“A sudden rush of empathy” — The Language of Kindness — service book review
Book summary
In this heartfelt and absorbing book, Christie Watson reflects on her years of nursing, through a tapestry of stories about kindness and caring, and the costs of this daily compassion for strangers, who pass continually in and out of her life. The book’s central thesis is that nursing, as well as being a technical skill, is move than anything about being kind — about helping others who can’t help themselves, even at the expense of your own wellbeing. It’s a very moving book, demanding that one rethink the value of carers and the burden’s we unthinkingly place on them. It leaves one in awe of nurses and enormously grateful for the service they provide.
Why choose this book
Nursing is all about service. Nurses are also critical right now as the world fights the pandemic, and nurses selflessly put themselves in the firing line of the virus. In fact the Covid nurse death toll is now as high as the number of nurses who died during World War One. So I thought I’d revisit this amazing book, and try and capture something of what it means to be a nurse in service of others.
A bit about the author
Christie Watson was a nurse for 20 years before becoming an award-winning fiction and non-fiction writer.
What the book has to say about service
1. How nursing is an act of service
Helping someone who needs help.
This is perhaps the simplest definition of service — to help someone who needs it. I often described service as the act of helping someone progress in life — to move from the place they are, to the place they want to be. In many organisations it is defined as a series of actions and interactions, and this is partly the case for nurses. But it is not the full story.
It is the nurse, or nursing assistant, who cleans, washes, dresses, disposes of body fluid, opens the windows and sprays air freshener. But for all that I’ve seen and touched and smelled, and as difficult as it is at the time, there is a patient at the centre of it, afraid and embarrassed.
Watson reminds us that there is a background continuum binding them
Sympathy, compassion, empathy: this is what history tells us makes a good nurse.
Nurses, and others who serve, know that behind all the surface actions and interactions runs a prevailing momentum that moves the person being served forward. It is the emotional quality of the act of service that truly defines it. This is an intrinsic factor in the act of service, and common to anyone who serves out of choice, yet hard to extrinsically create through incentives and training.
I learn then that nursing is not so much about tasks, but about how in every detail a nurse can provide comfort to a patient and a family. It is a privilege to witness people at the frailest, most significant and most extreme moments of life, and to have the capacity to love complete strangers. Nursing, like poetry, is the place where metaphorical and literal meanings cross borders. A hole in the heart is a hole in the heart; the nurse is the thing at the centre: between the surgeon’s skill at fixing the literal hole, and the patient’s anxiety and loss, the metaphorical hole. Nursing is or should be — an indiscriminate act of caring, compassion and empathy. It should be a reminder of our capacity to love one another. If the way we treat our most vulnerable is a measure of our society, then the act of nursing itself is a measure of our humanity. Yet it is the most undervalued of all the professions. Anyone who works with cancer, however, understands and values nursing, perhaps knowing that it is not the cure which so often is not possible — that matters in the end.
2. The skills nurses need to serve
a. Technical skill
As Florence Nightingale observed: If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing.
b. Emotional skill
What I thought nursing involved when I started: chemistry, biology, physics, pharmacology and anatomy. And what I now know to be the truth of nursing: philosophy, psychology, art, ethics and politics. We will meet people on the way: patients, relatives and staff people you may recognise already. Because we are all nursed at some point in our lives. We are all nurses.
c. Empathy and self control
Nurses make good poker players, understanding the importance of not breathing in; of breath-holding so subtly that the patient does not realise, and does not see any expression other than a matter-of-fact one. The horror of our bodies — our humanity, our flesh and blood — is something nurses must bear, lest the patient think too deeply, remember the lack of dignity that makes us all vulnerable. It is our vulnerability that unites us. Promoting dignity in the face of illness is one of the best gifts a nurse can give.
Nursing, Sue tells me, is sometimes simply listening for a while, providing reassurance, keeping people safe until they can keep themselves safe. Catching the bad dreams, until a person wakes.
d. Fluidity and gap-filling
Nursing requires fluidity, being able to adapt and push energy in the direction where patients and colleagues need you, even if it is unfamiliar.
The job of the doctor relies on extreme technical skill. The nurse’s job is less well defined. Keeping a toddler or a child completely still and calm, curled over for a painful procedure, is tricky, and any tiny movement is potentially dangerous. It relies on knowledge about that particular child.
e. Experience
They rely on experience to tell them when the time [of death] is coming, regardless of observations or clinical blood results. They rely on a million fragments of conversations they’ve had with relatives, to know how to word things so that the relative gets there quickly and safely; and if they don’t think it’s possible, they’ll call the local police to deliver the news
f. Reflection and a sense of meaning
It is a multitude of experiences that make an expert nurse, but the ability to think deeply about them, and to search for meaning, is what a good nurse is often born with.
Nurses do not explicitly search for meaning, but meaning is part and parcel of their day job. Nurses certainly use the language of the heart. They understand and describe patients as broken-hearted. Many nurses have seen it. And the best nursing comes from the heart, and not from the head.
3. The selflessness of nursing, and considerable personal cost
In Alexandria in the third century AD male nurses were known as parabalani, meaning ‘persons who risk their lives as nurses’, due to their exposure to people with infectious diseases.
Watson repeatedly describes the price she has paid to be a nurse. Not in a negative way, but simply making the pragmatic point that nursing — the act of technically caring and also providing kindness to strangers who are suffering, is both important, but also hard hard work.
Nursing is a career that demands a chunk of your soul on a daily basis. The emotional energy needed to care for people
To give that much of oneself is dangerous. Grief can only be swallowed so many times before it damages. There is too little clinical supervision for the weight of emotion that nurses feel, and the things they see or do are so little explored, in terms of how it may or may not affect their own lives. Good nurses, though, will risk the danger and hurt in order to help.
She even references “compassion fatigue” — the issue people in caring services experience when they are overwhelmed by this fatigue. And how colleagues develop defence mechanisms (toughenining up and thickening their skin) and coping mechanisms (high levels of alcohol and drug misues) to manage that fatigue. But we also hear stories about nurses who prevail through enormous obstacles to achieve great things, at enormous and unjust cost to themselves.
In 2015 Greater Manchester police apologised for their failure in the case of the Rochdale child sex-abuse ring between 2008 and 2010 — failure to conduct a more thorough investigation of the allegations, and failure for some of their dealings with the victims. No officers involved faced any misconduct hearings, though Sara Rowbotham, the sexual-health nurse who raised more than 100 concerns about the victims -and whose eyes and ears were wide open- was made redundant. Who safeguards the nurses?
5. Nurses serve everyone
Nurses are required to serve everyone. It’s written into the very first line of the code of conduct: “1. Treat people as individuals and uphold their dignity”. Watson describes nursing everyone and anyone, regardless of race, sex, background, or belief. And she sees this reflected in those around her.
In the NHS the staff completely reflect the patients they serve: the nurses, doctors, porters, healthcare assistants, catering staff, cleaners and technicians come from all corners of the world — every background, race, culture and religion possible. I have worked with nurses who are atheist, Buddhist, evangelical Christian, Muslim, Sikh and Catholic; nurses who were nuns, as well as those who belong to religions I’ve never heard of.
Nurses don’t just serve the patient. They also serve the doctors, consultants, surgeons and other team members around them. They act as the glue that binds much of the work in a hospital. As in any organisation, whether this is enjoyable or tough depends on the culture created by the team.
There is a definite culture on wards of leadership, mentoring and coaching: find the nurse in charge and the ward sister, to understand how kind the nurses will be.
Society of Service is a big believer in the power of service within organisations, between teams and individuals. Not just with the people outside — the ‘service-users’ as Watson occasionally calls them. Fostering a strong internal culture of service between employees is a foundational but much missed element to creating any culture of service at all.
6. Nurses are undervalued and overwhelmed
A consistent theme running through the book is how undervalued nursing is. How it’s seen as less important than the technical ‘fixing of people’s innards’. This is little surprise to us at Society of Service. The world operates on a deep contradiction that, although our economy relies on services, the act of serving is regarded as somehow not valuable.
Malin is not a nurse, and she is poorly paid. Her skills are often overlooked by the surgeons. Yet she can counsel a six-year-old through treatment for brain cancer, and can distract a child from extreme pain. Her understanding and knowledge of child development make an enormous difference to a child’s level of suffering and the memory of that experience. The child will not remember the surgeon who saved his or her life, but will always remember Malin.
Malin is supremely valuable to the person she cares for, but not to the system she cares in. This contradiction leads to many who serve not getting suitably rewarded for the role they play in so many service organisations. The professional skill of kindness does not derive the same economic value as other professional skills. As patients we are horrified by this. As citizens we are not. Resolving this is at the heart of Society of Service’s mission (see the end of the article for ways you can help).
This is nothing new.
Research about the mental-health impact of war has always been about the men, despite hundreds of women working as nurses, next to the soldiers. In their diaries and letters these nurses describe their time in no-man’s-land, suffering broken bones, amputations and gas attacks, as well as caring for soldiers with bits of their bodies blown off; the things they saw close up, the things they smelled and touched. Shell shock was never attributed to these women, and they were never diagnosed or offered treatment.
This historical devaluation of nursing is particularly hard to swallow given the growing demands placed on nurses in health services.
The staffing levels are so bad this week that the nurses, the ward sister tells me later, often don’t take a single break the entire day. A nurse I know who works on the ward carries glucose tablets in her pocket, in case her blood sugar drops dangerously low: she has fainted at work a few times on days when there hasn’t been enough time for lunch or dinner breaks. Another nurse has repeated cystitis and has been told it was because she didn’t go to the toilet when she needed to. There are times when you literally don’t have time to go to the toilet; days when you purposefully don’t drink water, as you know you won’t have time.
There is a sort of implicit abuse in here. I’ve heard the same in other service contexts, from call centres to retail environments. Those who are intrinsically motivated to serve are vulnerable to abuse. Their will-to-serve overrides an instinct for self-care, and few in the organisation are incentivised to prevent that from happening. This leads to an inevitable erosion of that will-to-serve. In June 2020 36% of nurses were thinking of leaving the profession, an increase from 27% reported in 2019. Reasons cited are low pay, poor staffing levels and lack of management support.
If we don’t resolve this we will all suffer. Quite literally.
Yet Watson is not without humour about this. Yet it is a sort of gallows humour.
If the Hippocratic Oath is to “Do no harm’, then a nurses oath should be to make sure the doctors can fulfil their Hippocratic Oath. She laughs. I think all junior doctors should spend a month as a nurse. Wed never have to clean a coffee cup left in the sink again, that’s for sure.
7. Why nurses serve
Watson reflects on why she serves as a nurse, and why others might. She touches on two of the reasons that we at Society of Service have catalogued for why people serve: sociological, spiritual, civic and economic.
a. Sociological
Since Darwin argued that morality pre-existed religion, altruism has been studied by scientists, theologians, mathematicians, evolutionists and even politicians, but the origins of kindness remain a mystery. Darwin himself acknowledged the idea that survival of the fittest perhaps encompassed survival of the kindest. For any civilisation to be fit, and to survive, its members had to be collectively kind to make personal sacrifices for the greater good of the group.
In this sense, nurses, like all of us, don’t know why we care, and sociologists don’t know either. Yet we all suspect it is built into our human nature, evolved through our very early years. We’ll explore this further when we review related books over the coming months, including Unto Others by Sober & Wilson, The Most Good You Can Do by Singer, and even The Selfish Gene by Dawkins (if we can make it through to the chapter called “Nice Guys Finish First”!). Subscribe over at Substack so you don’t miss ‘em.
b. Spiritual
From its earliest days, Christianity encouraged its devotees to attend to the sick. But from the earliest times many cultures produced nurses who were dedicated to service on religious principles. Many nurses now have no religion, or are of different faiths and spiritual backgrounds, but nurses are duty-bound to respect the differences. The best nurses treat each and every patient as if they are a relative or loved one. And caring for dying patients is the most creative aspect of nursing. The language of spirituality is a way of putting into words something we don’t understand.
Many people are motivated to serve by a ‘higher calling’, just as most churches motivate their followers towards act of charity. Nurses are no different, though as many established religions wane in influence in many parts of the world, it’s likely that this will decline as a motivator to become a nurse. (Though it’s interesting to note that Watson continually refers to her colleagues who have immigrated from still very religious countries, where the motivator might still be a factor). Again — we will return to the theme of spirituality as a service motivator when we look at books like The Call of Service by Coles, and The Power of Serving Others by Morsch and Nelson. We’ll also extend our view by looking at civic and economic motivators to serve.
8. Like any act of service, nursing is a two-way street
A nurse-patient relationship is a two-way process, and Tia’s laughter is infectious enough that it breaks through any of my self-inflicted emotional immunity. Her laughter makes me better. We can both cry, and we can both laugh. It is a beautiful sound.
In cold hard terms, there can be no service without both a provider and a user, working in concert, for mutual benefit. In caring for Tia, Watson is partly rewarded by Tia’s recover. But the outcome is only one element. The process of helping Tia also feeds her
Service has become so commodified that it is often defined in the cold hard terms of provider, user and outcome. Yet anyone who experiences greats service, or, like Watson, who provides great service, will describe it in much deeper terms. The act of serving is the profound bit. The bit that really fires the soul. Ironically, most services make it very hard for people to serve, especially as they scale — an issue we’ll doubtless return to in future editions.
Incidentally, I write this as my wife sits downstairs, volunteering for a local GP to phone 80-year-olds and book them in for Covid vaccines. She feels great afterwards. Her joy comes not just from booking them in for a potentially life saving appointment, but also from connecting with an old and often-isolated person, who just wants a chat.
I think Watson would understand this. People working together to help one another is at the core of service, out of which grows multifaceted healing and growth.
Nursing expert Hildegard Peplau first developed the Interpersonal Theory in the 1960s, and identified nursing as a healing art: the nurse and patient work together, so that both become mature and knowledgeable in the process.
Other things I learnt from the book
There is a thing called “skin-hunger” which is where patients starved of physical contact show improved signs when it is reintroduced. We all need a hug from time to time ❤️
They remind us of something that Florence Nightingale herself knew. Suffering, and even the sensation of pain, can be reduced by kindness. She found that giving a patient a window to look out of, or a bunch of flowers, will significantly
The word ‘psychiatry was identified in 1808 by Johann Christian Reil, a German doctor, and means ‘the medical treatment of the soul 🤯
Conclusion
Nurses form the very fabric of our National Health Service in the UK and equivalents around the world. They create countless moments of service everyday. Not just technical and transactional healthcare services, but also acts of kindness and caring that go way above and beyond the technical and transactional. The value we get from their service is enormous, but so is the price they individually pay.
So please take a moment to give thanks and gratitude to all the nurses who have lost their lives in the pandemic, and those that continue to selflessly serve. And if you feel so moved, please sign the petition for fairer pay for nurses.
