The last Florence Nightingale minisode: Observations

Michelle: Well, we have come to the end of the book, notes on Nursing by Florence Nightingale. Again, I want to thank my brother, Dr Chris Patty, for the loan of this book and, more importantly, his brotherly mentorship. Over the course of my life, I interviewed him on this podcast, and in case you missed his episode, I will link it in the show notes. We are at one of the last chapters, titled Observation of the Sick. I feel like Florence should have started with this chapter because as we all start out learning to be nurses in school, we start with our observations and our assessments. We start with what is normal, and what is abnormal. So I think it's interesting that this is in the very back of the book, but nonetheless, it's important. So let's get to it.
 Florence starts this chapter by saying, the most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, what symptoms indicate improvement, what the reverse, which are of importance, which are of none, which are of evidence of neglect, and what kind of neglect. Florence is essentially describing the first step in the nursing process, which came from Ida Jean Orlando, a nurse theorist in 1958, and which, you may recall, has five sequential steps: assessment, diagnosis, planning, implementation, and evaluation. And in case you need a refresher on the nursing process, like I did, I will link that in the show notes. Florence says there is no more silly or universal question scarcely asked than this: is he better? She says, what you want are facts, not opinions. And as a kid, I watched a lot of Dragnet, basically because my older brothers did. And one of the detectives, Joe Friday, will be forever immortalized as saying, just the facts, ma'am. And the first step toward making a good assessment or an observation is to ask the right questions. She said leading questions are useless or misleading. And she gave an example. She says, has he had a good night? Now, one patient will think he has had a bad night if he has not slept 10 hours without waking, and another does not think he had a bad night if he has had intervals of dozing. Occasionally, the same answer has actually been given as regarded to two patients. And why cannot be the question asked, how many hours sleep has he had? And what hours of the night? Her commentary takes us exactly to this point. Nurses need to ask open-ended questions. So instead of, how is your appetite? We should say, tell me what you've eaten today. Florence says nurses can cultivate good assessment skills. And she gives an example of this in a story. A man challenges his young son to a contest in order to give him a ready habit of accurate observation. Every day they walk by a toy store window and do a visual intake for a few minutes of the different toys on display. Then they walk around the corner, take out paper and pencils, and write down as many toys as they remember. Then they return to verify their accuracy. The boy always won. If the father identified 30, the boy did 40. And if you've ever attended a baby shower or a bridal shower, you've likely played this game. But it's true, and nurses can use this to their benefit. And then Florence says one final thing about this. I have often thought how wise a piece of education this would be for much higher objects. And in our calling of nurses, the thing itself is essential. For it may safely be said not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion. And then, if you cannot get the habit of observation one way or another, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be. Next, Florence goes on to talk about the power of observation and statistics. Now, anyone who knows anything about Florence Nightingale knows that in addition to being a nurse, she was also a statistician. And I'm going to link in the show notes a wonderful PubMed article titled Evidence-based, Medicine and Hospital Reform: Tracing Origins Back to Florence Nightingale. It highlights the contributions Florence made to evidence-based medicine. And this is a paper written by a medical student and a plastic surgeon from the University of Michigan Health System and was published in the Journal of Plastic Reconstructive Surgery in 2010. I add these details because I get sentimental, knowing two physicians are applauding the contributions of a nurse. But Florence talks about averages, and she says averages seduce us away from minute observation. Average mortalities merely tell us that so many percent die in this town and so many in that per annum. But whether A or B will be among these? The average, of course, does not tell. We know, say, that from 22 to 24 per 1000 will die in London next year. But minute inquiries into conditions enable us to know that in such a district, nay, in such a street, or even on one side of that street, in such a particular house, or even on one floor of that particular house, will be the excess of mortality. That is, the person will die who ought not to have died before old age. So good observations are critical to the success of a nurse, and not just skill, but the ability to communicate the observations made to the provider. And we, as nurses have many tools at our disposal to be able to do just that. Florence talks about the importance of physician-nurse communication. And you may remember in episode nine, I talked with my longtime friend and colleague, Dr. Christine Nelson, a pediatric hospitalist, and we discussed just how important physician-nurse communication is. In case you missed that episode, I'll link it in the show notes. But a widely used tool for effective communication is SBAR, which stands for Situation, Background, Assessment, and Recommendations. About physician-nurse communication, Florence says, I have often seen really good nurses distressed because they could not impress the doctor with the real danger of their patient, and quite provoked because the patient would look either so much better or so much worse than he really is when the doctor was there. The distress is very legitimate, but it generally arises from the nurse not having the power of laying clearly and shortly before the doctor, the facts from which she derives her opinion, or from the doctor being hasty and inexperienced and not capable of eliciting them. A man who really cares for his patients will soon learn to ask for and appreciate the information of a nurse who is at once a careful observer and a clear reporter. And I love how the nurse is always a female and the physician is always a male. But that was then, and thankfully, times have changed. Seriously, though, Dr. Nelson said this very thing in our discussion. She said, one of the frustrations to me is that some nurses are not comfortable bringing up issues with docs, and obviously some docs make themselves unapproachable as well, and that's a very real thing. But sometimes nurses are timid enough or insecure enough that they're not willing to stick their necks out and take a stab at, hey, I'm worried about such and so, or, what do you think about this? We need to be able to raise our hands to each other and say, something's wrong here. My gut tells me I don't know what it is, but something tells me that something's wrong. I'm uncomfortable with whatever, whether it's the diagnosis, the treatment plan, all of those things. Yes, Dr. Nelson, observations and assessments are crucial, but communicating your observations is just as critical. Next, Florence talks about superstitions. And as nurses, we all have superstitions, but this is what she says almost all superstitions are owing to bad observation to the post hoc, ergo proctor hoc. I love a good Latin phrase, but it means, after this, therefore, because of this, she says farmers used to attribute disease among cattle to witchcraft. Weddings have been attributed to seeing one, magpie deaths to three. And I have heard the most highly educated nowadays draw consequences for the sick. Closely remembering these got me thinking about some of the superstitions we have in nursing and how Florence says they might be related to our bad observations. I'm going to dispute Florence's opinion here. And this is why, for example, saying the Q word, we've all done it at least once in our careers, and we've suffered the consequences. One day in the NICU, we had very few patients, and as a new charge nurse, I walked in, looked around, and said, wow, where are all the babies? It's going to be a quiet day. We then proceeded to have seven admissions, the most ever that I experienced in a twelve-hour shift. By the end of the day, my coworkers were shooting daggers at me, and it's safe to say I have never uttered the Q word again. Another widely held superstition by labor & delivery, NICU, and postpartum nurses is that things get crazy during full moons and storms. And we believe that because we've actually experienced a surge of premature births and women going into spontaneous labor. And there are some studies that have actually backed this up. Florence's last words on the power of observation and what they are actually for are as follows in dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. And that's why, as nurses, we do what we do to save lives and promote health. Well said, Florence. Well said. Remember back to the first Nightingale minisode, Who is Florence Nightingale? In my introduction of Florence, I said that she was a feminist, and I stated my definition of a feminist as someone who advances the rights and the causes of women. And I think Florence did just that. She left us a footnote about this, and here it is. I would earnestly ask my sisters to keep clear of both the jargons now current everywhere of the jargon, namely, about the rights of women, which urges women to do all that men do merely because men do it and without regard to whether this is the best that women can do and because this is women's work and that is men's. And these are things which women should not do, which is all assertion and nothing more. Surely woman should bring the best she has, whatever it is, to the work of God's world, without attending to either of these cries. And as a wise man has said, no one has ever done anything great or useful by listening to the voices from without. You want to do the thing that is good, whether it is suitable for a woman or not. Leave these jargons and go your way straight to God's work in simplicity and singleness of heart. Florence didn't listen to the popular opinions of her day, and she didn't listen to the voices from without. She didn't accept that this is how people live or this is how hospitals are run. She had a strong inner voice that guided all she did. She was the very embodiment of her words, you want to do the thing that is good, whether it is suitable for a woman or not. And nurses are seen as the most trusted profession for over 20 years now, simply because we do what Florence emulated so well, for us to do what's good and what's right. 
It has been so much fun to bring Florence to you over the months, and I hope you have learned as much about Florence as I have in this process. Please let me know which nurse you'd like to hear about next. Will it be Clara Barton, the founder of the Red Cross? Or maybe Mary Breckenridge, who founded the Rural Healthcare and Frontier Nursing service in 1881? Let me know your thoughts. You can always find me on Instagram @theConversingNursePodcast as well as on my website, The Conversingnursepodcast.com. Thanks and I will see you soon.