The Francis Report, the result of a UK public inquiry into ongoing mistreatment of patients at a large teaching hospital, revealed deep-rooted flaws in care delivery and professional performance. It led to regulatory review, policy initiatives and public outcry. To this point, it has not led to any extended or focused discussion on the sustenance or well-being of nurses so that we might avoid it happening again. This paper emerges from the writing and publication of a novel called Stranger Than Kindness and a subsequent PhD. The novel explored the themes of damaged or hurt healthcare professionals and their attempts at restoration or in one case, redemption. The paper uses the novel as ‘data’ for an articulation of the emotional world of (some) nurses and imports three theoretical perspectives; McGilchrist's work on the divided brain, Damasio's work on emotion and Merleau-Ponty's phenomenology to support an emerging philosophical position of embodied cognition.
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This paper emerges from the writing and publication of a novel called Stranger Than Kindness.1 That book explored the themes of damaged or hurt healthcare professionals and their attempts at restoration or in one case, redemption. Stranger Than Kindness was written the way fiction tends to be, with a loosening of conscious thought,2 and a willingness to follow the characters and write down what happens to them.3 As such while I began the novel interested in the themes and imaginary world, I was not writing something that was wholly known; the writing was a process of finding out. It was only after the novel was completed and sent off to the publisher that I found myself thinking about what emerged in its production in a different, perhaps more philosophical way. What followed was a critical analysis of the process and emerging thematic that sought to import meaning into the conventional sociological world of healthcare and more specifically nursing. That critical analysis gathered and explored ideas from neuroscience and phenomenology and arrived at a philosophical position, embodied cognition, that offers a helpful and sympathetic—one might say nurse like—way of thinking more productively about the human experience of the nurse. The ensuing analysis formed a PhD at the University of Sussex.
It is my intention to present this inquiry without relying on the reader having read Stranger Than Kindness, although a précis is provided in the box 1. My aim is twofold. First, to offer an example of how knowledge generated from a novel might contribute to nursing knowledge. Second, to offer a route via three theoretical perspectives to a more progressive and comprehensive philosophy for nursing; that is embodied cognition.
Stranger Than Kindness is a two part novel about how nurses live with the gathered ‘sedimentatation’4 or traumatic experiences their work has offered them
The first part is set in 1989 in a large Victorian Asylum in London, England, as it closes down in preparation for Community Care. Adam Sands is feeling less like a purveyor of kindness and more like a prison guard. A particularly difficult suicide haunts him. He drinks too much, his relationships are destructive. His body aches. When a colleague dies, his own health disintegrates.
The second part is set in 2013; Adam runs a second hand bookshop and swims in the sea at every opportunity. When the relative of a former colleague asks him for help, he revisits his past and begins to try to redeem himself by being helpful.
Given the darkness in this brief description, it feels important to point out that Stranger Than Kindness takes a broadly comic form; the gaze is necessarily gentle rather than bleak. As The Guardian noted: ‘… we see Adam, so damaged, treating—and healing—both himself and others with nothing more than quiet respect and listening to the body’s needs’.32
Stranger Than Kindness satirises the pharmaceutical industry and gently teases the way truths, fashions and power are constructed and maintained in psychiatric settings, but what emerges along the way—from the 1980s’ hospitals to a 2013 cross-country conspiracy theory—is the extent to which difficulties of the mind are played out in and on the bodies of the characters.
Being human; making stories
Scottish moral philosopher Alistair Macintyre,5 locates us as a species that live in stories. For him, narrative is a constitutive of human identity. We can only answer the question ‘What am I to do?’ if we can first answer the prior questions ‘what story or stories do I find myself a part of’. But he does not simply locate us in stories; he observes that we derive at least some of what we must do from stories. For Macintyre, we are storytelling animals on a ‘narrative quest’. Here, at once, we locate stories at the heart of human identity and more boldly perhaps at the centre of ethics.
Macintyre is not alone. Stories make us human says Gottschall,6 they enable us to navigate the social and emotional world and to make sense of it. We are, demonstrably, a story-making species. We take comfort and make meaning from the fiction we read, and I notice as a lecturer of nurses that my students make sense, develop their skills, knowledge and capacity to nurse from the stories they construct of and around themselves in practice. Further, we are bound by our stories, the roles we play in them, the legitimacy they create for us and the place in the world they allow us to occupy.
Elsewhere, Hogan7 talks about literature acting as data for an account of the emotions. To the experimental psychologists eager to dismiss the idea that literature can be anything more than an acceptably formed anecdote, Hogan points to all corners of human history and its need to produce a story, to provoke, share, to make emotion literate. Literature generates emotional resonance and while that in itself raises many questions about the universality, interpretation or authenticity of that emotionality, it is in Hogan's view bizarre to denigrate literary data that require interpretation any more than ‘scientific’ data that require interpretation. For Hogan, artists encode and represent human experience, although in a different way, and he urges the development of a fourth culture that will freely transplant knowledge between the sciences and the humanities.
This all seems a particularly pertinent observation for nursing today, particularly in (the UK at least) its post-Francis struggles to reassert its moral authority. The Francis Report8 was a watershed moment for British nursing. The final report was published in 2013, and offered the findings of a public inquiry that followed the poor standards of care exposed at Stafford Hospital between January 2005 and March 2009. Those poor standards made national headlines, and it was widely reported in the media that an estimated 400–1200 people could have died unnecessarily there between 2005 and 2008.9
In the UK, at least this report articulated a clear shift in the relationship between the public and nurses. Indeed, it allowed nurses to be seen, perhaps for the first time, as something other than a force for good. It is perhaps not the place here to explore the mechanics of that shift fully, but one wonders if it is purely a coincidence that a 5-year pay freeze for nurses followed on from Francis.
Nursing is often characterised as broadly the ‘delivery of care’, but delivering care is not the same thing as caring. Caring involves something more than knowledge and skill; it is at once a feeling, a quality and a moment. It manifests a characteristic and a mood. And it appears to be required of the nurse. The nursing response to The Francis Report,8 in the UK at least came via the Department of Health's Chief Nurse in the shape of the 6 Cs. The 6 Cs lists six qualities: compassion, care, communication, courage, competence and commitment as underpinning requirements for the nurse.10 Issuing a ‘Vision and Strategy for Nursing Staff’ like this is essentially a call to attention. However, it also tells us (reminds us) that the nurse has to care and to be compassionate, and that requires something emotional, it requires us to call upon particular human qualities and to apply them in an appropriately ethical way. It, thus, involves a complexity that traditional social science—while having spent a couple of decades trying to reduce—cannot comfortably encapsulate. Greenhalgh and Hurwitz explain this in relation to patients saying:
The narrative provides meaning, context and perspective for the patient's predicament. It defines how, why, and in what way he or she is ill. It offers, in short, a way of understanding which cannot be arrived at by any other means.11
Indeed in much nursing research, policy and debate, there has long been something of an elephant in the room: nurses feel. What they feel may vary and be complex; they may feel tired, loving, annoyed, moved, cold, compassionate, frustrated, raged and tender all on the same day, and those feelings may leak into the clinical intervention or may even design it. Stranger Than Kindness probably revels in that. It does that by detailing the emotional context, the relationships, the reflexivity and accumulated struggle and the personal residue. In the context of nursing well, it seems to me that these are relevant, if complex, things. In terms of helping students to construct themselves in such a way as to care and nurse well, they seem essential.
The idea that the feeling nurse can be ignored or disregarded is surely absurd; the idea that we can explore the world of the nurse meaningfully without accessing these things is duplicitous and self-deceiving. Feelings in context exist; literature makes the felt world available. Fiction maps (in a particular way) the relationship between the felt world and the clinical world. Stories help us make sense of the world, and it seems clear that they can help us develop a more rounded analysis of the nursing experience.
And in principle, we are, it seems, prepared to accept that at least in certain circumstances. Grant and Zeeman12 say that storied lives enable us to present what is significant with hope for the future. They offer tales of cultural engagement that make available to us success, failure, resilience and resistance. I became very interested in that idea when reading Arthur Frank,13–15 who identified how patients restoried themselves in the face of ill health. He framed illness as a call for stories and identified archetypes: The Restitution Narrative, The Chaos Narrative, The Quest Narrative that lent bodies voices of varying control, hope, comfort and meaning. In so doing, he located narrative in a clinical setting in what I experience as an emancipatory way.
It is interesting that we can find a way of valuing this type of scholastic gaze when it is facing the patient, but are reluctant to apply it to clinicians. Perhaps, we disallow such reflections because they feel self-indulgent? Nurses and, to some extent, doctors are culturally inscribed as selfless, so, why would they require this counterintuitive gaze? This attention? Healthcare professionals are not ‘ill’ or dying; in fact, they are doing their job and being paid for their labour. Why should we care for them as well? Perhaps because of this logic one is invited to justify this attention in the broadly neoliberal terms of sustaining a workforce or protecting the health economy from negligence claims or too much sick time because that is the paradigm in which nursing is viewed now.
However, there is more to this than simple economics. If we believe that nursing well is characterised by well-constructed care and attention; that delivering interventions requires emotional energy, resilience, generosity of spirit and compassion, we surely need to establish philosophical tools that value the development and sustenance of those things, and also articulate their value alongside the more ‘rationalist’ (sic) knowledge and skills that constitute nursing. In order to do this, we need, in my view, to revisit the assumptions of Cartesianism itself and suggest that the premise of pure reason mastering both the body and the emotional world is inadequate.
Of course, to suggest such a thing is not in itself big or clever. Poststructuralists have been lining up for decades to show us the limits of metaphysics. But for better or for worse, this is not an exercise in poststructuralism. I am interested in a different type of philosophy here, and a different method. As such, I want to offer three distinct theoretical perspectives that come together to offer us a way of constructively and forcefully addressing the elephant in the room in healthcare delivery; the emotional world (and struggle) of the nurse and our reluctance to value it.
The divided brain
Iain McGilchrist,16 is a psychiatrist, researcher and former English lecturer at Oxford University. He is committed to the idea that the mind and brain can be understood only by seeing them in the broadest possible context, including the wider human culture in which they arise. The culture that helps to mould, and in turn is moulded by our minds. He writes in the first half of The Master and his Emissary about the complex, evolved and codependent relationship between the left and right hemispheres of the brain. The second half of the book traces the fluctuating influence between the two hemispheres on Western society over centuries. For McGilchrist, the recently increased left hemisphere dominance in the way humanity organises, values and constructs ‘reason’ has created an imbalance.
The left hemisphere point of view inevitably dominates.…The means of argument—the three Ls, language, logic and linearity—are all ultimately under left-hemisphere control, so, the cards are heavily stacked in favour of our conscious discourse enforcing the world view re-presented in the hemisphere that speaks, the left hemisphere, rather than the world that is present to the right hemisphere.…which construes the world as inherently giving rise to what the left hemisphere calls paradox and ambiguity. This is much like the problem of the analytic versus holistic understanding of what a metaphor is: to one hemisphere a perhaps beautiful, but ultimately irrelevant, lie; to the other the only path to truth.…
There is a huge disadvantage for the right hemisphere here. If… knowledge has to be conveyed to someone else, it is in fact essential to be able to offer (apparent) certainties: to be able to repeat the process for the other person, build it up from the bits. That kind of knowledge can be handed on.… By contrast, passing on what the right hemisphere knows requires the other party already to have an understanding of it, which can be awakened in them (p.28).16
McGilchrist emphasises two traits that distinguish the right hemisphere from the left: sustained and holistic attention and the capacity for empathy. He evidences the diminishing of empathy as the left hemisphere gradually dominates the former master, that is, the right, and whatever it is that underpins ‘pure’ reason gradually shifts with that domination. It is the lack of balance that concerns McGilchrist, a lack of balance that emerged in particular from the Enlightenment; the construction of an abstract reasoning that demanded all questions have answers and all answers come together to form a rational world. This, he suggests, has something to do with the loss of embodiment.
I think McGilchrist does something radical here in mapping the biology of mutuality in the brain. He offers a detailed cognitive neuroscience, which emphasises the gradual emerging dominance of one part of the brain and the failure of the left and right hemisphere to transcend opposition.
Embodiment is the unique gathering of data, history, intuition and emotion that rests beneath the skin. We cannot easily give voice to the knowledge. It constructs sometimes (when we say that someone ‘means a lot to us’ what can that actually mean?) and arguably even acknowledging it as present and influential lacks legitimacy given the nature of the rationality we have come to embrace. Yet, we know it is there, it is obvious to us; we feel it, and we are informed by it. But in order to give it voice, we access the language and logic of the left brain, and also, we place it in a constructed world that values or at least returns to the version of pure reason that has emerged from the increasing influence of the left brain. Thus, culture, reason and social relations develop as part of dialectic between the evolving (imbalance between) hemispheres and the existing social–cultural world our reason makes sense of and contributes to. The intuitive or felt world is diminished yet still it influences everything from the position we take in the world to the instinctive interaction with a particular bus driver or estate agent or patient.
McGilchrist's work is extraordinary: a detailed exposition of neuroscience, which explores the relationship between the hemispheres, followed by a historical and cultural mapping of social development against the influences of the hemispheres. For McGilchrist, the Renaissance marked the hemispheres working together, the Enlightenment marked the emerging dominance of the left, the beginnings of a reductive assumption that all questions have answers. In philosophical terms, it is the way in which McGilchrist observes the nature of consciousness as illustrated by some of the work from the Renaissance that is striking I think. Reflecting on a poem by Thomas Wyatt, McGilchrist says:
What we are being let into here is something profound about the betweenness of emotional memory. Our feelings are not ours, any more than as Scheler said, our thoughts are ours. We locate them in our heads, in our selves, but they cross interpersonal boundaries as though such limits had no meaning for them; passing back and forth from one mind to another, across space and time growing and breeding but where we do not know. What we feel arises out of what I feel for what you feel for what I feel about your feelings about me—and about many other things besides; it arises from the betweenness and in this way feeling binds us together, and, more than that, actually unites us, since the feelings are shared (p.303).16
What is striking here is not, in my view, the veracity of the reflection, but the hierarchy of reason that such a reflection finds itself located in now. If one were to talk to nurses about the crossing of feelings and the growing and breeding of what we know in-between us, the nearest thing to assent I could imagine would consist of ‘Are you talking about transference and counter-transference?’ The subtext being: ‘We have a language for that, it is scientific. It is reasoned’. To introduce curiosity born of poetics is to step outside of our well-established ‘common sense’, which is ironic and stifling, yet illustrative perhaps of the dominance of the left brain to discern the nature of reason.
I suppose, it is worth noting that in some respects McGilchrist's left–right brain dialogue reflects nursing's historic (if outdated) knowledge-intuition debate or more pertinently Benner's Techne-Phronesis distinction.17 Nursing has a history of understanding that a particular type of ‘wisdom’ can transcend certain types of ‘knowledge’. Its problem has perhaps been that it struggles to articulate that? One wonders if McGilchrist's work might help with that?
Antonio Damasio18 ,19 argues that the primacy of emotion is neurologically established and that emotions provide the scaffolding for cognition. We have long known that the body pumps out a wide range of somatic signals during a burst of emotion. Muscles, blood flow, breathing and heart rate are all affected by that process and that physicality is accompanied by subjective feelings along with thoughts, memories, images and responses. Margaret Wetherel describes this process thus:
[It] is not just a moment of coalescence. It is also a moment of recruitment where body/mind possibilities and body/mind states are gathered together into a particular assemblage and unleashed, censored or regulated in social contexts.20
Damasio expands on this observation and offers an analysis of what power the body—with emotions running like rail tracks through it—has on the formation of thought and the subconscious.
Damasio says18 that there are primary or innate emotions (happiness, anger, sadness, fear, disgust), which are wired into us and present a set of predetermined or preorganised physical manifestations. There are also secondary or social emotions (guilt, embarrassment, pride, envy) for which those physical manifestations are established in part by experience. We do not have conscious access to this effect in the same way as we do with the primary emotions at least until we are able to review it. He maintains that we can understand this process by dividing them into three stages: ‘state of emotion’, ‘state of feeling’ and a ‘state of knowing the feeling’. The first is the unfolding of the biological machinery; a physiological event beyond our control and beyond awareness at this point. The state of feeling is the process by which the brain begins to form a representation of what the body is doing; it is in essence the process of preconscious noticing. The last state, the state of knowing the feeling, brings the event that is consciousness of the feeling. It is at this point that the feeling belongs to me. This is a private, individual experience, the point where I am marked out as ‘unique’.
Damasio does something here that is powerful in terms of my political and professional understanding of nursing: he offers an emphasis on emotions, refocusing our attention on the diminished felt world.
When an experienced nurse in a difficult clinical environment working in a culture described by former chief of the Health Commission, Sir Ian Kennedy, giving evidence to the Francis Reports as ‘guerrilla warfare’4 approaches her 25th intervention of a busy morning, the nature of her response to the patient will be, in part, constructed by unprocessed emotion. If we do not acknowledge the emotion or even try to construct a language that notices it without condemning the nurse, we cannot act helpfully.
Damasio's somatic marker hypothesis explains how emotional processes can bias behaviour, particularly decision-making. The hypothesis is that bodily feelings normally accompany our representations of the anticipated outcomes of options.21 In essence, this neurobiology places an emphasis on the preconscious role of emotion in complex and uncertain situations, and challenges the assumed primacy of logic in decision-making.
For Damasio, it is wrong to imagine that only the brain thinks. The body and our emotions play a key role in how we make decisions. His is a cognitive neuroscience that reframes and revisits the idea of intuition or gut reaction in a way that might refresh our curiosity and challenge our prejudices about nursing knowledge and the construction of the casual nursing intervention. Further, it might offer a reinvigoration of the nurse as existing in the felt world rather than simply a rational and technical one.
As I wrote Stranger Than Kindness, my sense was that it was about how people carried their emotions, tried to live with and in spite of them and tried to engage morally, the way people with a duty to care must, with the world in a meaningful way. As I did that, it emerged that experience began to reside in the bodies of the characters, but the struggle with the body became a metaphor, running through the novel, from a character called Libby, a long-term patient who is holding the long-term delusional belief that she does not have a body (and has not had one for over 50 years), to the former charge nurse, Adam, constantly and obsessively taking to the sea in order to bathe and soothe himself (see box 1). As the work emerged, it became apparent that a book about feelings and emotion is a book about the body.
Phenomenology and nursing
‘…There is no inner man, man is in the world and only in the world does he know himself.’22
When Merleau-Ponty22 developed the concept of the body subject as a response to the Cartesian cogito, he perceived consciousness, the world and the human body as being intricately involved and mutually engaged. For Merleau-Ponty, lived experience, including collected emotionally laden human experience, is prior to reflection. It is prethematic; we live it, but we do not explicitly think about and calculate what we are doing. He observes that our history becomes sedimented in our bodily gestures (an idea not dissimilar to Damasio's analysis of secondary emotions or indeed Bourdieu's discussion of the habitus6), and they are contained there as latent and unconsidered, even though this embodied experience is meaningful and lived out in the world. For Merleau-Ponty, the ‘sedimentation’ of one's life means we develop an attitude towards the world as we become moulded by repeated experiences of it. It is, we can see in Stranger Than Kindness, the sediment that gathers in the nurse, for example, a traumatised Adam unable to sleep, ruminating about professional losses, sadness and mistakes and ultimately using medication to ‘manage’ his difficulties. This alternative embodied sense of consciousness anticipates McGilchrist and Damasio and offers a fuller and more sympathetic epistemology for nursing. At the heart of this epistemology is a nurse collecting the residue of distressing or painful experience.
I take sediment to mean what is left: a scar or stain, invisible or immovable (the ‘unseen wheals that still remain’).23 We may become familiar with it, we may be unaware of it, we may say we are unbothered by it, but if it is embodied, we will be influenced by it. The character, Adam, collects sediment throughout the first half of Stranger Than Kindness, and spends the second half trying to wash it away. Another character, Anna, arrives from a troubled youth already intractably stained. And if I may, if we imagine for a moment that the nurses at Mid Staffordshire are stained, might it not be the case that they cease to be the enemy of good and rather become people we have a collective responsibility for?
Paradoxically, the reflective nurse will notice the ‘sediment’ or at least they will notice the difference. They will see perhaps that they are ‘doing’ something different or ‘feeling’ something less helpful or simply ‘being’ something other than what they ‘know’ is required. They will labour emotionally24 ,25 in order to offer what is required, and it will perhaps cost something more than it might, otherwise, have done. And they will notice because they story themselves. That storying may be driven by curiosity, poetry, hope and professionalism, but nurses story in order to make sense. We all do.
This paper discusses how producing literature informs an emerging philosophy of care giving. Storying, in a range of forms, from creative writing groups through life writing, through reflective journals have contributed to healthcare delivery for some time. Their legitimacy is established by the institutions like the Medical Humanities foundation at Kings College, The Wellcome Trust and in books.26 And I am not the only (or most able) novelist to bring their attention seriously to the profession of caring.27 ,28 However, this paper attempts to articulate something else about how writing helps . It offers an example of how the act of writing fiction can generate knowledge about nursing and engender phenomenological enquiry.
There are clearly political and professional reasons why lived experience of a bruised or tired nurse is not central to any discussion about the ongoing education, standards and performance of nursing. The nursing role is a professional one; the patient comes first; if care delivery falls below acceptable standards, the nurse has to at least share responsibility for that, and if the nurse claims to be feeling tired, unhappy, frayed or even traumatised by her professional experiences, she is expected to either manage those feelings or transcend their consequences. This is what professionalism means.
Yet, in some ways, it amounts to demanding a patient with a difficult diagnosis ‘pull themselves together’. In some ways, it simply denies what is a physiological and significant reality; nurses’ experiences and feelings impact on how they nurse.
And even if we are uncomfortable with what might be construed as a liberal humanism asking to ‘care for the carers’, as people concerned with the viability of a sustainable and attentive workforce, we surely need to bring some attention to the collective and individual well-being of nurses.
This paper uses fiction as a form of inquiry. An inquiry that draws on neuroscience and phenomenology to arrive at a philosophy of embodied cognition. In so doing, it steps away from a Cartesian tradition that simply demands nurses apply ‘pure reason’ to the delivery of care, and offers a more sophisticated and holistic incorporation of the emotional residue that contributes to performance. Embodied cognition offers a recognition that the felt world has made manifest in the body of the nurse, and the difficulties, traumas, irritations and sadness that accumulate are not superficial experiences to be washed off, but are held.
It would be interesting to explore ways in which this philosophical perspective could practically inform clinical practice, and I am engaged in research into that. But in the first instance, I would suggest that simply by offering a route map to embodied cognition here, I am trying to establish three very simple, but worthwhile things.
First, the benefits of a greater scholarly breadth. Using a novel to make sense of the world is neither new nor radical. Articulating the way writing fiction can help construct nursing inquiry is one hopes of some interest, however, in terms of contributing to a scholastic dialogue and also by modelling reflective or academic practice for students, nurses or dare one suggest patients?
Second, in evolving a philosophical position that enables us to take a more sympathetic and mindful perspective on the underperforming or tired nurse, we are, I believe, offering a philosophy that characterises what we want from the modern nurse; sympathy, understanding, enquiry and compassion.
And third, we arrive at a modern philosophy that facilitates a fuller political response to the circumstances nursing finds itself in. We demean the nursing experience by trying to ignore the felt world. Nursing is an activity, it resides in the body, embodied cognition facilitates a broader understanding of nursing's uniqueness and its complexity, and if we are to respond in good faith to the lessons of The Francis Report and indeed failures of care wherever they emerge, we can surely benefit alternative academic traditions, and I would suggest we need to be prepared to explore both ourselves and our clinical worlds through story.