[This piece first published in Auto/Biography, 2002, Vol X, Nos 1 and 2, pp 107-113]

Being at the Receiving End: One Patient’s Experience of Nursing Care

by Phil Salmon

This paper draws upon my recent experience as a neurosurgical patient, in order to examine nursing practices. This experience enables some comparison between nursing care in an autonomous neurological unit, on the one hand, and its counterpart in a general, and then a teaching hospital, on the other. In line with the conclusions of recent research on nurse education and nursing practices, this comparison suggests that institutional factors are critical in enabling nurses to offer genuinely personal kinds of care.

During May 2000, I spent fourteen days in a specialised neurological unit, undergoing surgery to remove an acoustic neuroma. This was followed by in-patient care in a general, and then a teaching hospital, where I had plastic surgery. An acoustic neuroma is a non-malignant tumour on the auditory nerve. It is usually diagnosed by loss of hearing on the affected side. Untreated, it causes deafness, loss of balance, facial palsy, and ultimately death. However, surgical removal itself typically also produces all these sequelae except the final one.

* * *

The world’s spinning, spinning round. Inside and outside’s all mixed up. Am I upside down? Lines, lines everywhere, tangling, jangling, angles and crisscrosses. Dizzy, giddiness. A sound, a kind of moan. Here you are now, Phil. A jabbing pain in my hand, a coolness spreading there.

A butterfly upon a wheel. Odd phrases speak themselves. How are the mighty. And miles to go before I sleep.

Where am I? I look up. A dark red bag hanging, poles, wires. Something touches dry, cracked lips. My mouth feels full of teeth, not my own. My eye is scratchy, I move a hand, I can’t, it’s held somehow.

There’s a roaring, roaring in my head. They’ve made a clearing in the forest, among the thick white trunks. The fire goes blazing across the empty space, then flares, the flames shoot up through the trees. I stop breathing, the roaring stops. Begins again when I breathe. Fire needs oxygen.

A window, movement. Malignant little green figures, jinking and jeering. They rush up and press themselves against the glass, peering in, mocking. Then they retreat, whispering among themselves, teasing, malicious.

There’s a clock. But no time. The hands don’t move, or they move backwards.

* * *

I’m taken in a wheelchair to the washroom. Past a mirror. What horror! Emaciated body, stick limbs with strange attachments, a tufted head held at an angle. Oh, but the face! A jealous rival has spied out the sculptor’s clay model, still moist and malleable. Pressed his thumb down into one cheek just below the eye, and stirred the surface about. He stands back. Very satisfactory! The eye is sagging and enlarged, the mouth twisted sneeringly to one side. All form, all symmetry is lost.

My mind says savage, hateful things. A gargoyle, a monstrosity, ought to be put down.

* * *

Talk drifts about. Boyfriend on hold…electronics engineer…crowns drop out, yes…third vertebra, they say…doing his GCSEs…artificial tears…cos of the drilling. Alright, Phil? I try to lift my head, turn to the right. I’m deaf that side, blind too. No, Margaret has headphones on, she’s listening. I drag my head the other way. But Jill is talking to Tina.

Gradually we get to know each other. Margaret, blind, with a stately face. Jill, with her five large male visitors. Ukranian, they look. Standing motionless around her bed, heads bowed, like patient, kindly oxen. Pretty Yvonne, the would-be trouble-maker, soon mollified. Dorothy, who believes in guardian angels. One came to help with luggage at Heathrow. Another Margaret in the corner bed, with her attendant family. All feverish little people, burnt down to the bone by some inner intensity. And Bobby, but did Bobby exist? I saw her sloping truculently across the ward, her chin jutting forward above the surgical collar. But no one recognised such a person.

But it was the nurses, oh the nurses, who became supremely important. Even during the daze and muddle of intensive care, I had been conscious that those who carried out the numerous physical procedures were themselves graceful and tender presences. None of these procedures were baldly administered; with them came some light touch, a caress, a comforting word. And there was delicate attention to the body being ministered to; not a sigh, a tremble, a moan, a wince of pain, seemed to go unnoticed. ‘That was a big sigh, Phil,’ says Jo, as she and Toni help me from the bed to the chair; frighteningly, I can’t stand unaided. She kneels beside the chair, her large, concerned eyes near mine, and holds me gently as I burst into sobs.

With a tact characteristic of all the nurses, Holly draws my curtains, fetches the commode, helps me on to it, and then withdraws. When I call, she is there to help me back to bed. ‘As I was saying, it was in a crack in the wood.’ She sits on the bed and resumes our conversation. A tarantula, in her aunt’s house in Fellowship, Guyana. A house surrounded by trees, ‘quiet all the year round except when the young people came, and we made as much noise as we could.’ We are all on first name terms. And the nurses, no less than the patients, allow themselves to be personally known: recognised and treated as distinctive individuals, with their own lives, their pasts and futures.

These were not ritual conversations; they were real talk. There was a freedom and informality about them, a genuine spontaneity, far from the mere exercise of interpersonal skills. ‘It was a bit of a risky joke to make, don’t you think?’ I ask Margaret. ‘That’s what I thought, seeing as he didn’t know her’: standing nearby, listening, Lisa doesn’t hesitate to break into our conversation.

Our verbal currency, in these bedside chats, was not the standard phrases that have accrued around illness and recovery. A day at a time, two steps forward and one step back, early days, don’t run before you can walk: I never heard any of these. It can of course be a relief to resort to a pre-existing script. Both sides know their part, and can relax. But a greater mutuality is reached where each is feeling their way, shaping their words here, now, to say this to this particular person.

Talk, and the relationships it established, were genuine. Normal reserves and constraints applied, rather than being waived. ‘Oh Katya, you look so pretty today!’ I at once regretted my gushing remark, seeing her unmistakeable distaste; she was a cool, reserved person.. Yet I was glad not to be indulged, humoured, made allowances for. Lapses remained lapses. Early on, when I could not read, Lisa was reading out to me a lettter from my elderly aunt. It mentioned that both John Gielgud and Barbara Cartland had died. ‘Fancy putting those two in the same sentence!’ Lisa said. But worse was to come. ‘I expect the nurses are far more upset over Barbara Cartland’ my aunt had written. ‘What a thing to say!’ Lisa was outraged. I felt mortified. But despite my embarrassment, I was glad Lisa had not hidden her anger. Our relationship was not based on unconditional positive regard.

In such talk, what is said is credible, rather than being just a matter of ritual stock phrases. This meant that when the nursing staff spoke about progress, or otherwise, in recovery, it felt believable. ‘Not done so well today, then, Phil,’ says Louise, looking at my untouched meal. ‘You managed a bit yesterday, didn’t you.’ There was no forcing of the evidence to prove a positive story.

One day I’m taken in a wheelchair to an adjoining unit, over horribly bumpy ground, by a porter who does not speak to me, but only whistles. I give way to tears, a trickle down one cheek. Josie and Louise are suddenly there. Louise crouches down, visibly concerned. ‘It’s me, I’m too thin-skinned,’ I tell her. ‘It’s your fault, you’ve spoilt me, I’ve felt loved.’ ‘That’s a lovely thing to say,’ says Josie.

It was true, I did feel loved. But it was a love that involved acknowledgement of me as a person. Early on in my stay, Mandy cuddles me and whispers endearments. But then she says,

‘I spect you hate all this lovey-dovey stuff, don’t you!’ ‘Oh no I don’t, I like it’ I say truthfully; being cuddled is comforting. But in the end, this kind of love is generalised and indiscriminate, something to which any suffering body is entitled.

The degree to which I began to recover, and achieve a wavering sense that personal recovery might be possible, seemed to derive from the way these nurses spoke to me. Talk: it could be seen as no more than a pleasant adjunct to the really effective thing – medical treatment of one kind or another. But rehabilitation, as I came to realise with some panic, is not simply a matter of natural physical recuperation: the body gradually recovering strength and function. It is only through one’s own efforts at fighting dizziness, and trying to exercise paralysed muscles, that one may regain at least some of one’s former powers. The person: it is the person who is the real agent of treatment. And the extent to which one feels one’s person recognised and valued is crucial in being able to believe in one’s dismayingly altered self.

My own most painful uncertainties centred on my facial disfigurement. I did not know if this would be permanent. Surgery had damaged the facial nerve. It might recover at least partly, but no one could say when, or to what extent. Disfigurement touched deep feelings about myself. Faces, as T.S. Eliot once remarked, are the place where we prepare to meet the faces of others. I was intensely anxious about how other people would react. I anticipated controlled but perceptible revulsion: an attempt to hide the sense of shock which I felt myself when I looked in the mirror.

In this situation, the nurses’ responses proved crucial. Much of their nursing care was focussed on my face itself: treatment of my eye, feeding through my distorted mouth. But at no time did they avoid eye contact, or turn tactfully away. It seemed that they were not put off by my appearance. Without discounting the damage, like someone claiming not to see skin colour, they responded to me as a person, in an easy and unforced give and take.

Hospital wards are sites where, as patients, we begin the huge task of learning how to manage the sick role. As Radley (1994), in particular has insisted, being ill faces us with all kinds of personal choices and moral dilemmas. Illness and disability are not purely medical affairs; they represent, in Bury’s (1991) phrase, a biographical disruption. They throw into question fundamental and taken-for-granted features of one’s social role as an adult person.

How far it may be possible to retain one’s previous identity – to avoid giving disabilities a ‘master status’ – can only be discovered through interaction with others. It is through the context of relationships that we come to learn the human and social meaning of what has happened to us. The reactions and expectations of those around us tell us what is our new balance now, of entitlements and responsibilities. We learn, in all sorts of delicate and subtle ways, appropriate ways of behaving as a sick person. How should we now conduct ourselves, how avoid being an embarrassment or a liability to others? In the immediate hospital context itself, this includes knowing how to be a good patient: when and when not to complain.

For patients like myself, the regime of this neurological ward provided a benign social environment. The quality of care, and in particular the quality of nurse-patient talk, allowed a sense of personal recognition, and of continuing social viability. This had certainly not been true of the hospital I had been in many years previously, undergoing a haemorrhoidectomy. One major contrast was in the ward routine. In the neurological unit. the regime was highly flexible. The medications, the frequent ‘observations’, the bedside consultations with doctors, were all tailored to individual need. For instance, Justine, the physiotherapist, finding me asleep at last, mercifully chose to come back another time. Each person’s programme of physical treatment was evolved over time, in relation to individual response. If a particular drug, or form of physiotherapy, did not seem helpful, another one was tried. Nor was there any need to wait for pain relief, which was simply given by one of the nurses on demand in one form or another.

In the general hospital there had been no such flexibility. For each particular surgical condition, the treatment was highly standardised. In dispensing medication, the nurses had no leeway. Unlike the nurses in the neurological unit, who made many drug decisions on the spot, nursing staff could only dispense what had been previously prescribed by doctors, and only at specified times. Pain at the wrong time could not be relieved, however severe. ‘I’m sorry, dear, you’ll have to wait till Doctor comes round.’

The nursing order in the general hospital had been highly, and visibly, hierarchical and authoritarian. Differences in uniform clearly announced status differences. The uniforms themselves were stiffly starched and uncomfortable-looking, very different from the way these women would have dressed outside hospital. There were marked demarcations of role. And apart from what was strictly necessary, there were few interchanges between the nurses on ward duty, and a sense of tension when the sister was present. Only occasionally, a little huddle of young nurses would stand close together in the window, whispering and giggling, with a palpable release of strain. The nurses did not speak at all to the porters or ward orderlies.

All this could hardly have been more different from the neurological unit. The nurses there wore attractive, well-fitting clothes: blouses, skirts and dresses only identifiable as uniform by the colour of their stripes. Relations among themselves were easy and friendly; they all helped each other out, and there was no sense of rank. Among the staff I met there was a racial mix: Guyanese, German, Jamaican, Finnish, Irish, English. Everyone seemed equal; there was no hierarchy of skin colour. Their inclusive community also contained the catering staff, and at least one of the cleaners, though the other two – men who spoke to each other in an African language – remained determinedly apart. The absence of constraint had not quite reached relations with doctors, at whose ward rounds, attended by a respectful retinue, nurses always stood a little way behind, not offering opinions unless asked.

Unsurprisingly, the nurses in the general hospital had not been on first name terms with patients. They were simply Nurse, while we were universally addressed by meaningless endearments: sweetheart, dear, my love, darling. There was little divulging of personal details on either side, only a routine jocular banter - jokey talk, often with sexual innuendo.

The huge differences between these two hospitals, and the great improvement, from the patient’s point of view, in the quality of care, seemed to derive from developments in the philosophy of nursing. Things had evidently moved on. The bad old days were gone; time, apparently, had brought about a better nursing practice. But, as I soon discovered, things were not so simple. After two weeks I was transferred from the specialised unit to a local general hospital. The transfer happened without warning. As she began to pack away my things into a plastic bag, one of the nurses I particularly liked simply announced that the ambulance would be here in half an hour. In my debilitated state, this seemed a huge and traumatic event. I felt I was being exiled from what had become my home. The nurse hugged me, comforting me as best she could.

The next three weeks in the general hospital, and the teaching hospital which followed, felt very different from my earlier experience. In both, there was a bewildering succession of nurses, many of whom I saw only once. These included one nurse who came early on to introduce herself as ‘Wendy, your named nurse’, and never appeared again. The numerous changes were in part a function of the agency nurses on whom the hospitals depended; but they were also due, it seemed, to a policy of moving around even their own nursing staff. Though there were a few nurses whom I saw more regularly, these were generally very rushed, dashing in to take blood pressures, dispense medications, administer drops, and so on, before hurrying on to the next patient. Inevitably in this situation talk between nurse and patient was almost exclusively confined to medical matters, and there were few opportunities for developing any personal relationships.

Nor was it only the nursing staff who seemed to chop and change. As patients, we were subject to sudden unexplained moves. I was moved twice: once, from a side room to the main ward, and then from one bed in that ward to another. Though on the face of it these are petty events, experientally they can be traumatic. For me, they represented further exiles. Each time, I felt an acute sense of personal loss, of being suddenly uprooted from what was becoming familiar. My place, with its learned location, its view of the ward, its neighbouring fellow-patients, and the small arrangements I had made around the bed – all this was abruptly taken from me.

These experiences produced a setback in the faltering psychological, and physical, progress I had just begun to make. My contacts with the nurses were confined to necessary acts of physical care; and these acts were carried out hastily and without reference to me as a person. My previous sense of personal recognition and encouragement was replaced by something else: the sense that I was a burden to an already over-stretched staff. Here there was no one to look me in the face and address me as a fellow human being. This undermined the fragile confidence I had begun to feel, within the previous personally affirming ward context. My facial disfigurement again became salient. And I found I was becoming more fearful and incompetent in the tasks I was told to perform, particularly trying to stand.

It has long been known that there is a link between recovery from surgery, on the one hand, and ward relations on the other. Four decades ago, the pioneering work of Revans (1964) demonstrated a statistically significant association between the quality of ward relationships and speed of recovery from appendectomy. Other researchers have replicated Revans’ own work; and its implications are explicit in current expositions of nursing philosophy, and in the structures of contemporary nurse education.

Professional rather than technical competence is now generally seen as crucial in nursing practice: in the words of Nyberg (1999), ‘the days of being judged on our ability to scrub and circulate are quickly coming to an end.’ (p. &9). Others (Smith, P., Pill, R. and Stott, N.,1999) argue for the centrality of nurse-patient relationships, and insist that these be participatory, and based on equity and empowerment. For Walsh (1999) sensitive responsiveness to patients is the key to good nursing. Walsh writes:

‘What sets nursing apart? Perhaps the simplest and the truest answer is that we hear the need of each patient, whatever it might be, and however he chooses to communicate. Being open to another’s need and responding to it is the stuff nursing is made of.’ (p. 36)

Orlando (2001), an influential advocate of this approach, brings the evidence of her own research, over several decades, to support her claims. Patient outcomes, as she shows, are significantly improved by ‘deliberative’, as against ‘automatic’ nurse responses. Deliberative responses are defined as dynamic, responsive to changed patient behaviour, and concerned with enhancing the patient’s sense of being understood and accepted.

From the viewpoint of nurses themselves, however, the achievement of personal relationships such as these is typically complicated by tensions within the nursing role. This is illustrated in an Australian study (Ford and Turner, 2001), which focussed on nurses caring for children with special needs and their families, in an acute care setting. In a series of in-depth interviews designed to elicit personal meanings, these nurses told stories of their experience in providing care. Many spoke of developing ‘special’, as against routine, relationships with some patients, and of how rewarding these could be. Particular children somehow assumed special significance; they became known personally, they were thought about in their absence, remembered after they had gone. With these patients and their families, there were moments of intimacy, mutual openness and shared communication – an I-thou relationship, as Gadamer (1989) puts it, in his discussion of nursing. For the nurses concerned, these relationships were highly valued, and brought a sense of privilege.

But such relationships could not always be achieved. In part, this was because of variable chemistry; in the words of one nurse, ‘you sort of click with some people.’ (Ford and Turner, p. 289) Even with ‘special’ patients, institutional demands, with their pressures on time and resources, meant that it was often impossible to give individual patients sufficient personal attention. For nurses themselves, this inevitably entailed frustration and guilt. And in this particular setting, where parents were present, there were often tensions between conflicting claims to ‘expertise’ concerning the child patients.

For nurses who did develop close relationships, there was a difficult sense of going beyond normal boundaries: ‘Sometimes there is a need for you to overstep what you would normally do.’ (Op. cit. P. 292). Nor did every nurse in this study endorse the notion of establishing close and intense nurse-patient relationships. As one participant remarked, ‘I think you’d kill yourself.’ (Op. cit. P. 291).For her, as for some others, boundaries and limits were crucial. And even for those who related to their patients more personally, these relationships carried their own emotional cost. To one nurse, this entailed the need to ration her involvement: ‘you have to recover before you can invest again.’ (Op. cit. P. 291). Close relationships with patients carry constant risks of emotional burnout.

As this study suggests, personal involvement with patients, however desirable from a patient’s point of view, entails complex and difficult professional decisions. For some writers, such as Rushton, C., (1996), viewing certain patients as special suggests over-involvement on the nurse’s part. In the words of Benner and Wrubel (1989), there is ‘a narrow path that nurses may tread lightly in determining the right level of involvement.’ (Benner and Wrubel, p. 89).

In the first hospital context I experienced, nurses seemed readily prepared to become personally involved with patients. Yet in the other two hospital contexts, there appeared to be little attempt on the nurses’ part to relate personally to those in their care. How could these contexts produce such very different nursing practices? For me, my first hospital experience formed the ground from which I judged my later experiences, and found them wanting. But perhaps the appropriate question is not why the general and the teaching hospitals failed to measure up to the standards of the first hospital, but how the first hospital was able to achieve its exceptional level of personal care.

Health care, in the words of Obholzer (2000), is ‘a field irradiated by distress’. As Isabel Menzies (1958) first powerfully showed, daily contact with illness, with sick and dying people, arouses intense anxiety – an anxiety that in many institutions can be contained only by a series of defence mechanisms. In intimate contact with suffering bodies, with limited capacities to help, nurses struggle, through defensive strategies, to avoid being overwhelmed by painful feelings. And it is these defensive strategies which, as much research has shown, can become built into hospitals, as institutional policies.

Skogstad (2000), who over four months studied a general hospital medical ward, offers a picture of the hospital culture he observed. He found himself, as he describes, at the centre of great activity; there was a constant to and fro, with nurses moving abruptly around the ward. Relationships with patients appeared mechanical; there was a surface cheery friendliness, which bypassed feelings of fear, anger and despair, and, in his view, left patients in a state of loneliness and isolation. But this emotional neglect of patients did, as Skogstad argues, serve to protect nursing staff.

This picture accords with the one which Menzies (1958) herself describes as embodying typical institutional defensive strategies. Nurses move abruptly between wards and patients, do not use patients’ names, appear anonymous through wearing uniforms, and refer even trivial decisions to higher levels of the institutional hierarchy. All this is characteristic of institutions in which inter-professional relations are defined by an essentially authoritarian and hierarchical system. In such systems, power is unequally distributed within a pyramidal structure, at the peak of which stand medical staff.

The crucial importance of institutional power, for nursing practice, is illustrated by a large scale survey (Rafferty, A.M., Ball, J. and Aitken, L.H., 2001), of staff nurses in thirty two English hospitals. The focus of this study was the relation between quality of care, nurse autonomy and inter-disciplinary teamwork. The latter two features were found to be closely related, and to be associated with enhanced capacity for decision making, and more control over resources. In turn these factors were associated with a higher level of quality of nursing care.The authors argue that these findings exemplify the crucial importance of teamwork. Teamwork, with the mutual respect and reciprocity which it entails, was also vital in nurses’ own morale and professional satisfaction. Those who felt themselves to be part of a team were generally happier, more likely to want to remain in post, and suffered much less from emotional burnout. Similar factors are emphasised in a study of two intensive care wards (Zimmerman , J.E., Brown, L. and Conrad, D., 1994). These researchers found that better organisational practices were associated with a strong nursing culture and a sense, among nurses, of collegiality. Teamwork, again, seems vitally important.

The institutional culture of the hospitals in which nurses work is clearly crucial in determining the possibility or otherwise of teamwork. As Shortell (1994) argues, management structures and practices largely shape the way in which nurses actually perform their nursing role. Official definitions of the nursing role ‘map only loosely onto job content, the division of labour being the product of custom and a negotiated order.’ (Shortell, p. 512). As I saw for myself as a patient in three different hospital settings, certain institutions seem to produce nursing practices that are inimical to teamwork: the sense of community, collaboration and group solidarity among nurses themselves.

In the general and teaching hospitals, nurses apparently held low status in a relatively rigid and authoritarian hierarchy. This hierarchy, with its clear differentials of power, privileged a largely male medical staff over a largely female nursing staff. Gender antagonisms may therefore have additionally acted as a built-in obstacle to inter-professional teamwork.The regime itself seemed to treat nurses impersonally, and allow little recognition of or expression of their personal feelings. If their nursing practices produced in patients a sense of isolation and emotional neglect, this was an inevitable by-product of the lack of support available to themselves.

In the neurological unit, by contrast, the high level of nurse autonomy, and the large responsibilities carried by the nursing role, must have carried a sense of being institutionally valued. The personal recognition implicit in the absence of uniform enabled a comparable treatment of patients as equally individual. These nurses helped each other out, occasionally even taking over from catering or cleaning staff; there were no strict demarcations of role. There was a sense of easy and friendly ward relations, of reciprocity, respect and solidarity. Perhaps most importantly of all, nursing in this small, specialised and autonomous unit carried a proud group identity.

Unfortunately, all this will change, with the amalgamation of this unit into the teaching hospital where I spent time as a patient. This move is deeply unwanted by the nurses themselves, but comes as a product of the restructuring of healthcare management to fit an efficiency model, and which is geared to economic rather than social goals. I fear the unit, submerged within a far larger hospital, will lose the distinctive institutional culture which enabled its nursing staff to work so much against the grain, and of which I was a personal beneficiary. This is sad. Times change, but people’s need for dialogic and caring relations do not.

References

Benner, P. and Wrubel, J. (1989) The Primacy of Caring. Adison-Wesley Publishing Co., Menlo Park.

Bury, M. (1982) Chronic illness as biographical disruption. Sociology of Health and Ilness, 8, 137-169

Ford, K. and Turner, D. (2001) Stories seldom told: experiences of caring for hospitalised children with special needs and their families. J. Advanced Nursing, 33 (3) 288-295

Gadamer, H.G. (1989)Truth and Method. Continuum Publishing Co, Norton

Menzies, I. (1958) The functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital. In Menzies-Lyth I. (1988) Containing Anxiety in Institutions. London, Free Association Books.

Nyberg, D.B. (1999) Successful delegation skills enhance patient care. Nursing Times, April

Orlando, I.J. (2001) Theory of the deliberative nursing process.Nursing Times, May.

Radley, A. (1994) Making Sense of Illness. London, Sage.

Rafferty, A.M., Ball, J. and Aiken, L.H. (2001) Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Quality in Health Care, 10, 32-37 Suppl.2 Dec.

Revans, R.W. (1964) Standards for Morale: Cause and Effect in Hospital . London, Oxford University Press.

Rushton, C. (1996) Establishing therapeutic boundaries as patient advocates.Pediatric Nursing, 22, 158-189

Shortell, S.M., Calnan, M. and Johnson, B. (1994) The performance of ICUs: does good management make a difference? Medical Care, 32, 508-535

Skogstad, W. (2000) Working in a world of bodies: a medical ward. In Hinshelwood, R.D. and Skogstad, W. (eds) Observing Institutions: Anxiety, Defence and Culture in Health Care. London, Routledge.

Smith, P., Pill, R. and Stott, N. (1999) Health promotion versus disease and cure. Social Science and Medicine, 48, no 2, 220-237

Walsh, L. (1999) Lessons from the bedside. Nursing Times, Autumn Issue

Zimmerman, J.E., Brown, L. and Conrad, D. (1994) Intensive care at two teaching hospitals: an organisational study. Am. J.of Critical Care, 3, 129-136.

Biographical Note

Phil Salmon worked for eleven years as a clinical psychologist in the NHS, before moving into adult and higher education. She taught for Birkbeck College and the Open University, and also worked at the Medical Foundation for the Victims of Torture. Her books include Living in Time, (1985), Achieving a Ph.D. (1992), and Life at School, (1998).

Very sadly, Phil died of cancer on 13th May 2005. She was 71.

Back to:-
Guest essays
Homepage