It is Nurses Week, and I can’t help but write about Florence Nightingale. A few years ago, I projected a slide bearing the well-known image of Nightingale to a group of about 150 nursing students and asked, “Who is this woman?” About five hands went up tentatively.
Our current students’ lack of facial recognition of the founder of modern nursing is perhaps a telling commentary on the teaching gap concerning the history of nursing and the disconnect between nursing education and its prolific past. This also confirms the finding that the nursing curriculum does not do a great job in teaching the humanities. When I invoke Nightingale in clinical discussions, my comments are usually met with blank stares. Are her teachings still relevant to today’s patient care or is she merely a curious Victorian relic?
When famous historical figures are eulogized long after their deaths, we typically read a rehashing of their well-known achievements. When one ceases to exist, their words remain the living fossils of their legacy. In re-reading Nightingale’s Notes on Nursing, I realized that her terse, epigrammatic, and at times lyrical writings are fine examples of aphorisms. Although she is often quoted, I have never heard her writings referred to as aphorisms. That distinction seems to belong to Hippocrates (c. 460 BCE – c. 375 BCE) who wrote a book called Aphorisms, admonishing physicians to first do no harm among others. Moses Maimonides (1135-1204) and William Osler (1849-1919) are two other physicians whose writings are enshrined in the canon of medical aphorisms.
An aphorism is a terse, often witty, and memorable statement denoting a general truth based on the author’s personal experience. It is the head of a literary league that includes maxims, axioms, sayings, and proverbs. To be considered an aphorism, the statement must be brief, definitive, personal, have a twist, and be philosophical. By all accounts, Nightingale’s memorable injunctions meet these criteria.
Philosophy and pills
But what do we need aphorisms for in a healthcare era that prizes pills over philosophy? Apart from being considered historical platitudes, aphorisms can serve as memory-aid and help us remember what we didn’t know we knew. Their mindful use can add a positive nuance to clinical reasoning, enhance narrative sensibility, and reinforce professional comportment and identity. I propose that healthcare aphorisms validate, add value, and venerate the praxis and the practitioner of the healing arts.
Aphorisms prove the validity of plain truths. Nightingale paraphrased Hippocrates when she wrote on the preface of the 1863 edition of her book, Notes on Hospitals, “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” This aphorism gave substance to what we have known all along – then as now, hospitals remain a dangerous place for patients, and sometimes for the staff too. Its significance has reached fevered pitch when medical errors was proclaimed the third leading cause of death in the United States several years ago.
Nightingale wrote, “The most important practical lesson that can be given to nurses is to teach them what to observe – how to observe.” Careful observation as a requisite in science-based patient care is a competence that Nightingale understood well. In what might be a prelude to evidence-based practice, she wrote, “In dwelling upon the vital importance of sound observation, it must never be lost 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.” In short, scientific data is only as good as it is put into practice.
Aphorisms are distilled wisdom made elegant by their patina from historical use. When memorable quotes become axiomatic of the profession, they elevate the status of the profession. Nursing is now the undisputed most trusted profession. In Notes on Nursing, Nightingale extolled the virtue of being trustworthy as an essential competence for healthcare leadership. Her work in the Crimean war is credited for elevating the status of nurses. However, her most enduring legacy is ensconced in her contribution to sanitation and infection prevention. A few of her most popular quotes on the subject include:
“True nursing ignores infection, except to prevent it.”
“Does not the popular idea of ‘infection’ involve that people should take greater care of themselves than of the patient?”
“Every nurse ought to be careful to wash her hands very frequently during the day. If her face too, so much the better.”
“Use hygiene as the handmaid of civilization.”
The value of aphorisms depends on what was said and who said it. The practical wisdom Nightingale dispensed were influenced by her experiences as a nurse and a lifelong patient, not simply the histrionics of a professional invalid. Aphorisms are highly condensed provider and patients’ narratives. Nightingale’s words should be interpreted not simply for what they are but what they might become. The literal reading of aphorisms will reduce them to entertainment, but a literary interpretation can exalt the practice of self-reflection.
The invocation of aphorism is an homage to the great minds that came before us. When William Osler declared “Medicine is a science of uncertainty and an art of probability,” we bow to him and with him in acknowledging the limits of medicine; nudging us to value progress, not perfection. Nightingale portentously wrote, “The very elements of nursing are all but unknown.” She was telling us that embracing uncertainty may improve our tolerance for ambiguity. I regard Nightingale with reverence in her self-effacing advice to nurses: “I do not pretend to teach her how, I ask her to teach herself, and for this purpose I venture to give her some hints.” She sounded a prescient alarm of the current reinvention of what it means to be a nurse in modern times. Nightingale issued caution on the pitfalls of bookish learning by saying “Let experience, not theory decide upon this as upon all other things.” Aphorisms can stir the imagination and move someone to do the right thing. She warned us that reflection alone is not enough when she said “I think one’s feelings wasted themselves in words. They ought to be distilled into action, and into actions that bring result.” If aphorisms become a living element of professional practice, we might see more healthcare providers who will demonstrate the virtues of emotional intelligence such as self-awareness, self-regulation, motivation, empathy, and social skills.
Fidelindo Lim is a clinical associate professor at New York University – Rory Meyers College of Nursing.