Vulnerability as an existential experience

A contrasting discourse identifies that all human beings are vulnerable (Erlen 2006), as part of their humanity, for human beings are never totally free from the risk of harm (Sellman 2005). Indeed anthropological features of vulnerability identify that human beings are poorly equipped physically and socially, herein lying their potential flourishing, but also their vulnerability (Kottow 2004). Thus vulnerability is a “condition humana” which affects us all (Kottow 2003; p.461). Within this perspective it does recognise that some groups may be more than ordinarily vulnerable due to outside factors, whilst respecting the individualistic nature of vulnerability. This had advantages as it avoids assuming that vulnerability is an inevitable consequence of gender, age, socio-economic status. Vulnerability therefore exists as a lived experience of the individual’s perception of self and their resources to withstand such challenges. Identifying that vulnerability is based on the experience of exposure to harm through challenges to one’s integrity. Barker (2005) equates vulnerability to an epic story painted on canvas, which includes not only the biological threat, but just as important the psychological, social and spiritual dimension of the person that are also affected. Kottow (2003, 2004) argues that a

53 | P a g e distinction needs to be made to identify individuals who are more than ordinarily vulnerable, which he refers to as vulnerated or susceptible. In that these individuals suffer from double jeopardy; as they suffer from both an elevated risk of health problems as well as a greater likelihood of harm resulting from these problems.

Kottow (2003, 2004) argues that this should be separated from vulnerability and should be referred to as susceptibility, as vulnerability is an essential attribute of humanity, whereas susceptibility is a specific accidental condition to be diagnosed and treated. Using porcelain as an analogy, Kottow (2003, 2004) argues that the vulnerable are intact but at risk similar to a fine piece of porcelain that is unblemished but highly vulnerable to damage. Whereas the susceptible are already injured, having suffering from some sort of deficiency that handicaps them, renders them defenceless and predisposed to further injury (Kottow 2003).

Spiers’ (2000) emic perspective fits within the existential experience of vulnerability arguing that vulnerability is defined by the individual perceptions of oneself and of the resources to withstand challenges, therefore only the individual can define their vulnerability. Ultimately Spiers (2000) advocates an understanding of vulnerability as both an externally evaluated risk (etic view) or as an experiential state (emic).

Whilst there are multiple studies exploring the etic perspective of vulnerability (Rydeman and Törnkvist 2006; Clark 2007; Furumoto-Dawson et al. 2007; Pitkin Derose et al. 2007), and these studies have been useful in determining the health impact of social inequalities, they do little to understand the self-conceptualisations of health, threat or quality of life for these individuals. In contrast the literature is largely “silent” about the holistic health effects and lived experience of vulnerability and contains only “scattered references” (Rogers 1997, p.68). Few nursing scholars have attempted to understand vulnerability as an experiential quality of life (Spiers 2000), even though qualitative research could illuminate the experience of vulnerability from the individual perspective (Rogers 1997). Cowling (2000) argues that this occurs due to the “clinicalization” of human experience, resulting in the denial of important facets of human experience. There is increasing evidence that the human dimensions of care are being obscured by technological and specialised focus (Todres et al. 2009), and in social work by the economic, political and organisational constraints (Lloyd 2006).

54 | P a g e In contrast to this, Galvin and Todres (2009a) advocate the notion of “nursing open- heartedness” as a central element to caring, which consists of three dimensions.

Firstly is the infinity of otherness; which recognises that the meeting between nurse and patient is not simply an empathic encounter based on commonality or sameness, accepting that the other person cannot be reduced to what the nurse knows or be defined by the nurse’s own ideas. Next, is the notion of embodiment which recognises the shared vulnerable heritage in which the possibility of reversibility with the patient becomes apparent. The last dimension is related to practical responsiveness in which the authors argue that open-heartedness is very practical in that it responds from within the relational complexity of the situation rather than from a preconceived self-position. Therefore nurses need to become free from ideological or personal agenda to be able to freely respond to the situation at hand, and this includes preconceived diagnosis or routine ways of acting. Within social work, Dominelli (2002) argues that human behaviour is at the heart of professional social work practice and argues for the need for practitioners to focus and respond to individuals rather than focus upon services.

2.8.5.1 Humanisation framework

Todres et al. (2009) developed a humanisation of healthcare value framework reflecting their views on what it means to be human influenced by Husserl’s notion of the life-world (embodiment, temporality and spatiality) as well as Heidegger’s authentic “ownness” of self. Todres et al. (2009) identify that to be concerned with humanisation is to be concerned to uphold a particular view or value of what it means to be human. Within the conceptual framework are eight dimensions (Table 7) which can be used to examine the degree to which individuals are dehumanised or humanised. However they stress it is important to note that these aspects are not necessarily seen as binary opposites, instead offer a position to examine the experiences of others.

55 | P a g e

Table 7 Humanisation Framework

Conceptual framework of the dimensions of humanisation by Todres et al (2009)

Insiderness Objectification

Agency Passivity

Uniqueness Homogenization

Togetherness Isolation

Sense-Making Loss of Meaning

Personal Journey Loss of Personal Journey

Sense of Place Dislocation

Embodiment Reductionist body

This ideology of caring led to the development of a humanising framework (Table 7) which can be used to explore both humanising and dehumanising aspects of healthcare on a continuum (Todres et al. 2009). Elements of this framework can be linked to the exploration of vulnerability, for example “insiderness” relates to the view that humans carry a view of living from the inside, so only individuals themselves can authorise what it feels for them, thus linking to an emic perspective of vulnerability. In contrast “objectification” relates to the labelling of people into objects, relating to the view of vulnerability from an etic perspective, the favoured approach when viewing vulnerability as a mechanism to identify people at risk of ill health. Next the issue of “togetherness versus isolation”; togetherness recognises the need to belong with others as an essential human trait whereas isolation links to separation from others and this relates to the exploration of vulnerability as a consequence of social interaction influenced by societal values. It is proposed that this research will use this framework in order to understand and illuminate the practice implications of the study.