In my third year of undergraduate nursing school, I was assigned to an inpatient women’s trauma unit in a freestanding psychiatric hospital for a clinical rotation. The goal of this clinical experience was to engage in therapeutic communication with patients, a skillset very different from the physical assessments and medication administrations I learned in other rotations. What prepared me best for these patient encounters was not my previous nursing classes or clinical experience but rather the ability to listen in ways I developed while studying psychoanalytic theory in some non-nursing courses.
During this rotation, twice each week for eight weeks, I would spend four hours sitting and talking with patients. In a simulation laboratory, I had already been taught how to direct conversations and to rephrase or summarize what patients said to me, and I had been assured by various instructors that I had the foundational skills to help me keep patients safe. However, I was skeptical that these techniques alone could promote sufficient trust and empathy in the therapeutic setting. In a way, they felt like a series of mechanical techniques for standardized behaviors that neglected the therapeutic value of conversation—of bringing thoughts and emotions into conscious awareness through talking—that I had come to understand through studying psychoanalysis.
I had taken “Introduction to Psychoanalysis” in my first semester at the University of Pennsylvania, and, as I was preparing to meet with patients, I often thought about the case studies we had read—in particular, Breuer and Freud’s early case studies of “Anna O.” and “Dora.” I was intrigued by how much could be learned when the patient’s words were credited with as much importance as other clinical markers, and just how much a patient might reveal to a certain kind of listener.
On my first day in the trauma unit, one woman excitedly approached the seat in the dayroom next to mine. She immediately began talking, and continued to talk for the better part of four hours. I tried to keep up with her, nodding and meeting her gaze. She talked about the previous nursing students who had rotated through—how they both remained at the nurses station behind a plexiglass barrier. One student merely sat there and did homework; the other was moved to a different unit after witnessing a patient engaged in self-harming. As she told me about these students, I couldn’t help but empathize with them and their desire to evade the sorts of awkward moments and puzzling conversations that accompany this sort of clinical rotation. But because I had read about the discomfort of not-knowing while sitting with a patient, I felt able to acknowledge my unease and, as Nina Coltart puts it in Slouching Towards Bethlehem, to “sit it out with a patient, often for long periods…through the obfuscating darkness of resistance, complex defences, and the sheer unconscious of the unconscious” (1992, 3).
I talked with this same patient for several hours during each of my visits to the unit. I spent most of that time feeling lost while trying to remain present and to manage my own feelings of uncertainty—experiences I wish I’d encountered in a simulation laboratory before entering the clinical space. I reminded myself frequently that my patient was a person, not merely a pathology, and that we were talking person-to-person. During our post-clinical conference—spent reflecting on the day with classmates who had been assigned to different units in the same hospital—I learned that sitting for this much time with the same patient was unusual. It was nerve-wracking to have someone talk so freely with me, and I feared I would miss something important. Though I was still uncertain about my role, I began to imagine what it would be like to have a positive influence on her treatment, and I hoped that by listening more “analytically” I’d enable her to speak more freely. I clung to this idea of analytic listening—listening both to what she was saying and how she was saying it, and to what she was saying at certain times rather than at others, and to moments of silence, and to my own subjective experience of what she was saying.
The waiting and not-knowing that accompany analytic listening is very different from standard nursing practice in settings where certainty is essential. Accurately memorizing medications and dosages, anatomical features, procedures, and protocols is vital to keeping patients safe. But this encounter helped me see that a tolerance for not-knowing allowed me to do even more, simply by remaining curious and open to learning whatever I could about my patient.
At the same tike, analytic listening may also have made me apprehensive that I might hear something that others responsible for her care wouldn’t have heard. The unit treated many patients, and most of them didn’t receive this kind of attention. But, as an unlicensed and inexperienced student who would be leaving in a few short weeks, I wasn’t sure how to evaluate the importance of all the things she was telling me or who to share these things with.
Often, patient safety depended not on analytic listening but on decisive and urgent action. One morning several weeks into the rotation, breakfast conversation was interrupted by jarring, banging noises. They were hollow-sounding but kept increasing in tempo and volume. I rushed to the hallway where the noise was even louder, looking for its source. What I found was a disturbing scene of a patient in crisis. She was arching her back and extending her neck, stretching her body in a way that was almost graceful…before repeatedly dashing her forehead against the cinderblock wall with all the force she could muster.
For the first time, I saw nurses and doctors rush onto the unit, colliding with each other in their hurried attempt to wrestle the patient to the ground and inject her with a cocktail of medications. I watched her flailing limbs grow weak. A therapeutic hold, I thought to myself, and considered how ill-suited the word “therapeutic” was for this exigent situation as the other patients lined the windows of the dayroom to watch.
When I returned to the dayroom, the woman I’d been talking with grudgingly returned to her seat next to me. Folding her arms, she said indignantly: “That’s all they do. They give us the needle.”
I was still mentally trying to return to the dayroom and to metabolize the scene of self-harm I’d just witnessed. I didn’t yet have the right words, so I used hers: “All they do?”
“Yeah, and now they’re going to take you away, too, just like the last one,” she said (referring to the nursing student before me, who had been reassigned to a different unit after witnessing a similar patient crisis). Here, then, was this woman’s lived experience of abandonment, of inconsistent care and inadequate attention. If she hadn’t said this, I might have failed to register my own implication in her story. For several weeks, she had talked and I had listened. But here was a reminder that I, too, would be placed elsewhere and that she would remain under the care of the nurses and doctors who entered the unit only during crises. Even if I wasn’t relocated to a different unit, I would be moving on to a different rotation soon. Who would be the next nursing student to take my place? Would they listen, too? While it is good and necessary that there are crisis responses in place, I wondered what it would be like if all nurses were as well-trained in analytic listening as in crisis-response.
Studying psychoanalysis in the undergraduate classroom has made me a more present and responsive student nurse. Yet, to my knowledge, I’m the only student in my large nursing class that has taken even one course on psychoanalysis. I hope that my nursing peers will give this field of study serious consideration, and that programs that offer courses in psychoanalysis do more to encourage the enrollment of nursing students. My experience has shown me that there is a demonstrably valuable opportunity to enhance the field of nursing through psychoanalytic education and collaboration.
Work cited:
Coltart, Nina. 1992. Slouching Towards Bethlehem… and Further Psychoanalytical Explorations. London: Free Associations Books.
