Senses matter because people matter: The value of sensory history for improving healthcare systems
by Sarah Yardley, consultant in palliative medicine and clinical senior lecturer
Content warning: COVID-19; death.
On reading Smith’s Manifesto I was very taken with the arrangement into chapters of past, present and future as this recognises the importance of human historicity (the quality of being part of history). Chapter 1 raised questions about ‘a story of attention lost’ and I was particularly struck by the demonstration of past attention to interactions between emotions and the sensate. Looking to the future (Chapter 3) I was struck by the importance of being aware of ‘our own intellectual sensory preferences and prejudices’ (p. 90). It was, however, in Chapter 2 that I felt greatest resonance and a moment of insight into something that I had been unable to previously articulate, and on which I want to focus in this blog.
What can we learn from historical perspectives?
‘A history without the senses is not only impoverished but also fails to grant us access to how structures and belief systems are made, how countries are formed, how groups are empowered and subjugated, how our understanding of our sensory present is often beholden to our reading of our sensory pasts, and how historical memory itself is shaped. In other words, not to sense the past deadens us to critically important developments, ones that will remain occluded and opaque if we ignore the habit of sensory history’ (p. 44)
I’m a clinician, rather than a historian, albeit with a research practice firmly situated in the sociocultural. Ever curious about how sociocultural influences, informal learning and ‘real world’ practices shape healthcare, I have been exploring ideas of ‘relational glue’ and ‘relational reach’ as part of a study that seeks to rediscover the hidden value of relationships in healthcare. Our working definition of ‘relational glue’ is the support constructed between people to ‘make things work’ in the messiness of healthcare practice. ‘Relational reach’ is intended to capture the idea of the bridging work people do to link across parts of the system and ‘hold’ unfixable situations.
With patients, carers and professionals I have discussed the importance of understanding individual, group and institutional historicity within healthcare systems – drawing on the framework of Cultural-Historical-Activity-Theory (CHAT) – to unpick how what people think and feel affects what they do. CHAT provides a way of paying attention to the dynamic construction of ‘system’ by people, as well as showing how people act with agency within created structures.
I advocate for the importance of paying attention to the stories people tell themselves, and each other. Stories are a core human expression of sense-making. Through stories we create meanings from our experiences that allow us to reject or accommodate different ideas. The synthesis and assimilation of ideas becomes how we view ourselves, others and the wider world. It, therefore, follows that what has gone before, either direct experience, or indirect but shared cultural histories, will shape relationships.
How might a sensory perspective help clinicians, researchers and policy-makers to improve healthcare?
Smith’s Manifesto also suggests:
‘Structural shifts in sensory environments, changes in sensory perceptions and habits, shifts in the ways the senses were (and are) produced and consumed were (and are) not merely incidental to key developments but constitutive of them… not attending to the sensory presence in these developments impoverishes our understanding of their texture, denies us access to understanding how and why structures and perceptions emerged and changed as they did…’ (p. 62)
I suggest that the COVID-19 pandemic brought to crisis point things in hospitals that at best were ‘unhappy norms’ – normal in the sense of what we were all used to, familiar with, and had perhaps lost our expectations of being any different. Not normal in the sense of good. Without due attention to the emotional, the sensate and the intertwining of these with each other ‘holistic care’ can become empty rhetoric. Reading Manifesto has made me wonder if we, the people who create healthcare systems (clinicians, researchers and policy-makers), had been paying due attention to how important senses are not just for our patients but also for ourselves.
There is a lot of collective but depersonalised sensory stimulation and intrusion in hospitals. Sounds and smells are often unpleasant. Touch in clinical examination may be accepted as a necessity but is still an invasion of personal space. Pragmatism in the face of a ‘need to do’ the work of healthcare shapes who sees what but also how people see each other. With time, sensory overload can easily lead to apparent desensitisation as people become inured to it. It is often all too easy for patients and professionals to consciously or unconsciously enter into unhelpful fictions, i.e. tacitly or explicitly agreeing to pretend otherwise, as a solution to these challenges.
Early on in the pandemic, personal protective equipment (PPE) created a highly visible, barrier to sensory connection between people, disrupting even the most cautious of sensate social norms. The smell of the inside of a FFP3 mask and the taste of a dry mouth still takes me back in an instant. I can rapidly bring to mind examples that illustrate the human cost of this, when all types of cost are considered. I do not have the words to adequately explain what is like to lock eyes with a dying person, who has no means to speak and who cannot see or hear properly and can only feel my touch through a latex glove. I saw fear. I hope they saw care but it can only have been dulled though the reduced sensory experience.
Of course, I understand the reasons for these measures at the time. But now I worry about the unintended consequences of a culture that might be created through sensory deprivation in hospitals. Just recently, I told someone it was okay to kiss her dying husband goodbye. Her gratitude made me cry. He was in a side room, neither of them had tested positive for COVID-19, they had lived together at home for decades and there was no scientifically justifiable reason for her to wear a mask when only the two of them were in the room. Yet it still felt like I was engaging in a small act of resistance, and she clearly felt she needed my permission for doing the ‘wrong thing’ because it was the right thing to do.
I don’t make a habit of it but that was the second time I’d cried in one week. The first time was when I heard Chris Lubbe speak of growing up in South Africa during apartheid. Introducing the Zulu greeting ‘Sawubona’ he explained this was much more than a social nicety. Literally translated to ‘I see you’ in English it holds the essence of valuing the identity of each person, to see is to recognise intrinsic worth in each other.
Not taking up the challenge of paying greater attention (for example, because this will create an obligation to try do things differently) might prove to create short-term gains at the expense of longer-term losses. Overlooking sensory impact is a means of coping – whether as a giver or receiver of healthcare interventions – but it comes at the cost of implicitly denying a part of what makes people, people. On any given instance it is always easier to perpetuate the system than to demand change. Yet we would be wise to recognise our senses do not necessarily accommodate for boundaries we might cognitively seek to maintain between the personal and professional. Dissonance is problematic for patients and professionals alike.
I hope these ideas might make a small contribution to opening up debate about whether attention to multisensorial learning is an essential element for improving human factors issues in healthcare systems design. Perhaps if we paid more attention to all the senses we would have better understanding of how to address expectation-experience gaps constructively through system change, rather than through individuals engaging in ad hoc workarounds that can be exhausting.
With colleagues I have previously argued that: ‘Meta-cognition, emotional intelligence, and informal learning will either overcome system limitations or overwhelm system safeguards. Integration of human-centred co-design principles and informal learning theory into quality improvement may improve results’. Having read Manifesto I now add that, first, any model of good, or model of improvement needs to seek to integrate the multisensorial. Second, when we tell our stories to create meaning, conscious attention to the sensate may help us better ‘see’ ourselves and others.
 Yardley S, Williams H, Bowie P, et al. Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory BMJ Open 2022;12:e048045. doi: 10.1136/bmjopen-2020-048045
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