Lois Cox, RN, sighed

POSITIVE AND NEGATIVE COMMUNICATION TECHNIQUES

 

Things were not easy at home, this was her fourth 12-hour shift in a row, and now she was being told that the patient in 412 was just impossible. “Don’t be surprised if you spend all day in there,” Marilyn had said. “And, no matter what you do, it won’t be right. Good luck; you’ll need it.” Wearily, Lois started her morning assessments. Mr. Salcido in room 412 was grouchy and complained a lot. Lois could hardly complete a task before he expressed dissatisfaction or demanded something else. As Lois returned to the nurses’ station to chart vital signs, she mentally reviewed her patient assignment and decided that she would save Mr. Salcido’s morning care until last so that she could spend more time with him. The risk, of course, was that he would become impatient while waiting. In addition to providing more time with Mr. Salcido, Lois resolved to use all of her communication skills. She would greet him cheerfully, respond with kindness and patience regardless of his demeanor, make pleasant conversation, and-above all-would listen for clues to explain his behavior. Maybe she could do something to make him happier. Forty-five minutes later, Lois emerged from Mr. Salcido’s room humbled and once again acutely aware of how easily a patient’s deepest needs can go unrecognized. After rapport was finally established and Mr. Salcido decided he could trust Lois, he had confided to her that his wife had died in the same room 2 years earlier. He believed it was not masculine to cry or to express weakness with strangers. His anger was an expression of his unresolved grief over the death of his wife.

Questions to consider while reading this chapter

1. What communication techniques did Lois use to establish rapport with Mr. Salcido?

2. What nonverbal cues should Lois watch for as she begins initial care and communication with Mr. Salcido?

3. What strategies can Lois use to build trusting relationships with each of the patients she cares for?

4. How should Lois communicate her discovery about the source of Mr. Salcido’s anger to the other staff members? ‘

Terms

Blocking Obstructing communication through noncommittal answers, generalization, or other techniques that hamper continued interaction.

Communication components The sender, the receiver, the message.

Communication subcomponents Interpretation, filtration, feedback.

Feedback Response from the receiver, which can be verbal or nonverbal.

Filtration Unconscious exclusion of extraneous stimuli.

Interpretation Receiver’s understanding of the meaning of the communication. Negative communication techniques Behavior that blocks or impairs effective communication.

Nonverbal communication Unspoken cues (intentional or unintentional) from the communicant, such as body positioning, facial expression, or lack of attention.

Positive communication techniques Behavior that enhances effective communication.

Negative and Positive Listening / Communication Skills

 

Negative Listening/Communication Skills – The following behaviors interfere with listening and communication. Try to avoid these behaviors.

Ø Interrupting the person who is speaking to you.

Ø Rehearsing or planning what you’re going to say instead of actually

Ø listening to the other person.

Ø Second guessing or showing doubt towards what the other person is

Ø saying.

Ø Day dreaming or not paying attention to the speaker.

Ø Mind reading or predicting what the other person is going to say instead

Ø of listening to them.

Ø Realize that there are many more negative listening/communication skills that people

Ø use on a daily basis. Can you think of more?

 

 Positive Listening/Communication Skills – The following behaviors improve listening and communication.

Try to practice and implement these behaviors.

1. Set the stage by finding a proper time and place to talk.

 2. Express positive non-verbal body language, such as making eye contact and using

 positive facial expressions (e.g. nodding and other gestures that express that you are

 listening).

 3. Express verbal cues that illustrate you are listening.

 4. Paraphrase or summarize what has been said to you to ensure your

 understanding.

 5. Ask clarifying questions if you are unsure of what the person is saying to

 you.

6. Realize that there are many more positive listening/communication skills that people

 use on a daily basis. Can you think of more?

 

Outcomes After studying this chapter, the reader will be able to:

1. Apply effective oral communication techniques in diverse situations.

2. Evaluate conflicting verbal and nonverbal communication cues.

3. Implement effective written communication skills.

4. Apply effective strategies for managing conflict.

OVERVIEW

 

Communication is one of the most basic human endeavors. At the moment of birth with the wail of new life, the infant begins a journey toward development of an effective way to interface with the world. Webster’s New World Dictionary defines communication as, “

1. the act of transmitting,

2. a giving or exchanging of information, signals, or messages by talk, gestures, writing, etc. . . . ” There are many styles of transmitting information. Observation of a preverbal child for any time will yield creative, humorous, and usually fairly clear methods of disclosing desires and needs. The exchange of ideas and feelings is hardly limited to verbal communication. Although the spoken word is most commonly used for societal communication, a highly developed sign language exists for people who are unable to speak or hear. There are many types of nonverbal communication that often are as effective as, and in some instances more effective than, audible expression. Effective communication is a major part of the nursing profession. Nurses interact with patients, families and significant others, nursing peers, student nurses, physicians, other members of the transdisciplinary team, and the public. Nurses communicate through a variety of media, including the spoken and written word, demonstration, role modeling, and, on occasion, public appearances. This chapter reviews the components of the communication process, communication styles, and principles of effective communication in professional nursing. In addition, communication issues related to cultural diversity, collaboration, dealing with conflict, effective delegation, and documentation are addressed.

HISTORY Our nursing ancestors recognized the need for clear communication as a basic component of the profession. Their comments provide an interesting perspective on the development of nurse-patient and nurse-physician communication. Florence Nightingale (1859) admonished persons attending the sick to be cautious in speaking about the patient as if he or she were not present or in tones too low for the patient to hear. “I have often been surprised at the thoughtlessness… of friends or of doctors who will hold a long conversation just in the room or passage adjoining the room of the patient… who knows they are talking about him…. If it is a whispered conversation in the same room, then it is absolutely cruel.” Later, in the chapter “Chattering Hopes and Advices,” Nightingale inquires, “Do,you who are about the sick or who visit the sick, try and give them pleasure, remember to tell them what will do so. … A sick person does so enjoy hearing good news…. A sick person also intensely enjoys hearing of any material good, any positive or practical success of the right.” More than half a century later, Sue Parsons (1916) wrote regarding communication with the patient, “Just by your expression you may assure him that he is among friends. If you cannot speak his language, you will attempt to get an interpreter to explain what the examinations mean, what the doctors are trying to do to help him, and to ask him if there is anything he wishes.” Regarding communication with physicians, Parsons advises the young nurse, “When she becomes sufficiently experienced to detect a mistake, she will, of course, call his attention to it by asking if her understanding of the order is correct.” Under the subtitle of “Discretion,” Parsons (1916) warns, “Nurses and doctors are sometimes thoughtless in conversation; they discuss a patient’s condition before him, thinking he does not understand or care, and sometimes believing him too ill to notice what is said. This is a great mistake.” Regarding idle conversation that breaches patient confidentiality, Parsons observes, “If a nurse, when meeting friends, finds herself invariably talking shop, gossiping about doctors, nurses, and patients, she must realize that she is on the road to unhappiness and cynicism.” In today’s environment she would be on the road to litigation as well. In the same era Katharine DeWitt (1917) penned, “She [the nurse] must not only respect expressed preferences, but her imagination must be on the alert, ready to perceive, without the need of words, what is agreeable or disagreeable to her charge.” And, most profoundly, “Every nurse should be a health missionary, telling how to keep well, how to avoid disease, how to aid in the great campaign for public health, good living and morality.”

Healthcare professionals have looked to philosophy, especially the branch that deals with human behavior, for resolution of these issues. The field of biomedical ethics (or simply bioethics), a subdiscipline of the area known as ethics—or the philosophical study of morality, has evolved. In essence, bioethics is the study of medical morality, the moral and social implications of health care and science in human life (Mappes & Zembaty, 1991).

To understand biomedical ethics, we need to first consider the basic concepts of values, belief systems, and morality. We will then discuss the resolution of ethical dilemmas in health care.

The dictionary defines values as the “estimated or appraised worth of something, or that quality of a thing that makes it more or less desirable, useful’’ (Webster’s New World Dictionary, 1990). Values, then, are judgments about the importance or unimportance of objects, ideas, attitudes, and attributes. They become a part of a person’s conscience and worldview. Values provide a frame of reference and act as pilots to guide behaviors and assist people in making choices.

Two-Way Communication Trusting Relationships

Purpose { Define communication – including:

·        { Two-way communication

·        { Verbal and nonverbal communication

·        { Identify both positive and negative communication techniques

·        { Define a trusting relationship and list techniques essential to developing one

Value Systems

A value system is a set of related values. For example, one person may value (believe to be important) material things, such as money, objects, and social status. Another person may value more abstract concepts, such as kindness, charity, and caring. Values may vary significantly based on an individual’s culture. One’s system of values frequently affects how people make decisions. For example, one person may base a decision on cost, and another person placed in the same situation may base the decision on kindness. There are different kinds of values:

·         • Intrinsic values are those related to sustaining life, such as food and water (Steele & Harmon, 1983).

·         • Extrinsic values are not essential to life. Things, people, and ideas such as kindness, understanding, and material items are extrinsically valuable.

·         • Personal values are qualities that people consider valuable in their private lives. Such things as strong family ties and acceptance by others are personal values.

·         • Professional values are qualities considered important by a professional group. Autonomy, integrity, and commitment are examples of professional values.

People’s behavior is motivated by values. Individuals take risks, relinquish their own comfort and security, and generate extraordinary efforts because of their values (Edge & Groves, 1994). Stroke patients may overcome tremendous barriers because they value independence. Racecar drivers may risk death or other serious injury because they value competition and winning.

Values are also the basis of standards by which people judge others. For example, if you value work over leisure activities, you will look unfavorably on the coworker who refuses to work over the weekend. If you believe that health is more important than wealth, you would approve of spending money on a relaxing vacation or perhaps joining a health club, rather than putting it in the bank. Often people adopt the values of individuals they admire. For example, a nursing student may begin to value humor after observing it used effectively with clients. You can see that values provide a guide for decision making and give additional meaning to life. Individuals develop a sense of satisfaction when they work toward achieving values they believe are important.

How Values are Developed

Values are learned (Wright, 1987). Values can  be taught directly, incorporated through societal norms, or modeled through behavior. Children learn by watching their parents, friends, teachers, and religious leaders. Through continuous reinforcement, children eventually learn about and then adopt values as their own. Because of the values they hold dear, people often make great demands on themselves, ignoring the personal cost. Here is an example:

David grew up in a family in which educational achievement was highly valued. Not surprisingly, he adopted this as one of his own values. At school, he worked very hard because some of the subjects did not come easily to him. When his grades did not reflect his great effort, he felt as though he had disappointed his family as well as himself. By the time David reached the age of 15, he had developed severe migraine headaches.

Values change with experience and maturity.  For example, young children often value objects, such as a favorite blanket or stuffed animal. Older children are more likely to value a particular event, such as a scouting expedition. As they enter adolescence, they may value peer opinion over the opinions of their parents. Young adults often value certain ideals, such as beauty and heroism. The values of adults are formed from all of these experiences as well as from learning and thought. The number of values that people hold is not as important as what values they consider to be important. Choices are influenced by values. The way people use their own time and money, choose friends, and pursue a career are all influenced by values.

Values Clarification

Values clarification is deciding what you believe is important. It is the process that helps people become aware of their own values. Values play an important role in everyday decision making. For this reason, nurses need to be aware of what they value and what they do not. This process helps them to behave in a manner that is consistent with their values. Both personal and professional values can affect nurses’ decisions. Understanding your values simplifies solving problems, making decisions, and developing better relationships with others when you begin to realize how they develop their values. Raths, Harmon, and Simmons (1979) suggested using a threestep model of choosing, prizing, and acting, with seven substeps, to identify your own value.

You may have used this method when making the decision to return to school. Today, many career options are available to men and women. For some people, nursing is a first career; for others, it may be a second career. Using the model in Table 13–1, let’s analyze the valuing process:

1. Choosing. After researching alternative career options, you freely chose nursing school from a whole range of options. This choice was most likely influenced by factors such as educational achievement and abilities, finances, support and encouragement from others, time factors, and feelings about people.

2. Prizing. Once the choice was made, you were satisfied with it and told your friends about it.

3. Acting. You have entered school and begun the journey to your new career. Later in your career, you may decide to return to school for a bachelor’s or master’s degree.

As you have progressed through school, you have probably begun to develop a new set of values—your professional values. Professional values are those established as being important in your practice, such as caring, quality of care, and ethical behaviors.

BELIEF SYSTEMS

Belief systems are an organized way of thinking about why people exist within the universe. The purpose of belief systems is to explain such mysteries as life and death, good and evil, and health and illness. Usually these systems include an ethical code that specifies appropriate behavior. People may have a personal belief system or participate in a religion that provides such a system, or both.

Members of primitive societies worshiped events iature. Unable to understand the science of weather, for example, early civilizations believed these things to be under the control of someone or something that needed to be appeased, and they developed rituals and ceremonies to appease these unknown entities. In doing this, they named these entities gods, believing that certain behaviors either pleased or angered the gods. Because these societies associated certain behaviors with specific outcomes, they created a belief system that enabled them to function as a group.

As higher civilizations evolved, belief systems became more complex. Archeology has provided us with evidence of the religious practices of ancient civilizations (Wack, 1992). The Aztec, Mayan, Incan, and Polynesian cultures each had a religious belief system comprising  many gods and goddesses for the same functions. The Greek, Roman, Egyptian, and Scandinavian societies believed in a hierarchy of gods as well as individual gods and goddesses. Interestingly, although given different names by different cultures, most of the deities had similar purposes. For example, Zeus was the Greek king of the gods, and Thor was the Norse god of thunder. Both used a thunderbolt as their symbol. Sociologists believe that these religions developed to explain what was then unexplainable. Human beings have a deep need to create order from chaos and to have logical explanations regarding events. Religion explains theologically what objective science cannot.

Along with the creation of rites and rituals, religions also developed codes of behaviors, or ethical codes. These codes contribute to the social order. There are rules regarding how to treat members of the family, neighbors, the young, and the old. Many religions have also developed rules regarding marriage, sexual practices, business practices, the ownership of property, and rules of inheritance.

The advancement of science certainly has not made belief systems any less important. In fact, the technology explosion has created an even greater need for these systems. Technological advances often place people in situations that justify religious convictions rather than oppose them. Many religions, and particularly Christianity, focus on the will of a supreme being, and technology, for example, is considered a gift that allows healthcare personnel to maintain the life of a loved one. Other religions, such as certain branches of Judaism, focus on free choice or free will, leaving such decisions in the hands of humankind. Genetic testing is an example of this approach. Many religious leaders believe that if genetic testing indicates, for instance, that an infant will be born with a disease such as Tay-Sachs, which causes severe suffering and ultimately death, an abortion may be an acceptable option.

Belief systems often help survivors in making decisions and living with them afterward. So far, more questions than answers have emerged from these technological advances. As science explains more and more previously unexplainable phenomena, we need beliefs and values to guide our use of this new knowledge.

ETHICS AND MORALS

Morals

Although the terms morals and ethics are often used interchangeably, ethics usually refers to a standardized code as a guide to behaviors, whereas morals usually refers to an individual’s own code for acceptable behavior. Morals arise from an individual’s conscience. They act as a guide for individual behavior and are learned through instruction and socialization. You may find, for example, that you and your clients disagree on the acceptability of certain behaviors, such as premarital sex, taking drugs, or gambling. Even in your nursing class, you will probably encounter some disagreements because each of you has developed a personal code that defines acceptable behavior.

Ethical Principles

Ethics is the part of philosophy that deals with the rightness or wrongness of human behavior. It is also concerned with the motives behind behaviors. Bioethics, specifically, is the application of ethics to issues that pertain to life and death. The implication is that judgments can be made about the rightness or goodness of healthcare practices.

Ethical codes are based on principles that can be used to judge behavior. Ethical principles assist decision making because they are a standard for measuring actions. They may be the basis for laws, but they themselves are not laws. Laws are rules created by a governing body. Laws can operate because the government has the power to enforce them. They are usually quite specific, as are the punishments for disobeying them. Ethical principles are not confined to specific behaviors. They act as guides for appropriate behaviors. They also  take into account the situation in which a decision must be made. You might say that ethical principles speak to the essence or fundamentals of the law, rather than to the exactness of the law (Macklin, 2009). Here is an example:

Mrs. Van Gruen, 82 years old, was admitted to the hospital in acute respiratory distress. She was diagnosed with aspiration pneumonia and soon became septic, developing adult respiratory distress syndrome (ARDS). She had a living will, and her attorney was her designated healthcare surrogate. Her competence to make decisions was uncertain because of her illness. The physician presented the situation to the attorney, indicating that without a feeding tube and tracheostomy, Mrs. Van Gruen would die. According to the laws governing living wills and healthcare surrogates, the attorney could have made the decision to withhold all treatments. However, he felt he had an ethical obligation to still discuss the situation with his client. The client requested hat the tracheostomy and the feeding tube be inserted, which was done.

In some situations, two or more principles may conflict with each other. Making a decision under these circumstances is very difficult. We now consider several of the ethical principles that are most important to nursing practice—autonomy, nonmaleficence, beneficence, justice, confidentiality, veracity, and accountability — and then look at some of the ethical dilemmas nurses encounter in clinical practice.

Autonomy

Autonomy is the freedom to make decisions for oneself. This ethical principle requires that nurses respect clients’ rights to make their own choices about treatment. Informed consent before treatment, surgery, or participation in research is an example. To be able to make an autonomous choice, individuals need to be informed of the purpose, benefits, and risks of the procedures to which they are agreeing. Nurses accomplish this by providing information and supporting clients’ choices.

Nurses are often in a position to protect a client’s autonomy. They do this by ensuring that others do not interfere with the client’s right to proceed with a decision. If a nurse observes that a client has insufficient information to make an appropriate choice, is being forced into a decision, or is unable to understand the consequences of the choice, then the nurse may act as a client advocate to ensure the principle of autonomy.

Sometimes nurses have difficulty with the principle of autonomy because it also requires respecting another’s choice even if you disagree with it. According to the principle of autonomy, a nurse cannot replace a client’s decision with his or her own, even when the nurse honestly believes that the client has made the wrong choice. A nurse can, however, discuss concerns with clients and make sure they have thought about the consequences of the decision they are about to make.

The principle of beneficence demands that good be done for the benefit of others. For nurses, this is more than delivering competent physical or technical care. It requires helping clients meet all their needs, whether physical, social, or emotional. Beneficence is caring in the truest sense, and caring fuses thought, feeling, and action—knowing and being truly understanding of the situation and the thoughts and ideas of the individual (Benner & Wrubel, 1989).

Sometimes physicians, nurses, and families withhold information from clients for the sake of beneficence. The problem with doing this is that it does not allow competent individuals to make their own decisions based on all available information. In an attempt to be beneficent, the principle of autonomy is violated. This is just one of many examples of the ethical dilemmas encountered iursing practice. For instance:

Mrs. Gonzalez has just been admitted to the oncology unit with ovarian cancer. She is scheduled to begin chemotherapy treatment. Her two children and her husband have requested that the physician ensure that Mrs. Gonzalez not be told her diagnosis because they feel she would not be able to deal with it. The information is communicated to the nursing staff.

After the first treatment, Mrs. Gonzalez becomes very ill. She refuses the next treatment, stating that she didn’t feel sick until she came to the hospital. She asks the nurse what could possibly be wrong with her that she needs a medicine that makes her sick when she doesn’t feel sick. Only people who get cancer medicine get this sick! Mrs. Gonzalez then asks the nurse, “Do I have cancer?’’

As the nurse, you understand the order that the client is not to be told her diagnosis. You also understand your role as a patient advocate.

1. To whom do you owe your duty—the family or the client?

2. How do you think you may be able to be a client advocate in this situation?

3. What information would you communicate to the family, and how can you assist them in dealing with their mother’s concerns?

Justice

The principle of justice obliges nurses and other healthcare professionals to treat every person equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Edge & Groves, 1994). This principle also applies in the work and educational setting. Everyone should be treated and judged by the same criteria according to this principle. Here is an example:

Found on the street by the police, Mr. Johnson was admitted through the emergency room to a medical unit. He was in deplorable condition, wearing dirty, ragged clothes, unshaven, and covered with blood. His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver disease. Several nursing students overheard the staff discussing Mr. Johnson. The essence of the conversation was that no one wanted to care for him because he was dirty, smelly, and brought this condition on himself. The students, upset by what they heard, went to their instructor about the situation. The instructor explained that every individual has a right to good care despite his or her economic or social position. This is the principle of justice.

Confidentiality

The principle of confidentiality states that anything said to nurses and other healthcare providers by their clients must be held in the strictest confidence. Exceptions exist only when clients give permission for the release of information or when the law requires the release of specific information. Sometimes, just sharing information without revealing an individual’s name can be a breach in confidentiality because the situation and the individual are identifiable. It is important to realize that what seems like a harmless statement can become harmful if other people can piece together bits of information and identify the client.

Nurses come into contact with people from different walks of life. When working within communities, people are bound to know people,  who know other people, and so on. Individuals have lost families, jobs, and insurance coverage because nurses have shared confidential information and others have acted on that knowledge (AIDS Update Conference, 1995).

In today’s electronic environment the principle of confidentiality has become a major concern. Many healthcare institutions, insurance companies, and businesses use electronic media to transfer information. These institutions store sensitive and confidential information in computer databases. These databases need to have security safeguards to prevent unauthorized access. Healthcare institutions have addressed the situation through the use of limited access, authorization passwords, and security tracking systems. It is important to remember that even the most secure system developed is vulnerable and can be accessed by an individual who understands the complexities of computer systems.

 

 

COMPONENTS OF COMMUNICATION

Communication generally is thought to have three components — the sender, the receiver, and the message. As a dynamic process, communication is cyclic so that the receiver becomes the sender when responding. These roles then alternate as the communication process continues. Inherent in the process is a level of subcomponents, consisting of interpretation, filtration, and feedback. Fig. 17-1 is a visual representation of the basic communication process.

Interpretation

Interpretation of information can be influenced by such factors as context, environment, precipitating event, preconceived ideas, personal perceptions, style of transmission, and past experiences. Because of the interaction of these factors, the sender’s message may mean to the receiver something that was entirely unplanned or unexpected by the sender (Fig. 17-2).

Context and Environment.

Context refers to the entire situation relevant to the communication, such as the environment, the background, and the particular circumstances that lead to the discussion. Environment can denote physical surroundings and happenings and the emotional conditions involved in the communication. 388 qjnit Three Leadership and Management in Nursing

Precipitating Event

 Precipitating event refers specifically to the event or situation that prompted the communication. Precipitating event refers to a specific single event, whereas context describes the whole ambiance of the situation, with the inclusion of multiple circumstances that have led to the precipitating event.

Preconceived Ideas.

Preconceived ideas are conceptions, opinions, or thoughts that the receiver has developed before the encounter. Such ideas can dramatically affect the receiver’s acceptance and understanding of the message.

Style of Transmission.

Style of transmission involves many aspects of the manner of conveyance of the message. Transmission styles include aspects such as open or closed statements or questions, body language, method of organizing the message, degree of attention to the topic or to the receiver, vocabulary chosen (professional jargon vs. language a layperson could easily understand), and intonation.

Past Experiences.

Each person comes to any type of communication, whether it is friendly conversation, informational lecture, staff meeting, performance evaluation, or any other possible scenario, with baggage in terms of past experiences. Because past experiences will be a variety of positive, neutral, and negative events, the influence that the experiences can and will have on communication may be positive, neutral, or negative. The importance of recognizing that any reaction from the receiver may be biased by previous experiences cannot be overstated. A perfect example is presented in the vignette when Mr. Salcido was hospitalized in the same room in which his wife died 2 years earlier. An astute sender will begin to investigate such a possibility if the receiver reacts in an unexpected or inappropriate manner to information that was not expected to produce such a response, which may range from nonresponse to overly vehement response.

Personal Perceptions.

Personal perceptions can have a profound effect on the quality of communication. Perception is awareness through the excitation of all the senses. Perception can be .described as all that the person knows about a situation or circumstance based on what each of the senses—taste, smell, sight, sound, touch, and intuition—discover and interpret. Consider the processes of interpretation that occur in the following example. Donna was an industrious young wife who managed a job, children, and housekeeping. She rarely became sick, but, when an illness did occur, she felt considerable dismay at the response she received from her husband, Dave. When she most needed him to provide assistance and care, he seemed to grow irritable and pull away, leaving her with less physical and emotional support than when she was well. On one such occasion tempers flared, and an argument ensued. Suddenly Dave burst out, “You’re just like Mom. Sick all the time.” Donna and Dave were shocked at the remark. Donna was not sick all the time. Dave’s mother was sick all the time. Once the real issue, that of Dave’s frustration with his mother’s frequent illnesses, had been identified, Donna and Dave were able to work through the reality of the situation, and the problem was resolved.

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Filtration

The most concise delivery of information is subject to some amount of filtration. Compare the process to washing vegetables in a colander. A large amount of water is poured over the pro duce. Some of the water comes quickly through the colander holes, some water drips through more slowly; and some water hangs on the contents or settles in the solid portions of the colander and never filters through. If people were not able to filter out a part of the stimuli that bombard them daily, the clutter would be unmanageable! At the same time, however, it is possible to filter out some part of intended communication that is essential to facilitate understanding (Fig. 17-3).

Feedback

Feedback, simply put, is the response from the receiver. However, as with all communication, feedback is a dynamic process. As the receiver interprets and responds to the original message, the sender begins the same process of feedback to the receiver. Because of this circular property, the process frequently is referred to as the “feedback loop” (van Servellen, 1997). As with the original message, feedback is not confined to verbal responses alone. Both communicants constantly assess nonverbal communication as well. Feedback is formed based on all the components of interpretation and filtration.

Technology Informatics Guiding Educational Reform (TIGER)

TIGER Informatics Competencies Collaborative (TICC)

Brian Gugerty DNS, RN

Connie Delaney PhD, RN, FAAN, FACMI

Readers of this document are strongly urged to view the TIGER web site at http://www.tigersummit.com/ and download the Summary Report for the TIGER Phase II Collaboratives.  The Summary Report includes additional information about the TIGER Informatics Competencies Collaborative and provides much information about TIGER and its eight other initiatives.

Nurses are expected to provide safe, competent, and compassionate care in an increasingly technical and digital environment. A major theme in this new healthcare environment is the use of information systems and technologies to improve the quality and safety of patient care. Nurses are directly engaged with information systems and technologies as the foundation for evidence-based practice, clinical-decision support tools, and the electronic health record (EHR).

To help practicing nurses be responsive to the changes in their practice environments, a new specialty called Nursing Informatics has emerged over the past 20 years. The most recent 2008 American Nurses Association Nursing Informatics Scope and Standards defines nursing informatics as the integration of nursing science, computer and information science, and cognitive science to manage communication and expand the data, information, knowledge, and wisdom of nursing practice.

Nurses certified in Nursing Informatics are: * skilled in the analysis, design, and implementation of information systems that support

nursing in a variety of healthcare settings * function as translators betweeurse clinicians and information technology personnel

* insure that information systems capture critical nursing information 

These specialized nurses add value to an organization by:

·        increasing the accuracy and completeness of nursing documentation

·        improving the nurse’s workflow

·        eliminating redundant documentation

·        automating the collection and reuse of nursing data

·        facilitating the analysis of clinical data, including Joint Commission indicators, Core Measures, federal or state mandated data and facility specific data

While Nursing Informatics is a highly specialized field, there are foundational informatics competencies that all practicing nurses and graduating nursing students should possess to meet the standards of providing safe, quality, and competent care.

The Technology Informatics Guiding Education Reform (TIGER) Informatics Competency Collaborative was formed to develop informatics recommendations for all practicing nurses and graduating nursing students. Following an extensive review of the literature and survey of nursing informatics education, research, and practice groups, the TIGER Nursing Informatics Competencies Model consists of three parts, detailed in this document:

·        Basic Computer Competencies

·        Information Literacy

·        Information Management

VERBAL VS. NONVERBAL COMMUNICATION

Verbal Communication

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Verbal communication refers to the spoken word. Many factors influence the meaning of oral speech. An abundance of words can have several meanings. For example, consider the phrase, “He flew the plane.” Suppose more information is provided. “The cropduster flew the plane.” “The Air Force pilot flew the plane.” “The Coast Guard Search and Rescue pilot flew the plane.” The visual image of the plane changes with each statement from a small fixed-wing plane capable of dusting crops, to a jet, to an aquatic plane with pontoons for landing on 390 ‘Unit Three Leadership and Management in Nursing water. To carry the interpretation a step farther, it is likely that the impression of the intensity or style of flying also will change. Another clue to the meaning of oral communication is the tone or inflection with which the words are spoken. Suzette Haden Elgin (1993, p. 186) refers to the “… tune the words are set to.” More of Elgin’s work is available at www.sfwa.org/members/elgin/. The key to the true meaning of a statement may be contained in the emphasis placed on a specific word. Consider how differently the following phrase could be perceived based on the inflection or the emphasis on the wording:

• You are going to bed.

• You are going to bed.

• You are going to bed. With an emphasis on bed, the first phrase most likely will be perceived as an inquiry. The second phrase might imply that you are going to bed, but no one else is. The last phrase, an imperative, gives the impression of increased emotion such as anger or frustration.

Nonverbal Communication Nonverbal communication involves many factors that either confirm or deny the spoken word. Facial expression, the presence or absence of eye contact, posture, and body movement all project a direct message. Indirect messages that are nonverbal might include dressing style, lifestyle, or material possessions. Never presume that external trappings and physical presentation do not influence the quality of communication. Preconceived ideas and expectations interpret input from all such sources, often on an almost subconscious level. No one can miss the message regarding “body language” sung by the sea witch in the film The Little Mermaid (Ashman and Menken, 1988), which says that Ariel can win the Prince without her voice because of the power of body language. Body language can speak volumes—sometimes in support of the verbal message, but other times in direct opposition to the spoken words. Imagine being greeted by a door-to-door salesman with a proverbial silver tongue. He makes all the right statements about the lovely home and darling children but holds out a limp hand to shake and draws back when one of the children reaches toward him. Which message seems more likely to be true—the verbal or the nonverbal? The inability to make eye contact can be construed to mean that the speaker is shy, scared, or not telling the truth. The judgment of which condition is the correct one then is based on all the factors that feed into the receiver’s interpretation—perception, preconceptions, precipitating event, context, past experiences, environment, and transmission. Faced with the many opportunities for incorrect interpretation, is it any wonder that misunderstandings occur? An important concept to remember is that, when the verbal and nonverbal messages do hot agree, the receiver is more likely to believe the nonverbal message. Jan Hargrave (2001) tells us that our bodies give “hidden messages” all the time. We can’t get away from what our bodies say; they don’t lie! An understanding of the importance prescribed to body language and other nonverbal clues to the intent of the message explains the advantage of face-to-face communication whenever possible. Although a telephone conversation supplies verbal messages, intonation, and feedback, other signals are missing such as facial expression, body position, and environmental clues. The perils inherent in written communication are discussed later in this chapter.

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LOGICAL FALLACIES

Many times we find ourselves influenced by what appear to be justifiable arguments of others. Sometimes these arguments are not based on sound logic. Recognition of faulty logic will promote effective communication and save a lot of confusion or even conflict. The following are some logical fallacies that are frequently encountered. For more information on logical fallacies, you can visit the following sites: www.nizkor.org/features/fallacies/ or www. datanation.com/fallacies/index.htm.

Ad Hominem Abusive

Ad hominem abusive is an argument that attacks the person instead of the issue. The speaker hopes to discredit the other person by calling attention to some irrelevant fact about that person. Perhaps a nurse has just had a disagreement with a physician about laboratory results that were not properly reported. The nurse makes the following comment to colleagues: “She thinks she’s so smart just because she’s a doctor.” What does that have to do with the disagreement? Nothing. It is an unwarranted attack on the doctor. Does it accomplish the purpose? Very likely the group will be influenced by the disparaging comment. They may even become angry at the physician who had legitimate cause to be upset about not receiving laboratory results. Ultimately the issue of unreported laboratory values is lost in the attack against the doctor.

Appeal to Common Practice

Appeal to common practice occurs when the argument is made that something is okay because most people do it. This logic is likely to be faulty in two ways: (1) do “most” people really do it? (2) does common practice really make an action okay? It’s easy to imagine a situation in which using an explanation that you did something because you’d seen someone else do it that way, rather than checking the organization policy and procedure manual, could lead to significant professional and legal problems.

Appeal to Emotion

Appeal to emotion is an attempt to manipulate other people’s emotions to avoid the real issue. For example, consider Deb, RN, who has made a medication error. She has been called into the nurse manager’s office to discuss the incident and receives a written warning. She comes out tearful. It is obvious to her colleagues that she has been reprimanded. She begins to discuss the problem and makes the following statements: “I am the first person in my family to even go to college. I’m a single parent and I’ve worked so hard to get where I am. Our manager doesn’t care anything about that. She just wants to pass out written warnings to cover herself. She doesn’t care about us as individuals.” After a bit of this type of talk, the entire staff is probably becoming angry with the nurse manager—who may feel very badly about having had to give the written warning because she does care about her staff. However, Deb has successfully deflected the attention away from the real issue, the medication error that was legitimately addressed, and appealed to the emotions of her colleagues.

Appeal to Tradition

Appeal to tradition is the argument that doing things a certain way is best because they’ve always been done that way. This argument is often expressed as, “that’s just how it’s done here.” 392 (klnit ‘Three Leadership and Management in Nursing Another version would be, “Oh, we tried that once, and it didn’t work, so we went back to the old way.” Change always brings some uncertainty, but choosing to continue a practice just because “that’s the way we’ve always done it” is not very sound reasoning. Health care is a very dynamic arena. The old ways of doing things seldom work out to be the best in this time of rapid change.

Confusing Cause and Effect

Confusing cause and effect occurs when we assume that one event must cause another just because we often see the two events occur together. Amber and Chyane are nurses in labor and delivery. One night shift, two mothers delivered babies with significant “birthmarks.” It happened to be a night with a full moon. Amber states, “Clearly, babies born on a night during the full moon are more likely to have birthmarks.” She makes the assumption that since the moon was full and two babies were born with birthmarks, some cause-and-effect relationship must exist.

Hasty Generalization

Hasty generalization involves coming to a conclusion based on a very small number of examples. A hasty generalization occurs whenever an assumption is made that a small group represents the whole population. Two nurses are discussing a co-worker who seems a bit disorganized and always leaves a mess. One of the nurses makes the following statement, “Well, what do you expect from a blonde? You know how ditzy Capri was, and she was a blonde, too.” The hasty generalization here is that, because the nurse knew two blondes who were disorganized and messy, all blondes must be disorganized and messy.

Red Herring

Red herring is the introduction of an irrelevant topic to divert attention away from the real issue. Two nurses, Brian and Nikoah, are having an argument regarding Brian’s failure to complete his assigned tasks. Brian states, “It’s not my work that you’re really mad about. It’s that I’m a guy. You just don’t like male nurses.” Nikoah then begins to defend herself, denying any prejudice against male nurses. The focus of the argument has been turned from the real issue, Brian’s failure to complete his assigned tasks, to a situation in which Nikoah is on the defensive about her opinion of male nurses.

Slippery Slope

Slippery slope is the belief that an event will inevitably follow another without any real support for that belief. In fact, this type of logic often leads from a fairly harmless situation to an assumption akin to the notion that the sky is falling. Kathy and Janet are talking in the nurses’ lounge over lunch. Kathy is upset over the recent announcement that the unit is going to convert to computerized bedside charting. Kathy states, “It was bad enough having to chart all we do. Now we have to learn to use computers and make all kinds of entries. We’ll probably have just as much paperwork. We’ll end up spending even less time with the patients. The next thing you know, nurses will be sitting at a computer terminal, and someone else will be taking care of patients. Then they’ll decide they don’t really need nurses at all!” Kathy’s logic takes her from a simple unit change to the end of nursing as we know it! Yet we often hear that kind of “escalating disaster” logic when change is introduced.

Straw Man

Straw man occurs when the actual issue is ignored and replaced with a distorted or exaggerated version. Cindy and Toi, both labor and delivery nurses, are discussing one of the local politician’s stand on abortion. Toi states, “Dave Stroud said in an interview that he is very strongly opposed to late-term abortions.” Cindy becomes angered immediately and says, “Oh, so he doesn’t believe in abortion. He thinks a woman doesn’t have a right to choose, to say what happens to her own body. I figured him for that kind of a person.” In actuality, the interview said nothing about the politician’s opinion on abortion earlier in a pregnancy. Cindy’s faulty logic has effectively represented Mr. Stroud as insensitive to women, with nothing to support that position. She has not only exaggerated his stated opinion but distorted it to imply an attitude that was never addressed in the statement. Understanding these logical fallacies should help the nurse recognize the difference between legitimate and faulty reasoning. A clear understanding and use of sound logic will help health care providers present issues and resolve problems effectively.

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POSITIVE COMMUNICATION TECHNIQUES

Trust rust between the nurse and the patient is essential to effective communication and often must be cultivated. Factors that enhance the development of trust include openness on the part of the nurse, honesty, integrity, and dependability. These can be achieved by:

• Communicating clearly in language that laypersons can understand.

• Keeping promises.

• Protecting confidentiality.

• Avoiding negative communication techniques such as blocking and false reassurance.

• Being available to the patient.

The need for trust is not limited to the nurse-patient relationship, but rather it pervades all associations. Care is more effective when the nursing team and the transdisciplinary team share the essential element of trust.

“I Messages”

The use of “I messages” is a fundamental component in acceptable communication. Consider the following exchange. Laura: “You make me so mad, Donald.” Donald: “I don’t mean to make you mad.” Laura: “Well, you do. You never think about how I feel. You know I hate it when you leave a patient’s room as cluttered as 103.” Donald: “You don’t have the vaguest idea what went on here last night! That’s what I hate about you—always so quick to judge. You are so critical. You must think that you’re perfect!” When a comment starts with “you,” most commonly the receiver’s defenses will promptly go on alert. The use of “you” in such a context sounds—and most probably is meant to be— accusatory. Notice how the emotions quickly escalate to anger. Notice that, although initially the receiver tries to sound conciliatory, he soon begins to respond in like form. Instead of using accusatory and defensive language, the sender should place emphasis on his or her feelings, rather than on the receiver as the cause of the feelings.

“Donald, I feel so upset when I find a cluttered room like 103 at the beginning of my shift. I feel as if I’m behind when I start.” The difference is obvious. When “I messages” are used, they become less likely to sound accusatory. By using such an opening, the sender allows the receiver to respond to the true message rather than start to mount a defense. It allows for more effective communication because the receiver is more likely to offer an explanation such as the following. ‘Tm really sorry about room 103, Laura. I guess the wheel that doesn’t squeak doesn’t get oiled, as they say. Our shift started last night with a patient coding right after he arrived from the Emergency Department. There was no family here. It took forever to find them and then to support them through the shock. About the time things settled down, the patient in room 110 coded. It was quite a night.” In this instance the “I message” enhances communication by giving Donald the opportunity to address the real concern. In addition, if Laura is truly astute, she has a wonderful opportunity to support her colleague by voicing appreciation for the working circumstances of his shift. Most people respond gratefully to recognition and commiseration. The exchange could build collegiality between the two co-workers and perhaps between the two shifts.

Eye Contact

As mentioned previously, avoiding eye contact can be interpreted a number of different ways. A person who does not make eye contact may be thought to be shy, scared, insecure, preoccupied, unprepared, dishonest—the list could go on and on. None of these qualities is likely to be appreciated in a primary caregiver. By making direct eye contact, the nurse gives undivided attention to the patient, and the patient is likely to feel valued and understood by the nurse. Eye contact in essence says, “I am wholly available to you. What you are saying is important to me.” Eye contact is equally important in communication with co-workers and other members of the transdisciplinary team. This quality is lost in telephone conversations or written communications. Keep in mind that the use of direct eye contact is a Western value. In some cultures avoidance of eye contact is more appropriate social behavior. By careful observation, the nurse quickly will recognize whether direct eye contact is interpreted as inappropriate or disrespectful. Nurses must make every effort to be sensitive to the cultural values of the client and their co-workers to enhance effective communication.

Promise Keeping

Little else can destroy the fragile trust developing in any interpersonal relationship as quickly as making and then breaking promises. Inherent in the concept of promise keeping are the qualities of honesty and integrity. Once a commitment is made, every effort must be expended to fulfill the expectation. Sometimes the request is impossible to satisfy. If this happens, the nurse must explain the situation or circumstances. The fact that the patient understands that the nurse has made an effort to meet his or her needs or desires often is more important than whether the goal is accomplished. If the nurse responds, “I’ll check on that,” and then finds the request impossible to fulfill but never returns with an explanation, the lack of dependability per

Empathy

Empathy is the ability to mentally place oneself in another person’s situation to better understand the person and to share the emotions or feelings of the person. Empathy is not feeling sorry for another. Empathy is understanding the experiences of the other person. Devel opment of empathy builds the nurse’s ability to help the patient through a true understanding of the patient’s feelings and needs. Empathy is integral to the therapeutic relationship. The nurse is able to perceive and address the needs of the patient without emotional involvement to the point of becoming inappropriately immersed in the situation.

Open Communication Style

Certain styles of phrasing questions and statements lend themselves to obtaining more information. For example, suppose Chris asks Mr. Barrow, “Do you know where you are?” and Mr. Barrow responds, “Yes.” Can Chris assume that Mr. Barrow knows he is in the hospital? Not necessarily. Chris may be surprised to hear a completely unexpected response if he rephrases the inquiry. “Mr. Barrow, tell me where you are.” “Why I’m in the honeymoon berth of the Titanic, of course. Have you seen my lovely bride?” Using open-ended questions or statements that require more information than “yes” or “no” can augment gathering enough facts to build a more complete picture of the circumstances. Questions or statements that are phrased to require only one- or two-word responses may miss the mark entirely.

Clarification

Both communicants have a responsibility to clarify anything not understood. The sender should ask for feedback to be certain the receiver is correctly interpreting what is being said. The receiver should stop the sender anytime the message becomes unclear and should provide feedback regularly so that misinterpretation can be identified quickly. Such phrases as, “What I hear you saying is …” or “I understand you to mean …” help to communicate to the sender what is being perceived. Other techniques of clarification include using easily understood language, giving examples, drawing a picture, making a list, and finding ways to stimulate all the senses to enhance the ability to understand.

Body Language

Body positioning and movement send loud messages to others. The nurse can imply openness that facilitates effective communication by awareness of body position and movement. In addition to eye contact, effective communication is enriched through an open stance, such as holding one’s arms at the side or out toward the patient, rather than crossed, or leaning toward the patient as if to hear more clearly rather than away from the patient.

Touch

Most people have a fairly well-defined personal space. It is important for the nurse to be sensitive to each patient’s personal preference and cultural differences in terms of touch. However, for many people a gentle touch can scale mountains in terms of demonstrating genuine interest and concern. A pat on the back, a hand held, a back rub are all behaviors that indicate availability and accessibility on the part of the nurse.

 

NEGATIVE COMMUNICATION TECHNIQUES

Several negative communication techniques have been alluded to in the previous discussion. Closed communication styles such as asking yes-no questions or making inquiries or statements that require single-word answers potentially limits the response of the person and may prevent the discovery of pertinent facts. Closed body language also can hinder effective communication. Crossed arms, hands on the hips, avoidance of eye contact, and turning or moving away from the person all impose a sense of distance in the relationship.

Blocking

Another technique that is detrimental to good communication and the development of a trusting relationship is blocking. Blocking occurs when the nurse responds with noncommittal or generalized answers. For example: “Nurse, I’ve never had surgery before. I’m afraid I might not ever wake up.” Mr. Clayton is twisting the bedsheet as he speaks. “Oh, Mr. Clayton, many people feel that way. It’ll be okay.” Amanda Butler, RN, smiles brightly, pats his hand, picks up the dirty linen bag, and bounces out of the room. Does Mr. Clayton feel reassured? Not likely. Will he be inclined to broach the subject with Amanda again? Probably not. Amanda has incorporated some important aspects of communication into her response—cheerfulness and touch—but she has not truly communicated. She has effectively blocked Mr. Clayton’s attempt to get the reassurance he wanted from her. He may be too intimidated to ask anyone else, assuming that his fear is invalid. By generalizing in this way, Amanda has trivialized Mr. Clayton’s concerns. He is not “many people.” He needs to be validated as a person experiencing a legitimate feeling. Amanda can validate his fear and put it into perspective at the same time with a different approach. Nurse: What makes you think you might not wake up, Mr. Clayton? Patient: Well, my wife’s cousin’s husband had surgery about 25years ago, and he never woke up. Nurse: What kind of surgery did he have ? Patient: Uh, it was some kind of heart surgery, and he had another heart attack on the table and died right there. Nurse: It sounds like his condition was critical going into surgery. Patient: Yes, ma’am. He’d been sick for a long time. Nurse: It’s not uncommon to feel afraid of being put to sleep, especially if you have never had surgery before. There are rare cases in which complications do occur during surgery. That’s why we put the disclosures on the consent form, so that you will know just what the risks are. Thankfully most surgeries are without such drastic problems. Although your gallbladder certainly has made you uncomfortable, you are otherwise in good health. The tests that were done before surgery, like the chest radiograph and the laboratory work, show that you are healthy and should do well with the anesthesia. That drastically decreases the chance for complications in your case. I would be glad to answer any other questions you have or to ask the anesthetist to come and talk with you some more. Amanda has validated Mr. Clayton’s feeling as legitimate, provided an explanation with reasonable reassurances, and offered to explore the issue with him further, or to have someone else talk with him. Some things are difficult to talk about with another person. The dying patient may want to talk about how he or she feels, ask questions, or perform a life review. A nurse who is uncomfortable with such topics may consciously or unconsciously block communication through generalizations or closed responses. Avoiding the blocking technique requires a good understanding of oneself. If unable to provide the open communication the patient obviously needs, the nurse should access other personnel who are more comfortable in the situation. This might be another nurse, a social worker, a physician, a member of the clergy, a family member, or a friend of the patient.

False Assurances

False assurances are similar to and have about the same effect as blocking. When someone is trying to get real answers or express serious concerns, an answer such as “Don’t worry,” or “It’ll be okay” sends several unintended messages. Such an answer can be interpreted by the patient as placating or showing a lack of concern or a lack of knowledge. The patient might even conclude that the nurse is being neglectful through trivialization of an issue that is important to him or her. At the very least, the nurse has neither recognized the need the patient has expressed nor provided validation.

Conflicting Messages

Conflicting messages also have been alluded to in the previous discussion. If a person professes pleasure at seeing someone but draws back when that person extends a hand of greeting, the nonverbal message speaks more loudly than the words spoken. If a nurse enters a room and goes through the routine greeting by rote (even with a smiling face and a bouncing step), a patient can quickly perceive this and consider the nurse less approachable. The nurse’s statement that the patient’s condition is important to the nurse followed by failing to answer the call bell in a timely manner or by forgetting to bring items promised to the patient sends a double message. Such behavior can leave the patient confused, frustrated, or angry. Carrying through with a commitment, no matter how unimportant it may seem, is a premier method of saying to the patient, “You are important to me.”

LISTENING

Neal Samuels, RN, decided to make an unplanned stop at the clinic one evening after hours, arriving without his magnetized name badge that would let him in select doors. As he pushed the intercom button outside the door to contact security, he formulated a concise message to explain his predicament. He could see the security guard through the tinted window. A clear voice sounded through the speaker, “Police Department. Can I help you?” Neal responded, “Yes, my name is Neal Samuels. I am on the School of Nursing faculty. While I was out shopping, I realized I needed to stop by my office, and I don’t have my badge with me to open the door. Would you let me in?” “Do you work here?” the officer asked. “Yes, I work in the School of Nursing.” “Then use your badge to get in.” “I don’t have it with me,” Ned repeated. “What did you say your name was?” the officer responded. And so it went. Listening certainly is as important an element in clear and effective communication as any other component. Many distracters contribute to poor listening habits. Framing an answer while the other person is still talking interferes with receiving the entire message. Environmental disturbances can provide major disruption. A crying baby, a call light buzzing, or multiple concurrent conversations in a busy nurses’ station are a few of the interruptions that jumble the simplest of instructions. Preexisting concerns or worries can block absorption of conversation because of the preoccupation. Attempts to continue work in progress leads to inattention. Ineffective engagement or peculiar mannerisms on the part of the speaker can be distracting. A person who does not make eye contact, shuffles through papers while talking, or overuses hand movements actually can deter communication.

A number of techniques can be used by the receiver to facilitate the ability to listen.

• Give undivided attention to the sender by moving to a quieter area and stopping the speaker to clarify any points not understood.

• Provide feedback in terms of perceived meaning of the message rephrased in the receiver’s own words.

• Give attention to positioning to face the sender and make eye contact.

• Note nonverbal messages such as body language and respond to them.

Mindful listening will dramatically improve the likelihood of receiving the correct message. However, equally important is the fact that attentive listening implies a respect for the speaker and communicates a regard for what the speaker has to offer. The nonverbal message that keen listening delivers is, “I value you, and what you have to say is important to me.”

WRITTEN COMMUNICATION

Rhonda stared at the sign in amusement. Concurrent seminar sessions had been planned in a large room equipped with sliding soundproof panels that could be rolled along a track to effectively divide the large room into two smaller conference rooms. However, the sections had not been moved into place to create the dividing wall—the panels remained in two rows on short tracks against a structural wall. For the past 20 minutes, Rhonda had watched several of the attendees struggle to move the dividers along the track. The group quickly realized that the sections would need to be moved in an alternating fashion from first one side row and then the other row. When the last piece should have slid into place, it became obvious that the panels should have been pulled out in reverse order. All the panels had to be replaced in storage position. The process then was redone starting with the opposite panel row. When the last section finally was pulled into place, the audience burst into a round of applause. Simultaneously, the following sign, written in large black print on white paper and posted at eye level, came into view (Fig. 17-4). The message certainly is clear. Did the sign accomplish its intended mission? Not by a long stretch! Undoubtedly the placard was effective when the dividing wall was in use because it could be clearly seen. However, when the panels were stored, the sign was completely covered. Even the most carefully worded and designed message can go astray if not properly directed to the intended audience.

 

 

The professional nurse must interface with many forms of written communication on a daily basis. Nursing documentation includes a variety of reports—the nurse’s notes in patient charts, memos, kardexes, incident reports, discharge teaching forms, and written shift reports, to name a few. Many of the forms that nurses use for documentation are part of the legal record and require careful consideration. Unclear instructions or reports either written or read by the nurse can lead to misunderstandings, errors, and the potential for litigation. Most profoundly, misinformation potentially can lead to patient harm or injury. Therefore special attention must be paid to communicating effectively in writing.

Accuracy

Absolute accuracy is paramount in recording legal documentation. For the nurse, this most specifically applies to the nursing notes or any other entry in the patient’s chart. Every effort should be made to report concisely, descriptively, and truthfully. To write “Patient walked today” is not adequate. A more concise and descriptive entry reads, “Patient walked to the nurses’ station and back three times this shift, a total distance of 96 yards.” (Many hospitals have distance measures marked in the hallway for this purpose.) Cody Johnson, RN, entered a patient’s room and found her agitated and speaking loudly into the phone as she twisted her hair with her free hand. She was crying and periodically pounded the bedside table with her fist. Later the patient told Cody that she had been talking with her mother. Would it be appropriate for Cody to chart, “Patient became very angry with her mother while talking on the phone.” No! The nurse must be diligent not to include personal judgments or quantify the patient’s emotional state in such terms. More accurately, Cody could chart, “Patient found crying while talking on the phone in a loud tone to her mother. Patient was twisting her hair and hitting bedside table with her fist.” The information is descriptive and states exactly what Cody observed factually without any judgmental conclusions. If, however, the patient had said, “My mother makes me so mad,” Cody could have charted the statement as a direct quote (enclosed in quotation marks).

Attention to Detail

In addition to absolute accuracy, written documents should be descriptive. As mentioned in the previous section, information should be quantified whenever possible. How many feet did the patient walk? How many times was the patient out of bed? How many milliliters of fluid did the patient drink? Precisely what did the patient say? Words can be used to depict a verbal picture of a wound, rash, bruise, or any type of injury or situation. Illustrative terms can create a mental image for the person reading the notes, memo, or other communication. Descriptive categories can include measurement, color, position, location, drainage, or condition when speaking of a physical condition; or time, setting, people present, issues or goals discussed, or direct quotes when speaking of a meeting, conference, evaluation, or other interchange. Consider the differences between the following written communications. “1000 Dressing change completed. Site healthy.” “1000 Dressing change completed. Edges of 4-inch surgical wound approximated, no drainage noted. Skin pink without any redness or edema.”

The second entry allows the reader to “see” the wound mentally and follow the progress of healing even when unable to be present at the time of the dressing change. A good rule when describing any kind of break in skin integrity—whether from a stabbing, a surgical wound, an intravenous line, and so on—is to describe color, drainage, and presence or absence of edema. Consider the memo written in Box 1. What does this memo really tell the nurse manager? Not much—only that there is some kind of perceived problem between Lucas and the students. The nurse manager does not know based on the information provided if the problem is “real,” if it is based on a bias of Jessica’s or a student bias, if it has occurred more than once, if an interpersonal communication problem or misunderstanding exists, or if obvious mistreatment of a student or students has occurred. Now consider the memo written in Box 2. Carefully constructing a factual memo of this length is more time-consuming initially, but it will save a lot of frustration in the long run. The nurse manager now has a clear picture of what has occurred and knows that an ongoing problem exists. Most appropriately, Jessica will speak to Bonnie about the problem, even if only briefly, when she delivers the memo. However, a written account of the incident must be submitted and should be composed promptly while the facts are freshly remembered. In addition, written communication often is the first source of contact because the nurse manager is not likely to be immediately available on all shifts. The skill of writing concisely yet descriptively must be developed. Over some time, nurses build a repertoire of phrases and illustrative terminology that are useful and effective. Often, when a nurse is stumped as to how to express a situation, she or he will ask a colleague, “How would you write…?” Accessing the experience and expertise of nursing peers is productive in terms of problem solving while also demonstrating respect for the colleague.

 

 

 

I have had lots of complaints about Lucas Alfred’s treatment of students. I do not think he should be assigned as a preceptor anymore and do not plan to do so from now on.

Thoroughness

The memo example in the previous section also illustrates the need for thoroughness. In addition to being descriptive in terms of the incident, Jessica reported her interview with other nursing students. By doing so, Jessica has been thorough in describing and reporting the extent of the problem she has discovered. Providing such complete information helps to avoid communication breakdown. Anticipating and answering relevant questions before they are asked exemplifies thoroughness and clarifies communication.

Today (Monday, August 18) at 07101 observed what appeared to be an animated conversation between Lucas Alfred, RN, and John Roberts, SN, a student nurse from North Hills University. As I moved toward them, I heard Lucas say loudly, “Well, you better stay with me because I am not going to come looking for you all day. I know how lazy students are.” I asked Lucas, “Is there a problem?” He replied, “Oh, no problem. I just hate having students, that’s all. They’re more trouble than they’re worth.” I asked Lucas, “Would you prefer that I reassign the student?” He shrugged his shoulders and walked away. I suggested to the student that I assign him to another nurse for the day. He responded, “I’d really appreciate that. Mr. Alfred has let me know since I arrived that he didn’t want to work with me.”

Because this group of students has been on the unit 2 days a week for the past 3 weeks, I spoke to the other students who had worked with Lucas and asked them how things had gone. The other three students who have worked with him reported similar experiences.

I would like to arrange a time to meet with you and Lucas to address this problem.

 

 

Approach and Strategy

The TIGER Informatics Competency Collaborative (TICC) did an extensive review of the literature for informatics competencies for practicing nurses and nursing students. TICC also collected informatics competencies for nurses from over 50 healthcare delivery organizations. The results of these efforts are available on the TICC Wiki (http://tigercompetencies.pbwiki.com). This resulted in over 1000 individual competency statements. This body of competencies was synthesized to create the three parts of the TIGER Nursing Informatics Competencies Model: Basic Computer Competencies, Information Literacy, and Information Management.

Once we developed the model, we aligned each component with an existing set of competencies maintained by standard development organizations or defacto standards. We found very good fits with the existing standards of the European Computer Driving Licence Foundation, the Health Level 7’s electronic health record functional model clinical care components, and the American Library Association information literacy standards respectively. All of these sets of competencies are standards maintained by standard setting bodies or organizations. Finding sets of competencies that are maintained by standard setting bodies allow the TIGER Informatics Competency Collaborative (TICC) to recommend standards that are relevant to nurses and ones that will be sustainable as these

bodies evolve the standards as necessary. Of equal or perhaps greater importance, these standard-setting bodies all have put tremendous thought, energy and expertise into there recommended competencies. When those competencies aligned with the informatics competency needs for nurses, we adopted theirs, thus adding strength, rigor, and validity to the TICC recommendations. 

Component of the TIGER

·        Nursing Informatics Competencies Model

·        Standard Standard-Setting Body and Basic Computer

·        Competencies

·        European Computer Driving

·        Licence

·        European Computer

·        Driving Licence Foundation

·        Information Literacy Information Literacy v:shapes=”_x0000_i1033″>

·        Competency Standards

·        American Library

·        Association

·        Information Management Electronic Health Record v:shapes=”_x0000_i1034″>

·        Functional Model – Clinical

·        Care Components

·        Health Level Seven (HL7)

·        European Computer Driving

·        Licence – Health

·        European Computer

·        Driving Licence Foundation

·        Conciseness

Written communication must be concise. The message must state the necessary information as clearly and as briefly as possible. Consider the memo written in Box 3.

 

 

Whew! Extraneous details tend to confuse more than clarify. An inherent dilemma often develops as the nurse attempts to determine how to be descriptive and concise at the same time. One must determine what facts are pertinent to enable the reader to understand the true message. When in doubt and when appropriate, the writer can ask another party to read the message and provide feedback to the writer as to what the reader believes the message means. However, the right to confidentiality and privacy of the people involved must be observed. This basic principle applies to patients, families, students, members of the health care team—to all persons. Consequently, the nurse must be as judicious in handling written material in a confidential matter as with any other form of communication.

 

ELECTRONIC COMMUNICATION

More and more communication is computer-based using e-mail, chat rooms, attachments, and other electronic modes. The computer-based written record can be somewhat more transient than other written documents. For example, e-mails are often read and then deleted. However, remember that communication via the computer can be saved and is often retrievable even after deletion. As with any form of written communication, computer-based interaction loses nonverbal cues. Therefore it is important for the sender to elicit feedback and/or for the receiver to ask for clarification if the meaning of the communication is not clear.

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COMMUNICATION STYLES

Development of truly effective communication necessitates understanding various communication styles. In addition to the concepts discussed up to this point, characteristics exist that might impede efficacious exchange of information. Issues such as gender differences, cultural diversity, assertiveness vs. aggressiveness, and dissimilarities in the professional approach of the various health care disciplines all contribute to disparate understandings and interpretations.

Communication and Gender Differences

A significant clarification must be made regarding communication between men and women. Although research and many years of observations and writings have produced information about gender differences resulting from socialization, these are generalizations and should be viewed from that perspective. Attributes described do not necessarily apply to all persons or all of the time. Nevertheless, a plethora of observations indicate that men and women solve problems, make decisions, and communicate from different perspectives based on socialization that begins shortly after birth (Cummings, 1995; Elgin, 1993; Heim, 1995). Typically boys are taught to be tough and competitive; girls are taught to be nice and avoid conflict. Dr. Pat Heim (1995, p. 8) suggests, “Playing team sports boys learn to compete, be aggressive, play to win, strategize, take risks, mask emotions, and focus on the goal line.” Regarding girls’ play, Dr. Heim comments, “Relationships are central in girls’ culture and therefore they learn to negotiate differences, seek win-win solutions, and focus on what is fair for all instead of winning.” Clearly, learning to approach life on such different terms—with different rules—can lead to frustration, sometimes a sense of total defeat in the communication arena! For the most part women work toward compromise, even when it means relinquishing some of the original goal. Preserving relationships is usually of paramount importance to women. The role of peacemaker and nurturer has been a traditional expectation of women throughout the ages. Generally men work toward winning. Traditional role expectations of men have included provider and protector. Men learn early in life how to focus on goals and move aggressively toward accomplishment. Team sports teach men that relationships are not destroyed in the “battle” (Heim, 1995). Consequently, men have been socialized to behave assertively when such performance is needed in pursuit of the goal and then move on without loss of friendships. Women have been socialized that assertive behavior will endanger relationships and that conflict should be avoided to preserve friendships. On the other hand, men tend to communicate with a purpose to achieve an identified goal. If conflict occurs during the process, it is simply dealt with as part of the routine. Men are more likely to give concise responses and make prompt, straightforward decisions. Women most often seek to communicate with sensitivity (i.e., how the information is being received and what adjustments need to be made in the presentation, and perhaps the proposed solution, to avoid outright conflict). Decision making involves discussion as part of the problem-solving process. Men typically use communication as a tool to deliver information, whereas women value the process of communication itself as an important part of the relationship. Therefore, in an effort to improve communication, men might try spending more time in discussion, and women might try to phrase comments more succinctly. Consider the following conversation. Nurse: Dr. Vernon, I’m calling to talk to you about Mrs. Guevara. She says she’s having more pain and feels a little dizzy. I’ve given her her pain medicine as soon as I can each time. She says she’s a little nauseated. Her husband’s in the room, and he says she feels worse too. She did not sleep much last night and has not been able to nap today… Doctor: I have patients to see! Just give me the facts. Nurse: Okay, she’s had her medication every 4 to 5 hours this shift. I don’t know if she needs a higher dose or just needs the medication more frequently, or maybe we should try a different medicine. Doctor: What are her vitals? Does she have any drug allergies?” Nurse: Just a second, and I’ll get the chart. Doctor: Confound it, when you get your act together, call me back! Dr. Vernon slams down the phone.

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Consider the many communication styles and concepts illustrated by the previous conversation. Preparedness, conciseness, contributing environmental conditions (patients waiting), and even courtesy are issues that could be more competently addressed. The fact that the conversation is occurring by telephone instead of in person also is a factor, responsible for the lack of eye contact and the lost potential for additional information through other body language. Telephone conversations are a fact of life in health care. Careful planning and preparation of what will be said will facilitate effective information exchange. In the professional setting especially, men are more prone to favor brief, concise information exchange. In the professional setting women still tend to prefer verbal problem solving as the situation is discussed. Knowledge of the gender differences in communication style could have altered the nurse’s telephone call in the following manner. “Dr. Vernon, this is Holly Michaels, RN, from Fairmont General calling about Mrs. Guevara in room 496. She has been receiving her pain medication exactly every 4 hours and continues to complain of incisional pain. She currently is complaining of slight dizziness and nausea, although she has had no emesis. Her blood pressure is 135/86; pulse, 112; and respirations, 24, which are higher than they have been running. Her temperature is 98.8° F. She has no drug allergies. How would you like to change her orders?” Holly has prepared the information the physician will need and communicates it in an orderly fashion. The issue of gender differences deserves special consideration in health care. Most nurses are women, whereas male physicians significantly outnumber female physicians (Heim, 1995). The current gender mix in medical schools is approaching 50-50 (Heim, 1995), although a number of years will pass before that balance permeates the population of practicing physicians. Unfortunately the general public continues to view nurses and physicians somewhat stereotypically—the female nurse as the helper of the male physician. Consequently, the health care arena is almost “set up” to experience increased problems associated with differing communication styles between genders. Dealing with resultant conflict is discussed later in the chapter.

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Cultural Diversity

 Although Chapter 11 is devoted to cultural and social issues, it is important to highlight cultural issues specific to communication. Sensitivity to cultural differences is an integral part of the nurse’s responsibility. Many cultural beliefs are tightly interwoven with strong religious convictions. Societies throughout the world depend as strongly or even more strongly on a variety of alternative healing sources as they do on medical science. Some people rarely have an opportunity to interface with medical science as it is known in the “developed” countries. The obvious difficulty is a potential language barrier. Even if the person speaks English as a second language, the preponderance of slang terms and colloquialisms can confound a literal translation. In addition, the stress associated with illness and possibly hospitalization only adds to the potential for misunderstanding and frustration. Fortunately most communities have interpreters willing to translate in the health care setting. The variety of language interpreters (including sign language for the deaf) available even in smaller communities is surprising. Although many persons of various cultural backgrounds willingly access the health care system, they concurrently adhere to the beliefs and traditions of many generations of their ancestors. Health customs often involve a faith healer and the use of alternative treatments such as herbal remedies, rituals, and blessings. Attributing healing powers to material objects such as stones, statues, or blessed water (whether in containers or rivers) is not uncommon. Latasha Williams, RN, an intensive care unit nurse with many years of experience, recently relocated to the southwestern United States. On entering the room of a septic patient, she observed a family member slowly moving an egg above the prone body of the patient. Latasha was shocked at the peculiar behavior, hardly knowing how to respond. Because other family members encircled the bed in what appeared to be an almost prayerful stance, Latasha quickly backed out of the room and went to the nurses’ desk. Sitting down with a stunned expression, she said to a colleague, “Manuel, you will never believe what I saw in your patient’s room when I went in to check the monitor alarm.” Latasha proceeded to describe the scene. Manuel Garcia, RN, chuckled and responded, “Latasha, the family is removing the patient’s fever. The egg will absorb the fever and help make the patient well.” “You have got to be kidding,” snapped Latasha. “What kind of hocus-pocus is that?” “It is part of faith healing.” Manuel looked irritated. “Surely you do not believe in such a thing. Why don’t you stop them and teach them what will really help the patient? We’re supposed to teach patients and their families real health care.” Latasha was incredulous. “How can we judge what part faith plays in healing? I have taught the patient and family about sepsis and explained every procedure and treatment. They have expressed an understanding of what we are doing and how it is helping. Their use of the egg to remove fever is not disrupting patient care. They’re not even touching the patient! Don’t you think that in this case nontraditional healing practices and medical science can combine for the best treatment of the patient and the family?” Latasha’s reaction to a behavior unknown to her is neither surprising nor unusual. Her commitment to patient teaching to promote understanding of the medical beliefs she embraces as a nurse is exactly as it should be. However, Manuel’s approach to tolerance of cultural healing beliefs while delivering competent, scientific nursing care is vastly more sensitive. The balance between alternative healing and medical science sometimes is precarious. Maintaining equilibrium with quality patient care at the center requires knowledge and perceptivity.

Many forms of communication do not carry the same meanings in various cultures. In some instances direct eye contact is to be avoided if possible. Touch, also considered a positive communication technique in Western culture, may be perceived as a serious invasion of privacy. Some gestures considered innocuous in one culture may represent vulgarity in another. Some cultures strictly adhere to paternalism; unless the male head of the family agrees to a procedure or treatment, the family member will refuse under any circumstance. Although a sense of modesty is shared by many people, some cultures experience a greater feeling of violation at having to expose certain body parts than do others. The consumption of certain foods, the use of blood or blood products—the possibilities of culturally diverse practices are endless. The prudent nurse will become familiar with the specific cultural practices in the region of her or his employment.

Assertiveness vs. Aggressiveness There is a clear distinction between the terms assertive and aggressive. Aggressiveness implies an inclination to start quarrels or fights, whereas assertiveness connotes a style of positive declaration, a persistent demonstration of confidence. The difference becomes obviousaggression conveys dominance, assertion conveys confidence and competence. The line between the two behaviors can easily become blurred if one or both parties direct or receive controversial comments personally. A review of the vignette involving Donald and Laura (“I Messages”) provides an example of how easily a conversation can be perceived as a personal attack and escalate into aggressive behavior. All of the positive communication techniques and styles that have been discussed must be used to produce assertive rather than aggressive communication. To speak assertively, the person must be sure of the facts, have carefully considered the options, and exude confidence while making the observation, request, or point. Aggressive behavior often leads to conflict and seldom to resolution or effective communication.

The Transdisciplinary Team

The transdisciplinary team is composed of a variety of disciplines approaching health care from the unique perspective of the theories and therapies of the individual profession. Consider the variety represented by nurses, physicians, dietitians, respiratory therapists, pharmacists, physical therapists, psychologists, and social workers. Then add to the mosaic the sublevel of specialists: cardiologists, endocrinologists, oncologists, orthopedists, recreational therapists, occupational therapists, licensed vocational (or practical) nurses, registered nurses, nurse anesthetists, nurse practitioners, nurse scientists, and unlicensed assistive personnel. Registered nurses with varied educational backgrounds (diploma, associate degree, bachelor or master of science iursing) and licensed vocational nurses sometimes can be found in the same unit with similar assignments. Now add managers, administrators, clerical staff, accountants, and housekeeping, to name a few. Also consider cultural differences among health care professionals and workers. Is it any wonder that communication disasters occur? All of the positive communication techniques have to be used to clearly understand another’s perception. Listening is an essential tool for determination of the intended message as seen from the unique perspective of the other discipline. Frequent clarification and a sense of “safety” are paramount as people explore the meanings that each person attributes to the situation and the discipline-specific suggested solutions. Realization that the fundamental basis of all health care professionals and of ancillary staff is to provide quality patient care should keep all interactions focused on a common goal.

Confidentiality and Privacy

No discussion of communication would be complete without reference to the proverbial “grapevine,” which, despite consistent efforts to the contrary, appears to be alive and well. Breach of confidentiality and the patient’s right to privacy through careless gossip has ethical and legal ramifications. Thoughtless conversation in the elevator, the dining room, the parking lot, or any other public place has created heartache for the client and the health care provider. Other sites where communication about confidential or personal patient issues needs to be controlled include the nurses’ station, any desks or tables along the halls commonly used for charting, and the utility rooms. Such locations are not often viewed as “public” places, but many people pass by these areas and overhear information they should not, especially during change-of-shift reports. Unfortunately there is a great curiosity among people regarding illness and health care issues, and some people may linger in these areas to glean information. In some circumstances diagnoses carry major social implications that can easily lead to prejudicial treatment in terms of employment, insurance coverage, and social standing. The nurse is bound by the ethics of the profession and the laws of the United States to protect the patient and the patient’s family from improper disclosure of personal information. To carry the concept a step further, the nurse is limited in the type of information that is appropriate to access. In the age of informatics, more information is available, literally at the fingertips. For example, accessing the record of an acquaintance simply to know “what’s going on” with the patient is an absolute infraction of ethical and legal standards. The professional nurse is obligated to know only information that will facilitate quality physical, spiritual, and emotional care to his or her assigned patients. Satisfying curiosity beyond the legitimate requirements of providing care, engaging in gossip, or otherwise compromising the patient’s confidentiality is a grievous breach of nursing standards.

Delegation

Although an entire chapter is dedicated to delegation, the importance of effective communication in the delegation process cannot be overemphasized. Hansten and Washburn (1992) suggest that communication is frequently the primary stumbling block to the successful completion of a delegated task. Work satisfaction from the point of view of the delegatee is negatively affected by ambiguity and lack of courtesy (Hansten and Washburn, 1992). The delegation of duties requires a thorough explanation of exactly what is expected in terms of what is to be done, as well as any other informatioot likely to be known to the delegatee. Such information might include the location of supplies needed, time frame for completion of the work, how to document properly (if applicable), and who is available to answer questions or provide assistance if needed. Solicitation of verbal feedback for assurance of understanding can avoid complications that may result from delegation. The use of everyday courtesies such as “please,” “thank you,” and “you’re welcome” helps establish rapport in a situation that sometimes lends itself to the development of interpersonal friction. Establishing an interaction as a win-win situation and demonstrating intent to be available enforces a sense of collegiality and team work.

 

 

DEALING WITH VERBAL CONFLICT

The many styles of communication, varying beliefs and traditions, and even a level of “turf protection” can lead to misunderstandings. The stress inherent in the care of the sick, injured, and dying only adds to the likelihood that disagreements will occur. Box 17-4 presents some basic principles that can augment professional response to verbal conflict. For the most part, verbal conflict is the result of poor communication, distraction, or varying perspectives. However, some persons use verbal abuse as a tool. Whether the behavior is meant to draw attention, express anger, build a sense of power, or accomplish any other equally inappropriate objectives often is immaterial. Problems can be solved without demeaning another human or creating an unpleasant scene. The principles listed are remarkably effective in cases of verbal abuse. Considered together, the principles demonstrate a person of confidence, assurance, and competence who will not react to inappropriate behavior in like form but also will not withdraw from the issues. As always, the focus should be kept on the delivery of quality patient care.

PROFESSIONAL NURSING IMAGE

The discipline of nursing is recognized as a profession because of the standards of advanced education, licensure, intellectual challenge, and commitment to the greater good of humankind. The professional nurse will touch many lives during a career of caregiving, teaching, and leading. Through capable role modeling for patients, families and significant others, nurse colleagues, other health care professionals, and students, the professional nurse can facilitate positive health practices in unlimited numbers of people—just as the ripple of a stone thrown into a stream creates an ever-widening circle. The nurse who astutely uses positive communication techniques, provides a safe environment for a patient to ask questions and learn, and focuses energy toward the resolution of conflict has the opportunity to bring the best of nursing to the most of humanity. Through clear, open, sensitive communication, nurses portray the consummate professional image.

In a nursing education program, educators can only begin to introduce the nursing student to the complex and dynamic profession of nursing. Prelicensure nursing education is only an introduction to a discipline in which there are no knowledge boundaries. The abundance of nursing practice information is clear from a quick glance across the nursing textbook shelves in the college bookstore.

Most of that information addresses the “how to” aspects of nursing care. The scientific aspects of nursing care are evolving more rapidly than ever as a host of nurse researchers delve into questions about the safe, competent, and therapeutic aspects of professional nursing care. As quickly as nursing science produces new nursing knowledge, “how to” information is shared through professional journals, textbooks, and electronically through on-line Internet resources. The scientific aspects of care for someone like the elderly woman described in the opening vignette are evolving constantly through “how to” research.

A myriad of potential questions that surpass the “how to” body of knowledge are inherent in the patient care situation presented in the vignette. Everywhere in today’s health care delivery system are potential questions of another nature — the “how should” questions. “How should” questions sound something like this.

• How should I determine the competency of my acutely ill 80-year-old patient? Is her competency intact? How should I gain her informed consent?

• How should I act if it is determined that her wishes for aggressive care are not consistent with those of her family?

• How should I view her care? Is a resuscitation effort for an 80-year-old considered ordinary and routine, or is it considered extraordinary and heroic?

• How should I respond to her in the middle of the night when she awakens to ask me if she is dying?

• How much of the truth is warranted?

• How should I decide when the availability of ICU beds becomes threatened and the decision must be made to move someone out of ICU to make room for a new trauma patient?

• How should I make staffing assignments when the number of nurses on a given shift is insufficient to provide routine ICU care to all?

• Is the life of this 80-year-old woman any less significant than that of the 40-year-old father-of-four executive who has just been admitted after a tragic car accident?

• How should I feel when this 80-year-old patient is entered into a research study designed to test a new beta-blocker that has previously only been tested on a middle-age population?

This chapter introduces the nursing student to a different aspect of nursing care, this “how should” aspect or, as it is more appropriately called, the ethical aspect. Ethics is a system for deciding, based on principles, what should be done. Socrates once said, “The unexamined life is not worth living.” Ethics is about examining life in a way that will add a dimension to the understanding that goes beyond the scientific and moves toward a more complete and whole understanding of human existence.

NURSING ETHICS

Nursing ethics is a system of principles concerning the actions of the nurse in his or her relationships with patients, patients’ family members, other health care providers, policy makers, and society as a whole. A profession is characterized by its relationship to society. Codes of ethics provide implicit standards and values for the professions. A nursing code of ethics was first intro duced in the late nineteenth century and has evolved through the years as the profession itself has evolved and as changes in society and health have come about. Current dynamics such as emerging genetic interventions and new threats to the effective delivery of health care such as managed care and impending nursing shortages bring nursing’s code of ethics into the forefront.

BIOETHICS

Nursing ethics is a part of a broader system known as bioethics. Bioethics is an interdisciplinary field within the health care organization that has developed only in the past three decades. Bioethics can be differentiated from ethics as ethics has been discussed in the written word since there was written word, whereas bioethics has developed with the age of modern medicine. New questions surface as new science and technology produce new ways of knowing. Bioethics is a response to contemporary advances in health care.

Dilemmas for Health Professionals

Physicians, nurses, social workers, psychiatrists, clergy, philosophers, theologians, and policy makers axe joining to address ethical questions, difficult questions, and right vs. wrong questions. As they seek to deliver quality health care, these professionals debate situations that pose dilemmas. They are confronting situations for which there are no clear right or wrong answers. Because of the diverse society in which health care is practiced, there are at least two sides to almost every issue faced.

Every specialization in health care has its own set of questions. Life and death, quality of life, right to decide, informed consent, and alternative treatment issues prevail in every field of health care from maternal-child to geriatric care, from acute episodic to intensive, highly specialized care, and from hospital-based to community-based care. In every aspect of the nursing profession lie the more subtle and intricate questions of “how should” this care be delivered and “how should” one decide when choices are in conflict.

Many nursing students do not consider health care and the practice of nursing in terms of the personal and subjective side; rather they look at it only in terms of the technical and objective side. Yet there most definitely are factors that influence the way patients actually are treated, or at least the way they perceive their treatment, that go beyond the technical aspect. In many ways technology has changed the face of health care and created the troubling questions that have become central in the delivery of care.

Dilemmas Created by Technology

Advances in health care through technology have created new situations for health care professionals and their patients. For the very young and old and for generations in between, illnesses once leading to mortality have now become manageable and are classified as high-risk or chronic illness. Although people caow be saved, they are not being saved readily or inexpensively. Care of the acutely or chronically ill person sometimes creates hard questions for which there are no easy or apparent answers. Mortality for most will be a long, drawn-out phenomenon, laced with a lifetime of potential conflicts about what ought to be done. Health care professionals who adhere to an exclusively scientific or technologic approach to care will be seen as insensitive and will fail to meet the genuine needs of the patient, needs that include assistance with these more subjective concerns.

ETHICAL DECISION MAKING

A professional nurse in the twenty-first century will be deemed competent only if he or she can provide the scientific and technologic aspects of care and has the ability to deal effectively with the ethical problems encountered in patient care. A competent nurse must be able to deal with the human dimensions of that care. The previously listed “how should” questions should be just as important as the “how to” questions surrounding the care of the 80-year-old patient introduced previously. As the nurse seeks to understand the “how to” aspects of the patient’s care, such as comfort measures for dyspnea, pharmacologic care considering her organ dysfunction, and decubitus prevention in her immobile and malnourished state, he or she also must seek to understand more.

Answering Difficult Questions

Care combining human dimensions with scientific and technical dimensions forces some basic questions.

• What does it mean to be ill or well?

• What is the proper balance between science and technology and the good of humans?

• Where do we find balance when science will allow us to experiment with the basic origins of life?

• What happens when the proper balance is in tension?

No tension is created in the effort to save the life of a dying healthy adolescent or set the broken leg of a healthy elderly adult. Science and the human good are not in conflict here. However, what is the answer when modern medicine can save or prolong the life of an 8-year-old child but the child’s parents refuse treatment based on religious reasons? Or what is the answer when modern medicine has life to offer a 30-year-old mother ieed of a transplanted organ but the woman is without the financial means to cover the cost of the treatment? What is the answer when new discoveries allow some to even choose biologic characteristics of children not yet conceived? At one end of the spectrum lies the obvious; at the other there is often only uncertainty. Health care professionals in everyday practice often find themselves striving somewhere between the two.

Balancing Science and Morality

If nursing care is to be competent, the right balance between science and morality must be sought and understood. Nurses must first attempt to understand not just what they are to do for their patients but who their patients are. They must examine life and its origins, as well as its worth, usefulness, and importance. Nurses must determine their own values and seek to understand the values of others.

Health care decisions are seldom made independently of other people. Decisions are made with the patient, the family, other nurses, and other health care providers. Nurses must make a deliberate effort to recognize their own values and learn to consider and respect the values of others.

The nurse has an obligation to present himself or herself to the patient as competent. The dependent patient enters into a mutual relationship with the nurse. This exchange places a patient who is vulnerable and wounded with a nurse who is educated, licensed, and knowledgeable. The patient expects nursing actions to be thorough since total caring is the defining characteristic of the patient-nurse relationship. The nurse promises to deliver holistic care to the best of his or her ability. The patient’s expectations and the nurse’s promises require a commitment to develop a reasoned thought process and sound judgment in all situations that take place within this important relationship. The more personal, subjective, and value-laden situations are deemed to be among the most difficult situations for which the nurse must prepare.

VALUES FORMATION AND MORAL DEVELOPMENT

A value is a personal belief about worth that acts as a standard to guide behavior; a value system is an entire framework on which actions are based. Diane Uustal, a well-knowurse ethicist, describes values as being a basis for what a person thinks about, chooses, feels for, and acts on (1992). Perhaps many nursing students come to the educational setting with an intact value system. No doubt anyone living in these times has faced many situations in which important choices had to be made. The options available to this generation are too numerous to avoid hard choices. Values have been applied to those decisions. Yet often people do not take time to seriously contemplate their value system, the forces that shaped those values, and the life and world-view decisions that have been made based on them.

Examining Value Systems

To become a competent professional in every dimension of nursing care, nurses must examine their own system of values and commit themselves to a virtuous value system. A clear understanding of what is right and wrong is a necessary first step to a process sometimes referred to as values clarification, a process by which people attempt to examine the values they hold and how each of those values functions as part of a whole. Nurses must acknowledge their own values by considering how they would act in a particular situation.

A values clarification process (Uustal, 1992) is an important learning tool as nursing students prepare themselves to become competent professionals. The deliberate refinement of one’s own personal value system leads to a clearer lens through which nurses can view ethical questions in the practice of their profession. A refined value system and world view can serve professionals as they deal with the meaning of life and its many choices. A world view provides a cohesive model for life; it encourages personal responsibility for the living of that life, and it prepares one for making ethical choices encountered throughout life.

Forming a world view and a value system is an evolving, continuous, dynamic process that moves along a continuum of development often referred to as moral development. Just as there is an orderly sequence of physical and psychologic development, there is an orderly sequence of right and wrong conduct development. Consider an adult of mighty physical prowess and strong moral character. Just as with each biologic developmental milestone there is a more mature, more expanded physical being, with each life experience that has right and wrong choices there is a more mature, more virtuous person.

Learning Right and Wrong

The process of learning to distinguish right and wrong often is described in pediatric textbooks. Donna Wong describes such development in children (1999). Infants have no concept of right or wrong. Infants hold no beliefs and no convictions, although it is known that moral development begins in infancy. If the need for basic trust is met in infancy, children can begin to develop the foundation for secure moral thought. Toddlers begin to display behavior in response to the world around them. They will imitate behavior seen in others, even though they do not comprehend the meaning of the behavior that they are imitating. Further, even though toddlers may not know what they are doing or why they are doing it, they incorporate the values and beliefs of those around them into their own behavioral code.

By the time children reach school age, they have learned that behavior has consequences and that good behavior is associated with rewards and bad behavior is associated with punishment. Through their experiences and social interactions with people outside their home or immediate surroundings, school-age children begin to make choices about how they will act based on an understanding of good and bad. Their conscience is developing, and it begins to govern those choices they make (Wong, 1999).

The adolescent questions existing moral values and his or her relevance to society. Adolescents understand duty and obligation, but they sometimes seriously question the moral codes on which society operates as they become more aware of the contradictions they see in the value systems of adults.

Adults strive to make sense of the contradictions and learn to develop their own set of morals and values as autonomous people. They begin to make choices based on an internalized set of principles that provides them with the resources they need to evaluate situations in which they find themselves (Wong et al., 2009).

Understanding Moral Development Theory

Perhaps the most widely accepted theory on moral development is Lawrence Kohlberg’s theory (1971). Kohlberg theorizes a cognitive developmental process that is sequential in nature with progression through levels and stages, which vary dramatically within society. At first morality is all about rules imposed by some source of authority. Moral decisions made at this level (preconventional) are simply in response to some threat of punishment. The good-bad, right-wrong labels have meaning but are defined only in reference to a self-centered reward and punishment system. A person who is in the preconventional level has no concept of the underlying moral code informing the decision of good-bad or right-wrong.

At some point people begin to internalize their view of themselves in response to something more meaningful and interpersonal (conventional level). A desire to be viewed as a good boy or nice girl develops when the person wants to find approval from others. He or she may want to please, help others, be dutiful, and show respect for authority. Conformity to expected social and religious mores and a sense of loyalty may emerge.

Not all people develop beyond the conventional level of moral development. A morally mature individual (postconventional level), one of the few to reach moral completeness, is an autonomous thinker who strives for a moral code beyond issues of authority and reverence. The morally mature individual’s actions are based on principles of justice and respect for the dignity of all humankind and not just on principles of responsibility, duty, or self-edification (Kohlberg, 1971).

Moving Toward Moral Maturity

The Tightness or wrongness of the complex and confounding health care decisions that are being made today depends on the level of moral development of those professionals entrusted with the tough decisions. Moving toward the level of moral maturity required for such decision making is, for most, a learning endeavor that requires a strong commitment to the task. Nurses must commit themselves to such learning.

The American Association of Colleges of Nursing (AACN) provides the profession with the results of a study in which the essential knowledge, skilled practice, and values necessary for nursing were delineated. From a consensus-building effort across the nation, the AACN has recommended seven values that are essential for the professional nurse.

The study and examination of these nursing values is a worthwhile endeavor for the nursing student. Students who seek to become morally mature health care providers will appraise the values of the nursing profession and strive to find a comfortable union of those values with their own. Further, the study of ethical theory and ethical principles can provide a basis for moving forward as a morally mature professional nurse.

ETHICAL THEORY

Ethical theory is a system of principles by which a person can determine what ought and ought not to be done. Although there are others, utilitarianism and deontology are theories that encompass modern moral thought and provide approaches for answering the question regarding what is right to do in a given ethical dilemma (Davis et al., 2009).

Utilitarianism

Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Utilitarian ethics are noted to be the strongest approach used in bioethical decision making. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma.

Deontology

Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right. Ethics are based on a sense of universal principle to consistently act one way. In bioethical decision making, moral Tightness is the act that is determined not by the consequences it produces, but by the moral qualities intrinsic to the act itself. Deontologic theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. All decisions must be made in such a way that the decision could become universal law. Persons are to be treated as ends in themselves and never as means to the ends of others.

ETHICAL PRINCIPLES

Perhaps the most useful tool for the morally mature professional nurse is a set of principles, standards, or truths on which to base ethical actions. Common ground must be established between the nurse and the patient and the family, between fellow nurses, between the nurse and other health care providers, and between the nurse and other members of society. A set of mutually agreed on principles makes it possible for people to come together to discuss ethical questions and move toward a sense of understanding and agreement (Husted and Husted, 1995).

The practice of ethics involves applying principles to the two ethical theories described, utilitarianism and deontology, or to other theories that are described elsewhere. Principles can permit people to take a consistent position on specific or related issues. If the principles, when applied to a particular act, make the act right or wrong in one situation, it seems reasonable to assume that the same principle, when applied to a new situation, can share similar features. Three principles have proven to be highly relevant in bioethics: (1) autonomy, (2) beneficence, nonmaleficence, and (3) veracity.

These principles are not related in such a way that they jointly form a complete moral framework. One may be relevant to a situation, whereas the others are not. Yet these principles are sufficiently comprehensive to provide an analytic framework by which moral problems can be evaluated.

 

SUMMARY

The first attempts at communication begin shortly after birth and continue throughout life. Effective communication is an essential part of competent professional nursing care. Historically nurses recognized communication to be integral in the duties of the caregiver. Communication has three basic components: the sender, the receiver, and the message. Subcomponents consist of interpretation, filtration, and feedback. Interpretation of messages involves such factors as context, environment, precipitating event, preconceived ideas, personal perceptions, style of transmission, and past experiences. Communication can be verbal and nonverbal. If the verbal and nonverbal messages do not match, most people will believe the nonverbal message; they will be correct in that belief most of the time. Positive communication techniques include the development of trust; use of “I messages,” eye contact, empathy, open communication style, clarification, open body language, and touch; and commitment to keeping promises. Listening is an essential element in efficacious communication. Negative communication techniques include closed communication style, closed body language, blocking, false assurances, and conflicting messages. There are many differences in communication styles. Such variances include gender differences, cultural diversity, assertiveness vs. aggressiveness, and dissimilarities in the professional approach of various health care disciplines. Other concepts pertinent to communication within the health care arena include written communication techniques, the patient’s right to confidentiality and privacy, delegation, and the skill of dealing with verbal conflict. As a professional, the nurse must be committed to quality patient care. An essential component of quality care is the ability to communicate clearly and to listen well. The strong public image of the nurse is that of nurturer, caregiver, teacher, and leader. The development of effective communication skills can only enhance each nurse’s professional image while building strong relationships with patients and colleagues.

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Critical Thinkingc/ Ictwities

1. You have been assigned to care for Rhonda, a young wife and mother who was admitted through the Emergency Department last night with significant abdominal pain. As you inquire about her symptoms, she repeatedly glances at her husband,Tommy, before she answers. Although she denies any pain at this time, you observe that she guards her stomach, has a “clinched” jawline, and does not make eye contact with you. Her skin is warm and slightly diaphoretic. As you assess and question Rhonda, Tommy often interrupts with comments such as, “She’s just fine. It was only a big stomachache, and it’s gone this morning, isn’t it, dear?” You suspect that Rhonda is experiencing pain but is reluctant to increase her husband’s obvious concern. How will you address the nonverbal cues? How will you evaluate the conflicting cues? What strategies will you use to enhance communication with this couple?

2. Dr. Blademan, whom you recently paged to report an abnormal laboratory result, approaches you shouting angrily, “Why did you page me with that report? You know I make rounds in the evenings, and I would have been here soon.” You attempt to explain that the client was symptomatic, that the abnormal laboratory result was high enough to be labeled critical value, and that you believed prompt reporting was in the best interest of the client. You also are thinking about the fact that “in the evening” could be anytime from 6:00 PM to 11:00 PM for this particular physician. Nothing you say in defense of your decision appeases the physician, who has digressed to general statements about the lack of consideration that nurses give doctors. What do you perceive to be the true message here? How will you respond to the physician’s comments? What techniques can you use to prevent the situation from escalating? If the situation continues to escalate, what would be your next course of action?

3. You are talking with Mr. Phillips about his new diagnosis of diabetes mellitus. You state, “Mr. Phillips, I noticed that the diabetic educator was in to talk with you this morning. What did you talk about?” His response is, “Oh, she told me about the special d i e t . . . you know . . . no sugar and that stuff. But I’m going to tell you now that I drink sodas, and nobody is going to take those away from me!” You comment, “Have you tried diet sodas?” to which he responds, “Are you kidding? That stuff tastes like crankcase oil! I’m not using any of that sweetener stuff!” The conversation continues along the same lines, indicating a lack of commitment to healthy self-regulation on his part. What will you do? It appears that Mr. Phillips is resistant to the restrictions of his new diagnosis. What additional resources can you use to help interpret his health beliefs? What techniques will you use to clarify the issues he must address?

ETHICAL DECISION-MAKING MODEL

Theories provide a cognitive plan for considering ethical issues; principles offer guiding truths on which to base ethical decisions. Using these theories and principles, it seems appropriate to consider a system for moving beyond a specific ethical dilemma toward a morally mature and reasoned ethical action.

Many ethical decision-making models exist for the purpose of defining a process by which a nurse or another health care provider actually can move through an ethical dilemma toward an informed decision.

Box

9-3

depicts one ethical decision-making model.

Situation Assessment Procedure

Identify the Ethical Issues and Problems, in the first step of assessment there is an attempt to find out the technical and scientific facts and the human dimension of the situation— the feelings, emotions, attitudes, and opinions. A nurse must make an attempt to understand what values are inherent in the situation. Finally, the nurse must deliberately state the nature of the ethical dilemma. This first step is important because the issues and problems to be addressed are often complex. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort to understand an issue fully before moving forward in the assessment procedure. Wright (1987) poses some important questions that must be addressed in this first step.

1. What is the issue here?

2. What are the hidden issues?

3. What exactly are the complexities of this situation?

4. Is anything being overlooked?

Select One Alternative. Multiple factors come together in the third step. After identifying the issues and analyzing all possible alternatives, the skillful decision maker steps back to consider the situation again. There is an attempt to reflect on ethical theory and to mesh that thinking with the identified ethical principles for each alternative. The decision maker’s own value system is applied, along with an appraisal of the profession’s values for the care of others. A reasoned and purposeful decision results from the blending of each of these factors.

Justify the Selection. The rational discourse on which the decision is based must be shared in an effort to justify the decision. The decision maker must be prepared to communicate his or her thoughts through an explanation of the reasoning process used. According to Wright (1987), the justification for a resolution to an ethical issue is an argument wherein relevant and sufficient reasons for the correctness of that resolution are presented. Defending an argument is not an easy task, but it is a necessary step to communicate the reasons or premises on which the decision is based. A systematic and logical argument will show why the particular resolution chosen is the correct one. This final step is important to advance ethical thought and to express sound judgment. Wright’s formula for the justification process is as follows:

1. Specify reasons for the action.

2. Clearly present the ethical basis for these reasons.

3. Understand the shortcomings of the justification.

4. Anticipate objections to the justification.

 

REFERENCES

Ashman H, Menken A: The little mermaid, Burbank, Calif, 1988, Walt Disney Pictures. Cummings SH: Attila the Hun versus Attila the hen: gender socialization of the Americaurse, Nurs Admin Q 19(2): 19-29, 1995. DeWitt K: Private duty nursing, Philadelphia, 1917, JB Lippincott. Elgin SH: Genderspeak: men, women, and the gentle art of verbal self-defense, New York, 1993, John Wiley & Sons. Elgin SH: www.sfwa.org/members/elgin/ Hansten R, Washburn M: What do you say when you delegate work to others? Am J Nurs 92(7):48-50, 1992. Hargrave J: Nonverbal communication, 2001, www. janhargrave.com/index.html Heim P: Getting beyond “she said, he said,” Nurs Admin Q 19(2):6-18, 1995. Nightingale F: Notes oursing: what it is, and what it is not, London, 1859, Harrison. Parsons SE: Nursing problems and obligations, Boston, 1916, Whitcomb & Barrows. van Servellen G: Communication skills for the healthcare professional: concepts and techniques, Gaithersburg, MD, 1997, Aspen Publishers. 

The Importance of Goodwill in Couple Communication Skills

Communication is probably the number one stated problem area among the couples I work with in my practice. Common problem descriptions include, “We don’t communicate very well,” or “we argue too much,” or “we just don’t know how to communicate with each other.”

When couples experience frequent arguments and the heartache of unresolved conflict it is no wonder that they identify “lack of communication” as one of their central issues.

Good communication is an important part of keeping a relationship vibrant and strong. It seems a logical assumption that we might be able to reduce the divorce rate by ensuring that couples had the tools for improving their communication skills.

It is an appealing promise that if we teach and learn helpful skills such as using “I-statements,” paraphrasing each other’s feelings and thoughts, speaking one at a time, negotiating solutions together, and avoiding blame and faultfinding, then our marriages will improve.

Unfortunately, it isn’t so simple. As long as we are open, teachable, and willing; as long as we feel safe with each other; as long as we want to work together, then learning such couple communication skills can make a big difference in our relationships.

But there are many other factors at work besides knowledge and skills that affect not only the quality of a couple’s communication but the quality of their relationship in general. Such factors include commitment, willingness, intentions, desire, caring, and attitude.

Some couples are so entrenched iegative intentions and attitudes that they are either unwilling to use what they know or somehow they use communication techniques in ways that make matters worse.

Think about the statement, “We don’t know how to communicate effectively.” If you consider that the “effect” couples sometimes have on each other is clearly aligned with their desire to hurt or to push each other away, you might argue that they communicate very effectively. Perhaps what couples really mean when they say this is, “We don’t know how to connect effectively.“

Good communication is a tool, and good tools can make a task much easier to accomplish. But good tools can’t make up for the person using them. In the hands of a skilled cabinet-maker who sets out to create a beautiful piece of furniture, a hammer can be an important tool. But in the hands of someone with unkind intentions, a hammer can quickly become a weapon.

Some years ago I came across a research study (1) demonstrating that, contrary to popular wisdom, happily married couples do not possess any more communication skills than unhappily married couples.

This may sound sensational, until you understand how the researchers defined communication skill, which was proficiency in sending and receiving clear messages and the ability to accurately interpret the intent of each other’s message.

Overall, the happily married couples in this study were found to possess the same amount of communication skills as unhappily married couples. In other words, in both groups the researchers found the same proficiency levels at effectively sending and accurately receiving clear messages.

Where the two groups differed was in their intentions and in how they used their skills. Couples in high quality marriages acted with more positive intentions toward their spouses than did couples in distressed marriages. In addition, with the happily married couples only, there was a positive relationship between skill level and marital satisfaction, with higher skill levels associated with greater satisfaction levels.

The couples in distressed marriages, on the other hand, were motivated by more negative intentions in their communication with their spouses. In addition, the distressed couples either did not use the skills they possessed or they used their skills to harm each other. The authors of this study summed up their findings with the statement that relationship distress has much more to do with “ill will” than it does with “poor skill.”

Skill is only one element of positive communication, and it may not be the most important element. There are matters of the heart that affect how we use our skills, and that facilitate connection and caring even when we may not be that great with words.

Further, communication often improves naturally when we align our desires and attitudes with principles of commitment, honesty, personal accountability and loving actions. Putting our heart right has to come before putting our communication right.

The Communication Triangle

Positive communication can be boiled down to three essential elements: attitude, desire and skill.

Attitude refers to your sentiment toward your partner and the emotionally-laden perspectives that guide how you act in the relationship.

Attitude affects your willingness to accommodate to each other and to take personal responsibility for your part in relationship difficulties.

Desire refers to your intentions, desires, and yearnings for personal growth, for your spouse’s well-being and happiness, and for positive change in the relationship.

Skill refers to your ability to communicate directly and clearly, repair relationship ruptures, manage differences, negotiate solutions, and solve problems together.

Imagine these three elements arranged in a triangle, with attitude and desire forming the two points at the base of the triangle and skill forming the point at the top. This arrangement emphasizes that attitude and desire are the foundation for positive communication.

Helpful, positive attitudes and the desire to put each other first can sometimes make up for short-comings in communication skill level. High skill level, however, cannot make up for negative attitudes or lack of desire.

These distinctions are important because they help to explain why traditional marriage counselling approaches that emphasize communication skills sometimes do little good for couples.

Some couples are so embittered and full of negative attitudes and intentions that their ill will and resentments are like stored-up gasoline. Raising and trying to solve difficult issues in the absence of positive sentiment and goodwill is like the match.

All you need to do is put the match to the gasoline and …! Marriage counselling can end up becoming a battleground instead of a healing place.

This is not to say communication skills are unimportant. There are many useful strategies and principles to learn that can help couples manage conflict and handle disagreements more constructively. I use them in my work with couples and I have outlined some of them in previous articles.

But without a helpful, open attitude and the desire to connect with your spouse, then “communication skills training” can become like a hammer in the hands of someone with a score to settle or like a match set to gasoline.

Attitude

Synonyms for attitude include mindset, perspective, sentiment, outlook, demeanor, and philosophy. It’s the orientation of your mind and heart toward your spouse. Pause for a moment and reflect on the following questions:

·                     Are you oriented toward your spouse with a hostile outlook or a softened outlook?

·                     Are you overcome with negative sentiment toward your spouse or you filled with positive sentiment?

·                     Are you quick to assume ill will or are you willing to look for the good in each other and to assume that your spouse has goodwill toward you?

·                     Do you focus on blaming your partner and minimizing or justifying your owegative actions or are you willing to take responsibility for yourself and how you contribute to the relationship—both to its problems as well as to its strengths?

·                     Are you willing to apologize sincerely and fully? Are you willing to forgive?

·                     Do you strive to put the relationship first? Are you willing to put your partner’s needs before your own to show that you care and that you truly want your spouse to feel respected and cherished?

Desire

Now let’s look briefly at desire. Desire is a longing or a craving for something that brings satisfaction or enjoyment. What are you longing for in your relationship? What are you longing for personally? What are you longing for your spouse to experience? What direction are your desires taking you? Think about the following questions:

·                     Are you actively cultivating a desire for your spouse’s happiness, freedom of choice, and well-being, not just your own?

·                     Do you desire for your spouse to feel heard, understood, and validated as much as you desire these things for yourself?

·                     How strong is your desire for your spouse to feel included in your life, to feel that his or her opinions and feelings matter to you?

·                     Do you desire for your spouse to feel like you are “tuned in” to him or her?

·                     Do you desire for your spouse to feel loved enough that you are willing to expand your own ideas about how to express this love and really learn what your spouse needs from you in order to feel loved?

·                     Do you desire for your spouse’s hopes and dreams to come true?

·                     Do you desire to defend yourself and let yourself off the hook or do you desire to understand yourself and your spouse more fully?

·                     Do you desire to be teachable, humble, and open?

·                     Do you desire to overcome your own weaknesses and fears?

·                     Is your desire for a better relationship strong enough if you find it hard to take action to nurture it? How can you strengthen your desire?

Cultivating Positive Attitudes and Desires

Communication skills are about what you know and what you’ve learned. Attitudes and desires are more about who you are.

It is understandable why teaching communication skills is such a popular method for improving marriages, because it is easy to do and it seems so intuitive. Knowledge and strategies can be taught, and if people are open and willing to learn then both the teacher and the learner can be edified together.

But it is difficult to “teach” attitude and desire. Attitude and desire are matters of the heart. Positive attitudes and desires need to be invited, encouraged, cultivated, nurtured and consciously chosen in the face of difficulty. This is where lasting change begins.

So how do you cultivate positive attitudes and desires? Here are some tips:

1.     Consciously choose to focus on the positives in each other. Make a list of your spouse’s positive qualities and things you appreciate about your spouse. Think of what your spouse does that demonstrates his or her goodwill overall. If you catch yourself dwelling oegatives, stop yourself. Shift your thinking to something positive.

2.     Learn about each other’s emotional needs–things that allow your partner to feel loved and valued by you. It is unlikely that you both share the same emotional needs, so don’t make the mistake of only showing love in the way that you like to receive love. Instead, make intentional, regular, and daily deposits into each other’s emotional bank account in ways that your partner recognizes as loving, caring behavior. You might have to go out of your comfort zone. If your partner needs to be touched and you are not a “touchy” person, it is time to learn a new love language. It will be awkward at first, but refusing to do so sends the message, “I don’t really care enough about you to learn to love you in the way that you need me to. I just want to love you in a way that is easy or natural for me.”

3.     Build your friendship with each other by tuning in to each other’s feelings and needs, intentionally looking for ways to express caring, spending time with each other, and having fun together.

4.     Express fondness by touching each other affectionately every day. Tender touch is a fundamental need for human beings. Touch is healing. Your body is an extension of you, so when someone touches your body tenderly it is like they are touching and acknowledging you.

5.     When you are upset or angry about something your spouse has done, change your internal dialogue to emphasize friendship, fondness and goodwill. For example, “This really bothers me when he does this, but I know that he means well and he works hard and I am sure that he doesn’t mean for me to feel this way. It makes me angry but I need to remember that he is my friend and to respect him.” This internal dialogue will help you approach your spouse in a more loving way even when you bring up the issue that bothers you.

Conclusion

Attitudes and desires change for the better when couples shift their focus to connecting with each other and to re-building their friendship instead of hammering each other over hot topics. This is why it is so critical to build on positives before trying to overcome big relationship challenges.

Changing your attitudes and desires and putting your relationship first are neither easy nor simple. It doesn’t happen overnight and there will certainly be setbacks. But if you are committed to cultivating a caring attitude and heartfelt desire to connect with your spouse this will make it easier to work through difficult issues. The frequency and intensity of your arguments will decrease. Best of all, you will find that your friendship, fondness and admiration for each other grows stronger over time.