I. Nursing Times, 3 February
The matron of a general teaching hospital asked us to assist her colleagues and herself in developing a new method of allocating student nurses to practical work.
While engaged on this task we became interested in other aspects of the nurses’ experience. The nurses appeared to experience a great deal of stress in their work: for example, worry, fear, guilt, depression, shame, embarrassment, strain, distrust, disappointment. They made frequent references to such feelings when they talked to us. In addition, they behaved in ways which were familiar to us from working with normal people in situations where they experience stress.
Further, wastage among student nurses was heavy and sickness rates were high, mostly minor illnesses requiring only short spells of absence from duty. Social and medical research strongly suggests that such phenomena are an expression of a disturbed relationship between people and the organization in which they work, and are connected with stress. Such feelings may arise even when people have, in other respects, a good deal of satisfaction in their work, as the nurses did.
We have also noticed stress among nurses with whom we have worked in other hospitals and elsewhere. Phenomena such as high student wastage and sickness rales are common in British hospitals. Stress seemed to us, therefore, to be a problem of the profession arising from the professional situation, rather than a matter of the individual nurse’s personality. We set ourselves the task of trying to account for the stress in the hope that this might indicate steps which could be taken to change the professional situation and so relieve stress.
Souces of Stress
The sources of stress may seem so obvious as hardly to merit comment. For example, nurses confront suffering and death as few other people do. They work with ill people also under stress. They face heavy demands for pity, compassion and sympathy. They are often expected to do the impossible in the way of providing comfort or cure. Many nursing tasks are by ordinary standards disgusting, distasteful and frightening. Physical contact with patients may be over-stimulating and disturbing. Patients are sometimes difficult and nurses find themselves getting irritable or resentful. Such feelings seem unworthy of their profession and arouse guilt and anxiety. Indeed, there is no scarcity of situations which expose nurses to stress.
However, the fact that nurses are in a stressful situation is not a sufficient explanation of why they actually experience so much stress. One must consider also how they deal with stress. A nurse, like everyone else, has her personal defences, but these were not our concern. However, social organizations as such also develop defence mechanisms: that is, established methods of helping their members to deal with disturbing emotional experiences- methods which are built into the way the organization works. This is an extension of the familiar idea that a social organization must work in such a way as to provide adequate psychological satisfactions for its members as well as performing its tasks with reasonable efficiency. We could presume, therefore, that the nursing service would have set up social defences to protect its members against the stress arising from their work, although this would not, of course, have been the result of an explicit decision.
We examined the way the service worked with a view to evaluating the protection it gave against stress, while facilitating also the performance of the tasks of patient care and nurse training. This meant that we considered such questions as how the service was organized; how the task of patient care was actually carried out; what son of behaviour was prescribed for nurses; traditional attitudes to work, patients or colleagues; and interpersonal relationships.
I will confine myself in these articles mainly to phenomena within the nursing service, although I am aware that there are other important relationships, notably with doctors.
The core of the anxiety lies in patient care and in the relation ship with the patient. An examination of the ways in which the nursing service mediates the relation between patient and nurse, formally and informally, shows that they reduce the impact of patient on nurse and offer some protection from the subsequent anxiety. In general, the organization of the nursing service militates against close and prolonged contact between the individual patient and nurse, although nurses often want such contact and teaching emphasizes its importance. In a typical ward a group of about eight to ten student nurses with a sister and staff nurse look after about thirty patients. Consequently, the student nurses – and, indeed, the qualified nurses – perform a few tasks for each of a fairly large number of patients and it is difficult to establish close personal contact.
The service also reduces in various ways the direct impact of person on person. This amounts to a sort of depersonalizing of both nurse and patient. Patients tend to be described by bed numbers or illnesses. The nurses in this hospital, like other nurses, deprecate this practice, and senior nurses teach emphatically against it. But the practice continues by custom among student nurses because it alleviates stress. Nor is it easy to learn the names of patients, especially in large wards with a rapid change of patients and nurses. A common attitude among nurses, shown in behaviour rather than words, is that any patient is the same as any other patient. On the positive side, this implies that all must receive the same careful nursing. As a corollary, it implies that personalities should not matter nor be taken overmuch into account. This implication is being fought, but persists. Preferences for particular patients or even types of patient are discouraged and nurses find it hard to admit to them.
Much the same depersonalization is true about nurses. They are treated as ‘categories’ – for example ‘second-year’ – rather than as individuals. Duties, responsibilities and privileges are, on the whole, accorded to categories rather than to individuals with their own capacities and needs. If all patients are the same and all nurses are the same, at least by seniority, it follows that it should not matter to the patient which nurse or how many nurses nurse him, or to the nurse which patient she nurses. The nursing service functions as though this were true, although both patients and nurses know it is not. Patients are nursed by many nurses at one time, and even more over a period of time. The expression of the nurse’s individuality in work is discouraged. The nurse tends to be an agglomeration of nursing skills of a certain level depending on her phase of training, rather than a person doing a job according to her own capacities and skills.
The nursing service also helps in achieving detachment from patients, a necessary objective for all professions working with people. Thus, student nurses were constantly being literally ‘detached’ from one work situation, their colleagues and patients, and sent to another, as though these should not maner. In time one could say they learned by bitter experience not to become too ‘attached’ because that made the distress of constant parting too severe. The nursing service, as such, seemed to act as though that kind of ‘detachment’ was helpful, although most individuals were quite well aware of its painful effects and disliked it.
Protecting Nurses From Stress
The nursing service tries, therefore, to protect nurses from stress by fostering nurse-patient relationships which are often short and always rather tenuous. This does not prevent nurses from suffering great distress on occasion. Warm personal feelings still develop between nurses and patients; nurses care deeply about the welfare of their patients. They can be very upset by what happens to patients, by deaths, doctors’ or nurses’ mistakes, pain and emotional stress. Such feelings are hard to bear. There are certain accepted attitudes and behaviour in relation to such distress, at least while the nurse is on duty and in a working relationship with close colleagues. The emotional disturbance is denied as far as possible and dealt with by brisk, though kindly, remonstrances of the ‘pull yourself together’ variety. Expressions of strong feelings are discouraged. Comfort, reassurance or help from an understanding colleague or superior in the work situation are not usual, although nurses give each other much support in off-duty friendships. This learned attitude of denial of stress offers some protection against its conscious experience. Further, the restraint on expressing feelings offers some protection against spread of the distress among nurses who work closely together.
II. Nursing Times, 10 February
Making decisions is always stressful because it implies making a choice and committing oneself to a course of action without full knowledge of the outcome. The resultant stress is likely to be particularly acute when decisions directly or indirectly affect the well-being, health or even life of patients, as many nursing decisions do.
The nursing service seems to offer some protection against such stress by reducing the number of possible decisions that must actually be made, and substituting precise instructions. Nurses are implicitly or explicitly forbidden to make decisions about certain things. The reduction of decisions has been carried farthest in the work of the student nurse. Very precise intructions are given about the order and timing of her tasks, and the way they must be performed. The service expects her to follow these instructions exactly: she must not, for example, decide that a change in the workload of the ward merits a change in the order of her tasks or even the omission of some less necessary tasks. Similar attempts have been made to eliminate decisions made by senior staff, although this has inevitably not been carried so far, since their roles are more complex and precise instructions less possible. For example, they are not expected to decide what each student can and should do. This is determined by her category, except in unusual circumstances.
When decision-making cannot be avoided several techniques are used, both formally and informally, to minimize its impact on any one person. Decisions are checked and counterchecked, as are the executive actions consequent on them. Consultation about decisions is a deeply ingrained habit. This is not only true of certain obviously dangerous procedures such as the administration of dangerous drugs. It affects all kinds of decisions, including many that are neither important nor dangerous.
Responsibilty and Conflict
Taking responsibility may be satisfying and rewarding but always involves some conflict. Nurses experience this conflict acutely. The responsibilities of the nursing profession arc heavy and nurses usually have a strong sense of personal responsibility. They often discharge their responsibilities at considerable personal cost. However, the very weight of the responsibility makes it difficult to bear consistently over long periods and nurses are sometimes tempted to escape from it, and to behave irresponsibly.
We observed a customary but implicit technique through which nurses handled the painful conflict over responsibility. Briefly, this amounted to turning the personal conflict into an interpersonal one. The nurses tended to refer to nurses junior to themselves as ‘irresponsible’, and treated them as though this were true. On the other hand, most nurses referred to themselves and their seniors as ‘responsible’, the implication being that they were not only more responsible than their juniors now but always had been. In addition, they tended to regard their seniors as unduly harsh disciplinarians.
A Psychological Tidying-Up
What happens seems to be a kind of psychological ‘tidying-up ‘ through which one’s own irresponsible impulses and those of one’s equal and superiors are not perceived where they really are but are attributed to juniors. Thus one need not feel unduly guilty or critical of oneself, but takes action to discipline the ‘irresponsible’ juniors. Likewise, one’s own burdensome sense of responsibility and often harsh self-criticism are attributed to seniors. One therefore expects to be criticized harshly by seniors and may behave so as to provoke their criticism, but one avoids some painful self-criticism. This makes for rather tense relations between categories of nurses, but spares each individual a good deal of her personal conflict.
In a more formal sense, the burden of responsibility is avoided by a considerable vagueness in the definition of responsibili1ies throughout the nursing hierarchy. The student nurse’s task-lists look very specific, but students often exchange task-lists and not infrequently have two in the course of a single day, since nurses come on and go off duty at different times. So it becomes difficult to find out who has done, or even who should have done, what, and who is responsible for its being well or badly done. It is possible to be increasingly less specific about responsibility as the roles become more complex, and as the actual responsibilities become heavier. This prevents responsibility from falling fully and clearly on one person and protects nurses against the resultant conflict.
There also seemed to be a tendency to force responsibilities upwards through the nursing hierarchy, to try to hand over responsibility to people who are older or more experienced and who, because of the customary attitudes to seniors, are regarded as ‘ more responsible’. This seems to result in senior nurses having actually less responsibility than would be expected from comparing their hierarchical positions with similar positions in other organizations, and from an estimate of their personal capacities. Many nurses are better than their jobs. We were able to watch responsibility being pushed up the hierarchy in this way as new nursing tasks and responsibilities grew out of changes resulting from our study.
Resistance To Change
Change, like decision-making, arouses stress since it implies giving up a familiar present for a relatively unknown future. The nursing service seems to cope with this by avoiding change whenever possible and clinging to familiar ways of doing things, even when these are becoming demonstrably inappropriate. The case of student allocation was an example: the old method had long been a source of stress and the decision that it must be changed came very late. It is surprising to an outsider how little the service has changed to meet the increasing demands made by the introduction of the National Health Service and radical changes in medical practice.
III. Nursing Times, 17 February
I will now consider why the social defences of which I have given some typical examples in the first two parts of this article were inadequate, as shown by the persisting unduly high level of stress.
It has long been known that the individual whose psychic defences are based on evasion remains a prey to emotional disturbances and is vulnerable to stress. He cannot experience painful feelings fully enough and cannot, therefore, discharge them. On the other hand, the person who can face painful feelings and difficult situations more fully grows in psychic strength. He can understand better the nature of the stress and. of the situations which evoke it. He can reduce the degree of stress by developing greater capacity to deal with stressful situations. But if he is a member of an organization which relies heavily on evasive social defences, he is in much the same plight as an individual who uses evasive psychic defences because he cannot develop his own defences.
Evasion Inhibits Growth
This is the sitation of the nurse. While on duty she has little choice but to accept protection against stress by evasion, since her attitudes and behaviour must conform closely to those required by the service, implicitly or explicitly, formally or informally; that is, she must accept the social defences and use them as her own. The evasive social defence system actually inhibits the development of the nurse’s capacity to deal with her stress and to experience it less acutely.
An example may make the point clear. A student nurse is ‘protected ‘ against the stress arising from making decisions by having the decisions she is allowed to make reduced to a minimum. This deprives her of many opportunities to learn how to make decisions effectively, to test them and to experience their consequences. This slows the development of her skill in making decisions and her ability to reduce stress through the reassurance of decisions well made and growing confidence in the skill to nuke them. Instead, since decisions cannot always be eliminated, nurses come to face them without sufficient assurance from experience that they can make effective decisions, and therefore stress continues. One had the impression that few nurses were really secure about their ability to make wise decisions. In other words, one may say that the social defence system protects nurses, to some extent, from experiences of stress at the moment, but at the expense of its more permanent reduction.
The Responsible Nurse
In some ways the social defence system protects students and qualified nurses against stress and difficulties which many of them are quite capable of handling successfully. There seems little doubt that many student nurses could take and enjoy more responsibility than the service now allows.
To give point to this, it may be necessary to clarify what is meant by responsibility. It seems that in nursing circles a ‘responsible’ student nurse is one who loyally and faithfully carries out her prescribed tasks. This is a departure from ordinary usage, where responsibility is closely linked with using discretion. That is, a ‘responsible’ person is one who is capable of using discretion wisely in doing his job, ‘discretion’ being just what the student nurse may not use. Many student nurses are capable, given appropriate help, of making, maintaining and enjoying continuous relationships with patients. They want to do this and are taught that it is desirable, but the system of work organization prevents them from doing it.
People enjoy facing difficulties and enjoy and need the challenge they present, provided the difficulties are not beyond their capacities. Success can be a great reassurance. Overprotection makes it impossible for many nurses to deploy fully in their jobs their personal capacities and professional skills, and experience real success. Indeed, the more mature and capable the nurse, the greater the problem. This situation is extremely frustrating to nurses who feel inhibited from doing their best for their patients and colleagues. Student nurses tend to feel this most keenly, but the feeling is shared to some extent at all levels in the hierarchy. Nurses feel guilty and anxious about it. Thus the overprotection built into the social defence system itself evokes stress.
Efficiency and Responsibility
There are other ways in which the service itself gives rise to stress. For example, it is not very efficient as a method of organizing work. In this the nursing service is not at all unusual. Similar phenomena are to be observed in other kinds of social organization. They stem from the fact that in establishing a way of operating, a social organization cannot be concerned only with efficiency but must take into account the psychological needs of its members. Because of the high element of real danger in the nursing situation, care for the psychological needs of nurses tends to play a relatively large part vis-a-vis technical efficiency in determining the structure and method of functioning of the service. Some efficiency has had to be sacrificed, though not by conscious decision, to evasion of anxiety. Inefficiency in this sense is determined by the organization and is not a matter of an individual behaving inefficiently. Indeed, people who are behaving in one sense ‘efficiently’ – that is, carrying out instructions carefully and well – feel ‘inefficient’ because they consider they are violating the general principles of good nursing or of common sense.
I can give only a few examples of such service-determined inefficiency which increases stress. The fact that student nurses and staff cannot deploy their personal capacities fully, as described above, is one example. It is very wasteful of human resources. Further, nurses, at least student nurses, are on occasion not fully occupied. This arises from the rather rigid system of work organization which makes it difficult to adjust to changing demand in a ward by reorganizing their work. Ward establishments tend to be aimed at peak rather than average workloads and wards seem somewhat overstaffed. Nurses feel guilty about being underemployed whether in respect of time or capacity, and this increases stress. The system is also cumbersome and inflexible in a situation which increasingly demands flexibility: for example, decision- making tends to be slow. This makes nurses anxious lest decisions are not made in time and irritable about delays in important matters.
Satisfaction Balancing Stress
This account would be incomplete without referring to the satisfaction which nurses experience in their work; such satisfactions are a very important counterbalance to stress. The potential rewards of nursing are great in terms of such things as the recovery of patients, suffering relieved, and satisfying relationships with patients and colleagues. The nurses in this hospital clearly experienced their work as rewarding.
However, they did not seem to be experiencing the full potential reward because of certain features of the social system. For example, while the nursing service had considerable success in nursing patients, it was difficult for any one nurse to experience this in a personal way. The task-list system makes the contribution of one nurse to the nursing of one patient rather small. The reward is dissipated as well as the stress. Patients are grateful to ‘the hospital’ or ‘the nurses’ – that is, rather impersonally – and the individual nurse misses the personal gratitude which is part of her reward. For student nurses an important satisfaction is the development of their knowledge and skill in nursing patients. The training and work situations quite definitely slow down this development. The better the student the less satisfaction she finds in the rate of development of her nursing skills. Indeed, our feeling was that the better students suffered a good deal in this respect and a significant number of them could not tolerate it and gave up training.
Nor is it possible, under present conditions, to realize at all fully the potential satisfactions in working with colleagues. Student nurses feel this particularly. For example, the traditional relationship between juniors and seniors described above means that the student nurse feels herself singled out more for blame than praise. This she finds very distressing, as she has a particular need for encouragement in settling down to her difficult profession. The student nurse tends to feel she does not matter as a person. They complain: ‘nobody cares what happens to you’, ‘nobody helps you’, ‘you have no individuality’. They say the senior staff neither understand nor help them when they are in trouble – indeed, when they are worried and guilty about a mistake they are reprimanded instead of being comforted.
It was not, however, our experience that the senior staff did not understand or care. They understood only too well, many of them having vivid and still agonizing memories of their own training. They expressed their understanding and sympathy to us, but felt unable to do so within operational relationships. They were often uncertain about the wisdom of entering into a close emotional relationship with their students, and uncertain of their skill in handling it. Their training had not prepared them for this. They tended to fall back on the only behaviour they knew – the discipline and severity they experienced in their own training. In any case, it is not easy for student nurses to approach their seniors for that sort of help, since by tradition they expect seniors to be disciplinarians. However, as a result of this situation, many senior staff feel they are not helping their colleagues and juniors enough and, in turn, miss the satisfaction which comes from really helping colleagues in need.
We have little doubt that some action to remedy the situation described is desirable, especially since we have no reason to believe that this hospital differs in any significant way from other hospitals. It is clear that there is no simple solution; if there were, it would have been introduced long ago. The ultimate solution must be a restructuring of the system of work organization and nurse training, so that it incorporates a different kind of social defence system based less on evasion. For example, one might try systems of ward organization which give nurses more continuous and intensive contact with patients; this would require new techniques for dealing with the stress that would arise initially, especially among the junior student nurses. Together these would mean an earlier confrontation of stressful situations and, if successfully handled, would lead to an ultimate alleviation of stress.
In our opinion, blueprints for change are not possible although one has a general idea of direction. The most hopeful. approach to the problem of change at this stage would seem to be to tackle it in a concrete rather than an abstract way: for example, to work in one hospital or even a part of a hospital and try to build a working model. This approach, through model-building and progressive modification of models followed by dissemination of successful models, has proved successful in building and rebuilding other kinds of social organizations. It is our hope that we have been able to contribute to the understanding of the nursing situation and so to the design of such new models.
We began our study four years ago and our description of the hospital refers to that period. Since then a number of important developments have taken place partly as a result of the study. These can be regarded as attempts at partial new models. For example, a new system for allocation of student nurses is now in operation which gives longer continuous duty tours; new training has been introduced for the post-certificate student to give more experience of administration and more real responsibility; an attempt is being made to develop a closer and more supportive relationship between the teaching staff and the student. We are very grateful to the hospital which gave us the opportunity to carry out the study and permission to publish this paper. We are particularly grateful to the nurses for their serious and courageous co-operation with us in what proved to be a long and arduous investigation and for their sincere efforts to use the research findings.