Nursing Inquiry 2009; 16(3): 251–260

Feature

Discourses of anxiety and

transference in nursing practice: the
subject of knowledge
Alicia M Evans,a David A Pereirab and Judith M Parkerc
aDeakin University, Burwood, bPrivate practice, Melbourne, cUniversity of Melbourne, Melbourne, Vic., Australia

Accepted for publication 1 December 2008

EVANS AM, PEREIRA DA and PARKER JM. Nursing Inquiry 2009; 16: 251–260
Discourses of anxiety and transference in nursing practice: the subject of knowledge
The nurses’ relationship to knowledge has been theorised in a variety of different ways, not the least being in relation to medical
dominance. In this study, the authors report on one of the findings of a case study into nurses’ anxiety informed by psycho-
analytic theory. They argue that the nurse’s subjection to the knowledge of the other health professional, inclusive of the
doctor, can be a transference arising in the context of anxiety for the nurse. Grasped by anxiety, the nurse finds their own
knowledge insufficient and in this moment can operate a transference to their non-nursing colleague, who obligingly, responds.
This transference is not present in the change-of-shift handover report though, when the other’s knowledge is suspect, even
open to derision. Thus, this reference to the knowledge of the other is not consistently present in nursing and can be seen to
be just one way that nurses organise themselves in relation to anxiety. Therefore, those wanting to break down the medical
dominance of the nursing profession might consider other ways nurses might organise themselves in relation to anxiety, so that
the political dominance of the other is not reinforced via transference to that other.
Key words: anxiety, knowledge, medical dominance, psychoanalysis, transference.

In this study, we report one of the findings from a doctoral
study that considered how anxiety might be understood to
function as an organiser of clinical nursing practice (see
Evans 2005). The problem that gave rise to the doctoral
study came from the first author’s nursing practice. Some
years ago, after many years of clinical practice, the first
author was appointed as a Nurse Unit Manager (NUM).
The experience of managing and leading a nursing work-
group (as opposed to being a group member) was both
new and initially difficult in many ways, most particularly
in relation to understanding the group’s dynamics. The
ideal of democratic process and consultation were impor-
tant to the first author as a newly appointed NUM, how-
ever, the more she attempted to practise these ideals, the
more unsettled and demanding the group became. In an
attempt to conceptualise something of this dynamic, she
Correspondence: Alicia M Evans, School of Nursing, Deakin University,
221 Burwood Hwy, Burwood 3125, Vic., Australia.
E-mail: <alicia.evans@deakin.edu.au>
started to read studies on anxiety and group dynamics.
A seminal paper on the topic of anxiety and nursing is
Menzies (1959) paper; a work that has been identified as
an exemplary study and is extensively cited in the nursing
literature (Rafferty and Traynor 2002).
Menzies, a psychoanalyst, was working at the Tavistock
Institute of Human Relations in London at the time her
study was published, where there was considerable interest
in organisational and group consultation informed by
Bion’s significant work on groups (Winship and Hardy
1999). Bion’s approach to psychoanalysis followed that of
Melanie Klein (de Board 1978 ⁄ 1993a) and is but one of a
number of further theorisations of psychoanalysis following
Freud.
Contemporary work in this area is conducted at the
Tavistock Clinic in London. Obholzer (1998), for example,
argues that organisations manifest aspects of human charac-
ter and as such anxiety can be relevant to an analysis of their
functioning. Just as a subject can respond to their anxiety by
ignoring it, and any associated difficulties, through strict

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AM Evans, DA Pereira and JM Parker
adherence to individual rules and schedules, so work at
the institution can become structured and administered
with strict adherence to institutional rules and schedules.
Another psychoanalytically informed theorisation of organ-
isations, such as health services, is that they function at
a social level to keep anxiety about death at bay. Indeed
Obholzer (1998, 171) suggests that a health service could be
more aptly renamed a ‘keep-death-at-bay’ service and this
might explain, in some way at least, the outrage expressed
when advanced medical technologies are not made available
to all in the developed world (Obholzer 1998).
While some work has been undertaken on anxiety in
relation to group and institutional dynamics from a psycho-
analytic perspective in the Kleinian tradition (see e.g. Obholzer
and Roberts 1998),1 there is little on this topic from a Lacan-
ian psychoanalytic perspective and negligible in relation to
nursing work-groups or indeed in the field of nursing. For
example, a search of the database Citation Index for Nursing
and Allied Health (CINAHL) – full text, on 9 April 2008,
using the term ‘Lacan’ with no limiters, identified only six
papers.
Therefore, a Lacanian psychoanalytic theorisation holds
the prospect of bringing another dimension to the topic of
anxiety in nursing, as we have argued elsewhere (see Evans,
Pereira and Parker 2008), and potentially provides another
way to think about both how anxiety might manifest in a
nursing work-group and how nursing work is organised.
In addition, the psychoanalytic concept of transference
might also be considered relevant in this context. For exam-
ple de Board (1978 ⁄ 1993b) discusses the relevance of
transference to group behaviour via the work of Freud’s
colleague, Ferenczi. However, although transference is often
defined as a strong feeling being transferred unconsciously
from one person to another (e.g. see Dartington 1998), or as
either a displacement or projection (e.g. see Rycroft 1972),
these are not the only ways to theorise transference in psy-
choanalysis. Lacan’s theory of transference, more so in its latter
formulations, incorporates the idea of a subject of knowl-
edge; a concept that will be elucidated later in this paper, as
it becomes particularly relevant to our theorisation of the
nurse and their knowledge.
The field of knowledge and the nurse’s relationship to it
is of interest to the analysis presented in this study. The topic
of the nurse and their relationship to knowledge has been
considered from a number of perspectives. For example, in
the nursing literature, there has been consideration of what
1Although this text has the term ‘stress’ in its subtitle, in psychoanalysis the theory
being worked is more akin to that of ‘anxiety’ than ‘stress’, following Freud’s work
on anxiety.
252
has been called an anti-intellectualism in nursing (see
Walker 1997), on how nurses have been portrayed as an
un-thinking workforce (see Dartington 1998) and the role of
ritual in nursing practice in its function of eliminating the
need for thinking (Menzies 1959). Medical dominance
(Willis 1989, 2006) is yet another way to explain the position
of the non-medical professions in relation to an apparent
subjugation to the medical profession and their knowledge.
More recent work on the nursing profession’s position in
relation to knowledge has been put forward by Gordon and
Nelson (2006) who argue that nurses privilege the apparent
virtues of the profession at the expense of knowledge and in
doing so carry on a tradition that at one time was helpful to
the profession but no longer remains so.
Aforementioned are a few of the ways that the nursing
profession’s relationship to knowledge has been theorised.
One might perhaps question whether the nurse’s relation-
ship to knowledge is of importance though, given that much
of health-care is conducted in a multidisciplinary team and
considered more relevant is that the necessary knowledge is
located somewhere and is accessible to the nurse. However,
it has been argued that the hallmark of a professional is that
they create and apply their own body of knowledge and this
forms the basis of their professional authority, an authority
that bears a relationship to how well the administrative
authority can be challenged (Etzioni 1969) and a knowledge
that counts in terms of social influence (Katz 1969). This
capacity to have professional authority and social influence
could bring to bear on the situation where a hospital admin-
istration aims to dismantle a nursing service, as was the case
described by Weinberg (2006). Not only this, but it has been
said that being able to articulate that knowledge to hospital
administrators, in a way that clearly illustrates the relevance
of nursing knowledge and practice to health outcomes, is
important in terms of maintaining the employment of a suf-
ficient number of nurses to provide adequate treatment to
patients (Weinberg 2006). Thus, we contend that the
nurse’s relationship to knowledge is of considerable signifi-
cance, both to nurses and their patients. In this study, we
extend the aforementioned theorisation of nurses’ relation-
ship to knowledge by considering how anxiety may contrib-
ute to the way the nurse is positioned in relationship to
knowledge.
THEORETICAL FRAMEWORK
Jacques Lacan, an influential French psychoanalyst
(1901–81), claimed his work to be a ‘return to Freud’ in
reference to his critique of both the British school of psycho-
analysis (inclusive of the theories of Anna Freud, Melanie
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Klein and the object relations school) and the field of ego
psychology for eliding some of the more radical aspects of
Freud’s work. Important to understand in this ‘return’ was
that Lacan did not aim to rediscover some lost Freudian
ideas, as an archeologist might, but rather to consider
Freud’s work in the light of philosophy and structural
linguistics (Roudinesco 1997).
Lacan’s theories of anxiety and transference are of par-
ticular relevance to the argument being developed in this
study. Lacan contended that anxiety was produced with the
approach of the desire of the Other (Lacan 1962 ⁄ 2002). This
‘Other’ is quite different to any notion of the ‘other’ though,
as the latter represents one’s ego (Lacan 1955 ⁄ 1988b) and
that of one’s correspondent (Lacan 1955 ⁄ 1988a); rather the
Other bears a relationship to the function of speech (Lacan
1955 ⁄ 1988b). That is, the Other bears a relationship to
language and the subject’s subordination to it, referring to
the way the subject is grasped by language.
And in so far as we are the subject who thinks, we are impli-
cated in a quite different way, in as much as we depend on
the field of the Other, which was there long before we came
into the world, and whose circulating structures determine
us as subjects.(Lacan 1977a, 246)
Related to the Other is the notion that there is a knowl-
edge of the subject that is not known to them (Lacan 1975).
Another way of considering a knowledge of the subject that
is not known to them is via the concept of the unconscious.
This Other of the subject bears a relationship to the subject’s
unconscious, and to the function of speech. The dream, for
example, is not an unfathomable mystery as it can be read in
relation to what the subject speaks of it (Lacan 1975), and
yet prior to its analysis the dream can represent a knowledge
of the subject that is unknown to them.
The subject is born into a symbolic world, one of
language and of generations of prior family. Within this, the
child can be considered as one link in a circuit that they
are integrated into. This circuit is one in which the child’s
parents are also integrated (Lacan 1955 ⁄ 1988a). This inte-
gration within a circuit also finds expression in the notion of
discourse and discursive practices as theorised by Foucault
(1991); notions that have also informed the study reported
here.
When the subject is in a state of anxiety, they experience
the desire of this Other and are found to be insufficient.
Something is wanted of the subject by the Other in this
moment and it produces in the subject the question ‘What do
you want of me?’ (Lacan 1962 ⁄ 2002). However, the Other, as
a site of unknown knowledge, does not exist anywhere, that
is, except in language. The Other, when taken up as the
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Anxiety, transference and knowledge
unconscious, does not have material form, but rather is
‘unrealized’ (Lacan 1977a, 30).
However, sometimes this intangible ‘what is wanted’
(the desire of the Other) is given apparent substance by
the subject’s designation of an object that demands some-
thing of the subject, be it called ‘workload’ or one’s man-
ager, for example. That is, the subject’s experience of
anxiety and the associated unease about something being
required of them (something required that they have no
knowledge of) can result in the apparent materialisation of
this ‘something wanted’ via a designation of an external
object or person as the one who wants something of the
subject. This apparent materialisation of ‘what is wanted’
can be considered as a ‘stressor’ in some other concep-
tual frameworks. However, in a Lacanian theorisation, this
‘what is wanted’ bears reference to the Other, of language,
rather than being a ‘stressor’ external to the subject and
operating on them.
Another way the subject can unwittingly attribute
substance to this immateriality of the Other (the uncon-
scious) is by designating an other in the place of the Other.
When this happens, a transference can said to be operating.
That is, when there is a subject ‘supposed to know’ (supposed
of this knowledge of the Other), then there is transference to
this other in the place of the Other (Lacan 1977b). In other
words, there is always a knowledge of the subject that the
subject does not know about (one might call it the uncon-
scious or the Other). When one positions an other in the
place of the Other (which is not a deliberate or conscious
action), then the knowledge of the Other becomes attributed
to this other. It seems the other has certain knowledge and is
thus considered a ‘subject of knowledge’ by the one who has
the transference.
Put another way, while it is that the Other does not exist
in any material way, other subjects (little others) or things
(such as stressors or institutional demands for example) can
be given the status of Other by the subject, although this is
not a conscious designation. When this occurs, others come
to stand in for the Other of the subject, to which the subject
then subordinates themselves. In this way, something of this
supposed subject of knowledge seems to materialise in the
form of an-other person (or institutional policies, proce-
dures, rules, etc.) who is designated as knowing. This is, put
albeit briefly, the later formulation of Lacan’s formulation of
transference. If this other (in the place of the Other when
transference is operating) provides an answer to what is
wanted, this then may ease the anxiety for the subject as the
question of what is required appears to materialise and make
itself known.
253
AM Evans, DA Pereira and JM Parker
METHOD
We report on one of the findings from a study of clinical
nurses practicing in a medical ward of a publicly funded
teaching hospital in an Australian capital city. The aim of the
study was to consider how nurses organised themselves in
the clinical setting and whether a psychoanalytic theorisation
of anxiety might lend itself to an explanation of some of the
nurses’ group dynamics.
In a psychoanalytic tradition commenced by Freud,
the case study was the chosen method. Case study is a an
approach particularly suited to research into complex social
phenomena of an organisational, social or political nature
(Luck, Jackson, and Usher 2006) and allows the case to be
considered in all its complexity rather than be broken into
disaggregated variables (Sandelowski 1996) This was a case
of nurses and how they organised themselves, that is, as a
group; what might otherwise be called group dynamics in
nursing.
Field notes were taken during 17 periods of observation
conducted on the medical ward during 2002. The hospital
was well established and highly regarded. All the nurses were
registered with the state registering authority and had a
3-year undergraduate preparation, be that hospital-based or
at a university. Industrial negotiations had afforded nurse–
patient ratios of one nurse to four patients.
On this ward, a patient’s condition could deteriorate rap-
idly and a sense of the arbitrary was palpably present. This
was illustrated by how, between shifts, a patient might either
have become well enough for discharge or alternatively dete-
riorated and possibly died. Medical emergencies, while not
occurring on all shifts, or indeed on all days, nonetheless
were not uncommon. The introduction of various adminis-
trative systems into the hospital had resulted in patients
being discharged home earlier than in previous times, and
consequently the patients were all acutely unwell.
The field notes were not considered to be ‘empirical
data’, consistent with the assumption that the first author’s
presence in the field changed it in some way (Sandelowski
and Barroso 2002). The field notes consisted predominantly
of what was said in the field rather than observations of it,
thus an approach to analysis that was not inconsistent with
discourse analysis was taken, with recourse to Power’s (1996)
argument that discourse analysis is not conducted according
to a recipe, rather, research concerning itself with discourse
is directed by the issues and problems to be addressed
(Parker 1992).
In psychoanalytic theory, what repeats is considered to
be a return of the repressed (Rycroft 1972); thus repetition
suggests something of the unconscious that keeps returning.
254
In keeping with this idea, repetitions were identified in the
field notes and these were analysed in relation to psychoana-
lytic theory.
Approval for the study was granted from both the
Human Research Ethics Committee of the hospital of the
study site and the University of Melboume and fieldwork
commenced after participant consent was given. Pseud-
onyms are used throughout the paper.
THE NON-NURSING PROFESSIONAL’S
POSITION IN THE NURSING HANDOVER
The incoming nurses attend a handover where the nurses
gather together, in private, to receive a report from the previ-
ous shift of nurses, often conducted by the most senior nurse.
As this was a nursing-only forum, the other health profession-
als were represented only in the speech of the nurse. Of the
many non-nursing professional groups represented on the
ward of our study, the doctor2 was the professional colleague
mentioned the most; not surprising given they were the non-
nursing professional that the nurses engaged with most
during their working day. However, there were references to
other non-nurses in the handover, for example:
son wants to see the dietician as well as the doctor.
(Fieldwork 2)
nearly needed to call security staff. (Fieldwork 6)
However, this was the exception as it was to the doctors that
the nurses overwhelmingly referred during the handover.
On occasion, the doctor ⁄ s were referred to as ‘the doctor’
(as in the extract above), as ‘the unit’ (meaning the medical
unit), ‘the covers’ (the covering medical unit) or by way of
medical specialty. For example:
So the unit can do that. Maybe when they see how difficult
it is, they’ll. (Fieldwork 8)
Please pass on to the neuro people. (Fieldwork 2)
On one occasion a doctor was referred to by name:
Brendan said … Brendan’s been here a bit … Brendan’s
around today … In the end the covers just said pull it out …
Brendan wrote a big note in the history. Patient must, must,
must have a catheter. (Fieldwork 14)
However, the references to the medical staff in these terms
were far less frequent than the nurses’ repeated reference to
the doctors as ‘they’. For example:
2For the purpose of clarity, we have gendered the doctor and other non-nurses
as male and the nurse as female.
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They’re quite happy with her (Fieldwork 6); They think
something must be going on (Fieldwork 6); They’re think-
ing about an aged care facility (Fieldwork 6); They’re going
to talk to the relatives…and they’re planning on discharge
on the weekend (Fieldwork 6); They’re planning for her to
go home in a few days (Fieldwork 11); Did they transfer him
last night? (Fieldwork 13); They were querying maybe a
tumor or something (Fieldwork 13); They want her out
within a week, without the trache (Fieldwork 14); Are they
going to amputate her toes? (Fieldwork 15).
Occasionally other groups are described as ‘they’ also. For
example, ‘they said she was a transfer by two but we got her
up’ (Fieldwork 12). This may refer to the physiotherapy staff.
Or this: ‘Such a waste of money. They still bring them up’
(Fieldwork 8), a comment that seemed to refer to the dieti-
cians. These examples of reference to other non-nursing
groups were rare though by comparison to the frequency of
the reference to the doctors as ‘they’. This could be an illus-
tration of the way clinical nursing practice, on a ward such as
this, is so closely related to the medical work of doctors and
thus perhaps it is this that gives rise to so much reference to
what the doctors say and do.
Reference to the doctors as ‘they’ in the nursing hand-
over, has been noted previously (see Parker, Gardner, and
Wiltshire 1992; Ekman and Segesten 1995; Parker 1996;
Kelly 1999; Lally 1999). While the nurses, in the process of
group formation3 during the handover (Parker, Gardner,
and Wiltshire 1992; Parker and Wiltshire 1995), identify
with each other4 (Freud 1921 ⁄ 1991), the doctor and other
health professionals are in quite another position. This
other position can be considered as a subject position pres-
ent in the handover, that the non-nursing professionals (as
represented by the nurse) are placed in. This subject
position they occupy is one that is formed against the
subject position the nurse occupies. The other groups, the
non-nurses, are ‘they’, ‘them’; a group not like ours. (For
example, ‘We’ve had to play with it because they want him
saturated at 90%’ (Fieldwork 7).) In this way, ‘they’
become the group to which the nurses form themselves
against.
This positioning of the non-nursing professional can be
associated with some derision of their knowledge. Consider
these extracts from the handover field notes:
3 Groups form via the development of emotional ties between group members
but they do not form in isolation, needing something to form against. Within the
group, the common ideal unites its members and this is often embodied by the
group leader or, in leaderless groups, an ideal in the place of the leader (Freud
1921 ⁄ 1991).
4Freud (1921 ⁄ 1991) argued that in the process of group formation, group
members identify with one another.
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Anxiety, transference and knowledge
There is some laughter at a comment that a registrar5 is
coming to get a patient out of bed. (Field work 2)
The two nurses comment about a patient plan that has been
developed by a non-nurse. One nurse says, ‘You can buy a
Tattslotto ticket;6 that’s not going to work’. Both the nurses
laugh. (Fieldwork 13)
RN Davis says, ‘… the doctor says he’s like this all the time.
The doctor says he does this every night’. RN Patterson says,
‘He didn’t last night’. (Field work 7)
In the confines of the closed nursing workgroup of the
handover, there is only ‘we’ nurses and those other groups
(‘them’ doctors, physiotherapists, dieticians, etc.). It is within
this structure of the handover that the non-nurses become a
‘they’, whose knowledge can be questioned, even derided.
As it is the doctor to whom the nurse most frequently refers
in the handover, then it is the doctor whose knowledge
most often can potentially come into question. Sometimes,
a skepticism arises in relation to the doctor’s knowledge
(as illustrated in the last extract); something also noted
previously by Parker and colleagues (see Parker 1996; also
see Parker, Gardner, and Wiltshire 1992).
Thus in the handover, the non-nurse’s position (inclu-
sive of the doctor), from a nursing perspective, is that they
do not necessarily know, indeed what they know can be ques-
tioned, even laughed at by the nurses. If there is an Other in
this handover, it is the ritual (if it is present) that organises
the practice of the nurses, dictating the order and method
of it. As ritual bears a relationship to anxiety (Freud 1907 ⁄
1985), then the nurse’s anxiety can be seen to be manifest in
a ritual practice rather than in relation to a transference to
other health professionals; an argument we have made else-
where (see Evans, Pereira and Parker 2008).
THE NON-NURSING PROFESSIONAL’S
POSITION AT THE BEDSIDE
From the handover positioning of non-nursing professionals
comes something quite different when the handover is com-
plete and the nurses step out onto the ward. In the hand-
over, the nurses are forming into a group and, in doing so,
forming themselves against other groups (‘them others’)
whose knowledge can be viewed with skepticism and at times
even derided. Although the knowledge of the non-nursing
professional can be ‘looked down on’ in the handover, this
is transformed into a ‘looking up to’ at the bedside and can
come in the form of advice seeking. That is, once at the bed-
side, the skepticism and derision seemed to fall away in
5 A registrar is a doctor.
6 A lottery ticket.
255
AM Evans, DA Pereira and JM Parker
favour of a respect for the knowledge of non-nursing col-
leagues. For example:
I accompany RN Davis as she goes into the pharmacy on the
ward to speak with the pharmacist. He has two other people
with him. … RN Davis asks the pharmacist about the name
of a medication that has been prescribed. She asks why the
medication name has an additional letter after it. The phar-
macist explains why this is so. We all listen. Then the nurse
says to the pharmacist ‘Can I ask one other stupid question?’
As she says this she laughs in an embarrassed way and com-
ments that she has an audience. She then asks a technical
question regarding a medication. The answer the pharma-
cist gives her is highly technical. RN Davis seems to under-
stand what he says. She thanks him and leaves the room.
(Fieldwork 4)
In this moment the nurse positions herself as one who asks
stupid questions in relation to the pharmacist; maybe even
also in relation to those who listen. This positioning, in rela-
tion to the theoretical framework of the study reported here,
is not the position of an individual but rather a subject posi-
tion. The question needs then to be raised as to how this
position might function. Is it a position that arises in relation
to lack of knowledge or incapacity to think perhaps? Con-
sider these further extracts:
RN Wallis is busy taking the vital sign observations for the
four patients [assigned to her] and giving out their medica-
tion. She explains that the patients’ medication is replen-
ished by the ‘satellite pharmacist’ who is stationed in the
pharmacy room on this ward during office hours. She
explains that this is a good thing because the nurses and the
pharmacist work together and she can ask the pharmacist
questions during her working day. (Field work 2)
In the on and off conversation that RN Singh and I have,
she comments further on the changes she’s noted since
returning to nursing, mentioning that there are many
physiotherapists on the ward, whereas many years ago
they were only ever occasionally available. She indicates
this is an improvement and comments that this is good
because the nurse can seek advice from them. (Field
notes 8)
He [RN Nhugen] says that to ascertain if the patient needs
to fast he can check the notes, ask the doctor or phone Med-
ical Imaging. (Field work 9)
The experience of anxiety is well known to produce an
inhibition of thought and Menzies (1959) argued that the
constant, close proximity of the sick patient who does not
always recover is productive of anxiety for the nurse. In this
way, it is possible that the presence of non-nursing profes-
sionals to whom questions can be asked, even ones the nurse
herself may consider stupid, is comforting. Perhaps it is even
an acknowledgement that one’s capacity to think is affected,
which results in the reference to the ‘stupid’ question; a ques-
tion that in other less anxiety-provoking circumstances might
not need to be asked.
256
The nurses (as represented by the aforementioned
subject positions in the extracts) view these non-nursing
professionals as conveniently close by. At the bedside, these
non-nursing professionals, far from their knowledge being
derided as it was in the handover, are sought out for advice,
for knowledge and for the giving of certainty about something
the nurse experiences as uncertain, that is, her own knowl-
edge. Consider this:
She [a nurse] tells RN Leung that the woman appeared to
have a[n] [epileptic] fit but conveys that she isn’t con-
vinced of the authenticity of the fit. One of the nurses com-
ments that the doctors will say if it was a fit. The other
nurse doesn’t dispute this, although no doctors witnessed
the woman’s fit or saw her immediately afterwards. (Field
notes 12)
Health professionals are formed, in part, out of different
bodies of knowledge. Given this, one might expect a consul-
tative process occurring between clinicians of various back-
grounds. For example, the nurses are physically close to the
patients and therefore witness many things the other disci-
plines do not. However, in the fieldwork, neither the doctor
nor the pharmacist sought the nurse’s advice. The doctor,
although not present to witness what occurred, will decide if
it was a fit or not. The nurses subordinate their (uncertain)
knowledge to the doctor’s apparent (certain) knowledge.
This takes place even though the medical event occurs
within the context of scientific empiricism where observation
is paramount. The nurse observes the event but her sensory
perception, her observation, is not enough for her to deter-
mine whether the patient had a fit. The nurse’s observation
must first be read via the doctor’s knowledge.
That healthcare professionals do not work together in
the form of a clinical democracy can of course be conceptu-
alised in terms of medical dominance (Long et al. 2006);
however, it should be noted here that the subject positions
represented by the nurses in these extracts do not seek to
have a clinical democracy with the other health professionals
but rather state a preference for the other professionals to
be there and available so that the nurse can refer to their
knowledge.
Another example of the nurse’s relationship to knowl-
edge is given by a sign posted above a patient’s bed (fig. 1).
RN Patterson advised that signs, such as these, were
addressed to the nurses.
Although the nurses provide care to the patient to whom
the sign refers and have knowledge of the patient’s medical
condition, they are positioned by this sign as not able to
deduce from their knowledge that the patient requires small
amounts of food and should not have their mouth ‘stuffed’
with food. Although positioned by the sign as not able to
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Patient should be alert and sitting upright for all oral intake.
Reduce distraction
Single sips/teaspoon amounts only
Verbally prompt patient to chew and swallow
Chin down for swallows
Ensure mouth is clear before a new mouthful
Crush oral medication if possible
Cease feeding if choking/coughing, voice is gurgly or patient
becomes drowsy
Remain upright for 30 minutes after mealtimes.
Figure 1 Sign posted above patient’s bed.
deduce from their knowledge how to feed this patient, thus
positioned as not able to think, the nurses can take up or
refuse the positioning of them by the sign. That is, although
the sign positions the nurse as not able to think, this might
not be the only subject position available. Both RN Kelly and
RN Patterson were asked to comment on the sign.
RN Kelly says it [the sign] came from ‘Speech Pathology’.
She says that signs like this are good and that they are there
for the nurses, the regular nurses and the ‘bank’ nurses.
She indicates that she likes these signs and finds them help-
ful, explaining that the sign might instruct the nurse to get
the patient to turn right when eating if they’ve had a stroke,
and the food will be able to be swallowed much more easily
by the patient than if the patient’s face was not turned to
the right. Things ‘you wouldn’t think to do’ she says. (Field-
work 8)
When RN Patterson is in the Utility Room I ask her what
she ‘‘thinks about’’ these signs. She says: ‘That’s paramedics
for you. They have to tell everyone everything. They’re help-
ful for the Grad[uate nurse]s but most of us can work things
out for ourselves. Paramedics. They have to tell everyone.
That’s how they are today’. (Field work 13)
DISCUSSION
The nurse, as a person on the boundary of staff–patient rela-
tionships (Dartington 1998), when in the state of anxiety,
experiences the desire of the Other and finds themselves
insufficient (Lacan 1962 ⁄ 2002). In this case, the insuffi-
ciency takes the form of an insufficiency of knowledge.
The subject position RN Kelly occupies, in relation to the
aforementioned sign, is an example of the nurse positioning
something or someone in the place of knowledge. The sign’s
author, the speech pathologist, is positioned as knowing how
the patient needs to be fed. The nurse’s knowledge is posi-
tioned as inadequate for there is an Other who knows. This
Other, a structure formulated and functioning at the level of
the unconscious (Lacan 1955 ⁄ 1988a) is given material form
 2009 Blackwell Publishing Ltd
Anxiety, transference and knowledge
by the nurse in relation to the sign in the way she positions
herself as subject to the authority of it. The sign becomes the
site of knowledge and she subject to it. It knows; she does
not.
The knowledge that is insufficient is sought elsewhere
and, in this way, an other is supposed of knowledge. There is
an other in the place of an Other, thus a transference can be
considered to be operating with respect of this other (Lacan
1977b). As transference operates unconsciously, the nurse
does not do this deliberately nor is she necessarily aware that
it occurs; rather the nurse is aware primarily that the sign is
helpful.7
Anxiety, of course, can make thinking quite difficult and
one could speculate that it is in these moments of anxiety
that transference is more powerful. In the hospital, nurses
are in an environment of considerable uncertainty (Björns-
dóttir 1998) and due to their constant, close proximity to
the ill and injured hospitalised patient, one might expect
the prospect of considerable anxiety arising, as Menzies
(1959) noted.
One might refute, of course, that the discursive forma-
tions outlined in this study arise out of nurses’ anxiety, for
indeed ‘where is the proof?’ As we have argued elsewhere
(see Evans, Pereira and Parker 2008b), much work on anxi-
ety in nursing has been conducted by way of surveying nurses
in relation to their stressors. Yet there appears, despite the
huge volume of research in this area, little consensus among
nurses as to these stressors. This can be explained by psycho-
analytic theory because anxiety’s object is not a conscious
one but rather is experienced with the approach of the
desire of the Other, and consequent brushing up against
that which lacks (Lacan 1962 ⁄ 2002). Anxiety then appears as
the discourse that forms itself in response to this lack.
We are arguing that a discourse of anxiety, as illustrated
by these field notes, is one where advice is sought from others
and that these others might well be positioned in the place
of the Other, a place where missing knowledge seems to be
located. The doctor mainly, but also other health profession-
als, can occupy this position of Other for the nurse. She posi-
tions these non-nurses in the place of the Other and they
accept this location for her. She asks him for advice, for
knowledge, and they provide it for her, as do the signs
located around the ward, placed there by another non-nurse.
They all give to her the knowledge she seeks.
It is important to note that these are subject positions
though. The non-nurse whose advice and direction is sought
is not obliged to take this position up. They could abdicate
7Of course, signs and other external sources of knowledge can be helpful and this
does not of itself indicate that a transference is operating.
257
AM Evans, DA Pereira and JM Parker
this positioning and instead ask of the nurse what she thinks
is the best thing to do or indeed ask the nurse to seek her
answer from nursing colleagues or from some relevant read-
ing. To abdicate this position though, one needs to view one-
self as occupying a position for another rather than being
the one who is all-knowing. That is, if transference is operat-
ing, one can accept the transference of the nurse and occupy
this position so that the nurse can locate herself in a field
that is anxiety-provoking or one can decline the transfer-
ence, but only if one recognises it as such.
Of course, there is a difference between transference,
and considering the other to be well informed and authori-
tative about a particular subject (Safouan 1990) so that some-
times this advice-seeking on the part of the nurse may not be
due to transference. The difference is perhaps revealed in
how the nurse might relate to her various non-nursing col-
leagues and whether one or some of them always seem posi-
tioned by her as the one who knows.
However, this positioning of the non-nurse as the subject
of knowledge is not the only way nurses position themselves
in relation to knowledge on this ward. For example, there is
the subject position from which RN Patterson speaks. This
nurse does not need these signs to instruct her. She draws
on her own knowledge, and one that is by necessity uncer-
tain, to make decisions regarding patient care in relation to
the topics the signs address. This then represents either a
resistance to a sole subject position for the nurse, in relation
to knowledge, or an alternative subject position. It is worth
noting that this nurse suggests that the signs are helpful to
the graduate nurses8, who might be expected to experience
more anxiety in their practice.
The position RN Patterson occupies opens up the ques-
tion of whether the nurse, who does not operate a transfer-
ence to either signs or other professional groups, can resist
being made subject to them. For example, take the nurse
who can practice from a position where she does not operate
a transference to either a person or thing. Is this subject posi-
tion acceptable within the hospital where there are many
who accept this transference to them as if they really are all-
knowing? What of the numerous policies and procedures
generated within hospitals that subject nurses to their order,
perhaps even facilitating the prohibition of thought and
propping up the notion of an unthinking workforce referred
to by Dartington (1998)? Can an exceptional nurse be an
exception when it comes to subjection to these policies and
apparently all-knowing others without opening herself to dis-
ciplinary measures?
8 A graduate nurse is in the first year of practice.
258
CONCLUSION
The nurse’s relationship to knowledge has been theorised in
a number of different ways. Not the least of these has been
in relation to anxiety, virtue and medical dominance. In this
study, the authors have extended the work, instigated by the
psychoanalyst Isabel Menzies (1959), whereby psychoanalytic
theory provides the theoretical framework through which to
consider anxiety in nursing practice. It is through this theor-
isation that a relationship to knowledge is also reached.
At the handover, the non-nursing professionals are cast,
by the nurses’ representation of them, as having a knowledge
that can be critiqued and at times even derided. The nurses
hold their own knowledge in some regard and, through
their own knowledge, critique the knowledge of the other
(health professionals). Forming themselves into a group, at
the handover, the nurses form themselves against these
others.
At the bedside the nurse’s relationship to the knowledge
of the other health professionals is of a completely different
order. Instead of looking down on the other’s knowledge, it
is looked up to in the form of advice-seeking and direction-
giving. In this way, the nurse can be seen to operate a trans-
ference to the other health professionals. However, this
transference is not the only subject position available for the
nurse and it may be that it is more prevalent when anxiety is
present.
This has the following implication for the nursing profes-
sion. The nurse, if and when she has a transference to the
non-nursing professional, places him in a position of certain
knowledge, in contrast to the nurse’s uncertain knowledge.
This discursive formation constitutes and reproduces the
authoritative and unquestioning position of the non-nurses,
perhaps most frequently that of the doctor, given that it is the
doctor to whom the nurse most closely works. In this instance
then, the dominance of the medical profession is reinforced
by nurses themselves when they operate a transference to the
doctor. This, of course, is not a deliberate action; however, it
supports the position of the doctor as the all-knowing one
and the nurse as not-knowing. That is, something that works
in a top-down way (medical dominance) is supported by a
bottom-up corollary (transference to the doctor).
As we have argued that transference can bear a relation-
ship to anxiety, then those wanting to change some of the
dynamics of nursing practice might find it helpful to con-
sider how the nurse’s anxiety can work as an organising fac-
tor in these dynamics. In particular, those wanting to break
down some of the medical dominance of the nursing profes-
sion could consider other ways nurses might organise them-
selves in relation to anxiety, so that the political dominance
 2009 Blackwell Publishing Ltd

of the other is not reinforced via a transference to that
other.
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