Nursing Leadership & Essence of Nursing

T he essence of nursing It’s time to put basic nursing care back in the spotlight. By Melissa A. Fitzpatrick, MSN, RN, FAAN n health care today, technological advances grab headlines while clinicians’ documentation duties mount almost daily. Is basic nursing care receding into the background? Recently, American Nurse Today’s Editorial Advisory Board (EAB) had a spirited discussion on the current state of nursing and patient-care delivery. We concluded we need to shift the focus back to basic nursing care. Hence, the special supplement you’re now reading—The Essence of Nursing: Advancing the Art and Science of Patient Care, Quality, and Safety. So what is the essence of nursing? It’s what some people call “high-touch” nursing, where the nurse has plenty of face-to-face time and a personal connection with patients and their families. In a sense, the essence of nursing I 2 The Essence of Nursing May 2015 is the very heart of nursing. During our discussion, EAB members shared examples of extraordinary nurses who’ve had a significant impact on patient outcomes and the patient-family experience. We also shared anecdotes in which nurses didn’t behave like the compassionate, competent caregivers we all aspire to be. This dichotomy underscored our belief that nurses need to get back to the basics— to living and breathing the essence of nursing in every patient encounter to realize the full potential of our profession. Certain characteristics and competencies set nursing and nurses apart from other professions and practitioners. As EAB members discussed the essence of nursing, we asked each other: What’s distinctive about a nurse’s DNA? How does that distinction manifest when it comes to providing safe, high-quality patient care? How can nurses deliver the essence of nursing to its fullest extent possible—especially when caring for such vulnerable patients as low-birth-weight infants and elderly adults? What factors or circumstances enable or prohibit nurses from doing this? In today’s fast-paced, high-acuity, multidimensional, and penalty-driven healthcare delivery system, it’s crucial that we find answers to these and related questions. Nursing presence The nurse is the key to providing safe, effective, and compassion- ate care at both the individual and organizational levels. Nursing Leadership & Essence of Nursing

Despite the rapidly changing healthcare environment, one constant remains: The nurse, in a collective sense, is the healthcare professional who’s with the patient and family 24/7/365. The nurse creates and nurtures an intimate bond with the patient and family through a constant presence and hands-on care. She or he gets to know the patient and family better than any other healthcare provider, learning their wishes, fears, capabilities, and challenges. It’s the nurse in whom the patient confides in the middle of the night and to whom the patient’s loved ones turn for information, support, and solace. When a patient experiences overt distress or deteriorates suddenly, the nurse is likely to be the first one on the scene, initiating rescue procedures. More often than not, it’s the nurse who detects subtle changes in vital signs or behavior that signal a serious or life-threatening event. The literature tells us that when nurses have the right preparation and are present at the right place and the right time, patient outcomes improve. In collaboration with interdisciplinary colleagues, nurses’ highly skilled, competent, compassionate care can help prevent the patient’s functional decline, eliminate knowledge deficits for the patient and family, and promote their engagement in health care. www.AmericanNurseToday.com Presence and vigilance are key elements of the essence of nursing. But along with the privilege of being “the one who’s there” comes a tremendous responsibility and accountability. Nurses are, and always have been, the patient’s first and last line of defense. Keeping the patient safe from preventable adverse events—such as falls, pressure ulcers, infections, and immobility complications—are high on nurses’ priority list as they manage and coordinate the patient’s care to ensure safe passage through the care-delivery system. Spotlighting basic nursing care This supplement puts basic nursing care back in the spotlight where it belongs by: • revisiting key elements of • • • patient care, updating them in the context of today’s healthcare environment emphasizing the nurse as the patient’s sentinel, who protects the patient from injury and acts quickly when potential danger arises stressing the nurse’s role in marshalling appropriate resources to ensure optimal patient outcomes highlighting the significance of nursing observation and evaluation of the patient. Where the topic of technology arises in this supplement, the authors make it clear that its most important role is to support the decision making of nurses and other clinicians. Although technology can help improve patient care, it also can distract us from basic care. If we get caught up in technology, we can www.AmericanNurseToday.com lose sight of the higher purpose of health care. The essence of nursing and the organization Many of the indicators that drive a healthcare organization’s performance, profitability, and image in the community it serves hinge on how well its nurses practice the essence of nursing, The essential elements of nursing care are crucial in reducing lengths of stay, cost per case, adverse events, and litigation. Nurses have a measurable and significant impact not just on safety, quality, and economic outcomes but also on patient satisfaction and engagement, as shown in scores on Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Nursing Leadership & Essence of Nursing

Who better than the nurse to coordinate the many disciplines involved in a patient’s care? To consider the multiple facets of the patient-family dynamic when exploring care needs across the care-delivery system? Effective nursing care is critical in preventing readmissions and ensuring that patients successfully navigate the many hand-offs that occur during their stay. With today’s focus on quality and cost and the financial penalties of suboptimal care, validating and quantifying nurses’ impact and recognizing their value to healthcare organizations and communities at large is crucial. As we work to enhance the patient experience and promote care across the continuum, our ability to uphold the essence of nursing will make or break our efforts. Recipe for success The essence of nursing encompasses a fundamental set of in- gredients that serves as the “recipe” for success at many levels—the individual patient and family experience, an organization’s success as measured in outcomes and costs, and the health of our nation and the global community. Multiple factors influence how successfully this recipe turns out: • Everyone involved must un- • • derstand what it takes to create an environment that fosters full expression of the essence of nursing. Healthcare organizations must learn and replicate best practices that validate, appreciate, and recognize the essence of nursing. This, in turn, helps raise the standard of patient care while nurturing nursing staff and making their work more satisfying. The art of nursing must coexist with today’s technology-driven, evidence-based science of nursing. To ensure such coexistence, nurses must manifest the essence of nursing in every patient and family encounter. To a large degree, the future of healthcare delivery hinges on our ability to optimize the work of nurses and enable them to practice the essence of nursing. We believe this supplement gives you the tools you need to achieve that optimization and the power that comes with it. c Selected reference Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931):1824-30. Melissa A. Fitzpatrick is vice-president and chief clinical officer at Hill-Rom and a member of the Editorial Advisory Board at American Nurse Today. May 2015 The Essence of Nursing 3 Teaching-Learning Processes The Empty Carriage: Lessons in Leadership from Florence Nightingale Nursing Science Quarterly 24(1) 21­–25 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318410389068 http://nsq.sagepub.com Marge Hegge, RN; EdD1 Abstract Florence Nightingale made a profound statement about leadership when she returned from the Crimean War without the fanfare offered to her. Promoters paraded her empty carriage around the city of Southampton England to applaud her accomplishments in the war. Her absence signaled a new leadership, one of quiet determination, humility, and political strategy to improve quality of life. The lessons to be learned for today’s nurse leaders revolve around mindfulness, clarity of purpose, reverence for human life, collaborative partnerships, co-evolution, engagement, keeping up with a world in motion, and making meaning. Nursing Leadership & Essence of Nursing

Keywords Florence Nightingale, humanbecoming, leadership, nursing theory, Parse The Story Of The Empty Carriage Imagine standing amid a throng of spectators on a sunny morning in October 1856 as a ship from the Crimean Peninsula docks at Southampton, England. This signals the official end of the ghastly Crimean War. The gangplank lowers. A large wooden Russian built carriage with waterproof hood and curtains rolls off the ship into the streets. A voice through a megaphone announces that this carriage, drawn by two black horses carried the heroine Florence Nightingale throughout battle fronts in the Crimean War. Cheers explode. The voice continues telling stories of the Lady with the Lamp, who is inexplicably missing. In fact, no one knows where she is. A coach without a heroine is still an occasion for celebration of a war ended and some soldiers safely returned home, although far fewer than were left buried at Scutari. Life has returned to normal after the national nightmare of the Crimean War. Florence Nightingale was a national hero as the Crimean War ground to a halt in 1856. Over 30 songs had been written about her. She was featured in poetry as the Lady with the Lamp. William Russell, a war correspondent, made sure that her accomplishments were publicly lauded in the London Times. Returning soldiers told touching stories of her healing presence during tortured nights. Everyone knew what she had carved out of the chaos of incompetent, uncoordinated military operations. She had elevated the status of the soldier to one worthy of respect, dignity, and caring. She had given birth to the nursing profession as a respectable vocation for women. Queen Victoria publicly acknowledged her with the Order of Merit, never before bestowed to a woman. Yet with all these accolades, Miss Nightingale was distressed and unfulfilled, believing she had not done enough to stem the tide of disease and death at Scutari. She mourned the troops who had died needlessly. She blamed the military establishment for not expediting their care, or supplying the hospital with essential provisions to relieve their suffering (Bostridge, 2008). Rejecting an offer of three military bands and a parade to welcome her home to England, Miss Nightingale assumed the anonymous identity of Miss Smith arriving unannounced, walking the last miles to her home alone, exhausted. She shrank form public appearances, as she declared herself an invalid confining herself to her apartment. Yet, her accomplishments had only begun. Unhampered by her illness (chronic brucellosis) or immobility, she founded a nursing school, a midwifery school, a district nursing program for public health and undertook workhouse reform. She spearheaded military hospital reform and sanitation initiatives in India. She consulted with hospital personnel in Canada, America, New Zealand, Australia, and Germany. She wrote over 14,000 letters and 20 books, the most influential being Notes on Nursing (Nightingale, 1860). She was a selftaught expert in spirituality, statistics, and hospital design (Bostridge, 2008). The large horse drawn carriage in which she traveled throughout the Crimean Peninsula was left behind at Scutari when she departed. When packing cooking utensils, Alexis Sayer, the Scutari chef, noticed the abandoned carriage and 1 Distinguished Professor, South Dakota State University Downloaded from nsq.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016 22 Nursing Science Quarterly 24(1) Figure 1. Florence Nightingale’s carriage.  Nursing Leadership & Essence of Nursing

Note. Printed with permission. realized at once, its deep significance. Nightingale had traveled to battle fronts in this carriage to investigate delays in transport of wounded soldiers. This coach had carried her into danger, conflict with military officials, and endemic disease zones. This carriage had conveyed her prostrate ravaged body, near death during the peak of Crimean Fever in 1855 (Bostridge, 2008). Alexis had the carriage shipped back to England. The empty carriage arrived at Southampton where the mayor paraded it around city streets as a visible surrogate for the real heroine, Florence Nightingale, who was strangely absent. Throngs of people lined the streets to view the spectacle. Confetti and streamers added to the festivities. Cheers carried the joyous relief of the end of a victorious war, as well as a nation’s gratitude for the Nightingale nurses who eased suffering and comforted dying soldiers. When Nightingale heard of this empty carriage parade, she was livid. She sent a stable boy to retrieve the carriage and lock it in the stables at Embley Park where it remained hidden in the dark for 14 years (Bostridge, 2008). Nursing Leadership & Essence of Nursing

The carriage was eventually given to the Nightingale nursing school at St. Thomas Hospital where it was damaged by Nazi bombs during the Second World War. The carriage was restored and transferred to the Army Medical Services Museum in Mytchett, Surrey where it now resides. Why was Nightingale so repulsed by public accolades? Perhaps Nightingale was making a political statement by her absence. Her presence might have cast the spotlight on her, rather than the urgent social justice issues she sought to ameliorate. Her absence may have been a more powerful tool in raising public awareness. The empty carriage spoke volumes about her commitment to a cause and her altruism. Her call from God was to serve others. Her spiritual advisor, Madre Laure de Ste Colombe in Rome cautioned her to ensure that any glory be given to God, not to her (Bostridge, 2008). Nightingale published several works anonymously. She remained in the shadows of the military commission to overhaul war zone hospitals, while carrying the bulk of the responsibility for reporting accurately. Nightingale was not necessarily a humble person, she charged into situations with supreme confidence and authority. She had to work at shunning the limelight. When asked by a royal personage to loan a few Scutari artifacts and her portrait for public display, she refused, claiming this would be tantamount to idolatry. She finally agreed to send a several hundred page report she had penned on sanitary conditions in India to focus public attention on injustices there as leverage for political changes to correct them. These were rejected by officials as being of insufficient interest to the public (Bostridge, 2008). Scutari veterans pooled their small funds to hire a sculptor to create a bust of her, but she allowed only this one, in homage to the soldiers. At her request, she was buried quietly in a country cemetery, her family rejecting an offer of a state funeral and burial at Westminster Abbey. Her gravestone has only her initials and the date (Bostridge, 2008). Lessons On Leadership From The Empty Carriage Story Nightingale had a massive and clear vision, which was to improve the quality of life for soldiers whose care was deplorable during the Crimean War. She knew the work of nurses was never finished. There were always conditions to be improved, people needing care, systems clamoring to be reformed. Each required energy to overcome obstacles impeding change. She believed nurses should not be diverted from this important work by public adulation. “Every nurse must grow, no nurse can stand still, she must go forward or she will go backward every year” (Nightingale, as cited in Dossey, Selanders, Beck, & Attewell, 2005, p. 274). “We are only on the threshold of nursing” (Nightingale, as cited in Bostridge, 2008, p. 442). “Were there none who were discontented with what they have, the world would never reach anything better” (Nightingale, as cited in McDonald, 2008, p. 554). Nursing Leadership & Essence of Nursing

Lessons on Vigilance •• Mindfulness: Focused concentration is required to increase choices and opportunities. Vigilant watchfulness, attention to the newly visible, and a yearning for the unexpected enable observations of a larger universe (Wheatley & Kellner-Rogers, 1996) Urgent patience is needed to see clearly what is before you, what is wanting to emerge (Kotter, 2008). Present moment awareness enables flexibility to thrive in times of turmoil (Cashman, 1998). •• Clarity of purpose: A crystal clear purpose and the integrity to follow through to achieve that purpose are essential to the evolution of a new reality (Wheatley & Kellner-Rogers, 1996). Acting from a deep sense of purpose in all domains enables leaders to achieve meaningful transformation (Cashman, 1998). Downloaded from nsq.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016 23 Hegge •• Humanbecoming leading-following model: “Vigilant attending is cautiously witnessing” (Parse, 2008, p. 371). “Commitment to a vision is being passionately present with something of value” (Parse, 2008, p. 371). Because Nightingale had such a deep reverence for human dignity, she believed celebrating human suffering, death, and calamity was wrong, especially when caused or worsened by the blunders of those in charge of military hospitals. Ravages of war were real, leaving grieving families, broken dreams, and shattered hope. The cost of human suffering was diminished by cheering parades, Nightingale thought. “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm” (Nightingale, as cited in Woodham-Smith, 1951, p. 226). “I stand at the altar of murdered men and while I live, I fight their cause” (Nightingale as cited in Woodham-Smith, 1951, p. 181). Nursing Leadership & Essence of Nursing

Lessons on Reverence •• Reverence for human life: A deep abiding reverence for human life is a cornerstone of theories of human caring. Parse’s theory of humanbecoming (2010) raises reverence emanating from unconditional love as a solemn regard for human presence. •• Humanbecoming leading-following model: “Revering others is honoring uniqueness” (Parse, 2008, p. 371). People need a hero in times of turmoil. They create mythology to stabilize turbulence, but their expectations of a perfect hero can be daunting. No one person can achieve landmark reform in isolation. Nightingale’s network of influential political, military, and royal supporters kept her momentum going, despite fierce opposition. She did not want to take credit for the work of her devoted colleagues. “Let whoever is in charge keep this simple question in her head (not how can I always do this right thing myself, but) how can I provide for this right thing to be always done” (Nightingale, 1860, p. 24). “Let us each and all realizing the importance of our influence on others, stand shoulder to shoulder and not alone in the good cause” (Nightingale, as cited in Dossey et al., 2005, p. 266) Lessons on Collaboration and Coevolution •• Partnerships: “No one forges ahead indepen … Nursing Leadership & Essence of Nursing