Journal of Health Services Research & Policy >
Volume 13, Number 4 >
Pp. 249-250
Worth a second look |
National Primary Care Research and Development Centre, University of Manchester, UK
Correspondence to: ruth.mcdonald{at}manchester.ac.uk
To interpret events at the hospital Menzies-Lyth drew on the ideas of Melanie Klein1,2 and Elliot Jaques.3 The former conceptualized individuals as ‘splitting’ unwanted and anxiety provoking feelings into good and bad ‘part objects’. This splitting originated from early conflicts experienced at a subconscious or phantasy level in infanthood. Unless resolved, these conflicts persisted into adulthood, leading to adoption of the immature and dysfunctional position. Klein contrasted this with the mature integrative position where individuals were capable of accepting bad and good objects co-existing in themselves as well as other people. According to Klein, at times of stress adults may regress to splitting and project bad objects outside of themselves. Elliott Jaques, building on Klein's ideas viewed events in organizations in the context of social systems which develop as a defence against persecutory anxiety.
Menzies-Lyth described the way in which anxieties generated by the ‘primary task’ of a hospital (to care for the sick and dying) led to the development of collective defences that became institutionalized in working practices and social systems. The work situation facing nurses, caring for the sick and dying, aroused strong and mixed feelings in these members of staff (pity, compassion, guilt, anxiety and hatred, resentment and envy of the care given patients). She identified strong parallels between the ‘objective situation’ facing nurses in their working environment and the phantasy situations that exist within individuals in the deepest, most primitive levels of the mind. The nature of the nurses' work situation with proximity to intimate bodily processes and issues of life and death threatened to stimulate anew situations and associated emotions which can be traced back to early infancy. In addition she identified a number of overt and subtle factors – patients', relatives' and colleagues' demands on nurses, which reflect the anxieties of individuals – that increased nurses' experience of stress. However, these factors alone could not account for the high levels of anxiety she and her team observed.
She identified a range of techniques which developed at the hospital to contain anxiety in the nursing service. These include ‘splitting up the nurse–patient relationship’ by ensuring nurses deliver a small number of tasks to a large number of patients, ‘depersonalization and denial of significance of the individual’, ‘detachment and denial of feelings’, ‘the attempt to eliminate decisions by ritual task-performance’, reducing the weight of responsibility by checks and counter checks' and ‘avoidance of change’. Importantly these techniques although aimed at the alleviation of anxiety contributed little to its modification and reduction. Furthermore, they created secondary anxieties that themselves created defences.
She described how the heavy burden of taking responsibility and nurses' ‘irresponsible’ impulses (e.g. to avoid boring tasks, to become emotionally attached to a patient) had the potential to create intrapsychic conflict. To alleviate this, the conflict was converted into an interpersonal one with nurses habitually complaining that other nurses were irresponsible, behaved carelessly and impulsively and needed to be disciplined. At the same time, many complained that senior staff were unnecessarily strict, treating them as having no sense of responsibility. The complaints usually referred to whole categories of staff (juniors, seniors). Although anxiety was reduced by attributing all irresponsible impulses to the juniors and strictness and harsh discipline to the senior nurses, the result of this ‘collusive system of denial, splitting and projection’ was that such projective processes went beyond the psychic level since they became the reality of organizational life, with people acting according to these roles assigned to them.
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This study also suggests that the nature of the task in hospitals is a major source of workplace anxieties threatening the organization's culture, productivity and capacity to respond to change. In a context where great emphasis has been placed on learning from other industries (e.g. safety lessons from aviation), Menzies-Lyth demonstrates how the primary task facing hospital staff creates specific anxieties which may limit such learning. Building on this work, others have identified anxieties as relating not only to hospital staff but to patients and society more generally. For example, Obholzer4 writes that an ‘integral part of the unconscious social system that is intended to shield us all from death is the requirement that the office bearers of the system – in this case the doctors – be as powerful as possible... it is hard for the system and its functioning to be questioned... Any tampering with the system creates a great deal of anxiety and resistance on all sides.’
A key contribution of the study is that it draws our attention to the importance of anxiety5 and alerts us to the fact that organizational change is likely to be perceived as threatening defences against anxiety. This means that we need to explore the extent to which changes intended to improve quality are likely to produce maladaptive social defences, which prevent learning from occurring and/or increase anxiety. For example Menzies-Lyth found that reducing the exercise of discretion had little impact on the primary anxiety experienced by clinicians while at the same time arousing a great deal of secondary anxiety. Yet many quality initiatives aim to reduce the exercise of discretion by, for example, increasing use of guidelines and checklists. Furthermore, her findings draw our attention to the adverse effects of guidelines and checklists. They may reduce anxiety but at the cost of absolving staff of the requirement to exercise initiative and take responsibility. (In her study a nurse woke a sleeping patient in order to give him a sleeping draught as to do otherwise would have been to contravene the explicit instructions.)
Whereas most health services research tends to conceptualize health care staff as rational, if cognitively flawed, individuals, a major contribution from this study is that it highlights the importance of emotional and non-conscious human processes and their implications for conscious experiences, activities and interactions. When appeals to rationality fail, the policy response is often a call for greater effort, but as Menzies-Lyth illustrates the surface ‘problem’ may be merely a symptom. For those who wonder why progress on safety culture has been so slow,6 for example, this paper and consideration of subconscious processes more generally, may provide some answers. But it may make unsettling reading. I'm guessing, but focusing on the rational may reduce our anxiety, since framing problems in this way makes them appear easier to solve. Perhaps Menzies-Lyth would have something to say about that!
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