30. Ritualised nursing behaviour

Key words: Miss Radley, Principal Tutor, Brysson-Whyte, Principal Tutor at Guy's, mock final exams, Southey's tubes, Ward Procedure manual, Isabel Menzies (1959), anxiety amongst nurses, ritualised nursing behaviour, anxiety management, organizational strategies.

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Miss Radley, the Principal Nurse Tutor at Joyce Green Hospital for a good number of years, counted Beatrice Brysson-Whyte, the Principal Tutor at Guy’s Hospital amongst her friends and for this reason Mrs Brysson-Whyte used to come to the Dartford School of Nursing regularly during the 60’s to examine student nurses for the practical part of their SRN mock final exams.

If you can remember those mock practical exams, you will also remember perhaps that the main emphasis of these was on the ability of the would-be SRNs to lay-up examples of some the various trays and trolleys that might be required in caring for the particular patient that one was presented with - in the Practical Room - on the day of the examination care. In addition, one was obviously also expected to able to discuss that patient’s condition and management.

But no matter whether you were asked to lay up a trolley equipped for the insertion of Southey’s tubes (used in the past in the management of lower leg oedema), a trolley for urinary catheterisation or one for some other procedure the focus was always upon the appropriate cleaning of the metal trolley and the comprehensive assembling of all the components that would be required for the selected procedure and the correct presentation of the equipment. This last point seemed to be particularly important because the materials themselves had to be laid out in a prescribed manner following the plans that were contained within the Ward Procedure manual.

Why, I used to wonder, did it matter whether a stainless steel kidney dish was positioned to the right of the article that was pre-destined to sit in the middle of the top shelf or why was it so important a particular tube or a particular laboratory specimen container was carefully positioned on the lower shelf and ONLY on the lower shelf ?

There must have been some underlying reason for this pernickityness but when - as students - we demanded to know why such rigid adherence was required we were usually told that this was either accepted nursing procedure or hospital policy !

But it wasn’t until I was studying psychology during my psychiatric nurse training that I was introduced to some research conducted by Isabel Menzies in 1959 that help me to understand one of the factors that underpinned nurses’ commitment to this sort of ritualised behaviour.

Menzies reminded readers that nurses are continuously confronted by extremely anxiety-producing situations. By definition they are called upon to work with people who are seriously ill, some of whom are likely to die. Many of the tasks that they are called upon to fulfil were (and obviously still are) distasteful and/or repulsive. Wrong decisions have the potential to lead to devastating consequences and, in addition to having to deal with patient’s distress plus their own anxiety, nurses - she noted - also have to respond to the distress of relatives.

Most notably she reported that the way that nursing work was organized seemed directed at containing and modifying these high levels of anxiety. She observed that work practices seemed to encourage the maintenance of a high level of emotional distance between patients and staff. Nurses often performed specialized tasks on a large number of people, e.g. taking the blood pressure of everyone on a ward that required this observation, thereby restricting contact with any one patient. The weight of responsibility for making any final decision making was also mitigated in a number of ways. Even inconsequential decisions were checked and rechecked. Tasks were often "delegated" up the hierarchical ladder with the result that many nurses were doing work well below their competence and position. In some cases subordinates were reticent to make decisions; in others guidelines were not in place to implement delegation.

These processes she argued appeared to act as to work-related mental defence mechanisms.
However whilst they often protected nurses from their original anxieties they sometimes, she said, created new ones. For instance, staff members were given lists of tasks and procedures to fulfil without being given any discretion on how to perform them. Thus trays and trolleys HAD to be set up in the approved way, patients HAD to be woken and given their sleeping pills, patients HAD to be woken early to have their faces washed before breakfast time - despite nurses feeling that they would be better off sleeping. During the research interviews nurses expressed guilt that they were in fact practising bad nursing even though they carried out every procedure to the letter. They realised that quite often they were not responding to the patients’ needs but to the system’s needs.

Menzies argued that substantial elements of the way in which the hospital functioned were underpinned by mechanisms designed to help staff avoid anxiety. The Matron and her staff, she said, made no direct attempt to address these anxiety-provoking experiences nor to develop the capacity of nurses to respond to anxiety in a psychologically healthy way. They did not, for instance, acknowledge that a patient’s death affected nurses or provide support to deal with this and other types of distressing condition. Instead, the rationale developed that a "good nurse" was "detached".

She agreed with psychologists and psychiatrists that if support for anxiety is not provided individuals and will still need to seek out ways of easing the impact of personal stress although - she noted - these were likely to be unconscious and covert and the defences developed against anxiety were likely to become embedded in the organization’s structure and culture.

Most importantly though and using the nurses that she studied Menzies observed that these defences sometimes worked counter to the needs of the primary task. They certainly did not always make sense to the staff and/or the student nurses but since these compulsory behaviours had become part of the organization’s reality, individuals she said, were often faced with the choice of adapting or discontinuing their careers or their training.

Thus several years later the penny dropped for me and I understood some of the fixed nursing rituals and rigid behaviour patterns that I had seen acted-out at Joyce Green more clearly and I appreciated too - perhaps for the first time - what a heavy psychological burdens had been placed upon our young shoulders without any opportunity to talk-though some of the incredibly stressful situations that we came face-to-face with during our days of training.

29. Another bowl of cornflakes anyone ?

Key words/phrases: Origin of cornflakes, Battle Creek, Michigan, Seventh Day Adventists, Auto-intoxication, Christopher & Constance wards at West Hill Hospital, Stone House Hospital, Orchard House (Psychiatric Unit).

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Did you know that cornflakes were created by accident and that they were first used as a non-stimulating meal for patients in a mental hospital in Michigan, USA ?

Records show that a certain Dr. John H. Kellogg took up a Staff Physician’s post at Battle Creek Sanatorium in 1876 - when he was 24 years old - and that he served there until he was 62 years old, retiring as the Medical Superintendent.

The corn flakes it seems were produced by accident in 1894 when he and his brother Will left some cooked wheat sitting uncovered in the hospital kitchen while they attended to some other matters. When they returned the wheat had gone dry but because the hospital was on such a tight budget they decided to continue to process it by forcing it through a set of kitchen rollers in order to try and obtain some sheets of wheat dough. To their surprise what they got instead were flakes which they then decided to toast in an oven and then serve to their patients, adding milk but no sugar.

On May 31 1895, the Kellogg brothers filed a patent application for "Flaked Cereals and Process of Preparing the Same" and this was granted in 1896 under the trade name “Granose”.

Nowadays we would obviously consider this a very strange contribution to the treatment of the mentally ill patients but Dr Kellogg was obviously pleased to have an extra dish to use within the dietary component of his treatment regime. His brother though was more interested in making money and Will Kellogg - much to the disapproval of his medically qualified brother - went on to buy up the commercial rights for corn flakes, sweetened them with malt and then established The Battle Creek Toasted Corn Flake Company in 1906.

But what was he doing in the hospital kitchen with the cooked wheat in the first place ?

Apparently he was a member of the Seventh Day Adventists, a religious sect who sometimes experimented with new foods and dishes to in order to improve on their strict vegetarian obligations, the same strict vegetarian regimen that he imposed on his patients?

Kellogg forbade his mentally ill patients alcohol, tobacco, caffeine and denied them all spicy and sweet foods because of the likelihood that these would “inflame their passions”. Thus the diet that he imposed upon them consisted entirely of bland foods - including his new product, cornflakes - all of which he believed would have a sexually calming effect.

Kellogg was an early advocate of physical exercise and "biologic living"and he also opposed any type of sexual activity whatsoever. In fact he openly acknowledged that he had never made, and would never, make love to his wife.

It seems that he was also obsessed about the “auto-intoxication” of the human bowel and with the need for elimination. “Ninety percent of all illness originates in the stomach and bowel", he explained and so he also made sure that every patient was treated with enemas using an enema machine. However if the symptoms of their physical or mental illness persisted he would surgically remove stretches of intestine and Kellogg was said to have sometimes performed as many as twenty such operations per day.

The results, he claimed, were nothing short of a medical revolution and Kellogg argued that by this mixture of methods he had managed to cure "cancer of the stomach, ulcers, diabetes, schizophrenia, manic depressives, acne, anaemia, asthenia, migraine and premature old age."

50-60 years later patients from the Dartford area requiring psychiatric care were - in the main - cared for, either in Constance and Christopher wards of West Hill Hospital, or in nearby Stone House psychiatric hospital where new drug treatments and electro-convulsive therapy were being used to help to improve patient’s conditions.

By the time the mid 60’s had arrived the General Nursing Council for England & Wales also required SRN student nurses to spend 12 week placements at Stone House Hospital, in order to gain some insight into the care of people suffering from emotional and psychological problems. But in March 1969 a new psychiatric unit was opened in Blocks 18 and 19 of Joyce Green Hospital with enough beds for 40 women and 14 men plus the associated living and therapy facilities.

Perhaps some of you reading this entry have memories of Orchard House, as it became known, although I doubt that any of you will recall giving patients there cornflakes with milk to calm them down !

28. A Phoenix Arises ?

Key words/concepts: "Bridge" development project, London Science Park

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A reader wrote in recently to ask a couple of questions and made me aware at the same time of a new and very substantial project that is currently being developed on the old Littlebrook Power Station site to the East of (and bordering the boundary of) the old Joyce Green Hospital site.

Perhaps YOU are already aware of this prestigious building project but in case you are not, let me tell you a little of what I have been able to discover.

The project is called "The Bridge" and it involves Dartford Borough Council and ProLogis Developments Ltd working with two building companies: McAlpine plc and Wimpey, together with Hemingway Design to re-develop the whole 264 acre site for "mixed use".

The mix of buildings are going to include a science and technology park called The London Science Park, 710,000 sq ft of top quality office accommodation, 1,500 new homes laid out in districts - each with it's own character -and near to two newly created lakes, plus a mixture of hotels, leisure and retail facilities ... with integral transport links.

Gerardine and Wayne Hemingway - of Hemingway Design - who created the "Red or Dead" fashion label before branching out into housing project work (via the Staiths South Bank Project in Gatehead for instance) have been commissioned to assist with this one.

Building has apparently been progressing well and the "The Nucleus", the 30,000 sq ft innovation centre of the Science Park component of the project is due to be completed for Spring 2007.

It is anticipated that this innovation will create work for 7,500 people and an up-market environment for those who will soon be coming to live and work under the shadow of the now very familiar bridge linking Essex with Kent.

For more information why not visit the www.thebridgedartford.co.uk website?

Perhaps at the same time as wishing them well, we should keep our fingers crossed and hope at the same time that some of Joyce Green and its associated hospitals (and/or some of its personalities) will be remembered in the naming of some of the buildings, the roads and the 'districts', plus the hotels and the public facilities ?

27. Is this the road for Tarenteford ?

Key words and concepts : Darentford, Doomsday Book, Evidence of Anglo-Saxon presence, History (Early English), Old English + early language influences, Tarenteford.

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If someone had stopped you during the Anglo-Saxon era and asked you for directions to “Darentford” they would actually have being asking for your help to get to Dartford.

I appreciate that this will sound rather strange but this was the name that the town had then. However, according to the Domesday Book (of 1086), Dartford had an even stranger - earlier -name: “Tarenteford”. So where did the word Tarenteford come from ?

Well … to get a clearer understanding of this term we need first to review part of our very early history.

You’ll perhaps remember that the Romans occupied England between 55 B.C. - 410 A.D. Then, when the Visigoths continued attacking Rome, the Romans began to send some of their legions home to Italy.

Following years of occupation the native inhabitants of England (the Brythons, otherwise known as Britons and also the Celts) had lost their ability to defend themselves against the maurading tribes of the north i.e. the Picts and Scots. Thus once these early “Brits” started feeling vulnerable they began looking elsewhere for help in defending themselves.

In 449 A.D. Vortigern (the king of the early “Brits” or Celts) asked the Angles from across the North Sea, led by Hengest and Horsa, to help them to defend what would later become called "England" against the wild Picts.

In return for their military assistance the Angles it seems were granted lands in the southeast part of England. Further help was also sought from across the North Sea, and in response “came men of the three peoples of Germanie” (the Saxons, Angles and Jutes).

Eventually though other Germanic tribes began breaking through England’s poorly defended frontiers and to over-run the remaining Roman armies, who were eventually expelled.

The take-over of Kent by the Saxons began in the first half of the 5th century A.D. and it seems that one of their earliest settlements in the area was probably at Darenth, with the settlers coming primarily from Jutland in Denmark.

The Jutes settled mainly in East Kent along with tribes from Frisia whereas West Kent was gradually taken over by Saxon tribes and Frankish people.

The River Medway acted as a dividing line between the Jutish Kingdom of East Kent and the Saxon Kingdom of West Kent but by the 7th and 8th centuries A.D. these tribal divisions had almost disappeared as the result of trading relationships and tribal inter-marriages … thus the population became known collectively as 'Anglo-Saxons'.

The language that these tribespeople brought with them was of Germanic origin but consisting of lots of different dialects and so after years of our embryonic language having been exposed to Latin - because of the Roman culture - “Old English” began to be re-fashioned by it’s exposure to a strong Germanic influence.

Tarenteford it seems - which later became Darentford and then, finally, Dartford - is thought by some scholars to be derived from the German word (or more precisely the Bavarian word) ‘Teren’, a verb meaning: to tear apart/to destroy/to consume as with rage.

So perhaps Tarenteford (Dartford) was the name given to this area where skirmishes took place in which local people tried to defend their homes and agricultural land from the Germanic speaking Jutes ?

Although it had been agreed that the Jutes in East Kent and the Saxons in West Kent should receive certain gifts of land in return for the support against the Picts, it is still easy to image that the locals might still nonetheless have fiercely resisted the taking away of their land(s).

There is certainly irrefutible evidence of an Anglo-Saxon burial site in the Littlebrook/Temple Hill areas due to the discovery of 7th century pottery in this area and pottery dating from this same century was also retrieved from another Anglo-Saxon site during some excavations at the Welcome Chemical Works in 1955.

So … which is the route to Tarenteford ? Well fine sir, your best bet is to make for Tarenteford Heath and then turn left !

26.Take a deep breath.

Key words: Cuirass Respirator, Guinness Bk of Records, Harvard Uni., John Prestwich, London Hospitals, M.V. Herdsman, Texas (Corpus Christi), Ventilators (Drinker and Emerson)

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It’s difficult to say whether or not the Merchant Navy ship “the M.V.Herdsman” ever sailed up the Thames past Long Reach Hospital, but shortly after this particular vessel docked in Corpus Christi harbour on 24th November 1955 a story began to unfold that was to last another 51 years and which would put the achievement of a very brave patient into the Guinness Book of Records.

This was the ship’s final port of call and the baby of the crew, a certain John Prestwich, was looking forward to sailing back to England to be reunited with his family for Christmas. Coincidentally, he was also going to be celebrating his 17th birthday whilst the ship was docked in Corpus Christi and one can only imagine that he was really excited about that too.

Sadly however he collapsed onboard and following his transfer to a nearby hospital he was diagnosed as having bulbar polio. By the time the diagnosis was confirmed he was paralysed from the neck downwards unable to breath or cough. Thus when he finally did arrive back in England - three months later - via Heathrow Airport it was in what someone has referred to as "a coffin on legs".

John was initially admitted to the “fever ward” of the Royal Free Hospital in Hampstead where he continued to be nursed in his iron lung.

“Iron lungs” are in fact negative pressure ventilators and although there are still a few patients using these contraptions in their homes today - finding that they actually work better than their modern replacements - they have for the most part been replaced by positive pressure ventilators that blow air into patients’ lungs by via an intubation tube.

I can remember the one remaining female patient at Joyce Green Hospital in the mid 60s who was being nursed in an “Emerson-type” iron lung but perhaps some of you reading this entry will remember this particular lady, Gwen, and her ventilated daily life much more than I do ?
As for the creator of her type of ventilator John (or “Jack” as he was known) H. Emerson left his school in New York State without any educational certificates whatsoever and although all previous Emerson family teenagers had traditionally gone to Harvard University, Jack freely admitted that he only got in to this top University as "a floor sweeper in the Physics Lab" because of having family connections.

Whilst not at all academically-inclined Jack was nonetheless a very clever man and “an inveterate tinkerer” who - amongst many other devices - designed the quieter, more efficient iron lung of the type used at Joyce Green. Emerson respirators were, it seems, it was not only cheaper than the existing Drinker type but the they could also be hand-pumped should the electricity supply ever fail, something the must have been of comfort to patients and staff alike during the industrial unrest in the U.K. during the early 1970s ?

John Prestwich, the lad who contracted polio on the other side of the Atlantic Ocean, eventually progressed - as did many other polio victims - to using a Cuirass shell respirator. These take the form of an airtight dome-shaped fibreglass shell that is strapped in place over the chest and abdomen which is connected by a length of hose to a pump. They work on the same alternating-pressure principle as the iron lung but because this alternative was much lighter and more portable it allowed John (and so many others) to be nursed in bed and/or in a wheelchair.

As a young man John spent his first 7 years in an Emerson ‘lung’ during his 16 year period of hospitalisation but according to his website (www.johnprestwich.btinternet.co.uk) he went on live a satisfying life at home under the supervision of his personal Occupational Therapist (Yes, he married his O.T.), going to (or when necessary - being admitted to) the Respiratory Unit of St Thomas’ Hospital in London.

John Prestwich went on to became an inspirational “personality”. He was awarded an M.B.E. in 1994 in the Queen’s Birthday Honours list and when he died in 2006 he held the Guinness Book of Records world title for being the longest-ever mechanical respirator user.

For 25 years, with the help of his wife and thanks too to a specially modified wheelchair/bed - complete with respirator - he had been able to remain very independent at home. He had a specially converted 'minibus' for outings and John had mastered a wide range of activities via whistled codes and the help of some highly adapted computer ware.

One can’t help but be pleased that John Prestwich led such a satisfying and rewarding life, nonetheless I sometimes think about the richness of life which Gwen in Joyce Green Hospital, and thousands of others elsewhere, missed.