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One of the difficulties of the 1980s renal clinical computerisation in the UK was expressing the revelations of digitisation to a wider audience. The capacity to store, manipulate, retrieve and communicate what is now familiar as ‘data’ created a new dimension of clinical activity and transformed the healthcare context. Unfortunately, neither medical publication nor poster presentation suited a demonstration of that novelty, although attempts were made to convey some of the more coherent, abstract components.1,2 It was not possible to develop some of the incidental opportunities for demonstration and enthusiasts were left largely tinkering, even though the potential was well appreciated by them.3,4 The utilitarian domination of Results over Methods in medical publishing meant that journal publication demanded more systematic time and effort, when that was being taken up in rewarding development. A similar predicament faced the later introduction of Renal Patient View. More widespread appreciation had to wait for the characterisation of the specialty through the annual, computerised reporting of the UK Renal Registry after 1997 and the journal publications based on that material a decade later.
In retrospect, a closer reading of the obvious suitability of computing to the renal environment could have been made. In particular, the prescription, practical infrastructure and experience of each haemodialysis could be very well matched to sequential digital registration. That also facilitated subsequent review and the detection of exceptional features. The fact that each treatment carried potential consequences for the following prescription could be addressed systematically. The originator of the CCL system, Hugh de Wardener of Charing Cross Hospital, was said to have been partly motivated by being able to follow what he thought of as the unique experiment in salt and water balance represented by each haemodialysis! The flexible, bespoke graphics of the CCL system reflected that preoccupation and so facilitated the detailed examination of dialysis variables. The safe management of serial treatments was ensured by the computing, as well as the ability to trouble shoot any anomalies through exception reporting, for example in the remote satellite patient review system described for Leeds.5 The regular registration of symptoms in that centre allowed an insight into the quality of patient experience, two decades before that became a more general nephrological interest. 5,6
The comprehensive descriptive capacity of clinical IT was profitable because of the repeated, semi-standardised, numerical technology of dialysis, haemodialysis rather more than peritoneal. Similar benefits were apparent in other repeated, multi-faceted, clinical sequences, such as obstetrical delivery (in Nottingham) and chemotherapy. It is now obvious that the fit of clinical computing to these treatments and specialties depended on the uniform repetition of a particular mix of practical conditions and actions that were largely standardised. The uniformity of those conditions is exactly what characterises and allows a quite different aspect of treatment, what would be known in non-medical situations as a possible ritualisation. The periodic rehearsal of a sequence of actions in the hope of possible benefit is especially familiar in many religions and was the basis of the historical development of sacraments and rites.7 The uniformity and patient-staff exchanges of renal replacement provide the basis of a secular social psychology that has an understandable origin in human biology. 8,9 Dialysis as a tacit ritual, a ceremony, offers structure to the events and relationships of kidney replacement procedures. The repetitive elements, as well-anticipated rites, have a potential to promote acceptance and comfort bilaterally.
Repetition alone is used in very different circumstances to allay anxiety through a focus on breathing, for example, and even more fundamentally during the induction of hypnosis. Regardless of the form of the repeated element, it appears that a tranquillising mix of cerebral mechanism and social experience can be induced, with trainable subconscious elements.
We should consider this as more than mere repetitive routines, like coffee and newspaper at breakfast, but also as a performance that emphases the familiar roles and anticipated collusion of patients and staff. That performance need not be enacted consciously but has a shape, with beginning and ending felt to be a shared experience. The nurse’s ‘there we are’ betrays the sense of raising and then curtailing a recognised action, the bringing down of a curtain on a performance perhaps?
Discussion of ritual inevitably brings an awareness of multiple disciplines in the Humanities, not least Theology and Anthropology. Given that dialysis corrects the biochemical abnormalities of renal failure only temporarily, it seems unlikely that the cardinal benefit of a slide towards ritualisation should be seen as healing. Indeed, dialysis brings its own symptomatology and treatment is scarcely transformative, often leaving the patient fatigued and needing recuperation. The more prominent consequences of any ritualised element seem likely to be reassurance and some shared consolation of a coercive predicament necessitated by poor health.
Such complicated cultural consequences are not expected from medical technology. Perhaps they go some way to explaining the upbeat atmosphere in renal treatment areas and, especially, satellite units.10 The analogy of the process of restoring periodically distorted biochemistry and a spiritual cleansing from the participation and performance of religious sacraments is remarkable. In case that seems far-fetched, it is not surprising given the origin of historical religious ceremonies in taking advantage of the psychological and social benefits of repetitive, standardised experiences.7 Even the regular sharing of repeated events has a correspondence to renal unit shift organisation. The beneficial patient experience of regularly sharing the timing of treatment with known staff and patients would bear that out.
There is a literature of the role of ritual in nursing. Attitudes have ranged from the recognition of ritual as a useful psychological defence to concern in its use for the procrastinating continuation of outdated procedures.11,12 There has been a defence of ritual as supportive and not to be summarily dismissed.13 The potential for lapses into ritual of repeated procedures is obvious and haemodialysis is one of the very few standardised repetitions that afford, inevitably, such opportunities in healthcare.
Although the technical steps of dialysis are well defined, it would be interesting to research the range of routines and variants in individual renal units, since some elaboration often occurs spontaneously in procedures that might reflect a covert, idiosyncratic, ritualisation. Whether subconsciously evolved elements would be readily detectable by the participants remains to be seen!
Returning to the recording of repeated clinical treatments by UK clinical IT, it is apparent that it could have offered the exposure of a positive, if implicit, spiritual dimension to medical technologies. Renal computer enthusiasts took no advantage of that as a topic for discussion and publicity. In the event, the problem of computer application in clinical situations that were less structured was arguably one of the unexpected pitfalls of the NPfIT. That blind alley ultimately came to focus on emergency or primary health care encounters as one way of semi-standardising the context and requirements of clinical IT. Provisional diagnosis became a trope to allow development. In dismissing experienced renal clinicians, the NPfIT missed the insight of deducing a developmental pathway from the effective support of repeated clinical routines in renal replacement.
As indicated above, these observations have some relevance to the organisation of dialysis. The economic benefits of home dialysis dominated the strategies of early renal replacement in the UK and abroad and have returned to become important in the era of self-management and independence. The possibility of spiritual support and reassurance has probably been buried in the many factors that encourage patients to seek treatment at, or away from, an accompanied group setting. Perhaps an explicit recognition of otherwise covert ritual features would improve and sustain such treatment preferences and decisions.
The obvious economy of expert monitoring on open dialysis wards may be part rationalisation for the beneficial ‘lived experience’ of ritual ceremonial in the course of treatment. It seems likely that the idea of a ‘family’ of patients was more prescient and less sentimental than it has subsequently appeared.14 The shared, predictable, repeated predicament of dialysis seems not unlikely to offer an implicit security and consolation, as a scarcely recognised bonus to both patients and ministering staff. It can be seen as another incidental secret that nephrology has been keeping without knowing it!15
Last Updated on May 26, 2025 by John Feehally