Harnessing Emotion to Inform Clinical Practice John Mckinnon University College London Phd Education

1 Harnessing Emotion to Inform Clinical Practice John McKinnon University College London PhD Education 1 2 Declaration I, John McKinnon confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. John McKinnon 2 3 Abstract Harnessing Emotion to Inform Practice Background Clinical judgement is the application of evidence to decision making in a professional healthcare setting. Studies in neuroscience (Immordino -Yang and Damassio, 2007) have shown that effective judgement and decision-making require tempered emotion to provide a guiding ‘rudder’ revealing knowing to be a feeling state. Emotional labour as a central feature of nursing practice is well documented (Gray, 2009). Theorists have identified emotions as tools for reflection (Bradbury-Jones et al. 2009), but this area of knowledge remains underdeveloped. Aims This thesis enquires into the existence of a commonality of emotions in nursing practice with potential as core emotion concepts arising from diverse narratives for use as tools for reflection and professional judgement. Method In phase one thirty-three nurses across five specialist areas talked exhaustively about the emotions they experienced while immersed in practice and the causes of these emotions. The data was collected in a London teaching hospital NHS trust and in three community NHS trusts in the East Midlands of England. Following this, in a second phase, six nurses (two supervisors and four supervisees) in a London Teaching Hospital who had not taken part in the first part of the research talked about their experience after two months and four months of using a framework for reflection consisting of seven common core concepts identified in the first research phase. In both phases the interviews were audio-taped, transcribed verbatim and the data analysed using Grounded Theory Method. Results The data betrayed professional movement that was characterised by person centred care in the face of complex adversity. Seven core emotional concepts were found to have commonality across practice forming an ‘emotion map’. The ‘emotion framework’ for reflection was shown to increase self awareness, inform and empower practice Discussion The design is limited by the singularity of discourse and the sample size. The notion of emotional constituents of a framework for reflection opens up a new frontier in learning in which the details of an experience are the outcome of reflection on emotion rather than the reverse. The framework demonstrated ‘organic’ properties which permit a harnessing of the sense of salience that is central to human judgement. Increased credence has been given to personal knowledge and intuition. 3 4 Contents Page Number Chapter One: The Social Context of Nursing Theory and Practice 7 Genesis of Thesis 7 The Historical Context of Nursing 7 The Sociology of Caring 8 The Shape of Clinical Judgment in Nursing 10 Chapter Two: Toward the Notion of Emotion Concepts as Tools for Reflection 16 Defining Consciousness 16 Defining Learning 17 Neural Perspectives 19 Personal Ownership of Knowledge 21 The Social Learning Place 23 Emotion , Perception and Learning 27 Chapter Three: Methodology 34 Epistemology 34 Theoretical Perspective 37 Methods 39 Limitations of Research Design 57 Ethical Issues 58 Chapter Four: Literature Review 63 Chapter Five: The Emotion Map of Nursing Life 86 Formation of Themes and Clusters 86 Participant Representation in Data 96 Emotional Intelligence 96 Emotional Labour 114 Emotional Impact 125 Fear and Anxiety 137 Anger 153 Frustration 161 Satisfaction 184 Joy 204 Sadness 207 Chapter Six: Messages from the Emotion Map of Nursing Life 213 Commonality of Emotions in Clinical Practice 214 Potential of a Common Set of Core Emotions 214 Political Implications of the Emotion Map 217 Chapter Seven: Using a Emotion Framework for Practice 225 Managing Change 226 Organic Structure 232 4 5 Organic Process 236 Informing Practice 244 Chapter Eight: Conclusion 251 Bibliography 259 Appendix 273 List of Figures and Tables Figure 5.1. Empathy Process and Dynamics 106 . Figure 5.2. Catastrophising 141 Figure 5.3. The Anger Experience 155 Figure 5.4. The Frustration Vortex 173 Figure 5.5. The Satisfaction Spiral 187 Figure 5.6. Sadness Dynamic 209 Figure 6.1. Emotion Map of Nursing Life 213 Figure 6.2. Conditional Matrix 218 Figure 6.3. Emotional Taxation 221 Table 1.1. Standing’s Revised Continuum 12 Table 2.1. Illeris’ Tension Triangle of Learning 17 Table 2.2. Wenger’s Community of Practice 25 Table 5.1. Emotional Intelligence Theme Cluster 97 Table 5.2. Emotional Labour Theme Cluster 114 Table 5.3. Emotional Impact Theme Cluster 125 Table 5.4. Fear Theme Cluster 138 Table 5.5. Anxiety Theme Cluster 140 Table 5.6. The Anxiety Continuum 151 Table 5.7. Anger Theme Cluster 154 Table 5.8. Frustration Theme Cluster 161 5 6 Table 5.9. Satisfaction Theme Cluster 184 Table 5.10. Joy Theme Cluster 204 Table 5.11. Sadness Theme Cluster 207 Table 6.1. The Emotion Framework for Reflective Practice 216 Table 7.1. Framework Pilot Theme Clusters 227 List of Appendices Appendix 1 Standing’s Revised Continuum: an explanation 273 Appendix 2 Mazhindu’s Typology of Emotional Labour 275 Appendix 3 Framework Impact Charted by Participant 276 Appendix 4 Table of Codes for Phase One and Phase Two 277 Appendix 5 Sample Section of Coded Transcript 278 6 7 Chapter One The Social Context of Nursing Theory and Practice Introduction This chapter sets out the social context within which this doctoral thesis is based. First the origins of the thesis are explained. Afterwards nursing as a community of practice is discussed from historical social and professional perspectives. The notion of clinical judgment is critically considered enroot to the development of a rationale for a new framework to inform practice. Genesis of Thesis Some years ago as a nurse specialist in child protection, I became aware of practitioner frustration at the inadequacy of predetermined checklists and vulnerability criteria in representing the focus of concern in practice (Appleton and Cowley, 2004). At the same time I was aware of how often the terms “concern”, “suspicion” or “knowledge” occurred in the supportive practice documentation. I began to wonder why we did not reflect on concepts which relate to our experience rather than experience alone. In the course of my masters degree I became aware of the work of the neuroscientist Antonio Damassio and his colleagues (Damassio, 1999; Immordino-Yang and Damassio, 2007) demonstrating the role of emotions in guiding judgement. I reasoned that emotions could be used as pivotal concepts or triggers. Furthermore it seemed feasible that if a commonality of emotions could be found within a community of practice, those emotions could form a framework to guide practice. This marked the genesis of this thesis. The Historical Context of Nursing The writings of Florence Nightingale and the values of altruistic care she espoused have influenced nursing for over 150 years. The extent of Nightingale’s influence means that other salient roots and values which both complement and compete with her ethos risk being lost from public and political view. In fact the origins of modern nursing are as diverse as they are politically controversial. In the ancient world nurses were as likely to be men as women (Evans, 2004). In ancient India women were forbidden from some areas of nursing (Bett, 1960). The 7 8 biblical account at Exodus chapter 2 verse 9 in which Miriam is promised “wages” to nurse the infant Moses lends support to the view that paid caring has always been a respectable and legitimate activity. The idea that caring is provided by ‘good’ women for little or no payment is a Victorian preoccupation founded chiefly on religious ideals and social policy of past centuries. In Ancient Rome nursing became a vocation for women after Julius Caesar conferred Roman Citizenship on slave girls who assisted physicians (Baly, 1995). Florence Nightingale’s belief that she was preordained by God to become a nurse may relate to the ancient tradition that nursing was a role reserved for the rich and honourable (Ridgely- Seymer, 1954). By the 4th century C.E. nursing had become a local community service. However with the growth of the Christian Movement nursing became closely associated with holy service. By the 6th century C.E. and throughout the middle ages nursing was the exclusive domain of holy orders tending to the needs of the sick as the inevitable consequence of sin and a sinful world. At this point, nursing in Europe was set apart from any social movement for change within society and isolated from healing informed by science (Baly, 1995). With the founding of Royal Hospitals in the 16th century local women were employed under the control of a matron to care for the sick abandoned as a consequence of the Poor Laws. From the 18th century nurses were required to live and work within hospital premises for the purpose of giving governors more control over the workforce. This arrangement continued well into the second half of the 20th century (Goward, 1992). This tightly controlled residential system together with the politically disenfranchised status of the women who made up the nursing workforce meant that nursing was prevented from accessing scientific knowledge and skills contemporaneously available to medicine. Consequently nurses were deprived of the social mobility and political power with which medical doctors had been equipped (Davies, 1995). The Sociology of Caring The contrasting political and social interests, values and experiences of Nightingale as public health reformer (Monteiro, 1985), Bedford Fenwick as political activist (Baly, 1995), Fry as a campaigner for penal reform (Whitney, 2010) and Seacole as a 8 9 protagonist of innovative practice (Ramdin, 2011) foreshadow the tensions and divisive values pervasive in 20th and 21st century nursing.

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