Brilliant care: a conceptual argument for scholarship of the extraordinary

ABSTRACT

Critiques of healthcare often focus on negative experiences to address gaps, issues, and problems. While important, this often obscures care that exceeds expectation – that is, brilliant care. This article centres brilliant care by considering the questions that might be asked to surface it, and what might happen when brilliant care is centred. Specifically, a conceptual understanding of brilliant care is extended within health sociology. In doing so, the article draws on Mol’s research on the logic of care, Fredrickson’s broaden-and-build theory, and Hochschild’s notion of emotion work. Through an application of this conceptual framework to secondary data – namely, reported stories of healthcare experiences from the series ‘What’s right in health care’ – the article demonstrates how the framework surfaces and illuminates aspects of brilliance and its emergence. The article concludes by considering the implications this has on how we make sense of healthcare and the positive, social, and relational aspects that might be surfaced in current and future practices.

KEYWORDS:

• Brillance care
• knowledge translation
• logic of care
• broaden-and-build theory
• emotion work

Introduction

Patients and visitors at … [this] Hospital … greatly admire the expertise and brilliance of the facility’s physicians and employees. Every day, they witness … how the hospital’s employees … make … [the] … Hospital … an exceptional place of hope and healing (Studer Group, 2007, p. 255).

my … brother, David [was diagnosed with] … two malignant brain tumors … the worst day of my life … then Peggy appeared … a kind, caring … cleaning lady … She ministered to me, my husband, and my dad … telling us to ‘hold on.’ … David had to make some hard decisions about his care … He was confused and scared … [When] Peggy returned to visit [she] … handed David … a card … and that a gold cross … within that moment, he [made] … a decision about his surgery … he and Peggy had formed a special bond. David felt he had been touched by an angel … David took a turn for the worse, with cancer taking over his brain. But Peggy continued to stay in touch and was a great source of comfort and strength … David passed away … [yet] Peggy still calls us … To think a cleaning lady who works two full-time jobs and takes care of her own family would have time to be concerned about others is amazing (pp. 164–166).

These excerpts offer favourable reflections of care within healthcare settings. Observations deemed as ‘brilliant’ and ‘amazing’ are perhaps novel, representing irregular features in healthcare discourses. Healthcare scholarship primarily focuses on ‘gaps’ (DeRoche et al., 2023), ‘issues’ (Qin et al., 2023), and ‘problems’ (Adler-Milstein & Mehrotra, 2021).

While informative, the aforesaid scholarship obscures care that is brilliant, with limited understanding of practices and experiences that exceed expectation. For instance, of the health systems of 11 high-income countries, some performed better than others (Schneider et al., 2021). While the authors identified features of top-performing health systems, they did not clarify whether and how these features fostered the types of care that exceeded the expectations of patients, carers, practitioners, or service managers.

The imbalanced focus on healthcare as a problem to be ‘fixed’ can itself be a problem. For patients and carers, this focus can make invisible their positive experiences with health issues and/or health services (Kristjansdottir et al., 2018). For practitioners and service managers, this find-and-fix preoccupation risks unfairly positioning them as part of a systemic problem (Kakemam et al., 2021). And for policymakers, it might continue to direct their attention to ineffective and/or inefficient healthcare practices. This is because, rather than problematise beliefs and assumptions, the identification of gaps, issues, and problems is largely based on prevailing beliefs and assumptions, leaving little opportunity for innovation (Alvesson & Sandberg, 2011) – including that which might orient towards brilliance.

To redress the scholarly preoccupation with gaps, issues, and problems in healthcare, this article makes a conceptual argument for centring brilliant care – care that exceeds expectation. Brilliant care is not tied to a health service’s performance indicators or a patient’s specific health outcomes. Brilliant care scholarship discusses it as a relational experience that exceeds expectation (Fulop et al., 2019). Brilliant care can be unconventional, serendipitous, and does not necessarily represent business-as-usual within a service or a sector. Furthermore, brilliant care is uplifting, inspiring, and/or energising (Dadich et al., 2018). It can be found in (in)formal interactions (Collier et al., 2023; Dadich, Kaplun, et al., 2023), distinguishing it from ‘technical brilliance’, such as a practitioner’s ability to master a new treatment.

This article commences with an overview of brilliant care. It then explicates the framework that undergirds this concept. The framework is then applied to secondary data to demonstrate how brilliant care can be surfaced. The article concludes by considering the implications that brilliant care might have on how we make sense of healthcare practices and the positive, social, and relational aspects that might be surfaced.

Brilliant care

The social science of brilliance has often focused on how this concept has been constructed (and imagined) (Leslie et al., 2015). Research has shown how education infrastructure (Musto, 2019) often develops to accommodate and perpetuate ideas of brilliance (Bian et al., 2018). In its production, brilliance is often imagined as an innate trait or outcome of hard work, with the outcome exceeding some form of expectation. This latter focus – about exceeding expectation – frames this article on brilliant care. Rather than recognising brilliance as produced through an innate trait, it is located here as socially-produced and felt as brilliant. Thus, this article focuses on the conditions or structures of healthcare that can enable practices to positively deviate from routine care.

Despite health system issues (Debie et al., 2022), brilliant care happens. Research on the care of children with feeding difficulties and their families, for instance, indicated that brilliance flourished when practitioners: were carer-friendly and focused on carers’ needs; worked with families; went ‘above and beyond’; demonstrated attentiveness; empowered families; cultivated hope; promoted normalcy; and problem-solved in action (Dadich, Kaplun, et al., 2023). Similarly, research on cancer care revealed that team brilliance emerged when members: appreciated their positive points of difference, relative to their counterparts; were ‘pioneers, innovative, imaginative and creative in how and what they do and set priorities’; were ‘encouraged to take risks, think differently, and embrace challenges’; and ‘Fe[lt] … supported by colleagues and managers’ (Fulop et al., 2019, pp. 599–603). Similarly, brilliant renal care surfaced as ‘completely patient and relationally-centred, with high-quality connections, dedicated and competent staff providing a complete, responsive, and personalized service that is also like being in a family’ (Kippist et al., 2020, p. 355). These findings reflect scholarship about palliative and aged care. In the former, participants deemed care to be brilliant when it exemplified ‘anticipatory aptitude and action; a weave of commitment; flexible adaptability; and/or team capacity-building’ (Collier et al., 2019, p. 91). In the latter, participants recognised for their brilliant aged care embodied meaningful connections and relationships, as well as creativity and innovation (Dadich, Kearns, et al., 2023).

Although brilliant care might seem to reflect the safety and quality standards that guide health services, brilliant care is atypical of the care that people experience. Reflecting brilliant care literature, England’s independent regulator of health and adult social care states, ‘Everybody has the right to expect … care … [that] meets your needs and preferences’ as well as being ‘treated with dignity and respect’ (CQC, 2022, pp. para. 2–4) – however, this does not always occur (Martin et al., 2021). Similarly, the Australian standards recognise the importance of having ‘Patients as partners in their own care … [which] involves providing care that is respectful’ (ACSQHC, 2021, pp. 14–15). Yet, such standards are not always met (RCACQS, 2021). That care does not meet standards, let alone exceed them, partly explains why care that exceeds expectation is noteworthy.

Brilliant care literature suggests three conditions can enable it. First, it is relational, involving an ‘orientation to others’ (James, 2015, p. 1). Second, it involves a turn to the positive (Cameron et al., 2008), appreciating what is and could be. Third, as a form of positive deviance (Baxter et al., 2019), brilliant care is creative and innovative, deviating from expected standards of care. This suggests that brilliant care need not require additional resources – it is likely to be within reach for many who deliver, manage, and/or receive healthcare. This is not to ignore or accept structural or organisational challenges that stymie (brilliant) care, but to demonstrate: that care can involve carers, the cared for, infrastructures, and technologies; and the possibilities when infrastructures are tinkered with (Mol, 2008).

The aforesaid points are noteworthy because the need for brilliant care is critical. This follows (at least) three reasons. First, although ‘Health is a fundamental human right’ (WHO, 2024), many people continue to experience healthcare inequities (Yashadhana et al., 2020) – it is therefore important to identify and promote practices that exceed expectation and can (re)engage people with healthcare services, particularly people who have experienced substandard care. Second, with ageing populations (UN, n.d.) and the international rise of complex and chronic health conditions (WHO, 2018), the need for timely access to appropriate healthcare has never been greater – it is therefore important to ensure people want to access and engage with healthcare. Third, with stress, burnout, and the diminishing capacity of the healthcare workforce (Boland et al., 2023; ICN, 2022), it is important to acknowledge the brilliant care that is possible and occurs in the everyday. For these reasons, centring brilliant care is critical, attuning research to positive experiences and practices, and highlighting how brilliance occurs within the social and material relations of care and fragmented health systems.

Conceptual framework

Conceptually, brilliant care is undergirded by a logic of care and scholarship on emotions. First, Mol’s (2008, p. 8) logic of care draws attention to ‘the rationality, or rather the rationale, of the practices’. Rather than focus on the biomedical ‘find-and-fix’ premise of healthcare, the logic of care awards primacy to the complexities of healthcare practices and patients’ needs, preferences, and experiences. According to the logic of care, healthcare is not fixed or predetermined, but is underpinned by a logic. It is fluid, shaped by interactions, relationships, and contexts – from the micro (for instance, a health service) to the macro (for instance, the socio-cultural-political milieu). It then follows that healthcare requires more than scientific expertise or technical skills – it also requires a sophisticated understanding of contextualised ethical and moral concerns, relationships, and social norms, as well as the capacity to work with patients, carers, and colleagues, rather than on or for them. Thus, the logic requires ‘a style’ to create ‘a local, fragile and yet pertinent coherence’.

Second, brilliant care is related to positive emotions and the work involved in the performance of these emotions. Fredrickson’s (2004) broaden-and-build theory offers a useful framework to draw attention to the recognised benefits of positive emotions in diverse contexts, including healthcare. As a feature of brilliance, ‘Positive emotions … broaden people’s momentary thought-action repertoires and build their enduring personal resources’ (p. 147, original italics). Healthcare experiences can benefit from upward spirals as positive emotions and the expanded thinking they promote become mutually reinforcing (Fredrickson & Joiner, 2018). Hochschild’s (2012, original italics) notion of emotion work clarifies the work required to generate such emotion. Emotion work is ‘the management of feeling to create a[n] … observable facial and bodily display … in a private context where they have use value’. Specifically, it is ‘the act of trying to change in degree or quality an emotion or feeling’ (Herbert, 2022, p. 561) to ensure emotional displays are fit-for-purpose. It can involve suppressing, expressing, and/or amplifying emotions to present the self in particular ways and/or manage emotional experiences. Hochschild described two forms of emotion work – namely, surface acting and deep acting. The former involves displaying emotions that are not genuinely experienced – consider, for instance, the practitioner who feigns regret when conveying bad news to a patient. The latter involves a conscious effort to genuinely experience the required emotions – for example, the practitioner who situates themselves in a patient’s position to understand their hardship. Hochschild’s research also highlighted the gendered nature of emotion work, with women often performing (or expected to perform) more emotion work than men in their personal and professional lives. The gendered division of emotional labour can reinforce traditional gender roles and expectations. This might be partly because, like the logic of care and the broaden-and-build theory, emotion work is both an individual and a social process, shaped by micro and macro processes. While emotion work can be taxing as an individual moderates their emotions, it can also facilitate connections. This is because it can enable individuals and collectives to exercise empathy and relate to others.

Brilliant care is underpinned by a logic of care, positive emotions, and emotion work, locating the ways that care logics and emotions suffuse to produce brilliance. The logic of care can clarify what is and why (i.e. the underlying logic of the care that enables brilliance); the broaden-and-build theory offers a frame to illuminate what should or could be (i.e. the positive emotion associated with brilliance); and emotion work can elucidate how feelings are evoked, suppressed, and managed, particularly during the moments of brilliant care (i.e. the ways that people who deliver or receive healthcare engage in forms of labour to generate brilliance as an emotional experience). With this conceptual backdrop, the article now considers how brilliant care might be surfaced by applying this framework.

Methods

Illustration of the conceptual framework

To explore brilliance in practice and the types of questions that might surface brilliance, stories drawn from the publication, ‘What’s right in health care’ (Studer Group, 2007), were analysed. This serves to demonstrate the methodological value of the conceptual framework, and how it might situate and locate brilliance when it is occurs.

Published by the Studer Group – a for-profit healthcare consultancy firm – the publication is comprised of ‘365 stories of purpose, worthwhile work, and making a difference’ (Studer Group, 2007) – it was therefore germane for a study on brilliant care. According to the organisation’s founder, the stories were a response to his previous publication on ‘making a difference’ (Studer, 2003), reinforcing a collective interest in ‘stay[ing] focused on the positives’ (Studer Group, 2007, para. 3). While some authors were identified, others remained ‘Anonymous’ (p. 35). The perspectives represented in the stories were varied and included people who delivered, managed, and/or received healthcare. Thus, ‘The book … is a collaborative effort’ (2007, para. 4). As the founder explained, ‘Leaf through it, and you may see your own stories and those of friends and colleagues. They chronicle this journey we’re all on – the journey to make health care better’. Although the publication appears to be comprised of non-fictional stories, this could not be verified. Such work likely serves to promote the firm and might have excluded stories not considered to demonstrate a positive impact. Nevertheless, the publication was chosen because, in elevating positive (health)care, it had the potential to surface brilliant care.

Twenty stories were randomly selected (by selecting every tenth story until twenty were identified) and analysed to illustrate the conceptual framework. The lines of inquiry were guided by the logic of care (Mol, 2008), the broaden-and-build theory (Fredrickson, 2004), and emotion work (Hochschild, 2012). Both authors read the material and developed lines of inquiry, drawing on these theoretical approaches in conversation (see Table 1), to establish whether, how, and/or why the stories exemplified the three features of brilliant care. The findings, as they relate to each feature and how brilliance was surfaced, are discussed.

Table 1. Application of the conceptual framework.

Concept or Theory	Lines of Inquiry
1. Logic of care (Mol, 2008)	• How did care dynamics manifest?
	• How were needs, preferences, and experiences prioritised?
	• Who or what was involved?
	• How were ethical and moral concerns, relationships, or social norms demonstrated?
	• What helped or hindered the logic of care?
	• What effects were associated with the logic of care?
	• How was tinkering demonstrated and to what effect?
2. Broaden-and-build theory (Fredrickson, 2004)	• How was positive emotion narrativised?
	• How were thought-action repertoires broadened?
	• Who or what was involved and to what effect?
	• What helped or hindered the benefits of positive emotions?
	• What were the effects associated with the positive emotions?
3. Emotion work (Hochschild, 2012)	• How was emotion work performed?
	• How genuine was the emotion felt?
	• How did emotions change?
	• To what effect?
	• What connections were facilitated?
	• What helped or hindered emotion work?
	• What effects were associated with emotion work?

Results

Logic of care

Recognising that Mol focused on ‘the rationale, of the practices’ (2008, p. 8), the ways that a logic of care surfaces brilliant care, or makes it possible, were discerned in three ways. First, brilliant care was undergirded by social justice and relatedly, positive patient and carer experiences. The vignettes largely described individuals, including healthcare professionals, caterers, and volunteers, who often attempted to right, or at least address a perceived wrong – intentionally or unintentionally, or enhance a patient or carer’s experiences of care. They identified an instance of inequity, unreasonableness, or adversity and, from this, positively deviated from their remit or routine practices to exercise an action in consideration of the patients’ (or their families’) circumstances. Consider, for instance, Paula Lyons – a registered nurse, who surreptitiously offered her snow boots to a woman who gave birth at the hospital she worked at, after ‘overhear[ing] … the mother fretting over her bare feet in such weather’ (Studer Group, 2007, p. 658). This action might be deemed a situated ethic of care – the logic of care that Mol proposed (can) exist. As Mol argued, a logic of care requires exploring ‘what is appropriate or logical to do in some site or situation, and what is not’ and is thus attuned to patient needs. Not only was the action in this vignette attuned to a patient’s needs, but it also involved the act of sharing (the snow boots) that were beyond the remit of existing healthcare expectations – in short Paula offered brilliant care. This example is noteworthy because, reflecting Mol’s scholarship (2010), it draws attention to relationships between human and non-human actors – including (but not limited to) Paula Lyons, the mother, and the snow boots – in shaping social phenomena.

Second, a contextualised and relational ethic of care was evident across the vignettes. This was particularly the case in the vignettes that healthcare professionals had authored who spoke of their ability to connect and empathise with the person they supported. Regardless of whether this connection was near-immediate or grew over time, the person who enacted brilliant care considered others’ hardship and their role in alleviating this hardship. For instance, because of her personal experience as a migrant, Isabel Taylor – a guest service representative at a hospital – ‘had an immediate connection’ (Studer Group, 2007, p. 501) with Maryela who was ‘new from South America and was afraid to deliver her child in a strange country’. Isabel’s ability to relate to Maryela enabled her to locate Maryela’s anguish within a migrant context, motivating her to address it:

Isabel Taylor … could tell that it would not be long before this young woman was ready to deliver … she had an immediate connection with Maryela … Understanding the anxiety of being in a new country, Isabel gave her cell phone and home numbers for Maryela to use to contact her if she was at the hospital or needed help with translation … When the time came to deliver, Maryela called. ‘Will you please join me?’ she asked. Isabel returned to the hospital and stood by her side through the entire process. She acted as a translator and brought confidence to Maryela and the … Hospital team (pp. 500–501).

Isabel related to Maryela and sought to alleviate Maryela’s anxiety about her position, beyond that of a patient about to give birth. In so doing, Isabel was attentive and responsive to Maryela’s needs, even giving out ‘her cell phone and home numbers’, which was celebrated in this vignette as good care. The telephones and hospital space represented the objects and infrastructures involved in the care interaction – the material and social relations – connecting Isabel Taylor and Maryela. The logic of care demands attentiveness and responsiveness, encouraging Isabel to listen to Maryela, understand her views and experiences, as well as collaboratively make decisions with her, rather than impose preconceived solutions. The logic of care, which is relational and contextual, creates situations where individuals, materials, and their emergent relationships shape, and are shaped by each other and the situation they share.

A contextualised and relational ethic of care was also evident during the prognosis of Mary Beth Miller’s father. Dr Mary Valvano dedicated time during an otherwise chaotic moment for Mary Beth Miller and her parents to bid farewell to each other:

Dr. Valvano took my dad up to the [operating room] … she ran over and grabbed my mother and me to take us over to my dad.

It all happened so quickly … it is almost as if Dr. Valvano knew this could be the last time we got to see my dad awake. She rushed us to the elevator. My father’s stretcher was already halfway in … she gave us just a few moments with him before he was rushed into surgery. We were able to kiss Dad goodbye and tell him how much we loved him. It was the last time we saw him alive. He passed away nine days after his surgery, from which he never awoke … I remember … look[ing] at him one last time, kiss[ing] him, and tell[ing] him … I loved him. The moment is one of my most cherished memories, and I am so grateful that Dr. Valvano had the insight to give us this beautiful gift (p. 327).

The logic of care is ‘a style’ (Mol, 2008, p. 8) that is a dynamic, open-ended narrative. It involves identifying the need(s) of the person who is cared for and their families in collaborative efforts to attune knowledge, technologies, and in this case processes, to bodies that require care. Paula Lyons, Dr Mary Valvano, and others sought ‘a local, fragile and yet pertinent coherence’, experienced through fluid and adaptative processes. Instead of rigidly adhering to protocols and hospital schedules, the logic of care Mol described recognises that healthcare practices often need to be receptive, fluid, and adaptable to create the conditions for enacting brilliant care. Protocols here offer infrastructure that must be ‘tinkered’ with to perform care in this way. As Mol suggested, care is more than the carer and cared; it involves technologies and infrastructures. For instance, in the aforesaid vignette, material relations involved movement and temporality: the time pressure of the closing elevator, a stretcher ‘already halfway in’, and the scheduled procedure. Brilliant care thus requires being attuned to the ways that people find loopholes, fruitful workarounds, and moments of adaptation and/or pause, in systems designed to stymie such care.

Third, using Mol’s (2008) logic of care, brilliant care – as described in the vignettes – was evident in adaptive practices and attention to detail. The individuals who enacted brilliant care were informed by what they observed, adapting their actions, accordingly. Consider the intensive care unit (ICU) nurse who took the time to ask what a patient needed and attend to their need:

my mother became very ill with systemic lupus … Mom … [got] so frustrated sometimes and just cry. She went into a major depression. Sometimes all she asked for was to be able to sit up at the edge of the bed and look out the window … Her … nurse was … in the room talking softly to my mom and asking her what she needed. My mom started to cry and told her that she wanted to sit up and look out the window … I heard her nurse say, ‘Well then let’s go.’ She helped Mom sit up and dangle her legs over the side of the bed; ventilator tubing and dialysis tubing went too … She put her arm around Mom’s shoulders and let Mom rest her head on her. She rested her head softly on Mom’s head too … I think that an angel came that day to take care of my mom. The touch, the care, and the compassion made the difference that day for both the patient and her daughter (Studer Group, 2007, pp. 353–354).

Brilliant care emerged via the movement and touch of bodies as well as healthcare professional time spent on attuning to the patient’s needs. Similarly, Tara Ford – another nurse – was described as perceptive and responsive to the needs of a family, as their loved one – a father – was in a coma. Mindful of their grief, Tara exercised personal agency to demonstrate care, beyond what was expected:

my youngest brother said he wished he could have had his son christened before Dad became sick. My nephew wondered out loud whether the baby could be christened in Dad’s hospital room. I talked to his nurse, Tara Ford, and she said it wouldn’t be a problem … After the christening, we realized Dad was holding a package in his hand. Tara had gone down to the gift shop and purchased a present for our father to give to his grandson at his christening.

What a special nurse Tara is. She was so thoughtful and caring. We will always remember her (p. 347).

Care in this sense exceeded expectation, framed as ‘thoughtful and caring’. This care is reminiscent of a logic of care (Mol, 2008), which invites individuals to pay attention to the small details of (health)care – the everyday actions, routines, and interactions that collectively contribute to care processes. These details can provide valuable insights into how brilliant care is enacted within existing processes. The observations of the individuals described in the vignettes enabled them to act and tinker with caring technologies; and by orientating in this way to others, this resulted in a felt impact from such brilliant care.

Broaden-and-build theory

In all vignettes, the authors described the ways that care, when brilliant, involved positive emotions, expanded thought-action repertoires, and enhanced resources. These are all aspects of Fredrickson’s (2004) broaden-and-build theory of positive emotions. The individuals who embodied brilliance and performed brilliant care were framed around positive emotions, being known for their ‘warm[th]’ and their ‘serv[ic]e … with a smile’ (Studer Group, 2007, p. 412) – they ‘joke[d], laugh[ed]’ and ‘showed … immense gratitude’ (p. 627), all of which were examples of positive emotion. Positive emotions emerged as the ‘brief, multisystem responses to some change in the way people interpret – or appraise – their current circumstances’ (Fredrickson, 2013, p. 3), which were explained as part of the brilliant care encounter(s).

These and other positive emotions had what the broaden-and-build theory calls a ‘positive contagion effect’ (Fredrickson, 2013, p. 35), whereby positivity begot positivity. They reproduced positivity within and beyond the healthcare context:

Jodi took the time to help me when I was at the lowest point in my life. It reaffirmed to me that there are kind, considerate, and compassionate people in … health care … This entire experience only makes me want to ‘pay it forward’ (Studer Group, 2007, p. 121).

Positive emotions created different ways of thinking and acting, shifting patient interactions. Those who epitomised or received brilliant care entertained innovative possibilities and considered alternative solutions to problems through the reciprocal relationships that emerged between positive emotion, thought-action repertoires, and resources (Fredrickson & Joiner, 2018). Reflecting Fredrickson’s (2013) descriptions of upward spirals, positive emotions enabled the characters to experience better personal and social wellbeing. For example, Mary Beth Polston demonstrated this in her account of a patient who was ‘critically ill’ and ‘was on a transplant list, awaiting a suitable donor’ (Studer Group, 2007, p. 90). Upon admission, Mary Beth described the patient as ‘grumpy … unpleasant … and … scary’ (pp. 90–91). She often tried to avoid him, keeping each visit ‘as brief as possible because I did not want to upset the “scary biker man”’ (p. 91). However, through casual, friendly conversation, she learnt more about the patient, his family, and his worries. Appreciating him ‘as a person, not just a patient’ (p. 92), Mary Beth ‘felt his concerns’ and purposely spent more time with him because she came to enjoy his company. This demonstrates how positive emotion – as found in warm companionship – generated positive emotion. This in turn enabled Mary Beth to think imaginatively, use novel ways to propagate positivity, and equip herself and the patient with emotional, social, and material resources for future health encounters:

I no longer went in to see Chris last at night because I dreaded going into his room [because he seemed scary]. I went in there last so I could spend more time with him. I would go in his room, sit down … He counseled me just as I did him. Something came alive in him during those months … [While] He missed his family … we became their extended family … That is when Chris became healthy.

The broaden-and-build theory points towards the ways that positive emotions can work as resources within brilliant healthcare encounters, creating the contexts for brilliant care to emerge. Positive emotions extend the possibilities of healthcare that go above and beyond, bringing warmth to healthcare professionals, their patients, and patients’ families. Positive emotions can shift the possibilities of a healthcare encounter towards brilliant care as it is experienced and produced contextually.

Emotion work

In the vignettes, the authors described healthcare work or encounters with those who enacted brilliant care, as having the capacity to emotionally connect with the people they cared for. This is an example of what Hochschild (2012) called ‘deep acting’ – a component of emotion work and emotion management. Hochschild (1983, p. 47) described deep acting as deciding ‘what it is that we want to feel and on what we must do to induce the feeling’, thereby following structured feeling rules. For Hochschild, deep feeling requires a felt emotion and authenticity to that emotion for oneself and the other person who experiences the emotion. Consider for instance, the demonstrations of empathy that Nancy received from staff members at the Breast Health Center following the discovery of a ‘nodule … suspicious for cancer’ (Studer Group, 2007, p. 219). Team members accompanied Nancy on this journey, mindful of what she was likely to need and find useful:

Four days after her surgical appointment, Nancy met with the Breast Health Center nurse … On the day of surgery, the Breast Health Center nurse … accompanied her to the Operating Room … to support the patient. Holding the hand of a frightened patient as she goes to sleep under anesthesia is often the most comforting and appreciated unique practice of our care (pp. 219–220).

Here, the nurse had certain expectations and engagements of emotional labour to ‘support the patient’.

Similarly, Pat Holtman described a hospice team that cared for her mother who lived with cancer. According to Pat, the clinical and non-clinical staff members exceeded expectation, performing above and beyond their role and the associated emotional expectations:

The RNs [registered nurses], LPNs [licensed practical nurse], home health aides, chaplains, and physicians that visited and cared for my mom on each shift while she was there, were there because they wanted to be, not because it was their job. These individuals truly live the mission of ‘adding life to days when there aren’t many days left to live’ (p. 411).

In these instances, the healthcare professionals were described as exceeding the generalised feeling rules, offering brilliant care in their practices via ‘deep acting’.

The concomitant emotion work was not isolated to individuals affiliated with health services, as an employee or a volunteer – they were also demonstrated by patients. For instance, a patient referred to as ‘A.’ was admitted to a hospice, following a diagnosis of breast cancer. Estranged from family members, ‘A.’ relied on government welfare. Despite her hardship, she positively affected the people around her by emanating kindness and poise:

A.’s grace in the face of devastating circumstances made a profound impact on those who assisted her … A. showed immense gratitude for the hospice staff and volunteers who became her primary source of support … She called us her angel team … A.’s physical and financial resources were severely limited, but her capacity for caring was undiminished … she went to the effort of providing a Christmas gift for a needy family at her church … the patient had an impact on the staff, reminding us of why we choose to work in hospice and the value of the work we do (pp. 627–628).

Interesting here are the feeling rules that were surpassed to exceed expectation. While it is not possible to confirm whether the emotion work represented a conscious effort, this might be assumed, given literature suggesting that health issues, as well as the receipt and delivery of healthcare can be taxing (Boland et al., 2023). The emotion work on display in such moments can be associated with embodied dispositions; it can result from knowing the right ways to exceed expectations in such situations or not knowing the right ways to act and unintentionally enacting brilliant care. However, it is notable that brilliance was evident through emotion work that was not aligned with expectations of healthcare.

Echoing Hochschild’s (2012) scholarship, the vignettes largely portrayed women as enacting brilliant care. Of the twenty vignettes randomly selected for analysis, women featured in 14, while the brilliant care of a team (n = 6) or men (n = 2) featured in relatively few. Given the limited detail presented in the vignettes, it is not possible to account for this gendered division of brilliant care – nevertheless, these findings suggest a need for further research to clarify what enables some individuals and teams to exceed expectation:

I would like to comment on the kindness of … Dr.L. He came with the ambulance crew, checked out my grandson, and took two Polaroid pictures … he … took the pictures so that … [my daughter] and … son-in-law could both have one while their newborn baby was at a different hospital. The gesture was so touching that it brought tears to my eyes (Studer Group, 2007, p. 70).

Emotion work is useful here to consider how individuals showed emotions as both carers and the cared in healthcare contexts. This surfaced the feeling rules and the ways that brilliant care was situated in relation to these feeling rules. That is, brilliance emerged as beyond standards of care and who performed this work was ‘deep acting’.

Conclusion

This article has explicated and extended emergent scholarship on brilliant care – specifically, care that exceeds expectation (Dadich, Kaplun, et al., 2023). Bringing into conversation Mol’s (2008) logic of care, Fredrickson’s (2004) broaden-and-build theory, as well as Hochschild’s (2012) emotion work has surfaced brilliant care in practice. Surfacing brilliance was the focus here. The article illuminated assemblages of brilliance and brilliant care practices, which are embedded in the social milieu of the healthcare encounter and the intersectional lives of those involved. Centring brilliant care requires an awareness of how structural inequalities are entangled in the production of care – although they might not have been explicit in the vignettes analysed in this study, brilliant care was sometimes a response to structural inequalities that impact health (Bowleg, 2020). As demonstrated, it emerges in social, material, and technical relations of the care encounter, and involves human and non-human actors. The application of the conceptual framework to the vignettes suggests that brilliant care is contextual, relational, and ethical; furthermore, it involves tinkering with(in) existing infrastructures of care – a logic of care (Mol, 2008). It emerges through the positive emotions attached to brilliance and the ways that such positivity broadens solution repertoires (Fredrickson, 2004) in a logic of care that is enacted contextually and relationally. Additionally, it emerges in the emotion work (Hochschild, 1983) of healthcare professionals and patients, whereby it occurs when feeling rules are disrupted and/or exceeded (un)intentionally or tinkered with to achieve brilliance. Brilliance is notable for its relevance to patients’ intersectional lives in how it is produced and becomes noticeable in the ways it goes beyond expectations of healthcare with(in) prevailing health systems.

Surfacing brilliance offers a novel intellectual pathway, contrasting with research that locates deficits in health systems. The point is not to dismiss such work, but to consider how brilliance might be surfaced to reshape future health systems, infrastructures, and training. The point is also to show how people find cracks in systems to enable brilliant outcomes. In neoliberal contexts (Ratna, 2020), a focus on brilliance might spur new key performance indicators to emphasise brilliant care. This is not the point of this work – instead, it is to reveal: how brilliant care emerges within existing systems; how it is relative and relational; how it relies on strategic movements of healthcare professionals; and how it is likely to be gendered. Importantly, brilliant care sparks positive sentiments among the individuals involved and has bona fide positive effects in people’s everyday lives when they are faced with adversity. Such outcomes are worth pursuing. Instead of being translated into indicators (which is the risk), this article argues that a focus on brilliant care might serve to expose limits in existing systems and positive cracks that might be widened to better attune healthcare to the needs and imagined futures of patients with healthcare professionals.

Centring brilliant care then also requires being attuned to what constitutes brilliant care and what is (or should be) standard healthcare. Because the two are not synonymous, scholars and practitioners of brilliant care should observe the relationship between brilliant and standard care and how the two can feature together. For instance, in the vignette about Isabel Taylor and Maryela, the need for an interpreter was clearly a missing standard of care – however, the relational and emotional work with an interpreter might be considered brilliant, where such care exceeded expectation. Thus, scholarship on brilliant care requires due consideration of the cracks that enable brilliant care, as well as the systemic cracks that should be remedied. Brilliant care offers a conceptual intervention to surface these and potentially other cracks in health systems.

To further scholarship on brilliant care, research is required to address four questions. First, when, where, and why does it (not) emerge? Second, when and how does good (or substandard) care become brilliant – is there a threshold or tipping point for its emergence? Third, (how) can healthcare systems be transformed to be brilliant? And fourth, which methodologies and methods are (un)likely to further the scholarship on brilliant care? Furthermore, given this article was limited by its use of secondary data that could not be verified, health sociology scholarship would benefit from engagement with primary data to consider brilliance and its formulations in healthcare of the future.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.