Social Systems as a Defense Against Anxiety An Empirical Study of the Nursing Service of a General Hospital

Social Systems as a Defense Against Anxiety An Empirical Study of the Nursing Service of a General Hospital

Introduction

This study was initiated by the nursing service of a general teaching hospital in London which sought help in planning the training of student nurses of whom there were five hundred in the hospital. Trained nursing staff numbered one hundred fifty. The student nurses spent all but six months of their three years of undergraduate training working full-time in wards and departments as "staff" while learning and practicing nursing skills. They carried out most of the actual nursing. The task with which the nursing service was struggling was effectively to reconcile two needs: for wards and departments to have adequate numbers of appropriate student nurses as staff; for student nurses, as students, to have the practical experience required for their training. Senior nurses feared the system was at the point of breakdown with serious consequences for student nurse training since patient care naturally tended to take priority whenever there was conflict. The study was carried out within a sociotherapeutic relationship the outcome of which, it was hoped, would be institutional change. The early part was devoted to an exploration of the nature of the problem and its impact on the people involved. While doing this "diagnostic" exploration we became aware of the high level of tension, distress and anxiety in the nursing service. How could nurses tolerate so much anxiety? We found much evidence that they could not. Withdrawal from duty was common. One-third did not complete their training; the majority of these left at their own request. Senior staff changed their jobs appreciably more frequently than workers at similar levels in other professions. Sickness rates were high, especially for minor illnesses requiring only a few days' absence from duty.

The relief of this anxiety seemed to us an important therapeutic task in itself and, moreover, proved to have a close connection with the development of more effective techniques of student-nurse allocation. In this paper I attempt to elucidate the nature and effect of the anxiety level in the hospital.

Nature of the Anxiety

The primary task of a hospital is to care for ill people who cannot be cared for in their own homes. The major responsibility for this task lies with the nursing service, which provides continuous care, day and night, all year around. The nursing service bears the full, immediate and concentrated impact of stress arising from patient-care.

The situations likely to evoke stress in nurses are familiar. Nurses are in constant contact with people who are physically ill or injured, often seriously. The recovery of patients is not certain and may not be complete. Nursing patients with incurable diseases is one of the nurse's most distressing tasks. Nurses face the reality of suffering and death as few lay people do. Their work involves carrying out tasks which, by ordinary standards, are distasteful, disgusting and frightening. Intimate physical contact with patients arouses libidinal and erotic wishes that may be difficult to control. The work arouses strong and conflicting feelings: pity, compassion and love; guilt and anxiety; hatred and resentment of the patients who arouse these feelings; envy of the care they receive.

The objective situation confronting the nurse bears a striking resemblance to the phantasy situations that exist in every individual in the deepest and most primitive levels of the mind. The intensity and complexity of the nurse's anxieties are to be attributed primarily to the peculiar capacity of the objective features of the work to stimulate afresh these early situations and their accompanying emotions.

The elements of these phantasies may be traced back to earliest infancy. The infant experiences two opposing sets of feelings and impulses, libidinal and aggressive. These stem from instinctual sources and are described by the constructs of the life-instinct and the death-instinct. Feeling omnipotent and attributing dynamic reality to these feelings and impulses, the infant believes that the libidinal impulses are literally life-giving and the aggressive impulses death-dealing; similar feelings, impulses and powers are attributed to other people and to important parts of people. The objects and the instruments of the libidinal and aggressive impulses are phantasized as the infant's own and other people's bodies and bodily products. Physical and psychic experiences are intimately interwoven. The infant's psychic experience of objective reality is greatly influenced by its own feelings and phantasies, moods and wishes.

Through their psychic experience infants build up an inner world peopled by themselves and the objects of their feelings and impulses. In the inner world, these exist in a form and condition largely determined by phantasies. Because of the operation of aggressive forces, the inner world contains many damaged, injured or dead objects. The atmosphere is charged with death and destruction. This gives rise to great anxiety. Infants thus fear for the effect of aggressive forces on the people they love and on themselves, grieving and mourning over others' suffering and experiencing depression and despair about their own inadequate ability to right their wrongs. They fear the demands that will be made on them for reparation and the punishment and the revenge that may result, and that libidinal impulses (their own and those of other people) cannot control the aggressive impulses sufficiently to prevent chaos and destruction. The poignancy of the situation is increased because love and longing themselves are felt to be so close to aggression. Greed, frustration and envy so easily replace a loving relationship. This phantasy world is characterized by a violence and intensity of feeling quite foreign to the emotional life of the normal adult.

In the hospital situation the direct impact on the nurse of physical illness was intensified by having to meet and deal with psychological stress in other people, including colleagues. Quite short conversations with patients or relatives showed that their conscious concept of illness and treatment was a rich intermixture of objective knowledge, logical deduction and fantasy. The degree of stress was heavily conditioned by the fantasy, which was in turn, conditioned, as in nurses, by the early phantasy-situations. Unconsciously, the nurse associated the patients' and relatives' distress with that experienced by the people in the nurse's own phantasy-world, which increased personal anxiety and difficulty in handling it.

Patients and relatives had complicated feelings towards the hospital, which were expressed particularly and most directly to nurses, and often puzzled and distressed them. Patients and relatives showed appreciation, gratitude, affection, respect; a touching relief that the hospital coped; helpfulness and concern for the nurses. But patients often resented their dependence; accepted grudgingly the discipline imposed by treatment and hospital routine; envied nurses their health and skills; were demanding, possessive and jealous. Patients, like nurses, found strong libidinal and erotic feelings stimulated by nursing care, and sometimes behaved in ways that increased the nurses' difficulties, for example by unnecessary physical exposure. Relatives could also be demanding and critical, the more so because they resented the feeling that hospitalization implied inadequacies in themselves. They envied nurses their skill and jealously resented the nurse's intimate contact with "their" patient.

In a more subtle way, both patients and relatives made psychological demands on nurses that increased their experience of stress. The hospital was expected to do more than accept the ill patients, care for their physical needs, and help realistically with their psychological stress. Implicitly it was expected to accept and, by so doing, free patients and relatives from, certain aspects of the emotional problems aroused by the patient and the illness. The hospital, particularly the nurses, had projected into them feelings such as depression and anxiety, fear of the patient and the illness, disgust at the illness and necessary nursing tasks. Patients and relatives treated the staff in such a way as to ensure that the nurses experienced these feelings instead of, or partly instead of, themselves, for example by refusing or trying to refuse to participate in important decisions about the patient and so forcing responsibility and anxiety back on the hospital. Thus, to the nurses' own deep and intense anxieties were psychically added those of other people. We were struck by the number of patients whose physical condition alone did not warrant hospitalization. In some cases, it seemed clear that they had been hospitalized because they and their relatives could not tolerate the stress of their being ill at home.

The nurses projected infantile phantasy-situations into current work-situations and experienced the objective situations as a mixture of objective reality and phantasy. They then re-experienced painfully and vividly in relation to current objective reality many of the feelings appropriate to the phantasies. In thus projecting phantasy-situations into objective reality, the nurses were using an important and universal technique for mastering anxiety and modifying the phantasy-situations. The objective situations symbolize the phantasy-situations and successful mastery of the objective situations gives reassurance about the mastery of the phantasy-situations. To be effective, such symbolization requires that the symbol represents the phantasy object, but is not equated with it. The symbol's own distinctive, objective characteristics must also be recognized and used. If, for any reason, the symbol and the phantasy object become almost or completely equated, the anxieties aroused by the phantasy object are aroused in full intensity by the symbolic object. The symbol then ceases to perform its function in containing and modifying anxiety. The close resemblance of the phantasy and objective situations in nursing constitutes a threat that symbolic representation will degenerate into symbolic equation and that nurses will consequently experience the full force of their primitive infantile anxieties in consciousness. Modified instances of this phenomenon were not uncommon in this hospital. For example, a nurse whose mother had had several gynecological operations broke down and had to give up nursing shortly after beginning her tour of duty on the gynecological ward.

To understand the sources of the anxiety was one thing: to understand why overt anxiety remained chronically at so high a level was another. Therefore our attention was directed to the adaptive and defensive techniques within the nursing service.