Not Angels, Humans: Thoughts on Nurses and Nursing, for International Nurses Day by Tony Berendt

Today is International Nurses Day, and the 200th anniversary of the birth of Florence Nightingale, who did so much to establish the values and ethos of the nursing profession as we understand it today. As one of the Editorial team of BMJ Leader, I want to wish all nurses, of all seniorities and across the world, a very happy International Nurses Day. Today is an important day for recognising and honouring the commitment to care, and the sacrifices made, by all nurses through the generations, and across the many diverse cultures of the world. And as a clinical leadership journal, BMJ Leader has a strong focus on medical leadership, but celebrates (and welcomes contributions on) leadership in nursing too.

Caring for others requires expert knowledge, technical skill, and dedicated professionalism. Nurses rightly pride themselves on these qualities, and are valued for them. But caring also requires compassion and kindness, and for patients, the kindness and compassion of nurses is often most powerfully experienced when nurses provide physical care. This is often intimate and personal in nature, and is given to patients at their most physically and psychologically vulnerable – in responding to pain, assisting with feeding and drinking, dealing with excreta, sputum and vomit, or dressing wounds.  We recognise that the ability to take up that role is one that many of us can do only temporarily, and only for a loved partner or a child. Few can tolerate it indefinitely, or offer such care to strangers. That ability sets nurses aside from most of society, and draws our respect. We recognise that the relationship between nurse and patient is, as a result, a powerful one.

Over fifty years ago, the psychological implications of this relationship – on nurses and nursing culture – was observed and interpreted, through a systems-psychodynamic lens, by Isobel Menzies-Lyth and colleagues from the Tavistock Clinic (1). Systems-psychodynamics studies how the processes that underlie individual human psychological development also play a part in how groups of individuals organise themselves – into teams, and into organisations (2). It considers how system and context interact with the self when a person takes up a role, and how the work of the group is organised – not only to “get the job done”, but also to defend those engaged in the work from any distressing feelings it may evoke.

Menzies-Lyth was consulting to a major teaching hospital in London, which was having difficulties with its retention of student nurses, many of whom left before qualifying. Her team carried out observations of care and interviews of nurses at all levels in the hierarchy. She noticed many elements of nursing culture that appeared not to contribute to a compassionate and effective culture for patients or nurses. These included the establishment of rituals of care where the ritual appeared to overtake its purpose (for example, waking up patients in order to give them sleeping tablets, because not to do so would violate the rules); depersonalisation (for example, referring to patients by bed number or diagnosis, not by name); work rosters that minimised continuity of care (and so of attachment to patients) by reallocating nurses to different patients each day; and attitudes within the hierarchy that tended to denigrate the abilities of subordinates, while passing decision-making upwards (to a superior who mirrored the same behaviours), and dealt harshly with deviations from routines of care.

Menzies-Lyth went on to interpret the set of behaviours and attitudes she encountered, suggesting that the experience of illness in a nursed patient is full of distressing feelings; fear of death, disability and pain; shame and disgust at nakedness and bodily functions; envy of the health (and often youth) of the nurses caring for the patient; depression at their loss of health and all that goes with it; guilt at failing to get better or being unable to take their normal roles in society or their family.  She suggested that through our human propensity to “split off” those of our feelings that we find unacceptable or intolerable, and to locate these in others through the process of projection, patients project – into their nurses – their feelings of depression, envy, anger, and shame, leaving the patient temporarily unburdened but at the nurses’ emotional expense (and without resolving the underlying issue, the ill health of the patient). Nurses, in turn, dealt with their own feelings towards their patients – mixed with introjected feelings from them – by projecting feelings of inadequacy and persecution into each other across hierarchical levels. But in addition, the patterns of work that had developed – the rituals, the rosters, the styles of communication – were seen by Menzies-Lyth as a social defence, as a collective unconscious way of organising against anxiety; as a system that had evolved to minimise distress, but that now, in part, contributed to it.

The notion of social defences, as articulated by Menzies-Lyth, has since been widely applied to many other spheres of work. In nursing, even if some of her observations still resonate today, much has changed. Why, then, might this thinking still be relevant, especially on International Nursing Day, and in the midst of the global Covid-19 pandemic?

In the United Kingdom and other parts of the world, nurses are very visibly in “the front line” of the “battle” against the SARS-CoV-2 coronavirus that causes Covid-19. They are confronting a new infectious agent, full of terrifying unknowns regarding its behaviour, prognosis, treatment. They are highly exposed to infection, and if without adequate personal protective equipment (PPE), are at high risk of contracting infection from patients. They are in constant contact with patients fearful for their lives while simultaneously having the same emotion for themselves, and their colleagues and loved ones. Their normal abilities to display compassion, to comfort and support, and to help patients to mobilise their own strengths – through proximity, facial expression, and touch – are severely constrained by their own needs for safety. For many, their efforts to save life are less successful than they are used to; for all, the numbers of patients who die in a given time have been greater than they have ever experienced. The sights and sounds are new, and sometimes shocking.

Viewed today, the work of Menzies-Lyth prompts us to notice the power of the feelings evoked, in all of us, by the pandemic – feelings of fear, insecurity, loss of control, horror even – and to be mindful that we will be likely to locate these distressing feelings elsewhere if we can. At the moment it is our government that receives many of our negative projections (whatever we rationally think of our government’s performance), while health and care workers are recipients of our feelings of hope and gratitude. Because these feelings are not entirely rational (there are some good leaders, and some not-so-good health and care workers), all this can change, potentially quickly.

So while we applaud nurses and other health and care workers in our own weekly doorstep ritual (a social defence, perhaps, against our own powerlessness, as well as heartful gratitude for the carers), we should also be aware of the risk that we may, as the stresses and the death toll continue to rise, at some future point project our frustrations and powerlessness and anger – at the virus and how it has changed our lives –  into those same workers, blaming them for lapses in care or compassion, or for clinical decisions made under extreme pressure.

In celebrating International Nurses Day, then, let us celebrate nurses not only for their dedication and compassion, but also for their ability to persist despite occasional failings in their judgement, good humour, or compassion; not only for their tolerance of physical and emotional fatigue but also for their tiredness and frailty; and not only for caring despite having their own fears, but also for having and sharing those fears at times. On International Nurses Day, let us venerate and celebrate nurses not only for their angelic qualities, but also for their quintessential, and non-angelic, humanity, which makes them all the better, and all the more remarkable.

References.

  1. Menzies, I. E. P. (1960) ‘A case study in the functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital’, Human Relations, 13, pp. 95-121.
  2. Obholzer, A. and Roberts, V. Z. (2019) The Unconscious at Work. A Tavistock Approach to Making Sense of Organizational Life. 2nd Abingdon: Routledge. ISBN: 978-0-8153-6135-0 (pbk)

Anthony Berendt, BM, BCh, FRCP, SFFMLM

Tony is an Associate Editor of BMJ Leader. Tony trained in Medicine in Cambridge and Oxford, qualified in 1983, and studied the pathogenesis of severe malaria as an MRC Training Fellow (1987-1990) and a Lister Institute Research Fellow (1990). Completing specialist training in Infectious Diseases and General Medicine (1995), he developed interests in staphylococcal pathogenesis and musculoskeletal infection. He was Consultant Physician-in-Charge at the Bone Infection Unit (1997-2005) and Medical Director (2004-2011), at the Nuffield Orthopaedic Centre NHS Trust, then Deputy Medical Director (2011-2014) and Medical Director (2014-2018) of the Oxford University Hospitals NHS Trust. Since September 2018 he has worked as an organizational consultant and executive coach.

Declaration of Interest: Anthony Berendt is an Associate Editor of BMJ Leader, and a Director of Anthony Berendt Consulting, offering coaching and consultancy, including to health and care organisations.

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