When Florence met Freud: interaction and intersection between psychoanalysis and nursing

Abstract

A theoretical paper which considers the previous multiple attempts by nursing to engage with and usefully apply the theories of psychoanalysis to varying aspects of the nursing role. References to psychoanalysis within the nursing literature of the last century are reviewed and the legitimacy of the use of psychoanalytic theory ‘outside the clinic’ explored with reference to general hospital nursing in the UK’s National Health Service. Themes explored include unconscious motivation behind nursing as a career choice, with associated risks of stress and burnout when the unconscious drive to heal is thwarted. Psychoanalytic consideration of nurse-patient relationships provides insight into the patient experience on hospital wards, whilst exploration of other aspects of the nursing role was found to be limited. From a wider perspective, psychoanalysis offers nursing an insight into societal changes impacting the profession. The systems and processes of the healthcare institution have also been explored, particularly in relation to containment of anxiety, though limited practical impact has resulted from the psychoanalytic insight encountered in the literature. The limited engagement between psychoanalysis and general nursing is considered from both a psychoanalytic and nursing perspective; ongoing potentiality for enriching dialogue between the disciplines is established and potential barriers explored.

Keywords:

• psychoanalysis
• nursing
• healthcare
• psychosocial

Introduction

For Freud, psychoanalysis was knowledge of the mind, a method for treating neurosis and a tool for research, based on the use of free association to find patterns and meanings from speech. Freud was primarily a medical doctor who treated patients on the couch in his consulting room, an artificial setting which facilitated free association on the part of the patient and intense listening on the part of the analyst. The psychoanalytic clinic is therefore described as the space in which a patient in psychological distress encounters an analyst, who alleviates this distress through listening and interpretation (Frosh, 2010).

Within the nursing literature of the last century, there have been multiple attempts to apply the theories of psychoanalysis to different aspects of the nursing role; these will be reviewed and the legitimacy of the use of psychoanalytic theory outside the clinic setting explored with reference to nursing. Whilst emphasis is on general hospital nursing in the UK’s National Health Service (NHS), work conducted by nurses working in psychiatric and international settings has been included where this is of more general relevance. It is also worth highlighting the use of gendered language within this text. In earlier nursing literature, the convention was to refer to the nurse as female and the patient as male, as will be evident from quotations provided. Whilst academic conventions have changed, nursing as a profession does remain female-dominated – as of last year, only 11.5% of nurses in the UK identified as male (Nursing and Midwifery Council [NMC], 2022).

The role of the nurse needs little introduction or explanation; it is perhaps useful to provide Henderson’s (1966) classic definition of 1966: ‘the unique function of the nurse is to assist the individual, sick or well … to help him gain independence as rapidly as possible’. She later added ‘Florence Nightingale said that what nurses do is to put people in the best condition for nature to cure them’ (1980, p. 247). Dual-trained nurse/psychoanalyst Fabricius (1999, p. 205) described nursing as ‘the willingness and capacity to think about people who are suffering in order to give proper consideration to their problems and appropriate ways of helping’. The early nurse theorist Hildegarde Peplau, recognised as the ‘mother of psychiatric nursing’ (1952), drew on elements of psychoanalytic theory, influenced by Klein and the psychiatrist Sullivan in her development of an interpersonal theory of nursing and being (Winship et al., 2009). In 1963, Denn (1963) recommended that to improve psychiatric care, ‘opportunities be provided for the nurse to increase and enrich her background in the psychoanalytic field’ (p.97). In the 1990s, nursing theorists drew attention to a lack of definition of the relationship between psychoanalysis and nursing, described as an ‘uneasy alliance’ with feelings of antipathy towards psychoanalysis predominating among nurses (Winship, 1995). Whilst earlier references can be found in the literature, it was during this time that nurses began to more seriously engage with psychoanalysis (Fabricius, 1991a, 1991b, 1995; Wright, 1991). Watson, an American nursing theorist (1999) described a post-modern theory of nursing in Jungian terms, focussing on innate potential for growth and healing with a ‘shared consciousness’ between patient and nurse; ‘transpersonal caring moments’ were felt to invoke archetypes of the nurse as woman and mother and link to the collective unconscious. Lacanian theory in particular is seldom encountered within the general nursing literature; McSherry (2013) described how an understanding of Lacanian concepts of the real, symbolic and imaginary might helpfully inform psychiatric nursing practice in six ways: ‘against normalization, the importance of the function of the symptom, what cannot be known, meaning as ever-changing, against empathy and against holistic ideas of the self’ (p. 776).

While Peplau and her successor’s theories have had some influence among general nurses, particularly in the USA, British nursing theory has focussed on bio-psycho-social aspects of the nursing process with an underlying humanistic philosophy. Whilst psychiatric nurse training may include a brief introduction to psychoanalytic concepts, this is not typically incorporated within the training of general nurses. In 2003, Gallop and O’Brien (2003) noted that psychoanalytic approaches had fallen out of favour in nursing due to the length and financial cost of treatment and increased focus within both nursing and medicine on biological models of disease and evidence-based practice. However, some nursing academics did continue to engage with psychoanalysis during this time. The aim of this paper is to explore the relationship between psychoanalysis and nursing, with particular reference to general hospital nursing, before considering the impact of this relationship on the nursing profession and the potential for ongoing inter-disciplinary engagement.

Why nurse?

It has been suggested that personal motivation for choice of profession is largely unconscious (T. Main, 1957). From a psychoanalytic perspective, Stokes (2019b) links choice of profession to unconscious pre-disposition to relate to groups in a specific way, based on Bion’s concept of valency towards a basic assumption (Bion, 1961). Choice of profession has been linked to an unconscious desire to resolve past issues, with a decision to enter a helping profession potentially based on conscious idealism with unconscious determinants (Roberts, 2019). Such determinants are typically described in Kleinian terms as a drive to reparation, arising from concern or guilt, aiming to heal emotional wounds or damaged internal objects. For the nurse, reparation occurs through identification with patients as symbolic representatives of damaged internal objects, with some separation maintained in order to move between clinical professionalism and empathic identification (M. Evans, 2014; Fabricius, 1991b; Segal, 1957). Dual-trained general nurse/psychoanalytic psychotherapist Dartington (2007) describes how reparation may occur through aspects of nursing care which resemble situations from childhood or infancy and the ‘ordinary general nurse’ has been compared to the ‘ordinary devoted mother’ (Winnicott, 1960): ‘she looks after patients out of an inner need, and largely does what comes naturally’ (Fabricius, 1991b, p. 98). It has also been suggested that the use of the self in caring for patients is an unconscious attempt for the nurse to prove their inner ‘goodness’ (Roberts, 2019). Psychiatric nurses McMillan and Aiyegbusi (2009) advocate for self-awareness on the part of nurses, ideally developed through personal therapy, to identify the personal vulnerabilities that have drawn them to their choice of profession and which may interact with clinical work; they also view nurses as vulnerable to projection onto and from other disciplines within the healthcare team.

Nursing stress and burnout

Dartington (2007) describes desire for reparation as healthy, noting the psychic economy of stimulating healing in others whilst healing ourselves. However, such unconscious motivation has been linked to high levels of stress within the nursing profession. Burnout in particular has been linked to failure to heal the nurse’s own wounds through a failure to help patients or a feeling that their work is insignificant (Pines, 2002). Additionally, Speck describes how the desire to be the ‘perfect nurse’ can lead to significant stress, both for the nurse and their patients, whilst ‘the recognition that one can perhaps be a good enough [nurse] without being perfect, can be very liberating’ (2019, p. 125). According to M. Evans (2014), difficulties arise when a nurse loses the capacity to distinguish between their patients and their damaged internal objects, leading to confusion between their internal and external world and feelings of defeat or manic effort to heal the patient. Nurses frequently encounter failure to heal patients; if their work is not gratifying, they may respond through development of psychosomatic symptoms resulting in sickness absence from work and eventually resignation from their role. Alternatively, psychic defences may lead to development of ‘a hard external skin that gives the impression of cruel indifference’ in order to distance the nurse from their patients (M. Evans, 2014, p. 197). More recently, compassion fatigue and moral injury among nurses have been considered from a psychoanalytic perspective; stress of decision-making was framed as an assault on ego integrity with subsequent reduction in functioning (Gerard, 2017; Lesley, 2021).

Nurse-patient relationships

The nurse-patient relationship has been considered psychoanalytically; it has been recommended that nurses take into account Balint’s view of GPs, ‘that by far the most frequently used drug in general practice was the doctor himself’ (1957, p. 1). The nurse may identify with the patient through their own previous experience of anxiety and suffering, demonstrating understanding of the patient’s pain through carrying out clinical tasks with compassion. Provision of fundamental nursing care through supporting patients with activities of daily living has been described as psychotherapeutic in itself, linked to Anna Freud’s concept of developmental lines (1966; Roper et al., 2000). Nursing presence, viewed as a vital component of nursing care in ‘being there and being with’ the patient (Davis, 2005, p. 129) allows the nurse to be used psychically as the object required by the patient at the time, typically in terms of containment of anxiety (Bion, 1962; Fabricius, 1991b).

Dartington describes intimate moments between patient and nurse, involving strong emotions, for example, the nurse knows that ‘when patients wake up after major, life-risking surgery and see her face, they may experience her as an angel, not because they are hallucinating, but because she is associated at that moment with the beauty of being alive’ (2007, p. 177). Whilst nurses are aware of their impact on patients during moments of fear or pain and instances when patient and nurse ‘experience the individuality of the other’, there is limited acknowledgement among nurses of the job satisfaction to be gained in such moments. It is suggested that, as the nurse receives the patient’s embarrassment regarding their regression and dependency, ‘a degree of secrecy about the mutual fulfilment of the nurse’s reparative and maternal instincts and the patient’s appropriate dependency needs’ is maintained (Dartington, 2007, p. 177).

Medical doctor/psychoanalyst Conran compared the experiences of mentally and physically unwell patients in hospital from a psychoanalytic perspective, identifying many similarities between the two situations. Regression, dependency and projective identification were recognized in a patient’s response to unexpected illness and the loss of control this involved. Anxiety was projected into the patient’s family and healthcare professionals to be contained as the patient was cared for,

but with it has gone also the capacity to look after himself and take decisions about himself … bereft of that adult part of himself he is now child-like, indeed he has infantilized himself. To such a state of affairs we also offer the designations regression and dependancy, and, in such circumstances, we regard them as perfectly legitimate. (M. B. Conran, 2008, p. 33)

Regression of the physically unwell patient is viewed as adaptive, allowing them to conserve their physical and psychic resources for their healing process whilst the nurse supports some of their ego functions. This has been linked to Winnicott’s concept of maternal holding in both a physical and psychical sense by Fabricius, including the therapeutic use of touch and taking into account ‘the patient’s move forward from the regression and readiness to take back these functions for himself’ (1991b, p. 100).

Day-to-day nursing work

Within the nursing literature, psychoanalytic theory has typically been used to explore theoretical aspects of the nursing role, as described above, with less attention paid to practical use of the concepts in day-to-day work. Within psychiatric nursing, psychoanalytically informed clinical supervision has been recommended as ‘a framework for understanding the relationship between the internal world of the patients, the therapeutic relationship and the social system [in order to] develop and maintain therapeutic factors while reducing the risk of damaging behaviour and beliefs’ (M. Evans, 2006, p. 16). Foster (2020) recently evaluated the impact of a psychoanalytic work discussion group for mental health nurses; the group positively impacted on building therapeutic relationships, participant understanding and knowledge, leadership, team cohesion and professional identity. Mental health nurses have also used psychoanalytic theory to explore difficulties regarding maintenance of therapeutic boundaries, considering the impact of a patient’s early life experiences on staff/patient dynamics (Darnley et al., 2012) and the importance of organisational culture in addressing systemic factors which might compound boundary issues (Kelly & Wadey, 2012).

Integrating a psychodynamic aspect into nursing work has been advocated in order to improve patient care, particularly in forensic mental health nursing (Aiyegbusi, 2009). Working with neonatal intensive care nurses, child psychotherapist Bender (1981) discussed her experience of running a staff group where nurses expressed feelings of anger, rivalry and hostility, along with pain and helplessness around the death of infants; nurses were required to contain projections of idealisation, potency and hope from parents along with envy of them as capable surrogate mothers. Defence mechanisms employed included avoidance, denial, withdrawal of emotional investment and manic reparation such as superstition. Fabricius (1991a) described how general nursing students also benefitted from supervision groups in learning to work with their feelings about patients.

Wiltshire and Parker (1996) drew on the work of Winnicott and Bion to describe the end of shift nursing handover as a site of holding and containment; handovers have also been described in terms of ritual protection against unconscious phantasy, symbolic of ‘both erotic and sadistic prohibitions in nursing in that love and hate for the patient is a forbidden knowledge for the nurse’ (A. M. Evans et al., 2008b, p. 46; S. Freud, 1907). An observational study drew parallels between general and psychiatric intensive care nursing, with patients in both areas described as being vulnerable and regressed to even an in utero state where ‘the required response of the nurse … arguably epitomises the scientific maternal function of nursing’ (Winship, 1998, p. 361). In relation to mental health nursing, Kay notes that ‘it is clear then that of all the roles in the helping professions, the nurse’s is most akin to that of mother. It is the forensic mental nurse who is given the most complex demanding patient (baby) possible’ (2009, p. 39).

Transference and nursing

The psychoanalytic concept most widely encountered within the nursing literature is that of transference. Schroder encouraged psychiatric nurses to consider the possibility of transference and countertransference not only in their therapeutic relationships with patients but also when working with doctors or authority figures. He described a ‘generalised’ transference among nurses whereby a ‘childhood desire to please, to be complimented and treated warmly by the father, combined with some awe and fear, is recreated with the physician’ (1985, p. 23). This may be a somewhat dated view; it is important to acknowledge that nursing is not a static profession with a static identity.

Psychiatric nurse Kay describes the countertransference relationship with patients with complex, psychotic states of mind, who may ‘project their painful states of mind into those who “nurse” them. A consequence of this is that the nurse is often left feeling hopeless and despairing or hateful’ (2009, p. 39). T. Main (1957) described use of splitting mechanisms by nurses in terms of labelling particular patients as difficult, typically in response to feelings of helplessness. Whilst more widely explored within psychiatric nursing, attempts have been made to consider transference relationships in general nursing, for example, in relation to drug-dependent patients (Winship et al., 1995). Jones, a dual-trained general and psychiatric nurse/psychoanalytic psychotherapist, considered transference and repetition in relationships between general nurses, their patients and their managers, stressing the benefit of such exploration in terms of professional development and patient outcomes (2005); Australian nursing academic/Lacanian analyst A. M. Evans explored anxiety and transference in nursing practice in relation to patients and other healthcare professionals, noting that this could enable psychical holding within the nurse-patient relationship (2007; A. M. Evans et al., 2009). Splitting and projective identification were identified in the responses of patients with dementia towards nurses (Berman & Bezkor, 2010). A case study of a gastroenterology nurse working with an anorexic patient described the impact on the nurse in terms of envy and awareness of her own body image and ageing, with the nurse acting in response to anxiety rather than clinical need in her management of the patient (Swatton, 2011).

Within the nursing literature, definitions of transference and counter transference are diverse and contradictory. Attention is primarily drawn to nurse-patient relationships, typically the nurse’s emotional response to the patient (O’Kelly, 1998); nursing has been described as ‘a fervent testing ground’ for the effects of transference, given the context of empathic understanding and unacknowledged feelings (A. M. Evans et al., 2009). It has been suggested that greater attention could be paid to transference and countertransference during nursing assessment and care planning (Miles, 1993). The benefit of recognition of transference is described in terms of improved patient care, nursing knowledge and professional growth, with group supervision suggested as a useful means to highlight its occurrence (Regan, 2012).

Psychoanalysis and nursing research

Psychoanalytic theory has been utilised to a limited extent within nursing research. Jones conducted a psychoanalytic study of the Macmillan nurse role in palliative care based on Klein and Bion’s concepts of projective identification, containment and reverie (1999, 2001). Influenced by Sartre, Jones described his approach as ‘existential psychoanalysis’ as a research method useful to explore concepts which defied simple or logical definition and to make sense of ‘seemingly irrational behaviours’ linked to the experience of serious illness (2001, p. 371). Norwegian psychosocial researchers Ramvi et al. (2022) conducted a psychoanalytically informed interpretive study of nursing home staff responses to death, highlighting avoidance of talking about death as a defence against anxiety, with a research methodology aiming to identify unconscious material within data gathered through semi-structured interviews. The ‘free associative narrative interview method’ originally described by Hollway and Jefferson (2000) was found by nurse researcher/psychoanalytic psychotherapist Archard (2020, 2022) to be helpful in terms of developing nuanced accounts from qualitative interviewing. However, he cautioned that some non-psychoanalytically trained nursing researchers who describe their work as ‘psychoanalytic’ or ‘psychoanalytically informed’ have demonstrated lack of clarity around psychoanalytic concepts, suggesting that without psychoanalytic supervision of the work it remains simply in-depth qualitative interviewing. There has also been little consideration within such research of the implications of taking the concepts and techniques of psychoanalysis outside the consulting room (Archard & O’Reilly, 2022).

Lacanian psychoanalysis and nursing

Lacanian theory in particular is seldom encountered within the general nursing literature. McSherry (2013) described how an understanding of Lacanian concepts of the real, symbolic and imaginary might helpfully inform psychiatric nursing practice in six ways: ‘against normalization, the importance of the function of the symptom, what cannot be known, meaning as ever-changing, against empathy and against holistic ideas of the self’ (p. 776). Also, in the context of psychiatric nursing, Badin et al. (2018, p. 2161) suggested that transference could be utilised to guide nursing care through its ‘elaboration of what has no meaning in the symptom’ with symbolisation of the symptom being the overall aim of the nursing process. A. M. Evans et al. considered occupational stress in nursing, using a Lacanian approach to map ‘the discursive formations arising out of nurses’ distress’ to explore this from an alternative perspective (2008b, p. 202). The Lacanian concept of jouissance was applied to consideration of professional identify within nursing, drawing on Hegel’s master-slave dialectic (1807/1979). By positioning themselves as martyrs or slaves within the healthcare system, nurses were described as maintaining the fantasy of potential autonomy, avoiding ‘facing certain unsettling questions by continually understanding their lack of fulfilment as the responsibility of another’ (Traynor & Evans, 2014, p. 198). Recently, nursing theorist Traynor (2023) considered core nursing concepts through the work of Freud, Lacan and Žižek. Caring, compassion and empathy are described as signifiers of fundamental value within nursing ideology, problematic in the context of hostility in unconscious phantasy. Repeated research into caring is described as ‘an endless failure’ and viewed as a demonstration of the death drive, similar to repeated complaints about management or working conditions and leading to satisfaction through repetition of failure. It is concluded that psychoanalytic insights in relation to nursing may lead to ‘freedom from painful and self-destructive symptoms inherent in such work’ (Traynor, 2023, p. 1).

Societal changes and impact on nursing

From a wider perspective, psychoanalysis offers nursing an insight into societal changes impacting the profession. Bell describes an ideological shift occurring in 1980’s Britain, whereby the welfare state was reconceptualised from provision of basic necessities through state duty, to enabling disempowerment into helpless invalidism: to ask for one’s right to have one’s basic needs met is to be treated as if suffering from a state of infantile dependence and to be dominated by a delusion of an inexhaustible supply of provision for one’s needs (1996, p. 48). Attacks on human need were described as deriving from a split in the personality between awareness of vulnerability and a replacement of this with arrogance, hatred and idealisation of destructiveness, described as ‘destructive narcissism’ following the work of Herbert Rosenfeld (1971). Bell further describes ‘survivalist mentality’ within the NHS, whereby ‘survival itself becomes the only value, [and] life itself loses meaning’ (1996, p. 55). This is linked to the ‘stock market of health’ through which healthcare professionals are ‘commoditised’. A. M. Evans (2005) describes the ‘colonisation’ of the psychiatric service by managerialism, with positioning of patients as consumers potentially also positioning them as ‘illegitimate and unsuffering’. Within this system, where ‘materialism replaces the mother’, nursing as nurturing was denigrated by association with the maternal … ‘nurses are there to be used up and discarded, or so it would seem in the current climate’ (Wright, 1991, p. 148).

Shifts within the health service and wider society were highlighted within the nursing literature of the time, underpinning a quest for increased professional status for nursing from the late 19^th Century (Davies, 1995). Gordon (1991) described how need for care could be viewed as an emotional or physical flaw in a market society where individualism was emphasised. Contradictory societal attitudes towards nurses have been linked to them, serving as a reminder of dependency and vulnerability (Dartington, 2007). Nursing theorist Hart (2004) felt that it was the fear of nurses as liminal between patient and doctor and patient, life and death, which underpinned their devaluation in society. This has also been considered in terms of gender, with Davies (1995) noting that ‘nursing reminds us of the very vulnerabilities and dependencies that are edited out of masculinity’ (p. 183). She described nursing as ‘a much conflicted metaphor in our culture, reflecting all the ambivalences we give to the meaning of womanhood’ (p. 179). Nursing was further described as embodying the ‘feminine’ qualities of subordination, devotion, self-sacrifice and passivity which feminists found problematic (Hart, 2004); underpinnings of duty and servitude have also been highlighted as having a religious component (Traynor & Evans, 2014).

Drive for increased efficiency spurred movement towards positivism and ‘evidence-based practice’, which did not fit with a nursing knowledge base derived from the lived experience of nurses (Hagell, 1989). Nursing at the time was denigrated as ‘menial’ particularly in relation to medicine, with idealisation of ‘the cure’ and academic or technical competency, just as ‘the original nursing task, between a mother and her baby, is sometimes seen as menial’ (Fabricius, 1999, p. 206).

Health service processes and systems

The concept of a health service has been considered from a psychoanalytic perspective, described by Obholzer as ‘a receptacle for the nation’s projections of death … a collective unconscious system to shield us from the anxieties arising from an awareness of illness and mortality … our health service might more accurately be called a “keep-death-at-bay” service’ (2019, p. 177). This was particularly evident during the early stages of the COVID-19 pandemic, when ‘clapping for carers’ took on almost a religious significance and the NHS became something to be protected at all costs.

In terms of individual healthcare institutions, Conran describes how the splitting and projective processes of the patient are carried out through a variety of different staff members, including nurses;

the more there are who ‘understand’ the safer the patient feels, secure, as he must be, that nobody has it all and that therefore nobody understands. The general effect is then that so long as everyone knows, or thinks he knows, something, there is little likelihood of a synthesis occurring which risks being returned to the patient as words. (M. B. Conran, 2008, p. 39)

The systems and processes of the healthcare institution can therefore be seen to permit and encourage such transferential processes in an attempt to reduce both patient and staff/organisational anxiety (M. B. Conran, 2008). Bott (1976) described a situation where psychiatric hospitals were ‘used to treat and house, individuals who are acting as the receptacles of the madness that their relatives cannot bear to face’ (p. 97); one doctor she interviewed described the hospital as being ‘like schizophrenia itself, split up in bits, projections all over the place, parts not communicating with other parts. Things are always getting lost in this place – people, ideas, decisions’ (Hinshelwood & de Mare, 1979, p. 90). Scanlon and Adlam (2009, p. 134) describe how those working in forensic mental health institutions face pressure to ‘inhabit unhoused and violent states of mind’ with potential for such institutions themselves to become dismembered and traumatized through anxiety relating to failed dependency (Hopper, 2003). With the institution in a fragmented state, activities which would potentially develop group cohesion tend to be avoided or attacked (Hinshelwood, 1994).

In relation to nurses in particular, Isabel Menzies Lyth (1960) explored institutional management of anxiety. Contact with illness and death was linked to an arousal of primitive anxiety in the nurse, who projects their infantile phantasies into their work, which is then experienced as ‘a deeply painful mixture of objective reality and phantasy’ (Lawlor, 2009, p. 527). The nurse is also subjected to projection from patients and relatives and risks becoming overwhelmed by anxiety as a result; with reference to the work of Bion (1959) on containment, Menzies Lyth (1960) described how institutional policies and procedures served to manage this. This included task-focus to reduce nurse-patient contact, ritual and depersonalisation of both patients and nurses, for example, through wearing of uniform, avoidance of decision-making, initiative and individual accountability, with a tendency to pass uncertainty and decision-making upwards through the nursing hierarchy. Menzies Lyth (1979) further described how a lack of shared purpose and vision among staff could lead to confusion, conflict and reduced job satisfaction.

Commenting on Menzies’ work, Fabricius described how the shift from task-oriented care to the ‘nursing process’ of care planning and individualised care became a new defence focused around record keeping, preserving the dynamic equilibrium with ‘no real change … at the level of the nurse-patient relationship’ (1991a, p. 102). The force and quantity of projections aimed at nurses required a level of containment lacking in the NHS of the time (1991a). Reviewing Menzies Lyth’s work almost 50 years later, Lawlor found that it had made very little impact within healthcare institutions (2009); Menzies herself felt that whilst attention had been paid to her work on anxiety, no attempts had been made to re-design institutions in order to offer staff sufficient containment (1988). Containment could be provided through a relatively unchanging, coherent and clearly structured organisation, conversely, ‘when organisations seem fragile and unpredictable, they become more like a rather inadequate foster parent than a second home’ (Stokes, 2019a, p. 143). M. Evans described a combination of top-down management and target culture which had served to push survival anxiety down to front-line NHS staff, with insecure and anxious management being unable to provide containment and reverie; ‘anxiety and blame are pushed around the system like a pinball bouncing back and forth between the different areas of responsibility’ whilst ‘the institution employs defences based on splitting, projection, denial, idealisation, denigration and manic triumph’ (2014, p. 207). Fotaki and Hyde (2015) identified ‘organisational blind spots’ where splitting, blame and idealisation enabled the commitment of NHS organisations to unfeasible strategies, with significant impact on clinical staff.

Hinshelwood describes how staff morale is based on having both a sense of purpose and ‘a sense of securely belonging to an integrated social group that devotes itself to the purpose’ (1979, p. 93). If morale is lost, individual staff are forced to maintain their psychological wellbeing in ways which may increase institutional fragmentation and further erode the sense of common purpose, with the end result being hatred of the job, attacks on the institution, collective hopelessness and a ‘fragmented, demoralised hospital community’ with such institutional breakdown viewed as ‘a psychological illness of the hospital itself’ (Hinshelwood & de Mare, 1979, pp. 90–91).

Discussion

Through a review of the literature, it seems that psychoanalysis has much to offer nursing in terms of provocation and challenge, consideration of irrationality and phantasy and deepening insight into the complexity and difficulties faced by the profession. This seems to be an instance in which a meeting of minds may be mutually productive; the challenge here is not to justify the use of psychoanalysis, but to employ it productively and with integrity (Frosh, 2010).

Psychological reductiveness is a danger, for example, in theorizing around occupational choice; as of September 2022, there were 716,060 registered nurses in the UK (NMC, 2022). There is significant diversity among nurses in the UK; according to the NMC, 64% of nurse registrants identify as White English/Welsh/Scottish/Northern Irish, with the next highest responses being Black African (9%), Filipina/Filipino (6%) and Indian (5%) (NMC, 2022). In the year to March 2023, of 52,148 new NMC registrants, just under half were trained outside the UK (651 trained in the EU/EEA; 24355 trained outside the UK or EU/EEA) (Nursing and Midwifery Council [NMC], 2023). This may impact the relationship with psychoanalysis; as Frosh (2021) notes, psychoanalysis has had an uncomfortable history in relation to ‘race’ and racism’ with a previous tendency to align itself with colonial, conformist and potentially repressive tropes, ‘worlding’ people in ways that privilege some over others (Khanna, 2003). Whilst psychoanalysis could be criticised for eurocentric vision, failure to fully address racism and focus on the inner world rather than sociopolitical issues it is still possible to consider its potentiality for antiracism; ‘if the unconscious acts as a subversive, pleasure-seeking, disordered “space” within the psyche of every human subject, then it is not possible to hold onto a racist assumption that some groups are more “civilised” than others’ (Frosh, 2021, p. 415). El Shakry describes how psychoanalysis is potentially helpful in contemplation of relationships between the self and other, psychopolitics and decolonisation, and the psychoanalysis of race and racism, through consideration of categories such as race, religion and culture (2022, p. 21). Frosh (2021, p. 416) describes ‘a powerful influx of psychoanalytic work from writers of colour’ occurring over the last two decades, challenging absences previously identified in the literature, including the psychoanalytic work of antiracist social theorists (Butler, 2020). Therefore, there seems to be potential for nursing to benefit from psychoanalytic insight whilst supporting the psychoanalytic agenda towards decolonialisation and anti-racism.

Given the cultural diversity and significant age range of those in the nursing profession, it is evident that any generalisation must be extremely tentative. It is equally important to recognise, as Traynor and M. Evans (2014) emphasised when describing their work as speculative, that nurses’ unconscious fantasies are unconscious; we do not have direct access to them.

Caution has been advised when using psychoanalysis in relation to fields of which we do not have detailed knowledge, or when using psychoanalysis as a non-analyst, with associated risk of distortion of psychoanalytic concepts (Frosh, 2010). Within the nursing literature, such concerns seem to have been addressed only in relation to the use of psychoanalysis in nursing research, though interestingly, much of the literature concerning psychoanalysis and nursing has been composed by dual-trained nurse/analysts. For example, Wheeler (1991) described the profound effect of psychoanalytic training on her nursing practice in terms of developing therapeutic relationships and enabling her to ‘see’ on a different level. This does, however, raise the question of how much self-analysis is present in such authors’ generalist conceptualisations of the nursing profession as a whole.

The legitimacy of using psychoanalysis ‘outside the clinic’ has been questioned; given that the focus of this review has been general hospital nursing, this area is perhaps less ‘outside’ than others. For many nursing theorists at least, nursing presence and the therapeutic relationship are at the core of nursing practice; similarly, relationality has been described as the primary concern of psychoanalysis (Frosh, 2010). Nursing and psychoanalysis both take the form of ‘live encounters’ between nurse or analyst and patient. Freud noted that ‘the business of psychoanalysis is to secure the best possible psychological conditions for the functioning of the ego’ (1937, p. 402), which brings to mind the descriptions of nursing work with which this review was introduced. Multiple parallels with psychoanalytic work can be found in Wright’s description of nurses as working

on the edge between the psychical and the emotional, the self and the other, the conscious and the unconscious … we enter the private space of our patients when we deal with their physical needs, or administer treatments. We face difficult and embarrassing situations several times each working day. We undertake tasks which originally belonged to the maternal relationship. (Wright, 1991, p. 148)

Additionally, Conran describes how patients ‘get better and hit the distinction between needs which have to be met and wishes which it is not our business to gratify. In this respect, nursing and psychoanalysis share an identical principle’ (1991, p. 110).

Nursing has been described in terms of both art and science (Henderson, 1980), with conflicts between maternal, caring functions and technical skill and knowledge; the impact of positivism and evidence-based practice on nursing has been highlighted. Similarly, psychoanalysis has been criticised for a lack of empirical grounding; whilst Freud’s initial endeavours were rooted in scientific materialism, those who followed him have tended to focus on questions of meaning (Frosh, 2010). To differing extents, nursing and psychoanalysis seem to have both suffered from societal marginalisation in a culture of consumerism, ‘evidence-based practice’ and cost-effectiveness; whilst nursing responded by emphasising technical and managerial aspects of the role (removing much of the ‘nursing’ in the process), psychoanalysis maintained its focus and awaits a turning of the tide. In general, nurses are more of a ‘known quantity’ than psychoanalysts, though both figures attract curiosity, projection and phantasy such as the mother-nurse and father-analyst.

Psychoanalysis relies on an ‘artificiality’ of setting, regularity of presence and a specific relationship within which interpretation can take place. As psychoanalysts have specific expertise in working with patients in this setting, this may not be generalisable to other circumstances, though it has been extended to use in groups, therapeutic communities, and to some extent, in psychiatric hospitals (Frosh, 2010). A general hospital ward environment does have an element of artificiality and positions the ill person as playing the role of ‘patient’ with implicit expectations for both patient and staff. The nurse provides regularity of presence and a specific relationship; regression on the part of the patient is common; the nurse may adjust her way of working to meet the individual patient and in response to their feedback. The aim is for the patient to recover and be discharged through mechanisms which include a psychotherapeutic component, as whilst the nurse does not interpret the speech of their patients they may still offer holding and containment.

Of course, there are notable differences between the practices of psychoanalysis and nursing, for example, in terms of physical contact with patients, which in relation to nursing care may at times be very intimate. Treatment objectives differ, as do the financial and contractual agreements surrounding the work, and there is a significant difference in working conditions. A psychoanalyst arguably occupies a higher societal status, perhaps linked to the previously discussed positioning of nursing as female-dominated profession. It is interesting that nurses who re-train as psychoanalysts do seem to leave nursing behind to differing extents, though it might be argued that on some level, the psychoanalyst ‘nurses’ to a greater extent than does the typical nurse. Whilst similarities between the roles have been described, the role of the psychoanalyst may provide greater autonomy, transformative potential, deeper and longer-term patient-centred therapeutic relationships and greater freedom from the rigidity and bureaucracy of institutional practices.

Consideration of the similarities between psychoanalysis and nursing would suggest potential for a fertile relationship through which both disciplines could grow and develop, though this has not been the case thus far. The meeting point between psychoanalysis and nursing does not typically emerge as a conversation between professional colleagues. Rather, nursing seems to be cast in the ‘patient’ role, suggestive of Moi’s (1985) description of psychoanalysis as the ‘man of science’ encountering the ‘hysterical patient/nurse’ both in an attempt to reduce their suffering but also to bring them into line of order and reason. Nursing has long endured attempts of such nature; the nursing literature abounds with historical and feminist consideration of difficulties inherent in a ‘female’ profession in a society valuing the masculine. It seems clear that to put nursing ‘on the couch’ would generate a healthy level of resistance, as is found in any analysis. Psychoanalysis is critical, questioning of normalising tendencies; it generates insight which is disruptive of current positioning and can therefore be disturbing; ‘the “shock” of the unconscious is often too much to bear’ (Frosh, 2010, p. 8).

Nursing is not keen to be disturbed; we encounter the same issues time and again, each time devising a different strategy to combat them and each time failing. Healthcare has been described as ‘an industry largely ‘repressed’ (Gerard, 2017, p. 366), reinforcing anxiety through bureaucracy and setting of standards and reluctant to explore deeper issues. M. Evans (2014) describes the defence systems identified by Menzies Lyth (1960) as ‘illusive and hidden from view, and easily lost and forgotten, needing to be rediscovered again and again’ (p. 52). Whilst a small number of nurses have engaged with psychoanalysis, there has been very little feedback on suggested theories and conceptualisations; Menzies Lyth (1960) for example, is widely cited within nursing literature with little questioning or further development. Nursing seems unwilling to be psychoanalysed, as this would be antithetical to protocol, procedure and our ultimate defence of ‘evidence’; it would also involve nursing thinking on a level to which it is not accustomed.

Strategies to counter nursing’s suffering have been ‘prescribed’ in the literature, including greater support from senior colleagues (Dartington, 2007), improved management and increased clinical discussion (M. Evans, 2014), developing insight into the practitioner’s choice of profession and their personal valency and vulnerability to projection, ideally through personal therapy (Jones, 2005; Roberts, 2019; Swatton, 2011), maintaining an external perspective and monitoring projected anxiety (Obholzer, 2019), learning from related fields where psychoanalytic insights have been incorporated, application of psychoanalytic theory to current organisational structures and a deeper consideration of the ‘powerful motivations buried deep in the recesses of our minds that shape not just organizational life, but our very understandings of sickness and health’ (Gerard, 2017, p. 366). It does seem that many of these strategies represent better ‘parenting’ of NHS staff by their employing organisations. Initial work by Fabricius (1991a) suggests a psychoanalytic approach might be beneficial within nursing education, with student nurses invited to consider their own personal motivation for entering a helping profession, their feelings towards patients, how they interact within groups and so on; in addition to this, student nurses are ideally situated to notice and to challenge the status quo.

Whilst such suggestions have been made, implementation and evaluation within clinical practice has been minimal. Aside from nursing resistance, it is likely that psychoanalysis is responsible to some extent for its relative lack of impact on nursing. It may be that psychoanalytic rigidity and the limited way in which it has often dealt with social systems has reduced its relevance to nursing. Frosh (2010) describes the tension between the critical capacity of psychoanalysis and its tendency towards conformism in relation to its own theories, potentially due to resistance against accepting the implications of such discoveries. Perhaps psychoanalysts have been mindful of engagement with a field of which they have limited knowledge; perhaps they have taken notice of the limited impact of those who have gone before, such as Menzies; perhaps they have enough to grapple with within their own profession. Like nursing, psychoanalysis has sought professional status and academic respectability ‘against the more subversive and “radical” position which questions the possibility of incorporating psychoanalytic knowledge into conventional academic and professional structures’ (Frosh, 2010, p. 8).

Taking nursing off the couch and re-directing focus from the cure for professional suffering, it is worth considering how a more equal and yet productive alliance between nursing and psychoanalysis could be achieved. Nursing academics and historians who explore societal shifts impacting on the nursing profession might find engagement with the psychosocial to be productive; similarly, those who consider nursing from a feminist perspective. Within the ward environment, it would be interesting to consider whether the work of T. F. Main (1946) and others on the (psychiatric) hospital as a therapeutic institution could be applied within general hospitals. This is particularly relevant in the context of ongoing ‘#endpjparalysis’ and ‘#getupandgo’ campaigns which encourage patients to get out of bed and resist playing the ‘sick’ role, especially given previous discussion of regression among hospital inpatients. Use of therapeutic activities as advocated by McMillan and Aiyegbusi (2009) would support this, whilst also providing additional containment.

In a discussion of psychoanalytic theory and nursing models, Powers (1980) identified a biopsychosocial framework implicit in Freud’s work. Whilst the bio-psycho-social model is fundamental to the British nursing process, Frosh and Baraitser describe how psycho-social elements of this are generally considered in isolation, with interest focussing on the ‘ameliorative impact of one on the other’ (2008, p. 348). Within healthcare, it is typically only within the realm of psychosomatic medicine that work begins to approach a Freudian model of the biopsychosocial (Engel, 1979; Grassi et al., 2019). Frosh and Baraitser describe the ‘unhyphenated psychosocial’ as a Möbius strip: ‘underside and topside, inside and outside flow together as one, and the choice of how to see them is purely tactical’ (2008, p. 349). To conceptualise the unhyphenated biopsychosocial in this way might be a truly collaborative and ultimately productive endeavour for both psychoanalysis and nursing.

One way in which general nurses could begin to engage with psychoanalytic thinking would be through consideration and potential implementation of the work done by mental health nurses in this area. There remains an unfortunate split between mental and physical healthcare across the NHS as a whole and perhaps greater collaboration at the nursing level might go some way to mitigate this. For example, McMillan and Aiyegbusi (2009) outline their psychiatric nursing approach, emphasising empowerment of patients from a secure base of containment (Bowlby, 1988), with a nursing model developed to facilitate this. The model includes advanced training in psychodynamic psychosocial nursing for nurse leaders, use of the nurse-patient relationship as a therapeutic tool, awareness of both conscious and unconscious communication of distress, a focus on reflexivity and self-awareness. Alongside this, nurses are provided with the containing structure of clinical supervision and group reflection; overall ethos is inquisitive with openness to exploration of the unconscious processes operating at an individual, group and organisational level. Whilst the model was developed for use by mental health nurses, there seems much to be gained through incorporation of elements of this within general nursing, particularly given that it addresses many of the factors previously identified as contributing towards burnout and stress among nurses.

Review of psychoanalytic theory encountered within the nursing literature has identified multiple attempts to apply psychoanalytic concepts to aspects of general hospital nursing, generating intriguing theory and inviting debate, yet having little impact on day-to-day practice. Potential explanations for lack of ongoing engagement on behalf of both nursing and psychoanalysis have been considered, along with the legitimacy and potentiality of an ongoing dialogue between the two disciplines.

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Acknowledgements

I would like to thank Professor Stephen Frosh for his contribution of insightful suggestions for improvement of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).