IN A 2008 BIOGRAPHY, Florence Nightingale: The Making of an Icon, author Mark Bostridge observed that any aspiring chronicler of Nightingale has to struggle not to be buried in the details. Describing Nightingale as a prolific writer and a compulsive autobiographer, he remarked that the ordinary reader will never peruse all of Nightingale's 14,000 day-to-day “notes,” the 200 books she authored, and countless letters.1 But even a sampling of her writings showcases her brilliant power of contemplation and grasp of detail, products of practiced reflections and revelations of an examined life and nursing career.
Nightingale's Notes on Nursing, published in 1860 and still in print today, is one of the finest examples of masterful reflection on the art of nursing and perhaps the first official reference for quality professional nursing—long before best practices became the standard. This article takes a look at Nightingale's practice of self-reflection and how nurses today can infuse it into their practice.
“It is a much more difficult thing to speak the truth than people commonly imagine.”
Reflection as a conscious, dynamic process of thinking about, analyzing, and learning from clinical experience helps a nurse gain insight into self and practice.2 It's long been considered essential for building competence and professional comportment in nursing education.3 But even though much has been written on reflection as an educational tool, specific information and research on its sustained use by direct care nurses is limited.2
One important tool in reflection is narrative thinking in the form of storytelling.4 Nightingale's prodigious writing on reforming healthcare and elevating the stature of the nursing profession attests to her lifelong practice of narrative reflection. Benner informs us that through the comingling of reflection and experience, ethical expertise is born.5 This is also known as reflection-on-practice, which, one could argue, was pioneered by Nightingale.
Handoffs between nurses during shift change is one recurring occasion when nurses may use reflection-on-practice. For example, a nurse may think, “I can't understand my patient, he doesn't speak any English. It's making my job a lot harder.” This is an opportunity for shared reflection on the challenges of providing culturally competent care. Although the practice of reflection is often private and not explicitly shared, the mutual thinking through of a situation during handoff allows nurses to engage in shared reflection. This strategy helps nurses feel less isolated and powerless when faced with a practice dilemma.6 If nurses can discuss a problem, the mutual contemplation of the situation lets them engage in shared reflection and may help them resolve the problem.
In her research, Tanner found that reflection-on-practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.4 For example, Nightingale's work during the Crimean War was complicated by a massive breakdown of communication and the misjudgment of military officers in charge of a catastrophic health disaster.1 It comes as no surprise that she turned to self-reflection for solace amid incalculable misery—her patients' and her own. She lamented, “Exposed as I am to be misinterpreted and misunderstood, in a field of action in which the work is new, complicated, and distant from many who sit in judgment upon it...”1 This resonates with a modern-day nurse's observation of a practice breakdown.
Reflective practice is a means of self-examination that involves contemplating what happened in practice in order to improve or encourage professional growth.7 It's viewed in the literature as a central tenet of professional practice and a mechanism for continued professional development.8 In other words, to reflect is to grow and thrive in the nursing profession. When Nightingale wrote that “...the very elements of nursing are all but unknown,” perhaps she was admonishing future nurses to be open-minded and prepared to embrace lifelong learning.9
Two styles of reflection
Reflective skills are developed and cultivated over a nurse's lifetime. Both personal and professional experiences inevitably impact the way nurses reflect on their practice.
According to Tanner, a nurse reflects in one of two styles: reflection-in-action or reflection-on-action.4 In the moment a nurse is providing care to a patient, the nurse is reflecting-in-action by “reading the patient” and evaluating the patient's responses. The nurse may modify his or her actions based on the clinical interface. Nurses may not be aware that they're reflecting, as this form of reflection is often unconscious or intuitive; however, it may become noticeable when a practice breakdown occurs.
Reflection-on-action is what a nurse does after the fact.10 Schön called this activity reflection-on-action because it involves distancing oneself from the situation and conducting a self-debriefing on what occurred in practice.10 Reflection-on-action is a contemplative strategy for nurses to engage in ongoing clinical knowledge development and ethical comportment.5
Tips for self-debriefing
In general, nurses' reflections tend to focus on situations when nursing performance is substandard. When nursing performance excels, the occasion often passes unnoticed and without reflection.8 Self-reflection requires a balanced contemplation of all practice-based experiences. Dewey, a pioneer in reflective practice research, described this process as the “turning over of a subject in the mind and giving it serious and consecutive consideration.”11 The focus of the reflection may not only be on what could have been improved, but also on affirming the positive actions of both individual nurses and the team. Contextualizing practice breakdowns based on a fair and reflective analysis of the situation helps minimize blaming and promotes proactive solutions.
As a starting point in contemplation or writing down reflections, a nurse may wish to use guide questions:
- What did I believe guided my actions (or inactions) at the time?
- What do I think guided my actions as I think back now?
- What knowledge informed my actions?
- Did I possess the knowledge required in this situation?
- What values or ethical standards guided my actions?
- Were my actions harmonious with the situation? How so?
- What aspects of the situation influenced my actions?
- Were my intentions in agreement with the patient's goals?
- Why did I carry out the actions in the way I did?
- Did I get the outcomes I wanted in this situation?12
Journaling, diary writing, letter writing, and private blogging are some of the avenues for narrative reflection. Whatever medium is used, remember that it may be available to the public. Be sure to take precaution and follow the American Nurses Association guidelines for protecting patient confidentiality when using social media.13 Protecting a patient's privacy is a priority for healthcare professionals. Breaching a patient's trust is an ethical consideration and a violation of the Health Insurance Portability and Accountability Act (HIPAA). In publishing a reflection, the nurse shouldn't break the hard-earned public trust that they command from their patients. If a nurse does happen to reveal private information about a patient, he or she will face hefty consequences set forth under HIPAA.
Another challenge when reflecting, however, is delineating chatter from the contextual contemplation to debrief one's experience after a disagreeable or laudable patient care contact. For example, reflection must not be used as a forum for gossip. If a breach in practice was noted, self-introspection on meaningful solutions is in order. If the nurse or a colleague did the commendable or the “extra-ordinary” then write a celebratory reflection.
The literature states that written reflection is a higher form of purposeful reflection.4 Writing reflectively isn't an innate process and requires mindfulness and practice. In this age of “tweeting,” nurses may say that no one has the time for lengthy narrative reflection. But can one truly reflect in 140 characters? Meaningful reflection takes time and care, which is an antithesis to society's current obsession with speed and efficiency. Theoretical guides for reflection-on-practice may be helpful; however, simply being introspective and aware of one's thoughts and feelings is a vital first step.4,8
Reading the reflections of others
Those who don't wish to write their reflections may still quietly contemplate by reading the reflections of others. Engaging in purposeful reflection on Nightingale's Notes on Nursing is a good place to start. Her practical advice based on her experiences as a nurse and as a lifelong patient still rings true today. When she wrote “...don't let the patient be wearily waiting for when you will be out of the room or when you will be in it,” she anticipated by more than a century the present-day focus on customer service and patient satisfaction in healthcare.9 In what might be considered a prelude to evidence-based practice, she wrote, “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.”9 Ultimately, informed and contextual reading of Nightingale's work helps nurses establish a more patient-centered focus.
Bostridge's biography of Nightingale gives readers a glimpse at the imperfections of the iconic founder of modern nursing.1 Reflecting on Nightingale's fallibility will enable nurses to contextualize the challenges they face in upholding quality and safety in patient care. Nightingale was not perfect. Her legend has overshadowed the fragile, but tireless nurse reformer who was prone to outbursts.1 Nurses need to accept their limits while working in an imperfect system. A realistic awareness of what nurses can accomplish and what they're capable of within context will keep them grounded and allow them to gain a broader view of the complexity of care and cure.
Even though reflecting on nursing research is important, Nightingale cautions her readers about the pitfalls of scholarly reading as the only means of learning: “Let experience, not theory, decide upon this as upon all other things.”9 In essence, and in terms of meaningful reflection, lived experiences are a more compelling source for reflection than academic education alone.
From reflection to action
Nurses today are admonished to apply no less than the best practices at all times. Engaging in lifelong learning through education and reflection supports excellence in nursing practice.14 Nightingale cultivated nursing inquiry not only as a powerful organizer, health-reformer, and statistician, but as a pioneer of the art of reflection in nursing. She warns us, however, that reflection alone isn't enough. “I think one's feelings waste themselves in words. They ought to be distilled into actions, and into actions which bring results.”1
Notes on Nursing isn't a manual to teach nurses how to nurse; instead, it offers a guide to reflection for anyone in charge of the health of others.1 It's time once more for nurses to seek the guidance of Florence Nightingale by reflecting on her writings to find the inspiration to conduct their own reflections, leading to improved practice and optimal patient care.
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