The More Beautiful World Our Hearts Know is Possible. Part 2.
Part 1 discussed Charles Eisenstein’s outline of what he called the ‘old story’ of the world, at times called the ‘Story of Separation’. This was traced to its origins in western thought evolving into a ‘mechanistic’ view of life. I suggested that although nurse education understands concepts such a holism, actual adult nursing practice may still be based on the ‘old story’ which includes biomedical reductionism within a neoliberal discourse of ‘efficiency, economy and effectiveness’.
May 12th is ‘International Nurses Day’ and is being celebrated on twitter. For an, albeit self-selected, sample of nurses, and what they value, the tweets may present a particular view of what nursing is about. As such it is ‘espoused theory’, i.e. it is what we say we value and do. Following the #IND2016 reveals the thread and expressed values. It cannot however provide much of a clue as to the personal world views of nurses, their ‘epistemologies’, their ‘ways of knowing’ (empirical?) or their ‘ontologies’, ‘the meaning of existence or being’ (duality?).
An epistemology is how you think knowledge can be attained, it is about the nature, source and limits of knowledge, for example through sensory experience (empiricism). A biomedical epistemology bases its knowledge on physiology and anatomy, what can be measured and predicted according to laws of biological science. The subjective experience of illness cannot be taken as ‘proper knowledge’ because it cannot be seen, measured or is open to scientific experimentation or enquiry. The epistemology underpinning many alternative therapies accepts knowledge from theories of chakra, or theories such as ‘like cures like’ and argues that this knowledge is just as valid as knowledge derived from scientific randomised controlled trials favoured by biomedicine.
Ontology is the philosophical enquiry into the nature of being, becoming, existence and reality. A dualist ontology considers that there is a separation between the material existence of the human body and the external material world. It accepts that that mind and matter exist separately. Biomedicine adopts this understanding of the human body, that indeed the individual human body is a separate unit of existence from other human bodies, and indeed is separate from the whole of material existence. Therefore what happens to the individual affects only the individual, and what the individual does affects only their sphere of influence.
Student nurse education will be based on both these assumptions in the background. All of the work learning for example A and P and pharmacology are grounded in this world view. This holds for the majority of clinical skills learning. This holds true more for adult nursing than mental health and learning disabilities:
“Over the past few decades learning disability and mental health nurses…(are)… developing rapprochement with service users and a commitment to social models of care. In mental health care this can be seen in the development of recovery focussed care, while in learning disability Wolfensberger’s (1972) normalisation theory has had an equally radical impact. While adult nursing has also changed a great deal in the same time period, it has not undergone the seismic shifts in philosophy and approach to care that have taken place in these two disciplines. For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care.” (Ion and Lauder 2015).
The context in which adult nurses work, and the nature of illness experienced by their patients, means that understanding health from the ‘new story’ view is perhaps idealistic for the majority of adult nurses.
The above descriptions of empiricist and dualist epistemology and ontology is what Eisenstein calls the ‘old story’. Thus, a brief outline of Eisenstein’s view of the ‘new story’ might provide a basis for some critical reflexivity. He variously calls it the ‘Story of Interbeing’, the ‘Age of Reunion’, the ‘Ecological Age’ or the ‘World of the Gift’. Wendell Berry calls it the ‘world of love’ or ‘health as membership’.
This resonates with David Loy’s (1988) comment:
“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).
Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that:
“….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140).
This then is a non-dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.
The principles of Eisenstein’s ‘new story’ are (p15):
- That my being partakes of your being and that of all beings. Our very existence is relational going beyond interdependence.
- What we do to another, we do to ourselves.
- Each of us has a unique and necessary gift to give to the world.
- The purpose of life is to express our gifts.
- That every act is significant and has an effect on the cosmos.
- We are fundamentally unseparated from each other, from all beings, and from the universe.
- Every person we encounter and every experience we have mirrors something in ourselves.
- Humanity is meant to join fully the tribe of all life on earth, offering our uniquely human gifts towards the well-being and development of the whole.
- Purpose, consciousness, and intelligence are innate properties of matter and the universe.
This view may be more applicable to one’s personal view than to clinical practice. It might be interesting to think what clinical practice might look like if we took these precepts seriously? The current design of hospitals and clinics, the clinical pathways we develop and the sort of practitioner we educate is based on the ‘old story’ of biomedicine, so we know what that looks like. It is our current world. Could it be possible to redesign and to rethink?
This is philosophy, but Eisenstein argues this fits with what physics tells us about the world, it is more than ‘new age’ assertion and hope. There is a continuing divide however between the new paradigms of physics and biology and the Newtonian mechanistic world view of everyday experience. The one is the espoused theory – what scientists and philosophers say is so, and practical action – what we actually do and experience as adult nurses.
The issue goes beyond what clinical practice looks like and where it takes place. The ‘old story’ underpins our ecological, social and economic crises because it narrows the definition of what it is to be human, what reality is and thus what the possibilities are.
Yagelski (2011) calls this ‘the problem of the self’:
“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.
Student nurses in the Adult field in the UK are schooled, and experience, the ‘autonomous, thinking being’ separate from the natural, physical and social world. The political world is torn between Margaret Thatcher’s ‘no such thing as society, only individuals’ and a more social(ist) democracy. To date Thatcher’s view prevails as a core element of neoliberalism.
Adult nurses go to work within a mechanistic, empirical, patriarchal, separate, reductionist and biomedical context. This is a world in which the cause-effect relationship of the RCT is the gold standard for evidence. They will have a clear sense of boundaries between themselves and their patients and with other health professionals. The work context is similarly managed in a fragmentary way, units of work need to be measured and evaluated, processes clarified, evidence to be checked. Wendell Berry calls this the ‘world of efficiency’.
He also refers to the ‘world of love’, a world which Eisenstein might recognise as ‘Interbeing’.
However, this is a view that hospitals and industrialised medicine struggle to understand and thus cannot ‘heal’ or make ‘whole’. Berry accepts that the hospital does well at surgery and other procedures, treating the body and its parts as separate things.
Healing, however, meaning reconnecting and making whole, is alien to many medical practices. For example, any place of healing would emphasise and prioritise such things as rest and food. Whereas a hospital treats a body as a machine that needs fixing and that the rest it needs is a low priority. Both sleep and nutrition in acute hospitals continue to be topics addressed in the literature as not always delivered in the best way possible. The very design of hospitals seem antithetical to both.
Berry argues that rest, food and ecological health ought to be the basic principles of the art and science of healing, but currently healing is based on other principles: biomedicine technology and drugs. Berry criticises biomedical practices for making only tenuous links between healing, rest and food and no link at all between health and the soil:
“Industrial medicine is as little interested in ecological health as is industrial agriculture” (p98).
This sentence makes no sense unless health is defined within a non-dualist, non-reductive ontology.
This disconnect between healing, health and medicine is illustrated by Berry by describing the experience of his brother’s heart attack. The debt to the hospital is acknowledged, as John his brother underwent a Coronary Artery Bypass graph. In the hospital the ‘world of love’ confronts the ‘world of efficiency’ – i.e. medical specialisation, machinery and procedures.
John came from the ‘world of love’ of family, friends, neighbours which the hospital struggled to deal with. This world of love seeks for full membership, it seeks to be joined. However the world of efficiency ignores this love as it must ‘reduce experience to computation, particularity to abstraction and mystery to a small comprehensibility’. In other words any experience that cannot be objectively measured and calculated is devalued and takes second place to the ‘real’ work of diagnosis, intervention and evaluation. Hence the focus on vital signs, NEWS, blood gas analysis, blood tests (FBCs, U and Es), ECGs, urine output, X-rays and CT scans; the particularity of a patient’s pulse is abstracted to concepts such as hypovolaemia; the particularity of a real person is abstracted into a set pf physiological parameters transformed into documentation replete with risk scores and reduced into medical categories; the mystery of the pale, clammy patient, expressing chest pain has to be comprehended as myocardial infarction (or other diagnostic category that gives meaning).
Efficiency must ally itself to machinery – John was in the intensive care unit – to standardise, to provide numbers to predict and control. The efficient nurse will use all the tools that biomedical science gives to provide the best physical care. The effective nurse will use the appropriate biomedical tools and interventions which are evidenced based; the economic nurse will do so with the minimum of cost.
Love however cannot be standardised, is not a graph, a chart, anatomy, an explanation or a law:
“The world of love includes death, suffers it, and triumph over it. The world of efficiency is defeated by death; at death all its instruments and procedures stop. The world of love continues and of this grief is the proof” (p105).
The professional ‘field’ of adult acute care excludes the ‘amateur’, excludes the world of love. Descriptions from the professionals to the family that procedures were ‘normal’ failed to acknowledge that nothing about this was normal. Normality for them was biomedically defined, was what they have experienced with other patients. Lying in a hospital bed is pretty far from normal for everyone else.
The worlds of love and efficiency divided experience, however people can cross between. The amateur may not be able to cross into the world of efficiency. The machines and data are ‘a foreign land’, but the professional can cross into the world of love:
“During John’s stay…there were many moments in which doctors and nurses – especially nurses! – allowed or caused the professional relationship to become a meeting between two human beings” (p108).
Berry described on such moment. John’s wife Carol was waiting for news of the bypass operation, and as a nurse also knew the seriousness of the situation. Two nurses came to tell Carol that the operation had been a success and that during the procedure a balloon pump had been inserted into the aorta, a possibility that had never been mentioned.
Carol being unprepared for this news was disappointed and upset. The two nurses tried to reassure her by repeating what they had just said (professional and within the world of efficiency). Then there was a long moment when they just looked at Carol.
One of them then said “Do you need a hug?” Carol said “Yes”.
This brings us to a starting place, a starting place for healing and a crossing over into the world of love.
Many nurses today will understand this crossing over, many will intuit that the world of love is part of healing, of health as wholeness even while they work on the world of biomedical efficiency. This is a corrective to the isolationist, reductive and machine like process of ‘nursing’ care in some hospitals and care homes. However, at times we struggle to provide this ‘world of love’ as the Ombudsman report (2016) into the hospital discharge of older people testifies.
Eisenstein asks us to consider that separation causes distress and provides the wrong solutions. If we really believed and felt that the old person sitting alone in bedroom was us, would we want to change things?
I accept that I can’t do it. I can’t heal those around me. I’m stuck in the transition between the world of love and the world of efficiency. I am not able or willing to pay the heavy price to close the gap by myself. I can make a difference, though, to some and Eisenstein argues that little differences can add up. What is my gift to the world? Having read Eisenstein , I have to admit it is not a question I’ve ever addressed. My sense of self is individual, is separate, is ‘dualist’ and yet I know it could be different? The new story is a vision of where I could be, it is not where I am.
I don’t think this is matter for individuals to provide an individual response to such issues as loneliness. It would be a ‘good thing’ of course if isolated lonely old people had visitors, and that the visitors themselves would benefit from that. However, that is the ‘old story’s’ solution. Many individuals do not have the time, energy, resources emotional and physical, the geography or the history to close the gaps. That is because our total system of care mirrors the social, economic and political systems that emphasise efficiency, effectiveness and economy and the sovereign individual. That is why our culture is increasingly turning to individual responsibility for health, education and welfare. Health and social care is framed within austerity budgetary constraints, we cannot think about anything other than the financial costs.
This means we cannot imagine or vision “a more beautiful world our hearts know is possible”.