Florence Nightingale’s body concept: a dialogue with Merleau-Ponty’s existential phenomenology

Abstract

Objectives

The purpose is to develop Nightingale’s body concept by comparing it with the Merleau-Ponty’s existential phenomenology.

Methodology

This is an hermeneutic-qualitative analysis of the text Notes on Nursing: What is and what is not, together with Phenomenology of Perception. Given the confrontation with a text, the instrumental of interpretation has been sustained on the philosophical hermeneutics proposed by Hans-Georg Gadamer.

Results

Florence in Notes on Nursing rudimentarily proposes a comprehensive system of the body as the axis of appearance of reality, where the nursing task is to understand how this appearance of the patient configures the perception of his world and cooperates in uniting him to a new vital situation that requires a perception of spirit in the face of his own recovery, born from dialogue with Merleau-Ponty.

Conclusion and implication for practice

Understanding what is involved is essential for the professional nursing practice. Since Nightingale then, what is essential for discipline must be understood as the appearance of the reality of the patient to intervene in him as a whole.

Keywords:
Human Body; Existentialism; Nursing Philosophy; Hermeneutics; Knowledge

Resumen

Objetivos

El propósito es develar el concepto de cuerpo nightingaleano al compararlo con la fenomenología corporal de Merleau-Ponty.

Método

Análisis hermenéutico-cualitativo del texto “Notas sobre Enfermería: qué es y qué no es”, en conjunto con Fenomenología de la Percepción. Dado el enfrentamiento a un texto propiamente, el instrumental de interpretación se ha sostenido sobre la hermenéutica filosófica propuesta por Hans-Georg Gadamer.

Resultados

Florence, en Notas sobre Enfermería propone rudimentariamente un sistema comprensivo del cuerpo como eje del aparecer de la realidad, donde el quehacer enfermero es comprender cómo este aparecer del paciente configura la percepción de su mundo y coopera en unirlo a una nueva situación vital que exige una percepción de ánimo frente a su propia recuperación, nacido del diálogo con Merleau-Ponty.

Conclusiones e implicaciones para la práctica

La comprensión de lo que se interviene es primordial para el ejercicio profesional enfermero. Desde Nightingale, entonces, lo esencial para la disciplina debe ser entender el aparecer de la realidad del paciente para de intervenir en él en su totalidad.

Palabras claves:
Cuerpo humano; Existencialismo; Filosofía en Enfermería; Hermenéutica; Conocimiento

Resumo

Objetivos

O propósito é develar o conceito de corpo em Nightingale ao compará-lo com a fenomenologia existencial de Merleau-Ponty.

Método

Análise qualitativo-hermenêutico do texto Notas sobre Enfermagem: o que é e o que não é, com Fenomenologia da Percepção. Dado o confronto com o texto, o instrumento de interpretação tem o sustento sobre a hermenêutica filosófica de Hans-Georg Gadamer.

Resultados

Florence em Notas sobre Enfermagem propõe um rudimentar sistema compreensivo do corpo como o eixo de aparecer da realidade, onde o trabalho é entender como o aparecer do paciente configura a percepção de seu mundo e colabora em uni-lo com uma nova situação vital que exige uma percepção de encorajamento frente a sua própria recuperação, revelado após dialogar com Merleau-Ponty.

Conclusões e implicações para a prática: A compreensão do que se intervem é primordial para o exercício profissional da enfermagem. Então, desde Nightingale o essencial para a disciplina deve ser a compreensão do aparecer da realidade do paciente para intervir nele, na sua totalidade.

Palavras-chave:
Corpo Humano; Existencialismo; Filosofia em Enfermagem; Hermenêutica; Conhecimento

INTRODUCTION

The historical tradition of the cartesian inheritance has understood the body as a measurable object subject to the laws of the physical world. After the Copernican turn of Kantian philosophy, understanding emerges of the body in other schools of thought, among them phenomenology, which comes to understand it as the possibility of accessing the world and its incarnation, precisely in the existential tradition¹. Similarly, the body is interpreted as an object of molecular study and its intersystem interactions enable its definition² derived from the Cartesian understanding, being physically analyzable, with the question by its very nature acquiring relevance¹ and being answered by authors who propose different ways to understand it^1,3-5.

In approaching the body, nursing has proposed to explain the concepts of health, disease, person and nursing in each model or theory⁶ with the aim of defining its practices and thus integrating an intervention mechanism into the paradigm⁷. From there, the current questioning as to its theoretical limitations constitutes a development platform for nursing, opening up to other areas of knowledge.

Florence Nightingale, initiator of the modern nursing movement, had some concerns about the discipline motivated by an education in social ideals and mathematical and philosophical theoretical developments^8-11, added to a high-risk health context, where the major determinants of health at the time were the socioeconomic situation on the one hand and living conditions on the other, demonstrated by a life expectancy that for that era was 49 years in the professional class, 27 years in the merchant class and 16 years in the working class. Victorian cities had a shortage of sewage systems, unregulated slaughterhouses and streets without sanitation^12,13. The Crimean War exploded in this context, and under the inadequate conditions in the military hospitals of that time¹⁴, Nightingale was asked to organize an expedition of nurses to improve sanitary conditions, intervening effectively¹³ and reducing mortality from 60 to 2.2%⁸.

Florence was the first to generate nursing knowledge by writing of her experience in war with, Notes on Nursing: What It is and What It is Not, expressing her motivation towards professionalization through education¹⁰, because in the 19^th century women who practiced patient care had no formal education, and performed this function in homes and health establishments^8,10,12. Her way of thinking explains the meaning of the phenomena observed through analysis, reasoning and logical argumentation⁶, relating them to her philosophical orientation on patient-environment interaction^9,10, thereby defining the action of care⁵. In this book, Nightingale problematizes among many concepts, corporeality, describing the situation of getting sick as unique and underscoring its experience.

The care practices influenced by Florence continue to be described today, such as interpretations of how nurses act in the interaction with others and acts of care¹⁴, situations of professional responsibility and roles represented with body interactions in the health care scenario¹⁵.

For his part, Maurice Merleau-Ponty discusses corporeality, understanding it from the perspective of existentialism, the paradigm of the subjective body, i.e., the body is the form in which reality is perceived, being the incarnation of the lived situation^3,16.

This work approaches the interpretation of body/person in Notes on Nursing: What It is and What It is not by Florence Nightingale from Gadamer’s hermeneutic perspective in contrast to Merleau-Ponty’s existential phenomenology in Phenomenology of Perception.

METHODOLOGY

A hermeneutic-qualitative analysis of the texts Notes on Nursing: What It is and What It is not together with Phenomenology of the Perception is performed. Given the confrontation with a text, the interpretation apparatus is supported by the philosophical hermeneutics proposed by Gadamer¹⁷. For this thinker, access to the text occurs in the existential sense of the encounter with another^18,19. In this paradigm, the event of understanding is opened up in a dialogue between the reader and the text, with no impositions of the person who understands the writing²⁰, but rather, with an open mind occurring in the mutual enquiry, the supremacy of hermeneutics stems from the researcher’s willingness to let it speak for itself¹⁸.

Koskinen, in her article “Hermeneutic reading of classic texts”²¹, identifies a model of text interpretation for research in the care sciences, taking the author mentioned as a reference.

This model begins with (i) a first reading of the text chosen in its uniqueness, recognizing it as another; then (ii) the paragraphs that touched and astonished the reader are extracted from the text; after this, (iii) a new careful and flexible reading of the extracted fragments is performed, finding meaningful patterns that have relevance for care; and finally (iv) these patterns are interpreted for a new understanding of phenomena in the care sciences.

Hermeneutic reading is an individual work that positions the researcher as reader, who adopts an attitude of openness to the text that allows them to understand it, finding significant patterns that bear relation to the theoretical foundation of care²⁰.

The process for interpreting these classic books was carried out through hermeneutic reading, triangulating the information with two readers for interpretative validity.

The reading stages were: (i) A complete reading of Nightingale’s book, allowing it to speak for itself in its temporal uniqueness. (ii) There were extracts from the chapters on the body (described in the Preface, in the chapters Variety, Chattering Hopes and Advices and Observation of the Sick)⁵ that aroused curiosity and astonishment. (iii) A second rigorous reading was performed, in addition to being discussed by the researchers in terms of its interpretation, opening these fragments from the Phenomenology of Perception of Merleau-Ponty. (iv) The concept of body/being a patient understood by nursing dogma is surpassed by Florence, as she suggests a new understanding of the same, even re-interpreting the environmentalist theoretical model where it has historically been classified.

With respect to the text Phenomenology of Perception, (i) a reading of the book enabled its appearance in otherness as a deepening text in the post-Husserlian phenomenological trend. (ii) Portions of the text are worthy of note, where the spatiality of the body itself is approached. (iii) During a re-reading, consistencies are perceived between what was described by Nightingale and by Merleau-Ponty. (iv) In Merleau-Ponty the body itself is enshrined as a mechanism to open up reality, enabling perception.

The ethical criteria of Ezekiel Emanuel are considered of value due to the incidental contribution of the criticism to the discipline and its theoretical conceptualizations, of validity due to the consideration of a robust theory, selection of the text according to the classic value of the work, considering at the same time the benefits of this interpretation over the risks, without conflicts of interests, contemplating that there is respect and handling of the information of texts under the due recognition of the work of their authors.

RESULTS AND DISCUSSION

Corporeality in Merleau-Ponty: Living Body

Merleau-Ponty’s philosophy in Phenomenology of Perception takes into account the value of the ego as subjectivity in the perceptive process, not as a relativity but rather universal: Is it perhaps that things have space in themselves, or rather “being” if not in fact, always referring to someone who interprets them as “being in”?.

The question as to what the body is makes sense in the rationalistic context of the era; from phenomenology (philosophical discipline of Edmund Husserl) the question of the perceptual problem emerges as a dilemma of intentionality (things always appear referring to something, to itself). Thus, Merleau-Ponty constitutes the perception of the body as intentionality (i.e., the perception of things appears in reference to corporeality)²². Merleau-Ponty says: “If my arm is resting on the table I should never think of saying that it is beside the ash-tray in the way in which the ash-tray is beside the telephone. The outline of my body is a frontier which ordinary spatial relations do not cross”^3:115

Corporeality is lived and not understood in a physical space; it is understood as an encapsulated body “here”, full of organs acting in reality, given to one different from itself; but in a lived, or rather, embodied space of the situation in which the body is both there and here; i.e., corporeality is space that opens up to reality, meaning corporeality is a here in terms of the “ego” and a there in terms of the “ego”, as openings to reality (hereafter, world).

The words that explain the phenomenon of a body there and here can be related to the original terms in German: Leib and Körper, Leib being life or a living body and Körper an organic or physical body. The relation with “there” and “here” will be the development of Merleau-Pontin’s thought, although at first sight “here” is related to the organic body (Körper), and the Leib as its great thesis; a body that is “here” but that is living, and is also lived “there”, i.e., a body open to the world, finally a Körper-Leib³.

With respect to being the body, Merleau-Ponty refers to exemplifying the recognition of the body itself: “We do not merely behold as spectators the relations between the parts of our body, and the correlations between the visual and tactile body: we are ourselves the unifier of these arms and legs…”^3:167

It is inferred that the body interprets itself in its perception. When seeing the body, it is not in front of one as outside, it is it (one does not have a body, one is a body)³.

Understanding what was mentioned in the previous paragraphs, it follows that the essential in the body is its power to be; the body is possibility. As the element that has the faculty to put itself in the world, understood well from tradition to this point, an ego does not exist in itself, but rather in relation to the world that appears to it. This corporeal relation translates into a power to be who I am in the world of things.

For example, for the situation of a patient, being ill is not only the disease that occurs in a wound and its reparative molecular processes (the “here” body), but the psychic approach to their reality (i.e., perception “outside their body”) is “there”. The walls could seem to them grayer and the world sadder due to their disease⁵, because their entire being is ill; such a situation of “outside”, the grayness of the wall and the sad world, are not merely environmental characteristics, but in its situation of illness, the body is that same gray as outside and the appearance is sad, like its physical wound.

This is made visual when the corporeality is displayed in the world, where the body encompasses the possibilities of being. One sentence that displays this is: “In other words, consciousness changes the body”^23:106-107, i.e., corporeality in terms of relation to the world is not only a relation of a “here ego” and a “there ego” uniting both identities. In order to avoid such a question, reference must be made to the incarnation of the ego in its world. The “here ego” and the “there ego” constitute a body-world synthetic totality.

This is to say that the body in terms of Körper is simultaneously not only a physical vessel but a Leib, i.e., the living body together with its life situation; this life situation is the very unfolding as its living corporeality. Put another way, “I am” the situation that is lived, “I embody” the situation, then “I embody the world”, and without going too far, when my situation changes, my body changes with it. The Leib dimension affects the life situation and with it the body, and with the body this Körper-Leib synthetic totality; thus, “consciousness changes bodies”.

For Merleau-Ponty, the body is organic and physical life at the same time, but also an expression of the ego together with its life situation, unfolding in it; therefore, each situation also demands a body that expresses it.

Corporeality in Florence Nightingale

When the Notes are considered as a book on nursing work, how to care for the sick will be described experientially. Florence observes what the patient’s disease is like, and not the disease itself, as if they could be separated⁵. Her ideas of being a body border on dualist Christian concepts due to the world view expressed⁸, but highlight elements that escape this traditional view of the body, demonstrating notions of “being a body” and “being a body there” as follows:

Body as the possibility of becoming ill and healing

Florence insists on the natural possibility of the body becoming ill and healing, treating it as a total organicity capable of regenerating, granting it a concept of being able to restore itself to innate conditions, unlike a mechanistic view where tools are used for its biological restoration.

“The reparative process which Nature has instituted and which we call disease, has been hindered[…] If a patient is cold, if a patient is feverish, if a patient is faint, […] it is generally the fault not of the disease, but of the nursing […] (which) has been limited to signify little more than the administration of medicines and the application of poultices […](The art of nursing) seems to be expressly constituted to unmake what God had made disease to be, viz., a reparative process”^5:2.

Disease is a process of the same healthy body; therefore, it is not a mechanical situation of damage understood as a series of physiopathological processes described molecularly; the approach is to treat the conditions that the body knows to enable its health. For that reason, she insists that nursing is mainly observation and care, over the technique of the administration of medicines and poultices.

“In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. […] it is quite surprising how many men (some women do it too), practically behave as if the scientific end were the only one in view, or as if the sick body were but a reservoir for stowing medicines into, and the surgical disease only a curious case the sufferer has made for the attendant’s special information.” ^{5 :124}

Perceptual body from within

Florence reflects on the body as the possibility of appearing from the perceptual world, in which vulnerability is psychically manifest “outside”: the patient tends toward anxieties, and their world can be formed in worrisome problems.

“You who believe yourselves overwhelmed with anxieties, but are able every day to walk up Regent-street, or out in the country, to take your meals with others in other rooms, &c., &c., you little know how much your anxieties are thereby lightened; you little know how intensified they become to those who can have no change;* how the very walls of their sick rooms seem hung with their cares; how the ghosts of their troubles haunt their beds; how impossible it is for them to escape from a pursuing thought without some help from variety”^5:57.

She emphasizes that the configuration of physical disease influences the patient’s perceptive structure of the world, and the opposite is also true; manipulating this can influence their physical state, not as a merely environmental stimulation, but from recognizing the discomfort subjectively: “How little the real sufferings of illness are known or understood. How little does any one in good health fancy him or even herself into the life of a sick person”^5:101 The idea is to accompany a situation of improvement, considering that their environment is adapted according to their emotional well-being because it affects the situation of disease in itself.

Synthetic body of reality and organicity

From the same previous section, it is worth noting the body concept that Florence understands is a total body and not an integrality that comes together. As a result of this rudimentary synthetic understanding (more than the sum of the parts is a totality in itself), a perception of the world from within is proposed, thus implying a body concept that is more than an organism functioning as the main actor of reality; it is a synthetic gears whose relations to each other manifest as “the body influencing the mind” and vice versa: “Volumes are now written and spoken upon the effect of the mind upon the body. Much of it is true. But I wish a little more was thought of the effect of the body on the mind. It is a matter of painful wonder to the sick themselves, how much painful ideas predominate over pleasurable ones in their impressions; they reason with themselves; they think themselves ungrateful; it is all of no use”^5:56. In other words, recognizing the “power to be” not only from within, but from the externality that their subjective state also forms.

This work reveals theoretical aspects from its history. The body in Florence is conceptualized in contrast to the contemporary thought of Merleau-Ponty, fruitfully opening up this concept. These similarities found are described, discussed and finally the implications of the understanding discussed are reflected on.

In neither is the body a thing possessed, but rather as being one, and its perceptual borders are configured as world. This body concept is a conclusion detached from perception for Merleau-Ponty, as the embodiment of the situation, and for Nightingale as the appearance of psychic inwardness in the perceived world; in one as in the other there is the form of “situations that demand a body” (Figure 1).

Figure 1
Summary of common aspects in corporeality between Maurice Mearleau-Ponti and Florence Nightingale.

The concept of inwardness in Nightingale is comparable to the concept of the “here-body” in Merleau-Ponty, as is externality (environmental) to the “there-body”, understanding it in both as the unit that can synthesize the world in itself, in its perceptive dimension of the reality of the “biological” body and of its “situation”.

Finally, it emphasizes the application of a dualist overcoming (i.e., separation of the psyche or soul from the material body) in Nightingale, through the corporeal notion of appearing in the world from inwardness. This configures basic elements of the concept of being human that point not merely to a dimensional view of being (a mind, soul and body, or biopsychosocial), but to an integration of the human that is a synthetic totality enveloped in its situation of disease (thus the emphasis in the twelve chapters). At the same time, it may be restored in its materiality, changing the manifestation of its outwardness from its inwardness; therefore, it is concluded that appearing in the world becomes the most important area of nursing.

Some rudimentary ideas of phenomenological corporeality (Figure 2), more than seeking a positivist treatise, are raised from the purest experience to show with simplicity the synthetic totality that is to exist through the body, especially from one who is sick, innovating an elementary phenomenological dimension of being.

Figure 2
Philosofical distinctions of corporeality between Florence Nightingale (Notes on Nursing) and Maurice Merleau-Ponty (Phenomenology of Perception)

It has been written on Nightingale’s ideas that when they are contrasted with these results from Notes on Nursing, they demonstrate value differences.

According to Núñez²⁴, through Nightingale we can understand the history of nursing and its theoretical development as she was the pioneer in putting the knowledge in writing, revealing the rudimentary concepts of the discipline. According to this author, the accumulation of knowledge of the profession ends in caring for the environment as a form of health prevention or recovery. Pfettscher also solidifies in the author environmentalist theory as the first step toward the theoretical models of nursing that will base it as a discipline that reflects and validates its own activity²⁵. This results in Nightingale’s own reflection in reiteration of not making nursing a manual, but a reflective space, an activity that for her⁵ is not merely about the surroundings and their influence on the patient’s recovery, but a comprehensive mechanism of what is called the body’s influence on the mind, which allows the appearance of things in the world from their disease, in which the profession is not confined solely to the administration of external elements that change an environment. Other authors propose this same theory in Florence, where she has been placed historically, where changing the environment improved the restorative quality of the individual per se^25-27; what is posited in this reading, however, is to consider the understanding of the subject in their totality²⁸, where the disease is that situation that surrounds the world of the person affected. For that reason, the intervention itself is performed in the understanding of this appearing.

Meanwhile, another author proposes in Florence an epistemic obstacle to the scientific disciplinary development of nursing²⁹; in this reading an approach to the epistemic development contrary to the positivist view is recognized, given that there is an approach to the definition and understanding of the body closer to the philosophical discussions than its approach as a “thing of the world” inherent to rationalism and its later positivist development^1,30. By conceptually understanding the body in the way described, it results in a dehumanisation of people in the health system³¹.

CONCLUSION AND IMPLICATION FOR PRACTICE

The implications of mechanistic understandings of the body in the nursing and health care professions have current consequences for their practice. A dehumanized approach to the body subjects it to the things of the world. An example of this is the prioritization of the indicators of a health centre over the experiential well-being of the people it serves. In this, the understanding proposed by Nightingale from the practice itself goes beyond the quantitative or mechanistic approach of the system, opening the way to new questions by the subject to whom the profession is owed.

When a lack of knowledge of philosophical problems is perceived, an opening is observed that opens a space for high technology and the oblivion of the body represented in a lesser theoretical orientation of its being. Philosophy makes it possible to think and create a new way to analyze problems in the discipline that questions the existing values and ideas, not only to act according to science, but with a more integral understanding in the relation to people and their reality.

The development of a critical and reflective thought is urgent in the education of professionals based on the experience of disease, in order to continually raise questions to be answered by the philosophy needed to develop a person-centered nursing.

The challenge falls then in understanding her writings, which more than an instruction manual for practice, are a treatise on the beginning of the discipline’s experience. It is worth asking what she meant at the time of writing and what it says today as far as important concepts for the discipline. It is considered that her final call in the light of Notes is completely current: what is and who is the object of interest of care sciences when the body is assumed to be merely an organic system is little understood, hence losing its corporeality, which is the orienting and fundamental force to what nursing is and what is not.

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Edited by

ASSOCIATE EDITOR Sofia Sabina Lavado Huarcaya

Publication Dates

• Publication in this collection
  16 Nov 2020
• Date of issue
  2021

History

• Received
  01 July 2020
• Accepted
  02 Sept 2020