Poetry in leadership

The first point to make is how good leaders often master the effective use of poetic form. These two quotes by Dame Cicely Saunders, a pioneer of the palliative care movement, illustrate this and have been reproduced widely:

You matter because you are you, and you matter to the end of your life. 14

How people die remains in the memory of those who live on. 15

One reason for this is the poetic rhythm in these phrases that reaches out, taps into our minds and stays there. Cicely Saunders recognised the importance of creative writing and poetry, and published on this topic. In fact, a book she edited to celebrate 21 years of St Christopher’s Hospice, which she founded, was full of the writing and poetry of her patients and staff.16 It is not clear that she formed a judgement about its quality. She just knew that it was one part of the process of care that could do good.

Bravery with words is arguably a necessary part of leadership. A former English Prime minister Gordon Brown chose Cicely Saunders for a case study in his recent book Courage.17 He also reproduced one of her patients’ poems In the midst of life by Sidney Reeman, which she had published,16 to illustrate the gradual process of drawing close to death. This in turn prompts the question: when was the last time you heard a healthcare leader using a poem to make a point?

Poets, however, have always used poetry to make a political point, and in some countries simply writing has been a punished political act. The Irish Nobel prize winner Seamus Heaney describes how he recognised the power of new Irish poems in the 1960s to depict familiar scenes of potato farming and establish them as a valid subject matter.18 The British poet laureate Carol Ann Duffy has questioned the position of women,19 while Blake Morrison has criticised in ironic manner the behaviour of bankers and their bonuses.20 Established poets do not generally write on one theme, but there is nothing to stop health professionals, patients and their advocates from using their familiarity with palliative care to convey its importance in poetry or even draw attention to a lack of access to good care for some populations.

Many have written in a persuasive way to promote poetry in palliative care, but here are two points from three leaders: David Roy in an eloquent editorial speaks of the need ‘to mobilise the poets’.21 He distinguishes between the published poets whom we should attract to promote palliative care and the unpublished poets—the practitioners—who should not be afraid to use poetry in their everyday conversations to nurture their patients. Jack Coulehan and Patrick Clary have written a landmark paper in which they explore the use of poetry as reflective learning to sustain staff through demanding work,22 and more recently, Jack Coulehan conceptualised how poetry and writing may be one way of enabling people to reconnect with small elements of everyday life so acquiring meaning and deep hope.23

Poetry to develop organisational culture

The second theme is the culture of organisations that leadership creates and sustains. Would it be possible to use poetry as a kind of ‘glue’ to connect individuals together in more person-centred and caring institutions? As already described, Cicely Saunders included creative writing in the work of St Christopher’s Hospice,16 and an analysis of its arts service suggested this was one way of fostering patients’ hope, engagement in enjoyable social activities and of creating a sense of community.24

Arts in healthcare programmes seem better developed in the USA than elsewhere, but in the UK this area is gradually gaining ground. The Nuffield Trust in particular has championed the role of arts in both healthcare and public health systems.25 A 2007 Department of Health Working Group review,26 a 2013 Royal Society of Public Health Report27 and the All-Parliamentary Group on Arts, Health and Wellbeing28 also review a wide range of arts services operating across many organisations. Each suggests that the arts should be seen as integral to health and that information about their use promoted and disseminated more concertedly. But two of these reports26 27 also reveal the need for more robust and well-designed research ideally in studies using conceptual models and qualitative methods to capture the specific effects on individuals, compared where possible with those who did not receive the intervention. Often poetry appears as an option within an art intervention, but one specific and interesting published example is provided by nursing staff at The Aberdeen Royal Infirmary. They sought engagement with their patients, visitors and the wider community using short poems on postcards stationed at particular points around the hospital.29 The invitation to read and submit more poetry led to the submission of 100 new ones as well as the involvement of local poets in hospital readings. Another well-known initiative is ‘Poems in the Waiting Room’, a charity working in England and New Zealand to provide poetry cards to hospitals and health clinics.30

Poetry for health professionals and trainees

The third theme is how poetry may help health professionals and trainees sustain empathy for their patients and engagement in their work. In the USA, Rita Charon has led the study of literature within medical education.31 She proposes that reading literature can help clinicians better understand the impact serious illnesses have on peoples’ lives, how clinical actions may further influence experiences in positive and negative ways, how patients’ stories may be understood as ‘illness narratives’ and how these are best listened to or elicited.31 Less has been written about the specific benefits of studying poetry, but Bromberg makes the case that it also sharpens analytic skills and allows the acceptance of ambiguity.32 An initiative to provide every doctor qualifying in Scotland in 2014 with a collection of poetry about medicine elicited the advice from one former BMJ editor:

You cannot be a good doctor without some appreciation of, and infusion, of poetry.33

Ratcliffe also recently observed that attending poetry workshops gave health professionals a sense of improved well-being and a much needed space to reflect on their lives.34

So could more health professionals write and submit poetry? Radwany and colleagues describe how staff can use team meetings to write poems in collaboration with poets to honour their patients.35 A number of databases and organisations provide texts that might be useful for personal reflection and group teaching (box 1). Several medical journals do accept original poetry, and the international Hippocrates Poetry and Medicine competition that has been held annually since 2010 produces collections that include a growing number of poems about palliative care practice.36

Poetry for people with serious illness or nearing the end of life

The final theme is how poetry may provide spiritual and psychological benefit for those who are very ill or nearing the end of life. For many people, poetry is just not their thing or school experiences have put them off, but for others early teaching may leave a kernel of interest, perhaps only dimly perceived, which can be returned to and opened later in life. For example, Tamba describes using traditional Japanese Haiku and Tanka techniques to compose new poems that acknowledge the achievements and anxiety of his dying patients and their families’ grief.37 Some like Clive James11 have always written poetry and may return to this after a serious illness. For those who enjoy reading poetry, discussing or writing it can become a means of expressing emotion, making sense of events and putting a biographical story together. Clare Wilmot, Medical Director of North Country Home in New Hampshire, lived through a serious malignant illness that left her exhausted, dispirited and unable to care for herself.38 She describes what happened when, under the care of the palliative care team, the poet in residence at Shands Centre in Florida spent an hour helping with her writing.

Little by little I built up a compendium of poems that addressed what I was suffering. I shared these with the poet and eventually my family. The feedback was enchanting and encouraged another round of verse. The quality of the poetry was no measure of its effectiveness, but the effect of writing resulted in my being able to eat, because the act of expressing myself left me feeling better at mealtimes.38

Pennebaker has long proposed that expressive writing can allow people to deal with difficult emotions in a way that helps coping and brings coherence in the face of disruptive events.39 A review of the evidence in health suggested that ‘Finding one’s voice via poetic means can be a healing process because it opens up the opportunity for self-expression not otherwise felt through everyday words’.40

However, the evidence base for formal poetry therapy is mostly case reports or expert opinion from the USA, suggesting the need for more robust qualitative research.41 This would mean the more systematic collection of reflections like those from Claire Wilmot.38 One other interesting example of using poetry is a short poem as a mantra to help patients manage their breathing as one part of a palliative care package for breathlessness.42 Poetry for the relatives and friends of people who are nearing the end of life was not a focus for this review, but it is an area warranting further investigation. As well as providing solace to caregivers one narrative analysis study has shown how it may be possible by synthesising caregivers’ journal entries to create poems that give insight into the sense of chaos, anxiety and hope they experience.43

So I hope I have explained why we need more poetry in palliative care and why poetry need not be seen solely as an extracurricular pursuit. In an increasingly secular world, poetry can be an important way of seeking meaning, finding some pleasure in situation, a connection with others and a means of raising awareness of the importance of good medical and supportive care. It might also be useful for sustaining health professionals’ well-being through good leadership and organisational culture, and as a method for wider public engagement. More comprehensive and robust models for the evaluation of arts in healthcare are now emerging.44 I propose we are now at the point where we should develop and introduce imaginative poetry interventions and study their effects more systematically. It is time to try ‘Opening the floodgates’ just a bit.