Communication in a medical environment. Personality and disease.
The whole system of a person's attitude to other people
realises in communication. The concept of "communication" is one of the key
in the system of psychological knowledge: The social function of communication
is that it stands for transfer the social experience. The
result of communication is repairing certain relationships with other people. Because
communication is the integration of people, produced behavioral norms of
interaction. Talk
coordinating joint activities of people and satisfying needs in psychological
contact. The need to communicate is one of the primary needs of the child. It
develops from simple forms (the need for emotional contact) to more complex
(cooperation, intimate-personal communication). Scientists
outlined these stages of development needs of the child to communicate: the
need for adult attention and goodwill (the first six months of life), in
cooperation (early preschool age), in the interest of an adult child asking us
(junior and middle preschool age) and mutual
understanding and empathy (preschool age). Forms of Internet usage motives in
communication of preschool children.
Communication and activities
Communication
is closely linked with the activity. Any form of communication serves as a form
of joint activity, people are always talking during a particular activity. In a
joint activity of the forming not only subject-object but also subject-subject
relations (person - man). The essence of communication lies in the interaction
of national activi ties.
The development plan requires a superior
understanding of every human goal activities, means of implementation, the
distribution functions for its enrichment. The specifics of the communication process is to create opportunities to organize and coordinate the activities of
its individual members.
In communicating
important characteristic is its function. B. Lomov identifies three groups of
such functions - information and communication, regulative-communicative and
affective-communicative.
Information and
communication function of forming, the transmission and reception of
information. The implementation of this function has several levels. The first
is differences in the original alignment of human awareness. The second level -
the transfer of information and decision making. At this level of communication
has developed goals of informing, training and others. Third level associated
with the human desire to understand others. Communication
here is aimed at forming assessments of achieved results (approval -
incongruity, in the equation ¬ views, etc.).
Regulatory communicative function is to regulate behavior. Thanks sanctuary
provides regulatory not only his own conduct and behavior and other human, and
responds to their actions. There
appear to be phenomena that are specific cooperative activities, including the
compatibility of people, their ability to work together, mutual stimulation and
correction of behavior. Regulatory and communication function is carried out
phenomena such as imitation, suggestion, etc..
Affective communicative function well describes
the emotions sphere of a person. Communication affects the emotional states of
man. In the
emotional turns a person's attitude to the environment, including social.
One feature of communication is interpersonal
relationships.
Based on the above functions, Andreeva G.
outlines three sides of communication: communicative (exchange of information
that), interactive (interaction) and perceptual (understanding of human
rights).
Nonverbal
communication
The
communication process is implemented by using certain tools - sign systems.
According to the criterion of sign systems can provide non-verbal and verbal
communication.
Nonverbal communication is
usually unconsciously, spontaneously. While people in some way control
their speech is possible by analyzing facial expressions, gestures, intonation
evaluate the accuracy, sincerity of speech information. To understand the
elements of nonverbal communication is needed, usually special training.
Nonverbal transmission of
information a person develops earlier than verbal. The baby starts to
distinguish between emotional mother, responds to voice intonation, facial
expression, gestures, touch. Adults in contact with strangers, there is the first
impression through means of nonverbal communication (eye contact, expression).
One of the important
parameters that characterize non-verbal communication is interpersonal space -
the distance that you unconsciously set in the process of direct communication
between people. The
more closely th
e relationship
between people, the smaller the spatial distance between them in the process of
communication. This distance depends on the national standards of behavior,
social status, age, psychological features. Too close, as well as remote
distance is a negative effect on communication. "Closest"
associate close friends, relatives. Increase interpersonal space can cause
unpleasant feelings. Interested parties in each other reduce communication
distance, mentally disturbing to maximize distance. Women tend to be somewhat
closer to the source, than men. Beyond the average distance between the interlocutors are
friends of 0,5-1,2 m (interpersonal space), for informal social and business
relationships - 1,2 - 3,7 m (the social space) space, more than 3,7 m, makes it possible
to abstain from intercourse or put it into formal relations.
Interpersonal space affects the eye contact
(eye contact). More informative element of a person - face. Therefore eye
contact is extremely important in nonverbal communication. Fixing look at other
means not only interest but also concentration. But saw a long look at the
person she is feeling confused and can be interpreted as a sign of hostility.
Mutual eye contact is easier to maintain, pleasant discussing the issue. Since
people look at each other, you can find out which relations between them. We
tend to look longer for those who admire, avoid situations in terms of rivalry.
Maintain eye contact helps the partner to feel his attitude
to the interlocutor. The
view can regulate conversation. When one person finishes speaking dialogue, he looks at the
interlocutor, looking forward to continuing the conversation.
While talking to our information perform expressive
reactions (from Lat. Expressio - expression). These include: body language,
pantomimic, gestures, intonation vote. They characterises the intensity of expression
of human feelings. A characteristic feature mimic (expressive facial muscle
movements) is its universality and specificity for the expression of different
emotions. Interpretation of emotion associated with dual nature of
facial expressions. On the one hand, facial expressions caused by congenital
factors reflect universal emotions in the face, such as fear, joy, pain. They
understand people of different cultures. On
the other - body language will vary from a social culture, the specific rules,
standards.
Emotions of human can identify with her pantomimic: gestures,
postures, movements. Gestures, facial expressions, intonation help a person who
says, focus attention, to express their emotional attitude to the information
it conveys. A set of gestures that a person uses in communication, very
diverse. General
are as follows:
1) communicative gestures -
replaces broadcasting in communication and may be taken independently:
greetings and farewells; threats, drawing attention, invitations, prohibition, affirmative
asking, denying, thanksgiving, brutal and irritating;
2) emphasizing gestures -
accompany speech rights and strengthen the language context;
3) modal gestures - distinct
movements that mean assessment attitude to the situation. These
include gestures uncertainty, suffering, thought, concentrati
on,
frustration, disgust, surprise, frustration and more.
Analysis of nonverbal
communication you can find this aspect of the communication process, as the
intentions of its participants. They
have a significant impact on the nature of interpersonal relations.
Speaking in general about
the non-verbal communication can say that it plays a very important place in
our communication, because 38% of information is seen how the rumor words that
bear it, and 55% - the same facial expression.
Fundamentals of Communication:
Some experts believe that the ability of each person is
different and talk shows available in two qualities of man:
1. The
degree of confidence, is how many he feels confident, that is, how many he is
right.
2. His degree of insecurity.
Criteria for evaluating the confidence or
uncertainty are words that people take and the frequency of their recurrence.
Word inserts the words to
express uncertainty officials issued uncertainty: in general the same as to
say, I think, in my opinion, etc.
Affirmative statements describing confidence: 
clearly,
correctly, perfectly, etc.
There are several criteria which must meet our
language:
1.
What we say should be grounded.
2.
Make sense.
3.
Be interdependent.
4.
It is clear to others.
Public Speaking:
One of the basic
professional requirements for the entrepreneur is the ability to speak at
conferences, meetings, business meetings.
More efficiently is always interesting
short saturated and bright appearance, than a long speech.
You must speak rarely and in-being. To develop
the ability to speak calmly and clearly to an audience should consider several
points:
1.
Start it loud and persistent voice.
2. Prepared for presentation.
3.
Elicit confidence.
4.
Practice.
Preparing
for the speech:
Preparing for the speech one of the main parts
and an integral part of success in speech. Sometimes it may depend on the
preparation of the entire performance.
In
preparation to:
1. Ignore material by themselves.
2. Do not convert it into dry presentation of
facts and bring specific examples of "effect flacky pie.
3. Collect more information than you can use
(backup knowledge).
4. You must come up with plan language and the
main points in particular to build its beginning and end.
5. Record your speech and listen to the tape
6. Use association not read papers.
7. Rehearse ready language.
8. Take in the everyday conversations of those
moments that you wish to speak in a public speech, because you use the
construction firm grounds in memory.
9. Try to remember your language is not in one
sitting, and in the course of several days.
During
the speech:
1. Feel your audience, determine whether the
content of your speech to its
interests. If
not, you go bring your interests to the common denominator audience.
2. Before speech, take on attention.
3. Begin to speak only when silence.
4. Briefly and clearly refer to the entire
audience, and then pause.
5. Watch the reaction of the audience and try
to get its location.
6. Be careful when your words will find support
in the audience and immediately develop a theme and try to open it wider.
7. Only when you have achieved quite the
location of students go to the main theme of the speech
8. Do not lose control of provocative replicas.
9. Does not enter into discussion during the
speech, otherwise you "lead the side, and the performance will be"
has failed ". Tell that to all the questions you answer after the speech.
10. If performance is the place unpleasant
audience, must reinforce their obvious examples and facts, emphasize that just
makes you need to talk about them. And, necessarily, reduce severity of
multiple compliments.
11. Do not make unwarranted conclusions and generalizations.
12. Do not show the form that you are tired or
in some doubt.
13. After presentation to make audiences
compliment and thank you for your attention.
Beginning speech:
Getting the most important speech of all speeches.
Objective performance is beginning to attract attention and inciting audience's
interest. Do not start a speech with an apology or anecdote. The best
performance start with:
1. History of screamer.
2. From the observations directly kasayuschehosya audience.
3. With quotes known to man.
4. From the display of any article.
The
end of the speech:
As the saying goes:
"First tell that were going to tell, then tell that remember and done so
with our starting point."
Finalize statement follows
observing the following rules:
1. Summarize the main provisions of the speech.
2. Call for action if appropriate.
3. Make suitable compliment. a
4.
Panic.
5. Use appropriate quote.
6. Create a climax.
7. Try to finish the speech before this audience wants.
Some aspects are
necessary for good performance:
1.
The feeling of contact with the audience.
2.
Naturalness of speech:
a)
conversational tone, spontaneity,
b)
Highlight important words
c)
rate of change of language - pause before and after
important
ideas.
3. Manifestation of energy and emotional sincerity.
Telephone:
Telephone call - a "calling card" of the
entrepreneur. For some, that seem at first sight, small change can fairly
accurately estimate the level of culture of your caller. In this need to know
the rules of communication by phone and plan in advance to build a
conversation.
Universal
techniques for building a phone conversation:
1.
The obligatory congratulations.
2.
Representation.
3.
The main purpose of the call, taught briefly in 3-5 phrases, it is necessary to
emphasize the point a conflict of interest.
4.
End call, repeat basic ideas, requests, ideas.
5.
Farewell to say something nice, thank you for the conversation.
It should be noted that
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while business telephone conversations should have on hand: pens, weekly collections of documents are needed, because constant request of "wait time" creates negative emotions in your caller. Telephone conversation must be conducted in friendly tone, speak clearly, consistently, in short phrases.
Terms of communicating by phone:
1. Business conversations are carried on business phone if you want to talk on the phone home that need to apologize and to outline the essence of the case, arrange a meeting.
2. Call from 9.00 to 22.00.
3. When the bell should explain strangers who gave their phone.
4. Call back the one who called.
5. According to etiquette the called subscriber can not call itself.
6. If the right person is unavailable, then the third person asked him to convey that.
Nonverbal communication:
In humans as in animals have instincts, acquired or congenital. These instincts can be attributed and non-verbal means of communication.
Most of them were born, is inherited in genes such intimate zone. Similarly, some of them are purchased for example if carefully watching behavior of young people in a disco or a bar when meeting with a girl that you can see that approximately 50% more while constantly hand as it straightens itself hairstyle.
And although your friend about this may never even heard, but at the subconscious level, he will feel them, which significantly affect the outcome. Ie having nonverbal can have control and manage your interlocutor. Besides having these tools can work without much appreciate his sincerity and better understand it. Psychologists found that 60% to 80% of communication is through nonverbal, and only 20% -40% due to verbal expressions.
In humans, there are several zones and each zone has its role that everyone has their personal territory that surrounds it is as if his property, continuation of his physical body (house, car, etc.).
Length of personal territory in animals depends on population, so also in man, but his personal space area is divided into 4 zones:
1. Intimate zone 15-45 cm:
Protected as property. It allowed children, parents, wives, husbands, lovers and close relatives. Less than 15 cm - very intimate zone in which case you can not penetrate.
2. Personal Zone 46 cm - 1,2 m:
Distance to official receptions and parties.
3. Social zone 1,2 m - 3,6 m:
Foreign and unfamiliar people, new fringe.
4. Public area more than 3,6 m:
In addressing the large group of people (theater, lecture, performance).
In the case of an imminent invasion of inappropriate area to observe the following rules:
1. Anyone not to talk, even if you are familiar.
2. Do not look in focus, but not bury the eye.
3. Do not show nor any emotion.
4. If in the hands of newspaper or a book to deepen well in reading.
5. Knife in the vehicle closely, the restraint be your movements.
6. In the elevator is recommended to watch list
floors.
In recent years, in the west are going to give up skyscrapers, because while
increasing population density, leading to increased stress.
Should also be noted that different nations different zone spaces. For example, in an area less American than Japanese. Therefore, during negotiations between themselves, they often feel suspicious. In European countries, 23 - 25 sm. Similarly, different zonal space between townspeople and villagers.
In 1946 the townspeople see, while the peasants 1-2 m.
It can be concluded that the more densely populated areas - the lower zone space in the city.
Language of body moves:
Language of body moves, like any language consists of words, propositions, signs spelling. For correct interpretation of gestures should be considered:
1. Total gestures.
2. Congruence of verbal and nonverbal signals that match the words and gestures, the gesture must believe (non verbal).
3. Context.
4. Personal reasons (health, clothing, profession).
Language of body moves directly depends on the following criteria:
1. Social status and prestige of power (the higher the social
economic situation of the person, the better developed its verbal - nonverbal
and worse).
2. From the age (in children manifests itself in greater
degree).
Some elements of language and of body moves nonverbal:
Hands and arms:
Palms opened - it means honesty, sincerity,
trustfulness.
When a person is false, he holds his hands
behind his back or in pockets.
Coupled fingers mean intolerance, frustration
and desire to hide their negative human relations.
The
situation when a person keeps one hand on another, he is looking fo
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r support themselves.
Handshake:
A very important element is nonverbal handshake. Through it you can see one of the 3 types of relationships between people:
1. Advantage in this handshake advantage of the man whose hand is on top.
Since the study found that of 54 administrators prosperous 1942 protyahayut hand for a handshake at the top.
2. Obedience, suppleness. This handshake extends hand blown palm upwards.
3. Equality. Both hands are shaking hands at the upright position.
Similarly, when a handshake:
- If you come without an invitation will not have to take initiative on a handshake.
- "The Mitten" emphasizes the uncertainty.
- Live at hand handshake means aggressiveness.
WRONG:
When a person starts the conversation inadvertently scratch eyelid, neck, lobes of soup, it is quite likely that he was lying.
Evaluating the relationship:
Any head lean means boredom.
Stroking c
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hin - an attempt to take the required action.
Hands as barriers:
Crossed arms mean secrecy. Formed bio-energy barrier. For example, when you come to a psychologist he would not cross your arms and legs.
The situation in the chair:
If a person during a conversation sitting on the tip of the chair, it means he has already decided for himself and finished the conversation. In this case you should politely end the conversation.
Position benefits:
When a person hands behind his head and he leaned back in his chair.
Several ways to report rights of unwanted items during an interview:
- Mirror - repeat after him the sa
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me movements.
- Suggest to him watch something, for example, any document.
- Ask him to rate himself.
Opinion:
1. Business (in the eyes).
2. Social (from eye to mouth).
3. Intimate (from the eyes to the chest).
You can create the perception of the interlocutor that you look into his eyes. To do is to look him in the middle of his forehead.
Fundamentals of Communication:
Some experts believe that the ability of each person is different and talk shows available in two qualities of man:
1. The degree of confidence, is how many he feels confident, that is, how many he is right.
2. His degree of insecurity.
Criteria for evaluating the confidenc
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e or uncertainty are words that people take and the frequency of their recurrence.
Word inserts the words to express uncertainty officials issued uncertainty: in general the same as to say, I think, in my opinion, etc.
Affirmative statements describing confidence: clearly, correctly, perfectly, etc.
There are several criteria which must meet our language:
1. What we say should be grounded.
2. Make sense.
3. Be interdependent.
4. It is clear to others.
Communication is the exchange and flow of information and ideas from one person to another; it involves a sender transmitting an idea, information, or feeling to a receiver (U.S. Army, 1983). Effective communication occurs only if the receiver understands the exact information or idea that the sender intended to transmit. Many of the problems that occur in an organization are (Mistry, Jaggers, Lodge, Alton, Mericle, Frush, Meliones, 2008):
◦ the direct result of people failing to communicate
◦ processes that leads to confusion and can cause good plans to fail
Studying the communication process is important becaus
e you coach, coordinate, counsel, evaluate, and supervise throughout
this process. It is the chain of understanding that integrates the members of
an organization from top to bottom, bottom to top, and side to side.
The Communication Process
Communicating with others involves three primary steps:
◦ Thought: First, information exists in the mind of the sender. This can be a concept, idea, information, or feelings.
◦ Encoding: Next, a message is sent to a receiver in words or other symbols.
◦ Decoding: Lastly, the receiver translates the words or symbols into a concept or information that he or she can understand.
During the transmitting of the message, two elements will be received: content and context. Content is the actual words or symbols of the message that is known as language the spoken and written words combined into phrases that make grammatical and semantic sense. We all use and interpret the meanings of words differently, so even simple messages can be misunderstood. And many words have different meanings to confuse the issue even more.
Context is the way the message is delivered
and is known as paralanguage
it is
the nonverbal elements in
speech such as the tone of voice, the look in the
sender's eyes, body language, hand gestures, and state of emotions (anger,
fear, uncertainty, confidence, etc.) that can be detected. Although
paralanguage or context often cause messages to be misunderstood as we believe
what we see more than what we hear; they are powerful communicators that help
us to understand each other. Indeed, we often trust the accuracy of nonverbal
behaviors more than verbal behaviors.
Some leaders think they have communicated once they told someone to do something, I don't know why it did not get done. I told Jim to do it. More than likely, Jim misunderstood the message. A message has NOT been communicated unless it is understood by the receiver (decoded). How do you know it has been properly received? By two-way communication or feedback. This feedback tells the sender that the receiver understood the message, its level of imp
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ortance, and what must be done with it. Communication is an exchange, not a give, as all parties must participate to complete the information exchange.
Barriers to Communication
Nothing is so simple that it cannot be misunderstood. Freeman Teague, Jr.
Anything that prevents understanding of the message is a barrier to communication. Many physical and psychological barriers exist:
◦ Culture, background, and bias We allow our past experiences to change the meaning of the message. Our culture, background, and bias can be good as they allow us to use our past experiences to understand something new, it is when they change the meaning of the message that they interfere with the communication process.
◦ Noise Equipment or environmental noise impedes clear communication. The sender and the receiver must both be able to concentrate on the messages being sent to each other.
◦ Ourselves Focusing on ourselves, rather than the other person can lead to confusion and conflict. The Me Generation must be tossed aside for effective communication to occur. Some of the factors that cause this are defensiveness (we feel someone is attacking us), superiority (we feel we know more that the other), and ego (we feel we are the center of the activity).
◦ Perception If we feel the person is talking too fast, not fluently, does not articulate clearly, etc., we may dismiss the person. Also our preconceived attitudes affect our ability to listen. We may listen uncritically to persons of high status and dismiss those of low status.
◦ Message Distractions happen when we focus on the facts rather than the idea being communicated. Our educational institutions reinforce this with tests and questions. Semantic distractions occur when a word is used differently than you prefer. For example, the word chairman instead of chairperson, may cause you to focus on the word rather than the message.
◦ Environmental Bright lights, an attractive person, unusual sights, or any other stimulus provides a potential distraction.
◦ Smothering We take it for granted that the impulse to send useful information is automatic. Not true! Too often we believe that certain information has no value to others or they are already aware of the facts.
◦ S
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tress People do not see things the same way when under stress. What we see and believe at a given moment is influenced by our psychological frames of references our beliefs, values, knowledge, experiences, and goals.
These barriers can be thought of as filters, that is, the message leaves the sender, goes through the above filters, and is then heard by the receiver. These filters may muffle the message. And the way to overcome filters is through active listening and feedback.
Active Listening
Hearing and listening are not the same thing. Hearing is the act of perceiving sound. It is involuntary and simply refers to the reception of aural stimuli. Listening is a selective activity which involves the reception and the interpretation of aural stimuli. It involves decoding the sound into meaning.
Listening is divided into two main categories: passive and active. Passive listening is little more that hearing. It occurs when the receiver of the message has little motivation to listen carefully, such as we often do when listening to music, television, or when being polite.
People speak at 100 to 175 words per minute (WPM), but they can listen intelligently at 600 to 800 WPM. Since only a part of our mind is paying attention, it is easy to go into mind driftthinking about other things while listening to someone. The cure for this is active listeningwhich involves listening with a purpose. It may be to gain information, obtain directions, understand others, solve problems, share interest, see how another person feels, show support, etc. It requires that the listener attends to the words and the feelings of
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the sender for understanding. It requires the receiver to hear the various messages, understand the meaning, and then verify the meaning by offering feedback. It takes the same amount or more energy than speaking. The following are a few traits of active listeners:
◦ Spend more time listening than talking.
◦ Do not finish the sentences of others.
◦ Do not answer questions with questions.
◦ Are aware of biases. We all have them. We need to control them.
◦ Never daydreams or become preoccupied with their own thoughts when others talk.
◦ Let the other speakers talk. Do not dominate the conversations.
◦ Plan responses after the others have finished speaking, NOT while they are speaking.
◦ Provide feedback, but do not interrupt incessantly.
◦ Analyze by looking at all the relevant factors and asking open-ended questions. Walk others through by summarizing.
◦ Keep conversations on what others say, NOT on what interests them.
◦ Take brief notes. This forces them to concentrate on what is being said.
Feedback
When you know something, say what you know. When you don't know something, say that you don't know. That is knowledge. Kung Fu Tzu (Confucius)
The purpose of feedback is to alter messages so the intention of the original communicator is understood by the second communicator. It includes verbal and nonverbal responses to another person's message.
Providing feedback is accomplished by paraphrasing the words of the sender. Restate the sender's feelings or ideas in your own words, rather than repeating their words. Your words should be saying, This is what I understand your feelings to be, am I correct? It not only includes verbal
responses, but also nonverbal ones. Nodding your head or squeezing their hand to show agreement, dipping your eyebrows shows you don't quite understand the meaning of their last phrase, or sucking air in deeply and blowing it hard shows that you are also exasperated with the situation.
Carl Rogers listed five main categories of feedback. They are listed in the order in which they occur most frequently in daily conversations. Notice that
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we make judgments more often than we try to understand:
◦ Evaluative: Making a judgment about the worth, goodness, or appropriateness of the other person's statement.
◦ Interpretive: Paraphrasing attempting to explain what the other person's statement means.
◦ Supportive: Attempting to assist or bolster the other communicator.
◦ Probing: Attempting to gain additional information, continue the discussion, or clarify a point.
◦ Understanding: Attempting to discover completely what the other communicator
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means by her statements.
Imagine how much better daily communications would be if listeners tried to understand first, before they tried to evaluate what someone is saying.
Nonverbal Behaviors of Communication
To deliver the full impact of a message, use nonverbal behaviors to raise the channel of interpersonal communication:
◦ Eye contact: This helps to regulate the flow of communication. It signals interest in others and increases the speaker's credibility. People who make eye contact open the flow of communication and convey interest, concern, warmth, and credibility.
◦ Facial Expressions: Smiling is a powerful cue that transmits happiness, friendliness, warmth, and liking. So, if you smile frequently you will be p
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erceived as more likable, friendly, warm and approachable. Smiling is often contagious and people will react favorably. They will be more comfortable around you and will want to listen more.
◦ Gestures: If you fail to gesture while speaking you may be perceived as boring and stiff. A lively speaking style captures the listener's attention, makes the conversation more interesting, and facilitates understanding.
◦ Posture
and body orientation: You communicate numerous messages by the way you talk and
move. Standing erect and leaning forward communicate
s
to listeners that you are approachable, receptive and friendly. Interpersonal
closeness results when you and the listener face each other. Speaking with your
back turned or looking at the floor or ceiling should be avoided as it
communicates disinterest.
◦ Proximity: Cultural norms dictate a comfortable distance for interaction with others. You should look for signals of discomfort caused by invading the other person's space. Some of these are: rocking, leg swinging, tapping, and gaze aversion.
◦ Vocal: Speaking can signal nonverbal communication when you include such vocal elements as: tone, pitch, rhythm, timbre, loudness, and inflection. For maximum teaching effectiveness, learn to vary these six elements of your voice. One of the major criticisms of many speakers is that they speak in a monotone voice. Listeners perceive this type of speaker as boring and dull.
Speaking Hints
Speak comfortable words! William Shakespeare
◦ When speaking or trying to explain something, ask the listeners if they are following you.
◦ Ensure the receiver has a chance to comment or ask questions.
◦ Try to put yourself in the other person's shoes consider the feelings of the receiver.
◦ Be clear about what you say.
◦ Look at the receiver.
◦ Make sure your words match your tone
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and body language (nonverbal behaviors).
◦ Vary your tone and pace.
◦ Do not be vague, but on the other hand, do not complicate what you are saying with too much detail.
◦ Do not ignore signs of confusion.
On Communication a few random thoughts
Mehrabian and the 7%-38%-55% Myth
We often hear that the content of a message is composed of:
◦ 55% from the visual component
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◦ 38% from the auditory component
◦ 7% from language
However, the above percentages only apply in a very narrow context. A researcher named Mehrabian was interested in how listeners get their information about a speaker's general attitude in situations where the facial expression, tone, and/or words are sending conflicting signals.
Thus, he designed a couple of experiments. In one,
Mehrabian and Ferris (1967) researched the interaction of speech, facial
expressions, and tone. Three different speakers were instructed to say maybe with three different attitudes towards their listener
(positive, neutral, or negative). Next, photographs of the faces of three
female models were taken as they attempted 
to convey the emotions of like, neutrality, and dislike.
Test groups were then instructed to listen to the various renditions of the word maybe, with the pictures of the models, and were asked to rate the attitude of the speaker. Note that the emotion and tone were often mixed, such as a facial expression showing dislike, with the word maybe spoken in a positive tone.
Significant effects of facial expression and tone were found in that the study suggested that the combined effect of simultaneous verbal, vocal and facial attitude communications is a weighted sum of their independent effects with the coefficients of .07, .38, and .55, respectively.
Mehrabian and Ferris caution their readers about the limitation to their research, These findings regarding the relative contribution of the tonal component of a verbal message can be safely extended only to communication situations in which no additional information about the communicator/addressee relationship is available. Thus, what can be concluded is that when people communicate, listeners derive information about the speaker's attitudes towards the listener from visual, tonal, and verbal cues; yet the percentage derived can vary greatly depending upon a number of other factors, such as actions, context of the communication, and how well the communicators know each other.
Paul Ekman
In the mid 1960s, Paul Ekman studied emotions and discovered six facial expressions that almost everyone recognizes world-wide: happiness, sadness, anger, fear, disgust, and surprise. Although they were controversial at first (he was booed off the stage when he first presented it to a group of anthropologists and later called a fascist and a racist) they are now widely accepted. One of the controversies still lingering is the amount of context needed to interpret them. For example, if someone reports to me that they have this great ideal that they would like to implement, and I say that would be great, but I look on them with a frown, is it possible that I could be thinking about something else? The trouble with these extra signals is that we do not always have the full context. What if the person emailed me and I replied great (while frowning). Would it evoke the same response?
Emotions
Trust your instincts. Most emotions are difficult to imitate. For example, when you are truly happy, the muscles used for smiling are controlled by the limbic system and other parts of the brain, which are not under voluntary control. When you force a smile, a different part of the brain is used
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the cerebral cortex (under voluntary control), hence different muscles are used. This is why a clerk, who might not have any real interest in you, has a fake look when he forces a smile.
Of course, some actors learn to control all of their facial muscles, while others draw on a past emotional experience to produce the emotional state they want. But this is not an easy trick to pull off all the time. There is a good reason for thispart of our emotions evolved to deal with other people and our empathic nature. If these emotions could easily be faked, they would do more harm than good (Pinker, 1997).
So our emotions not only guide our decisions, they can
also
be communicated to others to help them in their decisions... of course
their emotions will be the ultimate guide, but the emotions they discover in
others become part of their knowledge base.
1 THE BENEFITS OF GOOD COMMUNICATION
Good communication:
builds trust between patient and doctor;
may help the patient disclose information;
enhances patient satisfaction;
involves the patient more fully in health decision making;
helps the patient make better health decisions;
leads to more realistic patient expectations;
produces more effective practice; and
reduces the risk of errors and mishaps.
These benefits in turn strengthen communication between patient and doctor and can contribute to better health outcomes for the patient
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.
2 THE IMPACT OF POOR COMMUNICATION
Poor communication:
decreases confidence and trust in medical care;
deters the patient from revealing important information;
causes significant patient distress;
leads to the patient not seeking further care;
leads to misunderstandings;
leads to the misinterpretation of medical advice;
underlies most patient complaints; and
predicts negligence claims.
These difficulties may lead to poor or sub-optimal outcomes for the patient.
4 ::Communicating with Patients:Advice for Medical Practitioners
3 OBSTACLES TO GOOD COMMUNICATION
There are many possible obstacles to clear and open comm
 |
unication between doctor and patient.
3.1 PHYSICAL ENVIRONMENT
The physical environment may:
discourage good communication; or
fail to provide sufficient privacy.
3.2 DOCTOR-RELATED OBSTACLES
The doctor may be:
inadequately trained in communication skills;
lacking in sensitivity or empathy;
unwilling to recognise patient autonomy;
unaware of problems arising from differences in language and culture;
affected by time pressures; or
distracted by external or personal factors.
3.3 PATIENT-RELATED OBSTACLES
The patient may be:
affected by the condition, illness or medication;
anxious, embarra
ssed or in denial about the medical condition;
inexperienced in identifying and describing symptoms;
intimidated by health care settings;
overawed by the doctors perceived status;
disadvantaged by differences in language and culture;
confused by the use of medical jargon;
reluctant to ask questions; or
concerned about time pressures.
All of these factors may impede the patients capacity to provide, take in and retain information.
3.4 CULTURAL AND SOCIAL DIVERSITY
Doctors see patients from a range of ethnic, cultural and socio-economic backgrounds. Social and cultural factors may determine such matters as why patients attend, and may influence the patient-doctor interaction and compliance. Doctors should strive
to ensure good communication regardless of the social or cultural background of patients. Communication is facilitated when the doctor is aware of and sensitive to the background or cultural needs of the particular patient.
Introduction
Communicating with Patients:Advice for Medical Practitioners :: 5 All of the advice in this document is relevant but additional measures to reduce the
risk of misunderstanding include:
asking questions to appreciate the patients understanding of health and disease; and
explaining the doctors understanding of health and disease.
In certain situations, the following strategies may also be helpful:
seeking to establish an environment which welcomes and affirms the different background of the patient;
in negotiation with the patient, considering the use of assistance of agents such as patient advocates, family members, pastoral care workers or spiritual leaders;
using local institutional protocols for cross-cultural health care practice; and
seeking advice from, and developing a working relationship with, community
agencies that understand and advocate for patients. Refer also to Section 6.9 - Use of Interpreters.
Introduction
Communicating with Patients:Advice for Medical Practitioners :: 7 C THE ADVICE
4 PRIOR TO THE CONSUL
TATION
Doctors should strive to reduce obstacles to good communication. In relation to the environment, doctors need to be mindful of the setting, including physical barriers and potential distractions, such as avoidable interruptions and excessive focus on the computer screen.
Guidelines for reception staff who are making appointments should include enquiring whether a standard or long consultation is required, and whether the patient has any special needs, such as the requirement for a carer or advocate, or access to an interpreter.
Where forewarned, longer time should be set aside for those consultations requiring greater attention to providing information and answering questions.
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In certain situations such as conveying bad news, patients may be advised to bring with them a companion of their choice.
5 INITIATING THE CONSULTATION
The foundations of good communication are establishing rapport and active listening. Personal introductions are an important part of establishing rapport, as is acknowledging issues such as appointment time delays. Evidence indicates that allowing patients to present their opening statements without interruption at the start makes it more likely that the issues of concern will be identified.
If the patient clearly has difficulty indicating the reason for the visit, the doctor should give some guidance by asking specific questions to assist the patient in describing the problem.
6 DURING THE CONSULTATION
Better communication can be fostered by active listening techniques, and by helping patients to express themselves and to understand the information given to them.
6.1 ACTIVE LISTENING
Active listening is closely linked to the doctors capacity to recognise em
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otional factors contributing to illness and distress. Active listening includes:
making appropriate eye contact early in the interview;
asking open-ended questions;
attending to verbal and non-verbal cues;
clarifying the information provided by the patient; and
clarifying the patients understanding of the information provided by the doctor.
8 ::Communicating with Patients:Advice for Medical Practitioners
6.2 ASSISTING THE PATIENT
In addition to active listening, the doctor can also assist the patient in other ways. The doctor can:
seek to understand the patients expectat
ions of the visit;
be sensitive to the needs and circumstances of the patient (including their beliefs,
values, fears and social and cultural backgrounds);
encourage the asking of questions;
repeat key information;
allow for note-taking by the patient;
ask if the patient would like another person of their choice to be present;
offer an early follow-up appointment for further discussion;
provide information in writing;
enlist the help of patient support organisations and other services; and
raise the idea of seeking a second opinion, where appropriate.
Positive encouragement may facilitate disclosure of relevant information by patients about their health. One current example is the desirability of encouraging patients
to discuss their use of complementary and
over-the-counter medicines, and other alternative therapies. Another issue
often overlooked is the desirability
of asking patients about other opinions they may have been given about
their condition.
6.3 HELPING UNDERSTANDING
The provision of information and advice to the patient can be facilitated by:
establishing what the patient wants and needs to know;
using plain English;
providing diagrams; and
providing written material, including consumer publications (translated if necessary).
Written information should not be excessive in quantity for the patient, taking into account his or her capacity, situation, condition and diagnosis. Written information should be provided to reinforce, not replace, an interactive verbal process.
6.4 COMMUNICATING TO FACILITATE INFORMED DECISION MAKING
Good communication is especially important when patients are faced with the need
to make decisions about or give consent to interventions.1 The type of information a person will require to make a decision will vary according to the individuals needs, the nature of the intervention, and the risks associated with intervening or not intervening.
1 The general term intervention is intended to cover diagnostic procedures and tests, and all forms of treatment (pharmaceutical, surgical etc). The principles involved in providing information for decision making may extend to other interventions including counselling and screening for diseases (eg genetic screening tests) wherever the intervention brings with it risks be they physical, emotional, financial or other.
The Advice
Communicating with Patients:Advice for Medical Practitioners :: 9
As has been emphasised previously, good communication enhances informed decision making, while poor communication increases the likelihood of dissatisfaction with unanticipated outcomes.
Both in this document and in the 1993 General Guidelines, general guidance is given about the nature of the information that may need to be provided in any situation. Conveying the necessary information requires skilled communication. Respect for patient autonomy and the right of the patient to accept or reject advice, avoiding any suggestion of coercion, and fostering patient understanding, are all integral parts of this process.
Patients seek many types of information and advice from doctors. To enable them to participate meaningfully in decisions affecting their health care, patients need relevant information presented in a way that they can understand. It is not possible, however, to provide information about every detail of all intervention options, potential benefits or harms, and all possible outcomes. It is also not possible to assess risks with complete certainty, and this uncertainty should be communicated to patients.
Where possible, information about the benefits and risks of interventions should be framed in ways which assist the patient to best understand his or her situation, (for example using absolute, rather than relative, risk data) and to understand the nature of risk. The patient should be advised of material risks, as described by the High Court in Rogers v Whitaker in 1992. Material risks are those to which a reasonable person in the patients position is likely to attach significance, or those to which the doctor knows or ought to know the particular patient is likely to attach significance.
Known risks that reasonable people would regard as significant should be disclosed, whether an adverse outcome is common and the detriment slight, or whether an adverse outcome is severe though its occurrence is rare.
The communication process described in this Advice should enable a doctor to become aware of risks that a particular patient would treat as significant.
6.5 PROVIDING INFORMATION ABOUT DIAGNOSIS
When discussing the diagnosis, the following should be considered:
the possible or likely nature of the illness or condition;
the degree of uncertainty of any diagnosis;
the possible need for referral for diagnostic confirmation or refutation;
the extent and soundness of medical knowledge about the specific condition;
the status of the patients illness, whether temporary, chronic or terminal;
the involvement of the patient in formulation of the ongoing care;
patients requests for information;
sensitivity to the patients wishes for information; and
alternative sources of reliable information.
Section 6.7 addresses additional considerations that should be taken into account if the doctor needs to communicate bad news to the patient.
The Advice
10 ::Communicating with Patients:Advice for Medical Practitioners
6.6 PROVIDING INFORMATION ABOUT INTERVENTIONS
When discussing what the proposed intervention involves with the patient, the following information should be conveyed in plain language:
a description of the intervention;
what will happen to the patient;
whether the proposed intervention is critical, essential, elective or discretionary;
whether the proposed intervention represents current accepted medical practice;
whether the
proposed intervention is conventional, experimental or
innovative;
whether the proposed intervention is part of a clinical trial or other research project;
the degree of uncertainty about the benefit(s) of the proposed intervention;
how quickly a decision about the proposed intervention needs to be made;
who will undertake the proposed intervention, including their status and the
extent of their experience, and that of any supervising doctor, where this
information is known;
how long the proposed intervention will take;
how long until the results of any intervention will be available;
how long will be needed for recuperation and/or rehabilitation;
what the estimated costs are (where known), including out-of-pocket costs; and
what, if any, conflicts of interest the doctor may have, including financial ones.
The potential consequences of any proposed intervention should be conveyed including:
the expected benefits;
common side-effects, common complications, contraindications and possible
harms, including their likelihood and degree;
uncommon side-effects to which the particular patient may be exposed,
or which are of concern to that patient;
any outcomes that may require further intervention; and
any significant long-term adverse outcomes (physical, emotional, mental,
social, sexual, financial or other).
The patient should be advised of alternative options including:
what those options are;
their availability and potential consequences;
likely short- and long-term consequences that may arise if they choose not
to proceed with the proposed intervention or with any intervention at all.
The patient should be advised of proposed follow-up arrangements including:
clearly stated arrangements for providing the results of the intervention (usually an investigation); and where relevant
feasibility and costs of the follow-up arrangements.
Complex interventions usually require the provision of detailed information, as do treatments where the patient has no physical illness, for example cosmetic surgery.
The Advice
Communicating with Patients:Advice for Medical Practitioners :: 11 6.7 COMMUNICATING BAD NEWS
Before communicating bad news, the environment and length of consultation require additional consideration, as does the patients preference for having a person of their choice present. In some circumstances, it may be necessary to suggest immediate or early access to additional counselling and/or support services. A prompt follow-up consultation may be helpful when a condition is diagnosed that is likely to involve hospitalisation, sustained treatment and/or lifestyle change, or risk of permanent impairment or death. This will give the patient an opportunity to absorb the information, and to think of questions they may wish to ask.
6.8 WITHHOLDING INFORMATION
Information should not be withheld from patients. There are very few exceptions to this principle, but these include:
Situations in which a patient expressly directs the doctor or another person to make the decisions, and does not want the offered information.
Even in these situations, the doctor should give the patient basic information about the illness, proposed treatments and the risks involved, and be satisfied that the patient understands both their right to receive information and that this right is being waived. Such decisions should be documented, along with the patients consent to proceed without detailed information. The patients decision should be reviewed over time to ensure that there has been no change of mind.
Situations where a patient has impaired decision-making capacity, and the legally appropriate person requests that information not be provided either to the patient or to that person.
The doctor should give the legally appropriate person basic information about the illness, proposed interventions and risks involved, and be satisfied that that person understands both the right to receive information and that this right is being waived.
Situations where there is good reason for the doctor to believe that the patients physical or mental health might be seriously harmed by the information.
Information should not be withheld simply because the patient might be disconcerted or dismayed, or because the doctor finds giving particular information difficult or unpleasant.
The doctor needs to identify and address the concerns of family and carers about perceptions that the patient will be harmed by full disclosure.
Situations where there is good reason for the doctor to believe that another persons physical or mental health might be seriously harmed by the information. Examples include issues such as domestic violence and intra-familial child abuse.
Situations as outlined above may have complex ethical, legal and privacy considerations, and doctors are advised to seek expert advice, eg from their medical indemnity organisation.
The Advice
12 ::Communicating with Patients:Advice for Medical Practitioners 6.9 USE OF INTERPRETERS
When and wherever possible use should be made of qualified interpreters, including Auslan and telephone interpreters when consulting with patients not fluent in English or those with special communication needs. Accredited interpreters receive formal training and are bound by ethical standards of patient confidentiality and accurate interpreting.
Accredited Auslan interpreters should be used for consultations with deaf or deaf/blind patients, at the patients request. English may be a second language for some deaf patients and relying on written notes and/or lip reading can lead to misunderstanding.
For privacy reasons it is inappropriate to use family members or friends to interpret at medical consultations. However, not all cultural groups welcome the use of non-family members in such circumstances, and doctors need to be aware of, and sensitive to, such a possibility. When using an interpreter, it is important to address the patient directly rather than the interpreter.
6.10 USE OF PATIENT ADVOCATES
Patient advocates can play an important role in assisting communication and patient decision making. For example, they may be involved in assisting patients with chronic illness, mental illness, intellectual disability or those from different cultural backgrounds. Hospitals may employ Aboriginal liaison officers as patient advocates. The use of
patient advocates must be negotiated with each patient as not all patients will want their involvement.
6.11 BRIEF CONSULTATIONS
Many doctor-patient contacts are relatively straightforward and brief, and may primarily involve the provision of information and advice, or repeat prescriptions.
This will usually mean that the exchange of information can be accomplished simply. These contacts are nevertheless significant, and the spirit and intent of this advice still applies.
6.12 ADVISING PATIENTS ABOUT ADDITIONAL SOURCES OF INFORMATION
Many patients will have had, or will seek, access to other sources of information about their condition, including information presented on the Internet. This information will be variable in quality, accuracy and scientific validity. Doctors should be courteous about such material as it can alert them to the patients desire for additional information and, if possible, offer guidance as to its usefulness and relevance.
Referral to appropriate sources of consumer information developed by the NHMRC and other organisations about different conditions and diseases is useful to some patients.
The Advice
Communicating with Patients:Advice for Medical Practitioners :: 13
An increasing number of States and Territories and private medical insurers have also introduced telephone assistance, which patients may find informative and helpful.
Section D provides some reputable sources of information to which the patient could be directed.
6.12 CLOSING THE CONSULTATION
Before ending the consultation, it may be useful to provide a further opportunity for questions. Patients may raise very significant issues in their parting comments.
7 RECORD KEEPING
Adequate, accurate and comprehensible medical records are an important part of good communication. The medical record is an essential part of the communication process because continuity of care involves continuity of communication. In many situations, a patient will communicate with more than one person in a medical practice or hospital, and good medical records facilitate this process. Good medical records will allow another practitioner to take up the care of the patient seamlessly, and be recognised by the patient as a fair report of what was said and done.
8 COMMUNICATION IN EMERGENCY SITUATIONS
Good communication is important during an emergency. Each emergency situation, where immediate intervention is necessary to preserve life or prevent serious harm, will determine what is communicated and how that occurs.
The patient should be offered information about their condition and the interventions undertaken at the earliest opportunity during or after the emergency. If time permits, and where appropriate, efforts should be made to communicate with other persons, such as the patients next of kin or legal guardian.
9 REFUSAL TO TREAT
There are situations where adequate communication is not possible. It is important to recognise that doctors have the right to refuse to consult and/or treat patients. This might apply when patients are violent or abusive, or when they fail to provide necessary information.
In these circumstances, doctors should communicate this refusal to the patient as courteously as circumstances permit, along with the reasons for the refusal, and ensure that alternative care is offered or made available.
The Advice
14 ::Communicating with Patients:Advice for Medical Practitioners
10 DISCLOSURE OF INFORMATION TO OTHERS
There are situations when it may be necessary to discuss sensitive information with people other than the patient, for example:
in emergencies (see section 8, above);
when patients have impaired decision-making capacity; and
when duty of care raises issues about protecting others, as may arise in genetic or
HIV counselling.
Such situations have complex ethical, legal and privacy considerations and doctors are advised to seek appropriate expert advice.
3.
Problems of collective psychology.
The word "collective" - from the
Latin. "Collectivus" from "collegere" - gather together.
But in the modern sense of team - this is not a mechanical combination of
individuals. Naturally, no team without individuals can not be, as there can be
no accounting for its water hydrogen atoms and oxygen.
Human life as social beings full of short-and
long contact with others with which it connects the common work and common
goals. In public life are important forms of communication between humans. They
form a certain social structures - the largest of: nations, classes, social
strata - to groups. The object of social-psychological analysis is primarily a
small group whose members know each other, bound by ties and shared norms,
binding on all members.
Psychology defines a group as a set of linked
systems of mutual relations. Common signs groups include: the presence in its
members a common goal, the existence of a specific organization, the purpose,
as a rule, the group has its own traditions that define the nature of actions
and relationships of its members, one from another group of different size and
degree of sustainability.
Everyone in life is a member of various social
groups. Depending on your direction to help the person they meet certain
requirements. Belonging to a group requires a person as promote the
establishment and development of her personality.
The staff is organized social unit, within
which the most important human activity - socially useful work. The staff can
be described as a set of connected active joint work with a common goal, the
only internal structure and leadership.
Most essential attributes of the staff is the
organization for execution of production tasks, ie work to create a full social
values. The main functions of the staff include manufacturing,
transportation and sale of products, training, education staff, care about
people, research and other activities. The staff also performs functions
that do not have a particular material embodiment, but significantly affect the
results of production activities, including - Medical team seeks to preserve
and restore health, prevention and a healthy lifestyle. Public opinion helps to
form a unity of views with team members, influences their lives outside now.
The structure of the staff there, regardless of
the will of its individual members. However, it gradually supplemented by the
structure of interpersonal relations officer. Last generated on the basis of
the relationship between individual team members (eg, friendship or enmity,
coincidence or opposition of interests, etc.).
The psychological climate in groups and conflict
situations.
In the workplace has always
produced a certain moral atmosphere. It either creates a sense of satisfaction
and good mood or, conversely, dissatisfaction, bad mood in the team members.
Influence of the staff has a profound influence on shaping the person by some
officials to develop specific skills, deepen knowledge, experience, skills. The
collective influences the overall motivational orientation of employees. Often
working group formed traits of its members (the desire to help each other, the
openness between people, etc...) It is important, of course, that team
positively affected the development of its members. Production depends on the
atmosphere of human relationships, joint positions and orientations of the
entire members of the workforce, as well as forms of management of this team.
Long experience shows that
unfavorable atmosphere significantly affects the mood of workers is harmful
affects their health, but particularly on their morale. Mostly unfavorable
atmosphere in the production turns out that the individual falls under strong
social pressure. Formed tension, which have a negative impact on the human
nervous system. Expressed is the number of manifestations of traits and
qualities of the person. The negative impact on a person can lead up to the
mental deviations (often in the form of neurosis, but possible other functional
disorders).
No less serious moral implications of the
negative atmosphere. In some cases it leads to the demoralization of labor
(labor apathy, violations of discipline, absenteeism, etc.). The negative impacts
of belonging and a tendency to change jobs, so-called unreasonable fluctuation,
repeated turnover, etc.)..
There are 3 groups of causes of conflicts in
the team:
1. Disadvantages associated with the organization of work
(rationing of labor, methods of payroll, the use of moral and material
incentives, the principles of ethics and deontology.
Disadvantages in management caused by the awkward arrangement of people according to their skills and psychological traits, attempts to administer.
Disadvantages
associated with interpersonal relationships within the team.
Forming a
healthy moral atmosphere in the workplace - a complicated, long process. Its
main goal - to achieve a situation where employees work gives satisfaction when
they work together and help each other with joy. To come to this could be only
through the organization of work, fair evaluation and compensation of
employees, attitude toward the prospects for their professional growth and
advancement and understanding of existing difficulties and problems.
Helps create healthy atmosphere in the
workplace team members participate actively in the life of the enterprise, the
office, the general community activities. But if it lacks weight gain petty
personal interests, which often form a negative atmosphere in the team.
Great value for performance
of the staff has a socio-psychological assessment of the processes occurring in
it. It depends on the views, positions and goals of people. In the process of
adaptation to objective circumstances of life, perception of social norms and
laws are formed joint incentives of individuals and various groups.
Individual and social
environment of mutually active. Everyone helps create a social environment by their
actions. Social activity of people shows that they affect each
other, react and expect certain actions and reactions of others. Thus, the
interaction can be described as mutual influence and reciprocal reaction among
people in groups or in another public building.
The basic mechanism of social interaction is
interpersonal contacts. Processes of interaction are known to occur in all
spheres of human life. They put considerable demands to conduct personal
qualities of the individual (eg, adaptability, social acceptability, etc.)..
Each of us in the process affects the other and waiting while the reaction to
this influence. If the feedback you do not, we adjust our behavior or action,
seeking an outcome. There is mutual ties binding appear to be mutually
acceptable form of communication.
Communication
relationships in the community.
During the exchange of public contact
information (transmission and perception of information), which is the basis of
mutual understanding, mutual. This process is called communication.
Communication means the transmission of certain knowledge in the course of
social contacts. It is the basic form of social interaction between people.
The communication process by
using some form of expression often written or verbal, and using symbols,
gestures and so on. Which are generally in a particular society or community
semantic content. Thus,
the communication process is always carried out within a certain environment,
where a common set of values to be fixed, especially in terms of a particular
language. With help of the people can understand each other.
In the course of the communication process
affects the social structure of a particular team and the public. In carrying
out public functions are different, people come in specific relationships,
cooperation, subordination or leadership. The communication process makes
possible a variety of relationships between people. However, individuals have
different social roles, unequal knowledge. This significantly affects the
communication process. Communication tools are used quite differently, which
affects the formation of information flow. Therefore, a communication process
can objectively or subjectively slowed.
The
key to effective understanding in the communication process is, according to D.
Porketa certain conditions. These mainly include: a) a sufficient volume of
incoming information b) compliance with form and content of messages in)
accuracy, ie the only possible understanding of the relevant facts, d)
reliability (truth), that compliance with the information objective reality, and
e) the relevance, timeliness of information; e) concise message is)
understandable, accessible form of presentation. Communication provides people
with information necessary for carrying out various activities and actions
affect the lives of participants of the communication process.
Understanding people who work
together over the performance of tasks is a prerequisite for employment as a
production problem and correct the deficiencies and correct, but it also
extends to informal contacts with team members.
In the workplace of any company shown all the
typical elements of society in general. Joining in the workplace is important
for everyone because it holds the company much of his life.
The staff affects their members. It is not
necessarily a conscious influence, though, naturally, is better when he is
conscious. The moral atmosphere of the staff puts into each employee certain
requirements. Some simplification, we can say that the positive or negative
impact on the workforce driven by its individual members the following
circumstances:
1. The degree of agreement or disagreement with
an individual team estimates the environment.
2. The degree of agreement or disagreement with
the team regarding the individual perspectives and goals of labor.
Hospitalizm and psychic deprivation
Hospitalizm and mental
deprivation is a psychological phenomena that develop in adults and children
due to long stay outside sim''yu - namely, hospitals, homes of baby nursery
week.
Hospitalizm develops in
adults, but usually the elderly, and mental phenomena of deprivation in
children.
Factors that contribute to their occurrence:
poor mental climate in the environment, lack of human attention to the child or
patient, lack of emotional display of party staff. These factors cause in
children, the so-called psychic deprivation, which manifested passivity
lingering of their agility skills and mental abilities. What happens - the
manifestations of mental regression. Child if returned to the last stage of
their development: lost some already acquired skills such as hygiene, such as
maintaining cleanliness of the body, independent of urination and defecation,
lose the ability to dress themselves, do not develop language skills, speak
less and worse, can not play with in games .
Reversal of children with the emotional
reaction:
A) depression, boredom and sore;
B) noisy, vicious running protest, search for
the mother;
B) autism, insularity, not "know" her
mother that her visit.
D) utilitarian attitude to the fact
hospitalization. The child begins to require a lot of attention because she was
"sick", or unwilling to check out of hospital to go to school;
Hospitalizm and mental deprivation is a
phenomenon of medical and social problem. Without solving the social aspect of
this problem the solving of problem of hospitalise is impossible. The doctor
must psychologically prepare the patient for discharge, and to take all
measures for prevention of psychological deprivation in children (together with
psychologists and teachers).
The doctornurse relationship
Psychiatric practice depends to a substantial degree on a good understanding between nurses and doctors. When this does not exist or is under threat, clinical care is impaired. Historically, the doctornurse relationship has aquired the status of a special relationship. This is particularly true in the in-patient setting and in the treatment of people with serious mental illnesses, where it becomes the dominant dyad, affecting other multidisciplinary interactions and, in particular, the nature of the association with patients.
This relationship has undergone major changes since the in-patient ward was the main focus of care. These are sumarised in Box 1⇓, and discussed in more detail below.
Factors of change in the doctornurse relationship
The workplace context
Multidisciplinary relationships
The status and experience of doctor and nurse
Patients expectations
Training and education
Institutional norms
Professional norms
Risk management and defensive practice
Change begets change
Perhaps the most obvious difference is that the context of the workplace has changed. Modern psychiatry now takes place in a number of different locations in addition to the acute in-patient ward. These include community mental health centres, patients homes and a variety of institutional and residential units caring for individuals with psychiatric disorders. These different milieux affect the nature of the relationship, simply because they result in different styles of working arrangements and determine different roles for the participants.
A consequence of this is that the nursedoctor pairing is no longer exclusive. Most of psychiatry operates within a multidisciplinary framework, and interactions with other professionals, such as psychiatric social workers, occupational therapists, psychologists, outside agencies and service managers, have an impact on the doctornurse dimension, diluting its specialness.
Changes in the workplace are reflected in professional and institutional norms (e.g. medico-legal responsibilities and working shifts), and these define the nature of the interaction, setting expectations and requirements.
Nursing and medical education are undergoing major changes in direction, making the boundaries between doctors as diagnosticians and prescribers of treatment and nurses as obeyers of orders and dispensers of treatment less clear and more permeable.
The relationship between doctor and nurse is to some extent affected by what the patients think of them. Radcliffe (2000) argued that the power within it is mediated by the patient: If in doubt ask the patient who is in control. The public may love its angels but it holds its medics in awe. This reflects the traditional, popular view of doctor and nurse roles. However, patients expectations of what nurses and doctors do and do not do is changing very quickly. Increasing publicity of medical and nursing fallibility and use of the internet have removed some of the magical aura and gloss from these professions (Stein et al, 1990).
Patients and their families are also major players in the current culture of litigation, and the consequent emphasis on risk management can induce defensive practices on the part of both doctors and nurses.
In this evolving world of psychiatric practice, how well have doctors and nurses coped with these changes? Has the dilution of the specialness of their relationship been more difficult for nurses or for doctors? How will future changes, such as those that will be determined by the European Working Directive, affect nurses and doctors roles, and thereby, their interaction? And how do new areas of collaboration between nurses and doctors become established so that improvements in patient care can take place?
The psychiatric in-patient setting
Who makes the decisions?
Traditional relationships have been slow to change in the in-patient environment. Institutional and professional norms still defer to medical decision-making, the nurses code of conduct and management lines of accountability. The in-patient setting highlights an essential aspect of the doctornurse relationship: its mutual interdependence. Neither can function independently of the other. If the psychiatrist is the responsible medical officer and a patient is on section under the Mental Health Act, that psychiatrist is dependent on the nurses for the containment and safe care of the patient while in hospital care. Nurses rely on aspects of the doctors authority and medico-legal responsibility to support them and help contain the situation.
Nevertheless, doctors in psychiatry still hold essential powers and responsibilities that have an impact on this interdependence: for example, doctors are the ones who decide, either formally or informally, whether a patient is admitted and discharged. Under Section 12 of the Mental Health Act 1983, doctors have specific responsibilities that are not shared with other professional groups.
And who should make the decisions?
Daily decisions such as agreeing to a patients leave or the need for close observation are rarely delegated to nurses, even though in these areas doctors may have no more knowledge than their nursing colleagues. If anything, they are probably less able to make appropriate judgements because of their more distant contact with in-patients, and yet deference is paid to their expertise.
Current pilot studies delegating some of these responsibilities to nurses have shown no major difficulties, and have in fact reduced the need for expensive close nursing observations and reliance on agency staff (T. Reynolds & L. Dimery, personal communication, 2003).
The closer relationship with community mental health centres has produced some shifts in the balance of power. Community staff, whether associated with community mental health teams, assertive outreach or home treatment teams, now have more say in admission and discharge arrangements, altering what was once the exclusive province of doctors.
Although the decision to admit rests finally with doctors, it is helpful to make explicit that different staff will be able to contribute different knowledge to the decision-making process.
Senior doctors appointed to cover a catchment area are likely to be more familiar with past events in a patients life than most other members of the team, simply by virtue of having worked in that catchment area for longer. They therefore use experience of previous psychiatric interventions to guide their thinking when a new episode occurs. There is some suggestion that nursing turnover, especially in metropolitan districts, is increasing, making it even more likely that doctors will hold the history of patients. Conversely, in the here and now of an in-patient stay, nurses will be much more in touch with a patients current state and preoccupations. Depending on the attitudes of those involved, the nurses knowledge can contribute to clinical care or can become a source of contention in the battle about who knows the patient best and whose decision should prevail.
Traditionally, doctors have been seen as the repositories of clinical knowledge and have been charged with keeping abreast of recent advances and imparting this knowledge not only to their own apprentices, but also to nurses within the team. University education as opposed to hospital experience accounts for the public view that doctors are educated whilst nurses are trained (Warelow, 1996). Purported knowledge, therefore, is a source of the differential power that underpins the doctornurse relationship. To some extent this differential has been reduced by increasing university training for nurses, as envisioned in the Department of Healths Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986). However, some critics have observed a gap between theory and practice and the creation of a training deficit at graduation, as it does not meet the practical nature of service demand (Department of Health, 1997). Shared learning (with doctors and other professional groups) is beginning to happen in areas such as Mental Health Act legislation, Health of the Nation Outcome Scales (HoNOS) and ethical issues.
Plus ça change?
A quarter of a century ago, a New Zealand anthropologist studied working relationships in a psychiatric hospital in Otago, New Zealand (Parks, 1979). Many of the interactions that she described can still be seen in the UK today. She recognised that the rules operating between different staff groups in terms of lines of authority, responsibility and reciprocity were not explicit. A lot of emphasis was placed on the notion of teamwork, which implies a democratic structure, but in reality many teams were autocratically led and hierarchically structured. She also analysed the nurses notion of supportive and unsupportive responses by doctors, and found that they thought the doctors agreement with their opinions to be supportive, whereas disagreement was unsupportive (rather than a factual correction or a constructive exchange of ideas). The third notion was that of responsibility: the nurses generally felt that it was the doctors responsibility to ensure patient compliance with the treatments they prescribed, even if the treatments were carried out by the nurses. These often unspoken beliefs indicated that there was still an expectation of a paternalistic, hierarchical relationship between doctors and nurses, even though nurses were demanding an equal say and influence. Most of these issues remained implicit and ambiguous, leading to conflict when the discrepancies were exposed.
The many hats of the psychiatric nurse
In a previous publication one of us (L.F.) discussed the apparent contradictory tasks of in-patient psychiatric nurses (Fagin, 2001). They are expected to be reality role models for patients, organising personal self-care, confronting inappropriate behaviour and encouraging community-mindedness, while at the same time providing care, nurture and emotional support. Nurses wear many different hats: they uphold institutional norms, contain physical aggression, set boundaries and timetables, and offer informal personal therapy to patients in states of heightened distress. Not surprisingly, nurses become the main recipients of patients projections. As a result they are often the targets of either erotic, loving gestures or hostile, aggressive and paranoid responses.
Nurses often comment on the distinction, in the patients eyes, between nurses, with their multiple roles, and doctors, who have a more distant and clearly outlined function. These varying roles, both within the nurses remit and between nurses and doctors, prompt split transference responses in patients, which can lead to splitting manoeuvres intended by the patients to accentuate disagreements between staff, particularly if these are unspoken.
Conflict between nurse and doctor
When conflict arises between nurses and doctors on communication and decision-making, the nurses objections are often buttressed by You are not here as much as we are. A familiar clinical situation is described in Vignette 1 below. The parental couple of doctor and nurse are in a conflict generated (or exacerbated) by the pathology of the patient, who has a propensity to idealise paternal figures and vilify maternal ones. Such situations tend to reinforce stereotypical roles and require successful clinical management with some insight into psychodynamic interaction.
Vignette 1
Dr S comes into the acute unit on Monday morning to attend a staff meeting and is met by a scowling Nurse T, the ward manager. She tells him that it has been a dreadful weekend, mostly because of a well-known young female patient whom Dr S had admitted in a frank psychotic state.
During the staff meeting, Nurse T launches into an attack on Dr S, stating that he is not listening to nurses. She describes how the patient, who is a crack cocaine addict, has been luring patients and visitors to import drugs into the unit: Its OK for you doctors. You admit the patient and then go off for the weekend, leaving us nurses to pick up the pieces. She reminds him that in previous conversations over her care, the nurses had conveyed to him their disquiet about the patient being readmitted to the unit, because of her positive HIV status, her flirtatiousness towards male patients and her total disregard for the consequences of possible sexual activity with other patients: Youve gone back on your word. She was up to all those tricks this weekend. She poured hot tea over one of the patients, and a nurse was hurt in the fracas whilst trying to contain her.
In front of other nursing staff and a junior doctor, who remain quiet during Nurse Ts diatribe, she says that the problem is poor communication and that the nurses views were not taken into account. Dr S reminds Nurse T that, although he was aware of the problems, he had had no option as the patient was psychiatrically ill on admission, that he had had no other place to admit her, and that these concerns had not been raised when the patient was discussed during the review before the weekend. He asks her why this matter had not been brought to his attention then.
With benefit of hindsight, Dr S, knowing the patient well, might have anticipated that she was likely to cause havoc during her initial stay on the unit and should have taken the opportunity of the ward review to discuss with the nurses beforehand risks and detailed joint clinical strategies. Had he done this, not only would there have been an agreed course of action, but also he would have communicated that he was aware of the potential problems the patient was likely to create on the unit.
Nurse T is communicating her sense that the doctor does not have the nurses in mind, and this is what she means by not being heard, rather than whether there was actual verbal communication taking place. Dr S focuses on the fact that nurses did not mention their concerns when they had the chance to do so. In future staff meetings, Dr S might explore why nurses sometimes have difficulties in communicating their concerns during his ward reviews.
Family roles, patients projections and gender issues
The doctornurse pairing, not surprisingly, also becomes a potent target for patient projection. Father/mother fantasies are often mentioned, particularly by patients in vulnerable and regressive states. They expect the same total, unconditional care that they expected from their real parents. The relationship that doctors and nurses have with patients is also of an intimate nature, not only because details of the patients lives are shared, but also because physical contact is often required during treatment and care, and the patients illnesses might bring to the fore discussion of life and death. This is a domain that is not often shared with others in the team. In this setting the specialness is regularly confirmed.
These projections are affected to some extent by gender. In contrast to general nursing, psychiatric nursing was traditionally a male domain, as working in asylums with potentially violent patients emphasised the need for physical containment. Although this is not the case today, in the UK male nurses are still relatively overrepresented in psychiatry (40%) compared with general nursing (1%; Royal College of Nursing, 2003). For obvious reasons, male nurses are still identified as those who will have a central role in control and restraint procedures when patients are agitated and at risk to themselves or others. In fact, anxiety can become palpable when there are not enough male nurses on a particular shift, especially when the unit is disturbed. These different roles and assignations have an impact on relationships between nurses as well as with doctors and patients.
Traditional sociological studies of the doctornurse relationship describe its patriarchal nature (Dingwall & McIntosh, 1978), understood in terms of sexual stereotypes, with gender assignations of nurturance and passivity to the female role, and decisiveness and competitiveness to the male role (Savage, 1987). Drawing parallels with family roles, doctors assumed the position of the head of the family, deciding where and how the important work had to be done, while nurses (their wives) looked after the physical and emotional needs of those dependent on them, whether they be patients, junior nurses or inexperienced doctors (Oakley, 1984; Willis & Parish, 1997; Gaze, 2001). Although this model still carries some validity, modern changes in nurses roles, particularly the introduction of clinical nurse specialists, nurse consultants and modern matrons, indicate major shifts in influential positions which are now fairly well established (Department of Health, 2003a, 2003b; NHS Modernisation Board, 2003). The replacement of the ward sister with the ward manager in the 1980s has had a profound impact, some say by selling nursing to management rather than being led by clinical imperatives (V. Franks, personal communication, 2004). Changes in the status of doctors have followed public airings of their fallibility, requirements to make them accountable for their actions and an increase in the general populations medical knowledge owing to widespread use of the internet. Despite such changes, which reflect parallel shifts in all occupations, trust in the medical profession persists. Militant nurses are advocating a radical move from the status quo in terms of power relationships, and have raised awareness of their potential as agents for change in the medico-political arena.
The community team
Vignette 2 illustrates some of the complex issues that arise from team working, for example issues of responsibility, authority and control.
Vignette 2
At the weekly allocation meeting at the Mental Health Resource Centre the team leader, who is a community psychiatric nurse (CPN), announces that the team has received 17 new referrals for the week and that it will not be possible, in the time available, to discuss details of each one. He suggests that the most practical solution would be for him to allocate referrals to professionals as he thinks fit. A doctor disagrees. He says that, as responsible medical officer, he has to have a say because referrals usually come from general practitioners addressed to him, and that he therefore needs to be reassured that referrals are screened for possible psychiatric presentations. He says that GPs expect a psychiatrist to be involved in decision-making over every referral received. The CPN says that he is an experienced nurse and capable of making those decisions too. The team spends a considerable time discussing responsibility, accountability and trust between members of the multidisciplinary team.
Conflicts about who is in control and who has ultimate responsibility for decisions about patients are more likely to emerge in community teams than in in-patient settings, where traditional medical hierarchies still exist and are accepted (even though this is rapidly changing). Very often, these conflicts represent not real differences in skills or ability, but notions of professional boundaries and perceived challenges to authority. With open discussion, explanation of how decisions are arrived at and clarification of appropriate delegation, these conflicts can easily be resolved, provided each member of the team takes responsibility for their own actions. In the case illustrated in Vignette 2, the team might decide that a small group of senior clinicians, including a psychiatrist, should meet separately from the main multidisciplinary meeting to allocate newly referred patients. This would free time for other clinical discussions during the full team meeting. If this solution is adopted, GPs must be informed and anyone can raise questions about these decisions if they have any objections.
The false lure of primary care
The move into the community opened the door for psychiatric nurses to show their independent skills, particularly when they left the domain of the psychiatric team to work in primary care settings. At first, many independently minded CPNs left secondary care psychiatric services to work in primary care, because they wanted to free themselves of the shackles of the authoritarian structure, not only within the psychiatrists domain but also within their own nursing hierarchy, which traditionally had been very controlling. Unfortunately, they soon discovered that they had switched one medically dominated field for another, in which GPs referred to them patients with complex problems and left them to their own devices, without the support of a psychiatric team. Some observers associated this development with the increase in job-related stress and burnout in psychiatric nurses (Carson et al, 1995; Fagin et al, 1995). Not surprisingly, the 1990s saw a retreat from primary care back into the fold of community mental health teams.
A flatter hierarchy
Traditionally trained psychiatrists accustomed to the formal protocol of hospitals and institutions can face stress when they move into the flattened hierarchy of multidisciplinary teams, albeit a hierarchy in which they still hold a central leadership role. Some have attempted to recreate an authoritative style of relationship in the community team, which inevitably has caused dissatisfaction and strain between professions, not least between doctors and CPNs, whose respective boundaries have had to be redefined.
Community teams tend to place greater weight on the combined efforts of all professions represented in them. In these multidisciplinary units, however, nurses often perceive that their contributions are less influential than those of others, or that they have been given much more restricted roles, for example dispensing depot injections or monitoring mental states. Even when this is not the case, however, nurses have to make adjustments in their professional relationships with doctors, which has become less unique.
Some nursing authors have cited the hierarchical nature of the nursing profession itself, which emphasises discipline, authority, punishment and adherence to rigid procedures, as the main barrier in their attempts to gain equality with other professions (Walsh & Ford, 1994; Oughtibridge, 1998). Another obstacle is the absence of a progression pathway in clinical practice for experienced senior nurses who do not wish to take on management responsibilities (an implicit denigration of nursing care). Farrell (2001) describes how aggression and hostility between nurses have undermined their position in relation to other groups within the medical profession. Observations of intraprofessional conflict suggest that nurses, unable to confront existing hierarchical structures, take their frustration and vindictiveness out on their peers, colleagues and juniors. Senior nurses, reacting to their awareness of their lower status relative to other professional groups, prefer to align themselves with those groups rather than with their own professional colleagues. These authors also suggest that, despite changes in the academic aspirations of nurses and the increasing numbers that gain a university education, there is still a prevalent anti-academic attitude among many, which again prevents them from seeing themselves as innovators, capable of reflective practice and embarking on research initiatives.
Changes in status and responsibilities
No man, not even a doctor, ever gives any other definition of what a nurse should be than these devoted and obedient! This definition would do just well for a porter. It might even do for a horse.
Were she alive today, even Florence Nightingale would say that the disparity in the doctornurse relationship is becoming less marked. Nurses have made considerable advances in their professional standing, supported by extensive university training, expansion of skills and a gradual taking over of responsibilities that used to be in the purview of medical practice, for example carrying out phlebotomies, offering independent consultations and possibly, in the future, taking over some prescribing decisions. In recent years, a range of legislative and organisational changes (some of which are listed in Box 2⇓) have conferred on nurses significantly wider responsibilities.
Areas in which nurses responsibilities are expanding
Section 5(4) of the Mental Health Act 1983
Nurses discretion regarding Section 17 leave
Care-coordination
Increasing prescription responsibilities
Screening and initial assessments
Determining levels of observation
Nurse therapists
Team leadership and ward management
Phlebotomisation
The establishment of NHS Direct in the UK and the skills and competency development work supported by care group workforce teams in England are greatly expanding the roles of nurses in the NHS. Furthermore, the introduction of the European Working Directive will inevitably result in a handing over of responsibilities to nurses, as doctors are unlikely to be available all of the time, even during crises. The Wanless Review, for example, has made planning assumptions whereby nurse practitioners could take over about 20% of work currently undertaken by physicians (Royal College of Nursing, 2003). Discussions are already well advanced focusing on the areas in which senior and trained nurses would be able to assess patients and decide on actions in place of doctors. Nurses have already moved into administration and supervisory roles, and control their own licensing processes. Senior nurse managers often operate as team leaders, particularly in community mental health teams, and doctors come within their purview. Some have said that these extra responsibilities and status symbols have been delegated down by physicians to share the workload rather than to establish parity of influence (Tellis-Nayak & Tellis-Nayak, 1984). Nurses are still not sure to whom they are accountable: their own professional hierarchy, the doctors or management.
Despite these advances, in hospital settings nurses remain in a subordinate role. A symbolic manifestation of this is the unequal allocation of space for personal offices, differential arrangements for eating facilities and the notion that doctors time is more valuable than nurses time. At a personal level, the relationship is viewed differently: nurses see the relationship with doctors as potentially ego-building, while doctors see it as ego-maintaining. Nurses have to prove their competence in every interaction with physicians, whereas doctors competencies are assumed and it is their fallibility and shortcomings that have to be proved.
Regardless of this inequality, nurses and doctors are required to work together towards a common goal, and they do so by adhering to social rituals and etiquette. Barriers to collaboration are exemplified by the class and gender differences between these professional groups, the value assigned to intellectual rather than manual activities and differences in educational standards (Fagin, 1992). For some time, however, excellent services, such as those following the tidal model (Barker, 2002), have highlighted the benefits of genuine collaboration between doctors and nurses as therapists and enablers, as opposed to collaboration governed by the hierarchical relationship. Such an arrangement can result in better care for the patient, improved outcomes and patient satisfaction, reduced workloads all round, and fewer fiscal demands on health care.
The doctornurse game
It is quite baffling to observe how the difference in standing continues to exert an influence even though in everyday practice experienced nurses are usually the ones who induct and guide inexperienced junior doctors into the essential aspects of their disciplines. Stein (1967) described this interaction as the doctornurse game, and it may still be seen in play today although times are indeed changing, as we discuss below.
To play the doctornurse game, nurses (in Steins time, usually female) learn to show initiative, devotion, care and advice, while appearing to defer to the authority of the doctor (then, usually male). They use subtle techniques to guide doctors into a decision, in order not to undermine their authority and to avoid interprofessional conflict. This must be done in such a manner that suggestions appear to be the physicians own. This apparent subservience to the doctor is inculcated early on in medical and nursing training. Doctors are very aware of the serious consequences of making mistakes: they deal with this by counter-phobic measures, assuming omniscient pretensions that cover their fear of failure. Nurses feed into this denial by not openly challenging the doctors omnipotence.
Novice doctors learn to play the game as they progress in their careers. Nurses are taught it even before they graduate. Playing the game successfully brings rewards such as good teamwork and mutual respect; failure to do so results in penalties such as conflicts and loss of career prospects.
Historically, becoming a good nurse has been equated with the fulfilment of doctors wishes and instructions and, by playing the game, nurses appear to do just that. There is growing evidence, however, that nurses do not always willingly play, or even wish to play. Some authors have suggested that ward managers prefer doctors to be incompetent zombies, so that they can run the ward in their own way (Graf, 1974). Behind the doctors backs, nurses can express resentment and act out their feelings (Kalisch & Kalisch, 1977; Keddy et al, 1986). Some become silent saboteurs, undermining or sabotaging, in a passive-aggressive way, decisions made by the team (Warelow, 1996). Not surprisingly, some doctors perceive this game as an elaborate charade, in which they feel manipulated by nurses. There are reports of verbal and even physical abuse by nurses, particularly if the doctors status is low owing to inexperience, youth, gender or race; the ensuing cycle of abuse resembles that seen in families (Hughes, 1988; Marsden, 1990).
We have often witnessed how nurses have difficulties in voicing their concerns or opinions directly, particularly if the content is critical of doctors or of other senior figures within the team. Not surprisingly, unvoiced bad feelings have a tendency to be expressed in other ways, for example by silent opposition, reluctance to come to agreements over care or sudden outbursts of angry condemnation that are not in proportion to the alleged triggering event. When open discussions are eventually held, nurses often bring up incidents that have occurred many months earlier, about which they had been unhappy at the time, but lacked the confidence to voice their concerns. This can have a detrimental effect on patient care (as seen in Vignette 1).
Many nurses have rebelled against the subservient role traditionally allocated to them through institutionalisation, gender-stereotyped attitudes and military-like organisation within the nursing profession. However, this state of affairs has not remained static. Gender roles have changed, with more female doctors and male nurses in evidence. Nurses have become more specialised and confident in their knowledge, and as a result are more likely to stand on an equal footing with doctors in some areas. Nurses are wishing to move from dependency to autonomy and mutual interdependency (Fagin, 1992). Furthermore, nurses increasingly are questioning narrow-minded approaches that follow the medical model, seeing themselves as champions of the holistic approach to care, which focuses on prevention, education and management of chronic illnesses. But other nursing writers (e.g. Radcliffe, 2000) suggest that, in order to elevate the status of their profession, nurses are mimicking doctors, redefining themselves in their image by becoming nurse consultants or nurse practitioners. This, they claim, is a mistake: nurses should stick to the basics of nursing, which is about nourishment, problem solving, and easing the experience of suffering, medical invasion, or death (Radcliffe, 2000).
Surveys
Although nursing journals contain an extensive literature on doctornurse relationships, it is interesting to note that this subject hardly figures in the medical literature. This probably reflects the traditional disparity in the relationship, particularly as far as the power differential is concerned (in status, prestige and economics) and how the under-dog profession perceives this (Devine, 1978; Wicker, 1989; Heenan, 1990). Heenan (1991) found that almost 50% of the nurses who participated in a UK Nursing Times survey were dissatisfied with their relationships with doctors, particularly in teaching hospitals, where there was an atmosphere of competitiveness. When asked how they saw the relationship, 42% said that it was a partnership and 31% considered themselves subordinate to the doctor. Despite this, some authors suggest that the core self-view of nurses and their roles is dependent on the perceptions of significant others, and significant among them have been doctors (Devine, 1978). Paradoxically, more than two-thirds of nurses in Heenans study thought that doctors failed to understand the nature of their work. Only 40% felt they were consulted about clinical matters, and almost 50% believed that doctors never read their notes. Nurses tended to feel more comfortable with junior doctors and to see consultants as desperately trying to keep hold of their authority.
However, in other surveys and participant observation studies in general nursing (Porter, 1991; Mackay, 1993) nurses reported feeling less subservient to doctors and experiencing much greater participation in informal decision-making; they appeared to be more concerned about their relationships and status within their own profession. The nursing hierarchy remains quite rigid in its control of nurses and has been slow in adapting to changes.
What can doctors do to improve the doctornurse relationship?
Doctors can do much to improve the nature of their relationship with nursing colleagues, and here we suggest how. Most of our suggestions follow common sense, involving awareness, professional respect, tact and sensitivity. Our advice falls into three categories: engagement (Box 3⇓); clinical management (Box 4⇓); and help and support (Box 5⇓). Finally, in Box 6⇓, we list areas of future collaboration
Engagement
Make sure you know the names of all the nurses on the unit, and introduce yourself to new arrivals; involve yourself in the orientation of new staff
Seek informal opportunities to meet with nurses; spend time in informal chat in the nurses office, hearing the issues of the day
Familiarise yourself with evolving nursing skills and changes to their roles and responsibilities
Ever considered spending some time with the night staff?
Clinical management
Make sure that your clinical decisions are well understood by others and that you have covered all contingency plans and set review dates
When giving instructions make sure that you address them to the senior nurse, who will delegate to other nurses if necessary
Do not volunteer nurses to carry out a task without asking them first
If you pick up early signs of disgruntlement, particularly with any decisions that you have made, dont let things fester, thinking that the problem will go away: be prepared to be criticised and to make changes to your clinical judgements when appropriate
When delegating, do not presume that nurses are there to carry out menial tasks or that they are less busy than you are: it might take the same time to explain what you want done, as to do it yourself; some tasks, such as finding out information or sending invitations to care programme approach meetings, can be carried out by administrative or clerical staff
Help and support
Create a culture in which all team members are encouraged to contribute and air their views
Discuss with nurses how they can take a leading role in ward reviews, organising priorities for discussion and timetabling of invitations to outside agencies and carers
Be prepared to muck in when there is a crisis: this may involve active participation in the control of a patient who is aggressive or agitated
Ensure that safety is high on your agenda; attend health and safety meetings with nurses
Let nurses know well in advance when you will and will not be available
When serious incidents occur, such as an unwarranted physical assault on a member of staff or a suicide on the ward, attend and lend support at the debriefing session, share feelings openly with staff involved and present an united front when having to address these issues with managers, patients and carers
Acknowledge and give recognition to nurses skills when the opportunity arises, and publicise them to outside agencies and management
Emphasise the team approach, the need for collaboration and mutual dependency on each others skills; refer to yourself as a member of the team
Be prepared to support nurses when they have arrived at decisions and independent judgements in your absence, even if you have reservations about them or they have had negative consequences; review judgements fairly in open, frank discussion in circumstances where all staff can feel comfortable
Have regular staff meetings, preferably chaired by nurses, and be prepared to take action when required; meet with the nurse manager and other senior staff to discuss policy, philosophy of care and management issues
If possible, organise away-days with the in-patient team, with workshops and interactive sessions, attended when appropriate by an external facilitator; this will give everyone time to think about topics that you do not have time to deal with during everyday practice
Be aware that your main role is to contain anxiety in a very stressful environment and one that exerts a considerable emotional strain on the nursing staff; it is expected that senior doctors will sort it out and that they ultimately carry clinical responsibility
Areas of future collaboration
The following areas present opportunities for practical arrangements for joint working
Joint training updates on, for example, control and restraint techniques in the management of violent, aggressive patients; resuscitation, management of anaphylactic shocks and epileptic seizures; child protection issues; benefits and housing; mental health law; human rights
Joint assessments, in crisis resolution teams, community mental health teams, at the point of admission to hospital, on prison visits, in the out-patient clinic and during a domiciliary visits
Joint opportunities for therapeutic interventions, for example in ward settings in in-patient groups, in family work or in consultations with outside agencies and services
Work on programmes dealing with adherence to medication regimes
Management of rapid tranquillisation
Care programme approach plans and meetings
Joint clinical audits examining areas of clinical practice
Arranging for nurses to train junior doctors in their initial placements on acute wards, or in their first forays into community care
Arranging for doctors to train junior nurses in aspects of clinical assessments, diagnosis and treatments
Joint presentations and publications on clinical practice
Conclusions
The nature of the doctornurse interaction is changing in substantial ways. Moving away from the traditional relationship, with its considerable differences in power and influence, nurses and doctors are now becoming equal partners in the clinical domain. Although it is important to understand the historical factors that have determined each professions roles and responsibilities, as well as areas of conflict and disagreement, it is the mutual interdependence of nurses and doctors that will lead the way to true collaborative clinical work in psychiatry. The nature of psychiatric practice makes it even more vital to communicate and clarify the ways in which that relationship can be affected by dynamic interactions with patients in community and in-patient environments.
Once again, the patient as a human being with worries, fears, hopes, and despairs, as an indivisible whole and not merely the bearer of organs of a diseased liver or stomach is becoming the legitimate object of medical interest
(Alexander, 1950, p. 17).
This opening quote from Franz Alexanders classic 1950 work Psychosomatic Medicine launches a discussion of what Alexander viewed as progress during the preceding two decades in understanding the role of emotional factors in disease. The quote also frames this special issue of Brain, Behavior, and Immunity: What generates the worries, fears, hopes, and despairs and what are the immunologic mechanisms by which they affect disease-related processes? We know now that there are many contributors, within the organism, to these psychological states, from many different levels of analysis genotype, levels of neurotransmitters, ones previous experiences, ones degree of emotional reactivity, and so forth. Of course, all of these levels are interrelated, and the role that worries, fears, hopes, and despairs play in health and disease can be investigated profitably at each. In this special issue, we focus on a hypothetical construct, personality, that represents the confluence of those contributors that the organism brings to the situations it encounters and chooses. There are three reviews and a dozen empirical papers that focus on the topic of personality and disease. In this Commentary, I provide some background and historical context for this special issue, and focus especially on how the reviews in this issue provide complementary perspectives on the topic.
At a fundamental level, personality refers to how and why an individual responds to her environment. Alexander (1950, p. 34) defined it as the expression of the unity of the organism, and the personality psychologist Gordon Allport considered it the dynamic organization within the individual of those psychophysical systems that determine his unique adjustments to his environment (Allport 1937, p. 48). Thus, personality is inside the individual, but it mediates her responses (adjustments) to the environment. This is an important distinction personality is related to behavior (i.e., responses, adjustments), but is not the same as behavior. Rather, it reflects a higher-order construct that we typically infer from behavior, and especially from patterns of behavior exhibited over time.
Importantly, nothing that Ive said so far about personality is specific to humans. Pet owners frequently describe their animals using personality-related terms because animals, too, have habitual patterns of response that they tend to use in similar situations. The scientific study of animal personality has grown rapidly in the past decade, and the review by Mehta and Gosling (2008) explicitly focuses on the issue of animal personality, and the benefits of a comparative approach to studying personality-health relationships. As Mehta and Gosling (2008) note, the term for the phenomenon under study sometimes varies according to scientific discipline (personality, temperament, behavioral syndromes), but the concepts are identical: patterns of behavior that are consistent over time. In fact, four of the 12 empirical papers in this issue are animal studies (Azpiroz et al., 2008; Capitanio et al., 2008; Cavigelli et al., 2008; and Sloan et al., 2008).
What are the dimensions of personality? Historically, personality has been conceptualized in two ways: as traits (which reflect dispositions to respond), and as motives (which reflect concern with, and striving toward, a certain class of incentives or goals [Emmons, 1989]). Trait approaches to personality have generally emphasized a small number of broad factors. The most popular trait approach in the current human literature is the Five Factor Model, comprising Agreeableness, Conscientiousness, Extraversion, Neuroticism, and Openness to Experience. Motive approaches have included the Big Three of Achievement, Affiliation, and Power.
Few psychologists would agree, however, that these eight terms describe all there is to know about personality or about adjustments to the environment. In fact, psychologists often invoke the concept of coping to describe explicitly how individuals adjust to stressful environments. How one copes is closely related to personality individuals high in neuroticism often employ less effective coping strategies, responding with self-blame and hostility, while extraverts often display more effective coping strategies, such as seeking social support. Characteristics of the specific context also affect how personality influences coping extraversion may not be influential in how one copes with being stranded alone on a desert island, but ones level of neuroticism might. And, of course, coping can reflect the interaction of personality and situational influences; for example, individuals with a different mix of personality characteristics may appraise, or cope with, a given situation very differently (Lee-Baggley et al., 2005).
The papers in this issue report research on a variety of personality traits, many of which are more specific than the broad ones just described; styles of coping with stress that have trait-like characteristics; and personality by situation interactions. The processes studied include active coping style (Azpiroz et al., 2008); trait anxiety (Buske-Kirschbaum et al., 2008); sociability (Capitanio et al., 2008; Sloan et al., 2008); active temperament (Cavigelli et al., 2008); Type D personality (a constellation of traits including negative affect and social inhibition; Denollet et al., 2008); the ability to regulate the expression of anger (Gouin et al., 2008); hostility and negative affect (Marsland et al., 2008); trait depression (Rohleder & Miller, 2008); trait repetitive thought (which is related to neuroticism and openness to experience; Segerstrom et al., 2008); self-regulation of emotion in relation to goals (which is related to negative affect; Strauman et al., 2008); and Type C coping (involving a lack of emotional expression and communication of emotions and needs; Temoshok et al., 2008).
Personality and disease in historical context
How does personality relate to disease? Interest in such a relationship dates back to Greek and Roman times and the humoral theory commonly associated with Hippocrates of Cos. Four fluids (or humors) blood, black bile, phlegm, and yellow bile filled the body; health resulted from a proper balance among the humors, and illness resulted from an imbalance. Five hundred years after Hippocrates made the humoral theory the basis for medicine, Galen broadened the theory to incorporate the concept of temperament. Although the meaning of temperament has evolved since Galens time (Siegel, 1973), the links were certainly there: black bile, for example, which was associated with the spleen, formed the basis for a melancholic temperament, manifested as fear, depression, and discontent with life. Galen identified three types of melancholia, one of which was melancholia hypochondriaca, where abdominal organs were involved, giving rise to flatulence and digestive disturbances (Jackson, 1978).
It was, however, the development of the field of psychosomatic medicine that elaborated the idea that personality was influential in the development of physical disease. Flanders Dunbar (1943) described personality profiles that were associated with particular diseases. For example, patients suffering from coronary insufficiency and occlusion were described as top-dogs or would-be-top-dogs. More specifically, such patients tended to work long hours and not take vacations; tended to seize authority; and used conversation as an instrument of domination and aggression (p. 586). These individuals had few early neurotic traits, except perhaps a tendency to brood, but later in life could develop a tendency toward depression as well as a compulsive asceticism and drive to work (p. 590). They tended to take stimulants to enable them to continue working, showed little interest in sports and had few hobbies, and were generally skeptical about religion. Dunbar recognized, of course, that many individuals with no disease share many of these characteristics. It was, rather, in their co-occurrence, that the characteristics possess diagnostic value.
Alexander (1950), however, discussed a need to understand the mechanisms by which personality could affect a disease process, and his focus was on emotional states and adjustments to the environment, rather than superficial personality types, per se. In talking specifically about Dunbars personality profile of the coronary patient, he states:
It might well be that a certain type of living, certain types of mental exertion, create somatic conditions conducive to certain progressive changes in the vascular system resulting ultimately in coronary disease. The true correlation may be not between personality make-up and coronary disease but between the mode of living and disease
and further:
For example, chronically sustained hostile impulses can be correlated with a chronic elevation of the blood pressure while dependent help seeking trends go with increased gastric secretions. These emotional states, however, may occur in a great number of very different personalities A mysterious and vague correlation between personality and disease does not exist; there is a distinct correlation between certain emotional constellations and certain vegetative innervations. Whatever correlation is found between personality type and somatic disease is only of relative statistical validity and often incidental The true psychosomatic correlations are between emotional constellations and vegetative responses (pp 7475).
Thus, for Alexander, the influence of personality on disease lay more in its relationship with emotional responsiveness to the conditions of ones life, rather than with superficial typologies. The same pattern of emotional responsiveness (what we might call coping) can be found in individuals with different personality types.
This more sophisticated view of the influence of personality that is, a focus on what personality DOES for individuals in the situations it encounters was evident in a more modern treatment of personality and disease (Friedman, 1990a). Many of the contributions in that volume emphasized the dynamic processes involved in psychological coping exemplified by individuals changing their cognitive and emotional efforts during the course of dealing with a stressful circumstance. Thus, the emphasis was more explicitly on emotional responses as a reflection of an interaction between an individual (and his personality) and the situation: The person-environment match or mismatch is sometimes more important than either the person or the environment (Friedman, 1990b, p. 284). And its important to recognize that the environment must be carefully considered: Individuals should be examined in their naturally occurring social contexts. Studies that bring Type A and Type B people into a lab and put their arms into an ice bucket have lots of experimental control but very little in the way of implications for the broader questions of personality and disease (p. 290). Koolhaas reiterates this point in his review in the present issue (2008), which places individual variation in coping style among animals within the broader context of evolution and ecology: Rather than pushing the animal towards a stress physiological ceiling, stressors should somehow challenge the natural defense mechanisms and hence call upon the adaptive capacity of the animal. The specific ecology and evolutionary biology of the species should be the basis to determine if one can expect the individual to have an adequate answer to a given challenge.
Complexity in personality/disease relationships
The empirical papers in this special issue focus on a variety of immune mechanisms that can mediate the relationship between personality and a disease process (or, in some cases, the prevention of a disease process, as in vaccination and rapid wound healing). It is important to note, however, that the personality/disease relationship may not always directly involve immunologic processes. This point is made clearly in the third review in this issue by Friedman (2008), who discusses multiple models of this relationship. Whole organisms make choices, and these choices involve, among others, which kinds of situations (healthy or unhealthy) they expose themselves to, their performance of particular health behaviors, and their adherence to recommended treatments. Personality can affect all of these processes. Thus, while the empirical papers in this issue report important advances in our understanding of how personality affects disease-related processes via immunologic mechanisms, its important to keep in mind that personality and disease are part of a larger biosocial and temporal context that involves non-immune-related mediators of personality/disease relationships as well as conditions upon which personality/disease relationships may be contingent (e.g., genetic disease risk, exposure to stressful situations that activate appraisal and coping, cultural norms surrounding illness).
Both personality and disease are complex constructs, and so, not surprisingly, is their interaction. On the one hand, diseases are quite variable, with different ones showing different characteristics time courses (e.g. HIV disease vs. influenza), type of immune involvement (e.g., depending on the mechanisms of action of different pathogens), and so on. Personality itself is a complex construct, involving multiple dimensions, each of which may be more important in some situations than in others, and each of which affects the expression of others (for example, consider how someone high in extraversion might behave in general, depending on whether they are high or low on neuroticism). And the situations of ones life are equally complex some are chosen (wisely or unwisely), while some are imposed upon us. While personality may exert main effects on disease processes (e.g., some traits may be associated with variation in lymph node innervation patterns, or with tendencies toward a general proinflammatory phenotype, or with regulation of the hypothalamic-pituitary-adrenal axis, each of which could influence a variety of diseases), much of the role played by personality in disease will be more interactionist, a reflection of personalitys role in affecting how individuals appraise and cope with situations, and the emotional responses they generate. Papers reflecting both of these approaches are present in this special issue.
One final note. When I give talks on the role of personality factors and disease, I often have someone ask me whether they are doomed because they are not conscientious or sociable. Personality is not destiny in this regard. A better understanding of the mechanisms by which personality affects disease processes will hopefully be accompanied by new options for treatment, either pharmacologic (e.g., drugs, like beta blockers, that might dampen sympathetic nervous system action in lymphoid tissue) or psychological (e.g., through helping individuals develop better coping strategies). This aspect of the personality/disease relationship is not addressed in this special issue, but will be an important direction in the future, as we attempt to translate our findings into clinical outcomes.
The authors in the present volume have generously contributed new data that improve our understanding of one component of the complex relationship between personality and disease, namely immune mechanisms that mediate this relationship. I thank them for their contributions, and their helpfulness during the development of this special issue. In addition, a special thanks goes to Keith Kelley, Editor-in-Chief of BBI, for the opportunity to assemble this collection of papers, and for advice and encouragement throughout the process. Finally, I greatly appreciate the logistic support provided by Shannon Tomlinson, in the BBI editorial office.
Personality types are the sort of subject you might glance at while flicking through a magazine in the GP's waiting room. Pretty frivolous stuff, you perhaps think.
However, new research suggests our personality traits are more significant than previously thought, and can play a key role in future health.
It's long been reported that people with socalled Type A personalities - hostile, highly competitive and impatient - are more prone to heart problems.
But now researchers are increasingly finding that a wider range of personalities and traits are linked to a host of medical problems, from stomach ulcers and viral infections to Parkinson's disease.
Could your personality make you ill? Probably, if this is making you worried!
When it comes to forming our personalities, it's increasingly accepted that early life experience plays a key role. Most human traits are also linked to genes, says Dr Dean Hamer of the U.S. National Cancer Institute, a world authority on the subject. For instance, neurotic behaviour is associated with the serotonin gene, or 5-HTTLPR.
Quite how personality then triggers increased vulnerability or resistance to disease is unknown, although there are various theories. Here we look at the personalities and their ailments - and what the scientists believe is going on.
IMPULSIVE
You might expect impulsive types to be at risk from accidents but, in fact, their big health danger is stomach ulcers. Researchers at the Finnish Institute of Occupational Health studied more than 4,000 people and found that those who had an impulsive personality were 2.4 times more at risk.
It's thought that impulsive people tend to respond to stress with higher than normal rates of acid production, triggering peptic ulcers.
Research at the University of Wales has also shown that impulsiveness is associated with poorer control over eating.
CHEERFUL
One of the most surprising findings is that cheerful people are more likely to die early.
'Children who were rated by their parents and teachers as more cheerful, and as having a sense of humour, died earlier in adulthood than those who were less cheerful,' say University of California researchers. 'Contrary to expectation, cheerfulness and sense of humour were inversely related to longevity.'
One theory is that cheerful people underestimate life's dangers and may also be more likely to have difficulty coping when things don't go as anticipated.
ANXIOUS
People with anxiety disorders are three times more likely to be treated for high blood pressure. A study from Northern Arizona University found stress hormones may be the reason.
Meanwhile, women with phobic anxieties, such as fear of heights, were at higher risk of heart disease, high blood pressure and cholesterol. Although behavioural differences - like a greater tendency to smoke among people with anxiety - go some way to explaining why this happens, they do not explain it all.
Here's something else to worry about: a University of Antwerp study found that within ten years of heart treatment, 27 per cent of anxious types were dead, compared to 7 per cent of others.
AGGRESSIVE
Hostile types are prone to a range of serious health conditions, and there is plenty of research to back this up.
People who suffer from artherosclerosis - furred up arteries - are more likely to have hostile personalities, according to a Scottish study based on almost 2,000 men and women.
An American study showed that aggressive types are at greater risk of chronic inflammation throughout the body, which is linked to a number of diseases including heart disease (inflammation is involved in the build-up of fatty deposits in the inner lining of the arteries).
This could be because this personality type has higher levels of an immune system protein linked to inflammation.
Another theory is that hostile people respond more quickly and strongly to stress, both mentally and physiologically, increasing blood pressure and heart rate which results in more wear and tear on the cardiovascular system.
Angry types also take longer to heal. Researchers at Ohio State University created small wounds on the arms of healthy people, and after four days, only 30 per cent of the angry patients' wounds had healed, compared to 70 per cent of placid patients.
Aggressive types are also at higher risk for recurrent bouts of severe depression, according to another American study.
SHY
Socially inhibited people are more vulnerable to viral infections, suggests research from the University of California.
In animal studies, scientists found that gregarious types had more active protective lymph nodes than shy types. Lymph nodes are part of the body's immune system and help to destroy infectious germs, such as viruses like the common cold virus and bacteria.
OPTIMISTIC
People who always look on the bright side live, on average, 7.5 years longer than those who take a gloomier view, according to work at the University of California.
And the risk of dying early from any disease is 55 per cent lower for optimists, say researchers at Wageningen University in the Netherlands who followed 1,000 people.
One theory is that optimism may increase the will to live, while another is that greater sociability plays a role; these in turn may lower levels of the stress haormone cortisol.
Researchers at Carnegie Mellon University in Pittsburgh say that optimism boosts the immune system and protects from psychological stress.
An American study showed that over a 30-year period, optimists had fewer disabilities and less chronic pain.
TIGHT-LIPPED
Distressed types (also known as Type D personalities) suffer from a high degree of emotional suffering, but consciously suppress their feelings - and as a result may be at higher risk of cancer and heart disease. And once Type Ds develop coronary artery disease, they are at greater risk of dying, according to a Harvard University study.
The authors suggest that these people have poorly regulated stress hormones, meaning their hearts beat faster, blood pressure rises and blood vessels tighten - all bad for the cardiovascular system. Such types may also have more active immune systems, and therefore more inflammation, which results in damage to blood vessels.
CONSCIENTIOUS
This is the personality trait most associated with long life, according to a University of California study. It has as significant an effect on longevity as maintaining healthy blood pressure and cholesterol levels, research from Nottingham University suggests.
It's thought conscientious people avoid risk and are more likely to adopt and maintain healthy behaviours.
NEUROTIC
If being a neurotic type wasn't hard work enough, it's also associated with asthma, headaches, stomach ulcers and heart disease, according to a University of California study.
It's suggested that neurotic types often employ less effective coping strategies, with lots of selfblame and hostility, rather than seeking help and support.
They therefore may become more stressed, resulting in a less effective immune system and greater vulnerability to disease. Another theory is that neurotics are more likely to be depressed, and depression lowers the immune system.
EXTROVERT
Like optimists, they are less likely to get heart disease, according to a Milan University study. Italian researchers found that the biggest extroverts were 15 per cent less likely to get disease.
They
are also more likely to recover quickly from disease, and less prone to
infections.
One theory is that they have more effective
coping strategies so fewer stress hormones. They may also be more likely to
seek medical help for symptoms.
But one downside is that, according to research at Yamagata University School of Medicine in Japan, they are more likely to be obese than neurotics.
Theories range from behavioural differences, with extroverts more likely to be sociable and therefore eat more, to genes.
PESSIMISTIC
Those who always expect the worst will find that when it comes to health, they're right: pessimists have a 19 per cent increased risk of dying early compared to optimists.
Researchers in America have also found that people who have high levels of pessimism and anxiety have an increased risk of developing Parkinson's disease decades later.
'What we have shown for the first time is that there's a link between an anxious or pessimistic personality and the future development of Parkinson's,' says neurologist Dr James Bower from the Mayo Clinic.
'What we didn't find is the explanation for that link. It remains unclear whether anxiety and pessimism are risk factors for Parkinson's disease, or are linked to Parkinson's disease via common risk factors or a common genetic predisposition.'
Research has established a relationship between personality type and susceptibility to heart disease. People with personality type A seem to be more prone to heart disease, are typically more driven, impatient, energetic and ambitious. In contrast, people with personality type B, seem to take life more slowly, are usually more relaxed and less likely to develop heart disease.
Two American cardiologists named Friedman and Rosenman who were running a busy practice in the early 1950s, wondered why the seats in their waiting room wore out so quickly. The upholsterer who fixed the seats noted that it was rather odd the way patients must sit on the edge of their seats, clutching at the armrests, as if they were anxious to get out of there as soon as possible. It was not surprising that the seats kept wearing out in the same place. The unusual "sitting behavior" of their patients led Friedman and Rosenman to uncover the link between the restless personality type and heart problems.
However, it is believed that individuals with personality type B is actually composed of several different traits. Also, there is generally little agreement as to which personality types are more susceptible to heart disease, although some interesting studies have been completed in recent years. One study included a group of men and women given a frustrating anagram puzzle to solve. When doing the puzzle, individuals who stated on a questionnaire to be more hostile and suspicious had a tendency to show a higher increase in blood pressure than their more trusting peers. This study and others began to provide evidence that some people are much more reactive in response to stress and are more susceptible to the development of hypertension, which is a major risk factor for heart disease.
Personality type C. and cancer:
Cancer is the leading cause of death in the more developed countries after heart disease. Does your personality type affect your chance of getting cancer? There is some research to suggest that it might although the cause and effect relationship between cancer and personality type is not as strong as it is between personality type and heart disease. Psychologists have now identified a "type C." (cancer-prone) personality which may be characterized as someone who responds to stress with depression and a sense of hopelessness. Type C personalities have a tendency to be introverted, respectful, eager to please, conforming and compliant. However, these same studies have not identified how personality may affect lifestyle choices such as are these same individuals more likely to smoke?
There has been some evidence to suggest that your personality type may have some relationship to your chance of surviving cancer. Those who respond with a "fighting spirit" or sense of denial seem to do better than the type C personalities who seem to accept their fate passively. A Stanford University (in the USA) professor named David Spiegel discovered that cancer patients who joined a support group which fostered a "fighting spirit" had a tendency to live on average, 18 months longer than those who were not in such a group.
However, the data is far from conclusive, and there are many problems with overemphasizing personality type without considering various other factors and their effect on the disease process. Taken to an extreme, some individuals may even feel guilty in considering that their personality type may be responsible for their disease, which may only add to their problems. If personality type does have some effect on the disease process, it is probably related more to the weakening affect on the immune functioning through an individual's response to stress. This can then undermine the body's defenses and make an individual more vulnerable to infection. However, much more research needs to be done to understand the effect of personality type on physical health