Shirley Bach, Alec Grant Communication and Interpersonal Skills For Nurses Transforming Nursing Practice PDF
Shirley Bach, Alec Grant Communication and Interpersonal Skills For Nurses Transforming Nursing Practice PDF
Shirley Bach, Alec Grant Communication and Interpersonal Skills For Nurses Transforming Nursing Practice PDF
Communication and
Interpersonal Skills
for Nurses
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Communication and
Interpersonal Skills
for Nurses
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First published in 2009 by Learning Matters Ltd 5
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All rights reserved. No part of this publication may be reproduced, stored in a 7
retrieval system, or transmitted in any form or by any means, electronic, 8
mechanical, photocopying, recording, or otherwise, without prior permission 9
in writing from Learning Matters. 10
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© 2009 Shirley Bach and Alec Grant 2
British Library Cataloguing in Publication Data 3
A CIP record for this book is available from the British Library 4
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ISBN: 978 1 844 451 623 6
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The right of Shirley Bach and Alec Grant to be identified as the authors of this 8
Work has been asserted by them in accordance with the Copyright, Designs and 9
Patents Act 1988. 20
Cover design by Toucan Design 1
Project Management by Diana Chambers 2
Typeset by Kelly Gray 3
Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall 4
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Learning Matters Ltd 6
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Tel: 01392 215560 9
E-mail: [email protected] 30
www.learningmatters.co.uk 1
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Contents
Foreword vi
Acknowledgements vii
About the authors viii
Introduction 1
2 Key concepts 24
3 Evidence-based principles 44
Glossary 168
References 171
Index 179
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Foreword
Dr Alan Simpson
Senior Research Fellow and Lecturer
Vice-Chair, Mental Health Nurse Academics (UK)
City University, London
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Acknowledgements
The authors and publisher would like to thank the following for permission to
reproduce copyright material:
Every effort has been made to trace all copyright holders within the book, but if any
have been inadvertently overlooked the publisher will be pleased to make the
necessary arrangements at the first opportunity.
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Dr Shirley Bach is Head of the School of Nursing and Midwifery at the University of
Brighton and also the Series Editor for Transforming Nursing Practice. In the past, she
designed curricula for nurses that integrated interpersonal relationship skills and
communication studies, before specialising in health psychology and the application
of psychology to health and illness settings. She has written a study guide in
psychology for nurses, and researched and developed a model for psychological care.
She has also led programmes that promote the professional practice of nursing and
midwifery, especially in the area of advanced nursing practice. Most recently, she has
developed an interest in new learning technologies and has drawn upon her
understanding of both communication and pedagogic theories to publish in this area.
Dr Alec Grant is Principal Lecturer in the School of Nursing and Midwifery at the
University of Brighton and is a Registered and Accredited Cognitive Psychotherapist.
With a background in, originally, mental health nursing, and more latterly
psychotherapy, social science and psychology, he is now a course leader for the M.Sc.
in Cognitive Behavioural Psychotherapy. He has taught, researched, practised and
written about communication and interpersonal skills – and related areas such as
clinical supervision – in the caring profession since the mid-1970s.
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Introduction
If we shine the spotlight on healthcare situations, where there are many complexities
that are often similar to our everyday lives but enhanced by factors such as healthcare
policy, environment, hierarchies of responsibility, physical discomfort, anxiety, sadness
and fear, we have an even more complicated set of circumstances to deal with than
when we communicate or interact with family or friends. Healthcare interactions are
with patients, carers and peers in often demanding and stressful circumstances,
which inevitably lead to further demands on our abilities to communicate effectively.
Therefore, it is important that students take time to learn in more detail about
communicating in healthcare settings in order to interact as effectively as possible.
This means becoming more aware of oneself as well as others.
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Introduction
factors that impact on our abilities to communicate ideas to one another in these 1
settings. We will try to rise to the challenge of improving CIPS interactions in our 2
different spheres of practice. 3
4
Learning features 5
6
We will draw on evidence from the nursing literature, theories of nursing, social 7
psychology, sociology, communication studies and contemporary issues for twenty- 8
first-century living to provide you with insights on improving your CIPS. There will be 9
activities to engage you with the ideas by utilising self-assessments, case studies and 10
scenarios. Some of these will be activities you undertake as self-reflection, while 1
others may involve discussion with your fellow students. There will also be practical 2
activities and references to further reading or websites for you to explore. We have 3
included a glossary of some terms that we also hope will help explain ideas and 4
concepts covered in the chapters (glossary terms are bold in the text). 5
6
Book structure 7
8
In Chapter 1, ‘Nursing, caring and interpersonal communication’, we introduce the 9
subject and examine the issues facing today’s nurses in achieving effective and safe 20
CIPS. We explore the fundamental concepts of communication and of interpersonal 1
skills and differentiate between the two. This is done through the lens of the caring 2
domain of nursing as a context for improving CIPS. The final section of the chapter 3
describes a systematic framework for CIPS in nursing. 4
5
In Chapter 2, ‘Key concepts’, the crucial need for effective and sophisticated 6
interpersonal communication in modern healthcare organisations is discussed. The 7
key concepts in CIPS are defined, and explained, together with the underpinning 8
theories. This discussion will help students to understand and justify why good 9
interpersonal communication makes a significant difference to nursing practice. The 30
chapter differentiates between CIPS in nursing and in counselling and psychotherapy. 1
The case for an evidence base for CIPS in nursing is outlined and the nursing, and 2
related, theories underpinning interpersonal communication in nursing are explored. 3
Finally, the organisational basis for healthy interpersonal relating in nursing is 4
discussed. 5
In Chapter 3, ‘Evidence-based principles’, we explore key issues in the historical 6
development of research in CIPS in nursing. The effectiveness of research into CIPS 7
teaching and experiential learning is discussed. The chapter articulates the problems 8
around a sole reliance on humanistic counselling/psychotherapy models of 9
communication. We evaluate the reasons for the importance of good interpersonal 40
and organisational climates in the practice of nursing CIPS. Patient/client first- and 1
second-level forms of communication are explored to provide a deeper 2
understanding. The meaning behind ‘blip cultures’ and the forms of communication 3
appropriate to such cultures is considered in relation to evidence-based practice. 4
5
Chapter 4, ‘Safe and effective practice’, aims to increase understanding of the 6
importance and relevance of a process for communicating safely and effectively. The 7111
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Introduction
safe manner, with examples of techniques to draw upon. The many roles that are
embedded in CIPS and the healthcare context are examined to enable clarity and
effectiveness. Strategies to identify and describe techniques to develop an effective
communication relationship process are explained and models for helping
relationships are described and compared before being applied to healthcare
situations.
Finally, Chapter 8, ‘Population and diversity contexts’, takes a look at the impact of our
contemporary society on CIPS by examining diversity from different perspectives.
We begin by considering the needs and diversity of populations and the individuals
within them. Our first approach to this is to recognise that care must be respectful
and anti-discriminatory and that there is a need for equity and fairness. Defining
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Introduction
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Introduction
● recognise the needs of patients and clients whose lives are affected by
disability, however manifest.
DOMAIN: CARE DELIVERY
Engage in, develop and disengage from therapeutic relationships through the use
of appropriate communication and interpersonal skills
Outcomes to be achieved for entry to the branch programme
Discuss methods of, barriers to, and the boundaries of, effective communication and
interpersonal relationships
● recognise the effect of one’s own values on interactions with patients and
clients and their carers, families and friends
● utilise appropriate communication skills with patients and clients
● acknowledge the boundaries of a professional caring relationship.
Demonstrate sensitivity when interacting with and providing information to patients
and clients.
Create and utilise opportunities to promote the health and well-being of patients,
clients and groups
Outcomes to be achieved for entry to the branch programme
Contribute to enhancing the health and social well-being of patients and clients by
understanding how, under the supervision of a registered practitioner, to:
● contribute to the assessment of health needs
● identify opportunities for health promotion.
Undertake and document a comprehensive, systematic and accurate nursing
assessment of the physical, psychological, social and spiritual needs of patients,
clients and communities
Outcomes to be achieved for entry to the branch programme
Contribute to the development and documentation of nursing assessments by
participating in comprehensive and systematic nursing assessment of the physical,
psychological, social and spiritual needs of patients and clients
● be aware of assessment strategies to guide the collection of data for assessing
patients and clients and use assessment tools under guidance
● discuss the prioritisation of care needs
● be aware of the need to reassess patients and clients as to their needs for
nursing care.
Formulate and document a plan of nursing care, where possible, in partnership
with patients, clients, their carers and family and friends, within a framework of
informed consent
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Introduction
1
Outcomes to be achieved for entry to the branch programme 2
Contribute to the planning of nursing care, involving patients and clients and, where 3
possible, their carers; demonstrating an understanding of helping patients and 4
clients to make informed decisions 5
6
● identify care needs based on the assessment of a patient or client 7
● participate in the negotiation and agreement of the care plan with the patient 8
or client and with their carer, family or friends, as appropriate, under the 9
supervision of a registered nurse 10
● inform patients and clients about intended nursing actions, respecting their 1
right to participate in decisions about their care. 2
3
Based on the best available evidence, apply knowledge and an appropriate 4
repertoire of skills indicative of safe and effective nursing practice 5
Outcomes to be achieved for entry to the branch programme 6
7
Contribute to the implementation of a programme of nursing care, designed and 8
supervised by registered practitioners
9
● undertake activities that are consistent with the care plan and within the 20
limits of one’s own abilities. 1
2
Demonstrate evidence of a developing knowledge base which underpins safe and 3
effective nursing practice 4
● access and discuss research and other evidence in nursing and related 5
disciplines 6
7
● identify examples of the use of evidence in planned nursing interventions.
8
Demonstrate a range of essential nursing skills, under the supervision of a registered 9
nurse, to meet individuals’ needs, which include: 30
1
● maintaining dignity, privacy and confidentiality; effective communication and
2
observational skills, including listening.
3
DOMAIN: CARE MANAGEMENT 4
5
Contribute to public protection by creating and maintaining a safe environment of
6
care through the use of quality assurance and risk management strategies
7
Outcomes to be achieved for entry to the branch programme 8
Contribute to the identification of actual and potential risks to patients, clients and 9
their carers, to oneself and to others, and participate in measures to promote and 40
ensure health and safety 1
2
● understand and implement health and safety principles and policies 3
● recognise and report situations that are potentially unsafe for patients, clients, 4
oneself and others. 5
6
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Introduction
Demonstrate knowledge of effective interprofessional working practices which
respect and utilise the contributions of members of the health and social care
team
Outcomes to be achieved for entry to the branch programme
Demonstrate an understanding of the role of others by participating in
interprofessional working practice
● identify the roles of the members of the health and social care team
● work within the health and social care team to maintain and enhance
integrated care.
DOMAIN: PERSONAL AND PROFESSIONAL DEVELOPMENT
Demonstrate a commitment to the need for continuing professional development
and personal supervision activities in order to enhance knowledge, skills, values
and attitudes needed for safe and effective nursing practice
Outcomes to be achieved for entry to the branch programme
Demonstrate responsibility for one’s own learning through the development of a
portfolio of practice and recognise when further learning is required
● identify specific learning needs and objectives
● begin to engage with, and interpret, the evidence base which underpins nursing
practice.
Acknowledge the importance of seeking supervision to develop safe and effective
nursing practice
Readers are encouraged to access these skills clusters to inform their practice
assessments.
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CHAPTER AIMS
Introduction
From very early times, when Homo sapiens began to evolve and cohabit in an
environment that was both hostile and primitive, one of the first skills it was
imperative to learn was the communication of ideas. This enabled the men and
women of those times to share understandings, protect one another and develop
new ideas to solve the problems they encountered in their everyday lives – in order
to survive. We can also hazard a guess that, after a while, they were not only
communicating facts about where to find the best berries or tracks of the nearest
herd of woolly mammoths. Could they have shared a joke, or expressed rage,
excitement, fear, desire or jealousy? Would they have sighed in mutual appreciation
over a beautiful sunset or puzzled over the origins of shooting stars? Could they
have pointed out the best and worst places to hunt or the value of one animal fur
garment over another? If they did, they would have added to their repertoire of
communication skills certain enhancements to elaborate concepts that could not
be drawn in the earth with a stick or painted on a cave wall.
These enhancements, due to the kinship groups and social networks evidenced by
anthropological evidence, would have developed from, and been based around, the
connectedness of the individuals and their relationships. These basic premises have
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not changed for us in our current day-to-day activities. The means of communication
● patient satisfaction;
● adherence to treatment options;
● patient health.
However, there is some evidence to suggest that, while qualified nurses often rate
their own communication skills as high, patients report less satisfaction and maintain
that communication could be improved. In addition, there is evidence that some
nurses stereotype patient groups (Timmins, 2007).
There are criticisms of teaching CIPS in nursing education that point to a lack of
systematic evaluation of teaching and a difficulty in resolving the difference between
the school way and the ward way (Chant et al., 2002). There is a need to consider
learning these skills in the clinical environment with greater involvement of clinical
staff. The aim of this book is to contribute to the learning of CIPS, to give students an
opportunity to think about their own CIPS and to seek opportunities to practise
achieving their CIPS learning outcomes in the practice environment.
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1
In another sentence, sum up what interpersonal means. 2
__________________________________________________________________________ 3
4
As this activity is based on your own reflection, there is no outline answer at the end 5
of the chapter. 6
7
8
9
Check out your sentences with the following definitions:
10
Communication is to exchange information between people by means of 1
speaking, writing or using a common system of signs or behaviour. 2
3
Interpersonal describes the connection between two or more people or groups 4
and their involvement with one another, especially as regards the way they 5
behave towards and feel about one another. 6
7
How close were you to the definitions supplied by Encarta?
8
9
20
1
THEORY SUMMARY 2
3
What is a concept? 4
In general, it is accepted that a concept is a broad theoretical idea that someone 5
has thought up, or named, to help us picture how an intangible idea can be 6
understood and to enable us to express this idea through language. To take this 7
discussion one step further, concepts are also deemed to be abstract, that is, not 8
concrete, but expressing a quality, emotion or thought, and thus something you 9
cannot necessarily see or touch. A concept can also be deemed a principle that 30
guides somebody’s actions, especially one that has a value or importance attached 1
to the ideas, to be followed as a guide for human behaviours and responses. 2
Exploring concepts is a means of describing and analysing incidents, and a 3
technique used extensively in this book, to capture the meaning of how, for 4
example, people behave, or how nature, reality or events are perceived. 5
It would be helpful to consider the difference between the two concepts of 6
communication and interpersonal skills and why we have brought them together 7
in this book. Exchanging information through the communication of ideas, fact 8
and emotions is a complex phenomenon, and cannot take place in nursing without 9
the recognition of the many context-specific factors that influence the 40
communication. Communication, as you will discover in subsequent chapters, 1
requires many different methods and processes to become effective. Even when 2
we are not communicating, invoking silence for example, we are communicating a 3
message with a meaning that will need to be interpreted. Consequently, the 4
communication needs interpreting, and the factors influencing the communication 5
need to be accounted for. 6
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Jones (2007) maintains that there is little research in nursing literature that discusses
interpersonal skills, particularly in nursing education, whereas there is a rich supply of
communication skills research and literatures. This is despite research and policy that
have promoted patient-centred communication as effective. There is also a critique
that nursing education is often removed from the realities that students experience
during their clinical practice, and a lack of literature on CIPS in nursing situations in
the clinical environment.
Specific areas of nursing specialty require tailored approaches to CIPS, for example in
palliative care, in care of the dying, or with children, persons with mental or physical
disabilities or patients with learning difficulties. Different settings, such as accident and
emergency or intensive care, long-stay wards, clinics and community settings will all
require different or particular approaches to CIPS. It is the responsibility of the nurse
to identify where these specific needs may be. There is literature and research
available in all these areas of practice. A good habit to develop is familiarity with
literature searching so that you can find the resources you need to help you with
specific settings or care groups. Some of these areas will be covered later in this
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book. You may be dealing with individuals or groups, for short or long periods of time 1
and in intense emotional situations or circumstances where emotional distance is 2
required. The variety and range of situations are almost infinite. 3
4
5
6
ASSESSMENT OF PRACTICE 7
8
You might want to search the literature for articles on communicating with
9
specific care groups when you are in practice to add to your practice assessment
10
portfolio.
1
2
3
This discussion is therefore implying that there are varying forms of interpersonal 4
proximity and degrees of intensity, purpose and significance that make up the 5
interpersonal aspects of communication in nursing. We are using communication 6
methods from the moment we are born, beginning with the intimacy of the 7
parent–infant interaction, through to the more diffuse connections we have with 8
social networks or in public places such as on the bus each morning travelling to 9
work. Developing our CIPS effectively in different circumstances and with different 20
people has helped us to hone our skills. There is a difference between the social 1
situation and the professional; in the latter there is more at stake if we are ineffective 2
with these skills. 3
4
5
Caring and nursing 6
7
Caring is nursing, and nursing is caring.
8
(Leininger, 1984)
9
The concept of caring in nursing was a subject of intense interest in the latter 30
decades of the twentieth century (Clarke and Wheeler,1992; Kyle, 1995). From a 1
perspective that takes into account cultural similarities and differences across 2
individuals and populations, Leininger (1981, 1994) argued that caring in nursing is 3
about the provision of comfort, concern and support, the development of trust and 4
the alleviation of stress. Clearly, whether practised across or within cultures, caring can 5
only be demonstrated when people interact with each other – hence its connection 6
to CIPS. 7
8
Interest in conceptualising and defining the concept of caring has developed since
9
the late 1980s. Morse et al. (1991) undertook a detailed analysis of the concept and
40
identified five major areas. They saw caring as:
1
● a human trait; 2
● a moral imperative; 3
4
● an affect;
5
● an interpersonal interaction; 6
● a therapeutic intervention. 7111
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Radsma (1994), like Leininger (1984) and Brykczynska (1997), considers caring
These are very different from those described by Watson’s (1988) transpersonal
theory. This theory is organised around concepts such as transpersonalism,
phenomenology, the self and the caring occasion, with ten curative factors that guide
nursing care. Watson’s theory is intended to encompass the whole of nursing;
however, it places most emphasis on the experiential, interpersonal processes
between the caregiver and recipient. It focuses on caring as a therapeutic relationship
and attempts to reduce the components of caring to describable parts, so that these
parts can be understood and learned. As such, the theory could be criticised for being
reductionist. Watson believes that nursing is a human-to-human relationship in which
the person of nurse affects and is affected by the person of the other (1988, p58).
This might usefully be regarded as ‘relational caring’ (Hartrick, 1997). Hartrick
suggests that more emphasis should be placed on relationship development than on
skills development.
Bach (2004) researched the relationship between psychology and caring, and found
that there were distinct characteristics that patients found nurses provided in what
they described as ‘psychological care’ – characteristics that were similar to the
therapeutic activities of formal psychological care. The nurse–patient relationship was
crucial to carrying out this care and a model was devised to capture those activities
that are often referred to as ‘unseen’ or ‘invisible’ care. The essential themes of
unseen care are represented as if refracted from a prism that is usually transparent,
and is a parallelogram (representing both pairs of opposite sides as parallel in the
nurse–patient/client relationship; see Figure 1.1).
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1
Effectiveness Sustenance 2
3
4
Continuity Frame of mind 5
6
7
Individual requirements Emotional well-being
8
9
10
Relationships Interdependence 1
2
Performance Behaviours 3
4
5
Psychological care 6
7
Figure 1.1: Psychological care. 8
9
20
1
ACTIVITY 1.4 PRACTICAL 2
3
Can you remember an encounter with someone you know and who you were 4
caring for? Describe the components of that encounter from both your and the 5
other person’s perspective. Use the model in Figure 1.1 to guide you. Are they 6
similar? 7
Compare this with an encounter with someone you do not know. What differences 8
did you find between the two encounters? 9
30
As this activity is based on your own reflection, there is no outline answer at the end 1
of the chapter. 2
3
4
5
The notion that caring is invisible, but ‘felt’ or experienced by both parties in the 6
relationship, is not new. Watson’s (1988) transpersonal theory also features this 7
phenomenon; however, Bach (2004) has illuminated the elements that nurses 8
described in the caring relationship, and that were corroborated by patients from a 9
variety of settings, so that the elements of the interaction have definition. This moves 40
the elements of the interaction from the abstract to the tangible, which means they 1
are more easily understood and integrated into practice. By describing the elements 2
in a more distinct, non-ambiguous and noticeable manner, the interaction can be 3
more effective, which is also the aim of improving CIPS in nursing and caring 4
contexts. 5
6
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Decision
making
Figure 1.2: Being systematic.
Assessment
This is the first stage of the process and involves gathering relevant information,
developing an overview of the general situation and thinking about what needs to
be done. It is also the preparatory stage for deciding whether to intervene in a
situation, an intermediate stage to review or evaluate what has happened so far,
or an end-of-care encounter to determine to what extent the intended outcomes of a
situation have been met. It is important to note that, while an assessment is often a
preliminary activity and will be written down and recorded, it is not just a bureaucratic
exercise and is part of a process that is often cyclical.
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1
referred to by both the staff on the unit and the patients, and are they specific to 2
the unit or generic health assessments? Ask the qualified staff for their views on 3
the assessments and then ask a patient, if this is possible. Compare the two 4
viewpoints. 5
As this activity is based on your own practice, there is no outline answer at the end of 6
the chapter. 7
8
9
10
Key issues in assessment 1
2
From a CIPS perspective, assessment begins with a consideration of a person’s ‘social
3
location’. Key aspects to consider are:
4
● race and likelihood of being exposed to racism; 5
6
● ethnicity – particular cultural or religious needs;
7
● gender – whether sexism is relevant to the situation; 8
● language – whether an interpreter is needed; 9
● disability – whether there is a physical or mental impairment; 20
1
● age – whether there are generational issues to respect and consider or any
2
developmental needs.
3
Are there legislative and policy requirements to acknowledge? For example, what are 4
you empowered to do by legislation, what are the contractual duties you are 5
expected to perform, and what limitations are there that restrict you in responding to 6
the situation? You may want to discuss this with your mentor. 7
8
The next step is to gather information using appropriate methods of communication. 9
We will be looking at the exact skills later in this book. However, you will need to think 30
about your non-verbal as well as verbal skills and consider the interpersonal dynamics 1
of power and authority between the nurse and the patient. For example, are you 2
paying due deference to the patient by seeking permissions or consents, is there a 3
balance of contribution to the communication, is the patient being excluded from 4
contributing or is the patient being spoken for? Who will be making the ultimate 5
decisions about the nursing interventions and are there reasons why the intervention 6
may not be negotiated between the professionals and the patient? 7
8
A common mistake is to gather as much information as possible, but this is
9
problematic. It could be an intrusion into a person’s privacy and has trust been
40
established? Gathering more information than necessary could be a waste of valuable
1
time. Being flooded with more information than necessary could confound the
2
picture and reduce clarity for planning.
3
A central feature is confidentiality. Environments in many settings are not conducive 4
to maintaining this aspect; however, efforts to maintain privacy should be made if at 5
all possible. Also, there are some circumstances where information belongs to the 6
organisation rather than the individual, for example in situations of suspected abuse. 7111
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Always seek guidance in these situations from a qualified person. The aim should be
Always attempt to separate fact from opinion. It is probable that both will be gleaned
in any assessment to get a whole picture. However, opinion may be wrong and
should be verified as a fact before any intervention is taken. In emotional situations,
fears, worries, anxieties and even exhilaration can distort facts and these
circumstances need careful management to gain an exact assessment of a situation.
Avoid jargon and vague terms that can confuse the patient. Establish their level of
understanding of any unusual terms. Be clear to yourself and the patient about how
the information you are gathering will feed into any plan of action. Link the
information you are gathering into potential and realistic timescales, as this will give
the patient a sense of points in time and priority.
Well-conducted assessments using the full range of CIPS skills are complex and
require patience, skill, clear thinking and vision. At the end of the assessment process
sufficient information is gathered to form a clear picture of the problem(s) requiring
intervention(s). It is helpful to set out aims or objectives of what is to be achieved at
this stage. This is the planning stage.
Planning
This stage in nursing is usually related to setting out the physical actions that need to
take place to improve a situation, such as arranging tests, preparation for procedures,
administering treatments, and giving information or education on conditions and
management of situations. From a CIPS perspective, planning is focused on less
tangible factors and is more concerned with establishing the direction and meaning
that a plan of action will have for a person; meeting the needs and effects of any
unmet needs; establishing the impact a plan will have on a person’s place in life,
developmentally or socially; identifying the motivators and reasons for acting out a
plan; establishing a ‘psychological contract’ or agreement to continue with the plan;
and the involvement or sign-up of other professionals, co-workers or carers in the
plan. This is a stage of explanation, exploration, negotiation and agreement.
CASE STUDY
Sheila was a woman in her fifties who had developed severe congestive cardiac failure.
Her husband had died a year earlier from bowel cancer and her three children,
although all adults and supportive of her, had their own families and children that
consumed much of their time. Sheila became very depressed and was reluctant to take
her medication. She felt she had lost all sense of purpose and her life had lost its
direction and meaning.
She was desperate to have a purposeful role back in her life, as she perceived that she
was no longer a mother or wife, which had been pivotal roles for her. She could not
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see that she could become involved in her grandparenting role and that, although her 1
condition was serious, the medication could help her to fulfil her life and maximise her 2
contribution to her children’s lives. The plan would also be to help her manage her 3
medications, so that they would become part of her life and not take over, thus 4
shifting the focus from dependence to independence. 5
Her family were approached, with her permission, to participate in the plan to help her 6
re-evaluate her life and find suitable activities and occasions for her to help with the 7
grandchildren. Her progress could be monitored by her GP or practice nurse. 8
9
10
1
A basic component of planning is to understand the roles and responsibilities of 2
others collaborating in the plan as well as what will be expected of the patient. There 3
will be different values and priorities to consider from different professional groups. 4
Professional hierarchies can sometimes become obstructive where rivalry and power 5
bids detract from the essential aim of the planning process. Partnership should 6
therefore be the aim, not hierarchies. 7
8
Decision making 9
20
The logical conclusion of any assessment and planning is to make a decision about 1
how to proceed, because it is unrealistic for anyone to carry out a plan by simply 2
following instructions. This stage is therefore an analysis of how effective the plan will 3
be and the success of subsequent interventions. This will involve weighing up the 4
pros and cons of the facts, and their value or priority in any situation, as well as the 5
worth given to the actions in the plan and subsequent interventions. Decision making 6
in the context of CIPS is to think about the significance and consequence of decisions 7
for patients as well as estimate the perceived risks and levels of uncertainty. This can 8
impact on adherence to treatment and the success of interventions. 9
30
The decision-making process is about evaluating options to decide the best course 1
of action. First, all the options have to be described. The questions to ask are as 2
follows. 3
4
● What obstacles are there in relation to each option?
5
● What risks are involved? 6
● How can these be removed or minimised? 7
● Which decisions are feasible? 8
9
● Which of these offer a realistic chance of success?
40
● How attractive are the available options? 1
● Does one simple decision need to be made or can a combination of decisions be 2
made? 3
4
● What timeframe are we working to?
5
● What might we need to do to keep options open for the future? 6
● How well does the decision fit in with existing strategies? 7111
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Not all of these questions need to be answered; however, they can usefully
To answer these questions you have to consider if the original objectives were
appropriate and if there remain any obstacles to achieving the desired outcome.
There may have been subtle and gradual changes in the situation, so the plan
may need to be reviewed in this light.
Evaluation seeks to measure how effective any intervention has been against the
original aims or objectives. A judgement can also be made on the efficiency of the
plan and the use of people’s time and resources. Did the nurse spend too long
talking to Mr Smith about his post-operative recovery period, in order to reduce his
anxieties? Alternatively, did the nurse not spend enough time with the parents of a
child who needed emergency interventions for an acute asthma attack, in order to
explain what was happening and the potential outcome? In particular, in CIPS, the
extent of human resources, such as emotions and personal value constructs, needs
to be considered. Evaluation in the nursing context takes account of moral and
professional requirements as well as principles of good practice. We are constantly
aiming to improve our performance to identify mistakes, so that they can be avoided
in future, and so that we can enhance professional credibility, provide opportunities
for learning for ourselves and others, and maintain our professional and personal
development.
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22
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Where you’re not confident in your knowledge of a topic, what will you do next?
Further reading
Chambers, C and Ryder, E (2009) Compassion and Caring in Nursing. Oxford: Radcliffe
Publishing.
Useful websites
www.culturediversity.org/basic.htm This site will introduce you to Leininger’s theory of
transcultural nursing. This is a humanistic and scientific area of formal study and
practice in nursing, which is focused on differences and similarities among cultures
with respect to human care, health and illness, based on people’s cultural values,
beliefs and practices. The intention is to promote the use of this knowledge to provide
cultural specific or culturally congruent nursing care to people.
Both these websites demonstrate the author’s work in these two major nursing
theories. You will revisit these theories in later chapters.
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2. Key concepts
CHAPTER AIMS
Introduction
Because we all believe we are good at communicating, we think there is no need to
think about how we do it. Yet, regrettably, there is ample literature to suggest that we
do not communicate as well as we might in healthcare settings. In this chapter, we
will be exploring those ideas and trying to come to terms with the notion that we can
rise to the challenge of improving CIPS interactions in our different spheres of
practice.
The NMC Standards of Proficiency (2004a) stress that nurses should commit
themselves to lifelong learning, safely and effectively extend the scope of their
professional practice and think in a future-directed and nursing branch-related way.
According to the NMC, this commitment should be made within the full range of,
often highly different, multidisciplinary team workplaces. These workplaces should
promote safety and responsiveness to the needs of the patients and clients within
them.
What would a commitment to these standards mean for the healthcare organisations,
and the nurses working in them, that were sensitive to the need for the development
of increasingly effective and sophisticated interpersonal communication for nurses
and midwives? Writers such as Benner et al. (cited in Frost et al., 2000), for example,
argue that CIPS are on just as much a continuum from ‘novice’ to ‘expert’ as are
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technical nursing skills. Benner and colleagues argue that highly proficient nurses
2/Key concepts
demonstrate the ability for ‘emotional attunement’ with their clients. In the context of
safe, effective and compassionate organisational work settings, this means that:
Attuned nurses have a capacity to read a situation in a patient and to grasp its
emotional tone: to know when something is ‘off’ when it looks ‘ok’ on the surface,
or to sense that it’s actually ‘ok’ despite appearances to the contrary.
(Frost et al., 2000, p32)
CASE STUDY
To help improve our CIPS, theorists have explored the manner in which we
communicate and relate to one another to provide us with explanations for why and
how we carry out what could be considered a fundamental human behaviour. In this
chapter, we will consider some of these theories and how they apply to healthcare
settings. We will also examine why evidence and research underpinning our practice
needs to be determined in this area in line with current thinking on the strength of
this evidence.
There are questions to ask about how well we consider our abilities to
communicate and, in this chapter, we will ask these questions. Because there are so
many different factors that can affect our ability to communicate, we will be
concentrating here on what we believe to be two very important aspects: how we
can better understand relating to one another in a healthy manner and how we can
understand each other’s emotional needs and perceptions. This latter aspect involves
considering the caring element of communication and the notion of suffering; each
firmly situated in healthcare. We move on to discuss the psychological basis for
healthy relationships by exploring the theory of mind, empathy and the notion of
valuing diversity.
The final section of the chapter concentrates on the environmental context and
discusses the organisational context for CIPS, as well as offering a challenging view on
nurses’ and midwives’ responsibilities to practise quality communication when
healthcare environments are subject to change and shifting priorities.
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2/Key concepts
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2/Key concepts
Sender → Message → Receiver
This model emphasises the complexity of communication and the many factors that
have to be taken into account. It also indicates that the ability of the communicator
has a significant effect and the internal value systems of the individuals involved in
communicating with each other play a part. There is also a strong hint in this model
that it is not just communicating that enables messages to be transmitted. The
interpersonal nature of one person’s response to another person counts. The
situational context in which the interaction takes place also has an effect.
Distracting
stimuli
Channels of
communication:
Sender vocal, visual, Receiver
kinetic, print,
devices
Interpersonal space
Context
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2/Key concepts
1
ACTIVITY 2.1 REFLECTIVE 2
3
What is the purpose of communication in healthcare settings? 4
5
Take a moment to think about the above question and to consider what 6
differences there are between communicating in your everyday life and in 7
healthcare settings. You may also want to consider what aspects are the same, not
8
forgetting that you are communicating with patients as well as colleagues.
9
You will find possible answers to this activity at the end of the chapter. 10
1
2
3
It should become clear from reading the rest of this chapter and the book as a whole 4
that some people are better at communicating than others. If skilled interpersonal 5
communication involves both giving and receiving information, and doing this to the 6
mutual satisfaction and benefit of sender and receiver, then not everyone is ‘naturally’ 7
very good at: 8
● figuring out what an individual is feeling from the way they look; 9
20
● getting a clear verbal message across so that someone understands it;
1
● gauging someone else’s level of distress on the basis of what they say or how 2
they appear; 3
● listening respectfully to the experiences and point of view of another person. 4
5
6
7
ACTIVITY 2.2 REFLECTIVE 8
9
Think about a time when you were in a situation when the communication from 30
you to someone was good, at least from your point of view. Why was this? What 1
indicators from the receiver to you confirmed that it was successful? Identify the 2
features of the communication that you felt enhanced the process. 3
In complete contrast, now think about a time when you were in receipt of a 4
message and it did not go as planned. This time you are at the wrong end of the 5
communication. How did you feel? Take time to analyse, using the circular model 6
in Figure 2.1. What could have improved the situation? 7
8
As this activity is based on your own observations, there is no outline answer at the
9
end of the chapter.
40
1
2
Given the above, it should hopefully be clear that the ability to be interpersonally 3
skilled communicators cannot be taken for granted by student nurses or midwives. 4
We wish to explode the myth that these skills come naturally to human beings and 5
require no effort to constantly hone, improve and develop them. 6
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2/Key concepts
ACTIVITY 2.3 PRACTICAL
Conduct an informal survey among either your student peers or your colleagues
on the ward or placement. Ask either group what makes for good communication
between staff and between staff and clients. Keep a brief written record of this
exercise and share it in class.
As this activity is based on your own observations, there is no outline answer at the
end of the chapter.
CASE STUDY
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2/Key concepts
1
2
3
4
5
6
7
8
9
10
1
In counselling and psychotherapy, the In nursing care, communication is 2
therapeutic relationship radiates one element of several that make 3
throughout the interactions between up holistic nursing practice. 4
counsellor/therapist and client.
5
6
Figure 2.2: Difference between therapeutic relationships in counselling and 7
psychotherapy and in nursing care. 8
9
20
There are some similarities, but equally there are many differences (see Figure 2.2). 1
All three disciplines aim to make helpful and effective use of CIPS. However, the 2
therapeutic relationship in counselling and psychotherapy is viewed as central and 3
pivotal, rather than being just one element of the many role aspects that go to make 4
up the job of nursing. In addition, issues emerging within the therapeutic relationship 5
between client and psychotherapist or counsellor are worked on in considerably 6
greater depth and sophistication, and treated with much greater significance than 7
they would be in a nurse–client/patient relationship (see, for example, Gilbert and 8
Leahy, 2007). 9
30
Evidence-based communication and interpersonal skills 1
2
The NMC Standards of Proficiency (2004a) argue that nursing practice, integrated 3
with theory, needs to be evidence-based, and thus safe. There are good reasons why 4
the safe and effective practice of CIPS in nursing should aim to be evidence-based 5
(the specific focus of Chapter 3). From a broad definition of evidence-based nursing, 6
practices are considered safe and effective either because of a developing body of 7
research-based scientific (sometimes called ‘empirical’) knowledge to support them, 8
or because of theoretical consensus. 9
40
‘Theoretical consensus’ means large-scale agreement, built up over a long time, by
1
communities of nursing practitioners and academics, and scholars from outside the
2
discipline whose work has been seen to have relevance for nursing.
3
Together, researchers and theorists have contributed to the systematic consideration 4
about, reflection on, and refinement of nursing CIPS practice. This contrasts strongly 5
with the notion of simply relating to, and communicating with, patients and clients in 6
particular styles because ‘it’s always been done that way’ or because it’s ‘quick and 7111
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easy’. This also points to CIPS in nursing with people having healthcare needs as
2/Key concepts
being distinct from everyday communication between people in general.
The box that follows will introduce you to key fundamental issues around evidence-
based healthcare practice, and the section and activities that follow this box will help
you begin to engage with some systematically developed theoretical and scientific
concerns.
THEORY SUMMARY
Evidence-based healthcare
Healthcare practice should be based on the combination of three factors (Muir
Gray, 1997; Trinder and Reynolds, 2000). These are:
1. Strong evidence from at least one systematic review of multiple and well-
designed randomised control trials.
2. Strong evidence from at least one properly designed randomised control trial
of an appropriate size.
3. Evidence from well-designed research trials that do not contain randomisation,
for example single-group, pre-post, cohort, time series or matched case-control
studies.
4. Evidence from well-designed non-experimental studies from more than one
centre or research group.
5. Opinions of respected authorities, based on clinical evidence, descriptive
studies, reports or expert committees.
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2/Key concepts
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suffering, individuals can be thought of as being in the process of losing their very
2/Key concepts
‘humanity’, and all the things that are considered to be related to humanness and
dignity.
(Rodgers and Cowles, 1997, p1050)
● What could be inferred about how the individual experienced their suffering?
● What communication/interpersonal interventions were helpful/would be
helpful/were needed?
As this activity is based on your own observations, there is no outline answer at the
end of the chapter.
Healthy relating
From the chapter so far, we can make the following summary statements: good CIPS
in nursing are respectful, non-exploitative, non-judgemental and not tainted by
everyday casualness. They must be based on the careful development of sensitive
helping-trusting relationships with individuals who are suffering because of their
perceived loss, and loss of control, of functions, abilities and other attributes that
make them human and give them dignity.
However, the above picture of the basis in nursing theory for good, effective and safe
CIPS can be broadened with reference to the NMC Standards of Proficiency (2004a).
The health promotion and education roles of nurses and midwives include a focus
that goes beyond a narrow disease orientation to address ‘healthy relating’. Healthy
relating, in turn, has a developmental basis, a moral basis, a psychological basis and
an organisational basis. We will go on to examine each of these now.
There are clear implications emerging from such ‘healthy’ and ‘unhealthy’ attachment
styles for interpersonal communication between nurses and midwives and their
patients or clients. Arguably the most important of these is that patients may need to
be helped to feel reasonably secure in their relationship with nurses. This is achieved
through nurses and midwives offering their patients and clients time, within which
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2/Key concepts
they listen non-judgementally to those they care for. From the perspective of secure 1
relationships, more healthily attached individuals, who feel listened to, understood 2
and supported, will be more able to take risks towards independent living and 3
increased health. 4
5
6
7
ACTIVITY 2.6 REFLECTIVE 8
9
● With your peers, think of children you knew when you were very young. Can 10
you distinguish between those who were timid and shy and those who were 1
very confident ‘natural leaders’? How might their respective home and 2
parental environments have contributed to their shyness and confidence? 3
● Think of people you know currently. Can you distinguish between ‘non-risk-takers’ 4
and ‘risk-takers’? Is there anything about the early lives of each group that may 5
have contributed to their current respective styles around risk? 6
7
Apply the two scenario questions above to clients/patients that you know.
8
What kinds of relationships with healthcare staff might help clients or patients 9
feel enabled to take risks towards independent living and increased health? 20
As this activity is based on your own observations and discussions, there is no outline 1
answer at the end of the chapter. 2
3
4
5
The moral basis for healthy relating 6
The provision of time to be listened to, by nurses and midwives, may be something 7
of a novelty for some patients. One reason for this is that they have gone through 8
their lives being treated as objects in various ways. This could include being treated as 9
a precious object who must not be damaged in any way, or an unwanted object 30
whose presence is a constant nuisance, or a useless object who can do nothing right. 1
2
The work of the philosopher Martin Buber (1958) is helpful in understanding the 3
ethical basis for healthy relationships. In simplified form, Buber’s argument is that we 4
all have a choice to relate to each other either as objects (what he terms ‘I–It’) or as 5
full human beings (‘I–Thou’). Full human relating amounts to the ethical practice of 6
respectful attention to, and respect for, the inner world, feelings, beliefs and 7
viewpoints of the other person. 8
9
40
ACTIVITY 2.7 REFLECTIVE 1
2
What makes you feel as if you are being treated as a person, and that your 3
individual needs are being recognised and regarded as valued? Write down your 4
ideas and think about whether or not these are the same as your friends’ or 5
family’s. 6
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2/Key concepts
As this activity is based on your own reflection, there is no outline answer at the end
of the chapter.
Using Buber’s terminology, the experience of being treated as an ‘I’ rather than an ‘it’
is more likely to lead to individuals feeling self-confident and independent and
trusting their own worth, judgement and feelings. This in turn may well help them to
begin to develop more healthy relationships, both with themselves, in terms of having
greater self-esteem, and with others.
THEORY SUMMARY
Self-esteem
Self-esteem reflects the emotions that result from individuals’ appraisal of their
overall effectiveness in the conduct of their lives (Hewitt, 1998). Self-esteem is
thus clearly subjective and develops from a person’s perceptions of themselves
and their achievements. This is particularly so in interpersonal relationships and
relates to the value and significance we place on our views of ourselves – or our
self-concept.
To complicate matters, a person may have many objective achievements and still
have a low self-esteem. Conversely, a person with few achievements who believes
they have conducted themselves as well as they could can have a high self-esteem.
In healthcare there is often a lowering of self-esteem because the person is unable
to function as they would normally. They may previously have had a satisfactory
level of self-esteem or an ability to aspire to achieve higher levels. Yet levels of
self-esteem can be maintained through ill-health if patients are given the
appropriate levels of support. This works in two ways. Either a person’s health
creates such a threat to their self-identity that they become emotionally
immobilised. Or they will be sufficiently challenged by the illness or change in
health that they develop new coping skills that result in an increase in self-
esteem. The nurse’s role is to provide support and confirmation of the person’s
efforts to help protect their self-esteem.
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2/Key concepts
1
● In general, what kind of actions do you think enhance self-esteem? 2
● What are some things (actions or words or both) that people do that diminish 3
self-esteem? 4
● What specific things in healthcare settings do you think you can do to enhance 5
self-esteem for patients and colleagues? 6
7
● What did you learn about yourself from this exercise? 8
As this activity is based on your own observations, there is no outline answer at the 9
end of the chapter. 10
1
2
3
The psychological basis for healthy relating 4
5
Some individuals who have experienced a lifetime of being mistreated, and who
6
therefore regard themselves in Buber’s terms as an ‘it’, have from a very young age
7
had their inner world of meanings and feelings constantly disregarded by those who
8
have been in the closest contact with them. Those in closest contact with young
9
children are normally their parents and, a little later, their teachers and peers at
20
school. The influence of these close contacts can have a considerable effect on a
1
person’s psychological well-being and sense of self-esteem and self-worth. These
2
ideas and interpretations of the meanings of experiences with others form the basis
3
of an individual’s own theory of concepts and imaginations – reasons why things
4
happen the way they do around them or to them. This is known as the ‘theory of
5
mind’ and plays a large part in influencing the psychological basis for healthy relating
6
to others.
7
8
9
THEORY SUMMARY 30
1
Theory of mind 2
3
In a dynamic interactive way, human beings make constant judgements about
4
each other. The ‘theory of mind’ concept refers to how all of us make inferences
5
and guesses about what we think are the causes of each other’s behaviours, and
what is going through each other’s minds (Baron-Cohen, 2003; Goleman, 2006). 6
7
The human ability to have a theory of mind seems to be important to us in order 8
to ‘read’ situations well enough to get by relatively smoothly and helpfully with 9
one another on a day-to-day basis. However, theory of mind is a specific skill and 40
some people have major difficulties in being able to guess what is going on in 1
other people’s minds. Sometimes, as in the case of how young children are treated 2
by their parents and teachers, it is sadly the case that what’s going on in the 3
minds of the former is of little importance to the latter.
4
The work of Baron-Cohen (2003), although in large part dealing with Asperger’s 5
syndrome, has wider implications for the psychological basis of healthy relating 6
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2/Key concepts
(Goleman, 2006). As with the ability to be empathic, described below, people in
general differ in their abilities to judge accurately the internal world of another.
This has clear implications for the ongoing development of skilled interpersonal
communication in nursing . Nursing students should not assume that they are
highly skilled in this area, and may have to work at developing this ability
(Goleman, 2006).
Empathy
In addition to understanding the complexity of an individual’s personal theory of mind
and its impact on CIPS, being empathic requires the ability to not just think about the
mind of the other but to identify emotionally with his or her feelings (Greenberg,
2007). Empathy can be described as the ability to be intuitively aware of what
another person is feeling as well as thinking.
We believe empathy is the ability of one person to perceive and understand another
person’s emotions. But this is not easy to do, as emotions can be hidden in an
internal world or displayed with behaviours that can contradict how a person actually
feels. Such are the complexities of human beings. In a primitive survival setting you
would not have wanted your opponent to know what you were feeling, so we have
learnt as a species to disguise how we really feel, and this often occurs when we are
most distressed.
In these situations, nurses and midwives have to draw upon their professional inner
emotional strengths and try to feel the emotions their patient/client feels, while at the
same time maintaining a separate identity. It is important to recognise which feelings
belong to the patient/client and which to the nurse. This is a difficult skill to learn and
Chapter 3 will provide more guidance on how to develop this ability.
Other theoretical concepts to consider when judging and engaging with patients in
relation to empathy are trust and respect. Trust is based upon our previous
experiences and enables individuals to cope with the world and resolve frustrations
about those things that may be unfamiliar or unknown. Respect, together with
honesty, consistency, faith and hope, is an element of a trusting relationship. Once
these elements are established, a sharing of emotions and thoughts can take place.
Empathic attunement
Complementing Benner’s views on ‘emotional attunement’ (discussed in the
introduction to this chapter) is Greenberg’s concept of ‘empathic attunement’, derived
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2/Key concepts
from scientific research. Empathic attunement suggests that nurses and midwives 1
who convey genuine interest, acceptance and caring are more likely to achieve a 2
secure emotional bond with their patients. In this regard, non-verbal facial 3
communication is extremely important. Essentially, patients and clients learn how 4
acceptable they are from the facial expressions of healthcare staff (Greenberg, 2007). 5
6
7
8
CASE STUDY 9
10
The in-patient adult nurse 1
2
While sitting by the bedside of one of her patients, the nurse hears a story from the 3
patient’s past which makes her feel disturbed and somewhat disgusted. The patient 4
has disclosed that she was sexually abused by her father over several years, when she 5
was very young. Mindful of the importance of facial expression in empathic 6
communication, the nurse makes an effort to match her supportive and sensitive
7
response to the patient’s disclosure with a facial expression that signifies care and
8
concern rather than shock and disgust.
9
20
1
Chapter 3 discusses this concept in more detail and examines the evidence
2
underpinning the concept.
3
4
Valuing diversity 5
Practice in developing increasingly honed skills around empathy and theory of mind 6
provides opportunities for nurses to appreciate the fact that other people do not feel and 7
think in the same way as them. It should be apparent that differences in feeling and 8
thinking between people may be based on age, gender, culture, sexual orientation, ethnic 9
origin and, as stated above, upbringing. Chapter 8 explores this area in more detail. 30
1
2
The organisational basis for healthy relating 3
The above section has hopefully illustrated the importance of nurses and midwives 4
working towards secure rather than insecure attachment styles in their patients and 5
clients, and supporting them in a health-promoting way to believe more in 6
themselves, and in their emotions and judgements. However, the above bases for 7
healthy relationships depend in turn upon healthy and health-promoting work 8
settings. These provide the organisational basis for good CIPS, a discussion of which 9
will bring this chapter to a close. 40
1
The NMC Standards of Proficiency (2004a) require nurses to be able to engage in 2
problem solving, critical thinking and reflection around safe and effective CIPS within 3
the complex and varied care environments that characterise health provision in the 4
twenty-first century. These behaviours should be carried out in the context of 5
multidisciplinary practice, and be fair, professionally and ethically appropriate, and 6
responsive to the needs of diverse patient/client populations. 7111
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2/Key concepts
Environments shape experience
Sadly, the nature and influence of healthcare organisations is a much neglected area
in nursing and health CIPS books. This is surprising, given the strong message
emerging from the social psychological literature that organisational environments
shape experience (Meyerson, 2002), at both conscious and unconscious levels
(Morgan, 1997).
THEORY SUMMARY
External and internal environments
By environment, we mean all the cultural, developmental, physical and
psychological features that are external to a person and that can have an influence
on their perception, reaction and involvement in healthcare. These are the features
that we bring as professionals to the healthcare setting, either as individuals or
collectively as part of an organisation.
In addition, we need to consider the effect of the internal environmental state of
the patient/client, which is derived from their physiological, spiritual, psychological
and developmental characteristics. These internal states will have been influenced
by beliefs from family, friends, the media, and any previous experiences they have
had of healthcare settings.
This view of organisations shifts the focus away from simple ‘bricks and mortar’
assumptions of what organisations are about. From a realist perspective, organisations
are simply physical structures within which employees work. From a social
constructionist perspective, organisations are social-psychological structures that
individuals create together in their day-to-day interactions.
An unfortunate fact is the reported experience of many clients and patients, often
confirmed by staff, of some work settings within which ‘the way things are done’ is
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2/Key concepts
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2/Key concepts
Busyness affecting group and individual behaviour
‘We’re too busy’ is a much-voiced reason given for why nurses often don’t find the
time simply to be with their patients, as opposed to doing nursing tasks. There may
be some truth in this assertion in circumstances where there are staff shortages.
However, a basic understanding of the ways in which nurses and other healthcare
staff think and behave in groups (Augoustinous et al., 2006) may help us better
understand the organisational social process by which clients’ communication and
interpersonal needs are either often ignored or treated as an irritant. This may
especially be the case if these needs are seen by staff to conflict with the real
business of the healthcare setting.
Augoustinous and her social psychologist colleagues describe the various ways in
which patients, who seek attention from nursing staff, often for very good reasons,
may be negatively ‘labelled’ in these circumstances. The kinds of mindsets that
develop in nursing workgroups in any discipline are often very defensive and,
complementary to Menzies Lyth’s and Morgan’s theorising, serve an anxiety
reduction function.
These mindsets may take the form of ‘them and us’ thinking, where ‘us’ is viewed
as reasonable and hardworking and ‘them’ as manipulative and troublesome.
Unfortunately, ‘them and us’ thinking is associated with the production of irrational
prejudice based on often insufficiently informed first impressions, with a failure to
correctly and fairly read patients and clients at either empathic or theory of mind
levels.
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2/Key concepts
CHAPTER SUMMARY 1
2
3
This chapter has introduced you to some of the key concepts and definitions related 4
to communication and interpersonal skills (CIPS). Two frameworks for communication 5
have been described. The rationales for safe practice and evidenced-based care have 6
been discussed. Concepts related to CIPS, such as suffering, healthy relating and 7
empathy, have been introduced to give you an understanding of their importance. 8
Such importance is particularly relevant in healthcare settings, where the careful 9
development of sensitive helping-trusting relationships with individuals is needed – 10
individuals who are suffering because of their potential loss of control of functions, 1
abilities and other attributes that make them human and give them dignity. 2
3
The organisational and environmental contexts have been explored to provide a
4
backdrop to the notion that organisational environments shape experience. Such
5
experience has a major impact on how we behave and respond in situations, and 6
therefore on our CIPS development. 7
8
Activities: brief outline answers 9
20
Activity 2.1 (page 28) 1
2
What is the purpose of communication in healthcare settings? 3
4
● To provide and share information.
5
● To promote understanding of patients’ and clients’ responses to health problems 6
or adjustments to their health. 7
● To explain options for care and treatment to patients and clients. 8
● To facilitate their well-being. 9
30
● To alleviate their anxieties.
1
2
Activity 2.4 (page 31)
3
What are the challenges to implementing evidence-based CIPS? 4
5
● Staff may find the need to alter the ways they have practised for a long time too 6
threatening to consider and do. 7
● If staff were to embrace evidence-based CIPS, it might indicate to them that what 8
they had been doing up to now, in the name of good communication, left a lot to 9
be desired. So, rather than face this implication, it may be better for them 40
psychologically to ignore attempts or imperatives to change. 1
● Staff may not be aware of evidence-based CIPS. 2
3
Activity 2.9 (page 40) 4
5
What prevents ward nurses from spending more time with their patients/clients and 6
talking with/listening to them? 7111
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Staff may say that they are too busy for this to happen.
2/Key concepts
●
● They may also say that, if they start to spend more time with their patients/clients,
then the latter might come to expect this on a regular and frequent basis.
KNOWLEDGE REVIEW
Having completed the chapter, how would you now rate your knowledge of the
following topics?
Where you’re not confident in your knowledge of a topic, what will you do next?
Further reading
Frost, PJ, Dutton, JE, Worlen, MC and Wilson, A (2000) Narratives of compassion in
organizations, in Fineman, S (ed.) Emotion in Organizations, 2nd edition. London:
SAGE Publications.
Useful websites
www.compassionatemind.co.uk/ Set up in 2006, The Compassionate Mind
Foundation aims to promote well-being through the scientific understanding and
application of compassion. We’re sure you will enjoy using this excellent website.
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3. Evidence-based principles
CHAPTER AIMS
Introduction
This chapter will enable you to analyse and evaluate critically the literature on
evidence-based communication and interpersonal skills (CIPS) that are relevant to
nursing practice. First, we will address the history and development of research in
interpersonal communication in nursing. We will then turn to issues around teaching
and learning, and the relative success of the uptake of skilled interpersonal
communication among nurses. You will hopefully see that the nursing literature in this
area ignores key research and theoretical work on the importance of the context of
interpersonal communication, including the organisational, or work-setting, context.
From this basis, you will be able to evaluate the relative contribution of counselling
and psychotherapy models of CIPS. We will argue that, while these models claim to
provide useful principles for practice, they must be modified according to work-
setting contexts, and must also be evaluated according to contemporary theory and
research in the area of social cognition, which is the study of how people process
social information (there is more on social cognition in Chapter 4).
The chapter will end with the provision for you of a set of evidence-based
principles for practice, and we will also include information from conceptual,
empirical and policy literature about what it means to be client/patient- and
carer-centred.
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3/Evidence-based principles
The historical development of research in CIPS in nursing
The historical development of an evidence-based interest in CIPS in nursing is well
documented (Macleod Clark, 1985). According to MacLeod Clark, research interest
in the area developed throughout the latter half of the twentieth century and
included patient satisfaction surveys; studies exploring the benefits of improved
communication; observational studies that described and analysed the ways in which
nurses and their patients and clients interacted; and studies on the effectiveness of
interpersonal skills teaching.
Banister and Kagan (1985) argued that research work on interpersonal skills in
nursing was influenced by research traditions in other fields, including sociology
and social, clinical, management and counselling psychology. From these disciplines,
a set of desirable skills emerged, particularly social skills, empathy and assertion
training.
Thus, during the latter decades of the twentieth century, nursing interpersonal
research was greatly influenced by social skills and assertion training assumptions
(Davidson, 1985). It was assumed that, in order to develop and hone interpersonal
skills, nurses and their patients and clients needed to be both socially skilled and
assertive. This is indicated by the circular view that the interpersonally skilled nurse is
defined as such by having social and assertiveness skills (and (group) facilitation
skills) (Morrison and Burnard, 1991).
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3/Evidence-based principles
1
CASE STUDY 2
3
4
A group of busy nurses go on a communication course and learn the principles of good
5
CIPS. They return to their ward and, after a month, the ward manager wonders why
the number of complaints about poor communication hasn’t gone down at all. Discuss
6
as a group why this may be so. 7
8
9
10
Brown et al. (2006) analysed the assumption that a communication skill, once 1
learned, can be readily transferred from one context to another. In particular, they 2
were critical of the assumptions displayed in the work of Burnard and colleagues that 3
communication skills, derived from counselling models that assume dedicated 4
communication time, can reasonably be transferred to busier contexts where there is 5
very little time available. 6
7
8
9
ACTIVITY 3.1 REFLECTIVE 20
1
Think about the various contexts within which you try to communicate effectively 2
with your clients. What are the contextual factors that both facilitate, and limit, 3
good communication? 4
As this activity is based on your own reflection, there is no outline answer at the end 5
of the chapter. 6
7
8
9
An apparent lack of attention to the ways in which organisational contextual factors 30
may undermine the practice of skilled interpersonal communication is shown by 1
much of the writing on CIPS in nursing. This may have influenced continual frustration 2
about the fact that, although skilled interpersonal communication is talked up in nurse 3
education and literature, its practice in real-life healthcare situations leaves a lot to be 4
desired (MacLeod Clark, 1985). Brown et al. argued that this is not really surprising, 5
since there are clear contextual differences between what is taught and what is 6
practised: 7
8
While practitioners may well have absorbed the professional wisdom about the
9
importance of communication in ensuring good outcomes for clients and
40
themselves, they may well continue using timeworn communicative strategies of
1
the kind that lead to complaints, poor outcomes and a sense of alienation
2
between client and practitioner.
3
(2006, p4)
4
5
6
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3/Evidence-based principles
The Hargie-Dickson model of interpersonal communication
and its relevance for nursing
In contrast to writing on interpersonal communication by nurse academics, Hargie
and Dickson (2004), who come from a communications rather than a nursing
background, were very clear about the major role of contextual factors. Summarising
and synthesising research, theory and practice in the area, these authors argued that
skilled interpersonal communication can be accounted for in terms of the person-
situation context. This means that all communication is context-bound, in that it is
always embedded in time, place, the specific form of the relationship of the
communicators, and the organisational frameworks within which communication
takes place. The personal characteristics of the communicators, together with the
above features of the shared situation, act to shape the interaction by determining the
goals pursued, and the responses, feedback and perception of the communication
event among all those involved. Therefore, if nursing research and teaching on
interpersonal communication took greater account of the contextual factors, this may
lead to improved CIPS.
Clearly, counselling and psychotherapy models have contributed greatly and have
transformed nursing theory, knowledge and practice from the latter half of the
twentieth century. The work of Carl Rogers (1961), for example, has influenced the
shift from a task- to a person-centred and holistic view of nursing care, with specific
regard to the adoption of Rogers’ ‘core conditions’ approach to human relating (now
known as the ‘Rogerian’ approach). Rogers identified what he claimed were three
‘necessary and sufficient’ conditions for helping someone change effectively through
a good therapeutic relationship. These are:
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3/Evidence-based principles
have made a major contribution to the developing theory and practice of both mental 1
health nursing generally (Newell and Gournay, 2000) and cognitive behavioural 2
psychotherapy specifically (Duncan-Grant, 2001). 3
4
Cognitive behavioural approaches are increasingly adopting an integrative stance 5
(Gilbert and Leahy, 2007; Grant et al., 2008). In simple terms, this means that 6
major theoretical and empirical developments, are being incorporated into cognitive 7
behavioural approaches. One such empirical development, having theoretical 8
roots in psychoanalytic psychotherapy and clear relevance for nursing practices is 9
the concept of ‘transference’. 10
1
2
THEORY SUMMARY 3
4
5
Transference
6
Psychotherapy theories have long suggested that the mental representations an 7
individual holds about significant others may either facilitate or impede an 8
individual’s progress towards recovery. Significant others are individuals that we 9
have either loved or loathed in our earlier life. A new person can be experienced as 20
either a friend or foe in a matter of moments. In support of psychotherapy 1
theories, and in line with contemporary developments in social cognition research, 2
Miranda and Andersen (2007) argue that transference occurs automatically in 3
everyday life, when representations of significant others are triggered.
4
Transference is thus a process by which people re-experience past relationships in
5
their everyday social relationships and interactions.
6
Mental representations of significant others exist in memory, and such 7
representations can easily be triggered by relevant cues in any context. Our global 8
view about ourselves and about significant others are linked in memory. 9
Concurrent activation occurs: when one is activated, the other is too. Transference 30
includes assumptions about the other’s presumed feelings about oneself and vice 1
versa, and is directly linked to the concepts of schema, prejudice and stereotyping 2
(see pages 50–2 in this chapter and also Chapter 7). 3
4
5
6
Criticisms of counselling and psychotherapy models for 7
interpersonal communication in nursing 8
9
It has been argued that, in spite of their benefits, the relevance of some counselling 40
and psychotherapeutic principles for day-to-day nursing care can be criticised from 1
several perspectives. Nurses are charged with the ability to be able to demonstrate 2
cultural and political awareness of their societal role and related professional 3
behaviours (see also Chapter 7). In this context, Grant (2002) has highlighted cultural 4
and political concerns with the appropriateness of the humanistic approach in 5
general. He encourages students to be engaged with the literature and debate the 6
role that individualistic psychology, which focuses on the individual without 7111
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considering societal influences such as politics and paternalism (for example, the
3/Evidence-based principles
‘nanny state’), plays in everyday healthcare practice.
Further specific criticisms of the relevance of Rogers’ core conditions, and related
concepts, for nursing practice include challenging the following assumptions:
● that the core conditions are indeed both necessary and sufficient;
● that non-judgementalism is indeed possible between people communicating;
● that self-awareness and empathic communication is practised successfully.
Non-judgementalism
There is a crucial question that must be asked by nurses interested in the use of
Rogerian core conditions for enhancing CIPS. This is: to what extent is the exercise of
non-judgementalism relevant and possible in nursing practice? Based on Rogers’
condition of acceptance or unconditional positive regard, humanistic practitioners and
writers often advocate non-judgementalism. Burnard, for example, urges health
professionals to Try suspending judgement on other people until you fully hear what
they say. Even then, try to remain non-judgemental! This skill is one of the basic pre-
requisites of effective counselling (1996, p14).
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3/Evidence-based principles
A major problem with this standpoint is that empirical work in social cognition (social 1
thinking; see also Chapter 4) suggests that it is impossible for human beings to be 2
non-judgemental. It seems necessary, and often helpful for all of us, to take ‘cognitive 3
shortcut’ judgements to make sense of contextual situations and individuals within 4
those (Augoustinos et al., 2006). As we grow up, we develop what are described as 5
‘schemas’ to make sense of the world (see also Chapter 7). Schemas can be 6
thought of as mental structures that contain general expectations and knowledge of 7
the world. This may include general expectations about people, social roles, social 8
events, and how to behave in specific situations (Hargie and Dickson, 2004). 9
10
1
2
THEORY SUMMARY 3
4
Different types of schema have been identified (Fiske and Taylor, 1991): 5
6
● Self-schemas: these have to do with knowledge of ourselves.
7
● Event schemas (or scripts): these relate to the sequence of events 8
characterising particular, frequently encountered, situations, such as buying an 9
item from a shop, organising a doctor’s appointment, or arranging a holiday. 20
● Role schemas: these guide our expectations of how people should behave 1
according to unspoken rules of gender, race, class, power and influence. 2
● Causal schemas: these enable us to form judgements about the relationship 3
between cause and effect in our material and social environment, and to adopt 4
problem-solving strategies based on these judgements. 5
6
● Person schemas: these enable us to make a judgement about the social
7
categories to fit other people into.
8
9
30
It is useful to think of schemas lying dormant, in the sense that we are usually not 1
always consciously aware of their influence on our emotions, thinking and behaviour. 2
However, there are times when our personal schemas can be activated so that we 3
are more ‘in touch’ with them (for example, the negatively held self-schema ‘I am 4
useless’ or ‘I am worthless’ may be activated at times of acute stress). Equally, our 5
personally held schemas may be violated (for example, getting into trouble over 6
something when you believe that you’ve done nothing wrong and that you are a 7
fundamentally good person). Finally, the actions of others may activate the schemas 8
we hold about either other people generally or particular groups of people. 9
40
1
2
ACTIVITY 3.2 REFLECTIVE 3
4
Imagine that, for the first time in your life, you have been stopped by a policeman 5
who accuses you of speeding while driving. With the different types of schemas in 6
7111
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3/Evidence-based principles
mind, from the theory summary box above, consider what schemas about yourself
and/or others have been either activated, violated, or both.
As this activity is based on your own reflection, there is no outline answer at the end
of the chapter.
The human ability to make shortcut judgements has clear advantages and
disadvantages. From Activity 3.2, on the one hand, it should be realised that it is to
our advantage to expect what kind of interpersonal encounter is likely to happen in
situations where there are clear contextual, situational and relational cues to
determine behaviour (Hargie and Dickson, 2004).
On the other hand, it is equally likely that many of us will make judgements based on
prejudice-related stereotyping (Augoustinous et al., 2006; Hargie and Dickson, 2004;
Oakes et al., 1994; Tourish, in Long, 1999). When we stereotype others, we place
them in general categories and ignore their individual characteristics. The cost of this
is that we fail to appreciate the complete uniqueness of the whole person, ensuring
that our stereotypes sometimes lead us into judgements that are both erroneous
and biased (Tourish, in Long, 1999, p193).
Prejudice and related stereotyping are particularly relevant problems for interpersonal
communication in nursing. As described above, if a nurse, for example, acts towards a
patient/client ‘as if ’ they were completely like the stereotype the nurse imagines, the
patient is likely to respond in, possibly, a defensive or angry way, often because they
are aware that they’ve been unjustly ‘put in a box’. The patient/client’s behaviour may
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3/Evidence-based principles
then confirm to the nurse that their (prejudiced, stereotyping) attitude was correct 1
and the nurse may not be sufficiently aware of the fact that they are acting towards 2
the patient/client on the basis of unfair and inappropriate judgemental attitudes. 3
4
Given the inevitability about making instant contextual evaluations about people, and 5
their advantages and disadvantages, it seems more reasonable for people to strive 6
towards being more constantly and critically aware of the judgements they are 7
making about people, rather than trying to be ‘non-judgemental’ in Burnard’s (1996) 8
sense. Critical awareness of such judgements can also, helpfully, contribute to their 9
modification when nurses try to get to know the person behind the stereotype. This 10
requires nurses to practise in a ‘metacognitive’ manner (Hargie and Dickson, 2004) 1
– in other words, to think about the ways in which they think about other people. 2
3
Self-awareness 4
A further question for nurses considering the viability of the humanistic approach for 5
CIPS is: what are the threats to the nursing practice of the humanistic principle of 6
‘self-awareness’? 7
8
It is often argued (for example, see McCabe and Timmins, 2006) that self-awareness 9
is a significant tool for improving nurse–patient/client interaction and should be an 20
integral part of nurse education. In this vein, based on the inherent benefits of being 1
self-aware, it is equally asserted that self-awareness is essential for the successful 2
implementation of the therapeutic relationship (McCabe and Timmins, 2006). 3
Others have flagged up the importance of its use in the professional and personal 4
development of nurses (see, for example, Burnard, 1996; McCabe and Timmins, 5
2006). In a style very characteristic of such uncritical acceptance of the ‘self- 6
awareness’ principle in the nursing CIPS literature, Kagan et al. (1986, 21) stated that: 7
8
self-awareness is central to interpersonal skill. We use knowledge about ourselves 9
to plan our part in any interaction, and to put these plans into practice: our past 30
experience contributes to our attitudes and values and affects what we notice 1
about other people’s behaviour, and how we interpret it. Understanding our 2
reactions to what others say and do will help us to relate more effectively to them. 3
Given the above, and the discussion that preceded it, it may not be unreasonable to 4
assume that it is important to strive to be as aware as possible of our attitudes, beliefs 5
about others and behaviour towards them. However, a fundamental problem with the 6
self-awareness concept is in regard to assumptions of the nature of ‘the self ’ 7
(Holstein and Gubrium, 2000). The notion of the coherent, single and developing 8
self belongs to the philosophical tradition, which gave rise to humanistic psychology 9
in the mid twentieth century, and to related counselling and psychotherapeutic 40
principles and interventions. (See Chapter 5 for further explanations of the concept of 1
self and self-disclosure.) 2
3
However, in line with findings from social psychology (Augoustinous et al., 2006; 4
Holstein and Gubrium, 2000), contemporary philosophy suggests that it is more 5
useful for us to consider ourselves to be often contradictory multiple selves, rather 6
than coherent and predictable single selves. From this perspective, each one of us is 7111
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likely to act in different, sometimes surprising and contradictory ways (to both
3/Evidence-based principles
ourselves and others), in different social contexts, thus behaving and experiencing
ourselves and others inconsistently over time.
The importance of sensitivity to often complex social contexts, and to the
corresponding shifting experiences of self and others, has important interrelated
implications for nurses who wish to practise safe and effective CIPS that adhere in a
balanced way to evidence-based principles. First, nurses should try to be constantly
mindful of contextual factors within which relationships with patients and clients are
embedded (Hargie and Dickson, 2004), rather than inflexibly trying to adhere to a
prescriptive set of communication rules and expectations of context-free and
predictable selves, which, by default, will ignore contextual factors.
Second, nurses need to be mindful of the lack of context in evidence-based practice
generally, including that which informs CIPS specifically (Brown et al., 2006; Hargie
and Dickson, 2004). In this regard, McCabe and Timmins argue that:
[the use of the] principles of good communication . . . rather than nurses in the
health care setting using static models of communication, results in more effective
patient-centred communication . . . Several contemporary authors contend that
current theories of nursing and models of nursing are inadequate to inform the
complexity of healthcare situations.
(2006, 167)
Essentially, McCabe and Timmins argue against a ‘one model fits all’ approach to both
evidence-based practice and related forms of communication and interpersonal
relating. In these authors’ view, nurses should always be mindful of, and respond to,
the individual meaning and context of each interpersonal situation in complex shifting
healthcare environments.
Empathy
Rogers defined empathy as occurring when:
the therapist is sensing the feelings and personal meanings which the client is
experiencing in each moment, when he can perceive these from ‘inside’, as they
seem to the client, and when he can successfully communicate something of that
understanding to his client.
(1967, p62)
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3/Evidence-based principles
● Would you rather that your clients or patients were happy, rather than sad or
angry, in your presence? Why?
● How ‘on duty’ and available are you for the people you try to help? Do you
ever find yourself drifting off into your own world?
● How comfortable are you with disclosing your feelings to your patients or
clients?
● How comfortable are you about showing grief in response to another’s grief?
Look at yourself in a mirror and imagine yourself to be in any of the six situations
listed above and move your face into an expression that you think you would have
in different interactions with patients. Assess for yourself whether you look
genuine, comfortable, masklike, disrespectful or disinterested.
As this activity is based on your own reflection (literally, this time!), there is no
outline answer at the end of the chapter.
From this basis, it might be reasonable to pose the question: what happens when
the interpersonal context and climate work against the development and practice of
empathy? Supporting the contemporary work on social cognition discussed earlier,
in particular the exercise of the five types of schema (self, event, role, causal and
person) and stereotyping, Rogers (1961) argued that a barrier to exploration of
feelings is a very natural tendency to evaluate, disapprove and judge, especially
when a patient/client’s communication is ambiguous or threatening. In these
circumstances, nurses can become:
defensive, often transmitting this to the client through unwanted advice, failure
to respond to direct questions, or curt unfriendly voice tone . . . [according to
Rogers. . .] the logical means of correcting this tendency is to work on achieving
genuineness . . . once this is established, the work of helping proceeds through
the helper’s moment-by-moment empathic grasp of the meaning and
significance of the client’s world.
(Reynolds and Scott, 2000, p229)
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1
ACTIVITY 3.6 REFLECTIVE 2
3
Consider the things that get in the way of you both experiencing, and practising, 4
empathy with your patients/clients on a day-to-day basis at work. 5
6
As this activity is based on your own reflection, there is no outline answer at the end 7
of the chapter.
8
9
10
1
2
RESEARCH SUMMARY 3
4
Work on achieving genuineness in order to enhance a nurse’s ability to be
5
empathic begs the question of how empathy is taught. Based on a review of the
6
literature, Reynolds et al. (1999) argued that empathy training in nurse education
7
is limited by a failure to define empathy specifically and to locate it within an
8
interpersonal theory. They also asserted that a further problem for empathy
education was related to its value for the realities of clinical practice. Reynolds and 9
his colleagues concluded that there is a need for new ways of helping nurses to 20
develop their abilities to express empathy in clinical contexts because of the low 1
levels of empathy in nursing and the limitations of existing empathy courses. 2
Among other conclusions from the literature reviewed, they highlighted that: 3
4
● the optimum length of an empathy course is unclear; 5
● there is no common agreement about which components of an empathy 6
course are effective; 7
● it is unclear what the long-term consequences of empathy training are for 8
nurse–patient relationships; 9
30
● empathy education needs to have relevance to the clinical circumstances in 1
which it really matters; 2
● therefore, clinically focused education may provide nurses with a more 3
meaningful development of empathy skills. 4
5
6
7
Patient/client first- and second-level forms of 8
9
communication 40
Of relevance to the argument for nurses so far is the work of Morse et al. (1992). 1
Morse and her colleagues discussed the differences between nurses behaving in a 2
client/patient-focused or nurse-focused way and whether the communication was 3
spontaneous (which Morse called ‘first level’) or learned (termed ‘second level). 4
5
According to these authors, client/patient-focused, first-level communication is 6
emotionally driven and culturally conditioned and, therefore, is often an unconscious 7111
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response on the part of the nurse. This type of communication includes responses
3/Evidence-based principles
such as pity, sympathy, consolation, compassion, commiseration and reflexive
reassurance. This is often regarded as normal, everyday communication, but is often
undervalued and seen as superficial.
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will enable exploration of the way they think about client groups and how such
3/Evidence-based principles
styles of thinking came about. This may include the personal characteristics of
communication, such as self, event, role, causal or person schemas; or
stereotyping; or unconsciously driven defences against intimacy with clients; or
first- and second-level forms of communication. Equally, it may relate to
characteristics of the organisational frameworks within which communication
takes place.
● Metacognitive practice by nurses is also necessary because of the way they may
have been socialised into particular organisational communication styles, which
may in turn either enhance or pose a threat to skilled interpersonal practice.
● Given the principle that all communication is governed by context, although –
usually unlikely – some environments may lend themselves to leisurely
interpersonal exchanges, others are more appropriate for brief, ‘blip culture’ forms
of communication. Equally, some organisational contexts may promote ineffective,
damaging or abusive types of communication.
● From the basis of the above principles, it will be useful for nurses to practice the
specifics of empathy. This includes empathy both in the interpersonal context and
in the work-setting, or interpersonal climate, context. To facilitate this, clinically
focused empathy education is relevant and much needed.
CHAPTER SUMMARY
This chapter has introduced you to the idea that there are key issues in the historical
development of research in CIPS in nursing. Specifically, there is a clear relationship
between research in CIPS and teaching and experiential learning. Nurses may give a
variety of reasons for spending insufficient time with their clients or patients. Some
of these reasons will constitute rationalisations. All communication is governed by
context. There are problems in nurses having a sole reliance on humanistic
counselling/psychotherapy models of communication. ‘Schema’-driven and schema-
activated behaviour is relevant to the practice of good CIPS in nursing. Also, good
interpersonal and organisational climates are relevant for the practice of good
nursing CIPS. An understanding of what is meant by patient/client first- and second-
level forms of communication is important for nurses. You should be able to
demonstrate an understanding of the organisational environmental threats to
counselling and psychotherapy nursing interventions. Finally, nurses should
understand what is meant by ‘blip cultures’ and the forms of communication
appropriate to such cultures.
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3/Evidence-based principles
KNOWLEDGE REVIEW
Having completed the chapter, how would you now rate your knowledge of the
following topics? 1
2
Good Adequate Poor 3
4
1. The understanding that all 5
communication is governed by 6
context. 7
8
2. What the term ‘schema’ means.
9
3. What first- and second-level forms 10
of communication are. 1
2
Where you’re not confident in your knowledge of a topic, what will you do next? 3
4
5
6
Further reading 7
8
Augoustinos, M, Walker, I and Donaghue, N (2006) Social Cognition: An integrated 9
introduction, 2nd edition. London: SAGE Publications. 20
This book will provide you with contemporary evidence-based information on social 1
cognition, and its relationship with social identity and communication. 2
Brown, B, Crawford, P and Carter, R (2006) Evidence-based Health Communication. 3
Maidenhead: Open University Press and McGraw-Hill Education. 4
This book offers a critical evaluation of the kinds of evidence that have been collected 5
concerning both effective communication and the training health professionals receive 6
in communication. 7
8
9
Useful website 30
1
www.indiana.edu/~soccog/scarch.html This is the website of the Social Cognition
2
Paper Archive and Information Center of Indiana University. There are lots of
3
downloads and links that will interest readers accessing this site. It is an excellent
4
website for link access to papers and homepages on the comprehensive range of
5
social cognition, including non-verbal communication.
6
7
8
9
40
1
2
3
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CHAPTER AIMS
Introduction
It is generally agreed that communication and interpersonal skills (CIPS) underpin an
effective and safe nurse–patient relationship. In order to understand the nature of
nurse–patient relationships, it is valuable to take time to appreciate the spectrum of
the different forms of relationship that occur within nurses’ professional lives. For
example, relationships can range from providing total physical and tangible care in
extreme cases of physical illness, to emotional support of an entirely invisible nature
or support through, for example, professional/social encounters in a community
setting. The nature of these encounters is as varied as a colour palette and different
nurses in different settings, such as caring for adults or children, in mental health
settings or with clients with learning disabilities, may experience more or less of one
particular area of the palette. But, in all likelihood, there will be elements of this
palette in all your interpersonal relationships with patients.
Knowing how to respond and react in these many situations can be bewildering if
you have to imagine how you will manage these different forms of relationships in
order to be effective. This chapter aims to provide a guide in these situations to give
you confidence as well as create a sense of self-awareness. This is a crucial ingredient
of a safe and effective nurse–patient relationship. We will explore what it means to be
safe and begin by examining some of the theory behind the way we think in social
situations and how that influences how we behave. Called the ‘social thinking’
processes, these are the hidden thought processes by which people process and
interpret information from and about themselves (their intrapersonal world) and
other persons (their interpersonal world).
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professional settings. The fundamental core general skills that are needed in CIPS will 1
be explained and demonstrated in practical, work-based contexts. The chapter 2
concludes by discussing the phases of the nurse–patient relationship and by 3
comparing two models. There is a discussion on the nature of the helping 4
relationship in nursing and the notion that this relationship can have a therapeutic 5
effect. The patient’s role in decision making in the nurse–patient relationship is 6
analysed in respect of recent health policy. 7
8
9
What does being safe mean? 10
‘Being safe’ is a term used to describe how nurse–patient relationships can be 1
conducted without either party being harmed. Our professional duty is to ensure that 2
patients are safe and the NMC Code of Professional Conduct states: 3
4
You have a duty of care at all times and people must be able to trust you with 5
their lives and health. To justify that, you must: 6
● make the care of people your first concern, treating them as individuals and 7
respecting their dignity; 8
● work with others to protect and promote the health and well-being of those in 9
your care, their families and carers, and the wider community; 20
1
● provide high standards of practice and care at all times;
2
● be open and honest, act with integrity and uphold the reputation of your 3
profession. 4
(Adapted from NMC, 2004b) 5
6
The key words in this opening extract from the Code are to protect and promote the
7
health and well-being of patients. To achieve that, we have to be mindful that, in our
8
communication and interpersonal relationships with patients, we are unlikely to cause
9
harm, injury or damage. How can we do that with words, you may be saying? Well, as
30
we know, words are powerful objects that shape the messages we are sending. How
1
we interpret the messages is where the damage may start.
2
The interpretation of the meanings of words varies from person to person. In addition 3
to this, in healthcare we are dealing with many words that are unfamiliar to patients 4
until they have understood and learned their meaning. This applies to the names of 5
conditions as well as the phrases and abbreviations we use as short cuts to describe 6
objects, processes, procedures and situations. 7
8
The way in which we transmit the words in our messages can be influenced by many 9
factors (as discussed in Chapter 2), which have to be interpreted and assimilated by 40
both parties in the interaction. Our body language and non-verbal signals can all lead 1
to misunderstanding and confusion if they are not correctly understood by the patient. 2
This is further complicated by the anxiety the patient may have about their health, their 3
previous experiences of healthcare and the relative success of those experiences, their 4
cultural or personalised view of the world and the degree of discomfort or pain they 5
may be experiencing during the communication. These are the distracting stimuli 6
described by Bateson (1979) in the circular model of communication. 7111
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It is not only the interpretation the patient may place on the messages that is
SCENARIO
Scenario 1
The pattern goes like this:
→ The nurse tells the patient that he must have a shower at 6 in preparation for a
surgical procedure. The patient is to undergo a routine procedure and has no major
health problems.
→ The patient nods, indicating he has understood. The patient has interpreted this as
taking a shower at 6 p.m., whereas the nurse meant 6 a.m. So this is a semi-correct
interpretation of the message. The patient is conscious of his health and keeps
himself fit and well; however, he is frightened of falling in the shower and does not
have a shower at home. At home he has a seat in the bath and uses a shower
attachment. The nurse looks very busy and the patient does not want to be a
nuisance, so he does not ask for clarification. The patient is worried about the
surgery and has not slept well, so his receptivity of information is compromised by
tiredness and anxiety.
→ Because the patient nodded in apparent agreement, the nurse says something like
‘That’s OK then’ and goes to the next patient.
It’s not difficult to anticipate what will happen next. The patient will not have the
shower at the correct time. If the nurse does spot this in time, the patient will take a
long time because he is nervous of falling in the shower; he may even fall because he
is unaccustomed to using a shower. The surgery is delayed; the operating theatre’s
schedule is put back, causing inconvenience to patients and staff alike. If the patient
were to fall, the surgery would probably be cancelled and the patient would suffer
more, in addition to suffering the delayed solution to their original problem.
Let’s try it again.
Scenario 2
→ The nurse tells the patient that he has to prepare for surgery (this tells the patient
what the communication is all about) that morning (this tells the patient when it
is going to happen). The patient needs to have a shower at 6 a.m. (it might seem
obvious to state the time as this communication is taking place in the morning,
but it makes it clearer and reinforces the time-frame for the patient).
→ The nurse asks the patient if he is comfortable having a shower or is there any
other way that he usually has a full wash. (This gives the patient the opportunity
to express his personal hygiene methods and confirm that he can shower or
describe what he needs to do.)
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Spontaneous means ‘off the top of your head’ responses, such as ‘all experts must
At other times, people will engage in a more deliberative response, taking time to
elaborate on the statement or follow different ideas that reach away from the
original thought to engage with new ideas. This comes with an analysis of problems
or wider impressions of a situation or context. It is where old habitual patterns of
response or assumptions are reconsidered and delved into more deeply to arrive at
a fuller picture of events, ideas and impressions. Based on the work of Wyer and
Srull (1986), a recipe for social thinking has been designed that describes these two
stages of a process that assembles impressions, conclusions, decisions and
intentions.
STAGE 1 – SPONTANEOUS
TAKE ➡ raw sensations such as sights, sounds, words and sentences
ADD ➡ these together to form an initial comprehension
ORGANISE ➡ without being aware of the decisions into handy, familiar
categories
INTEGRATE ➡ with whatever you happen to be thinking of at the time
GENERATE ➡ new thoughts, which are organised and integrated with the
original information.
These actions are undertaken as quickly and as automatically as possible and could
be the final impression, conclusion, decision or intention. Often this is as far as
people get in the recipe, because it is a quick and easy method. If, on the one hand,
the topic is not important, or they have other more pressing things to do, or they are
not particularly close to the person or persons involved in the situation, the process
stops here.
If, on the other hand, they are more interested, are closely involved in the outcome of
the situation or committed in some way – that is, more willing and able to do so –
they will progress to the second stage of the process.
STAGE 2 – DELIBERATIVE
USING ➡ your current goals or aims, what you want to achieve in the
situation
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1
APPLY ➡ your general world-view knowledge, schemas from your 2
personal previous experiences or underpinning research 3
evidence 4
APPLY ➡ your knowledge of people’s expectations of what they want to 5
achieve and how they would go about it in this situation 6
7
APPLY ➡ your knowledge of the specific individuals, groups,
8
communities and other situations such as this one that you
9
may not have experienced personally.
10
1
2
3
There is no order in applying these deliberations; they are merely different types of 4
knowledge that you can draw upon to assimilate information about a patient. The 5
finished product of these deliberations is a final summary of impressions, 6
conclusions, decisions or intentions. This may confirm an initial impression; however, 7
it may be adjusted or altered from the initial view. The process of deeper analysis 8
does not have to take a long time, but gathering together additional information upon 9
which to make a judgement can provide a safer and more informed way to proceed 20
in a nurse–patient relationship that is not based solely upon initial judgements. 1
2
Cognitive stores 3
4
Students are often surprised that experienced staff can draw conclusions about 5
complex situations or seem to have an intuitive understanding of patients’ needs, 6
without the patients appearing to have directly expressed those needs. One 7
explanation for this is that experienced staff have a store of previous experiences, 8
knowledge of different societal groups and up-to-date knowledge of contemporary 9
research that they synthesise rapidly to form their conclusions. Their spontaneous 30
recipe works for them. However, even the most experienced staff have occasions 1
when they have to reflect on their judgements to ensure that they are not using 2
habitual stereotypes or outdated research to make their decisions. 3
4
Cognitive misers 5
6
If staff do not use their cognitive stores effectively, they run the risk of becoming
7
‘cognitive misers’. A cognitive miser is someone who does not put effort into thinking
8
around the problem or situation, and only uses the minimum cognitive resources
9
they need. A consequence of this is that some knowledge becomes so automatic
40
that it is incorporated into the organising part of the recipe without any extra effort
1
ever being put into the deliberative stage. Vital information could be overlooked.
2
3
Recency
4
Another danger is the recency with which a category has been used. The more 5
recently a category is used, the more likely it is that it will be used again. The 6
consequence of this is that new information could be consigned to the same 7111
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category, when there may be differences that are relevant to consider. This can also
Self-generating thoughts
One final principle to discuss is how we self-generate our thoughts in the final part of
the spontaneous recipe stage and the pitfalls this may provide. Even when we are
tired, we generate thoughts. Our brains continue to run along by themselves even
when we are in a darkened room and have little information to receive, such as the
raw sensations of light, touch, heat, cold, etc. These are self-generated thoughts that
flit from one topic to another, but are organised insofar as they are recognisable to us
as we compare them to the knowledge categories we have established. These
thoughts are not entirely random, as they are linked to significant topics that have
been thought about recently (the recency factor again) and thus can be biased
towards these topics. These thoughts can also become organised and integrated into
familiar categories.
We can also generate scenarios that are figments of our imagination and our difficulty
is that we cannot always distinguish between these and the information that is drawn
from the raw sensations in the first stage of the recipe. For example, we cannot
always remember whether we put the keys in their usual place or whether we
imagined we did! In the same way, we cannot always differentiate between self-
generated imaginings and information from actual situations. This is because the
processing of the information is rapid, familiar and unconscious.
To guard against this human foible in healthcare, we need to use both spontaneous
and deliberative stages in appropriate situations. When a snap judgement is required
and time is not available, we make spontaneous decisions. However, to be safe and
to fully understand and interpret our patients’ needs, we need to communicate with
them to gather information in the spontaneous stage that we can then feed into the
deliberative stage. The summary from the first stage is combined with different types
of knowledge in the second stage to make an informed assessment of the patients’
understanding of how their health needs can be met.
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1
Think about where you would find further information. Would it be from research 2
or from your knowledge of social situations or societal groups and communities? 3
Has it occurred to you that you can assimilate this information to help you plan 4
your care of this patient without asking the patient a direct question? 5
6
There are further comments on this activity at the end of the chapter. 7
8
9
10
Most nurse–patient interactions are like social interactions in that they will be
1
dynamic, creative, responsive and usually socially constructed. The primary mode of
2
communication is talk enhanced with gestures, personal communication style and
3
body language. This enables the two partners to exchange information, agree
4
decisions, and develop and maintain the relationship. However, most healthcare
5
encounters can be thought of as an interaction between two distinct cultures
6
(Edelman, 2000) – the medical culture and the culture of the patient. The
7
differences between the two groups are that they think differently about health and
8
illness, and that they have different perceptions, attitudes, types of knowledge,
9
sources of knowledge and agendas. The patients’ agendas will be based upon their
20
expectations and experiences of illness, health, consultation and treatments, whereas
1
the healthcare professional is likely to reflect their own (usually Western) medical or
2
health-related training together with personal background factors. Reconciling these
3
differences is one of the major challenges to engaging in a successful nurse–patient
4
relationship.
5
One way to clarify and negotiate through this conjunction of cultures is to identify in 6
nurse–patient interactions two basic goals: either associated with information giving 7
and responding to questions, or relationship building, which is geared towards 8
socio-emotional gains. Separating out these goals within interactions can help clarify 9
what will be gained from the interaction. Information giving and responding to 30
question activities are related to adherence, or following instructions, and 1
remembering information, whereas patient satisfaction is related to the socio- 2
emotional aspects of interactions. Despite our best efforts at good communication, 3
patients report the highest levels of dissatisfaction over poor communication in 4
clinical settings (Caris-Verhallen et al., 1999). 5
6
For the nurse, there may be a desire for the patient to achieve a satisfactory 7
understanding of procedures and processes, whereas the patient may wish to have 8
satisfaction from receiving kindness, empathy and a sense of respect. Alternatively, 9
patients may want information and nurses may want recognition for the work they are 40
doing. Achieving a balance in reaching these respective goals is needed. The 1
responsibility for understanding the balance lies with the nurse, which is why 2
differentiating between the professional relationship and the social relationship is 3
necessary. This is discussed further in the following chapter. 4
5
6
7111
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Daughter
Subordinate
Mother
to manager
Colleague Me Wife
Lecturer Manager
Friend
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1
There are times when you may feel a conflict between roles that you have; such as 2
being a student, which is a childlike role, and yet being beyond childhood, which is 3
an adult role. Understanding this concept and maintaining a sense of self-identity 4
when we are in challenging professional roles (for example, are you feeling like a 5
nurse or a parent in a situation?) can help to manage role confusion and blurring 6
of roles. So your answer to which role defines you most should be that your 7
primary role may be influenced by one of your secondary roles, but the real you 8
will be a unique and separate set of characteristics. 9
Now draw a diagram of a clinical placement you were in recently and include all 10
the roles you observed there. Identify what characteristics, rules and expectations 1
define those roles – not forgetting the patient in this analysis. 2
3
● How much does clothing define the role? Or hierarchies of responsibilities? 4
● Are there traditions, rituals, myths and legends associated with the roles? 5
● Where are role boundaries traversed? Is this safe practice? 6
7
Discuss your thoughts and answers on these questions with your fellow students.
8
As this activity is based on your own reflection, there is no outline answer at the end 9
of the chapter. 20
1
2
3
4
Phases of the nurse–patient relationship 5
While there are no specific rules to guide the formation or stages of relationships, we 6
can see from our previous discussions that various cultures, societies and groups 7
have norms that guide how relationships and roles within those relationships should 8
be conducted. In a healthcare setting a slightly different set of rules applies and the 9
roles are going to be slightly different from those in a social setting. The main reason 30
for this is that the purpose is not social, but professional. The rate at which the 1
relationship is formed will also be different and determined by different settings. In a 2
pre-assessment surgical assessment unit you may have only 30 minutes, whereas on 3
a medical ward a patient may stay for a number of days. Children may have short or 4
long periods of time in hospital. In mental health settings there will be longer time 5
frames within which to build in-depth relationships, and in community settings the 6
context of being in the patients’ own homes provides a different pace for the stages 7
of relationships to develop. In residential settings with learning disability clients 8
relationships have an even longer time span in which to develop. In Chapter 1 we 9
explored an overarching framework for CIPS. We will now look at two examples of 40
specific relationship models. 1
2
Six-stage model of relationship formation 3
4
There will be uniformity to the phases of the relationship that can be mapped on to a 5
six-stage model proposed by DeVito (2007). Having such a model in mind enables 6
the nurse and patient to see how the relationship will develop and will give the 7111
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In the first stage, there is perceptual contact during which first impressions are made.
Physical appearance, friendliness, warmth and openness are noted. This quickly
leads into interactional contact during which opening words are offered in the form
of a welcome or greeting and involve ordinary conversation. Burnard (2003) has
called these openings phatic conversations, where ordinary conversation enhances
social fellowship and small talk helps to ease situations and develop rapport with
patients. Your demeanour and style set the tone for this and future conversations.
Involvement is where a sense of connection and mutuality are established.
Questions and answers are exchanged to establish likes and similarities or the
reasons for being in a situation. Intimacy, in social settings, is where friendships,
companionship and loving relationships are formed. In a professional relationship
this is where closeness and levels of appropriate touch and deeper emotional
connectedness through empathy and understanding are experienced. In Watson’s
(1988) transpersonal theory of nursing, she suggests that nurses can become so
close to patients that they experience a kind of presencing or ‘being with’ patients.
This can happen in circumstances when patients are dying or in the extreme stages
of illness.
The deterioration phase of the model is when the parties disengage and the end of
the relationship is ahead. In the professional sense this is where patients are
preparing to be discharged from care and they may reduce conversations or not
explore their healthcare questions with such frequency. This is an inevitable phase of
the nurse–patient relationship. If patients are tending towards overdependency in the
relationship, steps have to be taken to alter the intimacy of the interactions so that
the patient grows accustomed to the withdrawal of contact. If patients return to the
ward or unit, a process of relationship repair takes place and participants go back to a
previous stage and work forwards again. The final stage is relationship dissolution and
will involve patients being discharged from care or, in some cases, the death of a
patient. Because of the levels of intimacy a nurse can experience through these
stages, managing the closeness and remaining emotionally intact can pose challenges
even to the most experienced nurse.
It is worth mentioning that these stages are not only relevant to nurse–patient
relationships. Nurses are also in contact with patients’ relatives, friends and carers.
Often the nurse will establish a relationship with persons close to the patient that will
go through similar stages, and a marginally different relationship will emerge. The
relationship will be tailored to meet the requirements of those relationships yet
remain professional, with a similar purpose, which is to return the patient to health, or
maintain or promote health. This distinguishes these relationships from social
relationships.
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1
THEORY SUMMARY 2
3
Transpersonal theory of caring 4
5
Watson’s theory of transpersonal caring (Watson, 1988; Watson and Foster, 2003) 6
is useful to consider in this context. It is organised around concepts such as 7
transpersonalism, phenomenology, the self and the caring occasion, with ten
8
curative factors that guide nursing care. The theory is intended to encompass the
9
whole of nursing; however, it places most emphasis on the experiential,
10
interpersonal processes between the caregiver and recipient. It focuses on caring
1
as a therapeutic relationship and attempts to reduce the components of caring to
describable parts, so that these parts can be understood and learned. As such, the 2
theory could be criticised for being reductionist. However, this also enables a 3
complex phenomenon to be understood, and this is where tension exists between 4
reductionism and explanation. The theory claims to allow for, and be open to, 5
existential-phenomenological and spiritual dimensions of caring and healing that 6
cannot be fully explained scientifically through the Western mind of modern 7
society. More information on the theory can be obtained from the web resources 8
found at the end of the chapter. 9
20
1
2
The helping relationship 3
4
Within the relationship stages outlined above, the nurse will engage in specific 5
techniques to assist and help the patient. This is termed the ‘therapeutic relationship’. 6
According to Henderson (1967), this is: 7
8
the practice of those nursing activities which have a healing effect or those which
9
result in movement towards health or wellness.
30
(Henderson, 1967, px)
1
McMahon’s (1993) view is that nursing can be therapeutic. He claims that it centres 2
on the nurse–patient relationship and involves both overt and non-visible caring 3
techniques. 4
5
● Developing the nurse–patient relationship based upon partnership, intimacy and 6
reciprocity. 7
● Manipulating the environment – from the macro organisational level, through to 8
the meso patient environment level to the micro environment and the physical 9
features that impact on the well-being of the patient. 40
● Teaching – involving patient education and information. 1
2
● Providing comfort – physical and non-physical care.
3
● Adopting complementary health practices – these are creative approaches to 4
healing that are incorporated into nursing care. 5
● Utilising tested physical interventions – incorporating intuitive approaches to care 6
that can be supported by inductive research approaches. 7111
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To help nurses to carry out this aspect of their relationship with patients requires a
Each of the questions relates to a stage in the model that can be followed
sequentially but that may be used at any time. To answer any of the questions, the
individual who is seeking answers tells their story and then explores with the helper
ways to examine the options and solutions to the questions. The process involves
looking at information and clarifying meanings. Early on in this chapter we talked
about interpretations and perceptions and how they can exert influence. This model
is a way of exploring in detail what individuals want from their healthcare and how
nurses can assist them to gain the solutions they want, as well as exploring some of
the realistic options to achieving better health outcomes (see ‘Useful websites’ at the
end of the chapter for links to the model for further study).
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1
ACTIVITY 4.3 PRACTICAL 2
3
While you are on community placements, you may wish to enquire about local 4
EPPs. On the DH website you can use a postcode to find local programmes and 5
you may want to contact the programme organiser and meet with them to find 6
out about how the programmes are progressing and about the role of the 7
community nurse in relation to the programmes. 8
9
As this activity is based on your own observation, there is no outline answers at the
10
end of the chapter.
1
2
3
4
CHAPTER SUMMARY 5
6
7
In this chapter we have explored the meaning of being safe without harming
8
in interpersonal relationships in healthcare. We have also considered the
9
relevance of social thinking models as explanatory frameworks and have explored
20
the many roles in practice and the potential for role confusion. In addition, we
1
have identified a process for communication and interrelationship skills in
2
healthcare settings. 3
4
Activities: brief outline answers 5
6
Activity 4.1 (pages 67–8) 7
8
You may, however, want to verify or clarify if your judgement is correct by 9
probing questioning. In doing this you are demonstrating to the patient that you 30
are trying to understand their needs, that you are interested in them as a person 1
and that you are putting effort into your professional relationship. 2
3
You are not being intrusive or asking personal questions that many patients find 4
breach their personal boundaries. You are using your assimilated knowledge to 5
enable effective communication. 6
7
8
9
40
1
2
3
4
5
6
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Where you’re not confident in your knowledge of a topic, what will you do next?
Further reading
Crawford, P, Brown, B and Bonham, P (2006) Communication in Clinical Settings,
Foundations in Nursing and Health Care. Cheltenham: Nelson Thornes.
This is a useful book on core interpersonal skills.
Useful websites
www.gp-training.net/training/mentoring/egan.htm A website that gives information
on helping relationships.
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CHAPTER AIMS
Introduction
This chapter will explore those factors that may act as barriers and impede effective
communication and interpersonal relationships.
First, we will investigate the shift we make in our professional work from social to
professional relationships. The chapter considers how to develop safe professional
relationships, by examining the different degrees of intimacy between friend and
carer, and the rules of social engagement.
Next, we will consider the effect that emotions can have on communication and
interpersonal relationships. Emotions are a fundamental facet of human nature and
our ability to express how we feel. As such, they are a vital part of our communication
methods because, when we demonstrate our emotions to our friends, family and
colleagues, they can recognise how we feel and tune into our emotional needs. If
only it were this simple! This seemingly straightforward aspect of interrelationships is
made more complex by the need to balance our emotional expressiveness with the
need to construct new ways of coping with situations and with the extent to which we
express or repress our emotions. Emotions can therefore both enhance and impede
communication.
Other barriers to communication will also be explored in this chapter, such as how we
construct meaning and interpret communication as a function of this construction.
The effect of motivation on communicating health advice is also explored.
Finally, we will consider the nature of conflict, how it is derived and techniques to
diffuse conflict in healthcare situations.
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This requires nurses to set aside biases, prejudices and very often their own
emotions, although these very aspects of them as people are important as they bring
to the encounter the humanness that is crucial to a sound professional relationship.
To help you differentiate between social and professional relationships, you will see in
Table 5.1 comparisons of some of the major elements of social and professional
relationships. We will be exploring more of these elements as we go through the
chapter.
Social Professional
● You have no specific legal or ● A professional has the responsibility for
professional responsibility for helping the patient regain a state of
the person. health; this involves a spectrum of
● You may be related or have a activities that range from the physical
code of behavior that is either to the invisible. This is governed by a
explicitly or implicitly agreed professional Code of Conduct
between a group or community (NMC, 2004b).
that provides a framework for ● There is informality and formality in
sanctioning different codes of different settings and contexts.
behaviour. ● The patient and professional have to
● Social engagement can be more negotiate and agree the levels of
informal in some instances and formality, some of which may be
formal in others. dictated by the setting, e.g. a
multiprofessional case review.
● The purpose of the relationship is not ● The focus of the relationship is on the
necessarily specific or geared towards needs of the patient; often engaged
particular goals. through necessity rather than choice.
● The individuals know each other ● The behaviour of the professional will
through choice, social or family be planned, implemented and evaluated
connections. in a formal or semi-formal manner.
● There is often an element of ● The participants may not know each
spontaneity about engaging in other.
the relationship. ● The participants may not like each
other.
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CASE STUDY
Mary is a 79-year-old woman who has severely debilitating arthritis and is cared for in
a nursing home. She is a quiet, placid woman who is widowed and has five children,
and although they live some distance away they do visit regularly, especially her two
daughters and their children, who are now adults. Her favourite occupation is doing
crossword puzzles; she is a warm and kind person who is loved by her family. Her days
are long and filled with pain from her arthritis and yet her mind is still alert and she
loves to converse with the nurses. She can no longer mobilise on her own and has a
urinary catheter for her elimination needs, but she requires regular enemas to help
evacuate her bowels as the side effects of the pain medication mean she is always
constipated. She puts up with her discomforts valiantly and the nurses are noticing
that she is slowly becoming sleepier each day and less interested in conversing with
them. These are her twilight years.
It is very easy to become fond of Mary. She is pliant and gentle and, because she is so
uncomplaining about her situation, it is easy to become attached to Mary emotionally
and feel a fondness towards her. She may be like the grandma you wish you had or she
may be like the grandma you had and lost. If you did not have time to say goodbye, this
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could be even more poignant for you. It is in this kind of situation that you have to retain 1
your professional distance and yet still strike a balance between caring and becoming 2
over-involved. In Chapter 1, we discussed endings and it is in a situation like this that 3
endings need to be carefully and sensitively construed to avoid reliving previous 4
emotional situations or experiencing regrets and guilt. Talk through your feelings with 5
your mentor or colleagues to help you gain a sense of proportion in these situations. 6
7
8
9
Developing trusting relationships with colleagues with whom you can share your 10
feelings about situations or relationships is a strategy that will ensure that you are 1
being safe. Mentoring or supervision by senior staff are also effective methods for 2
supporting staff who are dealing with complex situations where there are no simple 3
solutions (Mullen, 2005). 4
5
Professional friend 6
The balance between being detached and over-involved is one that has to be finely 7
struck. Bach (2004) found that community nurses developed a specific kind of 8
professional relationship with their patients that they termed a ‘professional friend’. It 9
was not a social relationship and yet it was not a detached professional relationship. 20
This relationship was based on many of the social aspects of the relationships 1
described above, but there did remain a fine barrier and the patients/clients always 2
remained on one side of that line so that the professional integrity of the nurses 3
could remain intact. This is never more apparent than when an issue arises in a 4
relationship that requires the professional to act or respond in a way that would not 5
challenge a friendship but would create an inevitable problem in a professional 6
relationship. It is where codes of social behaviour are superseded by professional 7
codes of, for example, confidentiality, or where harm is being done to another person 8
that comes to light in the communications between professional and patient. 9
30
Professional relationships are controlled alliances that occur within a particular 1
context and are time limited. 2
(Arnold and Boggs, 2004, p80) 3
4
In this sense, Arnold and Boggs are suggesting that the professional relationship is 5
shaped by the professional because of the setting in which it is carried out. We would 6
add that it is contingent on the needs of the patient. To establish and sustain 7
interpersonal relationships, the nurse has to establish boundaries, or even constraints, 8
that limit and ultimately make safe the interaction between patient and nurse in these 9
settings. The boundaries are created from ethical, legal and professional codes of practice, 40
as well as a patient’s right to caring from nurses who appraise situations realistically in 1
order to ensure responsive actions towards a patient’s optimum health and well-being. 2
On the other hand, a friendship is defined as: 3
4
An interpersonal relationship between two persons that is mutually productive 5
and is characterized by mutual positive regard. 6
(DeVito, 2007, p282) 7111
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Your friendships, or how you perceive friendships, will be influenced by your culture,
or the type of society you inhabit, and your gender. In Middle Eastern, Asian and Latin
American friendships there is an expectation that you will go out of your way to help.
There is an expectation of self-sacrifice to maintain the friendship. Collectivist societies
that have an emphasis on groups and communities cooperating together expect
close friendship bonds to be established. However, in individualistic societies, such as
in North America, you are expected to look out for yourself. Women tend towards
more self-disclosure than men and men do not generally view intimate details as
necessary in friendships.
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Degrees of intimacy 1
2
When talking about intimacy in CIPS, we can be discussing two aspects. One is the 3
physical space between persons in an interaction, which is underpinned by studies in 4
proxemics. The other concerns the degree to which we disclose our inner feelings 5
and thoughts to another, and the extent of self-disclosure required in a relationship to 6
achieve a greater depth of intimacy in knowing and understanding between the 7
partners. Both have relevance to understanding the relative boundaries expected in 8
social and professional relationships. 9
10
Proxemics 1
2
Hall (1966) pioneered the study of proxemics and identified four spatial distances 3
that also correspond to types of social relationships. They are intimate, personal, 4
social and public. 5
6
7
RELATIONSHIPS AND PROXEMIC DISTANCES 8
9
Relationship Distance 20
1
Intimate 0 — 18 inches 2
Close — Far 3
4
Very close family and friends
5
Casual-Personal 1 —————— 4 feet 6
Close —————— Far 7
8
Informal conversations with friends and acquaintances 9
Social-Consultative 4 —————————— 12 feet 30
1
Close —————————— Far
2
More impersonal professional transactions 3
Public 12 ——————————————— 25 feet + 4
5
Close ——————————————— Far 6
Making speeches and addressing large groups at formal 7
gatherings 8
9
(Adapted from DeVito, 2007) 40
1
2
The four distances can be further divided into close and far phases. The far phase of 3
one level can blend into the close phase of the next level. This will depend on the 4
situation and degrees of comfort felt by individuals and also the shift from one 5
distance to another, either to increase or contract the distance. 6
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The theoretical explanations for these distances are conceptualised in three different
The final explanation is derived from responses where individuals find themselves
having their expectations of proximity ‘violated’. Called the expectancy violation
theory, it holds that, in these situations, the topic of conversation becomes less
important and the relationship comes into focus in its place. Those who violate
expected spatial relationships are judged to be less truthful. Yet, if you are perceived
positively, that is, of high status or particularly attractive, then you will be perceived
even more positively if you violate the norm. If, however, you are perceived
negatively and you violate the norm, you will be perceived even more negatively.
It is a minefield and nurses have to tread very carefully so as not to violate the
expected distance.
The way to do this is to seek permission from the patient before carrying out a
personal procedure and wait for a response before continuing. This may not be
possible in an emergency situation, but it is always advisable to explain to the patient
what you are doing and why; even a semi-comatose person can hear a voice and this
will enable the patient to be more aware of your actions. Similarly, the tone and pitch
of your voice, which should be gently questioning and not commanding, will give the
patient reassurance. Informing and negotiating consent to invade a patient’s personal
space demonstrates respect for the patient’s privacy and dignity.
Self-disclosure
How much do you tell a patient about yourself to gain a sense of closeness in your
professional relationship and to equalise the reciprocity between the information that
you have about them versus the amount they have about you? Creating this balance
is seen as a fundamental human need. First, let’s consider what we may mean by
‘self ’. Hargie and Dickson (2004) suggest that there are nine different types of self. To
help us understand these many facets, they have conceptualised these types as
shown in the following box (previously discussed in Chapter 3).
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1
TYPES OF SELF 2
3
Me as Type of self 4
5
I am Actual self 6
I would really like to be Ideal self 7
8
I used to be Past self
9
I should be Ought self 10
A new person Reconstructed self 1
2
I hope to become Expected self 3
I’m afraid of becoming Feared self 4
5
I could have been Missed self
6
Unwanted by one or more others Rejected self 7
8
9
20
1
2
ACTIVITY 5.2 PRACTICAL
3
4
Spend a few minutes going through the different facets of self in the first column
5
(Me as) and see if you can describe yourself in each one. As you are in transition at
6
the moment as a student hoping to become a qualified nurse, you may find it
easy. If you do not, you may wish to ask a close friend or family member to help 7
you. Do you agree with the corresponding description of ‘types of self ’? 8
Remember, these activities are not compulsory so do not feel you have to 9
complete the activity if it makes you feel uncomfortable. 30
1
As this activity is based on your own findings, there is no outline answer at the end of 2
the chapter. 3
4
5
Self-disclosure means communicating information about yourself. It may involve 6
information about your values (taking is not as important as giving love); beliefs 7
(I believe the world is square); desires (I would like to fly to the moon and back); 8
behaviour (I eat sweets all day long); or self-qualities or characteristics (I’m always 9
happy). It is a natural part of interpersonal communications and can be verbal or 40
non-verbal. In the former it can be voluntary or as a response to information from 1
another person. In the latter, it can manifest itself in the clothes you wear or the way 2
you speak. However it transpires, it can be best seen in the professional nurse–patient 3
relationship as a developing process in which information is exchanged over a period 4
of time and which changes as the relationship develops from an initial contact to more 5
intimacy and perhaps to eventual deterioration and closure. It depends very much on 6
the nature of the relationship, whether friend, family, parent, child or professional. 7111
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Think for the moment now about patients who are being assessed by you for
their health needs. Depending on the nature of their health problems, you may
ask them for very intimate information about their hygiene, bowel or urinary
functions. You may, if you are undertaking a social history, ask for details of their
cohabiting arrangements, family relationships or financial situations. Try to
imagine how they feel about divulging this information. Some may anticipate
that they will be expected to divulge personal information. For others it may be
excruciatingly embarrassing. How can you minimise their discomfort and what is
the appropriate amount of self-disclosure you can enter into in this situation?
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1
Some self-disclosure from a nurse in these situations can give an indication of 2
the nurse’s understanding of the patient’s feelings. 3
As this activity is based on your own reflection, there is no outline answer at the end 4
of the chapter. 5
6
7
8
Self-disclosure can be about facts or feelings. When meeting for the first time it is 9
likely that the interaction will be about facts. While you would not be expected to 10
reveal facts about your intimate personal details, you can reveal facts about yourself 1
to equalise the balance, for example how long you have been a nurse or working on 2
the unit. An acknowledgement to the patient that these are personal questions will 3
help create a recognition of the embarrassment factor. 4
5
It is accepted in relationships that there is a gradual progression from lower to higher 6
levels of self-disclosure. However, in the professional nurse–patient relationship it has 7
to be accepted that this is not the case. As deeper levels of disclosure are expected 8
from the patient, the nurse’s responsibility is to reassure the patient of the 9
confidentiality related to the assessment and establish levels of trust, respect and 20
confidence in the assessment process so that the patient feels comfortable with what 1
will be an imbalance in reciprocity. A major factor is explaining why the information is 2
needed. 3
4
Rules of social engagement 5
6
In most social situations, we know how to behave because we have learned the 7
social rules that govern or guide the interactions. These have evolved from our 8
experiences of family networks and social groups. Examples are the different words 9
we use to initiate an encounter, such as Hello, Hi, How ya doin’?, What’s up? and 30
G’day, which all indicate the appropriate response to follow, which would be Hello, Hi, 1
Jus’ fine, Not much and Aw right mate. 2
3
We have also learned from our regular involvement with activities and events – such 4
as attending lectures, participating in handovers on the unit or having a meal out – 5
the parts we have to play, such as student, staff or friend. This familiarity with social 6
interactions, the expected verbal responses and behaviours gives us a sense of 7
security. We know what to expect, but in new situations, where we might not know 8
the ‘rules of engagement’ or have an understanding of the shared representations or 9
intersubjective knowledge of what to do, we can feel anxious and isolated. We have 40
to search for clues, observe behaviour patterns or listen to exchanges of information 1
from those already established in the group. This applies to students on their 2
placements for the first time and for patients newly admitted or receiving care for the 3
first time. 4
5
6
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Once the social rules have been learned, people can work and cooperate with a
minimum of negotiation. This shared knowledge not only allows us to take for
granted social situations, but also makes any kind of adaptation or change to another
set of social representations difficult, challenging and at times threatening. Not only
do we not know how to behave, because we are so accustomed to behaving in a
certain manner, but we associate this with a central perception of ourselves that is
also challenged. Our notion of who we are and what role we have to play is
compromised and causes, for some people, a profound sense of disequilibrium.
Patients can also experience this disequilibrium when they enter healthcare settings.
Understanding their perspective and enabling them to have a clear view of what is
expected and the role they have to play can reduce anxiety and make
communication more effective.
Making the rules explicit rather than implicit can also help. For example, rules
forbidding smoking are explicit. Rules for rewarding or punishing behaviours that are
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perceived to be bad or do not conform to the shared social rules are not so explicit. 1
This is why patients often do not ask questions – because they are wary of breaking a 2
rule and do not know what the sanctions will be if they do not behave in an expected 3
manner. 4
5
Goffman (1972) was a seminal investigator of social rules. An example of how rules 6
determine how we behave was better understood from his studies into the social 7
rules around proximity, personal space and gaze, which are socially and implicitly 8
derived. Humans establish rules concerning the distance they feel comfortable with 9
(see the discussion on ‘proxemics’ earlier in this chapter, pages 82–3) and the 10
amount of touching that is acceptable between persons. Gaze is crucial in controlling 1
any invasion of this personal space. Looking into someone’s eyes implies an intimacy 2
and a closeness, indicating a desire to know someone well. To avoid a ‘forced 3
violation of space’ or intimacy we look away. No one usually tells you this rule; 4
instead you find it out by observing adults as a child or in social situations in adult 5
life, which is why it is both social and implicit. If you get it wrong you would 6
experience some disfavour or a rebuff, which is the human way to help individuals 7
to learn the rules. 8
9
20
ACTIVITY 5.6 REFLECTIVE 1
2
● What are the social rules of your closest friends? 3
4
● When you meet, what are the words you use to signal a friendly greeting and
5
what is the expected response? Has this changed over time?
6
● Do you use different responses with a different social group? 7
● How do you signal to each other that you are going to buy the next round of 8
drinks? Or in your group do only the girls buy the drinks? 9
● How did you learn these codes of behaviour or social rules? Did someone tell 30
you or did you find out by observing others? 1
2
● How could it have been made easier to join the group?
3
● How can you assist patients to understand and become familiar with the social 4
rules of a ward or clinic? 5
As this activity is based on your own reflection, there is no outline answer at the end 6
of the chapter. 7
8
9
Because of the complexity of these rules, we sometimes cannot avoid breaking a few. 40
To overcome this Goffman suggests minimising the damage by convincing others that 1
we are to be trusted, and that we are competent and worthy. He suggests three 2
tactics. 3
4
● Offer an account of why the error happened and give an explanation. This shows 5
that no one is to blame and the error could not be helped – ‘I needed to see the 6
other person first because she was just about to go off duty.’ 7111
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Offer an apology that accepts part of the blame. This is also an implicit promise
that no harm was intended, that you are aware of the rules and that you can be
trusted not to transgress again – ‘I’m sorry. I don’t know why I did that. I knew
immediately afterwards that it was wrong.’
● Reconstrue the behaviour as one that was not breaking any rules, but was part of
another activity – ‘I was only joking.’
There are times when the transgression is too serious and these tactics are
insufficient. There is a likelihood that sanctions and damage will follow. Gaining
support from colleagues is needed to approach the situation in a professional
manner with a plan of action to reduce any harm. Explanations and apologies are
required to those who feel injured by the mistakes. Avoiding the mistakes will lead to
unresolved guilt on the part of the perpetrator and potential repeated incidents of
misunderstanding and mistrust.
THEORY SUMMARY
The five emotions most often regarded as being fundamental for human beings
are as follows.
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1
Fear and anxiety ● Fear is characterised by being afraid of a threat, danger or 2
harm and by being focused on a particular object or 3
experience. 4
● Anxiety is a generalised, diffused feeling of being 5
threatened without being able to pinpoint the source of 6
the distress. 7
● In fear, we can point to the cause, in anxiety we cannot. 8
● Anxiety is more pervasive and tends to last longer. 9
Anger ● Anger is often precipitated by frustration at not achieving 10
a goal, suffering injustice, or receiving an insult or 1
intentional injury. 2
● Believing behaviour is unintentional, unavoidable or 3
accidental diminishes anger. 4
● We are most likely to be angry with people we love than 5
with those we dislike and only slightly towards those we 6
do not know. 7
Sadness and grief ● Sadness is a mild and relatively brief emotion, whereas 8
grief is a deep and long-lasting period of great sorrow, 9
usually associated with loss. 20
● Sadness is often caused by making mistakes, being forced 1
to do something against one’s judgement, or doing harm 2
to others. 3
● While it is uncomfortable, sadness has an adaptive 4
quality in that people will try to make redress as a result 5
of sadness. 6
Disgust ● Disgust is a response to objects or experiences deemed 7
repulsive due to their nature, origin or social history. 8
● It also has an adaptive function as a motivator to remove 9
ourselves from harm and to reject things that are unsafe. 30
1
(Adapted from Dai and Sternberg, 2004) 2
3
4
5
To the emotions above, you could add surprise, guilt (a private sense of culpability) 6
and shame (public humiliation). 7
8
Feelings and emotions allow individuals to experience sensitivity and compassion for 9
another, even though they might not fully understand the situation. In nursing, our 40
emotions are important, as they are an inevitable part of how we respond and react 1
to the persons in our care and to each other. Caring for someone with feeling is also 2
qualitatively different from caring for someone in a distant and dispassionate manner. 3
We utilise the information we receive about how a person is responding, whether it is 4
with happiness, sadness or fear, to judge how we manage the interaction and carry 5
out therapeutic interventions. If a person is very fearful of a procedure, the 6
explanation and management of that person will require specific tuning to that 7111
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Balancing emotions
Our aim in life is to have a healthy balance of emotional experiences. This involves
letting go of feelings that are damaging or restricting adjustments to new situations
and searching for new ways of dealing with situations that provoke emotional
responses. This is complicated when a person is unable to express their emotions,
which may in turn be a function of not knowing what emotions they are feeling due
to confusion, unusual circumstances or changes in the status quo. Alternatively, a
person may know what they are feeling but not understand why, or may be
experiencing conflicting emotions about the same situation. The nurse’s role in these
circumstances is to help patients clarify and identify their feelings with the aim of
enabling a healthy expression or outlet for the feelings. The best way to do this is to:
● understand the underlying reasons that have provoked the emotional response;
● allow the person to tell their story;
● identify an emotion that is being labelled in the story, for example ‘ It must be
frightening not to understand what is happening to your body right now.’
● ask to help in a non-reactive way, which demonstrates caring by helping to obtain
the needed information and validate the fears;
● identify if the person needs a break from the intensity of the situation, for example
arrange to come back later to talk over their concerns again.
All these actions are key to developing an understanding and appreciation of the
emotional context of a situation from the patient’s perspective.
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1
CASE STUDY 2
3
4
A nurse has to carry out a procedure on a patient that is going to be uncomfortable,
5
but which is essential to the treatment, for example giving an intramuscular injection.
The nurse explains to the patient what is going to happen and why. The patient replies
6
that she hates injections because every injection she has had in the past has been 7
extremely painful and she has never met a nurse who can give an injection without 8
causing bruising. The patient is probably speaking from fear of pain and feels a lack of 9
control. The nurse will feel insecure about his or her skills. 10
1
What would you do in this situation? 2
There is a brief outline answer to this question at the end of the chapter. 3
4
5
6
Barriers to communication and interpersonal 7
relationships 8
9
Before considering the barriers, it is relevant to review the aims of communication 20
and initiating relationships in the healthcare context. From your reading in this 1
book, we hope you will have gathered your own precepts to guide you towards 2
effective interactions; however, here are a few that we hope you have included in 3
your list. 4
5
● Establishing a trusting and respectful relationship.
6
● Transmitting and sharing information. 7
● Exchanging ideas and understanding perceptions. 8
● Creating a platform for renewed understanding. 9
30
● Enhancing understanding of attitudes, ideas and beliefs.
1
● Achieving mutually acceptable goals for discourse, interventions and therapy. 2
3
An essential ingredient for interactions to be effective is for meanings to be shared
4
and understood. To do this, meanings have to be checked and an awareness created
5
to intercept blocks to communication that can arise from the many differences in
6
individuals, such as authority, power, language, ability and disability, personality,
7
background, gender, health, age, race and socio-economic group.
8
9
40
1
ACTIVITY 5.7 PRACTICAL
2
3
What other barriers have you observed in your personal and student experiences
4
that may impede communication?
5
There is a brief outline answer to this activity at the end of the chapter. 6
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It is not just the words that people use; it is the meaning or interpretation that each
person gives to the words that construct the meaning. If the understanding of the
meaning is shared, there is less likely to be a barrier to communication.
An added challenge is that no two persons are likely to derive exactly the same
meaning and, because people change their views and ideas about life, it is not always
possible to predict accurately another’s sense of meaning. Indeed, your own
meanings may change from one day to the next depending on your experiences. To
refine this process as much as possible, verify the perception you have of another’s
meanings by asking probing questions, echoing what you perceive to be the other’s
feelings or thoughts, and seeking elaboration or clarification. In general, practise the
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Conflict can serve as an alarm to indicate that a relationship needs closer attention. It
sometimes offers an opportunity to clarify differences of opinion and in a therapeutic
relationship may be necessary to work towards achieving a different set of behaviours
or responses from the patient. The disadvantages of conflict are increasing negativity,
hurting others and depleting energy that is needed for other emotional tasks. The
positive effects are that it can lead to a closer examination of issues that are rearing
up in a relationship or group. Examining the problems and finding solutions to the
conflict can be a way to mend bridges and strengthen relationships. Nonetheless,
experiencing conflict can be disquieting and uncomfortable, giving rise to feelings that
can be challenging or in opposition to closely held beliefs or values.
The first step in conflict resolution is to analyse the situation. Arnold and Boggs
(2007) state that the things to consider are:
● previous experiences with conflict situations;
● the degree to which the conflict is acceptable;
● the intensity of the feeling it arouses;
● the physical, cognitive and emotional health or stamina of the persons involved;
● the subjective interpretation of the event or conflict;
● the consequences.
Conflict can become manageable when the causes, sources and issues underpinning
the conflict are clearly articulated by the parties involved. This needs time and the use
of non-judgemental listening skills to collect the stories. By drawing out hidden
feelings or repressed ideas that otherwise may not have been known, barriers to
communication can be identified and resolved.
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1
THEORY SUMMARY 2
3
The human response to conflict is defensive and this can be aggressive; however, 4
there are three forms of aggressive behaviour: aggressive, passive or passive- 5
aggressive. The aggressive response is to deflect the attack through personal 6
attack or blaming, generating feelings in the other person of anger and 7
resentment. The passive response is self-preservation by not engaging or by 8
wishing to resolve the conflict. This generates feelings of frustration and loss of 9
respect. The passive-aggressive response is where, on the surface, a person appears 10
to be agreeing to plans and arrangements that are made, but in reality is not 1
engaging with the activities designed to solve the problems. There can be verbal 2
agreement at the same time as sabotaging or discrediting activities undertaken by 3
the passive-aggressor, which leads to confusion and mistrust. 4
5
6
7
8
ACTIVITY 5.10 PRACTICAL 9
20
With a group of peers, identify the sources of conflict that you have witnessed in 1
the clinical areas you have experienced so far. Separate out those situations that 2
involved staff to staff, staff to patients and vice versa, and patient to patient. 3
Analyse these situations to identify common features of the causes of conflict. 4
5
What examples have you witnessed of good conflict management? Compare 6
these with poorly managed examples. 7
As this activity is based on your own observations, there is no outline answer at the 8
end of the chapter. 9
30
1
2
The second step in conflict resolution is to identify the potential solutions to the 3
problems or issues that are causing the conflict. Key elements for any professional 4
involved in a conflict situation are to remember that the rights of the individuals 5
involved are to be respected and to behave in an assertive manner. Assertiveness 6
needs to be learned and the websites listed at the end of the chapter will provide 7
you with some resources to work through. If you are going to set up a meeting to 8
resolve conflict, Arnold and Boggs (2007) suggest that you will need to consider the 9
following. 40
1
● Prepare for the encounter – be clear about the purpose, what the major points to 2
discuss are going to be and whether the information you have is complete and 3
can be shared. Give careful consideration to the language used and the choice of 4
words so that messages are clear and unambiguous. 5
● Organise your information and consult with another to validate your approach, 6
preferably someone who is objective. Rehearse. 7111
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Manage your own anxiety – use breathing and relaxation techniques to calm you.
Taking steps to solve problems and reduce conflict requires skilled handling and can
be achieved through observation and practice in role play.
CHAPTER SUMMARY
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fear and apprehension. Is it due to fear of pain or lack of confidence in the staff, or 1
uncertainty about why this treatment is necessary? By clarifying the reasons for the 2
emotions, the nurse can help to put the patient at ease. This will also establish a 3
relationship that is more than just carrying out a procedure and one that can be 4
productive in the future. 5
6
Activity 5.7 (page 92) 7
8
Barriers to communication that you may have observed include: 9
● organisational structures; 10
1
● pressure of limited available time;
2
● involvement of other people; 3
● the physical environment; 4
● interruptions; 5
6
● fear, anxiety, embarrassment or lack of self-confidence;
7
● lack of information. 8
9
20
KNOWLEDGE REVIEW 1
2
3
Having completed the chapter, how would you now rate your knowledge of the
4
following topics?
5
Good Adequate Poor 6
7
1. The relevance of the professional 8
relationship in CIPS. 9
30
2. How emotions can impact 1
communication.
2
3. The construction and interpretation 3
of meaning in interpersonal interactions. 4
4. How conflicts can be resolved. 5
6
Where you’re not confident in your knowledge of a topic, what will you do next? 7
8
9
40
1
Further reading 2
Arnold, E and Boggs, KU (2007) Interpersonal Relationships: Professional 3
communication skills for nurses, 5th edition. Philadelphia, PA: WB.Saunders. 4
5
6
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CHAPTER AIMS
Introduction
You will have many learning goals in your time as a student and this chapter will
guide you in achieving these through enhanced communication and interpersonal
skills (CIPS). So far in this book we have been focusing on CIPS for your role as a
professional. In this chapter we will be focusing on how CIPS can support you and
your individual learning pathway – now and throughout your career. The way we will
do this is to look at a spectrum of your role as learner through to educator and
eventually your own continuing learning needs as a lifelong learner (see Figure 6.1).
This chapter will examine each of these three stages in the spectrum, beginning with
a discussion on you as a student and learner. We will explore some of the issues
related to the integration of theory and practice. This leads us to discuss how learning
should be realistic and relevant to your practice and learning needs. One way to
achieve this is through experiential learning techniques, which we will explore through
a model. Learning through experience is regarded as learning by doing, rather than by
listening to others or reading. This form of learning involves active, rather than
passive, learning through interactions, self-awareness, expression, flexibility and
reciprocity, and with relevance or meaning. All these characteristics are present in
CIPS as they are very much related to how you behave in interpersonal situations.
Consequently, learning through experience, which refers to deliberately planned
learning experiences, and learning from experience, which refers to past experiences
to gain new insights, are two highly relevant learning approaches in CIPS.
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environments for decision making, and will facilitate problem solving, critical thinking
and reflective capacities. We have drawn links to the assessment of practice
requirements to enable you to have a clearer idea of how to gain proficiency in skills.
We have also included sections on reflective writing, learning styles and the
characteristics of a skilled performance, which will help you complete your practice
learning assessments and put CIPS into practice.
There are many different contexts in which students can act as educators among
colleagues and with patients, in order to give instruction or guidance on health
promotion or health education perspectives. Guidelines for improving communication
in these settings are provided, along with a description of the professional standards
required in these circumstances.
The final section of the chapter looks to the future and considers the role of a student
in formulating a frame of mind to include lifelong learning. We look at the importance
of skills from a health policy perspective and consider the extended scope of practice
through career trajectories and forward thinking.
Student as learner
Integration of theory and practice
One of the constant dilemmas for nursing students during their studies is striving to
integrate the theories learned in the classroom with the practice of nursing performed
in clinical, real-world situations. This is no easier with CIPS, which can seem so
obvious and yet, as this book demonstrates, are not just simple skill sets to be
learned in a rote fashion. We all have CIPS abilities and what has to be achieved
during studies is enhancing, improving and making more effective these skills in
healthcare settings. We have already explored some theories in this book and have
attempted to use practical exercises to demonstrate how the theory can be applied.
Judging how meaningful these are and how they can be applied to good effect helps
with the integration of theory with practice. But it may not be enough.
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The NMC Standards of Proficiency (2004a) argue that practice, integrated with 1
theory, needs to be evidence-based, thus safe. In Chapter 2, we explored the 2
importance of integrating theory with practice and the relationship to research that 3
provides the evidence for safe practice. As with any practice-based skill, practice 4
makes perfect and this applies equally to CIPS. Practising using the skills by working 5
with models in an environment that is safe, exactly in the same way that you might 6
practise inserting a naso-gastric tube, is as essential as rehearsing practical skills. The 7
difference may be the self-consciousness or self-awareness you may have as you say 8
words that are unfamiliar or use phrases that, at first, sound false and stilted. The 9
conditions you need in order to practise are therefore important. 10
1
2
3
ACTIVITY 6.1 REFLECTIVE 4
5
What are the ideal conditions that you need in order to practise a new 6
communication or interpersonal skill? 7
Do you need to be alone and in front of a mirror? With a close friend, or in a 8
group? Each of these situations can pose different levels of complexity in 9
communication, how you use your interpersonal skills and the feedback you will 20
get on the effectiveness of your skills. 1
2
As this activity is based on your own reflection, there is no outline answer at the end
of the chapter. 3
4
5
6
Disconcertingly, there is continuing evidence that final-year nursing students and 7
immediately post-qualifying nurses have difficulty sustaining the values and ideals 8
they gained during their training (Maben et al., 2006, 2007; Jasper, 1996). Maben et 9
al. (2006) found that, while nurses had gained a strong set of values during their 30
programmes of study, there were professional and organisational factors that 1
prevented them from taking their ideas into practice. The study felt that this had 2
serious consequences for the integration of theory with practice, as the need to obey 3
covert rules, lack of support and poor role models inhibited newly qualified nurses in 4
carrying out their ideas of evidenced-based practice and appropriate standards of 5
care. There were additional demands, such as time pressures, constraints on roles – 6
that is, boundaries and opportunities – shortages of staff and work overload. By 7
practising and applying the ideas, concepts and theories (the summaries of how 8
these concepts are organised) during and beyond your course, you will be working 9
towards closing the theory–practice gap. 40
1
Learning for reality 2
3
Eve Bendall (1976) was one of the first nurse researchers to study the 4
theory–practice gap. In her seminal work on how students learn clinical skills, which 5
she called learning for reality, she found that, by observing students in practice and 6
comparing this with what they wrote, they described one thing in writing and then did 7111
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Today’s nurses are deemed to be more patient-focused and more effective with
social interaction. This is credited to the inclusion of theoretical concepts drawn from
the social sciences into nursing care. These are integrated into theoretical models of
nursing specifically designed to guide care, yet nursing remains a practice-based
profession requiring the demonstration of skills proficiencies. Over time, nursing skills
have expanded from purely physical activities with, for example, visual, auditory,
verbal, tactile, kinaesthetic and organisational factors, to include those underpinned by
the social sciences, including, for example, the psychological, social, interactive,
interpretive and conceptual factors we are exploring in this book (Bendall, 2006).
To enable nurses to learn practical skills, there are different viewpoints on how this
can best be achieved. One view is that principles should be taught early in the
course, so that they can then be taken to the practice settings and applied and
practised in different situations until competency is reached. In this approach,
evidence-based care is taken to the practice area and carried out in vivo – in the
living and real environment. The tasks are supervised by a qualified mentor and then
assessed.
Another view is for students to observe care being delivered and for the elements of
nursing care in any one situation to be identified by the students. So, for example, in
a practice setting the nurse carries out different actions with and for the patients. The
task of the student is to make note of these activities and assemble these into a
whole picture of care that is required for that particular setting. Once assembled, the
student follows up the tasks to discover if there is evidence underpinning the
activities, discriminates between the essential or unessential elements and
determines if there are sequences or levels of ordering in the elements to enable
them to apply the activities when they are required to do so without supervision. This
is a more complex method, but is more detailed, and requires mentors to establish
whether or not students have identified the relevant parts of the whole, their relative
significance and appropriateness in the situation.
Each of these approaches has advantages. The first is that students are prepared with
ideas and strategies before they enter the practice setting. Many students find this
comforting, as they do not wish to be seen as incompetent when they first go into
practice. It also enables students to feel confident about a situation that has the
potential to undermine their confidence. The second is based on the Gestalt idea
that all experiences are based on the sum of the individual parts and that, by
examining the parts, a whole can be assembled with better understanding of how the
parts interact. The term ‘gestalt’ is derived from the German term meaning ‘pattern’ or
‘configuration’ and this enables learning. The patterns are thought to stand out from
the background against which they are seen, giving rise to the concepts of figure and
ground in perceiving phenomena.
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Experiential learning 1
2
A third approach to practice learning is through experiential learning. This is where 3
individuals go through a process of experiencing, reflecting, thinking and acting. Kolb 4
and Fry (1975) proposed this theory, which claims that experiencing a phenomenon 5
leads to observations and reflections. They believed that these activities form a cycle 6
of activities that make up a four-stage learning cycle. Feeling in this context does not 7
describe an emotional experience, although that may contribute to the experience. 8
Feeling is intended to mean a perceived physical or mental sensation. It could also 9
relate to a particular impression, appearance, effect or atmosphere sensed from 10
something, such as a feeling of abandonment about a building. We cannot also rule 1
out that feeling can relate to an instinctive awareness or presentiment of something, 2
such as a prediction that someone will be disappointed with some news. A simple 3
model of these activities is represented in Figure 6.2. 4
5
6
7
Feeling Watching 8
9
20
1
2
3
Doing 4
Thinking
5
6
7
Figure 6.2: A simplistic model of Kolb and Fry’s experiential learning theory.
8
9
Kolb and Fry originally based this model on their work with groups. The model has 30
been further adapted to include the processes of reviewing data and information that 1
will happen during thinking about the experience. The next stage is to puzzle out or 2
give some meaning to the experience. This is then added to the ideas that will 3
influence any further experiences or responses to situations (see Figure 6.3). The 4
main premise is that we all have an intrinsic tendency to draw upon our experiences 5
of the world we live in. This helps us to improve our knowledge of what happens to 6
us, and to formulate our opinions and extend our range of skills and knowledge. 7
We are constantly taking in information through our senses and digesting this 8
information as we experience events, which means that we are never completely in 9
static situations. Even those folk who give the appearance of ‘switching off’ are still 40
receiving some information, although they wish to give the impression that they are 1
not dealing with it for one reason or another, such as tiredness, dislike of a situation 2
or, in the case of illness, pain and discomfort. They are deliberately turning off that 3
engagement switch or, more likely, tuning down. 4
5
Using experience to guide our actions and beliefs does, however, present its 6
challenges. If we only gauge our current reactions based on previous experiences, 7111
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we are, in fact, limited only to those previous experiences. While our experiences
may stand us in good stead in most situations, they may also not always provide
us with sufficient solutions to the problems we have to solve. We cannot have
experienced every phenomenon in the world in preparation for the next
experience, whatever that may be. Thus, our wisdom is limited by our past
experiences.
Our decisions to base our actions on previous experiences may also be founded
on assumptions, whether ‘true’ or ‘false’, and either our conscious or unconscious
assimilation of ideas. It is the stage of the cycle where we ascribe meaning to
events and experiences. By interpreting the experiences, and in an attempt to
understand why something is happening, we use different strategies to give an
event meaning. Meaning can be divined from the symbolism of an event, such
as a memorial service, which means sadness; here, the concrete symbolises the
abstract. Or it can be drawn from the notion of what the significance or magnitude
of an event represents to someone. Some experiences will therefore have more
significance to some than others. Meaning can also be constructed from a moral
or psychological sense that relates to a sense of purpose or reason.
We rely on our previous experiences to guide our responses but do not
necessarily learn from, or adjust, our responses to improve how we react in
situations. Most of the time we store our memories of experiences in ‘cold
storage’ or classify them as ‘unfinished business’ to be returned to when we have
enough psychological energy. This explanation can help us understand why
some people never learn from experience, because they never return to the
cold storage of their memories. To enable us to learn from those experiences we
need to combine ‘here and now ’ learning and reflection (see Siviter and Stevens
(2004) for practical guidance on surviving as student nurse).
This is the essence of experiential learning. It is not just learning to do something
differently next time, but is more about actively engaging in an analysis and reflection
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on what has been learned, how it compares with previous learning and how this 1
accumulative store of learning can be built upon further to improve skills and 2
knowledge. This is so relevant when learning about CIPS. You will have already stored 3
up many experiences of your own and will have also refined some of your 4
interpersonal skills as a result of those experiences. 5
6
7
8
ACTIVITY 6.2 REFLECTIVE 9
10
Take a moment to think about a communication misunderstanding that you have 1
experienced. Now take a moment to think about what you learned from that 2
experience. What was your interpretation of it? How would you improve your 3
communication of information in that experience the next time you face a similar 4
situation? 5
As this activity is based on your own reflection, there is no outline answer at the end 6
of the chapter. 7
8
9
20
In nursing, students are given time to learn in practice under the guidance of mentors 1
or experienced healthcare practitioners. In the same way that you learn to carry out a 2
physical procedure, it is important first to observe communication and interpersonal 3
interactions. You can then practise under supervision and be prepared to undertake 4
communication of information on your own. At each stage of the process, you will 5
continue to learn and you will need to create opportunities to review what you are 6
learning, clarify what you have learned from past experiences and think about future 7
experiences to extend your skills. So that you can also gain optimally from these 8
experiences, it is important to know when you are learning by experience as distinct 9
from learning from experience. 30
1
Learning by experience is more or less an unconscious process. It is a realisation
2
after the experience that we have learned something significant. These experiences
3
are gained through the reality of professional life, varying and unpredictable
4
demands and changing circumstances. An example of this is that we can often be
5
so preoccupied with getting something right that, when we forget to try and we get it
6
right, there is a sudden integration of knowledge and surprise that the skill can be
7
mastered after all.
8
To draw optimally from these experiences, you need to hone your skills of attention 9
to both external events and what you are experiencing internally. Internal processes 40
include noticing your thoughts, intuitions, emotions, bodily sensations, intentions for 1
yourself and others, needs, what you are doing, how you are doing it and how all this 2
relates together (see Figure 6.4). 3
4
There is a balance to be struck between being immersed in an experience and totally 5
absorbed by it, and being a witness. So that you can learn from the experience, ask 6
yourself the following questions. 7111
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Problem solving
Rehearsing
Figure 6.4: Visualising
Examples of thoughts Forecasting
and intuitions. Understanding
To help you become more aware, begin to verbalise your thoughts and feelings about
experiences to fellow students or mentors.
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Using the experiential learning cycle (look back to Figure 6.3 on page 105) requires 1
time for thinking and reflection. Some of this goes on informally in social groups or at 2
the end of a shift with groups of peers. The more aware we become of our feelings 3
and intuitions about experiences and the comparison of these reflections of both 4
inner and outer experiences, the more objective our memories of the experiences will 5
be. By practising using the experiential cycle, students can begin to work through the 6
stages without checking where they are at each stage. Thus, the process of reflection 7
becomes integrated as an evaluative process for refining skills. This will serve to 8
enhance the reflections and learning through experience to greater effect. 9
10
1
Levels of learning 2
Many students ask lecturers what is wanted from them as they progress from one 3
level of learning to another. One reason for this is that students want to see how they 4
are progressing during their studies and how they are improving or, as we have said 5
above, enhancing their skills and knowledge. A starting point is to decide what is 6
meant by levels in relation to learning in higher education (HE). 7
8
Diplomas, degrees and postgraduate courses have the levels determined by the 9
Higher Education Funding Council (HEFC) of the UK, which utilises standards set by 20
the Quality Assurance Agency (QAA) in a framework for academic achievement (the 1
Qualification Framework in Higher Education). The QAA has produced a booklet for 2
students explaining the qualifications framework (see ‘Useful websites’ at the end of 3
this chapter) and has identified five levels, three of which are undergraduate and two 4
postgraduate, as shown in the box below. 5
6
Table 6.1: Qualifications framework 7
8
Certificate C Level Certificates of Education. 9
30
Intermediate I Level Foundation degrees, ordinary Bachelor’s degrees, Diplomas
1
of Higher Education, and other Higher Diplomas.
2
Degree D level Bachelor’s degrees with honours, Graduate Certificates 3
and Graduate Diplomas. 4
Masters M level Master’s degrees, Postgraduate Certificates and 5
Postgraduate Diplomas. 6
7
Doctoral D level Doctorates. 8
9
40
Each level has a descriptor outlining what is expected and demonstrates the nature
1
of change at each level. The descriptors are further subdivided into two parts. In
2
the first part are the outcomes against which the awards will be judged and granted.
3
The second part describes the wider, more general, abilities a student should be
4
able to achieve after following such a programme and is intended to inform
5
employers.
6
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To overcome this, a model used by the Southern England Consortium for Credit
Accumulation and Transfer (known as SEEC) has been favoured by many institutions
as it includes a reference to practical skills in conjunction with knowledge gained
through a progressive hierarchy. The levels were devised as a response to the
changing face of HE, where academic levels could no longer always be described in
close relation to years of study. For example, an undergraduate programme would
always be three years when, with the success of the Open University providing
flexible learning opportunities, a student could take up to six years to complete a
degree. Also, courses were changing to include elements or modules within courses
that required a framework to clarify the level and the extent of academic effort
required to complete these elements. A definition of an academic level in this context
has therefore been given as:
Before moving on to examine the level descriptors provided by the SEEC, we can
think about the general expectations that can be used to map or guide the level at
which you are functioning with your CIPS in the following activity.
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1
ACTIVITY 6.4 PRACTICAL 2
3
Think of a recent interaction you have had with a patient who asked you to help 4
solve a problem or correct a misunderstanding concerning their treatment or 5
illness. Write down a short account of the episode. It does not have to be a 6
situation that you regard as being particularly satisfactory or, conversely, needing 7
improvement; just be spontaneous here. 8
9
Then analyse the situation using the following steps and questions.
10
1. How would you rate the complexity of knowledge and understanding you need 1
to undertake this interaction from 1 to 5 (5 being highly complex and involving 2
detailed knowledge). Was it an everyday situation or were you thinking on your 3
feet because you had not encountered this situation before? Did you have to 4
draw on some knowledge gleaned from one of your sessions at the university 5
or some nugget of information that your mentor had recently shared with 6
you? Did something you had read in a nursing journal or textbook come to 7
mind? Were you aware of any ethical issues underpinning or influencing this 8
situation? 9
2. How would you rate your standard of cognitive skills? Were you able to analyse 20
and break down the elements of the situation into segments that enabled you 1
to understand the situation better? Did it help you when you put back the 2
parts of the interaction to see a different aspect to the relationship you have 3
with the patient, or identify influences and ideas? This would be synthesising 4
information. To what extent did you make a judgement on the value, 5
importance, extent or condition of the situation and interaction between you 6
and the patient? This would constitute your evaluation of the situation. 7
How did steps 1 and 2 affect your response and behaviour towards the 8
patient? This would be the result of your thinking or cognitive processes and 9
application of your knowledge. 30
3. The third step is to assess your ability to use generic or transferable skills. 1
These are life skills that you acquire through extending your learning 2
opportunities. You should ask yourself if you have drawn on any of the 3
experiences you have had from working with your fellow students or teams in 4
your practice experience (i.e. group working). Have you learned to react 5
differently, or use new or different phrases to express yourself, in order to help 6
you be more clearly understood by patients and colleagues? Are you willing to 7
put effort into your learning or do you expect it all to be easy and not to 8
require any additional work (ethos towards learning)? Did you turn to any 9
learning resources, books, articles or the internet to help you understand this
40
situation more fully, and how effective did you think you were in finding,
1
synthesising and utilising the resources (use of learning resources and
2
management of information)? Do you rely on others to find things out or do
3
you actively go and independently seek out information for your studies to
4
improve your knowledge (autonomy)? How do you know if your
communication style was appropriate and effective? When you report back to 5
6
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All the phrases and words highlighted in italic in the above activity are key words
in the descriptors for estimating levels of learning. If you ask yourself these
questions each time you undertake an assessment or want to improve your CIPS,
you will be extending your own levels of learning (see the guidance on study skills
in Taylor (2003)).
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these have been consistently developed and improved from initially being bulky 1
repositories for sheaves of paper to slimmer versions providing a succinct method for 2
collating evidence. They have now become an integral part of the majority of nursing 3
education programmes (see Maslin-Prothero (2005) for further guidance). 4
5
Reflective writing 6
7
It is generally agreed that reflective writing is considered the key to assessment by 8
portfolio. This is because it provides evidence of the development of skills and can 9
demonstrate increasing clinical competence over a period of time. We would expect 10
to see development over time as you cannot expect to be competent straightaway. 1
Smith (1997) found some evidence that reflection assisted the integration of practice 2
experience with academic knowledge. Development over time was also another 3
feature of this study. However, in a study by Smith and Jack (2005) students were 4
asked if reflection was a meaningful activity and no consensus of opinion was 5
reached. The authors did find that the students’ learning style was highly pertinent to 6
their perception of the usefulness of reflection (see Rolfe et al. (2001) for further 7
guidance on reflection). 8
9
Learning styles 20
There are several theories on learning styles and these have been reviewed by 1
Coffield et al. (2004). The majority focus around three or four main attributes. Two of 2
the most widely used are the learning style inventories of Kolb (2000) (whose 3
experiential learning theory we examined earlier in this chapter) and of Honey and 4
Mumford (1992). Both of these versions can easily be found on the internet for you 5
to test out yourself (see ‘Useful websites’ at the end of the chapter). Essentially, 6
Kolb’s inventory suggests that we each have a preference for one of four styles: 7
concrete experience (feeling), reflective observation (watching), abstract 8
conceptualisation (thinking) and active experimentation (doing). These are clustered 9
into two continuums with conflicting axes: feeling and thinking vs. watching and 30
doing. He believes that we choose to learn by grasping at an experience to transform 1
it into something that is meaningful and useful. Our learning styles are therefore a 2
product of these two decisions: either preferring to watch and do, or thinking and 3
feeling. 4
5
Honey and Mumford, however, believe there are also four dimensions to learning 6
styles. They describe these as characteristics and divide people into activists, who 7
learn by doing, reflectors, who stand back and observe first, theorists, who prefer to 8
adapt and integrate experiences into a conceptual whole or framework, and 9
pragmatists, who, while on the look out for new ideas, will only adopt ideas if they 40
have a practical benefit. There are some similarities between the two approaches to 1
learning styles, but you may want to ponder over which is your preferred style, as the 2
research suggests that those students who could relate to the tasks through 3
meaningful reflection were best able to utilise the experience of portfolio learning and 4
the impact that reflection could have on their learning. Therefore, identifying which is 5
your preferred learning style will help you recognise the effort you will require in 6
another style on the axis of the dimensions to become more reflective if, for example, 7111
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RESEARCH SUMMARY
If you are a person who finds reflection difficult and who has a tendency to
pragmatism and learning only for reality, you may want to consider the research
of Teekman (2000) on exploring reflection in nursing practice using a sense-
making approach. He searched for sense-making activities in a group of qualified
nurses to examine how they made sense of situations as well as their thought
processes. He found that reflective thinking was apparent in moments of doubt
and perplexity, categorising perceptions, framing and self-questioning to gain
sense and understanding of what was happening in situations. You may be using
reflective thinking without realising if you have ever had a mental tussle over
what to do in a difficult situation. You now need to use those same thinking
activities and apply them to all situations. This will help you delve deeper into
your levels of learning and improve your analytical abilities. In the sense-making
theory utilised in Teekman’s research, situations are identified as the inexplicable
inconsistencies of human experience that are influenced by culture, social
organisation and individual perception. There is then a gap where the individual is
stopped in their tracks (that is, in a state of discontinuity), where routine thinking
is no longer applicable and where new constructions or solutions are required in
order to create a personal sense of the situation. ‘Uses’ is the last stage of the
activity, where the individual puts the new thinking into practical use.
Skilled performance
While you may now realise that experiential learning, reflective writing and your
preferred learning style may influence how you achieve your learning goals in the
assessment of your practice, you will want to know what makes a skilled performance
stand out when practice is being assessed. Some essential characteristics are outlined
below.
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patient to receive feedback that they have been understood or for you to receive
2 Listening attentively
This means actively attending to what is being said and how it is being said. It is
listening without making judgements or letting your own perceptions act as a
barrier to what is being said by the other person. It requires giving signals that
you are actively listening by using appropriate prompts, such as ‘mmm’, ‘I see’,
‘how interesting’ or ‘OK’, and non-verbal prompts, such as nodding and smiling, and
also giving feedback to show that you understand what is being said or conveyed.
Active listening enables trusting relationships, rapport, mutual interest and
understanding.
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1
ACTIVITY 6.7 PRACTICAL 2
3
Arrange two chairs back to back. Have a friend sit on one chair and yourself on the 4
other. Have the friend tell you about a journey they have just taken. Let them 5
speak for a couple of minutes. Do not interrupt your friend or ask any questions. 6
When they have stopped, recount to them what they told you. Then place the 7
chairs facing each other. Sit opposite your friend and ask them to tell you about 8
their day at work for two minutes. Again, do not interrupt or ask questions. When 9
they have finished, relate back to them what they have recounted to you. 10
1
Compare the two experiences from two points:
2
● How did it feel to listen and not speak? 3
● Did you remember more from the first or the second task about the events? 4
5
As this activity is based on your own observations, there is no outline answer at the 6
end of the chapter. 7
8
9
20
3 Interpreting accurately 1
2
To begin interpreting information that has been verbalised begins, not by leaping in 3
to form an opinion on what has been said, but with assessing the extent of the 4
other person’s level of understanding. It also requires collecting any cues from non- 5
verbal information and assessing the extent of this influence on what has been said. 6
To make this estimation, you will use as your baseline your own experience or level 7
of knowledge and expertise about the situation or condition. It is then possible to 8
make a judgement or evaluation on the accuracy of this understanding, which can 9
then be utilised, for example, to help a patient gain further understanding of health 30
advice on weight management or to improve accuracy of a procedure in the case of 1
a fellow student. Therefore, interpreting means gathering information before you 2
form an explanation of a situation or events with the intention of improving 3
understanding. 4
Interpreting messages is also a form of translating and you may be called upon to 5
translate from one language to another, such as from bioscientific terms used in 6
medicine into everyday language, to enable understanding or meaningful 7
comprehension. It could also involve taking a complex idea and transforming it into a 8
simpler and more understandable idea that is related to the real-world situation of the 9
patient or setting. 40
1
4 Giving clear instructions 2
3
This is a skill that requires practice and is harder than it seems. One way to 4
become accomplished is to talk through what you are doing as you are carrying 5
out an activity, and (this is most important) say why you are doing what you are 6
doing. 7111
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Always begin with the simplest explanation and work towards the more complex. This
is invaluable when you are carrying out procedures with patients whom you require
to participate, but who may be anxious. In these situations gradual exposure to
information is needed so that their anxiety is not further increased by unnecessary
information and the information should be paced according to their information
needs. However, when teaching a skill to colleagues, a different tack is needed
whereby all the information will need to be transmitted; yet this can also be in a
graded and staged approach to facilitate assimilation and retention of information.
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1900s, when education was proposed as a continuing aspect of everyday life. The
Career Framework
In 2001, the Department of Health announced proposals for a five-year action plan to
encourage lifelong learning opportunities for all levels of staff in the NHS (DH, 2001).
The plan was intended to reinforce the importance of learning and personal
development for all staff to be linked to patient care and service improvement. This
was a clear indicator that staff in the NHS need to continue to develop their
knowledge and skills in order to remain current over their lifetime in the organisation,
but also to provide a progressive and explicit staged approach to career opportunity
and development. This was further explored by the Skills for Health Department,
which produced a Career Framework in 2006 (www.skillsforhealth.org.uk/page/
career-framework).
The framework has nine levels, each relating to a higher level of seniority and level of
skill acquisition. The aim is to provide a guide for NHS and partner organisations on
the implementation of a flexible career and skills escalation, thus enabling an
individual member of staff to progress in a direction that meets workforce, service
and individual needs.
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1
Level Advanced Practitioners
2
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years and 450 hours of practice in each area of registration. Lifelong learning will be 1
integral to your continuing professional knowledge and competence. You may also 2
wish to continue to learn and develop areas of knowledge that give you additional 3
interest and pleasure in life. Alongside this will be your continuing development of 4
CIPS at each stage of your professional life. 5
6
CHAPTER SUMMARY 7
8
In this chapter, we have looked at three stages of learning opportunity for students. 9
Rather than concentrate on the classical approach to study skills, which can be found 10
in excellent resources such as Maslin-Prothero and Taylor (2005) and Taylor (2003), 1
we have taken a path that discusses how students can integrate theory with practice. 2
There is no doubt that learning for reality should be the goal for nursing students as 3
they combine theory with practice. In this chapter, we have suggested that this can be 4
achieved by experiential learning and have provided a model to develop this skill. To 5
enable a clearer understanding of what is expected in academic studies, we have 6
examined academic frameworks and considered how practice can be aligned by 7
utilising the SEEC descriptors. The relevance of reflective learning was established, 8
although there remain concerns that learning styles are an important consideration if 9
reflection is to be effective. Guidance on how to achieve a skilled performance has 20
been provided for skills development. The role of a student as educator was explored, 1
and guidance has been given for achieving effective communication in healthcare 2
settings. Finally, the relevance of lifelong learning, both personal and professional, has 3
been examined and we have given brief consideration to future career possibilities 4
following completion of the course. 5
6
Activities: brief outline answers 7
8
As the results of all the activities in this chapter are based on your own observations 9
and decision-making abilities, there are no outline answers for this chapter. 30
1
2
3
KNOWLEDGE REVIEW
4
5
Having completed the chapter, how would you now rate your knowledge of the
6
following topics?
7
Good Adequate Poor 8
9
1. Integration of theory and practice. 40
2. Reflective writing. 1
2
3. Health communication skills.
3
4. Lifelong learning. 4
5
Where you’re not confident in your knowledge of a topic, what will you do next? 6
7111
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Maslin-Prothero, S (ed.) (2005) Bailliere’s Study Skills for Nurses and Midwives. Oxford:
Bailliere Tindall.
Quinn, F and Hughes, S (2007) Quinn’s Principles and Practice of Nurse Education.
Oxford: Nelson Thornes.
Rolfe, G, Freshwater, D and Jasper, M. (2001) Critical Reflection for Nursing and the
Helping Professions: A user’s guide. Basingstoke: Palgrave.
Taylor, J (2003) Foundations in Nursing and Health Care: Study skills in health care.
Cheltenham: Nelson Thornes.
Useful websites
www.businessballs.com/kolblearningstyles.htm This site has details on Kolb’s learning
styles inventory, and a brief comparison with Honey and Mumford’s variation on the
theory.
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CHAPTER AIMS
Introduction
The environmental context of communication and interpersonal skills (CIPS) for
nurses includes multidisciplinary team practice and interprofessional working, across
different care settings, within a safe environment. The Concise Oxford Dictionary of
Current English (Thompson, 1995) defines ‘safety’ in two ways, one positive and one
negative: first, as free of danger or injury; affording security and being free of harm;
second, in terms of being cautious, unenterprising and consistently moderate.
The first way of defining safety seems both helpful and non-contentious. The second,
however, might speak to the use of ‘safety in practice’ in anti-therapeutic, risk-averse
ways, which can undermine the deployment of good CIPS (see the section below
entitled ‘A specific environmental example: endless rows of chairs’ in illustration of
this point). Clearly, different care settings will either promote or undermine the
concept of ‘safe environments’.
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With the above in mind, this chapter will begin by introducing you to a discussion on
CASE STUDY
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her medication. At that time, her family made the assumption that this behaviour was 1
related to an inevitable progression of her slide towards Alzheimer’s that had begun 2
some years earlier. However, soon afterwards, she exhibited terror each time her 3
formerly beloved son-in-law entered her room at her nursing home. Again, her family 4
made sense of this in terms of her illness progressing very quickly. 5
It was only when the owner of the nursing home was arrested for sexual attacks on 6
the elderly women in his care that the family began to piece together a number of 7
strange incidents that had escaped their notice at the time. At that point the old lady 8
had since died. Her daughter was of the opinion that her mother wasn’t listed as a 9
victim in the court case because the authorities didn’t seem to want to go into it. She 10
further asserted that none of the children whose mothers were abused in the home 1
knew what was going on. 2
3
The owner of the nursing home – a man in his mid-sixties – was sentenced to
4
four years in jail. That was in 1997. But the probability is that the sexual abuse
of old people by care workers is still going on today and could be as common as
5
that suffered by children in the days before the paedophile problem was 6
recognised. 7
8
Some years later, the Director of the website and helpline, Action on Elder Abuse 9
(www.elderabuse.org.uk), expressed the view that sexual abuse of elderly people in 20
care and nursing homes was extremely prevalent. She stated that the helpline received 1
lots of calls from frantic families and care home staff concerning extreme sexual abuse
2
in these homes, and was of the opinion that the number of calls grossly under-
3
represented the true level of abuse taking place. She gave the view that someone
4
suffering from mental and physical frailty was the perfect victim for such abuse, given
5
that they can’t defend themselves or get away from the environment they find
6
themselves in.
7
She added that, in her view, such abuse was more about power than sex, and that 8
there were even pages on paedophile websites encouraging men finding it hard to 9
access children to gain employment at care homes. 30
1
2
3
Catalogue of assault 4
According to the Action on Elder Abuse handbook, there are five main types of abuse 5
in care homes. 6
7
● Physical – includes hitting and restraining, or giving too much, or the wrong, 8
medication. 9
● Psychological – shouting, swearing, frightening or humiliating a person. 40
1
● Financial – illegal or unauthorised use of a person’s property, money, pension
2
book or other valuables.
3
● Sexual – forcing a person to take part in any sexual activity without his or her 4
consent. 5
● Neglect – where a person is deprived of food, heat, clothing, comfort or essential 6
medication. 7111
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1
environment that enable good communication between healthcare workers and 2
patients/clients. In the other, list the aspects that inhibit or undermine the 3
possibility of such good communication. 4
As this activity is based on your own observations, there is no outline answer at the 5
end of the chapter. 6
7
8
9
A specific environmental example: endless rows of chairs 10
The second author spent some time in the early 1980s as a charge nurse in an acute 1
unit for mentally ill older people. Throughout his nurse training, he had noticed the 2
tendency of chairs on ward dayrooms, especially on wards for older people, to be in a 3
row against the dayroom walls. In his view, also expressed by many other nurse 4
writers and practitioners at the time, this reinforced isolation and prevented 5
communication among patients/clients. 6
7
8
9
ACTIVITY 7.3 PRACTICAL 20
1
With your student colleagues, try sitting in a row of chairs as described above. 2
Note how this affects communication between you all and list these after a group 3
discussion of the experience. 4
As this activity is based on your own observations, there is no outline answer at the 5
end of the chapter. 6
7
8
9
In the second author’s first few days in charge of the acute unit, he imagined he had 30
the power to make environmental changes to improve communication by changing 1
the position of the chairs in the dayroom to allow for, rather than inhibit, 2
communication among the patients. The chairs were arranged in small circles of four
3
and the intention was to keep them this way and observe for any increase in
4
communication between the patients. When he next came back on shift he noticed,
5
to his dismay and irritation, that the chairs had been moved back to their original
6
position in rows against each wall. Once again, he had them moved back into small
7
circles of four, but each time he went off duty they were moved back against the wall.
8
This rearrangement of the chairs went on for several days until he found out that the 9
ward cleaners, with the blessing of their managers, had been moving them back to 40
their original positions to ease their cleaning duties. He found his own, nursing, 1
management unsupportive of his idea of moving chairs to improve communication 2
on ‘health and safety’ grounds (‘the patients might trip over the chairs’). This example 3
of a failed experiment aimed to improve communication between patients clearly 4
illustrates the double-sided nature of safety mentioned in the introduction to this 5
chapter. Questions arise as to who wins and who loses in this picture of chairs placed 6
in rows in the interest of ‘safety’. 7111
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The use of baby talk and ‘Vicky Pollard’ behaviour raises interesting questions about
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The Macpherson Report (1999) suggested that most of Britain’s public institutions
displayed institutional racism, defined as:
The collective failure of an organisation to provide an appropriate and professional
service to people because of their colour, culture or ethnic origin. It can be seen or
detected in processes, attitudes and behaviour which amount to discrimination
through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping
which disadvantage minority ethnic people.
(Macpherson, 1999, p10)
CASE STUDY
Google ‘Rocky Bennett Inquiry’ and read the websites that come up. In October 1998,
David ‘Rocky’ Bennett died as a result of forced restraint by up to five nurses at the
Norvic Clinic psychiatric in-patient unit. Preceding this event, he was the victim of
sustained institutional racism by both staff and clients alike. Narayanasamy and White
(2005) assert the belief that institutional racism pervades healthcare, including
nursing. It certainly seems to be the case that Rocky Bennett was the tragic victim of
this problem, but how representative of a more general trend is this? One thing’s for
sure: ask many nurses if it goes on in their workplace and they’ll deny it. This kind of
response represents a kind of defensive ‘NIMBYism’ (not in my back yard) that should
alert the enquirer to the possible operation of organisational defence mechanisms
(Morgan, 1997).
135
Table 7.1: Organisational defence mechanisms.
Repression Pushing unacceptable ideas and The possibility that abuse and communication neglect goes
impulses into the unconscious. on in our organisation is relegated to the organisational
COM & INTER SKILLS PT_gk.QXD
unconscious.
Denial Refusing to acknowledge a disturbing Presenting a public face of transculturalism while maintaining
fact, feeling or memory. institutionally racist forms of communication and refusing to
17/7/09
underlying motives and intentions. groups are due to circumstances outside our control, including
the failure of those patient groups to adapt sufficiently to take
advantage of the care on offer.
Regression Adopting behavioural patterns found Sending ethnic clients ‘to Coventry’, by avoiding them and
satisfying and effective in childhood in avoiding talking with them.
order to reduce the effect of
uncomfortable demands.
Splitting and idealisation Inappropriately separating different We represent a centre of excellence in many aspects of our
elements of experience, and talking up care and this has been acknowledged by feedback from many
the good aspects of a situation to avoid patients and articles in the local press.
facing the bad ones.
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
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6
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4
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From an individualistic position, patients/clients and nurses are assumed to have the
innate psychological ability to have the power to find their own solutions to their
problems, independent of cultural or organisational constraining factors. This includes
being able to speak more effectively and genuinely through communication facilitated
by the Rogerian core conditions.
The humanistic picture of interaction in Figure 7.1 both contrasts with and masks a
more challenging image of the nurse and patient/client interacting within multiple
cultural and organisational-environmental contexts, which have the power to shape
and limit what can be said and done in the name of ‘communication and
interpersonal skills in nursing’ (see Figure 7.2).
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1
2
3
4
5
6
7
8
9
10
1
2
3
4
Environmental influences impacting
5
interpersonal relationships
6
7
Organisational rules impacting 8
interpersonal relationships 9
20
Broader cultural impacting 1
interpersonal relationships 2
3
4
Figure 7.2: Complex picture of interaction.
5
6
7
The individualist/counselling model of skilled 8
9
communication 30
There is no such thing as society. 1
(Margaret Thatcher, 1987) 2
3
By placing sole responsibility for good CIPS on nurses, the organisation is let ‘off the 4
hook’ for the kinds of environmental factors, described above, that work to 5
undermine good communication (Grant, 2002). At a local cultural level, the kinds of 6
unwritten rules, also described above, that result from socialisation into the 7
organisational level, impact communication styles (Morgan, 1997). These rules will 8
affect the quantity and quality of communication between different professional 9
groups and between health workers, including nurses, and patients/clients. 40
1
Task, rather than holistic client/patient, workplace cultures will result in ‘I–It’ rather 2
than ‘I–Thou’ relationships (see Buber (1958), Chapter 2, pages 34–5). At a broader 3
cultural level, institutional racism and cultural incompetence, and the prejudice that 4
accompanies these problems, are often likely to influence the quality and quantity of 5
nurse–client/patient interpersonal communication, but, unfortunately, remain 6
underacknowledged or denied. 7111
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Different care settings might undermine the practice of safe and effective CIPS.
Physical and social environmental factors are very important with regard to the
practice of good communication in healthcare, in relation to communication both
within groups or families, and between younger and older people. ‘Prejudice’ and
‘schema development’, and their relation to language use, are key to understanding
examples of poor CIPS in nursing practice. Multiculturalism places demands on CIPS
in British nursing, while institutional racism impacts on communication and
interpersonal exchanges in British nursing practice. There is a variety of ways in
which healthcare organisations defend themselves from accepting that they may be
institutionally racist. ‘Cultural competence’, ‘cultural awareness’ and ‘transcultural
nursing care’ are crucial skills relating to good communication in British nursing
practice. Finally, the ‘fallacy of individualism’ in CIPS practice in British nursing care
masks the important role of environmental, organisational and broader cultural
influences impacting such care.
KNOWLEDGE REVIEW
Having completed the chapter, how would you now rate your knowledge of the
following topics?
Where you’re not confident in your knowledge of a topic, what will you do next?
Further reading
Cioffi, J (2006) Culturally diverse patient–nurse interactions on acute care wards.
International Journal of Nursing Practice, 12(6): 319–25.
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CHAPTER AIMS
Introduction
Society today is enriched by multicultural, ethnic and social diversity. The focus of this
chapter will be on the interpersonal and ethical contexts of nursing people from
different backgrounds and cultures. By looking at how populations have evolved in
the UK, we will begin by studying the statistical data on immigration and migration
to help understand how diverse ethnic populations in many of our neighbourhoods
have developed. We will also explore the motivators behind human migration.
The chapter then divides into two sections, with one focusing on cultures and the
next on diversity. Beginning with cultures, we will take into account the range we
experience in nursing and the differences that make up a society of diverse groups
and identities. Culture is a sociological concept and we will be investigating some of
this terrain to gain a deeper understanding of the diversity (the differences between
people) and the potential for discrimination. We will concentrate on communicating
with cultural diversity by exploring concepts such as cultural preservation, negotiation
and repatterning, or restructuring. These are interventions that are geared to changing
previously held patterns of behaviour that can have a major detrimental effect on
patients’ lives and are linked to discriminatory practices.
We explore some of the issues of nursing in a multicultural Britain and the need for
cultural awareness and cultural competence, and we compare two theories of
transcultural care.
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We will conclude with a section that considers the ethical and moral consequences of 1
communication and personal interactions. 2
3
4
Populations and diversity 5
From the earliest of times, the islands that make up the United Kingdom (UK) 6
have been settled or invaded by many different peoples: Romans, Saxons, Goths, 7
Vikings and Normans. In more recent times, we have seen, as a result of the two 8
world wars in the last century and the harmonisation policies of the European Union 9
(EU) in this century, people from Europe finding sanctuary, work and education in 10
the UK. 1
2
3
4
ACTIVITY 8.1 REFLECTIVE 5
6
Using a range of different sources (e.g. local and national newspapers, magazines, 7
television serials or ‘soaps’), make a simple analysis of their portrayal and coverage 8
of peoples of different gender, age, ethnicity and/or religion. Reflect on any 9
differences between local and national media representations. How are messages 20
communicated about culture and diversity in these media? Are there any specific 1
references to culture and diversity and healthcare, and how do they relate to your
2
experiences so far in practice settings?
3
As this activity is based on your own observations, there is no outline answer at the 4
end of the chapter. 5
6
7
8
The UK has a history of colonialism – a policy of acquiring land for exploitation and 9
trade that broadened the economic reaches of the UK and set up administration 30
systems in many countries around the globe. This in turn established a network of 1
trade, migration and immigration opportunities that led to the UK recruiting colonial 2
subjects in the Second World War as soldiers; it also recruited men from the 3
Caribbean to work in munitions factories and in Scottish forests. After the war, the UK 4
continued to recruit from the West Indies and Commonwealth countries to meet 5
labour shortages in transport and in the NHS. Links with Africa, Asia and the Far East 6
have also developed immigration routes to the UK and people have settled, bringing 7
with them their cultural practices, traditions, customs, religious beliefs and attitudes, 8
thus providing a rich multicultural tapestry. 9
40
1
2
ACTIVITY 8.2 PRACTICAL 3
4
Produce a restaurant menu to reflect the multicultural society of the UK. 5
Remember to consider and include religious and cultural traditions when selecting 6
7111
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● Settlers – These are people who intend to live permanently in a new country,
mostly in the main countries of settlement such as the United States of America,
Canada, Australia and New Zealand. To be a settler you need to qualify in some
way and being a skills immigrant, or already having family in the country are
usually the main criteria.
● Contract workers – These are admitted to other countries on the understanding
that they will stay only a short time. Many are seasonal workers in the agricultural
industry. Included in this category are nurses from the Philippines and Eire who
are contracted to work in the NHS for short periods. It also includes students
attending universities. In nursing, this currently only refers to post-qualifying
studies, as the NMC states that only UK citizens can qualify for NMC-regulated
pre-registration courses conducted in the UK.
● Professionals – These are people who are employees of transnational companies
and who are moved from one country to another. All industrial countries have a
system of work permits that regulates the time and scale of residency.
● Undocumented workers – This is a polite term for illegal immigrants. Some have
been smuggled into the country and others may have stayed beyond the ends of
their work permits.
● Refugees and asylum seekers – A refugee is defined by the United Nations (UN)
as someone who has well-founded fear of persecution for reasons of race,
religion, nationality, membership of a particular social group or political opinion.
During the 1990s, more and more receiving governments started referring to such
people as ‘asylum seekers’ and only termed them ‘refugees’ when their claims
were accepted.
These categories are not exhaustive and do overlap as an Indian medical practitioner
working in an NHS hospital may be both a professional and a contract worker.
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● alienating people – by making groups feel that they do not belong to society;
● invalidating people – which creates the feeling that views are not valid because
they are different;
● missing key issues – by not noticing crucial factors because we are not sensitive to
the significance they have for others;
● becoming part of the problem – which is failing to challenge discrimination and
oppression and thereby playing a part in their continuance.
Focusing on culture
Culture is a complex and multifaceted social phenomenon that affects our lives. To be
an effective communicator with culturally diverse patients, a nurse has to be able to
understand different social structures and norms that influence values and behaviour
in different societies.. By having this knowledge, nurses can understand unfamiliar
behaviour patterns and attitudes without dismissing or devaluing them. On a practical
level, this requires speaking to patients in appropriate ways with knowledge of
culturally congruent language to manage intercultural healthcare episodes.
Generally speaking, culture is a learned social experience that is often handed down
through generations, thus providing a continuing connectedness with others in a
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community. Over periods of time, social rules and norms are established that provide 1
a code of behaviour for the community and that also provide safety and security. 2
Within the culture, there may be differential status roles and yet persons connected 3
within the culture are regarded as like-minded persons, whereas someone who is not 4
part of the culture can be treated with mistrust and suspicion. 5
6
According to Henley and Schott (1999), culture affects every aspect of daily life: how 7
we think, feel and behave, and make decisions and judgements. Culture can be 8
defined as ‘how we do and view things in our group’, which in large part is acquired 9
unconsciously in early childhood (Hofstede, 1991). 10
1
2
ACTIVITY 8.4 PRACTICAL 3
4
To appreciate how culture is learned, identify and describe one family custom or 5
tradition in your own family or community group. Ask your parent, grandparent or 6
an elder where the custom originated. Has the custom or tradition changed over 7
the years and can they tell you why? This might help you understand how some 8
cultures become assimilated into the mainstream, or not, and relates to the next 9
topics of multiculturalism and acculturation. 20
1
Can you also think of a custom that you have adopted, but that is relatively new
2
in your family or social group? Can you trace why this has happened, and the
3
source of this custom?
4
As this activity is based on your own observations, there is no outline answer at the 5
end of the chapter. 6
7
8
Multiculturalism is the term used to describe a heterogeneous society in which many 9
diverse cultural groups coexist with some general ‘etic’ characteristics, which are 30
shared by the entire group, and some ‘emic’ perspectives, which are unique to 1
particular groups within the larger multicultural group. Bearing in mind the discussion 2
above on migration, which indicates a society that is progressively more mobile, 3
society is increasingly considered to be global due to changes in demographics and 4
an interdependent world economy. The movement towards shared cultural 5
characteristics and social mores is due to increased interracial marriage or 6
relationships between communities and the increased use of media and the internet 7
to shared cultural behaviours and beliefs. Conversely, this can also create a cultural 8
conservatism, where groups invest energy to retain cultural differences in an attempt 9
to ward off change and a diminishing of their cultural beliefs. 40
1
Acculturation represents an adaptive cultural process whereby biological, 2
environmental and traditional forms of culture adapt to prevailing contextual mores, in 3
order to survive or to maintain economic and social status. This can be seen in 4
groups who have moved from an agricultural life to an urban existence, and is 5
particularly evident in the creation of food and eating rituals, for example a current 6
TV cooking programme that teaches Asian women how to make club sandwiches. 7111
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A further example is family size – in many cultures a large family represents security
There is also a cultural diversity in health and social care settings among professions,
for example physicians, social workers, healthcare assistants, nurses, administrators,
porters and physiotherapists each can have their own cultural identities, rituals and
practices that can affect decisions and the allocation of tasks.
‘Cultural relativism’ refers to the understanding that cultures are not inferior or
superior to one another and that there is no method of measuring the value of one
culture against another. Furthermore, within cultures individuals will ascribe different
levels of meaning and importance to cultural beliefs and behaviours. This means that,
just because an individual appears to belong to a culture, they may not follow all the
practices of that culture, particularly if they have adopted elements of
acculturalisation. The implications for nurses are that some may have made major
modifications in their cultural beliefs to be either more extensive or more moderate.
Consequently, customs, attitudes, rituals and beliefs have to be understood according
to the individual needs of each patient.
Ethnicity derives from the Greek word ‘ethnos’ meaning ‘people’. An ethnic group
is a social grouping of people who share a common racial, geographical, religious
or historical culture. Ethnicity is different from culture in that it represents a
symbolic awareness of elements that bind people together in a social context.
Ethnicity is a deliberate and chosen awareness of norms and symbols, whereas
culture does not always involve a conscious awareness and commitment to a
cultural identity.
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1
ACTIVITY 8.5 PRACTICAL 2
3
The discussions above highlight the many different interpretations of culture. Take 4
a few moments to jot down the words and phrases you can think of in response to 5
the word ‘culture’. There are no right or wrong answers to this. 6
7
● What does your list reveal to you about your attitude to culture? 8
● In what ways does it reflect your own cultural background? 9
● How can you use these notes to improve your approach to culturally 10
congruent care? 1
2
As this activity is based on your own reflection, there is no outline answer at the end 3
of the chapter. 4
5
6
7
Communicating with cultural diversity 8
9
Communication is often the first barrier when considering cultural diversity. The 20
language barrier may be the most obvious difficulty to overcome, and if English is a 1
second language, there may not be complete mastery of the terminology and ways 2
of describing problems and symptoms. In addition, there may be conflicting 3
assumptions and expectations about health and healthcare due to culturally based 4
health beliefs. This is, however, the tip of the iceberg, as there are many other, not 5
always evident, cultural barriers that lie beneath the water’s surface. Figure 8.1 6
illustrates these factors, those that may be readily evident and those that may not be
7
so evident in initial communications but that will have an impact on the effectiveness
8
of communication and the relationship between patient and nurse.
9
Communication requires recognition of care alternatives, confidence in cross-cultural 30
communication skills and the ability to analyse situations in specifically situated 1
contexts. Leininger (1988) has suggested that there are three possible modes of 2
support: cultural preservation, cultural negotiation and cultural repatterning. 3
4
Cultural preservation 5
6
This facilitates the retention or incorporation of helpful or harmless health- and illness-
7
related practices, such as traditional herbal teas and ethnic foods, which are integral
8
cultural practices. Wearing garments that are specific to a designation or talismans that
9
maintain cultural beliefs should be retained, for the meaning and symbolism of these
40
artefacts are important to maintaining health in many cultures. Respect for these
1
artefacts is paramount and they should be valued as inclusive contributions to health
2
maintenance.
3
4
Cultural negotiation, or accommodation 5
This means bringing together the biomedical and the cultural by negotiation and 6
understanding. For example, in some cultures a bed facing in a certain direction can 7111
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Socio-economic status
Occupation
Health condition
Religion
Sexual preference
Group membership
Educational background
Political orientation
mean the person is facing death, so turning the bed around or finding another bed
facing a different direction can allay fears and improve cooperation. In another
example, a family of a terminally ill child would not return the child to the unit on
time for his medications. The hospital staff interpreted this as the family refusing
treatment and were reluctant for the child to go on outings. On discussion, it was
discovered that the family wanted to spend as much time as possible with the child
because they knew he was going to die, whereas the goal of the staff was to prolong
his life as much as possible by using the therapies they had devised. Negotiation
between the staff and the family and exploring the conflicting goals enabled both
sides to find a new understanding and a way forward, so that the staff supported the
outings and the family made efforts to bring the child back on time.
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addition to the patient’s wishes. For situations of abuse or neglect, referral should be 1
made to specialist services for consultation and actions. 2
3
Leininger (1978) has suggested using a template of information for Culturally Diverse 4
Clients, which could be considered as a guide for exploring individual patients’ cultural 5
needs and includes the following. 6
1. Patterns or lifestyles of an individual or group. 7
8
2. Specific cultural values, norms, and experiences of a patient or group 9
regarding the health and caring behaviours of their culture. 10
3. Cultural taboos or myths. 1
2
4. The worldview and ethnocentric tendencies of an individual (or group). 3
4
5. General features the patient (or group) perceives as different from, or similar
5
to, other cultures in or near their environment.
6
6. The health and life-care rituals and rites of passage to maintain health and 7
avoid illness. 8
9
7. Folk and professional health–illness systems.
20
8. Detailed caring behaviours and nursing care for self and others. 1
2
9. Indicators of cultural changes and acculturation processes influencing health
3
care.
4
(Leininger, 1978, pp88–9)
5
6
7
ACTIVITY 8.6 REFLECTIVE 8
9
Take a moment to think about your own cultural roots. Following the guide above, 30
see if you can complete the template by describing your cultural roots. When you 1
have done this, think of a culture that you know very little about and spend some 2
time researching in the library or on the internet for information that would 3
complete the template for that group. Maybe you have encountered a person 4
from a group that you know little about and can use this as an opportunity to 5
enhance your understanding. 6
7
Then think about how you would communicate with a person to provide you with
8
the information if you were to do this in a practice setting. You could imagine
9
being on a ward, in an accident and emergency department, a community health
clinic, a person’s home or with a homeless person on an outreach experience, or 40
with a child or a person with mental health problems or a person with learning 1
difficulties. Each of these situations requires an additional level of sensitivity from 2
the nurse and adjustment, so take these into consideration. 3
4
As this activity is based on your own reflection and observations, there is no outline 5
answer at the end of the chapter. 6
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The skills that a nurse uses to communicate with patients cross-culturally are an
● Can you tell me something about the reasons you are seeking health care?
● Can you tell me something about how a person in your culture would be cared
for if they had a similar condition?
● Have you been treated for a similar problem in the past? (If the patient answers
yes, more information about the precise nature of treatment is elicited.)
● Can you tell me what people do in your culture/community to remain healthy?
● Can you tell me something about the foods you like and how they are
prepared?
● Are there any special cultural beliefs about your illness that might help me give
you better care?
Multicultural Britain
Britain is regarded as one of the most ethnically diverse countries in Europe
(Narayanasamy and White, 2005). Therefore, healthcare providers must deliver a
service that is culturally sensitive, competent and appropriate to meet specific and
diverse needs (Narayanasamy, 2002). However, Narayanasamy and White (2005)
argue from a historical perspective (Cortis, 1993; Wilkins, 1993) that, since its
inception, the NHS can be viewed as a service that was created to meet the
healthcare needs of the British people. Its provision:
evolved around British social and family patterns, embracing religious and cultural
beliefs . . . It responded predominantly to the expectations and health needs of
the indigenous population in 1948.
(Narayanasamy and White, 2005, p103)
THEORY SUMMARY
Ethnocentrism
The process of socialisation into the occupation of nursing carries with it the need
to internalise the dominant cultural values. Because of this, nursing is not culture-
free, but is embedded in cultural values that pervade all aspects of care, practice
and knowledge, including CIPS. So nursing is culturally determined. If this is neither
acknowledged nor understood then nurses can be charged with being guilty of
gross ethnocentrism (Stokes, 1991). In the words of Parfitt:
Nurses who hold ethnocentric views will be unable to interpret their patients’
behaviour appropriately as they will judge it according to the norms of their own
behaviour.
(1998, p52)
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The extent to which ethnocentric cultural values still prevail in the NHS is an 1
interesting and crucial question. According to Parfitt (1998, p50), the NHS reflects the 2
cultural norm of not only the white majority but the middle class white majority. 3
From this critical position, privileged white British values and assumptions are taken as 4
‘common sense’ and ‘right and proper’, against which ethnic and cultural minorities 5
are located and labelled as ‘the other’. This has obvious implications for the 6
prevalence of institutional racism and witting or unwitting prejudice among healthcare 7
workers. 8
9
Sawley (2001) highlights racist incidents in nursing and healthcare. These include 10
black colleagues being referred to in derogatory terms; white relatives being allowed 1
to use the patients’ toilets while Asian relatives are barred; white staff making racist 2
remarks against Asians; and Asian patients not being permitted to have large numbers 3
of visitors, while white patients were not subjected to such controls. These practices 4
are clearly reflective of racist prejudice in the wider societal context, which Figure 8.2 5
may help illustrate. 6
7
8
9
Wider societal culture, 20
including ethnocentric Nursing/healthcare 1
views, racism and culture 2
prejudice, influences 3
4
5
6
7
8
Which affects the way 9
clients and patients are 30
seen, experienced, 1
described and treated. 2
3
Figure 8.2: Racist prejudice in the wider societal context.
4
5
Cultural competence 6
7
Cultural competence refers to an ability to interact effectively with people of different 8
cultures. It is is comprised of four components: 9
40
● awareness of one’s own cultural world-view;
1
● attitude towards cultural differences; 2
● knowledge of different cultural practices and world-views; 3
● cross-cultural skills. 4
5
Developing cultural competence results in an ability to understand, communicate with, 6
and effectively interact with people across cultures – in short, to be culturally sensitive. 7111
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In support of all of the above, Gerrish et al. (1996) recommended ways in which
transcultural healthcare might be transmitted. According to these authors, the
overarching need is the development of cultural sensitivity: in this context, the
practitioner should assume the role of tourist (with the good manners that go with
that role), reflexive honesty (including the ways in which power may be distributed in
favour of the health practitioner), exploration of the cultural meanings of ethnicity,
striving for intercultural communication, and a strong focus to eradicate all forms of
racism, including institutional.
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Transcultural nursing 1
2
As was made clear in Chapter 1, ‘caring’ needs to be appraised through a 3
transcultural lens (Leininger, 1997). In related terms, the quest for ‘self-awareness’ 4
needs to be broadened to subjecting oneself to challenges to one’s assumptions 5
(Gerrish et al., 1996), because without the opportunities for self-awareness 6
development in this transcultural sense, healthcare workers are likely to remain 7
insensitive to other cultural values. This speaks to relational ethics (see Chapter 2) in 8
that the imposition of one’s own values on others can be offensive and 9
unprofessional (Baxter, 2000; MacNaught, 1994). 10
1
In the early 1970s the second author trained as a student mental health nurse. He
2
witnessed several examples of cultural insensitivity through British nurses renaming
3
their ethnically different colleagues with British names. So, for example, a male
4
colleague from the Republic of the Philippines, whose first name was difficult to
5
pronounce by British colleagues, became ‘Fred’. Less understandably, a Danish nurse
6
named ‘Elsa’ was renamed ‘Elsie’.
7
Fortunately, cultural sensitivity seems to be beginning to impact nursing more now. For 8
example, Narayanasamy and White (2005) argue that healthcare services should be 9
culturally responsive and that the cultural healthcare needs of ethnic minority groups are 20
still not adequately met. Specifically, there is a failure of multicultural education, 1
structures and policies, and transcultural healthcare practice (Gerrish et al., 1996), which 2
may be being met, at least in part, by developing models of transcultural nursing. 3
4
5
6
THE ACCESS MODEL OF TRANSCULTURAL NURSING 7
(NARAYANASAMY, 2002) 8
9
Assessment: The assessment process focuses on the cultural dimensions 30
of the client’s lifestyle, and beliefs and practices about 1
health. 2
3
Communication: The nurse strives for awareness of, and differences in,
variations in verbal and non-verbal responses. 4
5
Cultural negotiation The nurse strives to become aware of aspects of other 6
and compromise: people’s cultures, understand their viewpoints, and tries to 7
explain their problems in an acceptable and accessible way. 8
Establishing respect What is required is a therapeutic relationship which 9
and rapport: embodies genuine respect for varieties in culture beliefs 40
and values. 1
2
Sensitivity: Nurses deliver diverse culturally sensitive care to diverse
3
cultural groups.
4
Safety: Clients/patients are enabled to derive a sense of cultural 5
safety (see introduction to this chapter). 6
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The questions raised in Activity 8.7 hopefully demonstrate the complexities of the
issues, rather than easy answers. The answers you came up with will relate to your
understanding of the nature of ‘difference’, how it is produced and how it should be
responded to. For example, one possible answer is that the ‘cause’ of the problem
was the woman’s poor command of spoken English coupled with her lack of
confidence, either because of her language difficulties or her cultural background.
However, equally, it could be argued that the communication problem arose because
of the hospital’s failure to address indirect and direct discrimination in its practices.
Indirect discrimination was apparent in the failure to take account of the diverse
needs of patients by, for example, failing to ensure the provision of bilingual workers
or interpreters available for the main community languages in the area. Direct
discrimination was apparent in how the two nurses ignored the woman.
The point is that nurses, like all humans, understand ‘difference’ differently. Related to
social cognition-based discussions in this book on labelling, ‘cognitive miserliness’
(see Chapter 4) and prejudices, health workers often associate ‘difference’ with the
membership of particular groups. These groups are seen to have specific qualities,
ways of communicating and communication needs, such as those described in
Activity 8.8 below:
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1
ACTIVITY 8.8 PRACTICAL 2
3
Consider the following statements, and rate them on the following scale: 4
5
0 2 4 6 8 6
absolutely probably not probably absolutely 7
untrue untrue sure true true
8
● Latin people use their bodies and hands more expressively than British people 9
when they are communicating. 10
● Asian women lack confidence in talking with white nurses. 1
2
● People with learning disabilities find speaking in groups very stressful.
3
● Women let their emotions get the better of them when they’re under pressure. 4
● The Scots and the Irish are always looking for a fight rather than trying to 5
resolve differences of opinion through discussion. 6
● Lesbians don’t like being cared for by male nurses. 7
Share your results with other people in your group and discuss. 8
9
As this activity is based on your own observations, there is no outline answer at the 20
end of the chapter. 1
2
3
4
Focusing on diversity 5
6
Diversity is about us as individual beings. However, as we have discussed earlier,
7
society is made up of a variety of groups and we will explore those groups in this
8
section from a sociological perspective. Again, it is these differences that will influence
9
the character and nature of our interpersonal interactions with patients and fellow
30
workers. We will explore socio-economic position, race and culture, gender, sexual
1
orientation, age and disability.
2
3
Socio-economic position 4
This is also described as a person’s class and is closely linked to factors such as 5
income, wealth and social status. The ONS uses a classification system to gather data 6
on the population that is constructed around employment roles and economic 7
output. The first detailed classification was designed in 1928 and was intended to 8
identify differences in economic distribution and status. 9
40
1
2
SOCIAL CLASS BASED ON OCCUPATION 3
4
I Professional etc. occupations 5
II Managerial and technical occupations 6
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The occupation groups included in each of these categories were selected in such a
way as to bring together, as far as possible, people with similar levels of occupational
skill. In general, each occupation group was assigned as a whole to one or other
social class and no account was taken of differences between individuals in the same
occupation group, for example differences in education. However, for persons having
the employment status of foreman or manager, the following additional rules
applied:
(a) each occupation was given a basic social class;
(b) persons of foreman status whose basic social class was IV or V were
allocated to Social Class III;
(c) persons of manager status were allocated to Social Class II with certain
exceptions.
(Adapted from Rose and Pevalin, 2005, p5)
This ethos has prevailed and a further more comprehensive classification system was
developed in 1951.
SOCIO-ECONOMIC GROUPS
Classification by Socio-economic Group (SEG) was introduced in 1951 and
extensively amended in 1961. The classification aimed to bring together people with
jobs of similar social and economic status. The allocation of occupied persons to SEG
was determined by considering their employment status and occupation (and
industry, though for practical purposes no direct reference was made since it was
possible in Great Britain to use classification by occupation as a means of
distinguishing effectively those engaged in agriculture).
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1
5.1 Intermediate non-manual workers – ancillary workers and artists 2
5.2 Intermediate non-manual workers – foremen and supervisors non-manual 3
6. Junior non-manual workers 4
7. Personal service workers 5
6
8. Foremen and supervisors – manual
7
9. Skilled manual workers 8
10. Semi-skilled manual workers 9
11. Unskilled manual workers 10
12. Own-account workers (other than professional) 1
13. Farmers – employers and managers 2
3
14. Farmers – own account
4
15. Agricultural workers 5
16. Members of armed forces 6
17. Inadequately described and not stated occupations 7
(Adapted from Rose and Pevalin, 2005, p7) 8
9
20
1
However, this has been subject to criticism as being inadequately sensitive for 2
contemporary statistical analysis and for capturing the inadequacies of the state in 3
providing equal access to health, education, housing and employment, so a further 4
classification model has been developed. 5
6
7
8
OPERATIONAL CATEGORIES OF THE NATIONAL STATISTICS 9
SOCIO-ECONOMIC CLASSIFICATION (NS-SEC) 30
1
L1 Employers in Large Establishments
L2 Higher Managerial Occupations 2
L3 Higher Professional Occupations 3
L3.1 ‘Traditional’ employees 4
L3.2 ‘New’ employees 5
L3.3 ‘Traditional’ self-employed 6
L3.4 ‘New’ self-employed 7
L4 Lower Professional and Higher Technical Occupations 8
L4.1 ‘Traditional’ employees 9
L4.2 ‘New’ employees 40
L4.3 ‘Traditional’ self-employed 1
L4.4 ‘New’ self-employed 2
L5 Lower Managerial Occupations 3
L6 Higher Supervisory Occupations 4
L7 Intermediate Occupations 5
L7.1 Intermediate clerical and administrative occupations 6
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Politically and sociologically, class differentials have been the subject of much debate
and continue to be used to delineate social divisions in society and the distribution of
wealth. The impact of social origins on life chances continues to be researched (Platt,
2005). The gap in the share of income between the richest and the poorest has
increased and also employment and educational achievements continue to be
determined by social background (Devine et al., 2004). Added to this are economic
changes that are affecting society, such as the decrease in traditional working-class
employment in the manufacturing industry and the increase in the service industry.
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Sexual orientation
Taking the biological view that sexuality is purely, or primarily, a biological
phenomenon, and heterosexuality deemed to be natural and normal, inevitably
defines homosexuality as unnatural and abnormal. This view, however, rules out
those in society who have chosen an alternative sexual orientation. The social and
psychological dimensions of sexuality are relevant in this discussion as they provide
explanations for an alternative view of sexuality that cannot be ignored or
marginalised. If not considered, the only concept of sexuality is one that is limited to
the biological argument and has the potential to lead to misunderstandings, prejudice
and discrimination.
It has to be acknowledged that gay and lesbian relationships, which are accepted in
some cultures, are not in others. In many countries, same-sex couples could face
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person. There is also a danger of concentrating on the physical needs of the older
Disability
Disability is often viewed as a physical problem that stands in the way of normal
social functioning. An alternative view is that social attitudes to disability are the
disabling function rather than the impairment itself. An example of this is that it is not
the use of a wheelchair that bars access to buildings, it is the lack of disabled access
and a ramp that causes the disability. The social model of disability draws attention to
the tendency of disabled people to be marginalised, dehumanised and patronised
(there are similarities here to ageism). There is a focus on limitations rather than
potential and capability. There is also a lack of awareness of the barriers, both physical
and attitudinal, that prevent disabled persons from becoming integrated into society.
Finally, there is a tendency to focus on dependency rather than empowerment
(Oliver, 1990).
● Avoid negative terms and terms that define the person as disabled, such as ‘the
disabled man’ or ‘the handicapped child’.
● Instead, say ‘person with a disability’, always emphasising the person rather than
the disability. Avoid describing the person with a disability as ‘abnormal’; when you
define people without disabilities as ‘normal’, you say, in effect, that the person
with the disability isn’t normal.
● Treat assistive devices such as wheelchairs, canes, walkers or crutches as the
personal property of the user. Don’t move these out of your way; they’re for the
convenience of the person with the disability. Avoid leaning on a person’s
wheelchair – it is similar to leaning on the person.
● Shake hands with the person with the disability if you shake hands with others in
the group. Don’t avoid shaking hands because the individual’s hand is disfigured
or misshapen, for example.
● Avoid talking about the person with a disability in the third person. For example,
avoid saying ‘Doesn’t he get around beautifully with the new crutches’. Direct your
comments to the individual.
● Don’t assume that people who have a disability are intellectually impaired. Slurred
speech, such as may occur with cerebral palsy or cleft palate, should never be
taken as indicating a low-level intellect. So be especially careful not to talk down to
people, as many do.
● When you’re not sure of how to act, ask. For example, if you’re not sure if you
should offer walking assistance, say ‘Would you like me to help you into the dining
room.’ And, more importantly, accept the person’s response. If he or she says no,
then that means no! So don’t insist.
● Maintain similar eye level. If the person is in a wheelchair, for example, it might be
helpful for you to sit down or kneel down to maintain the same eye level.
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This case study gives an example of the centrality of culture in the perception of
health and illness. It also illuminates the different resources and organisational
structures that individuals may resort to for solutions to health problems. The notion
of a divine origin of health, and models other than the biomedical utilised by Alisha to
understand the cause and cure of illness, indicate a complex terrain of a cultural
space where health and illness are negotiated.
CASE STUDY
Jane, a single woman, was diagnosed with breast cancer at the age of 43. Even though
Jane, who works as a hospital secretary, had good relationships with medical and
nursing staff and had faith in their abilities, she decided to explore other treatment
options. She surfed the internet for articles and gathered feedback from her friends
and family. The most common response she found was, ‘have it removed’. She thought
this was good advice and made an appointment for surgery. As the date approached,
she became more and more unsure. She read more articles that questioned the
efficacy of surgery and she found alternative suggestions. These ranged from yoga to
meditation and guided imagery. She was thinking of delaying the surgery and her
friends advised her that she was losing precious time, yet she felt that the alternative
approaches had more meaning for her.
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1
ACTIVITY 8.10 PRACTICAL 2
3
List the differences and similarities between the two cases above. What is the 4
prevailing similarity and the most significant difference and can these be 5
reconciled in the healthcare system we have in the UK? Can you describe the 6
cultural origins of these two cases without stereotyping? (Hint: only use the facts 7
that are before you.) 8
9
What can be learned from the second case and the health decisions and choices
10
Jane has to make when she navigates the healthcare system? If you were Jane’s
1
friend, how would you advise her? Would this be different from the advice you
would give as a professional? What are the moral obligations you have as a 2
professional? (Hint: think of evidenced-based practice and your role as an 3
advocate.) 4
5
As this activity is based on your own reflection, there is no outline answer at the end 6
of the chapter. 7
8
9
20
Alisha’s story involves shifting from one form of treatment to another depending on 1
the nature of the illness, the location of the person in the family structure, the price 2
and the time it takes to receive treatment and transport. These options are 3
interwoven into a complex web of meaning involving hierarchies and resources. The 4
treatments lie outside the biomedical model as well as engage with it, indicating a 5
crossroads between a culture-centred approach and a biomedical approach. Here is a 6
nexus for ethical decision making using communication skills that enable a deeper 7
understanding of cultural values and issues. 8
9
CHAPTER SUMMARY 30
1
2
In this chapter we have considered the extent to which our population is changing 3
and the need for increased understanding and awareness of multicultural needs in 4
healthcare. We have also explored the definitions of culture and have discussed the 5
socio-economic factors impacting today’s healthcare recipients. As well as considering 6
the diverse population needs of groups in society in relation to socio-economic 7
position, race and culture, gender, sexual orientation, age and disability, we have 8
examined the ethical and moral dimensions of communication and interpersonal 9
relationships in a culturally diverse world. 40
1
2
3
4
5
6
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Where you’re not confident in your knowledge of a topic, what will you do next?
Further reading
Dutte, MJ (2008) Communicating Health: A culture-centred approach. Cambridge: Polity
Press.
Useful websites
www.ons.gov.uk/census/index.html This website has information on the National
Census.
www.statistics.gov.uk/methods_quality/ns_sec/downloads/NS-SEC_Origins.pdf
www.statistics.gov.uk/pdfdir/intmigrat1106.pdf
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Glossary
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Glossary
a whole and regarded as amounting to more than the sum of its parts; a set of items
or things that are regarded as a whole
healthy relating refers to the use of good CIPS between nurses, their colleagues,
and their patients/clients; good communication is respectful, non-exploitative, non-
judgemental and formal rather than casual
humanistic humanistic psychology implies that individuals can solve their own
problems independent of cultural and organisational constraints
immigration coming to a foreign country to settle there
individualism from an ‘individualistic’ perspective, individuals are assumed to have
the power to find their own solutions to their problems, independent of cultural or
organisational constraining factors
interpersonal skills are exhibited when nurses demonstrate their abilities to use
evidence-based, and theory-based, styles of communication with their patients/clients
and colleagues
level descriptors a range of relative scales or values that are used to categorise,
describe and sort ideas, activities or responsibilities
loss is a feature of the subjective experience of depression or low mood
metacognitive refers to the idea of ‘thinking about thinking’; this means, in
practice, thinking about the ways in which you, as a nurse, and your patients/clients,
think about the ways in which you and they think
migration going from one place to another
moral practice in nursing refers to the respectful treatment of a patient/client as a
fully human being, rather than an object or an ‘it’
nurse-focused refers to the defensive ways in which nurses often communicate
with their patients/clients; these forms of communication are often guarded,
withdrawn and distancing, leaving patients/clients feeling more anxious and lonely
than they otherwise might be
prejudice bigoted views held by members of one culture against members of
another
professional friend a relationship that conforms to the standards of skill,
competence or character normally expected of a properly qualified and experienced
person in a work environment and combines this with elements of friendship
characterised by mutual assistance, approval and support
professional relationship the connection between two or more people or groups
and their involvement with one another, especially with regard to the way they
behave towards and feel about one another, which is focused around an occupation
as a paid job rather than as a hobby
rationalisation finding reasons to explain or justify one’s actions
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Glossary
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References
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References
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Index
feeling 123
experiential learning 104 Howard, Alex 49
see also emotions humanistic approach 48–50, 58, 125, 169
feminism 161 fallacy of individualism 125, 137–8
first-level (spontaneous) communication
56–7 I
Fiske, Susan 50 iceberg model, cultural factors 148, 149
framework for CIPS 17 idealisation, organisations 136
assessment 17–19 identities and roles 69–70
decision making 20–1 I–It/I–Thou theory 34–5, 138, 153
ending and closure 21–2 immigration 141, 143–5, 169
planning 19–20 individualism 49, 169
review and evaluation 21 fallacy of 125, 137–8
frameworks, communication 26–9 infantilisation/baby talk, elderly people
friendships 77–80 130–1, 162
professional friends 80–1, 169 information
Fry, Roger, experiential learning theory 104 gathering 17–19
interpretation/clarity of 62–4, 93–4, 116,
G 117–18
gaze 88 processing 62–4, 104
gender diversity 160–2 see also social thinking
Gerrish, Kate 153 institutional racism 125, 134–6, 152
Gestalt theory 103, 168 instructions, clarity of 116–17, 118
Goffman, Erving 88–9 interpersonal skills
Greenberg, Leslie 37–8, 54 definitions 12, 169
grief 90 relationship with communication
see also loss; suffering 13–14
interpretation of information 62–4, 93–4,
H 116, 117–18
Hall, Edward 82 see also social thinking
Hamilton, Janet 130 intimacy, degrees of 82
happiness 89 nurse–patient relationships 71
Hargie, Owen, Hargie-Dickson model 47, proxemics 82–3, 88
83–4, 127 self-disclosure 83–6
Hartrick, Gwen 15 invisible/unseen care 15–16
health promotion model 94, 99
healthy relating 32, 33, 169 J
and attachment 33–4 Jack, Kirsten 112
empathy 37–8, 53–6, 59, 168 jargon 19
I–It/I–Thou theory 34–5, 138, 153 Jones, Aled 13
and organisational cultures 38–41
theory of mind 36–7, 170 K
helping relationships 72–3, 75 Kagan, Carolyn 45, 52
Henderson, IW 72 Kohut, Heinz 54
Hendricks, Jon and C Davis 127 Kolb, David
Henley, Alix 146 experiential learning theory 104
hierarchies, professional 20 learning styles inventory 112, 123
hierarchy of needs 94
higher education (HE), level descriptors L
108–11, 169 language 8
Hofstede, Geert 146 Sapir–Whorf hypothesis 132–4
homosexuality 161–2 language barrier 148, 155
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professional hierarchies 20 Rogerian principles 47, 49, 58, 137, 169
professional migrants 143 roles and identities 69–70
professional relationships 71, 77–81, 169 Rose, David 157–9
professionalism 117 Ruesch, Jurgen 26
proxemics 82–3, 88 Ryan, Ellen 130
psychological care 15–16
psychology, healthy relating 36–7 S
psychotherapy see counselling/psychotherapy sadness 90
models of CIPS see also loss; suffering
safety 62–4, 124
Q Sapir, Edward, Sapir–Whorf hypothesis
qualifications framework 108–11 132–4
Quality Assurance Agency (QAA) 108–9, Sawley, Linda 152
123 schemas 50–1, 55, 125, 170
quantitative/qualitative research 32 as self-prejudice 131–4
Schott, Judith 146
R Scott, Brian 55
race see immigration; multiculturalism SCT see self-categorisation theory
racism, institutional 125, 134–6, 152 second-level (learned) communication
Radsma, Jenny 15 56–7
rationalisation 40, 136, 169 SEEC 109
realist view of organisations 39 self 52
recency, social thinking 66–7 types of 83–4
reciprocity/receptivity, friendship 81 self-awareness 52–3, 154, 170
Rees, Charlotte 113 self-categorisation theory (SCT) 129, 134
reflection 108, 112–13 self-disclosure 83–6
reflective writing 112, 169 self-esteem 35, 57, 170
refugees 143 self-generating thoughts 67–8
regression, organisations 136 self-prejudice, schemas as 131–4
relational caring 15 sense-making activities 113
relationship formation sensitivity, and suffering 32
helping relationships 72–3, 75 settlers 143
six-stage model 70–2 sexual abuse, elderly people 125–6
skilled helper model 73 sexual orientation 161–2
relationships Sheard, Charlotte 113
barriers to 92–7 significant others 48
and emotions 76, 89–92 SIT see social identity theory
I–It/I–Thou 34–5, 138, 153 six-stage model, relationship formation
over-involvement 79–80 70–2
professional/social 71, 77–81, 169, skilled helper model, relationship formation
170 73
rules of engagement 86–9 skills, importance of 121–2
safe 62–4 Skills for Health Career Framework 119–20,
see also healthy relating; intimacy, degrees 121–1, 123
of; therapeutic relationships Smith, Anne 112
repression, organisations 136 Smith, Carol 94
research see evidence-based CIPS social cognition 50, 55, 60
respect 37 social thinking 61, 64, 64–8, 170
review, CIPS framework 21 Social Cognition Paper Archive and
Reynolds, William 55, 56 Information Center 60
Robb, Martin 155 social constructionist view of organisations 39
Rodgers, Beth 32–3 social-environment theory 127
183
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