Friday, 6 July 2012

An Art?

Gabriel Orozco 'My Hands are My Heart' 1991

Last week I attended a study day for intensive care nurses and AHPS (yet another acronym to digest – for those who don’t know, it stands for Allied Health Professionals - physiotherapists and speech therapists, for instance)

At lunchtime I got talking to some experienced ICU nurses. We’d been discussing a presentation we’d been given about agitation in ICU patients, and how careful monitoring of sedation levels was needed to find the right balance between wakefulness and unconciousness. As I understand it, sedation that is too deep can hold back a patient’s recovery, while too little can make it difficult for a patient to tolerate the invasive breathing tube, not to mention the various lines, drains and cannulae.‘Of course,’ one woman remarked,  ‘A lot depends on the nurse.’

When I asked what she meant she said that older or more experienced nurses were more likely to have developed strategies to calm a patient. Really good nurses had the ability, she said, to create a tranquil atmosphere, just through the quality of their presence. ‘Are you saying it’s an art?’ I asked. ‘Yes,’ she said, clear as a bell, ‘It’s an art.’

It is so much easier to talk about clinical techniques, about monitoring and measurements and checklists than it is to talk this way, about art and intangibles, how nursing can work on a level that I can only, godless heathen that I am, describe as spiritual.

In my reading I come across accounts by individuals who have suffered life threatening illnesses and who write about the importance of certain subtle interactions to their recovery. Richard Selzer, an American surgeon and writer receiving treatment for Legionnaire's Disease in an ICU wrote of the skilled nursing care he received, calling it ‘transformative’. He describes being carried back to bed by a male nurse after a bath as the moment when his ‘molecules rearranged themselves’ ‘It is the true moment of cure,’ he writes.

David Rier, an Israeli sociologist, was admitted to an intensive care unit with a virulent form of pneumonia. Unusually for an ICU patient, he was alert or semi-alert much of the time and the notes and observations he made provide an insight into patient experience in the ICU that is rare in its thoroughness and which changed his own thinking about medicine. In his fascinating account, he credits a large part of his recovery to the atmosphere of the ward.

“The staff’s cheerfulness, and the personal attention they lavished on me, gave me a strong sense of security. As mentioned earlier, this conviction that everything was under control and would turn out all right remained with me through most of even the most critical phase of my illness. But given my weakness, not even the staff’s smiles and attention could have sustained this security had they given me the full, discouraging story they were giving to my wife,” Rier is of the opinion that at his most ill, bad news would have killed him.

“These points are crucial” he writes, “because I am convinced that this cocoon of optimism helped save my life.”  David A. Rier The Missing Voice of the Critically Ill (in Sociology of Health and Illness vol 22, 2000)

The non-clinical aspects of care – human interaction, empathy, encouragement, nurture – are often referred to as ‘soft skills’. It’s not a good phrase. Within a society so devoted to the hard and fast and innovative, it is belittling and dismissive. Yet what evidence there is points to these intangible exchanges as essential to recovery and healing.

1 comment:

  1. Jon Kabat-Zinn, an American medical doctor and founder of the Centre for Mindfulness in Medicine makes the same argument as David Rier: a story told by someone in authority can change a patient's prognosis. Unless, the patient has learned to detach him or herself from stories through Buddhist-based mindfulness practice. It appears that the old nursery rhyme, "sticks and stones will break my bones but words will never hurt me," has some hidden caveats attached to it.