In this paper, we present a synthesis of ideas from two PhD theses, where following a shared interest in clinical supervision, links were made between the intersubjective, relational dynamics present in clinical supervision (Nolan, 2008a, b) and applied in practice to a framework for emotional labor as experienced by prison nurses in HM Prison Service (Walsh, 2009). It is not our intention to provide detailed information regarding these in this paper, as further information can be obtained in Walsh (2009) and Nolan (2008a). Rather we aim to utilize our models of intersubjectivity and emotional labor as vehicles to support the development of both practice and the workforce through clinical supervision.
Emotional labor is known to impact on professional burnout (Huynh, Alderson, & Thompson, 2008) and is a significant cause of workplace stress (Mann, 2004). Clinical supervision is one way of managing the effects of emotional labor on prison nurses (Walsh, 2009) and as such we suggest that effective, regular clinical supervision is a useful mechanism to support nurses in managing this stress. Through our work described in this paper, we acknowledge the value of clinical supervision as a space to understand and appreciate the intersubjective web of relationships in prison healthcare. Through deeper understanding of this web of relationships, we suggest that practitioners can gain a better understanding of their reactions to both patients and colleagues, which, in turn, will promote better working relationships.
In order that the reader can follow our thinking and subsequent development of ideas, we begin with an outline of the development of the knowledge base underpinning intersubjectivity, which is situated within the field of psychotherapy. This is then linked with an exploration of how intersubjectivity impacts on the nurse–patient relationship in prison, while being mindful of the emotional labor of prison nurses. We then provide an alternative approach to reflecting on practice in prison healthcare, which takes account of both the emotional labor of prison nurses (using the framework identified) and an understanding of the complex intersubjective web of relationships they work with. Clinical supervision is discussed and promoted as a space in which this web can be explored to identify intersubjective relations impacting on emotional labor, thus enabling prison nurses to truly understand their practice and the impact of it on their own mental well-being.
A sense of identity, who we think and feel we are, is built up through social relationships and learning to be in relationship with “other.” What we think and feel is built up from relational experiences and remembered events as a “felt sense” (Gendlin, 1997, 2003), contained in sounds and smells triggering “embodied” memories (Rothschild, 2000). These collected elements of memory affect how we function moment-by-moment in daily life.
Ideas from relational psychoanalysis and psychotherapy (Aron & Harris, 2005; Mitchell & Aron, 1999; Stern, 2008, Stern, 2010; Suchet, Harris, & Aron, 2007) and neuroscience (Cozolino, 2002, 2006; Gallese, 2009; Ginot, 2007; Lepage & Theret, 2007) recognize that the way we perceive meaning is intersubjectively influenced when with others: I look you in the eyes and communicate with you, my thoughts and emerging actions are affected by your responses, but also by retained memories of previous experiences and relationships.
Psychoanalyst Benjamin (1990, p. 33) sees “intersubjectivity” as recognition that our subjective perceptions are in relational proximity, and they are affected by feelings about their relationship with us, and us about them. There is a continual breakdown and repair of mutuality that is directly affected by the thoughts and fears that we have about ourselves, described by Benjamin as “intrapsychic fantasies”—in other words, we imagine what others think and feel about us and then act accordingly.
Writings and research on intersubjectivity (Benjamin, 2005; Stolorow, 2005; Stolorow, Atwood & Brandchaft, 1994) see meanings in relationships as always existing in a social context, each with differing life histories and worldviews. Research from the Boston Change Process Study Group (2010) at Harvard University explores the nature of cocreated meanings, when one is subject moment-by-moment to being influenced by the presence of “other.”
Stolorow (2005) sees the degree of interpersonal attunement as being dependant on our communicated response to the meanings derived from our prior experiences. I experience you, and you me, with memories of previous relationships and events, some of which may be in my conscious awareness, others not. It is these elements of instinctive in-the-moment reactions that have a direct impact on the outcome of a particular encounter.
Making sense of these interpersonal responses, or “dynamics,” can be helped by the use of visual representation, illustrated in the diagrams below (A–D), (Nolan, 2008a; 2008b). A relational interplay of intersubjective processes can be tracked within the intersubjective space, where we experience the other person, the “analytic third” (Ogden, 1994) and a region of focused attention, notated below as the fourth. In illustrating this concept, consider what would appear to be a simple interaction between nurse and offender/patient. Color figures can be found in the online version of this article.
A: Relational frame
Each person is contained in a field of influence, a boundaried space as a projection of “self” which the “other” senses and perceives, a three-dimensional “bubble” containing the embodied “presence” of each. The interacting bubbles create a “third” element (in purple); focused attention defines a minibubble “fourth,” seen as the area of bright yellow.
In our example, an offender (left bubble) is with a nurse (right bubble), each aware of the other's presence (overlap). The nurse begins to talk (small circle), the offender replies (second small circle) creating a focused area of attention between them (bright overlap).
B: Precomplex frame
The “other” brings a preexisting “presence” or remembered event (broken line) to the frame, generating reactions, feelings, and thoughts. In this frame, the offender recalls previous experiences when with a nurse, the memory of which informs/affects the ways in which he continues his response. The nurse responds accordingly.
C: Complex frame with “populated dyad”
Additional “presences,” introduced by the other's narrative, feed a complex “fourth,” adding complexity. To continue using our example of the nurse offender/patient interaction, another previous memory intrudes, perhaps triggered by a word or phrase from the nurse, adding to the offender's evaluation of what to say, or do, next.
D: Reflection and insight
Moving in and out of focused engagement, observing at the time or on subsequent reflection, can enable insight and understanding. In this situation, the nurse senses a change in his or her emotional perception of the offender, considers how best to respond, and then reengages with the encounter.
Each of these stages (A–D) might occur in a moment, sometimes not in either person's conscious awareness. The encounter may develop purposefully, or not; the nurse may or may not be fully aware of how responses might be perceived. If the nurse is at ease with the encounter, then reflection in-the-moment would allow clear evaluation—if not, then reactions might be not fully understood and feelings may remain unprocessed, the containment of which contributing to stress. Talking about such an encounter afterward in collegial discussion or in clinical supervision would enable reflection on the event and time to consider any contributing factors that were unrecognized at the time. The diagrammatic “tool” illustrated here helps in seeing influences and factors that might have affected the encounter.
However, our illustration does not take account of the nurses' own processes. For example, they may have had a disagreement with their partner that morning, an altercation with their line manager, or retained a memory of a previous encounter that had proved problematic. They may also need to be mindful of the expectations and ethos of the institution. Any of which might potentially impact on this scenario.
Reflection and insight (D above) shows a moment of “potential space” in which to think (Kounios et al., 2008; Kounios & Beeman, 2009; Ogden, 1997), and provides an opportunity to avoid “abandonment” of communication and breakdown in the relationship. Such a space where these ways of thinking might be provided is within clinical supervision or in group debriefing meetings following an incident. However, thinking in such terms is a challenge when three or more people might be interacting in the prison context, where the environment does not often lend itself to providing space and time to reflect, especially in moments of crisis and emergency.
Intersubjectivity and emotional labor: A prison nursing perspective
According to Pierson (1999), the relationship between nurse and patient is an intersubjective process between individuals. Therefore, consideration of the concept of intersubjectivity is essential as it constitutes an integral element of nursing practice. Previous work exploring the nature of emotional labor in prison nurses highlighted three key relationships as having a significant impact on the emotion work of prison nurses, with a fourth, interpersonal relationship, that can cause professional and personal disease (Walsh 2009). Emotional labor is defined by Mann (2004) as having three components “the faking of emotion that is not felt and/or the hiding of emotion that is felt, and the performance of emotion management in order to meet expectations within a work environment” (p. 208). Mann continues to note that emotional labor can be a significant source of work stress, and effective management of it, is of particular importance for those in the caring and counseling professions. Zapf (2002) also discusses the way in which emotional work is linked to high levels of burnout and its impact on psychological well-being. In their concept analysis of emotional labor, Huynh, Alderson, and Thompson (2008) noted the correlation between emotional labor and professional burnout, and highlighted the need for nurses to have time and support to reflect on their practice to understand their emotional labor. Since 2009, a framework for the emotional labor of prison nurses has been further developed to make the “intranurse” relationship more explicit. See Figure 1 below.
In considering the nature of intersubjectivity and its impact on relationships, we can see that all external relationships that contribute to the emotional labor of the nurse will have an intersubjective element to them. The relationship with custodial personnel and prisoner patients is impacted upon by the way in which each party to that relationship views themselves and the other, while being influenced by their own previous experiences. This is also true to some extent of the more abstract external relationship where the nurse engages with the organizational norms and expectations regarding practice. Nurses' responses to the organization will be based on their own prior experiences of it, and indeed others.
Of importance here is the way in which these relationships, with their intersubjective influences, impact on the internal, intrapersonal relationship that nurses have with themselves, which we suggest is at the heart of the dissonance that prison nurses experience on a regular basis. We suggest that this internal relationship is akin to the concept of the internal supervisor, where, as identified above, nurses inner professional voices supervise their own personal views and motivations. For example, when caring for challenging prisoners, who have a history of offending behavior that nurses find difficult to deal with, they may find it difficult to provide nonjudgmental care, or indeed care at all. However, their inner professional supervisor may well be in conflict with their personal thoughts and feelings, which can lead to high levels of emotional labor, stress, burnout, and subsequently impact on mental well-being (see Walsh & Freshwater, 2009).
In considering the nature of emotional labor in prison nursing, it is clear that the relationships between nurse, prisoner, and prison officer are not only subjected to influence through intersubjectivity on one level, but in a “web” of interacting levels. This is particularly true when both nurse and prison officer are working together with the prisoner patient, within the context of the prison environment. We term this an intersubjective web, as illustrated in Figure 2. Such a structure can help visualize underlying meanings to behaviors and reactions, particularly in a critical incident debriefing.
The intersubjective web: A reflection on practice
Having worked in a residential wing treatment room for many years, Jane felt as though she was able to deal with any difficult prisoner patient who came to her for care. However, one prisoner had recently assaulted a close colleague, leaving her feeling quite bitter and angry with him. Providing a caring approach to him, which is what she expected of herself as a nurse, was proving too difficult, and she engaged with him on a distanced, professional level, with no sense or feeling of any connection. Jane had always prided herself on her ability to care for any prisoner, regardless of the offence; however, this particular prisoner stirred up feelings of anger and hatred. Her expectations of herself as a professional were tested and the internal supervisor, which quietly questioned her behavior and feelings toward this patient, became louder as she attempted to interact with him. As she was treating him, she felt hostility both personally toward him and reciprocated by him. A prison officer colleague was standing outside her treatment room at the time, and, sensing that tensions were rising, intervened to curtail the prisoner's behavior toward Jane.
If this interaction is viewed through exploring the emotional labor Jane experienced, the relationship between her, the prisoner and the prison officer, and the organizational policies and culture could easily be unpacked to expose conflict and dissonance. However, in viewing the episode of practice through the lens of emotional labor and intersubjectivity, a more complex picture emerges that takes account of the effects and affects of each actor. We suggest that this would have lead to a better awareness of the way in which all involved, behaved, and impacted upon one another. Being aware of the way in which this intersubjective web impacts on thoughts and feelings is crucial in addressing practice behavior, identifying support required by the nurse and further learning that may be required.
Reflection on difficult practice experiences will often allow a deeper understanding of a situation to emerge; however, informal reflection, which often takes place immediately following difficult interactions, rarely provides space for nurses to consider the intersubjective relations. Indeed, in our experience, the intrapersonal relationship (i.e., the internal supervisory relationship) is rarely explored in any depth. We suggest that this is as a consequence of what Menzies-Lyth (1988) refers to as a defense against anxiety. However, it is not without appropriate and adequate reflection on practice that a changed perspective is enabled. Without this change in perspective, practice remains stagnant.
If we consider the way in which intersubjectivity impacts on the relationships that result in high levels of emotional labor for prison nurses, regular opportunity is required to reflect on both relationships and intersubjective space. An understanding of the complex web of interactions in these relationships will enable prison nurses to manage and work with the dissonance they face. The space available to nurses to reflect on and understand this intersubjective web is found in clinical supervision. It is well documented that there are barriers to engaging in clinical supervision, particularly in the prison setting, where reflecting on practice can be challenging both in terms of resources and inclination, where defenses against anxiety are commonplace, (see Menzies-Lyth, 1988), and where prizing open practice through reflection can feel threatening (Walsh & Freshwater, 2009).
In areas where engaging in clinical supervision is a challenge, consideration of the impact of relationships and intersubjective spaces could form part of more informal reflection on practice and take place during regular interactions between staff where peer support is a central focus. We suggest that informal reflection occurs regularly between practitioners during breaks in the working day, as they talk with one another to make sense of their experiences. Utilizing this space more effectively to consider relationships and the influence of intersubjectivity is recommended where clinical supervision is not possible.
The relationships identified as underpinning the emotional labor of prison nurses are clearly influenced by intersubjectivity. Therefore, if there is effective understanding of how this intersubjective web is created, and its subsequent impact on practice, its effects can be managed to protect the mental health of the nurse and promote practice development. A clear understanding of the complexity of emotional projection can lead to clearer thinking while receiving emotional information and understanding the impact of external issues on emotional responses. For example, if we return to the care and management of a challenging prisoner patient, with whom nurses have difficulty caring for due to offending behavior, an understanding of the intersubjective processes occurring at all three levels of the external relationships could assist the nurses in understanding and managing their own internal relationships.
We suggest that one way of promoting insight and understanding of the complex emotional arena of caring in prison, and the impact of intersubjectivity on practice, is through regular, formal clinical supervision. Various definitions of clinical supervision exist, all of which identify support for the practitioner, the development of practice, and the maintenance of standards as central. Cassedy (2010) defines clinical supervision in nursing as “a regular and formal agreement to engage in a professional working relationship, facilitated by the supervisor to support the supervisee to reflect on practice, with the aim of developing quality care, accountability, personal competence, and learning” (p. 5). Bond and Holland (2010) suggest that “clinical supervision is regular, protected time for facilitated, in-depth reflection on complex issues influencing clinical practice. It aims to enable the supervisee to achieve, sustain, and creatively develop a high quality of practice through the means of focused support and development” (p. 15).
Through utilizing a framework in supervision where relationships, known to impact on emotional labor, are viewed through the lens of intersubjectivity, a better understanding of the rationale for behaviors, attitudes, actions, and reactions will enable prison nurses to nurture and develop their practice, understand and improve their relationships with prisoner patients, colleagues, and with themselves, by exploring their intrapersonal relationships. In exploring the intersubjective web that envelops all interactions within a prison setting, where care and custody are competing priorities, supervisees are ultimately supported, through the safe space of clinical supervision, to make meaning from their interactions with others.
Implications for practice
In this paper, we have presented an alternative approach to understanding the emotional labor of prison nurses through exploring and utilizing the notion of intersubjectivity. This “intersubjective web of emotional labor” can be utilized as a tool in clinical supervision by prison nurses who wish to explore the emotional labor of their practice in order to gain insight and new perspectives, while obtaining support for their own mental well-being.
The use of the intersubjective web of emotional labor in reflecting on practice can provide a deeper understanding of the nature of the relationships with which prison nurses engage, which impact on the emotional labor of their work. Through understanding how relationships are influenced by intersubjectivity, nurses can gain a better insight into the rationale for their practice and the consequences of it on their own well-being. New insights into practice will enable the development of practice through provision of effective support of the workforce, through clinical supervision.
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