3 Petty Management
Much of Florence Nightingale’s approach to nursing, and to life in general, was based on perceptive planning and good management – what she called being ‘in charge.’ In Notes on Nursing this became the chapter on ‘petty management,’ meaning the organization of details which would help ensure that care was provided efficiently and in a consistent manner. While the focus of her advice was on the most important aspects of care, she shared with readers what she had learned from long experience about the need to go beyond this to an understanding of the patient’s mentality, because this would enable the caregiver to be attentive to secondary aspects of care that might also contribute to well-being and recovery. These could range from decorating the bedroom with flowers and plants, depending on the patient’s condition, or recognizing the soothing effect on patients of household pets. She also stressed the absolute necessity for a caregiver to foresee periods of regular rest from caregiving, by ensuring that others could take over their responsibilities. Again, this required planning to ensure the replacement is able to assume responsibility for all essential aspects of the patient’s plan of care. This last element has become more important with the advent of new medications and methods of treatment. The development of a care plan is the first, essential step for a successful program of care. It is dealt with in this modern edition in the following section in this chapter.
Notes on Nursing – Florence Nightingale
Delivery and non-delivery of letters and messages.
An agitating letter or message may be delivered, or an important letter or message not delivered; a visitor whom it was of consequence to see, may be refused, or one whom it was of still more consequence to not see may be admitted – because the person in charge has never asked herself this question, What is done when I am not there?
For the same reasons, always tell a patient and tell him beforehand when you are going out and when you will be back, whether it is for a day, an hour, or ten minutes. You fancy perhaps that it is better for him if he does not find out your going at all, better for him if you do not make yourself “of too much importance” to him; or else you cannot bear to give him the pain or the anxiety of the temporary separation.
What it is to be “in charge”?
How few men, or even women, understand, either in great or in little things, what it is the being “in charge” – I mean, know how to carry out a “charge.” From the most colossal calamities, down to the most trifling accidents, results are often traced (or rather not traced) to such want of someone “in charge” or of his knowing how to be “in charge.” To be “in charge” is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either wilfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed.
Noise which excites expectation.
I have often been surprised at the thoughtlessness, (resulting in cruelty, quite unintentionally) of friends or of Physicians who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him. If he is an amiable patient, he will try to occupy his attention elsewhere and not to listen – and this makes matters worse – for the strain upon his attention and the effort he makes are so great that it is well if he is not worse for hours after. If it is a whispered conversation in the same room, then it is absolutely cruel; for it is impossible that the patient’s attention should not be involuntarily strained to hear. Walking on tip-toe, doing anything in the room very slowly, are injurious, for exactly the same reasons. A firm light quick step, a steady quick hand are the desiderata; not the slow, lingering, shuffling foot, the timid, uncertain touch. Slowness is not gentleness, though it is often mistaken for such: quickness, lightness, and gentleness are quite compatible. Again, if friends and Physicians did but watch, as Nurses can and should watch, the features sharpening, the eyes growing almost wild, of fever patients who are listening for the entrance from the corridor of the persons whose voices they are hearing there, these would never run the risk again of creating such expectation, or irritation of mind.
Noise of female dress.
Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well. For, in all these remarks, the sick are only mentioned as suffering in a greater proportion than the well from precisely the same causes. Unnecessary (although slight) noise injures a sick person much more than necessary noise (of a much greater amount).
Patient’s repulsion to Nurses who rustle.
If there are blinds to your windows, always take care to have them well up, when they are not being used. A little piece slipping down, and flapping with every draught, will distract a patient.
How to visit the sick and not hurt them.
It is really less exertion to him to write his letters himself. This is the almost universal experience of occupied invalids. This brings us to another caution. Never speak to an invalid from behind, nor from the door, nor from any distance from him, nor when he is doing anything.
And to well.
This rule, indeed, applies to the well quite as much as to the sick. I have never known persons who exposed themselves for years to constant interruption who did not muddle away their intellects by it at last. The process with them may be accomplished without pain. With the sick, pain gives warning of the injury.
Patients dread surprise.
Patients are often accused of being able to “do much more when nobody is by.” It is quite true that they can. Unless Nurses can be brought to attend to considerations of the kind of which we have given here but a few specimens, a very weak patient finds it really much less exertion to do things for himself than to ask for them. And he will, in order to do them, (very innocently and from instinct) calculate the time his nurse is likely to be absent, from a fear of her “coming in upon” him or speaking to him, just at the moment when he finds it quite as much as he can do to crawl from his bed to his chair, or from one room to another, or down stairs, or out of doors for a few minutes. Some extra call made upon his attention at that moment will quite upset him. In these cases you may be sure that a patient in the state we have described does not make such exertions more than once or twice a day, and probably much about the same hour every day. And it is hard, indeed, if nurse and friends cannot calculate so as to let him make them undisturbed. Remember, that many patients can walk who cannot stand or even sit up. Standing is, of all positions, the most trying to a weak patient.
Reading aloud.
Read aloud slowly, distinctly, and steadily to the sick.
But two things are certain: –If there is some matter which must be read to a sick person, do it slowly. People often think that the way to get it over with least fatigue to him is to get it over in least time. They gabble; they plunge and gallop through the reading. There never was a greater mistake. Houdin, the conjuror, says that the way to make a story seem short is to tell it slowly. So it is with reading to the sick. I have often heard a patient say to such a mistaken reader, “Don’t read it to me; tell it me.” Unconsciously he is aware that this will regulate the plunging, the reading with unequal paces, slurring over one part, instead of leaving it out altogether, if it is unimportant, and mumbling another. If the reader lets his own attention wander, and then stops to read up to himself, or finds he has read the wrong bit, then it is all over with the poor patient’s chance of not suffering. Very few people know how to read to the sick; very few read aloud as pleasantly even as they speak. In reading they sing, they hesitate, they stammer, they hurry, they mumble; when in speaking they do none of these things. Reading aloud to the sick ought always to be rather slow, and exceedingly distinct, but not mouthing – rather monotonous, but not sing song – rather loud but not noisy – and, above all, not too long. Be very sure of what your patient can bear.
Variety a means of recovery.
To any but an old nurse, or an old patient, the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a long confinement to one or two rooms. The superior cheerfulness of persons suffering severe paroxysms of pain over that of persons suffering from nervous debility has often been remarked upon, and attributed to the enjoyment of the former of their intervals of respite. I incline to think that the majority of cheerful cases is to be found among those patients who are not confined to one room, whatever their suffering, and that the majority of depressed cases will be seen among those subjected to a long monotony of objects about them.
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