9 Jan, 14 | by BMJ
As a frontline nurse for nearly 40 years, I was intrigued to read Isabel Menzies Lyth’s 1960 paper on why a nursing service in a general hospital was on the point of breakdown. My main reaction was that the paper reflected less something universal in healthcare and more the particular circumstances of the time when Menzies Lyth did her study (in the 50s) and the hospital where she did it. There may still, however, be lessons for today.
Menzies Lyth concentrates a lot on the stress that nurses experience and the psychoanalytical factors that may increase that stress. The environment is stressful: people are ill, some are dying, and, yes, there are times when families offload their stress onto nursing staff. I think that these are situations that healthcare professionals learn to deal with in their professional lives. This is how we form professional friendships—networks develop among people who have worked together and shared problems.
What struck me particularly in Menzies Lyth’s article was the practicalities of establishing of staff. I gasped when I first read it and had to check that I’d read it right. A large London hospital had 150 qualified nurses and 500 students, meaning that there would be no room for individual mentorship. The work was organised in a “task orientated” fashion, a method that prevented close bonds developing between patients and nurses and ensured a uniformity in the care given. It was stifling and stunted any “feel” for patient care.
Loading a trolley and going from patient to patient doing exactly the same task takes away the ability to think about what you’re doing. Nurses didn’t seem to be encouraged to think. If you think about what you are doing you may want to change something to improve patient care, and it appears that in this hospital change was a dirty word. There was control from the upper echelons in the form of fear. I can imagine those young students daren’t put a foot out of place, and some probably had psychological damage from the way they were treated by the senior nurses. This is demonstrated well in the comment that when something had gone wrong the student was reprimanded four times by the senior nurses. No guidance or reassurance was given, and naturally the students felt uncared for. The lack of communication was justified by the senior nurses who said, “In any case the students won’t come and talk to us.”
The culture sounds “blinkered.” There was no mechanism in place to improve the service to the patients, or, indeed, to look at the quality of training the students were receiving. They appear to have been working almost as robots, giving care that might or might not have benefitted their patients. In moments of reflection this must have caused anxiety as it dawned on the students that there is a better way to treat patients, but the reality was that the service didn’t allow the nurses any autonomy to think about their practice and make any brave decisions about the care they were providing.
Team spirit, such an important part of nursing, is noted by Menzies Lyth to be almost absent. How very odd that one student working alongside another had no idea what the other was doing; on one occasion one was undoing (unwittingly) the work of the other. My experience in wards today is that nurses work together. There is communication throughout the day: who needs help, who is getting behind, how are they managing with the ill lady in the cubicle, who’s had a tea break, who needs one, has anybody brought in any cake, that F1 looks shattered make sure you give her a cuppa and something to eat. This part of nursing gets us all through the difficult days.
Could it be that by separating the students and discouraging any camaraderie it was easy to foster the blame culture. It is so much easier to blame those with whom you have no close ties when things go wrong.
Is it too cynical to suggest that by staffing the hospital with student nurses on tiny bursaries they were saving plenty of money with scant regard as to the quality of care? Clearly the ratio of qualified nurses to student nurses, the poor communication between the senior nurses and the students, and the huge drop out rate indicate poor training. The training may not have been up to scratch, but the hospital was staffed cheaply by students who were not allowed to think. Students then would have viewed carrying out a prescription to the letter as good practice whether it benefitted the patient or not. Now, it would be viewed as a guideline whereby you make a decision that reflects your patient’s needs.
I wonder how anybody stayed in nursing. The lack of a nurturing environment that encouraged students to flourish was lacking, and the total disregard for the patients’ needs was astounding.
I wonder if a similar impasse had been reached in Mid Staffs, whereby a culture developed that allowed bullying and slack practice to flourish. The management was target driven, and if it was cheap it worked for them. Patients’ needs became insignificant in the rush to hit that target.
Alison Spurrier is a nurse. She has been practising in the NHS for 25 years.