Nursing, masks, COVID-19 and change.

In this commentary, we draw on disparate ontological and epistemological traditions to explore and reframe the implications of the COVID‐19 pandemic for nursing. In doing so, we join many other nurse commentators in reaffirming the centrality of the nursing profession during times of social crisis. In particular, we want to demonstrate how the current pandemic has highlighted the importance of the relationships between people and things (nurses and things), mutual obligation as an act of caring, depersonalization, nurses embodied caring counter‐practices and adherence to the ethical demand.

NURSES AND MASKS

Masks have for a long time been a feature of human existence worldwide. They are associated with rituals and ceremonies, theatre and industry, crime, punishment, war and more latterly, disease (Napier, 1986). In Napier’s (1986) anthropological treatise on masks, he alerts us to the paradoxes and transformative qualities of mask‐wearing. However, as one reviewer of this book points out, Napier fails to explicate more fully, ‘what paradoxes’ and ‘what transformations’ (Rayfield, 1988). Problematization of masks as paradoxical and transformative from the perspectives of biopolitics and material semiotics can help resolve purported shortcomings in Napier's arguments. From these perspectives, we can explore how persons and things might be viewed as co‐constitutive. In this article, we ask nurses to consider the implications of these paradoxes and transformations for nursing and nursing practice and their relationship to things emanating from the current COVID‐19 pandemic.

Fast‐forward to the present time amidst the global crisis triggered by COVID‐19, where, in many places around the world, wearing masks has become mandatory to prevent the spread of the virus. Dualist notions of people and things (eg masks) have meant that they are often subjected to quite separate lines of enquiry which has limited estimations of the ways in which one impacts the other or the effects of these very specific types of relationships. The current pandemic brings the importance of the relationships between people and things back into focus like never before. It also provides an opportunity for nurses to re‐examine the relationships between themselves and things and the effects this relating has on patient care.

Key contributors to studies in actor‐network theory (ANT) have long sought to undermine the division of people and things insisting instead that they be viewed ‘symmetrically’ (Murdoch, 1997). Some ANT scholars went one step further by seeking to resolve the conceptual division between people and things by using the term ‘actant’ to represent their interdependence. For example, In his whimsical account entitled, ‘Where are the missing masses...’, Latour (1992) described how actants are ‘performed’ in our everyday lives. The missing masses are, of course, ‘things’. Latour (1992) describes, in detail, how ‘mundane artefacts’ such as the seatbelt of a car or a photocopier steers human action. Another social scientist describes the relationship between persons and things as paradoxical, as an ‘intersection between unity and division: one serves as the locus where the other is put into effect’ (Esposito, 2015, p. 8). But unlike ANT scholars, rather than a assuming semiotic approach, Esposito (2015) argues instead that the only way to resolve the division between people and things is to view it from the perspective of the body. The body, he suggests, should be seen as ‘the unique locus where our individual and collective experiences are united’ (p.10), as both the object and subject of power and the site of competing, perhaps oppositional, interests, culminating in either inclusive or exclusive consequences.

The utility of these theorizations is that they move us beyond the absolutism of modernist medical thinking and the intellectual straight jacketing that occurs with the slavish adherence to binaries such as people and things. We are reminded instead to explore the specificity and every day‐ness of any given situation in which people and things ‘perform’ to produce particular relational effects. For example, some state authorities in Australia have made wearing masks mandatory and those found not wearing a mask are fined. Women who routinely wear the burqa have reported how wide‐spread wearing of masks brought a new and unanticipated sense of inclusion (Booth et al., 2020). Conversely, in the UK, people with hearing‐impairment have called for transparent masks to be made more readily available to overcome exclusion they experience due to communication difficulties brought about by wearing masks that make it impossible to lip read.

Today, for many of us, living together in the presence of COVID‐19, means wearing a mask, which both enables people to continue to relate while at the same time remaining separate. Wearing a mask represents the dual risk and mutual obligation to ourselves, of not becoming infected and/or of spreading the infecting in the community. For example, in public health advertisements on Australian television, repeated use of the pronouns ‘you’ and ‘we’ help to emphasize shared risk and responsibility—‘Staying apart keeps us together’ (Inspector General for Emergency Management, 2020), as long as you wear a mask. Here, the ‘table analogy’ coined by Arendt and Canovan (1959, p. 52) might be used to sum up by way of metaphor, how human relations are mediated and manipulated by things to create paradoxical, even ambiguous relational effects such as those characterized by the above public health slogan.

‘To live together in the world means essentially that a world of things is between those who have it in common, as a table is located between those who sit around it; the world, like every in‐between, relates and separates men at the same time’.

COVID‐19 has become the common enemy, which requires that we continue to relate in order to overcome it. Epidemiological implications aside, masks are actants performed which become not only barriers to disease but symbols of the mutual obligations to one and all in combating the disease.

In 2020, mask‐wearing in response to COVID‐19 serves as a proxy for the transformation alluded to, but not elaborated by Napier (1986). Transformation is necessary to resolve paradox of having to ‘stay together while remaining apart’; however, the full extent of the transformations invoked by COVID‐19 and the many more that are to come are incomprehensible. These transformations must not be viewed as wholly negative despite the association of mask‐wearing with menace, demons and disease. In their book, ‘The Human Condition’, Arendt and Canovan (1959, p. 47) remind us of: ‘The miracle that saves the world, the realm of human affairs, from its normal, "natural" ruin is ultimately the fact of natality…’ For Arendt, natality encapsulates the ways in which people are able to begin again and to reinvent.

The question is, how and what will nurses’ and nursing reinvent and begin again in the wake of COVID‐19? And will these new beginnings seek out those ‘mundane artifacts’ (Latour, 1992) that help shape and are shaped by nurses and their practice?

PERSONAL PROTECTIVE EQUIPMENT, DEPERSONALIZATION AND NURSES EMBODIED COUNTER‐PRACTICES

Personal protective equipment (PPE) in general, and face masks in particular, can and should be seen as a caring act in that it aims to protect others from droplets and sources of infection from the bearer inasmuch as it aims to protect the bearer. However, PPE can also be interpreted as a distancing act by virtue of veiling the facial features and expressions of the bearer that plays a significant part in expressing emotion and forming of relationships and bonds between people. As described by Benner and Wrubel (1989), in their seminal piece on caring, we need to understand the both the context and the involvement in the relationship to understand caring, as different actions may be interpreted as caring or noncaring based on both the context and the relationship. How then, may the wearing of face masks and other PPE influence the caring context and relationship, as they inevitably and purposefully provide a barrier to separate subjects? Perhaps nurses need to draw more explicitly on other facilitators for feeling cared for such as acknowledging and bridging the possible metaphorical meanings, subjective interpretations and personal experiences of illness and PPE that others may hold. Perhaps the importance of the ‘being with’ of nursing increases (somewhat contradictory) in times of PPE, to facilitate experiences of caring and recognition of the vulnerability, subjectivity and existentiality in illness experience and in midst of all the ‘doing for’ of nursing practice in a pandemic?

Depersonalization is a present risk with face masks and PPE by virtue of reducing the visual cues to subjectivity and identity and by placing known facilitators of depersonalization such as focus on the technical aspects, objects, mechanistic/reductionistic views and medical technology in the forefront of care, literally ‘in your face’. How can such a risk for depersonalization be counteracted? As nurses, we may now need to increase our attention to how to convey caring actions as well as caring expressions of familiarity, compassion, welcoming, happiness and care more with our eyes, and in other embodied ways beyond the facial. Reflective and purposeful nursing presence and use of touch may be a strategy to counteract depersonalization, despite some of the intuitive and physical barriers to touch introduced by PPE. In a recent study by Kelly et al. (2020), they described how physicians use touch to share emotions, demonstrate empathy and presence to patients. Touch was described as embodied empathic communication constituting a personal and fragile process in which non‐verbal patient cues such as facial expressions and body language are carefully interpreted to determine whether or not touch is appropriate. As such, it may work to counter the risks of depersonalization with masks and PPE. In a much earlier study, Edvardsson et al. (2003) described the use of touch in nursing as a powerful tool in easing suffering and how touch was experienced by staff to bridge the roles of the nurse and patient by promoting increasingly seeing the patient as a person and facilitating a caring relationship, again providing support that touch could be a potent way to bridge barriers from PPE and veiling of expressions.

There may be an increased place for verbal elaborations on the caring rationales behind PPE and other infection control measures to assist in understanding how they are put in place to keep patients safe as much as they are for keeping staff safe. Perhaps sometimes this mutuality can become lost when extreme demands are placed on individuals and systems in the midst of a pandemic. Creativity as well as compassionate reflection could be helpful in communicating caring in all contexts and due to COVID‐19, relationships are forced to become hyper‐sensitive, risk‐aware and infection‐smart (DeLaune, 2020).

Albert Camus, The Plague, it a stark portrayal of how the individuality of man and the controlling of one's individual health and existence is the usually the first casualty of epidemic infectious disease, as the raging infections described in Camus’ work show, inevitably, how persons (not individuals) become and un‐become, inand through relations, within the interconnectedness of existence. Similarly today, it can be seen and felt, how the deployment of public health advice and more or less invasive infection control measures, forces decisions to be made that involve giving up individual freedoms, choices and pastimes, for better collective health and the common good. As such, face masks can be seen as an existential choice between one's own personal preference, comfort and/or choice, and the health and welfare of others (of which I am dependent). As with the individuals and communities of Oran, in Camus existentialist masterpiece, we will need to sacrifice some of our pastimes, choices and comforts in recognizing and saving others and ourselves as we now are forced to rediscover the fragility, vulnerability and interconnectedness of existence and human life.

From a nursing theory perspective, face masks and PPE can also be interpreted as reinforcing the case for, and clarity in person‐centred care, in contrast to individualistic care (DeLaune, 2020; Edvardsson, 2015). Building on continental existentialist philosophy, person‐centred care builds fundamentally on the notion of a person as an entity constructed, deconstructed and reconstructed in, and through, relations with other persons. Accordingly, a person always is a person in relation to others, in contrast to an individual is separated from the collective and from others. Person‐centred care recognizes that we are all connected and seeks to understand and respect this connectedness and uniqueness in this connectedness, for the purpose of facilitating health in others. As such, using masks and other forms of personal protective equipment can be seen essentially as person‐centredness in action: by virtue of me wearing a mask, ‘I acknowledge the connectedness and interdependency of myself and others and I have made a caring choice to forego my own comfort to protect others while at the same time protecting myself’. As such, these types of infection control measures may then be an indicator of personal ethics? The readiness, extent and sincerity, with which people observe forced changes to their own comfort and ways of life, may indicate the extent to which people are willing to negotiate and sacrifice their own personal desires, needs and wants for the benefit of others.

In his philosophical work, the Danish ethicist Knud Løgstrup (Løgstrup et al., 2007) argues that the ethical demand impacts on all interactions with other persons and involve a basic trust that the other's intentions are good and something which emerges from being dependent upon others. Løgstrup's ethics is built upon the notion that by being interconnected, we are also dependent on others to a greater or lesser extent, and this interdependency implies an ethical demand to do good for the other, for the sake of the other, to take care of and help others to the best of 'my' ability. Think of a rural highway for example, where we expect to stay safe despite the fact that people drive their cars towards us at high speed, each separated only by a metre or so from the oncoming traffic. This is only possible because we enter into an implied, mutual obligation to do good to each other which relies on trust and the assumption that, myself as well as the other person, honours the ethical demand of doing good to others by not veering across the line into oncoming traffic.

In the midst of a COVID‐19 pandemic, doing what is best for the other involves wearing masks and observing other infection control measures, and in some countries, this renewed focus on adhering to the ethical demand is enforced by way of social stigma, fines and even imprisonment. As we navigate carefully between infection control measures, the ethical demand, metaphorical interpretations as well as facilitators and barriers to caring and person‐centred care in pandemic times, nurses also need to remember that in addition to talking about ‘R0 values’, ‘risk reduction strategies’, ‘odds ratios and treatment options’, we are facing people who are living and experiencing the multidimensional and largely unknown impact, effects and stigma of this virus and the need to approach this with transformational care and person‐centredness.

In this commentary, we wanted to foreground the importance of the relationships between people and things (nurses and things), mutual obligation as an act of caring, depersonalization, embodied caring counter‐practices and adherence to the ethical demand. We argued how, despite the paradoxes and constraints invoked by the current pandemic, this period in history should be seen instead by nurses as an opportunity for them to reflect and transform key aspects of their practice not only for themselves but also for the greater good and, for the sake of the other.