Wednesday, September 24, 2008

Tacit knowledge

It has been a pretty exhausting week at my place of work, with a spate of sickness affecting several of the carers, so that everyone unaffected has had to pitch in to cover for absent colleagues, work extra shifts, and generally 'burn the candle at both ends'. In the last weeks I have worked several back-to-back shifts of fourteen consecutive hours duty, mostly engaged in 'hands-on' care, interspersed with such activities as helping to cook and serve meals, wash up pots, pans and dishes, do laundry, and variety of administrative chores besides.

At such times nerves can get frayed, patience is strained, and mistakes and accidents are more likely to happen. This morning, arriving at work at about 0645, I looked in on the laundry room to find that one of our washing machines had been loaded with two sets of nightclothes, both of which sets had been subject to a hot wash while still containing incontinence pads, which ought to have been removed. These 'pads' are disposable adult garments like large 'nappies' made of cellulose padding inside a thin plastic envelope, designed - of course - to capture and contain human wastes.

Presumably the overworked and overtired careworker who did the washing had been too distracted to remember to separate out the pads from the garments so as to put them in the clinical waste bin. Of course, they had disintegrated in the machines, dispersing the contents throughout the wash, and liberally coating the inside of the drum with unpleasant emulsified pap. Not a bright start to the day, but not unusual either.

After work this evening I turned to an article in my daily paper, hoping to take my mind off things clinical, but my eye was caught by an article, a critique, about the training of young doctors. Not a lot has changed in the fifty or years I have been in a position to observe this happening except, perhaps, that doctors have grown unaccountably younger, like policemen. Training is still very much hospital-based, and possibly even more fragmented and modularised than ever, with more tick-box-type assessments, and less time at the bedside.

Patients are in hospital for much shorter periods than twenty years ago, so that doctors have less time to get to know their charges, less time to see changes in their patients over time, for getting a feel for how people respond over time to disease, and watching what happens as they get better. The wisdom that emerges from being able to witness such evolutionary change is called "tacit knowledge".

One of its characteristics is a growth in the necessary humility that a practitioner develops about her own part in the processes of recovery and 'cure', and a deeper respect for the adaptive potential of the human organism, in both the physical and the psychological domains. Medicine, after all, is just a set of interventions that help to put the patient into a condition that allows nature to take its healing course. The same is true of nursing and all 'healing arts'.

In this respect, I believe, nurses are at an advantage over doctors, and many doctors (certainly most senior or older doctors) acknowledge the wider and deeper clinical acumen of nurses in making a difficult diagnosis, and a more reliable prognosis, than less seasoned doctors. Nurses, unlike doctors, see their patients day-in-day out, are privy to their informal conversations and reflections, and see them in a far wider repertoire of activities than doctors, sleeping, eating, eliminating, attending to their own needs, in relation to their families etc. Unfortunately, changes in the way nurse training has been structured and delivered have made for a much less coherent and "wholistic" relationship between nurse and patient, less physical intimacy, less thorough-going trust and rapport, and less of a long view on events in the curriculum of health and illness.

There are times when I am attending to one of my own patients, that I am thrown back in my experience to an earlier time when I first began to learn to nurse, fifty years ago. It's not memory in the sense of a picture in the mind, it's a felt physical thing, a reassurance of close contact, warmth, the complex scent of a close-held body, the touch of skin, awareness of a tremor, of a small weakness, of effort, of courage that always springs up in the other to meet the challenge of the moment, and something eternal too about trust and vulnerability.

Today I was helping an old fellow off his commode, helping him hitch his underpants and trousers up, his head against my chest, his arms round me in a politically incorrect and improperly conducted lift by Health and Safety rules, telling him, when he said "You know how to help me", "Yes, we know how to work well together", and meaning it, and knowing it's meaning is not to be found in me, but in the way things are, in that tacit knowledge, that unspoken wisdom that pervades everything, and always. Help is not something I do to another, it's a resource two people in a relationship share, born of the relationship and its circumstances, and always in perfect reciprocity, whatever happens.

"Though the Path is vast and fathomless I vow to understand it.

Though enlightenment is beyond attainment I vow to embody it fully."

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