Much of the content on our site is available to our registered users only. If you're already registered, just click the 'Log in' button then enter your email address and password.
If you're not already registered on the site, you'll need to do so in order to gain unrestricted access to all our content. There are two types of registration:
1. If you're a current subscriber, you can register for access to our protected content at no additional cost. You'll need your subscription number in order to complete your registration, which is on the polythene wrapper in which your journal is delivered. Click the Register button to begin your registration.
2. If you don't currently subscribe you can do so now by taking out a secure online subscription. Not only will this give you instant access to our protected online content, but you'll also get every issue of Nursing Standard - the UK's best selling nursing journal - delivered straight to your door. Click the Register button to begin your subscription and registration.
Felicity Stockwell uses Nursing Standard's first webcast to call for better care for patients - and for nurses. Interview by Adele Waters.
Forty years ago Ms Stockwell researched the nurse-patient relationship in her seminal study 'The Unpopular Patient'. Today, having witnessed a steady stream of reports about poor nursing standards, she says her research is as relevant as ever. In this interview, the celebrated nurse author talks about the importance of maternal-infant bonding and how to apply this knowledge of human social behaviour to reduce patient anxiety.
What nurses need to understand
Adele Waters: Today I would like to introduce you to Felicity Stockwell, who is going to talk about the importance of good communication in nursing care. Felicity, your research on 'The Unpopular Patient' was recently voted the most influential piece of nursing research. Did that make you feel proud?
Felicity Stockwell: Well it should have made me really proud, but in point of fact it didn't. When somebody came up to tell me the result my heart sank and I felt really disappointed. When I did the study I wanted people to gain from it some understanding about maternal-infant bonding but, since then, much later since then, I discovered that people don't bother to read the theory at the back. I think, sad to say, that nurses haven't taken on board anything about the maternal-infant bonding.
AW: And why is it important that they do?
FS: Understanding people's emotional needs and all the factors that make humans sociable is at the core of the nurses' task in caring for patients. I do believe that my research is as relevant as it ever was and it is even more relevant now because when I look around there are increasingly reports of lowering standards of nursing care and, being an elderly person who lives in a local community, I'm increasingly hearing people who have had pretty horrendous accounts of being looked after in hospitals these days. It makes me and my companions really scared of needing to go into hospital.
The importance of maternal-infant bonding
AW: Can you explain the significance of maternal-infant bonding?
FS: When the mother is nurturing the baby she is setting up a whole lot of sensations that feed into the baby's brain and get remembered, and can be established as needs that they need for the rest of their life. Now these needs we usually call needs for acceptance and needs for approval, but it means we need to be liked and loved. In order to get these needs met we have to learn what we've got to give in order to get. When needs are met then cholines released and they go to special endorphin areas in the brain and when needs are not met then adrenalin is produced. With the physical needs not being met then adrenalin sets up an alerting system and causes physical changes in the body. Everybody knows the symptoms of anxiety - palpitations and stomach upset. We are motivated to mix with other people, depend on other people, and give to other people for contentment.
Now when emotional needs are not met and anybody has had some experience of this, you know if you are at a party and nobody takes any notice of you - you feel dreadful and humans will run away and won't stay there. But if you are a patient in the ward then you can't run away, they won't let you. So the anxiety that is felt when emotional needs are not met is exactly the same as when physical needs are not met. The big difference being that when physical emotional needs are met - when you are hungry and you have eaten - then the adrenalin absolutely goes back to its normal level and the anxiety goes away. But when emotional needs are not met then that anxiety does not go away because the memory circuits make you remember that humiliating moment or how lonely you are - it's present with you all the time. So the anxiety levels don't go down if emotional needs remain unmet. And that is not a good place to be.
Socialisation when it goes wrong
FS: Evolution has so cleverly provided for us to become friendly and sociable by imprinting into us the pressure to be altruistic and cooperative. The baby, from very early on, has to learn the give and take of social behaviour. For humans, this probably takes them up until the end of adolescence and when they become adult. So the baby to begin with is very passive and just accepts they can have lovely feelings with these nurturing attentions. But very soon it learns that there is a give and take and that it can smile and what it receives is better than when it's yowling. And little bit by little bit then it learns what behaviours are useful for it in order to get its needs met.
So the really important part once the bonding process is there is the amount of social interaction that the baby receives. So those coffee mornings with the toddlers all around the floor are very important for it to learn about others. It is the positive rewards that are much more teaching than the negatives. As the baby is socialising with others then it's learning what it has to do to get the people around being friendly and happy. Then our little ones go to nursery school where they're competing with others for what is coming from the adults and they are learning from each other what gets them accepted and what doesn't.
It's a truth in life that we always change our behaviour much more for reward, or entirely for reward; very little do we change our behaviour for punishment. There is a saying that goes 'it is always better the carrot than the stick' to change human behaviour and that is explaining exactly what that saying is.
However, as this child is developing its social skills there can be occasions when its needs are not being met and into the bonding process there is built a mechanism, it's a reflex, that says where other people are getting their needs met and one isn't, then the reflex kicks in and says 'it's better to be noticed than ignored' and that reflex is what we all recognise very readily and it is called attention-seeking behaviour. Now it's not a child thinking inside itself how can I get attention - it is absolutely programmed to produce this negative behaviour, and what is also a reflex is in the people who are withholding meeting the needs, and their reflex is to say 'get lost'; 'I don't like you'. Of course that just makes the behaviour worse.
This is what 'The Difficult Patient' was about - because this is what happens to people in hospital and in other group situations, and in toddlers in the nursery, and mothers with toddlers in the supermarket. When their attention is on chatting with their friends, and they are worrying about whether they have everything on the list, and the baby is sitting there, waiting, knowing, wanting to be loved and mum hasn't got any time for it - and then it starts attention seeking. And if mother still says 'shut up' it gets worse and worse and worse, until they've got a real problem on their hands, because when our needs are severely not met we can't trust people to have it within them to give it to us. This is one of the really difficult problems in human social behaviour, because it puts the individual in a real fix. When our needs are not being met we need people to meet them, but people have also been the threat that deprives us of our needs. So we have this dilemma within ourselves of whether we dare go and see whether we can try a bit better next time and be liked, or whether the risk of being more hurt is worse. And that leads us eventually to mental illness problems.
As the child ventures further into the world and arrives in the primary school playground that is when they learn where their strengths are and what their identity is. It varies of course a lot with what's gone before, and you will always get in the playground children whose needs haven't really been met very adequately and they will become the bullies, or the very shy retiring ones who don't give themselves a learning opportunity because they can't. It is a good school that can enable the children to put their best forward as much of the time as possible with as many of the other people of the time as possible.
So as the child learns there what they can do and what they are better steering away from, and how best to help people like them, then they move on to secondary school where they are doing much more of their social learning, particularly with groups of people. It is lucky the child that is part of a good school group as they learn about affiliations and being insiders and outsiders, which is a very important part of being adult. Then they have also got to learn about their sexual relationships and also their strengths for the jobs that are going to most meet their particular endowments.
All the offerings actually of socialising, the most important two of which are our time and our attention, because we have only got our time once, and attention we have to work at. The example I always give for attention is that if somebody wants to give their girlfriend a bunch of flowers and they ring the secretary and say can you go and order some flowers for Joanna or whatever, and get them delivered because it's her birthday today - what happens when that card comes written from the florist arrives at home and it is for a bunch of red roses that he should know you don't like? Compared with somebody who actually remembers the birthday, who knows which flowers she likes the best, and who makes sure that even if they come from the florist they do have his writing on the card. Now what is it in that that makes the difference? The first doesn't meet emotional needs in any way whatsoever; whereas the other says I am telling you that I think you are ace!
The other emotional needs are all what I call the currencies of friendship - which are sympathy, kindness, humour (very important), knowledge... Once a baby has successfully been through the maternal-infant bonding process and has got their need system established, and then they have negotiated all the social learning as they go through their childhood - then they should emerge as adults, feeling self-confident, well-esteemed, and well-prepared for successful social relationships with all the people that they should bump into. But if a baby doesn't get adequate input of feeling contentment, then adrenalin is switched on very readily and is around much more throughout the day and the night. It affects aspects of their physical growing up.
Babies give signals that they are unhappy, and they cry, and this is one of the sadness's of the bonding process is that we don't do 'owt for nowt' in this life, and mums need even their new-born babies to give them feedback of approval. So there is a real difficulty if a mother is too tired, too ill, or even perhaps isn't there enough for a baby's start in life. Now the best thing and here it is to the health visitors I guess, is for the mother to be helped to relax and be enabled to be giving to her squawking child. It very quickly, and if she really is relaxed and does the cuddling, cooing, talking to them and rocking them, that in a baby very quickly actually does lower its adrenalin levels.
So if people's emotional needs aren't met and they aren't socialised adequately, then it leads to huge troubles for them as they go through life. In children they will be naughty, rude and grumpy to the people that are depriving them. When they get to school they may well join up with other kids who are equally deprived of emotional needs and then they form deviant groups which are very difficult to cope with and they become naughty as a gang.
AW: And in adulthood...
FS: And then as they move to adulthood this still will look to meet with people that are equally deprived, because all the other adults are threats rather than sources of meeting their needs. So they find their needs are met by being naughty together and doing things that upset other people - by cheating, lying, trying to get their own way to get things rather than the love that they are wanting and needing. Basically all human beings are motivated to get on with each other and nobody actually wants to upset other people and be put in the dog house which is what happens so wherever there is problem behaviour really, one has to ask whether their emotional needs are being met and this applies on the ward as well as anywhere else.
What nurses need to do
FS: When the nursing team are all working together and know that they're competent and doing a good job then that aspect very readily communicates to anxious patients. Over and above that the individual way in which they go about their work, and in the individual way in which they can see a patient who is in distress and is perhaps tearful, and notice it and go along and hold their hand, offer a listening ear and some positive input then that patient will very readily relax. Nurses need to understand that when patients are admitted to hospital they have many factors that are making them anxious - they are ill, they are in a strange situation, and they don't know the rules of the wards. So you have to bear that in mind when you make your first contacts with them.
AW: How should a nurse approach a patient in the first contact, what should they do?
FS: In the general way of ensuring that people's emotional needs are met, it starts with friendly, smiling, welcoming, remembering people's names, and listening to what they have to say, and then remembering things they have told them and feedback that remembrance because that is the very best way of showing people that they mean something to us, and that is very reassuring.
Nurses can help the patients by understanding that the mere fact of being a patient is stressful because they are ill, and is also a huge facer coming as an outside person into an established group of people and not knowing what the rules of behaviour are when you are there. Nurses can help overcome this by the nature of the job and their training and everything, their emotional needs are very well met and so they are in a very good position as a social relationship to be enabling and to greet the patients with a smile and to make them feel relaxed by their body language, and to listen to what they have to say - to give them opportunity. It is then very important, and throughout the patients stay, that they remember what the patients have said to them about likes and dislikes or about anything really, and feedback to them at points later that they have remembered those things as socially that is the most efficient way of showing people that they like them is remembering things about them.
AW: You've talked about nurses being 'top dog's' in an unequal relationship, what do you mean by that?
FS: In social relationships people are always looking for the common denominators in order to reach across to each other. So a ward is a very unusual social situation because there are a group of top dogs who have got it all and then the underdogs who are dependent, and that makes the actual social meeting between them, in a way, more difficult because somebody who is dependent can't always trust the top dog to be on their wavelength. Nurses have to be good actors because they have to bridge this gap from their side and so in ordinary society they might not like the person very much, or feel like they haven't got anything in common, but they have to override that and show that they have got areas in which they can meet, and that is just in their common humanity.
Good and bad care
FS: So when people complain about the nurses sitting around near the office, chatting to each other and laughing and talking about their nights out the night before, and when they talk over them when they are attending to them, and when they ignore people in distress around the place and generally look after their own needs before the patients - that has a horrendous effect on patients who already have a lot of adrenalin racing around. And this certainly adds a lot more.
Somebody who has a lot of adrenalin going around them will much more readily pick up the clues that people aren't really taking their distress seriously and again it puts them into testing behaviour. They'll do something to see whether the nurses have got anything that is kind.
Very recently I had a friend who was in hospital having a very minor operation and she rang me up to say she'd she got home and there were deficits in various directions. She said the care was so uncaring; and she finished up by describing to me nurses sitting on the desk - one rather stout nurse sitting up swinging her legs - and just laughing away and no interest or concerns with the patients at all. She rang me up to tell me about this and finished up by saying they were ill-mannered, had no respect and no caring, and were only there for the money.
AW: And how did that make you feel?
FS: That made me feel... well, it's a mixture isn't it? Very negative, cross - but sad, because no nurses want to behave like that. They don't want to behave like that.
AW: And so why might they behave like that?
FS: Because they will be people who are experiencing not having their emotional needs met by the system. And because it's not met by the system, they don't meet it for the patients and the patients don't give them feedback of approval and it's a very negative situation.
Nurses don't want to behave like this. They don't get up in the morning saying how can I upset all the patients? Their motive is to be kind and caring so when they are not, the solution to the problem is to ensure that people give them kindness and care. So it really starts from the very top of the organisation, right from the top down each level, people at their work should feel that they are appreciated and this ensures their emotional needs are met as every minute of every day every interaction we have with other people is positive or negative and so they have to feed in the positives on that personal social basis as they get the work done.
On top of that then they have to make sure at all levels that all members of the organisation are fully skilled, fully resourced and given the time and the personnel to achieve the objectives.
AW: And so are you saying that we can expect to hear more stories about poor patient care?
FS: Well, as I look at the whole world around, yes I think it will be likely as there is more pressures on financing and on the members of staff. When nurses feel as a group that they are undervalued then we are into a lose/lose situation, because their emotional needs are not met - they can't begin to meet the patient's emotional needs - so they become careless and even unkind sometimes. They make mistakes, and they fail to do anything positive to make the patients feel that they are belonging there or that they are likeable, and even more importantly it makes the patients feel unsafe.
The sort of things that make a nursing team feel undervalued are such things as unrealistic workload expectations - this comes from weak leadership and their poor communications and probably most important, lack of appreciation.
...but do nurses have time?
FS: Some people might say that nurses don't have enough time in these hectic days to make meeting the patients' emotional needs a priority or even a necessity. In answer to that I would say that they probably are right in that they haven't got the time but it is absolutely wrong that they should go along with that.
When patients feel unsafe they are producing a whole lot more adrenalin that is racing around their body and this has some very negative effects on the body. It reduces their immunity, it reduces their healing, and it increases their pain, and it makes them feel jolly miserable. And when they get miserable they get crotchety and demanding and that makes huge demands on the nurses' time. It is at the time when patients first meet up with the nurses and they are having their assessment done that investing in time and really being relaxed and listening properly that the patients anxiety will be reduced, they will remember more what you have told them for later and you will learn in a non-threatening way much more about them that can save a lot of time later on, because having to go back to look at the form and think 'oh dear I forgot to ask them about so-and-so' becomes an enormous time waster. So the win/win situation is that if you invest time in the first encounter with the patient then the patient will settle in and be more contented and save time along the way.
It is interesting that there are studies, both in America and in this country, that show where there is investment in providing adequate numbers of nurses that care does significantly improve. I believe that health care managers can help nurses, and they can do this best by ensuring that first of all that teams have enough time i.e. they have enough staff to cover full time, 24-hour working, seven days a week, 365-days a year absolutely non-stop. So if there isn't enough time, enough nurses, then you have got people having to do a lot of overtime and this is one of the most detrimental things to nurses not feeling cherished. So this in fact is a win/win situation because if management invest in more nurses and give them more time, then they produce better care and with the patients' emotional needs met and they will recover more quickly and they will be more contented, and they will say what a wonderful place they have been looked after in.
Bring back sister!
AW: How significant is the role of a ward sister or charge nurse in improving patient care?
FS: This is, I think, one of the problems of the change in society as a whole, but in the reorganisation of nursing and it going into the universities. A ward sister, in the previous dispensation, was the king pin in the whole of the administration - the doctors, the administrators, everybody - she was the king pin to ensuring that patient care throughout the hospital was excellent. Now I call this the wisdom of the ward sister, because at that time the ward sisters were esteemed not only within the hospital, but outside the hospital in the greater community. They were recognised by the doctors as being absolutely part of the team who were more than necessary because doctors can look after patients but patients need nursing if they are going to survive what the doctor has done to them.
And overall, this is one of the key factors of nursing having lost some of its status really, as contributors to the whole organisation and as contributors in society because we have lost those career ward sisters. The student nurses, under the old system, learnt all their (what one may call) emotional nursing skills from ward sisters, by example...by osmosis really - nurses picked up the art of nursing rather than the skills, but they also picked up skills better as they were learning on the job and anybody who has done a teaching qualification knows that you can't teach skills unless you are teaching the theory and the doing in tandem and that doesn't happen now.
FS: I believe that the reputation of nursing is in serious trouble now. I think this is actually a very opportune moment for nurses to use new understandings to reclaim the important part of nursing which is caring for people.
I believe nurses are the cornerstone of the health service, and I have written innumerable letters to Ministers telling then that unless we treat the nurses well they will not be able to treat the patients well.
What we need now is wise leadership, and it is possible to look around the country and see where there has been wise nursing leadership that's overcome some of the many difficulties and managed to maintain high standards; that it is possible to do this.
Florence Nightingale said that the most important task of nursing was to care for the patients in such a way that the body was enabled to do the best of its own healing. That is exactly what we have been talking about today and exactly what we need to get back to.
I hope that there will be improvements in standards of care, and the key to this is good communications. I hope that will be my legacy.
The Unpopular Patient, Felicity Stockwell. 1972
For feedback, email your thoughts on this interview to email@example.com