8. Awareness of different environments
CHAPTER OBJECTIVES
• Recognise the physical factors within the environment that influence the quality of the service and the outcomes of a health profession
• Understand the importance of the emotional environment for all individuals in a healthcare service
• Recognise the factors contributing to the creation of the emotional environment
• Identify the benefits of acknowledging and accommodating the emotional environments of all relevant people to ensure family/person-centred practice
• Justify the importance of considering the cultural environment of the individuals in a healthcare service
• Recognise some of the elements of a culture that vary across cultures
• Appreciate the possibility of varying sexual environments and understand that the sexual environment can influence health service delivery
• Demonstrate understanding of various social environments and their influence on the individuals in a healthcare service
• State the benefits of being aware of and understanding the spiritual environments of the individuals in a healthcare service
• Explain the importance of openness to all the environments that affect the outcomes of any health service.
Individuals develop in many types of environments. Such environments initially include the physical settings within the family home, the local community and the school. These physical environments provide the setting for other environments, particularly emotional, cultural, sexual, social and spiritual environments. These environments interact to form a dynamic system that determines the development and expectations of each individual. These expectations influence the expectations and outcomes of communicative interactions.
ACTIVITY
• Divide a page into two, top to bottom. On one side list the factors that have assisted your ability to understand in particular environments and on the other list those that have limited your comprehension (e.g. noisy, emotionally tense or spiritually unfamiliar environments). Consider the aspects of your whole person as well as cultural and financial aspects.
• Using this list construct the environment that best assists in establishing comprehension when providing or receiving information. Consider the perspectives of the health professional and the person receiving assistance.
There are unique factors that affect the responses within and the results of interactions. Some of these factors are age, gender, social expectations, economic status, cultural norms, sexual preferences, attitudes, experience, professional knowledge and associated expectations, problem-solving strategies, types of thinking, personality types and motivational forces (Blanche 2007, Chen 2006, Slahova et al 2007). Environmental factors also affect the outcomes of interactions. They are many and varied and each has its own effect on potential outcomes. Environmental factors are akin to the factors affecting the ‘other’, with some being obvious and others more obscure. Some are more immediate than others – directly affecting the individual in the present – while others have shaped them in their past. Some the health professional can manage within the routine of practice, while others require specific understanding and tolerance.
The physical environment
Physical appearance: Dress
The health professional has immediate control over their physical appearance, specifically clothing, jewellery and personal grooming. Certainly facial features and other inherited characteristics are uncontrollable, but consideration of personal codes of dress and grooming is essential for health professionals. While dress and grooming are components of body language (see Ch 12), from the perspective of the person seeking assistance the physical appearance of the health professional is part of the new and unfamiliar physical environment. Most healthcare services have specific codes of dress for some staff members, however, it is important to consider the effect of personal appearance upon the ‘others’ in the health service.
CASE STUDY
A health professional recently joined a health service. Upon arrival, the manager explained the personal appearance code along with many other behavioural expectations. The personal appearance code included smart conservative dress, removal of nose or lip rings, particular footwear and guidelines for jewellery and hair.
GROUP ACTIVITY
• List the reasons for and against such codes; consider healthcare interventions for individuals in various stages of the lifespan.
This new staff member chose to ignore many of the codes, arguing they wanted to maintain their individuality and that they were neat and clean. A nose ring, loose-fitting ‘hippy’ clothing, several large skull finger rings, sandals and unrestrained beautiful long hair were typical of the personal appearance of this health professional.
GROUP DISCUSSION
• If this were you, how would you respond to any attempt to change how you dress or groom yourself in a professional setting?
• How would your grandmother respond to a health professional with this physical appearance?
• Now think of a small child you know – how would they respond?
• Decide the best way to manage this behaviour to achieve a positive outcome for all.
When dressing as a health professional it is important to avoid expressions of economic status – either wealth or poverty – in clothing, footwear or jewellery (Holli et al 2003). Appearance of wealth or poverty might be intimidating and is sometimes misinterpreted by those seeking assistance.
REFLECTIVE GROUP ACTIVITY
• Discuss reasons for restrictive codes of personal appearance in health services – consider uniforms, hair restraint, jewellery and footwear.
– Consider the importance of comfort and safety for all stakeholders.
– List the benefits and disadvantages of wearing a uniform regularly.
• Decide whether restrictive codes of personal appearance are necessary and appropriate in every healthcare setting.
Familiarity with the physical environment and the usual procedures
Person seeking assistance
REFLECTION
• Have you ever sought assistance from a service about which you knew very little?
• How did you feel initially?
• What made you feel more comfortable?
Most people feel apprehensive when entering a new environment for the first time. New environments typically stimulate unsure and hesitant behaviours. If the new environment holds unknown procedures and perhaps pain there might even be feelings of fear and anger. Investing time to familiarise people to a new environment can avoid any negative emotions related to the novelty of the environment and the unknown procedures associated with the environment (Purtilo & Haddad 2002). In such situations it is helpful to imagine what the personal reaction of the health professional might be in a similar situation.
CASE STUDY
A person waking from a 10-day coma asks to get up to go to the toilet. A helpful nurse returns a few minutes later with a commode chair on wheels. This is a standard procedure where the person transfers onto the commode chair and the nurse wheels the person and commode to the toilet cubicle. This is appropriate for someone who is weak from lack of sustenance and exercise. Upon seeing the commode chair the person bursts into tears and states I don’t want to go that much!
REFLECTION
• Can you explain this reaction? How would you react?
• Is there anything that could be done to avoid this reaction?
• If so, what? If not, why?
• Can you think of a regular procedure in your health profession that might illicit a similar reaction?
Knowing where to find toilets and other necessary facilities is reassuring, however, understanding what to expect during a procedure or intervention, or as a result of a particular need, is equally important. Assisting the person to become familiar with the environment – the facilities, people and procedures – is essential to ensure positive responses and outcomes (see Ch 3).
Health professional
There are times when health professionals may find themselves in unfamiliar environments when assisting a person. Some of these environments may feel cosy and relaxing, while others seem daunting, smelly or cluttered. (A visit to the home of a person who lives adjacent to a fertiliser factory does test the ability of the health professional to successfully complete their task in such an environment.) When visiting a person in their home or taking them to an unfamiliar environment as part of the intervention, it is important for health professionals to take the necessary measures to minimise their anxiety related to the novelty of the environment (e.g. outline every expectation and indicate the level of assistance available). In such circumstances it is imperative that the health professional continues to respond with respect and empathy.
Rooms
Furniture placement and physical comfort
Various factors require consideration when choosing the type of furniture and how to place the furniture within a room. Placement of furniture can encourage or discourage interaction. Chairs side-by-side facing the same direction do not encourage communication, nor do they demonstrate interest and care. A desk between the people communicating is not only a physical barrier, it is also an emotional barrier. Such a desk communicates a desire to keep others distant. It is important to avoid using furniture as a physical barrier when aiming at family/person-centred practice. Arranging the chairs around a desk, a comfortable distance apart, so they face each other or are adjacent to each other promotes communication that is more personal. This configuration facilitates eye contact, which is valued in most western cultures, although may not be in other cultures. It is important to ensure that all communicating individuals are physically comfortable before the commencement of the interaction. If a table is required for placement of written material, a round table allows a clear view for everyone seated at the table.
REFLECTIVE ACTIVITY
• Consider the effect of your physical comfort on your ability to concentrate, understand and remember specific details. Can you concentrate regardless of your comfort?
• Decide on the best way to establish whether a person is physically comfortable. Remember they are feeling vulnerable so may not tell you directly they are physically uncomfortable. How will you know they are comfortable or uncomfortable? What might you do to make them physically comfortable if you establish they are uncomfortable?
Waiting rooms
Waiting rooms are often crowded and noisy. Regardless of the busy nature of the room or the size of the room, there are basic principles that make a waiting room pleasant for those waiting. The colour of the room (paint and furniture), the texture and type of furniture, the lighting and the ventilation present either a warm, welcoming atmosphere or a cold, clinical feeling. The first encourages a feeling of comfort, relaxation and safety, while the other feels impersonal and unfriendly. The first encourages people to linger, while the other encourages people to leave as quickly as possible (Northouse & Northouse 1992). The more impersonal the waiting room, the greater the likelihood of expressions of frustration and hostility (Purtilo & Haddad 2002). Such behaviour can result from personal factors or having to wait too long, but may also result from the impersonal or clinical nature of the environment.
GROUP ACTIVITY
• For each member of the group list the colours and textures that create a feeling of comfort and emotional warmth. Have these changed with age?
• Consider the variations in personal taste.
• What does this mean for a health service and the health professional?
The feeling of comfort gained from sitting or lying on particular types of furniture varies from person to person according to size, height, physical condition, age and gender. Equipping waiting rooms with varying types of chairs and mattresses can assist to overcome these personal variations. Ventilation and natural light also contribute to the ambience of any room, but if these are not possible the colour and type of furniture can adequately compensate for their lack.
Treatment rooms and rooms with beds
The same principles outlined for creation of an appropriate waiting room atmosphere also apply to treatment areas. However, it is important to consider additional environmental factors when in such areas. Many treatment areas do not naturally facilitate confidential and private communication. It is important for health professionals working in such environments to consider individual needs for privacy.
REFLECTION
• How do you feel if you discover someone talking about something personal when they do not know you can hear the conversation?
• What do you do in such situations – do you keep listening or do you move? What does this reveal about you?
• What implications does this have for a health professional?
• How do you feel if you discover someone talking about you when they do not know you can hear? What do you do then?
• What does this mean for a health professional?
The need for privacy may vary according to personality type and the emotional state of the individual at any given time. Consistent consideration of these needs will promote personal disclosure when required and the development of rapport. It is important to consider the difference between visual privacy and auditory privacy. Drawing curtains around a treatment bed or a bed in a ward does not guarantee privacy. A private room will facilitate personal communication, while a public space will keep the communication at a superficial level in order to protect confidentiality.
Avoiding distractions and interruptions
The use of a private room for discussion of personal information is very important but may not achieve personal disclosure if there are constant distractions. Distractions come from the telephone, people, regular or loud noises, particular objects in the room and sometimes movement outside a window.
REFLECTION
Think of a time when someone or something distracted you during a conversation or lecture. What was the distraction? Was it important? How did you feel about the distraction? Were you able to return to the exact point after the distraction occurred? How long did it take to regain concentration and the ‘flow’ of the information?
GROUP ACTIVITY
• Every other member of the group takes turns to interrupt the retelling with an unrelated statement or noise – asking for the time or when the next bus is due, tapping on the floor, or pointing out an event outside the window etc.
• The person listening responds to each distraction, taking interest and where necessary answering or commenting.
• As a group, observe the effect of the distractions on the flow of the story and on the person attempting to tell the story.
• Have the listening person retell the story of the movie and check for accuracy.
Personal and emotional communication requires concentration and focus. Distractions make this focus difficult and disturb the flow of the communication. Restoring the concentration and information flow during exploration of emotion is often difficult. More importantly, responding to distractions communicates that the distraction is more important to the health professional than the communicating ‘other’. Thus, avoidance of such distractions is very important (Bergland & Saltman 2002). This is achieved by not answering the telephone, leaving a message that indicates disturbances are not acceptable (e.g. a sign on the door indicating ‘Do Not Disturb’), decreasing or removing distracting noises and/or objects where possible, and organising the seating to avoid distractions outside a window. If in a hospital ward, it is appropriate to arrange a time when there are no expectations from other health professionals or visitors.
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