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&not witholae somejustiflcation,
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 undermining
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 rewmmendations
(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 reexamination
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 necessarily
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 mnsuitation
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.