Article
Care
Change
6 min read

Are we forgetting how to care?

The profound act at the heart of nursing.

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient
Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care.   Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions? 

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.  

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers. 

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.  

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired  infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’. 

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care. 

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?” 

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. 

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.” 

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.  

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.  

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”    

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.  

Article
Character
Culture
Leading
Virtues
6 min read

What is Putin thinking? And how would you know?

The self-centeredness of modern culture is antithetical to strategic thinking.

Emerson writes on geopolitics. He is also a business executive and holds a doctorate in theology.

Preisdent Putin stands behind a lectern with a gold door and Russian flag behind him.
What is Putin thinking?

In a world of Google Maps when walking on city streets, or of Waze when driving, it is difficult to ever become lost.  

The AI algorithm provides us with the shortest route to our destination, adjusting whenever we make the wrong turn. We do not need to think for ourselves, technology instead showing the way forward.  

But there are times where it is possible to get lost. This happens less in a city with its clearly set-out streets, and more so when taking the wrong turn in open expanses: hiking in the mountains, traversing farmers’ fields or while navigating at sea. In each of these situations, a miscalculation may lead to peril.  

It is in these situations that we must carefully think through our steps, determining how to proceed, or whether to turn back. Often, these situations are ambiguous, the right way forward unclear.  

Much of life – perhaps more than we wish to acknowledge – is like this, more akin to a walk across an open field with multiple possible routes forward, than a technology-enabled walk through a city.  

When making important decisions, our grasp of a given situation, of others’ intentions and motives, and the networks facilitating and constraining action, are less evident than we may initially think.  

This acknowledgement of uncertainty is no reason for delay, but rather a basis for careful deliberation in determining what to do, and how to proceed. It is necessary if we are to pursue what we believe is right, in a manner that may produce positive results.   

In a recent interview with the BBC Newscast podcast, University of Durham Chancellor Dr Fiona Hill – who previously served as White House National Security Council Senior Director for European and Russian Affairs, and currently as Co-Lead of the UK’s Strategic Defence Review – provides listeners with a powerful reminder on how to proceed within ambiguous situations, especially in navigating the choppy seas, or rocky terrains, of human relationships.  

Strategic empathy requires self-restraint when natural impulses urge a person to make rapid conclusions about the reality of a given situation – the default human tendency. 

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Dr Hill uses the term “strategic empathy” to consider how the political West might proceed in its relationship with Russia, and specifically with Vladimir Putin.  

Strategic empathy is a serious commitment to understanding how another person thinks, considering their worldview, their key sources of information (in other words, their main three or four advisors, who have a person’s ear), and other emotional considerations that underpin decision-making.  

It is much more than just putting oneself in other’s shoes, as is often said about empathy. The approach is one of realism, suspending judgment based on self-protective or self-aggrandising illusions, in favour of what is actually the case.  

In the case of Putin, Dr Hill helpfully reminds listeners that his worldview is drastically different than that of Westerners, and that significant intellectual effort (and specifically, intellectual humility in setting aside one’s own default frames of reference) is necessary to consider decisions from Putin’s perspective, and so make the right decisions from ours.  

Technology is here an assistant but not a cure-all. Whereas AI might – based on a gathering of all possible publicly available information written by and about a particular person – help to predict a person’s next move, this prediction is imperfect at best.  

There are underlying factors – perhaps a deeply engrained sense of historical grievance and resentment in the case of Putin – that shapes another’s action and that can scarcely be picked up through initial conversation. These factors may not make sense from our perspectives, or be logical, but they exist and must be treated seriously.  

This empathy is strategic, because effective strategy is the “How?” of any mission. Whereas a person’s or organisation’s mission, vocation or purpose (all words that can be used relatively interchangeably) is the “Why?” of a pursuit, strategy is the “How?” which itself consists of the questions “Who?” “What?” “When?” and “Where?”  

To understand how to act strategically requires a prior effective assessment of reality. This requires going beyond what others say, our initial perception of a situation, any haughty beliefs that we simply know what is happening, or even the assessments of supposedly well-connected and expert contacts.  

Dr Hill’s strategic empathy is an appeal to listeners to ask questions – digging as much as possible – to arrive at an assessment that approximates reality to the greatest degree possible.  This exercise might be aided by AI, but it is at its heart a human endeavour. 

Strategic empathy requires self-restraint when natural impulses urge a person to make rapid conclusions about the reality of a given situation – the default human tendency. The persistent asking of questions is difficult – requiring mental, emotional and intellectual endurance. 

There is considerable wisdom in Dr Hill’s reflections on strategic empathy, which extend well beyond the fields of intelligence, geopolitics or defence. The idea of strategic empathy helps show us that in much of modern culture – which glorifies the self, individuals putting their wants, needs and desires before those of others – developing strategy is very difficult.  

The key then, when deliberating on potential right courses of action in ambiguous situations, is to not begin believing that the right way is clear. It rarely is.

Why is this the case? When popular culture favours phrases such as “You do you,” the you becomes a barrier to asking questions, with some aloofness to the situation, necessary for understanding how another thinks. People are encouraged to focus on themselves at the expense of others, and so fail to understand others’ worldviews and ways of operating. 

Simply put, the self-centeredness of modern culture is antithetical to strategy. It impedes deliberation, which involves patience in the gradual formation of purpose for action. It wages war against the considered politics or statesmanship that many want to see return. In place of this is crisis or catastrophe, in which self-focus leads to clashes with others that could otherwise be avoided or worked through carefully.   

The Biblical story of the serpent in the garden is another vantage point for the idea of strategic empathy. Soon after Adam and Eve eat the apple in the garden and become “like gods, knowing good and evil,” God searches for them and asks “Where are you?” 

It is right after individuals try to become the judges of good and evil – “like gods,” that Adam and Eve find themselves lost: God’s “Where are you?”  

Put differently, when a person is convinced they are right, but without asking questions, they make mistakes, they likely suffer unnecessarily because of this, and then become anchorless – the “Where are you?”  

This applies to countries as much as it does to people: the more they moralize, seeking to become the judges of good and evil in a complex geopolitical landscape, the more they drift from their sense of purpose.  

The key then, when deliberating on potential right courses of action in ambiguous situations, is to not begin believing that the right way is clear. It rarely is. A belief in evident rightness often leads to error, whereas the ability to suspend such judgment helps reveal – often gradually – the right path forward.   

The strategic empathy approach requires both assertiveness – in asking good questions and maintaining persistence in doing so – and self-restraint in the face of believing that the right answer is clear.  

The glue between assertiveness on the one hand and restraint on the other is faith, which helps a person to move forward in a trusting manner, but without exerting oneself so much so that they become the centre of the situation.  

So, while Google Maps, Waze or other technologies might be at our disposal in our travels, both real and metaphorical, these technologies only get us so far.  

The right way forward is seldom initially clear when navigating ambiguous situations, the frequency and stakes of which increase as we embark boldly – with faith – on the adventure of life.  

Dr Hill’s strategic empathy – asking questions, listening carefully, suspending a self of sense, seriously considering diverging worldviews, and adjusting as necessary – helps us to achieve the understanding and direction we need.  

Indeed, this approach is fundamental to a more effective and resilient political West. It is necessary for sounder deliberation, better strategy and statesmanship, in an increasingly ambiguous world.