There has been a lot in the news recently about the pressures on the NHS, and particularly upon A&E services. Linked to this are concerns about access to GP services – which is one of the reasons why many people choose to wait for hours in their local A&E department rather than booking an appointment to see their GP. Another reason, which I discovered when I did some work as part of an urgent care project in an East London borough a few years ago, is that many people do not trust GPs, i.e. they do not consider them to be ‘proper’ doctors, whereas they assume the ones in A&E are.
Leading aside the question of what constitutes a ‘proper’ doctor, one of the issues that perhaps get less coverage in the media, and possibly less public sympathy, are the pressures on NHS staff themselves. To get a flavour of such pressures I would recommend reading the recent accounts of an young nurse in a busy A&E department who wonders if she can survive another 40 years of working in such a stressful environment1, and a GP who is currently on a sabbatical because she feared she was heading for burnout.2
One of the things that strikes me about both of these stories is that not only are these medical professionals under extreme, constant pressure, day after day, but there seems to be a lack of understanding or sympathy amongst their employers concerning their mental (and physical) wellbeing. For example, the A&E nurse tells of the advice she was given from the Royal College of Nursing, which included discussing how she was feeling with supportive friends and family. As she somewhat sardonically remarks:
Imagine this – I come home and my boyfriend asks: “How was your day at work?” If I were to reply honestly, my answer would be something along the lines of:”In between running from my post seizure patient to stop them falling off the trolley and harming themselves, and the 89-year-old lady, I had to treat a young girl who had taken a life threatening dose of heroin and drunk a considerable amount of alcohol. She was shouting profanities at me and threatening to kill someone, which in turn was upsetting the 89-year-old. I then found five minutes to eat my breakfast before returning to tell the family of my cardiac arrest that their husband, father and son had died at the age of 57. How was your day?” Unfortunately, this is never how I respond when I come home from work. I don’t expect someone else to have to live through the day I have just had. My response is usually: “I’ve had a busy day, where’s the wine?”
There is, however, another side to this and one that is perhaps more difficult for many people who work in stressful environments to come to terms with: this is the fact that, in some almost perverse way, the stress and, in some cases the burnout, has become addictive, is somehow ‘hooking them in’ to what is potentially a very harmful (and sometimes fatal) way of working. To put it another way, many people actually ‘enjoy’ their stress.
I use the quotation marks around ‘enjoy’ deliberately because I am not suggesting that that stress makes people happy or is pleasurable. Rather, this is an ‘enjoyment’ that is way beyond pleasure and happiness, as Freud pointed out in his paper Beyond the Pleasure Principle.3 Lacan had a term for this ‘enjoyment’ that is beyond pleasure: jouissance. Now, jouissance is often translated as ‘enjoyment’, but it is usually left untranslated because in English the word ‘enjoyment’ has particular connotations which are not intended in the original French term. Perhaps a more helpful way to think of jouissance, as a lived experience, is in terms of passion, which has its roots in the Latin pati, to suffer.
To get an understanding of how this might relate to stress in the workplace, there is an interesting quote in a research paper by Bicknell and Liefooghe which explores the relationship between workplace stress and enjoyment (jouissance).4 One of the employees they interviewed, a chef in a prestigious London restaurant remarked: “It’s passion. It’s passion that kills all of us in here.”5 This individual was describing life in an extremely busy and stressful environment, where all the staff were under continual pressure to ‘perform’ and give an excellent service to their customers. It’s clear from reading the accounts of these interviews that although the staff are working flat out and often getting angry with their colleagues, they are also ‘enjoying’ their suffering. To quote another employee:
When I first came here I thought it was absolutely crazy, doing 18 hour days and all the shouting, but here I am doing those 18 hour days and I’m still here […] [because] you really feel like you’re living.6
This reference to ‘you really feel like you’re living’ suggests that there is something deeply meaningful and perhaps even real in the midst of this suffering. With regards to stress and suffering in the health and caring professions, an idea of what this ‘something’ might be is perhaps better illustrated in another part of Bicknell and Liefooghe’s paper where they discuss interviews carried out with fire-fighters at a London fire station. Here it becomes clear that there are a number of different fantasises operating for the fire-fighters which include those of the victim of fire or other type of disaster as a someone wanting to be rescued, the fire-fighter as the perfect rescuer, and the fire-fighter as someone who stands guard against risk.
As in the health and social care professions, the efforts to be the perfect rescuer sometimes comes to nothing, and the victim is consumed by the flames. Similarly, in the A&E department, the patient, in spite of the best efforts of the medical team, sometimes succumbs to their cardiac arrest, their drug overdose or their major injuries. Furthermore, and this applies especially to A&E departments, many of those attending either shouldn’t be there in the first place and/or show little or no gratitude for the care and treatment they receive.
And, as Bicknell and Liefooghe point out, here lies the real paradox: rather than giving up and thinking ‘what’s the point?’, the fire fighter, the paramedic, the doctor, the nurse, redoubles their efforts, and tries even harder to get it right next time. And it’s precisely this trying to get it right next time, to be the perfect rescuer, to stand as the guardian against risk, illness and death, that sustains the passion of the professional. In other words, it’s precisely the failure to realise the fantasy (of being the perfect rescuer, the guardian against risk and so on) which sustains the ‘enjoyment’, i.e. the stress and the suffering of the individual concerned.
But where does the fantasy of being the ‘perfect rescuer’, or, indeed, the fantasy of the patient or some other ‘victim’ as someone wanting to be rescued, come from in the first place? For Lacanians, this is rooted in the efforts by the subject (in this case the fire-fighter, the doctor, the nurse, etc) to try and figure out what the other person (in Lacanese, the Other) wants from them, and for them to try and ‘realise’ this desire. So, going back to the example of A&E, it could be argued that the nurses and doctors are (unconsciously) motivated by their desire to ‘realise’ the (perceived) desire of their patients to be cured, cared for, saved. The irony, and in some ways the tragedy, of this is that this attempt to realise the Other’s desire is doomed to failure; and yet it’s precisely the failure that spurs the individual on, that injects the passion, the jouissance, the suffering, into their work. And so they just carry on getting more and more stressed, and suffer more and more…….
- http://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2015/jan/14/a-and-e-nurse-burnout [↩]
- http://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2014/sep/15/burnout-gp-nhs [↩]
- Freud, S., 1920. ‘Beyond the Pleasure Principle’. In The Standard Edition. London: Vintage/Hogarth Press, pp. 3-64. [↩]
- Bicknell, M. & Liefooghe, A. (2010) ‘Enjoy your Stress! Using Lacan to enrich transactional models of stress’. Organization, 17 (3), pp.317-330. [↩]
- ibid p. 317 [↩]
- ibid p.326 [↩]