6 QUESTIONS OF VALUES AND ETHICS
Legal and Ethical
Knowledge for Nurses
Understanding the legal and ethical issues involved in nursing practice is critical for all nurses, especially managers and leaders. Legal and ethical issues are intertwined in many ways, but the two entities are distinct bodies of thought and practice. Ethics and laws both derive from societal values. Ethics is a branch of philosophy that involves clarification of the “shoulds” and “oughts” of individuals and society. Ethical decision making entails a distinctive choice between undesirable options. Ethical algorithms help to guide decisions by looking at multiple dimensions of the situation under review. Laws, on the other hand, are set down by the state or federal governments, administrative agencies, or courts, to establish boundaries of behaviors for society. The legal process constantly questions and debates the law on both legal and ethical planes. To clear some of the confusion that often sur-rounds ethics and law, it is important to point out that ethics deals with the “should and should nots” that are related to behavior or actions taken by an individual. Ethics also deals with the questions of why an action is reprehensible or not reprehensible (Fry & Veatch, 1992). The legality of these choices is always a strong consideration when attempting to resolve ethical dilemmas. Ethical dilemmas in health care come up frequently, and they often address life and death issues. Nurse leaders must be prepared to address these issues in order to guide the members of their nursing staff. This chapter considers the aspects of the legal system with which the nurse leader must become familiar and then explores the foundations of ethics and ethical decision making.
The Legal System
The American legal system is based on the early English system of common law. Common law refers to case law that is directed and made by a judge rather than by a governmental legislative body. This type of law is set by precedent or the principles of stare decisis, along with the factual scenario of a given case. These laws build from one case to the next, as each judge’s decision sets the precedent for future cases. In addition to federal law, Pohlman points out that each state court system has it own “case law [emphasis added] based on the interpretation of its respective statutes” (Pohlman, 1990, p. 296). State and federal legislative bodies create statutes according to societal need. Administrative agencies detail the implementation of these statutes, and the courts interpret confusion over the meaning of the statutes.
FEDERAL LEGISLATION
Federal laws affect nursing practice by setting minimum standards of care for all agencies receiving federal funding. Nurses must become familiar with federal legislation, such as the Health Insurance Portability and Accountability Act, which guarantees the privacy of a patient’s personal health information; the Emergency Medical Treatment and Active Labor Law (EMTALA), and the Americans With Disabilities Act (ADA). According to Moy (2003), EMTALA prohibits refusal of care for indigent and uninsured patients seeking emergency care in the emergency department. It prevents hospitals from “dumping” indigent individuals on other hospitals. The ADA also affects nursing intimately. This law proscribes any discrimination against individuals with disabilities by offering them the same opportunities as individuals without disabilities. For instance, if an individual with disabilities is the most qualified individual for a job but requires reasonable accommodations by the employer in order to take the job, the employer must make these accommodations. See Box 5-1 for others federal laws affecting nurses.
STATE
LEGISLATION
State laws also regulate nurses. Nurse practice acts (NPAs) are created by state legislatures to define, limit, and oversee nursing practice. Nurses must be familiar with the NPA in the state in which they are practicing. NPAs set the requirements for becoming licensed as a nurse in a given state, for renewing one’s license, and for continuing education. They define the duties and responsibilities of nurses in the state and limit the scope of practice. Many NPAs include safe harbor laws, which limit nurses to practicing only in their area of expertise. For example, they prevent a rehabilitation nurse from being pulled into intensive care because of a staff shortage. Other NPAs include good samaritan provisions, which protect nurses from liability for
volunteering to help in an emergency situation. These provisions apply, for example, if a nurse stops at the scene of a car accident to assist victims. If something goes wrong, the victims of the car accident could not sue the nurse for malpractice. NPAs also address charting and physician orders. They specify that nurses must be skillful, correct, timely, and thorough in their charting. With respect to physician orders, most NPAs make nurses responsible for ensuring that orders are clear and accurate. If the nurse needs clarification, she must seek it from the physician giving the orders. The nurse is obligated to follow the physician order, but if she believes that doing so would be dangerous to the health of the patient, she is responsible for contacting her supervisor and following through with the institution’s policy regarding physician orders.
COMMON LAW
Along with federal and state statutes, common law guides nursing practice. In order to understand how common law works in practice, consider the precedent-setting case of Utter v. United Hospital Center, Inc. (Giordano, 2003). This case involved a patient developing compartment syndrome after his arm was put in a cast. The nurse caring for this patient failed to acknowledge and recognize the signs and symptoms of compartment syndrome and did not request medical intervention. This case set a legal precedent that is still followed by other courts: nurses are required to exercise independent judgment to ensure patient safety and to prevent harm. Case law touches on a range of issues that involve nursing practice, including nursing malpractice, practicing medicine without a license, wrongful termination, legal challenges to a nurse’s license, and questions regarding collective bargaining and labor laws. Nurse managers must work in collaboration with risk managers to make staff nurses aware of and educated about relevant case law.
There are two major categories of common law that nurses must understand: civil and criminal law. Civil law involves violations between people regarding everyday matters. Criminal law regulates offenses against individuals and society, violations made with criminal intent. Tort law is one of the major branches of civil law. Contracts is the other major branch. According to Hall (1990), a tort is a wrongdoing or injury that is committed against a person’s property or person. The basis of this type of action is the liability by one individual against another. Contracts law revolves around an offer and acceptance of terms between two or more individuals or organizations. The law specifies when these agreements should be upheld and when they should not be upheld.
Torts
There are two types of torts: unintentional and intentional.
Unintentional Torts
Unintentional torts include the two types of tort that most frequently affect nurses, negligence and malpractice. Negligence is the failure to act as a reasonable or prudent person would act in the same or similar circumstances. Malpractice is a form of negligence committed by a professional, such as a nurse, by which professional misconduct, unreasonable lack of professional skills, and/or noncompliance with accepted standards of care causes injury to the client (Creighton, 1986).
There are a number of elements involved in both negligence and malpractice (Box 5-2). In order to establish liability for negligence, the existence of a duty must first be established. This duty and/or
obligation from the nurse to the patient is created by law, standards of practice, or contract (Creighton, 1986). For instance, if a nurse is late to shift change, the nurse waiting for the nurse running late may not leave or abandon the clients in their care until the other nurse arrives because that nurse hasa legal duty to the clients. If there is an urgent reason that the nurse on duty must leave, then the manager or supervisor must be notified so that another nurse may fill the position until the late nurse arrives. This leads to the second element needed to establish negligence, a breach of duty by the nurse. If the nurse breaches a duty (i.e., left the clients without waiting for the late nurse to arrive and without finding a replacement), there is evidence of the second element of negligence (Fry & Johnstone, 2002).
The third element needed to establish liability for malpractice is causation, or proximate cause. Causation means that the nurse’s breach of duty is reasonably close to or causally connected to the injury or damage to the client. Damage or actual harm is the fourth element needed to prove malpractice. Without harm or injury, no cause of action exists. This harm may be physical, emotional, and/or financial (Furrow, et al., 1991). There must be proof of a direct relationship between not meeting a standard and the injury sustained by the client. The fifth and final element of malpractice is the forseeability of an event. Foreseeability in this context means that the damages must be a reasonably expected result from the breach of duty. Nurse executives/managers need to be aware of the current trend toward the criminalization of professional nurses’ negligence. A nurse-attorney shares a personal communication of May 14, 1997, reported by Burkhardt and Nathaniel (1998). The communication is as follows: “Until recently, the risk of criminal prosecution for nursing practice was non-existent unless nursing action arose to the level of criminal intent, such as the case of euthanasia leading to murder charges. However, in April, 1997, three nurses were indicted by a Colorado grand jury for criminally negligent homicide in the death of a newborn. Public records show that one nurse was assigned to care for the baby. A second nurse offered to assist her colleague in caring for the baby. A third nurse was a nurse practitioner working in the hospital nursery. Because the baby was at risk for congenital syphilis, the physician ordered that the nurse give 150,000 units of intramuscular penicillin, which would have required five separate injections. In relation to other problems the same day, the baby was subjected to a lumbar puncture, which required six painful attempts. To avoid inflicting further pain, Nurse Two asked the nurse practitioner if there was another route available for administration of the penicillin. Nurse Two and the nurse practitioner searched recognized pharmacology references and determined that IV administration would be acceptable. The nurse practitioner had the authority to change the route and directed Nurse Two to administer the medication intravenously rather than intramuscularly. Unrecognized by the nurses, the pharmacy erroneously delivered the medication prepared and ready to administer in a dose ten times greater than was ordered—1.5 million units.
As Nurse Two was administering the medication IV, the baby died. The Colorado Board of Nursing initiated disciplinary proceedings against Nurse Two and the Nurse Practitioner, but not against Nurse One. The grand jury indicted all three nurses on charges of criminally negligent homicide, but did not indict the pharmacist” (Burkhardt & Nathaniel, 1998, p. 124). This is a very disturbing example of the criminalization of negligence. The case should be made that the nurses should have double-checked the medication, but there really does not seem to be criminal intent involved. However, recklessness can rise to the level of crimi nal negligence, and in this case recklessness, not intent, became the issue. Extreme cases of negligence that rise to the level of recklessness, however, can sometimes replace the need for criminal intent. Vicarious liability arises when other parties are held responsible for causes of negligence. In these cases, employers become responsible for employees’ actions. Most employees are supervised, so employers, by virtue of their oversight responsibilities, are held accountable for negligent acts employees commit in the course of employment. Employers also tend to have “deeper pockets” than individual employees, so the doctrine of vicarious liability affords injured clients a greater pool of resources from which to draw. There is often the temptation by nurses to believe they are protected by their employer, but they need to keep in mind the principle of indemnification when practicing.Under this doctrine, the institution may in turn sue the nurses for damages paid out for substandard care. Nurse managers play an important role in avoiding corporate liability problems by ensuring that employees are delivering high-quality care to their consumers. They must recognize the significance of information gathered, reports, implementation of plans, and evaluation of care on an ongoing basis. This includes client satisfaction surveys and/or other tools, which give information on the consumers’ perception of the care they have received in the institution.
Intentional Torts
Intentional torts are “willful or intentional acts that violate another person’s rights or property” (Berzweig, 1996). There are basically three components to intentional torts:
■ The acts are intended to interfere with the plaintiff and/or the plaintiff’s property.
■ The acts are intentional by the defendant.
■ The acts cause the consequences.
There is no legal requirement for the act causing injury or damage, only proof of intention is sufficient for the courts (Fiesta, 1988). Intentional torts include fraud, assault, battery, informed consent, false imprisonment, invasion of privacy, and defamation, which includes slander and libel. This section briefly describes each in turn. Fraud is deliberate deception to gain unfair or unlawful advantage of a situation. Fraud may occur if a nurse falsifies her employment record or any records at her disposal. According to Guido (2001), civil assault is a threat to touch an individual without consent and causing an immediate fear of harm. The touch does not have to take place; the individual just has to be fearful that it will take place. Battery, on the other hand, is the actual and unlawful touching of the individual’s body or clothes or anything attached to the individual without the individual’s consent. The nurse manager must make sure that their employees understand these two intentional torts and the differences. Fiesta (1988) presents an interesting case in which a Christian Scientist client refused medication and treatment. This client was nonetheless forced to take medication, which the courts ultimately ruled was a battery and awarded remuneration.
Interestingly, one of the most common examples of battery in a hospital setting is surgery being performed without informed consent. Informed consent is the process whereby a client is informed of all possible outcomes, risks of treatments, and alternatives in order to be able to consent freely to the recommended procedure. This means the client has the opportunity and the freedom to make choices in health-care treatment. Confusion arises when the patient is not mentally competent to make decisions about treatment, when there is a language or cultural barrier to understanding the explanation of the treatment and risks, when the patient has not reached legal age to consent but is an emancipated minor, in emergency situations, and when patients refuse to consent despite expected dire consequences for refusal. State laws vary on these subjects. Informed consent is an active and complex area of litigation. Nurses should ensure that valid informed consent exists before performing or assisting with any procedure or treatment. Otherwise, nurses risk possible cause of action for battery. According to Creighton (1986, p. 197), false imprisonment is the unjustifiable and unlawful detention of a client within fixed boundaries or an act with the intention to keep the individual in such a confinement. There are many cases involving false imprisonment. In Big Town Nursing Home, Inc. v. Newman (1970), a 67-year-old man was brought to the nursing home by a nephew, and when he tried to leave, the staff restrained him and denied him use of the telephone or his clothes. The court found the reckless actions of the nursing home willful and malicious in detaining him.
Invasion of privacy is the right to be left alone or free from unwanted publicity. Fiesta (1988) describes four types of privacy invasion: the intrusion of the client’s physical and mental solitude, public disclosure of private facts, any type of publicity that puts the client in the public eye under false pretenses, and any type of appropriation that is a benefit due to the client’s name or likeness (p.160). The case of Bethiaume v. Pratt involved a dying client who had cancer of the larynx and was repeatedly photographed for use by the physician.
The client asked not to be photographed, but these wishes were ignored, and the court found the physician liable for invasion of privacy (Fiesta, 1988, p.160). Nurse leaders and managers must make sure that a client’s privacy is not invaded during their care. This includes ethical as well as legal overtones in client care delivery. Confidentiality is one of the ethical principles that nursing practice upholds via the American Nurses Association Code of Ethics with Interpretative Statements (2001). Nurse managers must make certain that the privileged information regarding clients in their care is kept confidential. Nurses are privy to highly confidential information regarding client care. Information should be disseminated exclusively on a need-to know basis. Nurse managers should also caution their staff not to discuss interesting client cases in open areas. Nurse managers are charged with the maintenance of nursing standards within the ranks of their nursing staff.
Contract Law
The area of contract law most relevant to nurse managers is employment. Most employment relationships between nurses and employers are “at will,” which allows the employees to quit “at will” and the employer to terminate “at will,” for no reason. An actual employment contract between employee and employer is more binding, however. The nurse promises to provide specific nursing services in exchange for financial reimbursement. If either side violates its promises under the contract, the contract has been breached, and the other part may seek damages.
Contracts also come into play in the labor law arena. Many nurses work under the auspices of a union. The Massachusetts Nurses Association (2003) points out that 35% of nurses with union affiliation make a higher wage and work less mandatory overtime than nonunion nurses. This brings into play collective bargaining agreements, which protect the nurse and will not allow the discharge of a nurse without “good cause.” Nurse
Practice to Strive
supervisors are not allowed to participate in collective bargaining.
Ethical Foundations
Ethics is a philosophy based on moral values and reasoning. It contains distinct conduct rules that
regulate particular choices of actions or decisions (Mappes & DeGrazia, 2001). These rules are based on philosophical theories. Ethics and ethical decision making stem from works of major philosophers, such as Immanuel Kant, Rawls, and Mill (Brannigan & DeGrazia, 2001). Deontology, or formalism, is a theory that focuses on an individual’s motives rather than on the consequences of actions.
Deontology encompasses natural law and incorporates dutiful actions of the individual (Hill & Zweig, 2003). Kant further recognized that reasoning is sufficient in leading an individual to moral actions and that these actions should be commenced as ends in themselves rather than as means to an end (Raphael, 1994). For example, a physician asks a nurse to monitor a depressed 40-year-old patient who has been placed on a new, experimental antidepressant medication. The nurse monitors the patient and tells the physician that the patient said,“The medication makes me feel nauseated all of the time,” but the depression has lifted. The physician makes the decision to maintain the patient on the medication because of the need to continue testing on this new medication. The physician is using the patient as a means to an end rather than demonstrating concerns for the patient’s needs and feelings. Kant insisted that moral actions be placed within the boundaries of reason. He further pointed out that an action is not right unless it has the capability of becoming a binding law for everyone. For instance, in truth telling, if the caveat of telling a lie to please a patient exists, then to tell the truth is not a categorical imperative for everyone.
The other major ethical theory is teleology, or consequentialism. Utilitarianism, which is part of teleology and supports the “the greatest good for the greatest number of people,” considers consequences of actions (Beauchamp & Childress, 2001). For instance, if there were to be a flu epidemic and flu vaccine was limited, the decision would be to allow the greatest number of individuals who would be affected to receive the vaccine first. If after their vaccinations, more vaccine became available, then the remainder of the population could be vaccinated. Utilitarianism truly considers real-life and commonsense approaches. John Stuart Mill expressed the view that pleasure and happiness have different qualities. This followed with the distinction that applying the golden rule in one’s conduct takes precedence over immediate gratifications. Mill thought that the greatest happiness must involve everyone concerned, not just an individual. Therefore, the emphasis of this principle is based on groups aimed at producing the most happiness, focusing on utility, consequences, and means to an end (Raphael, 1994).
Another ethical theory is the more contemporary ethics of care. Mappes and DeGrazia (2001) point toaccepting complex circumstances, the people involved must utilize critical thinking within the context of solving or coming to a resolution of the ethical situation.
Mappes and DeGrazia (2001) also considered virtue ethics as part of the ethical picture. Virtue ethics, according to these authors, originated with Aristotle and is based on the character of the individual. Virtue ethics deals with the good or virtuous character traits that may be engendered within the individual. Aristotle named courage as a virtue, striking a balance between excess courage (rashness) and appropriate courage within a situation. The Greek philosophers always strove for balance between two ends of excesses. Balance was always considered the best approach in dealing with virtues. Aristotle also believed that virtues were attained and developed through training and routine practice. In understanding virtue ethics, it would be reasonable to believe that virtuous individuals facing complex ethical dilemmas would make the right decisions due to their virtuous character.
Beauchamp and Childress (2001) laid the foundation for ethical dilemma resolution in their first edition of Principles of Biomedical Ethics. This book is now into its fifth edition and continues to act as a guide for ethical decision making. Nurse leaders/managers need to consider the following ethical principles in their decision-making process or if they are participating on an ethical committee.
ETHICAL PRINCIPLES
The principles listed in Box 5-3 act as a basic foundation for ethical decision making. The first principle is autonomy, which involves the right to self-determination and to make independent personal decisions regarding care. Beauchamp and Childress (2001) imply that the principle of autonomy is sometimes described as respect for autonomy. An example in health care is the patient’s right to refuse treatment. The only restriction on autonomy that may preclude this right would be a com
municable disease, in which case the patient’s autonomy would be restricted. Devettere (2000) points to the Patient Self-Determination Act of 1990 as the first federal initiative that was introduced and designed to educate patients on the use of advance directives. Currently, hospitals and other institutions provide education and paperwork for patients being admitted who have not implemented an advance directive.
Beneficence is a principle that speaks to deeds of charity, mercy, and kindness toward the individual. It also means promoting the welfare of others (Beauchamp & Childress, 2001) or doing good. Nurses, by the nature of nursing practice, perform beneficent acts.
Nonmaleficence literally means to not harm the patient. Munson (2004) believes this is the overriding principle in the care of patients. Aiken and Catalano (1994) declares that nonmaleficence is the other side of beneficence but that the two cannot be considered independent of each other. Nurses may sometimes violate this principle in the short term in order to give a positive long-term result. An example is chest compressions in the event of heart stoppage in an elderly patient; ribs may be broken, and/or sternal fractures may occur that are harmful, but recovering the patient’s life takes precedence over the harm.
The principle of justice is actually the deontological ethical theory. According to Beauchamp and Childress (2001), it encompasses the entire field of ethics and refers to the right to be treated justly, fairly, and equally. Munson (2004) points out that justice in health care often refers to distributive justice and/or the distribution of scarce health-care resources. Social justice becomes a part of this;
Munson continues that it implies fairness in the treatment of individuals. Nurses should be aware that when indigent patients arrive in the emergency department, they must be treated in an equitable way and that if persons require emergency service due to trauma, nurses must proceed to deliver the service as deemed appropriate. This goes along with Rawls’ concept of a Theory of Justice (1971). Brannigan and DeGrazia (2001) cited Rawls’ two principles of equality and justice: (1) that everyone should be given equal liberty no matter what adversities exist; and (2) that differences among people ought to be recognized by being inclusive of the least advantaged and given their share of improvements. Others have explored this concept in health care, according to Brannigan and Boss, by proposingequitable health-care systems, benchmarks, and accessible points of entry. Fidelity focuses more on the delivery of health care and literally means keeping one’s promises or obligations to an individual. Munson (2004) suggests that keeping these commitments becomes of paramount importance when considering patient care standards that are to be met by the nurse.
Likewise, nurse managers are bound by their commitments to their employees. In particular, a verbal commitment involving a shift change is a contract with the employee and should be considered as such by the manager.
Veracity involves truth telling by all concerned in patient care. The nurse certainly has an obligation to tell the truth, for instance, when a patient asks about his or her condition. This, however, can take on tones of nonmaleficence when, for example, a cancer patient asks the nurse how long he might live. In this instance, it may be the duty of the nurse not to take hope away from the patient and to provide a positive answer to this question. The answer might include the idea that no one is able to predict death and that there is always hope in life. Here again the balancing of beneficence and nonmalfeasance within the boundaries of veracity is important in the nurse’s actions (Munson, 2004).
The sanctity of life principle is a part of ethical decisions when it comes to withholding or with drawing life-sustaining treatments or assisting sui cide. Sanctity of human life is defined as the obligation not to take human life (Fry & Veatch, 2000). The American Nurses Association (ANA) implies that nurses caring for patients should direct their care toward the relief and prevention of the suffering that is often associated with the process of dying (ANA, 1985, p. 4). This brings into focus the ANA’s position statement (1994) on active euthanasia and its position statement on withholding nutrition and hydration for the patient (ANA, 2001). The latter position should be made by the client or surrogate with the health-care team. Theeducate client family members about the dying process and provision of comfort measures (ANA Ethics and Human Rights Position Statements, April 2, 1992).
ETHICAL DECISION
MAKING
Nurses must learn how to make ethical decisions, and nurse managers/leaders must direct and guide nurses in making such decisions. Nurses, in increasing numbers, are being invited to participate on ethical committees. These committees are structured with members of the health-care team, administrators, risk managers, attorneys for the institution, and others. A popular ethical decision model called MORAL was put forward by Thiroux (1977) and Halloran (1982). This model offers a very concise and systematic way of making ethical decisions (Box 5-4). It is most important that ANA carefully considered the benefit-and-harm relationship of withholding nutrition, recognizing that, sometimes, living causes more harm to the individual than dying. The ANA differentiates between artificial nutrition and the individual being able to consume food and water by mouth. The ANA states that only artificial nutrition may or may not be justified. If the individual is unable to make decisions, then the surrogate must be relied upon. Nurses must continue to give good care and
ethical decisions be reached in a timely manner. and the use of this model certainly facilitates the process.
Ethics and ethical decision making have become a thread that is followed throughout the nursing curriculum. The American Association of Colleges of Nursing (AACN) has presented a set of nursing values for nursing students to internalize into their nursing education (Box 5-5). These essential values follow closely the aforementioned ethical principles as a guide for the profession and provide a foundation for future nursing leaders and managers to build upon.
All Good Things…
Legal and ethical issues are moving to the forefront of professional nursing practice. The current societal values are changing, and there is an increasing abundance of litigation in the health-care arena. Along with this, the rapid changes in technological advancement keep health professionals in a constant state of training. Nurse executives and managers must know the law and ethics as well as understand the ramifications of making sure their employees are also knowledgeable of the law and ethical dilemmas. The laws that affect nurses are critical for nurse executives to understand and follow by making their employees knowledgeable about the pitfalls that may arise due to not meeting standards of care in their units and what may happen to them legally due to this failure to meet standards of care. Along with the legalities of practice and care go the ethical issues involved in practice. Understanding ethical foundations, ethical decision making, and ethical committees is an important part of the nurse executive/managerial role.
NCLEX Questions
1. Legal and ethical issues are intertwined but:
A. They are not distinct bodies of thought or practice.
B. They are individual and distinct bodies of thought and practice.
C. Have no effect on each other.
D. Are not of great influence on each other.
2. Ethics is a body of knowledge that deals with:
A. Primarily legal aspects of health care.
B. Trying to get individuals to behave correctly.
C. The “shoulds” and “should nots” of individual behavior or actions.
D. Religion only
3. Common law refers to:
A. Laws that societies have in common.
B. Ethical ideas only.
C. Statutes.
D. Case law.
4. Some of the federal laws affecting nurses are:
A. Not important because only state laws impact nursing.
B. Age discrimination act and equal pay act.
C. Very important but not relevant to practice.
D. The nurse practice acts.
5. It is important for nurses to know the Nurse
Practice Act in their state because:
A. It affects their practice.
B. It authorizes their licensure.
C. Neither a nor b.
D. Both a and b.
6. Nonmaleficence actually means:
A. For the nurse to take care of the client.
B. There is negligence.
C. To not harm the patient.
D. Malpractice.
7. Deontology encompasses:
A. Duty.
B. Natural law.
C. Utilitarianism.
D. All of the above.
8. Ethic of care is:
A. Part of all health-care philosophy.
B. Consequentialism.
C. Formulated by John Mill.
D. Based on the moral experiences of women.
9. Ethics is:
A. Based on moral values and reasoning.
B. Only part of the legal system.
C. Not as important as the legal system.
D. Important to philosophical studies.
10. Ethical principles are:
A. Autonomy, fidelity, veracity.
B. Only abstract ideas.
C. Not used in practice.
D. Not applicable to legal situations.
Workplace Communication Relationships
Effective communication demands that
the parties involved in communication have a shared and clear appreciation of the
various definitions and parameters about which information is being
exchanged. According to Stefano Baldi and Ed Gelbstein (“Jargon, Protocols and
Uniforms as barriers to effective communication”): Workplaces are witness to
generally five types of communication relationships: Collaborative, Negotiative,
Competitive, Conflictive and Non-recognition.
The diagram below illustrates how
these are connected to each other and how these relationships are potentially
unstable and as a result of which a relationship can develop from one
type to another either to improve the effectiveness of communication (the
positive development path) or slide into a complete collapse of communication
(the negative development path).
Non-recognition relationship blocks any meaningful exchange by refusing to acknowledge
that one or more of the players in the desired exchange has no rights whatsoever.
Conflictual relationship is a
situation in which the parties recognize each other but
are no longer able to work
towards a win-win result and resort to verbal abuse and
physical violence
instead. These types of relationships present a fundamental obstacle to effective communication.
The other three relationships are often of an unstable nature, in the sense that a
change in the relationship can be triggered by a relatively minor event – even just
one word that is inappropriate at the time - and this can happen very quickly. In the
collaborative relationship the needs and positions of all the parties are
clearly defined and understood and everyone involved shares the will to succeed,
as well as information, equipment, accommodation and logistic arrangements, for
example. The negotiative relationship has much in common with the collaborative
scenario except that some needs and positions may not have been defined clearly
enough and require discussion and trading to reach a mutually acceptable outcome. Collaborative
and negotiative relationships can quickly become competitive relationships when one of the
players needs to (or decides to) play a role different from that which was originally
agreed upon. This new role could also result in some form of overlap with the
responsibilities of others. Another kind of competitive
relationship occurs
when a “new player” joins an established effort and expects to obtain
rights, privileges and concessions from other players. Competitive
relationships can, if not properly managed, quickly deteriorate into non-recognition,
conflict and exclusion.
At this point, the concepts of
credibility and trust become important. Without either of these,
effective communication is simply not possible. Neither credibility nor trust
is automatically and instantly given – they need to be earned.
The diagram below attempts to show
how credibility and trust develop over time. At the early stages of a relationship
one’s own character will determine that whether she assigns the person s/he is dealing
with an optimistic profile of credibility and trustworthiness or a cautious
profile. As the relationship develops over time it can follow many different
paths – the diagram pictures a happy situation where the
credibility and trustworthiness of the person in question actually increases after
the early relationship (if only this were the case all the time!)
until it reaches a high level denoting a mature and stable relationship.
The one curve that matters in this
diagram is the one showing the catastrophic loss of credibility or trust, which is
usually irrecoverable, as this implies the end of any meaningful and
effective communication.
Four responses or roles that often
cause difficulty in communications, as well as in relationships and task activities,
are the:
1. Placater: The Placater always
talks in an ingratiating way, trying to please, apologizing and never disagreeing,
no matter what.
• WITH WORDS the placater always
agrees. For example: “Whatever you want is okay. I am just here to make
you happy.”
• WITH BODY the placater indicates a
sense of helplessness.
• WHILE ON THE INSIDE the placater
feels: “I feel like nothing: without him or her, I am dead. I am worthless.”
2. Blamer: The Blamer is a
fault-finder, a dictator, a boss and always acts superior.
• WITH WORDS the blamer always
disagrees, and says (or seems to say): “You never do anything right. What is
the matter with you?” Or, “If it weren’t for you, everything would be all right.”
• WITH BODY the blamer indicates: “I
am the boss around here.”
• WHILE INSIDE the feeling is: “I am
lonely and unsuccessful.”
3. Computer: The Computer is very
correct, very reasonable with no semblance of any feeling showing. He or she is
calm, cool and collected, and is almost totally disinterested and tries to sound
intellectual. The computer uses big words.
• WITH WORDS the computer is
ultra-reasonable. For example: “If one were to observe carefully, one might
notice the work-worn hands of someone present here.”
• WITH BODY the computer is stoic
like a machine and seems to be saying: “I’m calm, cool and collected.”
• WHILE ON THE INSIDE the computer
may really be saying:“I feel vulnerable.”
4. Distracter: The Distracter never
makes a direct response to anything. Anything he or she says is totally irrelevant to
what anyone else is saying or doing.
• WITH WORDS the distracter makes no
sense and is totally irrelevant.
• WITH BODY the distracter is
angular and off somewhere else.
• WHILE ON THE INSIDE the distracter
may be saying:“Nobody cares. There is no place for me.”
Mutual trust and respect are the
foundation for effective communications. When both of these exist, goals can be developed
to which all individuals and groups are committed.
Communication systems and procedures
based on shared goals and developed cooperatively are those most
supported, most adhered to, and consequently most efficient.
Interpersonal Relations and Group Processes
Social facilitation
Intuitively, most of us probably
think the term ‘social’ means doing things with (or being in the presence of
) other people, and that social psychology is therefore about the
causes and effects of this ‘social presence’. Although social
psychologists use the term ‘social’ in a much broader way than this, the
effect of the physical presence of other people on our behaviour
remains an important research question.
In fact, in 1898 Triplett designed
one of the earliest social psychology experiments to address this very question. He discovered from
analysis of published records that cyclists go faster when paced by another cyclist, and
he decided to investigate this phenomenon under more controlled conditions.
Triplett had 40 children reel in fishing lines, either alone or in pairs,
and he discovered that the children tended to perform the task more quickly
when in the presence of someone else doing the same task. Triplett attributed this
‘quickening effect’ to the arousal of a competitive instinct. Some years
later, F. Allport coined the term social facilitation to refer to a more clearly
defined effect in which the mere presence of conspecifics (i.e.
members of the same species) would improve individual
task performance.
These conspecifics might be co-actors
(i.e. doing the same task but not interacting) or simply a passive
audience (i.e. observing the task performance). Research (much of it with an exotic
array of different species) seemed to confirm this. We now know that
cockroaches run faster, chickens, fish and rats eat more,
and pairs of rats copulate more when being ‘watched’ by members of their
own species. However,
later research found that the presence of conspecifics
sometimes impairs performance, although it was often unclear what degree of
social presence produced impairment (i.e. coaction or a passive audience). Zajonc put
forward a drive theory to explain social facilitation effects. He argued that,
because people are unpredictable, the mere presence of a passive audience
instinctively and automatically produces increased arousal and motivation. This
was proposed to act as a drive that produces dominant responses for that
situation (i.e. well learned, instinctive or habitual behaviours that take
precedence over alternative responses under conditions of heightened arousal or
motivation). But do dominant responses improve task performance? Zajonc
argued that if the dominant response is the correct behaviour for that
situation (e.g. pedaling when we get on a bicycle), then social presence
improves performance (social facilitation).
Zajonc’s explanation of
social facilitation/inhibition
But if the dominant response is an incorrect
behaviour (e.g. trying to write notes in a lecture before we have
understood properly what is being said), then social presence can impair
performance (social inhibition). Zajonc believed that drive was an
innate reaction to the mere presence of others. Other views are that drive
results from an acquired apprehension about being evaluated by
others or from conflict between paying attention to a task and to an audience
. Still other researchers discard the notion of drive entirely. They
suggest that social facilitation may occur because of distraction and
subsequent narrowing of attention, which hinders performance of poorly
learned or difficult tasks but leaves unaffected or improves
performance of well learned or easy tasks.
Alternatively, social presence might
motivate concern with self-presentation – i.e. how we appear to
others (rather than concern specifically about being evaluated by them)
or make us more self-aware. This might then increase cognitive effort, which is
considered to improve performance on easy tasks but not on difficult
tasks (where failure and social embarrassment might be anticipated). Overall,
then, the empirical finding from this body of research is that the
presence of others improves performance on easy tasks, but impairs performance on
difficult tasks. But no single explanation seems to account for social facilitation
and social inhibition effects. Instead, several concepts – including
arousal, evaluation apprehension, and distraction conflict – are
involved. Bystander apathy and intervention One type of behaviour that might be
affected by the presence of other people is our inclination to offer help
to someone who needs it. This question can be studied from
many perspectives. One of these is evolutionary psychology – do
people help others simply as members of their own species, or only
those with whom they shares genes? (see Batson, 1983; and
Dawkins’, 1976, notion of the ‘selfish gene’). Another
perspective is that of socialization – do we learn to help others as a result
of direct instructions, reinforcement, social learning and modelling?
Two of the most important lines of
research on helping by social psychologists have focused on
situational factors that encourage or discourage helping, and on what
motives may underlie helping others.
A critical feature of the immediate situation that determines whether by standers help someone who is in need of help (bystander intervention) is the number of potential helpers who are present. This approach was stimulated by the widely reported murder of Kitty Genovese in New York in 1964: although 38 people admitted witnessing the murder, not a single person ran to her aid. To explain bystander intervention (or its opposite – apathy), Darley, Latané and others carried out a series of classic experiments.
Numerous studies indicate that the
willingness to intervene in emergencies is higher when a bystander is
alone. In one of the first experiments showing this effect, students
overheard that a woman working in the office next door had climbed
onto a chair, fallen on the floor and lay moaning in pain. This incident
lasted 130 seconds. In one condition, the student who overheard the information
was alone. In a second condition, another student (a confederate of the experimenter,
who had been instructed to be passive) was also present. In a third
condition, the student participant was with a stranger at the time of
the accident, and in a fourth condition the student participant was with a friend.
Although two people could have
intervened in the third and fourth conditions, in only 40 per cent of
stranger dyads and 70 per cent of friend dyads did at least one student
intervene. The individual likelihood of intervention has to be calculated
according to a special formula that corrects for the fact that two people are free to act in
two conditions (with stranger; with friend), but only one person is
free to act in the remaining two conditions (with passive confederate;
alone). The individual likelihood of intervention was in fact twice as high when students
were with a friend (i.e. fourth condition) compared with a stranger
(i.e. third condition). Both of these corrected intervention rates for the
third and fourth conditions were lower than in the condition where the
participant was alone (first condition), but higher than in the second
condition, where there was a passive confederate present at the time of the accident
(see figure 18.3).
The effect of the
presence and identity of others on bystander intervention
in an emergency
Subsequent research indicated that
three types of social process seem to cause the social inhibition of helping
in such situations:
1. diffusion of responsibility (when
others are present, our own perceived responsibility is lowered);
2. ignorance about how others
interpret the event; and
3. feelings of unease about how our
own behaviour will be evaluated by others present.
So, witnesses to the Kitty Genovese
murder may have failed to intervene because:
1. they saw other people present,
and so did not feel responsible;
2. they were unsure about how the
others present interpreted the situation; and
3. they were embarrassed about how
they might look if they rushed in to help when, for some reason, this
might be inappropriate.
On the basis of studies such as
this, Latané and Darley proposed a cognitive model of bystander
intervention. Helping (or not) was considered to depend on a series
of decisions:
1. noticing that something is wrong;
2. defining it as an
emergency;
3. deciding whether to take personal
responsibility;
4. deciding what type of help to
give; and
5. implementing the decision.
Bystanders also seem to weigh up
costs and benefits of intervention vs. apathy before deciding what to do.
Piliavin, Dovidio, Gaertner and Clark proposed a bystander
calculus model that assigns a key role to arousal. They
proposed that emergencies make us aroused, situational factors determine how
that arousal is labelled and what emotion is felt (see chapter 6), and then we assess
the costs and benefits of helping or not helping before deciding what to do.
To summarize findings from
this area of research, the presence of multiple bystanders seems the
strongest inhibitor of bystander intervention due to diffusion of
personal responsibility, fear of social blunders and social
reinforcement for inaction. In addition, the costs of not helping are
apparently reduced by the presence of other potential helpers. People tend
to help more if they are alone or among friends, if situational norms or
others’ behaviour prescribe helping, if they feel they have the skills to offer
effective help, or if the personal costs of not helping are high.
Motives for helping
A rather different line of research
has concentrated on the motives underlying helping (or, more generally,
prosocial behaviour) – in particular, whether people help for altruistic or egoistic
motives. A discussion of the genetic argument is beyond
this chapter.
Batson and colleagues had female
students observe ‘Elaine’, an experimental confederate, who was
apparently receiving electric shocks. In the second trial of the experiment, Elaine
appeared to be suffering greatly from the shocks, at which point the
experimenter asked the female observer whether she would be willing to continue with
the experiment by taking Elaine’s place.
In one condition, participants
believed that Elaine shared many attitudes with them. In another
condition, they were led to think that she held dissimilar attitudes.
The experiment also manipulated difficulty of escape. In the ‘easy
escape’ condition, participants knew that they could leave the observation room
after the second trial, which meant that they would not be forced to continue
observing Elaine’s plight if the experiment continued with her. In the
‘difficult escape’ condition, they were instructed to observe the
victim through to the end of the study.
Percentage of
participants who helped Elaine, depending on similarity/empathy and
difficulty of escape
As figure shows, participants
only took up the option offered by the ‘easy escape’ condition and
failed to help when the victim had dissimilar attitudes. These results
were interpreted as being consistent with the hypothesis that high
attitude similarity increases altruistic motivation, whereas low
attitude similarity encourages egoistic motivation.
Batson’s altruism theory was opposed
by the view that people were, in fact, helping for selfish,
rather than altruistic, motives. So helping could sometimes be motivated by an
egoistic desire to gain relief from a negative state (such as
distress, guilt or unhappiness) when faced with another person in need of help.
Although a meta-analysis by Carlson and Miller did not support this idea, there
is continued controversy between the ‘altruists’ and ‘egoists’ as to why we help. Batson continues to maintain
that helping under the conditions investigated by him is motivated positively by the
feeling of ‘situational empathy’, rather than by an egoistic desire to
relieve the ‘situational distress’ of watching another person suffer.
Helping is also increased by
prosocial societal or group norms.These can be general norms of reciprocity or
social responsibility, or more specific helping norms tied to the nature
of a social group (e.g. ‘we should help older people’).
Other factors that increase helping
include being in a good mood and assuming a leadership role in the situation. Research
has also shown that, relative to situational variables, personality and gender
are poor predictors of helping.
Note that many of these studies on
helping are ‘high impact’ experiments – fascinating to read about but
potentially distressing to participate in. Because of the greater
sensitivity to ethical issues in research today (see chapter 2), it would be
difficult now to conduct some of these studies, as well as other studies
described in this chapter.
The influence of authority
The research on both social
facilitation and helping shows that the mere presence of other people
can have a clear effect on behaviour. But this effect can be tremendously
amplified if those others actively try to influence us – for
example, from a position of authority.
Legitimate authority figures
can be particularly influential; they can give orders that people blindly
obey without really thinking about the consequences. This has been the focus
of one of social psychology’s most significant and
socially meaningful pieces of research.
Milgram discovered that quite
ordinary people taking part in a laboratory experiment were prepared to administer
electric shocks (450V), which they believed would harm another participant, simply because
an authoritative experimenter told them to do so. This study showed that
apparently ‘pathological’ behaviour may not be due to individual pathology (the
participants were ‘normal’) but to particular social circumstances. The
situation encouraged extreme obedience.
Milgram subsequently conducted a
whole series of studies using this paradigm. One of his most
significant findings was that social support is the
single strongest moderator of the effect. So, obedience is
strengthened if others are obedient, and massively reduced if others are
disobedient.
Milgram investigated the role of
peer pressure by creating a situation with three ‘co-teachers’, the
participant and two confederates. The first confederate presented the
task, the second registered the learner’s responses, and the
participant actually administered the shocks. At 150V, the
first confederate refused to continue and took a seat away from
the shock generator. At 210V, the second confederate refused to
continue. The effect of their behaviour on the participants was
dramatic: only 10 per cent of the participants were now maximally obedient
(see figure 18.5). In contrast, if the teacher
administering the learning task was accompanied by a co-teacher, who
gave the shocks, 92 per cent of the participants continued to be
obedient to the end of the study. The powerful role of interpersonal
factors (i.e. peers who had the temerity to disobey) was evident from
this investigation.
One unanticipated consequence of
Milgram’s research was a fierce debate about the ethics of social
psychological research. Although no electric shocks were actually
given in Milgram’s study, participants genuinely believed that they
were administering shocks and showed great distress.
Was it right to conduct this study?
This debate led to strict guidelines
for psychological research. Three of the main components of this code are
(i) that participants must give their fully informed consent to take part, (ii)
that they can withdraw at any point without penalty, and (iii) that after
participation they must be fully debriefed
Obedience as a function
of peer behaviour.
AFFILIATION, ATTRACTION AND CLOSE RELATIONSHIPS
Seeking the company of others
Human beings have a strong need to
affiliate with other people, through belonging to groups and
developing close interpersonal relationships. The consequences of social
deprivation are severely maladaptive (ranging from loneliness
to psychosis), and social isolation is a potent punishment that
can take many forms (solitary confinement, shunning,
ostracism, the ‘silent treatment’).
Most of us choose to spend a great
deal of time with others, especially when we
experience threat or feel anxious.
Our motives for affiliation include
social comparison, anxiety reduction and information seeking. Hospitals
now routinely encourage surgical patients who have undergone the same medical
procedure to talk to others to help reduce anxiety.
People usually seek out and maintain
the company of people they like. We tend to like others whom we
consider physically attractive, and who are nearby, familiar and
available, and with whom we expect continued interaction. How many
of your friends at college live close to you on campus? The likely answer is ‘many of
them’. We also tend to like people who have similar attitudes and values to our own,
especially when these attitudes and values are personally important to us.
The importance of social support Generally,
having appropriate social support is a
very powerful ‘buffer’ against stressful events. Cohen and Hoberman
found that, among individuals who felt that their life was very stressful,
those who perceived themselves to have low social support
reported many more physical symptoms (e.g. headaches, insomnia)
than those who felt they had high social support (see
figure 18.6).
The relationship between perceived
stress and physical symptomatology for individuals low and high in social
support.
Overall, the evidence is clear –
social integration is good for our physical and psychological health. Social
exchange theory A general theoretical framework for the study
of interpersonal relationships is social exchange theory. This approach regards
relationships as effectively trading interactions, including goods (e.g. birthday presents),
information (e.g. advice), love (affection, warmth), money
(things of value), services (e.g. shopping, childcare) and status (e.g.
evaluative judgements). A relationship continues when both partners feel that
the benefits of remaining in the relationship outweigh the costs and the
benefits of other relationships.
According to this framework, these
considerations apply to even our most intimate friendships. We now turn
to a consideration of these closest relationships in our lives. It is argued
that these relationships are also based on complex cost–benefit analyses
(‘she brings the money in and is practical, but I have a secure pension and do
more for the children’). According to the more specific equity theory, partners in such relationships are
happier if they feel that both partners’ outcomes are
proportional to their inputs, rather than one partner receiving more
than they give.
Happy vs. distressed relationships A major
characteristic of happy, close relationships is a high degree of
intimacy. According to Reis and Patrick (1996), we view our closest
relationships as intimate if we see them as: caring (we feel that the other
person loves and cares about us); understanding (we feel that the other
person has an accurate understanding of us); and validating (our partner
communicates his or her acceptance, acknowledgement and support for our point
of view).
Unhappy or ‘distressed’
relationships, on the other hand, are characterized by higher rates of
negative behaviour, reciprocating with such negative behaviour when the partner
behaves negatively towards us. Reciprocation, or retaliation, is the most reliable
sign of relationship distress. Those in unhappy relationships also tend to
ignore or cover up differences, compare themselves negatively with other
couples and perceive their relationship as less
equitable than others. They also make negative causal attributions of their
partner’s behaviours and characteristics. For example, being given flowers
might be explained away with ‘He’s just trying to deal with his guilt;
he’ll be the same as usual tomorrow.’ In a happy relationship, the explanation
is more likely to be something like ‘It was nice of him to
find time for that; I know how stressed he is at the moment.’
The investment model
Ultimately, what holds a
relationship together is commitment – the inclination to maintain a
relationship and to feel psychologically attached to it. According to
the investment model, commitment is based on one or
more of the following factors: high satisfaction, low quality of alternatives, and a high
level of investments. Highly committed individuals are more willing to make
sacrifices for their relationship, and to continue it even when forced to
give up important aspects of their life.
Close relationships do, regrettably,
often dissolve, sometimes as a result of extreme levels of violence
committed within intimate relationships. The ending of a relationship is often a
lengthy, complex process, with repeated episodes of conflict and reconciliation.
Women tend to terminate intimate relationships more often than do men and are more
distressed by relationship conflict.
But for both partners the consequences can be devastating. The physical and mental health of divorced people is generally worse than that of married people, or even people who have been widowed or never married. Factors that predict better adjustment to divorce include having taken the initiative to divorce, being embedded in social networks, and having another satisfying and intimate relationship.
Group structure and process
One morning before class the
psychology instructor wrote something at the end of the
chalkboard, intending
it for discussion later in the hour. After class had begun, a student waved his
hand and stood up, asking about the irrelevant material. Chiefly to avoid
embarrassment to the student, the instructor gave a brief explanation. The
young man then took his seat amid glances from others.
Later, the same student rose again.
This time he declared in a loud voice: "I don't like this class. This is the
worst lecture I've ever heard." The glances of the other students
changed to snickers and whispers, undoubtedly concerning the instructor as well as the
student. After a brief response by the instructor, the young man took his seat once
again.
Roles and Hierarchies
The student's reaction distinctly
disrupted the class, for he did not confine his comments to academic issues.
This out-of-role behavior, as attested by the whispers and giggles,
was given considerable weight in forming an impression of the student.
Formal and Informal Roles In class,
each student has a formal role, which is a pattern of behavior expected of a
group member. A role typically is associated with a certain status or standing in the
group. The student, who occupies a position of less overall responsibility than the
instructor, has a narrower role in the classroom. The student is expected to learn from
the instructor, not to make criticisms. The instructor has overall responsibility for the
class and its members, a role that entails leadership responsibilities.
Roles are often complementary. The
role of instructor cannot be described without reference to the role of
student. Politicians have no role without a constituency. Short-order
cooks respond to hungry patrons and vice versa. Appropriate behavior for a given
role depends upon the roles played by others.
An individual also may have an
informal role, apart from any official position in a group. When among friends, a
light-hearted student may assume the role of jokester, although never elected
or appointed to this position. A humorous remark about the lecture would not be surprising
outside of class; it might be all too common in some instances.
In daily life most of us assume
several roles and become adept at changing from one to the other. A man assumes
the role of instructor in class, the role of husband with his wife, the role of spectator
at a sporting event, and that of father with his children. Social scientists say that
he exhibits different "selves" in these various roles.
Human Hierarchies Among human beings
playful aggressiveness in children, if unchecked or unsupervised, should
theoretically result in a dominance based on fighting, and such a hierarchy develops in
street gangs and certain primitive societies. A member of one city gang said,
"Nutsy was the head of our gang once. I was his lieutenant. He was bigger than
me, and he walloped me different times before I walloped him….After I walloped him, I told the
boys what to do".
Usually a person's status is based
on something other than physical domination. Bowling performance was closely
associated with status in this city gang because it became the chief social activity
of the group. It was the means by which an individual could gain, lose, or maintain
prestige.
Important determinants of status in
human society include money, education, intelligence, and also physical
competence, as demonstrated in entertainment and athletics. Social hierarchies
are based on the interaction of many such characteristics.
Taking our place in the group
Almost all groups are structured
into specific roles. People move in and out of roles, and in and out
of groups. Groups are dynamic in terms of their structure and their
membership. But first of all, of course, people need to join
groups.
Joining groups
We join groups for all sorts of
reasons, but in many cases we are looking for company (e.g.
friendships and hobby groups) or to get things done that we cannot do on our
own (e.g. therapy groups, work groups and professional
organizations). We also tend to identify with large groups (social
categories) that we belong to – national or ethnic groups,
political parties, religions, and so forth.
Research on group formation
generally examines the process, not the reasons. One view is that
joining a group is a matter of establishing bonds of attraction to the group,
its goals and its members. So a group is a collection of people
who are attracted to one another in such a way as to form a
cohesive entity. This approach has been used extensively to study
the cohesiveness of military groups, organizational units and sports
teams. Another perspective, based on social comparison theory, is that we
affiliate with similar others in order to obtain support and consensus for
our own perceptions, opinions and attitudes.
A third approach rests on social
identity theory. According to this frame-work, group formation involves a
process of defining ourselves as group members, and conforming to
what we see as the stereotype of our group, as distinct from other groups. We
categorize ourselves in terms of our group’s defining features – e.g. ‘we are
psychology students, we are studying a useful subject’. This process describes
and evaluates who we are and is responsible for group phenomena such as group
cohesion, conformity to norms, discrimination between different groups, and so forth.
Group development
The process of joining and being
influenced by a group doesn’t generally happen all at once. It is
an ongoing process. The relevant mechanisms have been investigated by many
social psychologists interested in group development, or how groups change over time. One very
well established general model of group development is Tuckman’s
five-stage model:
forming – initially people orient
themselves to one another;
storming – they then struggle with
one another over leadership and group definition;
norming – this leads into agreement
on norms and roles;
performing – the group is now well
regulated internally and can perform smoothly and efficiently;
adjourning – this final stage
involves issues of independence within the group, and possible group
dissolution.
More recently, Levine and Moreland
have provided a detailed account of group socialization – how
groups and their members adapt to one another, and how people
join groups, maintain their membership and leave groups. According to this account,
groups and their members engage in an ongoing cost–benefit analysis of
membership (similar to the kinds of analyses that we have already discussed as
being relevant in regulating dyadic interpersonal relationships). If the benefits of the group
membership outweigh the costs, the group and its members become committed to one
another.
This approach highlights five
generic roles that people occupy in groups:
prospective member – potential
members reconnoitre the group to decide whether to commit;
new member – members learn the norms
and practices of the group;
full member – members are fully
socialized, and can now negotiate more specific roles within the group;
marginal member – members can drift
out of step with group life, but may be re-socialized if they drift
back again; and ex-member – members have left the group, but
previous commitment has an enduring effect on the group and on the ex-member. Levine and
Moreland believe that people move through these different roles during the
lifetime of the group.
Roles
Almost all groups are internally
structured into roles. These prescribe different activities that exist
in relation to one another to facilitate overall group
functioning. In addition to task-specific roles, there are also
general roles that describe each member’s place in the life of the
group (e.g. newcomer, old-timer).
Rites of passage, such as initiation
rites, often mark movement between generic roles, which are characterized
by varying degrees of mutual commitment between member and group.
Roles can be very real in their
consequences. In the famous Stanford Prison Study , researchers randomly
assigned students to play the roles of prisoners or guards in a
simulated prison set-up. The ‘prison’ was located in the basement of the
psychology department at Stanford University.
Before the study began, all
participants were carefully screened to ensure they were psychologically
stable. Zimbardo and his team planned to run the study for two weeks, while
observing the participants. In fact, they had to terminate it after six days
because the participants were conforming so extremely to their roles. The guards
harassed, humiliated and intimidated the prisoners, often quite
brutally, and the prisoners increasingly showed signs of individual
and group disintegration, including severe emotional disturbance and some psychosomatic
problems. The importance of this classic study was shown recently by the
appalling treatment of Iraqi prisoners recorded inside Abu Ghraib jail in 2003. Roles also
define functions within a group, and the different parts of
the group normally need to communicate with one another. Research on communication
networks focuses on centralization as
the critical factor.
Some communication
networks that have been studied experimentally
More centralized networks have a hub
person or group that regulates communication flow, whereas less centralized
networks allow free communication among all roles. Centralized networks work well for
simple tasks (they liberate peripheral members to perform their role) but
not for more complex tasks – the hub becomes overwhelmed, delays and
mis-communications occur, frustration and stress increase, and peripheral
members feel loss of autonomy.
Leadership
In a psychology class, knowledge of
the subject matter is the chief means by which an individual gains status, though
other factors are also important. The anticipated class
leader therefore would
be the instructor, whose authority clearly was challenged by the
student's derogatory comments. On that occasion the instructor merely paused
for a moment, and then he returned to the lecture.
After a few moments the student
stood up once again, and this time he walked slowly to the lecture platform,
mounted the steps, and confronted the instructor directly. As he stood there in
shorts, sandals, and tee shirt, the room became completely silent.
Then the student announced unsteadily, "I hate your necktie." In a
truly quavering voice, he added, "It reminds me of my father." Some
students, thinking it was a joke, which it was not, made derisive
catcalls. Others gasped or sat dumbfounded.
Those near the front rose from their
seats to leave the area, for there was a look of terror in the man's face. The
student's remarks and the agitation in his whole person
left little doubt that
he was experiencing a severe emotional disturbance.
The instructor looked at the young
man for several moments, and then the class episode ended as abruptly as
it had begun. The young man inexplicably returned to his seat, picked up his books,
and left the room. In the interim another student had departed to telephone the campus
police, instructing his classmates not to interfere with the distraught young man. Soon
the entire affair was under proper jurisdiction, and several weeks later the young
man was released from the treatment facility to which he had been sent.
Great-Person Theory In some
situations the role of helper or leader is assigned, as it was for the police officer on
duty. In others it is adopted, which happened when the student telephoned for
assistance. But just how and when an individual is suited for this
role, assigned or adopted, has been difficult to determine. Studies of
leadership for many years occupied an important niche in psychology, as
investigators attempted to discover the essential traits of an
effective leader.
Intelligence, flexibility, and
strength of character were prominently mentioned, and it was assumed that the
leader was the best-liked, most active, and most able member of the group. This
expectation is known as the great-person theory of leadership. The idea here is that
each person has a single status, and there is an all around "great person" at
the top. It is assumed that there are differences in roles among the group
members but only along a single dimension, general leadership status. The leader,
furthermore, would be a leader in almost any group in which he or she was a member.
But as the research continued, the
hopes for a prescriptive set of characteristics faded for two reasons. First,
it was discovered that different situations usually require somewhat different traits in
a leader. Even if a hierarchy could be established for one situation, it would have to
be reestablished in another, depending upon the traits of the group members. Second, even
within one situation, there seem to be at least two distinctly different leadership
roles, each making its own contribution to the group process.
Complementary Leaders These findings
on modes of leadership have been obtained in studies of group discussions by
using a method called interaction process analysis, in which the interactions of group
members are analyzed with respect to several response categories. The aim is to discover
the ways in which each member contributes to or detracts from progress toward group
goals. When data from many sessions have been examined, they usually indicate two
general leadership styles.
There is a task specialist, who is
concerned with analyzing the problem, discovering methods of dealing with it,
and implementing the best solution. This person is oriented to a specific obstacle
or threat in the group, and usually he or she ranks highest on activity and best ideas.
There is also a social specialist, who emerges as the central figure in group cohesion and
maintenance of group morale. Also called the maintenance specialist, this person
often has a good sense of humor and usually ranks highest on likeability.
On rare occasions the two roles are
held by the same person, lending some small support for the great-person
theory. But especially as the group continues to function, different individuals
emerge in these capacities.
Some cautions are in order, however.
First, the method of interaction process analysis is intended to have broad
usefulness, but the findings have been derived largely from a laboratory context. We cannot
be confident that two separate leadership styles would emerge in spontaneous
situations. The student who gave instructions to his classmates and then
telephoned for assistance might also have been the social specialist in that
instance. Or there may be no significant social-emotional specialist during an emergency.
Leaders and Situations There are,
however, a few general characteristics of leadership. The individual who
assumes control is usually above average in intelligence, though not
necessarily the most brilliant individual in the group. The leader must be bright but
not deviant, perhaps demonstrating some truth in an old political maxim:
The best-qualified person, in terms
of ability, is not popular enough to be elected. Second, any enduring leader
must be close to the group members in attitudes and interests. If the members tend
to be authoritarian, the leader must be at least moderately authoritarian as well.
If just one person is to be chosen
leader, certain factors will be influential. A task leader is likely to be most
suitable if the morale of the group is unusually good or if the group has deteriorated
almost to the point of disintegration. In both cases a task-oriented, almost dictatorial
leader may be acceptable. When conditions are neither extremely favorable nor
extremely unfavorable, a social leader is likely to be effective for group
performance. The primary need here is to maintain solidarity and cohesion in
the group.
As the group goals change, a leader
may become a follower, especially in a very large group, such as a whole
nation. Different situations require different leadership abilities, as we saw
earlier. Here again, we encounter an interaction effect. The type of
leadership that proves most effective depends upon the situation, the level of development
of the group, and its goals (Figure 18.20).
As we conclude this chapter, you are
perhaps wondering how your authors knew this psychology class so well.
The leadership role in this particular instance fell to one of us, the course instructor.
But which of us wears traditional neckties, gives rousing lectures, and participated
in this unexpected episode? The reader is left to decide.
The most basic role differentiation
within groups is into leaders and followers. Are some people ‘born to lead’
(think of Lady Margaret Thatcher, Sir Ernest Shackleton or Sir
Alex Ferguson), or do they acquire leadership personalities
that predispose them to leadership in many situations?
Extensive research has revealed that
there are almost no personality traits that are reliably associated with
effective leadership in all situations. This finding suggests
that many of us can be effective leaders, given the right match
between our leadership style and the situation. For example, leader
categorization theory states that we have leadership schemas
(concerning what the leader should do and how) for different group tasks, and
that we categorize people as effective leaders on the basis of their
‘fit’ to the task-activated schema. A variant of this idea, based on social
identity theory (see below), is that in some groups what really
matters is that you fit the group’s defining attributes
and norms and that, if you are categorized as a good fit, you will be endorsed as
an effective leader.
Perhaps the most enduring leadership
theory in social psychology is Fiedler’s contingency theory.
Fiedler believed that the effectiveness of a particular leadership style was
contingent (or dependent) on situational and task demands. He distinguished between
two general types of leadership style (people differ in terms of which style
they naturally adopt): a relationship-oriented style that
focuses on the quality of people’s relationships and their satisfaction
with group life; and a task-oriented style that focuses on getting the task
done efficiently and well.
Are some people ‘born to
lead’, or do they acquire leadership personalities that predispose them
to leadership?
Relationship-oriented leaders are
relaxed, friendly and sociable, and derive satisfaction from harmonious
group relations. Task oriented leaders are more aloof and directive,
are not concerned with whether the group likes them, and derive
satisfaction from task accomplishment.
Fiedler measured leadership style
using his ‘least preferred coworker’ (LPC) scale. The idea is to measure how
positively a leader views the co-worker that they hold in lowest esteem. He predicted
that relationship-oriented leaders would be much more positive about their least preferred
co-worker than task-oriented leaders. So, for relationship-oriented leaders,
even the least-liked group member is still quite liked.
Fiedler was also able to classify
situations in terms of how much control was required for the group task to
be effectively executed. A substantial amount of research has
shown that task oriented leaders are superior to
relationship-oriented leaders when situational control is very low (i.e.
poorly structured task, disorganized group) or very high (i.e. clearly
structured task, highly organized group). But
relationship-oriented leaders do better in situations with intermediate levels
of control.
Fiedler’s model of leadership is,
however, a little static. Other approaches have focused instead on
the dynamic transactional relationship between leaders and followers.
According to these approaches,
people who are disproportionately responsible for helping a group achieve its
goals are subsequently rewarded by the group with the trappings of leadership, in order to
restore equity. Hollander suggested that part of the reward for such
individuals is their being able to be relatively idiosyncratic and innovative.
So, people who are highly conformist and attain leadership in a
democratic manner tend to accumulate significant idiosyncrasy credits that they can
then expend on innovation once they achieve leadership.
In other words, you first have to conform before you
can innovate. (For a different view to this one, see the section
below on ‘minority influence’.)
Leaders who have a high idiosyncrasy
credit rating are imbued with charisma by the group, and may be able to function as transformational leaders (see chapter 20).
Charismatic transformational leaders are
able to motivate followers to work for collective goals that
transcend self-interest and transform organizations. They are proactive,
change-orientated, innovative, motivating and inspiring and have a vision or
mission with which they infuse the group. Transformational leaders are
also interested in others, able to create commitment to the group and can
extract extra effort from (and generally empower) members of the group.
How groups influence their members
We have seen how the presence of other people can make us less inclined to help someone, and how other people can persuade us to obey their orders. Groups can also exert enormous influence on individuals through the medium of norms.
Group norms
Although group norms are relatively
enduring, they do change in line with changing circumstances to prescribe
attitudes, feelings and behaviours that are appropriate for group
members in a particular context. Norms relating to group loyalty and central aspects of
group life are usually more specific, and have a more restricted
range of acceptable behaviour than norms relating to more peripheral features of the
group. High-status group members also tend to be allowed more deviation from
group norms than lower-status members.
Sherif carried out one of the
earliest, and still most convincing, demonstrations of the impact of
social norms, deliberately using an ambiguous stimulus. He placed participants alone or in
groups of two or three in a completely darkened room. At a distance of about 5 m, a
single and small stationary light was presented to them. In the absence of
reference points, the light appeared to move rather erratically
in all directions – a perceptual illusion known as the
autokinetic effect.
Sherif asked his participants to
call out an estimate of the extent of movement of the light,
obviously without informing them of the autokinetic effect. Half
of the participants made their first 100 judgements alone. On
three subsequent days they went through three more sets of trials,
but this time in groups of two or three. For the other half of
the participants, the procedure was reversed. They underwent the
three group sessions first and ended with a session alone.
Participants who first made
their judgements alone developed rather quickly a standard estimate
(a personal norm) around which their judgements fluctuated. This
personal norm was stable within individuals, but it varied highly between
individuals. In the group phases of the experiment, which brought together people with
different personal norms, participants’ judgements converged towards a more or less
common position – a ‘group norm’. With the reverse procedure employed with
the other half of the participants, this group norm developed
in the first session and persisted into the later session, when
participants were evaluated alone. Figure 18.9 illustrates both sets of
findings. The funnel effect in the left panel reveals the
convergence in the (median) judge ments of three participants who
first judged alone (session I) then later on in each other’s presence
(sessions II, III and IV). The right panel shows the judgements of a
group of three participants who went through the procedure in the
reverse order (i.e. first judged together, then alone). Here the group
convergence is already present in the first session, and there is no sign
of funnelling out in the final ‘alone’ session.
In subsequent studies, Sherif found
that, once established, this group norm persisted, and that it strongly
influenced the estimations of new members of the group.
In another study, Jacobs and
Campbell used a group of confederates who unanimously agreed upon a
particular judgement. After every 30 judgements, they replaced a confederate by a naive
participant until the whole group was made up of naive participants. Their results
indicated that the norm had a significant effect on the naive
participants’ judgements, even after all the confederates had been removed from
the judgement situation.
Conformity
Sherif ’s autokinetic experiments
show how norms develop and influence people – but the actual process
through which people conform is less obvious. The participants in
Sherif’s study were publicly calling out their estimates of a
highly ambiguous stimulus. Perhaps they were worried about looking foolish, or
were simply uncertain. People may have conformed for one of two reasons,
each linked to a distinct form of social influence:
1. They may have been concerned
about social evaluation (e.g. being liked or being thought badly of )
by the others in the group (normative influence).
2. They may have used the other
group members’ judgements as useful information to guide them in an ambiguous task on
which they had no previous experience (informational influence).
A series of experiments by Asch
tried to rule out informational influence by using clearly unambiguous stimuli. In his first study,
Asch invited students to participate in an experiment on visual discrimination.
Their task was simple enough: they would have to decide which of
three comparison lines was equal in length to a standard line.
On each trial, one comparison line was equal in length to the
standard line, but the other two were different (see figure
18.10).
The task was apparently very easy: a
control group (who made their judgements in isolation) made almost no
errors, ruling out the informational influence component of
this study. In the experimental condition, participants were
seated in a semicircle and requested to give their judgements aloud,
in the order in which they were seated, from position 1 to
position 7. In fact, there was only one real participant, seated in
position 6. All the other ‘participants’ were in fact confederates
of the experimenter who, on each trial, unanimously gave a
predetermined answer. On six ‘neutral’ trials (the first two
trials and four other trials distributed over the remaining set), the
confederates gave correct answers. On the other 12 ‘critical’ trials, the
confederates unanimously agreed on a predetermined, incorrect line. The neutral trials,
particularly the first two trials, were added to avoid suspicion on the
part of the real participant, and to ensure that the confederates’ responses
were not attributed to poor eyesight by the participant.
Like Milgram’s obedience study, this
paradigm had a tangibleimpact on the real participants. They showed signs of
being uncomfortable and upset, gave the experimenter and the other participants
nervous looks, sweated nervously and gesticulated in vain. The results
reveal the powerful influence of an obviously incorrect but unanimous majority on
the judgements of a lone participant. In comparison with the control
condition (which yielded only 0.7 per cent errors), the
experimental particpants made almost 37 per cent errors. Not every
participant made that many errors, but only about 25 per cent
of Asch’s 123 participants did not make a single error. Presumably, conformity
was produced through normative social influence operating in the line
judgement task.
Subsequent Asch-type experiments
have investigated how majority influence varies over a range of
social situations. These studies found that conformity reaches full strength with three to
five apparently independent sources of influence. Larger
groups of independent sources are not stronger, which perhaps runs
counter to our intuitions, and non-independent sources (e.g. several members
of the same coalition or subgroup) are seemingly treated as a single source.
Conformity is significantly
reduced if the majority is not unanimous. Dissenters and deviates of almost any
type can produce this effect. For example, Allen and Levine showed
that conformity is even reduced by a deviate who has visibly thick lenses in
his glasses, although this ‘invalid’ supporter had much
less impact than a
‘valid’ supporter with no glasses (see figure 18.11).
Minority influence
For most of us, conformity means
coming into line with majority attitudes and behaviours. But what about
minority influence? Minorities face a social influence
challenge. By definition, they have relatively few members; they
also tend to enjoy little power, can be vilified as outsiders,
hold ‘unorthodox’ opinions, and have limited access to mainstream mass
communication channels. And yet minorities often prevail, bringing about
social change. Research suggests that minorities must actively
create and accentuate conflict to draw attention to themselves and achieve influence
. Members of the majority may be persuaded to move in the
direction of the minority, in order to reduce the conflict they provoke.
To have an impact, minorities need to present a message that is consistent across
group members and through time, but not rigidly presented. Minorities are also
more effective if they appear to be acting on principle and making
personal sacrifices for their beliefs.
These strategies disrupt majority
consensus and raise uncertainty, draw attention to the minority as a group that
is committed to its perspective, and convey a coherent alternative viewpoint
that challenges the dominant majority views. It also helps if the minority can present
itself as an ingroup for the majority. For example, you might be opposed to
increased tuition fees at university. But a minority of students
from your own university (an ingroup minority) could conceivably win you round by arguing
that such fees would provide bursaries for less well-off students.
The film Twelve Angry Men provides
a dramatic fictitious example of how minority influence occurs.
Twelve jurors have to decide over the guilt or innocence of a young
man charged with the murder of his father. At the outset, all
but one of the jurors are convinced of the youth’s guilt. The lone
juror (played by Henry Fonda) actively attempts to change their
minds, standing firm, committed, self-confident and
unwavering. One by one the other jurors change sides, until in the end
they all agree that the accused is not guilty.
Other examples of minority
influence include Bob Geldof ’s Band Aid movement to raise money for
famine relief, and new forms of music and fashion. Moscovici
proposed a dual-process theory of majority/minority influence. He
suggested that people conform to majority views fairly automatically,
superficially and without much thought because they are
informationally or normatively dependent on the majority.
In contrast, effective minorities
influence by conversion. The deviant message achieves little influence
in public, but it is processed systematically to produce
influence (e.g. attitude change) that emerges later, in private
and indirectly. Subsequent research has demonstrated minority
influence occurring after the main part of the experiment
has finished, i.e. later, revealed by written answers rather than
spoken responses, i.e. in private, and on indirectly related
issues as opposed to the target issue, e.g. attitude change regarding
euthanasia, following direct influence on the topic of abortion. Support for
Moscovici’s dual-process theory is mixed. Using the framework of cognitive theories
of persuasion (see discussion of the ‘elaboration likelihood model’ in
chapter 17), it appears that both minorities and majorities can
instigate either superficial or systematic processing of their message,
depending on situational factors and constraints. But overall, the weight of evidence
is tipped slightly towards Moscovici’s claim that minorities instigate deeper
processing of their message. Nemeth proposed that minorities induce more divergent
thinking (thinking beyond a focal issue), whereas majorities induce more convergent
thinking (concentrating narrowly on the focal issue). Evidence supporting this
contention reveals that exposure to a consistent, dissenting minority leads to generation
of more creative and novel judgements or solutions to problems, use of multiple
strategies in problem solving, and better performance on tasks that
benefit from divergent thinking. In contrast, convergent thinking induced by majorities
tends to lead to mere imitation of the belief or course of action that is proposed by
the majority source.
How groups get things done
Most groups exist to get things
done, including making decisions and collaborating on group projects.
Working in groups has some obvious attractions – more hands are involved,
the human resource pool is enlarged, and there are social benefits. Yet
group performance is often worse than you might expect. Potential
group gains in effectiveness and creativity seem to be offset by negative characteristics
of group performance, including the tendency to let others do the
work, sub-optimal decision making, and becoming more extreme as a group than as
individual members. As we shall see, some of these drawbacks are due to problems of
coordination, and others are due to reduced individual motivation.
Social loafing
Individual motivation can suffer in
groups, particularly where the task is relatively meaningless and uninvolving,
the group is large and unimportant, and each individual’s contribution to the
group is not personally identifiable. This phenomenon has been
termed social loafing (see chapter 20).
Latané and colleagues asked
experimental participants (who were blindfolded and wearing headsets that
played loud noise) to shout as loudly as they could under three
conditions: as a single individual, as a member of a dyad or as a
member of a six-person group. In a further twist, this experiment also
manipulated whether participants actually did shout either alone or in the presence of
one or five other group members (‘real groups’), or were merely
led to believe that they were cheering with one or five others (while, in fact,
they were shouting alone; so-called ‘pseudo-groups’). The blindfolds and
the headphones made this deception possible.
Although groups obviously produced
more noise in total than single individuals, group productivity failed
to reach its full potential, since it was found that individual productivity
decreased as group size increased. In figure 18.12, the dashed line along the
top represents the potential performance we would expect if there were no
losses or gains as individuals were combined into groups.
The line marked ‘real groups’ shows
actual group performance. By creating both real and pseudo groups,
Latané et al. were able to estimate how much performance loss was
due to coordination and motivation losses (about 50 per cent was in fact due to each). Any productivity loss observed in the
pseudo groups could only be attributed to reduced motivation, not faulty coordination,
since there were no ‘co-workers’ engaged in the shouting. In the real groups,
however, coordination loss could occur due to the physical phenomenon
of ‘sound cancellation’ – when multiple sources produce sound, some of it
is cancelled out by other sound.
Subsequent research using this and similar paradigms has shown that social loafing is minimized when groups work on challenging and involving tasks, and when group members believe that their own inputs can be fully identified and evaluated through comparison with fellow members or with another group. In fact, when people work either on important tasks or in groups which are important to them, they may even work harder collectively than alone – so, in these circumstances, ‘social loafing’ turns into ‘social striving’.
Group decision making
An important group function is to
reach a collective decision, through discussion, from an initial diversity
of views. Research on
social decision schemes identifies a number of implicit or explicit
decision-making rules that groups can adopt to
transform diversity into a group decision. These include:
·
unanimity
– discussion puts pressure on deviants to conform;
·
majority
wins – discussion confirms the majority position,
which becomes the group
decision;
·
truth
wins – discussion reveals the position that is demonstrably correct;
and
·
two-thirds
majority – discussion establishes a two-thirds majority, which
becomes the group decision.
The type of rule that is adopted can
affect both the group atmosphere and the decision-making process.
We often work harder on
group activities, especially when the task is challenging and involving
For example, unanimity often creates a
pleasant atmosphere but can make decision making painfully slow, whereas
‘majority wins’can make many group members feel dissatisfied but speeds
up decision making.
Juries provide an ideal context for
research on decision schemes. Not only are they socially relevant in
their own right, but they can be simulated under controlled
laboratory conditions. For example, Stasser, Kerr and Bray found that a two-thirds
majority rule prevails in many juries. Furthermore, they discovered that it was possible
to predict accurately the outcome of jury deliberations from knowledge of the
initial distribution of verdict preferences (‘initial’ here means before any
discussion has taken place). If two thirds or more initially favoured
guilt, then that was the final verdict, but if there was initially no
two-thirds majority, then the outcome was a hung jury.
Group polarization and ‘groupthink’
Popular opinion and research on
conformity both suggest that groups are conservative and cautious entities,
and that they exclude extremes by a process of averaging. But two phenomena that
challenge this view are group polarization and groupthink.
Group polarization is the tendency
for groups to make decisions that are more
extreme than the average
of pre-discussion opinions in the
group, in the direction towards the position originally favoured by the
average. For example, four students whose averaged individual attitudes are
mildly against abortion are likely to form an attitude as a group that is more
extremely against abortion. Group polarization therefore makes group
decisions more extreme. Furthermore, it can sometimes shift
individual members’enduring attitudes towards the more polarized group
position.
The explanation for this lies partly
in the same processes of informational and normative social
influence we discussed earlier. Group members learn from other group members’
arguments, and engage in mutual persuasion, but they are also
influenced by where others stand on the issue, even if they do not hear
each other’s arguments.
This polarization is particularly
likely to occur when an important group to which an individual belongs (i.e. an ingroup) confronts a
salient group to which she does not belong (i.e. an outgroup) that holds an
opposing view. Here, group members seem to conform to what they see as the
prototypical view held by other ingroup members (i.e. the view or position that is
most similar to that of all the other ingroup members, but most different from
that of the outgroup members). It is thought that conformity to the
prototypical view helps to differentiate the ingroup from the outgroup.
Finally, mere repetition of
arguments, which also tends to occur within groups (especially when the
discussion lasts a long time, and all group members wish to express
their views) can also produce polarization.
Groupthink is a more extreme
phenomenon. Janis argued that highly cohesive groups that are under
stress, insulated from external influence, and which lack
impartial leadership and norms for proper decision making
procedures, adopt a mode of thinking (groupthink) in which the
desire for unanimity overrides all else. The members of such groups
apparently feel invulnerable, unanimous and absolutely correct. They also discredit
contradictory information, pressurize deviants and stereotype outgroups.
The consequences can be disastrous –
particularly if the decision making group is a government body. A dramatic
example attributed to groupthink is the decision of NASA officials to
press ahead with the launch of the space shuttle Challenger in 1986, despite
warnings from engineers.The shuttle crashed seconds into its flight (see
next Everyday Psychology box).
Brainstorming
A popular method of harnessing group
potential is brainstorming – the uninhibited generation of as many ideas as
possible, regardless of quality, in an interactive group.
Although it is commonly thought that brainstorming enhances individual
creativity, research shows convincingly that this is not the case. Stroebe and
Diehl considered various possible explanations for this finding. They
hypothesized that ‘process loss’ in brainstorming groups is due to an informal
coordination rule of such groups which specifies that only one
group member may speak at a time. During this time, other group
members have to keep silent, and they may be distracted by the
content of the group discussion, or forget their own ideas. Stroebe and
Diehl termed this phenomenon ‘production blocking’, because the waiting time
before speaking and the distracting influence of others’ ideas could
potentially block individuals from coming up with their own ideas. Stroebe and
Diehl tested their hypothesis by creating five different conditions. In
one condition, participants brainstormed in real interacting four-person groups
(‘interactive group’ condition).
Participants in four other
conditions were physically separated from one another in different
cubicles. Even though participants in these conditions were seated
alone, they expressed their ideas via a clip-on microphone so that
they could be tape-recorded. In an ‘alone, individual, no
communication’ condition participants brainstormed individually. In the
three remaining ‘alone’ conditions, each cubicle contained an intercom and a
display with lights, each light representing one specific group member. These lights
functioned like a set of traffic lights. As soon as one member of the
four-person group started to speak, a voice-activated sensor switched her light to green
in all of the other three cubicles. Meanwhile the other three lights on the
display were red. Each individual could only speak when his or
her light was green, and all the other lights were red. This
technology allowed the researchers to create three different ‘alone’
conditions. In the ‘alone, blocking, communication’ condition
participants took their turns following the lights, and were able
to hear via the earphones what was being said by the other participants. In the ‘alone,
blocking, no communication’ condition participants also had to wait for their
turn before expressing their ideas, but could not hear each other’s ideas
via the intercom. In the ‘alone, no blocking, no communication’
condition participants were instructed to disregard the lights and the
intercom and to express their ideas whenever they wanted to.
To compare the productivity of
participants working under these different conditions afterwards, Diehl
and Stroebe pooled the ideas expressed by the four individuals who
brainstormed alone and without communication, to make a ‘nominal group’product. Since
the same idea might be suggested several times by four people working alone, without
communication, whereas such repetition would not be allowed in case of
free communication, redundant ideas were eliminated from the pooled set of ideas that
constituted the ‘nominal group’ product.
The results of this clever study
were clear-cut. Participants generated approximately twice as many ideas when
they were allowed to express their ideas as they occurred (i.e. in the two non-blocking
conditions) than when they had to wait their turn (i.e. in the three blocking
conditions). These results suggest that ‘production blocking’ is indeed an
important factor explaining the inferiority of interactive
brainstorming groups. This suggests that it may be more effective to ask
group members to develop their ideas separately, and only then have these
ideas expressed, discussed and evaluated in a subsequent joint meeting.
Of interest, electronic
brainstorming (via computers linked on a network) can be very effective,
because the lack of face-to-face interaction minimizes production
blocking.
Intergroup relations
Through the study of intergroup
relations – how people in one group (the ‘ingroup’) think about and act
towards members of another group (the ‘outgroup’) – social
psychologists seek to understand a range of critical issues, including:
·
crowd
behaviour;
·
cooperation
and competition between groups;
·
social
identity;
·
prejudice
and discrimination; and
·
how
to replace social conflict with social harmony.
Deindividuation, collective behaviour and the crowd
Many researchers have emphasized the
tendency of group members to act in unison, like a single entity. Early writers
on crowd behaviour (who were not trained social psychologists) tended to view
collective behaviour as irrational, aggressive, antisocial and primitive –
reflecting the emergence of a ‘group mind’ in collective/ crowd situations.
In a crowd, individuals
will often identify very strongly with the group and adhere very closely to
group norms
The general model is that people
in interactive groups such as crowds are anonymous
and distracted, which causes them to lose their sense
of individuality and become deindividuated. Deindividuation
is thought to prevent people from following the prosocial norms of society that
usually govern behaviour, because they are no longer
identifiable (and hence no longer feel compelled to conform to
social norms). It is argued that people regress to a primitive,
selfish and uncivilized behavioural level. Research that has manipulated
anonymity by placing people in dark rooms, or having them wear hoods
and robes reminiscent of the Ku Klux Klan, has generally found that deindividuation
does increase aggression and antisocial behavior. On the other hand, when
participants were deindividuated by wearing nursing uniforms,
anonymity produced more prosocial behaviour.
More recent research has discarded
the idea that crowds are irrational, and has concentrated instead on
understanding how people in crowds develop a shared identity, a
shared purpose and shared norms. In crowd situations, people often
identify very strongly with the group defined by the crowd, and
therefore adhere very closely to the norms of the crowd. Crowds may only appear
irrational and fickle from the outside – more often than
not, their behavior seems rational to members of the crowd, who may
also identify specific other groups (e.g. the police, ethnic/racial groups) as a legitimate
target for aggression.
Cooperation and competition between groups
Sherif provided a far-reaching and
influential perspective on intergroupbehaviour. In a series of
naturalistic field experiments on conflict and cooperation at boys’ camps in
the United States in the early 1950s, Sherif and colleagues studied group
formation, intergroup competition and conflict reduction.
In the group-formation phase, Sherif
divided new arrivals at the camps into two groups and isolated them in
separate living quarters to allow them to develop their own
internal structures and norms.
In the intergroup competition phase,
Sherif then brought the two groups together for a series of zero-sum
competitions (what one group won, the other group lost), such as
tug-of-war. The typical finding at this stage was
‘ingroup favouritism’ – each group judged fellow ingroup members’
performance to be superior to that of outgroup members (see figure
18.16).
In group
favouritism in estimates of performance by other ingroup and outgroup members during
intergroup competition
Of especial note, the
competitiveness of the between-group interactions subsequently pervaded
all aspects of intergroup behaviour, becoming so extreme and
conflictual (e.g. involving negative stereotyping of, and aggression
towards, the outgroup) that most of Sherif ’s studies had to be
concluded at this stage. In a replication conducted in the Lebanon, the
study had to be stopped because members of one group came out
with knives to attack the other group.
Having found it so easy to trigger
intergroup hostility, in the conflict reduction phase Sherif
discovered how hard it was to reduce conflict. The most effective
strategy was to introduce a series of superordinate goals, i.e.
goals that both groups desired but could only attain if they acted together.
For example, when the camp truck broke down delivering
supplies, neither group could push-start it on their own; but both groups working
together managed to move the truck by pulling on a rope attached to the
front bumper.
Impact of competition
vs. superordinate goals on negative stereotypes
of the outgroup
As figure 18.17
shows, negative stereotypes of the outgroup which resulted after a
period of intergroup competition were considerably less
negative after the
manipulation of superordinate goals. To explain his findings,
Sherif focused on the importance of goals. Mutually exclusive goals cause competitive intergroup behaviour, and superordinate goals
improve intergroup relations. As he pointed to the real nature
of goal relations determinining
intergroup behaviour, Sherif ’s theory is often called realistic conflict theory.
But Sherif ’s studies also found that
first expressions of ingroup favouritism occurred in the group
formation phase, when the groups were isolated fromone another and knew only of
each other’s existence. So the mere existence of two groups seemed to
trigger intergroup behaviour, before any mutually exclusive goals had been
introduced.
Social categories and social identity
Experiments by Tajfel and colleagues
provided the most convincing evidence that competitive goals are not a necessary
condition for intergroup conflict. In fact, merely being categorized as a
group member can cause negative intergroup behaviour. In Tajfel’s studies,
participants were randomly divided into two groups and asked to distribute
points or money between anonymous members of their own group and anonymous members of
the other group. There was no personal interaction, group members were
anonymous, and the groups had no ‘past’ and no ‘future’ – for these reasons these
groups are called ‘minimal groups’, and this experimental procedure
is called the minimal group paradigm.
The consistent finding of this
research is that the mere fact of being categorized is enough to
cause people to discriminate in favour of the ingroup and
against the outgroup. This research spawned the ‘social identity
perspective’ on group processes and intergroup relations.
According to this perspective, the groups that we belong to define who
we are. Part of our identity and how we feel about ourselves is derived from
the groups we belong to, and how we evaluate them. When we categorize ourselves
and others in groups, we stereotype ourselves and outgroup members in terms of
our respective group memberships, and our own group identity helps to
determine our attitudes, feelings and behaviours. This process produces a sense
of group identification and belonging, as well as ingroup solidarity, conformity
and bias.
According to this social identity
perspective, because groups define and evaluate who we are,
intergroup relations are a continual struggle to gain superiority for the in group over
the outgroup. How the struggle is conducted – and the specific nature of intergroup
behaviour (e.g. competitive, conflictual, destructively aggressive)
– is thought to depend on people’s beliefs about the status relations between groups. Are
status relations between groups stable or unstable, legitimate or
illegitimate? And is it possible to pass from one group to another (see Tajfel,
1978)?
Effective interpersonal communication (IPC) between health care provider
and client one of the most important elements for
improving client satisfaction, compliance and health outcomes. Patients who
understand the nature of their illness and its treatment, and who believe the
provider is concerned about their well-being, show greater satisfaction with
the care received and are more likely to comply with treatment regimes. Despite
widespread acknowledgement of the importance of interpersonal communication, the
subject is not always emphasized in medical training.
Over the past 30 years substantial investments have been made to enhance access to basic health services in developing countries. However, there have been relatively few studies that investigate the quality of the services delivered, and fewer still that study the quality of interpersonal communication.
The quality of care research that has been done shows that health counseling and provider-client communication are consistently weak across countries, regions and health services.
Even when providers know what messages to communicate, they do not have the interpersonal skills to communicate them most effectively. They often do not know how to communicate with their patients. Despite widespread acknowledgement of the critical importance of face-to-face communication between client and provider, there are few rigorous studies of health communication in developing countries.
Evidence of positive health outcomes associated with effective communication from developed countries is strong. Patient satisfaction, recall of information, compliance with therapeutic regimens and appointment keeping, as well as improvements in physiological markers such as blood pressure and blood glucose levels and functional status measures have all been linked to provider-client communication.
Thus, experience in the developed
world has shown that providers can improve their interpersonal
skills, leading to better health outcomes. The research described here explores
whether these findings are valid and replicable in the developing countries.
Unfortunately, effective
communication does not always occur naturally, nor it is easily acquired. Even
when client and provider come from the same geographic area and speak the same
language, they often have different educational, socio-economic and cultural
backgrounds. Moreover, their expectations about the health encounter may be different,
or they may be faced with other problems, such as lack of privacy during the
encounter, or time constraints due to heavy patient loads.
Better communication leads to
extended dialogue which enables patients to disclose critical information
about their health problems and providers to make more accurate diagnoses. Good
communication enhances health care education and counseling, resulting in more
appropriate treatment regimes and better patient compliance. Effective
interpersonal communication also benefits the health system as a whole by
making it more efficient and cost effective. Thus, clients, providers,
administrators and policy makers all have a stake in improved provider-client
interactions.
This monograph discusses the
importance of IPC as a tool for improving health care outcomes in developing
countries and describes techniques for enhancing provider communication skills.
It also provides a job aid and several data collection instruments that can be
used in various settings. Our field experiences in Honduras, Egypt and
Trinidad, described later in the text, suggest that test results in
developed countries are valid and replicable in developing countries.
Therefore, we hope that our findings will serve as useful models for implementing
future interpersonal communication programs, and that the monograph will help interested
health care policy makers and practitioners improve the quality of health care
in their facilities through improved interpersonal communication. The
monograph can serve as:
·
an
introductory overview on provider-client communication skills
·
a
framework for assessing IPC skills
·
a
guide for developing IPC training activities
·
a
resource describing important IPC experiences in selected developing countries.
Because each health care setting
requires locally-appropriate strategies, the guide prov ides only a
general framework for action, leaving health care policy makers, managers and
providers to develop their own analyses and interventions. Therefore, we
encourage readers to modify the content of the monograph as needed
and to develop locally-appropriate examples for training and other IPC
interventions.
Why Is Interpersonal Communication
Important? III. Why Is Interpersonal Communication Important? III. Why Is
Interpersonal Communication Important? III. Why Is Interpersonal Communication
Important? III. Why Is Interpersonal Communication Important?
IPC is important because it leads
directly to better health outcomes. A pathway is clearly established
which links processes, such as the way health care providers communicate, to proximate
outcomes, such as patient satisfaction and recall, to final outcomes, such as
client compliance with treatment regimes and improved health results. Hence,
our emphasis on the importance of improving provider communication skills. Figure 1
illustrates a system linking communication processes with
short-term, intermediate and long-term outcomes.
As can be seen in Figure 1, the
communication context is shaped by the socio-demographic characteristics
of the patient and provider, as well as by the environment in which the communication
takes place. The age, sex, ethnicity, and educational background of providers and clients
affect how they communicate with each other. Other factors such as degree of privacy,
time allotted for encounters, comfort and cleanliness of the clinic, and
treatment of clients from the time they enter the clinic until they are seen by a
provider, can also inhibit or enhance client-provider interaction.
While many of these
socio-demographic and environmental factors are beyond their control, providers
can improve IPC practices in their own clinics by adopting specific behaviors
and techniques which lead to distinct positive outcomes. In the short-term,
improved communication leads to more effective diagnosis and treatment of
health problems; in the mediumterm, to greater compliance with treatment
programs, better utilization of services, and enhanced feelings of awareness and
confidence for both client and provider; in the longterm, to greater relief of
symptoms, enhanced prevention and reductions in morbidity and mortality.
In some cases, overall health care costs are also reduced.
What Are the Characteristics of
Effective IPC? IV. What Are the Characteristics of Effective IPC? IV. What Are
the Characteristics of Effective IPC? IV. What Are the Characteristics of
Effective IPC? IV. What Are the Characteristics of Effective IPC?
IPC is effective when it leads to the following five outcomes:
1) the patient discloses enough information about the illness to lead to an accurate diagnosis;
2) the provider, in consultation with the client, selects a medically appropriate treatment acceptable to the client;
3) the client understands his or her condition and the prescribed treatment regimen;
4) the provider and the client establish a positive rapport;
5) the client and the provider are
both committed to fulfilling their responsibilities during treatment and
follow-up care.
The above outcomes, however, do not
describe the steps in the process of effective communication. These steps
generally include encouraging a two-way dialogue, establishing a partnership
between patient and provider, creating an atmosphere of caring, bridging any
social gaps between provider and client, accounting for social influences,
effectively using verbal and non-verbal communication, and allowing
patients ample time to tell their story.
Two-way Dialogue
Good interpersonal interaction
between client and provider is, by definition, a two-way street where both
speak and are listened to without interruption, both ask questions, express
opinions and exchange information and both are able to fully understand what
the other is trying to say.
Partnership Between Provider and Client
Providers and clients should view
health care as a partnership in which each party contributes to maximize end
results. Mutual respect and trust and joint decision-making will result in a
greater likelihood of a positive outcome. Both provider and client must realize
that, even though the provider is the medical expert, both are responsible for
the outcome of their interaction. The patient must disclose all
relevant information in order for the provider to determine a proper diagnosis and
treatment; the provider must interpret and analyze the information received and effectively
explain the condition and treatment options to the patient. Both should make
decisions about treatment regimes, with the client making every effort to
comply with the prescribed treatment and any necessary lifestyle changes the
treatment implies. Providers should foster an active role for patients in their
care and treatment.
Providers should encourage active
questioning and interaction during office visits and should involve
patients in their own health care regimes.
Atmosphere of Caring
Patients need to believe that their
provider cares about them and is committed to their welfare. Both verbal and
non-verbal communication help the provider convey interest and concern to
patients. Being attentive, making eye contact, listening and questioning
thoughtfully, and demonstrating understanding and empathy make patients feel important
and worthy. On the other hand, being brusk or appearing busy or distracted makes
patients feel insecure, anxious or fearful of their relationship with the provider.
Effective Bridging of Social Distance
Social distance refers to the
socio-cultural-economic factors that make people feel they belong to different
class tiers. Education, economic status, class, race or ethnicity, gender and age may all
contribute to how close or distant two individuals feel about each other. For example, an
illiterate peasant woman and a young, highly trained, city-dwelling male physician
who share the same language and were raised within miles of each other are
still worlds apart socially. Clients bring to medical visits a whole range of
emotional, socio-cultural, economic, educational and psychological traits
that affect communication. Social distance should not impede good
communication, and providers must realize that many people, even those in
their own circles, may not be conversant with their “language.” Therefore, they
should strive to bridge any social gap that might exist between them and their
clients and establish an open dialogue, a partnership and an
atmosphere of caring. Clients must also do their part to bridge the social distance
by being candid and communicative.
Social Networks
Social networks refer to those
interpersonal relationships that bind people together. Typically consisting
of family, friends, acquaintances, neighbors and colleagues, social networks influence
differently—depending on the individual and his or her environment—a person’s
desire and ability to understand and comply with professional advice. For
example, in some societies the mother or mother-in-law is key decision-maker in
the extended family. Therefore, teaching the young woman about the
benefits and methods of birth spacing may be ineffective if her mother or
mother-in-law is uninformed or opposed to this practice. Similarly, in a home
where a woman cooks for the whole family, dietary recommendations that could enhance her
health may not be put into effect if they interfere with the family’s culinary
customs and tastes.
Effective Use of Verbal Communication
Verbal communication consists of
spoken and written words people use to convey ideas. In
a health care
encounter, the choice of words clients and providers use greatly influences how well they
understand each other. The medical jargon physicians use to describe symptoms and
treatments allows them to communicate clearly and precisely with other
clinicians. However, because the scientific and clinical terms may be confusing
to patients, the use of such terms with patients is inappropriate.
Patients communicate during medical
visits in their particular dialects, accents, cadences and slang,
often making comprehension difficult for providers from other parts or regions
of the country. Patients also describe health problems in peculiar ways, often
reflecting their unique perspective on the illness’ origin or severity.
Sometimes local perceptions can influence the way a patient describes the illness’
onset and symptoms. For example, if diarrheal diseases are common in their area, patients
may not report symptoms of the disease unless they are quite severe. Because they view the
symptoms as routine, patients simply neglect to mention
them. For the provider,
however, detection of early symptoms, even mild ones, is important in making
proper diagnoses and developing appropriate treatment regimes.
Use Simple Language Medical jargon
The clinical spectrum of cholera is
broad, ranging from inapparent infection to severe cholera gravis, which may be
fatal in a short time period. After an incubation period of 6 to 48 hours,
there is an abrupt onset of watery diarrhea. Vomiting often follows in the
early stages of the illness. Signs of severity include cyanosis, tachycardia,
hypotension, and tachypnea. The symptoms and signs of cholera
are entirely due to the loss of large volumes of isotonic fluid and resultant
depletion of intravascular and extracellular fluid, metabolic acidosis, and hypokalemia.
Simple explanation
Not all persons that get cholera
look equally sick. Some cholera patients seem to have a
minor illness, while
others look very sick. Some others can even die after hours of getting cholera.
Because cholera germs spread within 6 to 48 hours of entering the body, the person may
suddenly have a lot of watery diarrhea. Many patients also begin to vomit.
When the sick person is getting
worse, his skin can become blue (especially at the lips, nose, and
fingertips), he may begin to breathe quickly, his heart works very rapidly, and blood
pressure drops. All this happens because the body has lost a lot of liquids and minerals
through diarrhea and vomiting. The body cannot survive when it loses too much liquid and
minerals.
Effective Use of Non-verbal Communication
Words express only part of a message
being conveyed; tone, attitude and gestures convey the rest. Avoiding distractions, such as
answering the telephone during a patient’s visit or scribbling notes on other
cases, and appearing fully attentive communicate positive messages to clients.
Smiling, listening thoughtfully, sitting on the same level as the patient also
enhance interaction. Much non-verbal communication is specific to cultural
customs. For example, while in some cultures direct eye contact is a
sign of positive regard and respect, in others it is deemed improper or aggressive,
particularly with members of the opposite sex. Also, while in some cultures physical
contact during a conversation is considered a sign of affection, in others it
might be construed as highly improper. What is important to remember is that all
forms of non-verbal communication convey a message.
Often, simple gestures by the provider,
such as a warm greeting or a thoughtful question, can help put the client at ease and
enhance communication. Such actions do not require great effort but can have
significant results. Following is an example of non-verbal communication
conveying a positive message.
Non-verbal communication can have as
great an impact as verbal communication but can be more easily misinterpreted. Thus,
it is important for health care providers to be aware of the
non-verbal messages they convey to their patients and of those their patients
convey to them.
Opportunity for Patients to Speak About Their Illness
The medical visit should provide
ample opportunity for a patient to describe his or her illness. Storytelling
has its own healing value in that it provides patients with a release and opportunity
for insight and perspective. It may also afford the health provider the
insights needed to understand, interpret and explore the significance of the
symptoms and clues the patient provides. A patient’s comprehension and feelings
about a medical problem may be extremely important in prescribing appropriate
treatment. A great deal of distress, for example, may stem from a patient’s
perception about the seriousness of his or her illness, not from its
actual seriousness. Providers should not minimize a patient’s anxieties, but
strive to alleviate them.
All of the factors described above
have been shown to enhance communication between patient and provider. However,
the fact that providers follow individual approaches increases the
complexity of formulating a communication skill program. To change provider
behavior in concrete ways, the above factors must first be broken down into
concrete skills and behaviors as illustrated in the following guidelines.
Guidelines and Norms for Effective
IPC V. Guidelines and Norms for Effective IPC V. Guidelines and Norms for
Effective IPC V. Guidelines and Norms for Effective IPC V. Guidelines and Norms
for Effective IPC
Our research and analysis of
effective IPC has led us to develop a set of guidelines and norms for health
care providers. While these norms should be further tested, refined, and
validated, we are confident that the issues and skills presented here are both
useful and valid in improving IPC. We define three types of IPC.
·
Caring/socio-emotional
communication: The objective of caring or socioemotional communication is to
establish and maintain a positive rapport with the patient throughout the encounter.
This is an integral part of all IPC and enhances patient disclosure and compliance.
·
Diagnostic
communication/problem solving: The objective of diagnostic communication
is for the patient and provider to share all the information needed for
accurate diagnoses and appropriate treatment prescriptions.
·
Counseling:
The objective of counseling is to ensure that clients understand their condition
and treatment options. Counseling helps them to follow treatment regimes and
behavioral change recommendations, by ensuring that these are comprehensible,
acceptable, and feasible. Counseling emphasizes making decisions together
with the client and helping solve actual or anticipated problems.
A provider should convey expressions
of caring at the outset of the encounter when rapport with the client is being
established; rely on diagnostic or problem solving techniques during the history
taking portion of the encounter; and use counseling skills at the end of the encounter
to explain treatment and provide health education. However, all three
approaches may be applicable throughout the encounter.
Within the broad category of each
approach, specific communication techniques or behaviors can be identified
which can improve IPC. These and related examples are presented in the
following section.
Caring
A caring behavior emphasizes respect for patients and recognition that their concerns are important. Health care providers should display caring throughout the medical encounter in order to establish a trusting relationship and good rapport with the patient.
Frame the encounter — Set the tone
for the interaction by greeting clients in culturally appropriate ways that
communicate openness and concern. For example, the provider might frame an
encounter by saying “Good morning Mrs. N., my name is Dr. N.. I’d like you to feel
free to tell me about any health concerns you have.”
Use appropriate non-verbal
communication — Be sure your posture, eye contact, gestures, tone of voice,
manner and attitude are appropriate and conducive to dialogue with the client.
For example, a provider who is scribbling notes on a chart when a patient enters,
might put down the pen, close the chart, and stand up or lean forward as he
greets the patient. This shows the patient that he or she has the provider’s full
attention.
Solicit feelings — Invite patients
to talk about how they feel, both physically and emotionally. A provider might
ask a patient who is describing symptoms of her headaches, “How do the headaches
make you feel? How do they affect your other activities?”
Show positive regard — Show clients,
explicitly and implicitly, that they are respected and valued. For example, a
provider might show positive regard for a patient by being courteous, smiling,
asking the patient whether he or she is satisfied with the care received so
far, or complimenting the patient’s efforts in seeking medical assistance or
following treatment recommendations. Positive regard is especially important when dealing
with conditions that may have a social stigma attached to them, such as
tuberculosis and AIDS. It is also helpful to bridge any
social distance between
provider and client that might be based on age, sex, social and
educational status, race, religion, or ethnicity.
Validate the patient’s experience
and efforts — Recognize the patient’s experience and efforts in an honest
and straightforward manner. This may be done through statements of concern,
empathy or legitimizing that show the provider cares about the patient and his
or her problem. For example, when dealing with a hypertensive patient who does
not take his or her medicine regularly, a provider might say, “ I’m concerned
that you’re not taking care of yourself.” This is likely to be more effective than
scolding. Statements of empathy show that the provider understands and shares the
patient’s feelings. Legitimizing statements validate the patient’s feelings. For
example, a provider might tell a patient who is nervous about surgery, “I understand
that you are worried about this operation,” or when counseling a cancer patient,
a provider might say, “It’s easy to understand why you feel afraid and angry.
Most people in your situation feel the same way at first.”
Echo patients’ emotions — Help
patients express their feelings by echoing them. For example, when a patient
says “I’ve been feeling very depressed lately,” the provider might respond with “It
sounds like something is really getting you down.” This technique provides the
patient with an invitation to elaborate further on the topic.
Express support and partnership —
Let clients know you will work with them to help them get better. A
provider might say, “I’m going to use all my skills and expertise to help you get
better, and I’m counting on you to do your part to take care of yourself.”
Give reassurance — Encourage and
reassure clients about the outcome of their condition. For example, a midwife
might say to a patient, “I know you’re feeling a lot of pain and anxiety right now,
but tomorrow you’ll feel much better, and you’ll have a new baby to take home
with you.” In reassuring patients, it is important to be honest and realistic
about the medical prognosis and to avoid premature or unjustified
reassurance.
Diagnosis and Problem Solving
These skills help health care
providers gather critical information for diagnoses. Use of data-gathering
skills enables them to improve their accuracy and effectiveness in performing this
function. The skills involve a variety of questioning techniques designed to
encourage the patient to talk about all aspects relevant to the problem.
·
Listen
attentively and actively — Use gestures to show patients they have your full
attention and ask relevant questions to indicate your understanding of what they
say. You may want to face patients and nod or comment occasionally as they
describe their medical condition.
·
Encourage
dialogue — In addition to yes/no questions, ask patients open-ended questions
that encourage them to provide details about their problem. Often, one open-ended
question will elicit a response that covers several yes/no questions.
·
For
example, instead of asking a patient “Do you have a fever? Do you get headaches?
Are you nauseated?” You may simply say “Tell me about any pain and discomfort
you’ve been feeling.” Once the patient describes the condition, you might need
to ask one or two yes/no questions to supplement the information.
·
Avoid
interruptions — Do not interrupt patients when they are speaking. Wait until they
have finished their thought before asking a new question. Also, avoid being
interrupted by the telephone or other distractions during a patient’s visit.
·
Avoid
premature diagnosis and resist immediate follow-up — Wait until you have
listened to the patient’s full story and have asked all the relevant questions
before determining a diagnosis and treatment. The patient’s first complaints are not
always the most important ones. Hasty conclusions can lead to diagnostic error. For
example, when a patient reports headache pain, resist the urge to immediately
assume the ailment is minor and to prescribe pain relief drugs. Instead you might
say “Tell me more about how you’re feeling.” Often, a simple cure for headaches
is all that is needed, but at other times the client might respond, “I’m so worried
and upset, there are times when I don’t feel like getting out of bed and feel
like I could die.” Such a case warrants further inquiry into the psychological
and physical causes of the condition.
·
Probe
— Encourage patients to provide more information by asking questions or inviting
them to continue speaking. For example, the provider might use phrases like “Tell
me more” or “Please go on” to help patients delve deeper into the nature of their
problem and their reaction to it.
·
Ask
about causes — Help patients share more information about their condition by
asking their opinion on the causes of the ailment and what they think might help
them. This technique will provide information needed to make a diagnosis and
help providers evaluate the patient’s understanding of the illness.
Counseling and Education
These skills enhance providers’
ability to explain to patients their conditions, the circumstances of their
illness, diagnoses and treatment options. Providers should remember that patients’
compliance with treatment regimes depends on how well they understand the nature
of their illness and how they feel about the prescribed treatment.
·
Explore
patient understanding — Find out patients’ opinions of their illness by asking
how they contracted it, whether they had the problem before and what they
did about it at that time. For example, if a mother is seeking care for a child
with diarrhea, the provider might ask, “How do you think children usually get
diarrhea?” “How do you think your child got it?” “How did you take care of it in
the past?”
·
Correct
misunderstandings or misinformation — Sometimes clients hold inaccurate
notions about the etiology or effects of a disease, which can affect their behavior
toward treatment and adversely impact on their recovery. Providers should
determine a patient’s understanding of his or her problem, and politely correct any
misconceptions the client may have. For example, a provider might say, “While
many people believe that taking the birth control pill right before intercourse
will be effective, that’s incorrect. You need to take the pill every day, whether you
are going to have sex or not.” Providers should be careful not to make the client
feel uneasy or inadequate for having inaccurate ideas or information, and
should strive to educate by providing appropriate information.
·
Use
appropriate vocabulary — Providers should avoid using jargon or technical
language when speaking with patients, making instead every effort to use terms that
are meaningful to patients. For example, instead of asking “Have you had any
respiratory difficulties lately?” the provider might say, “Have you had any
difficulty breathing lately?” or “Tell me about your breathing?”
·
Present
information in blocks — It is important to present information in a way that
the patient can easily absorb and remember. Providers should explain the
diagnosis in a clear and comprehensible fashion, never in a condescending or
patronizing manner. Subdividing the information into separate categories may help this
process. Presenting separate blocks of information sequentially, enables the
provider to monitor for understanding and absorption before moving on to the next
block. This kind of presentation helps patients internalize the information
presented and enhances the likelihood of effective compliance with the
treatment prescribed. For example, the provider may address and sequentially
convey brief information on the following topics:
• name of the disease and its
etiology
• recommended treatment for the
patient
• ways to prevent recurrence of the
disease
• other relevant information.
·
Use
visual aids and/or printed materials when possible — When conveying information
to patients on diseases, preventive or treatment programs, or medical
devices, it is often helpful to refer to a visual display. Visual aids help patients
better understand and remember the information provided. It is also helpful to
make use of pamphlets with simple text and pictures about important health problems,
their prevention, and their treatment.
·
Recommend
concrete behavioral changes — After making a diagnosis and prescribing
a treatment regime, providers may recommend certain behavioral changes to
their patients that would prevent the illness from recurring. These recommendations
should take into consideration the patient’s ability to implement them.
Rather than simply emphasizing the end results of the behavioral change, providers
should identify and suggest specific steps in the behavioral change. For example,
instead of telling a hypertensive patient that he needs to lose 30 pounds, the
provider might say, “I’d like you to try to lose some weight by taking a 20 minute walk
every day and cutting down on the amount of sugar and oil you eat.”
·
Select
an acceptable and feasible treatment — To the extent possible, provide the
patient with a range of treatment options from which to select the one he or
she prefers. For example, in providing family planning services to a mother,
discuss available options and help her select the one that is best suited to her
lifestyle. Conditions such as pain management, weight loss, etc., may have a number of
treatment options from which the patient may choose.
·
Motivate
patients to comply with treatment — Once a treatment has been mapped out,
the provider should try to motivate compliance with the treatment prescribed
by pointing out to the patient the importance and benefits of such action. For
example, in prescribing antibiotic treatment, a provider might say, “It is
important for you to take your medicine three times a day until all the pills are gone.
You may feel better after a few days, but if you don’t take all the pills the illness
will come back, and it may be harder to cure the next time.”
·
Summarize
— Restate the diagnosis, treatment and its recommended steps in simple
terms. In summarizing, repeat only key points. For example, a provider might
conclude a counseling session by saying “I think you have a respiratory infection.
Take these antibiotics with every meal until they are all gone. I’d like to see you
again in two weeks to make sure you’ve completely recovered.”
·
Check
for understanding and absorption — Ask the client to repeat or describe
the treatment instructions. Then clarify any misunderstandings the patient
might have and find out whether there are any reasons that would impede the
patient’s compliance with the prescribed treatment. For example, a provider might say
“Just to be sure you understand how to take your medicine, would you tell me how
much and how often you’ll take it?”
·
Additional
questions — Urge patients to ask any additional questions they may have on
their current or any other medical problem. Allow ample time for a response.
Avoid missing the opportunity to consult. For example, if prompted to share any
additional health concerns, a mother seeking care for a baby with diarrhea may
mention that she is interested in exploring birth spacing techniques, or that she
is not sure of the vaccination schedule for another of her children.
·
Confirm
follow-up actions — Remind the patient of the next appointment date or of
the next treatment action he or she will need to take. Remind the patient what
to do if symptoms persist or worsen, and about danger signs that indicate he or
she should seek prompt medical assistance.
In this section, we have presented a
set of specific guidelines for improving the IPC skills of health care
providers. The next section will outline steps in planning and implementing a training
program designed to further develop these skills.
Planning and Implementing Training
Activities VI. Planning and Implementing Training Activities VI. Planning and
Implementing Training Activities VI. Planning and Implementing Training
Activities VI. Planning and Implementing Training Activities This
section deals with planning and implementation of training activities. The
information provided should enable health care providers to conduct small training
workshops in their own clinics or enable outside experts to train
health care providers in their areas or communities. The training format and
methods presented here have been tested in a variety of settings and have
proven effective in the IPC training of health care providers. We have found that
revisions in our training methods are always necessary to adapt the techniques
to local circumstances and insights. We, therefore, encourage providers and
trainers to use their own ingenuity and expertise to modify the techniques
to suit local realities.
Improving IPC skills generally
implies some behavior change on the part of health care providers. Programs
inducing effective behavior change require both an understanding of the issues and
skills involved and practice sessions in the new skills. Practice may entail
first conducting exercises among peers in a controlled environment (involving
self-evaluations or evaluations and feedback from colleagues or
supervisors), then holding supervised or selfmonitored practice runs with
actual patients and leading eventually to internalization of the new skills
when they become second nature to providers who apply them instinctively.
Overall Training Approach
The IPC training program is highly
flexible, allowing participants to adapt the program to
local socio-cultural
realities or to pinpoint specific techniques that can improve daily operations.
The training activities employ a variety of methods to ensure that participants
develop and learn to effectively apply new IPC skills. The methods used include:
·
participatory
plenary sessions that employ brainstorming and question and answer sessions,
allowing participants to discover and tailor new IPC skills;
·
dynamic
role playing which illustrates various communication strategies and allows
participants to practice them;
·
mental
rehearsal techniques which allow participants to test the degree of difficulty
of individual IPC skills and to develop methods to master them;
·
videotapes
on non-verbal communication skills which are used as instructional tools.
Prior to the course, we developed:
·
a
guide to help participants practice the skills, which is referred in the text
as “the pocket guide”, or “job aid”;8
·
a
training manual which allows the trainer to adapt the manual to the participants’
needs and to local realities.
Training Agenda and Format
Our IPC training program consists of
approximately 20 course hours covering a 3 to 4 day span. The initial session focuses on
the relevance of the skills. The following session deals with the
guidelines and gives participants an opportunity to practice the new skills.
The training course has a prepared list of skills or behaviors the trainer
introduces to the group (Table 1).9
Each type of behavior is discussed
and practiced in the participants’ native language aiming for potential
improvements and adaptation to the local environment. In many of the courses given, we
encouraged providers to complement training activities by trying out
the skills they learned in their own practice between course sessions. These
“transitional” encounters were often taped, allowing providers to work in
groups to review their shared experiences, apply the skills in their
local setting, and critique their newly acquired skills in a supportive environment.
Different agendas for the course are included at the beginning of the training
manuals presented in Appendices B, C and D.
Interpersonal Communication Behaviors
Overall socio-emotional communication
The following nine behaviors
reinforce ways to make people feel comfortable during medical visits:
• Welcome patient in a warm and
culturally acceptable manner.
• Use appropriate verbal and
non-verbal communication (gestures, attitude, words).
• Inquire about the patient’s
feelings.
• Acknowledge the patient’s
initiative (to have come, to have brought the child).
• Enhance legitimizing. (Reinforce feelings
that are normal.)
• Show empathy.
• Echo the patient’s emotions by
encouraging him or her to express feelings freely. (Paraphrase what patient says.)
• Convey support and partnership.
• Reassure the patient. (Ease the
patient’s concern by suggesting specific things he or she can do.) The health
provider’s tone of voice and attitude are primarily responsible for setting the
socio-emotional tone of the encounter.
Problem solving skills
Systematic use of data gathering
skills enables providers to become more efficient. The following seven behaviors
help providers gather necessary information for determining diagnoses:
• Listen attentively (actively).
• Encourage dialogue by asking
open-ended questions.
• Avoid interruptions.
• Avoid premature diagnosis
(Determine the problem only after all facts have been gathered.)
• Resist immediate follow up by
listening carefully before making clinical decisions.
• Probe (explore) for more
information.
• Inquire into causes, difficulties
and worries related to the problem.
Counseling and Information-Education-Communication (IEC)
The following ten behaviors are
effective ways to explain health issues, treatment and decisions taken.
• Check the patient’s understanding
of the illness.
• Correct misunderstandings about facts.
• Use appropriate vocabulary.
• Present (explain) what the patient
needs to know or do in a logical way (in blocks).
• Correct misconceptions.
• Discuss and prescribe concrete
behavioral changes that are appropriate for the patient.
• Repeat, summarize key information.
• Motivate the patient to follow the
recommended treatment.
• Check on acceptability/mutuality
of decision making (if patient will follow the treatment).
• Make sure patient knows when to
return for a follow-up visit.
• Ask patient if there is anything
else he or she would like to know.
Training Materials and Methods Used
The use of training materials that
document the concepts and guidelines presented is essential. Without this
written documentation, participants do not have an opportunity for
self-evaluation and will not be able to follow through in gaining an in-depth
understanding of the new skills. The training manuals presented
in the Appendices include materials that have occasionally been adapted and
completed prior to the start of training sessions with the local team. For
example, training methods include:
Role playing. One of the most
effective methods for learning skills in a controlled setting is through
role playing. Role playing enables providers to “try on” a variety of different
styles and identify the ones that best suit them. Role playing also requires
providers to play the part of a patient and, therefore, to experience
the other side of the health care diad, and learn how providers’ different IPC
styles can affect patients’ attitudes. One of the great benefits of role
playing is that it can be both educational and fun. A variation on standard
role playing is pantomime role playing in which the players act out a
particular scene without speaking. Pantomime is particularly useful for
analyzing the impact of non-verbal communication such as eye contact, physical
contact, postures, gestures, smiles, attitude, etc. Because no words are
spoken, players and observers can focus all their attention on the slightly exaggerated
non-verbal communication.
Video and audio-taping. Another
highly effective training device includes video or audio taping.
Seeing or hearing oneself on tape makes one much more aware of one’s own communication
style. Video or audiotape can be used in a variety of ways. Role playing can be recorded
and played back instantly so that players can see how they acted and how their behavior
impacted on others. Real clinical encounters can also be video or audio-taped
and played back for group analysis. This technique was used effectively in
training workshops in Egypt. The advantage of recording role plays or
actual encounters is that the tapes can be played over and over and used to
analyze various points. Moreover, tapes can be made following the training program to monitor
the program participants’ IPC improvements. (Improvements can be measured more
accurately and easily when a recorded baseline for comparison exists.)
Video playing. In Honduras the
participants saw a video on IPC provided by the Ministry of Health in
addition to a Spanish language video provided by AED.10
Unfortunately, we did not have a
similar video in Arabic. In Egypt, participants expressed, in their course
evaluation, a desire to view such a video, which they believed would help them
more accurately master the skills required.
Mini case study or simulation guide.
Throughout the course, mini case studies or simulation guides were used to
develop understanding and reinforcement of IPC skills. Often these mini case
studies were developed or adapted in-country, based on actual encounters. For example, to
“Practice problem solving skills: Gathering data to understand client
situations and problems,” participants received simulation guides for role playing
of the health provider and patient. Practice sessions with open-ended questions
and increased interaction between participants led to improved skills.
Examples of these mini case studies are presented in the training manuals. Mini
cases for Honduras can be found in Annex 8 and 8bis (Appendix D). In Egypt, the last day
of training focused on improving the quality of IPC skills among colleagues and on
teamwork. Following a brainstorming exercise in which participants complained
about poor leadership, poor group dynamics and poor supervision in their work
environment, trainers developed three mini case studies to be used as group exercises
at a later date. These exercises are presented in Annexes 8, 9, and 12 of the
Egyptian training manual in Appendix B.
Evaluation form. At the end of the
course, participants were asked to complete evaluation forms assessing trainer
effectiveness. The forms provided participants with the opportunity to comment
on their learning experience and course methodology. At the same time, it provided
trainers with the necessary feedback for improving their workshops. Moreover,
each training day began with a plenary discussion among participants, which
allowed them to focus on essential elements discussed the
previous day.
Training Supervision, Monitoring, Evaluation and Follow-up
An effective training program does
not end at the conclusion of the workshop but represents an element
in a protracted learning cycle. After the workshop or intensive training
program, providers are expected to return to their clinical settings and apply what
they have learned to their daily work environment. Effective
supervision and support is critical at this time to ensure that providers adopt the new
skills within their old settings. In order to establish a true
learning environment, supervision should be supportive rather than
constraining, providing feedback and encouragement rather than threats or
punishments. An important aspect of supervision and feedback is monitoring—a
process in which information is collected in an ongoing manner to measure
progress toward established goals or objectives. Monitoring can take a variety
of forms, including (but not limited to):
·
providing
self-evaluation on a variety of behaviors, using a check list or other
·
standard
form such as a questionnaire
·
having
a supervisor or colleague observe an encounter with a patient
·
recording
audio or video tape encounters, followed by self and/or team evaluations
·
conducting
exit interviews with clients.
Sustained routine monitoring of
clinical practices is an effective tool for improving the quality of health
care services and follow-up of training programs. Monitoring procedures and protocols
should be simple, user-friendly, and limited to a few key questions or
observations that will yield information by which progress and the design of
follow-up training activities can be gauged.
Follow-up is the process by which
trainers, supervisors or colleagues determine which skills need
reinforcing, additional training, or further development. Follow-up is based on
the understanding that learning occurs through repetitive drill, practice,
and constructive feedback. Follow-up is, therefore, an integral part of the
learning cycle, as it allows for focusing on problem areas or delving deeper
into areas of particular interest to participants.
Six months after the IPC training in
Egypt, a follow-up effort was carried out in response to a wish by
physicians to improve the quality of health services delivery and enhance
patient satisfaction. These activities consisted of field visits to work sites,
discussions with health providers on the relevancy of the IPC skills
acquired during the training session, observation of provider-patient encounters, the
compilation of physician questionnaires, and the recording of patient
exit interviews. Details of the results of these follow-up activities are
explained in the next chapter which presents the country’s case study.
VII. Case Studies VII. Case Studies
VII. Case Studies VII. Case Studies VII. Case Studies Sections I through VI have presented
a conceptual framework, outlined training strategies and described tools that can help
improve the quality of IPC between providers and patients.
This section presents our research
experiences to date in three countries—Honduras, Trinidad and Tobago,
and Egypt. We hope that our field experiences will complement the theory presented,
so that readers may feel confident in experimenting with IPC improvement
efforts. In all three countries we focused on training doctors. In Honduras and
Egypt a number of nurses were included in the IPC training
effort. We expect that the materials derived are appropriate for training all
professional health personnel, but may need some adaptation and
simplification for use with peripheral health workers or community health
volunteers.
In each of the three countries the
training sessions covered approximately 10-15 hours of classroom work, which included
presentation, discussion and practice of the new skills. The training
manuals are included in their entirety in the appendices, because we felt they could provide,
with minor adaptations, the basis of IPC interventions in new settings. The
training manual used in Trinidad most closely follows IPC improvement models that
are used in developed countries. The training manual for Honduras relates more
to a developing country setting. The training manual for Egypt is based
on the manual from Honduras, but benefits from revisions and improvements that
were made as a result of the Honduras experience.
All three countries also used a job
aid, the IPC Pocket Guide, to reinforce the training content. The job aid is
presented in Appendix A in English and Spanish. In our experience, we found that
it was important to allow each training group to modify the job aid as they saw fit,
adapting and personalizing the IPC norms to the local environment and to
individual needs.
All three case studies had a
research component. The research component in Honduras was the most
rigorous in terms of sampling, methods, and research design. It was based on analysis of
audio-tapes and of patient exit surveys. As a result of the IPC interventions,
the research resulted in improvements in practices and in documented
satisfaction of providers and patients. In Trinidad, the research also
relied on audio-tapes and exit interviews. Even though sampling methods were
simpler, we found that the method was able to detect improvements in practices
and satisfactions. In Egypt we attempted to replace the audio-tapes with an
observation check list and had an even smaller sample. Unfortunately, the observation
method used was not reliable, and we were unable to detect improvement in prov
ider practices. We feel that this situation resulted from a lack of adequate
training for all observers. We hope to continue to experiment at a later date
using a different research procedure.
While our field experiences yielded
much information on how IPC improvement strategies can be adapted to different cultures
and health settings, we feel that our findings are still incomplete
and that many additional insights on cross-cultural and organizational issues
will emerge as these survey tools and approaches are applied to other
geographic regions (such as Africa and Asia), and in other settings
(especially peripheral health services in rural areas). We would like to encourage
those who experiment with IPC interventions to share their experiences
with the QAP staff, so that these experiences can be used to further develop
the IPC framework and its strategies.
Prejudice and discrimination
Some of the most negative forms of intergroup
behaviour are demonstrations of prejudice and discrimination. Prejudice refers to a
derogatory attitude towards a group and its members, whereas discrimination refers to
negative behaviour. The two are often closely interconnected.
Prejudiced personalities
Some theories of prejudice focus on
personality, arguing that there are certain personality types that
predispose people to intolerance and prejudice. The best known of these
theories concerns the authoritarian personality. According
to this view, harsh family rearing strategies produce a love–hate
conflict in children’s feelings towards their parents. The
conflict is resolved by idolizing all power figures, despising
weaker others and striving for a rigidly unchanging and hierarchical world
order. People with this personality syndrome are predisposed to be prejudiced.
This ‘personality’ approach has now
been largely discredited, partly because it underestimates the importance
of current situations in shaping people’s attitudes, and partly because it
cannot explain sudden rises or falls in prejudice against specific racial groups. On
the other hand, a fairly small number of people do hold generalized negative
attitudes towards all outgroups (e.g. the stereotypical bigot who dislikes
blacks, Asians, gays and communists), and authoritarianism is
indeed associated with various forms of prejudice.
Society and identity
Contrary to personality
explanations, by far the best predictor of prejudice is the existence of a
culture of prejudice legitimized by societal norms. For example,
Pettigrew measured authoritarianism and racist attitudes among whites in South
Africa, the northern United States and the southern United States. He found more racist
attitudes in South Africa and the southern United States than in the northern United
States, but he found no differences in authoritarianism between these two
groups.
How do such prejudiced ‘cultures’
arise? Both social identity theory and social dominance theory may provide
part of the answer.
According to social identity theory,
group members strive to promote a favourable identity for their group.
They do this by maximizing their group’s real status advantage
over other groups, and by developing belief systems that justify
and legitimize their superiority. Group members achieve or maintain
a positive social identity by differentiating their group from
outgroups.
From the perspective of social
dominance theory, people also differ in their social dominance orientation
(SDO) – the extent to which they desire their own group to be dominant
and superior to outgroups. According to this framework, people who have a high SDO
are likely to be more prejudiced.
Modern forms of prejudice
Prejudiced attitudes are often
deeply entrenched, may be passed from parents to children and are
supported by the views of significant others. Yet societal norms
for acceptable behavior can and do change, sometimes creating a
conflict between personal feelings and how they can be expressed.
For example, modern liberal norms
and legislation in the United States stand against prejudice, and yet
centuries of history have entrenched racist attitudes in US society.
Researchers suggest that, rather than abolishing prejudice, this dynamic transforms
overt ‘redneck’ prejudice into more ‘modern’ forms. Modern prejudice often
presents itself as denial of the claim that minorities are disadvantaged,
opposition to special measures to rectify disadvantage, and systematic
avoidance of minorities and the entire question of prejudice against these
minorities. New, more subtle measures are required to detect these modern forms of
prejudice. For example, increasing use is being made of implicit measures (see
chapter 17), which are beyond the intentional control of the individual, and so can
detect prejudice even when people are aware of societal norms regarding
tolerance or political correctness. Research using the ‘Implicit Association Test’ has shown that white Americans have
relatively strong automatic negative associations with African
Americans, but positive associations with whites (they respond faster to
pairings of white faces with ‘good’ words and black faces with ‘bad’ words, than to
pairings of white faces with ‘bad’ words and black faces with ‘good’
words).
Building social harmony
Prejudice and conflict are
significant social ills that produce enormous human suffering, ranging
from damaged self-esteem, reduced opportunities, stigma and socio-economic
disadvantage, all the way to intergroup violence, war and genocide.
Prejudice can be attacked by public
service propaganda and educational campaigns, which convey societal disapproval
of prejudice and may overcome some of the anxiety and fear that fuel it. But
the problem with these strategies is that the very people being targeted may
choose not to attend to the new information. Two prominent social-psychological
approaches to building social harmony avoid this problem by promoting increased
positive intergroup contact and changing the nature of social categorization.
Intergroup contact
There is now extensive evidence for
the contact hypothesis, which states that contact between members of different
groups, under appropriate conditions, can improve intergroup relations.
Favourable conditions include
cooperative contact between equal-status members of the two groups in a situation
that allows them to get to know each other on more than a superficial
basis, and with the support of relevant social groups and authorities.
Contact appears to work best by
reducing ‘intergroup anxiety’about meeting members of the other group and by
promoting positive intergroup orientations, such as empathy and perspective
taking.
One difficulty is that, even
if they do come to view some individuals from the other group more positively,
participants in such studies do not necessarily generalize their positive
perceptions beyond the specific contact situation or contact partners
with whom they have engaged, to the group as a whole.
Recent work supports the idea that
clear group affiliations should be maintained in contact situations, and
that participating members should be seen as being (at least to some extent)
typical of their groups. Only under these circumstances does it appear that
cooperative contact is likely to lead to more positive ratings of the out group
as a whole. A further limitation is that optimal intergroup contact may be hard
to bring about on a large scale. Wright and colleagues therefore proposed an
‘extended contact effect’, in which knowledge that a fellow in group member has
a close relationship with an out group member is used as a catalyst to promote
more positive intergroup attitudes. This extended contact is therefore
second-hand, rather than involving the participants in direct intergroup
contact themselves, and so could potentially bring about widespread reductions
in prejudice without everyone having to develop out group friendships (which
anyway may be impracticable, depending on the nature of the groups).
Paolini, Hewstone, Cairns and Voci
(2004) have recently shown that, by reducing intergroup anxiety, both direct
and extended forms of contact contribute towards more positive views of the outgroup
among Catholics and Protestants in Northern Ireland.
Decategorization and recategorization
Prejudice depends on
ingroup–outgroup categorizations. So if the categorization disappears, then so
should the prejudice. Is this the case, and are these kinds of interventions
practical?
There are various ways in which
dissolution of categories might occur, two of the most prominent being:
1. decategorization, where people
from different groups come to view each other as individuals; and
2. recategorization, where people
from different subgroups, such as Scots and English, come to view each other as
members of a single superordinate group, such as British.
Decategorization can be
difficult to achieve when groups are very obviously different (e.g.
Muslim girls and women who wear headscarves, compared with non-Muslims who
typically do not), and where feelings run high it can be almost impossible to prevent
intergroup categorizations from coming to the fore.
Recategorization may be more
attainable, but it can still be difficult to get people from opposing
groups with a history of antipathy and conflict to regard themselves as
members of one superordinate group. (This is part of the problem in Northern Ireland,
for example.) Recategorization can also pose a threat to social identity at the
subgroup level, because people do not want to abandon their cherished subgroup
identities for more general (and less distinctive) superordinate identities.
A more successful strategy may be a
combination of a superordinate identity and distinctive subgroup identities, so
that each group preserves its distinctive subgroup identity within a common,
superordinate identity. A nice example is the Barbarians invitation rugby team,
which regularly plays matches against visiting international teams to the UK. They
all wear the same famous blue-and-white hooped shirts, but they each wear the
socks of their club team. So subgroup (club) identities are effectively viewed
as complementary and valued roles within a larger, superordinate identity – the
Barbarians.
At the societal level this notion
relates to the social policy of multiculturalism or cultural pluralism, in
which group differences are recognized and nurtured within a common
superordinate identity that stresses cooperative interdependence and diversity.
This notion has been especially
cultivated in some societies and countries, especially ‘immigrant countries’
such as Australia, New Zealand and Canada.
Clearly, our behaviour is
influenced in complex ways by other people and the groups to which they
belong. Sometimes the presence of other people can improve our performance and
judgement, but sometimes their presence worsens it. Sometimes other people can encourage
us to intervene and help others; sometimes they inhibit us. The outcome depends
on a complex weighing up of ‘costs’ and ‘benefits’ of intervening vs. not
intervening. And sometimes they can make us behave in ways of which we would
never have thought ourselves capable.
The social support of others can,
then, be a source of physical and psychological strength. It can help us to
resist pressures to conform to group norms, or give us the moral courage to
disobey orders from an authority figure. But the social categorization
that is a common consequence of group membership can also be a source of
prejudice and conflict. The role of psychological research can here serve
a very important professional and public role: by understanding the underlying
processes, social psychology can contribute towards greater societal harmony by
reducing prejudice and conflict.
There is a wide range of evidence
regarding the effects of other people on social behaviour.
·
We
have highlighted some of the key theories in interpersonal relations, group
processes and intergroup relations, and we have summarized the methods and
findings of some of the most important studies.
·
Generally,
performing a task in the presence of other people improves performance on easy
tasks, but impairs performance on difficult tasks.
·
People
are more likely to help if they are on their own, or with friends. The presence
of multiple bystanders inhibits intervention because responsibility is diffused
and the costs of not helping are reduced.
· People are especially likely to obey
orders from a legitimate authority figure, and when others are obedient.
·
We
are motivated to seek the company of others to compare ourselves with them,
reduce anxiety and acquire new information from them. Social support from
others provides a ‘buffer’ against stress.
·
Close
interpersonal relationships can be analysed in terms of social exchange of
goods, love, information and so on. Happy close relationships are characterized
by high intimacy, whereas distressed relationships tend to involve
reciprocation of negative behaviour.
·
We
join social groups for multiple reasons, and frequently define ourselves,
in part, as group members. This social identity develops over a series of
stages, in which we are socialized into groups.
·
Groups
are typically structured into roles, of which the distinction between leader
and followers is central. Group influence is affected by norms, and both
majorities and minorities within groups can exert influence, albeit in
different ways.
·
Performance
of groups is often worse than performance of individuals, because potential
gains in effectiveness are offset by social loafing and poor decision
making. Decisions made in groups tend to be more extreme than individual
decisions, sometimes with disastrous consequences. Individuals are also less
creative in groups, because their ideas are blocked by those of other group members.
Our View of Self and Others
The way we
look at ourselves plays an important role in how we see the world. The way we
see the world plays an important role in how we see ourselves. In this sense,
our view of self and others is an ever-changing circle of influence. We know
that those who are happy see more positive aspects of the world than those who
are depressed. We also know that living in an abusive household or an overly
restrictive environment can both lead to depression. This section will explore
the social areas of attribution (how we interpret those around us) and
attraction (what we seek in a friend or partner).
Attribution Theory
We tend to
explain our own behavior and the behavior of others by assigning attributes to
these behavior. An attribute is an inference about the cause of
a behavior. According to the Attribution Theory, we tend to explain our own
behavior and the behavior of others by assigning attributes to these behavior.
There are
basically two sources for our behavior; those influenced by Situational
(external) factors and those influenced by Dispositional (internal) factors.
Imagine walking into your boss's office and he immediately tells you, in an
angry tone, not to bother him. An external explanation of this behavior might
be, "He's really a nice guy but the stress is overwhelming. He needs a
vacation." On the other hand, you might see the same behavior and say,
"What a jerk, I don't know why is is so angry all the time." The same
behavior is given two very opposite explanations.
Many factors play a role in how we
assign attributes to behaviors. Obviously our view of the world, our previous
experience with a particular person or situation, and our knowledge of the
behavior play an important role. Other factors can influence our interpretation
as well, and there are two important errors or mistakes we tend make when
assigning these attributes.
1. Fundamental Attribution Error.
This
refers to the tendency to over estimate the internal and underestimate the
external factors when explaining the behaviors of others. This may be a result
of our tendency to pay more attention to the situation rather than to the
individual (Heider, 1958) and is especially true when we know little about the
other person. For example, the last time you were driving and got cut off did
you say to yourself "What an idiot" (or something similar), or did
you say "She must be having a rough day." Chances are that this behavior
was assigned mostly internal attributes and you didn't give a second thought to
what external factors are playing a role in her driving behavior.
2. Self-Serving Bias.
We tend to
equate successes to internal and failures to external attributes (Miller &
Ross, 1975). Imagine getting a promotion. Most of us will feel that this
success is due to hard work, intelligence, dedication, and similar internal
factors. But if you are fired, well obviously your boss wouldn't know a good
thing if it were staring her in the face.
This bias
is true for most people, but for those who are depressed, have low self-esteem,
or view themselves negatively, the bias is typically opposite. For these
people, a success may mean that a multitude of negatives have been overlooked
or that luck was the primary reason. For failures, the depressed individual
will likely see their own negative qualities, such as stupidity, as being the
primary factor.
Attraction
Why are we attracted to certain
people and not others? Why do our friends tend to be very similar to each
other? And what causes us to decide on a mate? Many of these questions relate
to social psychology in that society's influence and our own beliefs and traits
play an important role. Research has found five reasons why we choose our
friends.:
1.
Proximity - The vast
majority of our friends live close to where we live, or at least where we lived
during the time period the friendship developed (Nahemow & Lawton, 1975).
Obviously friendships develop after getting to know someone, and this closeness
provides the easiest way to accomplish this goal. Having assigned seats in a
class or group setting would result in more friends who's last name started
with the same letter as yours (Segal, 1974).
2.
Association
- We tend to associate our opinions about other people with our current state.
In other words, if you meet someone during a class you really enjoy, they may
get more 'likeability points' then if you met them during that class you can't
stand.
3.
Similarity - On the other
hand, imagine that person above agrees with you this particular class is the
worse they have taken. The agreement or similarity between the two of you would
likely result in more attractiveness (Neimeyer & Mitchell, 1988)
4.
Reciprocal Liking - Simply put, we tend to like those better who also like us back. This
may be a result of the feeling we get about ourselves knowing that we are
likable. When we feel good when we are around somebody, we tend to report a
higher level of attraction toward that person (Forgas, 1992; Zajonc &
McIntosh, 1992)
5.
Physical Attractiveness - Physical attraction plays a role in who we choose as friends, although
not as much so as in who we choose as a mate. Nonetheless, we tend to choose
people who we believe to be attractive and who are close to how we see our own
physical attractiveness.
This last
statement brings up an important factor in how we determine our friends and
partner. Ever wonder why very attractive people tend to 'hang around' other
very attractive people? Or why wealthy men seem to end up with physically
attractive, perhaps even much younger, women? There is some truth to these
stereotypical scenarios because we tend to assign "social assets" or
"attraction points" to everyone we meet.
These points are divided into
categories such as physical attractiveness, sense of humor, education, and
wealth. If we view education as very important, we may assign more points to
this category making it more likely that our friends or our mate will have more
education. If we view wealth as more important then we will be more likely to
find a mate who has more money.
We rate ourselves on these same
categories and, at least at some level, know our score. We tend to then pick
friends and partners who have a similar score that we do. Hence an attractive
person hangs with other attractive people; or a wealthy older man gets the
beautiful younger woman. Think about your friends and how you would rate them
in these categories to find out what is important to you.
Obedience and Power
Why do we obey some people and not
others? Why are you able to influence your friends? What attributes cause a
person to be more influential? These questions are paramount in understanding
social order. The answers to these questions also play an important role in
many professions, such as sales and marketing and of course politics.
Lets start with a closer look at
what 'power' is. Power is typically thought of has having a certain attribute
which gives one person more influence over another. This attribute could be
intelligence or experience, it could be job title, or perhaps money. According
to most social psychologists, there are five types of power: coercive, reward,
legitimate, expert, and referent.
Coercive power means the power punish.
Parents
are said to have coercive power because they can place their child in time-out,
for example; bosses have coercive power because they can fire an employee or
assign an employee a less pleasing job. Reward power is almost the opposite; it is the power to
reward. In that sense parents and bosses have this type of power as well, as do
many others in our lives. Legitimate
power
refers to the power granted by some authority, such as the power a police
officer has due to the local or state government or the power a professor has
due to the rules of a college or university.
Expert power results from experience or education. Those
individuals with more knowledge tend to have more power in situations where
that knowledge is important.
For
instance, the physician will have more power in a medical emergency than the
plumber. But, when the pipes explode and the house is being flooded, the
physician is not the person to call. Finally, referent power refers to admiration or respect. When we look
up to people because of their accomplishments, their attitude, or any other
personal attribute, we tend to give them more power over us. Imagine being
asked to do something by your "hero" or your favorite movie star; we
are very likely to comply out of admiration or respect.
Using Power to Influence Others
Now that we know what power is and
how people get it, lets talk about how this power is used to influence others.
Most of us know that liking and agreeing tend to go together. We agree with our
friends about many issues, especially the bigger ones, and often disagree with
our opponents. Also, beliefs and behaviors tend to go together. For instance,
most people who believe stealing is very immoral would not steal, most who
believe littering is wrong, do not litter.
What's interesting about this latter
concept is what happens when our belief and our behavior do not correspond. You
might think that we would change the way we act, but in the real world, we tend
to change our belief about a topic before we would change our behavior. The
person who believes littering is wrong, after throwing a soda can from their
car window, might say to himself, "It was only one time," or
"look at all the other trash on the freeway." in this sense, his belief
has changed; littering is now okay if it is only done once or if others have
littered first.
To equate this with influencing
others, we see that if we can change the way a person behaves, we can change
the way they think or feel. Imagine the car salesman who is able to convince
the potential buyer that this new car is the one he wants to buy. The sales man
might try to use many different techniques, but one is the 'test drive.' The
theory behind this is that if the person's actions include driving the car,
they are more likely to change their belief about the car.
There are other variables associated
with influencing others or attitude change. Lets take a look first at what
attributes the source or the talker help her influence others. First of all is
power, as discussed above. The more types of power and the stronger each of
these is, the more influential she will be. Second, a person must be believable
in order to influence us. The source must therefore be trustworthy, after all,
if we don't believe someone, they're going to have a much more difficult time
changing our minds. Finally, attractiveness plays a role in how influence us.
We tend to be influenced more by attractive people, including physical and
social attractiveness, likeability, demeanor, and dress.
The target or listener plays a role
in how he will be influenced as well. Those with low self-esteem and/or high
self-doubt tend to be more influenced that others. The more we doubt our own
ability, the more we look to others for guidance or input. Other factors such as
age, IQ, gender, or social status do not appear to play a significant role in
how we are influenced by others.
Finally, lets look at the
relationship between the source and the target. First of all, there needs to be
some similarity between the two people. If the target or listener does not feel
any similarity with the talker, he is much less likely to accept what she is
saying. After all, we have nothing in common so what could she possible know
about my life. The more similar the two, the greater the influential ability.
Second, there needs to be a moderate discrepancy in attitude. If the difference
between the two is too large, changing the listener's attitude or belief will
be too difficult. If the difference is too small, then no significant change will
take place at all. The difference must be great enough that a change is
possible but small enough that the listener is open to the change.
The Role of Groups
Do you think you act differently
when alone than when other people are around? The answer to this question is
typically a resounding 'yes.' We are concerned with our social image or how
other people see us; some more than others, but very few people see no
difference in their behavior. This section will discuss various theories
relating to our behavior in group settings or when others are present.
Lets start
with one of the most simple theory related to social psychology. When alone, we
tend to be more relaxed, less concerned with the outward expression of our
behavior, and are basically 'ourselves.' Add just one other person, even if we
don't know that person, our behavior tends to change, and not always for the
better. Research has found that when others are present, our level of arousal
is increased (Zajonc, 1965). In other words, we are suddenly more aware of
what's going on around us. Because of this, we tend to perform better at tasks
that are well learned or simple (Guerin, 1993). When completing a difficult or
new task, however, our performance level decreases and we tend to do more
poorly.
This
phenomenon is called Social Facilitation (Guerin, 1993), and as we try harder
due to the presence of others, our performance actually decreases for difficult
or unlearned tasks. Think about learning to play basketball for the first time.
If you are alone, you will likely be more relaxed, and better able to
concentrate. When others are watching you, however, you are more likely to be
self-conscious, and therefore make more mistakes. Professional basketball
players, however, because the task is so well learned, perform better when
others are watching and they are able demonstrate their confidence and ability.
Group Think and Group Polarization
If you've ever been involved in a
group decision making process, you've probably seen one of two things happen:
either the group agrees on all of the major issues, or there is significant
dissent that splits the group. If the group is cohesive; if they agree on most
issues, they tend to stifle dissent because group harmony is the anticipated
outcome (Janis, 1972). When we all agree, and are happy with that agreement, we
typically do not want to hearopposing arguments. This phenomenon is referred to
as Group Think. It can lead to impulsive decisions
and a failure to identify and/or consider all sides of an argument. Some
classic examples of group decisions going bad include lynch mobs, actions of
the Ku Klux Klan, discrimination among hate groups, and mass riots.
Similar to this, Group Polarization refers to a groups tendency to talk
itself into extreme positions. In this case, a group gets so focused and
energized about a decision that it creates an internal fuel, so to speak, which
pushes itself forward faster than originally intended. Imagine a group of
protesters, all agreeing and deciding to picket. You can see how this could get
out of hand because opposing views (Group Think) are not considered and the
push to move forward for the cause is fueled internally (Group Polarization).
Another
phenomenon that occurs in groups is referred to as Social Loafing. This theory
states that as a group gets larger, the individual contribution decreases
disproportionate to the group size (Everett, Smith, & Williams, 1992; Hardy
& Latane, 1986; Ingham et al., 1974). This is due to the diffusion of
responsibility created as the size of the group increases. Imagine being
assigned a project to complete by yourself. Most likely you would complete 100%
of it. Now if two people are involved, the percentage will typically not be
50/50. As more people are added to the group, you will end up with a small
percentage doing a large portion of the work and a large percentage doing a
much smaller proportion.
Bystander Effect
This last
phenomenon is an unfortunate reality which has been observed far to many times
in groups and in larger cities. We've all heard stories of people getting
mugged, or beaten, or raped in broad daylight while people around offered no
assistance. We have found that the internal push to help a person in need
decreases as the group gets larger, very similar to Social Loafing. In this
instance, however, people tend to be followers and will only get involved if
they witness another person getting involved. What results is a group of people
witnessing a crime and wondering why nobody is helping. This does not occur if
you are the only person witnessing the crime. If nobody else is around, a
person will tend to help the victim. The more people, however, the less likely
someone will offer assistance.
The effect of illness and hospitalization
Physically
isolated
Surrounded
by strangers
Visiting
hours
Procedures
that are intimate
At first
very dependent – then learn to move back to balance of independence/dependence
What can
studying communication skills offer us as medical practitioners?
Increased
nurse Job Satisfaction
Decreased
Conflict Within The Consultation
More
Accurate And Efficient Interviews
Better
Clinical Hypothesis Generation
Increased
Patient Satisfaction
Increased
Patient Understanding And Recall
Improved
Compliance And Disease Outcome
Decreased
Medico Legal Complaints
Actual
Savings In Time
More
Structure And Control Of The Difficult Consultation
Patient’s Satisfaction.
Many researches have also shown a significant
relationship between the clinician’s interpersonal skills and patient’s
motivation and satisfaction. When the nurse dominates the interview, verbally
and emotionally, the result is always leads to dissatisfaction of the patients
and their relatives. This may also be related to the patient’s expectation about
the role of the nurse.
Patient’s satisfaction plays a major role in
assessing quality medical care in the newly adopted health system (manages
care) in the
Cognitive Satisfaction: How satisfied is the patient with their
understanding of the diagnoses, treatment, and prognoses. This is related to
the nurse’s Verbal Behavior.
Emotional Satisfaction: This is related to the nurse’s non-verbal
behavior. The ability to show care and concern by tone of voice, eye gaze,
facial expression, body movement and posture.
Treatment Outcome:
Effective
diagnoses and treatment depends not only on identifying physical symptoms of
illness, but also on the nurse’s ability to detect and respond to verbal and
non-verbal cues, to elicit all relevant information (physical and
psychosocial), relevant to diagnoses and treatment.
Patient’s Adherence:
A poor
communication skill is related to poor compliance. Communication skill training
has a positive influence on patient compliance with prescribed medication. Effective
communication enables nurses/Nurse and other health professions to pass on
relevant health information, and to motivate patient to pursue healthier
lifestyle. This is a very important part on health promotion.
Nurse’s Competence & Self-Assertion:
Research has
also shown that better nurse’s patient’s communication can also contribute to
the clinical professional and personality (self-confidence) aspects.
CORE
COMMUNICATION SKILLS
Core
communication skills covers three dimensions:
• nurse -patient interpersonal skills
• Information gathering skills
• Information giving skills and patient education
Advanced
Communication Skills
• Skills
for motivating patient adherence to treatment plans
• Other
applications of core communication skills in specific situations.
Nurse-patient
interpersonal skills
Appropriate physical environment
The need to establish an appropriate physical
environment to enhance privacy and attentiveness. Small things like arranging
seating in a manner which neither threatening nor distant, or having a curtain
to create a sense of privacy will in outcome of the interview.
Greeting patients in a manner acceptable within
the cultural norms in relation to age, sex. etc. will help maintain their
dignity and encourage their participation.
Active listening involves using both verbal and
non-verbal communication techniques. The nurse should clearly signal that the
patient has his/her full attention by look, by offering acceptance and
continuation signals such as nods, phrases such as “right”/”I see” etc. A willingness
to listen actively is however best signaled by use of open questions
to promote fuller answer.
Empathy,
respect, interest, warmth and support
These issues are at the heart of interpersonal
skills. They cannot easily be faked, and if nurse do not have them, they cannot
easily be taught things to do by way of them. Success in this area is
not a matter of skills but of attitude. However, health practitioners
should clearly signal their interest in how the patient’s problem is perceived,
whether it concerns them, what their hopes and expectations are.
Nurse should ask questions to discover patient
perception “Does the thought of the operation worry you?”. The
nurse should also learn to show respect, interest, warmth and support. This
will also involve being non-judgmental in attitude. THESE ARE THE CORE FACTORS
IN RAPPORT BUILDING.
Language
Avoid medical jargon. You should consider the
educational cultural and developmental level of the patient e.g., “ You have
got appendicitis” is appropriate for most adults but not young children etc),.
It is also important for nurses to monitor their use of potentially frightening
words “Cancer”/”lump” etc.
Non-verbal communication
Skills in
non-verbal communication like eye contact, physical proximity, and facial expression
need to be improved to enhance patient’s satisfaction and adherence to
treatment. This should convey to the patient that the Health practitioner is
attentive and interested.
Avoid
Overreacting
Some
patients may appear demanding, dependent or even at times, adversarial. It is
the physician's responsibility to not overreact to these situations. This can
be achieved by establishing limitations (boundaries) on what can be provided
and suggesting appropriate ways for the patients to contact them.
Establishing Boundaries
Frequent
phone calls, unscheduled visits, and unrealistic expectations, are ways in
which some patients lose perspective of the shared responsibility of their
care. Nurses need to establish boundaries for patients in a way that doesn't belittle
them.
Closing the interview
In addition
to the skills of setting up, beginning and continuing an interview, the way of
closing the interview is also important. The nurse should clearly signal that
the interview is drawing to a close, usually by summarizing what has been said
and what has been negotiated.
Basic to interpersonal skills is to consider
the importance of such factors as gender, cultural and socioeconomic factors,
which could greatly affect perceptions of norms and standards of appropriate
communication.
It is also essential for all practitioners to
realize that what is needed is not only to know how to recognize a disease, but
also how to recognize and to respond to a patient’s emotional response to their disease. In their
interactions with patients, it is important for the clinicians to be aware of
patients’ emotional responses to their situation and at the same -aware of
their own emotional reactions toward the patients.
Information gathering skills
A critical part of all nurse-patient interactions
involves eliciting information from patient. The core skills which are needed
to facilitate the process of information gathering are skills
which help to facilitate the patients’ involvement in the medical
interview in away that enables the nurse to arrive at an accurate diagnosis of
a patient’s problem or symptoms.
Using an appropriate balance of open to closed
questions
Open
questions invite an extended answer, not a “Yes/No” response. Generally
questions such as “Please tell me about your pain” are better at eliciting
information than closed questions such as “Is it a stabbing pain?”. Open
questions are particularly useful patients are being asked to describe their
problem; which they should be allowed to do minimal interruption early on in the
consultation.
Silence
You need to learn to use silence appropriately
as a way to encourage express themselves more fully, raise difficult topics and
remember important
Clarifying patient expectations about the
consultation
You need to clarify with the patient what their
expectations are consultation, and should avoid making premature conclusions
about the reason person’s visit to the nurse. This may helps to reveal cases
where the symptom the patient is not in fact the patient’s main concern, and
will also help to avoid inaccurate diagnosis of the patient’s complaints.
Clarifying the information given by the patient
You need to clarify the meaning of what the
patient is saying and the nurse perceives from the patient’s non-verbal
communication in order to he/she understands the patient fully.
Sequencing of events
After eliciting a broad description of the
patient’s situation, students need to help the patient to sequence events and
experiences in order to develop a logical of the patient’s situation.
Directing
the flow of information
While it is important that patients be allowed
the opportunity to communicate at the same time the student needs to learn to
maintain control of the interview, by guiding the interview content towards a
diagnosis of the problem.
Summarizing
Since a lot of information can be exchanged in
consultations, you should be able to summarize the main issues raised during
the consultation and should ensure that a shared understanding of these.
Information giving skills and patient education
The medical interview usually involves the
nurse in providing information to the patient about their illness or problem,
and when appropriate the nurse will give inform and advise about the proposed
treatment plan or treatment options.
Providing clear and simple information by monitoring jargon, and by checking the
patient’s understanding before (“What do you know about asthma?”) and during
(“Have I made myself clear?”) the explanation process.
Using specific advice with concrete examples. Abstract or general advice/inform should be
exemplified in terms that make sense to the patient “Don’t use acidic foods for
example steer clear of fried things”.
Putting important things first. Research suggests that what is said first is
remembered. A nurse should say first what it is most important for the patient
to recall
Using repetition. Repetition should be used carefully to a level
appropriate to patient. Often it is best to recycle information using slightly
different words, in case the formulation has been only partly understood.
Summarizing. This is an important interview-closing skill (see above). Sum should be
brief, and repeat the main points agreed in language, which is unambiguous
clear. Patients may also be invited to repeat the nurse’s instruction to ensure
that they shared understanding.
Categorizing information to reduce complexity
and aid recall. Where the
information to be conveyed is complex, or where there is a lot to be said, it
should be clearly b down into manageable units which are clearly signaled to
the patient, using markers s “there are three things we need to think about ...
firstly/secondly/thirdly etc”.
Using tools: Complex information could well be accompanied by a series of heading
and diagrams. Some nurses offer tape recorders of their consultations to
patients where the information has been intellectually demanding and
psychologically distressing.
Checking
patient understanding of what has been said. Repeating instructions, using
diagrams, written instructions, and sometimes-technical aids to explain
difficult concepts are useful. The student must be competent in summarizing the
information given and in checking patient understanding by asking the patient
to repeat what heard and understood.
Skills for
motivating patient adherence to treatment plans
The list below includes skills for the
promotion of behaviour. Realistic compliance with treatment plans may require
patients to make significant changes in their diet, lifestyle or daily routine
on a short term or long term basis.
Providing a rationale for behavior change
Providing examples of role models
Allowing opportunities for verbal rehearsal of
the details of the treatment
Feedback (positive reinforcement of
constructive behaviour changes already achieved since earlier consultations)
Finally, nurses should be aware about the clincial,
communication and interpersonal skills that are required when dealing with
difficult patients,(e.g., overdependent, dramatizing and exaggerating,
aggressive, and antisocoial personalit.
Collaboration with patients and families
To win the collaboration of patients and their
families, those providing care need to
elicit, negotiate and agree on a definition of
the problem they are working on with each patient.
They must
then agree on the targets and goals for management and develop an individualised collaborative self
management plan. This plan should be based
on established cognitive behavioural principles
and on the evidence relating to the management of the
chronic condition.
Principles of collaboration
Understanding
of patients’ beliefs, wishes, and circumstances
Understanding
of family beliefs and needs
Identification
of a single person to be main link with each patient
Collaborative
definition of problems and goals
Negotiated
agreed plans regularly reviewed
Active
follow up with patients
Regular
team review
List of educational
literature:
A. Main:
1. Kelly, P. (2008). Nursing Leadership and Management. (2nd ed.). Clifton Park,
NY: Delmar Learning
2.
Huber, D. (2000), Leadership and Nursing Care Management, (2nd ed.),
Philadelphia: W.B. Saunders.
3.
Nagelkerk, J. (2000), Study Guide for Huber Leadership and Nursing Care
Management, (2nd ed.), Philadelphia: W.B. Saunders.
4.
Sullivan, E. J. (2004). Becoming influential: A guide for nurses. Upper Saddle
River, NJ: Pearson.
B. Additional:
1. See required Websites:
http://www.health.gov/healthypeople/.
www.health.state.mn.us/divs/chs/phn/definitions.pdf
2. Course Website – Log in @ http://www.tdmu.edu.te.ua/ukr/general/index.php
Prepared by
Volkova N.M.
Adopted by Department of Medical Bioethics and Deontology sitting
11 June 2012, Minute ¹ 2