How can unintentional communication affect the welfare of others? Consider the following example.
Vignette Keeping up appearances
Aisha is in the second year of her nurse training. She moved to live in university accommodation from where she travels to her placements. It is the first time that she has lived away from home and has had to take responsibility for her day-to-day living arrangements. She is considered to be a competent and caring nurse. When she is getting ready to travel to the hospital for her shift one morning she realizes that her uniform dress is rather crumpled, but as she has to catch a bus she does not have time to iron it. She arrives at work on time but her unironed dress makes her look rather unkempt.
Is the state of Aisha’s dress an ethical issue? On one level no−she is on time and ready for work, and she is likely to be able to complete her work in a satisfactory manner despite looking rather untidy. She is judged a competent and caring nurse, which ought to be enough. She will gain experience in the delivery of care and also provide, as a part of this, some contribution to the care of patients. However, it is not merely a matter of being able to complete her work in a purely practical way.
One aspect of her role is gaining and maintaining the trust of her patients−she is a representative of the nursing profession while at work. On this basis she runs the risk of creating a bad impression and undermining the confidence that patients and colleagues have in her. If patients are put off by her appearance, or feel that she is behaving in an unprofessional way, she may not be able to gain their confidence and work as effectively. While this may seem trivial, consider the following patient perspective.
Patient perspective
The comments made by Lord Mancroft on his experience while a patient in hospital suggest that this unintentional aspect of non-verbal communication is more important than we might realize. Speaking in the House of Lords about his time in hospital he described nurses as ‘mostly grubby, with dirty fingernails and hair. . .slipshod, lazy and worst of all drunken and promiscuous’ (Hansard 2008). He went on to add that as a patient in hospital he noticed that when lying in bed with nurses on each side he felt that they spoke to each other as though he were not there.
Whether Lord Mancroft’s observations are an accurate reflection of nurses and contemporary nursing practice can be debated; however, they are based on a pa- tient’s personal observations of nurses in practice, their appearance and conversa- tions. They demonstrate the way behaviour and conversations are interpreted and understood by those around us and hence the importance of non-verbal communi- cation. They also show that the most significant component of this can be entirely unintentional. Aisha, like many other nurses, would be mortified by an assessment such as Lord Mancroft’s, however, it makes clear just how important attention to minor details can be.
Reflection point
r Was Aisha’s approach and attitude unprofessional?
r Should her mentor comment on the importance of being smartly turned out?
Even if we think of ourselves as open minded and liberal in our attitudes, we still have clear expectations of those who present themselves to us as professionals. We expect them to be courteous and neatly dressed, to notice that we are present and conduct themselves in what we consider to be an appropriate fashion. This is often conditioned and conventional but that does not make it unimportant. While we may be happy to talk to a car mechanic in oily overalls or discuss our plans for home improvements with a builder in clothes which indicate he has just come from another job, we would not be comfortable to see a consultant surgeon or a nurse in a clinic wearing blood-spattered clothing. As noted above, this is not just a nicety but a reflection of what we consider to be reasonable expectations and a means of gaining our trust. In addition to being competent in a practical sense, Aisha needs to recognize and meet the expectations of her patients in terms of her appearance.
A further aspect of interactions with patients at this level concerns the way we react to them and their problems. Most of us feel either frightened or awkward when we need to seek the support and help of others in relation to our health. We feel reassured by professionals who are not disturbed by our medical problems but take them in their stride.
Vignette Establishing trust and confidence
Carly was asked to attend to Simeon, who was recovering from major surgery for bowel cancer. He had a colostomy and a wound infection. Simeon was not yet able to attend to his own colostomy and both this and the wound infection gave rise to very unpleasant odours. Grace was asked to assist Carly and when the dressing was to be removed for changing, Grace immediately looked away, murmured that she could not stay and promptly left the room.
As with Aisha in the first vignette, there is an ethical dimension involved here.
A key element of providing nursing care is that of being able to establish and maintain the trust and confidence of patients. Simeon needs to feel his problems are not so awful that others cannot cope, especially those who are expected to deal with his care. A nurse who induces concern or embarrassment in her patients by her reactions is behaving in a way that is in a very real sense unethical, in much the same way as the flight attendant who lost her nerve in unexpected turbulence on a transatlantic flight and began screaming, ‘We’re crashing!’. One of the passengers commented later that passengers expect flight attendants to be able to reassure them in such situations rather than induce uncertainty and panic (Hickman 2006).
Both Aisha’s crumpled dress and Grace’s sudden departure reflect unintentional rather than intentional communication and should be judged accordingly. In an- other context they would simply be regarded as aspects of professional etiquette, rather than being seen as communication. It should be clear that this distinction is more imaginary than real and that lack of attention to detail or sudden and un- expected reactions by nurses and other health professionals can be interpreted as disinterest or distaste by those who depend on them. Medicine has been described as a paradoxical art (Weston 2009) and nursing can be viewed in the same way.
Gabriel Weston suggests that a good doctor needs to be able to get close enough to patients for them to feel able to disclose important and personal information and yet remain distant enough to be unaffected. Nursing is similarly paradoxical.