Attention and awareness

When I watch my daughters drawing a picture, I can see the concentration and focus expressed in their faces and bodies. There are slight frowns of concentration, their faces are held close to the paper.  Fingers are white where they press against crayons and scissors, and their eyes follow the images that emerge on the page.  Sometimes they don’t change position until limbs are numb and tingling. 
In this state of absorption, they do not notice the traffic noises in the distance, the warmth of sunlight on skin, the insects crawling through the grass.  Their focus on the task in hand is intense.  This phenomenon, known as “inattentional blindness“, has been repeatedly demonstrated in cognitive psychology research since the beginning of the last century, mostly with reference to visual stimuli.  But could inattentional blindness also be demonstrated in relation to emotional cues and thoughts?  Silva‘s research appears to show that emotion is highly influential on attention.  When confronted by competing stimuli, we have evolved to pay attention to the stimulus perceived as the most threatening.  We would not want to continue to nibble away at delicious berries whilst being charged by a sabre-toothed tiger.
Research and opinion on attention has been cropping up regularly during my literature review.  My interest was sparked by the thought that challenges in care are so often explained away by explicit or implicit recourse to some impact upon attention.  Research on drug errors repeatedly identifies distraction to be a key contributory factor, leading to all sorts of initiatives such as red “do not disturb” tabards (in my opinion, the best way to brightly label a nurse in charge so that everyone knows who to disturb in case of questions – but that is another matter).  Mind-wandering as an explanatory factor in other medical errors has also led to some interesting research in neuroscience.  
Our scope of attention varies in different situations.  My daughters’ concentration may be conceptualised as a “narrow-angle lens” – all senses are directed towards a single task or cluster of tasks, and any stimuli perceived as superfluous (such as burning houses) are filtered out in the name of achieving the desired goal (a completed drawing).  Mihaly Csikszentmihalyi describes a state known as “flow” in which one is utterly absorbed in an activity such that external stimuli are ignored.  In this state, we experience increased energy and a merging of the action with our awareness of the action.  We also experience diminished reflective self-consciousness during flow.  He proposes that in order to be absorbed in a task in this way, the challenge of the task must equal the skills of the individual to complete the task.  A task that is too challenging will create anxiety and insecurity, leading to diverted attention, whilst one that is not challenging enough may lead to boredom and distraction by other extraneous stimuli.
Attention means to “notice taken of someone or something, the regarding of someone or something as interesting or important“. Other definitions include “the act or faculty of mentally concentrating on a single object, thought, or event”, or alternatively a “state of consciousness characterised by such concentration”.  According to this definition, for something to capture our attention, some feature of someone/something must be evaluated as “interesting or important”.  We cannot simply instruct healthcare professionals to concentrate on something because it is important to someone else, to an organisation or other individual, unless that value is internalised by the healthcare professional themselves.  Ritualised healthcare practices may result from healthcare professionals undertaking tasks that they simply do not perceive to be interesting or important.  It is easy to imagine how this can then lead to important elements of the situation being ignored or simply not perceived, in a selective channeling of attention to those aspects that do stimulate.  Unless a healthcare support worker understands the significance of pressure ulcer prevention and has insight into the impact of ulcers on someone’s quality of life, they are unlikely to pay much attention to the instruction to “check Elsie’s pressure areas”.  It simply will not be registered as important.
But is attention the same as awareness? I believe that  awareness refers to a different state altogether, something more akin to mindfulness.  It could be viewed as a specific type of attention, or described as a “wide-angled lens”.  In a state of awareness, the individual pays attention to a broad range of stimuli, regardless of whether they are judged to be superfluous or not.  An example of this might be when we take a walk in an unfamiliar part of the countryside.  Our “task” is taking a walk, but our attention involves absorbing in a non-judgmental way all stimuli that our senses perceive.  These may be visual (light through trees), olfactory (damp earth), aural (spring fledglings in the undergrowth), or oral (salty sweat on your upper lip as you scramble up a bank).  These disparate stimuli are examined by our higher cognitive centres, and collectively build up the picture of “this country walk I went on at this particular point in my life”.  At some point, almost simultaneously, values will be assigned to these experiences. For example, we will decide whether a particular smell is pleasant or unpleasant.  Before these value-judgments were assigned by our higher cognitive processes, there was a brief moment when we were just aware of the full range of present-moment experiences.  This is one aspect of mindfulness.  There is an additional element however; once our value-judgments and narratives begin to crowd in (and they do, with great rapidity) we are able to observe them too.  “I really shouldn’t be out on this walk when I have my literature review to write up”, “I love this light, it reminds me of a walk I went on last year with an old friend, I miss her so much”, “why did I wear these boots when I know they give me blisters?” And before we know it we have been swept away in the story of our thoughts, the emotions that have been evoked, and we find ourselves miles away from the immediacy of our sensory experiences.
Mindfulness has been described as awareness that arises by paying attention, on purpose, to present moment experiences and non-judgementally (for more on mindfulness, see John Kabat-Zinn 2013, Dane 2011 , Stanley 2013 and others).  In this case, non-judgmental means “suspending judgement” rather than aspiring to avoid judgement at all.  It is impossible to avoid judging; human nature is to make meaning of situations, which involves subjective evaluation.  In mindfulness, the aim is to become more aware of those natural judgments that occur, and to actively choose not to pursue them or assign any great important to their presence.  
Allocating attention to aspects of our experience is largely subconscious.  When you are engaged in helping Fatima to wash herself despite her dense hemiplegia, you are aware in each unfolding moment of where her limitations lies, the warm flannel passes from her hand to yours, you simultaneously speak gently and reassuringly to her, knowing her speech has not yet returned, closely observing her face for signs of distress, and simultaneously comparing the tone in the muscles of her arm to what you remembered from the previous shift.  These may only be a few of the stimuli that you would be paying attention to in the moment.  Subconsciously, you will have been filtering out large numbers of other stimuli in order that you can complete the “task” safely.  
But what if the stimuli you have filtered out are important? If this filtering happens subconsciously you may never become aware of this.  The political fallout post-Neuberger paints a picture of neglectful healthcare professionals failing to have conversations with distraught relatives about imminent death.  But an alternative discourse is possible.  What if the stimuli that signaled impending death never entered the consciousness of the healthcare professional?  Perhaps a lack of previous experience and knowledge of the importance of these physical signs led to filtering out of these stimuli as unimportant? Or perhaps something more primal is at play here (more on death anxiety and it’s impact on attention in a future blog).
A potential benefit of mindfulness practice for healthcare professionals is that these subconscious processes are made more accessible to the conscious mind, so that we become aware of why certain stimuli have been rejected as unimportant or uninteresting.  We need to draw on different types of attention and awareness – use both our narrow and our wide-angled lenses – at different times during our working day.  Taking stock of a range of stimuli, including our own physical and emotional states, allows us to plan and prioritise our foci.  It may be a useful reflective exercise to try observing your own oscillations from narrow-angle lens to wide-angle lens throughout your day.   Does the focus of your attention narrow down when you are speaking with a distressed patient or relative? Do extraneous stimuli that would normally elicit a response become filtered out to enable you to concentrate on the task at hand? Or do they create stress and anxiety? What is the influence of coffee, for example, on your attention? Or fatigue?  When overwhelmed with competing and conflicting demands, which ones come into sharpest focus as you make a decision? What stimuli do you find most distracting when you are trying to concentrate? 

One thought on “Attention and awareness

  1. This is great. I love the simplicity and clarity of comparing different types of attention to narrow and wide angled lenses. It has been interesting at work this week to reflect on how frequently I need to switch between the two views in order to work effectively, particularly when interacting with colleagues and patients. It has reminded me of the ideas written about by Roger Neighbour in his book ‘The Inner Consultation’. I first read it 25 years ago when doing GP training and I have gone back to read sections of it again now.

    The book was written to help trainee GPs make sense of what happens in doctor-patient interactions, particularly in terms of their own thought processes during a consultation. He talks about us having two concurrent thought processes, which he imagines as ‘two heads’ called the Organiser and the Responder. The Organiser plans, analyses, structures, anticipates, judges, tries to control and to make things happen. The Responder is an explorer, open to everything that is happening externally, as well as to our own imagination and feelings. It is uncritical, good at pattern recognition and is non judgemental. ‘It is happy to be carried along by our experience of the present moment’ – I like that phrase.

    Roger explains why we obviously need to use both types of thinking (or both heads) for something like a consultation to be successful. However, he suggests that difficulties arise because the two heads are continually in dialogue with each other (what he terms ‘the inner consultation’). They easily end up competing, working against each other rather than collaboratively. He talks about evidence from, for example, sports psychology in which someone can be taught to consciously distract one head, allowing the other to function effectively (in sport it’s generally the Responder which needs to predominate). He goes on to suggest that every consultation consists of three core components, each of which ideally needs one of the heads to predominate, whilst the other takes a back seat:

    • Listening (the Responder)
    • Thinking (the Organiser)
    • Speaking (the Responder)

    From experience, he found that during each of the activities, the non dominant head can be distracted by getting it to focus on the following specifics:

    • Listening (Organiser pays attention to the patient’s non verbal behaviour)
    • Thinking (Responder pays attention to its own breathing)
    • Speaking (the Organiser pays attention to ‘where the words land’ ie the effect they have on the patient’s posture, expressions, eye movements etc. I think that’s another good phrase).

    He suggests that using these techniques quietens the internal dialogue between the heads, reduces the way they tend to interfere with each other. It makes it easier to choose which type of thinking (which lens?) to use at a given point in the consultation. And it gives the Responder a much greater role than is customary in traditional medical consultations which I think must greatly increase the degree of empathy and compassion demonstrated.

    I guess Roger’s two heads correspond to familiar ideas about left and right brain activity and they feel to me to map quite nicely to the narrow/wide angle lens concept. I like his ideas about how we can improve our ability to switch between the two heads and to manage their interactions better. What I’m a bit unclear about (probably because I haven’t done any reading on it) is how the concepts of reflective and automatic thinking fit into all this: it feels reasonable to me to equate reflective thinking with the Organiser/left brain/narrow angle lens function. However, whilst I presume automatic thinking is part of the Responder/right brain/wide angle lens function (the pattern recognition part?), this is also the part of the brain which can be open and alert to new sensory input and which doesn’t leap to conclusions. I wonder whether training ourselves to more consciously distinguish and follow the steps of listening, thinking and speaking in a consultation would be sufficient to prevent automatic thinking coming into play inappropriately?

    Looking forward to your next blog!

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