235

Practice

jhn
The Influence of Nightingale
Rounding by the Liaison Nurse Journal of Holistic Nursing

on Surgical Patient Families With

American Holistic Nurses Association
Volume 28 Number 4
December 2010 235-243
Attention to Differing Cultural Needs © 2010 AHNA
10.1177/0898010110368862
http://jhn.sagepub.com
Priscilla E. Neils, DHSc, BSN, MEd, CNOR

This article is a tribute to Florence Nightingale whose book Notes on Nursing was published 150 years
ago in 1860. Nightingale was a proponent of rounding on patients to ensure their environment contrib-
uted to healing. Patients and their families experience greater satisfaction when a registered nurse rounds
on them. The liaison nurse provides the connection between a surgical patient and the family in the
waiting room. This activity promotes communication and spiritual support for family members who will
participate in patient care both during hospitalization and after the patient returns home. Nursing theo-
rists support the interconnectedness that takes place during rounding. Story theory directs the nurse to
connect with the patient’s story so that holistic care, recognizing body, mind, and spirit, can take place.
High-touch/low-tech as practiced in Asia includes nurse–family interaction, integrating knowledge about
the patient’s history and preferences with nursing assessment, planning, interventions, and evaluation
of care. Nursing diagnoses support critical thinking for the nurse during rounding and interaction with
family members. Hospice care includes family stories, humor, and the comfort of presence of loved ones.

Keywords:  culture; family relations; spirituality

This article is a tribute to Florence Nightingale on
the 150th anniversary year of the publication of her
book Notes on Nursing in 1860. Her contribution to
the profession of nursing is incalculable. Nightingale’s
fivefold focus is as vital to our practice today as it was
150 years ago. Her five areas of patient focus are the
healing environment, rounding, communication with
the patient, teaching family members holistic care,
and statistical support of process change to drive
outcomes.
This important focus has a personal component.
My story describes my experience in the hospital with
a family member undergoing a procedure in the operat-
ing room (OR). There was no Liaison Nurse, that is, a
nurse who maintains communication between the sur-
gical patient and the family, to continue contact with
me about the progress of the surgery or the condition
of my husband. In the holding area, a nurse pointed at
my chair and said, “I need to sit there.” Otherwise, she
did not look at me or talk with me. In a busy hallway,
rather than a quiet, private place, the surgeon announced
to me that the biopsy revealed “a malignant, aggressive
tumor in his tibia. He will need chemotherapy and
further surgery” and he walked away.
Author’s Note: This article was prepared in anticipation of a
trip to China in August 2009 with People to People, an organiza-
tion founded by Dwight D. Eisenhower and based in Spokane,
Washington. The article was presented in Beijing, China, during
a professional exchange of ideas with Chinese nurses, winners of
the national Nightingale Award. The delegation of 24 holistic
nurses, participating in a life-changing experience, was lead by
Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN, pioneer
in the holistic nursing movement and author of the authoritative
book on the life and work of Florence Nightingale, Florence
Nightingale: Mystic, Visionary, Healer, Commemorative Edition
(2010). Please address correspondence to Priscilla E. Neils, Liaison
Nurse Initiative, 609 Willowwood Trail, Keller, TX 76248; e-mail:
pneils@mac.com.

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236   Journal of Holistic Nursing / Vol. 28, No. 4, December 2010
This was the first of six surgeries, 12 hospitaliza-
tions, and numerous radiation treatments that my
husband and I, as his family, encountered in the past
2 years. During these experiences, only once did a
nurse take the time to call and ask how I was doing.
It seemed to me that the nurses in the perioperative
area and OR had abdicated their responsibility to care
for the family of the surgical patient.
As a perioperative services director, I have discov-
ered that families experience dissatisfaction with
health care services because of lack of communication
both intra- and postoperatively. Nurses are focused
on the patients or procedures and may not think about
talking with the families in the waiting room or may
not understand the importance of this activity.
At St. Luke’s Episcopal Hospital in Houston,
Texas, a Liaison Nurse program was started with sev-
eral interested nurses. However, they were only
allowed to act in this role when the schedule was light,
causing inconsistency of care and frustration on the
part of the nurses. Finally, a true Liaison Nurse role
was established, and written guidelines were devel-
oped. A Nurse Liaison practitioner was dedicated to
maintaining communication with the families when
the patient was in the OR and postanesthesia care
unit (PACU). Satisfaction of patient families, sur-
geons, and nurses increased with this new program
in place (Robles, Windle, Santiago, & Rivera, 2005).
Rounding
The activities of the Liaison Nurse are accomplished
through the process of rounding, both on patients and
on families. The model for rounding by the professional
nurse comes to us from the 19th century. England’s
poor were a servant class with no hope of upward mobil-
ity, living in squalid, unsanitary conditions. Their lives
are described in the literature of the day, especially in
the stories by Charles Dickens. His writings give us a
picture of the horrific circumstances under which the
poor lived and worked. From this class came the nurses
who, with minimal training, usually cared for the sick.
Florence Nightingale was born in the early 1800s
in England to a wealthy family. Her parents would
never have considered nursing as a suitable lifetime
career for their daughter. At the age of 31, Florence
Nightingale, this woman whom the world knows as
the inventor and founder of modern nursing practice,
wanted to die. Her privilege of birth no longer satisfied
her. She looked to a future filled with the trappings
of wealth, uselessness, and boredom. At this critical
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juncture in her life, Nightingale consciously made the
decision to study nursing. With this decision she paid
a steep price, losing the respect and love of her family
for several years. However, she changed the practice
of hospital nursing forever.
Nightingale started her nursing practice in England.
She heard reports of the many casualties suffered by
the English soldiers fighting against Russia in the
Crimean war on the Crimean Peninsula in the Black
Sea. Moved to do something for her countrymen, she
gathered together a group of nurses to take with her.
All she could promise them was hard work and the
chance to make a difference in the lives of wounded
soldiers (Nightingale, 1860/2003).
Florence Nightingale’s patients in the Crimean War
did not have families in attendance at their bedside.
Thus, Nightingale became both their nurse and their
family. She is known as the “Lady With the Lamp”
because she made rounds at night, carrying a lamp with
her through the dark wards where the soldiers lay.
Nightingale learned by observation and experience
what other leaders and writers outside of the nursing
profession have known. First, she advised that teaching
and coaching of nurses, patients, and families must
result in an individual achieving self-care as much as
they are able. This keeps them engaged in the healing
process. And second, that the nurses must continue to
care for their patients in the same focused, expert man-
ner whether the supervisor/manager is present or not
(Nightingale, 1860/2003).
Great coaches or leaders share many of the same
characteristics. They are able to codify a vision and
pass it on to others. Once Nightingale had instructed
her nurses concerning the goals and processes in car-
ing for their patients, she gave them the authority to
act, realizing she could not be everywhere at once.
She deemed this much more effective than attempting
to do everything herself. As President Ronald Reagan
said, “The greatest leader is not necessarily the one
who does the greatest things; he is the one who
gets the people to do the greatest things” (Strock,
1998, p. 17).
Hourly rounds in the patient’s room, that include
pertinent questions and service based on the three
Ps, position, potty, and pain, have been shown to
greatly reduce the number of nurse call bells, patient
falls, and pressure sores. Unfortunately, families note
that documentation of hourly rounding does not
always match the experience. Ethical practice requires
a face-to-face experience. On each hourly round, the
last question should be, “Is there anything else I can
do for you at this time?”

Nightingale tells us that a nurse who bathes a
patient has an opportunity to assess the skin, mobility,
and neurological status of that person. The nurse
can assure that the linens are clean, the room air is
fresh and at the correct temperature, and the sur-
roundings are safe. Nightingale declared that transfer-
ring these duties to outside contractors does not allow
the nurse to “exercise her intelligence in these things
. . . . If a nurse declines to do these kinds of things
for her patient, because it is not her business, I should
say that nursing is not her calling” (Jones, Spinks,
Birrell, & Young, 2009, Section Jo Birrell ¶ 6).
Studies show that rounding assists the patients in
coping with their hospitalization (Starr, 2009). Round-
ing provides benefits as well for the family members
who may be separated from the patient for a time dur-
ing surgical or other procedures. Often a bit of humor
will strengthen the bond between families and caregiv-
ers. Florence Nightingale concludes, “painful impres-
sions are far better dismissed by a real laugh” (Starr,
2009, p. 72AAA). More advice from Starr (2009): start
slowly, watch how families interact, take your cue from
the situation, but consider that laughter can be good
medicine for both the patient and his family.
According to Smith and Liehr (2008), nursing theo-
rist, Hildegard E Peplau, “describes human connected-
ness as essential to health, and the nurse–patient
relationship as human connectedness that transpires
in nursing practice” (p. 175) This human connected-
ness takes place during the nurse rounding activity.
Story theory, introduced in 1999, also speaks to
the interconnection between patient and nurse as it
supports health, healing, and well-being. Comparing
patient outcomes with documentation of patient–
nurse interactions or rounding notes measures the
strength of this theory of nursing. To create an inten-
tional connection, the nurse listens and asks questions
and encourages the patients to tell their story. Asking
patients during rounding what is most important to
them opens the pathway to health and the healing
process (Smith & Liehr, 2008).
Metrics for Change
We do not know if Florence Nightingale considered
either herself a researcher or her activities as research.
Bailey (2007) tells us that she changed nursing for-
ever by her focus on the unsanitary conditions of the
hospitals for soldiers during the Crimean War.
Nightingale analyzed mortality data among British
troops in 1855 and learned that a clean environment
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Influence of Nightingale Rounding / Neils   237
significantly reduced the death rate in her hospitals.
Nightingale’s top priorities for a healing environment
for her patients were clean air, water, linens, and food.
She learned that the disposal of sewage had to be
controlled and continually monitored so that the pri-
orities of healing and positive outcomes could be met.
A statistician, Nightingale created the first health
care facility performance measures in 1859. She dem-
onstrated that research informs nursing practice and
leads to continuous process improvement. She was
able, through her nurses, to translate research-based
evidence into everyday care (Aiello, Larson, & Sedlak,
2008). In 1860, Nightingale developed a uniform sta-
tistical method for hospitals that showed which hos-
pitals in England had the best outcomes. Based on
these data, she could identify where hospitals should
be located to provide best opportunities for patients
to receive care in their own neighborhoods (Ulrich,
2008). A model developed in the United States after
this fashion is the county hospital, located in com-
munities where the need is greatest, and patients can
receive care regardless of ability to pay.
Nightingale continued her work after her return to
England in 1857 to ensure her policies and methods
of patient care would benefit community hospitals. She
engaged families in the patient care process by teaching
and encouragement. Her focus on the importance of
both the environment and rounding assessment of the
patient is summed up by the statement: “A patient may
be left to bleed to death in a sanitary place. Another
who cannot move himself may die of bed-sores, because
the nurse does not know how to change and clean him
. . .” (Nightingale, 1860/2003, p. 98).
This is the most powerful statement in her book
regarding rounding. I was assigned as the circulating
nurse on a case in the OR. The case was going well,
although the patient’s blood pressure was dropping slowly
but steadily. I crawled under the drapes and found a pool
of blood and saline from the IV site that had become
disconnected. Though all the drapes and instruments
were sterile, the documentation was perfect, and the
surgery was proceeding in a proper manner, the patient
might have bled to death had I not “rounded” on him.
Environment of Care
As she made rounds, Florence Nightingale took
responsibility to assess and improve the environment
of care, an unusual activity for a nurse in her era.
Today, we assume that clean air and pure water in our
cities and towns are guaranteed, but these are very
238   Journal of Holistic Nursing / Vol. 28, No. 4, December 2010
recent concepts. Governments in the mid-19th century
finally realized they would gain an economic benefit
from cleaning up the living and working environment
for their inhabitants. Getting rid of mosquitoes, creat-
ing sewage disposal systems, and rodent control as a
consequence of garbage disposal allowed for protection
of the earning power of all citizens, particularly the
working class. And so, in the middle 1800s, the gov-
ernments of France, the United States and England
took on the task of saving lives and the economy
through sanitary reform.
To this end, a General Board of Health was estab-
lished in England in 1848. Sanitarians thought that
bad air, or mal-aria, caused disease. Following the lead
of writers and thinkers of their time, “They took heroic
steps to clean up the miasma sources—water, sewage,
factories, and homes” (Aiello et al., 2008, p. S129).
About the same time that Florence Nightingale pub-
lished her first book (1860), John Snow, William Budd,
and Ignaz Semmelweis published their classic studies
on the epidemiology and control of infectious disease
(Aiello et al., 2008).
As a more sterile environment was shown to
improve surgical outcomes in the late 19th century,
the focus on family involvement in patient care dimin-
ished. Hospitals were built with stark, unattractive
facilities, and, sadly, policies were written limiting
access to patients by families (Stichler, 2008). Surgical
patients were separated from their families throughout
the hospital experience, increasing the level of anxiety
both in the patient and in the family members. Visiting
hours limited family interaction with health care pro-
viders and shortened time for teaching and discharge
instructions.
Angelica Thieriot, founder of the Planetree orga-
nization, made improvements in this environment of
care in the 1970s. Thieriot wanted to ensure that
patient families did not have the same unhappy experi-
ence that she had as a patient. The Planetree organiza-
tion, named after the sycamore tree where Hippocrates
allegedly sat to teach his medical students, has nine
elements:
(1) human interaction, (2) consumer and patient edu-
cation, (3) healing partnerships with the patients’
family and friends, (4) food and nutritional nurtur-
ance, (5) spirituality, (6) human touch, (7) healing
arts and visual therapy, (8) integration of complemen-
tary therapies, and (9) healing environments created
in the architecture and design of the healthcare set-
ting. (Stichler, 2008, p. 506)
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In hospitals designed with the Planetree guidelines,
lounges near patient rooms allow families to gather
in a welcoming place and keep them close by to sup-
port and comfort the patient so they can participate
as care partners (Stichler, 2008).
Student nurses are now taught to use their pres-
ence, as did Nightingale, to comfort patients and cre-
ate security and trust. The patient’s sense of loneliness
or loss of control can be a significant hindrance to
the healing process. The elderly patient, the patient
who is not mobile, or the patient from a different
culture than the nursing staff may experience loneli-
ness. They may have difficulty with communication
and experience distress in a hospital setting where
they cannot view the nursing station. Our current
view of privacy demands that patients are isolated
rather than positioned in open wards as was the cus-
tom in Nightingale’s time, thus the name, Nightingale
Wards (Hardy, 2008).
Teaching Families Holistic Care
So how can nurses work together with families to
reduce stress for the individual hospitalized patient?
Nurses should encourage families to contribute stories
that provide insight into patient needs and desires.
The family knows the patient best and knows what
current condition may be different from usual status
of their family members. Some hospitals have initiated
programs that allow the family to call a rapid response
team (RRT) if the patient may be experiencing prob-
lems of which the nurse is not aware (e.g., Baylor
Regional Medical Center at Grapevine, Texas).
Families can help with sharing information from
the health care team to the patient. They can be a
sounding board and a bridge from patient to nurse to
assist in the flow of essential information. Care must
be taken to recognize that, in some cultures, family
will express the desire to hide bad news from the
patient. They will absorb negative details about the
patient’s condition to spare him or her from sadness
or dismay. Family members believe that in shielding
the patient from the seriousness of his or her illness,
they preserve hope for their loved one.
Patient satisfaction scores have become an impor-
tant performance metric in the past few years to deter-
mine the effectiveness in dealing with the patient/
family experience. A set of questions developed by the
Hospital Quality Alliance is found in the Hospital
Consumer Assessment of Healthcare Providers and

Systems survey. This survey allows hospitals to mea-
sure patient and family satisfaction. A key finding is
that, in all conditions studied, patient satisfaction
with care was directly related to the quality of care
and availability of qualified nursing staff.
Jha, Orav, Zheng, and Epstein (2008) found that,
during nurse rounding, clear discharge instructions
and understandable communication related to medi-
cation were essential to quality and a positive experi-
ence These data can be used to drive process decisions
and be correlated with outcomes to determine what
elements patients and their families believe are
required for Safe, Timely, Efficient, Effective, Equi-
table, and Patient-Centered Care (Brassard & Ritter,
1994).
Research shows that the discharge instruction
process is thought by many patients to be inadequate
(Jha et al., 2008). If there is poor communication with
patient and family at discharge, there is an increased
patient risk for medication errors and readmission.
Jha et al. (2008) recommend that more research must
be done on the cause and effect relationship between
nurse staffing levels and patient satisfaction. It is nec-
essary to determine the elements that must be altered
to effect improvement in the patient/family surgical
and hospital experience.
Regional and cultural differences and expectations
show differing patterns in how patients and their fami-
lies describe the care experience. Jha et al. (2008)
have shown that higher satisfaction expectations of
patients in for-profit institutions may result in lower
satisfaction scores for those facilities than for non-
profits. They also found that hospitals in the North
tend to have lower scores than those in the South (Jha
et al., 2008). The Southern culture, which lends itself
to taking more time with rounds, may affect patient
and family satisfaction in a positive direction.
The Spiritual Foundation of Care
Three Rivers Community Hospital in Grants Pass,
Oregon, has developed a nursing care model that takes
into account the sacred and infinite nature of the being
and life of our patients. Use of this model has increased
patient and employee satisfaction and enhanced the
healing environment. Known as “The Model of Whole-
Person Caring,” it provides an environment where
the patient and family are viewed as spiritual beings.
Three nursing theorists, Florence Nightingale, Martha
Rogers, and Jean Watson, described human beings in
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Influence of Nightingale Rounding / Neils   239
terms that included the combination of physical and
spiritual beings. Thornton (2005) quotes the three as
follows:
Florence Nightingale stated, “We are a reflection of
the divine, with physical, metaphysical, and intellec-
tual attributes.” Martha Rogers saw each person as
an “irreducible, indivisible, pandimensional [sic]
energy field that is open and infinite in nature, and
inseparable from the environment.” Jean Watson, a
contemporary nurse theorist, states, “We are sacred
beings [and] we must regard ourselves and others with
deepest respect, dignity, mystery, and awe.” (¶ 3)
This model is transformational, as the spiritual side
of the patient becomes the foundation of the person
and not just one aspect of the nurse–patient experience.
“The spiritual dimension [is] a unifying force that inte-
grates the physical, mental, emotional, and social/
relational [friends and family] aspects of being”
(Thornton, 2005, Our Spiritual Dimension ¶ 1). Liaison
Nurses acts on this theoretical base as they fulfill and
recognize their role. This role is one of connecting the
patient, as a spiritual being, to the family as that force
from which the patient derives spiritual support.
Separation anxiety occurs especially when the
patient is a parent and the family member is a child.
“One study showed that children of ICU patients fear
their parent’s death and that these fears lessen when
children were allowed to visit” (Davidson et al., 2005,
Family Coping ¶ 6)
At a hospital where I worked, a boy about 8 years
of age crouched on the floor outside the PACU where
his father lay asleep on a stretcher, recovering from
major surgery. He had asked the secretary at the desk
if his father was still alive. It was not the custom in
that PACU to allow family members into the unit to
visit with patients for privacy and other reasons. PACU
nurses tend not to approve of visitors on their unit as
they focus intently on this critical phase of the patient
experience and do not wish to divide their attention
between patient and family. I checked the condition
of the father and pulled the privacy curtains between
him and the other patients. I took the hand of the
small boy, and we tiptoed into the PACU where he
could see his father propped up on pillows and sleep-
ing comfortably. Satisfied, the child turned a brave
face to me and said, “Thank you, nurse.” It is interest-
ing that at his young age, he recognized the connection
between the surgical patient and his family member
as a nursing activity.
240   Journal of Holistic Nursing / Vol. 28, No. 4, December 2010
Another development that sheds light on the con-
nection between nurse and patient/family is the change
in the training and education of nurses themselves.
The change from task-oriented training to critical-
thinking education is important to acknowledge and
understand as hospital nursing moves into research-
based practice and holistic care of patient and family.
A comparison of Western and Eastern nursing edu-
cational programs can be useful in helping to under-
stand the metamorphosis from apprentice to student
(Hargreaves, 2008).
Western medicine can be characterized as disease-
focused, employing high-tech/low-touch interven-
tions, as typified by such invasive procedures as
coronary artery bypass grafts, organ transplantations,
joint replacements, and other technology-based thera-
pies, whereas Eastern medical practice can be char-
acterized as low-tech/high-touch and holistically
focused. Incorporation of such interventions as acu-
puncture, herbal and vitamin remedies, meditation,
and prayer are often part of Eastern medical modalities.
(Rath, 2009, Practices ¶ 1)
In Chinese hospitals, family members are present
during acupuncture and other treatments to provide
comfort and support. Doctors and nurses provide
explanations about procedures, valuing the presence
of the family at the bedside.
Spiritual Care
Spiritual care is a central aspect of holistic care of
the patient and family. Rath (2009) writes that most
adults in the United States, according to surveys,
believe that prayer and faith can help patients recover
from illness, and more than one half report that they
pray at least once daily. Florence Nightingale docu-
mented that nurses throughout history provide spiri-
tual care for their patients (Rath, 2009). She states
that a nurse must be a “religious and devoted woman;
she must have a respect for her own calling, because
God’s precious gift of life is often literally place in
her hands” (Nightingale, 1860/2003, p. 96). She also
advised her nurses against preaching religion to her
patients. Families and nurses have a long history of
using this intervention as a mind–body–spirit con-
nection. Critical care nurses believe prayer is therapy—
about 60% of these nurses pray privately for their
patients (Rath, 2009).
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Research shows that a majority of hospitalized
patients want nurses to ask them about their spiritual-
ity and pray with them if they request this intervention
(Taylor, 2003). Rounding gives nurses the opportunity
to ask whether prayer would benefit the patient and/
or family and if a priest, chaplain, or rabbi is wanted
for ministry to the family. I have found that one of the
most precious times of the day is that brief respite
holding hands in a circle of prayer with a family and
their spiritual leader, joining in a sacred experience
that connects caregiver to God, patient, and family.
The nurse should also be sensitive about meals
and other specific food preferences. It may be neces-
sary to provide items other than the usual hospital diet
for the patient so that he or she can adhere to the
tenets of his or her religion. Those patients who do
not drink coffee or tea may become discouraged with
lack of attention to their preferences if these beverages
continually show up on their tray and may begin to
wonder what else is not correct about their care.
In some countries such as the Congo, Africa, fami-
lies bring food and prepare it at the hospital so that
patients will enjoy familiar food with their loved ones.
On the other hand, in impoverished communities,
hospitals provide food available in that region for the
whole family, so that families can learn what foods are
good for healing and nutrition.
Family and self-management of the patient must
involve active collaboration between interdisciplinary
team members and families. The Institute of Medicine
Patient-Centered Care Model from 2001 recommends
that:
a) patients and families are kept informed and
actively involved in medical decision-making and
self-management; b) patient care is coordinated
and integrated across groups of healthcare providers;
c) healthcare delivery systems provide for the physical
comfort and emotional support of patients and family
members; d) healthcare providers have a clear under-
standing of patients’ concepts of illness and their
cultural beliefs; and e) healthcare providers under-
stand and apply principles of disease prevention and
behavioral change appropriate for diverse populations.
(Davidson et al., 2005, Conclusions ¶ 2)
In the intensive care unit (ICU), as in the OR,
families may feel disenfranchised from decision mak-
ing and care of loved ones. They know the patient best
and want to be involved in multidisciplinary decision
making, especially when patients are unable to speak

for themselves. Data from both North America and
Europe indicate that families favor this model and
expect that their cultural attitudes will be respected
in this process (Davidson et al., 2007). Other benefits
reported by the authors are fewer decision-making
conflicts, fewer unrealistic family expectations, and
better communication and collaboration between fami-
lies and health care providers.
Family stress levels rise when the patient is moved
from the ICU to the floor. They express anxiety that
the patient will not be as well cared for if the nurse
has several other patients. Davidson et al. (2007) tells
us that surveys show nurses are only about 50% accu-
rate in predicting what a family needs to know and do
to reduce their level of stress. This is a teaching oppor-
tunity for the Liaison Nurse.
The Liaison Nurse
Every day, in my role as the Surgical Liaison Nurse,
I round in the surgical holding area and the surgical
family waiting room, greeting patients and family
members. I confirm their type of surgery and the
name of their surgeon. I hand out my business cards
to patient family members and invite phone calls
regarding concerns about patient care. I occasionally
receive a phone call that confirms this is a valuable
service.
A gentleman called because his mother had been
moved from her postoperative ICU bed to the floor,
and he was having no luck in contacting her. He
was not able to come to the hospital, and no one
was answering the phone number he had been given.
I was able to refer him to a charge nurse who helped
him find his mother. Other patients have called me
about needing clean linens or about discharge
orders that are not clear. I communicate with the
floor, visit the patient, and ensure the problem is
addressed.
One postoperative patient was bleeding and did
not want to bother her physician. I recommended an
immediate trip to the emergency room. She received
treatment and was safely discharged back home to
recover. I have not found a substitute for personal
contact and the development of a trust relationship
with patients and their families.
A script used in the role of Liaison Nurse recog-
nizes the importance of family and home to healing
for the surgical patient. The script states to the family
member:
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Influence of Nightingale Rounding / Neils   241
You are essential to a positive outcome for this patient.
You will need to ask questions and get all the informa-
tion you need to heal them. We just do surgery here,
and you do the healing, a much more important job.
Family members indicate that they agree with me
and nod yes every time.
Marshall (2008) describes the healing process in
this manner:
Healing cannot happen in a surgical suite where the pain
is only a sleepy memory. Cure is passive, as you submit
your body to the practitioner. Healing is active. It
requires all the energy of your entire being. You have to
be there, fully awake, aware, and participating when it
happens. (Healing is Active You Have To Be There ¶ 3)
Healing can begin before surgery as the anesthesia
provider works with the patient on a plan of care
including visualizing positive conditions of comfort
and location where initial sleep and relaxation will take
place. Suggestions to the patient emerging from anes-
thesia as to physical and spiritual strength present for
healing move the patient toward awareness of postop-
erative well-being. Nursing is the best discipline to
recognize and support the importance of home and
family for the healing part of the injury, comfort, inter-
vention, recovery, and healing continuum.
Nursing diagnoses, developed through the decades
of the 1970s and 1980s, reflect concern for the whole
person and the need to view the patient as both
a physical and spiritual being. These diagnoses pro-
pose potential conditions for which the nurse can
create a personalized plan of care with the goal of pre-
vention of these conditions. For example, a list of risk
diagnoses for the surgical patient or family might
include one or all of the following: (a) potential for
separation anxiety during the surgical process, (b)
potential for loss of control, (c) potential for fear of the
unknown, (d) potential for fear of financial impact of
surgery on family resources, (e) potential for fear of
impending death of emergency surgery patient. Round-
ing by the Liaison Nurse and appropriate interventions
on behalf of the family are effective methods that con-
tribute to the prevention of these stated conditions.
Nightingale’s Impact in Asia
Nightingale’s Notes on Nursing (1860) text is as rel-
evant today as it was 150 years ago. Her influence has
242   Journal of Holistic Nursing / Vol. 28, No. 4, December 2010
reached throughout the world. Let us consider her early
impact in Asia, beginning in China, where the first
school of nursing based on the Florence Nightingale
system was opened in 1888. By 1920, the program
had expanded to include a Bachelor of Science (BSN)
program in the People’s Republic of China. Little
change was noticed in the style of nursing education
between 1920 and the year 2000. Most modern nurs-
ing education in China is hospital based and modeled
after the medical school pattern of disease and treat-
ment (Harmon, 2008).
But this teaching model is slowly changing with
increasing numbers of Bachelor-prepared nurses prac-
ticing currently, an exciting and encouraging trend.
Florence Nightingale is called Nan Ting Ger in China.
She is greatly respected in China, where every year the
Chinese government presents the Nightingale Award
to outstanding nurses. Western medicine, heavily influ-
enced throughout the 19th and 20th centuries by Plato,
Aristotle, and Descartes, sees the mind and body as sepa-
rate entities. This duality “is incongruent with Asian
perspectives that emphasize an indivisible phenom-
enological holism” (Dodgson, 2008, Background ¶ 4).
Nurses on both sides of the Pacific Ocean recog-
nize that Asian philosophical belief encourages holistic
care for surgical patients and their families. Profes-
sional nursing language or descriptions of nursing care
in China, when it reflects the Daoist and Confucian
perspectives, connect and support Nightingale’s con-
cept of holistic care. Combining the Nightingale
method with their own cultural teachings, Chinese
nurses optimize the influences of family, health care
provider, and patient cocreative environment. The term
for this interconnectedness is wanwu (Dodgson, 2008).
In Chinese thinking, there is no independent self,
but one is always described according to the relation-
ship with others (wife, mother, daughter). Therefore,
nursing is practiced within the family environment and
context, with the goal of transforming all, optimizing
outcomes for the patient and the family at the same
time (Dodgson, 2008).
The family concept of decision making and treat-
ment is confirmed by a study in a Chinese community
in Toronto, Canada. Study results showed that the
families of patients rejected the idea and process of
advanced directives. This would be looking forward to
the possibility of bad news or negative thoughts, pro-
ducing negative outcomes (Davidson et al., 2007). The
family focuses on the happiness of the patient and
encourages hope for recovery.
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Conclusion
In summary, Davidson et al. (2007) has recommended
five steps nurses must follow to build an effective rela-
tionship between themselves and their patients and
families. The following parts of the knowledge base
must be fulfilled: First, the nurses must have self-
awareness, both of their own biases and culture and
of their clinical expertise; second, they must have
knowledge of the patient’s and family’s cultural beliefs
as pertains to health care; third, they must be compe-
tent to do a cultural assessment; fourth, they must
know the dynamics of difference between their own
culture and that of the patient; and, finally, they must
be able to effectively communicate with both patient
and family that this knowledge base is active and accu-
rate and that they will support the family in the health
care process. The nurse who is aware of applicable
nursing diagnoses and the cultural beliefs of his or her
patients, can do a cultural assessment, knows how to
work with families different from his or her own, and
is an effective communicator has a strong base on
which to plan and implement interventions.
Nurses who nurture and comfort both patient and
family provide a context and environment that positively
affects physical health, particularly as science runs out
of remedies, surgeries, and medical solutions toward the
end of life. Nursing continues to focus on providing
care along the holistic continuum. Hospice patients have
expressed a need for “being with family, seeing smiles of
others, thinking happy thoughts, laughing, talking about
day-to-day things, and being with friends” (Ruder, 2008,
Spirituality, Religion, and Health ¶ 2). These events are
encouraged and facilitated by nurses, who use Nightin-
gale Rounding with their patients, ensure the environ-
ment is clean and supports healing, communicate with
families, provide interventions to meet both physical and
spiritual needs, and ensure the positive outcomes and
full benefits of the nurse rounding activity.
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Priscilla E. Neils, DHSc, BSN, MEd, CNOR, has enjoyed careers
as an opera singer, educator, certified scrub technician, operating
room staff nurse, manager, and director. She has taught science
and health courses in junior high school and junior college and
English in Japan. In her role as scrub technician, she participated
in two mission trips to Africa, assisting in surgery, predominantly
release of joint contractures on polio patients. As director of peri-
operative services, she has designed operating rooms, gastroin-
testinal labs and pre- and postanesthesia recovery units for a new
hospital. She has built service lines in spinal surgery, bariatric
surgery, and robotics. She has developed a nurse liaison model of
holistic care for patients and their families, to ensure the safe and
appropriate flow of information and communication to support
whole person caring. She is married to Dr. Scott R. Neils. Together
they have nine children.