Participatory Inquiry in Health-Care

This is a draft of some writing intended to follow an introduction to my research.  The introduction includes a précis of my MSc work (‘Co-operative Inquiry in Nursing’) as well as an autobiographical summary.   I’m a nurse working mainly in hospitals in West Wales; I’m also a research student at CARPP. 
Part 1
There are a number of possible follow-on’s to this introduction of my work.  There’s the possibility of an historical account of my written academic work since I began studies eight years ago, where the text sits as central and the story of my research progress/interest is set about those writings – an academic tale, with text at heart.
There’s also the possibility of an historical account of the micro and macro politics, the structure and culture of the health-care world within which I practice:  the organisation of health-care, of ‘evidence-based practice’, ‘audit’ and ‘clinical excellence’.  Through a review and analysis of these I can position myself and speak to you in ways that would comprise an account of my inquiry.
Yet my starting point in ‘real life’ has not been via these approaches - my research starting point has been my practice as a nurse.  Research is the process of my answering to myself as a nurse trying to nurse well.  For me, caring for people does not begin with written texts, politics, cultural analysis or idealism. It is far simpler. Far less complicated.  It’s about making for health through personal body-to-body encounters – for the most part it’s practical work.  Exposing some of what I do when I nurse may help explain how inquiry is integral in this. 
Nursing work is often silent work, involving neither speech nor writing.  The activity of nursing - the action, reflection, review and re-action of practice – involves a physical articulation, a body conversation, as much if not more often as it does a verbal exchange.  The extent of our bodywork is what necessarily sets the practicing clinician apart from the health-care academic or the health-care manager.  We know things about people and their needs that can only be known and responded to through bodily engagement.  We are practiced in ways those removed from the ‘point of care’ simply cannot be.  This knowledge held in practice has been referred to by nurse academics as ‘secret’ (Procter and Reed 1994) or ‘hidden’ knowledge (Benner 1984). From an academic point of view this may seem so, but in practice - in real life - it is not secret or hidden, quite the opposite, it is knowledge which is lived out in public and directly shared with others, many thousands of others. It is certainly not secret or hidden, but it is not often abstracted into (or confined within) written text. 
To give you some idea of what I do when I nurse, this piece of writing is edited from a diary account I wrote whilst working two nights a week as a Staff Nurse on a 32-bed medical/coronary care unit. I don’t normally keep a diary, but at the time I was studying for an MSc (Nursing) degree and was asked to.  It is a telling of just three very brief pieces of nursing, ordinary nursing, involving a person I had never met before and myself. Each encounter occurred amidst a night full of other such encounters with the thirty or so patients and three or four other staff I worked with during these shifts. The first encounter with Kevin is what I and my nurse colleagues call “just doing the obs”.  When I was at work last week I worked on another medical ward in a similar way.
‘I went to take Kevin’s obs. He was in a side ward on a cardiac monitor. Just inside the doorway of his single room was a television and on it a bizarre bed scene was being enacted – it was so bizarre it was funny.  Kevin had not been watching, but looked now and laughed easily with a passing nurse colleague/friend and me.  
Before the laughter, at first glance, he appeared languid and melancholic.  His colour was poor, but not such that it concerned me greatly. His oxygen mask lay blowing on the pillow, he did not appear breathless.  I was confident from the look of things at the moment that he was physically ok.  Emotionally, I had an impression, but could not tell the extent to which he was feeling sad and withdrawn.  
The way he moved to sit up and reach for his glasses to view the TV, the amount of energy he put into it, the speed of it, the effect of the action on his breathing and heart rate reaffirmed the first impression of his physical state.  After the laughing I knew he was able and willing to communicate; I did not see him as being in a deep depression, but it was equally obvious from his response to subsequent brief small talk that he was mentally preoccupied and worried.  
The task of ‘doing the obs’ followed.  It was what he and ward protocol expected of me.  He took off his glasses and relaxed back as I went about my work.  I need not have taken his pulse – I had been taking note of the atrial fibrillation shown by the cardiac monitor since I had arrived in the room two minutes before. I was happy to trust the monitor and record the average rate it showed, but I did not.  Not because I wanted to feel the force of his pulse or confirm the precise rate – though I might have – but because I wanted to touch him to see how he felt.  And although it is difficult to express in words, I also wanted to touch as a sort of symbol or sign that I was present for him.
He was passive as I took the obs.  We were both fairly quiet.  It was a transition time from fun to seriousness, though the sense of intimacy had carried over.  Quite naturally, I was preparing to listen to him – how did he feel, what did he need or want?  I took the out the thermometer - I was sitting still on his bed. I did not get up to chart the observations.  I asked him, “How’s your breathing?” and it was enough.  He told me the history of his breathing since he’d been ill.  The effects it had had on his lifestyle: how he and his wife had moved from the farm to a bungalow last autumn. They were just adjusting to the change when she was diagnosed as having cancer, now she was dying in a nursing home.  He told me about his visit to his wife two days ago just before his admission, when she had asked him not to call on her the next day but to rest instead.  His manner of telling was frank and resigned.
I mainly listened, sometimes reflecting back.  I felt a need to know whether, in spite of the obstacles, he wanted to see her now.  I cannot remember exactly how the conversation went but I know that I was content that he had accepted that, for the time being, he could not be with her.  I got the feeling that in some ways this was a relief to him.  What he had told me was how, over time, he had been coming to terms with his chronic ill health, his changed lifestyle, living alone, and his wife’s imminent death.  A lot of grieving had been done; he seemed to be telling me life was hard, but he had lived through it and was preparing himself for the next phase.  
A colleague arrived with the medicine trolley and I charted the observations and left him.  I had been in the room about seven minutes. 
Towards the end of my shift the following night, Sunday morning, a call came from the nursing home – his wife had died.  I gave him the telephone and held his shoulders.  We went back to the bedside together.  He wanted some help to change his pyjamas, they were wet with sweat - he said they always were in the morning.  Then he wanted to use the commode – he was in a hurry. After this I settled him back in bed. I listened - he talked about his life and his wife. 
I was off the next night.  When I saw him on Monday evening he told me about the funeral arrangements, he was not sure he wanted to go, though the nurses and doctor had said it could be organised.  He was off his monitor and in a seven-bedded bay.  I listened, and talked with him for a short time.  Then I spoke with the nurses who were caring for him as I was with different patients that night.  For me this was an ordinary nursing experience, for him it was a time of trauma, a personal life crisis.’
Talk was important to our responses to one another but, particularly clearly when his wife died, our efforts towards health seemed to foreground a physical call and response, what might be termed ‘body-conversation’, rather than words.  I say ‘our’ because the process is participatory: we were both making efforts towards being better, or being well/well being together.  The description of this physical work finds less space in terms of words or explanations – but writing more would be to somehow risk reduction, and that would be dishonourable and wrong. 
In passing on the gist of this experience with Kevin to other nurses both verbally and in writing during and at the end of the shift I could only outline Kevin’s possible needs, just as I had only received an outline when I was given report.  But I don’t believe this was necessarily detrimental to his later care.  There is an accord amongst my colleagues which flourishes because there exists, though unwritten, a strong unity of purpose in our nursing care, even though our approaches are individual and varied.  I think this results from bodily sharing the way we are as nurses together.  Because of this ‘body sharing’ of ourselves as we work together we gain an appreciation as to what we can expect from one another.  Working together we also incline ourselves in ways that, at their best, move us towards caring well or caring better both as individuals and as a team.
When health-care practice is ‘researched’ or ‘audited’, abstracted into text by academics or bureaucrats who are not in work-a-day touch with its qualities, it is often presented as unenlightened practice that needs to be sophisticated through attention to the work of academics and/or the latest management directive.  For example, my work with Kevin ‘doing the obs’, because it is ‘routine’ and ‘task-allocated’, has been subject to all sorts of maligning.  It seems to me important to challenge this.  Misunderstanding because of lack of proximity means that the knowledge that many healthcare managers, academics and researchers exhibit and communicate in relation to health-care is not only insufficiently informed by health-care practice, but also misses out on the health of the ‘we’ that can come through such close work. (I mean that not only do they miss out in theory, but they also miss out in practice.) 
Part 2 
Reviewing the historian Theodore Zeldin’s book ‘Conversation’, John Shotter (1999) argues:
there is no doubt that there is an increasing recognition that the administrative and organization systems, within which we have long tried to relate ourselves to each other and our surroundings, are crippling us. Something is amiss. They have no place in them for us, for our humanness.
And goes on to summarise Zeldin’s thesis thus:
 it is not just us talking to each other that matters - the one-way sending and receiving of information - but us being able to enter into conversation with each other. When you sensitively and responsively listen to me, and I see you doing so, and sensitively and responsively shape my talk to you accordingly, then something very special happens. You and I become co-authors of what I say: you become a co-speaker, and become a co-listener. We form a 'we'. But more than this. In not being planned by either of us, what occurs in a conversation in which people are truly intimate with each other, is genuinely creative. A unique response to currently shared circumstances emerges. The face-to-face responsive intimacy matters. 

It was important to me to read this point of view as an academic account that confirmed (part) of my practice knowledge, and to make public my critique of this reading through my practice – my doing at work. The following account, my academic presentation of that effort (my effort at iteration-in-action) was written in response to an academic Email exchange concerning Shotter’s review, which was circulated to the CARPP community by Peter Reason in March 2000.
The way I titled my writing must have seemed confusing.  I had been reading about, and was applying, an idea Philip Barker explains and uses in his book on Foucault, which he calls ‘thinking against’:
Thinking against is a form of critical interaction that involves touching the work of the other.  This is a meeting of surfaces: to be against is to be touching, so this critical encounter is not a reading, not a seeing, but a feeling, a touching difference.  In the interplay of surfaces against each other, new lines of attachment are made, new forms of experience take shape.  To think against is to expand and multiply possible encounters – to think against is to seriously take on the concept of agonism.					         (Barker 1998: 119-120)
I used the term without explanation hoping to bring the reader, through the apparent mistake of the title, to experience ‘a feeling, a touching difference’.   (Two CARPP friends wrote to me privately in response, but nobody did actually question me re the title.)
‘Thinking against’ Shotter’s review of Zeldin's 'Conversation'
I read and copied this review from John Shotter's web pages last August:  http://pubpages.unh.edu/~jds/  (where he makes available his work-in-progress, as well as other published papers). I emailed a copy to Peter in October after we referred to Zeldin and Shotter in our supervision meeting. 
At the time I was working as a night nurse in a small hospital that was about to close. There was time, and the right sort of space, to have more/longer-than-usual conversations with the nurses and doctors I worked with and the people we were caring for.  Conversations are supportive of, part of the foreground of, my care giving (and receiving): they bring about a depth of knowing, an accord, an intimacy, through which we (the people I work with - colleagues and patients) co-express ourselves as care-givers- receivers...as human beings together. Conversations are a part of my nursing... my nursing better.... and having noticed this and wanting to communicate it in 'academic' terms, for me, reading this review of Shotter's, encouraged me to name and proclaim that which I would otherwise tend to hide as knowledge crucial to me and my work mates (in practice) but academically (theoretically) illegitimate (whilst at the same time I passionately believe in the primacy of practical knowledge and the importance of making this public in academic terms). 
By conversation I mean gossip, idle talk, pieces of life history, chat about family, reflections, sharing information, experiences etc. etc. For me, the conversations and reading Shotter's review sustain(ed) me as nurse, mother, person: growing in knowing.... growing in co-relation.  Both the practice/experience (my being nurse) and the theory (my being academic) make present for me a capacity to care more (as 'the-to-be' nurse, and 'the-to-be' academic).  This transformation would not be halted by not making public (in academic terms) my experience of conversation as contributive, but it would be inhibited.... 
Further to this, and more important to me, I believe it is physical co-relation that facilitates my care more than words uttered (speech) or words written (text).  My way of knowing and responding (moving with the world), conversing as nurse/self (extending limits), is 'whole self' and my whole is lived in physical relation.  In my experience, the development of physical co-relation happens within a body-to-body conversation in a way that it cannot by remote means... it is not that remote communication cannot be health-giving or sustaining in ways... but it is necessarily not quite in step... 
Now I am nursing in a busier area physical interaction predominates my practice...but somehow, the constancy and depth of my physical caring - the intimacy, the care/regard for person - is more constantly present (more often and more easily remembered and lived) since the conversations in the quiet hospital and the reading/study that further presences them for me. Yes, it is difficult to share this with, for example, the wider health care system (that is to say, that part of it which is 'third person' to me) - because communication is limited to text and/or oral/aural methods and the 'evidence' for what I am saying is bodied and not yet convincingly exposed theoretically.  But as I stretch my limits and determine to express the 'ordinary' (extraordinary) through ever improving information communication and other technologies, I think the transformational capacity of care through intimacy expressed in conversation will be more celebrated in the world...both in theory and in practice. 
 Is any of what I'm saying useful? Or is traditional academic critique a better way to continue to explicate Shotter's text or Zeldin's fancies?
What I noticed as I worked at the community hospital was that I would sit and talk with whoever I happened to be working with and then we would get up, for example to go to turn somebody, and would share the understanding (exhibit the values?) we expressed through the conversation by continuing the exchange through our movement with one another.  But more than this, we would naturally extend this ‘conversation’ or ‘being against’ to include the third person.  Sometimes this was literally by continuing in verbal conversation as well as movement together with the person we had gone to turn, or sometimes it involved silently acting together, all three of us, in the turn.
People who are immobile often need to be turned every two or three hours to help prevent pressure sores, so even within one shift these cycles of what I would call ‘co-inquiry’ are repeated again and again.  Since a short talk with Jack Whitehead last week, maybe I want to say that it is the sharing of values expressed in action that I’m also on about here, and the way in which our practice (of bodywork and talk) naturally engages us in an exchange and development or accommodation of these (‘we’ being the people I work with in practice – patients, relatives and staff etc.). When I’m working I’m not so interested in a retrospective critique in terms of an intellectual analysis (i.e. good turn, bad turn?), so much as living a response to my/our desire to turn well in the circumstance:
to be against is to be touching, so this critical encounter is not a reading, not a seeing, but a feeling, a touching difference.  In the interplay of surfaces against each other, new lines of attachment are made, new forms of experience take shape.  To think against is to expand and multiply possible encounters – to think against is to seriously take on the concept of agonism.
And I can’t help longing for the academics who write about my work, or the managers who usually resist this proximity to care, to come close to care and to experience the health of this turn with me.

Part 3 – Thinking against Leah
The way I am in my practice as a nurse is guided by all my experience of being and that experience consists in large measure of my being with my family.  I want to try and expose what this experience brings to me.  
When I first read Barker’s idea of ‘thinking against’, I was in my bedroom with my 12-month-old granddaughter playing around me and I paused to make sense, to contemplate the relevance of the idea to me; in particular, the possibility of living, or framing how I already live out, these ideas in my actions.  I needed to articulate my way of inquiry in academic terms, to answer the methodological questions put by my research supervision group concerning my inquiry practice:
“Who’s ‘we’ and what are the kinds of relationship which forms we? What’s the process of engaging with we and how do you imagine it developing? What is your role in this?”
And I was staring into space and doing this sort of thinking, this day reading about Foucault in my bedroom, when my granddaughter’s hand came toward my face and brought me straight to my (physical) senses.  So that the contemplation changed to a here and now experiential opportunity for the thoughts - a healthy and real testing out: a somatic expression – a living, stretching, integration/interrogation/feeling/exercise of these concepts in my experience: a progression in inquiry with my grandchild.  What happened was not deliberate and conscious – I wasn’t planning it, I didn’t even think “ah- an opportunity to begin to make sense of these ideas” – what happened is just what happened.  
This text account of my experience was written in the bedroom, as Leah continued her adventuring around me, directly after the events it recounts.  And I could have left the account as it was – as text.  But I wanted to take it beyond itself somehow – to introduce the person of my granddaughter to you.  I wanted to be more explicit.  I wanted to bring you to touch – so you too might experience the health (?) of her way of being in the world. I think I want too much!  Nonetheless, I felt a need to somehow set the event in context in my inquiry, to enmesh it within my account of my work as a nurse in the health-service, just as it is enmeshed within the practice of my work in the health-service. 
It happened that a few days after this time with Leah (mid February this year), I fell into conversation with my brother Thomas, who was an undergraduate nearing the end of his studies in Information Technology and Theology. The upshot of the conversation was that he would help with the technicalities of constructing a multimedia paper, so that together we could begin to explore the possibilities of this sort of representation for my research through this encounter with Leah.  He wanted to (and did) write-up this action research work as his dissertation (Fernandez 2000).  His writing focuses on technological matters of hardware, software, skills and techniques necessary to the creation of this hypermedia document.
This is a first attempt at a representation of this sort for me; it is relatively crude and not as effective as it could be - but it can be revised (or deleted!)  It is exciting because the further possibilities are clearer since we have created the thing, and I imagine those possibilities themselves may open the way to apprehending differently. (And as I write I’m remembering the directions of thought, the articulations, of Luce Irigaray, Helene Cisioux and Julia Kristeva).  Foucault suggests ‘there is an attempt at modifying one’s being through the act of writing’ (1986: 182), and through changing the shape and matter of writing to include other media, I am trying to do this in more ways.  
So the text story of being against Leah now also contains hyper-linked audio video illustrations (or references). This was possible because Leah cycles and reapplies/repeats her experience in later contexts and we were able to capture some of these on video.  Leah is also living her life as inquiry - but how awarely? - How can I answer except to say, would that I was as ‘aware’ as she!
I’ll bring this story with links on the 1st December. The plain text is given on the next page.
LEAH
Leah pulls the baby wipes one at time, systematically, from the packet and delivers them to me with great ceremony, “Dar”; And in between makes garish faces and cackles out loud.  
Music comes on the TV and she stops to dance.  Then, taking up a wedge of wipes she stuffs them between her jaws and screws her face, strangles the foul offenders and expletes angrily: “Urrghh”, moving her reproach with her gaze - from object to subject- as she ends the sound, full and direct, at me. 
(I begin to take on the reproach, feel the anxiety - the feeling seeking to settle in mind to be worked on and exorcised through reflection…)
But that little self, that little self - incapable of conversation - arrests the thought, brings me to my senses (enlightenment?) and answers my angst with a ‘raspberry’ and a “Ha Ha!!”