Richard Smith: Work from the 1950s that can help us reform healthcare today

Richard SmithOne of the questions that occurred to many after the public inquiry into Mid Staffordshire NHS Trust was “How could nurses and doctors behave like that and not do anything?” Similar thoughts arise after multiple examples of patients in care homes being abused and hover in the recurring questions of “Whatever happened to old fashioned nursing? Why don’t nurses care anymore?” These questions are not wholly different from the questions of “How could the Nazis do what they did in concentration camps? Would I have done the same or been able to resist?” I have some tentative answers to the questions about doctors and nurses that come from a famous paper published in 1960.

The paper was written by Isabel Menzies Lyth, a psychoananalyst, who was asked to advise on why a nursing service in a general hospital was on the point of breakdown. The paper was pointed out to me by my friend Jocelyn Cornwell, who directs the Point of Care Foundation and is a senior fellow at the King’s Fund. The Point of Care Foundation is nothing to do with bedside tests (the association doctors tend to have) but with improving patient experience. Jocelyn and others have also written about Menzies Lyth’s paper in less dramatic and more constructive terms than I’m going to write about it.

I hope too that my blog will be followed by one by another friend, Alison Spurrier, a frontline nurse for close to 40 years. I asked her to read Menzies Lyth’s paper, and she is more sceptical than me. She points out that the nursing service in the hospital had 500 student nurses but only 150 trained staff, something that wouldn’t be seen now.

(As an aside, I’ve never bought the myth of a golden age when all nurses cared ever since my father describing having his tonsils removed in the 1930s and a nurse slapping his face when he spat out blood and saying to him “You dirty boy.” Another colleague with psoriasis was chained to her bed by nurses when a child in the 1950s to stop her scratching.)

Menzies Lyth’s starting point is that looking after sick and dying people creates great stress and anxiety. “Nurses face the reality of suffering and death as few lay people do.” They must do things that ordinary people regard as “disgusting and frightening.” Plus “intimate physical contact arouses libidinal and erotic wishes that may be difficult to control.”

I’m sceptical about psychoanalysis, and talk of “libidinal and erotic wishes” is the talk of psychoanalysis. But Menzies Lyth goes further: she thinks that, “The objective situation confronting the nurse bears a striking resemblance to the fantasy situations that exist in every individual in the deepest and most primitive levels of the mind.” That primitive level is “charged with death and destruction” and “characterised by a violence and intensity of feeling quite foreign to the emotional life of the normal adult.” The nurses’ experience with suffering patients and distressed relatives, intense in themselves, are magnified by stirring up these primitive and largely unconscious states of mind.

Then the nurses suffer still more stress because patients’ relatives resent, “the nurse’s intimate contact with ‘their’ patient” and project into them their fears and disgust. Patients and their relatives may also “refuse to participate in important decisions about the patient and so force responsibility and anxiety back on the hospital” and nurses.

The risk for the nurses is that they may “experience the full force of their primitive infantile anxieties in consciousness.”  Such an experience might make it impossible for nurses to carry on with their work.

Most of Menzies Lyth’s article is devoted to the defences that the nursing service developed in order to cope with the stress and the anxiety and with the risk that the nurses could be overwhelmed.

These defences were mostly not consciously developed, but most are easily recognised in hospitals. They may be essential for emotional survival, but they are not optimal either for patient care or for nurses to learn to cope with the inevitable stress.

1. Splitting up the nurses and the patients. Instead of nurses concentrating on one or two patients they were required to do different tasks for different patients. Close relationships could not develop.

2. Depersonalisation, categorisation, and denial of the significance of the individual. These are the processes that led to talk of “the ulcer in bed two.” Patients were treated in categories rather than by their idiosyncratic needs. Beds would be made in the same way, and patients  fed at the same time. Hospitals are, after all, “total institutions,” like prisons or asylums, where everything is controlled and regulated.

3. Detachment and denial of feelings. A “good nurse” would not get too attached to a patient and would be willing to move to another ward at a moment’s notice. Physical detachment thus supported psychological detachment. Emotional outbursts were unacceptable, and Menzies Lyth observed nurses who had made mistakes being told off for being upset rather than being comforted.

4. Attempting to eliminate decisions by performing ritual tasks. Making decisions is stressful because of the uncertainty and the possibility of a bad outcome, so the nursing service tried to minimise decisions by wherever possible standardising procedures.

5. Reduce the weight of responsibility in decision-making by checks and counterchecks. The nursing service tried to reduce the stress on individual nurses by involving as many nurses as possible in decisions, having decisions checked and rechecked, and putting off commitment to a decision as long as possible.

6. Collusive redistribution of responsibility and irresponsibility. The intrapsychic conflict that arose from responsibility for patients and actions was, writes Menzies Lyth, “alleviated by a technique that party converted it to an interpersonal conflict. Nurses habitually complained that other nurses were irresponsible.” As happens in the broader world, complaints were often about categories of nurses, usually more junior ones, than individual nurses.

7. Purposeful obscurity in the formal distribution of responsibility. It was unclear who was responsible for what and to whom. Accountability was diffused. (Hence perhaps the current enthusiasm for “named nurses.”)

8. Reduction in the impact of responsibility by delegation to superiors. “Tasks,” writes Menzies Lyth, “were frequently forced upwards in the hierarchy so that all responsibility for their performance could be disclaimed.” Nurses tended to carry out mostly tasks well below what they were capable of.

9. Idealisation and underestimation of personal developmental possibilities. To avoid the anxiety from underperforming and the responsibility to develop nurses tended to adopt beliefs like “nurses are born not made.”

10. Avoidance of change. “Change,” writes Menzies Lyth, “is an excursion into the unknown.” Terrible consequences may follow. Change threatens existing social defences against the deep and intense anxieties that accompany nursing. “It is understandable that the nursing service…should anticipate change with unusually severe anxiety.” Nurses would cling to the familiar even when it was clearly inappropriate. “Changes tended to be initiated only at the point of crisis.”

The point of this social defence system, concludes Menzies Lyth, is to help the individual “avoid the conscious experience of anxiety, guilt, doubt, and uncertainty.” The result was that “the nursing service was cumbersome and inflexible” and organised in a way that made rapid and effective decision making difficult. Change was strongly resisted, and the defences made it hard for nurses to mature. “Indeed, in many cases, it forced the individual to regress to a maturational level below that achieved before entering the hospital.” (This sentence reminded me of the often heard accusation that a medical education causes students to regress in many ways: “they arrive so fresh and leave so jaded.”)

Menzies Lyth died in 2008 aged 90, and her obituary said of her famous study of nurses: “Her message remains relevant to NHS management today, and it was her regret that it had less influence than it should.”

Perhaps her time has come now when there is much broader recognition of the importance of culture in healthcare and the failure of endless reforms and restructuring to make a difference to healthcare. We need to look deeper and avoid mechanistic solutions to deep human problems.

I doubt that many BMJ readers will accept all of Menzies Lyth’s diagnosis, but surely most will recognise at least some of the defence mechanisms she describes. You will probably agree as well that constant contact with suffering, pain, and death takes a toll and needs to be acknowledged not denied. The Point of Care Foundation is trying to develop practical ways of helping staff in hospitals, all staff, find time to reflect on the non-clinical aspects of care.

Most doctors are simply not exposed to pain, suffering, and death to the same extent that nurses are in that they come and go more frequently, and it always embarrasses me (as an ex-doctor of some stripe) that doctors are rarely accused of being uncaring in the way that nurses are all the time. It seems that people simply don’t expect doctors to be caring or perhaps people project their own anxieties onto nurses because they are closest to hand. But surely some of what Menzies Lyth describes for nurses is applicable to doctors.

My final thought is to reflect on the relationship between the thinking of Menzies Lyth and that of Ivan Illich. Illich’s core argument was that pain, suffering, and death are part of being human and that every culture has developed ways of dealing with them. Then, he argues, along came modern medicine with an implicit promise to abolish pain, suffering, and death through technical means. It was an impossible promise but destroyed those cultural mechanisms, leaving people existentially adrift. The thinking of Menzies Lyth shows how the health professions, particularly nurses, have damaged themselves by gathering the pain, suffering, and death into huge hospitals. A way forward is for people to reclaim pain, suffering, and death; there is a role for health professionals, but it needs to be a smaller, more humble role. Many of “the people” will be horrified by this idea, but we harm ourselves, particularly in age of chronic disease and multimorbidity, by trying to unload it all onto doctors and nurses.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.