Blood, Sweat and Tears: Making Sense of Senses in Expert Nursing

knowledge acquired through higher education is regarded essential in defining professionalism, fundamental to professional autonomy and the solving of expert tasks (Abbott 1988, Parsons and Platt 1973, Freidson 2001). Within a hospital context, the prevalence of evidence-based medicine (EBM) also bears elements of this way of reasoning about the relationship between theory and practice, with randomized controlled trials (RCT) Blood, Sweat and Tears 5 ranking highest as the golden standard (Timmermans and Berg 2003). According to Lambert, Gordon, and Bogdan-Lovis (2006, 2613): ”evidence-based approaches have come to play an increasingly important role in many national health systems, not only in guiding clinical practice but also in shaping research agendas, formulating policy and allocating financial resources”. Other conceptualizations of knowledge and learning have contested this privileging of theoretical over practical and embodied ways of knowing, claiming that the ability “to do something”, in contrast to “knowing that something is”, is also knowledge (Ryle 1963). Thus, theoretical knowledge is seen as inseparable and arising from practical knowledge (Schön 1983, Dreyfus and Dreyfus 1986, Benner 1984). According to Grimen (2008), practical knowledge is “indexed”, i.e. inseparable from the person who holds it or the situations in which it is used. It has tacit dimensions and includes embodied skills that may be difficult to put into words (Polanyi and Sen 2009 [1966]). Within these perspectives, learning is contingent on its connectedness, historically and with others (Wenger 1998). It needs to be understood as what Lave (1990) calls “understanding in practice”. Thus, learning is a process of “enskilment”, inseparable from doing, and both are embedded in a context of practical engagement in the world (Ingold 2011 [2000], 416). Investigating senses as knowledge is dependent on such a broadened understanding of the scope of knowledge, as know-how, indexed and hence personal, embodied, and sometimes tacit, and a notion of learning as doing. Yet this does not imply that knowledge necessarily become private in any individual sense (Barth 2002). Every person’s knowledge, Barth claims, is constructed within the traditions of knowledge of which each of use partakes, and personal skills and embodied knowledge are largely constituted on the bases of activity into which the person has been socialised. Exploring knowledge, we need to investigate the particulars of action in which knowledge is realised and applied, paying attention to the agency and acts of knowers, and how substantive ideas, representations and communication of knowledge mutually determine each other, in addition to being restricted by material circumstances and relations of power and disempowerment (Barth 2002). Drawing on these conceptualizations of knowledge in the exploration of how nurses acquire and use their senses in everyday clinical practice, this article contributes to the study of sensory knowledge and expertise in two respects. First, it foregrounds the processes and Blood, Sweat and Tears 6 practices in which sensory knowledge is actually formed and used at a micro-level. The connection between senses and knowledge is not new. The anthropology of the senses, represented by the work of Howes (1991) and Classen (1993, 1997), has highlighted how senses can be seen as foundational knowledge that structures and facilitates thought at a societal level (Maslen 2015). However, according to Maslen (2015) few studies have explored how senses are actually formed and come to act, i.e. how sensory knowledge is acquired and used. Aiming to fill this gap Maslen has investigated how doctors learn to hear medically (Maslen 2015), and the nature and role of diagnostic sensory work in the meeting with new management regimes and techno-scientific changes in healthcare environments (Maslen 2016, 2017). In the discussion, I will argue that her conclusions are relevant to the study of how the senses are cultivated and used also among nurses, who are frequently being delegated the role of making sensory judgements on behalf of physicians (Oudshoorn 2008, 2009). Drawing on Maslen’s work I claim that building sensory knowledge involves a complex interdependence between different types of knowledge, constituted in the nurses’ continuous interaction with people and technologies in the clinical environment. Second, the article highlights how a phenomenological and ethnographic exploration of the acquisition and use of sensory knowledge can contribute valuable insights into how expertise is cultivated in everyday clinical practice. According to Lawlor and Solomon (2017), numerous studies have examined the role of guided participation and apprenticeship, involving various forms of novice-expert interaction, in establishing expertise. However, anthropology has focused little on the cultivation and spread of expertise, particularly from an ethnographic and phenomenological standpoint (Lawlor and Solomon 2017). Within anthropology expertise is understood as inherently interactional, involving the participation of objects, producers and consumers of knowledge, enacted in real-time communicative practice (Carr 2010). Contemporary developments in the expert literature emphasis that expert decision-making is an intuitive competence, rather than rational, based on logical knowledge and ability (Collins and Evans 2007). Combining a phenomenological an ethnographic approach in the study of sensory knowledge and expertise, this study aims to demonstrate how nurses’ expertise is cultivated in continuous, embodied, sensory and intersubjective relations, in the doing of nursing. Blood, Sweat and Tears 7 Methodology and Research Phenomenological methods have been considered of great utility to anthropological inquires over the past three decades, grounding theories, descriptions and analysis in examination of peoples’ lived experiences and concrete bodily experiences, forms of knowledge and practice. This has made phenomenological anthropologist prone to one of the main critiques of phenomenology, namely that it ignores broader structural, social and historical influences, focusing only on the subjective and experiential (Desjarlais and Throop 2011). The phenomenological focus on the “subject body” (Jackson 1989) and embodiment, pursuing “how the world is felt and experienced from a first person point of view” (Hollan 2012, 37), does however not imply taking the individual as an isolated and self-contained object of scrutiny as the point of departure. Rather, it contains that even our most basic experiences entail a foundational intersubjectivity, i.e. thinking, perceiving, remembering and learning are fashioned in the ongoing relations with others and the environment, and need to be studied within the political and cultural context where people’s practical involvement with the livedin world takes place (Jackson 1998, Ingold 2011 [2000], 171, Desjarlais and Throop 2011). Thus, the critique of phenomenological methods can be counteracted in the “convergence” between phenomenology and ethnography, i.e. using phenomenological method, concepts or sensibilities in the interpretation of ethnographic data, or ethnographic data as basis for phenomenological reflection (Csordas 2012). This convergence has implications for ethnographic practice, which consequently must entail multisensorial embodied engagement with others and with their social, material, discursive and sensory environments. Furthermore, it requires critical reflection on these engagements (Pink 2015, 28). Paul Stoller (1989, 1997), promoted the reflexive and embodied turn in social theory, arguing that anthropologists should not only consider the multisensory experience of others, but also attend to their own senses, and thereby produce evocative and tasteful ethnographies. Linking Merleau-Ponty’s phenomenology of perception with the practice theory of Pierre Bourdieu, Csordas (1990) outlined embodiment as a methodological orientation, a paradigm, for anthropological empirical research, taking the body as a productive starting point for analyzing culture and self. He introduced the notion of “somatic modes of attention” to describe “the culturally embodied ways of attending to and with one’s body in surroundings that include the embodied presence of others” (Csordas 1993, 138). Blood, Sweat and Tears 8 According to Ingold (2011 [2000]), the fact that sociality is given from the start, in the direct, perceptual involvement of fellow participants in a shared environment, is what makes anthropological fieldwork possible. It allows the fieldworker and local people to inhabit a common ground of experience. Because people make sense of their experiences by constructing a narrative based on strands of practical, perceptual activity, understanding of meaning production must start from the processes of social life, with how people sense the world. Participant observation allows the ethnographer to access other people’s ways of perceiving by joining with them in the same currents of practical activity, learning to attend to necessary tasks, as would any novice practitioner. This communion of experiences establishes a baseline of sociality for all subsequent attempts at verbal communication (Ingold 2011, 314). Guided by these methodological perspectives, my fieldwork involved drawing on sensory and embodied knowledge, attending to bodily sensations as a mode of attending to the intersubjective milieu of the cancer unit that caused these sensations and thus paying attention with my body (Csordas 1990). I accessed the nurses’ ways of perceiving by joining them in their practical work, learning to attend to what they attended to and engaging in talk to make sense of our shared experiences. This involved aiming for an understanding that was “as loyal as possible to the contexts, the embodied, sensory and affective experiences, and the neg