Four years ago, at Newton Wellesley Hospital School of Nursing, instructor and student evaluations revealed the need for a nursing course that would clearly present communication skills applicable to the clinical setting. Communications theory, a major thread of the school's conceptual framework previously was the responsibility of the Social Science Department. Communication theory is now integrated into the first nursing course. Principles and techniques learned in the first level provide a foundation for clinical application throughout our two-year program. One of the strongest reasons for this change was the school's philosophy of man.
Man may be considered as a "world" within himself, with the ability and the right to think, act, feel, react to his environment. As he reacts and interacts, he is continually changing in response to his surroundings.
We believe that it is from this holistic view of man that nurses function to deliver individualized care - care which requires sharing, processing, and disseminating of information occurring in the presence of a therapeutic nurse-patient relationship.
Pluckham (1978, p. 152) defines the therapeutic relationship as one "in which the psychological climate ie such that it facilitates positive change and growth in the client." She further describes the therapeutic use of self as a "necessary part of the professional paraphernalia of all nurses irrespective of their area of practice."
Communication takes place on many levels; verbal, nonverbal, overt, and covert interaction is implicit in all behavior. Communication may be perceived in ways that are not always intended. Awareness of these perceptions, or misperceptions, needs to be validated by those involved, emphasizing the necessity of a thorough understanding of cOmmunications theory. Communications theory is a major thread of the conceptual framework at Newton Wellesley Hospital School of Nursing, Principles and techniques learned in the first level provide a foundation for clinical application throughout our two-year program.
Theory presented includes the nursepatient relationship: principles and techniques of interviewing and values clarification, process recording, evaluation of nurse-patient interaction, the Carkhuff (1979, p. 11) model of helping - paraphrasing and feedback skills, death and dying, and communicating to an audience.
The first level nursing course includes 15 hours of classroom theory and 11 hours of group discussion (Table 1). Each discussion group is made up of clinically assigned students moderated by their clinical instructor, thus reinforcing the development of group process. Prior to the time when students enter the clinical area in the third week of the first term, the nurse-patient relationship is the focal point of classroom learning. The major rationale is that some students, because of previous life experience, have been involved in helping relationships; for others this is the first encounter with the helping role.
A helping relationship differs from other relationships hi that it is directed towards assisting a hospitalized patient to cope more effectively. While some effects of hospitalization are unique to the individual, others may be common to all - for example, separation from family and friends; financial considerations; change in body image; inability to meet social commitments; and feelings of helplessness in the sick role.
Basic elements of a therapeutic helping relationship include trust, confidentiality, humor, objectivity, empathy and sensitivity.
There are many sources of information available to students to establish a data base before initial contact with the patient. The primary source of preliminary information is the patient's record. The interview is another means of gathering new data and validating previously determined needs.
Students learn principles of interviewing and use of communication skills in structuring the relationship with clients. This includes theoretical orientation to the nurse's role and limitations of a relationship. Examples of specific interviewing techniques are: giving recognition and offering self, focusing, clarifying, paraphrasing and feedback, open-ended questions, restricting pursuit of topic, perception checking, giving information, touch and other non-verbal methods. A one-hour clinical group session reinforces lecture material through use of an interviewing tool. This process is further reinforced through group analysis.
COMMUNICATION COURSE CONTENT*
All students actively participate in each group session. Giving and receiving feedback becomes an important part of group activities either in a direct or indirect way. Students continue to examine learned techniques through writing process recordings of observed interactions between health team members and patients. The process recording continues to be useful, periodically, in the evaluation of the student's ability to develop nurse-patient interactions.
Lectures and groups introduce and reinforce Carkhuffs method of helping which involves attending, responding, initiating and communicating responses.
In the group session, two students role play a helper-helpee situation. The interaction is followed by an evaluation by other members of the group using a tool based on Carkhuffs and helpers responses. Group members also evaluate the feeling tone of the environment created, i.e. trust, caring, positive regard.
Communicating to a group is equally as important as communicating to an individual. Principles are presented in the classroom followed by small group exercise. Students speak extemporaneously on a topic of their choice. Evaluation by the group includes positive feedback related to the following: self-confidence; physical appearance and mannerisms; diction and volume of voice; eye contact and interest in the subject.
At this point in the communications course the student is ready to participate in simulated nurse-patient situations. Role playing exercises provide an opportunity to practice communication skills in nursepatient interactions. The duo or two-person exercise allows the patient to give feedback to the nurse about helping and non-helping responses. Trio or three-people exercises involve a relater, a listener, and an observer further reinforcing the giving and receiving of feedback.
Many nursing actions involve a decision making process. Decisions are based, consciously or unconsciously upon one's personal philosophy or system of beliefs and values. We believe it is important for students to clarify those personal beliefs and values which may affect interpersonal relationships. Classroom discussions revolve around defining values, forming values, and the influence of values on communication and relationships.
Students learn three ways in which their values are formed. The least effective method is moralizing, or the societal laying down of rigid laws and rules of behavior in an attempt to impose a traditional set of values. The laissez-faire approach allows broad tolerance of individual rights; but the lack of guidance creates dissention, disorientation and disillusionment. Modeling, or setting a "good" example is yet another way by which people form values.
In addition to learning how values are formed, students participate in exercises which assist them in a process called values-clarification. Values clarification focus attention on present and future attitudes and behaviors enabling a person to know oneself and his individual values. This provides a means for growth in communications skills and an insight into future decision making practices. With knowledge and understanding of his own values, the student is better able to accept the values and subsequent behavior of others.
An example of one of the exercises is as follows: Make a list often things you love to do (Column 1). There are many ways to look at this list. In the second column, if you do the activity alone, place the letter "A" beside it; if you need other people or do it with other people, place the letter "P" beside it. Place a "CR" beside those activities that involve a calculated risk for you to do them. If it costs money to do an activity, place a dollar sign "$" beside it; if you have been praised for the activities, place a star "*" beside them. In the third column, write down when you did the activity last (Table 2). Now ask yourself the following questions:
* What can you learn from this kind of game?
* What do you see on your list?
* Are there a number of activities that you love to do but haven't done for a long time?
* How important are these activities in your life?
* Are there a number of activities for which you have been praised?
* Is that the reason that the activities are so important to you?
Completing this exercise is probably most useful if you can use it to effect change in your life. Can you or should you make a bigger place in your life for a particular activity? What do you gain by having a particular activity in your life - especially those that you think you love but don't ever get to do? Do your responses indicate a change in past values? Are you taking time for yourself?
Student evaluation indicates that foundations developed in the communication course are used throughout the two-year program. Group process and communication theory increases the studenti ability to use and understand classroom content. For example, in the first year small group discussions focus on the issues of death and dying, providing a forum for dialogue and expression of feelings. In addition, group discussion aids students to clarify and apply components of nursing process presented in the classroom.
As the first year progresses, students conduct client centered conferences. Preparation for these conferences requires communication technique in collecting data and presenting information to the group.
On the second level, students again utilize these same skills in presenting an interdisciplinary conference involving many members of the health team.
Our curriculum change has been in effect for three years. The most immediate positive impact, which is apparent, is the ability of the student to enter into a therapeutic goal directed nurse-client relationship.
Former reluctance in communicating meaningfully with a client is not evident in most cases. Emphasis placed on communication skills from the student's first day of clinical exposure has provided a foundation for self-confidence which will continue to develop throughout their nursing career.
In the spring of this year, freshmen students were asked to rate on a scale of 5 to 1 (5 - excellent; 4 - good; 3 - satisfactory; 2 - satisfactory in some areas; 1 - unsatisfactory) the effectiveness of communication skills learned in Nursing I as it related to meeting the course objective on communication "establishing a short-term positive nurse-patient relationship which is supportive and facilitates goal achievement with the patient who is not critically ill." In making the decision, the student considered the following behaviors:
* Uses appropriate communication techniques
* Observes client for clues indicating need for emotional support
* Encourages client to express feelings
* Uses attending behavior when client is speaking
* Accepts client dependency and assists toward independency
* Strives toward maintaining interdependency in this relationship
Methods evaluated included: Carkhuffs model of communication, interviewing skills, paraphrasing and feedback skills, role playing of client-nurse situation, process recordings, direct and indirect communications, communicating to an audience, and values clarification. Eightyfive point five percent of the class responded to the survey. All methods were rated as satisfactory or above in ah* areas evaluated by the respondents. The results supported our faculty belief in the value of learning communication skills early in the nursing curriculum.
- Carkhuff, R. R. (1979). The art of helping. Amherst, MA: Human Resources Development Press.
- Pluckham, M. (1978). The nurse client relationship. New York: McGraw-Hill Book Co.
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