Presence.  When you've got it, you're at your professional best. You walk into your patient's room and from the first step all your senses are trained on what's there.  A whiff of C-Diff, perhaps, or that unmistakable pitch to the cries that mean kidney stones.  All your experience and judgment is in action.  This is what it feels like to be a truly great nurse, the kind patients hope for and doctors trust.  Can we be that kind of nurse?  Can we do it consistently?  How do we get there?  What are the obstacles?  How can we overcome them?

As we've grown more skilled, we've grown more expensive.  As we command higher salaries, more of the routine work -- taking vital signs, ambulation, hygiene, that kept us in touch with our patients -- must of economic necessity be delegated to nursing assistants and others.  We used to give bed baths, and we multitasked:  assessing for skin breakdown, listening for level of consciousness, checking mobility, emotional status, and discussing family and social concerns. These routines supported us in staying present.  Even without them we can do so, though with less experiential information of and fewer minutes with our patients.

It's subtle.  It's more than knowledge of physiology, diagnostics, or accurate performance of nursing procedures.  It's more than caring, empathy and sensitivity.  Patricia Benner wrote about this in  From Novice to Expert.  Every nursing school would love to possess the magic formula that would enable them to bestow this mindset on their disciples.

Though Benner didn't call it presence, we find that term useful.  It represents a state of mind in which listening and attending to details is foremost.  It's almost a Zen state of mindfulness, though the nurses who do it are the opposite of zoned-out -- they are supremely present.

The obstacles to presence are numerous.  Piled onto nurses by their hospitals, their unions, regulatory agencies, certifying boards, and insurers are ever more strictures, guidelines and regulations.  The work grows ever more technical, with elaborate procedures involving medication regimens and treatment protocols.  The job is now extremely technical, with many details to manage and opportunities for error.  It's hard to be present when you're worried about forgetting something.

Remembering everything is a remarkable challenge.  One reason is that there's so much to remember.  Another is that the workplace is so dynamic, with patients' health statuses changing from moment to moment in today's health care system in which inpatients are sicker than ever.  On top of this is frequent interruption.  Often even the interruptions are interrupted.  One easily forgets to complete the original task.  To reduce medication errors, Kaiser now has a policy that requires nurses to wear a yellow sash when passing meds, to tell other clinicians that these nurses are not to be interrupted.  Many nursing procedures demand follow-up such as checking, half an hour after administering it, that a pain med is effective.  Another example is paging a physician or the pharmacy with a question and remembering to follow-up if they don't call back.  Another example is remembering to turn your unconscious patient in their bed every couple of hours so that painful and expensive pressure ulcers don't develop.

These examples and many more comprise the cognitive burden of nursing.  NASA has made extensive studies of the cognitive burdens of spacecraft piloting.  When the mental load is excessive, pilots make mistakes.  Control panels and workflow receive great design effort to make sure this doesn't happen.  Nursing deserves no less.  It also deserves tools to support those busy brains.

The cognitive burden is a big obstacle.  To overcome it, we devise tools -- for example, those paper "brains" we carry in our pockets to jot and consult.  We are clever, for example using colored pens so that a notation in red reminds us that an IV med is due.  They help us remember things, but they are rudimentary and inflexible. Electronic tools offer the promise of speedier access, and built-in "knowledge" of nursing processes.  For example, it is easy to program a "smart" alarm clock to ring every couple of hours as a reminder to turn that bed-bound patient.  Generalizing this concept yields a to-do list with timings;  it knows not only what must be done but when.

When you can proceed with confidence that nothing's being forgotten, you can relax and be present.  And when you're fully present, your patients get the best care and you are the best nurse you can be.

PS -- Here is my paean to the professor who taught me about nursing presence.