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Wireless Blockchain
Wireless Blockchain

Principles, Technologies and Applications

Edited by

Bin Cao
Beijing University of Posts and Telecommunications
Beijing, China

Lei Zhang
University of Glasgow
Glasgow, UK

Mugen Peng
Beijing University of Posts and Telecommunications
Beijing, China

Muhammad Ali Imran

University of Glasgow
Glasgow, UK
Copyright © 2022 by John Wiley & Sons Ltd. All rights reserved.

Published by John Wiley & Sons Ltd., Chichester, United Kingdom.

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Library of Congress Cataloging-in-Publication Data

Names: Cao, Bin, editor. | Zhang, Lei, editor. | Peng, Mugen, editor. |
Imran, Muhammad Ali, editor.
Title: Wireless blockchain : principles, technologies and applications /
Bin Cao, Beijing University of Posts and Telecommunications, Beijing,
China, Lei Zhang, University of Glasgow, Glasgow, UK, Mugen Peng,
Beijing University of Posts and Telecommunications, Beijing, China,
Muhammad Ali Imran, University of Glasgow, Glasgow, UK.
Description: Chichester, United Kingdom ; Hoboken : Wiley-IEEE Press,
[2022] | Includes bibliographical references and index.
Identifiers: LCCN 2021034990 (print) | LCCN 2021034991 (ebook) | ISBN
9781119790808 (cloth) | ISBN 9781119790815 (adobe pdf) | ISBN
9781119790822 (epub)
Subjects: LCSH: Blockchains (Databases) | Wireless communication
systems–Industrial applications. | Personal communication service
systems.
Classification: LCC QA76.9.B56 W57 2022 (print) | LCC QA76.9.B56 (ebook)
| DDC 005.74–dc23
LC record available at https://lccn.loc.gov/2021034990
LC ebook record available at https://lccn.loc.gov/2021034991

Cover Design: Wiley

Cover Image: © phive/Shutterstock

Set in 9.5/12.5pt STIXTwoText by Straive, Chennai, India

10 9 8 7 6 5 4 3 2 1
 v

Contents

List of Contributors xiii

Preface xvii
Abbreviations xxiii

1 What is Blockchain Radio Access Network? 1

Xintong Ling, Yuwei Le, Jiaheng Wang, Zhi Ding, and Xiqi Gao
1.1 Introduction 1
1.2 What is B-RAN 3
1.2.1 B-RAN Framework 3
1.2.2 Consensus Mechanism 6
1.2.3 Implementation 6
1.3 Mining Model 7
1.3.1 Hash-Based Mining 7
1.3.2 Modeling of Hash Trials 7
1.3.3 Threat Model 10
1.4 B-RAN Queuing Model 10
1.5 Latency Analysis of B-RAN 12
1.5.1 Steady-State Analysis 12
1.5.2 Average Service Latency 16
1.6 Security Considerations 18
1.6.1 Alternative History Attack 18
1.6.2 Probability of a Successful Attack 19
1.7 Latency-Security Trade-off 20
1.8 Conclusions and Future Works 22
1.8.1 Network Effect and Congest Effect 22
1.8.2 Chicken and Eggs 22
1.8.3 Decentralization and Centralization 22
1.8.4 Beyond Bitcoin Blockchain 22
References 23

2 Consensus Algorithm Analysis in Blockchain: PoW and Raft 27

Taotao Wang, Dongyan Huang, and Shengli Zhang
2.1 Introduction 27
2.2 Mining Strategy Analysis for the PoW Consensus-Based Blockchain 30
vi Contents

2.2.1 Blockchain Preliminaries 30

2.2.2 Proof of Work and Mining 30
2.2.3 Honest Mining Strategy 31
2.2.4 PoW Blockchain Mining Model 32
2.2.4.1 State 33
2.2.4.2 Action 33
2.2.4.3 Transition and Reward 34
2.2.4.4 Objective Function 39
2.2.4.5 Honest Mining 40
2.2.4.6 Selfish Mining 40
2.2.4.7 Lead Stubborn Mining 40
2.2.4.8 Optimal Mining 41
2.2.5 Mining Through RL 41
2.2.5.1 Preliminaries for Original Reinforcement Learning Algorithm 41
2.2.5.2 New Reinforcement Learning Algorithm for Mining 42
2.2.6 Performance Evaluations 44
2.3 Performance Analysis of the Raft Consensus Algorithm 52
2.3.1 Review of Raft Algorithm 52
2.3.2 System Model 53
2.3.3 Network Model 53
2.3.4 Network Split Probability 55
2.3.5 Average Number of Replies 57
2.3.6 Expected Number of Received Heartbeats for a Follower 57
2.3.7 Time to Transition to Candidate 58
2.3.8 Time to Elect a New Leader 59
2.3.9 Simulation Results 60
2.3.10 Discussion 67
2.3.10.1 Extended Model 67
2.3.10.2 System Availability and Consensus Efficiency 68
2.4 Conclusion 69
Appendix A.2 69
References 70

3 A Low Communication Complexity Double-layer PBFT Consensus 73

Chenglin Feng, Wenyu Li, Bowen Yang, Yao Sun, and Lei Zhang
3.1 Introduction 73
3.1.1 PBFT Applied to Blockchain 74
3.1.2 From CFT to BFT 74
3.1.2.1 State Machine Replication 74
3.1.2.2 Primary Copy 75
3.1.2.3 Quorum Voting 75
3.1.3 Byzantine Generals Problem 76
3.1.4 Byzantine Consensus Protocols 76
3.1.4.1 Two-Phase Commit 76
3.1.4.2 View Stamp 76
 Contents vii

3.1.4.3 PBFT Protocol 76

3.1.5 Motivations 78
3.1.6 Chapter Organizations 78
3.2 Double-Layer PBFT-Based Protocol 79
3.2.1 Consensus Flow 79
3.2.1.1 The Client 79
3.2.1.2 First-Layer Protocol 81
3.2.1.3 Second-Layer Protocol 81
3.2.2 Faulty Primary Elimination 82
3.2.2.1 Faulty Primary Detection 82
3.2.2.2 View Change 83
3.2.3 Garbage Cleaning 84
3.3 Communication Reduction 84
3.3.1 Operation Synchronization 85
3.3.2 Safety and Liveness 85
3.4 Communication Complexity of Double-Layer PBFT 85
3.5 Security Threshold Analysis 86
3.5.1 Faulty Probability Determined 87
3.5.2 Faulty Number Determined 89
3.6 Conclusion 90
References 90

4 Blockchain-Driven Internet of Things 93

Bin Cao, Weikang Liu, and Mugen Peng
4.1 Introduction 93
4.1.1 Challenges and Issues in IoT 93
4.1.2 Advantages of Blockchain for IoT 94
4.1.3 Integration of IoT and Blockchain 94
4.2 Consensus Mechanism in Blockchain 96
4.2.1 PoW 96
4.2.2 PoS 97
4.2.3 Limitations of PoW and PoS for IoT 98
4.2.3.1 Resource Consumption 98
4.2.3.2 Transaction Fee 98
4.2.3.3 Throughput Limitation 98
4.2.3.4 Confirmation Delay 98
4.2.4 PBFT 98
4.2.5 DAG 100
4.2.5.1 Tangle 101
4.2.5.2 Hashgraph 102
4.3 Applications of Blockchain in IoT 102
4.3.1 Supply Chain 102
4.3.1.1 Introduction 102
4.3.1.2 Modified Blockchain 103
4.3.1.3 Integrated Architecture 104
viii Contents

4.3.1.4 Security Analysis 105

4.3.2 Smart City 106
4.3.2.1 Introduction 106
4.3.2.2 Smart Contract System 107
4.3.2.3 Main Functions of the Framework 109
4.3.2.4 Discussion 110
4.4 Issues and Challenges of Blockchain in IoT 111
4.4.1 Resource Constraints 111
4.4.2 Security Vulnerability 111
4.4.3 Privacy Leakage 112
4.4.4 Incentive Mechanism 112
4.5 Conclusion 112
References 112

5 Hyperledger Blockchain-Based Distributed Marketplaces for

5G Networks 117
Nima Afraz, Marco Ruffini, and Hamed Ahmadi
5.1 Introduction 117
5.2 Marketplaces in Telecommunications 118
5.2.1 Wireless Spectrum Allocation 119
5.2.2 Network Slicing 119
5.2.3 Passive optical networks (PON) Sharing 120
5.2.4 Enterprise Blockchain: Hyperledger Fabric 121
5.2.4.1 Shared Ledger 122
5.2.4.2 Organizations 122
5.2.4.3 Consensus Protocol 122
5.2.4.4 Network Peers 122
5.2.4.5 Smart Contracts (chaincodes) 123
5.2.4.6 Channels 123
5.3 Distributed Resource Sharing Market 123
5.3.1 Market Mechanism (Auction) 125
5.3.2 Preliminaries 125
5.4 Experimental Design and Results 126
5.4.1 Experimental Blockchain Deployment 127
5.4.1.1 Cloud Infrastructure 127
5.4.1.2 Container Orchestration: Docker Swarm 127
5.4.2 Blockchain Performance Evaluation 127
5.4.3 Benchmark Apparatus 128
5.4.3.1 Hyperledger Caliper 130
5.4.3.2 Data Collection: Prometheus Monitor 130
5.4.4 Experimental Results 131
5.4.4.1 Maximum Transaction Throughput 131
5.4.4.2 Block Size 131
5.4.4.3 Network Size 131
5.5 Conclusions 133
References 133
 Contents ix

6 Blockchain for Spectrum Management in 6G Networks 137

Asuquo A. Okon, Olusegun S. Sholiyi, Jaafar M. H. Elmirghani, and Kumudu
Munasighe
6.1 Introduction 137
6.2 Background 139
6.2.1 Rise of Micro-operators 139
6.2.2 Case for Novel Spectrum Sharing Models 140
6.2.2.1 Blockchain for Spectrum Sharing 141
6.2.2.2 Blockchain in 6G Networks 142
6.3 Architecture of an Integrated SDN and Blockchain Model 143
6.3.1 SDN Platform Design 143
6.3.2 Blockchain Network Layer Design 144
6.3.3 Network Operation and Spectrum Management 146
6.4 Simulation Design 149
6.5 Results and Analysis 152
6.5.1 Radio Access Network and Throughput 152
6.5.2 Blockchain Performance 154
6.5.3 Blockchain Scalability Performance 155
6.6 Conclusion 156
Acknowledgments 156
References 157

7 Integration of MEC and Blockchain 161

Bin Cao, Weikang Liu, and Mugen Peng
7.1 Introduction 161
7.2 Typical Framework 162
7.2.1 Blockchain-Enabled MEC 162
7.2.1.1 Background 162
7.2.1.2 Framework Description 162
7.2.2 MEC-Based Blockchain 164
7.2.2.1 Background 164
7.2.2.2 Framework Description 164
7.3 Use Cases 166
7.3.1 Security Federated Learning via MEC-Enabled Blockchain Network 166
7.3.1.1 Background 166
7.3.1.2 Blockchain-Driven Federated Learning 167
7.3.1.3 Experimental Results 168
7.3.2 Blockchain-Assisted Secure Authentication for Cross-Domain Industrial
IoT 170
7.3.2.1 Background 170
7.3.2.2 Blockchain-Driven Cross-Domain Authentication 170
7.3.2.3 Experimental Results 172
7.4 Conclusion 174
References 174
x Contents

8 Performance Analysis on Wireless Blockchain IoT System 179

Yao Sun, Lei Zhang, Paulo Klaine, Bin Cao, and Muhammad Ali Imran
8.1 Introduction 179
8.2 System Model 181
8.2.1 Blockchain-Enabled IoT Network Model 181
8.2.2 Wireless Communication Model 183
8.3 Performance Analysis in Blockchain-Enabled Wireless IoT Networks 184
8.3.1 Probability Density Function of SINR 185
8.3.2 TDP Transmission Successful Rate 187
8.3.3 Overall Communication Throughput 189
8.4 Optimal FN Deployment 189
8.5 Security Performance Analysis 190
8.5.1 Eclipse Attacks 190
8.5.2 Random Link Attacks 192
8.5.3 Random FN Attacks 192
8.6 Numerical Results and Discussion 192
8.6.1 Simulation Settings 193
8.6.2 Performance Evaluation without Attacks 193
8.7 Chapter Summary 197
References 197

9 Utilizing Blockchain as a Citizen-Utility for Future Smart Grids 201

Samuel Karumba, Volkan Dedeoglu, Ali Dorri, Raja Jurdak, and Salil S. Kanhere
9.1 Introduction 201
9.2 DET Using Citizen-Utilities 204
9.2.1 Prosumer Community Groups 204
9.2.1.1 Microgrids 205
9.2.1.2 Virtual Power Plants (VPP) 206
9.2.1.3 Vehicular Energy Networks (VEN) 206
9.2.2 Demand Side Management 207
9.2.2.1 Energy Efficiency 208
9.2.2.2 Demand Response 209
9.2.2.3 Spinning Reserves 210
9.2.3 Open Research Challenges 211
9.2.3.1 Scalability and IoT Overhead Issues 211
9.2.3.2 Privacy Leakage Issues 212
9.2.3.3 Standardization and Interoperability Issues 212
9.3 Improved Citizen-Utilities 213
9.3.1 Toward Scalable Citizen-Utilities 213
9.3.1.1 Challenges 213
9.3.1.2 HARB Framework-Based Citizen-Utility 214
9.3.2 Toward Privacy-Preserving Citizen-Utilities 216
9.3.2.1 Threat Model 217
9.3.2.2 PDCH System 219
9.4 Conclusions 220
References 221
 Contents xi

10 Blockchain-enabled COVID-19 Contact Tracing Solutions 225

Hong Kang, Zaixin Zhang, Junyi Dong, Hao Xu, Paulo Valente Klaine, and Lei Zhang
10.1 Introduction 225
10.2 Preliminaries of BeepTrace 228
10.2.1 Motivation 228
10.2.1.1 Comprehensive Privacy Protection 229
10.2.1.2 Performance is Uncompromising 229
10.2.1.3 Broad Community Participation 229
10.2.1.4 Inclusiveness and Openness 230
10.2.2 Two Implementations are Based on Different Matching Protocols 230
10.3 Modes of BeepTrace 231
10.3.1 BeepTrace-Active 231
10.3.1.1 Active Mode Workflow 231
10.3.1.2 Privacy Protection of BeepTrace-Active 232
10.3.2 BeepTrace-Passive 233
10.3.2.1 Two-Chain Architecture and Workflow 233
10.3.2.2 Privacy Protection in BeepTrace-Passive 235
10.4 Future Opportunity and Conclusions 237
10.4.1 Preliminary Approach 237
10.4.2 Future Directions 238
10.4.2.1 Network Throughput and Scalability 238
10.4.2.2 Technology for Elders and Minors 239
10.4.2.3 Battery Drainage and Storage Optimization 240
10.4.2.4 Social and Economic Aspects 240
10.4.3 Concluding Remarks 240
References 241

11 Blockchain Medical Data Sharing 245

Qi Xia, Jianbin Gao, and Sandro Amofa
11.1 Introduction 245
11.1.1 General Overview 248
11.1.2 Defining Challenges 248
11.1.2.1 Data Security 248
11.1.2.2 Data Privacy 248
11.1.2.3 Source Identity 248
11.1.2.4 Data Utility 249
11.1.2.5 Data Interoperability 249
11.1.2.6 Trust 249
11.1.2.7 Data Provenance 249
11.1.2.8 Authenticity 250
11.1.3 Sharing Paradigms 250
11.1.3.1 Institution-to-Institution Data Sharing 251
11.1.3.2 Patient-to-Institution Data Sharing 256
11.1.3.3 Patient-to-Patient Data Sharing 257
11.1.4 Special Use Cases 260
xii Contents

11.1.4.1 Precision Medicine 261

11.1.4.2 Monetization of Medical Data 263
11.1.4.3 Patient Record Regeneration 264
11.1.5 Conclusion 266
Acknowledgments 266
References 266

12 Decentralized Content Vetting in Social Network with

Blockchain 269
Subhasis Thakur and John G. Breslin
12.1 Introduction 269
12.2 Related Literature 270
12.3 Content Propagation Models in Social Network 271
12.4 Content Vetting with Blockchains 273
12.4.1 Overview of the Solution 273
12.4.2 Unidirectional Offline Channel 273
12.4.3 Content Vetting with Blockchains 275
12.5 Optimized Channel Networks 278
12.6 Simulations of Content Propagation 280
12.7 Evaluation with Simulations of Social Network 286
12.8 Conclusion 293
Acknowledgment 293
References 294

Index 297
 xiii

List of Contributors

Nima Afraz Bin Cao

CONNECT Center, Trinity College State Key Laboratory of Networking and
Dublin Switching Technology, Beijing University
Ireland of Posts and Telecommunications
Beijing
and China
School of Computer Science
University College Dublin Volkan Dedeoglu
Dublin Data61, CSIRO
Ireland Brisbane
Australia
Hamed Ahmadi
Department of Electronic Engineering Zhi Ding
University of York Department of Electrical and Computer
York Engineering, University of California
UK Davis, CA
USA
Sandro Amofa
University of Electronic Science and Junyi Dong
Technology of China James Watt School of Engineering
Chengdu University of Glasgow
China Glasgow
UK
John G. Breslin
National University of Ireland Ali Dorri
Galway School of Computer Science, QUT
Ireland Brisbane
Australia
xiv List of Contributors

Jaafar M. H. Elmirghani Raja Jurdak

School of Electronic and Electrical School of Computer Science, QUT
Engineering, University of Leeds Brisbane
Leeds Australia
UK
and
Chenglin Feng Data61, CSIRO
College of Science and Engineering Brisbane
University of Glasgow Australia
Glasgow
UK Hong Kang
James Watt School of Engineering
Jianbin Gao University of Glasgow
University of Electronic Science and Glasgow
Technology of China UK
Chengdu
China Salil S. Kanhere
School of Computer Science and
Xiqi Gao Engineering, UNSW
National Mobile Communications Sydney
Research Laboratory, Southeast University Australia
Nanjing
China Samuel Karumba
and School of Computer Science and
Engineering, UNSW
Purple Mountain Laboratories Sydney
Nanjing, Jiangsu Australia
China
Paulo Valente Klaine
Dongyan Huang James Watt School of Engineering
College of Information and University of Glasgow
Communications, Guilin University of Glasgow
Electronic Technology UK
Guilin
China Yuwei Le
National Mobile Communications
Muhammad Ali Imran Research Laboratory, Southeast University
James Watt School of Engineering Nanjing
University of Glasgow China
Glasgow
UK
 List of Contributors xv

Wenyu Li Marco Ruffini

College of Science and Engineering CONNECT Center, Trinity College
University of Glasgow Dublin
Glasgow Ireland
UK
Olusegun S. Sholiyi
Xintong Ling National Space Research and Development
National Mobile Communications Agency, Obasanjo Space Centre
Research Laboratory, Southeast University Abuja
Nanjing Nigeria
China
Yao Sun
and James Watt School of Engineering
Purple Mountain Laboratories College of Science and Engineering
Nanjing, Jiangsu University of Glasgow
China Glasgow
UK
Weikang Liu
State Key Laboratory of Networking and Subhasis Thakur
Switching Technology, Beijing University National University of Ireland
of Posts and Telecommunications Galway
Beijing Ireland
China
Jiaheng Wang
Kumudu Munasighe National Mobile Communications
Faculty of Science and Technology Research Laboratory, Southeast University
University of Canberra Nanjing
Canberra China
Australia and

Asuquo A. Okon Purple Mountain Laboratories

Faculty of Science and Technology Nanjing, Jiangsu
University of Canberra China
Canberra
Australia Taotao Wang
College of Electronics and Information
Mugen Peng Engineering, Shenzhen University
State Key Laboratory of Networking and Shenzhen
Switching Technology, Beijing University China
of Posts and Telecommunications
Beijing
China
xvi List of Contributors

Qi Xia Lei Zhang

University of Electronic Science and James Watt School of Engineering
Technology of China College of Science and Engineering
Chengdu University of Glasgow
China Glasgow
UK
Hao Xu
James Watt School of Engineering Shengli Zhang
University of Glasgow College of Electronics and Information
Glasgow Engineering, Shenzhen University
UK Shenzhen
China
Bowen Yang
James Watt School of Engineering Zaixin Zhang
College of Science and Engineering James Watt School of Engineering
University of Glasgow University of Glasgow
Glasgow Glasgow
UK UK
 xvii

Preface

Originally proposed as the backbone technology of Bitcoin, Ethereum, and many other
cryptocurrencies, blockchain has become a revolutionary decentralized data management
framework that establishes consensuses and agreements in trustless and distributed envi-
ronments. Thus, in addition to its soaring popularity in the finance sector, blockchain has
attracted much attention from many other major industrial sectors ranging from supply
chain, transportation, entertainment, retail, healthcare, information management to finan-
cial services, etc.
Essentially, blockchain is built on a physical network that relies on the communications,
computing, and caching, which serves the basis for blockchain functions such as incentive
mechanism or consensus. As such, blockchain systems can be depicted as a two-tier archi-
tecture: an infrastructure layer and a blockchain layer. The infrastructure layer is the under-
lying entity responsible for maintaining the P2P network, building connection through
wired/wireless communication, and computing and storing data. On the other hand, the
top layer is the blockchain that is responsible for trust and security functions based on
the underlying exchange of information. More specifically, blockchain features several key
components that are summarized as transactions, blocks, and the chain of blocks. Transac-
tions contain the information requested by the client and need to be recorded by the public
ledger; blocks securely record a number of transactions or other useful information; using
a consensus mechanism, blocks are linked orderly to constitute a chain of blocks, which
indicates logical relation among the blocks to construct the blockchain.
As a core function of the blockchain, the consensus mechanism (CM, also referred to as
consensus algorithm or consensus protocol) works in the blockchain layer in order to ensure
a clear sequence of transactions and the integrity and consistency of the blockchain across
geographically distributed nodes. The CM largely determines the blockchain system perfor-
mance in terms of security level (fault tolerance level), transaction throughput, delay, and
node scalability. Depending on application scenarios and performance requirements, differ-
ent CMs can be used. In a permissionless public chain, nodes are allowed to join/leave the
network without permission and authentication. Therefore, proof-based algorithms (PoX),
such as proof-of-work (PoW), proof-of-stake (PoS), and their variants, are commonly used
in many public blockchain applications (e.g. Bitcoin and Ethereum). PoX algorithms are
designed with excellent node scalability performance through node competition; however,
they could be very resource demanding. Also, these CMs have other limitations such as
long transaction confirmation latency and low throughput. Unlike public chains, private
xviii Preface

and consortium blockchains prefer to adopt lighter protocols such as Raft and practical
Byzantine fault tolerance (PBFT) to reduce computational power demand and improve
the transaction throughput. A well-known example of PBFT implementation is the Hyper-
Ledger Fabric, part of HyperLedger business blockchain frameworks. However, such CMs
may require heavy communication resources.
Today, most state-of-the-art blockchains are primarily designed in stable wired commu-
nication networks running in advanced devices with sufficient communication resource
provision. Hence, the blockchain performance degradation caused by communication is
negligible. Nevertheless, this is not the case for the highly dynamic wireless connected
digital society that is mainly composed of massive wireless devices encompassing finance,
supply chain, healthcare, transportation, and energy. Especially through the upcoming 5G
network, the majority of valuable information exchange may be through a wireless medium.
Thus, it is critically important to answer one question, how much communication resource
is needed to run a blockchain network (i.e. communication for blockchain).
From another equally important aspect when combining blockchain with communi-
cation (especially wireless communication), many works have focused on how to use
blockchain to improve the communication network performance (i.e. blockchain for
communication). This integration between wireless networks and blockchain allows the
network to monitor and manage communication resource utilization in a more efficient
manner, reducing its administration costs and improving the speed of communication
resource trading. In addition, because it is the blockchain’s inherit transparency, it can
also record real-time spectrum utilization and massively improve spectrum efficiency by
dynamically allocating spectrum bands according to the dynamic demands of devices.
Moreover, it can also provide the necessary incentive for spectrum and resource sharing
between devices, fully enabling new technologies and services that are bound to emerge.
The resource coordination and optimization between resource requesters and providers
can be automatically completed through smart contracts, thus improving the efficiency of
resource optimization. Furthermore, with future wireless networks shifting toward decen-
tralized solutions, with thousands of mobile cells deployed by operators and billions of
devices communicating with each other, fixed spectrum allocation and operator-controlled
resource sharing algorithms will not be scalable nor effective in future networks. As such,
by designing a communications network coupled with blockchain as its underlying infras-
tructure from the beginning, the networks can be more scalable and provide better and more
efficient solutions in terms of spectrum sharing and resource optimization, for example.
The book falls under a broad category of security and communication network and their
transformation and development, which itself is a very hot topic for research these years.
The book is written in such a way that it offers a wide range of benefits to the scientific
community: while beginners can learn about blockchain technologies, experienced
researchers and scientists can understand the extensive theoretical design and architecture
development of blockchain, and industrial experts can learn about various perspectives
of application-driven blockchains to facilitate different vertical sectors. Therefore, this
feature topic can attract graduate/undergraduate level students, as well as researchers and
leading experts from both academia and industry. In particular, some blockchain-enabled
use cases included in the book are suitable for audiences from healthcare, computer,
telecommunication, network, and automation societies.
 Preface xix

In Chapter 1, the authors provide an overview of blockchain radio access network

(B-RAN), which is a decentralized and secure wireless access paradigm. It leverages
the principle of blockchain to integrate multiple trustless networks into a larger shared
network and benefits multiple parties from positive network effects. The authors start
from the block generation process and develop an analytical model to characterize B-RAN
behaviors. By defining the work flow of B-RAN and introducing an original queuing model
based on a time-homogeneous Markov chain, the steady state of B-RAN is characterized
and the average service latency is derived. The authors then use the probability of a
successful attack to define the safety property of B-RAN and evaluate potential factors
that influence its security. Based on the modeling and analysis, the authors uncover an
inherent trade-off relationship between security and latency and develop an in-depth
understanding regarding the achievable performance of B-RAN. Finally, the authors verify
the efficiency of the model through an innovative B-RAN prototype.
Chapter 2 theoretically and experimentally analyses different consensus algorithms
in blockchains. The chapter firstly analyses the PoW consensus algorithm. The authors
employ reinforcement learning (RL) to dynamically learn a mining strategy with the
performance approaching that of the optimal mining strategy. Because the mining Markov
decision process (MDP) problem has a non-linear objective function (rather than linear
functions of standard MDP problems), the authors design a new multi-dimensional RL
algorithm to solve the problem. Experimental results indicate that, without knowing
the parameter values of the mining MDP model, the proposed multi-dimensional RL
mining algorithm can still achieve optimal performance over time-varying blockchain
networks. Moreover, the chapter analyzes the Raft consensus algorithm that is usually
adopted in consortium/private blockchains. The authors investigate the performance of
Raft in networks with non-negligible packet loss rate. They propose a simple but accurate
analytical model to analyze the distributed network split probability. The authors conclude
the chapter by providing simulation results to validate the analysis.
Chapter 3 describes a PBFT-based blockchain system, which makes it possible to break
the communication complexity bottleneck of traditional PoW- or BFT-based systems. The
authors discuss a double-layer PBFT-based consensus mechanism, which re-distributes
nodes into two layers in groups. The analysis shows that this double-layer PBFT signifi-
cantly reduces communication complexity. The authors then prove that the complexity is
optimal when the nodes are evenly distributed in each group in the second layer. Further,
the security threshold is analyzed based on faulty probability-determined (FPD) and the
faulty number-determined (FND) models in the chapter. Finally, the chapter provides a
practical protocol for the proposed double-layer PBFT system with a review of how PBFT
is developed.
In Chapter 4, the authors start by introducing the basic concepts of blockchain and illus-
trating why a consensus mechanism plays an indispensable role in a blockchain-enabled
Internet of Things (IoT) system. Then, the authors discuss the main ideas of two famous
consensus mechanisms, PoW and PoS, and list their limitations in IoT. After that, the
authors introduce PBFT and direct acyclic graph (DAG)-based consensus mechanisms as
an effective solution. Next, several classic scenarios of blockchain applications in the IoT
are introduced. Finally, the chapter is concluded with the discussion of potential issues
and challenges of blockchain in IoT to be addressed in the future.
xx Preface

Chapter 5 addresses the issues associated with centralized marketplaces in 5G networks.

The authors firstly study how a distributed alternative based on blockchain and smart
contract technology could replace the costly and inefficient third-party-based trust
intermediaries. Next, the authors propose a smart contract based on a sealed-bid double
auction to allow resource providers and enterprise users to trade resources on a distributed
marketplace. In addition, the authors explain the implementation of this marketplace
application on HyperLedger Fabric permissioned blockchain while deploying the network
using a pragmatic scenario over a public, commercial cloud. Finally, the authors evaluated
the distributed marketplace’s performance under different transaction loads.
In Chapter 6, the authors describe an integrated blockchain and software-defined net-
work (SDN) architecture for multi-operator support in 6G networks. They present a uni-
fied SDN and blockchain architecture with enhanced spectrum management features for
enabling seamless user roaming capabilities between mobile network operators (MNOs).
The authors employ the smart contract feature of blockchain to enable the creation of busi-
ness and technical agreements between MNOs for intelligent and efficient management
of spectrum assets (i.e. the radio access network). The study shows that by integrating
blockchain and SDN, the foundation for creating trusted interactions in a trustless envi-
ronment can be established, and users can experience no disruption in service with very
minimal delay as they traverse between operators.
Chapter 7 investigates and discusses the integration of blockchain and mobile edge
computing (MEC). The authors firstly provide an overview of the MEC, which sinks
computing power to the edge of networks and integrates mobile access networks and
Internet services in 5G and beyond. Next, the authors introduce the typical framework for
blockchain-enabled MEC and MEC-based blockchain, respectively. The authors further
show that blockchain can be employed to ensure the reliability and irreversibility of data
in MEC systems, and in turn, MEC can also solve the major challenge in the development
of blockchain in IoT applications.
Chapter 8 establishes an analytical model for PoW-based blockchain-enabled wireless
IoT systems by modeling their spatial and temporal characteristics as Poisson point pro-
cesses (PPP). The authors derive the distribution of signal-to-interference-plus-noise ratio
(SINR), blockchain transaction successful rate, as well as its overall throughput. Based on
this performance analysis, the authors design an algorithm to determine the optimal full
function node deployment for blockchain systems under the criterion of maximizing trans-
action throughput. In addition, the security performance of the proposed system is analyzed
in the chapter considering three different types of malicious attacks. The chapter ends with
a series of numerical results to validate the accuracy of the theoretical analysis and optimal
node deployment algorithm.
In Chapter 9, the authors examine the factors governing successful deployment of
blockchain-based distributed energy trading (DET) applications and their technical
challenges. The chapter walks through the fundamentals of “citizen-utilities,” primarily
assessing its impact on efforts to manage distributed generation, storage, and consumption
on the consumer side of the distribution network, while intelligently coordinating DET
without relying on trusted third parties. Additionally, the chapter highlights some of the
open research challenges including scalability, interoperability, and privacy that hinder
the mainstream adoption of “citizen-utilities” in the energy sector. Then, to address these
 Preface xxi

research challenges, the authors propose a scalable citizen-utility that supports interoper-
ability and a Privacy-preserving Data Clearing House (PDCH), which is a blockchain-based
data management tool for preserving on-ledger and off-ledger transactions data privacy.
The chapter is finished with outlines of future research directions of PDCH.
In Chapter 10, the authors introduce a blockchain-enabled COVID-19 contact tracing
solution named BeepTrace. This novel technology inherits the advantages of digital con-
tract tracing (DCT) and blockchain, ensuring the privacy of users and eliminating the con-
cerns about the third-party trust while protecting the population’s health. Then, based on
different sensing technologies, i.e. Bluetooth and GPS, the authors categorize BeepTrace
into BeepTrace-active mode and BeepTrace-passive mode, respectively. In addition, the
authors summarize and compare the two BeepTrace modes and indicate their working prin-
ciples and privacy preservation mechanisms in detail. After that, the authors demonstrate
a preliminary approach of BeepTrace to prove the feasibility of the scheme. At last, further
development prospects of BeepTrace or other decentralized contact tracing applications are
discussed, and potential challenges are pointed out.
Chapter 11 looks at the infusion of blockchain technology into medical data sharing. The
chapter provides an overview of medical data sharing and defines the challenges in this
filed. The authors revisit some already established angles of blockchain medical data shar-
ing in order to properly contextualize it and to highlight new perspectives on the logical
outworking of blockchain-enabled sharing arrangements. Then, the authors present three
cases that are especially suited to blockchain medical data sharing. They also present an
architecture to support each paradigm presented and analyze medical data sharing to high-
light privacy and security benefits to data owners. Finally, the authors highlight some new
and emerging services that can benefit from the security, privacy, data control, granular data
access, and trust blockchain medical data sharing infuses into healthcare.
In Chapter 12, the authors propose a blockchain-based decentralized content vetting for
social networks. The authors use Bitcoin as the underlying blockchain model and develop
an unidirectional channel model to execute the vetting procedure. In this vetting procedure,
all users get a chance to vote for and against a content. Content with sufficient positive votes
is considered as vetted content. The authors then optimize the offline channel network
topology to reduce computation overhead because of using blockchains. At last, the authors
prove the efficiency of the vetting procedure with experiments using simulations of content
propagation in social network.

Bin Cao, Lei Zhang, Mugen Peng, Muhammad Ali Imran

August 2021
 xxiii

Abbreviations

3GPP third-Generation Partnership Project

4G fourth generation
5G fifth generation
6G sixth generation
AAS Authentication Agent Server
ABAC Attribute-Based Access Control
ABIs Application Binary Interfaces
ABM Adaptive Blockchain Module
Abstract Abortable Byzantine faulT toleRant stAte maChine replicaTion
ACC Access Control Contract
AI artificial intelligence
API application programming interface
APs access points
BaaS Blockchain as a Service
BAS Blockchain Agent Server
BASA Blockchain-assisted Secure Authentication
BFT Byzantine fault tolerance
BLE Bluetooth low energy
BMap Bandwidth Map
BN blockchain network
BPL building penetration losses
BPM Business Process Management
bps bits per second
B-RAN Blockchain radio access network
BTC bitcoin
CA Certification Authority
CAGR Compound annual growth rate
CAPEX Capital expenditure
CBRS Citizens Broadband Radio Services
CDC Center for Diseases Control
CDF cumulative distribution function
CFT crash fault tolerance
CM consensus mechanism
xxiv Abbreviations

CoAP Constrained application protocol

COVID-19 Coronavirus Disease 2019
CPU Central Processing Unit
DAG direct acyclic graph
DAS distributed antenna systems
DCT digital contact tracing
DDoS Distributed Denial of Service
DEPs Distributed Energy Prosumers
DER Distributed Energy Resources
DET Distributed Energy Trading
DIS Data integrity verification systems
DLT Distributed ledger technology
DoS Denial of Service
DPoS Delegate Proof-of-Stake
DR demand response
DS Directory Service
DSM Demand Side Management
DSO distributed system operator
dTAM data Tagging and Anonymization Module
DTLS Datagram Transport Layer Security
E2E end to end
ECO Energy Company Obligation
EE energy efficiency
EMR electronic medical record
eNBs eNodeBs
ESPs Edge computing service providers
ESS energy storage systems
EV electric vehicles
EVN Electric Vehicle Networks
FAPs femtocell access points
FCC Federal Communications Commission
FDI false data injection
FeGW Femtocell gateways
FiT Feedin Tariff
FL Federated learning
FND faulty number determined
FNs function nodes
FPD faulty probability determined
FSC food supply chain
FSCD fast smart contract deployment
FTTH Fiber-to-the-Home
G2V grid-to-vehicle
Gb/s gigabyte per second
GDPR General Data Protection Regulation
Geth go-Ethereum
 Abbreviations xxv

GPS Global Position System

GTP GPRS tunneling protocol
HARB Hypergraph-based Adaptive Consortium Blockchain
HARQ Hybrid Automatic Repeat Request
HeNB home eNB
HLF Hyperledger fabric
HSS home subscriber server
HTLC hash time-locked contract
HVAC heating, ventilation, cooling, and air conditioning
IaaS Infrastructure as a Service
IBC Identity-based Cryptography
IBS Identity-based Signature
IDC International Data Corporation
IDE Integrated development environment
IFA Dentifier for advertisers
IIoT Industrial Internet of things
IMDs Internet of things/mobile devices
IMEI International mobile equipment identity
IMT International Mobile Telecommunications
InPs Infrastructure Providers
IoT Internet of things
IoVs Internet of vehicles
KGC Key Generation Center
KPIs Key performance indicators
LAN Local area network
LRSig Linkable Ring Signatures
LSA Licensed shared access
LTE long-term evolution
MAC Media access control
MadIoT Manipulation of demand via IoT
MBS Macrocell base station
MCMC Markov Chain Monte Carlo
MDP Markov decision process
MEC mobile edge computing
MIMO multiple-input, multiple-output
MME mobility management entity
MNOs mobile network operators
MOCN multi-operator core network
μOs micro-operators
MSP Membership Service Providers
MSP multi-sided platform
MTT maximum transaction throughput
MVNO Mobile Virtual Network Operator
MW megawatts
Naas Network as a Service
xxvi Abbreviations

NAT nucleic acid testing

NFV Network Function Virtualization
NGN next-generation network
NHS National Health Service
NPI Non-pharmaceutical intervention
ns-3 Network simulator 3
OAMC Object Attribute Management Contract
ODN Optical Distribution Network
OFSwitch open-flow switch
OPEX Operating expenditure
OSN Online Social Network
OTP one time programmable
OTT over-the-top
P2P peer-to-peer
PaaS Platform as a Service
PBFT Practical Byzantine Fault Tolerance
PBN public blockchain network
PCG Prosumer Community Groups
PCRF Policy Charging and Rules Function
PDCH Privacy-preserving Data Clearing House
PDF probability density function
P-GW packet data network gateway
PHY physical
PKI Public key infrastructure
PMC Policy Management Contract
PoD proof-of-device
PONs Passive optical networks
PoO proof-of-object
PoS proof of stake
PoW proof of work
PPP Poisson point processes
QoS Quality of Service
RAN Radio access network
RES renewable energy sources
RL reinforcement learning
RMG relative mining gain
RSRP reference signal received power
RSRQ reference signal received quality
SaaS software as a Service
SAMC Subject Attribute Management Contract
SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2
SBCs single-board computers
SBSs small base stations
SDN software-defined network
SEMC Smart Energy Management Controller
 Abbreviations xxvii

S-GW Serving gateway

SHeNB Serving HeNB
SINR signal-to-interference-plus-noise ratio
SLA service-level agreement
SM supermassive
SPF single point of failure
SPs service providers
SR spinning reserve
SUTs System under tests
Tb/s terabyte per second
TDP transaction data packet
THeNB target HeNB
TNs transaction nodes
TPA Third Party Auditor
TPS transactions per second
TTI transmission time interval
TTP Trusted Third Party
TTT time to trigger
UE user equipment
UE RRC UE radio resource control
URI Uniform Resource Identifier
URL Uniform Resource Locator
UUID Universally Unique Identifier
V2G vehicle-to-grid
V2V vehicle-to-vehicle
vCPUs Virtual Central Processing Units
VEN Vehicular energy networks
VLC visible light communications
VM virtual machine
VNO Virtual Network Operator
VPP Virtual Power Plants
WAN Wide Area Network
WHO World Health Organization
ZKP zero-knowledge-proofs
Discovering Diverse Content Through
Random Scribd Documents
against tuberculosis work, and it is well not to increase it by having a
nurse break down soon after going on duty. In Baltimore, all
applicants are examined by a specialist before they are accepted.
Note that this is done by a specialist, and that the applicant is not
permitted to go to her own “family physician” who may or may not
be able to make a proper examination. The candidate is given a
choice of several specialists, to any one of whom she may go. The
report of her physical condition, mailed to the superintendent,
determines her eligibility from the standpoint of health. In this way,
the responsibility is assumed by those most capable of assuming it,
and neither the health of the nurse nor the prestige of the work is
jeopardized.
After the preliminary examination, it is well for the nurse on duty
to be re-examined every six months. If suspicious symptoms present
themselves, this should be done oftener. Part of the superintendent’s
duties are to watch the health of her workers, and keep a sharp look-
out for suspicious symptoms—symptoms which the nurse herself
may be unaware of or afraid to acknowledge. Each nurse, however,
should assume the responsibility for her own health; she should
remember that she is dealing with a highly infectious disease, and
that it behooves her to keep in as good physical condition as possible.
Nurses with a predisposition to tuberculosis should not undertake
this work.
The question often arises as to whether this visiting work is
suitable employment for arrested cases—for nurses who have had
tuberculosis and recovered. It is not suitable. It is far too hard and
trying, for it must be done day in and day out, at all seasons and in
all weathers, and involves severe physical strain. For that reason it is
not proper occupation for one whose health is in any way precarious.
The danger of relapse is too great. Nor should this work be done by
those who are afraid of tuberculosis. If fear of tuberculosis develops
after a nurse goes on duty, she should be released at once. Under
such circumstances she cannot do good work, while to persuade her
to remain on duty, contrary to her instincts, is a responsibility too
grave for any one to assume.
Hours off Duty. At this point we should like to speak of the
nurse’s hours off duty, though strictly speaking they are not within
our scope. As a rule, the hours on duty are eight—from 9 a.m. till 5
p.m., with an hour in the middle of the day for lunch. This is a long
day, and at the end of it, any woman is in a condition of mental and
physical fatigue. The constant nervous strain occasioned by
contending with the ignorance and stubbornness which a nurse must
encounter, is particularly wearing.
The hours off duty are for recuperation from the day’s toil, and if
this recuperation is insufficient, it will manifest itself in various
ways. A tired nurse is of no use as a teacher—she cannot cope
successfully with the obstinate wills of her patients, nor with the
trying demands of the daily routine. Moreover, a physically tired
person is one who offers ready soil for the development of
tuberculosis. These two facts must be constantly borne in mind.
Therefore we should like to impress upon all nurses who undertake
this work that they must take excellent care of themselves. Rest,
sleep, and food are the three essentials to good health, and any
scheme of life which reduces these below a certain level is bound to
lead to disaster.
No one condemns reasonable pleasures, and in no other work is
relaxation and recreation so much required, but one must be careful
not to burn the candle at both ends. It is no part of the
superintendent’s duties to regulate the life of her nurses outside of
working hours, but when their life off duty diminishes their working
ability, she is then called upon to interfere. Tuberculosis work is
trying, serious, and difficult, and demands a high degree of mental
and physical strength and freshness. If a nurse is not willing to give
this, she should not undertake public health work.
Afternoons Off. Each nurse should be given one afternoon a
week off duty. It is more satisfactory to give this half-day in the
middle of the week, on Wednesday or Thursday, rather than on
Saturday, at the week’s end. In this way, the rest period breaks the
long stretch of days, and the nurse is enabled to rest before she
becomes too tired. Sundays, of course, should always be free. Under
no consideration should the nurse be subject to night calls and it is
well to have this fact understood at the outset of the work. A nurse
cannot be on duty night and day both, and certain rules should be
established, regarding her hours on duty, and be rigidly adhered to.
Character. The questions of training and of health having been
satisfactorily answered, there remains a third great essential to be
considered—the question of personality. Social nursing differs from
all other branches of nursing, since in this specialty there is a wider
departure from the routine and mechanical duties which form so
large a part of nursing work. Those qualities which make a good
institutional, or a good private nurse, do not necessarily make a good
social or public health nurse. Something more is demanded.
Broadly speaking, apart from professional training, the more
highly educated and cultivated the woman, the better will she be
qualified. This, one may say, would apply to all branches of the
profession, but we believe these qualities are more necessary in the
tuberculosis nurse than in the operating-room nurse, for example.
The latter does work which demands mechanical quickness and
coolness; the former requires a personality capable of dealing with
human beings in all stages of refractoriness, over whom she has no
authority, but from whom she is expected to obtain results. As every
one knows, it is far easier to deal with things than with people.
The qualities of a teacher are requisite. No matter how well one
may know a subject, if one cannot present it clearly and impressively,
small progress will be made. Nor is it the patient alone that the nurse
is called upon to deal with. Her activities bring her into close
relations with physicians, social workers, politicians, boards of
directors, and “benevolent individuals” of all classes, whose interest
and good-will it is necessary to secure. She must be as well able to
meet people of this sort, as to teach the humblest patient in her
district.
Since this is social work, the so-called social virtues are a necessity
—and these exclude a bad temper or a quarrelsome disposition. It is
as essential to work in harmony with other social workers as with the
patients themselves—the two relationships are interdependent.
Needless to say, a nurse who cannot get on with her patients is a
failure. No matter how experienced she may be, or how well trained,
if she cannot gain the confidence and friendship of her families she is
unfitted to deal with them. It frequently happens that for the first few
visits a family may be uncordial and suspicious, but within a short
time a well trained, sympathetic nurse should be able to change this
attitude into one of confidence and appreciation. A few, a very few
families remain unchangeable of course, but their number is so small
that they form a negligible quantity.
 Neither should a nurse fraternize with her patients. Through
familiarity she loses the personal dignity which means so much to
her authority. Authority is a term somewhat subtle in its definition—
it means that hint of power, of sureness, of knowledge, which enables
one to speak with a confidence which transmits itself to others, and
compels them to accept one’s point of view. A strong personality
easily conveys this sense of authority, but it may also be conveyed by
a personality less strong, when the nurse is well assured of her facts
and cannot be caught tripping. It is the hall-mark of the successful
teacher—this ability to impress her points upon others, and to make
them see that what she proposes is right, reasonable, and
advantageous.
It seems hardly necessary to speak of the qualities of honesty,
loyalty, and conscientiousness. When they are lacking, all or any one
of them, the nurse is useless. The nurse is alone in her district all day
long, from early morning till late in the afternoon, and she must be a
woman with a high sense of responsibility and worthy of her trust.
Patience, that despised virtue, is also an essential part of the nurse’s
equipment, for she must listen to long details of illness, and must be
willing to reiterate, over and over again, without show of annoyance,
the rules which have been needlessly and exasperatingly ignored. No
one knows better than the nurse the awful hiatus that exists between
preaching and practising—the glib promise and the broken pledge—
but she must never show her irritation. We have known many
excellent nurses who gave up this work because they could not stand
discouragement of this sort, and who had not vision enough to look
into the future for results.
This standard of requirements may seem high, but it is not
impossible. In fact, it is the minimum from which successful work
can be expected. A superintendent who has a choice of nurses will of
course approximate it as nearly as possible, in choosing her staff. The
higher and finer the type of woman, the more valuable she will be—
probably in no other field do fine instincts and fine feeling tell so
strongly.
 CHAPTER III

Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation—
Sick-Leave—Uniforms—Badges.

Salary. A good nurse should command a good salary—she is

worth it. There is a tendency to underpay nurses even at the present
day, because of the tradition handed down from the Middle Ages,
that nursing service should be given largely as a matter of love or
charity. A woman who gives up her whole time to district nursing,
doing highly specialized work, should at the very least receive a living
wage. Associations are often asked to supply nurses at a salary of
forty or fifty dollars a month, and surprise and indignation have been
expressed because such a woman was not forthcoming. Salaries
should be large enough to attract and retain efficient women; a small
salary does not attract desirable applicants, as a rule, and this limits
the field of selection. Large sums are appropriated for hospitals,
sanatoriums, dispensaries, and physicians’ services, but
retrenchment takes place when it comes to the nurse. Her work
seems to be the one point where economy prevails.
In Baltimore, the staff nurses are paid seventy-five dollars a
month, and this is the very least that any woman should receive. A
small town or country community would doubtless have to pay more
than this, especially if it looks to the city for an experienced nurse.
The reason is simple enough—other things being equal and the
character of work the same, one would hardly expect a nurse to
prefer an unknown locality, away from home and friends, unless
some extra inducement were offered. A nurse might be willing to
organize work in a small city, at a low salary, for the sake of the
experience. In that case, it is the experience which offers the
inducement. This once gained, however, she would shortly be in a
position to demand more salary or seek a wider field of service.
Increase of Salary. The question constantly arises whether or
not it is well to increase the salary of the staff nurse from year to
year. If she enters the work at seventy-five dollars a month for the
first year, is it well to increase this to eighty dollars a month for the
second year, eighty-five dollars the third, and so on till a definite
maximum has been reached? To this question there are two answers.
Undoubtedly a nurse becomes more valuable as her experience
ripens. Her first six months on duty are largely spent merely in
acquiring rudimentary knowledge concerning her work. As she
learns to know her district, her patients, the doctors, the institutions,
the social workers, her value to the community increases. Each
succeeding year, therefore, which increases her knowledge of social
conditions, should make her in so far more valuable. It would seem
but just, under these conditions, that her remuneration should be
raised accordingly. But at this point there enters a factor which we
must recognize. To specialize in tuberculosis work makes peculiar
demands upon one’s strength. Quite apart from the physical strain,
which is always great, it demands the expenditure of a vast amount
of nervous force, required in the constant combat with opposition.
For this reason it is peculiarly wearing and exhausting. Also, by its
nature, it tends to become monotonous. These two factors—one of
which tends to wear out the individual, the other to make her
indifferent and stale—make us hesitate to say that the nurse’s value
keeps increasing year after year. It undoubtedly does increase up to a
certain point, but after that point has been reached, it tends to
diminish. Such being the case, the obligation of raising the salary is
debatable.
Two kinds of nurses are usually found on the staff. One is the
ambitious nurse, who comes for the experience and training, to fit
herself for an executive position elsewhere. To such a woman, the
routine of field work will not be desirable for long—not for more than
a year or two, or until she has gained enough experience to prepare
herself for a wider field of service. That point being reached, her
executive ability will seek an outlet in work where she herself may
become the organizing and directing force. To such a nurse, salary
increase will offer no inducement, since she will seek that increase
through work which provides greater opportunities and
responsibilities.
There is another sort of nurse on the staff however, who has no
such ambition; no executive ability, no desire to occupy any other
than a subordinate position. This one will never venture into a
position of responsibility, such as her experience might warrant, but
prefers instead the easier path, choosing to be guided rather than to
guide. She prefers to work under direction, rather than to direct
others. To such, an increase in salary would seem but a just reward
for faithful service. But, as we have said before, the monotony of
tuberculosis work tends to produce stale workers. There is danger,
after a time, that the first alertness and energy may wear off, the
nurse may settle down into a rut, and her daily task, though faithfully
performed, tends to become one of mechanical routine.
One of the chief duties of the superintendent is to train new
nurses, and she should renew the personnel of her staff whenever the
welfare of the work demands a change. Sometimes, when a nurse
shows flagging energy and interest, sufficient stimulus may be given
by removing her to another district, where she will encounter new
patients and new problems, and so regain her old keenness and
ability. When one once becomes thoroughly tired of this work,
however, it is unwise and futile to attempt to continue it. Therefore,
in the interest both of the nurse and of her work, it does not seem
wise to offer inducements for prolonged service, unless the
individual characteristics of any given nurse make this wholly
desirable.
Carfare. In addition to salary, a reasonable sum of money should
be allowed for carfare. This allowance should vary in accordance with
the territory to be covered, those nurses who visit in smaller areas
naturally having a smaller allowance for the purpose. While economy
in this matter is always necessary, it must be remembered that undue
economy in carfare is wasteful of something still more important,—
the nurse’s time and strength. If she is obliged to walk long distances
between cases, this will greatly reduce the number of visits she can
make in a day. Moreover, she will spend so much energy in mere
walking that she will become too tired for effective teaching. Only
fresh, energetic people can teach; those who are physically tired are
apt unconsciously to let the obstinate patient have his own way.
 Transportation. In small towns and country districts the
problem of transportation is often a difficult one. There are either no
street cars, or their service is very restricted and inadequate. Under
such circumstances it will be necessary to provide the nurse with a
horse and runabout, especially if she is expected to cover a large
territory. Unless there is proper provision for transportation, it will
be impossible for her to visit the patients often enough to make any
impression,—her teaching will be laid on too thin to have much
value. And to depend upon haphazard, volunteer offers of
transportation is almost as bad as to expect her to make her rounds
on foot. She should be given proper facilities for going from case to
case, and should be able to plan a day’s work unhampered by any
considerations as to if or how she can reach her patients.
Telephone. In making up the budget of necessary expenses, a
reasonable sum should be set aside for telephone calls. The nurse has
constant occasion to communicate with doctors, institutions, social
workers, and so forth, and this item of expense should not come out
of her own pocket. A careful weekly account of all expenditures,
including telephone calls and carfare should be rendered by her.
Vacation. A vacation of at least one month should be given
during the year. Less than a month is not sufficient time in which to
recover the physical and nervous energy expended during the rest of
the year. This holiday should be taken all at one time, rather than
split up into shorter vacations, taken at intervals throughout the
year. We all know that a week or two is not sufficient time in which
to restore a thoroughly tired person; at the end of such a short
period, one is just beginning to feel rested, and there has been no
margin left over for amusement, which is a necessary part of all
holidays.
Strong emphasis must be laid on the fact that if a nurse expects to
return to her work and continue it successfully for another year, she
should use this vacation as a means of fitting herself for another
year’s close contact with an infectious disease. She should return to
work thoroughly rested, with her resistance increased by rest and
recreation, not lowered by injudicious use of this time off duty.
Sick-Leave. While a nurse is supposed to be sufficiently well and
strong to go on duty every day, in all weathers and at all seasons of
the year, a reasonable allowance for illness should nevertheless be
made. Two weeks’ annual sick-leave is a good allowance. If a woman
is off duty for longer time than that, needless to say her work must
suffer and her patients must be neglected. If a nurse is constantly off
duty for small ailments, this shows that she is not strong enough to
undertake this arduous work. A fixed allowance for sick-leave,
therefore, will tend to work automatically, and will eliminate the
unfit, whose burden of work is otherwise added to that of the steady
working members of the staff.
In the case of acute illness, such as typhoid fever or appendicitis, it
would be perfectly possible to appoint a substitute until the nurse
was able to resume her duties. If no time has been taken off for sick-
leave during the year, the two weeks should be added to the time
granted for vacation. If exceeded during the year, the salary for every
day thus lost should be deducted from the monthly salary. This
procedure may seem harsh, but with a large staff it is necessary. It
places a double incentive on keeping well, and nurses who would
otherwise have been thoughtless and careless as to their health, will
take excellent care of themselves, in order not to lose one day of their
coveted vacation.
In Baltimore, the municipality gives two weeks’ vacation, and two
weeks’ sick-leave. If the sick-leave is unused, a reasonable vacation is
the result.
Uniforms. The question as to whether or not a nurse shall wear a
uniform is one which usually excites much discussion. The one or
two disadvantages of such a dress are more than offset by the
numerous reasons in its favour. Two objections are usually raised to
wearing it: by the nurse, because it makes her conspicuous; and by
the patient, because the uniform makes him a target for neighbourly
gossip.
Let us consider the first objection, that made by the nurse. A nurse
does not feel conspicuous when on duty in her district. Her busy,
daily routine, taking her in and out of homes where she is needed,
soon causes her to forget her personal appearance. A self-conscious
woman is hardly the right sort for this work. The only rub comes
when she is off duty and going to and from her district, but this
cannot be held to constitute a serious objection.
As for the patient’s objection—he would be equally conspicuous if
regularly visited by any woman unknown to the neighbourhood, no
matter how attired. Prying eyes would recognize her as an alien, and
the neighbours would speculate accordingly. We have often heard of
patients who for fear of what the neighbours would say objected to
being visited by agents of the Charity Organization Society. Yet the
agents of that Organization wear no sort of uniform. The truth is, it is
usually really the visit itself which is objected to, rather than the
costume of the visitor—the costume merely serving as an excuse. On
analysing the objections of a group of patients who disliked the
uniform, they were found to be, without exception, patients who
strongly resented every suggestion made to them. Their one desire
was to be let alone, to be as careless as they chose.
On the other hand, the advantages of the uniform are many. In the
first place, all effective care given to a consumptive has to include
nursing as well as teaching. Now, one can “educate” in a woollen
dress, but one certainly cannot give bed-baths in anything but a
cotton dress, which can be plunged into a tub and washed. And
whether she enters the home to give a bed-bath, or whether she goes
in merely to distribute prophylactic supplies, the fact remains that a
nurse spends some eight hours a day in contact with an infectious
disease. Good technique demands that she be dressed in washable
material.
In summer, a dress of washable material is not conspicuous. In
winter, it may be covered with a long coat. And if we admit that such
a dress is necessary, what objection can there be to making it of
simple and uniform design? A single nurse so arrayed looks neat and
business-like; a staff of nurses looks equally so. Moreover,
uniformity of dress suggests uniformity of method, standard, and
character of work, and hence inspires confidence. A staff of nurses,
each one dressed according to the hazard of her own fancy, would
hardly create the same impression.
In itself, the uniform is a protection to its wearer. It enables her to
go freely and without molestation into all kinds of tenements and
lodging houses, into side alleys and back streets. The well-known
dress surrounds her with recognition, affection, and respect.
The uniform is also of value to the patients and to their friends. It
enables them to recognize the nurse as she passes, and to call upon
her as she goes by.
 The uniform worn in Baltimore consists of a plain shirtwaist suit,
worn with white linen collar and black necktie. The dress is made of
blue denim, such as is used for overalls. Denim of this sort has two
sides, a light and a dark; the dress is made up with the light side out,
as in washing it seems to “do up” better than the darker side. Black
sailor hats are worn, and in winter long, dark coats protect the
dresses. This uniform is not necessarily the last word as to what a
uniform should be, but it is simple and inexpensive, and the nurses
look well in it.
Badges. The staff of a municipal nursing force is usually provided
with badges to denote that they are connected with the Health
Department. These badges should never be worn conspicuously,
although they should be readily accessible. They are only
occasionally needed, however, as when entering some lodging or
rooming houses, or houses of prostitution, or other places where
there may be marked opposition. To show them when entering a
private home would be bad policy. A nurse usually enters a private
house as a friend, but a public house she is sometimes obliged to
enter in her official capacity. In dealing with all her patients,
however, no matter where they are situated, the less show made of
officialdom the better. By the time her patient finds out that she is
connected with the Health Department, she should be already firmly
established as his friend, and then the discovery will have no terrors.
Indeed, at that stage, it very often enhances her value, and patients
often feel intense pride at being visited by the “city nurse.”
 CHAPTER IV

Object of Work—Districts—Hours on Duty—Number of Daily Visits—The

Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic Supplies—
Cups, Fillers, and Napkins—Disinfectant—Waterproof Pockets—Books of
Instruction—Stocking the Bag and Distributing Supplies—Nursing Supplies.

Object of Work. The object of tuberculosis nursing is the home

supervision of all persons suffering from pulmonary tuberculosis.
This supervision should include patients in all stages of the disease,
and not be limited to those who are in some particular stage, such as
early, in contradistinction to advanced, cases. No organization which
expects to do effective work should deal with one class of patients
alone, since the boundary lines between the different stages are
constantly shifting; the ambulatory case of to-day may be the bed-
ridden case of to-morrow, and vice versa, and any attempt to limit
the nurse to one class or the other would mean neglect of both.
Unless the work is planned on such inclusive lines, it will be
necessary to place a second organization in the field, to care for those
cases which have been thrown out by the first. Policy of this sort
would mean a number of similar organizations, duplicating and
overlapping each other’s work at every turn. Thus, in the same
household, we should see the early, ambulatory patient “advised” by
the nurse of one organization, while the advanced, bed-ridden, more
infectious case is being bathed and cared for by the nurse from
another. Invidious comparisons would doubtless be made by the
family, with the decision in favour of “deeds, not words.” True, there
would be co-operation between these two societies,—which would
mean, as a rule, double work, duplication of visits, endless
transferring of cases backwards and forwards, and opening and
closing of records. From whatever point of view we consider it, this is
a very poor plan of work, and a wasteful method. The nurse should
be in a position to follow the fortunes of her patients for months and
years. Any scheme which involves transferring him to a stranger,
from an old friend to a new, at the moment when he slips from an
early into a most infectious stage, is to lose sight of him and of his
family at a most critical time.
Adequate supervision means that the nurse must teach, nurse, and
ferret out patients, and her patients must include advanced, early,
and suspicious cases. The care should be of two kinds—instruction as
to the nature of tuberculosis, with general teaching along the lines of
prevention and prophylaxis; as well as actual nursing service,
rendered to advanced and bed-ridden cases. The Baltimore nurses
take charge of all tuberculous patients, in whatever stage, and we feel
that this is the most effective way to carry on the work.
Districts. A small town, of course, constitutes but one district in
itself. A larger town may be divided into two or three districts; a city,
into as many as may be necessary. The principles upon which the
work is conducted are the same in each case. The nurse is
responsible for every consumptive in her district, and her constant
endeavour should be to bring under supervision every case of
tuberculosis that exists. She must visit all patients referred to her—
give them instruction, prophylactic supplies, and nursing care;
unearth suspicious cases and send them to a physician for diagnosis;
secure hospital or sanatorium treatment for those who are eligible,
and arrange all details connected with their admission. To
accomplish these duties, she must know the physicians of her
district, the dispensaries and institutions where she may send her
patients, the philanthropic or relief-giving agencies whose aid is so
often needed, and all social workers whose co-operation is necessary
for the furtherance of the work in hand.
Hours on Duty. Eight hours should constitute the working day,
from eight or nine in the morning, till four or five in the afternoon.
With a large staff, the day will probably not begin till 9 A.M., while a
single nurse, in a small community, may prefer to begin earlier and
so finish earlier, especially in summer. It is a mistake to work
overtime, no matter how interested and enthusiastic one may be. A
peculiarity of tuberculosis work is its unending character—there is
always more to do than can be crowded into the longest day, and
even after working ten, twelve, fourteen hours, one would always feel
that some important thing was being left undone. It is well to
recognize this fact in the beginning, although the temptation to make
“just one more” visit is often hard to resist. The nurse who habitually
works overtime only wears herself out the faster, and in the end her
patients will suffer through her loss of health and energy.
Number of Daily Visits. This is a variable factor, and depends
in great measure upon the size of the district, as well as the number
of patients it contains. The character of the service rendered also
determines the number of visits, as new patients and bed-ridden
patients always demand considerable time. If a nurse calls on ten
patients in a block, and finds none of them in, she naturally can
make more visits than when compelled to spend a long time in each
house. As in everything else, it is the quality that counts, rather than
the quantity; the day which shows few visits may have been spent
more profitably than that on which she scored a high total. There is
no general rule as to a nurse’s capacity, yet it is always well to suspect
the value of a large total of daily visits; if a nurse dashes in and out of
a house, spending but a few moments with her patients, she has
probably done her work so superficially that nothing has been
accomplished.
On the other hand, some nurses pay far too few visits because they
have no head for planning their work, but linger, past all necessity,
over unimportant details. To judge if a district is being properly
visited, the superintendent should know the district, and she should
also know her nurse’s capacity. To estimate the value of the day’s
work by the number of visits alone, is like those societies who reckon
their value by the number of pieces of literature they distribute,
totally regardless as to whether any of it bears fruit.
Roughly speaking, each patient should be visited once a week;
failing this, once every ten days or two weeks. In a few exceptional
instances, this time between visits may be still further extended, but
this should happen only when the patient is doing extremely well,
following all the rules, and giving efficient and intelligent co-
operation. There are not many patients in this class—for the average,
supervision to be adequate must be frequent.
Very ill patients, however, must be seen two or three times a week
—every day would not be too often, did the work permit.
Unfortunately, if the visiting list is large, these sick patients can be
visited only at the expense of other cases better able to take care of
themselves. For this reason, the visits to ambulatory patients may
become as infrequent as once every three weeks. If the visiting list
grows so large that these infrequent visits are all that the nurse can
give, then her instruction is laid on so thin as to be nearly worthless,
a condition of affairs which calls for another nurse.
The Nurse’s Office. An office is a necessity for the nurse as a
place where she may keep her nursing and prophylactic supplies, and
at which she will report at certain hours of the day, say at 9 A.M., at
lunch time, and possibly again in the afternoon before going off duty.
At certain specified hours, therefore, it will be possible to reach her,
either in person or by telephone, and her office hours should be
known to doctors, social workers, patients, or to any who have need
to call upon her. In a small town or country district, there will of
course be only one office, but in a city it will be necessary to have
several branch offices, accessible to the nurses of the different
districts. These branch offices should be situated on the border lines
of two or three adjoining districts, so that one office may be used in
common by several nurses. In a city there is also the central office,
from which the superintendent directs the work, and where the staff
nurses report daily.
In Baltimore[2] these branch offices are usually in the same
building which houses a branch of the Federated Charities, the
branch office of the Visiting Nurse Association, the Infant Welfare
Association, and other similar agencies. In this way, the various
social workers learn to know each other, and to secure close co-
operation and understanding. The different agencies, however, each
have their separate rooms or offices.
2. Baltimore is divided into sixteen nursing districts, with eight branch offices
or sub-stations, for the use of the sixteen nurses.
The nurse’s office should be simply but comfortably furnished. It is
used for several purposes—as a store room for supplies, and as a rest
room, where she takes her lunch and spends an hour off duty in the
middle of the day. The furniture should consist of a large writing
table, which may also be used for a dining table; chairs, a lounge or
couch, and a small gas stove or Bunsen burner for cooking simple
meals. If there is no available closet, there will have to be a
commodious cupboard for storing the prophylactic supplies. A large
stock of these must always be kept on hand, so that the nurse may
refill her bag before starting out again on her afternoon rounds. A
telephone in the office, or at least in the same building, is of course
necessary.
Lunch and the Noon Hour. It is not within the province of a
superintendent to dictate to her nurses as to what they shall eat. The
association, be it private or municipal, furnishes the office and the
hour, but the nurse must provide her own lunch and select it
according to her fancy. A word, however, in regard to this lunch. It
should be as nourishing as possible, and should consist of such
wholesome food as eggs, milk, cocoa, and so forth. If a nurse
substitutes a pint of milk for a cup of tea or coffee, she is wise.
In addition to nourishing, wholesome food (in contradistinction to
unprofitable pie and buns from the neighbouring bakeshop), a short
period of relaxation on the lounge or couch is a wise way in which to
spend a portion of the noon hour. In dealing with tuberculosis, food
and rest are necessary to keep one strong and well, and no nurse can
afford to trifle with her health when engaged in this serious work. On
no account should the noon hour be cut short, no matter how little
tired she may be. Better work can be done if one is well fed and
rested.
Bags. The association which employs the nurse should also
provide her with the bag for carrying the supplies. The kind of bag
needed is a much discussed question. It should be strong, even
though this necessitates its being heavy. There is no other way out of
it—for unless the bag has the first qualification, strength, the weight
of the supplies will soon wear it out. Very light bags are not practical.
The bags used in Baltimore are made somewhat like the ordinary
Boston bag, about fourteen inches long, and of good black leather.
They weigh a few more ounces than those used by other associations,
but they last longer. It must also be remembered that the bag used by
the tuberculosis nurse, no matter how heavy it is when she starts
forth on her rounds, grows lighter and lighter as she goes from house
to house, leaving the supplies. Thus, at the end of the day, when she
is most tired, it is practically empty.
Prophylactic Supplies. The prophylactic supplies used for the
patients consist of tin sputum cups, cardboard fillers, paper napkins,
waterproof pockets, disinfectant, and books of instruction. The first
three are of primary importance. The Health Department of a
community usually provides these supplies, even when the nursing
work is carried on by a private association. Thus, in Baltimore, where
for six years the tuberculosis work was done by the Visiting Nurse
Association, an arrangement was entered into between this
Association and the State Board of Health, according to which, the
latter paid for and provided the supplies which the nurses
distributed. The only condition imposed was that each case should be
reported to the Health Department, and that the Health Department
should be constantly advised as to the number of cases under
supervision. If no such arrangement is possible, then the private
association supporting the nurse must be put to the additional
expense of buying the supplies.
It is impossible to make the patients themselves pay for them.
Naturally, they consider them a nuisance and a bother, and it is
difficult enough to persuade them to use them, even when given free.
The cost is not great, however.

Tin sputum cups, (in lots of 5000) 7 cents apiece.

Fillers, (in lots of 1,000,000) $3.50 per thousand.
Paper napkins, (in lots of 5,000,000) $.55 per thousand.
Disinfectant, 10 cents a bottle.
Waterproof pockets 4 cents apiece.
Books of instruction 2 or 3 cents apiece.

Disinfectant. The most expensive of the supplies is the

disinfectant, which is also probably the least valuable. That used in
Baltimore is a special preparation, consisting largely of creolin; it is
put up in pint bottles by one of the large wholesale drug houses. For
use, it is diluted in water, a tablespoonful to a pint, and used in
wiping up floors, furniture, and so forth. It is of necessity too dilute
to have much germicidal action, and the patients place far too much
reliance upon its odor—which, to the ignorant mind, is of prime
importance. Although we use this disinfectant, we prefer to teach our
patients that better results may be obtained by the lavish use of hot
water, brown soap, and a scrubbing brush, and that thorough
cleaning of this kind is of more value than the most malodorous drug
ever dispensed. Disinfectant to be of real use must be strong and
powerful, and it is dangerous to distribute such powerful drugs
promiscuously. Several of our patients have tried to commit suicide
by drinking even the weak preparation that we gave them. On the
whole, we believe that an anti-tuberculosis society would lose
nothing by omitting disinfectant from its list of prophylactic
supplies, and better results could be obtained by substituting a
thorough grounding as to the value of soap and water.
Waterproof Pockets. These are little calico bags, dipped in
paraffin, or some similar preparation which makes them fairly
waterproof. These are pinned inside the coat pocket, and the patient
uses them as a receptacle for his soiled napkins, when he is out on
the street, or in other places where he cannot carry his sputum cup.
The napkins are burned upon his return.
Books of Instruction. These little books are more or less
valuable, but are by no means intended to take the place of the verbal
instruction which it is the nurse’s duty to give. They serve merely to
refresh the memory after she has gone. They can be procured at
small cost through the various anti-tuberculosis organizations, and
most Boards of Health print them for their own distribution. The
best of them are inadequate.
Stocking the Bag and Distributing Supplies. When the
nurse starts forth on her morning rounds, her bag should contain
enough supplies for the patients she proposes to call on. Each should
be given enough to last until her next arrival. It is sometimes possible
to direct either the patient himself, or some member of his family, to
come to the office and get a fresh stock whenever necessary. By
putting this slight responsibility on the family, it is made to realize
how necessary are these supplies, but it should not relieve the nurse
of her obligation to visit such a household, and keep it under as close
observation as any other case. If a nurse thus trains a certain number
of patients to come themselves for the supplies, she will be able to
reserve the contents of her satchel for those patients who cannot call
for them, or who are too indifferent to do so.
Supplies should always be given out freely, and the patient should
not feel that he is put under any obligation by accepting them. They
are intended for his personal use and convenience, and he should be
made to realize this. Otherwise, some patients may hesitate to accept
all that they really need. If a patient needs four or five fillers a day, he
should unquestionably have them—otherwise he may practise small
economies which will mean unnecessary exposure for his family. On
the other hand, the nurse must see that the supplies are used for the
purpose intended—we have sometimes known handkerchiefs used as
a decoration for kitchen shelves, simply because the nurse had given
away far more than was necessary.
Nursing Supplies. In addition to the prophylactic supplies, the
bag also contains a number of articles used in caring for bed-ridden
or very ill cases. Naturally, these articles are not given to the patients,
but are used from case to case, as necessity arises. They include a
bottle of alcohol, boracic ointment, talcum powder, gauze, adhesive
strapping, absorbent cotton, and a thermometer. The nurse should
always carry an apron, to be worn when doing any nursing work.
The most common dressing is that of bedsores; many patients with
pleurisy have to be strapped; others have drainage tubes, which must
be taken out and cleaned. These extensive dressings are not those
which the nurse should properly be required to attend to, since a
patient ill enough to require an extensive dressing, is a patient who
should be sent to a hospital. Hospital accommodation, however, is
unfortunately very limited, and the nurse is often obliged to do these
dressings while waiting for a vacancy to occur. It is no part of the
programme to keep these advanced cases at home rather than in an
institution; on the contrary, the nurse must make every effort to get
them away—but until this can be accomplished, it is her duty to care
for them at home.
 CHAPTER V

Records and Reports—The Patient’s Chart—Closing the Chart—The Card Index

—Nurse’s Daily Report Sheet—Weekly and Monthly Reports—Examination
of Charts.

Records and Reports. Every association, whether it be private

or municipal, supporting one nurse or fifty, should keep careful
records concerning its patients, and concerning its nurses’ work.
These two sets of records should dovetail and form a cross file; by
looking at the patient’s chart, one should be able to note the
condition of each individual case, and how often and on what dates
he was visited. By looking at the nurse’s record, one should be able to
know exactly how she had employed every moment of her day, and to
see the number of patients she had visited during the course of it.
The patients’ charts account for the patients—the nurse’s daily report
accounts for her work among them.
The Patient’s Chart. Each patient should have a chart made out
for him at the moment when he is taken on the visiting list. This also
applies to suspects, or those for whom the diagnosis is not positive,
but whom the nurse is required to visit and care for. This also applies
to those moribund patients, who may live but a few hours after being
reported, and who die before a second visit can be made. Whether he
has been on the list a year or an hour, it is necessary to account for
every patient who passes under supervision, and to record the result
in each case. Unless this is done, accurately and promptly, it will be
impossible to estimate the amount of work, and its value to the
community.
The patient’s chart should contain name, sex, age, colour, address,
occupation, social status (married, single, or widowed), and a brief
history concerning the onset and progress of his disease. These
charts may be as simple or as elaborate as one desires. Herewith is
submitted a specimen chart, such as are used in Baltimore; they are
not perfect, nor the acme of all that is or might be desirable in a
record of this kind, but they have proved simple and fairly
satisfactory. There is much left out which with advantage might have
been added, but in this connection it is well to remember that an
elaborate and exhaustive history, one demanding dozens of intimate
details, is apt to alarm the patient excessively. To collect exhaustive
statistics would be valuable for the sociologist, but to do so at the
expense of the patients’ confidence and trust would be to defeat the
object of the work itself.

Patient’s Chart. Cardboard, five by eight inches

 Reverse side of Patient’s Chart, showing spaces for recording
visits. The Second Chart Sheets are similar to this, but alike on
both sides

The reverse side of this chart contains spaces in which each visit
may be recorded. Sometimes these charts are kept up for months and
years, and it is therefore necessary to have what are called second
sheets—alike on both sides, and resembling the reverse side of the
first sheet, which contains the patient’s history. These sheets are
fastened together, and the chart of a chronic case may thus record
hundreds of visits. Each nurse is responsible for keeping up the
charts of all patients under her supervision. The notes should be
carefully recorded at the end of each day’s work, for it is bad policy to
let this charting accumulate for even two or three days. The entries
should be brief and concise, and should describe the patient’s
condition, or the work done for him.
Each nurse should have a filing box or drawer in which to keep
these charts; they should be arranged in alphabetical order, and kept
at the central office, where the superintendent may have ready access
to them. These charts are the property of the association, and under
no circumstances are to be removed from the central office. The
nurse may make her entries upon them either at the end of the day’s
work, or before she goes on duty the next morning.
 Closing the Chart. Patients are removed from the visiting list
when they die, or when they are discharged. They are discharged
only for one of three reasons—either they leave the city, or they move
and their address is lost, or they prove not to be tuberculous. When a
patient dies or is discharged, a suitable entry is made on his chart,
which is then turned in to the superintendent of nurses, or to
whomever is responsible for the records. If there is only one nurse, it
is of course her duty to file these closed histories. These records
should be rich mines of sociological information, and should contain
valuable material for those who have access to them, such as
municipal authorities, physicians, and social workers. Except for the
access allowed to these, the files should be confidential.
The Card Index. All offices should contain a card index, giving
the name and address of each patient under supervision. Change of
address should always be noted, since it is only by means of this card
index that the particular chart desired can be referred to. For
example: the card index contains the names of some 3000 cases, all
under supervision, and each one having its own chart. The charts
themselves, however, are distributed among the filing boxes of
several nurses. If particulars are wanted concerning John Doe, it
would be necessary to turn first to the card index, find his address
and the district in which he lives, and then turn to the filing box of
that district and take out the chart. If it were not for the card index, it
would be necessary to search through all the filing boxes before
finding the desired chart.
 Card, three by five inches, used in Card Index

As the discharged charts are handed in, the corresponding card in

the index is withdrawn and filed away in a drawer containing either
the dead or the discharged cases according to circumstances. This is
a very simple way of keeping records, and of balancing from day to
day the number of patients on the visiting list. This balance may be
made every week or every month, as desired, for it is a simple
method and reduces to a minimum the opportunities for mistakes in
addition and subtraction. Needless to say, no one but the
superintendent or her secretary should have access to, or touch these
files in any way.
Nurse’s Daily Report Sheet. Beside the patients’ charts, the
nurse must fill in a day sheet, or daily report of her work, to be
handed to the superintendent, or to whomever she is responsible.
This sheet accounts for her time and occupation all through the day.
Beginning with the time she goes on duty in the morning, she will
record each visit to each patient, the service rendered, and the time
spent on him. She will also record the time she reached her office for
lunch, and the time she left it for her afternoon rounds, also the hour
at which she went off duty for the day. A record of this kind means
additional clerical work, but how else is the nurse to account for her
day? And be it noted, it is always a satisfaction to the nurse to place
on record the summary of her day’s work.
 Nurse’s Daily Report Sheet,
seven by nine inches

This daily report sheet is of great value to the superintendent:

without it, there is no way in which she can estimate either the
quality or the quantity of each nurse’s work. A glance at the report
will show whether the day has been light or heavy; it will show the
number of new patients and ill patients, and how many bed-baths
and dressings were given; how much time was spent in calling on
doctors, dispensaries, social workers, and so forth, and arranging
houses for fumigation. In short, a record of this kind shows the day’s
work at a glance, and is the only way in which it can be satisfactorily
accounted for, and if necessary verified.
 Day Sheet, used for summarizing
the day’s work. From this sheet
the weekly and monthly reports
are made out

True, this information may be obtained by going over the charts

one by one, and verifying the records made upon them. But this is a
clumsy and laborious way of doing it. If a nurse has two hundred
charts in her box, and pays fifteen visits a day, it would be necessary
to search through the whole boxful of charts in order to find the
fifteen cases visited. A day sheet therefore, is not only a simple and
practical way of recording a day’s work, but it is a protection both to
the nurse and the work itself.
Weekly and Monthly Reports. From her daily report sheet,
the nurse should make up a weekly or monthly report, to be turned
in at specified intervals. This weekly or monthly balance sheet should
be presented to the superintendent, or to the officers of the
association to whom the nurse is responsible. Herewith is given a
sample of the monthly report cards used in Baltimore, but again
attention is called to the fact that these are not the last word in
desirability. In using them as models, they would of course be altered
to meet local needs or conditions, and enlarged or changed to suit
other requirements. These monthly reports should be carefully filed
away; they are needed for the construction of the annual report, and
it may be necessary to refer to them on other occasions.

Card, four by six inches, used for summarizing the weekly and
monthly reports

Examination of Charts. One of the duties of the superintendent

is to examine the patients’ charts from time to time, to see how well
the nurses do the clerical work, which is quite as important as the
visiting itself. By carefully examining the charts, the superintendent
is able to call the nurse’s attention to any lapses in them—incomplete
histories, long intervals between visits, and so forth. If, for any
reason, the nurse allows considerable time to elapse between her
visits to a patient, the reasons for this should be fully noted on his
chart. For example: some one wants to know when Mrs. Jones was
last visited. On looking at the chart, we find the last visit was made
on June first—and it is now August first. A two-months’ gap between
visits looks like careless and inattentive work. The nurse, being
questioned, however, is able to give a satisfactory explanation—Mrs.
Jones had gone to pick berries, leaving the city the first of June, and
not due to return till the first of September. This important fact,
however, should have been noted on the chart, since it is almost as
careless not to have made this entry, as it would have been to neglect
the patient for so long a time. If a chart is to have any value, it should
tell its own story, briefly and clearly.
These charts, therefore, should be examined every two or three
weeks. It is the duty of the superintendent to go over these records,
just as it is her duty to make rounds from time to time among the
patients, and visit them in their homes. This is done by the
superintendent, not in a spirit of distrust or suspicion, but because
she is the person responsible for the work, and it is her duty to
oversee it, and bring it to its highest degree of efficiency.
 CHAPTER VI

Finding Patients and Building up the Visiting List—Increasing the Visiting List—
Social Workers—Dispensaries—Patients’ Family and Friends—Nurses’
Cases—Physicians.

Finding Patients and Building up the Visiting List. The

first thing for a nurse to do when she begins her work in a new
community is to find the patients she is to instruct and care for. And
the question naturally arises; how are these patients to be
discovered?
The campaign of propaganda concerning the need of tuberculosis
work has aroused the interest of people of all classes. The funds to
support the nurse are evidence of this. But the people who pay the
bills are not those who can produce the patients. To get in touch with
the patients, it is necessary to approach people of another class,
those whose work brings them in contact with the very poor. For, as
a rule, in beginning tuberculosis work, it is only patients of the
poorest class who find their way to the nurse’s visiting list. Later, as
the work becomes more firmly established, and better known and
understood, her visiting list will include not only the poor, but those
in well-to-do and comfortable circumstances.
The Board of Managers of the new association may interest
themselves in finding the patients, but in the end it is the nurse
herself upon whom this responsibility rests. Upon her initiative and
ability depends the success of the work. Her first step, therefore,
should be to call upon all those who can in any way be of service, and
who can direct her to the patients she is anxious to reach. She should
call upon the physicians of the community, the dispensaries and
hospitals (if there are any), social workers, such as the agents of
charitable associations; priests, clergymen, and all those who come
into contact with the suffering and the destitute. Her visits should be
made in person, since a personal interview makes a stronger appeal
to the memory of the busy man than the most convincing letter or
the most eloquent report. This involves one great reason why the
nurse should be thoroughly equipped in character and training; the
colourless, uneducated, unconvincing woman carries with her no
conviction, and inspires no confidence either in herself, or in what
she proposes to do. A physician may well hesitate about turning over
his patients to a woman who is unable to put her case before him.
It may be that considerable time will thus have to be spent in
calling upon all those likely to know of tuberculous patients, and
therefore able to furnish the nurse with the necessary names and
addresses. That the response is not great should cause no
discouragement. As we have said elsewhere, the tuberculosis death-
rate, multiplied by five, will give a conservative estimate of the
number of tuberculous individuals in a community. It is the nurse’s
duty to unearth them. They exist—she must find them, and the
greater the obstacles, the greater the incentive to overcome them.
The total result of a two or three weeks’ campaign may be a mere
handful of cases reluctantly handed over by a few physicians, and a
few undiagnosed suspects, reported by an earnest priest. In this way
the visiting list is begun.
Increasing the Visiting List. To increase the visiting list—that
is, to bring under her care an increasingly larger proportion of the
total number of tuberculous patients, even though the list becomes
so large and unwieldy that she cannot manage it, should be the
ambition of every tuberculosis nurse. At present, in every city in the
country, there is so much undiscovered and unreported tuberculosis,
that the failure of the nurse to increase the visiting list is an
indication of poor work, not an indication that a full round-up has
been made of all those suffering from this disease. This is especially
true in a new community; a small or stationary visiting list is a sure
sign, not necessarily of lazy or unconscientious work, but at least that
the undertaking is being managed by someone who does not know
how.
To illustrate this: A nurse is sent to a certain house, to see a
specified patient. She does her work well—gives him a bed-bath,
shows the family what to do, and makes considerable impression