In a nutshell . . . .

In this page you're introduced the idea of "Perfect" skill in fostering safety and comfort. This idea is the other of the two Practice Competence & Excellence (PCE) dimension ideas that underlie how the other six PCE ideas are implemented.

You'll find that although 19^th century nurses placed great value on aiming for "perfect" skill, many contemporary nurses reject the idea of perfection because it can't be attained. Instead, of aiming for perfection, contemporary nurses aim for excellence because they think everyone can attain excellence.

You'll find a discussion about these different points of view. You'll be able to consider the Careful Nursing conclusion – that the quotation marks around "perfect" indicate that although perfection in itself is not possible in nursing practice, it is an ideal to be worked toward.

Further, you'll find the Careful Nursing interpretation of what the 19^th century nurses actually meant by aiming for perfection; they related it the art of practicing beautifully. Thus, "Perfect" skill in fostering patients' safety and comfort concerns the art of nursing. This interpretation is discussed in light of comments by the great artist, Michelangelo Buonarroti, on achieving beauty in one's work.

Keep in mind that "Perfect" skill in fostering safety and comfort, together with Great tenderness in all things, indicate the behavioural quality that underlies the PCE dimension as a whole. The clinical actions described in the remaining six ideas are implemented with Great tenderness . . . and "Perfect" skill . . . 

Introduction

"Perfect" skill in fostering safety and comfort is the second of the two Practice Competence and Excellence (PCE) concepts that underpin how nurses implement the additional six concepts of this dimension; together with great tenderness in all things this concept provides the context for PCE. Before continuing, please take a minute to review the two figures on the PCE introduction page above to remind yourself how this concept relates to the other seven PCE concepts.

This concept is currently defined as:

Nurses' meticulous attention to all details of patient care, from the most elementary personal care to the most complex interactions and techniques. This includes precision in intellectual skills, such as theorizing about processes of care, diagnostic accuracy in selecting correct nursing diagnoses and achievable outcomes, and administering appropriate nursing interventions. The quotation marks around "perfect" emphasize that although faultless detail can be essential, for example, in medication administration, perfection is also an ideal to be worked towards. (Meehan, 2012, p. 2911).

The 19th-century nurses combined the ideas of "perfection" and skill into a standard they applied to all aspects of their clinical practice in order to achieve for patients the highest possible levels of safety and comfort. At the same time, their understanding and use of these words was somewhat different from how the words are understood today. 

Skill

In the 19^th century, the highest nurse designation was skilled nurse because the professional nurse did not yet exist.

Skill was defined as "the familiar knowledge of any art or science, united with readiness and dexterity in execution and performance, or in the application of the art or science to practical purposes" (Webster's, 1891, p. 1349). Importantly, this definition assumes that a practical skill is based on knowledge of an art or science.

Today the common definition of a skill is the ability to do something with expertise acquired through training, experience, or practice, for example, to perform physical skills and procedures with expertise. But today a skill is often conflated with a task, which can mean a chore or burdensome activity sometimes done unwillingly.

Careful Nursing follows the 19^th century definition of skill because it specifies that intellectual skill is as important as actual practice skill; both provide the foundation for practice performance. Careful Nursing also proposes that nurses can take skill to a higher level by aiming for "perfection".

"Perfect" skill questioned

But, what is perfection?

Should nurses really take a skill to a higher level by aiming for perfection?

Why quotation marks around "perfect"?

Perfect

The nature of perfection and whether human beings can be perfect is widely debated in philosophy, literature, theology and bioethics.

Generally, the word perfect has two shades of meaning (Perfect 2019):

1. to make something as good as possible, e.g., nurses strive to make the people they care for as safe and comfortable as possible.
2. something completely free from faults or defects, e.g., nurses can achieve absolute safety and comfort for all people they care for.

Contemporary views of perfection

In contemporary popular media the idea of perfection and aiming for perfection is widely rejected. It is recognised that perfection cannot be attained so it is considered unrealistic and self-defeating to even aim for perfection. It is claimed that aiming for perfection can only lead to fear of failure and disapproval, and feelings of dissatisfaction, unworthiness and humiliation.

Broadly, in place of perfection, it is advocated to aim for excellence. Although excellence is defined in different ways, it is mostly understood as demonstrating a good quality to a higher than usual degree; everyone is considered to be capable of excellence.

In nursing literature it is generally accepted that most nurses seek to practice their profession as well as they possibly can; to aim to for perfection, even in the face of many stresses and pressures and their recognition that they are not perfect. Nurses also aim for perfection in the process of achieving excellence.

However, some nurses who argue from a post-modern social constructionist viewpoint interpret nurses' natural desire to practice as well as possible as their expectation that they can practice perfectly (Morgan & Georges 2015). These authors view perfection as a socially constructed concept that distorts nurses' understanding of their practice and of themselves, thereby oppressing nurses and robbing them of power in their practice setting.

But the nursing literature and everyday practice experience show that most nurses value seeking to practice their chosen profession as well as possible; to aim for perfection while at the same time knowing that absolute perfection is not humanly possible. 

Perfection in Careful Nursing philosophy

Aristotle (circa 350 BC/1993) defines perfect as:

1.  that which contains all its requisite parts
2.  is so good that nothing of its kind could be better
3.  it attains its purpose

Aristotle encompasses the idea of perfection in his virtue theory, which in a certain sense can also be thought of as a value theory. Aristotle's virtue (value) theory proposes that perfection and excellence foster human flourishing and can be attained through the practice of virtues, that is, behaviours of high moral value, for example, having self-control (temperance), being courageous, being prudent or being just.

Although Aristotle thinks a God exists and is perfect being, he thinks this reality is far too distant from human beings to have any relationship with them. Overall, Aristotle reasons that perfection, excellence and human flourishing can be attained in this life, but only by very few people.

Aquinas (1265-1274/2007, II, II, Q 184, Art. 1) builds on Aristotle's definition of perfect and proposes that something can be perfect in two ways:

1. perfect in itself
2. perfect in the way it serves its purpose

Aquinas both builds on and transforms Aristotle's virtue (value) theory. He interchanges Aristotle's distant God with the personal, transcendent, creator God of Christianity who seeks to be personally present to all human beings.

Aquinas also proposes that virtues (values) are desirable because their purpose is to help human beings to aim for perfection, making them and their activities good. Aquinas adds to his virtue (value) theory three additional virtues (values); faith, hope and love. The virtue (value) of love has a fundamental influence on how perfection, excellence and human flourishing are understood. According to Aquinas, God (Infinite Transcendent Reality) is love and is absolute perfection. For Aquinas, human perfection is a metaphysical reality that can be understood in the mind but cannot be achieved in action in this life; it can only be aspired to. 

Does Careful Nursing philosophy support perfection in nursing?

Careful Nursing gives precedence to Aquinas, thus the answer is that nursing practice cannot be perfect in itself.

At first glance, it may seem that nursing practice could be perfect in the way it serves its purpose, that is, helps nurses aim for perfection, for example: nurses' provide all steps of oral health maintenance for disabled persons with kindness and gentleness such that disabled persons' always score 5 on oral hygiene (highest possible score).

However, if the example is changed to: nurses' follow all the required steps of medication administration for disabled persons with kindness and gentleness such that disabled persons' always receive their correct medication and dose of medication, it appears that nursing practice cannot be perfect in the way it serves its purpose. The literature certainly demonstrates that medication errors by nurses have long been and remain a major concern in healthcare.

The quotation marks around "perfect" indicate that perfection in itself is not possible in nursing practice but is an ideal to be worked toward.

The idea of perfection transformed: practicing nursing beautifully

In Careful Nursing, understanding of perfections is linked to understanding of Infinite Transcendent Reality as perfect being which infuses the human mind with love, goodness, truth and beauty. "True beauty and goodness then nourish the [human] soul and enable [human beings] to see the real; and therefore beauty contributes to the perfection of our lives (Ramos, 2013, pp 6-7).

Nurses can know in their intellect or mind the perfection, love and beauty of Infinite Transcendent Reality; they can also know in themselves and in the people they care for "the beauty that [radiates] from the interior of human persons and their actions" (Ramos 2004). Good actions are also beautiful actions because they are harmonious, proportioned and moderated by reason.

Thus, good nursing actions are also beautiful nursing actions because they are harmonious, proportioned and moderated by nursing knowledge. For example, in assisting disabled persons with oral health maintenance nurses assist them with tooth brushing in a kind, gentle, rhythmic and balanced manner.

Perception of the beauty of good nursing actions is pleasing, even joyful, for nurses; it fosters their desire to practice with "perfect" skill.

"Perfect" skill, beauty and nursing as an art 

In effect, "perfect" skill means practicing nursing beautifully. The 19^th century nurses' documents fully support this meaning. To do something beautifully means that it is aesthetically pleasing to the mind and done to a very high standard (Beautifully 2019). This meaning leads us to nursing as an art; practicing nursing beautifully is intrinsic in the art of nursing. Timmons (2011) reminds us about the importance of "Remembering the art of nursing in a technological age" (p. 161). Practicing nursing beautifully is central to the art of Careful Nursing.

Hints from a master on 'perfect' skill, beauty and art

Let us consider our practice in light of comments attributed to Michelangelo Buonarroti (Goodreads, 2015).

"Trifles make perfection, but perfection is no trifle". Small things, which could seem unimportant, contribute to perfection. For example, small acts of kindness such as a passing smile, patiently giving sips of fluid or noticing the need for gentle repositioning of a limb.

"The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark". There is a certain danger in complacency. Why not aim toward perfection; even knowing that perfection is not possible in itself, there is pleasure and beauty of intention in doing one's best.

"A man paints with his brains and not with his hands". Another way of saying that how we practice depends on how we use or intellect; on what we know.

"The true work of art is but a shadow of the divine perfection". This reflects what the 19th century nurses had in mind as they aimed for "perfect" skill in their practice. We are reminded that art, our nursing art, has a spiritual dimension.

 "Lord, grant that I may always desire more than I accomplish." Here is where we reach for the stars.

 "Perfect" skill in fostering safety and comfort: A possible revision of definition:

Nurses' recognition of the art, goodness and beauty of nursing practice achieved by harmonious and meticulous attention to all details of patient care, from the most elementary personal care to the most complex interactions and techniques, including precision in intellectual skills, such as theorizing about processes of care, diagnostic accuracy in selecting correct nursing diagnoses and achievable outcomes, and administering appropriate nursing interventions. Quotation marks around "perfect" indicate that "perfect" skill in itself is not possible, but an ideal to work towards. 

Your "perfect" skill in fostering safety and comfort self-rating:

On a scale of 1 to 10, how do you rate your capacity to demonstrate "perfect" skill in fostering patient' safety and comfort?

Based on your assessment of your current capacity to demonstrate "perfect" skill in fostering patient' safety and comfort in your care of patients, decide what you will do to further develop this capacity in your practice.

Make your own 'I will' statements . . .

Examples of "perfect" skill in fostering safety and comfort 'I will' statements:

 . . . give greater attention to the small details of how I interact with patients.

. . . identify small things that I can do "in passing" for patients that will

 comfort and assure them if my attention to them

. . . reflect on and make notes about what it means to me to practice

 beautifully

  . . . always think of my care of patients in terms of how I am supporting their

 safety. 

References

Aristotle (circa 350BC) (C. Kirwan trans.) (1993) Metaphysics: Books Gamma, Delta, and Epsilon (Clarendon Aristotle Series) (Bks.4-6) (2^nd ed.). Oxford, Oxford University Press.

Aquinas T (1265-1274/2007) Summa Theologiae. Cambridge University Press, Cambridge.

Beautifully (2019) https://www.merriam-webster.com/dictionary/beautiful.

Goodreads. (2015). Retrieved from https://www.goodreads.com/author/quotes/182763. Michelangelo_Buonarroti

Meehan TC. (2012). The Careful Nursing philosophy and professional practice model. Journal of Clinical Nursing, 21, 2905-2916.

Morgan SN. & Georges JM. (2015). Refocusing a nursing lens distorted by perfection: the call for a mid-range theory. The Journal of Theory Construction & Testing, 19, 26-32.

Perfection. (2015). Merriam-Webster Online Dictionary Retrieved from http://www.merriam-webster.com/dictionary/perfection.

Ramos A. (2004) Moral Beauty and Affective Knowledge in Aquinas. Acta Philosophica, 13, 321-337.

Ramos A. (2013) Beauty and the Real. The Art of the Beautiful Lecture Series, New York University, New York, December 14.

Timmons F. (2011). [Editorial]. Remembering the art of nursing in a technological age. Nursing in Critical Care, 16, 161-163.

Webster's (1891). International Dictionary of the English Language. (revised ed.). Springfield, Mass: G. & C. Merriman & Co.

 

Therese C. Meehan^© July 2020