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A brief history of common sense

July 3, 2014

‘Perhaps in no one single thing is so little common sense shown, in all ranks, as in nursing’. So wrote a despairing Florence Nightingale in Notes on Nursing (1859). Flo’s particular beef was with ‘nurses’ who, incapable of grasping the first rule of nursing (‘TO KEEP THE AIR [THE PATIENT] BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM’) instead filled the sick-room with air ‘from a corridor into which other wards are ventilated, from a hall, always unaired, always full of the fumes of gas, dinner, of various kinds of mustiness; from an underground kitchen, sink, washhouse, water-closet, or even…from open sewers, loaded with filth’.

Nightingale’s irritation has to be seen in the historical context of her championship of the so-called ‘miasma theory’ of disease transmission (defined by Wikipedia as the belief that ‘diseases…were caused by…a noxious form of “bad air”) – already under attack at the time of publication and superseded by the more accurate ‘germ theory’ a few short years later. It would be a mistake, however, to view her as nothing more than an explorer of scientific cul-de-sacs: zeal for hygiene and cleanliness meant less opportunity for the agents of infection to proliferate, and according to the Florence Nightingale Museum website, it was miasma theory that prompted scientists to investigate decaying matter and discover the existence of microbes in the first place.

But it does raise an interesting question: if ‘common sense will point out, that, while purity of air is essential, a temperature must be secured which shall not chill the patient’, why do ‘the most extraordinary misconceptions reign about it’? If ‘common sense’ represents the outcome some kind of universal innate system of human reasoning, why doesn’t everyone simply follow its dictates? Why do people have to be told how to exercise it? Could it be that ‘common sense’, while sounding so nice and consensual, is actually a weapon in the war of furthering the agenda of whoever claims a monopoly of it?

One day in about 1990, a nurse on my ward who was ‘doing the conversion course’ (Enrolled to Registered Nurse) arrived at work brandishing a book with a green cover. It was called Nursing Rituals, Research and Rational Actions by Mike Walsh and Pauline Ford. “At the university” she told me proudly (she was a bit of a snob) “we’ve all been told we must read it. It’s the future”. “Blimey” I thought. “I’d better get a copy of my own”. I’ve still got it.

The premise of Nursing Rituals (as set out in the Introduction) is that ‘nursing care is failing the patient because it is institution- rather than patient-driven…the cause of this failure is rooted in the traditional rituals and myths that still abound in hospitals today’. Ritual action was defined as ‘carrying out a task without thinking it through in a problem-solving, logical way. The nurse does something because this is the way it has always been done’. The irony is that in order to convey this message, the book seems to rely on a whole series of unexamined assumptions of its own – which, if anyone’s interested, I’d love to explore in another article at some future time.

One of the more overt premises is the idea that to be rational is to be caring. What constitutes ‘rationality’ is not clear-cut however. ‘Professional judgement’ is dismissed as ‘at best…a rather nebulous concept and at worst little more than a subjective hunch’ (p73). ‘Common sense’ on the other hand ‘involves working out a solution to a problem, not carrying out ritualistic actions’ and is feted as ‘highly preferable to ritualistic actions’ (Introduction). Why the difference in attitude to two outwardly similar concepts? My guess is that the emphasis on ‘common sense’ is a brazen play to the gallery – and a rather astute one at that.

Telling nurses that ‘common sense’ was desirable was telling them what they longed to hear – because ‘common sense’ was probably the most highly-prized nursing attribute of the period. It was nothing remarkable, back then, to hear nurses wave away any talk of evidence or university with an impatient declaration that nursing was ‘ninety per cent common sense’. Nurses whose personalities were judged to be well-endowed with it were held in high esteem; meanwhile, those whom consensus deemed to be in want of it would wait in vain for an invitation to join the in-crowd.

My own experience of the meaning of ‘common sense’ is rather different. As a nurse with a degree at a time when that wasn’t common, my recollection is that your ranking in the Ward League of Common Sense was often determined as much by gender and educational attainment as anything else. Female nurses used it as a criticism of male colleagues; traditionally-educated nurses invoked it as a reason to dislike nurses with degrees. A cultural shibboleth, it had little, if anything, to do with ‘problem solving’ and everything to do with the dominant group’s defence against perceived threats. Hardly a basis for rational action – or good care.

So where are we now? In recent years – and despite Walsh and Ford – ‘professional judgement’ has undergone something of a rehabilitation. This is partly a reaction to research findings that have suggested that the widespread use of ‘risk assessment tools’ may actually have little impact on outcomes such as falls and incidence of pressure sores; and partly the result of a welcome maturity in nursing as a profession. Because of this, practitioners feel increasingly able to apply their own experience and knowledge – and weigh them with patient views – in order to reach decisions about the best way forward in any given situation. The point about professional judgement is that the reasons for adopting any particular course of action can be both rationalised and justified. This is entirely positive – and neither nebulous nor subjective.

But one subjective problem still remains – and it’s the question of whether some people’s professional judgement is still worth more than others’. It’s relevant to ask this question in the light of the recent publication of Trusts’ official staffing figures. Trusts’ targets for staffing must be evidence-based, but, as I have argued before, safe staffing is an area where there is sometimes very little reliable evidence to go on. In its absence, the NICE Safe Staffing Committee (as Professor Gillian Leng acknowledged in an article she kindly wrote for this very blog) relied for guidance on the experience and expertise of its (extremely senior) members; quite rightly, this included the testimony of a service user.

What they did not hear, or so it appears from the documents, was the experience of a real ward nurse who, when the night staff have gone home in the morning has three staff for eight to twelve patients. That’s great on paper, but what it translates into is one trained nurse to do the drugs round; the other to prepare the copious IV drugs, answer the phone, liase with the multi-disciplinary team and field the incessant nagging from bed management; and a solitary health care support worker to do the observations, make the beds, prepare the patients for breakfast and feed the ones who need help. Walsh and Ford’s original diagnosis was that nursing care was ‘failing the patient because it is institution- rather than patient-driven’. What does common sense tell you?

Mike Walsh and Pauline Ford (1989) Nursing Rituals, Research and Rational Action. Oxford; Butterworth Heineman

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7 Comments
  1. Elaine Maxwell permalink

    You make a good point about the Nursing Rituals book, which in my opinion did a lot if harm to British Nursing.The absence of evidence does not mean evidence of absence of effect.
    Common sense can be experiential hypothesis that need further exploration not derision. I applaud the return of professional judgement as a basis for research.

  2. Thank you for commenting. I am not a great enthusiast of common sense as a guiding principle of nursing because to me, it’s a vague term that’s used as a way of justifying the user’s way of doing things, and identifying those who agree with him/her. As such, I think it diminishes us. Professional judgement, on the other hand, is, as you rightly say, an area about which we need to know much more: how practitioners arrive at decisions, what factors they take into account, how competing discourses interact with each other in complex interpersonal interactions. But precisely because it’s so important, we need to guard against its debasement.
    I was going to write in more detail about the impact of the publication of Trusts’ safety figures last week (and spent ages agonizing about it, hence the lateness of this post), but an article from the Guardian that I followed up after seeing a tweet of yours seemed to say everything I would have said, and I couldn’t see how I could better it. Richard Vize (the author’s) opinion that ‘Yet again we have a government quality initiative that is useful and reasonable, yet somehow misses the point. It is another opportunity for managers to focus on measurement rather than leading change’ made me think that – despite the welcome acknowledgement of the need to examine culture – we have not yet solved the problem of how to shift away from institutions and towards a recognition of the positive impact of good care. Perhaps the underlying problem is that moves to introduce a market economy into health care provision inevitably impose a discourse of competition, comparability and ‘choice’ and it is obviously easier to present this in terms of institutions.
    http://www.theguardian.com/healthcare-network/2014/jun/26/jeremy-hunt-nhs-safety-league-tables?CMP=twt_gu for the Richard Vize piece.

  3. “This is partly a reaction to research findings that have suggested that the widespread use of ‘risk assessment tools’ may actually have little impact on outcomes such as falls and incidence of pressure sores” – Can you point me to this material? I’d be very interested to read further as I find these risk assessments such a pain in long-term care. On the surface they are a check against laziness but appear, so far, to simply be a conduit for more laziness.

  4. I see from your Twitter bio that you are in Canada; as I am writing in a British context my sources mostly relate to that but even so, you might find the following useful. For a examination of whether the use of pressure ulcer assessment tools makes a difference to patient outcomes, see the work of the UK Cochrane Collaboration, available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006471.pub3/abstract;jsessionid=369C5DEBC13AB99C9EA61A12095820E2.f02t02 .
    The Nursing Times recently published an article about the helpfulness (or otherwise) of Early Warning Scores in identifying patients who are deteriorating – see http://www.nursingtimes.net/home/clinical-zones/assessment-skills/how-helpful-are-early-warning-scores/5066944.article. It’s 10th January 2014 edition – if you can’t see it when you click on the link, you can access it by registering. It’s free.

  5. Common sense should be banished from discussions and decision making. Its shorthand for what people are assuming are societal norms of behaviour or treatment, and completely ignores the way that common sense comes about through a process of struggle over ideas. Today’s “common sense” is tomorrows reactionary nonsense once enough evidence has been accumulated and enough peoples ideas changed about what constitutes “common sense”.

    Personal or professional judgement is much more useful as it locates the decision in the mind of the professional, not in an appeal to a nebulous societal or professional norm which may be based on questionable evidence, and allows the persons own judgement and the intereaction of knowledge, evidence and experience to be explored and accounted for in the decision making process.

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