When I hear nurses say that they leave their jobs at the workplace, I wonder: how do you not think about the patient you couldn't rescue? Or the patient so afraid of dying she couldn't stand to be alone but whom you didn't have time to talk with?
For the past five summers I've had the privilege of attending a symposium on improving the quality of health care with other nurses, physicians, and administrators who come together to explore a specific theme. This year's was reflection.
At the event, sponsored by the Institute for Healthcare Improvement and the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice, we talked about what constitutes reflection, how providers reflect on their work, how the health care system values reflection (or doesn't), and the consequences of failing to make time for reflection. It became apparent just how important self-reflection is-as did the fact that self-reflection alone isn't enough to fix our health care system. As one participant put it, the Institute of Medicine has given us permission to blame the system for errors, but we are the system. "Community is the antidote to institutional culture," said another, implying that health care providers must participate in community reflection in order to take ownership of their own organizations.
One approach is the clinical narrative. Patricia Benner, professor of nursing at the University of California at San Francisco, has promoted this practice and has mentored nurses such as Eloise Cathcart and Patricia Hooper-Kyriakidis as they've extended this work. I spoke with these nurses as I prepared a presentation on reflective practice for the symposium. They believe that the clinical narrative helps nurses reclaim their practice by revealing the depth of judgment and moral agency involved in exquisite nursing care. Joan Vitello, chief operating officer at Hallmark Health in Massachusetts, told me that staff nurses are asked to write about an experience with a patient that stands out for them-not necessarily a crisis but an encounter that represents remarkable daily work or something gone awry. They tell the story: what happened, what they felt, how the patient appeared, what the patient said-details that give a reader or listener a real understanding of what transpired.
Clinical narratives shine a light on what matters to patients and the importance of everyday nursing and can help disengaged nurses tap into the meaning of their work. They remind institutions that nursing is more than its quantifiable outcomes. Vitello told me that she asks some nurses to read their narratives to an interdisciplinary group during Nurses Week. Senior administrators said that they received a new understanding of the value of nursing.
Vitello provides protected time for nurses to reflect and a template for writing narratives using the parameters that Benner developed (see http://www.links.lww.com/ A538 for a list of resources on clinical narrative). Self- and community reflection can be incorporated into root-cause analyses of errors, weekly discharge rounds, staff meetings, debriefings after a particularly difficult death or case, and even change-of-shift reports.
To the nurse who says, "I don't have time to reflect," I offer a poem by William Stafford, "The Way It Is," that we read at the symposium:
There's a thread you follow. It goes among
things that change. But it doesn't change.
People wonder about what you are pursuing.
You have to explain about the thread.
But it is hard for others to see.
While you hold it you can't get lost.
Tragedies happen; people get hurt
or die; and you suffer and get old.
Nothing you do can stop time's unfolding.
You don't ever let go of the thread.