ROBERTS, V.Z.: Till detah us do part. Caring and undcaring in work with elderly. str. 75-83 74 Chh Mawson mocking took the place d ~ 4 ~ b e s smd loss until the feelings could be worked through in the p u p &scussions. Ihave tried to demonstratehow impoptantitisforstaffinvolvedin gainfuland stressful work to be given space to think about the anxieties s h e d up by the work and the effects d these anxieties on them. The cost of not having this is considerable, both to clients and to workers. As well as offering much needed suppod, consultation c m offer the opportunity for insight and change in the ,pup and wider institution,ifthe pains and difficultiescan be tolerated. Chapter 8 Till death us do pa^ Caring and uncaringinwork with the elderly VegaZsgierRobeHs Cuing forelderly p p l e bringswith it particularstresses,insofar asageingis the fate of all who live long enough. It inevitably stirs up anxieties about our own future physical and mental decay, md loss of inckpndence. It also stirs up memories and fern about ow selationships with olde~generations, especially parents, but also grandparents,teachers and others, towards whom we have felt and shown a mixture of caring and uncaring. This chapter discusses how these anxieties were dealt with in one geriatric hospital. However, the processes describedexist to some extent in all caring work. Shady Glen was a specializedhospitalfor severelyimpairedelderly p p 1 e who, without being pafticularly ill, required intensive, long-term nursing care.It had two wings: the smaller North %ng had three rehabilitation wads for those patients who were thought Bilrely b be able to leave the hospital eventually; South W i g had four 'continuing-care' war& for those who were not expected ever to be able to live outsidethe hospitai again. The four wards of South W i g were particulariy bleak and depressing. The beds were arrangedina circlearoundtheedgeof eachwad,pintkg towardsthe centre, from where the nurse in cchage could keep a watchful eye on everyone. Squeezedbetween each bed and the next one stood a small wad-oise a d chest of hwers; here was little space for p m d pssessions, and virtually no privacy. A few patients couldmove aboutwith walkers,but theothersspentmost of their time in bed or sittingimmobilein chaips. Most were totally dependenton ihe nwsing staff for dl their physicd needs, md were fed, toileted andbathed on a fixed schedule. The nurses maintained a high standard of physical care. TRw were few bedsores or accidents, little illness, and the patients were clean and well wourished. However, the managersof Shady Glen were concernedaboutthe poor quality of Me for h e patients in South Wing, and asked the senior nurses of the South Wing waPds to form a working party to explore what could be done to improve the situation. It quickly became apparent &at patients9quality of life 76 Vem Zagier Robe* could examined medn@liy odgi in conjeahac~onwith the q d g d Efe for the staffworking on the wards, and dso that other si@ficant hospi@l st& m i d not be leftout of the projectif heal chmge were to take place. The working party was therefore expanded to indude ffie beA of other d e p m e n b proviang patient treatment. Two exbmd cons&-& wen?.bmught into assisttheworkbg ~ a r t y h g a'mut h e stressesin b e conthuing-cm w d , mdconsi&hiwg how these might be mpedwith better. mey were then FQ present heir findings and momendations in a rep13 to fhe se&or nmagers of ShadyGlen. M o d e among the nurses was very Tow, and relationsbetweenthem and theother pmfessional goups involved in the treatment of patients were antagonistic and competitiverather than cohbrative. The rims Eel¬ witholae somejustifl- cation, that they were left to bear the bmnt of the stxenuousbut s routine of physical care, unsupported mi3 mqpe&ciated. This kind o has low statuswithinthe nursing profession -just asthe patientson these wads wuId be said to have low statlas in society- older nurses at ShadyGlen Backed the aaining and technical elcge for jobs elsewhere. They felt their wards were used as a dwping- people that everyone else - doctors, families, society -had given up on and wanted kept out of h e way. but well enough looked aMer thatno one would have t~ feel tm @ty h u t bavhg rejected them. Not only did the nurses get little positive feedback from colleagues, patients or patients9 families, but they got little inner satisfaction from the sense of ajob well done. None of them felt these wads were a place I where they would wish themselves or their loved ones to spend their last years. The division of he hospital into two pats, one for patients who would improve, andmother for thosewho would not, exacerbated the problem fotboth I patients and staff. Many patients did s o n aMer king transferred from M o d Wing to South Wing, as if they had received a death sentence. Staff on the conhuingeare w d s were deprived both of hope and of the satisfaction of seeingat least someof their patientsimprove and movebackintothe c o m ~ v . 1 The alleged rationae fosthis division was that the two kids dpatientsrequired differenttreatmentapproaches. and&atthepresenceof 'incmbbs' would retard the progress of the bss impabed patients, as if their condition were contagious, though there was W e evidencefoe this. i At the sametime,the nurseswere not in the businessdhelpingpatientsto &a, as in a hospice, shce most d&eri~mte$only very slowly and remained on tbe wards for mmy years. Ii was as if & padents were 'on hold', the DUES just 1 strugglingagainst the gradual encm&&ament d decay.]in the face of dlthis,my idealism or enthusiasm in newly arrived naarses. was rapidly extinguished. New ideas they offem? were rejected as hpracticak, OF even sabotaged. As a asal~ tho= with idem md choicesrarely stayed long, md &e staff from @ Caringand uncaringin work with the elderiy 77 other than nursing tended to focus. most of heir sfforts on the re'nabilitaajion wards, adding to the continuing-care nursesbense of being abandoned. In the absence of the usud nursing goal of assisting patients to get well, the nurses did the best they couM to keep patients as well as possible, which transIated &to keeping them safe: preventing accidentsby keeping mobility a~ a minirnm discouragingthekeepingof personalpossessionswhichmight get bst or stolen, keepingpatientsonstof thekitchenin casetheyburnedthemselves. This policy, while depriving the patients of in&vidd$ and &,pity, addpd to the, quantity of work to be done by the nurses, so bere were rigid schedules for ,tosetjinganddressingIsLordertogetitdrill b e . Fuathe / . e omis, like occuptional thempkts and pbsiotRmpists, Y oriented towards increasing patients9mobility and ~nd~bndence,and since the services they offered tended to clash with ward routine, friction bet wee^ the various disciplines was inevitable. CONSrnTATEON The antagonismbetween the nurses and s h y &omotber depamnents was so gxat that the two consdtants initially worked q m b 1 y , one c t~ the senior nurses on South Wing and the other to the heads of the nts glr~vidiing specialistinputst~ the wards: spec4 occupationaltherapy and physiotherapy. The plan was hat the two p u p s would each h t explore their own concerns md develop their own ideas for impving the quality d life on Swth Wing,and later cometogether to work onjoint rec(p-n&h to makeb management. The nurses were at first apatheticandresistant to the whole project. They had worked on the continuing-care wads for a long time, were cynical about managers' implementingmy of their suggestions,and were in my case sure that very little could be done, given the extent of the pa?ients' disabilities. Everyone found their attitude very frustrating;even the senior nursing offlcer, who usually defended 'her' nurses from chiticism from outsiders, chided them for under- mining the project. En contrast, the members of the oher p u p were young, enthusiastic md full of ideas. As Reads of their own departments, they were zcustomd to making decisions fairly autonomonsly, and for many weeks they worked eagerly at coming rap with new programmes and plans for improving the quality of life on the wads. But the initial excitementgradually gave way to &scomgement, as they anticipated -or actually encounte~d-the nurses' resistance to their ideas. Finally, the group became listless and work ground to a hale, everyone complaining, 'What's the point when they just won't CQ-operate?' The project had reached an impasse. A chance occurrence some months into the consultancy changed this. Someone intempted a meeting to ask for a patient's record, and it was reveaied &at many speech, occupational md physiotherapyrecords were months behind. This was the first h e that any deficiencyin Me work of these departments was 78 Vega Zagier Roberts recognized. The group now began to work at reviewing their own services and improving them, rather than blaming everything on the nurses and focusing on how to make them change. They worked without the earlier excitement, but with more effect. At the same time, without there having been any formal c~ntact between the two groups, the nurses became livelier in their meetings with their consultant, corning up with ideas of their own to contribute to the project. Within a few weeks, the two groups started joint work onwhat could now be experienced genuinely as a shared task, rather than a vehicle for apportioning blame. They drafted proposals for a new approach to continuing care, and these became the core of the mnsultants' report to management of their findings and rewmmend- ations (Millar and Zagier Roberts 1986). THE REPORT ?he central recommendation was to re-defie the primary task (see Chapter 3)of the wards. Up to this point this seemed to have been to prolong physical life, keeping the patients in as good physical condition as possible for as tong as possible. The proposal was that it should be 'to enable patients to Live out the remainder of their lives in as full, dignified and satisfying a way as possible', which might or might not includetheir moving out of the hospital. This definition would mean that all the various professionais involved in patient care could see their particular work as contributing to a common purpose, rather than having conflicting and competing aims. This change in task definition had major implications. It invited re- examination of practices previously taken for granted, such as the nurses' emphasis on safety as a priority, with its consequent depersonalization and loss of dignity for patients. Instead, the new aim required considering how to encourage such independence and autonomy as were possible, identifying differences between patients, so that somecould make their own tea or leave the ward unescorted, even if others could not, and even if some moderate risk were involved brovided thepatient wished to do so). 'This not only gave patients more self-respect and choices, but lightened the workload for staff and restored some meaning to their work. The greater dignity and sense of personal identity for patients if they wore their own clothes, no longer had wristband identification and had their personal possessions around them came to be regarded as outweighing the risks involved. The new primary task definition also had implications for how the hospital was structured, that is, where boundaries needed to Se redrawn. Boundm.es delimit task-systems (see Chapter 3). Wereas before each discipline or department had had its own discrete task, and,was therefore managed as a separate system, the new definition of a shared task required a new boundary around all those involved in patient care. (This is described in more detail in Chapter 20.) Furthemore, the separation of rehabilitation from continuing-care wards no longer had any rationale, since their previously different aimswere now Caring and uncaring inwork with the dderly 79 subsumed under a single task definition. By doing away with this, some hopefulness wuld be restored to the work. Finally, the report recommended developing improved support system for staff, particularly during the period of transition from the old way of working to the new. This is discussed further near the end of this chapter. ANXTETIESAND DEFENCES IN IMSTmBmONS FOR INCI The situation of severely disabled people who arG neither dyingnor likely ever to improve enough to leave an institution produces particular anxieties both in the residents and in those caring for them. Miller and Cwynne (1972)made a study of institutions caring for people with incurable, mostly deteriorating, physically disabling illnesses, but much of what they described is very similar to what was happening on South Wing. For the residents, entering this kind of institution is inevitably accompanied by a sense of having been rejected - by family, employers and society generally. Those inside such institutions are not neces- sarily more handicapped than those outside, but they have actually been rejected, if only by having no family to look after them, or no money to pay for care at home. Crossing the boundary Lito such institutions meansjoining the categoryof non-contributing non-participants in society: they lose any productive role they may have had, and with this, often, all opportunity to continue making decisions for themselves. Being treated differently from self-caring and able-bodied people, they experience great 10s:'I am no longer what (who) 1was.' Ht is as if they are aiready socially dead, although they may be years away from physical death. The staff of such institutionscan also have feelingsof having been rejected and abandoned. Projective identification processes (see Chapter 5) can contribute to their over-protectiveness of the patients and their anger at patients' relatives and their own colleagues. These were not the only diffacult feelings which emerged during the mn- suitation to Shady Glen. Others included staff members' anger at uncooperative patients and hatred of their failure to improve; discomfort with being still relatively young and healthy; anxieties about their relationships with fhe ageing members o i their own families, and about their own ageing; and guilt for preferring someof their charges and treating them differently, while wishing they could be rid of some of the others, which could happen only through death. Defences by the staff against becoming too aware of ibese disturbing feelings included depersonalizing relations with patients by treating them as objects, and by sticking to rigid routines; avoiding seeing common elements between themselves and the patients; illness, absenteeism and exhausting themselves to avoid feeling guilty. There was also an enormous anxiety throughout the care 1 Readers who have struggled to promote the personalization and dignity of clients and patients in institutions like those described here may object to the use of words iike 'incurables' and 'inmates'. However, these stark terms, used by Miller and Gwynne in 1972, have been retained here not only for historical ieasons but aiso to underline the harshness of the expxiences being discussed, which can be glossed over by using more modem and politically correct language. 80 V q a Zagier Roberts staff doout being blamed. This probably arose Iagely from the& internal and unconscious conflicts, but was attributed to their being held responsible for keeping patients safe and well. lt produced a preoccupation with patients' safety, rigid routines designed to minimize the chance of making mistakes, and a hostile defensiveness towards colleagues and paiients' relatives. The widely felt, but largely denied. doubts about the adequacy of the semice contributed to the pervasive tendency towards blaming others. W0 MODELS OF @ anxieties inherent in any work give rise to institutional defences in the form of structures and practices which serve primarily io defend staff from mxiety. rather than to promote task performance. Miller and Gwynne (1972) identified rwo models of care in institutions for incurables, each involving a different central defence.The first, the medrcal or humanitarian defence,was based on the principle that prolongation of life is a good thing. This tends to be acmmpanied by denial of the inmates' unhappiness, lack of fulfilment and sense of futility. Inmates' ingratitude is an affront to these vaiues. Tnis defenceproduced what the researchers called the warehousing model of care, that is, encouraging dependence, and depersonalizing inmate-staff relations and care. A 'good' inmate 1s one who passiveiy and gratefully accepts being looked after. The s a n d , the anti-medical or liberal defence, was based on the view that inmateswere really normal, 'just like everyone else', and could have as fulia Me as i before, if only they could develop all their potential. This defense produced what Miller and Gwynnecalled the horticultural modelof care, defining the aim of the instirution in terms of providing opportunities for the growth of abilities, while , denyingdisabilities.The= tends to be excessive praise for minor achievements,like the praise adults give for a smalI child's first drawings, and denial of inmates' failure to achieve social status. A 'good' inmate here is one who is happy and I fulfilled, active and independent. Eventually, of course, nearly all of them fail. I It is easier to see the inadequacies of the warehousing model, but the other is also inadequate: the demand for independence may be distressing to somepeople whose physical and mental strength is declining. In many cases, they have been I struggling for years against increasing infirmity, and some may give up this struggle with relief upon entering a nursing institution. Others want to continue to fight. These two types need different kinds of care and different atritudes in their carers. When models of treatment arebased on defensive needs in the staff, however, these kinds of distinctions among different clients' needs may not be made, since they require tho~ghtand fadng reality. Instead, one rnodeh is likely to be applied indiscriminately to all, on the basis of being the 'right' way towork, rather than as appropriate for the needs of a given individuaI at a particular time. Both models represent unconscious psychological defences against unbearable anxieties aroused by the work, and by the very meaning of the inmates' having entered the institutiorn. There is guilt about the social Caring and uncaring inwork with the elderly 89 death-sentence that has been passed, and ambivalence about whether at least some of the patients might not be better off dead than alive. Simiiar splits occur in other institutions, for example, between cure and care in work with the mentally ill (see Chapter 13) or with the dying (see Chapter 10). In a13 these cases, care terids to be unjustly devalued, while cure is p;ursued against ail odds. Both the medical and the liberai defences were operating at Shady ~len,'hefirst 1 among the nurses, the second among the specialist therapists. Each g h u p was unquestioningly committed to its own model. The therapists blamed the poor quality of life forpatients at Shady Glen on the nurses' being unco-operative and too set in their ways to entertain new ideas. The nurses agreed they were resistant to the quality-of-life project, but insisted this was for good reason: no one else was placed asthey were to realize the fullextent of the patients' disabilities. They also felt hostile towards the more privileged staffwhocould leave work at 5 p.m. and did not have to dirty their hands with the 'real' work: easy for them to have these airy-fairy ideas! Only they behaved redistically and responsibly; it was thanks only totheir disciplined care and unswerving routines that the patients had any quality of life, free of the bedsores, iiinesses and injuries soprevalent in other geriatric care settings. Each group had split off and disowned unacceptable parts of themselves, projecting these into the other group, who were identified with the projections (see Chapter 5).Tne therapists unconsciously counted on the nurses to attend to details, and so did not take responsibility for these, which led to the nurses' being all the more weighed down and having to stick to routine all the more rigidly. Similarly, liveliness and hopefulness were split off in the nurses and projected, defending them against guilt and disappointment, while the therapists became virtually manic in their planning. As a result of these intergroup projections, the nurses actually were rigid, and the therapists were inclined to be careless. In the first phase of the consultation, members of the specialist group were excited and hyperactive in producing ideas and plans, the impracticality of which they blamed on the nurses -and the nurses accepted this blame. Over time, the euphoria associated with this kind of manic defence - that everything was possible, if only others would not stand in the way - gave way to angry helplessness and a listless feeling of being stuck. The recognition by rhe therapists of a shortcoming in themselves - small enough not to have to be immediately denied, but significant enough to provoke self-examination - led to their beginning to re-introject split-off parts of themselves, including responsibility for routine, and recognition of their own and also their patients' limitations. Taking back these projections not only increased their capacity for realistic work, but permitted them to value more the actual and potential contribution by nurses to patient care. Freed of the projections, the nurses were enabled to re-own hopeful parts of themselves, previously split off to defend against disappointment and depressive conCems, and to be@ $0e,rhaquish some of heir o m obsessive preoccupation with mutine. As aschgroup becamemore able to value the other, less anxiousabut king blamedand therefopeless prone toblaming the other, it became possible for them to think together about "now to bring about improvements in h e patients' q d t y d Me, and &us also in their o m . The 8econusnenalatiom to the naamagemml5, to =-define ?he primary a t and d r a w the defensiveboundariesbetween gmfessionaldepartments(see Chapter 20) and between rehabilitation aad conthuing-care w d s , were designed to reduce the institutional splits which were impairing rather than supportimg the q&ty of Eie at Shady Glen. However, since institutional defences arise in response b the anxieties inherent in h e work, dismantling defensive structures requires providingalternativesfmctures tocontainthese anxieties.The find paat of the q r t , therefore, focused on ways of developing new kinds of support systems. 'Wese were of threeEn&. In the first instance, because of the stress&ess a d strenuousnessof their work, the swff needed their efforts to be recognized and valued, with explicit acknowledgement of work well done. They a h needed more face-to-face contact with the hospital management to counteract their sense of being marginalized,rejected and of bw s&W.This mightbeachieved b u g h regular visitsto the war& by seniormanagers, to review s t a R n d and *rRedevelopment of their new practices. Second, staff needed a time md glace where it would be possible - and actively encouraged - to reflect together on heir work md how it was carried out. In small goups with continuity of membersip, amd with positive support from management, staff might then begin to acknowledge some of the unacceptable feelings m s e d by their work: b e few, &s&e and even hatred they sometimesfelt towards theif work and the patients, and the anxieties s h d up by &e constankproximity to human decay. Wenvise, they could onjly defend &emelves in the kinds of cwnteqrductive ways we have seen. Often, just king able to face these feelings with coUeagues can reduce the need for such defences. This, in &m,can lead to more effective task p d o m c e , which produces more work satisfaction,which hrtber reduces anxiety: a benign cycle. (For M e r examples of this prwess, see Chapters7 and 10.) Finally, there needed to be mechanisms for inviting, considering and implerwenhg ideas for change froma everyone in the system, whatever heir status (mcluding patients and their relatives), so hat everyonecould participate in joint problem-solving and feel a sense of conhbuting towards a s h a d purpose. Such a forumcould sene to support thoughthi ks~mtionalself-=view and development, as described towards the end of the next chapter, In place of tbe rigid, stagnant working practices and entrenched intergroup conflicts wMch had previously characterized Shady Glen. Cadng and urnring Inwork dega ;he elderty 33 CONCL%ISIOM Dictionary defitions of care range from affection and soFcihde, to caution, tesponsibi2ity, oppression of the mind, anxiety and grief, Cafe staff can experience their work in all of these ways. Containing such a specmm of emotions is psychologicdiy stresshi. Simce ageing is the inevitable fate of,,dl who live long enough, personal mxieties znd primitive fantasies a b u t death sr,ddecay add to the strains of loohring after the elderly. The pressures to &lit pos~tivefrom negativefeelings are likely to be.particularly acute. We have seen how at Shady Glen this splitting was exacerbat& by the waiy the hospital was organized, with its divisions among the disciplines amd between rehabilitation Tind continuing care. In all caring work there are elements of uncaring. To be 'weighed down by responsibility' invites flight h r n the caring task, which can at h e s be hateful. Obsessional routines of care can serve to protect patients from carers' uslconscioushate, from what staff fear they might do to those in their charges if not controlled by rigid discipline. At the same dme, these routines can provide organizationally sanctioned ways of expressing hate of patients who exhaust, disgust or disappoint staff. Alternatively, all hate is projected, amd the patients9 hatefulnessdenied by seeingihem as totally curable. Tn his short but seminal paper, 'Hate in the Countertransference', Wmicott (1947)discussed the hate inevitablyfeltby psychoanalystsfortheirpatients, and by mothers for heir babies. He stressed that the capacity to tolerate hating 'without doing mything about it' depends on ow's being thoroughly aware of one's hate. Otherwise, he warned, one is at risk of fallingback on masochism. Alternatively, hate -or, in less atic tern, uncaring -will be split off and projected,with ihnpovemshent of the capacity to offer god-enough care. Whicoa's p a p has given 'permission9to generations of psychotheqists to face previously unascepealble -and &ereforedemied and projected -aegative feelingstowards their patients. hdeed, to become conscious of such feliragshas become a hndawental paxt of their irainhg. Such permission - from within ourselves md from the envbment - to xbowhedge and o m the uncaring elementsin omelves and our 'caring' 'isasdtutionsis a c i d , both for b&vi&al well-being, and for the provisionof effectiveservices.