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.  

Review
Books
Culture
Film & TV
Purpose
8 min read

You may never take the Salt Path but here's why the tale makes sense

Kindness runs deep in the architecture of reality.

Roger is a Baptist minister, author and Senior Research Fellow at Spurgeon’s College in London. 

A hiking couple sit on the grass next to a pack.
Gillian Anderson and Jason Isaacs.
BBC Films.

The Salt Path is a phenomenon.  

An internationally best-selling book and now a movie starring Gillian Anderson and Jason Isaacs. How is it that a memoir of a middle-aged couple walking the South West Coast Path from Somerset to Dorset, via Land’s End, has had such an impact? 

Well, it’s because it resonates. It rings true. It’s about life as we know it, even if we haven’t hiked the 630 miles of the path from start to finish. A journey that is also, incidentally, the equivalent of climbing Mt Everest four times over. 

In the events leading up to their walk Raynor (Ray) and Moth Winn are dealt a series of body blows. They’re left bankrupt and homeless empty-nesters, struggling to come to terms with Moth’s deteriorating health.  

It was just as the bailiffs were seeking to gain access to their farm and take possession of it that Ray spotted an old book, 500 Hundred Mile Walkies, and took inspiration. 

‘We could just walk.’ 

And that’s what they did. 

So, what are the truths about life and our human experience that this story opens up for us? 

Life is precarious  

Bad stuff happens. Sometimes we bring it on ourselves, the consequence of wrong or ill-judged decisions. Other times it is thoroughly undeserved. Life turns around and bites us, hard. We’re left with our heads numb and spinning round with the persistent but unanswered question, ‘why me?’ 

For the Winns, an investment in the business of a trusted, life-long friend failed. The deal he structured left them responsible for the debts of his company. The end of a prolonged legal battle meant they lost everything, their farm, their home, their business, and the life-long friend. 

The same week also found them in a hospital in Liverpool getting the diagnosis for Moth’s chronic shoulder pain. It was not the suspected nerve damage, but rather the fatal neurological condition corticobasal degeneration. CBD. A diagnosis that was untreatable and only finally confirmed postmortem. 

Whether it’s the South West Coast Path or the familiar details of our own life, we can never fully anticipate tomorrow. We do not know what lies behind the next headland or what unwelcome surprises life may spring on us. No, we need to live in the moment. It’s pointless worrying about tomorrow and we ought to let it worry about itself. We can only live in today. As Ray reflected towards the end of their time on the path: 

“This second in the millions of seconds was the only one, the only one that we could live in.” 

Who am I, really? 

Early in the book Ray recalls: 

“I once heard a lecture by Stephen Hawking, when he said, ‘It’s the past that tells us who we are. Without it we lose our identity.’ Perhaps I was trying to lose my identity, so I could invent a new one.” 

Who are we when everything is stripped away? What defines us? Homeless and jobless, questions about where we’re from and what we do are not only awkward, they also create an existential void.  

Often mistaken for tramps, Ray and Moth noticed people treating them differently. Some quietly moved away, others were more forthright, “disgusting!” But the judgement of others does not define who we are. Yet, who actually were they in this new world of theirs?  

And then there’s the impact of failing health. Each stage of deterioration promising to erode what can be physically done and requiring a redefinition until there is nothing left at all.  

Yet identity is deeper than that. It is at the core of who we are, at the very heart of us. It is the sum of our experiences and choices, our successes and failures, of what we have gladly embraced and that which life has unexpectedly thrown at us. We are unique individuals with intrinsic value, worth and dignity. People who love and are loved. 

At the end of the path Ray muses: 

“Most people go through their whole lives without answering their own questions: What am I, who do I have within me? The big stuff. What a waste.” 

I guess that’s one of the attractions of making space to walk. To lose the distractions and busyness of our over-complicated lives for self-discovery to break in. 

One step at a time 

How do you get your head around walking 630 miles? How can you appreciate the demands of climbing unknown hills and cliffs and navigating their gullies and ravines.  

On top of the terrain there’s the notorious English weather to negotiate. With little money and only a tent for respite: when it rains you get wet and stay wet, when it’s cold, you shiver and put on as many layers as you can. Even in August it can be challenging. 

Walk, eat, sleep, repeat. 

Sometimes the only thing to do is put one foot in front of the other.  

“Each step had its own resonance, its moment of power or failure. That step, and the next and the next and the next, was the reason and the future. … each day survived a reason to live through the next.” 

There is always agency. There is always the opportunity to choose today which path to travel and which attitude to serve. To give in or go on, to be a defeatist or hopeful, complaining or generous, those choices are always there, even when they’re limited. Even in the wake of unfair decisions and unexpected tragedy, we choose today the way we take. And sometimes that’s all we can muster. 

The kindness of strangers 

Ray and Moth’s story is littered with moments of kindness and warmth. From the lovelorn waitress who sneaks them the day’s leftover pasties to the generosity of a hippie commune there is a recurring theme that echoes an underlying goodness in the nature of people. And often it is those with the least who prove to be the most open-handed and thoughtful. 

On more than one occasion the Winn’s themselves share from their own meagre supply of food, especially their precious fudge bars, with those in a more uncertain state than their own. On another occasion they step into a tense and potentially violent situation with a young woman, Sealy, the subject of an abusive relationship. They offer her company and a way out, ultimately paying for her £5 bus journey to get away to family. 

There is something heartwarming about kindness, something elevating. Both the giver and the receiver feel encouraged, lighter, happier. The abiding truth continues to stand the test of time that it is ‘better to give than to receive’.  

Strangely, watching these scenes play out in my local Showcase Cinema was an uplifting and inspiring experience. You can never predict or properly anticipate when a tear will unexpectedly present itself to the corner of your eye. I suspect that kindness runs more deeply in the nature of things than we comprehend. It is part of the deep architecture of reality.

Love and relationship in tough times 

When it comes down to it, The Salt Path is about Ray’s relationship with Moth. How they face an unimaginably difficult set of circumstances and find a way through together. This is a profoundly hopeful story. And from it we can draw hope too. 

There was nothing religious about what they were doing, “It’s not a pilgrimage. Is it?”  

At one level it is purely a response to desperation. But in the midst of it all they have each other. Thirty-two years together, having begun their relationship when Ray was 18, they are still deeply in love. They epitomise the values enshrined in the marriage vows. 

“… to have and to hold from this day forward, for better for worse, for richer for poorer, in sickness and in health, to love and to cherish, till death us do part …” 

This is not slushy sentimentality but rather love that proves itself in the face of the onslaught of ‘worse … poorer … sickness … death’. 

The conclusion of their journey led Ray to a realisation: “I was home, there was nothing left to search for, he was my home.” As the ancient poet wrote: 

“Set me as a seal upon your heart,  

as a seal upon your arm; 

for love is strong as death, 

passion fierce as the grave. 

Its flashes are flashes of fire, 

a raging flame. 

 

Many waters cannot quench love, 

neither can floods drown it. 

If one offered for love 

all the wealth of one's house, 

it would be utterly scorned.” 

(Song of Solomon) 

That’s it then. The book and the movie work because they reflect back to us the life we know, the lives we live. Yes, they’re in high relief in the choices that Ray and Moth take, but that clarifies things for us. Most of us won’t ever find ourselves in the position they were in, but we can empathise. Most of us would never think to do what they did even if we were. But for all that, we see, we understand and it makes sense. 

If you get a chance to see the film, then do. Gillian Anderson and Jeremy Isaacs are exceptionally good in their understated performances. The visual experience of the South West coast is everything you would expect it to be, sounding as majestic and immersive as if you were there. A real treat. 

For me, the most poignant and telling moment of the story happens at Lyme Regis. Moth says: 

“When it does come, the end, I want you to have me cremated. …keep me in a box somewhere, then when you die the kids can put you in, give us a shake and send us on our way … They can let us go on the coast, in the wind, and we’ll find the horizon together.” 

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