Communication education
for nurses: implications for nure
Sally Candlin
To prepare the student of nursing to meet the demands of caring for the individual or a community within a dynamic and multi-cultural society, it is important that the nurse and the client see the healing process as being a co-operative venture. This co-operation relies on the growth of trust and confidence between interlocutors. Underpinning this is not only a sound clinical knowledge base but a sophisticated communication process at which individuals must be competent. The author argues that this competence is not automatic; it must be worked at and developed if the nurse is to be truly committed to the healing process. It is the responsibility of nurse educators to facilitate the growth and development of this competence in the students of today, if they are to be the nurses of tomorrow meeting new challenges. This paper examines some of the issues involved.
WHAT IS NURSING? To prepare the student of nursing to meet the demands of a changing society, it is important that one addresses the basic question - ‘What is nursing? Is it an art or is it a science?’ While there are articulate exponents in each camp, increasingly it is being recognised that in fact it is both an art and a science (Benner Carson 1989). To consider the multi-dimensional needs of the client - socially, psychologically and spiritually - in an atmosphere of technological growth and sophistication, increasing litigation, and in a culturally pluralistic society, a nurse must be prepared to recognise, research and Sally Candlin RN RM BA (Hans) MSc Senior Lecturer, School of Nursing, Health Studies, University of Technology, Sydney, Broadway, NSW 20, Australia (Requests for offprints to SC) Manuscript accepted 6 May 1992
critically analyse situations with all the rigour of a science-based discipline. Only then will she display the credibility of a sound, technically competent practitioner, mindful of the legal and ethical parameters within which the clinical situation must operate. But nursing is not simply the application of technology to the sick person. It involves first and foremost a commitment to the health of the individual/community within the environment. It matters not whether the environment is the family, workplace or an urban/rural based society. It necessitates promoting and maintaining health, preventing disease and participating in the restoration of the sick person to optimal health. It takes cognisance of the relationship of the person with significant others in his world-a world where individuals and groups form, change and grow. It involves establishing and maintaining trust and confidence between groups and individuals. This is the art of nursing 445
446
NURSEEDU~:A1‘ION-TODAY
- -.
-an art that is built upon the successful workings of interpersonal relationships.
healer/ technologist
carer
THE GROWTH OF RELATIONSHIPS The individual Underpinning any relationship, and indeed the foundation of its growth, is a sophisticated communication process which involves an ability to manipulate linguistic systems, This ability is dependent on the interaction of a complex set of variables, one of which is the situational context of the speech event. For example, the language that one uses to one’s lover, is not the language one uses to one’s employer, a parent or to a sporting colleague. Similarly, the styles - or language varieties - used in these situations are quite different from those used in the pulpit, a political platform, a court of law or the lecture theatre. How then does a nurse talk to a client? What are the conventions employed in the nursing context? What are the considerations which she makes when addressing a person in the clinical situation? What constitutes the complex set of features that are relevant to the successful growth of the nurse/client relationship? I would suggest that they include age, gender, occupation, education, social class, culture, mood and health of the interlocutors. The list is lengthy and the computations of these variables seemingly infinite. Nevertheless, they are vital elements which must be recognised by the nurse if her communication strategies are to succeed.
The nursing context When engaging in a communication event, there are further considerations to be made if the caring is to take place within the framework of a therapeutic relationship. The variables which influence the nurse’s language stem not just from the individual differences of both nurse and client. They involve differences that are unique to specific situations. Here one must examine the role and functions of the nurse. The Royal Australian Nurses Federation is just one
communicator
,-:I,&manager/ policy maker CLINICIAN
advocate
researcher counsellor crilical lhinkcr
colleague
/
\;.I Fig 1 The role and functions of the nurse. Reproduced with kind permission from Candlin S
1988. professional body which has proposed a number of functions which one performs in the course of delivering care. The Department of Nursing Studies at what was the Kuring-gai College of Advanced Education (KCAE) in New South Wales proposed a very simple, but nevertheless very rich, model of nursing (Fig. l), its simplicity belying the complexity of the nursing role. From this model, it can be seen that no one component part of the role, i.e. the clinician, is complete within itself. Each part - or function is influenced by, and influences, any or aIf of the constituents of the central clinical focus. One might be tempted to argue that the language used to communicate the needs and functions of each facet of the role, and to achieve the goals circumscribed by it, is unique to itself. The approach and methods of, for example, the counsellor - at least in theory - are quite different from those of the technologist, and yet each is essential for an effective therapeutic relationship to be established and maintained. But at another level, it could be claimed that the language of the counsellor & the language of the technologist, an example of which is to be found when the nurse is counselling the client and family in the coronary care unit. Yet another, is the situation where the nurse is udvocubng for the
NURSE EDU(:ATION
elderly person who is thought care in a nursing
to need extended
they themselves
home, and is also educuling the
family in the needs of the dependent simultaneously
coun.selling them
feel guilty that they cannot
relative,
because
themselves
they under-
take the necessary 24-hour care. Neither in the situation in the coronary care unit nor the unit for the elderly
is the language
attitudes
values
manager
and
-
the
researcher
or
of the
being used. The nurse is seen to adapt
and accommodate
to the needs and demands
each set of circumstances. however,
- or indeed
In many
of
situations
there might well be overlapping
goals
might
seems so unfair: the grandmother seemingly
feel burdened
the younger
boyfriend
brother
requires
permanent has
so much
and
of course might also be between her
goals and those of the client/family.
What goes through
her mind as she tries to come stroke
- aphasia,
incontinence?
to terms
right hemiplegia,
life, or babysit,
care for her husband?
or care for her
the
concept
of difference
and
with those which underlie
daily interactions
overlap
at
and rule the
of individuals?
her relaWho will
Will she die? Does she the nurse
to
care?
The interacting worlds of the nurse and the client Is
with a
headaches,
Is she ever going to walk again, or
want to live? How can we enable
variance
too
babysits for the family, runs her own home and cares for an ailing husband?
husband? How will this stroke affect tionship with her family and friends?
competition
a
are
And what of the elderly person who has been a pillar in the community, attends evening classes,
confines
This
the
with
stressed and tired to offer support?
talk, or enjoy
reiationship.
care,
parents
which the clinician will have to address within the of the therapeutic
and life
has cancer,
relationship
ended,
447
TODAY
THE COMPLEXITY COMMUNICATION
OF THE PROCESS
I think not. I
suggest that one can draw parallels between the differences in the role and functions of the nurse
Perhaps one of the first things that we can do is to acknowledge the complexity of the communica-
and the role and functions
tion process.
outside
of the clinical
basis of difference
of the individuals
situation.
It is from
that the relationship
the
between
Contrary
to the belief of some, we
do not all know how to communicate. there
If we did
would be fewer misunderstandings,
mis-
the nurse and the client grows. This seemingly
takes and breakdowns
presents a complex situation, but its complexity cannot be considered without first acknowledg-
our values, beliefs and attitudes
ing not only the multi-faceted nature of the individual who is the nurse, but also the multi-
has demonstrated convincingly. sensitive to the needs of others?
faceted
the background of our interlocutorthe history, the culture, the values - in fact all the variables
nature of the person who is the client. It
is important
that one understands
the effects
which one has upon the other and the impact of this on the caring situation At thisjuncture the implications
it is worth
students
How
pdUSing
to
which the proposed
on our understanding tionship.
(Fig. 2).
can
consider
model has
of the nurse/client we as educators
to build up relationships
rela-
prepare
with clients,
being aware that they bring to the caring situation their own unique experiences: the broken relationship,
the dying brother,
the demanding
grandmother, the stressed parents. How can we as educators prepare them to care for clients who have such heavy burdens when
in the process. Often,
way as work by Moore (1985) and Greene
that we discussed earlier class education etc.?
too,
can get in the (199 1)
Are we always Do we consider
- age gender,
social
Do we know how and when to accommodate linguistically neurological
to
another?
Can
we
recognize
deficits in our interlocutor’s
speech
and behaviour, and do we respond appropriately? Do we unthinkingly switch into ‘baby talk’/gerontese/elderspeak elderly
- regardless background
dency, (Culbertson
when we talk to the
of their degree of depenand mental capacity
& Caporeal
1983).
It is important
that we observe the co-operative principle of communication when we are talking to others,
448
NURSE EDUCATION
TODAY
The social world of Jane/John
The cerlrln world of b(s) Jones
co,,g/,
“;fl
\\\
IMPACTS ON . The unceri.aln>orld of disease, didunction and the Pallent
‘_a/ -
/
-
Tho Clinical world of the Nurse
-
Fig 2 The interacting worlds of individuals
attending
to the
maxims
of‘ quantity,
quality,
relevance and relation proposed by Grice (1975). In essence this demands that our conversation be truthful (quality), that we give enough, but not too much information (quantity), and that our contributions
be relevant,
appropriate
and pur-
poseful to that situation (relevance and relation). We must also consider the issue of how we address people and why we sometimes speak indirectly to them. For example, why do we ask a student if she has handed in an assignment, believing that she probably hasn’t; or ask a client
if’ he is keeping
to the recommended diet, again with reason to believe that he isn’t. It is because we want to warn the student that she is likely to lose marks if work isn’t completed, or is it because
we are opening
munication
up channels
of com-
and giving her the opportunity
discuss problems that we know ing? And what of the patient? make an opening so that he can losing face - anxieties about his relates to his employment using it as an introduction
to
she is experiencAre we trying to discuss - without health status as it
situation, or are we to counsel someone
NURSE
whose attitude must change before behaviour change can be effected? In both of these situations the underlying variables are going to affect the communication process. Often the degree of indirectness is dependent on the degree of social distance between speakers. Or indirectness could be used as an acknowledgement of cultural differences in the use of communication strategies. It may be used strategically to maintain politeness, or to avoid face-threatening or confrontational situations and still maintain open channels of communication. It might be used as a means of maintaining power over another person, or to add rhetorical effect to our speech. Its use is one example of how we manipulate our language to our advantage, or to what we believe is the advantage of our interlocutor. There are other considerations too. For example, is our non-verbal behaviour congruent with our spoken word? Or does our behaviour - eye contact, gestures, use of touch and space, our intonation patterns and our silences - carry perceived and/or hidden messages? Underpinning all of these questions and considerations of course is our nursing knowledge base. It is on this that our relationships in our professional world are built. Without it, trust and respect are misplaced, support and comis short-term passion is shallow, commitment and availability and accountability is at risk of being undervalued. Conversely, the greater the knowledge base, the richer are the stated aspects of caring. One could persuasively suggest that successful communication, and certain and rich knowledge are the hallmarks of the competent and caring practitioner. A model that encompasses all of the demands of this competence, both clinically and communicatively must itself be rich and all encompassing. It must allow for the changes occurring in nursing, as well as for those in a dynamic multi-cultural society. Such a model is proposed in Figure 3. Where a person is aware of the sensitivities demanded by the other person’s needs - culture, values, beliefs, affect, mood, health etc. - the developing relationship is not one that is bound in chains (Malinowski 1935), but one where both members of the dyad are free to enjoy the N.E.T.
C
EDU(:ATI
for nurses: implications for nure
Sally Candlin
To prepare the student of nursing to meet the demands of caring for the individual or a community within a dynamic and multi-cultural society, it is important that the nurse and the client see the healing process as being a co-operative venture. This co-operation relies on the growth of trust and confidence between interlocutors. Underpinning this is not only a sound clinical knowledge base but a sophisticated communication process at which individuals must be competent. The author argues that this competence is not automatic; it must be worked at and developed if the nurse is to be truly committed to the healing process. It is the responsibility of nurse educators to facilitate the growth and development of this competence in the students of today, if they are to be the nurses of tomorrow meeting new challenges. This paper examines some of the issues involved.
WHAT IS NURSING? To prepare the student of nursing to meet the demands of a changing society, it is important that one addresses the basic question - ‘What is nursing? Is it an art or is it a science?’ While there are articulate exponents in each camp, increasingly it is being recognised that in fact it is both an art and a science (Benner Carson 1989). To consider the multi-dimensional needs of the client - socially, psychologically and spiritually - in an atmosphere of technological growth and sophistication, increasing litigation, and in a culturally pluralistic society, a nurse must be prepared to recognise, research and Sally Candlin RN RM BA (Hans) MSc Senior Lecturer, School of Nursing, Health Studies, University of Technology, Sydney, Broadway, NSW 20, Australia (Requests for offprints to SC) Manuscript accepted 6 May 1992
critically analyse situations with all the rigour of a science-based discipline. Only then will she display the credibility of a sound, technically competent practitioner, mindful of the legal and ethical parameters within which the clinical situation must operate. But nursing is not simply the application of technology to the sick person. It involves first and foremost a commitment to the health of the individual/community within the environment. It matters not whether the environment is the family, workplace or an urban/rural based society. It necessitates promoting and maintaining health, preventing disease and participating in the restoration of the sick person to optimal health. It takes cognisance of the relationship of the person with significant others in his world-a world where individuals and groups form, change and grow. It involves establishing and maintaining trust and confidence between groups and individuals. This is the art of nursing 445
446
NURSEEDU~:A1‘ION-TODAY
- -.
-an art that is built upon the successful workings of interpersonal relationships.
healer/ technologist
carer
THE GROWTH OF RELATIONSHIPS The individual Underpinning any relationship, and indeed the foundation of its growth, is a sophisticated communication process which involves an ability to manipulate linguistic systems, This ability is dependent on the interaction of a complex set of variables, one of which is the situational context of the speech event. For example, the language that one uses to one’s lover, is not the language one uses to one’s employer, a parent or to a sporting colleague. Similarly, the styles - or language varieties - used in these situations are quite different from those used in the pulpit, a political platform, a court of law or the lecture theatre. How then does a nurse talk to a client? What are the conventions employed in the nursing context? What are the considerations which she makes when addressing a person in the clinical situation? What constitutes the complex set of features that are relevant to the successful growth of the nurse/client relationship? I would suggest that they include age, gender, occupation, education, social class, culture, mood and health of the interlocutors. The list is lengthy and the computations of these variables seemingly infinite. Nevertheless, they are vital elements which must be recognised by the nurse if her communication strategies are to succeed.
The nursing context When engaging in a communication event, there are further considerations to be made if the caring is to take place within the framework of a therapeutic relationship. The variables which influence the nurse’s language stem not just from the individual differences of both nurse and client. They involve differences that are unique to specific situations. Here one must examine the role and functions of the nurse. The Royal Australian Nurses Federation is just one
communicator
,-:I,&manager/ policy maker CLINICIAN
advocate
researcher counsellor crilical lhinkcr
colleague
/
\;.I Fig 1 The role and functions of the nurse. Reproduced with kind permission from Candlin S
1988. professional body which has proposed a number of functions which one performs in the course of delivering care. The Department of Nursing Studies at what was the Kuring-gai College of Advanced Education (KCAE) in New South Wales proposed a very simple, but nevertheless very rich, model of nursing (Fig. l), its simplicity belying the complexity of the nursing role. From this model, it can be seen that no one component part of the role, i.e. the clinician, is complete within itself. Each part - or function is influenced by, and influences, any or aIf of the constituents of the central clinical focus. One might be tempted to argue that the language used to communicate the needs and functions of each facet of the role, and to achieve the goals circumscribed by it, is unique to itself. The approach and methods of, for example, the counsellor - at least in theory - are quite different from those of the technologist, and yet each is essential for an effective therapeutic relationship to be established and maintained. But at another level, it could be claimed that the language of the counsellor & the language of the technologist, an example of which is to be found when the nurse is counselling the client and family in the coronary care unit. Yet another, is the situation where the nurse is udvocubng for the
NURSE EDU(:ATION
elderly person who is thought care in a nursing
to need extended
they themselves
home, and is also educuling the
family in the needs of the dependent simultaneously
coun.selling them
feel guilty that they cannot
relative,
because
themselves
they under-
take the necessary 24-hour care. Neither in the situation in the coronary care unit nor the unit for the elderly
is the language
attitudes
values
manager
and
-
the
researcher
or
of the
being used. The nurse is seen to adapt
and accommodate
to the needs and demands
each set of circumstances. however,
- or indeed
In many
of
situations
there might well be overlapping
goals
might
seems so unfair: the grandmother seemingly
feel burdened
the younger
boyfriend
brother
requires
permanent has
so much
and
of course might also be between her
goals and those of the client/family.
What goes through
her mind as she tries to come stroke
- aphasia,
incontinence?
to terms
right hemiplegia,
life, or babysit,
care for her husband?
or care for her
the
concept
of difference
and
with those which underlie
daily interactions
overlap
at
and rule the
of individuals?
her relaWho will
Will she die? Does she the nurse
to
care?
The interacting worlds of the nurse and the client Is
with a
headaches,
Is she ever going to walk again, or
want to live? How can we enable
variance
too
babysits for the family, runs her own home and cares for an ailing husband?
husband? How will this stroke affect tionship with her family and friends?
competition
a
are
And what of the elderly person who has been a pillar in the community, attends evening classes,
confines
This
the
with
stressed and tired to offer support?
talk, or enjoy
reiationship.
care,
parents
which the clinician will have to address within the of the therapeutic
and life
has cancer,
relationship
ended,
447
TODAY
THE COMPLEXITY COMMUNICATION
OF THE PROCESS
I think not. I
suggest that one can draw parallels between the differences in the role and functions of the nurse
Perhaps one of the first things that we can do is to acknowledge the complexity of the communica-
and the role and functions
tion process.
outside
of the clinical
basis of difference
of the individuals
situation.
It is from
that the relationship
the
between
Contrary
to the belief of some, we
do not all know how to communicate. there
If we did
would be fewer misunderstandings,
mis-
the nurse and the client grows. This seemingly
takes and breakdowns
presents a complex situation, but its complexity cannot be considered without first acknowledg-
our values, beliefs and attitudes
ing not only the multi-faceted nature of the individual who is the nurse, but also the multi-
has demonstrated convincingly. sensitive to the needs of others?
faceted
the background of our interlocutorthe history, the culture, the values - in fact all the variables
nature of the person who is the client. It
is important
that one understands
the effects
which one has upon the other and the impact of this on the caring situation At thisjuncture the implications
it is worth
students
How
pdUSing
to
which the proposed
on our understanding tionship.
(Fig. 2).
can
consider
model has
of the nurse/client we as educators
to build up relationships
rela-
prepare
with clients,
being aware that they bring to the caring situation their own unique experiences: the broken relationship,
the dying brother,
the demanding
grandmother, the stressed parents. How can we as educators prepare them to care for clients who have such heavy burdens when
in the process. Often,
way as work by Moore (1985) and Greene
that we discussed earlier class education etc.?
too,
can get in the (199 1)
Are we always Do we consider
- age gender,
social
Do we know how and when to accommodate linguistically neurological
to
another?
Can
we
recognize
deficits in our interlocutor’s
speech
and behaviour, and do we respond appropriately? Do we unthinkingly switch into ‘baby talk’/gerontese/elderspeak elderly
- regardless background
dency, (Culbertson
when we talk to the
of their degree of depenand mental capacity
& Caporeal
1983).
It is important
that we observe the co-operative principle of communication when we are talking to others,
448
NURSE EDUCATION
TODAY
The social world of Jane/John
The cerlrln world of b(s) Jones
co,,g/,
“;fl
\\\
IMPACTS ON . The unceri.aln>orld of disease, didunction and the Pallent
‘_a/ -
/
-
Tho Clinical world of the Nurse
-
Fig 2 The interacting worlds of individuals
attending
to the
maxims
of‘ quantity,
quality,
relevance and relation proposed by Grice (1975). In essence this demands that our conversation be truthful (quality), that we give enough, but not too much information (quantity), and that our contributions
be relevant,
appropriate
and pur-
poseful to that situation (relevance and relation). We must also consider the issue of how we address people and why we sometimes speak indirectly to them. For example, why do we ask a student if she has handed in an assignment, believing that she probably hasn’t; or ask a client
if’ he is keeping
to the recommended diet, again with reason to believe that he isn’t. It is because we want to warn the student that she is likely to lose marks if work isn’t completed, or is it because
we are opening
munication
up channels
of com-
and giving her the opportunity
discuss problems that we know ing? And what of the patient? make an opening so that he can losing face - anxieties about his relates to his employment using it as an introduction
to
she is experiencAre we trying to discuss - without health status as it
situation, or are we to counsel someone
NURSE
whose attitude must change before behaviour change can be effected? In both of these situations the underlying variables are going to affect the communication process. Often the degree of indirectness is dependent on the degree of social distance between speakers. Or indirectness could be used as an acknowledgement of cultural differences in the use of communication strategies. It may be used strategically to maintain politeness, or to avoid face-threatening or confrontational situations and still maintain open channels of communication. It might be used as a means of maintaining power over another person, or to add rhetorical effect to our speech. Its use is one example of how we manipulate our language to our advantage, or to what we believe is the advantage of our interlocutor. There are other considerations too. For example, is our non-verbal behaviour congruent with our spoken word? Or does our behaviour - eye contact, gestures, use of touch and space, our intonation patterns and our silences - carry perceived and/or hidden messages? Underpinning all of these questions and considerations of course is our nursing knowledge base. It is on this that our relationships in our professional world are built. Without it, trust and respect are misplaced, support and comis short-term passion is shallow, commitment and availability and accountability is at risk of being undervalued. Conversely, the greater the knowledge base, the richer are the stated aspects of caring. One could persuasively suggest that successful communication, and certain and rich knowledge are the hallmarks of the competent and caring practitioner. A model that encompasses all of the demands of this competence, both clinically and communicatively must itself be rich and all encompassing. It must allow for the changes occurring in nursing, as well as for those in a dynamic multi-cultural society. Such a model is proposed in Figure 3. Where a person is aware of the sensitivities demanded by the other person’s needs - culture, values, beliefs, affect, mood, health etc. - the developing relationship is not one that is bound in chains (Malinowski 1935), but one where both members of the dyad are free to enjoy the N.E.T.
C
EDU(:ATI
