Writing
Reflections by Dr Marion Lynch
Making Visible What Matters: Professional Culture, Nursing Narrative, and Global Health
Nursing is indispensable to global health systems. It constitutes the largest health workforce globally and is central to universal health coverage and health promotion (ICN, 2025). Yet the way nursing is described in policy is often narrow missing what some call the art of nursing. Nursing appears as workforce capacity, service delivery, productivity, and resilience. These are important descriptors. They are not sufficient ones, they are not what brings people to nursing, makes people stay in nursing, and are not the aspect that people remember when they remember a nurse.
There is therefore a gap between how nursing is measured and how it is lived. The measurable aspects, staffing ratios, cost-effectiveness, mortality reduction, productivity through digital care, virtual wards are visible in strategy documents and current Trust and Neighbourhood Health cases. The less visible aspects, dignity building, relational labour, moral judgement, organisational memory, creativity and managing complexity, rarely shape system design. Their absence is most apparent when they are missing: when care becomes efficient but impersonal; think of all the inquiries into failed care, throughput increases but trust diminishes, think of all the referrals to the NMC, when we stop seeing people and only see patients, see the rise is corridor care.
Abimbola (2026), in the article evidence of things not seen, opens with Hebrews 11:1: “Now faith is the substance of things hoped for, the evidence of things not seen” .
Whilst a religious phrase it is an example of a universal human dilemma and so a current methodological problem in how nursing is seen, heard and harmed. Not everything that matters is immediately visible. Structural inequities, epistemic injustice, and professional dignity are real forces in global health systems, and in nursing, yet they do not readily appear in dashboards or in debates about what the future of health, and of nursing will be.
The challenge for 21st century nursing is therefore cultural as much as it is technical. What counts? Who counts? What forms of knowledge are recognised as legitimate?
This paper argues that developing a professional culture for nursing that will contribute to global health and 21st century nursing practice requires balancing nursing’s utilitarian and emancipatory dimensions, grounding that balance in all of Carper’s (1978) ways of knowing, and making visible the relational and structural dimensions of nursing practice and global health through the arts.
Holding the tension between utility of nursing and emancipation of nursing.
Haddara and Lingard (2013) describe utilitarian and emancipatory discourses within interprofessional collaboration. The utilitarian discourse privileges measurable outcomes, efficiency, and demonstrable impact. The emancipatory discourse focuses on power, hierarchy, and structural inequity.
Nursing operates within both, yet one is seen more than the other. The utilitarian dimension is clear in policy documents and for those looking at nursing through a ‘jobs done’ lens. Investment in nursing numbers improves patient outcomes, reduces complications, and strengthens system efficiency. In resource-constrained contexts, nursing capacity is central to universal health coverage. On a global level we are, and will be, too short of nurses to provide the health systems needed to improve health. In this sense, nursing contributes to human capital formation and economic stability and the problem of too few nurses to do what needs to be done suggests a new approach is needed. To ignore this utilitarian view of nurses would be irresponsible, to think this is all nursing is, is just not true.
Nursing is also emancipatory. It is historically embedded in struggles against gendered subordination and professional marginalisation. It witnesses, daily, how poverty, precarious housing, debt, racism, and environmental degradation shape illness trajectories, and creates ways for people to continue to live in health and with hope.
Abimbola (2026) reminds us that public health repeatedly declares the structural determination of health, yet often defaults to downstream action. It is a concern if NHS nursing strategy is only focused on such downstream action and not on the real reasons why health is unjust and nursing is undervalued and unfair. Nursing cannot be reduced to efficiency interventions within inequitable systems.
The problem is when nurse utility is the sole narrative, when nursing is described exclusively in terms of outputs, its ethical and political dimensions so unseen, unless you are in need of a nurse, or are a nurse. A professional culture that seeks to evolve and have legitimacy in the 21st century needs to hold effectiveness and equity, utility and emancipation together.
Carper’s epistemic spine.
Carper’s (1978) four patterns of knowing, empirical, ethical, personal, and aesthetic, have informed nursing for 50 years yet seem forgotten in policy development. Her work provides a coherent framework for the integration needed to form a nursing profession fit for the future.
Empirical knowing values research evidence and measurable outcomes.
Ethical knowing addresses questions of social justice and professional responsibility.
Personal knowing situates care within a trusted person centred relationship and professional reflexivity.
Aesthetic enables nurses to make sense of what cannot be seen, create safe trusted spaces and use the human aspects of nursing care to create meaning, see patterns, and practice the embodiment of care.
Global health discourse, and current UK nursing policy papers frequently privilege empirical knowing. Funding streams require measurable return. Health systems reward what can be counted. Beyond the tangible impact on waiting lists and mortality there is another measure system evolving. Even the social return on investment measures in healthcare are calculating how interventions in health will improve people’s fitness to work. This is understandable in contexts of limited resources and with a bio medical model influencing what matters.
However, Abimbola (2026) argues that knowledge must also be contextual and transformational. From his perspective this is within global health, but the same thinking informs how one may think of nursing. Local sensemaking and lived experience are not secondary forms of knowledge, they are not less.
Carper anticipated this epistemic breadth in her work, but in 2026 policy it seems empirical knowing is the only one that counts. Ethical, personal, and aesthetic knowing are foundational to safe and humane practice. They are what make nurses human.
When only empirical knowing is seen and heard and so valued, relational labour becomes invisible. And so unvalued. And so unnecessary. When ethical knowing is sidelined, moral dilemmas appear and moral injury occurs. When aesthetic knowing is dismissed, meaning making of what health means to one’s life, the human element, becomes unnecessary for health. We become merely meat.
Developing global health and a professional culture for nursing requires explicit recognition of all four patterns in education, evaluation, and leadership, and of the structural violence, the systems we as people have designed, and accepted to get exactly the inequality in health and in nursing we currently have.
The upstream question and some poetry.
The global distribution of health resources remains profoundly unequal and these disparities are linked to economic and political arrangements that extend beyond clinical care, (Abimbola, 2026). Nursing is part of this inequity as a gendered and unequally distributed and unvalued workforce. The issues faced by people with less means, and the nurses who are part of their lives are not new. The arts can help show them.
Brecht’s poem A Worker’s Speech to a Doctor crystallises the upstream question and this is the world nurses live alongside too. One part of the poem sums up poverty and structural violence within health.
The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So, tell us;
Where does the damp come from?
Bertolt Brecht
The bio medical clinician identifies symptom and the cause. The worker asks about the conditions that produce the damp. Housing, wages, labour markets, political economy.
This poem exposes the limits of interventions that address symptoms without addressing context. If we only address nursing’s pain we will not address the issues causing the pain.
Brecht’s poem demonstrates how the arts can illuminate health determinants that lie beyond immediate clinical focus, and when applied to nursing, why nursing numbers are not enough to understand the issues.
Getting back to health. Nurses encounter the ‘damp’ daily, it is more than damp. The damp for people cared for is insecure employment, overcrowded housing, environmental stress, cumulative disadvantage.
The damp in nursing is, lack of regard, lack of professional value, lack of autonomy, increased moral injury, gender inequality, racism, and then recruitment challenges and retention challenges.
Professional culture must legitimise the capacity to ask upstream questions as to why there are issues alongside designing services and education to deliver competent care. Without this dual orientation, nursing risks being seen as a task based profession and confined to symptom management within inequitable systems.
Relational Labour, health, interdependence and One Health.
The upstream question leads directly to relational health. Health is not solely an individual attribute; it is produced within networks of relationship, between people, professions, communities, and ecosystems.
Carper’s personal and aesthetic knowing enables one to see this relational dimension. Ethical knowing extends responsibility beyond the individual to the social conditions that generate illness. Empirical knowing can measure outcomes within this relational field, the social return on investment, but this is not built into nursing knowledge as yet.
‘One Health’ approaches reinforce this wider than ‘my health’ perspective. Human health is connected to environmental sustainability and animal health. Climate instability, antimicrobial resistance, and zoonotic disease reveal the limits of purely clinical responses and nursing is noticing it is nursing the planet too.
The question “Where does the damp come from?” becomes ecological as well as social. It requires collaboration across disciplines and sectors, the public health aspect of nursing that cannot be seen if nurses are task based and medically managed. Nursing’s professional culture must therefore be seen beyond task delivery and as relational stewardship within people, communities and the planet too.
Evidence of Things not seen. Nursing and the Exhibition.
Returning to Hebrews 11:1, cited by Abimbola (2026): “Now faith is the substance of things hoped for, the evidence of things not seen”. Professional culture is built as much through what is unseen and unvalued as through what is seen and valued measured.
The arts are part of evidence making and sense making in society; the arts are what make us human. The arts make the relational and human dimensions of health visible in ways that conventional metrics cannot.
And so there is an exhibition to show the emancipatory aspect of nursing.
The three-day exhibition at the Clore Learning Centre, Kensington Palace, is designed as a nursing narrative to support professional culture and a new narrative on nursing.
HIVStory demonstrates relational care and professional autonomy through testimony of nurses
SHIFT the play stages the sharing of power between nurses and patients as a dance, a lived encounter.
Embers of Care portrays migration and professional identity through portraits.
Capes of Home, Health and Hope carries intergenerational narrative and seven-generation thinking in one artifact.
Mrs Drake’s Lace makes personhood visible beyond cognitive decline with dementia.
Can You See Me Now? a menopause sculpture and The Pause, a story that translates evaluation findings on menopause into a story.
Queens and Vaccines connects historical public health leadership of women of colour or from royal households to current trust of vaccines.
Heads of Nursing presents collective identity from student nurses.
Art of Care explores different kinds of love and ways of knowing using artifacts from caring during the middle 1900’s.
The Face of Nursing, an 8ft by 4ft montage of hand-drawn portraits, situates each person attending within a collective professional narrative.
Each work makes visible a dimension of nurses and nursing care that policy texts rarely do. Together, they show how relational care, dignity, and belonging are core components of health systems and professional culture. They tell a new nursing narrative through the arts
Conclusion
Developing a professional culture for nursing requires three shifts: balancing utility and emancipation thinking, using all of Carper’s ways of knowing and using the arts to help address inequity and improve health as well as advance nursing for 21st century care.
It must count what can be counted and insist that what cannot easily be measured still matters.
Professional culture is shaped by what is rewarded, published, funded, and exhibited. It is also shaped by evidence unseen. If relational and ethical dimensions are excluded from the design these disappear.
Brecht’s work asked where the damp comes from. Nursing, as profession and as cultural force, must continue to ask this and sort it out, and the damp is more than damp. It cannot be painted over and be fine. Nurses help with health and relationships and trust and avoid the ‘damp’ happening, nurses build health systems that have humans at the core, nurses’ skills in doing this can be shown through the arts, they cannot be seen on a RAG rating score.
References
Abimbola, S. (2026). The evidence of things not seen. Health Promotion International, 41(1), daag016.
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.
Haddara, W., & Lingard, L. (2013). Are we all on the same page? A discourse analysis of interprofessional collaboration. Academic Medicine, 88(10), 1509–1515.
King James Bible. (2017). Cambridge University Press. (Original work published 1769)
ICN (2025) New Definition of Nursing.
MacGregor W, Horn M, Raphael D. Beyond Empathy to System Change: Four Poems on Health by Bertolt Brecht. J Med Humanit. 2024 Mar;45(1):53-77. doi: 10.1007/s10912-023-09801-5. Epub 2023 Jun 21. PMID: 37341851.
There is more we can do together.
Bring us a question, a story, an idea.