During my senior-year public health nursing rotation, I regularly visited an elderly woman to administer an injectable medication. She lived in an inner city neighborhood in a modest row house with an open porch and a large bay window. I recall this clearly because each time I visited she insisted that I administer the gluteal injection while she reclined on a bench in front of the window. We chatted as I took her vital signs and observed the injection site. She always invited me to stay for tea but I never did. It was not until the final clinical postconference that I realize what I had missed.
Ms Murphy, the public health nursing instructor, asked me to present my observations and experiences in visiting the elderly patient over the past weeks. I was very proud of my thorough and professional report; vital signs before administering the meds, condition of skin before injection and maintenance of aseptic technique, observation of the patient postinjection-you get the picture. I was focused on medical task first and the patient's response to it but not much else. I mentioned at the end of my presentation that the patient was very nice and always invited me to tea. And then came the barrage of Ms Murphy's questions and comments, "Did you accept the patient's invitation? Do you realize the opportunity you missed to observe the patient, to learn about her life, her family? Does she have family or supportive neighbors? Did you ever wonder why the patient wanted to be near the window during the injection?"
I haltingly explained that I had focused primarily on the patient's condition and the task at hand. Ms Murphy continued, "Were photographs displayed in the home? What was the condition of the home environment? Did you ever have an opportunity to look in the refrigerator? Every public health nurse worth her salt finds a way to look into the patient's fridge to get a sense of nutritional resources?" I stared into space and never responded. Ms Murphy then referred me to Nightingale's book, Notes on Nursing.1 "Read the chapter on Observation and then let's talk!"
This year is the 160th anniversary of the publication of Nightingale's Notes on Nursing. Over time I came to realize the importance of Nightingale's assertion that observational skills, in the broadest sense, are at the core of nurses' work. The chapter on observation is the longest of the 14 chapters. "In dwelling upon the 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."1
Listening to patients and families, observing nonverbal communication, surveying environmental characteristics whether in the hospital, the home, or the community, and gaging our own reactions provide crucial data in the equation for effective care. It takes skill to focus narrowly on a problem and to observe the broader context at the same time, but "for the sake of saving life and increasing health and comfort," it is necessary. Happy Anniversary, Notes on Nursing!
-Gloria F. Donnelly, PhD, RN, FAAN, FCPP
Editor-in-Chief
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