Using the Self to Promote Health
Christine L. Williams DNSc, APRN, BC
Carol M. Davis DPT, EdD, MS, FAPTA
OBJECTIVES
To consider the purpose of helping
To explore the behaviors that promote or interfere with effective helping
To describe some of the characteristics of therapeutic communication
To distinguish empathy from related interpersonal interactions
To reveal the characteristics of effective helpers
Nurses assist clients to achieve their health-related goals including improving their relationships with others. Using intentionality, nurses work with clients to promote health when possible or, at the end of life, to promote a peaceful death. Each encounter with a client, regardless of how brief, is an important opportunity to develop a healing relationship. (Intentionality is defined as focused awareness accessing universal life energy in the present moment to promote client well-being and healing.)1 Therapeutic communication is an integral part of the nurse-patient relationship. It involves commitment and caring.2 It helps us to transcend the “doing” that is characteristic of task-focused nursing and to participate in the important tasks of “being” including finding meaning in our relationships with clients.1 The help that nurses offer to their clients is much more than technical expertise. The relationship between nurse and client is a powerful healing force by itself. This chapter focuses on the general nature of effective communication in the helping process.
Hildegard Peplau,3 the “mother of psychiatric nursing” wrote that “nursing is a human relationship between an individual who is sick or in need of health services and a nurse especially educated to recognize and to respond to the need for help.” Peplau also wrote that nursing is both educative and therapeutic. Every interaction between a nurse and a client includes a learning experience for the client about relationships—helping relationships in particular. If the client experiences a collaborative relationship with the nurse in which he or she is accepted and valued, the result will be personal growth and development. The client will be strengthened and better able to meet similar crises in the future.
Effective helping involves identifying opportunities for growth as well as problems. As nurses, we bring important knowledge and skills and offer them to clients who need help to understand their health and to act in ways that promote health. We provide the conditions for our clients to identify their goals and then help them to meet those goals.
Therapeutic communication, or the use of verbal and nonverbal messages to establish a therapeutic relationship, is also essential to the use of the self as an instrument of healing. Therapeutic communication will be explained in greater detail in this chapter and throughout this book.
How you view yourself will markedly affect your communication with clients. Remember that your self-concept affects the way you view the world and the way you communicate. Most of us have felt the discomfort of interacting with a person who continually apologizes for him- or herself, who distorts what we say, or who responds
with negativity and self-contempt. Each of us holds opinions and ideas about ourselves, but our essential self-worth forms the core around which those ideas merge. Negative self-worth is the most important factor that nurses must change in themselves to communicate from a healing perspective.
with negativity and self-contempt. Each of us holds opinions and ideas about ourselves, but our essential self-worth forms the core around which those ideas merge. Negative self-worth is the most important factor that nurses must change in themselves to communicate from a healing perspective.
To develop your role as an effective, compassionate communicator, observe people around you. Are there nurses who you think of as role models? Observe their communication styles and the reactions they receive from their clients. How would you characterize their interactions? How do they balance the demands of nursing tasks with presence and communication with clients? Are they satisfied with their role as nurses? Positive role models can challenge each of us to continue to develop our skills in relating to clients.
Nurse-patient relationships have been described over and over in the nursing literature.4 Assumptions underlying effective helping relationships in nursing include that the relationship must be
linear—allowing for progression through orientation, working, and termination phases;
based on client trust;
enduring in time;
cooperative (welcomed by clients who are willing to collaborate with nurses).4
Although these characteristics may be an ideal that nurses have come to expect, we will not always meet these expectations. In reality, nurses help clients even when the nurse-patient relationship is brief. It may involve one encounter that may last only minutes. Some nurse-patient relationships do not involve trust. Clients are sometimes uncooperative or even rejecting. Psychiatric nurses often encounter these conditions in their work with psychotic patients. In even the most challenging relationships, nurses can assist clients toward meeting their health-related goals. We can make the most of each interaction to provide care, healing, and comfort.
When the client’s and nurse’s expectations about the relationship differ, there is decreased client and nurse satisfaction. One example is the nurse who expects to be in control and the client who expects to be self-reliant. Nurses who are accustomed to a position of authority may insist on relating as an authority figure and rely on giving advice as a strategy for helping. Clients who are placed in a relatively powerless position will feel dependent and helpless. Many adults will feel resentful rather than grateful. Such interactions are troubling for both the client and the nurse. No person can take responsibility for another person. We can only take responsibility for ourselves. Sometimes clients do not have the ability to be in charge of their own lives—small children or adults who are unconscious, for example. Even then, we consider the perspective of the family.
Another example of a troubled interaction is the nurse who has a need to be told how helpful or even how irreplaceable he or she is to the client. In this case, the client’s needs become secondary and the nurse loses effectiveness. We cannot expect clients to meet our needs for approval and belonging.
Clients may come to us for many reasons, but the key questions remain: What are the health issues from the client’s perspective? And what are the client’s goals in the healing process? How can we partner with the client/family to resolve their health issues? Therapeutic communication is a strategy that supports the development of effective partnerships.
▪ THERAPEUTIC COMMUNICATION
Certain identifiable elements characterize therapeutic or healing communication. In the nurse-client interaction, the nurse:
Is fully present—Is totally focused on the client and his or her ideas about the situation. Does not get preoccupied with the client’s past or future or in the nurse’s own problems. Allows interaction with the client to command the nurse’s full attention.
Listens—Listens with the whole self to ascertain the client’s meanings and goals. Clarifies interpretations of what is heard. Resists categorizing or projecting personal beliefs and values. Resists giving quick advice or telling the client what to do.
Speaks—Communicates hope not just with an expression of ideas but with the ability to express those ideas from inner conviction to outer clarity. Self-awareness enables the nurse to articulate well thought-out ideas regarding the role of the client in the healing process.
Honors the client’s autonomy—Asks questions to ascertain the truth about the situation as the client perceives it. Communicates that the client is worth
listening to, that he or she has important information to add to this process. Conveys expertise, maintains confidentiality and informed consent.1,5,7
Thus, the therapeutic use of oneself includes communication that places the client in a position of informed equal, inevitably responsible for any positive outcomes in the helping process.
▪ A CLOSER LOOK AT INTERPERSONAL INTERACTION
A key element of therapeutic communication is having an attitude of respect for the client. Respect includes a nonjudgmental approach and a belief that the client is capable of learning and growing. Ultimately, clients are entitled to manage their own lives in a way that is best for them. As obvious as this may seem, it is not always easy to have a nonjudgmental attitude. This attitude of acceptance can be quite challenging when one disapproves of the client’s behavior. Approving of the client’s behavior is not the same as acceptance. It is not necessary to approve. It is possible to understand why the client has made certain life choices. For example, a client may be involved in an illegal activity and was raised in an environment where this activity was commonplace. It is still possible to respect the dignity and worth of this client as a person despite disagreeing with his or her lifestyle choices or behaviors. The nurse can practice being nonjudgmental by giving undivided attention when listening and by refraining from offering advice. Suspending judgment is facilitated by purposefully viewing the situation from the client’s point of view.
There are several possible interpersonal processes within the nurse-client relationship that must be understood.
Sympathy involves having similar feelings about something. If the nurse is in agreement with the client’s feelings, the nurse experiences sympathy. The nurse can feel joyful about the client’s success or feel sadness about the client’s bad news. This is sympathy, or “fellow feeling.” It is very commonly felt in health care and it is appropriate in the healing relationship with clients.5,6
Pity, on the other hand, rarely, if ever, is appropriate. When a nurse pities a client, he or she feels sympathy with condescension. “You poor thing,” conveys an inappropriate inequality between the nurse and the client. It demeans the personhood of the client. Pity may draw us to help others, but to help with condescension gives the message to the client that the nurse is judging him or her to be “pitiful.”5,6
Identification can interfere with healing communication as well. When the nurse identifies with the client, he or she begins to feel at one with the client. In that process, he or she may lose sight of their differences. For example, just because the nurse and client both have the same last name or both come from similar backgrounds does not mean that they do not have different values about health care. The nurse may assume that the client wants to know everything there is to know about a disease or disorder because that is what the nurse would want. The nurse may project his or her values onto the client and act in ways that make the client less important or less relevant to the healing process.5,6
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