By: Dr Jennifer Tylee

This module deals with two variables that need to be considered in interpersonal interactions with patients. These variables are age and health. Relating to children is different from relating to adults and the elderly. Similarly, the health/illness circumstances that surround the nurse-patient relationship will influence the interaction. For example the emotions involved when a patient is in the terminal stages of a disease are different from those when patients are receiving health education. The interactions and therefore the relationship between the patient and the nurse will vary according to the patient’s age and health.

At the completion of this module you will be able to:

1. Outline the impact of cognitive development, and psychosocial development on interpersonal interactions.
2. Outline the impact of ageing on interpersonal interactions.
3. Outline the impact of the experience of illness on the nurse-patient interaction.
4. List practical steps for interacting with the blind, deaf and speech impaired.

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Effective communication with children, adolescents, adults and the elderly all contain three qualities: genuineness, non-possessive regard and empathy (Bolton, 1986,259).

Genuineness means to be who and what you are; being honest about your feelings, needs and ideas.

Non-possessive regard involves accepting, respecting and supporting another person in a non-paternalistic way.

Empathy is the ability to really see, hear and understand from another person’s perspective.

These variables are the same no matter which age group is being considered. However there are a number of differences in relating to the different age groups that need to be considered.

Relating to children is different from relating to adults in that children have a limited amount of experience with health care institutions and they have cognitive structures that make it more difficult to assimilate new experiences and information. An understanding of the major theories of child development provides a framework for interacting with children.

You need to become familiar with Piaget’s theory of cognitive development and Erikson’s theory of psychosocial development. What is presented in this module is a summary and is to be considered a starting point.

All children do not go through the same stages at the same ages but they do pass through them in the same order.

As the child passes through the stages they change from an organism incapable of thought and dependent on the senses and motor activity to know the world, to an individual who is capable of great flexibility of thought and abstract reasoning.

Piaget’s stages of intellectual development (Richmond, 1970) are presented in the following table.

An understanding of the child’s cognitive development provides a starting point when deciding how to discuss particular subjects with children. Stein-Parbury (1993, 257 cites Ross & Ross, 1984) who suggest that children often perceive that health care workers do not tell them the truth. However, in order for the truth to be heard by the children it needs to be couched in terms that can be absorbed, and in a form that is relatively compatible with the child’s view of the world. Bibace and Walsh (1981 in Stein-Parbury, 1993, 257) provide examples of how children view illness and disease. This is based on Piaget’s understanding of cognitive development. Bibace and Walsh (1981) have two sub-stages in Piaget’s pre-operational, concrete and formal operations stages. These sub-stages and examples of the thinking from these are presented in the following table.

Psychosocial development

Another important factor to be considered in the interaction with children and adolescents is their level of psychosocial development. Erikson (1965, 239-266) presents the eight stages of man (sic). This is a theory of the psychosocial development of humans. It is concerned not only with the developmental needs of children but the themes that are current throughout life. Like the stages of Piaget the age timing of Erickson’s stages varies and there is a need to complete the previous stage before a person is able move onto the issues of the next stage. Erickson considers that people can become stuck when the tasks of a previous stage have not been completed.

Erikson’s Psychosocial Stages

This demonstrates the psychosocial issues that are common at the various stages and the aspects of the stage that need to be resolved before the person can move onto the tasks of the next stage.

These stages need to be taken into account when a nurse interacts with patients. An infant will be developing basic trust and will need to have the reassurance of the primary caretaker’s (usually the mother) presence when procedures are undertaken. An adolescent will want to be fully included in any decision making. This is a part of their increasing self-identity.

Interacting effectively with the elderly involves an understanding of the issues and difficulties faced by the elderly in our society. The difficulties according to Stein-Parbury (1993, 260) include:

1. Physical losses that are often associated with aging (including declining health and the loss of partners and friends).
2. Generational differences in worldviews. Our views of the world are shaped by the circumstances surrounding our life. A person who grew up in poverty due to the unemployment in the depression and then faced World War II will have a different worldview from someone who grew up in prosperity in the 1950s and 1960s. In addition to this a young person tends to live in the future whereas the elderly person lives in the past. Reminiscing is important for the resolution of the integrity vs despair issues in this life stage (Erikson, 1965). It has been found to be therapeutic for the elderly to be able to talk about their past. Listening to the life stories of the elderly enables nurses to gain an insight into the patient’s worldview.
3. An ‘ageist’ society with the accompanying social and economic losses.

Exercise:

Outline ways that nurses can reduce interaction difficulties with their patients that are due to generation’s differences in worldview.

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Calnan (1983, 64) suggests a number of practical measures to undertake when interacting with the hearing impaired.

1. Most people with a hearing deficiency can lip read to some extent if they can see the speaker’s mouth so be sure to stand in front of the patient.

2. Speak slowly, but not loudly, and do not contort your face or exaggerate your lip movements.
3. Stop talking when moving away from the patient or moving behind them and tell the patient what you are going to do before you move.
4. Make sure the patient can see you when you talk and does not have to face a bright light.
5. Make sure there is no unnecessary extraneous noise in the room. Even people with normal hearing tend to loose half of what is said in a noisy environment.
6. Use appropriate non-verbal language to reinforce what you are communicating.
7. Use creative means such as pictures, writing or drawings and so forth to communicate the meaning.

A review of module 4 will indicate the level of importance that is attached in communication to the non-verbal aspects of interpersonal interaction. The person with sight impairment has fewer non-verbal cues as to what is actually being communicated. Calnan (1983, 64) suggests some practical steps that can be undertaken by the nurse to limit interaction difficulties with the visually impaired.

1. The visually impaired can hear so talk to the patient directly, but not loudly.
2. Greet the patient with a handshake or a touch on the arm, say who you are and mention others around you.
3. Always say what you are doing and what you are about to do and mention the objects that you place near the patient.
4. Make sure there is no unexpected equipment or steps when you move a visually impaired patient.
5. If you want the patient to move, for example to a chair, ask them to stand and give them your arm to hold. Don’t attempt to steer the patient as you would a car. When you reach the chair place the patient’s hand on the chair and allow them to seat themselves in their own way. (This is provided they don’t also need your assistance with mobility.)

The speech impaired refers to those who have lost their speech after a stroke, those who can manage a few words and those who can speak reasonably well but with an impediment. Some may have difficulty with expressive speech (that is, they know what they want to say but they have difficulty finding the words) and others with understanding language. It is important to distinguish the two. Calnan (1983, 65) provides the following guidelines when interacting with the speech impaired.

1. Speak more slowly than normal and face the patient so that they have the benefit of lip reading and facial gestures to help with the meaning.
2. Treat the patient with respect and pay attention when the patient is speaking. The speech may be laboured and somewhat slower than normal. It is important to listen attentively so that you are able to understand what the patient is communicating. Do not try to finish what the patient is saying for them – be patient and relaxed. Give the patient the time to find the right word.
3. Where appropriate, encourage the patient to write down what they have to say.
4. Do not pretend to understand the patient when you do not.
5. Speaking can be tiring for patients so give them a rest when asking a lot of questions.
6. When it is appropriate keep the questions straightforward so there is no need for a choice. In this situation it may be better to ask yes/no questions than questions that require the patients to formulate a lengthy response.

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Considering the patient’s health

The circumstances that surround the patient’s interaction with the nurse affect the type of interaction that is possible and the subsequent relationship between the nurse and patient. For example, a patient who is critically ill will interact differently from one who is attending a health eduction session. In this example the physical care would be different but also the level of emotional involvement would be greater with the patient who may be living with the knowledge they are dying (Stein-Parbury, 1993, 272).

Illness, especially a significant illness, is a stressful event. Interaction with the nurse can assist patients to mobilise their coping abilities so they are able to effectively manage the challenges and demands of illness. Understanding the nature of illness experiences will enable nurses to provide effective assistance (Stein-Parbury, 1993, 287).

Benner and Wrubel (1989, 88 in Stein-Parbury 1993, 287) state "When illness strikes, the illness and possible ways to cope with it are understood in the light of personal background meanings, the situation and the ongoing concerns in the patient’s life." Every illness has a story in terms of the relationships that are disrupted, the plans that are spoilt, and the symptoms have a meaning of their own depending on what else is happening in the patient’s life.

In tutorial session 3 you explored the nature of perception as it related to interacting with others. In the same way as we build our perceptions of others we build perceptions of life events such as illness. We attach a meaning to the event and the way we perceive the event affects our reaction to the event. When interacting with someone who is ill it is necessary to understand how the patient is experiencing and perceiving the illness. Some of the perceptions are as follows:

1. As a threat – that the person’s life may no longer be the same; that they may not be able to carry out the plans that have been laid; that the body may not be able to function as it used to. This sense of threat is often accompanied by anxiety and fear that may become distressing for the patient.
2. Denial – this is used as a means of containing the anxiety associated with what the patient perceives as consequences of an illness. Denial provides a buffer from the patient’s perceived reality. There is often an automatic response on the part of nurses to challenge the denial as it is frequently seen as an ineffective coping mechanism. However before proceeding it is necessary for the nurse to consider the meaning of the denial for the patient and what perception the nurse has for the ‘ideal’ patient coping approach. It may be that the patient is not yet ready to face the challenge of reality.
3. As a challenge – this is seen as an opportunity for personal growth and development in terms of understanding. An illness presents challenges to the patient and accepting the illness with this perception means that the demands of the illness will be faced with a ‘fighting spirit’.

There are common themes that run through all serious illnesses. These themes are:

1. Uncertainty – Questions such as What is wrong? Will I recover? Can I manage? and so forth are a part of the illness experience.
2. Vulnerability – this is a feeling that one’s capacities are insufficient for dealing with the situation.
3. Loss – is often experienced as a part of illness. The losses include: the ability to achieve life goals; the functions of parts of the body; freedom and so forth.
4. Grief – this is connected to the experience of loss. The more significant the loss to the patient the greater the grief. It is a part of the process of mourning, reflecting and eventually proceeding with life even though that life may not be the same as it was before the loss. Some of the feelings associated with grief include: numbness, tightness in the throat, pining and searching, anger and depression.

Exercise: Themes in Illness

A. Read the following patient statements and identify the theme they each contain, that is, either:
    (U)ncertainty,
    (V)ulnerability,
    (L)oss, or
    (G)rief.

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There are many factors to be considered when interacting with patients and two of these are their age and health status. Interacting with children is different from interacting with adults because their cognitive structures make it more difficult for them to assimilate new experiences and information. As well as considering a child’s cognitive abilities their psychosocial development and the issues that are relevant to the various stages of development also need to be taken into account. An individual’s psychosocial development proceeds throughout life and an elderly person will be dealing with issues associated with the worth and uniqueness of their life. Many elderly are however faced with loss and ageist attitudes. Some of the losses can be in sight, hearing and speech.

As well as considering age related issues when interacting with patients it is necessary to consider their health status. All illness, especially that of a serious nature, carries with it certain experiences. These may include the feelings of loss, grief, uncertainty and vulnerability. How the challenges of an illness situation are met by a patient will often depend on their perception of the nature of the illness. The nurse needs to understand how the patient views their illness in order to be able to assist them in the process of handling the challenges that are presented by the illness.

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Additional Reading and Exercises

1. Read Chapter 9 Considering Patient Health Status in:

Stein-Parbury, J. 1993, Patient and Person: Developing Interpersonal Skills in Nursing, Churchill Livingstone, Melbourne.

2. Read either Section 1 in:

Richmond, P.G. 1970, An Introduction to Piaget, Routledge & Kegan Paul, London.

        or Chapter 7 Eight Stages of Man in:

        Erikson, E.H. 1965, Childhood and Society, Pelican, London.

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Bolton, R. 1986, People Skills: How to Assert Yourself, Listen to Others, and Resolve Conflict, Simon & Schuster, Sydney.

Calnan, J. 1983, Talking with Patients, William Heinemann, London.

Erikson, E.H. 1965, Childhood and Society, Penguin, London.

Richmond, P.G. 1970, An Introduction to Piaget, Routledge & Kegan Paul, London.

Stein-Parbury, J. 1993, Patient and Person: Developing Interpersonal Skills in Nursing, Churchill Livingstone, Melbourne.

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