Patricia Benner, R.N., Ph.D., FAAN
EducatingNurses.com, copyright May 10, 2020
The 200th birthday of Florence Nightingale finds nursing under the COVID-19 spotlight. While it will take years to capture and absorb what this time has meant, I encourage nurses on the front line to tell their stories; clarify and record their experiences. Rather than try to protect ourselves from the pain through objectivity and “control” — we need to recognize how nursing invites intimate strangers to meet in common humanity inviting us to respond to the vulnerability and suffering of others.
On the Occasion of the 200th Anniversary of Florence Nightingale and Year of the Nurse and Nurse Midwife 2020, here’s a special video message during the Nursing Week 2020:
Nurses, patients, and families have been impacted in immeasurable ways by the COVID-19 pandemic. Many nurses report their anguish as they try to comfort dying patients who are isolated from their families. Patients, families, and healthcare workers worry about their own and others’ safety. Some of our colleagues have developed COVID-19, and we’ve mourned nurses’ loss of life to this virus. We have had too little time to pause for reflection, and indeed, we will be absorbing the tragedy of this pandemic for many years to come. In the midst of this crisis, it is wise to make time for listening, reflecting, and acknowledging our shared sorrows and trials as a result of this pandemic. This reflection is needed, even when we don’t feel like we have time for it. For this time of crisis, we need the best science can offer, but we also need human sciences, humanities, and spiritual traditions to express our concerns, fears, sorrow, and to help us cope. We do not think that this kind of reflection beyond what science offers is trivial, or should be marginalized while we meet the demands of the crisis. It seems like a good time to pause and reflect on the human experiences of illness and suffering, and for that, we turn to art and the humanities.
Health care delivery is plagued with economic and organizational pressures to work quickly and use abbreviated objectified impersonal language, as Dr. Kari Martinsen pointed out in our March 2020 interview (EducatingNurses.com February 11, 2020). Nurses daily struggle with constant time demands due to emergency situations and work overload. In such speeded-up communication, patient/family concerns, context of clinical information, questions, and unknowns fall out. This is much to the detriment of patient safety, understanding of patient/family experience and empathic care. Our language and our abbreviated descriptions of nursing work reflects this. Both charting in the electronic record and reports to colleagues about patients are as brief as possible, often leaving out the patient’s current concerns, worries and vulnerabilities, and what kind of day the patient is experiencing. Speeded-up forms of communication also impact student clinical experiences, and opportunities to learn the nuances of supporting patients in times of vulnerability.
Scientific, diagnostic language does not lend itself to speaking about the human experience of illness and vulnerability, or as Dr. Martinsen describes “sacred moments” in being present and caring for patients and families in the extremities and uncertainties of illness (Educating Nurses, March 2020). In her 2019 Thelma Shobe Lecture at the University of California, San Francisco School of Nursing, Dr. Eva Gjengedal stated:
While our scientific language mainly appeals to our cognitive capacity, artistic expressions may appeal to our entire sensory register. Art may evoke associations to experiences that traditional language is struggling to formulate. Hence, as I have tried to argue; artistic expressions may be an important supplement both in clinical practice and in qualitative research.
This interview with Dr.Eva Gjengedal, a researcher who is interested in the role of arts and esthetics in understanding and articulating the nature of nursing and caring practices, points out that the essential nature of nursing caring practices requires a richer and more nuanced language that includes human concerns, meanings and lived experiences. Dr. Gjengedal, who has been influenced by Dr. Kari Martinsen, has advocated using the humanities to capture caring and caring practices in nursing:
In Norway although the discussion between the two camps of science and the humanities gradually slowed down and is now replaced with a greater acceptance for pluralism, which I find both reasonable and crucial. I still believe that a humanistic approach is important when it comes to taking care of the traditional values of nursing practice. In general, the aim of humanistic research is not to establish general laws or causal relationships, but to understand human beings in their cultural and historical context…My empirical research has mainly been based on the first-person perspective inspired by phenomenological philosophy, in particular, the philosophy of the late Edmund Husserl (1936/1970) and Maurice Merleau Ponty (1945/2014), an approach that may be denoted “life world phenomenology.” This perspective may open up opportunities for nurses to gain insight into the patient’s situation beyond a purely biomedical understanding…and in this regard, artistic expressions can be helpful. Using the language of art also in research may help make silent experiences easier to express and therefore be made available for scientific reflection and greater human understanding.
Dr. Gjengedal’s early research studied patients’ recent experience of being on a ventilator (Gjengedal 1994). Her participants’ first-person narratives revealed their fears, discomforts, and misunderstandings of ventilatory therapy. Dr. Gjengedal’s humanistic approach to research also includes having patients write poems to express their illness experience, concerns, and meanings related to vulnerability and illness. She also uses theatre plays, poems, and novels to explore caring practices, and the relational dynamics between the one caring and the one cared for in her humanistic research and in her teaching (Gjengedal et al.,2013, 2018, Synnes et al., 2020).
Dr. Gjengedal’s work seeks to uncover and give enriched imaginative language to the lived experience of illness, vulnerability, and caring practices. Scientific language focuses on representation, presenting objective decontextualized knowledge (Taylor, 2016). Objectification and detachment become ways caregivers, distance themselves from patient’s suffering. Objectified scientific language allows for detachment and the covering-over of the lived embodied experience of the patient and family. Yet, we cannot meet the person until we can truly see their human face, and we are open and curious about their concerns and experience from a perspective of our common humanity and common vulnerability (Levinas, 1998). We have to be open and responsive to sense another person’s concerns, fears, and meanings. Because scientific language discloses only the objective, physiological body, and not the lived, vulnerable body, the caring practices, and attunement essential to good nursing care are short-changed or avoided altogether. Using decontextualized, objectified language necessarily leaves out concerns, relational issues, patient experience, understanding of the patient’s plight, and relational caring practices, all essential to good nursing practice. The language of natural science emphasizes causal explanations, while the human sciences includes understanding. Understanding, in human life, is often the best explanation for human actions and concerns. This is why art, poetry, fiction, and the language central to human concerns, action, relationships, and lived history are essential to health care where suffering and vulnerability are ubiquitous.
In a highly individualistic society, our social existence depends on having our life story and embodied identity known and socially recognized (Taylor, 1991). I think this professional level of detachment, and lack of empathy are fostered by our professional, sterile, scientized, objective accounts of physical illnesses, injuries, and losses, along with the rapid pace of health care delivery environments. Health care cannot be conducted without the objectified language of science but neither can it be effective and empathic without art and human sciences. The scientific process identifies discrete elements that are then reconnected through a causal theory, with sets of generalizations. This is necessary for explanation and for the development of therapies, but not sufficient for understanding human experience.
Human sciences and art can address the meaning side of any illness. Meanings, dwelling in a particular lifeworld complete with loss and suffering, must be addressed to promote coping, recovery, self-understanding, and healing. Poetics, story, meanings, and the nature of one’s footing in the world (Taylor, 2016) are what philosophers such as Charles Taylor refer to as the expressive and constitutive functions of language. Taylor, Gjengedal, and Bennerargue that we cannot understand human meanings, identity, and footing in the world without personal stories, without exploring the person’s meanings and concerns related to their illness, suffering, well-being and lifeworld concerns. One’s personal story, as well as the stories, read in biographies and great novels address changes across time, i.e., “transitions.” Transitions are what Taylor (2016) calls the process of moving from some form of misunderstanding or impeded stance to a more capacious or liberating stance. The human experience of a changed damaged body, with physical and social losses, forever alter one’s identity, meanings, and footing in the world. As health care providers, we dare not exclude this richer language to capture the human experience of illness, suffering, and loss. The language used by science cannot address meanings, self-understanding, shared social understandings, as Taylor (2016) notes, “one’s footing” in his or her lifeworld.
Capturing our patients’ self-understanding, meanings, and concerns in the midst of radical traumatic changes in their body and personhood require metaphorical and storied accounts. Every injury and illness is experienced to some degree as a story of an illness experience in the context of the person’s lived experience (Benner & Wrubel, 1989). As professional healthcare providers, we typically “cut to the chase”— capturing the disease and injury account in mechanistic, functional, scientific language. We have much to learn from Dr. Eva Gjengedal’s humanistic research and quest for giving a broader understanding of the patient’s lived body, their experience of illness, their concerns, and vulnerabilities in the midst of illness and suffering.
Understanding and instantiating caring practices requires the insights, knowledge, and more expressive language of the humanities. Both patients and nurses require insights and expressive language of art and humanities to capture the full scope of human experience in health and illness. In this time of crisis, I hope you will write, record, tell storied, narrative accounts (protecting identities, of course) of the intense experiences you and your students are having during this time of world-wide suffering and the need for care. Nurses are front-line caregivers and bear witness to our collective stories at this time. Your front-line experiences, in this ongoing pandemic, is vital to our collective understanding and coping. We would love to hear your stories below and will be happy to help you further develop and share such accounts.
(Please scroll down to share your experience or comment.)
Benner, P., Wrubel, (1989) The Primacy of Caring: Stress and Coping in Health and Illness. Upper Saddle Back: New Jersey. Prentice-Hall.
Gjengedal, E. (1994) Understanding a World of Critical Illness. A Phenomenological Study of the Experiences of Respirator Patients and their Caregivers. Doctoral thesis. Department of Public Health and Primary Care, University of Bergen.
Gjengedal E; Lykkeslet E; Sørbø JI; Sæther, WH: “Brigthness in Dark Places—Theatre as an Arena for Communicating Life with Dementia. Dementia,2013, 13 (5), 598-612.
Gjengedal E; Lykkeslet E; Sæther WH; Sørbø JI: ‘Theatre as an eye-opener’: how theatre may contribute to knowledge about living close to persons with dementia. Dementia2018, 17 (4), 439-451.
Husserl, E. (1936/1970) The Crisis of European Sciences an Transcendental Phenomenology.David Carr (transl) Evanston:Northwestern University Press.
Levinas, E. (1998) Entre Nous, Thinking of the Other. New York, N.Y.: Columbia University Press.
Merleau-Ponty, Maurice (1945; 2014) The Phenomenology of Perception. New York, New York: Routledge.Synnes O; Gjengedal, E; Råheim M: Lykkeslet E. (2020) A complex reminding: The ethics of poetry writing in dementia care. Accepted for publication in Dementia, 02.042020.
Taylor, Charles (2016) The Language Animal. The Full Shape of Human Linguistic Capacity. Cambridge, Mass.: Harvard University Belknap Press.
Taylor, Charles (1991) The Ethics of Authenticity. (Paperback edition) Cambridge, Mass.: Harvard University Press