Nursing and Humanities

Graham McCaffrey

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000033557
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería

The humanities have long been recognized as having a place in nursing knowledge, and have been used in education, theory, and research by nurses. However, the place of humanities in nursing has always remained ambiguous. This book offers an in-depth exploration of the relationship between humanities and nursing.

The book starts with a survey of the history of humanities in nursing, in comparison with medical humanities and in the context of the emergence of interdisciplinary health humanities. There is a description of applications of humanities within nursing. A central section offers an argument for placing the humanities firmly within a mixed model of nursing knowledge that is based upon embodied cognition. Final chapters explore these ideas through a series of essays on topics of humanities as a form of intervention, prose and poetry in relation to nursing, and applications of the Buddhist concept of interdependence.

Nursing and Humanities is intended primarily for nurse academics and graduate students, who have an interest in nursing theory, applications of arts and humanities in education, and qualitative research approaches. It will also interest practicing nurses who are looking for an account of nursing that combines the technical and the human.

1 Nursing and the humanities

Medical and health humanities

In this chapter I give an overview of the current context for thinking about nursing and the humanities, in relation to the field of medical humanities and the trend towards interdisciplinary health humanities. I start with medical humanities because it is more well established and knowing something about this related field and its origins helps to clarify what is different for nursing in taking up the humanities. I then discuss the emerging field of health humanities and suggesting how nursing can contribute to an interdisciplinary field. In the final section, I introduce voices from the humanities themselves, expressing ideas about the value of the humanities and seeing how they meet up with perspectives that start out from healthcare.

Medical humanities

Medical humanities, as a term, is well established and well recognized in a way that nursing humanities is not. One reason is that medical humanities evolved out of developments in medical education during the late nineteenth century when modern professionalized nursing was only just coming into being. Medical education in the West has its roots in the humanist education of early modernity, when learning from the Classical world informed all branches of knowledge and humanism embraced both cultural and naturalist dimensions of human life. Following the development of scientific method starting in the seventeenth century, there began to be a divergence between the natural sciences and humanities. Medicine, then as now, was compelled to follow the undeniable successes of science as applied to knowledge of physiology, illness, and treatments, yet as a practical occupation it could not be wholly subsumed into the natural sciences.

Bleakley (2015) puts the first appearance of the term “medical humanities” in 1948 although Cole, Carlin, and Carson (2015) note that it did not come into common usage until the 1980s and 1990s. However, there was already a sense of dislocation or even identity crisis, at least among some physicians, in the face of rapid advances in scientific medicine in the latter half of the nineteenth century. Germ theory, anaesthesia and surgical procedures created new demands for the education of doctors as scientifically knowledgeable and technically skilled. The associated trend towards specialization was seen as a threat to the unified identity of the profession (Cole et al., 2015).

Advocates of restoring the moral core of medicine initially saw history as the best way of realigning the profession with its highest traditions. According to one historian of medicine, “history was to be the cornerstone of a new humanism in medicine that would promote cross-cultural dialogue between the sciences and the humanities” (Warner, 2011, p. 92). This initial turn towards the humanities was not made in opposition to the rise of modern scientific medicine, but as a corrective to its alienating tendencies. History was considered the most direct way of reconnecting with the humanist tradition of education, predicated on “an ideal of the ‘gentleman-physician’ well versed in the classic liberal arts” (Warner, 2011, p. 92). William Osler, a prominent doctor of this period, is the figure most associated with the concern for the humanity of medicine. As well as looking back to humanism, he was an advocate of reform in clinical teaching to emphasize bedside teaching and face-to-face patient contact (Bleakley, 2015). At the same time, there was an element of maintaining prestige and class status based on a traditional education in so-called high culture. The concern for humanism in medicine brought with it questions about quite what this meant, and how it was, or could be, linked to the humanities. Harvey Cushing, a neurosurgeon who like Osler was both an advocate of scientific progress and concerned with the loss of humanist values, worried that “the very terms humanism, humanities and humanization could be vague and their meanings fluid” (Warner, 2011, p. 93). This is a question that continues to show up in the field of medical humanities, and for that matter in health humanities or nursing humanities.

The next signal figure in trying to establish a place for the humanities in medical education is Abraham Flexner, who wrote a report on medical education for the Carnegie Foundation in 1910 which was massively influential (Doukas, McCullough, & Wear, 2010). Flexner advocated for higher and more uniform standards in medical education and saw the physician primarily as a scientist. However, he also assumed that applicants for medical school would come with a sound, broadly based education, and that the practice of medicine required contextualized judgement that was best achieved through a grounding in the humanities (Doukas et al., 2010).

Thus, alongside the emergence of modern medicine from the late nineteenth century onwards, there has been a concern with the potential for the loss of humanity, ethical clarity, and cohesive professional identity in the face of reductionism, standardization, and specialization. It is worth noting that these ideals do not all amount to the same thing. Professionalism can either denote (as it usually does in relation to medical humanities) a comportment of concern and respect towards individual patients, or a self-interested concern with group status. As Cushing noted early on, the handy etymological associations between humane-humanism-humanities can elide the differences between them and slide over more complex questions of what is meant by humanism, or if there is any good reason why the humanities would make people more humane. In addition to these questions, there are some characteristics of medical humanities that are already visible in these early developments that have shaped the field and are important to note when it comes to distinguishing the very different course of humanities in relation to nursing. First, medical humanities are closely associated with medical education. Medical humanities are one answer to the question of how to produce doctors who are not only competent but also kind. Second, medical humanities are involved over a concern with professionalism in the first sense above – questions of comportment and disposition towards others.

The questions raised by the early advocates of humanities in medicine, such as Osler, Cushing, and Flexner did not go away in the early decades of the twentieth century, but in the 1960s and 1970s there began to be a renewed attention to humanities. History of medicine, for example, was taken up less as a way of sustaining tradition and in a more critical, reflective way to examine medical culture (Warner, 2011). Edmund Pellegrino was a leading voice for humanizing medicine in the 1970s (Cole et al., 2015). He started from the assertion that medicine, though necessarily involving scientific knowledge and skills, was not reducible to science. “Medicine enjoys a unique position among disciplines – as a humane science whose technology must ever be person-oriented. Its practitioners are, therefore, under an extraordinary mandate to live and work within a humanistic frame” (Pellegrino, 1974, p. 1288). Here he is making a point that is not new or unique, but worth quoting because it states so well the relational and ethical commitments that are inherent in medical practice (though I question whether these are unique to medicine as Pellegrino states here, or applicable also to other health professions including nursing). From this standpoint, he asks, “What does it mean to educate a humanist physician in contemporary society?” (p. 1288). For Pellegrino, a grounding in the traditional canon of Western humanism is less important than a liberal education that serves to cultivate socially and contextually aware, other-oriented care. He is more interested ultimately in values that will humanize the physician’s practice with scientific knowledge than in any particular attainment in arts or literature.

Medical humanities have developed in scope since the 1970s, becoming recognized as a distinctive field, as a widely accepted component of medical education, and as a focus for institutions and publications. In recent years, there has been a flurry of excellent new books in the field, including Cole, Carlin, and Carson’s Medical Humanities textbook and Bleakley’s Medical Humanities and Medical Education, both in 2015. I draw primarily on these two sources to give a brief survey of the range of goals for medical humanities that are currently motivating those working in the field.

Cole et al. (2015) identify four goals for medical humanities, as “bridge between science and experience” (p. 9), “educating more humane physicians” (p. 10), “recovering a learned profession” (p. 11), and “moral critique and political aspiration” (p. 11). Taking each of these in turn, bridging science and experience starts with the concrete clinical situation that the physician deals with objective data to diagnose and treat a disorder of some kind, while the patient has the experience of their own self altered by illness (and the physician too is an experiencing subject, however focused he or she is on rational evaluation of information). Arts and literature have always been a means of conveying experience, of imaginative transport into other realms of experience that can then also be shared, discussed, and compared with others. Thus, the humanities can provide ways of gaining insight into the doubled experience of objective and subjective that is a mark of modern medicine, and as we have seen a preoccupation for at least some physicians since the advent of modern medicine.

Educating more humane physicians is probably the most prevalent goal for medical humanities, partly because it becomes visible in the complicated and politicized environment of curriculum and programme design in medical schools. Advocacy of medical humanities is concretized in competition for space in crowded schedules. It has been driven by a concern that empathy in medical students declines over the course of their studies (Neumann et al., 2011). Using resources from the arts and the humanities to prompt reflection and alternative perspective taking, to look at things from others’ points of view, is intended to support empathy and compassion in clinical practice.

Recovering a learned profession is a goal that reaches back, through Pellegrino, to Osler and Flexner and the idea that practitioners with broad learning can bring richer understanding to their professional lives. It also reasserts a claim to the value of pursuing intellectual questions that do not have an immediate instrumental value or that cannot be answered with quantified measures.

The fourth goal, of humanities as moral critique and political aspirations, is a development of the critical self-awareness that became a feature of medical humanities, as well as many other disciplines, in the 1960s and 1970s. Technical advances in medicine have afforded effective, even life-saving treatments, but have raised unforeseen questions such as the prolongation of life with progressive conditions, iatrogenic side effects, or the fair distribution of expensive resources. None of these kinds of questions are answerable by the technologies themselves, nor by a simple resort to evidence which might be used to support opposing positions. History and philosophy provide ways of thinking about difficult moral and political problems, while arts and literature can be used to explore ambiguity, paradox, and indeed, the tragic.

For Bleakley, the “critical” (2015, p. 33) medical humanities are of foremost importance, serving the project of what he calls “the democratizing of medicine – shifting medical practice from an authority-led hierarchy that is doctor-centred to a patient-centred and interprofessional team process” (p. 2). He argues that “the humanities can offer an education into seeing otherwise” (p. 16). Seeing otherwise, being open and responsive to other perspectives, is not only a matter of empathy towards individuals, but a political commitment to reflect critically upon established values and institutions, and to exploring alternative ways of thinking and doing. He notes a tension between viewing the arts as a healing force, essentially as soothing and calming, and the intention of many artists to disrupt the status quo, to upset familiar assumptions that may in fact conceal problematic relationships. He envisages a pluralistic landscape of “interacting networks” (p. 32), at times in tension, and at times in productive conversation with each other, that draw on the humanities in different ways in pursuit of different goals.

Narrative medicine

One development in medical humanities that deserves separate mention is narrative medicine, since it has assumed a major place in the field (Charon, 2006; Frank, 2002, 2013; Kumagi, 2008). Narrative medicine pays attention to patient stories, to what the experience of illness, as opposed to the diagnosis of a disease or condition, means to the person undergoing it. Narrative medicine is rooted in the basic medical practice of taking a history, but is a reaction against a narrow focus on gathering information in order to make a diagnosis, which puts the priority on the needs of the physician rather than the actual concerns of the patient. It may also exclude or discount information that does turn out to have a bearing on how best the physician should proceed to heal the person, and not just treat the presenting problem. Narrative medicine restores the story to a medical history. One of the key works in the development of narrative medicine is by Arthur Kleinman (1988) who was both a psychiatrist and an anthropologist. He was alive to the importance of the patient’s inner life and experience, as well as to how individual illness is expressed through a dense mesh of cultural values and meanings. More recently, Rita Charon has developed narrative medicine by bringing to bear the knowledge and methods of literary analysis to the doctor-patient dialogue. The doctor thus becomes not just a professional seeking prescribed pieces of information, but the audience for a narrative, an informed audience attuned to how meaning appears through plot, character, and purpose (Charon, 2006; Charon & Montello, 2002). Narrative medicine is important because it has become a major element in medical humanities and because it is a significant example of how interdisciplinary approaches can be brought to bear on clinical practice. Its wider significance, is that narrative is one opening – though not the only one – to the role of language and dialogue in clinical encounters, education, and research for all health professionals.

Nursing and humanities

Against the background of medical humanities, there is no such well-defined tradition in nursing, although there has been much debate in nursing literature about the humanities. Davis wrote an editorial in the American Journal of Nursing in 2003 calling for the systematic inclusion of humanities in nursing education along the lines of medical humanities, under the heading “Nursing humanities: The time has come” (p. 13). It is unusual, however, to find the term nursing humanities as a distinct category in nursing literature. It has never caught on in direct equivalence to medical humanities, although there has been no shortage of engagement with the humanities on the part of nurses, as clinicians, educators, scholars, and researchers.

Others who have promoted the humanities in nursing have sometimes taken medical humanities in a generic sense to include health professions more generally, such that they could be imported into nurse education (Corri, 2003; Robb & Murray, 1992). Darbyshire combined “medical/nursing humanities” (1994, p. 856) to describe a new course using arts and humanities within an interdisciplinary health studies programme. Dellasega et al. (2007) advanced a model for interdisciplinary education at the “humanities interface of nursing and medicine” (p. 174). Variations in terminology show an interest in medical humanities on the part of nurses and often a desire to find in the humanities a bridge between disciplines.

Authors have reflected on why nursing humanities have never developed as a discrete field like medical humanities. Dellasega et al. (2007) identified a move away from humanities in nursing curricula during the 1980s with increasing amounts of science content following developments in medical science, even while medical humanities had been becoming more prominent since the 1970s. Davis (2003) suggested that nurses tend to think that they are less in need than medical students of the humanizing influence promised by exposure to humanities.

There may be something in this when you compare the historical trajectories of the two professions. Warner, in his historical survey of medical humanities observed that, “… humanistic medicine first emerged at precisely the moment when modern Western biomedicine became ascendant” (Warner, 2011, p. 91). This was at the same historical moment that modern nursing emerged, with its vexed relationship with medicine right out of the gate. Nurses claimed to encompass precisely the humane values that doctors were felt to be shedding under the pressure of scientific medicine. Thus, nursing never experienced a rupture between an earlier perception of itself and a new, modern, scientific identity. Nurses took on as part of their professional identity caring for each person, and creating the best conditions for healing without feeling a need to find their way back to what Kleinman (1988) dubbed “illness narratives” by means of the humanities. Later on, in the latter part of the twentieth century, with the growth of academic nursing and theory and in the face of rapid technological change, there was still not much movement towards the humanities as such. Instead, theo reticians tended to double down on caring and holism as the distinguishing characteristics of nursing, packaged into elaborate theories. The need for grand theory was justified under the rubric of nursing science, despite the overtly metaphysical and spiritual content of some...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction
• 1 Nursing and the humanities: medical and health humanities
• 2 Nursing and humanities: history and uses
• 3 What is nursing?
• 4 Epistemic differences in nursing
• 5 Cognitive science and experience
• 6 Compassion and the pharmakon of the health humanities
• 7 Prose and poetry in nursing
• 8 Nursing, Buddhism, interdependence
• 9 Nursing and humanities in the age of the post-human
• Conclusion
• Index