This is the text of a keynote address for the Enhancing Practice 14 conference for Practice Development in Toronto in 2014. A formal version of this talk will, all being well, be published in the International Practice Development Journal in the New Year.
The audio recording of the talk is available here: http://soundcloud.com/dr-anthony-mccann/the-heart-of-care-changing-the-culture-change-equation.
I’d like to thank Nadine and the organisers for the invitation to speak here today.
If keynotes are anything like giving a speech at a wedding, I suppose I’m obliged to start with a joke. Two fish in a tank. One turns to the other and says, “How do you drive this thing?”
My relationship with healthcare goes back a long way.
I was born in a hospital.
And I wouldn’t have been born at all if my Dad, a young seminarian training for the priesthood, hadn’t fallen in love with the good-looking nurse that tended to him while he was waiting for an operation.
And on behalf of my family, thanks to all of you who work in hospitals as nurses and doctors. You’re awesome. My wife is chronically ill and lives with a myriad of complications that come with Ehlers Danlos Syndrome, a connective tissue disorder, and epilepsy, and we have two kids under two. Without the support of health workers our lives would be very, very hard indeed. You make our lives and the lives of many others less difficult and more meaningful. Thank you.
Would you like a cup of tea?
Imagine we’re having a cup of tea and a chat, just you and me in a kitchen. We’ve munched through a few biscuits, or cookies if you prefer, and the tea in my cup has gone a little cold. I don’t like cold tea. If pushed, I can struggle through, but you’re sitting beside the tea pot, and chances are there’s still a drop of hot tea left in the pot. You’re beside the teapot. I’m not. From my perspective, you’re in an active position to be helpful on account of your possibilities of proximity. You are here, you are now, you are with, and you are near, and in a position to help, and likely to help, I would hope.
You are in a place of garaíocht.
I came across the word garaíocht while reading the Irish-language short stories of the Donegal writer Séamus Ó Grianna from the turn of the last century. It was a simple, colloquial word that I missed the first twenty times I read the text. Lately, however, it jumped off the page and called for my attention.
The word “garaíocht” tends to be used in the phrase, “bheith in áit na garaíochta.” It roughly means, “to be in the place where you are close enough to help.” The word “garaíocht” is derived from the adjective “gar”, meaning “near”, and possibly also from the noun “gar”, meaning favour, and then by extension from the adjective “garach” or “garaí”, meaning “helpful”. The “ocht” part also signals that “garaíocht” is a verbal noun, a noun with the quality of an action, something that you don’t get in English, meaning that garaíocht always-already involves action, activity, happening, participation.
This term “garaíocht” resonated with me, because I realised it could reach far beyond the kitchen table and serve to encapsulate the best of what I would like to think it means to be human.
Garaíocht has become for me a way to speak of a particular quality of relationship, a particular tone, atmosphere, disposition, or texture of relationship in which the most helpful aspects of the he(art) of being human are most likely to happen. Kindness, caring, generosity, gentleness, trust, nurturing, sharing, gratitude, honesty, creativity, gentle humour. All of these feel more appropriate in an environment of garaíocht. When garaíocht is present, they tend to simply happen. It’s a quality of being human.
I once had the privilege to spend a year with a Fulbright Award at the Smithsonian Center for Folklife and Cultural Heritage in Washington DC. As part of the award, I was invited one night to attend a reception at the Irish Embassy. I wasn’t all that used to formal receptions, and I have always been quite nervous in crowds of people I don’t know, but I managed to get through the night clutching onto short conversations as one might clutch random flotsam and jetsam to stay afloat in the open ocean. Eventually I got to meet the Irish Ambassador, and he asked me what I was studying. I told him I was doing a Ph.D. focusing on the social and ethical dynamics in Irish traditional music, and that I was using the increasing influence of copyright thinking and practice as a way to highlight the ethics that I felt were now being displaced. As it happened, the Ambassador was a major fan of Irish traditional music. We had a nice chat, parted ways, and I eventually made my way home with that uncanny feeling that you get when you step from a formal evening event into dark and empty city streets, with just a little sparkly from the free wine and just an edge of hunger from the inability of canapés to truly hit the spot.
Soon afterwards, I was surprised to receive a personal invitation to join the Ambassador for drinks in the Embassy. He wanted to chat more about the traditional music and copyright issue, so I happily went along. It was an interesting evening. I had no idea how incredibly erudite the Ambassador would turn out to be. He was able to recite 18th-century poetry by the poets Antoine Ó Raifteirí and Eoghan Rua Ó Súilleabháin verbatim in the original Irish language. He would drop in proverbs in the original ancient Greek. And he knew how to pour Irish whiskey of excellent vintage.
A few glasses of whiskey into the evening the conversation turned to Irish traditional music. While playing a CD of his favourite musicians playing his favourite tunes, he spoke of the sublime beauty of the music and he turned to me with a degree of earnestness that immediately raised the intensity of the evening.
“Promise me,” he said “that you will tell people what’s beautiful about the music. Will you do that?”
Feeling slightly pressured, and slightly inebriated, and philosophically slightly resistant to the essential beauty of anything, but not at all in disagreement with the sentiment, I said, “I will.”
After all, I was an ethnomusicologist, an anthropologist of music. Surely it wasn’t unreasonable to expect that this was something I could do.
“Promise me,” he said “that you will tell people what’s beautiful about the music. Will you do that?”
I’ve loved tunes. I’ve loved songs. I’ve loved musicians. I’ve loved singers. Sometimes all of the above have broken my heart with a joyful, glorious, and beautiful sadness.
What I find most beautiful about Irish traditional music is something that isn’t at all exclusive to Irish traditional music. Studying the social and ethical dynamics among musicians and singers has opened my eyes to a powerful form of politics that persists at the heart of everyday life, a powerful form of politics that tends to remain largely unnoticed and unspoken, but which cradles the heart of what it means to be human.
What’s beautiful for me about Irish traditional music and song is what is also beautiful to me about watching my Mum hold my Dad’s hand in silence during his final year before he died, or watching my wife blow bubbles as our two-yr-old Aodan’s eyes light up, or watching that old lady in the café come up to our newborn son, Owen, smile, and place a coin in his hand for luck. Or the unquestioning love and support we have received from family members in times of difficulty. Or the help, support, and deeply personal care and attention we have experienced in visit after visit to the antenatal clinic and maternity wards of the Royal Victoria Hospital.
In some ways, I wouldn’t care if I woke up tomorrow and found all of the tunes and songs were gone, as long as we had retained the gentle, generous, uncommodifying qualities of relationship and social life from which they emerged in the first place.
While I can personally recognise and validate quieter, gentler, kinder and more patient practitioners of the art of being human, and personally value those beautiful moments of social encounter, in my studies I found it very hard to find anything in the serious books I was reading that allowed those people and those moments to be possible. Maybe I was reading the wrong books, but there was nothing that I could find in standard social, political, legal, and economic theory that acknowledged that such people or qualities of relationship that I had personally experienced and often loved even existed.
Gentle, generous, uncommodifying qualities of relationship and social life, the warp core of the he(art) of being human and of the he(art) of care more specifically, tend to suffer in orthodox social, political, legal, and economic theory from the triple silencing of cultural illegibililty, discursive invisibility, and political irrelevancy. What for many cannot even be possible within social, political, and economic theory cannot easily, then, become plausible as a viable option for transformative action in the discursive and institutional orthodoxies of regulated and regulating life.
I would invite you to close your eyes. Remember one of your healthiest and most helpful moments of relationship where you felt most comfortable, most welcome, most supported, and most generous within yourself. It may have been with other people. It may have been in the company of a favourite animal, or even in the company of a favourite object. You may even have been on your own. Try to feel again how it felt to be in that moment.
If we were to build our lives, our relationships, our organisations, institutions, and political systems on our understanding of such possible moments, what would they look like?
How would we get there from here?
Why would we want to?
For me, Garaíocht is the organisational form, or rather self-organisational form of human flourishing, where every moment becomes a moment of possibility, every interaction becomes a resource for collaborative and critical imaginations.
There is a story often told in Ireland about these tourists who have managed to get themselves lost while driving around on Irish country roads. They have a map, but of course it’s not much help to them as most of the roads they’re on don’t exist on the map. Feeling a little panicky about the lack of signage and their inability to tell one hedge from another, one cow from another, one country lane from another, they keep their eyes peeled for someone they can ask for directions. Time passes, daylight starts to fade, and they are just about to lose hope when they spy an auld country farmer with a tweed cap, a walking stick, and, inevitably, a sheep dog. They bring the car to a stop and roll down the window.
“Good evenin’ to ya,” says the farmer, “tis’ a fine evenin’ to be out and about”
“Good evening. We were wondering if you could help us. We’re trying to make our way back to Belfast and we’re terribly lost. Is there any chance you might be able to tell us the best way to go from here.”
“Och,” he says, “to be honest, if I were you, and I was wanting to go to Belfast, I wouldn’t be startin’ from here.”
It’s an old one, and it’s a little hackneyed, but I can‘t help thinking that when it comes to leadership and culture change in the organisations and institutions of healthcare it’s a story that rings somewhat true.
For all the wonderful intentions of universal healthcare as an aspiration, we are the first generations of the human race to have successfully created and constructed systems for healing and healthcare which seem to be, by the logics of their very construction, culturally unsustainable. Not only that, but “healthcare” has largely become a synonym for sickness, illness, trauma, and death. Internationally, healthcare has also become a synonym for crisis.
On the way over on the plane I watched a movie called The Angriest Man in Brooklyn. It was uncomfortable viewing, as Robin Williams plays a man who has been told he has 90 minutes to live, and at one point his character jumps off the Brooklyn Bridge in an attempt to end his life. I found it a very sad and very bizarre last movie for Robin Williams to have made. The reason I bring it up, however, is because of the Mila Kunis character, a young doctor called Sharon. To the image of Sharon squeezing her way through the horribly crowded waiting room in a threadbare city hospital, Mila Kunis recites in third-person voiceover that Sharon went to medical school to save the world. “No-one told her,” the voiceover continues, “that care does not equal need; care being finite, need being infinite.”
That’s the kind of equation that can easily drive you to hopelessness.
If you were to design healing places, healing spaces from scratch you probably wouldn’t start from a centralised administration, make budgetary considerations the main priority, or design buildings that are more or less identical. You probably wouldn’t have people working 60-100 hours a week, putting in double shifts, or carrying extra workloads to cover for colleagues who are off work with stress and work-related illness. You probably wouldn’t use a trauma or infectious medicine model to frame and organise every level of healthcare. You probably wouldn’t consider lack of psychological safety as the regrettable but inevitable collateral of the healthcare battlefield.
The sensationalism of newspaper headlines aside, healthcare internationally is increasing being trapped in a bottleneck of enclosing industrial logics that are all-too-familiar in many other sectors – managerialism; bureaucracy; administration; accountancy; risk management; transactional and command-and-control leadership; neo-classical, neo-liberal, and neo-conservative economics; litigious legal consciousness; risk management; project management; the pharmaceutical industry; privatization generally. And many more.
If I were you, and I was wanting to get to a place of healing, I wouldn’t want to start from here.
Of course, we are starting from here, and you work hard to do your best with what you’ve got. And every now and then you do a great job. But you’d like to have the wiggle room to do a better job, one where being a healer is what you get on and do, not what you have to fight to defend.
If we want to get to a different here, one that feels differently most of the time, that works better most of the time for what we say we want to do, a hereness that is the best hereness for healing and support and helpfulness, a hereness where healing doesn’t take as much work and energy as it does now, then it’s important to have a clear vision, a clear understanding of how we want it to feel for ourselves and others when we get there, and how that’s significantly distinct from what we are already involved in. Otherwise, we have little to guide us in truly changing the cultural climate equation.
I am reminded of one of my favourite quotes from Edward De Bono: “Logic is the tool that is used to dig holes deeper and bigger, to make them altogether bigger holes. But if the hole is in the wrong place, then no amount of improvement is going to put it in the right place.” I think a lot of the holes we’re digging are in the wrong place, and it ain’t necessarily so.
There are lots of people trying to make a difference, but consultant’s report after consultant’s report we find ourselves with ever more detailed descriptions of what’s happening, with very little indication of how to do things differently in a way that truly makes a difference.
Audre Lorde famously wrote: “For we have, built into all of us, old blueprints of expectation and response, old structures of oppression, and these must be altered at the same time as we alter the living conditions which are a result of those structures. For the master’s tools will never dismantle the master’s house. (Audre Lorde “Age, Race, Class, and Sex: Women Redefining Difference”). When thinking about culture change in healthcare systems, people are feeling stuck because, to echo Audre Lorde, the master’s tools will never heal the master’s house, and certainly not in the middle of a cultural climate traffic jam.
The most significant unhelpful changes in any environment aren’t usually heralded by drumrolls or the sound of trumpet fanfares. Although it would be terribly helpful if they were.
It is widely reported that if you take a frog and drop it into a pot of boiling water it will immediately jump out of it before it has a chance to say “rebbit!” (I also do a very good donkey) Frog. Boiling water. Jumps out. However, if you were to put a frog in a pot of cold water and slowly raise the temperature of the water in increments, the wee frog will swim about quite comfortably in the water, not noticing the subtle changes as the temperature rises, until such time as he’s not noticing anything at all, having been boiled alive.
I’m guessing this story may not have been tested under laboratory conditions, or even have been certified by the Humane Society, but the meaning of it is hard to ignore – if changes and escalations are small, slow, and subtle, it is very easy to miss the wood for the trees and not be aware of the bigger picture, that conditions can become harmful to us without us even noticing.
If we’re going to be frogs we need a temperature gauge.
Two fish in a tank. One turns to the other and says, “How do you drive this thing?”
That joke, which gets even funnier the second time you hear it, reminds me of two things. One, that we can start off just wanting to go for a swim and very easily find ourselves driving a tank. Two, that once we find ourselves driving a tank, we can easily just decide to get with the program and become better drivers of tanks.
If we’re going to be fish, we need to work out whether or not we want to be driving a tank, and what we’re going to do if we take a look around and find we’re already driving one.
It may be the world’s only culture change joke.
I’m not sure this needs to be said, but change isn’t the aim of culture change. Change happens: It just does. And it doesn’t stop. And it doesn’t always look like change. And it’s not always helpful. But it can be.
If change simply happens, then the aim of culture change isn’t change, but, rather, particular kinds of change – it is important to be clear about what qualities of change you want to happen, and, perhaps more importantly, what kinds of change you don’t want. If the purpose for culture change isn’t clear and transparent, the culture change process can be confused, frustrating, and divisive. The phrase should really be, “Helpful Culture Change”.
The unhelpful trajectories of cultural climate change are just as real and just as potentially catastrophic as the unhelpful trajectories of environmental climate change.
The sensitive presence of a healing relationship doesn’t flourish in just any environment. In some environments we get crushed; skin shrivels, muscles atrophy, blood thickens, trust collapses, collaboration founders, cynicism runs riot, ideas shut down, vulnerabilities are targeted, denied, or ignored. In some environments we fly; bodies shimmer with energy, hearts respond adaptively, muscles pulse, people build on each other’s insights, help each other out, nurture each other in a common spirit, make space for physical and emotional vulnerabilities.
It is important to know how and why this happens.
If we’re going to be frogs we need a temperature gauge.
I was born a theorist, so I got to theorising.
The task was to design a model that could handle transitions from the best of what it means to be human to the toxicities of humans at our worst and, maybe more importantly, transitions from our most toxic selves to the helpful transformations of human flourishing, and all points in between.
Cultural climate is the term I use for what most people refer to loosely and colloquially as ‘culture’ when speaking about organisations or institutions, for example, in terms such as ‘a culture of bullying’, ‘a culture of excellence’, or ‘a culture of misogyny’.
I make a clear distinction between culture and cultural climate.
To speak of “an organisational culture”, for me, is to speak of “what has happened, what is happening, and what will happen in a particular environment (specified by location(s) over a designated time)“. This includes the everyday details of our organisational lives, an infinitely rich context of habits, gestures, norms, rules, learned behaviours, aversions, attractions, fears, hopes, language, beliefs, memories, expectations, values, and many other dimensions of being human, down to the clothes we wear and the food we eat.
This is incredibly broad, classically anthropological, and, of course, covers just about everything, It’s a lot to get your head around, and, analytically, it’s about as helpful as a squashed banana. So, to avoid getting overwhelmed, the most crucial aspect in the analysis of the cultures of organisations or institutions is the identification of appropriate variables on which to focus analysis.
How, why, and with what consequences do patterns of attitude, behaviour, and social interaction vary from situation to situation? What are the general principles which govern variations in thinking, feeling, and doing from situation to situation? What is the specific character of what is happening, understood in comparative relation to other situations, and why does it matter?
When I speak of “cultural climate” I speak of the dispositional quality, the tone, the texture, the colour, the temperature, the ‘feel’ of a particular organisational culture, considered in comparison to other organisational cultures or to other times or places within the same organisation. In colloquial terms, the cultural climate of an organisation here means, “what has tended to happen, what tends to happen, and what will tend to happen in a particular organisation (specified by location(s) over a designated time). Cultural climates in organisations differ in the way that each person has a different personality, that is, a dynamic pattern of variation in attitude, behaviour, and social interaction that tends to be consistent over long periods. The better you understand the personality of your organisation, the better you will be able to respond to the challenges you face within it.
I turned to sociolinguistic register theory to help me make sense of this.
As Michael Halliday has written:
“The notion of register is at once very simple and very powerful. It refers to the fact that the language we speak or write varies according to the type of situation. This is itself is no more than stating the obvious. What the theory of register does is to attempt to uncover the general principles which govern this variation, so that we can begin to understand what situational factors determine what linguistic features.” (Halliday 1978:31-32).
Register theory allows sociolinguists to compare particular qualities of language, and I found it provided a useful launching-off point for comparing particular qualities of relationship across different contexts. When transforming a theory of linguistic register into a theory of cultural climate I found it helpful, though, to take language away from the centre of the model.
The heart of my work as a coach and consultant is the identification of three key variables in situations which I regard as the most important governing variables in the structuring of expectation in social interaction, social environments, and social behaviour, and by extension, in cultural climate and culture change:
- Intensity of affect or emotion (ranging from more intense to less intense)
- Character of power or influencing (ranging from more directive to less directive)
- Discursive relationship to uncertainty (ranging from the ‘elimination’ of uncertainty to the acceptance of fluidity, ambiguity, and emergence)
The most important point in this work is that I have found these three variables to be direct correlates.
For example, the more intense the affectual environment, the more appropriate highly directive influencing becomes, and the more ‘elimination’ of uncertainty thinking is likely to dominate within the situation. Likewise, the more ‘elimination’ of uncertainty thinking is used within a particular situation, the more likely it is that responses will be highly directive and the affectual environment will intensify.
In effect, it’s a map of human nature that is both dynamic and variable, pathologically particularist in it’s application. Or should that be mapplication? It can also be read as a map of escalation and de-escalation, mapping and tracking particular kinds of change, and mapping and tracking my own participation in and contribution to those changes.
As I use it, the notion of cultural climate implies that the most important questions you can ask might be, “how does it feel?” and “how do I want it to feel for myself and others?”
A core insight of my work is that within any particular cultural climate it becomes appropriate for only certain kinds of thinking, feeling, and doing to happen. A sensitivity to the poetics of appropriateness-to-context becomes one of the most valuable skills in analysis and leadership.
Cultural Climate speaks to how certain climates will foster, nourish, and sustain particular ways of thinking, feeling, and doing and render other ways of thinking, feeling, and doing inappropriate, illegible, irrelevant, and, often, invisible.
Most organisations committed to culture change focus on changing visible norms, customs, and behaviours within their organisation, which tend to have little impact on performance. A large number of small-scale changes may not effect the necessary shifts in the organisational environment to embed true, lasting, meaningful change.
Because the present is also pre-sent. The cultural climates of situations, places, and gatherings of people have always-already settled into emotional patterns that constrain and guide our expectations. Within institutions and organisations this is even more the case.
To transpose Karl Marx, we make our own organisations, but not quite as we please.
Within any particular cultural system, prolonged participation in the cultural climate has a tendency to prime people to reproduce the dynamics of that climate (either in that system or upon having moved to another). Within particular qualities of environment people tend to default to particular kinds of change. While it is possible to overcome this priming to a greater or lesser extent, for the most part in cultural priming people turn towards what I call “the adjacent probable.”
I’ve developed the term “adjacent probable” from the term “adjacent possible” in the work of Stuart Kauffman, a biologist and complex and adaptive systems researcher. This concept speaks to the way that biological developments can only happen within their specific conditions of possibility, “the range of biochemical changes that any living system … could reach without destroying its internal organization.” (Peter H Jones 2013:324). As interpreted by Stephen Johnson (2010), “The adjacent possible is a kind of shadow future, hovering on the edge of the present state of things, a map of all the ways in which the present can reinvent itself. Yet it is not an infinite space, or a totally open playing field …. What the adjacent possible tells us is that at any moment the world is capable of extraordinary things, but only certain changes can happen.”(Johnson 2010, p. 30-31).
In the context of the Cultural Climate Framework, the adjacent probable tells us is that at any moment we are capable of many things, but we tend to reach for architectures and dynamics of thinking, feeling, and doing that are already dominant in the cultural climate we inhabit, and it doesn’t matter whether our intention is supportive or oppositional. The adjacent probable refers to our default responses in a particular situation, both tacit and explicit, that are both symptomatic of and constitutive of the dominant expectations in the cultural climate.
For me, cultural climate is not only the dynamic pattern of behaviour and expectations but also the key driver of behaviour and expectations within an environment. The biggest driver of change, whether helpful or unhelpful, is the dominant quality of relationship within an environment, the dispositional quality of an environment – how it feels.
In some environments we get crushed.
How does an environment designed for and, at least initially, conducive to healing and human flourishing become culturally unsustainable?
The term “enclosure” is frequently used to speak of broad social processes and pervasive social change, and variously equated with commodification, privatisation, commercialisation, and the marketisation of everyday life. In this way, “enclosure” has become very much about the identification of the threat of unwelcome social changes, driven by often anonymous corporate agents, fueled by the expansionary logic of free-market capitalism.
For me, enclosure is the broader process in play when good situations go bad and when bad situations get worse.
Three primary drivers of enclosure stand out, which I have come to think of as the Enclosure Triad –
- The Elimination of Uncertainty
- Heightened Affectual Intensity
- Heightened Directivity
While I have identified many more features of enclosing environments, these three are, for me, the primary drivers of unhelpful change within a cultural system. These features, more than any others, are what will most affect the relational climate of an organisation, being both symptomatic of and constitutive of the unhelpful dynamics of enclosure.
I’ve found that the process of enclosure, in turn, leads, beyond a certain point, to the emergence of what I call ‘environments of enclosure’ or ‘enclosing environments’. These tend to be culturally unsustainable, even toxic environments, which tend towards crisis.
February 2013 saw the presentation to parliament in London of the Francis Report into the Mid-Staffordshire NHS Foundation Trust. As I’m sure you know, this was the last in a series of inquiries and reports responding to concerns of poor care and high mortality rates at Stafford Hospital.
Inquiries included, and I quote, “harrowing personal stories from patients and patients’ families about the appalling care received at the Trust.” As the report states clearly, “The extensive system of checks and balances intended to detect and prevent such failures did not work. Large numbers of patients were left unprotected, exposed to risk, and subjected to quite unacceptable risks of harm and indignity over a period of years.” (Francis Report 2013 Executive Summary para 73 p25)
Reports speak of,
“a lack of basic care across a number of wards and departments at the Trust; The culture at the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff; there was an atmosphere of fear of adverse repercussions; a high priority was placed on the achievement of targets; the consultant body largely dissociated itself from management; there was low morale amongst staff; there was a lack of openness and an acceptance of poor standards; Management thinking during the period under review was dominated by financial pressures … to the detriment of quality of care.”
The epitome of an environment of enclosure.
Of crucial importance is the suggestion in the Francis Report that Stafford should not at all be considered an anomalous exception to current practice. Francis writes that:
“Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated or that the risk of a recurrence was so low that major preventative measures would be disproportionate. The consequences for patients are such that it would be quite wrong to use a belief that it was unique or very rare to justify inaction.” (Francis Report 2013 Executive Summary para 76 p25)
Neither rare, unique, nor improbable.
There comes a tipping point in the escalation of dynamics of enclosure where human flourishing simply becomes inappropriate.
In many places, there seems to be little room for garaíocht in institutionally managed healthcare. As Ivan Illich phrased it, beyond a certain intensity, “what was meant to constitute health care will turn into a specific form of health denial”.
We have constructed institutions, organisations, and management systems for the purposes of healing, nurturing, and caring in which the qualities of relationship most conducive to healing, nurturing, and caring have increasingly come to feel inappropriate, improbable, unlikely, and a struggle to achieve.
The words of Peta Bowden back in 1997 still hold true, “The nexus of formal knowledge, authority and institutional control has characteristically overwhelmed the claims of personal, experiential and responsive caring that are so central to ethical excellence in nursing” (Peta Bowden, Caring: Gender-Sensitive Ethics, 1997:140).
This is deeply counterintuitive for people who are vocationally drawn to be carers and healers. Part of the core difficulty of national healthcare systems is that the need felt by a decent carer or a practised healer to reduce intensity, reduce uncertainty, reduce directivity, tends to be caged within practices, logics, habits, norms, and traditions designed in principle to increase intensity and increase directivity.
If the administrators, managers, and accountants within a health service system cannot conceive of themselves as healers, then they are in the wrong job.
The rhythm of illness is not the rhythm of documentation, spreadsheets, bottom lines, and project management. You do what you can when you can, as best you can. Often as patiently as you can. Life with illness is what happens when you’re busy making other plans.
The three elements of the enclosure triad are frequently to be found in the heart of workaday orthodoxies in accepted organisational, institutional, economic, or political practice. The logics of the triad are embedded and nested within the language, habits, norms, and rules of much standard, recommended, and even “best” practice.
I have found that enclosure tends to be the underlying logic of “business as usual”, a structural logic that consistently undermines best intentions. When the tenor of the cultural climate is driven by goal-achievement, command-and-control, chronic high pressure, and financial growth rather than a more integrative understanding of cultural sustainability and systemic wellbeing, the intensifications of enclosure will follow like night follows day. The “adjacent probables” of goal-driven and profit-driven organisational, institutional, and political practice within an environment of enclosure are what take their toll on employee engagement, strategic direction, and the health of a system’s future.
Enclosure also frequently provides the underlying logic of first responses to the need for helpful culture change. The interventions of culture change are called for in times of difficulty, stagnation, or crisis. However, in culture change interventions within cultural climates of enclosure we often systematically reinforce and recreate the enclosing dynamics we are seeking to change. What seems like a good and very fresh idea at the time often ends up having very similar consequences to the thing you are trying to avoid.
To effect a dispositional shift in the cultural climate of an organisation or institution takes time. It also takes sensitive leadership. Until the cultural climate, the personality, of an organisation changes, nothing substantially changes.
The faster the change happens, the more likely it is that very little has changed.
Culture change is about people – what they think, how they feel, what they do. You can restructure, rebrand, and reorganise, you can change the language of the workplace and re-arrange the furniture; but if the cultural climate of the organisation doesn’t substantially shift, then all you are left with are a series of very expensive cosmetic changes, even higher levels of employee cynicism, most likely high levels of emotional estrangement (as people’s sense of how it actually feels goes against the grain of how they are professionally obliged to feel), and a greater culture-change challenge. In healthcare you are also increasing the possibility that people will get harmed or die.
Unless the assertion and declaration of positive values is met with dispositional change within people and across organisational policy and practice, then, in time, the enclosing gravities of organisational and institutional practice will come back around, moving cyclically through the exciting and inspiring semblance of revolution to eventually settle back into the rebranded reproduction of enclosing dynamics, now wearing a different and more attractive mask, but nonetheless the smiling mask of enclosure.
How can we helpfully respond to our participation in challenging environments in a way that reforms, reimagines, renews, and nurtures environments for optimal human flourishing rather than making them worse in spite of our best intentions?
How can we preventatively identify the threatening possibilities of unhelpful change before they start to gather speed and become all too significant?
The paradox of garaíocht is that you cannot prescribe, plan, or legislate it into existence. The harder you push to make it happen, the less likely it is to happen. Often efforts are made within an enclosing work environment to perform some equivalent of garaíocht as a visible behaviour before the necessary shift in cultural climate has taken place to support it as a lived experience. This is an easy road to emotional exhaustion and burnout.
Having outlined the Cultural Climate Framework and the dynamics of enclosure, I can now revisit garaíocht as:
“A dispositional quality of relationships and environments (i.e. a particular cultural climate) in which we tend to experience as probable a willingness, desire, and ability for sensitive, responsive, and adaptive presence, thereby influencing, supporting, sustaining, and nurturing helpful change. This optimal dispositional quality for human flourishing becomes most available when the “elimination of uncertainty”, heightened intensity, and heightened directivity do not dominate as dispositional qualities in any particular situation.”
To champion garaíocht as an aspiration in relationship is by default to adopt a position of critique, resistance, and response to the structural violences and dynamic hegemonies of enclosure.
Garaíocht, which in English I sometimes refer to as ‘ordinary ethics’, is a way to talk about the invitation of withness, being-with, the call to a culturally sustainable future.
After all of it, after all I’ve heard and all I’ve seen, what I’ve come to believe is most beautiful about Irish traditional music and song is something I neither hear nor see. It is something I feel. I have a word for it now. Garaíocht.
If defaulting to the adjacent probable of a particular cultural climate runs the risk of doubling us back into the dynamics of enclosure and further crisis, the need for interventions invites us to challenge the priming logics within the situation and within ourselves and to reach for the “adjacent unlikely” that will change the cultural climate equation.
To construct healing environments, the key is to create and maintain an environment in which the qualities appropriate to healing are felt to be the “adjacent probables” of personal endeavour, social interaction, and working life, as possible, plausible, and desirable in the quest to design optimal conditions for human flourishing.
It is possible for us to integratively design and engineer conditions that contribute to healing and human flourishing, across entire systems, that can persist without the threat of crisis, simply because we designed them that way.
But that calls for us to do more than damage-limitation work within environments of enclosure, as crucially important as that is.
Our responsibility to the generations yet to come is an enormous opportunity. I have a dream that across the world seven generations from now we will have universal healthcare that has been integratively designed from the ground up according to what appropriately supports and nourishes environments for healing. All that’s required is that we not succumb to failures of our imagination, plant seeds now wherever we can, and trust that most of what we want has already been imagined and is being practised somewhere, probably somewhere quiet, unnoticed, and undervalued.
There is plenty of hope. Remembering to remember the best of what it means to be human is the he(art) of care, the he(art) of culture change, and the he(art) of leadership.
You are here, you are now, you are with, and you are near, and in a position to help.
I’ll finish with two poems …
The He(art) of Care
Good morning, Sadie
How did you sleep?
The other 129 people I’m looking after have stories
Just as sad as yours.
Those are lovely flowers, did your daughter bring those in?
Just as courageous as yours.
Sorry, this vein’s hard to find. I’ll have to try that again.
Just as wounded as yours
Don’t worry, it’s not the end of the world. We’ll soon get you cleaned up.
Just as funny as yours.
Would you like me to bring you a cup of tea?
Just as feckin’ unfair as yours.
Looks like we might get some sun today.
And if I listen, really listen
Stay a while,
Cradle the silences between us like I would a sleeping baby
Sit till the rhythm of my breathing matches yours
All of your stories
All of their stories
Will break my heart
So I just go about my business.
But not so much that you’d know.
Listen, really listen.
Bhí Mé Réidh Leis (a folklorist who cared)
Bhí mé réidh leis,
Séamus the Folklorist wrote in his diary,
and left, off on his bicycle,
Leather satchel bulging at the seams,
off to the next
by the sea,
near a field
without a cow.
Bhí mé réidh leis.
Too easily translated as
“I was finished with him.”
Primary target acquired.
Primo Levi once wrote:
“To give a name to a thing
is as gratifying
as giving a name to an island,
but it is also dangerous:
the danger consists
in one’s becoming convinced
that all is taken care of
and that once named
the phenomenon has also been explained.”
When naming people.
When watching people.
When describing people.
When making a good living from
Bhí mé réidh leis,
Séamus the Folklorist wrote in his diary.
He could have meant
“I was ready with him,”
To talk like neighbours.
To keep good company.
To be with.
To sit in silence.
To chat about those near and dear to him.
To share a cup of tea.
To wile away the hours
Where words matter less
than the heart that dances.
I wonder if
Séamus the Folklorist
(as he cocked his leg over his bike
and wiggled his bum
and uilleann pipes
into position for the rocky road)
that he was carrying
a leather satchel bulging at the seams,
chock-full of the sparkling delights of
For, in truth, he loved that man.
it didn’t feel right.
And sometimes, late at night,
He would stay behind
After a paperful day
And walk through the stacks
Drenching himself in the names
of old friends, dear friends,
Showering himself in half-glances
warm cups of tea
a devilish drop of poitín
a dirty joke
And a broad choir of grins.
And in the light of morning
In office hours
At the start of another paperful day
while walking his fingers through
the cabinet of the card catalogue
for references to that stirring tune
He would again feel a stirring of regret
that there was no card for “love”.