Journal of Advanced Nursing, 1991,16, 929-938
Being friendly and infoimal: reflected in nurses', terminally ill patients' and relatives' conversations at home* Maura Hunt PhD MPhil RGN RM RHV RHVT Regional Nursing Research Officer, South East Thames Regional Health Authonty, Thnft House, Collmgton Avenue, Bexhill-on-Sea, East Sussex TN39 3NQ, England
Accepted for publicahon 4 February 1991
HUNT M (1991) Journal of Advanced Nursmg 1 6 , 929-938
Being friendly and informal: reflected in nurses', terminally ill patients' and relatives' conversations at home The aspect of the study discussed is part of the analysis of audio-recorded, naturally occurring conversations between symptom control team (SCT) nurses, terminally ill cancer patients and their relatives in their own homes over a 3-month penod Usmg an ethnographic, extended case-study approach, four 'role formats' were identified as consistently used by the SCT nurses to carry out their work through conversation, one of them being 'friendly and informal' The SCT nurses explicitly made it known to patients and their relatives that they intended to be 'fnendly and informal' How such a claim was translated mto practice, both non-conversationally and through conversation, is the focus of this paper Being 'fnends' and being 'friendly and informal' with patients and clients IS frequently advocated m medical and nursmg literature, but how this is achieved m practice and the responses of patients seems unstudied Therefore, the analysis discussed m this paper opens up for cntical reflection an unquestioned, taken-for-granted aspect of practice where it is demonstrated how 'friendlmess and informality' are conveyed through chattmg and how it differs from 'formal' conversations
INTRODUCTION
The Royal College of Nursing (1987) has suggested, without any supporting evidence, that patients expect It IS not uncommon for Bntish health service personnel, from a nurse particularly health visitors, distnct nurses, community midwives and general practitioners to claim that they become someone who provides fnendship, understanding, 'friends' with their patients and families (Brewin 1990) As warmth, someone who tells him how things are, and how far back as 1905, it was claimed (Newman 1906) that the thmgs might be, someone who listens health visitor 'Informality' m nurse-^atient interactions is advocated isnotanmspectormanysenseofthewordHerfunctions are rather those of fnend of the household to which she gams j^j^gj
mcreasmgly with the discardmg of unifomis and use of fast "a^es, allegedly to promote 'partnerships' and equitable relationships (Sparrow 1988, Hawkey & Clarise 1990, Mayer & Whiteley 1990) This trend was discernible ako in -Basedonapapergivenatth Sevmth ^-"'^f/«««=. of t)»ftihsHP^f^«>^ the study discussed m this paper when symptom contro OKOII^
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team (SCT) nurses, canng tor terminally ill cancer patients 929
MHurtt in thar own homes, made expliat their mtentions to be 'friendly and informal' How such mtentions were displayed in the nurses' audio-recorded conversahons are analysed, illuminating an apparently unexplored area of nursmg practice
THE STUDY POPULATION AND DESIGN The asped of the study (Hunt 1989) discussed m this paper IS generated from audio-recordings of naturally occurrmg conversations between five SCT nurses and 54 tenninally ill cancer patients and their families m their own homes, over a penod of 3 months Thirty of the patients were female and 24 were male Eighty-six per cent were over 60 years of age and five of them lived alone but had 'family' help and support Pahents were referred to the SCT nurses by hospital staff, general practitioners and commimity nurses The SCT nurses were all female, over 40 years of age, and expenenced commimity nurses with specialist trammg m terminal care A consultant surgeon, a soaal worker and a clergyman gave their services part-time to the SCT but the nurses did all the home visiting, covenng all of one health authonty The SCT nurses did not do 'hands on' nursmg, which was done by the patients' usual community nurses, but acted m an advisory consultative capaaty, plaang emphasis on the control of distressing physical symptoms The study was approved by the health authonty's ethical committee and hospital staff and general prachtioners were notified that the study was takmg place The patients' and relatives' parhapation in the study was requested after verbal and wntten mformahon were given Nobody refused to partiapate The audio-recorders used were unobtrusive and it was claimed by the nurses and patients that their use did not influence their mterachons
THE IDENTIFICATION OF ROLE FORMATS While the concepts of professional roles and relationships have been widely used, their limitahons have been recogmzed in recent years Strong (1979) has suggested that the mam defiaency of role theones was the assumption that rolerelationswere unchangmg, as if representing detailed pre-ordained scnpts which players learnt off by heart and repeated word for word on relevant ooasions They omit the sense in which soaal occasions are contmuously constructed by partiapants
To refled the dynamic and contextually influenced nature of role interactions. Strong (1979) developed the concept of 'role formats', based on Goffrnan's (1974) formulation of 'role frames' Schon (1982) also refers to 'frame' analysis as 'the study of ways in which practitioners frame problems and roles' The concept of 'role format', according to Strong (1979), mcorporates the acceptance of soaal mterachons as highly structured but able to accommodate wide vanahons within them representing the repertoire of ways by which prachtioners consistently and repeatedly 'frame' problems to which they will pay attention The processes used determme strategies of attenhon, diredions taken to change situations and the values shaping practice Withm this framework, four role formats were determined as repeatedly and consistently used by the SCT nurses in stmdunng their mterachons with pahents and their relatives
Role formats used by symptom control team nurses Aims of the study The aims of the study were to describe and explam how allegedly competent nurses did their woik through talk An extended case study approach (Mitchell 1983) and ethnographic theones were used to analyse the conversations (Silveiman 1985, Garfinkle 1967) These approaches faabtate the ldentificahon of everyday, common-sense meanings m conversations and the regulmihes and strategies used by parhapants m managmg the dymg processes at home The analysis is based on the assumphon that talk has meanmg only withm Uie contexts m whicdi it is used, reflecting shared taken-for-granted understandings among 'members' of the contexts. 930
The role formats used by the SCT nurses were 1
2 3
4
Bureaucratic — represented by collegial authonty, subshtution of staff, compilation of records, moral neutrabty Bio-medical — mcorporatmg illness histones, assessments of physical symptoms, treatment of symptoms Soaal therapy — involving talking about cancer and its prognosis, copmg with the dymg process, expressmg emohons, matenal and finanaal requirements Fnendly informal — symbolized by non-uniforms, use offirstnames, self-disdosures, use of soaal talk.
The last named 'role format' ts the focus of this paper
Conveying friendliness and informality
THE EVALUATIVE NATURE OF INFORMALITY' Atkmson (1982) has argued that lay' usage of the tenms 'lnformahty' and 'formality' impute an evaluative distinction to them As he points out
Patient Nurse
you see [the consultiant] and he doesn't have many people so he sits and talks to you and talks to your wife or whoever is there with you So you see, it's completely different, it's not like other dimes Got to be better It will be much better
perhaps the most obvious point that can be made about Nurse We have a nicefriendlyclinic We don't have many lay analyses of 'formality' and 'informality' is that the use of patients so nobody is rushed and we've got time to such concepts almost invanably involves the making of an talk about your problems evaluative distinction Thus, it appears to be the case that to descnbe some set of social arrangements as 'formal' has A pahent also similarly evaluated the chnic, companng it become synonymous with cnhasmg them This has resulted favourably with previous hospital dmics attended m recent years m a range of dififerent reforms being initiated or recomm«ided m the name of bnnging about 'more desirable' Patient Fnendly, friendly team, very nice atmosphere when levels of 'informality' you go over there Nurse The clinic is nice Yes, it's very dififerent The basic procedure used by both 'lay' and 'professional' Patient Very nice analysts, m ldentifymg interactions as 'formal', involves Relative Doesn't smack of hospital a form of 'comparative analysis' (Atkinson 1982) This Nurse No, it doesn't, it's informal We hope to keep it that procedure is ldenhftable m the SCT nurses', patients' and way I think it helps people because a lot of people are very apprehensive coming in and they can relax in relatives' conversations when the symbols of 'friendliness there and informality' are discussed At all first visits, the nurses, m giving information about their services, presented themselves as 'fnendly and informal' because, though they had Influence on organizational processes the stahis of nursing sisters, they did not wear umform and used their first names The process of 'comparative The nurses demonstrated their awareness that numbers of analysis' is lmphcit m the followmg extracts from their patients attending the dime influenced its organizahonal processes Atkinson (1982) reached a similar conclusion on mtroductions, when they told patients and relatives askmg what practical purposes 'formality' served m the There's five of us nursing sisters and we don't wear our accomplishment of interachonal tasks He suggested that a common charactenstic found present in all settmgs which uniforms because we feel it's fnendlier
were regarded as formal (large meetings, court hearings, We are all sisters and we are very informal We usually go by Chnstian names and mine is X They don't usually do it in hospitals around here
ceremonies, etc) was that they were 'Multi-party gathermgs in which a single sequence of mteraetion is onented to by all co-present parties' In such settmgs, 'formal' procedures therefore seem to serve the purposes of The SCT nurses did not make expliat the purposes of being 'Achieving and sustaining the shared attentiveness of co'fnendly and informal' Their comments on the provisions present parties to a single sequenee of achons' (Atkmson of the dimes they organized for pahents supported 1982) Atkinson's (1982) finding about the perceived value of As group membership mcreases, the procedures used in employing 'informality' m small court proceedings, when smaller gathenngs for distnbutmg tum-takmg and mam'formality was seen as taimng the attentiveness of all present become mefifective and need modifications Formal procedures seem functional A source of nervousness and something to be avoided, and m such sihiations 'informality' being equated with a relaxed atmosphere in whichrtiereneed be few inhibitions about speaking A similar percephon was conveyed m the SCT nurses' descnphons of their clmic, as seen m the followmg Nurse
NON-CONVERSATIONAL ASPECTS OF FORMALITY
Some features of 'formal' and 'informal' mterachons It's a much better dinic, we give you cups of tea sit perceived by both lay and professional analysts can be and have a chat, you don't have to wait very long. categonzed as 'non-conversahonal' Accordmg to Atkinson 931
MHunt (1982), when partiapants in small claims courts descnbed them as bemg 'informal', they provided details m the organization that are also to be found m everyday conversational interactions rally a few people present, the absence of professional lawyers, bemg able to sit down to talk without an audience present, being able to say what one wants to say, etc Though not all professional-client mterachons take place in 'mulh-party settings' necessitating 'formality', it has been suggested that, even in one-to-one situations, such mterachons differ from those occurring between friends, family members and in casual meetings Goffman (1959) demonstrates the differences that occur between two friends at lunch, a reaprocal show of affection, respect and concern for the other is mamtamed In service occupations, on the other hand, the speaahst often maintains an image of dismterested mvolvement m the problem of the dient, while the client responds with a show of respect for the competence and mtegnty of the specialist
Qosely linked to dhanging ccmc^tions of the sort of r^tionsbps a HV should adopt towards her dient and the sort of person she should present herself to be Thus SCT nurses' emphasis on presentmg themselves to pahents as having the status of nursing sisters but using their fa^t names and not weanng uniform for home visits, symbolizes their efforts to highlight their individuality and change the nature of their professional-pahent relahonships The presentahon of their individuality conflicts with how they presented themselves at all first visits, when they relied on collegial authonty for professional legitimahon rather than on their personal and individual skills and qualificahons All the nurses introduced themselves as 'sisters' m the SCT, from the hospital and sent by the patients' doctors Friendliness and friendship
Although in nursmg, the terms Ijeing fnendly' and Ijeing fnends' with pahents are often used interchangeably, Stadmore (1986) has pointed out that they are not the same While being fnendly can be displayed through ways Jourard (1971) and Lythe Menzies (1988) have also individuals present themselves to others, eg smilmg, a argued that many health care workers assume 'pro- parhcular tone of voice, use of 'soaal' talk, etc, these fessional' manners which distance them emohonally from charactenshcs are superfiaal in contrast to those attnbuted pahents and, in particular, that the organization of nursing to 'friendship' Friendliness and informality, however, work promotes detachment, suppression of emotions and appear to have similar features Evidence of such features repression of individuality The wearing of uniform, it is displayed in the nurses', patients' and relatives' converargued, is not only funchonal as a means of idenhficahon in sations will be discussed and elements of what might mulh-party sethngs but has symbolic significance Lythe constitute 'fnendship' explored Menzies (1988) proposed that the wearing of uniform by nurses was PRE-ACTIVITY TALK A symbol of an expected inner and behavioural uniformity, a nurse becomes a kmd of agglomeration of nursmg skills without mdividuality, each is thus perfectly mterchangeable with another of the same skill level
Goffrnan (1959) draws attention to the use of appropnate 'props' as an integral part of establishing claims as to the kind of person one wishes to be, while Atkinson (1981) presents the wearing of white coats by doctors as
Shong (1979), m his study of medical consultahons in a paediatnc dinic, observed that while staff talked to children about a number of personal matters, other than related to the reasons for their dmical attendances, conversations with parents were all of a piece the transaction was rapid, focused and, above all impersonal
There was no 'pre- or post-achvity talk' with parents, accordmg to Sfrong (1979), and consultahons consisted of nothing but talk on medical matters which represented An important dramaturgical'prop' it declares the wearer of 'formal' interactions (Atkmson 1982) In conhast, Silverman the white coat as a medical person to others m the hospital (1984) identified that in a pnvate oncology dmic a doctor, before embarking on med^cii matters, engaged in 'K>aal The intense debate about the wearing of uniform urtder- ehatahon' forms of interactions whidi mduded personal taken m a health viator ccnirse has been ated by Dingwall remaiks and enquines about the pahents and their families (1977) as This parhcular doctor, when observed in a Nahcmal Health 932
Conveying friendliness and informality
Service oncology dime, engaged in consultahons similar to those in Strong's shidy, suggesting that the differences noted in the pnvate dime cannot be athibuted to personality charactenstics At all visits, the SCT nurses engaged in 'pre-activity' talk at the start of their visits This served to 'ease' them into the apparent purposes of their visits The 'pre-actmty' talk focused on the weather, pets, and observahons about flowers or children, as in the following three exhacts Nurse
Nurse Patient Nurse
Nurse Patient's relative Nurse Relative Nurse
Hello, Mr G [patient's husband] Oh, what lovely flowers Aren't they gorgeous, those crysanths they're lovely Hello, Mrs G [pahent] How are you?
CREATION OF ACTIVITY BOUNDARIES The SCT nurses engaged m 'small talk' between their engagement m 'fonnal' activities, such as compiling records, taking illness histones and assessing needs This 'boundary small talk' is evident in the following conversahon which occurs on complehon of illness history Nurse
Patient Relative Nurse
[refemng to a chess board] Are you one of these f)eople who sit for hours and hours at your chess board? No We take longer over backgammon [discuss this game] Now, how's your appetite?
Hello, you've got a big fat cat, too That's a beauty, too Aren't you beautiful? She's too fat does nothmg but go out there Great, isn't it I'll leave that [a leaflet] with you Now, I'm afraid as usual with hospital work, my love, it's a case of filling m forms
While completing a wnhng achvity, or on complehon ofa topic before moving to another one, the SCT nurses generally mihated 'small talk' boundanes and the mhoduchon of new topics, thus conhollmg the flow of conversahons
Hello
Closing sequences
You know your way up Yes What a lovely mommg It is beautiful out Really is can't believe it [to patient] Hello, love, how are you?
The SCT nurses seemed to be usmg 'pre-achvity' talk, not only to ease into the purposes of their visits, but as a means of avoiding such engagement with relatives until they were in the presence of the pahents representing the mam focus of their visits This strategy of 'domg-waihng' was identified too m Robmson's (1987) study of health visitor's home visits as mdication that the context is not yet appropnate for health visitmg to start talking to animals and children can be a way of avoiding the burden of takmg on mteractional mitiative while mdicating that such an initiative is required 'Pre-activity' talk seems to serve the purpose of creating boundanes between 'soaal talk' and the imhahon of the pnmary purposes of the visits It is suggested that 'soaal' talk engaged m pnor to mitiatmg the purpose of professional encounters may not count as data for professional ]uc%ements unhl 'formal' mterachons are mhoduced to sigmd the beginmng of 'woric' (Tumer 1972) This process IS evident m the preceedmg SCT nurses' conversahons with pahents and relahves
The SCT nurses not only had to have shategies for gaimng entry into pahents' homes and for starting conversahons but had to manage bnngmg visits to a close Such a process IS taken for granted m everyday situahons, but Schegloff & Sacks (1973) have presented potential problems that may be encountered m dosing mundane conversations The latter is not achieved by the continuance of the tum-takmg system which could go on mdefimtely or by the silence of one tum taker So the problem becomes how to organise the simultaneous amval of the coconversationalists at a pomt where one speaker's complehon will not occasion another speaker's talk and that will not be heard as some speaker's silence (Schegloff & Sacks 1973) The solution which Schegloff & Sacks present is a feature of everyday interactions, when the use of 'pre-closure' and terminal exchange' shategies are employed to dose conversations representing 'informal' exchanges (Atkmson 1982) Such shategies were evident m the SCT nurses' conversahons
Pre-closure and terminal exdianges The use of pre-dosure sequences gives advance wammgs that the dosure of conversahons are lmmmoit At a number of visits, advance wammgs of their dosures were 933
M.Hmi given expliatly by the SCT nurses, as the followmg mdicate Well, I'd better be on my way I'll leave you alone now because I'm sure you are tired from your bathing and ail OK, I've got lots to do so I am gomg to press on, love Not all pre-dosure mteradion are as expliat as those used by the nurses Schegloff & Sacb (1973) identified that other pre-dosure conversahonal strategies are used, such as 'Well', 'OK' and 'So' on their own But while these kmds of pre-dosures on their own may not interrupt the flow of talk, the use of Td better be on my way', 'I'm off', Tm gomg', as used by the nurses, does so Smce the use of 'Well', 'OK', 'Right' are used elsewhere m conversations, they are not m themselves mdicahve of pre-dosmg sequences Their placement, therefore, m the mteractions is significant, as is the recogmtion given by parhapants that they are servmg as pre-dosures The above terms tend to occur at the end of topics, as when a nurse said
Sacks (1973) as found m 'informal' mundane ccmversahons These findings are strikingly d&exoA from the dosings of medical consultations in Strong's (1979) study, when no 'pre-dosure' sequences or informal exchanges were observed but the ending of medical activity was also the endmg of talk Once doctors had either discharged the pahent orfixeda new appointment, patients left the room Non-urgency of visits The SCT nurses' home visits were very lengthy with few first visits less than an hour and follow-up visits rarely shorter than 20 mmutes Through their use of 'informal talk' and lengthy 'pre-dosure' sequences the SCT nurses seemed to be not only signallmg that the 'work' of the visits was achieved and topics exhausted but were mdicatmg that there was no urgency about their departure This strategy offered pahents and relahves opportumties to present other issues of concem to them not raised previously A nurse made this dear to a relahve who lmhated a discussion durmg a pre-dosure sequence and apologetically said 'we are holdmg you back' The nurse reassured the relahve, saymg
Right, then, well, I'm very pleased to see you lookmg so well Though the nurse goes on to discuss the patient's mediane after the above statement, the pahent shows his recogmhon of the delivered pre-dosure sequence by responding I see, OK then, nght, thank you very much and I'll see you agam next week As m openmg conversations when greehngs are used, terminahng talk employs the exchanges of 'Goodb y e — Gocxl-bye' and 'Bye-Bye — Bye' These termmal exchanges dose encounters swiftly and do not allow for any end-of-conversahon adivities In contrast, the signallmg of a pre-dosure does not mdicate when actual dosure will take place The SCT nurses often had to engage m two sets of termmal exchanges with pahents and with their relatives who usually accompamed the nurse to front doors out of hearmg of pahents These m-between sessions were often 'filled-m' by the nurses with 'mfonmal' talk on topics similar to those m openmg sequences, with a {^rallei purpose that the visit 'proper' was endmg TTie dosmg sequences of the SCT visits were ccmtparable to those used by health visitors m Rdnmon's (1987) study, containmg the elonents uknhfied by ScheglcrfF k 934
you are not holding us up My time is your time, love, OK and don't ever worry about whether you should Robinson's (1987) observahons about the similar dosmgs of health visitors' visits support that of the SCT findmgs, when she daimed There is little sense m the data of the health visitors havmg to go now because of external constramts The movements into dosure oflfer a heanng of we've exhausted all the potential subjects for talk, and conveys a sense of nonurgency
SELF-DISCLOSURES While fiiendships can be developed through shared mterests and for non-uhlitanan purposes, common features have been identified Such features are the reaprocal, interdependent and equitable nature of fiierdships with the exchange of perscmal and mhmate infomiahon and feelmgs (Sadmcjre 1986) &jch self-cbsdosures have been defined as the commumcatum to others of perscmal informahon which IS of sudi a nature that it is unhkely to be known to others unless the peraon WHIWS to disdose it and is asked to do so Oourard 1971) To achieve mutual self-disdosuies
Conveying friendliness and informahty
for the attamment of equality in chent-psychotherapist relationships, Jourard (1971) has argued that Professional counsellors should let the chent mterview them as thoroughly as they intend to mterview the client The SCT nurses, m common with other 'professionals' such as doctors, soaal workers and teachers (Atkinson 1981, Hughes 1982, Smith 1973), interviewed all patients visited using a sequence of questions and answers The nurses' method of interviewing, to compile records and make assessments, conformed to Strong's (1979) descnption of doctors' consultation m paediatnc chnics which consisted of largely question-and-answer talk and nghts within this were unequally distnbuted Doctors by and large asked the questions, patients did the answenng
Marking receipt of news In a study of small claim courts, Atkmson (1982) found an aspect missing m formal talk which commonly occurs in everyday conversations This was the mariang by a recipient of a piece of news by its receipt as news for him immediately after the other's tum The most heavily used 'news receipt token' identified was 'Oh' In the SCT nurses' self-disclosures to patients and relatives, this 'news receipt token' was conmionly used as the foUowmg demonstrate Nurse Relative
and my two boys aren't mamed, of course Oh
Patient Nurse
Got two grandsons Oh, you've got grandsons Oh, aren't they smashing?
ASSESSMENTS A N D STORY-TELLING SEQUENCES
In mundane conversations, it has been demonstrated that Such question-and-answer sequences can occur m munwhen an assessment is made by one speaker it is often dane, 'informal' conversations, but as Silverman (1985) followed in the next tum by another assessment made by points out, the chaining sequences of questions and the second speaker which is not merely agreement with answers seem to represent a defining charactenstic of the first but upgrades it (Pomerantz 1975, Atkmson 1982) 'formal' interview talk. This provides the interviewer with a Such sequences were discernible in the nurses' selfgreat deal of opportunity to control the flow of topics disclosure sequences introduced, while the mterviewees have to depend on being aUowed to ask questions themselves (Silverman Nurse Do you remember I told you my daughter was 1973) This IS unlike the format used between fnends m the expecting last Sunday? She's had a gorgeous little form of mundane conversations which allows contnbutors girl, so I'm delighted that's all over before Qinstmjis, equal chances for participation (Dingwall 1980) you know Oh, how lovely, before Chnstmas, yes The SCT nurses' conversations were analysed to deter- Patient mine the extent to which features of self-disclosures were I've got three girls and two boys apparent, as evidence of fnendship development In con- Nurse Relative Yours are the same as mine, I expect We're very, trast to the amount of personal and intimate information very close acquired openly by the SCT nurses from all patients and Nurse All love to be together, they love to be together relatives visited, the extent of comparable self-disclosures offered by the nurses was hmited With the exception of A further type of mundane conversahonal achvity that mtroducmg themselves by first names, the information IS regularly followed by a similar exchange is reaprocal given by the nurses about themselves was professionai and story-tellmg, as Atkmson (1982) descnbes collegia!, such as they were members of a team, from the hospital and referred by general practitioners One SCT first stones arefrequentlyfollowed by second stones in which nurse volunteered more personal self-disclosure about hera speaker may display his understandmg and appreaahon of self and her family than her colleagues thefirstby selecting an appropnate relevant one with which to follow it Such processes and the ways the pahents and reiahves responded provide evidence of the difiFerent conversahonal formats which occur m such exchanges but rarely occur in This reaprocal story-teUing was evident m self-disdosmg professional-dient interactions Atkinson (1982) presents sequences mitiated by the SCT nurses when reiahves and aspects of 'answer' turns, which are absent from 'formal' patients responded by tellmg further stones conversations, but are regular occurrences m 'everyday' mterachons sudi as 'marking receipt of news' received, Nurse I had a granddaughter the week before last my second grsiddaughter 'assessment' and 'story-telhng' sequences 935
M Hunt Relahve
Aren't you lucky Oh, a second cme I couldn't get one, isn't it a shame7
When another nurse told the story of her son's operation for an impacted wisdom tooth, a pahent's relahve responded by tellmg a second story of a similar situahon she had expenenced The above conversahonal features demonstrate that self-disdosing conversahons conform more to 'informal' interactions than to professional-client ones The avoidance of mundane phenomena m the latter conversahons is functional, according to Atkinson (1982), because Arbitrators who did second assessments, television interviewers who marked receipt of news with 'oh', or doctors who told second stones about their own ailments would not be regarded by other partiapants (or observers) as 'prof>er professionals' In other words were they routmely to produce conversational next turns, their specialist competence or expertise might be senously put in doubt with the interaction becoming so 'informal' as to be more or less indistinguishable from any other conversational encounter Such a dilemma of conformmg to 'professional' work and simultaneously engaging m self-disdosmg, 'informal' or 'fnendly' communications with pahents is portrayed when a SCT nurse was told by a patient We had a doctor here this morning By the time we'd heard about his caranoma, he hadn't much time for me It may be doubtful that patients desire or want personal disclosures from nurses because there were only eight mstances when attempts were made by pahents to acquire such informahon from the SCT nurses Some unease was shown by some patients m acquinng personal informahon, as m the apologehc queshon of one patient asking a nurse 'where do you hve, my dear? Excuse me askmg'
DISCUSSION The impetus for promotmg 'informality' and 'finendlmess' m nurse-pahent relationships seems mohvated by desires to break down tradihonal, authontanan, professionalclient bamers, thus creatmg more equit^le encounters and 'partnerships' The expected outconws appear to be that pahents and relatives wiU be encouraged to feel at ease and express themselves more freely Though the SCT nurses woriced m the 'mfonnal' a»4ext of pahents' homes without the trapfm^s of uniforms and 9J6
usmg their first names, their use of 'informal' modes of conversations were restricted To achieve the purpoi^s of their visits, the nurses adopted formal mterviewmg styles of mteraetion It could be argued that a more 'lnfoimal' style could have been adopted throughout But if this were so it might be unclear to patients and relahves what the nurses' mtenhons were and information might be acquired m surrephhous ways without the patients' and relahves' full awareness The mequity m the self-disdosures of pahents and nurses makes the aim of achievmg 'partnerships' seem debatable Besides, the acquisition of as much psychosoaal informahon as possible bemg advocated in nursing may mcrease the power of the professional For, as Foucault (1979) suggests, power is increased more by gaming knowledge than by havmg too little Armstrong (1982) also considers that the alleged medical concentration on biological concems limited the informahon required, but the extension mto psychosocial aspects provides no limitations on the potenhal intrusions mto people's lives The SCT nurses confined their 'informal' interactions to the opening and dosmg sequences of their visits and as boundanes between 'informal' activites Because the nurses were workmg m pahents' homes, they seoned to be trymg to adiieve a balance between the 'lnfonnahty' inherent m the context, such as bemg given cups of tea, copmg with the presence of pets and children, and presentmg themselves authontahvely Mdntosh (1979) noted similar tensions m distnct nursmg when The district nurse fulfrls two piotentially conflicting roles, she IS at once a guest in the home and skilled professional She must be enough of the guest to enable relatives or patients to maintain the feelmg that they are shll master or mistress of their own home, but she must also exert sufhaent influence to estabLsh her own authonty The claim made by professionals to becommg 'fnends' with pahents and clients seems problemahc and needs queshonmg since, as in the analysis of the SCT nurses' mteractions, none of the charactenstics of 'fnendsbp' can be distinguished m the communicahons Fnends are voluntarily chosen, from compatibibty rather than usefulness, laid are based on reaprocal enjoyment and sociability (Skidmore 1986, Matthews 1987) Prafessional-dient situahons do not fulfil such requirements and it seons doubtful that pahents and relatives m the SCT study wanted much personal seif-disdosure from nurses Rather than settmg 'idealized' and unattainable aims for nursing relationships with paberAs, it might be more realishc to recognize the inho'ait mequakhes that exist
Conveying friendliness and informality SO that their exploitation can be avoided It may need to be accepted that professionai mterviews 'may well have necessary differences from ordinary conversahons' (Silverman 1987) Elimmating all 'formality' may neither be possible or desirable for, as Athnson (1982) concluded,
Foucault M (1979) The History of Sexuality vol 1 Allen Lane, London Garfinkle H (1967) Studies in Ethnomethodology Prentice Hall, Englewood Cliffs, New Jersey Gofiman E (1959) The Presentation of Self in Everyday Life Penguin, Harmondsworth, Middlesex Gofiman E (1974) Frame Analysts An Essay on the Organisation of Expenence Penguin, Harmondsworth, Middlesex evaluative interpretations or policy recommendations Hawkey B & Clarke M (1990) Dress sense or nonsense? N«rs/n^ designed to eliminate or reduce 'formality' from various Times 86(3), 28-31 settmgs may have the effect of elimmatmg or reducing the Hunt M W (1989) Dymg at home its basic 'ordmanness' dischances of certain sorts of practical tasks bemg accomplished played in patients', relatives' and nurses' talk Unpublished at all PhD thesis Department of Sociology, Goldsmith's College, University of London The use of 'informal' modes of interaction by the Hughes D (1982) Control m the medical consultation orgarusSCT nurses appeared to be of functional and symbohc mg talk m a situation where co-participants have differential value to them m 'doing—waiting' at the beginning of competence Soaology 16(3), 359-376 visits, m defirung boundanes between achvihes and m Jourard S M (1971) The Transparent Self Van Nostrand Reinhold, projecting unhumed conclusions But m order to carry New York out assessments of needs and treat patients' distressing Lythe Menzies I (1988) Containing Anxiety m Institutions Selected sjonptoms, it seemed necessary for the SCT nurses to reEssays Free Association Books, London vert to 'formal' means of commurucahons not commonly Mclntosh J B (1979) The nurse-pahent relationship Nursing Mirror, 148(4), Suppl, 1-20 forming part of mundane, 'mformal' conversations Matthews S (1987) Definitions of fnendship and their consequences m old age Agemg and Soaety 3(2), 141-155 Mayer A & Whiteley A (1990) Nurses in their 'own clothes' Acknowledgements views of staff and patients on the wearing of non-umform m a rehabilitation ward Unpublished study Bnghton Distnct To the memory of the patients so willing to share the end General Hospital, Bnghton of their lives and with grahtude to their reiahves who partiapated The co-operation of the SCT nurses m dis- Mitchell C J (1983) Case and situation analysis The Soaological Review 31(2), 187-211 playing their practice to public scrutmy was impressive Newman G (1906) Infant Mortality A Soaal Problem Methuen, and much appreaated, as was the guidance of Dr David London Silverman, Department of Soaology, Goldsmith's College, Pomerantz A (1975) Second assessments Unpublished PhD University of London thesis Uruversity of California, Los Angeles Robmson K M (1987) The social construction of health visitmg Unpublished PhD thesis Polytechnic of the South Bank, References London Royal College of Nursmg (1987) In Pursuit of Excellence A Positton Armstrong D (1982) Medical knowledge and the modalities of Paper on Nursmg RCN, London soaal control Mimeo, Sociology Umt, Guy's Medical School, Schegloff E A & Sacks H (1973) Opening up closmgs Semiotica London 8,289-327 Atkinson M J (1982) Understandmg fonmality the categonsation and production of "formal" mteraction Bntish foumal of Schon D A (1982) The Reflective Practitioner How Professionals Think m Action Basic Books, New York Soaology 33(1), 86-117 Silvemian D (1973) Interview talk bnnging off a research Atkmson P (1981) Inspecting classroom talk. In Uttenng instrument Soaology 7(1), 32-48 Muttenng (Adelman C ed). Grant Mclntyre, London, Silverman D (1984) Gomg pnvate ceremorual forms m a pnvate pp 98-113 oncology clinic Soaology 8,191-201 BrewmTB (1990) Not TLC but FPI Joumal of the Royal Soaety of Silverman D (1985) QfMlttattve Methodology and Sociology Mediane 83,172-175 Dingwall R (1977) The Soaal Organisation of Health Visitor Gower, Aldershot Silverman D (1987) Communication and Medical Practice Soaal Training Croom Helm, London Relations in the Clinic Sage, London Dingwall R. (1980) Orchestrated encounter an essay m the ccwnparative analysis of speech-exchange systems Soaology of Skidmore D (1986) The soaology of fiiendship histoncal literary and empirical perspechves Unpubhshed PhD thesis Hmtih and Illness 2(2), 154-173 937
M Hunt Department of Soaology and Social Pobcy, University of Keeie, Keele &nithG (1973) Ideologies, beliefs and pattems of admimstration m the orgamsahon of social work practice Unpublished PhD thesis University of Aberdeen, Aberdeen Sparrow S (1988) The role of the nurse's uniform Sentor Nurse 8(5), 34-36
938
Strong P M (1979) The Ceremonial Order of the Cltmc Parents, Doctors and Medical Bweaucraaa Routkdge and Kegan Paul, London Tumer R (1972) Some formal properties of t h e r ^ y talk In Studtes in Soctal Interachon (Sudnow D ed). Free Press, New York, pp 307-396
Being friendly and infoimal: reflected in nurses', terminally ill patients' and relatives' conversations at home* Maura Hunt PhD MPhil RGN RM RHV RHVT Regional Nursing Research Officer, South East Thames Regional Health Authonty, Thnft House, Collmgton Avenue, Bexhill-on-Sea, East Sussex TN39 3NQ, England
Accepted for publicahon 4 February 1991
HUNT M (1991) Journal of Advanced Nursmg 1 6 , 929-938
Being friendly and informal: reflected in nurses', terminally ill patients' and relatives' conversations at home The aspect of the study discussed is part of the analysis of audio-recorded, naturally occurring conversations between symptom control team (SCT) nurses, terminally ill cancer patients and their relatives in their own homes over a 3-month penod Usmg an ethnographic, extended case-study approach, four 'role formats' were identified as consistently used by the SCT nurses to carry out their work through conversation, one of them being 'friendly and informal' The SCT nurses explicitly made it known to patients and their relatives that they intended to be 'fnendly and informal' How such a claim was translated mto practice, both non-conversationally and through conversation, is the focus of this paper Being 'fnends' and being 'friendly and informal' with patients and clients IS frequently advocated m medical and nursmg literature, but how this is achieved m practice and the responses of patients seems unstudied Therefore, the analysis discussed m this paper opens up for cntical reflection an unquestioned, taken-for-granted aspect of practice where it is demonstrated how 'friendlmess and informality' are conveyed through chattmg and how it differs from 'formal' conversations
INTRODUCTION
The Royal College of Nursing (1987) has suggested, without any supporting evidence, that patients expect It IS not uncommon for Bntish health service personnel, from a nurse particularly health visitors, distnct nurses, community midwives and general practitioners to claim that they become someone who provides fnendship, understanding, 'friends' with their patients and families (Brewin 1990) As warmth, someone who tells him how things are, and how far back as 1905, it was claimed (Newman 1906) that the thmgs might be, someone who listens health visitor 'Informality' m nurse-^atient interactions is advocated isnotanmspectormanysenseofthewordHerfunctions are rather those of fnend of the household to which she gams j^j^gj
mcreasmgly with the discardmg of unifomis and use of fast "a^es, allegedly to promote 'partnerships' and equitable relationships (Sparrow 1988, Hawkey & Clarise 1990, Mayer & Whiteley 1990) This trend was discernible ako in -Basedonapapergivenatth Sevmth ^-"'^f/«««=. of t)»ftihsHP^f^«>^ the study discussed m this paper when symptom contro OKOII^
jggo
Group lit the College of Ripon and York st John, York, Bigland] 7 Deamber
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f
f
,,
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team (SCT) nurses, canng tor terminally ill cancer patients 929
MHurtt in thar own homes, made expliat their mtentions to be 'friendly and informal' How such mtentions were displayed in the nurses' audio-recorded conversahons are analysed, illuminating an apparently unexplored area of nursmg practice
THE STUDY POPULATION AND DESIGN The asped of the study (Hunt 1989) discussed m this paper IS generated from audio-recordings of naturally occurrmg conversations between five SCT nurses and 54 tenninally ill cancer patients and their families m their own homes, over a penod of 3 months Thirty of the patients were female and 24 were male Eighty-six per cent were over 60 years of age and five of them lived alone but had 'family' help and support Pahents were referred to the SCT nurses by hospital staff, general practitioners and commimity nurses The SCT nurses were all female, over 40 years of age, and expenenced commimity nurses with specialist trammg m terminal care A consultant surgeon, a soaal worker and a clergyman gave their services part-time to the SCT but the nurses did all the home visiting, covenng all of one health authonty The SCT nurses did not do 'hands on' nursmg, which was done by the patients' usual community nurses, but acted m an advisory consultative capaaty, plaang emphasis on the control of distressing physical symptoms The study was approved by the health authonty's ethical committee and hospital staff and general prachtioners were notified that the study was takmg place The patients' and relatives' parhapation in the study was requested after verbal and wntten mformahon were given Nobody refused to partiapate The audio-recorders used were unobtrusive and it was claimed by the nurses and patients that their use did not influence their mterachons
THE IDENTIFICATION OF ROLE FORMATS While the concepts of professional roles and relationships have been widely used, their limitahons have been recogmzed in recent years Strong (1979) has suggested that the mam defiaency of role theones was the assumption that rolerelationswere unchangmg, as if representing detailed pre-ordained scnpts which players learnt off by heart and repeated word for word on relevant ooasions They omit the sense in which soaal occasions are contmuously constructed by partiapants
To refled the dynamic and contextually influenced nature of role interactions. Strong (1979) developed the concept of 'role formats', based on Goffrnan's (1974) formulation of 'role frames' Schon (1982) also refers to 'frame' analysis as 'the study of ways in which practitioners frame problems and roles' The concept of 'role format', according to Strong (1979), mcorporates the acceptance of soaal mterachons as highly structured but able to accommodate wide vanahons within them representing the repertoire of ways by which prachtioners consistently and repeatedly 'frame' problems to which they will pay attention The processes used determme strategies of attenhon, diredions taken to change situations and the values shaping practice Withm this framework, four role formats were determined as repeatedly and consistently used by the SCT nurses in stmdunng their mterachons with pahents and their relatives
Role formats used by symptom control team nurses Aims of the study The aims of the study were to describe and explam how allegedly competent nurses did their woik through talk An extended case study approach (Mitchell 1983) and ethnographic theones were used to analyse the conversations (Silveiman 1985, Garfinkle 1967) These approaches faabtate the ldentificahon of everyday, common-sense meanings m conversations and the regulmihes and strategies used by parhapants m managmg the dymg processes at home The analysis is based on the assumphon that talk has meanmg only withm Uie contexts m whicdi it is used, reflecting shared taken-for-granted understandings among 'members' of the contexts. 930
The role formats used by the SCT nurses were 1
2 3
4
Bureaucratic — represented by collegial authonty, subshtution of staff, compilation of records, moral neutrabty Bio-medical — mcorporatmg illness histones, assessments of physical symptoms, treatment of symptoms Soaal therapy — involving talking about cancer and its prognosis, copmg with the dymg process, expressmg emohons, matenal and finanaal requirements Fnendly informal — symbolized by non-uniforms, use offirstnames, self-disdosures, use of soaal talk.
The last named 'role format' ts the focus of this paper
Conveying friendliness and informality
THE EVALUATIVE NATURE OF INFORMALITY' Atkmson (1982) has argued that lay' usage of the tenms 'lnformahty' and 'formality' impute an evaluative distinction to them As he points out
Patient Nurse
you see [the consultiant] and he doesn't have many people so he sits and talks to you and talks to your wife or whoever is there with you So you see, it's completely different, it's not like other dimes Got to be better It will be much better
perhaps the most obvious point that can be made about Nurse We have a nicefriendlyclinic We don't have many lay analyses of 'formality' and 'informality' is that the use of patients so nobody is rushed and we've got time to such concepts almost invanably involves the making of an talk about your problems evaluative distinction Thus, it appears to be the case that to descnbe some set of social arrangements as 'formal' has A pahent also similarly evaluated the chnic, companng it become synonymous with cnhasmg them This has resulted favourably with previous hospital dmics attended m recent years m a range of dififerent reforms being initiated or recomm«ided m the name of bnnging about 'more desirable' Patient Fnendly, friendly team, very nice atmosphere when levels of 'informality' you go over there Nurse The clinic is nice Yes, it's very dififerent The basic procedure used by both 'lay' and 'professional' Patient Very nice analysts, m ldentifymg interactions as 'formal', involves Relative Doesn't smack of hospital a form of 'comparative analysis' (Atkinson 1982) This Nurse No, it doesn't, it's informal We hope to keep it that procedure is ldenhftable m the SCT nurses', patients' and way I think it helps people because a lot of people are very apprehensive coming in and they can relax in relatives' conversations when the symbols of 'friendliness there and informality' are discussed At all first visits, the nurses, m giving information about their services, presented themselves as 'fnendly and informal' because, though they had Influence on organizational processes the stahis of nursing sisters, they did not wear umform and used their first names The process of 'comparative The nurses demonstrated their awareness that numbers of analysis' is lmphcit m the followmg extracts from their patients attending the dime influenced its organizahonal processes Atkinson (1982) reached a similar conclusion on mtroductions, when they told patients and relatives askmg what practical purposes 'formality' served m the There's five of us nursing sisters and we don't wear our accomplishment of interachonal tasks He suggested that a common charactenstic found present in all settmgs which uniforms because we feel it's fnendlier
were regarded as formal (large meetings, court hearings, We are all sisters and we are very informal We usually go by Chnstian names and mine is X They don't usually do it in hospitals around here
ceremonies, etc) was that they were 'Multi-party gathermgs in which a single sequence of mteraetion is onented to by all co-present parties' In such settmgs, 'formal' procedures therefore seem to serve the purposes of The SCT nurses did not make expliat the purposes of being 'Achieving and sustaining the shared attentiveness of co'fnendly and informal' Their comments on the provisions present parties to a single sequenee of achons' (Atkmson of the dimes they organized for pahents supported 1982) Atkinson's (1982) finding about the perceived value of As group membership mcreases, the procedures used in employing 'informality' m small court proceedings, when smaller gathenngs for distnbutmg tum-takmg and mam'formality was seen as taimng the attentiveness of all present become mefifective and need modifications Formal procedures seem functional A source of nervousness and something to be avoided, and m such sihiations 'informality' being equated with a relaxed atmosphere in whichrtiereneed be few inhibitions about speaking A similar percephon was conveyed m the SCT nurses' descnphons of their clmic, as seen m the followmg Nurse
NON-CONVERSATIONAL ASPECTS OF FORMALITY
Some features of 'formal' and 'informal' mterachons It's a much better dinic, we give you cups of tea sit perceived by both lay and professional analysts can be and have a chat, you don't have to wait very long. categonzed as 'non-conversahonal' Accordmg to Atkinson 931
MHunt (1982), when partiapants in small claims courts descnbed them as bemg 'informal', they provided details m the organization that are also to be found m everyday conversational interactions rally a few people present, the absence of professional lawyers, bemg able to sit down to talk without an audience present, being able to say what one wants to say, etc Though not all professional-client mterachons take place in 'mulh-party settings' necessitating 'formality', it has been suggested that, even in one-to-one situations, such mterachons differ from those occurring between friends, family members and in casual meetings Goffman (1959) demonstrates the differences that occur between two friends at lunch, a reaprocal show of affection, respect and concern for the other is mamtamed In service occupations, on the other hand, the speaahst often maintains an image of dismterested mvolvement m the problem of the dient, while the client responds with a show of respect for the competence and mtegnty of the specialist
Qosely linked to dhanging ccmc^tions of the sort of r^tionsbps a HV should adopt towards her dient and the sort of person she should present herself to be Thus SCT nurses' emphasis on presentmg themselves to pahents as having the status of nursing sisters but using their fa^t names and not weanng uniform for home visits, symbolizes their efforts to highlight their individuality and change the nature of their professional-pahent relahonships The presentahon of their individuality conflicts with how they presented themselves at all first visits, when they relied on collegial authonty for professional legitimahon rather than on their personal and individual skills and qualificahons All the nurses introduced themselves as 'sisters' m the SCT, from the hospital and sent by the patients' doctors Friendliness and friendship
Although in nursmg, the terms Ijeing fnendly' and Ijeing fnends' with pahents are often used interchangeably, Stadmore (1986) has pointed out that they are not the same While being fnendly can be displayed through ways Jourard (1971) and Lythe Menzies (1988) have also individuals present themselves to others, eg smilmg, a argued that many health care workers assume 'pro- parhcular tone of voice, use of 'soaal' talk, etc, these fessional' manners which distance them emohonally from charactenshcs are superfiaal in contrast to those attnbuted pahents and, in particular, that the organization of nursing to 'friendship' Friendliness and informality, however, work promotes detachment, suppression of emotions and appear to have similar features Evidence of such features repression of individuality The wearing of uniform, it is displayed in the nurses', patients' and relatives' converargued, is not only funchonal as a means of idenhficahon in sations will be discussed and elements of what might mulh-party sethngs but has symbolic significance Lythe constitute 'fnendship' explored Menzies (1988) proposed that the wearing of uniform by nurses was PRE-ACTIVITY TALK A symbol of an expected inner and behavioural uniformity, a nurse becomes a kmd of agglomeration of nursmg skills without mdividuality, each is thus perfectly mterchangeable with another of the same skill level
Goffrnan (1959) draws attention to the use of appropnate 'props' as an integral part of establishing claims as to the kind of person one wishes to be, while Atkinson (1981) presents the wearing of white coats by doctors as
Shong (1979), m his study of medical consultahons in a paediatnc dinic, observed that while staff talked to children about a number of personal matters, other than related to the reasons for their dmical attendances, conversations with parents were all of a piece the transaction was rapid, focused and, above all impersonal
There was no 'pre- or post-achvity talk' with parents, accordmg to Sfrong (1979), and consultahons consisted of nothing but talk on medical matters which represented An important dramaturgical'prop' it declares the wearer of 'formal' interactions (Atkmson 1982) In conhast, Silverman the white coat as a medical person to others m the hospital (1984) identified that in a pnvate oncology dmic a doctor, before embarking on med^cii matters, engaged in 'K>aal The intense debate about the wearing of uniform urtder- ehatahon' forms of interactions whidi mduded personal taken m a health viator ccnirse has been ated by Dingwall remaiks and enquines about the pahents and their families (1977) as This parhcular doctor, when observed in a Nahcmal Health 932
Conveying friendliness and informality
Service oncology dime, engaged in consultahons similar to those in Strong's shidy, suggesting that the differences noted in the pnvate dime cannot be athibuted to personality charactenstics At all visits, the SCT nurses engaged in 'pre-activity' talk at the start of their visits This served to 'ease' them into the apparent purposes of their visits The 'pre-actmty' talk focused on the weather, pets, and observahons about flowers or children, as in the following three exhacts Nurse
Nurse Patient Nurse
Nurse Patient's relative Nurse Relative Nurse
Hello, Mr G [patient's husband] Oh, what lovely flowers Aren't they gorgeous, those crysanths they're lovely Hello, Mrs G [pahent] How are you?
CREATION OF ACTIVITY BOUNDARIES The SCT nurses engaged m 'small talk' between their engagement m 'fonnal' activities, such as compiling records, taking illness histones and assessing needs This 'boundary small talk' is evident in the following conversahon which occurs on complehon of illness history Nurse
Patient Relative Nurse
[refemng to a chess board] Are you one of these f)eople who sit for hours and hours at your chess board? No We take longer over backgammon [discuss this game] Now, how's your appetite?
Hello, you've got a big fat cat, too That's a beauty, too Aren't you beautiful? She's too fat does nothmg but go out there Great, isn't it I'll leave that [a leaflet] with you Now, I'm afraid as usual with hospital work, my love, it's a case of filling m forms
While completing a wnhng achvity, or on complehon ofa topic before moving to another one, the SCT nurses generally mihated 'small talk' boundanes and the mhoduchon of new topics, thus conhollmg the flow of conversahons
Hello
Closing sequences
You know your way up Yes What a lovely mommg It is beautiful out Really is can't believe it [to patient] Hello, love, how are you?
The SCT nurses seemed to be usmg 'pre-achvity' talk, not only to ease into the purposes of their visits, but as a means of avoiding such engagement with relatives until they were in the presence of the pahents representing the mam focus of their visits This strategy of 'domg-waihng' was identified too m Robmson's (1987) study of health visitor's home visits as mdication that the context is not yet appropnate for health visitmg to start talking to animals and children can be a way of avoiding the burden of takmg on mteractional mitiative while mdicating that such an initiative is required 'Pre-activity' talk seems to serve the purpose of creating boundanes between 'soaal talk' and the imhahon of the pnmary purposes of the visits It is suggested that 'soaal' talk engaged m pnor to mitiatmg the purpose of professional encounters may not count as data for professional ]uc%ements unhl 'formal' mterachons are mhoduced to sigmd the beginmng of 'woric' (Tumer 1972) This process IS evident m the preceedmg SCT nurses' conversahons with pahents and relahves
The SCT nurses not only had to have shategies for gaimng entry into pahents' homes and for starting conversahons but had to manage bnngmg visits to a close Such a process IS taken for granted m everyday situahons, but Schegloff & Sacks (1973) have presented potential problems that may be encountered m dosing mundane conversations The latter is not achieved by the continuance of the tum-takmg system which could go on mdefimtely or by the silence of one tum taker So the problem becomes how to organise the simultaneous amval of the coconversationalists at a pomt where one speaker's complehon will not occasion another speaker's talk and that will not be heard as some speaker's silence (Schegloff & Sacks 1973) The solution which Schegloff & Sacks present is a feature of everyday interactions, when the use of 'pre-closure' and terminal exchange' shategies are employed to dose conversations representing 'informal' exchanges (Atkmson 1982) Such shategies were evident m the SCT nurses' conversahons
Pre-closure and terminal exdianges The use of pre-dosure sequences gives advance wammgs that the dosure of conversahons are lmmmoit At a number of visits, advance wammgs of their dosures were 933
M.Hmi given expliatly by the SCT nurses, as the followmg mdicate Well, I'd better be on my way I'll leave you alone now because I'm sure you are tired from your bathing and ail OK, I've got lots to do so I am gomg to press on, love Not all pre-dosure mteradion are as expliat as those used by the nurses Schegloff & Sacb (1973) identified that other pre-dosure conversahonal strategies are used, such as 'Well', 'OK' and 'So' on their own But while these kmds of pre-dosures on their own may not interrupt the flow of talk, the use of Td better be on my way', 'I'm off', Tm gomg', as used by the nurses, does so Smce the use of 'Well', 'OK', 'Right' are used elsewhere m conversations, they are not m themselves mdicahve of pre-dosmg sequences Their placement, therefore, m the mteractions is significant, as is the recogmtion given by parhapants that they are servmg as pre-dosures The above terms tend to occur at the end of topics, as when a nurse said
Sacks (1973) as found m 'informal' mundane ccmversahons These findings are strikingly d&exoA from the dosings of medical consultations in Strong's (1979) study, when no 'pre-dosure' sequences or informal exchanges were observed but the ending of medical activity was also the endmg of talk Once doctors had either discharged the pahent orfixeda new appointment, patients left the room Non-urgency of visits The SCT nurses' home visits were very lengthy with few first visits less than an hour and follow-up visits rarely shorter than 20 mmutes Through their use of 'informal talk' and lengthy 'pre-dosure' sequences the SCT nurses seemed to be not only signallmg that the 'work' of the visits was achieved and topics exhausted but were mdicatmg that there was no urgency about their departure This strategy offered pahents and relahves opportumties to present other issues of concem to them not raised previously A nurse made this dear to a relahve who lmhated a discussion durmg a pre-dosure sequence and apologetically said 'we are holdmg you back' The nurse reassured the relahve, saymg
Right, then, well, I'm very pleased to see you lookmg so well Though the nurse goes on to discuss the patient's mediane after the above statement, the pahent shows his recogmhon of the delivered pre-dosure sequence by responding I see, OK then, nght, thank you very much and I'll see you agam next week As m openmg conversations when greehngs are used, terminahng talk employs the exchanges of 'Goodb y e — Gocxl-bye' and 'Bye-Bye — Bye' These termmal exchanges dose encounters swiftly and do not allow for any end-of-conversahon adivities In contrast, the signallmg of a pre-dosure does not mdicate when actual dosure will take place The SCT nurses often had to engage m two sets of termmal exchanges with pahents and with their relatives who usually accompamed the nurse to front doors out of hearmg of pahents These m-between sessions were often 'filled-m' by the nurses with 'mfonmal' talk on topics similar to those m openmg sequences, with a {^rallei purpose that the visit 'proper' was endmg TTie dosmg sequences of the SCT visits were ccmtparable to those used by health visitors m Rdnmon's (1987) study, containmg the elonents uknhfied by ScheglcrfF k 934
you are not holding us up My time is your time, love, OK and don't ever worry about whether you should Robinson's (1987) observahons about the similar dosmgs of health visitors' visits support that of the SCT findmgs, when she daimed There is little sense m the data of the health visitors havmg to go now because of external constramts The movements into dosure oflfer a heanng of we've exhausted all the potential subjects for talk, and conveys a sense of nonurgency
SELF-DISCLOSURES While fiiendships can be developed through shared mterests and for non-uhlitanan purposes, common features have been identified Such features are the reaprocal, interdependent and equitable nature of fiierdships with the exchange of perscmal and mhmate infomiahon and feelmgs (Sadmcjre 1986) &jch self-cbsdosures have been defined as the commumcatum to others of perscmal informahon which IS of sudi a nature that it is unhkely to be known to others unless the peraon WHIWS to disdose it and is asked to do so Oourard 1971) To achieve mutual self-disdosuies
Conveying friendliness and informahty
for the attamment of equality in chent-psychotherapist relationships, Jourard (1971) has argued that Professional counsellors should let the chent mterview them as thoroughly as they intend to mterview the client The SCT nurses, m common with other 'professionals' such as doctors, soaal workers and teachers (Atkinson 1981, Hughes 1982, Smith 1973), interviewed all patients visited using a sequence of questions and answers The nurses' method of interviewing, to compile records and make assessments, conformed to Strong's (1979) descnption of doctors' consultation m paediatnc chnics which consisted of largely question-and-answer talk and nghts within this were unequally distnbuted Doctors by and large asked the questions, patients did the answenng
Marking receipt of news In a study of small claim courts, Atkmson (1982) found an aspect missing m formal talk which commonly occurs in everyday conversations This was the mariang by a recipient of a piece of news by its receipt as news for him immediately after the other's tum The most heavily used 'news receipt token' identified was 'Oh' In the SCT nurses' self-disclosures to patients and relatives, this 'news receipt token' was conmionly used as the foUowmg demonstrate Nurse Relative
and my two boys aren't mamed, of course Oh
Patient Nurse
Got two grandsons Oh, you've got grandsons Oh, aren't they smashing?
ASSESSMENTS A N D STORY-TELLING SEQUENCES
In mundane conversations, it has been demonstrated that Such question-and-answer sequences can occur m munwhen an assessment is made by one speaker it is often dane, 'informal' conversations, but as Silverman (1985) followed in the next tum by another assessment made by points out, the chaining sequences of questions and the second speaker which is not merely agreement with answers seem to represent a defining charactenstic of the first but upgrades it (Pomerantz 1975, Atkmson 1982) 'formal' interview talk. This provides the interviewer with a Such sequences were discernible in the nurses' selfgreat deal of opportunity to control the flow of topics disclosure sequences introduced, while the mterviewees have to depend on being aUowed to ask questions themselves (Silverman Nurse Do you remember I told you my daughter was 1973) This IS unlike the format used between fnends m the expecting last Sunday? She's had a gorgeous little form of mundane conversations which allows contnbutors girl, so I'm delighted that's all over before Qinstmjis, equal chances for participation (Dingwall 1980) you know Oh, how lovely, before Chnstmas, yes The SCT nurses' conversations were analysed to deter- Patient mine the extent to which features of self-disclosures were I've got three girls and two boys apparent, as evidence of fnendship development In con- Nurse Relative Yours are the same as mine, I expect We're very, trast to the amount of personal and intimate information very close acquired openly by the SCT nurses from all patients and Nurse All love to be together, they love to be together relatives visited, the extent of comparable self-disclosures offered by the nurses was hmited With the exception of A further type of mundane conversahonal achvity that mtroducmg themselves by first names, the information IS regularly followed by a similar exchange is reaprocal given by the nurses about themselves was professionai and story-tellmg, as Atkmson (1982) descnbes collegia!, such as they were members of a team, from the hospital and referred by general practitioners One SCT first stones arefrequentlyfollowed by second stones in which nurse volunteered more personal self-disclosure about hera speaker may display his understandmg and appreaahon of self and her family than her colleagues thefirstby selecting an appropnate relevant one with which to follow it Such processes and the ways the pahents and reiahves responded provide evidence of the difiFerent conversahonal formats which occur m such exchanges but rarely occur in This reaprocal story-teUing was evident m self-disdosmg professional-dient interactions Atkinson (1982) presents sequences mitiated by the SCT nurses when reiahves and aspects of 'answer' turns, which are absent from 'formal' patients responded by tellmg further stones conversations, but are regular occurrences m 'everyday' mterachons sudi as 'marking receipt of news' received, Nurse I had a granddaughter the week before last my second grsiddaughter 'assessment' and 'story-telhng' sequences 935
M Hunt Relahve
Aren't you lucky Oh, a second cme I couldn't get one, isn't it a shame7
When another nurse told the story of her son's operation for an impacted wisdom tooth, a pahent's relahve responded by tellmg a second story of a similar situahon she had expenenced The above conversahonal features demonstrate that self-disdosing conversahons conform more to 'informal' interactions than to professional-client ones The avoidance of mundane phenomena m the latter conversahons is functional, according to Atkinson (1982), because Arbitrators who did second assessments, television interviewers who marked receipt of news with 'oh', or doctors who told second stones about their own ailments would not be regarded by other partiapants (or observers) as 'prof>er professionals' In other words were they routmely to produce conversational next turns, their specialist competence or expertise might be senously put in doubt with the interaction becoming so 'informal' as to be more or less indistinguishable from any other conversational encounter Such a dilemma of conformmg to 'professional' work and simultaneously engaging m self-disdosmg, 'informal' or 'fnendly' communications with pahents is portrayed when a SCT nurse was told by a patient We had a doctor here this morning By the time we'd heard about his caranoma, he hadn't much time for me It may be doubtful that patients desire or want personal disclosures from nurses because there were only eight mstances when attempts were made by pahents to acquire such informahon from the SCT nurses Some unease was shown by some patients m acquinng personal informahon, as m the apologehc queshon of one patient asking a nurse 'where do you hve, my dear? Excuse me askmg'
DISCUSSION The impetus for promotmg 'informality' and 'finendlmess' m nurse-pahent relationships seems mohvated by desires to break down tradihonal, authontanan, professionalclient bamers, thus creatmg more equit^le encounters and 'partnerships' The expected outconws appear to be that pahents and relatives wiU be encouraged to feel at ease and express themselves more freely Though the SCT nurses woriced m the 'mfonnal' a»4ext of pahents' homes without the trapfm^s of uniforms and 9J6
usmg their first names, their use of 'informal' modes of conversations were restricted To achieve the purpoi^s of their visits, the nurses adopted formal mterviewmg styles of mteraetion It could be argued that a more 'lnfoimal' style could have been adopted throughout But if this were so it might be unclear to patients and relahves what the nurses' mtenhons were and information might be acquired m surrephhous ways without the patients' and relahves' full awareness The mequity m the self-disdosures of pahents and nurses makes the aim of achievmg 'partnerships' seem debatable Besides, the acquisition of as much psychosoaal informahon as possible bemg advocated in nursing may mcrease the power of the professional For, as Foucault (1979) suggests, power is increased more by gaming knowledge than by havmg too little Armstrong (1982) also considers that the alleged medical concentration on biological concems limited the informahon required, but the extension mto psychosocial aspects provides no limitations on the potenhal intrusions mto people's lives The SCT nurses confined their 'informal' interactions to the opening and dosmg sequences of their visits and as boundanes between 'informal' activites Because the nurses were workmg m pahents' homes, they seoned to be trymg to adiieve a balance between the 'lnfonnahty' inherent m the context, such as bemg given cups of tea, copmg with the presence of pets and children, and presentmg themselves authontahvely Mdntosh (1979) noted similar tensions m distnct nursmg when The district nurse fulfrls two piotentially conflicting roles, she IS at once a guest in the home and skilled professional She must be enough of the guest to enable relatives or patients to maintain the feelmg that they are shll master or mistress of their own home, but she must also exert sufhaent influence to estabLsh her own authonty The claim made by professionals to becommg 'fnends' with pahents and clients seems problemahc and needs queshonmg since, as in the analysis of the SCT nurses' mteractions, none of the charactenstics of 'fnendsbp' can be distinguished m the communicahons Fnends are voluntarily chosen, from compatibibty rather than usefulness, laid are based on reaprocal enjoyment and sociability (Skidmore 1986, Matthews 1987) Prafessional-dient situahons do not fulfil such requirements and it seons doubtful that pahents and relatives m the SCT study wanted much personal seif-disdosure from nurses Rather than settmg 'idealized' and unattainable aims for nursing relationships with paberAs, it might be more realishc to recognize the inho'ait mequakhes that exist
Conveying friendliness and informality SO that their exploitation can be avoided It may need to be accepted that professionai mterviews 'may well have necessary differences from ordinary conversahons' (Silverman 1987) Elimmating all 'formality' may neither be possible or desirable for, as Athnson (1982) concluded,
Foucault M (1979) The History of Sexuality vol 1 Allen Lane, London Garfinkle H (1967) Studies in Ethnomethodology Prentice Hall, Englewood Cliffs, New Jersey Gofiman E (1959) The Presentation of Self in Everyday Life Penguin, Harmondsworth, Middlesex Gofiman E (1974) Frame Analysts An Essay on the Organisation of Expenence Penguin, Harmondsworth, Middlesex evaluative interpretations or policy recommendations Hawkey B & Clarke M (1990) Dress sense or nonsense? N«rs/n^ designed to eliminate or reduce 'formality' from various Times 86(3), 28-31 settmgs may have the effect of elimmatmg or reducing the Hunt M W (1989) Dymg at home its basic 'ordmanness' dischances of certain sorts of practical tasks bemg accomplished played in patients', relatives' and nurses' talk Unpublished at all PhD thesis Department of Sociology, Goldsmith's College, University of London The use of 'informal' modes of interaction by the Hughes D (1982) Control m the medical consultation orgarusSCT nurses appeared to be of functional and symbohc mg talk m a situation where co-participants have differential value to them m 'doing—waiting' at the beginning of competence Soaology 16(3), 359-376 visits, m defirung boundanes between achvihes and m Jourard S M (1971) The Transparent Self Van Nostrand Reinhold, projecting unhumed conclusions But m order to carry New York out assessments of needs and treat patients' distressing Lythe Menzies I (1988) Containing Anxiety m Institutions Selected sjonptoms, it seemed necessary for the SCT nurses to reEssays Free Association Books, London vert to 'formal' means of commurucahons not commonly Mclntosh J B (1979) The nurse-pahent relationship Nursing Mirror, 148(4), Suppl, 1-20 forming part of mundane, 'mformal' conversations Matthews S (1987) Definitions of fnendship and their consequences m old age Agemg and Soaety 3(2), 141-155 Mayer A & Whiteley A (1990) Nurses in their 'own clothes' Acknowledgements views of staff and patients on the wearing of non-umform m a rehabilitation ward Unpublished study Bnghton Distnct To the memory of the patients so willing to share the end General Hospital, Bnghton of their lives and with grahtude to their reiahves who partiapated The co-operation of the SCT nurses m dis- Mitchell C J (1983) Case and situation analysis The Soaological Review 31(2), 187-211 playing their practice to public scrutmy was impressive Newman G (1906) Infant Mortality A Soaal Problem Methuen, and much appreaated, as was the guidance of Dr David London Silverman, Department of Soaology, Goldsmith's College, Pomerantz A (1975) Second assessments Unpublished PhD University of London thesis Uruversity of California, Los Angeles Robmson K M (1987) The social construction of health visitmg Unpublished PhD thesis Polytechnic of the South Bank, References London Royal College of Nursmg (1987) In Pursuit of Excellence A Positton Armstrong D (1982) Medical knowledge and the modalities of Paper on Nursmg RCN, London soaal control Mimeo, Sociology Umt, Guy's Medical School, Schegloff E A & Sacks H (1973) Opening up closmgs Semiotica London 8,289-327 Atkinson M J (1982) Understandmg fonmality the categonsation and production of "formal" mteraction Bntish foumal of Schon D A (1982) The Reflective Practitioner How Professionals Think m Action Basic Books, New York Soaology 33(1), 86-117 Silvemian D (1973) Interview talk bnnging off a research Atkmson P (1981) Inspecting classroom talk. In Uttenng instrument Soaology 7(1), 32-48 Muttenng (Adelman C ed). Grant Mclntyre, London, Silverman D (1984) Gomg pnvate ceremorual forms m a pnvate pp 98-113 oncology clinic Soaology 8,191-201 BrewmTB (1990) Not TLC but FPI Joumal of the Royal Soaety of Silverman D (1985) QfMlttattve Methodology and Sociology Mediane 83,172-175 Dingwall R (1977) The Soaal Organisation of Health Visitor Gower, Aldershot Silverman D (1987) Communication and Medical Practice Soaal Training Croom Helm, London Relations in the Clinic Sage, London Dingwall R. (1980) Orchestrated encounter an essay m the ccwnparative analysis of speech-exchange systems Soaology of Skidmore D (1986) The soaology of fiiendship histoncal literary and empirical perspechves Unpubhshed PhD thesis Hmtih and Illness 2(2), 154-173 937
M Hunt Department of Soaology and Social Pobcy, University of Keeie, Keele &nithG (1973) Ideologies, beliefs and pattems of admimstration m the orgamsahon of social work practice Unpublished PhD thesis University of Aberdeen, Aberdeen Sparrow S (1988) The role of the nurse's uniform Sentor Nurse 8(5), 34-36
938
Strong P M (1979) The Ceremonial Order of the Cltmc Parents, Doctors and Medical Bweaucraaa Routkdge and Kegan Paul, London Tumer R (1972) Some formal properties of t h e r ^ y talk In Studtes in Soctal Interachon (Sudnow D ed). Free Press, New York, pp 307-396
