Care Coordination: Opportunities for Nursing

Posted in Nursing

Coordination of care is not a new role for nurses, but it has never been fully appreciated. As nurses, we coordinate patient care and ease the transition from hospital to home, often preventing readmission to hospital and improving the quality of patients’ lives. Finally, this vital role is being seen as a valuable one, not just in terms of patient care, but in financial terms for nurses who perform this essential service.

The Medicare fee schedule is set to change in January of 2013. It contains new codes that will have a great impact on care coordination, which is typically performed by nurses in a physician-supervised setting. Currently, reimbursement for non-face-to-face visits is lumped under payment for face-to-face visits. Both physicians and nurses have argued that the current codes are insufficient, as they do not account for communication with persons other than the patient, home visits or conveyance of patient information over the phone, common practices which are not adequately addressed under the current codes.

“Specifically, this HCPCS G code would describe all non-face-to-face services related to the TCM furnished by the community physician or qualified nonphysician practitioner within 30 calendar days following the date of discharge… The post-discharge TCM service includes non-face-to-face care management services furnished by clinical staff member(s) or office-based case manager(s) under the supervision of the community physician or qualified nonphysician practitioner” (Centers for Medicare and Medicaid Services, 2012).

Required elements for post-discharge transitional care management include:

  • communication with the patient/caregiver within two (business) days of discharge (communication by phone, electronically or face-to-face)
  • medical decision-making of moderate to high complexity
  • to be eligible to bill for the service, there must be a face-to-face visit with the patient within 30 days of the transition in care or within 14 (business) days following the transition in care

What does this mean for nurses? Nurses provide an essential service and should be reimbursed for this service, according to the American Nurses Association. Care coordination activities are often performed by RNs and have been shown to reduce patient costs, improve outcomes, prevent readmission to hospital and increase patient satisfaction. This move by the CMS increases the likelihood that nurses may soon be able to directly reimburse for these services. This may create the need for new nursing jobs to fill the growing need for nurses skilled in this area, particularly as the population is aging rapidly and more elderly individuals are living in the community.

As physicians will be able to bill for services performed by nurses who provide transition services, this will encourage the growth in jobs in this area. “Although the rule does not allow separate billing for care coordination, some private insurers likely will use the codes to reimburse providers directly for the service…[reimbursement policy] could expand the RN job market and raise recognition for nurses” (, 2012).


Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DMEFace-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013. Centers for Medicare and Medicaid Services, 2012.

CMS rule creates reimbursement opportunities for RNs., November 15, 2012.

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The Affordable Care Act

Posted in Nursing, Nursing News

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The election is over and Barack Obama has won a second term. Although many people may have been hedging their bets, waiting on the outcome of the election, the Affordable Care Act is here to stay. What does this mean for Medicare, healthcare institutions, healthcare workers and the general public? As nurses, we care for our patients regardless of insurance status, but we all know that insurance is a major issue for many of our patients. Keeping in mind that some of the key features won’t be implemented until 2014, here are some of the highlights of the Act and how they will affect individuals and corporate entities:

Health insurance: At the present time, no one is required to have health insurance, but by 2014 this will change. Most individuals will be required to have health insurance or face a fine of up to 1% of their income (or $95 per year, whichever is greater). By 2016 the fine will rise to 2.5% of income or $695, whichever is greater. For families, the penalty for not having insurance will be 2.5% of the combined household income. However, these requirements could be waived when financial hardship is an issue. Some states have passed laws to block the necessity of carrying health insurance; however, federal law supersedes state law. Many more people are expected to be eligible for Medicaid or will be able to access federal subsidies to buy health insurance.

Current health insurance plans: For those individuals who already have insurance through their current employer, it is possible that nothing will change. However, employers may change premiums, network coverage, co-pay amounts and deductibles, just as they could before the Affordable Care Act. Some of the effects of the Affordable Care Act have already been enacted; for example, lifetime coverage limits have now been banned, and adult children (up to the age of 26) who don’t have health insurance through work can stay on their parent’s plan.

Medicaid: For people who want health insurance but can’t afford it, starting in 2014 the federal government is offering to expand the Medicaid program so that individuals and families who earn incomes at or lower than 133% of the federal poverty level will be eligible for this benefit. This is not yet a hard-and-fast law — the governors of several states, such as Alabama, have stated that they will refuse the expansion of Medicaid and the Supreme Court has ruled that states cannot be mandated into making this change to Medicaid. For people who earn too much money for Medicaid but still can’t afford health insurance, government subsidies will be put in place to allow them to purchase insurance from state-based exchanges, which will sell insurance to small businesses and individuals.

Seniors: Changes to the Medicare Part D prescription plan will mean that seniors will only be required to pay for 25% of their prescription costs, without a certain initial cost to be paid first before coverage begins. Preventive services will be expanded and seniors will be allowed a free annual wellness visit.

Other changes:
– No out-of-pocket costs for certain screening tests (i.e., mammography, cholesterol tests)

– Coverage cannot be cancelled if you become ill (known as rescission)

– Coverage for pre-existing conditions cannot be refused (for children this is already the case, for adults will be enacted by 2014)

– Rebates to be provided to customers if they spend less than 80-85% of premium dollars on medical care

Like it or hate it, agree or disagree, the Affordable Care Act is here to stay. Although there is apt to be some confusion over the next two years, as well as some contention as the last kinks in the plan get worked out between Democrats and Republicans, the end result will be that most people will have health insurance by 2014.

Addicted to Helping People

Posted in Nursing, Nursing Jobs, Nursing News, Nursing Specialties


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A new book focusing on American nurses is nominally a book of portraits, intended for coffee tables. But a doctor writing in the New York Times, Abigal Zuker, found the the narrative to be the most affecting part, hitting her “in the solar plexus.”

For example, she appreciated the observation of a hospice nurse named Jason Short in rural Kentucky who has had a number of jobs, including auto mechanic and commercial trucker. He turned to nursing when the economy went under. This pragmatic decision turned into something more, and Mr. Short says he’s a nurse for good. “Once you get a taste for helping people, it’s kind of addictive,” he says in the book, called “The American Nurse.”

The book tells the stories of 75 nurses. Some of them wanted to be nurses from when they were very young, while others took Mr. Short’s more pragmatic approach. All of the nurses profiled exhibit the same “surprised gratitude,” according to Dr. Zuker.

The nurses profiled come from many different health care settings from many different places in America, ranging from large academic institutions like Johns Hopkins to very small places like the Villa Loretto Nursing Home in Mount Calvary, Wisconsin. There are administrators, home health care workers, emergency room nurses, military nurses, and much more.

All describe unique professional paths in short first-person essays culled from video interviews conducted by the photographer Carolyn Jones. Their faces beam out from the book in Ms. Jones’s black-and-white headshots, a few posing with a favorite patient or with their work tools — a medevac helicopter, a stack of prosthetic limbs or a couple of goats.

But even the best photographs are too static to capture people who never stop moving once they get to work. For a real idea of what goes on in their lives, you have to listen to them talk.

Here is Mary Helen Barletti, an intensive care nurse in the Bronx: “My whole life I’ve marched to a the beat of a different drummer. I used to have purple hair, which I’d blow-dry straight up. I wore tight jeans, high heels and — God forgive me — fur (now I am an animal rights activist). My patients loved it. They said I was like sunshine coming into their room.”

Says Judy Ramsay, a pediatric nurse in Chicago: “For twelve years I took care of children who would never get better. People ask how I could do it, but it was the most fulfilling job of my life. We couldn’t cure these kids, but we could give them a better hour or even a better minute of life. All we wanted to do was make their day a little brighter.”

Says Brad Henderson, a nursing student in Wyoming: “I decided to be a nurse because taking care of patients interested me. Once I started, nursing just grabbed me and made me grow up.”

Says Amanda Owen, a wound care nurse at Johns Hopkins: “My nickname here is ‘Pus Princess.’ I don’t talk about my work at cocktail parties.”

John Barbe, a hospice nurse in Florida, sums it up: “When I am out in the community and get asked what I do for a living, I say that I work at Tidewell Hospice, and there’s complete silence. You can hear the crickets chirping. It doesn’t matter because I love what I do; I can’t stay away from this place.”

The Skills of Advocacy

Posted in Nursing, Nursing News


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Nurses are often strong advocates for their patients, but have traditionally been less effective in advocating for their own needs. Advocacy can be defined as supporting a cause — it’s as simple as that. Advocates are people who identify a need or an issue that must be addressed, then work through different channels to achieve a goal. Political lobbyists have perfected advocacy, but nurses have been slower to mobilize and understand that real change in healthcare is possible when nurses become strong advocates for themselves, for their peers, and for the nursing profession.

Identifying a problem and desiring change is not enough — nurses must utilize the skills they learn in advocating for their patients and transfer these skills to a broader arena in advocating for the nursing profession. So what skills are needed? Karen Tomajan (Medscape, 2012) outlines the necessary skills as follows:

Problem solving: As nurses, we problem-solve on a daily basis. Problem solving involves identifying an issue and developing a strategy to solve the issue or problem. While this is easy enough to do in our daily working life, it becomes more difficult when advocating for a broader issue or change. The bigger the arena and the issue, the greater the number of people that must be convinced and the longer it takes to effect change. Doing our homework beforehand thus becomes necessary if we want to be effective advocates. This may involve identifying key stakeholders, researching the issue at hand to ferret out compelling evidence to support the chosen stance, and determining the best time and place to go forward.

Communication: Although we talk about communication a great deal in nursing and communicate on a daily basis, advocacy means effectively delivering your message to the right people in the right way. Communication may be verbal, written or electronic in nature and must fit the target audience’s needs. Using real examples backed up by facts, rather than opinions, can make an argument more compelling. Discussing the positive impact of an issue or change is crucial to winning the approval of those you have identified as key decision-makers.

Influence: Influence refers to one’s ability to alter individual or group thoughts, actions or beliefs. Advocacy requires influence to succeed, and the person or persons delivering the message must be credible, trustworthy and competent in order to successfully sway others to their position. This requires the ability to build a compelling case for change, back up the argument with hard facts and convey the positive impact that the desired change will have on the issue at hand. Influence must be tempered with relatively small amounts of persuasion which, according to Tomajan, can backfire if utilized too heavily.

Collaboration: As nurses, we frequently work with a wide variety of other healthcare professionals. Advocacy for a cause may require nurses to move beyond other healthcare workers and seek out groups or individuals that can further the cause, such as people who will be affected by the issue or individuals/groups with their own intersecting agendas (i.e. members of the legal community, government or special interest groups). Collaboration requires mutual respect, trust and credibility, as well as frequent and honest communication. What is the end result of collaboration? When groups with similar concerns or interests work together, they can achieve more than if they were to tackle the issue alone; in other words, there is strength in numbers.

Given the rapid changes occurring in the healthcare system, nurses need to come together to advocate for themselves and the profession. As more and more pressure is placed on nurses to do more with less, advocating for our patients is no longer enough — we must also advocate for ourselves to ensure that the future of healthcare is bright and sustainable. As Tomajan points out, “Despite nursing’s strengths inherent in its size, diversity, and unique relationship with the public, the full potential for influence by the nursing profession has yet to be realized.”

Getting Political

Posted in Nursing, Nursing Jobs, Nursing News, Nursing Specialties


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“Healthcare is political,” says a nurse quoted in this article on The article looks at why some nurses have become politically active.

Pat Barnett was motivated to get involved in the legislative process in 1976, when she was a young nurse working for a state psychiatric hospital. At the time, deinstitutionalization was underway, with attempts by the state to move people from state facilities to the community. Barnett felt that she couldn’t just stand by and watch what she saw as a great injustice, as people were discharged from the state institutions but then had nowhere to go, and were given very little support. “So you would see people end up in the No. 1 institution for the mentally ill,” says Barnett. “Jail.”

She testified along with other nurses and they were able to get more funding for the mental health system, allowing some facilities to remain open.

Barnett points out that nursing is a highly regulated profession, which means that it’s especially important for nurses to be active and engaged politically.

The current state of healthcare and the upcoming presidential election add to that urgency, Barnett says. The points out that the Affordable Care Act alone has a great impact on nurses. If it stands, there will be 900,000 new patients in the state of New Jersey who will have new health coverage. Right now there are 1,400 too few primary care doctors — Barnett sees nurses as possible saviors.

“We have 5,000 advanced practice nurses, 80% of whom actually practice in primary care, and many of those take Medicaid and Medicare patients,” Barnett said. “So I think nurses need to be involved because the Affordable Care Act creates opportunity for nurses, whether or not they are advanced practice nurses. Also, there is money in the Affordable Care Act to create nurse-run clinics — and money for nursing education. That happened only because the American Nurses Association, other nursing associations and individual nurses lobbied the legislature and their individual legislators to make that happen.”

The Institute of Medicine weighed in on the importance of nursing input in its October 2010 report, “The Future of Nursing: Leading Change, Advancing Health.” According to the IOM, nursing is at a pivotal point.

“Nurses’ roles, responsibilities and education should change significantly to meet the increased demand for care that will be created by healthcare reform and to advance improvements in America’s increasingly complex health system,” the IOM announced after releasing its report.

Even as the largest healthcare profession, nursing’s voices often are silent or ignored, according to Vance.

“I believe our values and concerns should be heard to help our patients and our profession,” she said. “We have to decide whether we want to make our voices heard, [and have] input in the decision-making around our practice. Or, they’ll make these decisions without our input.”

Many nurses, like a number of Americans, think politics is a dirty word, according to Linda Parry-Carney, RN-BC, MA, education specialist at Hackensack (N.J.) University Medical Center.

Parry-Carney is a former president of the New Jersey State Nurses Association and the current chairwoman of the board for the New Jersey Collaborating Center for Nursing.

What nurses might not realize, she said, is they already are politicians, whether they’re negotiating with patients at the bedside, with employers, on hospital committees or as members of organizations.

Legislators don’t act alone. They make decisions based on what their constituents want, according to Parry-Carney.

“[As NJSNA president,] when I needed to talk to the Governor’s staff, an assemblyperson, senator or the commissioner of health, it wasn’t just me sitting in front of him,” she said. “He knew I represented the interests of all the people who were members of our organization, and, in fact, all nurses in New Jersey.”

One nurse sharing his or her perspective helps formulate strategies that groups use in an effort to influence policy and make changes.

“Every nurse should be a ‘political’ nurse because we are such a caring, large constituency for people,” Vance said. “We are important to society. We’re important to people. So we have to take our practice beyond the bedside, beyond the school, beyond our research, and set it in a larger way into community involvement, which means being an activist, being a volunteer, being an informed citizen.”

Mandatory Flu Shots for Healthcare Workers

Posted in Nurse Safety, Nursing, Nursing News


Rhode Island has officially become the first state in the United States to mandate flu shots for all healthcare workers, despite objections from unions and the local affiliate of the ACLU (American Civil Liberties Union). This means that all healthcare workers employed by hospitals, nursing homes, home care agencies, or any other healthcare organizations in the state will be forced to roll up their sleeves.

Of course, anyone who has a valid medical reason can be exempted from getting a flu shot. Employees can also refuse to get a flue shot by signing a document; however, these workers must wear a mask at all times when in contact with patients when flu activity is noted in the state.

Arguments Against

– The “Nanny State” argument: Our bodies and anything we put in our bodies should not be controlled by the government. Many people disagree that the government has any right to tell healthcare workers to get a vaccine that is potentially dangerous and could cause dangerous side effects. This argument seems to be the most commonly cited argument against getting an influenza vaccine. Health concerns aside, many people are firmly against the government forcing healthcare workers to get a flu shot, as a matter of principle.

– Ineffectiveness of the vaccine: Many of those against mandatory vaccination state that they do not believe the vaccination is effective in preventing influenza.

– Danger associated with vaccination: Many healthcare workers state that they became ill after receiving a vaccination at some time in the past, and so they have refused to get the vaccine ever since. Although serious reactions are rare, the fact that serious reactions do sometimes occur, even if very rarely, makes many people adamant that they will not get the shot and will not be forced into it by anyone, especially the government.

Arguments For

– Patient protection: We owe it to our patients to get vaccinated. In doing so, we protect those who are vulnerable (i.e., infants, the elderly, immunosuppressed individuals) and could potentially die should they come in contact with the virus.

– Herd immunity: When a large enough portion of the population is immunized against a particular disease, most members of the community will be protected because there is little opportunity for the disease to spread. Herd immunity protects the most vulnerable members of society and, as nurses, it is our duty to protect others.

– Role modeling: Many nurses state that, although they are not against the vaccine per se, they are against the vaccine for themselves. As nurses we are role models for others. When members of the community hear nurses speak out against influenza vaccination, it makes them less likely to get vaccinated, as nurses are respected as being knowledgeable about disease prevention.

– Vaccination reduces sick time: When nurses are immunized, there is less sick time, resulting in lower absenteeism, less overtime and less need to replace ill staff members. This could be an enormous cost-saving measure at a time when many organizations are struggling financially.

There are other arguments, but these arguments cover some of the biggest reasons for and against influenza vaccination. When it comes right down to it, we all have choices. Even the nurses in Rhode Island have a choice — they can get the vaccine or wear a mask when in contact with patients during the height of flu season. Getting the vaccine must be a personal choice for all nurses, one that many nurses struggle with every year.

Popularity of Nurse-Midwives is Rising Again

Posted in Nursing, Nursing Jobs, Nursing News, Nursing Specialties

October 1st, 2012
Jenna Fischer

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This article on the Boston Channel website looks into the increasing popularity of nurse-midwives after a period of decline.

For example, a woman named Carla Tonks decided to switch to a nurse-midwife program when she was pregnant with her first child seven years ago. She hadn’t been impressed with her experience with the ob-gyn, especially the long waits at his office that resulted in actually seeing the ob-gyn for only 10 minutes.

She switched over to a nurse-midwife program and was much happier. She moved away from Massachusetts and became pregnant with her second child, and this time sought out a nurse-midwife in North Carolina, her new location. This experience went well too, and she kept up the trend with her third child after she returned to Massachusetts. In the article she pronounces herself “very happy” with nurse-midwives, and appreciates that they can spend more time with mothers-to-be.

Midwives, which were the rule until the mid-20th Century, are becoming more popular again. According to a report by the American College of Nurse-Midwives, 11.3 percent of vaginal births and 7.6 percent of all births were attended by either certified nurse midwives (CNMs) or certified midwives (CMs) in 2009. The number has risen each year since 1989. Certified midwives are not nurses but have Master’s degrees.

Anna Jaques offers nurse-midwives. Either type provides care to women during pregnancy, labor and birth, as well as during the postpartum period. They typically handle low-risk pregnancies.

“We do all the check-ups, all the prenatal care,” says Walsh, one of five nurse-midwives on staff at Anna Jaques. “If a complication arises, we consult with the physicians. They are always on call. If the patient needs a C-section, the physicians take over. But we are still in the operating room.”

Tonks said she did develop high blood pressure during her most recent pregnancy, but she decided not to transfer to a doctor’s care.

“The nurse-midwives can take on a lot more than you think,” she says.

Another plus was that over the course of her pregnancy, Tonks developed close relationships with all the nurse-midwives at the hospital, so if Walsh, for some reason, was unavailable at the time of delivery, Tonks would still know the person performing the delivery in her stead.

Are Nurses Too Noisy?

Posted in Nursing, Nursing Jobs, Nursing News

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As nurses, we are sometimes guilty of making a little too much noise, especially at shift change when our numbers temporarily swell, and during the night when we are attempting to stay awake using any means at our disposal. Sometimes noise is not entirely our fault, such as when a confused patient cries out in the night, oblivious to others who are trying to rest. Let’s face it — hospitals can be noisy places, and while certain noises can be controlled, others cannot.

Some areas are understandably noisier than others. Newborn nurseries can be loud, especially when several infants are vying for attention at the same time. The emergency room can be a very noisy environment, usually full to overflowing with multiple patients in extremis.

Patients in the ICU are exposed to not only the noise emanating from other patients, but from a variety of equipment that beeps, honks, rings and clangs — it’s enough to drive anyone mad! So how do patients perceive the noises encountered in the ICU? A study from the University of Gothenburg set out to answer this question.

Researchers registered and recorded the level of sound around thirteen seriously ill ICU patients over a full 24-hour period of time. On average, the sound levels around the patients fell between 51 and 55 decibels (dB). How loud is 55 decibels? This level of noise can be compared to lying beside a busy road. This level of sound is approximately 20 decibels higher than the level recommended by the World Health Organization. Worse, the noise level surrounding the study participants sometimes rose to a level of 100 decibels in short bursts.

The patients categorized the noises they experienced as being either positive or negative. The positive noises included staff members chatting quietly among themselves or providing information regarding a patient’s conditions or treatment. These sounds were viewed as comforting and soothing, rather than annoying or bothersome.

Negative sounds were those sounds that were unpredictable and/or uncontrollable. Examples included noises from machinery, other patients or treatments. Sounds that were loud and unidentifiable were also frightening. Sounds even became part of the hallucinatory landscape for one patient in the study. Sudden loud noises were deemed to be more disturbing than a generally loud and constant noise level.

What level of noise is acceptable? The World Health Organization actually recommends a level of 30 decibels for patient rooms. Most of us do not walk around with a sound pressure level meter in our pocket to determine how much noise we are making; however, we should make every effort to provide a quiet, calm and restful environment for our patients. Being in a loud environment is not only unpleasant, but the resulting lack of sleep has been found to have a real impact on health outcomes.

Of course, we are only human and are sometimes guilty of laughing or talking a little too loudly, but on the whole we should be cognizant that sound travels and can reach the ears of patients who are trying to earn that most valuable of commodities in a busy hospital environment — a good night’s sleep.

Nurses Mentoring Nurses

Posted in Nursing, Nursing News, Nursing School

September 17th, 2012
Jenna Fischer

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A pilot mentoring program based in Nevada is hoping to accomplish at least two things. First, help nurses figure out how to take their “book learning” from nursing school and put it into practice. The program also aims to help the experiences nurses who will serve as mentors to rekindle their own excitement about the profession.

The program is called the Nevada Nurses Association Mentoring project, and is sponsored by a grant from the American Nurses Association, according to this article on Nurses with at least three years’ experience and newly licensed nurses each complete profiles and then are matched according to compatibility. Then the mentor-and-mentee pairs communicate via email about any questions or concerns the mentees may have.

The time commitment is minimal — the article states that only 15 minutes a week for 8 weeks is required from the mentor nurses.

Nurses who have just graduated and are facing the real-life challenges of their first shifts often are left “without the parachute” of a classroom environment, said Denise Ogletree McGuinn, RN, APN, who is one of the mentors and the director of the program. “It’s a critical time,” she said. “They need someone who can take them by the hand and tell them what they’re feeling is normal.”

Networking can be difficult, especially in Nevada where vast open spaces separate large population centers. Nurses with questions about a particular specialty may have to travel a long way to mingle with someone in their field.

For experienced nurses it’s a chance to remember why they chose nursing in the first place and an opportunity to “rediscover our joy,” McGuinn said. For struggling nurses, she said having someone to turn to who is not a boss or co-worker can be “like a hot bowl of macaroni and cheese.”

By early September, 10 matches had been made and five mentors were awaiting mentees. McGuinn said they are hoping for at least 250 matches in the next month.

The hope of the program is not only to help nurses through the early years, but also to get them engaged in their profession and ready to help the people who come after them. “These are our leaders of tomorrow,” McGuinn said.

Making Time for Reflective Practice

Posted in Nursing, Nursing News, Nursing School

September 12th, 2012

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An interesting question was raised online in Nursing Times: Do nurses have time for reflective practice?

Reflective practice can be defined as reflecting on experiences in order to critically evaluate what you do well and how you might improve your personal nursing practice (i.e. skills, communication, interpersonal relationships, professionalism, beliefs, values and behavior). It involves the process of critical thinking. Nursing students are encouraged to perform reflective practice throughout their nursing education; in fact, reflective practice is often a formal component of nursing education in the form of journaling or other forms of writing that are evaluated by nursing instructors.

What happens when we graduate from nursing school and enter the “real world”? How many of us take the time to reflect critically on our nursing practice? How many of us have the time to practice critical reflection?

Some might argue that nurses are not allowed the time to practice critical reflection in the workplace. Many nurses are overworked, with too many patients and too few staff members available. Many nurses are focused on whether they will have time to break for lunch or visit the washroom, let alone take the time to engage in reflective practice.

However, reflective practice does not need to be as formal as it was in nursing school. Most of us engage in reflective behavior regarding our experiences as nurses on a daily basis, but don’t recognize that that is what we are actually doing. For example, when conflict arises with a patient’s family member, we may spend time thinking about how we responded to the family member’s criticism. We may take it a step further when we discuss the issue with our colleagues and ask their opinion about how we handled the situation, perhaps soliciting advice on how to better handle a similar situation in the future. We may grieve the loss of a patient to whom we had grown close, or dread the imminent loss, and spend time reflecting on how the relationship we formed with the patient was special or different from relationships with other patients, and why this particular patient moved us. We may engage in an informal debriefing session following a particularly difficult trauma in the ER, identifying ways to improve performance and what might have been done differently. These are all common scenarios and are examples of reflective practice, whether we think of them in that fashion or not.

The bottom line is that reflection does not need to be a formal process (although it can be if you prefer). As nurses, we constantly strive to become better practitioners. Just as formal continuing education is a requirement of the profession, so too is reflective practice. Reflection is a skill that we learn in nursing school that becomes engrained in our psyche.

We first learn the practice of critical reflection in the form of reflective activities and assignments that nursing instructors comment on, pointing out things we perhaps did not or would not have realized without someone’s greater experience. As we evolve in our ability to reflect critically in regards to our practice, our reflection becomes a reflex, a skill we have learned that we no longer think about consciously while performing, much like the physical skill of inserting an IV or taking a blood pressure reading.