example the presenting problem at one meeting was the difficulties the Doctors have in communicating with bereaved parents. 1 tried to convey the notion that parents might "hear" what the Doctors were saying as an accusatory statement. This was difficult for the Doctors to accept. The case discussed at that meeting was that of a baby that had died after 5 months on the Unit. The Doctor had told the parents that their baby had had "the worst pair of lungs" he had seen in 15 years. 1 believe the parents might have interpreted this as the Doctor accusing them of producing "a damaged pair of lungs". The Doctor in turn might have interpreted this suggestion from me as questionning his ability to be sensitive to the
The ideas of Lewin, as developed in his writing on action research were enormously useful in the assessment stage and in the work in the group in this project. However the type and level of anxieties met on the Unit meant that theories and ideas on paranoid anxieties and defences had also to be incorporated into the theoretical framework of this work.
The term "Action Research" was coined by Kurt Lewin, (a Jewish German psychologist, 1890-1947). It is discussed in his papers published between 1947-1952. The main characteristic of this research methodology is its focus on the "involvement in change"; it links to a need to solve a problem, usually a social, practical one rather than a theoretical question. It has a collaborative characteristic in as much as it generates knowledge that is produced and shared in the setting in which the research is taking place.
Kurt Lewin had great personal influence through the applied research institutions that he established e.g. the Committee on Community Interrelation (CCI) and the Centre for Group Dynamics (CGD). One of L e w i n ’s primary objectives was to close the gap between abstract social theory and particular concrete field work: action research was intended to solve a concrete problem such as racial prejudice and discover "general laws of group life".
Lewin conducted controlled empirical research that was inspired by among other theories, that of psychoanalysis. "From these efforts, psychoanalysis received a graver lustre of investigative respectability and this in turn led other more conventional psychologists to conduct related research"(Hall & Lindzey, 1968). According to
Robert de Board, it shows a passionate concern for democracy in general, and minorities in particular. "Even greater than this was his desire to make psychology an applied science, something that would change and improve the social conditions of men and women. As a German Jew he was forced to leave Germany and flee from the Nazis in 1933. Lewin believed that social psychology based on an intimate combination of experiments and empirical theory could do as much or more, for human betterment than the natural sciences have done."(de Board 1978)
In the 1920s Lewin wrote that "every job has a life value" meaning that work has to sustain and enhance. The task to accomplish this cannot be achieved by the efficiency expert alone. Lewin brought his research methodology into the mass production field, for example
looking at an American factory. Many others followed.
For Lewin, action research provided a way both to solve practical problems, such as racial prejudice, and to discover "general laws of group life... A knowledge of group laws is, however, insufficient for the resolution of a social problem. One must supplement this knowledge with knowledge of the specific character of the situation, which, through a process of scientific fact finding is called diagnosis" (Lewin 1948). He describes the stages of the action research cycle: the diagnostic stage of fact finding, reflection and planning which together with relevant laws produces a change strategy. This is followed by an action and evaluation stage.
In the first issue of the Human Relation Journal which he founded with Trist, he writes:
"One of the by-products of World War 2 of which society is hardly aware is the new stage of development which the social sciences have reached. This development indeed may prove to be as revolutionary as the atom bomb. Applying cultural anthropology to modern rather than "primitive" culture, experimentation with groups inside and outside the laboratory, the measurement of socio-psychological aspects of large social bodies, the combination of economic, cultural and psychological fact finding, all of these developments started before the war. But by providing unprecedented facilities and by demanding realistic and workable solutions to scientific problems, the war has accelerated greatly the change of social sciences to a new development level. The scientific aspects of this development centre around three objectives;
1.Integrating social sciences.
2.Moving from the description of social bodies to dynamic problems of changing group life.
3.Developing new instruments and techniques of social research"(Human Relation Journal 1).
He argues that social events were treated in the past as non-existent, or as unscientific phenomena that could not be explored. They were a scientific taboo, like a social taboo and any investigation of them was seen to be in opposition to the scientific common belief. He developed the concept of "field of force" and "life space", and applied these to the way groups behave. One of his most important works was in the field of mass production, exemplified by action research in a pyjama factory.
Experience in Action research
Lewin visited a pyjama factory that employed young women in Marion, Virginia. He had previously shown how group democracy enhances productivity, and helped Bavelas to develop the faunous experiment that showed how productivity rose with the introduction of a more democratic way of managing the work.
The productivity of one group of workers, who paced their hourly work by using "pacing cards" rose from 67 units to 82 units, while the control group's productivity stayed the same.
Later the factory had to move, and an experiment devised by Coch and French showed that the involved group of workers (who had been consulted throughout the move) reached the pre-move productivity level after only two days. Levels of 14% higher productivity were recorded later and were maintained. In the other group of workers (who were merely informed about the move) a reduction of output was recorded, and 17% of workers subsequently left the factory (Human Relation Journal, 1948,1).
Sharing information in the Neo-natal Unit:
The Neo-natal Unit divides into two main groups: staff and parents. These then sub-divide further, for exeimple into Medical and Nursing staff, which again sub-divide along lines of seniority. The notion of consulting staff and involving them in what takes place around them is very popular, at least officially, and medical decisions are shared with Nursing staff. However the example below
illustrates the exclusion of the parents from the sharing of information.
One mother spent three months on the Unit, visiting her baby who was very ill. She had got to know another mother who had a very sick baby girl. The second baby died. The first mother complained in the Parents Meeting that the death had been kept a secret. Staff did not tell her: she had seen a great commotion, people running and she had understood but she had wanted to be informed. She wanted to send a card or attend the funeral. This came up in a Staff Meeting. Should she have been told or not? Do mothers who spend months on the Unit become almost part of an artificial family and should therefore be told what is going on rather than discover it?
It beccune clear that the staff had never thought about this. One nurse told us that she supposed that it was never talked about. Years ago when she was training on an adult ward, when a patient died the curtains were closed and when asked by another patient where he was, she was told to say that he had been moved to another ward. Death did not exist.
Some members of staff felt that there was an issue of confidentiality here; some thought that you cannot hide a death: it is no longer a private matter.
I feel that Lewin's theories do not take on board the dynamic issues that are alive here. The fact is that babies do die on the Unit, and staff can no longer pretend to themselves or to parents that all babies are saved. One mother (who had herself nearly died) almost accused the
staff of denying this and of hiding the truth. She was not prepared to be patronised.
Issues of life and death, of babies surviving or not, need a theory that takes on board paranoid anxieties and primitive defences. I thought that in order to get mothers and staff to think about these issues I needed not only action research theories, but also theories on early anxieties and early defences.
The training groups
From 1944 Lewin became more and more interested in Group issues. In his new centre based in the Massachussetts Institute of Technology, he studied group dynamics with many colleagues (Cartwright, Lippitt, McGregor, Allport). The Centre explored issues such as: anti-semitism in every aspect of social life, the employment of negroes on sale counters, and gang fights.
Perhaps's Lewin's most enduring achievement was the creation of the "T groups". These training groups were the model for many groups training in America and elsewhere in the world, including the Tavistock-Leicester conferences (Sofer and Trist, 1959).
In 1946 Lewin organised and directed a conference to look at the most useful way to counter religious and racial prejudices. This, the Conneticut Conference, comprised 30 members including teachers, social workers, labour leaders and a businessman. The Conference divided into three groups of ten. Through role-plays and group discussions social issues were looked at. Lewin led the team of
researchers and Lippitt, Bradford and Benne were the training leaders.
The trainers concluded that they had found an effective way to retrain. "Group members, if they were confronted more or less objectively with data concerning their own behaviour and its effects, and if they came to participate non defensively in thinking about these data, might achieve highly meaningful learnings about themselves, about the responses of others to them , and about group behaviour and group development in general" (Bradford, Gibb and Benne, 1964). Further references to action research are to be found in work on Social and Community Action: Ketterer, Price and Politser (1980), Rapaport
(1970); Organizational Development: French and Bell (1973) and Transformation of Educational Organisation and Practices: Corey (1953), Elliot (1978), Kemmis (1991).
Lewin was full of optimism and trust in the efficacy of action research as a tool of change in institutional life. My very limited experience in work in the Neo-natal Unit makes me wonder if he did not underplay the resistance to change that has to do with unconscious anxieties that is highlighted in the work of Bion.
The work of other researchers;Some of Bowlbv's contributions.
Bowlby, more than any other psycho -analyst influenced social policy in the areas of care for children in institutions and of policy towards visiting children in hospital.
From early on he was very interested in the environmental impact on the psychological development of the child.
His work in a maladjusted school and in a child guidance clinic was the background to his papers on attachment. He showed that a child's attachment to its parents is made more difficult by the psychological difficulties of parents. Further children develop similar difficulties to those of their parents and the parents have enormous problems in tolerating this.One case he wrote about was that of a mother who could not tolerate sibling rivalry in her child and who was herself very jealous of her sister
(1977).
His fcumous paper Forty four juvenile thieves (1944) linked lack of caring input into the child's life with the creation of a juvenile criminal who is uncaring for others.
The work on the impact of separation on the personality development of young children that was done by Bowlby, the Robertsons and Ainsworth who co-founded the Attachment Theory, is the most relevant to my work in the hospital.
The very moving film "A two year old goes to hôpital " made by the Robertsons and the research work Bowlby did
later for the World Health Organisation transformed policy towards visiting ill children in hospitals (1951). Today it is difficult to think about a pre-Bowlby children's ward.
In one of the meetings of the Journal Club on the Neo natal Unit (discussed in Chapter 3) we were listening to
the director of the service talking about her 40 years as a nurse. She recalled that as a child she contracted an infectious disease. She was placed in an isolation ward, and her parents were allowed to come to the door of the ward and look at her from there once a month.Miss D stayed in hospital for a few months and she thought that that experience was one of the reasons she decided to become a nurse when she grew up.
The change Bowlby's work brought to hospitals was enormous and is reflected in the official policy on the Unit which is to try and make parents do as much as possible, as soon as possible for their babies.Babies of 29 weeks gestation or less are breast fed if they are well enough.They are brought out of the incubator even earlier for a cuddle and "kangaroo care" if they are stable.Parents are addressed by the posters on the walls telling them that the doctors and nurses of the unit know that only they the parents can love and give a sense of warmth and continuity to their infants.They are encouraged to stay as long as the can and talk, sing, stroke, clean and feed their infants
(discussed in Chapters 5 and 6).
The work on Open System Theory (Trist and Bamforth, 1960) and on the Socio-Technical System (Rice, 1963) interested me when I thought about the complex interactions on the Unit. The obvious conflict between two systems is the conflict between what is medically necessary for a baby to survive, and what is necessary for a mother to maintain her confidence in her maternal role. Women must feel defeated and devalued as mothers, in the face of all the machines that are essential, and take over from them in sustaining the lives of their babies. There is tension all the time between the two systems: there is internal tension and conflict, between the mother feeling devalued
and feeling paranoid about what is being done to her infant, and feeling grateful to the team that save her baby's life.
I tried to introduce a way of working and thinking in which the medical system adjusts to the needs of the mother-infant closeness, thus minimising the damage to the mother's confidence in her role as a mother, in order that she can tolerate more easily the medical input into her baby's life.
Trist's work in the mining industry and Rice's work in India describe changes introduced into systems to take into account the psychological needs of the people involved. Chapter 3 describes the changes that I introduced in an attempt to facilitate a similar effect. The Tavistock Institute of Human Relations was born after Dunkirk in 1940 when a team of psychiatrists, clinical and social psychologists, sociologists and anthropologists was established in London. The team played an important role in various military issues such as Officer selection, morale in Officer Cadet training. Officer selection boards, and civil resettlement units for repatriated prisoners of war. This team formed the core of what was to become the Tavistock Institute of Human Relations (Trist "The social engagement of Social science").
They brought to the field of group and organisation study original complementary ideas. Lewin's ideas on action research, group dynamics and field theory, life space and Training groups, proved to be central to the development of group research and the Tavistock Conferences.
B i o n 's work on groups was the other major influence in the