Assessment and communication in nursing inevitably involve dealing with per- sonal information, sometimes discussing issues that are sensitive in nature. Hence, nurses must show respect, use tact and diplomacy, and take care around the bound- aries people use to protect themselves. First and foremost, self-awareness on the nurse’s part is essential. The ability to establish trust combined with finely-tuned listening and observation skills is critical (Harris 2007). To make this less abstract, consider the vignette below.
Vignette Family matters
Robert Thurston, a self-employed painter and decorator, has been admitted today with a diagnosis of acute chest infection. He is aged 64, married to Mar- garet, who is 20 years his junior and has an 18-year-old son called Peter from a previous marriage. Mr Thurston is an ex-smoker, weighs 100 kilograms and is 1.72 metres tall.
He was diagnosed with asthma five years ago and has had two related admis- sions. For the past few days he has had difficulty managing his self-care because
of the chest infection. His respiratory rate is now around 24 per minute and he appears comfortable while sitting upright in bed. He has a productive cough and has requested the commode twice since his arrival.
Mrs Thurston has spoken with staff and says they are both worried about the financial implications of Robert being off work. The couple recently moved and were hoping to retire soon, handing over the business to Peter. Peter, however, has stated that he intends to go to university before following into the business.
Just as she is about to leave the ward, Mrs Thurston also says that she thinks her husband needs a laxative.
Activity
r Having read through the above, identify the questions you would like to ask Mr Thurston.
r Make use of the activities of living listed in Chapter 1, Table 1.2, to group your questions into a list.
r From your list, identify the issues that would be the most sensitive.
r Ask yourself if there are any questions that you would not wish to ask and, if so, why that might be the case.
A sensitive issue can be defined as any matter a person finds difficult to discuss publicly or causes them some degree of embarrassment or emotional discomfort.
However, knowing which issues are sensitive to a person is not always straighfor- ward. Different people find different issues sensitive – almost any personal topic has the potential to be ‘sensitive’. In fact, few people feel comfortable discussing private areas of their lives, even with their partners, closest friends and family.
Patient perspective
A patient like Mr Thurston might be thinking, ‘I hate being in hospital. I am sure my coughing keeps the others awake. The stuff I cough up is nasty and it’s really embarrassing for me to have to spit it into a pot. I feel for the nurses having to look at it. . .I just wish I was well enough to go home and do things for myself. . .’
Working in healthcare and regularly meeting people with health problems, it is easy to become desensitized to these issues. However, we must never forget the personal nature of the matters we discuss and how this can threaten dignity if not handled with care.
Some areas are, of course, known to be sensitive. Cultural mores dictate the ac- ceptable or unacceptable areas for public discussion. For example, we tend not to
talk about using the toilet, personal sexual activity or even personal hygiene. In nursing, because these areas may be associated with health, we may have licence to mention them – but only when there is clear relevance to health problems and nursing care (Field and Smith 2008; Kozier et al. 2008) (see Chapter 1).
Looking at the activities of living, areas such as ‘expressing sexuality’, ‘elimi- nating’ and ‘dying’ may immediately stand out, but all the others are potentially sensitive too. Take for example the activity of personal cleansing and dressing. A discussion of this may impart values about frequency of washing or changing of clothes. Questions about cleaning teeth or washing hair can be similarly awkward, especially if the patient wears a wig or dentures and feels concerned about their appearance.
Careful observation and listening will usually give a cue that a topic is difficult territory for the patient. There may be, for example, a change in the person’s body language, their posture may close or seem guarded, they may avoid eye contact or blush. Other obvious signs include inappropriate laughter, uncomfortable coughs or deliberate changes of subject.
Awareness of our own boundaries is important too. Knowing what we feel happy to discuss sometimes helps us to understand the information others are happy to share. The framing of questions is crucial – if people are asked open-ended ques- tions and are not rushed, they may respond more freely. Using a non-judgemental approach coupled with active listening is important.
Knowing how to tackle embarrassment is also important. Sometimes a very matter-of-fact approach is helpful. This means being direct but respectful−never badgering or labouring a point when someone is obviously embarrassed.
Sometimes, a topic should be left until a person has had a chance to compose themselves or think through their answer. It is quite acceptable to say something like, ‘I noticed you needed the commode twice today and wondered if you have a problem with your bowels?’. If the patient says a hurried and uncomfortable ‘No’, accept this (it is something you can return to later), thank them and say something along the lines of, ‘Okay, but please let us know if you need any help.’
In many ways, effective communication in sensitive areas is about giving people permission to say something they believe is impolite or indelicate, or may show them in an unfavourable light. That does not mean health professionals should tolerate lewd or offensive language, it simply means respecting the individual’s dignity, taking their problems seriously and responding with maturity and genuine concern.
Another of the issues raised in the scenario was the Thurstons’ concerns about financial matters. The reason this may be sensitive is that Mr Thurston’s wife raised the issue, not him. It may be that he is neither concerned nor embarrassed to discuss this. The problem, however, is one of collusion. Mrs Thurston is asking staff to be aware of a possible problem, but it is not clear if her husband has agreed to this.
The tensions arising from this type of scenario are all too common in health- care. On the one hand, relatives and carers are great sources of information and contribute significantly to the assessment process (Holland 2008; Duffy 2009). Re- specting their input is essential – nurses need to show that they value it and listen
carefully to any concerns they raise. However, on the other hand, nurses should avoid situations where patient information is discussed away from the patient or without the patient’s consent. There is a fine line between giving comfort to a relative and breaking the trust a patient has shown in the professional responsible for their care.
Sometimes nurses can feel out of their depth when dealing with sensitive issues.
It is therefore important to know how and when to refer an issue to others with more expertise. Nurses are in a privileged position; patients often share intimate information, sometimes without any prompting. However, if the issues raised re- quire a level of expertise beyond our own, we must use others within the team – either more experienced nurses or colleagues from other professions.
One final point in this section – there is a need to carefully think through the information asked of patients. They are under no obligation to tell staff more than they wish, and although we may be involved with very personal matters, this does not give us the right to pry. Assessment may cover areas from dying to expressing sexuality, but this does not mean that we can blunder in and question indiscrimi- nately.