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July 17, 2000

What Ever Happened To Common Sense?

All truth is only common sense clarified.
Thomas Huxley

Healthcare has become so organized, codified, outcome analyzed and protocol bound that it has lost sight of the rich common knowledge of its early teachers.

The change has had a terrible impact on the angels of healthcare, its nurses. My mother was a nurse, my wife is a nurse, and I have 35 years experience in dealing with the physician-patient-nurse relationship. Florence Nightingale, whose book 1860's book, Notes on Nursing prompted these thoughts would be struck speechless by what nursing has become. The subtitle of her book; Notes on Nursing:What It Is And What It Is Not,says it all. I believe she would put much of the current nursing duties into the "What It Is Not" category.

It is true that health care is a science. However as Huxley states, truth begins with common sense observations. Plato's Republic wisely divides awareness into opinion and knowledge. Opinion involved sense experience and knowledge evolved from sense experience by means of reasoning. Sense experience is the base and science evolves from this.

The two concepts are a whole and need each other. Sense experience can be somewhat mystical. I have always felt that skilled members of the healthcare profession reach out with their self, their life force, to touch those that they were caring for. It is my observation after 35 years experience that this caring for the patient enhances the patient's confidence and healing.

The preface for this book of the 1860's clearly distinguishes between genralized caring for someone and the specialized knowledge required in the healthcare field.

"Every woman, or at least almost every woman, ...has, at one time or another in her life, charge of the personal health of somebody, whether child or invalid, in other words every woman is a nurse. "(1)

She recognized that in the healthcare field special knowledge will be required.

"It is recognized as the knowledge which every one ought to have ...distinct from medical knowledge, which only a professional can have." (2)
Unfortunately the rush to codify and quantify everything in order to cost-account has tended to lose the caring needed in this profession. A narrow focus on quantifying the patient in order to generate and acuity score in order to substantiate the need for a certain number of staff has lost sight of another of Florence's observations.
"In watching diseases, both in private houses and in public hospitals, the thing which strikes the experienced observor most forcibly is this, that the symptoms or sufferings genrally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but something quite different - of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and acare in the administration of diet, or each or all of these." (3)

When I myself was a patient, the warm blanket after surgery, the treating of parched lips with lemony glycerin, and luxury of luxuries, a backrub were in that instant more important to me that the intravenous antibiotic. Florence knew this in 1860.

"...that in these and many similar diseases the exact value of particular remedies and modes of treatment is by no means ascertained, while there is universal experience as to the extreme importance of careful nursing in determining the issue of disease."

The personnel in the medical facilities where I work went through their annual, mandatory OSHA(Occupational Safety and Health Administration) training and examination. They must be familiar with voluminous MSDS(Material Data Safety Sheets) and be able to pass an examination on this knowledge. Florence had some essential points that cover this subject in a common sense way.

"There are five essential points in securing the health of houses
1. Pure Air
2. Pure Water
3. Efficient drainage
4. Cleanliness
5. Light
Without these no house can be healthy. And it will be unhealthy just in proportion as they are deficient. " (5)

Her approach to these principles in the sick room environment was equally common sense.

"In disease where everything given off from the body is highly noxious and dangerous not only must there be plenty of ventilation to carry of the effluvia, but everything the patient passes must be instantly be removed away, as being more noxious than even the emmanations from the sick." (6)

The "Ten Minute Medicine"of today's efficient managed care does not allow the depth of observation necessary to know the whole of the patient and the extent of the disease effects, physiologic and psychologic, upon the patient. Florence devotes considerable discussion to this art/science of observation.

"...if you cannot get the habit of had better give up being a nurse, for it is not your calling, however kind and anxious you may be. " (7)
"Almost all superstitions are owing to bad observation, ...and bad observations are almost all superstitions."(8)

I have seen a system in use that allegedly determines how many nursing personnel are needed for any given number of patients. This Acuity Grading System develops a score for each patient and then this score allegedly determines how much nursing a given patient needs. The scores of each patient in each ward are totaled and that allegedly guides one to adequate staffing for that number of patients. This system takes some time to enter the scoring information for each patient and thus takes away from "hands on" nursing time. I believe Florence would have said,

"A want of the habit of observing conditions and an inveterate habit of taking averages are each of them equally misleading"(9)

A current trend in nursing seems to be using RN's and those with more advanced degrees to manage staff of less training. There is now a Masters Degree program in business management for nurses. Florence knew the basics of being "in charge".

"...not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one willfully or ignorantly thwarts or prevents such measures." (10)

If one is "in charge" then one is responsible for the "well being" of the patient. This means much more than just being sure that a certain medication is given at a certain time. Florence's little book speaks to a "community of care" to a depth not seen in modern texts. She considered that the nurse was responsible for the "well being" of her patient.

"Apprehension, uncertainty, waiting, expectation, fear of surprise do a patient more harm than any exertion" (11)

"Always sit down when a sick person is talking business to you, show no signs of hurry, give complete attention and full consideration if your advice is wanted, and go away the moment the subject is ended."(12)

Florence's book embodies the meaning of caring for the whole patient - the beneficial effects of little things like flowers, the detrimental effects of leaving the patient in a condition of uncertainty, the beneficial effect of stimulating the patient's interest and attention to things outside their condition, contrasted with the detrimental effect of leaving them in a chronic bare walled condition to vegetate more into their illness.

The concepts of patient nutrition are basic common sense. Florence did not have the benefit of knowing each tiny ingredient to the last iota. However she did know how nutritionrelated to illness, to health and to getting one's patient well.

"...careful observation of the sick is the only clue to the best dietary." (13)

"The main question is what the patient's stomach can assimilate or derive nourishment from, and of this the patient's stomach is the sole judge."(14)

She comments on four possible causes of the patient not eating.

"1. Defect in cooking
2. Defect in choice of diet
3. Defect in choice of hours for taking diet
4. Defect in appetite in patient."

She notes that these are all generally lumped under the comment "no appetite"

When I was a medical student at a prestigious teaching hospital in the Eastern United States I observed the wisdom of those observations Florence made about appetite. The situation was "Rounds" with an esteemed senior professor of Internal Medicine. The patient was a man recovering from hepatitis. The case was presented by a knowledgeable Resident physician in his fresh white uniform. The presentation was flawless and covered all aspects of the diesase with voluminous laboratory testing. When the young man had proudly completed the presentation, not once referring to any written notes or charts the professor asked, "Is he getting better?" Once again the white coated paragon of academic knowledge presented the case pointing out aspects of improving laboratory data. Once again the professor asked, "Is he getting better?" Again the recitation of data and again the question. The crowd, as well as the Resident were perplexed. The Professor then turned to the patient and asked, "Are you hungry?" The patient replied that he was very hungry. The Professor then announced, "He is getting better."

This vignette on patient appetite illustrates Florence's insistence on accurate observation.

"...if you cannot get the habit of had better give up being a nurse, for it is not your calling, however kind and anxious you may be." (7)
"Almost all superstitions are owing to bad observation, ...and bad observations are almost all superstitions." (8)

However, not all observations are equal and the current trend to quatitfy the needed levels of care can ignore the evaluation of the total patient. that Florence was so insistent of.

" it not to be feared that observation, as an essential part of medicine has been declining?"(16)

"A want of the habit of observing conditions and an inveterate habit of taking averages are each of them equally misleading"(9)

"...practical manual is impossible to learn from any book, and that it can be thoroughly learnt in the wards of a hospital..." (17)

Florence Nightingale was a remarkable woman who wrote of the very basics of excellent nursing care. Her conclusions and recommendations are based on common sense. She analyzed her observations and created knowledge. Her basic knowledge and rules of good nursing are just as valid today as they were in 1860.

The rush to get the most for the least expense has led us away from many of these basics of good patient care. Acuity analysis with breakpoints for care by certain levels of training has gotten to the point of having the lowest trained personnel that can give care with acceptable outcomes for the least cost.

In many instances nursing care has become a financial risk analysis that is far from Florence Nightingale's principles of what nursing care is and is approaching her Principles of what it is not.

I am of the opinion that this little book should be required reading for every first year nursing school student.

1. Notes on Nursing:What It Is And What It Is Not,
Florence Nightingale, D. Appleton and Company, New York, NY, 1860, preface.
2. Ibid, preface
3. Ibid, page 8
5. Ibid, page 24
6. Ibid, page 21
7. Ibid, page 113
8. Ibid, page 115
9. Ibid, page 120
10. Ibid, page 42
11. Ibid, page 38
12. Ibid, page 49
13. Ibid, page 73
14. Ibid, page 74
15. Ibid, page 110
16. Ibid, page 119
16. Ibid, page 127

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