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Get Real

October 21, 2014

Some years ago, when I was doing a Masters module on Women’s Health, the class was given a couple of newspaper articles to read. The first one dated from somewhere around the middle of the twentieth century and told sad the story of a new father who, hoping to be present at the birth of his child, had instead had the door of the labour room slammed in his face because at the time such things ‘simply weren’t done’.

The second article was also about a father’s experience of childbirth, but was more recent. By the time it was written, social mores had been turned on their heads and paternal presence at the birth, once unconscionable, was now more-or-less obligatory. But this particular man, for perfectly good reasons, felt that he would rather wait outside – only to find himself hustled willy nilly into the delivery suite because for the expectant father to absent himself ‘simply wasn’t done’.

There were two messages. Firstly, that one size never fits all. However much we try to channel everyone along the broad highway of approved social narrative, there will always be some who – whether they express their disagreement loud and proud, or limit themselves to silent despair – are more at home in the back alleys of subversion. And secondly – all areas of life are subject to change. What we should be asking is: what drives these changes?

Thirty years ago, ‘professional distance’ was considered the only basis for the nurse-patient relationship, and as students we were constantly reminded that the one pitfall we should avoid at all costs was ‘getting emotionally involved’. But in recent years – at least, this is the impression I get from nursing conversations on Twitter – ‘professional distance’ has become something of a dirty word (or phrase if you prefer): on the odd occasion when I’ve used it myself, I’ve been greeted with howls of incredulity. These days, the consensus is that nurses should aim for a more collegiate relationship with service users, to be achieved through the use of quasi-psychological tools such as compassion, empathy and authenticity. But is this what’s happening on the ground?

Last weekend, I got involved in a fairly lengthy Twitter conversation about the essence of communication. The starting point was that it’s a ‘natural’ skill which should not need to be taught. One contributor lamented the ‘contrived’ nature of much of what passes for patient/professional interaction these days and (in a comment with which I had some sympathy) observed that ‘it feels radical to relate normally now’. Someone else suggested a ‘get real’ campaign to ‘change the way communication is taught’. Anecdotally at least, it seems fairly clear that despite all the fanfare of 6Cs, health care professionals are still regularly failing to get communication right. So is ‘real communication’ the solution we’ve been looking for?

It all depends, of course, on what you mean by ‘real communication’. One possibility put forward by my Twitter friends was that ‘real communication’ means ‘engagement, playful attention, with humour…short cut to connection’. I don’t, as it happens, have a problem with any of that; it’s exactly the kind of light-hearted banter about the weather or last night’s crap TV that I often use when getting to know my patients. What I have a profound problem with, however, is the word that was – in all seriousness – agreed upon as a good way of summing it up: flirtation.

For anyone who doesn’t know what ‘flirtation’ means, here’s the primary definition from the Online Dictionary: ‘behaviour that demonstrates a playful sexual attraction to someone’. That’s right: ‘playful sexual attraction‘. People, how can this possibly be appropriate behaviour for a health care professional? Even if you concede that the accent should be on ‘playful’ rather than ‘sexual’, the word will always carry sexual connotations and for that reason is wide open to misinterpretation. For nurses, it also flatly contravenes article twenty of the Code of Conduct (You must establish and actively maintain clear sexual boundaries at all times with people in your care, their families and carers). And to plead that ‘women want to be recognised as women’ is just…creepy.

Because the push for ‘compassionate care’ has, apparently, not fully delivered the results we want, or has not delivered them evenly, one reaction is to argue that we have not yet succeeded in bringing sufficient emotion into play – we need to ‘love’ our patients, and now it seems we need to ‘flirt’ with them too.

I’m not convinced by this. I think the problem is more that many nurses feel so cowed by firstly by patients’ rights to make complaints and secondly by the suspicion that management will almost always side with patients over them (I’m aware that patients’ groups will dispute this, but my guess is that it’s the way many staff see it – perhaps nurses and patients have more in common than they think!) that interactions between nurses and patients are often characterised by, at best, caution, and at worst, by outright fear. This is the state of mind that lies behind the ‘contrived’ communication – the same state of mind that has necessitated the introduction into nursing of of semi-scripted conversations (‘hello my name is…’).

The reality is that the empowered consumer (or goods or services) is here to stay. Firstly because ‘consumer choice’ is one of the main drivers of the free-market economy, but also because it is patently desirable for individuals to be in charge of their own destinies. But it is disingenuous to believe that a major shift of power and focus within the health service can be achieved without pain being felt somewhere. The problem for nurses and other front line health care workers is that there is no language to articulate this pain. Fear of appearing (Heaven forbid) ‘anti-patient’ means that it cannot even be recognised.

The result is that while many nurses do indeed embody the compassion and deep engagement that is the public face of nursing, many others continue to cling to professional distance as their most readily-available defence against anger and confrontation that has no official existence. I want to be clear that I am absolutely not arguing for a reduction in patients’ rights; nor am I arguing that patients should not be equal partners and as involved as they want to be in decisions about their care and treatment – quite the reverse in fact. What I am arguing is that this can’t happen unless we are honest about the effects of the disempowerment that many nurses feel.

If the future of nursing is as enabler and facilitator of empowered patients, we need to be clear about the challenges this entails. Tutting and sighing that communication should be ‘second nature’ is all very well when it’s only a bit of sociable moaning about the weather or crap TV, but knowing how deal professionally with an arrogant or patronising man who knows far more about his condition than you do is a skill few are born with. Yet these people exist. Now, where did I put my false eyelashes?

  1. Barbara Bradbury, Halland Solutions permalink

    Knowing how to deal with an arrogant man or woman, expert patient or not,is a skill many people don’t have. As for being flirtatious – I almost can’t believe I read that! The fact is, most health care professionals need to learn how to communicate appropriately with patients – and staff colleagues.

    • Hi Barbara, thanks for commenting. I too was rather surprised that ‘flirting’ could be seriously proposed as a strategy for better communication – and even more surprised that others seemed to think I was being unreasonable when I queried it!
      My personal experience has always been that talking to patients/service users about ‘normal’ things is a good way for a professional to make contact and demonstrate shared human values, and to establish a basis for discussion of more difficult subjects at a later stage if need be. But time pressures mean that nurses often get little opportunity for this kind of background social chit-chat.
      Being thrust into a major, ‘big issues’ conversation with someone you have had very little chance to get to know is a difficult proposition for anyone – and this is one area where I think the trend for personal care to be delivered by health care support workers rather than trained nurses is causing problems.
      I absolutely believe that to successfully navigate the particular set of circumstances outlined in the piece, communication training is not only desirable, but essential. As much as anything else, it’s about understanding your own reactions and learning strategies for keeping the less helpful aspects under control. Saying we should simply be ‘normal’ or ‘natural’ is no help when one finds oneself in these situations. My ‘natural’ impulse outside work when confronted with the arrogant man or woman might well be sarcasm. But I don’t think anyone’s going to be advocating that as an appropriate professional response.

  2. Reblogged this on LYPFT Planning Care Network and commented:
    Interesting piece about nursing – communication, engagement and the empowered service user – does this resonate with mental health nurses?

  3. Hi Donna! Thanks for re-blogging. Glad you found my post interesting.

  4. YES to Exploration – NO to Flirtation

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