in specialization, challenges await in
many areas such as:
Neonatology Nursing
Intensive Care (General & Neurosurgical)
Inservice Education
Caidio-Thoracic Surgery
Coronary Care Unit
Burn Unit
Hyperalimentation Program
Paediatrics Psychiatry
Renal Dialysis & Transplantation
Extended Care
If you are a Nurse considering a move please submit resume to :
Mrs. J. MacPhail
Employee Relations
Vancouver General Hospital
855 West 12th Avenue
Vancouver, British Columbia
V5Z 1M9
Assistant Director, School of Nursing
Brandon Mental Health Centre
Duties: The incumbent carries both teaching and admin
istrative responsibilities; assists the director in planning,
directing and evaluating programs carried out by school
faculty. In the absence of the Director, assumes full ad
ministrative responsibilities.
Qualifications: Relevant degree in Nursing or Health
Administrative plus R.P.N. or R.N. supplemented by
two years teaching experience at school of nursing.
Salary: $20,205-$27,541 per annum.
Competition No.: CN-843. Closing: Immediately.
Please send completed Civil Service application, quoting
competition number, directly to:
Dept. of Health
Personnel Management Services
270 Osborne Street North
Winnipeg, Manitoba K H l\ rVl I
R3COV8 IVIMI^I I
BA
The Canadian Nurse
Royal
Alexandra
Hospital
This 938 bed active treatment hospital invites
applications from nurses across Canada.
We offer experience in all areas of patient care
including intensive care, neonatal intensive care
and obstetrical perinatology. The extended work
day and compressed work week is currently in
effect in the Intensive Care areas and Emergency.
Applicants must be eligible for registration with
the Alberta Association of Registered Nurses.
Please direct inquiries to :
Mrs. D. Kivell
Personnel Officer
Nursing Recruitment
Royal Alexandra Hospital
Room 1108
10204 Kingsway
Edmonton, Alberta
T5H 3V9
Foothills Hospital
Calgary
Director of Nursing
The Hospital invites applications for the position of
Director of Nursing. Foothills Hospital is a 761 bed
teaching hospital and referral centre for Southern
Alberta.
This key position requires a dynamic nursing executive
with proven management experience, preferably in a
teaching hospital. The successful applicant should have
advanced educational preparation in nursing or health
administration complemented by senior nursing
administration experience, plus strong interpersonal
skills, high energy and the ability to successfully
introduce innovative changes.
Interested applicants are asked to submit a detailed
resume to:
Director of Personnel
Foothills Hospital
1403 - 29 Street N. W.
Calgary, Alberta
T2N 2T9
NURSES
You are a Canadian nurse - interested in serving
people where your help is needed. You would like
to build your nursing career - and see Canada
while doing it.
We are Canada s Medical Services. We provide
health care to the peoples of Canada s north
country. We d like to have you on our team.
If you qualify you will begin your career at
one of our outpost nursing stations, an important
member of a small community. Here you will be
able to use your self-reliance, good judgment and
sense of responsibility, supported by experienced
senior nursing and medical personnel, both
"on call" and on "routine visits".
There will be opportunities for promotion -
for moving to other locations across Canada in
our hospitals, outpost nursing stations, health
centres, major clinics, occupational health units
and in other health areas.
Salaries are supplemented by special allowances,
overtime compensation and pension benefits, in
addition to holidays and an opportunity for travel.
For further information, mail the coupon below.
1
Nursing Advisor
Human Resource Planning
Medical Services Branch
Department of National Health and Welfare
Ottawa, Ontario K1AOL3
NAMF
AODR F^s
CITY
PROV CODE
^ Health and Welfare Sante et Bien-elre social
1 ^r Canada Canada
1
Canada
Choose a
Nursing
Career _
in Canada s Ocean Playground
The Victoria General Hospital, Halifax, Nova Scotia is the Maritime s largest
teaching hospital. Close association with Dalhousie University and our own
extensive continuing education program provide excellent opportunities for
learning and career development.
The Victoria General Hospital offers a variety of nursing specialities for exper
ienced people looking for a professional environment and challenge. Victoria
General Nurses have full civil service benefits.
- GENERAL DUTY NURSES work in our 28 general nursing .units, each of
which have specific sub-specialties in Medicine and Surgery.
- INTENSIVE CARE NURSES are part of five specialized units such as
Coronary, Cardiovascular, Medical, Surgical and Neurosurgery.
- SPECIALTY AREA NURSES work in the Burn Unit, Renal Unit, Emergency,
Operating Room, Recovery Room or Out-Patients.
- NURSING ADMINISTRATION. We encourage promotion through an on-going
program of leadership development.
Please quote Competition Number: 80-310.
For details on nursing opportunities contact:
Mrs. Betty Elliot, R.N.
Personnel Department, Victoria General Hospital
5788 University Avenue
Halifax, Nova Scotia B3H1V8
Telephone: 1 (902) 428-3484
Director of Nursing
Churchill Health Centre, Churchill, Manitoba requires a Director of Nursing.
Churchill Health Centre is a community-governed health and social development service
encompassing public health, social services, medical-dental ambulatory and in-patient care.
It serves Churchill and the surrounding area of Manitoba as well as being a referral centre
for the Keewatin District of the Northwest Territories, and varies from active community
clinic and outreach services to a 31 bed in-patient unit.
The successful candidate will be able to organize and administer all the patient care
services of Churchill Health Centre including the in-patient unit, ambulatory, clinic nursing
services and a small surgical suite. This is a senior professional position that offers
challenge and excitement to the successful applicant who will have an opportunity to
exercise innovative ability in meeting the needs of patients from the Keewatin while
working within a unique community oriented organization.
Qualifications: We require a nurse who is eligible for registration in Manitoba, preferably
with a degree and/or administrative experience.
Salary: Will commensurate with qualifications and experience; but not less than
$23,000.00 per year.
Benefits: Northern Living Allowance, 20 days paid vacation annually with removal
assistance, inward and outward removal assistance, group life, pension and other benefits
available and fully modern furnished subsidized housing.
Apply to:
Executive Director
Churchill Health Centre
Churchill, Manitoba
ROB OEO
Phone: 1-204-675-8881, ext. 125
The Izaak Walton Killam
Hospital for Children
Assistant Head Nurse
Neo-Natal
The I.W.K. Hospital for Children requires
an Assistant Head Nurse for our Neo-
Natal Unit, which is a 32-bed referral
centre providing intensive, intermediate
and convalescent care.
Applicants must be a graduate of an
accredited School of Nursing and eligible
for registration in Nova Scotia. Degree or
Diploma in Nursing Service Administrat
ion is preferred. Must have a good know
ledge of Neo-Natal nursing principles and
techniques.
Inquiries and applications should be
directed to:
Karen Lyle, Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Full time and part time Registered
Nurses required for modern accredited
60 bed active general hospital, for
Supervisory and General Duty
positions.
1 2 hour shifts in effect.
Please apply in writing to:
(Miss) E. Locke, Reg. N.
Director of Nursing
Lady Minto Hospital
P. O. Box 4000
Cochrane, Ontario
POL ICO
McMaster University
Educational Program
For Nurses In
Primary Care
McMaster University School of Nurs
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 Canadian Regist
ration. Preceptorship from a medical
practioner. At least one year of work
experience, preferably in primary care.
For further information write to:
Joan Eagle, Director
Educational Program for Nurses
in Primary Care
Faculty of Health Sciences
McMaster University
Hamilton, Ontario L8S 4J9
.chilK Hospital
lgar*. \lbtr1a
Ki\e Month Cosl
(iradualr (. oun.es
Advanced Neurological
& Neurosurgical Nursing
This course serves as an extension of basic
knowledge of neurological problems gained in
an under graduate program. Instruction
proceeds from normal to abnormal.
Opportunities are provided to study and care
for persons of all ages who have had an
interruption in neurological function.
Ad\anced Neonatal Nursing
This course allows the nurse to gain knowledge
and expertise in the Intensive Care Nursery
setting. An overview of life as well as
experience in related settings are also
included.
lonlh*
Applkation
prior lo Th
Sf ptrmhf
KM mt.Mi
Departmen ofNurx
Foothills Hospital
140.1- 29th St. V W
Calgar>. Alberta
; completed Ihrt
nl dates of Mar
Prince George
Regional Hospital
Positions available for experienced nurses
or nurses interested in developing their
skills in specialty nursing-Operating
Room, ICU/CCU, Neonatalogy Nursing.
Positions also available in general nursing
areas and float pool. Must be eligible for
B.C. Registration.
Well developed orientation program
Inservice Education
Expanding Operating Room and
Obstetrical Suite
10 bed ICU/CCU
Prince George Regional Hospital is a
340 bed acute regional referral hospital
with a 75 bed extended care unit and has
a planned program of expansion.
For further information contact the:
Personnel Department
Prince George Regional Hospital
2000-lSth Avenue
Prince George, British Columbia
V2M 1S2
University of British Columbia
M.Sc. Program
(Health Services Planning)
A program is offered which isspecifically
designed for persons with experience in
health and/or social services. Applicants
must be graduates in on of the health,
social or life sciences, or commerce. Pre
ference will be given to practising health
professionals or managers who have 4-5
years experience.
It is anticipated that graduates will find
appointments at relatively senior plann ing-
policy levels of Canadian or international
health services or in health care research.
Students taking the research option are
eligible to apply for National Health
Grant Student Fellowships.
Applications should be completed by
February, 1981.
For details, write to:
Morton M. Warner, Ph.D.
Director Epidemiology Program in
Health Services Planning
Department of Health Care &
Epidemiology
University of British Columbia
2975 Wesbrook Mall
Vancouver, B.C. V6T 1W5
or Telephone (604) 228-2772
Trail Regional Hospital
Trail, British Columbia
Position Open
General Duty Nurse
Head Nurse
Applications are invited for the follow
ing full-time position of Head Nurse on:
2nd Medical/Cardio Pulmonary Rehab
The successful candidate must have
demonstrated supervisory ability,
including ability to direct a staff of
various personnel categories.
Previous and recent management expe
rience and post-basic academic training
considered an asset.
Hours of Work: Days - Monday to Friday.
Salary: As per R.N.A.B.C. Contract.
Position Available: Immediately.
Apply in writing to:
Mr. Lawrence H. Jones, BScN., R.N.
Assistant Administrator, Nursing Services
Trail Regional Hospital
Trail, British Columbia
V1R 4M1
Registered Nurses
300 bed Accredited general hospital in
Vancouver requires full-time, part-time
and casual R.N.s for general duty and
ICU nursing. Candidates should be
eligible for registration in B.C. Recent
nursing experience preferred. ICU
candidates must have previous ICU
experience.
Please apply to:
Employee Relations Department
Mount Saint Joseph Hospital
3080 Prince Edward Street
Vancouver, B.C.
VST 3N4
Royal Jubilee Hospital
Victoria, B.C.
Applications are invited from Register
ed Nurses or those eligible for B.C.
Registration with recent nursing ex
perience.
Positions are available in all services
of this 950 bed accredited hospital
which includes Acute and Specialty
Care, Obstetrics and Paediatrics,
Psychiatry and Extended Care for
Full Time, Part Time and Casual
Employment.
Benefits in accordance with
R.N.A.B.C. contract.
Please send resume to:
Director of Nursing
Royal Jubilee Hospital
1900 Fort St.
Victoria, B.C.
VSR 1J8
Registered Nurses
required
Applications are invited from Registered
Nurses interested in full-time employ
ment in a fully-accredited, 65-bed
personal care home in Notre Dame de
Lourdes, Manitoba, 90 miles Southwest
of Winnipeg.
Excellent personnel benefits as well as
rotations of Days/Evenings with every
other weekend off are offered. Salary
range is in accordance with current
contract.
Qualified individuals are directed to
forward their applications to the
attention of:
Jacqueline Theroux
Director of Nursing
Foyer Notre Dame Incorporated
Notre Dame de Lourdes, Manitoba
ROG 1MO
Telephone: (204) 248-2092
The Izaak Walton Killam
Hospital For Children
Staff Nurses
The I.W.K. Hospital for Children has
vacancies for Staff Nurses on our
Intensive Care Unit and Neo-Natal Unit.
Must be a graduate from an accredited
School of Nursing and be eligible for
registration in Nova Scotia. Previous
pediatric experience would be an asset.
Inquiries and applications should be
directed to:
Karen Lyle
Personnel Officer
The I.W.K. Hospital for Children
P.O. Box 3070
Halifax, Nova Scotia
B3J 3G9
Registered Nurses
Registered Nurses are required for an 87
bed accredited Hospital in Northern
Ontario.
Applicants must be eligible for
Registration with the College of Nurses
ofOntario.
Bilingualism is an asset.
Salary and Fringe Benefits in accordance
withO.N.A. Contract.
Temporary residence accommodation is
available.
Please apply in writing to:
Director of Nursing
Sensenbrenner Hospital
10 Drury Street
Kapuskasing, Ontario
PSN 1K9
Registered Nurses
We are presently seeking Nurses eligible for registration
in the province of Ontario who would like to work in
one of Canada s leading active cancer treatment and
research centres located in downtown Toronto.
Plans to increase our bed size to 200 have created open
ings for permanent staff on our Chemotherapy and
Radiotherapy in-patient units and applicants must be
available for both 8 and 12 hour shifts.
We place strong emphasis on the psycho-social support
aspect of nursing care and seek nurses with a desire to
learn and practise these skills.
If you are interested in specialized nursing in a cancer
treatment centre, please submit your resume to:
Mrs. L. Mills
Personnel Department
Princess Margaret Hospital
500 Sherbourne Street
Toronto, Ontario
M4X 1K9
1-416-924-0671 Ext. 211
Advertising Rates
For All Classified Advertising
$25. 00 for 6 lines or less
$3.50 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 Assoc
iation of the Province in which they are interest
ed in working.
Address correspondence to:
The Canadian Nurse
50 The Driveway
Ottawa, Ontario
K2P 1E2
Registered Nurses
1200 bed hospital adjacent to University of
Alberta campus offers employment in
medicine, surgery, pediatrics, orthopaedics,
obstetrics, psychiatry, rehabilitation and
extended care including.
Intensive care
Coronary observation unit
Cardiovascular surgery
Burns and plastics
Neonatal intensive care
Renal dialysis
Neuro -surgery
Planned Orientation and In-Service Education
Programs. Post Graduate Clinical Courses in
Cardiovascular Intensive Care Nursing and
Operating Room Nursing.
Apply to.
Recruitment Officer - Nursing
University of Alberta Hospital
8440- 11 2th Street
Edmonton, Alberta
T6G 2B7
University of
Alberta Hospital
Edmonton, Alberta
o
Index to
Advertisers
December 1980
Ayerst Laboratories, Division of
Ayerst, McKenna & Harrison Inc.
43
Career Dress, A Division of
White Sister Uniform Inc.
IFC
The Canada Starch Company Limited
The Canadian Armed Forces
The Canadian Nurse s Cap Reg d.
13
The Clinic Shoemakers
Equity Medical Supply Company
62
Ford Motor Company of Canada
OBC
Health Sciences Centre
14
Hollister Limited
28, 29, 36, 37,IBC
Frank W. Homer Limited
45,62
International Development Research Centre
41
Just Uniforms
12
Medical Personnel Pool
11
Posey Company
51
Roussel Canada Inc.
46,47
W.B. Saunders Company
49
Standard Brands Limited
70
Stiefel Laboratories (Canada) Limited
47
Advertising Representatives Advertising Manager
Jean Malboeuf Gerry Kavanaugh
601, Cote Vertu The Canadian Nurse
St-Laurent, Quebec H4L 1X8 50 The Driveway
Telephone: (514) 748-6561 Ottawa, Ontario K2P 1E2
Telephone: (613)237-2133
Gordon Tiffin
190 Main Street
Unionville, Ontario L3R 2G9
Telephone: (416) 297-2030
Richard P. Wilson
P. O. Box 482
Ardmore, Pennsylvania 19003
Telephone: (215)363-6063
Member of Canadian
Circulations Audit Board Inc.
news briefs
News (continued from page 13)
Did you know...
An Ohio company,
Microcomputer Ventures
Inc., has started paying health
bonuses to its employees in
an attempt to make it
worthwhile for them to stay
healthy. To qualify for the
bonus, workers must exercise
at least three days a week;
running six miles a week
qualifies an employee for a
$25 bonus while 14 miles a
week earns $35. Although the
bonuses are not large they
have provided the necessary
encouragement to get
workers exercising and
already the company s
employees have lost an
average of 13 pounds each.
Did you know...
Canadian researchers have
found body weight to be the
only risk factor associated
with statistically significant
differences in survival among
750 breast cancer patients.
The Medical Post reports
Dr. Norman Boyd of the
Princess Margaret and
Sunnybrook Hospitals in
Toronto as saying that as far
as he knows his study is the
first to show an interaction
between treatment and
weight among breast cancer
patients. This seems to hold
true even if other factors
including the severity of
disease at admission are taken
into account. The one
exception to the finding was
in premenopausal women
aged between 40 and 45.
Health happenings
The Canadian Council of
Cardiovascular Nurses has is
sued a statement on their posi
tion on cardiopulmonary re-
scusitation (CPR). The CC of
CN recommends that basic
CPR be taught in all accredi
ted schools of nursing, that
basic CPR classes be available
to all RN s, and that the ability
to perform CPR be an em
ployment prerequisite for
nurses who are working in
critical care areas or in occu
pational health.
A spokesman for the
group at the Canadian Heart
Foundation says that, con
trary to popular belief, all
nurses are not currently qual
ified to provide life support
through CPR.
Health happenings
An Indian Health Care
Commission consisting of
five Alberta natives has been
set up in that province to
oversee administration of
existing health programs and
to plan and implement new
activities.
Federal contributions
of up to $2.5 million have
been promised. Included in
the plans are new alcohol
treatment centers, a
detoxification center,
provision of health workers at
Indian friendship centers in
Edmonton and Calgary, and
a nurses training program.
Did you know...
A new vaccine, considered a
breakthrough in anti-rabies
treatment, is now available.
The Human Diploid Cell
Vaccine (HDVC), which
provides higher levels of
protection than previously
used vaccines, has shown no
evidence of severe reactions
and is more easily and less
painfully administered. The
new vaccine requires only six
innoculations, four during the
first two weeks, a booster on
the 30th day and a final
booster on the 60th day.
Although the cost of HDCV
is considerably higher, this
difference may be offset by
fewer physician visits.
Did you know...
A drug, Ibuprofen, commonly
called Motrin 8 , is being tested
at the University of Western
Ontario as a treatment for
inflamed joints commonly
suffered by hemophiliacs. Up
until now, no single safe drug
could reduce both the pain
and inflammation caused by
hemophilia. The most
common anti-inflammatory
drug aspirin cannot be
used in hemophiliacs because
it prolongs bleeding time.
Typical aspirin substitutes
such as acetaminophen can
relieve such pain but not
inflammation.
The investigators of
Ibuprofen tested a single small
dose in two groups of
volunteer patients and found
that it has only minimal effects
on bleeding time in both
normal and hemophiliac
subjects.
The Canadian Nuraa
The problem: flatulence.
Although flatulence is normal to a
certain degree, some conditions
tend to produce, or exacerbate it. In particular, when
patients are supine for lengthy periods, gas may be
unable to escape through the oesophago-gastric
junction. The result is distention, bloating, discomfort,
borborygmi, and pain.
A solution: Ovol 80 mg.
Ovol 80 mg contains simethicone, a proven
antiflatulent compound. It is an inert silicone agent that
rapidly lowers surface tension and causes small
"bubbles" in the stomach to coalesce, thereby
releasing "trapped" gas. Ovol 80 mg is supplied as
white, chewabie tablets pleasantly flavoured with mint.
Recommended dosage is 1 tablet
after meals as required.
Also
a| supplied as
|| peppermint-
*\ flavoured
if Ovol Drops
H for relief
^ of infant
! colic
SOME OVOL8O try
FAST,
EFFECTIVE RELIEF
OF GAS.
Montreal. Canada
Prescribing information on page 45
SPHYGMOMANOMETERS
TYCOS-TAYLOfl
STETHOSCOPES
Famous brand-nai
MERCURY TYPE. The ultima!
accuracy- Folds into figh! but
duty Velcro cull and
inflation sysiem
professionals the world over.
tty
transmission Adjustable light
weight bmaurals. has Doth
diaphragm and bell with non-
chill ring. Choose Black, Red,
Green, Blue or Gold
No 5079 $23 95 ea
SINGLE-HEAD TYPE, As abov
but without bell Same large
diaphragm for high sensitivity. No 5079A $18 95 ea
ECONOMY MODEL STETHOSCOPES. Similar to abov
but not TYCOS brand Same 2 vear guarantee Comple
with spare diapfiram and ear tipsw:o (ours as above.
SingU-HMd No I00$i395ea
DualHeadNo 110$l785ea
No 502 Practical Nursi
NURSES EARRINGS. For pierced No 503 Nun* * Aid*
ears Dainty CarJuceus m gold plate All $8 59 each
with gold Idled posts. Beautifully rviff>
gift boxed. No 325 $1i49 pr. -K^"
DELUXE POCKET SAVER
Dr frayed edges 3
ifnpartments for pens,
ors. etc , plus change
pocket and key chain
White calf Plastahide
No 505 $1 95 each
CADUCEUS PIN GUARD
Chained lo your professional lett
gold plated
ANEROID TYPE
Rugged and dependable. 10
guarantee of accuracy to
m. No stop-pin lo Hide
errors Handsome zippered case
lo fit vour pocket
$32 60 complete
URING TAPE
ng plastic case
button (or sprm
Measures tc
e, 200 C
e $5. 95 each
TIMER Time hot pac
park meters Remember to
itai signs, give medication, etc
light, compacl {1 Vj" dia.l, seta
5 to 60 mm. Key ring Swiss
$13 95 each
L/STEfi BANDAGE SCISSORS
Manufactured ol finest ste
Ho 698
Jo 699,
No 700, 5V!
No 702. 7V-
HAEMOSTATIC
FORCEPS <Kfly>
Ideal lor clamping
off tubing, etc.
Dozens of uses
Stainless steel,
locking type, 5Vj"
long.
Pl20 straight $698
P422 curved J6 98
NURSES PENLIGHT. Powerful beam for examination
throat, etc Durable stamless-sieei case with pocket
Clip. Made m U.S A No. 28 $5 98 complete with
totttrta*.
NOTE: WE SERVICE AND
STOCK SPARE PARTS FOR
ALL ITEMS.
OTOSCOPE SET. One
any s finest inst
NURSES WHITE CAP CLIPS. Made in Canada for
Canadian nurses. Strong steel boDby pins with nylo
tips 3"stze$1 29; card of 15.2 size $1.00 / card
NURSES 4 COLOUR PEN for recording temperature,
blood pressure, etc. One-hand operation selects red
black, blue or green. NO. 32 $2.97 each
powerful magnifying lens, 3
standard size specula. SizeC
batteries included. Metal carry
ing case lined *>rh sof! cioth
No 309 $79.95 each
ENGRAVED NAME-PINS IN 4 SMART STYLES -SIX DIFFERENT COLOURS... Z^l
TO ORDER NAME PINS ..
FILL IN LETTERING ^^k
DESIRED & CHECK
BOXES ON CHART
PLEASE PRINT
SEND TO EQUITY MEDICAL SUPPLY CO ALL ORDERS SHIPPED
P O. BOX 726-S. BROCKVILLE, ONT K6V 5V8 WITHIN 24 HOURS
Be sure to enclose your name and address.
SOLID PLEXIGLASS. ..Molded from solid Plexiglas
Smoothly rounded edges and corners Letters deeply
engraved and filled with laquer colour o( your choice
ASTIC LAMINATE. ..Lightweight out strong. Wil
""^ak or chip Engraved through surface into
sting colour core Bevelled edges malch
Satin limsh. Excellent value at this price.
ETAL FRAMED... Similar (o above out mounted n
ed metal frame with rounded edges and
S Engraved insert can be changed or
ed Our smartest and neatest design
OLID METAL. ..Extremely strong and durable but
(weight Letters deeply engraved for absolute
lur Corners and edges smoothly rounded Sad
$3.59
$1.57
$248
$3.22
$326
$424
$399
55.22
$5.73
$7.29
$405
$579
$544
$7.07
$6.39
$835
SORRY
C.O.D. & billing
lor institution*
Total for merchandise
Ontario residents add 7%
Add 50 handling if less than $10
Total enclosed
Because the post-op patient is so totally
in the hands of a trained nurse or ET. HoIIister
has designed a special pouch. One that gives
those trained nursing hands advantages they ve
never had before.
Like easier access to a wound or stoma.
By widening our pouch, making more room for
your hands, we ve given you greater control
and flexibility.
We ve also made you more productive by
taking busy work off your hands.
Seven pre-printed stoma/ wound sizes save
you tracing and measuring steps. And a pre-cut
% inch starter hole is not only convenient, it
lessens the chance of puncturing a pouch while
scissoring.
We ve even had a hand in making post-op
care neater and more pleasant.
Our exclusive twist-tie closure secures
the pouch more effectively than anything yet de
veloped.
And a unique free-floating patch makes
handling our pouch easier than ever before.
Of course, in designing a pouch nurses will
want to get their hands on, we haven t short
changed the patients. Not by a long shot.
Our exclusive fluid barrier Microporous II
tape dramatically reduces painful skin problems.
And our odor-proof fiJm provides unsur
passed odor resistance.
The HoIIister * Post-Operative Pouch.
Patients will appreciate it. But it s really designed
for the people whose hands are on pouches the
most. Nurses and ET s. Which should make it
the hands down fav-
orite at your hospital.
Hollister Incorporated 211 East Chicane Avenue. Chicago. ILNftll Distributed in Canada h> HoIIister Limited.
.122 Consumers Road. WJHowdale. Ontario M2J IP* tNKll Holhster Incorporated. All rinhtsreserved.
Meet the 42 MPG
lorth American bui
MERCURY LYNX.
MERCURY LYNX
LYNX LS 3-Door Hatchback
A front wheel drive world-class car that s a totally new North American automobile
World-class engineering.
Lynx was developed by Ford Motor
Company engineers around the world.
It s sophisticated world-class design
and technology has resulted thus
far in the issue of 13 patents-with
14 more pending approval. And Lynx
is being acclaimed for engineering
innovations like our new Compound
Valve Hemi-head (CVH) engine that s
one of the most power efficient engines
for its size built in North America.
Highest fuel economy rating of
any North American car sold in Canada.
\ highway rating of 54 MPG and a combined city/highway
rating of 42 MPG*(6.7L100km) make Mercury Lynx one of
the best gas mileage rated cars made in North America. The
four-cylinder CVH engine is designed to squeeze the most
power possible out of every drop of fuel. Teamed with the
new CVH engine, the standard four-speed, fully synchro
nized manual transaxle with fuel-efficient fourth-gear over
drive, or the optional all-new
three-speed automatic trans-
axle give Lynx truly world-class
fuel economy.
42 MPG
*Transport Canada Fuel Guide
City/Highway rating with standard powertrain
Your results may vary.
6.7L/100 km
Four wheel independent suspension and
front wheel drive.
Lynx features perfor
mance that ll win
you over: smooth
road-holding
four-wheel in
dependent sus
pension system,
with steel-belted
radial tires; new
design split-diagonal dual brakes for greater braking
confidence; a new rack-and-pinion steering system for
precise cornering; and front wheel drive for better
traction on snow and wet roads.
Surprising space.
A surprise comes inside every Lynx: a roomy interior
that seats four adults with new, comfortably contoured
front bucket seats and
generous cargo space in
both the hatchback and
four door liftgate models with
the back seat up or down.
A world of choice.
Lynx is available in three-door
hatchback or four-door liftgate
wagon (shown left) body styles
Your choices include Lynx,
LynxGL, GS, RSforthe
sporty car enthusiast and
the elegant Lynx LS.
RS 4-Door Liftgate Station Wagon
MERCURY LYNX.
The cat among the pigeons.
NOV
La
Universite" d 1 Ottawa
Eche"ance
The. Li.bn.aA.ij
University of Ottawa
Date Due
FEB -8
AUG 1 5 1983
02
APR 2 9 1988
iili
Live Music Archive
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Understanding 9/11