Communication in Palliative Nursing PDF

Communication in
Palliative Nursing
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Communication in
Palliative Nursing
Elaine Wittenberg-Lyles
Joy Goldsmith
Betty Ferrell
Sandra L. Ragan
1
1
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Library of Congress Cataloging-in-Publication Data

Communication in palliative nursing / Elaine Wittenberg-Lyles . . . [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN: 978-0-19-979682-3
I. Wittenberg-Lyles, Elaine.
[DNLM: 1. Nursing Care—methods. 2. Palliative Care—methods.
3. Communication. WY 152.3]
LC Classification not assigned
616.02'9—dc23
2012021001
9 8 7 6 5 4 3 2 1
Printed in the United States of America on acid-free paper
iv
contents
Foreword vii
Nessa Coyle
Preface ix
Acknowledgments xvii
1. Defining and Understanding Communication 1
2. Communicate 23
3. Orientation and Opportunity 59
4. Mindful Presence 93
5. Family 119
6. Openings 151
7. Relating 187
8. Team 225
9. Communicating Self-Care Needs 253
Index 273
v
foreword
Nessa Coyle
Communication is a powerful therapeutic tool. When used well communication can

empower patients and families with a sense of control; it can reduce uncertainty and
provide a basis for action. Effective communication creates an environment of safety,
trust, and hope in times of crisis and threat. The practice of thoughtful clinical com-
munication has the power to strengthen the patient/nurse relationship. In contrast,
inattentive communication may deprive the patient of hope, create loss of control, and
silence the patient’s voice. If the patient and family story is never elicited, queried, or
engaged, the quality of care delivered can be diminished and the cost for the institu-
tion, exponential. This is especially salient during end-of-life care when nurses face
decisions that become memoralized by the patient and family.
Communication is a continuous process of making meaning, occurring con-
sciously and unconsciously, verbally and nonverbally—think of the power of com-
munication as its own clinical practice. Communication is central to nursing care,
especially in the setting of progressive disease that will end in the patient’s death. All
interactions between the patient and health care team are mediated through com-
munication. A function of clinical communication is to reduce uncertainty and to
provide a basis for action. Ineffective communication can increase anxiety, impede
action, extinguish hope, and lead to a diminished sense of personal dignity as well
as feelings of abandonment. Unproductive communication can cause more distress
and suffering for patients and their families than anything other than unrelieved
physical pain. Because the nurse is at the hub of an interdisciplinary palliative care
or hospice team—the channel through which the expertise of various team members
is often brought to the bedside—the ability to communicate skillfully with the team
is also essential.
How do we communicate—how much does it matter—how can we do better?
Elaine Wittenberg-Lyles, Joy Goldsmith, Betty Ferrell, and Sandra Ragan recognize
that nothing deserves higher priority than effective palliative care communication and
have taken up the challenge. They begin by exploring a number of myths about what
constitutes effective communication and the definition of communication itself, pre-
ferring to define communication as “the mutual creation of meaning by both commu-
nicators.” The authors of this volume acknowledge that communication that enables
transitions in care and at the end-of-life is difficult but can be taught. They outline
vii
viii foreword
a holistic communication model—COMFORT—an acronym for seven principles

designed to be taught and implemented in palliative care communication and end-
of-life communication. Case examples are liberally used to illustrate each component
of the model and to guide the nurse through the process. This is a necessary book and
has been long in coming.
preface
The field of palliative care espouses the importance of interdisciplinary care, and this
book is a product of the blending of disciplines. It began in 2010 when two scholars
with doctoral degrees in communication (Elaine Wittenberg-Lyles and Joy Goldsmith)
approached a palliative care nurse researcher and educator (Betty Ferrell) to suggest
that perhaps a different paradigm should be applied from their field of communica-
tion to understand and advance the concept of communication in palliative nursing.
Through their innovative and provocative research in areas such as communication
in hospice settings and interdisciplinary team meetings, Wittenberg-Lyles, Goldsmith,
and their mentor, a senior scholar in health communication, Sandra Ragan, began to
question existing thought and literature related to communication in palliative nurs-
ing. Thus began the collaboration that led to this book and a new way of approaching
the essential concept of communication in palliative nursing.
The chapters of this book are organized according to the elements of the commu-
nication model, COMFORT, developed by these communication scholars (Ragan,
Wittenberg-Lyles, Goldsmith, & Sanchez-Reilly, 2008; Wittenberg-Lyles, Gee, Parker
Oliver, & Demiris, 2009; Wittenberg-Lyles, Goldsmith, Demiris, Parker Oliver, & Stone,
2012; Wittenberg-Lyles, Goldsmith, & Ragan, 2010; Wittenberg-Lyles, Goldsmith,
Ragan, & Sanchez-Reilly, 2010; Wittenberg-Lyles, Goldsmith, Sanchez-Reilly, & Ragan,
2008). Each element is described in detail with supporting communication theory,
empirical support, clinical evidence, and case examples. Collectively these elements
challenge the notion that communication is simply sending and receiving information
or that communication in palliative care is limited to breaking bad news. The intent
of this book is to present the COMFORT model as a more honest representation of
communication in palliative nursing. Through application of the model, our hope is
to improve the care of patients and families while advancing our professional practice.
In much the same ways that we move from novice to expert palliative care nurses by
refining our skills in symptom assessment, care of the physical body, pain management
practice, or grief interventions, we also become expert practitioners through develop-
ing proficiency in communication (Dahlin, 2010).
A critical reality, reinforced in this volume, is that no aspect of expert palliative
nursing practice can be realized without proficiency in communication. Pain manage-
ment requires skillful communication to assess the patient’s pain, identify and over-
come fears of addiction, and provide information about optimal use of analgesics and
management of side effects. Similarly, compassionate, skillful listening to the family
caregiver’s grief, hearing the depth of his or her emotion, and responding verbally and
nonverbally with communication that validates the loss and the suffering of the loss
ix
x preface
are key to quality palliative nursing care. For every aspect of palliative nursing care,
communication is not only key, but it is also the foundational substance upon which
other critical nursing practices depend.
CLINICAL PRACTICE GUIDELINES FOR QUALITY

PALLIATIVE CARE
In 2006, a consortium of the leading palliative care organizations in the United
States developed clinical practice guidelines in order to establish quality standards
for the practice of palliative care (National Consensus Project for Quality Palliative
Care, 2009). This National Consensus Project (NCP) effort was intended to pro-
vide shared definitions of the domains of palliative care and to challenge organiza-
tions to “reach” to a higher level to promote increased quality in this developing
field. The NCP guidelines define each domain but ultimately create the whole con-
cept of quality palliative care.
The NCP guidelines are expressly intended as an interdisciplinary document, rep-
resentative of the inherent interdisciplinary nature of palliative care, which has been a
fundamental characteristic of our field since the origins of hospice as conceived by our
founders including Dame Cicely Saunders, Balfour Mount, Florence Wald, and others
who challenged the ways that care was provided to the dying (Coyle, 2010). The NCP
guidelines direct the interdisciplinary team but also hold special significance to nurses
as the providers most often at the bedside of patients and families across all settings
of care from diagnosis to death. The NCP domains are listed in Table 1. Following is a
review of these quality domains in order to illustrate how essential communication is
to every aspect of quality palliative care.
DOMAIN 1: STRUCTURE AND PROCESSES OF CARE

The NCP guidelines begin with this domain as an intentional message of the impor-
tance of creating structures that will support each of the domains and collectively
promote palliative care. Yet palliative care clinicians in most every setting can easily
identify daily operations that obstruct rather than promote effective communication.
Table 1 Domains of Quality Palliative Care

Domain 1: Structure and processes of care
Domain 2: Physical aspects of care
Domain 3: Psychological and psychiatric aspects of care
Domain 4: Social aspects of care
Domain 5: Spiritual, religious, and existential aspects of care
Domain 6: Cultural aspects of care
Domain 7: Care of the imminently dying patient
Domain 8: Ethical and legal aspects of care
xi Preface
The field of palliative care is by its very nature fraught with factors that challenge
the goal of supportive structures and processes. Palliative care is complex, multidi-
mensional, and is concerned with care in the most intimate and intense weeks of life.
Palliative care requires multiple disciplines, settings, transitions, and enormous cul-
tural variation. Quite often, the well-intended professionals working in this field may
believe that effective communication will just happen because, after all, we are com-
passionate and dedicated clinicians. But the reality is that effective communication will
not happen unless the structures and processes of care within an organization support
communication.
Technological advances such as electronic medical records, cell phones, e-mail,
Skype, and a host of other electronic means can greatly facilitate communication or
conversely create significant barriers to communication. The challenge is for adminis-
trators and managers in palliative care settings to seriously consider the ways in which
policies and procedures can best support effective communication.
Ellington and colleagues (Ellington et al., 2008; Ellington, Reblin, Clayton, Berry,
& Mooney, 2012) have recently studied the interactions and communication between
hospice nurses, patients, and families through audio recordings of these visits. Their
initial findings have described how nurses devote the majority of their communication
to topics of physical care. The recordings revealed many encouraging findings such
as the tendency for nurses to devote substantial time to building partnerships with
family caregivers and patients. Nurses also were flexible and adaptive, altering their
communication to the changing circumstances of patients and families as the disease
progressed. Ellington and colleagues are continuing their research in nursing commu-
nication, which will identify areas needed for more effective communication. Their
research and others will help identify structures and processes of care that best support
nurses in effective communication.
DOMAIN 2: PHYSICAL ASPECTS OF CARE

The great complexity of communication regarding physical aspects of care promi-
nently involves the experience of symptoms. Communication skills are essential in
order to elicit patient pain levels, but there must also be attention to the mitigating
factors that influence patient pain tolerance, administration of pain medication,
and decision making about treatment options. Varying responses to the question
“How would you rate your pain, on a scale of 0 to 10?” can be the result of how the
question was asked, who was in the room, or the patient’s prior life experiences
and choices. Communication about physical care involves learning to recognize
the mediating effects of stoicism and its impact on pain management administra-
tion, recognizing what triggers patient complaints and when patients minimize
symptoms, and understanding the inherent connection between physical pain and
existential suffering. The dynamics between patients, providers, and family care-
givers as well as the relationships between physical problems and other domains
such as psychological or spiritual care are prominent when working to provide
physical care.
xii preface
DOMAIN 3: PSYCHOLOGICAL AND PSYCHIATRIC

ASPECTS OF CARE
Psychological responses to illness are ever present in palliative care, and attention to
these needs is integral to quality care. In this domain, the essential communication
skill of listening is paramount. Palliative care nurses listen intently and through care-
ful assessment identify the need for consultation by other professionals. The assess-
ment of anxiety, depression, and other psychiatric responses is critical as is attention to
responses to facing the end of life. Attentive communication gives voice to fears, uncer-
tainty, anger, and sadness and also provides opportunity for life review. Nurses hold a
special place in these last days and weeks of life as confidantes and as central support
to recognize expected psychological responses to life-threatening disease as well as the
urgent psychiatric symptoms that can greatly improve quality of life at end of life.
DOMAIN 4: SOCIAL ASPECTS OF CARE

The social domain of quality palliative care includes aspects of the patient’s life in rela-
tionship with others. Social aspects include issues such as financial impact of illness,
family dynamics, and sexuality as well as the very critical aspect of culture. Relational
issues are central to the COMFORT model, which guides the remaining chapters of this
text. Treatment decisions and the entire family experience of illness are greatly influ-
enced by culture, family communication patterns, other family death experiences as
well as a host of other factors. Nurses need to communicate with respect for the family
system, honoring the dignity of the patient, and to facilitate bereavement support for
loved ones. Effective communication means more than finding “the right words” as it
also involves deep and attentive listening, strategic communication with other health
care professionals, and a deliberate plan for the communication with the patient and
family (Steinhauser, K. E. et. al, 2000).
DOMAIN 5: SPIRITUAL, RELIGIOUS, AND EXISTENTIAL

ASPECTS OF CARE
Spiritual care is also an essential element of palliative care, encompassing a broad range of
issues both religious and secular in nature. Patients and families face aspects of care such
as hopefulness, life meaning and purpose, faith, forgiveness, abandonment from God, rela-
tionships with a higher being, and the profound connection to others and the universe.
Communication about spiritual issues is a challenge for most professionals and an
area where nurses may feel ill prepared. We call on our spiritual care experts, chaplain,
or other spiritual leaders for guidance and support of patients. Yet these issues are
also often a topic of the routine encounters between nurses and patients. As a nurse
conducts an initial assessment, these concerns may be voiced, and as disease progresses
and death nears, it is often a nurse who hears the patient suffering and spiritual dis-
tress. In this domain as with the others, skillful communication is a part of nursing
assessment and intervention.
xiii Preface
DOMAIN 6: CULTURAL ASPECTS OF CARE

The overwhelming influence of culture in palliative care reveals the intertwining forces
of cultural beliefs, religion, relationships, family history, and the fragility of family rec-
onciliation. These factors are well described in the literature as influences on patient
care (Clayton, Butow, Arnold, & Tattersall, 2005; Kruijver, Kerkstra, Bensing, & van de
Wiel, 2000; O’Baugh, Wilkes, Sneesby, & George, 2009). The consequences of decisions
and ensuing actions by the patient, family, and health care team are monumental.
DOMAIN 7: CARE OF THE IMMINENTLY DYING PATIENT

Professionals working with the imminently dying across settings know that the final
hours are the ultimate test of our ability to provide compassionate care. Regardless of
the diagnosis, length of time of the illness, or the highly varied family circumstances,
care in the last days and hours is paramount (Berry & Griffie, 2010). This is also a
challenging time for communication when family caregivers are physically and emo-
tionally exhausted, grief is intense, and when the health care providers also confront
the emotional burden of witnessing death and feeling responsible for this intensive
care at life’s end. The nurse’s response and support of family will undoubtedly involve
important information about signs and symptoms of approaching death and the dying
process but will also respond to the emotions and grief.
Quality-of-Life Model Applied to Cancer Survivors
Physical Well-Being and Symptoms Psychological Well-Being
• Functional Ability • Anxiety

• Strength/Fatigue • Depression
• Sleep & Rest • Enjoyment/Leisure
• Nausea • Pain Distress
• Appetite • Happiness
• Constipation • Fear
• Cognitive Changes
QOL
Social Well-Being Spiritual Well-Being
• Caregiver Burden • Suffering

• Roles and Relationship • Meaning of Pain
• Affection/Sexual Function • Religiosity
• Appearance • Transcendence
figure 1 Quality-of-Life Model

Ferrell, B & Grant, M. City of Hope Medical Center, last retrieved on August 23, 2012, from http://prc.coh.org
xiv preface
DOMAIN 8: ETHICAL AND LEGAL ASPECTS OF CARE

When prognosis is poor and clear advance care planning is absent, it is not uncommon
for intense ethical and legal concerns to become a focal point of care. Issues of proxy
decision makers, advance directives, family conflict regarding goals of care, and chal-
lenges with communication amid acute illness in intensive care are common (Cherlin
et al., 2005; Royak-Schaler et al., 2006). Skillful communication by all involved is essen-
tial to avoid disastrous care and potentially contribute to quality care for the patient
and family.
Ultimately, communication is the cornerstone of quality of life and quality patient
care. Figure 1 illustrates the quality-of-life (QOL) model developed at the City of
Hope Medical Center by Ferrell and Grant (Ferrell, 1996, 2008; Ferrell & Grant, 2003),
which has been used by many scholars, students, and nurses over the past 20 years. This
depiction of QOL includes four key domains of physical, psychological, social, and
spiritual well-being. Meeting the needs of patients in each of the areas requires effec-
tive communication so that patient needs can be identified, the patient can be heard,
and a plan of care can be developed that addresses these needs.
A review of the National Consensus Project domains of quality care illustrates that
the need for effective and compassionate communication in palliative care is unques-
tionable (NCP, 2009). Communication is the essence of our practice. It is the foun-
dation of all that we embrace as palliative care nurses. Communication is in some
ways the inherent art of our practice. It is also the skill that we seek to acquire having
entered our practice with little preparation for the effective communication that is
required hourly in our work as nurses caring for the seriously ill and dying. The chap-
ters that follow provide a new approach for nurses and all professionals to guide this
communication.
REFERENCES
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Cherlin, E., Fried, T., Prigerson, H. G., Schulman-Green, D., Johnson-Hurzeler, R., & Bradley,
E. H. (2005). Communication between physicians and family caregivers about care at the
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Clayton, J. M., Butow, P. N., Arnold, R. M., & Tattersall, M. H. (2005). Discussing end-of-life
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New York: Oxford University Press.
xv Preface
Ellington, L., Matwin, S., Uchino, B. N., Jasti, S., Dudley, W. N., & Roter, D. (2008). The body’s
response to health care provider communication: The impact of dominant versus facilita-
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acknowledgments
Though the sparkle of an idea for this collaboration emerged in a hotel room in
Lexington, KY, it was the gracefully, generously, and deliciously appointed Italian
meal in the home of Michael A. Mollica that brought us together. The authors are
also deeply thankful to our editorial assistant, Andrea Garcia, who worked with us
throughout every step of this manuscript. Her expert eyes and attention to detail were
the secret ingredient to success.
xvii
Communication in
Palliative Nursing
1
defining and understanding
communication
I am already a good communicator—what can you teach me? One of the problems
communication experts encounter in attempting to teach effective communica-
tion is this: everyone already knows what good communication is, and many people
believe that communication skills are innate, much like the hardwired ability we are
born with that enables us to acquire and to understand language. Yet communication
researchers have unearthed a number of myths that are popularly held about what
constitutes good communication, even about the definition of “communication” itself.
For example, a commonly accepted definition of effective communication is the trans-
mission of information—what is in the speaker’s head gets somehow magically trans-
ported to the listener’s head so that both agree about the content of the message.
What we suggest in this chapter and throughout this text is that communication is,
instead, the mutual creation of meaning by both communicators.
This revised definition has rich implications for all of us but particularly for palliative
care nurses as they communicate with a host of audiences: physicians, patients, family
members, interdisciplinary palliative care team members, and fellow nurses. Seeing the
act of communicating as mutually creating meaning rather than transmitting informa-
tion implies that the traditional roles of speaker and listener (also termed sender and
receiver) do not really make sense. Both communicators are speaking and listening, send-
ing and receiving, in any communication event. Further, both communicators are mutu-
ally and reciprocally influencing what the other party will say next or how he or she will
react nonverbally. Let’s look at an example of how mutual influence works when a nurse
asks her dying patient about how the family is dealing with her impending death:
rn: How is your family doing with all of this?

pt: None of them are talking to me.
rn: They might be afraid—you might need to bring it up.
pt: Yes they are.
(long pause)
rn: You might need to bring it up.
pt: I have a niece and nephew. I haven’t seen them in 2 years, and they live right
here in town. They said they were coming yesterday, and they didn’t. But
maybe I was sleeping. I feel like they are using it as an excuse, but I don’t
1
2 communication in palliative nursing
care. They have an excuse now. I was not the most popular person in my
family. I’m the oldest, and I’ve always had to do the most, and sometimes it
put me in an unpopular position. I was the tattle-tale. Mommy and Daddy
expected me to report everything. (Wittenberg-Lyles, Goldsmith, Ragan,
& Sanchez-Reilly, 2010, pp. 69–70.)
In the example above, both nurse and patient affect the other’s communication beha-
vior. This may appear a simple notion, yet it has profound implications: how we
communicate (what we say verbally and nonverbally) significantly influences com-
munication effectiveness. Analyzing the conversational exemplar above reveals how
the nurse’s responsiveness to her patient’s communication results in repetition of her
advice (“you might need to bring it up”). This is offered after the patient’s truncated
admission that her family is afraid and then a lengthy pause: taking into account
the verbal utterance of the patient and the long pause, the nurse repeats her advice.
The patient’s next utterance is an elaborated response to the nurse’s original ques-
tion about how her family is doing. The patient has modified her original response,
perhaps because the nurse’s repeated advice has freed her to disclose fully her family
situation. The nurse now has a deeper understanding of this patient’s limited social
support as well as how she sees herself in relation to her family. Knowing this may
prompt the RN to consult the social worker on the palliative care team.
This mutual influence model of communication (rather than the traditional
sender-receiver model) means that both parties are simultaneously and reciprocally design-
ing (encoding), delivering (both verbally and nonverbally), and interpreting (decoding)
messages: both are creating the meaning of each other’s messages. It also means that both
speaking and listening are critical communication skills—for nurse and patient alike.
Epstein and Street (2007) note in their book on communication skills for
patient-centered cancer care that clinicians and patients constantly influence each oth-
er’s communication in ways that facilitate more effective patient care. For example, a
patient can use such active communication strategies as asking questions, interrupt-
ing, and expressing concerns in an attempt to elicit more interest and more inquiry
from the clinician. Concomitantly, if a patient appears passive, clinicians can use facil-
itative behaviors (e.g., asking for the patient’s opinion and concerns, offering encour-
agement) that might elicit more patient involvement. This is because the clinician’s
communication “both legitimizes and specifically asks for the patient’s views” (p. 6).
Note how this mutual influence might function in a palliative care context:
nurse: How are you feeling today?

(lengthy pause before patient responds)
patient: Same as yesterday.
nurse: When we talked yesterday, you mentioned some pain in your upper
abdomen. You said it was a “6”—has it gotten better?
patient: A little.
nurse: What number would you give it today? I’d really like to know whether
you think the new medication is working better. We want you to be as pain
free as possible.
3 Defining and Understanding Communication
patient: Yeah, well I’d say it’s about a “4” this morning, so I guess that means
that the new meds are working some.
nurse: Going from “6” to “4” is in the right direction, and I’m glad your pain
is less severe, but I think a “4” is still too high. I’d like for us to get your pain
down to a “3” or lower. We will work to get the dosage exactly right for you
so that your pain will not be more than a “3.”
patient: I’m still worried that I won’t get enough pain medicine to control
my pain.
nurse: I’ll increase your pain meds today to make sure that you’re receiving
enough medication to keep your pain at a level of “3” or less. That is our
number one priority in caring for you: to make you as comfortable as we
know how to do.
In the above example, the patient first appears passive, giving only minimal responses
to the nurse’s questions about her pain level. When the nurse tells the patient that she
wants to know the number of the patient’s pain level in order to gauge whether the
new meds are working so that her pain can be better controlled, the patient gives a
more elaborated response. After the nurse’s next empathic response and her assurance
that they’re working to deliver the right dosage, the patient apparently feels trusting
enough to disclose that she’s still worried about not receiving enough pain meds to
control her pain. Can you imagine how this conversation might have played out had
the nurse not asked more questions of the patient or had she not expressed empathy for
the patient’s situation? Worse yet, what would have been the possible consequence
of the nurse’s replying to the patient’s telling her that the pain was “a little better”
today: “Oh, okay, well that’s good to hear”? It’s probable that this remark would have
ended the conversation abruptly, that the patient would not have felt any empathy
from the nurse, and that the patient’s fears about not receiving enough pain meds
would have gone undisclosed.
Of course, the verbal messages in this dialogue between patient and nurse are made more
complex by both communicators’ nonverbal messages—messages that are constantly and
often unwittingly being conveyed along with their words. The next section of this chapter
will discuss the preeminence of nonverbal communication as it affects the patient care (or
task) and the communication climate (or relationship) between nurse and patient.
COMMUNICATION AXIOMS
Two central laws or axioms of communication (Watzlawick, Beavin, & Jackson, 1967)
recognize the critical importance of nonverbal communication in every communica-
tion context, personal or professional:
(1) One cannot not communicate. While this verity may appear simplistic, it
reminds us that it is impossible not to be sending messages when we are
interacting with another. All of our words, gestures, facial expressions, gaze,
touch, and tone of voice communicate loudly. Even our silence is profoundly
communicative. The person we are talking to will attribute meaning to silences,
pauses, hesitations, and other nonverbal communication. For example, in the

dialogue above, the long pause between the nurse’s question (“How are you
feeling today?”) and the patient’s response (“Same as yesterday”) might indicate
several things to the nurse: she might interpret the pause to mean that the
patient really doesn’t believe that the nurse is interested in how she’s feeling, or
that the patient wishes to deliberate about her answer before responding, or that
the patient is feeling too bad to want to answer the question at all, among other
possible meanings. Whatever the meaning, it is vital to remember that both
communicators will try to make sense of the other’s verbal and nonverbal (e.g.,
silence) messages. This leads us to the second law.
(2) Every message has two levels of meaning: the content level and the relationship
level. In professional contexts, we often speak of these as the task and relationship
levels since message content generally concerns the “tasks” of communication—
for example, instructing, diagnosing, encouraging, supporting, and so on.
“Relationship” refers both to how communicators interpret the content message
and also to how they see the relationship between them: for example, if the nurse
in our conversation above asks the patient, “How are you feeling today?,” the
content is obviously an inquiry designed to get information about the patient’s
status. But the relationship level of meaning is determined by how these words
are spoken: if the nurse is glancing at the patient’s chart while she asks the
question, if she doesn’t make eye contact with the patient, if she is standing at
the door rather than at the patient’s bedside, the patient likely will interpret the
question as phatic (or as a rote greeting rather than a genuine inquiry) and will
see the nurse—and their relationship—as distant, perhaps cold and unfeeling.
While the content level of a message is conveyed by the words themselves, the rela-
tional level generally is manifested by nonverbal communication. We are often una-
ware of the nonverbal messages we are communicating—we don’t hear our tone of
voice or see our facial expressions or appreciate what touch, distance, and timing
might be communicating to the other. Yet our nonverbal messages are powerful in
communicating meaning and relationship; according to an eminent psychologist,
Mehrabian (1981), nonverbals communicate three dimensions of relationship-level
meaning: power or influence, affection or liking, and responsiveness or attentiveness
or inattentiveness to others.
Not only does nonverbal communication help communicators interpret their mes-
sages and assign relationship cues; it is also preeminent because most of the mean-
ing of a message (some researchers says as much as 80%) is communicated through
nonverbal means, not through words. This may be because we believe that nonverbal
communication is more credible than verbal communication and that nonverbal com-
munication is not under our conscious control as much as verbal communication and
is thus more believable. We also know that when verbal and nonverbal messages con-
tradict each other (or are incongruent), we are much more likely to believe what the
nonverbal messages are telling us. For example, in the above conversation, the nurse’s
verbal communication (“How are you feeling today?”) appears to exhibit her genuine
concern for the patient and her need for this information in order to facilitate the
patient’s care. But if she asks this question as she reads the patient’s chart, failing to
make any eye contact, the patient is likely to believe that the nurse is uncaring. That
is, the patient attributes meaning to the interaction by believing that the inattentive
nonverbal messages are more telling than what the nurse says. For this reason, it is
imperative that we bring our nonverbal communication into conscious awareness and
that we attempt to make what we say and how we say it match.
NONVERBAL CODES
Nonverbal communication has been defined as all those behaviors other than words
themselves that form a socially shared coding system (Burgoon, 1994). That nonver-
bal communication is “socially shared” assumes that people recognize (decode) the
meaning of nonverbal behaviors within their social/cultural settings, though it does
not imply that nonverbal communication is necessarily universal in its meaning. We
all have heard jokes about how leaders of state traveling abroad unwittingly have used
a nonverbal sign (such as making a “V” with the index and third fingers) to signify
“victory,” only to learn that this sign communicated an obscene expression in the cul-
ture in which they found themselves. Yet it is also true that some nonverbal behaviors
are understood cross-culturally—for example, smiling generally means the same thing
across cultures (Afifi, 2007).
To complicate the nonverbal picture further, communication researchers divide
nonverbal communication into seven different codes or forms (Afifi, 2007). All seven
of these codes can be sending messages simultaneously, or only one or more codes can
be utilized. The seven codes—kinesics, haptics, proxemics, physical appearance, vocal-
ics, chronemics, and artifacts—are described in the next section.
Kinesics involves every form of movement of the body, including gestures, eye con-
tact, and body position. Kinesics is particularly important in health care contexts as
affect (or emotional) displays—body movements that express emotion without the
use of touch or verbal accompaniment. Many kinesic gestures are understood across
cultures; for example, sadness is expressed by constricting the eyes and forehead region,
flattening the cheeks, and showing a slight downward curve of the mouth.
Nonverbal immediacy, which is a cluster of nonverbal behaviors that communi-
cate how much one is involved in the interaction, is a concept that has been shown
to be effective in many professional contexts. It involves several kinesic channels (eye
contact; body orientation—toward or away from the other; body lean—forward or
backward; and head nods) as well as behaviors from other nonverbal codes: inter-
personal distance (proxemics) and touch (haptics). Immediacy is a critical concept in
health care interactions as it demonstrates how physically and emotionally accessible
the health caregiver is to the patient—changes in the level of immediacy will dramat-
ically affect interaction outcomes. For example, if the nurse in the previous interac-
tion is reading the patient’s chart while she inquires about how the patient is feeling,
this will show nonimmediacy, or lack of involvement to the patient and may elicit a
delayed or minimal response. On the other hand, if the nurse asks the same question
and accompanies it with eye contact, a forward body lean, and a touch of the patient’s
hand, the patient might respond more completely, interpreting the nonverbal com-
munication as indication that the nurse is fully involved in the interaction. Nonverbal
immediacy is an excellent example of the concept of mutual influence in communi-
cation. It will be further detailed later in this chapter when the COMFORT model is
introduced and also will be discussed at length in Chapter 2.
While not as elaborated as kinesics, the other six nonverbal codes include:
Haptics—the use of touch, which in professional contexts can be task related but
can also convey relational messages of warmth and caring. This is, of course, a
critical component of palliative care.
Proxemics—the way we use space and distance. As nurses, it is generally accept-
able to invade a patient’s “personal bubble of space” whereas this might be con-
sidered offensive and inappropriate in other contexts. However, personal space
remains an important element to be assessed by nurses and respected.
Physical appearance—includes body type and clothing, both of which influence
perception. A nurse’s unprofessional appearance communicates an important
image to patients. Nurses similarly develop perceptions about patients based on
their physical appearance—this may be the first “red flag” to nurses signaling
potential depression or other psychosocial needs.
Vocalics—include all aspects of the voice—volume, pitch, accent, rate of speech,
pauses, tone, and so on. The way we use our voices communicates loudly on
a relational level. Communication accommodation theory suggests that we
moderate our speech and vocalics to either be similar to (to converge with)
or be different from (to diverge from) the person to whom we’re talking. That
is why MDs and nurses who use medical jargon—or who talk to patients in
a condescending tone of voice—are perceived as distancing themselves from
their patients. And, of course, patients perceive this distancing as relationship
distancing, believing that the caregiver is not emotionally accessible to them.
Chronemics—the use of and perception of time. If nurses devote only minimal
time to talk with a patient, if they only take the time for administering medica-
tions and procedures rather than stopping to hear patients’ concerns and fears,
they are likely perceived as uncaring. The gift of time is vital not only to our
close interpersonal relationships but also to our patients and to other health
caregivers. While time is very limited in most clinical settings, even a few min-
utes devoted to active listening and presence can make an enormous impact.
Artifacts—the presence of physical and environmental objects. Nurses are often
physically separated from their patients by objects in the patient’s room: bedrails,
bedside tables, medical equipment, and the like. Such barriers can reduce emo-
tional connection or relationships unless the nurse intentionally employs those
nonverbal behaviors that promote immediacy: for example, touch, pleasant
tone of voice, and sustained eye contact while seeking to eliminate artifacts
when possible. A nurse sitting for a short time at the bedside versus standing at
a distance and separated by bedrails can greatly impact communication.
If we look again at the dialogue on pages 3–4 and insert appropriate nonverbal
communication (in brackets) to complement the words used by the nurse, we see dra-
matic changes in the effectiveness of the nurse’s questions and responses:
nurse: How are you feeling today? [walking to patient’s bed as she asks this
question and pulling up a chair at patient’s bedside]
(lengthy pause before patient responds)
patient: Same as yesterday.
nurse: When we talked yesterday, you mentioned some pain in your upper
abdomen. You said it was a “6”—has it gotten better? [asked in a caring
tone of voice]
patient: A little.
nurse: What number would you give it today? I’d really like to know whether
you think the new medication is working better. We want you to be as pain
free as possible. [lightly touching patient’s hand]
patient: Yeah, well I’d say it’s about a “4” this morning, so I guess that means
that the new meds are working some.
nurse: Going from “6” to “4” is in the right direction, and I’m glad your pain
is less severe, but I think a “4” is still too high. I’d like for us to get your
pain down to a “3” or lower. We’ll monitor your pain very closely and will
work to get the dosage exactly right for you so that your pain will not be
more than a “3.” [said with sustained eye contact and with an encouraging
tone of voice]
patient: I’m still worried that I won’t get enough pain medicine to control
my pain.
nurse: Can we talk a little more about why you are worried? [With this prob-
ing question, conversation can ensue that attempts to discover the source
of the patient’s fears about inadequate pain control. Throughout the con-
versation, the nurse will sustain eye contact, speak in a gentle, reassuring
tone, and lightly touch the patient if this seems appropriate.]
I’ll increase your pain meds today to make sure that you’re receiving enough
medication to keep your pain at a level of “3” or less. That is our number one
priority in caring for you: to make you as comfortable as we know how to do.
Equally important in the interaction is the nurse’s attentiveness to the patient’s non-
verbal responses. We’ve already mentioned that a perceptive nurse will note the lengthy
pause that occurs after she asks how the patient is feeling today. If the patient’s eventual
response (“same as yesterday”) is said in a wooden tone of voice and/or if the patient
mutters this without establishing eye contact, this should alert the nurse that she must
continue to probe gently in order to communicate to the patient that she really cares.
Later in the dialogue when the patient discloses that she’s worried about not getting
enough pain medication, the nurse should also be responsive to accompanying non-
verbals (e.g., frowning and other facial expressions) that further communicate the
patient’s fear and concern.
In sum, the nurse should be as attuned to and responsive to a patient’s nonverbal

communication as she is to a patient’s words. If the nonverbal communication belies
the words (for example, in our dialogue above, if the patient answers—“Oh, I’m feel-
ing on top of the world” with a sneer and a sarcastic tone of voice in response to the
nurse’s query), then the nurse likely will believe the nonverbal message. She might
then smile and question again, “Okay, how are you really feeling?” It is essential that
nurses be aware of the message that their own nonverbal communication carries as
well as those messages conveyed by the patient’s nonverbals. Since such messages are
frequently “under the radar,” nurses must train themselves to be particularly sensitive
to this aspect of communication.
Of course, the skill of close listening is paramount in detecting the nuances of both
verbal and nonverbal communication. Likewise, the use of silence can be an important
communication strategy: recall that the axiom “one cannot not communicate” (p. 6)
means that pauses and lengthier silences in conversation will still have communica-
tive import. In addition, nurses can use silence as a means of probing further into a
patient’s feelings and concerns. Both listening and silence will be discussed in more
detail in Chapter 4, “Mindful Presence.”
TASK AND RELATIONSHIP AND THE

FIVE ROLES OF NURSING
We have mentioned that the content of a message can also be considered the task of
the interaction, particularly in professional contexts, and that the other dimension of
meaning in the message, relationship, refers to how the interactants perceive the rela-
tionship between them. Specific aspects of task and relationship pertinent to palliative
care will be discussed more thoroughly in Chapter 2; this next section deals with how
the five nursing roles (Pavlish & Ceronsky, 2009) also demonstrate the task and rela-
tionship goals of communication.
Pavlish and Ceronsky (2009) explored oncology nurses’ perspectives of pallia-
tive care through narrative analysis of participants’ descriptions of life experiences.
Findings from the nurses’ focus group interactions revealed five primary nursing roles:
teaching, caring, coordinating, advocating, and mobilizing. Seven professional attri-
butes occurred in all five of these roles: clinical expertise, honesty, family orientation,
perceptive attentiveness, presence, collaboration, and deliberateness. Note that each of
the five primary nursing roles involves communication in which both task and rela-
tionship are conveyed:
Teaching—A sample quotation illustrating this role was: “You help them figure
out what they’re going to do about comfort, pain control, spirituality and help
them maximize their days” (2009, p. 406). Task is communicated in that nurses
are preparing patients and their families to make informed decisions, including
those regarding symptom management. Relationship is interpreted by patients
and families as they receive nonverbal cues from the nurse’s tone of voice, her
use of touch, and eye contact.
Caring—A sample quotation illustrating this role was: “I talk about the hard stuff
with them. Sometimes I put an arm around them and say, ‘I am so sorry for what
you have to go through. What can I do to help you?” (2009, p. 406). Task and
relationship are communicated simultaneously in the act of caring. Note that the
“hard stuff” gets talked out (task) while the nurse uses touch (an arm around the
patient) to communicate her emotional accessibility and concern (relationship).
Coordinating—A sample quotation illustrating this role was: “We have to be dip-
lomatic and work with the whole team, I mean everyone from environmental
services to chaplains to pharmacy, everyone. It’s a big difference when we’re all
working together” (2009, p. 406). Again, in performing the role of coordinating,
nurses must attend both to task—that is, getting everyone to work together—
and relationship—communicating diplomatically and carefully with each team
member as well as with the patient and his/her family.
Advocating—A sample quotation illustrating this role was: “So we have to advo-
cate for patients and bring up these [needs] to doctors” (2009, p. 406). Advocacy
is obviously the primary task of communication in this role, yet, because of
the sensitivity of talking to patients, their families, and medical staff about
patients’ and families’ quality-of-life (QOL) issues, nonverbal communication
that signifies relationship must also be chosen with care and appropriateness.
Mobilizing—A sample quotation illustrating this role was: “We assess them and
try to bring help into [the care situation] as much as we can” (2009, p. 406).
Responding to patients’ and families’ changing needs requires task communi-
cation that is “attentive, assertive, and resourceful” (p. 406). Yet mobilizing also
relies on nonverbal communication that is congruent with these messages and
that exhibits a caring relationship.
It is of further interest to note that four of the seven professional attributes of

palliative care nurses that are exhibited in all of these five nursing roles (Pavlish &
Ceronsky, 2009)—honesty, family orientation, perceptive attentiveness, and presence—
inherently emphasize the preeminence of relationship as these attributes are manifested.
In discussing the attribute of honesty, research participants talked about the importance
of remaining in a caring relationship, even when the patient is in denial, and accepting
patients “where they are with the disease” (p. 407). They stressed the importance of being
honest in end-of-life situations without taking all hope away: for example, “You have to
be truthful without knocking the pins out from underneath them” (p. 407). Likewise
with family orientation, nurses attended to relationship goals, including teaching families
how to relate to a dying loved one, assisting families to accept a patient’s preferences for
end-of-life treatment, and helping them prepare for the grieving process. Perhaps per-
ceptive attentiveness is the attribute in which relationship is manifested most by palliative
care nurses: responding to a patient’s unspoken needs requires finely tuned nonverbal
sensitivity. Nurses in the study commented on “recognizing the need in someone’s eyes”
and “feeling the need in the room” (p. 407). This attentiveness is especially valuable in
sensing a patient’s psychological needs; as one nurse expressed, “Physical needs might
not change often, but emotional needs change all the time” (p. 408).
The attribute of presence is, of course, all about relationship: described as “calmness
or peacefulness” and “spiritual and existential connection” (2009, p. 407), presence
is that quality that makes patients and their families feel that their nurses are there
for them. “Listening carefully,” “speaking last,” and “making people feel cared about”
were all listed as examples of presence (p. 408). One nurse saw presence as caring as
she stated: “Palliative always comes with care behind it, which means we’re able to take
the care path rather than focusing just on all the nursing tasks that have to get done”
(p. 408). Surely this nurse understands the nexus of task and relationship.
The task and relationship dimensions of the five roles of palliative care nursing
and the corresponding seven professional attributes that nurses exhibit in these roles
are further supported by Epstein and Street (2007), who discuss six functions of
patient–clinician communication in their book on patient-centered communication
in cancer care. These six functions include:
x Fostering healing relationships

x Exchanging information
x Responding to emotions
x Managing uncertainty
x Making decisions
x Enabling patient self-management
As do the nurses’ roles and attributes, each of these functions involves both task
and relationship goals and, concomitantly, task and relationship communication in
order to achieve these goals. Epstein and Street (2007, p. 4) further provide examples
of patient-centered clinician communication:
NONVERBAL BEHAVIORS
x Maintaining eye contact
x Forward lean to indicate attentiveness
x Nodding to indicate understanding
x Absence of distracting movements (e.g., fidgeting)
VERBAL BEHAVIORS
x Avoiding interruptions
x Establishing purpose of the visit
x Encouraging patient participation
x Soliciting the patient’s beliefs, values, and preferences
x Eliciting and validating the patient’s emotions
x Asking about family and social context
x Providing sufficient information
x Providing clear, jargon-free explanations
x Checking for patient understanding
x Offering reassurance
x Offering encouragement and support
There is remarkable similarity between these listings and the five roles and seven
professional attributes of palliative care nurses outlined by Pavlish and Ceronsky
(2009). All of these authors describe ideal patient–clinician communication, particu-
larly when that patient is suffering from cancer or another life-threatening illness: it is
communication characterized by an alignment of verbal and nonverbal messages that
are directed to treating both the patient’s physiological and psychological concerns,
not to merely treating the patient as his/her disease.
INTRODUCING THE COMFORT MODEL

We know that palliative care nurses must face many communication challenges as they
deal with patients and families confronting end of life, and yet there are few guidelines
currently for teaching nurses end-of-life communication skills. The ELNEC Project
(End-of-Life Nursing Education Consortium Training Manual, 2010) curriculum and
other palliative nursing educational programs have applied a physician-derived model
for delivering bad news, SPIKES (setting, perception, invitation, knowledge, empathy,
and strategy/summary) (Baile et al., 2000; Buckman, 2005). A number of deficiencies exist
in this model and other physician-based communication training protocols—including
(1) the approach to communication as sender-receiver rather than as mutual influence
and hence the communication priority on dispensing information, (2) the emphasis on
the dyad of physician–patient rather than the multiparty inclusion of family and other
health care providers, and (3) the failure to address the ongoing concerns of patients
and families after a patient has received bad medical news. These deficiencies as a whole
necessitate the need for a new model of palliative care communication, one that embraces
the nurse’s various roles and professional attributes (Pavlish & Ceronsky, 2009) and one
that is built around patient-centered communication.
Based on their empirical research on medical communication training in pal-
liative care, family communication at end of life, and conversations among hospice
and palliative care staff, patients, and families (Ragan & Goldsmith, 2008; Ragan,
Wittenberg, & Hall, 2003; Ragan, Wittenberg-Lyles, Goldsmith, & Sanchez-Reilly, 2008;
Wittenberg-Lyles, Greene, & Sanchez-Reilly, 2007; Wittenberg-Lyles & Thompson,
2006) as well as several years of participation in a medical school elective on geriatric
and palliative care, in a palliative care facility, and in a number of hospices (Goldsmith,
Wittenberg-Lyles, Rodriguez, & Sanchez-Reilly, 2010; Ragan, Wittenberg-Lyles,
Goldsmith, & Sanchez-Reilly, 2008; Sanchez-Reilly, Wittenberg-Lyles, & Villagran, 2007;
Villagran, Goldsmith, Wittenberg-Lyles, & Baldwin, 2010), communication scholars
(and editors of this textbook) Wittenberg-Lyles, Goldsmith, and Ragan developed a
set of themes critical to palliative care. They then organized these themes into a com-
munication curriculum, COMFORT, an acronym for seven principles designed to be
taught and implemented in early palliative care communication and breaking ongoing
bad news in life-limiting illness contexts.
These principles find their theoretical roots in patient-centered care and also in the
narrative medicine movement (Charon, 2004). Narrative medicine, which subscribes
to our communication model of mutual influence and coconstructed conversational
outcomes, privileges and values the stories of both patients and clinicians. It is intrinsic
to the practice of palliative care in that the founder of the modern hospice movement,
Dame Cicely Saunders, listened to and collected the stories of illness and suffering of
more than a thousand of her dying patients. Through these stories, she developed a
more expansive understanding of pain so that she came to see pain as not merely phys-
ical but also psychological, spiritual, and existential (Saunders, 1967). Because palli-
ative care nurses must address all these aspects of pain in their patients, and because
listening to patients’ and family members’ stories is fundamental to clinical practice,
we believe that a narrative approach to palliative nursing is a pivotal place of conver-
gence between clinical and communication studies (Wittenberg-Lyles, Goldsmith, &
Ragan, 2010).
The COMFORT model (Table 1.1) is thus offered to assist nurses in their practice
of narrative nursing and patient-centered communication in end-of-life care. The fol-
lowing section will briefly describe the seven principles of COMFORT—communicate,
Table 1.1 The COMFORT Model

The COMFORT Model Communication Skills to Develop
C—Communicate x Learning to bear witness

x Using person-centered messages
x Recognizing communication expectations
O—Orientation and x Gauging health literacy levels
opportunity x Acknowledging vulnerability
x Understanding cultural humility
x Formulating a pathway of care
M—Mindful presence x Practicing empathy
x Engaging in active listening
x Demonstrating cultural humility
x Employing nonverbal communication
F—Family x Viewing the family as an open or closed system
x Recognizing predictable family communication patterns
x Responding to the varying needs of family caregivers
O—Openings x Identifying pivotal events of change in patient/family care
x Communicating despite tension
x Practicing complementary disclosure
R—Relating x Embracing the multiple goals of a patient/family
x Accepting inherent conflicts in goals
x Using communication with patient/family to practice care
T—Team x Contributing to interdisciplinary collaboration
x Distinguishing successful collaboration from group cohesion
orientation and opportunity, mindful presence, family, openings, relating, and

team—which also organize the remaining chapters of this book and are discussed in
detail in Chapters 2–8. We emphasize that these seven themes or principles are not a
linear guide or algorithm as most of the physician-based communication protocols
are; rather, they are principles that should be used concurrently and reflectively as
palliative care nurses care for patients/families with life-limiting illness (Wittenberg-
Lyles, Goldsmith, & Ragan, 2010).
Communicate
A detailed discussion of this principle is found in Chapter 2. Communication describes
behaviors that constitute a narrative nursing approach, namely, the use of verbal
clarity and nonverbal immediacy (sustained eye contact, forward lean, nodding to
indicate understanding, avoidance of fidgeting). Both of these behaviors exemplify
a patient-centered approach to care: using language that is clear, unambiguous, and
understandable not only communicates more accurately but also communicates more
compassionately; likewise, using congruent nonverbals that signify physical and emo-
tional accessibility (i.e., nonverbal immediacy) conveys empathy, support, and under-
standing to patients.
Practice Example
A nurse must explain to a patient and his family the typical side effects of a round of
chemotherapy that the patient will soon undergo.
Communication Behaviors
The nurse first tries to elicit the patient’s understanding of and concerns about his
chemotherapy (narrative nursing approach). She uses language that is free of medical
jargon and that is direct and unequivocal (verbal clarity) while maintaining sustained
eye contact with the patient, leaning toward him, and nodding after he has spoken
(nonverbal immediacy). As a result, the task of the encounter (giving information) is
achieved with relationship warmth and caring. The patient and his family perceive that
the nurse is concerned with his overall quality of life, not just with the physical effects
of the chemotherapy.
Orientation and Opportunity

A detailed discussion of this principle is found in Chapter 3. Orientation and opportu-
nity occur when the nurse communicates the entire story of the patient’s prognosis and
options for care so that understanding occurs (i.e, orientation) and then helps educate
the patient and her family about all options for treatment and care (i.e., opportunity).
Nurses must practice this principle with the full awareness that patients’ limited health
literacy skills may hamper their ability to make optimal health care decisions; thus,
nurses must serve to support and nurture health literacy. A patient’s vulnerability due
to her incomplete understanding of her disease and its projected course, available treat-
ment options, and involvement in research protocols needs to be acknowledged and
addressed so that the patient can receive optimal care—as well as care that is self-selected.
Helping patients and their families articulate and prioritize health care goals and then
helping them implement such goals with a pathway of care are paramount.
Practice Example
A very elderly (and thus marginalized) patient must make a decision to have heart sur-
gery that carries significant risks. The palliative care nurses assess her health literacy as
extremely limited and yet must explore the surgical option with her and help her find
an optimal pathway of care.
Using the same verbal and nonverbal behaviors as described above (under
“Communicate”), the nurse must first be completely aware of the patient’s vulner-
able status and then must attempt to educate the patient about the risks that surgery
would entail. With the patient’s and family members’ assistance, the patient’s goals
of care must then be determined, and the full range of options—curative and palli-
ative—must be explored. The primary task of this encounter (helping to educate the
patient and establish a pathway of care) is thus achieved with empathy for the patient’s
limited health literacy and the use of verbal clarity and nonverbal immediacy to estab-
lish rapport and support (relationship).
Mindful Presence
A detailed discussion of this principle is found in Chapter 4. Mindful presence involves
those psychological attributes of staying in the moment, refusing to prejudge patients,
families, and ensuing interactions, and adapting to rapid changes in these interactions.
Staying in the moment entails a reduction of self-talk and predetermined scripts; the
nurse is willing to operate without a script as she recognizes the complexity of the
end-of-life situation and the need for adaptation and spontaneity. As Wittenberg-Lyles,
Goldsmith, and Ragan (2010) describe it, “characteristics of mindful self-monitoring
include an ability to describe your inner experience, adopting more than one perspec-
tive, openness to possibilities, curiosity, and attentiveness” (p. 287).
Practice Example
A palliative care nurse is making a routine visit to an elderly female patient who resides
in a group home. He is aware that the patient is dying of heart disease, but recalling that
she appeared content and physically stable when he saw her last week, he anticipates a
routine, quick visit. When he arrives, he finds the patient sitting alone in a dark room,
appearing withdrawn, and ignoring the nurse’s presence. The patient responds with
only minimal utterances to the nurse’s questions, yet she does not report any pain.
Since mindful presence is as much a psychological attribute as a communication
behavior, this nurse must adopt a mindset that permits him to quickly adapt to the
situation: it is not as he expected. While it might be tempting to judge his patient as
depressed given her behavior (after all, she is in a comfortable family setting and is
not experiencing physical pain), mindfulness entails a complete lack of judgment and
a willingness to adapt to the patient’s interaction needs. In this case, narrative nurs-
ing comes to the forefront, for the nurse must try to elicit the patient’s story: what are
the causes of her sadness? What has changed since his visit with her last week? In the
course of their interaction when the patient complains that she feels imprisoned in the
group home and at age 92 knows she’s capable of driving although that privilege has
been denied her, the nurse needs to hear her out without prejudgment or a scripted
admonishment or solution. While he may not succeed in changing her feelings or
materially improving her quality of life (task), he can at least exhibit caring, empathic,
verbal and nonverbal communication, which assures her of a supportive relationship.
And because he is willing to take the time to hear her story, he might enable his patient
to be open to possibilities for improved quality of life that she has overlooked.
Family
A detailed discussion of this principle is found in Chapter 5. Family acknowledges that
both patient and family members form the unit of care in palliative care interactions.
The principle of family also means that nurses recognize the complexity of multiparty
communication in this context in that both the patient’s needs and family members’
needs must be considered. Further, family is seen as a conduit to the patient: it carries
primary responsibility for the implementation of patient care and as such is viewed as
a partner in the caretaking process. Honoring family members in this way also entails
encouraging their voices and their stories in family meetings that help to establish and
to clarify the patient’s goals of care.
Practice Example
The palliative care team meets with four family members of their comatose dying
grandmother, who does not have an advance directive. The goal of the meeting is to
try to determine what their grandmother’s wishes would be regarding aggressive treat-
ment at end of life, and DNR (do-not-resuscitate) orders.
The communication task, in this case, is daunting: the palliative care nurse, along
with other team members, must help the family arrive at consensus about their
grandmother’s end-of-life care. In doing so, they must mindfully listen to each fam-
ily member’s perspective and story; they then need to facilitate problem solving and
conflict resolution if family members are divided about the course of care. Even if the
discussion gets heated, nurses must exhibit supportive, empathic, verbal and nonver-
bal communication in order to assure family members that their opinions are valued
and that they are considered a vital component of the unit of care (relationship).
Openings
A detailed discussion of this principle is found in Chapter 6. Openings are those critical
opportunities in patient care in which nurses’ skilled and strategic communication can
create the possibility for positive change. Such opportunities frequently occur around
painful transitions in patient care (e.g., initial diagnosis, decisions about treatment
options, disease recurrence). Through their roles as mediator, coach, and advocate
with patients and their families, nurses can help reframe these moments of tension so
that they become opportunities for resilience and coping.
Practice Example
Mr. Jones was a 68-year-old man with a 40-year history of chronic illnesses including
diabetes, obesity, hypertension, and COPD (chronic obstructive pulmonary disease).
Over the past year, he has also developed renal failure. Mr. Jones, his family, and his
primary care physician have discussed his declining health status, recent new diagnosis
of heart failure, and the resulting decline in his QOL and function. Over the weekend,
he informed his family that he is “done” and wants to discontinue his renal dialysis,
recognizing that this decision will lead to his death. His wife and daughter are appro-
priately sad but support and understand his decision. His brother, age 60 and also
diagnosed with renal disease and heart failure, has strongly opposed his decision and
insisted they all come in to the renal clinic today so that the staff can “straighten this
out.” He is very hostile toward Mrs. Jones and is emotionally distressed yet strongly
advocating for his brother’s care.
This case example illustrates tremendous opportunity for nursing. The nurse in the
renal clinic can apply the principle of opening, using this change in the patient status
and goals of care to facilitate family communication. Careful assessment, listening to
each family member’s perspectives, and being present to the tension will be essential to
facilitating the next phase of care.
Relating
A detailed discussion of this principle is found in Chapter 7. Relating means that nurses
are willing to meet patients and their families where they are in their acceptance and
understanding of their disease and its course. This principle thus may entail a repeti-
tion of prognosis and treatment options to patients/families regardless of how many
times they have heard the bad medical news. As a patient’s/family’s awareness level
deepens, previous discussions will be repeated or revisited with the same or different
outcomes. The SPIKES model is limited in addressing only the initial encounter of a
physician’s confronting a patient with bad news. Yet a terminal diagnosis or equally
upsetting medical news cannot be processed instantaneously by the patient/family.
Patients and families need to digest the news incrementally and frequently in a non-
linear fashion—with subsequent questions about treatment options and prognosis,
which are often heard by nurses. This principle values family as a vehicle for reiterating
the bad news to the patient if she/he resists the diagnosis initially (Wittenberg-Lyles,
Goldsmith, Ragan, & Sanchez-Reilly, 2010). It champions adaptive communication
based on the patient’s/family’s acceptance of information concerning disease, progno-
sis, and plan of care, and it emphasizes team-based family communication over dyadic
communication between clinician and patient.
Relating involves prioritizing the relationship between the clinician and the patient/
family and attending to the goal of relationship in order to facilitate instrumental (task)
goals of nursing. Often this involves the ability of the nurse to be radically adaptive, that
is, to take into account the patient’s/family’s experiences rather than rely on her own
script for an encounter. Removing the clinician’s habituated response to an interaction
and adapting to the patient’s/family’s unique perspective means that the nurse values
that perspective over her own. This underscores a primary tenet of narrative nursing
and of the mutual influence model of communication discussed in this chapter: out-
comes of clinician–patient interactions—and patients’/families’ stories—are as depen-
dent on patients/families as they are on clinicians.
Practice Example
A palliative care nurse must face a family that remains convinced that the patient’s
end-stage esophageal cancer can be cured; rather than opting for hospice, as the phy-
sician has encouraged, they are demanding to enroll in a clinical trial for which the
patient is ineligible. In this instance, it will not be helpful for the nurse to simply repeat
the clinical trial requirements (habituated response). Rather, the nurse needs to be
radically adaptive, relating to the dynamics of the situation.
The communication task is a challenging one, which involves careful repetition of the
prognosis and care options to both patient and family. The nurse needs to exercise
perceptive attentiveness, presence, and empathy (Pavlish & Ceronsky, 2009) at times
when it will be tempting to become impatient with a resistant family that not only
is in denial about impending death but, in refusing hospice, is denying the patient
the quality-of-life benefits of hospice. Relating to their conflicting goals, talking about
those goals, and working toward the goals are opportunities for nurses to be active in
their engagement of relating. Caring is obviously the relationship message that must be
communicated both verbally and nonverbally.
Team
A detailed discussion of this principle is found in Chapter 8. Team implies that a mul-
tidisciplinary group of individuals trained in various aspects of palliative care will
ensure the highest standard of care for end-of-life patients. This also means that team
members must communicate with each other about their patients in order to keep
abreast of a patient’s status, share information about her needs and concerns, and
skillfully coordinate her care; thus, team meetings are an essential component of this
principle. A team approach can also assure patients and family that they will not be
abandoned by medical caregivers, either during or after a patient’s illness and death.
The collaborative efforts of team members can aid each other in optimizing care for
both patient and family.
Practice Example
A palliative care nurse visits an elderly man dying of prostate cancer. While his pain
and other symptoms are being satisfactorily managed, he is quite anxious about what
will happen to his wife when he dies, as she suffers from severe diabetes and is unable
to care for herself. The nurse also learns that he is a deeply devout Roman Catholic.
This nurse must consult with palliative care team members, primarily a social worker
and a chaplain but perhaps a psychologist as well, in order to address the patient’s
nonphysical suffering. The communication task is likely twofold: she must convince
the patient, if he is resistant, that self-disclosing his concerns to other professional
members of the team is potentially advantageous; likewise, she must influence her
team members to visit and assist this patient. In doing so, she takes an active role in
coordinating his care. Verbally and nonverbally, she must choose messages that mani-
fest caring, advocacy, and confidence (relationship).
According to Wittenberg-Lyles, Goldsmith, and Ragan (2010), the COMFORT con-
cept “is driven by narrative practice in nursing, the prioritization of family, early inter-
vention of palliative care, and radically adaptive communication between and among
patient/family/team members/clinicians” (p. 291). Its primary function is to assist
palliative care nurses in implementing the paramount goal of their patient-centered
care: preserving their patients’ quality of life. We believe that the COMFORT model
in its acknowledgment of the complex, multiparty, nonlinear, and repetitive nature of
communication in the palliative care context promises a more effective and humane
approach to patients and families than do traditional physician-derived commu-
nication protocols. We emphasize that the seven COMFORT principles be used
“concurrently and reflectively” (p. 284) rather than sequentially or as an algorithm

for communication. Rather than being mutually exclusive, the principles work collec-
tively and in tandem to offer a model of palliative care communication that we believe
affords the best chances for maximizing patient-centered care.
To summarize, this chapter has emphasized that communication between nurses
and their patients/family members does not consist merely of disseminating informa-
tion: instead, nurses must view communication as the mutual creation of meaning in
that both nurse and patient mutually affect the other’s communication.
Thus, both speaking and listening skills are pivotal to effective communication.
Every message has two levels of meaning: the content level, usually conveyed by
the words themselves, and the relationship level, generally conveyed by nonverbals.
Nonverbal communication (kinesics, haptics, proxemics, etc.) relays most of the mean-
ing of a message and affects both the task (patient care) and the relationship (commu-
nication climate) between nurses and patients/families. For this reason, it is essential
that verbal and nonverbal communication match each other: for example, you would
not ask how a patient is feeling while focusing on her chart!
The five roles of nursing revealed in Pavlish & Cerosky’s (2009) research include
teaching, caring, coordinating, advocating, and mobilizing: each of these roles involves
communication that conveys both task and relationship aspects of patient care. In
addition, the verbal and nonverbal behaviors of patient-centered care outlined by
Epstein & Street (2007) both facilitate the task of caring for patients as well as influ-
ence the nature of the relationship between them.
The chapter ends with a brief description of the communication model that under-
girds the entire book, a new model of palliative care communication termed the
COMFORT model. This model is based on seven components of effective end-of-life
communication:
C—Communicate
O—Orientation and opportunity
M—Mindful presence
F—Family
O—Openings
R—Relating
T—Team
In the next chapter, we discuss more specifically the principle of communication in

this model.
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DISCUSSION QUESTIONS
1. How is the COMFORT model different from other models with communication?
2. What is meant by the phrase “We cannot not communicate”?
2
communicate
Eileen is an oncology nurse employed in a women’s cancer clinic. She previously

worked on an inpatient medical surgical unit but decided to move to oncol-
ogy as she felt it might be more meaningful work. She has enjoyed the change
to oncology but admits feeling overwhelmed by the emotions of the patients.
Eileen works with Dr. Martee, an excellent oncologist, but she has found that
while his medical knowledge is excellent, his communication skills are lacking.
Dr. Martee’s clinic is always overbooked, and he often is in a position to inform
patients of a new cancer diagnosis amidst a busy clinic, leaving Eileen alone to
support the patient and answer their questions and witness their shock and dis-
tress after hearing the life-altering words “you have cancer.”
A month ago Eileen had a very difficult encounter with a new patient, Mrs.
Williams, who was newly diagnosed with Stage III ovarian cancer. Following Dr.
Martee’s brief explanation of the diagnosis and treatment options, Eileen was
left to answer Mrs. Williams’ many questions. Mrs. Williams cried intensely, and
Eileen tried as best as she could to offer support, assuring her that Dr. Martee
would provide the best treatment possible.
Mrs. Williams began a rigorous treatment regimen of weekly chemotherapy.
Eileen noticed that Mrs. Williams always comes alone for treatment, and after
the initial appointment she has been very stoic, rarely expressing any emotion.
Eileen reacts to her stoicism by offering constant reassurance and “cheering her
on” through each treatment.
As Eileen becomes more frustrated with her ability to communicate with the
complex oncology patients, she seeks advice from the clinic social worker, Ronald. He
offers support based on his many years in the clinic and advises Eileen on essential
skills such as attentive listening and ways to illicit the patient’s experience. Ronald
agrees to continue meeting with Eileen as she gains experience in these skills.
Mrs. Williams completes her initial course of chemotherapy and returns to the
clinic for an appointment following reevaluation of her tumor status. Unfortunately,
Dr. Martee informs her that the tumor has not responded to the therapy as hoped
and the latest scan reveals she has developed metastasis to the liver. Dr. Martee
asks Eileen to spend a few minutes with Mrs. Williams. Eileen enters the room, sits
quietly with Mrs. Williams, resisting the urge to offer reassurances and listens as
she sobs. Eileen at first thinks of the best response she can offer but instead applies
23
Ronald’s advice to seek to understand Mrs. William’s experience. She asks Mrs.
Williams to share what it felt like to hear that the treatment wasn’t working. Mrs.
Williams has spoken little about her family but she opens up to Eileen and with
great distress says that her greatest concern is “abandoning her mother-in-law.”
Eileen listens as Mrs. Williams shares that when her husband died from colon can-
cer 5 years ago she promised him that she would care for his elderly mother. Her
greatest concern is now feeling that she is abandoning her mother-in-law and the
promise to her beloved husband.
Eileen experiences the struggles that many nurses face when it comes to communica-
tion. She is left with the responsibility of compensating for a physician’s lack of com-
munication skills, alone with a patient who is emotionally distraught from hearing bad
news. Awkward communication situations like this come often in palliative care, and
few nurses receive adequate preparation for what to do or say. Eileen’s reaction to this
problem is very common—she seeks help from coworkers or team members. She feels
compelled to cheer her patient (and family, when applicable) through treatment, see-
ing this as a primary way of communicating patient support. But still, these attempts
have left her feeling as if she has failed. She still continues to share in the suffering of
patients and families, wanting to do more, say more.
Palliative care nurses do much more than simply provide presence when physicians
break bad news by giving patients and families a serious or life-threatening progno-
sis. Nurses are there before this happens, while it happens, and after it happens. The
ongoing presence of nurses affords an opportunity for both task-based and relational
communication. This chapter presents the basic communication characteristics of
these health care interactions. Communication is the cornerstone of palliative nursing.
Awareness of the unique role of nurses in patient/family encounters guides this discus-
sion so that we may illustrate specific ways to shape nurse communication practices.
This chapter will outline three foundational components for communication in
palliative nursing. The first section will detail narrative clinical practice and describe
how to approach patients/families so nurses have an understanding of the duality of
task and relational communication in their every interaction. The next section focuses
on verbal clarity and how to practice person-centered communication with patients,
family, and team members. Finally, the last section will feature nonverbal immediacy
and an awareness of the mistaken assumptions that can lead to miscommunication
and conflict. These three principles will serve as tools to initiate and respond to dif-
ficult communication encounters. Throughout this chapter and the next, we will dem-
onstrate how these principles overlap and offer specific strategies that can be used to
achieve both relational and task-oriented goals.
WHAT IS MY ROLE IN COMMUNICATING

IN PALLIATIVE CARE?
Nurse communication in palliative care is inaccurately depicted as a supportive role
during breaking-bad-news exchanges between physicians, patients, and families
25 Communicate
(Malloy, Paice, Virani, Ferrell, & Bednash, 2008). Although communication protocols
and guidelines exist, there is no one protocol that explicitly focuses on the unique
role of the nurse in this process (Price, McNeilly, & Surgenor, 2006). Instead, guide-
lines summarize four domains of action, beginning with preparation, message deliv-
ery, empathizing with emotional response, and summarizing the encounter; however,
nurses do so much more (Dahlin, 2010). For the nurse, supporting patients and fami-
lies receiving bad news is a process that happens before, during, and after the actual
delivery of bad news (Warnock, Tod, Foster, & Soreny, 2010). The intimacy of nursing
communication is the relationship a nurse shares with a family and patient during dis-
ease progression. The nurse is unable to control events surrounding bad news, as these
disclosures often occur in “uncontrolled” and unplanned moments with patients and
families (Warnock et al., 2010). The nurses’ role requires flexibility and attention to
the task and relational dimensions of communication during interactions that depart
from the familiar or known path.
Task Communication in the Bad News Context

Simply put, task communication includes the nurse’s role in confirming and explaining
the bad news delivered by the physician. If faced with a situation where the physician
does not do an adequate job conveying bad news, the nurse may find herself in Eileen’s
shoes attempting to compensate for a lack of information. In some instances, the nurse
may be the one to deliver the bad news. For example, increasingly nurse practitioners
(NPs) play a role as primary caregivers, and the NP may be giving the news of a biopsy
or other diagnostic tests. Either way, nurses should be prepared to provide supplemen-
tal information and ongoing evaluation of the patient’s condition (Price et al., 2006).
Educating families enables them to engage in decision making (Pavlish & Ceronsky,
2009). The nurses’ supportive role includes but is not limited to assessing informa-
tional needs, clarifying misunderstandings, and educating about medical information
(Warnock et al., 2010). All of these tasks will be unpacked in the coming chapters.
To validate bad news, nurses must engage in extended discussions of prognosis and
care options and when appropriate assist with planning end-of-life care (Radziewicz &
Baile, 2001). Preparing to deliver bad news can often fall to the nurse who will facilitate
selecting and arranging for a place of care and gathering patient/family information
(Price et al., 2006). An additional and often overlooked communication task is to share
information with the health care team and provide support to the physician (Price
et al., 2006; Radziewicz & Baile, 2001). Reporting to the team helps the nurse coordi-
nate multiple services in the delivery of a cohesive treatment plan and mobilization of
needed resources (Pavlish & Ceronsky, 2009).
Relational Communication in the Bad News Context

As nurses work to confirm and explain bad news, these efforts must include com-
forting patients and families and attempting to reduce their uncertainty. During bad
news encounters, patients and families need empathy and support (Price et al., 2006).
Nurses can extend their physical care tasks to include the psychosocial aspects of illness
(Pavlish & Ceronsky, 2009). Relational communication is so much more than meeting
with the patient/family for comfort (Radziewicz & Baile, 2001). It includes facilitating
emotional reactions and providing opportunities to process the bad news (Warnock et
al., 2010). For Eileen, this meant engaging in active listening and trying to elicit patient
experiences. Teaching, caring, coordinating, and advocating are all enabled through a
communication behavior called narrative clinical practice.
NARRATIVE CLINICAL PRACTICE

Narratives reveal who people are and where they are headed—or where they think they
are headed (Aloi, 2009; Hess, 2003). In hospice and palliative care, these are typically
stories of pain and suffering. A meaningful story no longer exists as illness produces
incongruity—patients and families who do not understand or talk about this incon-
gruity are still attempting to live a normal story without illness (Hess, 2003). Their
stories remain general, and focus on a clinician’s orders in order to live a longer life,
rather than a patient-specific story of illness (Hess, 2003). A palliative story includes
recognition of the turning point toward decline. This is important when attempting to
gauge patient/family understanding about prognosis.
As people negotiate illness, struggle to make decisions, and experience pain, nurses
bear witness to these struggles. To engage in narrative clinical practice, the nurse must
allow herself to witness. Bearing witness involves “being with and relating to others”
while at the same time honoring their voice, their lived experience (Naef, 2006, p. 147).
One way to do this is to acknowledge the patient/family through listening, writing,
and speaking about their story (Naef, 2006). Be open to others’ judgments, beliefs, val-
ues, and actions (Hess, 2003). Narrative clinical practice involves helping patients and
families rewrite or reauthor their story to focus on quality of life (Aloi, 2009).
Witnessing with patients and the family consists of three principles. First, the nurse
must recognize their individuality (Kendall, 2007). A special form of active listening
called deconstruction will help focus on gaps, ambiguities, and conflicting plots within
the story (Aloi, 2009). This allows the nurse to notice the vulnerability of patients/
family members and to recognize their profound difference. Each has a unique story.
When sharing patient/family information with others, use adjectives to describe their
uniqueness (this can also be helpful in remembering each patient/family!) For exam-
ple, nurses can describe patients by the information they learn about their childhood
or their personality.
Second, it is useful for nurses to get to know what the patient/family was like prior to the
diagnosis and illness/prognosis (Kendall, 2007). Allowing patients and families to reflect
on their personal lives helps to incorporate the psychosocial history in the diagnostic
assessment. As the story is told, the nurse should solicit and employ externalization—or
information the storyteller might include—for example, to express his or her self-blame
about the illness or life regrets (Aloi, 2009). Acknowledging and responding to these
moments of externalization with affirmation and acceptance will facilitate the patients’
coping with the illness. Prior patient histories by the patient or by family members can
27 Communicate
reveal common forms of self-blame, including life decisions/actions that lead to illness,
feelings of guilt for poor decisions, and the desire to cure at all costs. As nurses witness
these stories, they address these feelings and work to help the patient rewrite the story to
include quality of life as central in all decision making.
Finally, nurses need to go beyond the medical facts associated with each patient
(Kendall, 2007). The nurse can work on reauthoring the story by seeing problems as
care goals rather than cure goals. Reauthoring alters the patient/family narrative in a
way that includes the total impact on the storyteller, and widens the lens beyond the
borders of the illness alone (Aloi, 2009). This involves refocusing the story in order to
redefine the person (i.e., patient/family). As the story unfolds, the nurse can gather
an understanding of prior biomedical interventions to grasp an understanding of the
present complaint. As the story emerges and the nurse begins to understand where the
patient and family are in terms of understanding and acceptability, verbal clarity will
help to communicate and process appropriate goals of care.
VERBAL CLARITY
While verbal clarity is an important feature of health literacy—to ensure that patients/
families receive information given to them by the nurse—it is important in hospice and
palliative care as a communicative feature that conveys emotional support. We assume
that there is a direct connection between communication behaviors and well-being,
and that some forms of supportive communication are more effective than others
(Burleson & MacGeorge, 2002). Supportive communication is in direct response to a
need—and the variation of these responses is how we characterize verbal clarity.
Person-centered messages are one way to convey supportive communication.
Person-centeredness is “the extent to which the perspectives and feelings of distressed
others are acknowledged, elaborated and granted legitimacy,” and has been empiri-
cally validated as a key dimension of emotion support skill (Burleson, 1994, p. 258).
Comforting behaviors expressed through supportive messages termed person-centered
messages (PCMs) have consistently been judged as more supportive and encourag-
ing for those having difficulty addressing their feelings (Jones, 2004). PCM can draw
out the thoughts and feelings of patient/families as they face a life-threatening illness,
making their challenges, symptoms, and fears known by their nurse.
PCMs range from low emotional support to high emotional support (MacGeorge,
Gillihan, Samter, & Clark, 2003). To achieve verbal clarity, the goal is to use PCMs
that are high in emotional support. Low–emotional support messages include
criticism, challenging legitimacy, and telling the patient/family how they feel. Low
PCMs deny the patient and family’s feelings. Middle-level emotional support mes-
sages explicitly recognize the patient/family’s feelings albeit through distraction,
offering sympathy, or explaining the situation. Highest forms of PCMs include
explicitly recognizing and legitimating the patient/family’s feelings by elaborating
and articulating feelings.
Communicating social support during care allows the nurse to accomplish task
goals and still be relational. Oncology nurses who provided chemotherapy to patients
reported that they worried that they provided too much irrelevant information, didn’t
really answer patient/family questions, assumed instructions were easy, and did not
provide enough opportunity for the patient/family to talk (O’Baugh, Wilkes, Sneesby,
& George, 2009). A PCM allows the nurse to present a realistic picture for the patient/
family, clarifying what the “silent” patient is experiencing and reminding families of all
that is being done to the “person in the bed” (Robichaux & Clark, 2006). PCMs lead
to: perceived communication competence of the nurse, improved coping skills for the
patient, increased liking of the nurse, and increased relational satisfaction between the
nurse and the patient (Jones & Guerrero, 2001). PCMs are used in conjunction with
nonverbal immediacy.
NONVERBAL IMMEDIACY
In short, nonverbal immediacy communicates liking (Burgoon, Birk, & Pfau, 1990).
Facial expressions, body movements, interactional distance, vocal tone—all of these
behaviors communicate dimensions of the interpersonal relationship between nurses
and patients and families (Haskard, Williams, DiMatteo, Heritage, & Rosenthal, 2008).
Appropriate nonverbal behaviors for nurses who share in the delivery of bad news
include maintaining eye contact with patients, leaning forward to show attentiveness,
self-awareness of the body to avoid fidgeting or other distracting movements, and
nodding to indicate agreement or understanding when the patient speaks. Nonverbal
immediacy can improve the cognitive learning of patients and increase the perceived
credibility of the nurse. Even though the verbal content of each bad news interaction
will change based on the patient, family, and team, the need to mirror and model
nonverbal immediacy proves to be the most beneficial for all parties in the interaction
(Ragan, Wittenberg-Lyles, Goldsmith, & Sanchez-Reilly, 2008).
Particularly in breaking bad news interactions, the patient fears the nurse’s message
and the nurse fears the patient’s response (McGuigan, 2009). While the patient fears
that bad news is coming and then more uncertainty following bad news, nurses fear
that their communication may evoke intense emotional reactions that they are unable
to handle (McGuigan, 2009). According to expectancy violations theory, we all have
expectations of how others will behave and react. We use these expectations to gauge
our idea of “appropriate” and “normal” nonverbal responses. General expectations
involve our expectations for behavior in certain environments. In hospice and pallia-
tive care, nurses expect patients and families to be respectful of their work by follow-
ing directions and collaborating with them to reach goals of care. When expectancies
are violated, individuals focus less on the conversation and more on the violation of
expectations. Our focus shifts to the communicator, our relationship with him or her,
and the context.
First, nurses reflect on communicator characteristics and consider the demo-
graphics of the patient/family member. Does the gender of the patient conjure
up specific patient expectations? Does the nurse have different expectations for
patients/family members with health care backgrounds (i.e., retired nurse, prac-
ticing physician)? Second, we reflect on our relationship to the patient/family
29 Communicate
member—do they have power over us? How long has the nurse known them? Is
this a patient the nurse has cared for many times over the last year? Or is this a new
patient? Power and intimacy compose relationship expectations. Finally, context
characteristics concern our reflections on specific interactions, such as breaking bad
news, and often involve third parties. It is in these instances that nurses are more apt
to have preinteraction expectations.
Take, for example, Donald, a hospice nurse who goes to see a patient in the pallia-
tive care unit of a large metropolitan hospital to talk to the family about hospice. Upon
entering the patient’s room, he is greeted by a woman relative sitting by the bedside:
“We’re going to go out of town today. We’ve said our good-byes. I’m at peace with all
of this. If he goes while I’m gone it will be okay. I just need to get the paperwork done
today before I leave.”
Immediately, this family member violates Donald’s general expectations. Donald
expects to be greeted by a family relative and allowed to provide his opening intro-
duction of hospice as well as assessment. Since he has no prior relationship with
this patient and knows nothing about the woman relative, he relies on his expecta-
tions for the interaction. He finds a seat directly across from her—instead of going
directly to paperwork (a communication task that she expects), he violates her
expectations by engaging in a conversation about the patient, saying in a quiet tone
with his paperwork lying on his lap: “Okay, well can you catch me up on what’s been
going on?” His nonverbal communication (sitting down, neglecting paperwork)
indicates to her that he is interested in what she has to say. The woman explains
that she has cared for her father for 3 years, they have shared open communication
about death and dying, that her father has a living will, and she is a medical assis-
tant in the hospital who is familiar with hospice and palliative care services. Further
into the conversation, Donald reveals his expectations for the interaction to her:
“Typically in hospice we have to convince people that hospice is appropriate.” She
replies, “I’m just sorry it’s taken this long. This was his fear—that this would hap-
pen and he would linger.” Donald then inquires, “Even though your father has been
ill a long time and you have prepared for his death, is this a difficult time for you?”
After further conversation, hospice paperwork was completed. Donald’s reaction to
expectancy violation could have very easily have been to go straight to paperwork,
speaking very little with this woman. Instead, he set his assumptions aside about
why she was okay to leave her dying father and prioritized relational communica-
tion alongside communication tasks.
Violations of expectations associated with breaking bad news come when nurses
judge whether or not emotional reactions are “normal” or “abnormal” (Radziewicz
& Baile, 2001). When expectations aren’t met, we socially evaluate the patient/family
member and adjust our communication accordingly. This evaluation is perceived as
either positive or negative, depending on many factors. Similarly, for patients, breaking
bad news interactions violates expectations as they are incongruent with expectations
for cure and thus increase uncertainty in communication (Afifi & Burgoon, 2000).
Expectancy violations can exist for both parties and highly impact clinical communi-
cation from that point forward.
Patient/family members’ emotional reactions to bad news can trigger viola-

tion expectations, a point at which nonverbal immediacy moves center stage. The
nurse’s reaction to how bad news is handled will impact his/her ability to commu-
nicate comfort and support. Patient sadness often elicits a relational communica-
tion response; however, patient/family anger is more likely to trigger task-related
communication only (Sheldon, et al., 2009). Nurses should anticipate that they will
experience many types of emotional reactions in their career. Proximity, eye contact,
and demonstrated caring about what the patient is saying and feeling are key behav-
iors that help nurses express nonverbal immediacy (Andersen & Guerrero, 1998;
Epstein & Street, 2007). Nonverbal immediacy communicates involvement and per-
sonal engagement—body language, gestures, and vocal tone are all related to patient
satisfaction (Haskard et al., 2008).
Self-awareness is important. Self-awareness allows nurses to appreciate their own
self-worth and care for themselves before caring for others (see Chapter 9 for self-
care) (McGuigan, 2009). A nurse’s opinions, values, and ideas about patients and their
families impact how they approach the situation, and shape communicative choices
and strategies. Nurses can practice humility by allowing themselves to be equal to the
patient/family, by not presuming to be an expert in a story they have not even told, and
have faith that other clinicians can also demonstrate this humility (Hess, 2003). Self-
awareness about individual ideas and opinions can aid in the recognition of ideas that
are separate or different from the patient/family.
DEVELOPING CLINICAL PRACTICE SKILLS

This chapter reviews communication in palliative nursing, identifying three over-
arching features for the nurse’s involvement in breaking bad news communication.
Considering the unique role of the nurse in bad news interactions and his or her
unlimited and unprotected exposure to patients/families, we offer the following com-
munication strategies to demonstrate specific communication concepts in each step
of nursing practice.
Assessment
Earlier in the chapter, we described the process of witnessing as a way of listening
and capturing the patient/family’s story. In the case study that opened this chapter,
Eileen was advised by Ronald, a social worker, to be an attentive listener and to elicit
the patient’s experiences. To accomplish this, nurses can engage in witnessing by using
questions that capture meaningful aspects of the patient/family’s life (Aloi, 2009). The
following checklist (Table 2.1) can be used as a guide:
The nurse’s goal is to listen to the story, share it with others, and record it.
Witnessing is so much more than prompting patients/families to share, and listen-
ing (task communication) is about incorporating comfort communication into feed-
back and interpretation (relational communication). The following vignette serves to
illustrate the process of witnessing. A meeting with the adult son of a patient (S), the
31 Communicate
Table 2.1 Checklist of Witnessing Skills

What to
Principle Listen for What Questions to Ask
Recognize Identify “Tell me about times when you aren’t thinking about
individuality vulnerabilities, illness/your loved one’s disease.”
uniqueness “How would you describe this illness/the shared
experience of illness?”
“Is there anything else that could explain your/his/her
illness?”
“I’m wondering if there is more to this than meets the
eye.”
“Who else is involved in your/his/her illness?”
Understand life Encourage “How has your illness (or his/her illness) affected your
prior to illness sharing, life and your relationships?”
address “How do you think ignoring this will affect your life?”
feelings “How does your illness (or his/her illness) reflect on
you as a person?”
“How do you see the future?”
“How are you affected by others’ opinions?”
“What do you think influences this experience?”
Go beyond Consider “What people in your life are supporting you?”
medical the mental “What do you think needs to happen in order for you
information health of to be able to care for your loved one/yourself?”
patient/ “What needs to change?”
family “What does your success in solving problems related
caregiver to care say about your abilities?”
“How is this experience affecting your life?”
“What do you see in yourself now that you didn’t see
before?”
Adapted from: Aloi, J. A. (2009). The nurse and the use of narrative: An approach to caring. Journal
of Psychiatric and Mental Health Nursing, 16 (8), 711–715.
patient’s daughter-in-law (DIL), and a hospice nurse (RN) took place in a hospital
family room:
s: He’s got terminal cancer. We’ve talked before he came into the hospital. He
has a will. I’m just doing what he wants.
dil: He’s gone blind now.
s: It’s like I told my brother. If two could go out and one could stay, I would . . .
dil: It’s in his lungs, his liver, it’s ate [sic] up everywhere. He took chemo
3 weeks ago today, and he’s had two blood transfusions since then. I talked
to his cancer doctor, and now he’s had three strokes. So, now with the
strokes, it’s time for you. Dr. [X] told me yesterday that he’d be better off in
hospice, and with his will, he did not want to live like this.
rn: In hospice, we do what’s needed. We do what we need to do. With his can-
cer, he must be in pain.
s: Well, he has no spleen, no kidney—he lost those to cancer. He’s had heartat-
tacks, a heartattack a month ago. That’s how we found out he had cancer
again. [Son further explains that this is a second type of cancer]. So when
can we move him? How does this work? (Note: Son is urgent to move the
patient from hospital to hospice facility.)
rn: We are guests here [referring to hospice in the hospital], but we could do the
paperwork today and have him moved this afternoon to our inpatient facility.
s: I don’t want him moved today. I need to get used to this. (Note: Despite
urgency, son does not want patient moved today. The nurse recognizes this gap
inconsistency and addresses it through externalization.)
rn: After this long haul, as you are approaching the end, you are afraid of
what’s next . . .
dil: We don’t know want to do. My husband lost his job and has been taking
care of him. Then I lost my job, and we’ve just been taking care of dad.
s: My priority is my dad. They didn’t understand why I kept having to leave
work to take care of him, so they let me go.
dil: [begins to cry] This has been our life for 2 years.
rn: I hope you find peace knowing that you did do it. Not many people do it.
Do you feel like everything has been tried? (Note: Family reveals life prior to
hospice referral. Nurse responds by reauthoring, going beyond medical facts to
understand prior interventions)
dil: Yes, everything has been tried.
rn: Hospice does not start with consents. It starts with a hospice evaluation
[explains process]. As far as pain management, I would recommend a sub-
cutaneous infusion. I did it for my own grandmother. It provides the relief
needed for his extensive cancer pain [explains]. Once you stop artificial
hydration, we can expect 7–10 days. But once you factor in extensive can-
cer, as he has, strokes which keep a person from taking in fluid, it will be
shorter [explains]. And in hospice, we won’t judge you if you aren’t camp-
ing out and staying by his side. That’s okay. (Note: Nurse deconstructs any
preconceived ideas about hospice—recognizes family’s individuality.)
s: Yeah, I won’t be there. I don’t deal well with this. I need some time alone.
rn: (to DIL) Just the fact that he’s able to admit that to you, that’s healthy. Well,
we can move him tomorrow if that’s what you’d like. (Note: Nurse recog-
nizes his individuality, uses positive adjective to reauthor.)
Plan
As the nurse moves from listening and responding to patients/families through wit-
nessing, the next step is to determine what to do with the information. This was most
33 Communicate
problematic for Eileen—she knew to prompt Mrs. Williams to share her feelings but
did not know what to do when Mrs. Williams began sharing. For Eileen, the emo-
tional reaction shared by Mrs. Williams felt uncomfortable, yet understandable. The
intimacy of nursing creates opportunities where patients and nurses are vulnerable to
witnessing the reciprocal suffering of patients and families. Nurses can prepare them-
selves by learning to listen for key patient/family features as well as how to negotiate
problematic situations.
It is helpful to sort and organize the patient/family story according to the four qual-
ity-of-life dimensions (Table 2.2) that comprise palliative nursing. Use the checklists
provided in Table 2.2 for each of these dimensions.
Sorting the story’s content according to physical, social, spiritual, and/or psycho-
logical care will naturally help the nurse to identify specific assessments, resources,
and additional involvement from interdisciplinary team members (for more on this,
see Chapter 8). For example, Eileen’s patient, Mrs. Williams, reported that she worried
about “abandoning her mother-in-law.” Eileen learns that Mrs. Williams is a widow,
responsible for providing care for another family member. This is how Mrs. Williams
defines the priorities in her life and thus her quality of life—and the nurse’s job is to
develop a plan of care that recognizes this. The precedence for care planning should be
Table 2.2 Overview of Quality-of-Life Dimensions

✓ Checklist
✓ Physical Well-Being and Symptoms ✓ Psychological Well-Being

Fatigue Anxiety
Sleep disruption Depression
Function Helplessness
Nausea Difficulty coping
Appetite Fear
Constipation Uselessness
Aches/Pain Concentration
Control
Distress
✓ Social Well-Being ✓ Spiritual Well-Being
Isolation Meaning
Role adjustment Uncertainty
Financial burden Hope
Roles/Relationships Religiosity
Affection/Sexual function Transcendence
Leisure activities Positive change
Burden
Employment
Used with permission from: Ferrell, B., & Grant, M. (2011). Quality of life: 1525 voices of cancer.
Oncology Nursing Forum, 23 (6), 907–916.
Table 2.3 Overview of Breaking Bad News Scenarios and Suggested Communication
Barriers to Breaking
Bad News How to Handle/What to Say
Lack of privacy x “I know this is not ideal, but let’s try to find as much privacy as
possible to talk. We will have more opportunity later for a quieter
space, but this is an important time to talk together.”
x “It would be good if you talked with each other [family] and decided
if all of you want to be included in decisions of care discussions. Can
we talk again this afternoon after you have had time to visit together?”
Over the phone x “I know this not ideal, but I can talk to you now over the phone
about your health and we can meet together tomorrow to talk more.”
x “Is it alright with you if I visit with you about your recent test?
I know that a phone call discussion is not my favorite, but this way
I can get you the information now and we can meet face to face
when it works with your schedule.”
Unable to contact x [by phone]: “I am so glad to reach you. I am Karen, a clinical nurse
family until after from Memorial Hospital. I have been with your Dad this afternoon
medical event and I need to talk to you about what we have been going through
here. Your father is very ill. Can I explain more details now about
your Dad?”
x [in person]: “I am so glad you are here. Can I talk to you about what
we have been facing with your Dad today?”
Lack of time to x “Let me apologize up front for being short on time in this moment,
explain but I do want to you give you a sense of what we know about your
blood levels. I promise to come back by this afternoon and talk more
with you about your questions and concerns.”
x “I have just a few minutes to update you on your blood work. I
know this is not enough time to process any questions or concerns
you might have, so I will be back by to talk more with you and your
family after lunch. Is that a good time for you?”
Cognitive x “Julie, I want to talk to you about how you are doing, and what
impairment the tests we have been running are telling us. In case you need help
understanding what we know, I think it would be helpful to share
this information with your family, too.”
x “Because Julie’s having a hard time understanding what we are
learning about her kidney function, I am glad I can share the
information with you [family]. Can you talk with me about Julie?”
Interpreter x Explain to patient/family that you are using the help of an interpreter
required to take the best care of the patient/make the best decisions.
x When the interpreter translates, look at the patient/family.
x Confirm that the patient/family have asked the questions that they
have.
(continued)
35 Communicate
Table 2.3 (continued)

Cultural x “Are there any care needs that your family would specifically like to
differences see happen?”
x “What can we do to better support your family’s traditions? There is
a lot we can do, even in this environment, as long as we know what
you would like.”
x “How does your family want to be included in care decisions? We
want to be as attentive as we can to the needs of your family.”
Lack of x “It is so good to meet you. Can you help me understand who else is
knowledge in your family?”
about patient/ x “I have been helping Ken this evening on my shift. Who is part of his
family family here?”
x “I think we have learned this evening that Ken has been struggling
with some of the medications he has been taking.”
Lack of x “I understand you are concerned about the changes you see from
knowledge this morning. I will absolutely check with the nurses’ station as well
of events as call his physician. I will get back to visit more with you.”
x “Let me repeat to you what I hear are your questions . . . and then
I will go seek out the answers. Since I am new to your brother’s
situation, this will help me learn about him and your family as well.”
Concerns x “The most important thing for me is to understand your concerns
about own and questions. I will work diligently to get you the answers you need
clinical to make the best care choices for your family/self.”
knowledge x “This is the news I do know and can share with you. If there is
something I am unfamiliar with, I will find out the answers. We can
make a list of questions together.”
x (Note—In this instance ask your colleagues and team members
about the patients status.)
Family is not x “I am glad we have an opportunity to discuss your Mom’s health. She
present did want us to give her the assessment from the tests this morning,
despite your absence. Now that we are all here together, how can I help
you [family] as we understand that surgery will not be possible?”
x “I understand you [patient] had a visit with Dr. X about your CT scan.
I know you would like your family to have been here for that conversation.
Would it be helpful to have Dr. X meet with you and your family and me
to talk more about how you are feeling in light of this news?”
You are not x “Since I was not here for the news, can you tell me how the
present conversation with the team went? [response] Now, as I listened
to you these are the questions I think you still have [relay patient
questions discerned], is that right? I will be sure to get these answers
and come talk with you.”
(continued)

x [to team member] “Can you help me understand the care decisions
that Dr. X proposed? How do you think the patient understood this
conversation and is feeling about it?”
Own doctor not x [to family] “I will pass on your concerns and questions to your
present primary doctor and seek some response about these issues. I know it
is important after you have spent so much time with a physician and
be placed with a new doctor.”
x “I am sorry you are upset. We will do all we can to provide
information and comfort that will help you through this. And we
will be with you in this struggle.”
Dying without x “There is some very difficult news I need to share with you about
relatives present Joe. Can you come with me to the family room to visit about the
events of this afternoon?”
x “I want to ensure your privacy. Can we go together to a quiet place
and talk about Joe?”
x “You are part of our care effort. Let’s go to my office so we can have
some time to process the events of the day in a quiet place.”
Providing x “I know this information is not at all congruent with what we knew
information earlier in the day about your brother. I am so sorry for the sudden
in difficult change in things.”
circumstances x [family members feuding violently] “I wanted to share information
about Joan with you. We are also talking with your mother in
another room about the very same information. What else can
we do to help you manage this information in the midst of your
difficult family dynamics?”
Family unprepared x [phone] “We have been caring for Steve during the last hour. He is
not responding well, and we are worried that he is really declining
quickly. I am so sorry to give you this news. I want you to know what
we know and give you the chance to get here if that is important to
you.”
x “I need to try and prepare you that Steve is not doing well. We
are surprised and saddened by his turn this evening. This is your
opportunity to spend time with him. He is declining.”
Patient not told at x [to a 9-year-old unaware of impending death] “We are all working
relative’s request to take the very best care of you we can. We want you to feel as good
as you can so make sure you tell us about your pain, or any worries
so we can help you.”
x [to a 90-year-old Latina woman] “You have a loving family. We are
going to take the best care of you we can and help you feel as good
as possible.”
(continued)
37 Communicate

Patient told despite x [to family] “What are the positive aspects of [patient] knowing the
family request news about his health?”
Patient doesn’t x “Tell me why you don’t want to know about your health and the
want to know problem you have had with your leg?”
x “Where do you eventually want to be to face the rest of this illness?
At home? In the hospital?”
Relatives not being x [with patient and family] “Can we come together and think about
honest the pros and cons of moving Jade home for the rest of her illness?
I think it would be important to think about these things together
to ensure that Jade gets all the care she needs, and that [family
member] can be a caregiver in the way that he really can.”
x [among family members] “Could we talk about who can provide
the care at home if that is really what [patient] wants? This is a
great opportunity to come together and make the best decision for
[patient].”
Patient/relatives x “Let me go over the news about your blood work and fill in the
poorly informed blanks that might exist. I know this can seem very frustrating to not
have all the information at once to process the overall situation. As
we talk, keep your questions coming.”
x “I am here just to process this with you and make sure you feel like
you understand the information and this procedure. Stop me at any
point and ask questions if you need to.”
Not understanding x “Ben, I want to revisit this news with you and make sure you
the implications of understand these developments. Can you describe to me what you
the information understand to be the news so I can see if we are on the same page?”
x “I am worried that you might not understand the gravity of this
information. Let me try to explain in different words, and please
stop me at any point and we can go over this until it makes sense.”
Emotionally x “Beth, I know this is the hardest news you could hear. I want to help
significant events you process this in any way that would be helpful. I know there are
things we need to think about regarding your family. What is your
biggest concern or fear?”
x “I know this is very difficult. Do you think it would be helpful if we
all met with [social worker] to process the impact of this news on
your husband?”
Challenging deaths x “We can never know when death really will come. I still cannot
predict as well as you might imagine I could. So, we need to continue
to provide support for [patient], but especially for you [family].
Can you think of a few things that we can help you manage as we
continue to support [patient]?”
(continued)

x “I can tell you that [patient] is receiving the best comfort care there
is. She is not showing any signs of pain or distress. Letting go of life
can be long work, longer than we would like or expect sometimes.
But that is why we are here, to make her comfortable.”
Adapted from Warnock, C., Tod, A., Foster, J., & Soreny, C. (2010). Breaking bad news in inpatient
clinical settings: Role of the nurse. Journal of Advanced Nursing, 66 (7), 1548–1549.
psychological well-being, as Mrs. Williams describes stress, anxiety, and helplessness.

Eileen’s plan of care and communication with Mrs. Williams should first address psy-
chological burden, followed by the other dimensions of care.
Patient and family stories are loaded with emotional weight, and a multitude of
reactions and scenarios may exist—especially surrounding bad news. Reactions to bad
news can include verbal abuse, anger, hysteria, threatening, and physical aggression.
Dealing with the emotions of patients and family members is routine in palliative set-
tings; interactions that involve bad news are especially problematic in hospital settings
where information barriers are abundant and relationships are complex. Even though
nurses are well trained and knowledgeable about palliative care, there will be daily
events and situations that are uncomfortable and awkward when it comes to commu-
nicating. As nurses work to soothe and comfort during these interactions, they must
also acknowledge the barriers present. Table 2.3 identifies some of the barriers found
in palliative care nursing and examples of how to work within these constraints.
INTERVENE
By recognizing the defining features of the patient/family’s story and identifying their
own definition of quality of life, nurses can tailor their own supportive communica-
tion while providing primary care. In our opening case study, Eileen learns that the
most devastating aspect of bad news for Mrs. Williams is the psychological burden
associated with her obligation to oversee care for her mother-in-law. As Eileen nego-
tiates care-planning needs in terms of coordination of care and possibly referral to
hospice care for Mrs. Williams, she must acknowledge this burden (relational commu-
nication) while at the same time work to ensure that Mrs. Williams understands her
prognosis and transition to palliative/hospice care (task). To accomplish comfort care
and communication, nurses must recognize their own assumptions and emotional
involvement as well as practice person-centered messages.
How we feel about others impacts how we communicate—how much attention we
give to patients/family members varies based on how we feel about them. Some get
more attention, and others get limited time and effort. It is important to recognize our
39 Communicate
Table 2.4 ✓ Checklist

✓ How do you feel about the patient?
✓ Will your feelings make the discussion more difficult?
✓ How will you react if the patient gets more upset?
✓ Do you and the patient/family share the same values?
✓ Are you critical of the life choices this patient/family member has made?
✓ Do you find their lifestyle to be appropriate based on your standards?
Adapted from Radziewicz, R., & Baile, W. F. (2001). Communication skills: Breaking bad news in
the clinical setting. Oncology Nursing Forum, 28 (6), 951–953.
own assumptions about patients/family members, especially when we haven’t worked

closely with them and don’t know their story well. Use the above checklist (Table 2.4)
to help discern assumptions from facts.
Practicing self-awareness helps nurses realize how emotionally involved they are
with patients/family members and whether or not they are able to provide objective
primary care. Does the nurse answer the call button immediately for their favorite
patient? The one who reminds them of their own parent or the patient they have
known throughout 4 years of treatment? Is it easier for the nurse to return calls to fam-
ily members whose lives are similar to their own and who have a similar family struc-
ture? The answer is probably “yes” because their communication style is familiar. But
what about patients/family members who are dissimilar to the nurse? Is the nurse slow
to answer these patients’ and families’ requests? The yardstick for determining whether
or not patients/families meet communication expectations, verbally and nonverbally,
is based on the nurse’s assumptions of them. Nurses need to be mindful of how they
assess the stories that they hear—and recognize when and where their thoughts and
feelings are separate from the story they are being told. For more on this topic, see
Chapter 9 on self-care.
As we noted earlier in the chapter, practicing person-centered messages is one way
to communicate relational support. Table 2.5 provides examples to demonstrate the
variation and types of supportive messages that can be offered to patients and families
following bad news.
Keep in mind that these messages are examples and the real power of a message is
in the nurse’s ability to match the patient/family member’s quality-of-life issues with
an appropriate response and feedback. For more on this, see Chapter 7. The goal is to
recognize that some messages are more powerful than others, and the incorporation
of I-Thou statements, as discussed in detail in Chapter 4, will prove powerful in letting
patients and family members know that their nurse cares.
Person-centered messages are just one way of practicing verbal clarity. The role of
the palliative nurse is to teach, advocate, mobilize, and care for patients and their fami-
lies. The nurse’s ability to talk about death and dying compassionately requires verbal
acknowledgment of dying and mortality in order to educate about hospice care and
Table 2.5 Variation of Person-Centered Messages Following Bad News

Low–Emotional Support Messages
Messages that do not acknowledge the patient/family’s feelings
Communicative Behavior Example Message
Nurse condemns patient’s feelings. “You knew this was coming. I don’t know
why you are so shocked.”
Nurse challenges the legitimacy of the “You should not feel bad because this is
patient’s feelings or actions following not your fault.”
from those feelings.
Nurse ignores the patient’s feelings. “Let’s talk about your treatment from this
point forward.”
Moderate–Emotional Support Messages

Messages that explicitly recognize the patient/family’s feelings
Nurse attempts to reframe the situation “You should at least be happy that you
in a positive way by diverting the patient’s know for sure now and can deal with the
attention away from the event, smoothing situation.”
over the negative feelings, or offering some
sort of consolation, or suggested method to
deal with the bad news.
Nurse acknowledges the patients’ feelings “I can see why you are upset.”
but does not attempt to help the patient
understand how to cope with them.
Nurse provides a non-feeling-centered “It is very normal to be upset. I see
explanation of the situation intended to people get upset like this all the time
reduce the patient’s distressed emotional when they have to deal with a diagnosis
state. This explanation offers some principle like this.”
for interpreting the situation.
High–Emotional Support Messages
Messages that recognize and legitimize the patient/family’s feelings
Nurse explicitly recognizes and “I’m so sorry this has happened. Did
acknowledges the patients feelings you think this was coming? I realize it’s
but does not elaborate on those frustrating, especially since you’ve been
feelings. sick for so long. Please talk to me about
how you feel.”
Nurse provides an elaborated “You may not be ready to talk about this
acknowledgment and explanation now, but I want you to know that I am
of the patient’s feelings here for you. I will continue to be your
nurse. I am going to do my best to make
(continued)
41 Communicate
you comfortable. I want you to know

that this is nothing that you did, that
this is not your fault. I don’t want you to
second-guess the decisions that you have
made. You’ve done everything that you
could.”
Nurse helps the patient to gain a perspective on “I’m so sorry. I know how much you
his or her feelings. Feelings about the bad news wanted to beat this disease and how
are explicitly elaborated and legitimized. Nurse hard you have fought. And I know that
attempts to help the patient see how his or her you would do anything you could to feel
feelings fit into a broader context. better. You must be thinking so many
things right now. You must feel hurt and
anger and question why this is happening
to you. I know that you have seen many
specialists and that there have been many
mixed messages—which makes this hard
to believe. I’m going to make sure that
you are comfortable. We have a team
here to help you with anything that you
need. It is important to take advantage of
this time that you have to talk with your
family, friends, and those that you love.”
Adapted from: MacGeorge, E. L., Gillihan, S. J., Samter, W., & Clark, R. A. (2003). Skill deficit or
differential motivation: Testing alternative explanations of gender differences in the provision of
emotional support. Communication Research, 30 (3), 272–303.
philosophy and the dying process. Remember, many of these patients and families have
only thought about cure until the nurse, the physician, or a member of the health care
team begins to talk about palliative care.
The following example illustrates how a nurse can be both verbally clear, yet elo-
quent in these discussions:
An initial hospice visit to the emergency room of the local hospital reveals that the
patient is an elderly woman recently placed on a bi-pap machine. Two sons and one
daughter (D) are present, and another daughter who serves as the primary caregiver is
absent. The hospice nurse (RN) enters the patient’s room and sees that the patient is
sitting up in bed and is communicating—however, the family quickly escorts him out
of the room into a private family meeting room:
d: They called us yesterday and said she probably wouldn’t make it through the
day. We did comfort only. Today we are just waiting.
rn: So today she has a little rally, a little more “umph.” So today you are won-
dering: am I doing the right thing by talking to hospice? (Note: Although
family has been told that patient is dying, they are reluctant to elect for hos-
pice care. The nurse summarizes this experience.)
d: Yes, we are confused.
rn: When you have a person who is elderly and you have the day-to-day care
and events, it changes. Today is an “up” day and a good day. But, could
tomorrow be a down day? So you need to step back and look at things
globally. What can we fix? What is her quality of life? What are the things
in life she’s been losing that we can get back? [pause] Is there no fixing?
Then it’s time for hospice. (Note: The nurse begins to educate about hospice
philosophy by focusing attention on quality of life and helps the family recog-
nize how quality of life is compromised.)
Yesterday was a bad day. Today is a good day. I saw that she is on a bi-pap
machine. Can she be without the bi-pap?
son-1: Only for about an hour.
d: And she told me she doesn’t want that machine but that she doesn’t want
to die. (Note: The family is first to bring up death and dying. The nurse
acknowledges and educates.)
rn: Yes, well no one really wants to die. [lowered voice] Even a terminal person
doesn’t want to die.
son-2: She hasn’t slept in 3 days.
rn: That could be part of the medications.
son-2: I don’t think so. She told me that she won’t go to sleep because she’s
afraid she won’t wake up.
rn: That tells me that she’s pretty aware of what’s in front of her. That she
knows she’s dying. (Note: The nurse vocalizes a conclusion for this family.)
Educating patients and families can be accomplished by using storytelling,

metaphors, and analogies to describe physical decline. For example, the body can
be described in terms of a system, an assembly line, a machine, or a car to illustrate the
process of decline and loss of function. Compassionate education is about teaching the
patient and family what is normal and then helping them to identify what is abnor-
mal. The goal is to help patients/families become aware of abnormalities that represent
disease progression and loss of quality of life. This approach conveys sensitivity to the
situation and is less abrupt than structured education. The following excerpt is from a
palliative care nurse (RN) sitting bedside with a family member (FM):
rn: I am watching his breathing.

fm: Yes, it’s changed since Tuesday. Yesterday he was breathing a lot and hard.
Now he goes 2 seconds and then breathes.
rn: It’s not that. . . . Is he breathing? It’s about the quality and effort of the
breathing. He is now working to breathe and doing it less often. (Note: The
nurse uses the patient’s breathing to teach about dying.)
43 Communicate
EVALUATE
Encouraging patients and families in sharing their stories, listening and sorting perti-
nent information relative to the quality-of-life domains, and practicing self-awareness
and person-centered messages will collectively produce quality palliative commu-
nication. Still, the nurse’s ability to reflect on his/her own communication choices
and its impact on delivery of care will reveal strengths and highlight areas in need
of improvement. Essentially, best practices for communication are ones we learn in
hindsight!
Evaluation is particularly important following emotionally charged interactions
and upon a patient’s death or discharge. Taking the time to understand our reactions
and assess how well the situation met task and relational goals is important. Try using
the following questions (Figure 2.1) to guide the reflective process:
Stage 1
Description
What happened?
Stage 6 Stage 2
Action plan Feelings
If it arose again, What were you
what would you thinking and
do? feeling?
Stage 5 Stage 3
Conclusion Evaluation
What else could What was good
have been done? and bad about
the experience?
Stage 4
Analysis
What sense
can you make
of the situation?
figure 2.1 Gibbs Reflective Cycle

Used with permission from: Gibbs, G. (1988). Learning by doing: A Guide to Teaching and Learning
Methods. Oxford, UK: Oxford Polytechnic.
Family and patient feedback is also important, as their thoughts and feelings may be
different from those of the nurse. Patient and family feedback should be encouraged to
determine if a communication goal was accomplished and whether or not verbal and
nonverbal communication conveyed support. Use the following checklist (Table 2.6)
to generate talking points with patients and families:
Table 2.6 Checklist

What happened in the effort to provide care?
What were you thinking and feeling in the course of care?
What was good about the experience?
What was bad about the experience?
What sense can you make of the experience now?
Could we have done something else, or done something differently?
If something similar happens again, what would you prefer us to do?
CHAPTER SUMMARY
Patients and families facing serious, chronic, or terminal illness have a story to tell.
Most of them want to share their journey and talk about the trials and tribulations of
illness. Most of them want to share it with their nurse. Learning to listen to these sto-
ries and capturing important information about what they value, what’s important to
them, and what is meaningful about their life can lead to comforting communication.
Encouraging storytelling, listening to quality-of-life issues, and practicing person-
centered communication are cornerstones of communication in palliative nursing.
These principles work together to accomplish task and relational communication at the
same time. Chapter 3 will illustrate how the nurse can tailor communication messages
to meet the health literacy needs and cultural sensitivity of patients and families.
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1. How are task and relational communication provided in palliative nursing?

2. What are some implications of patient/family stories? What can they tell you?
3. In what ways can you encourage patients and families to share their stories?
4. What are the varying levels of person-centered messages?
5. What nonverbal behavior can be used to convey that you like someone?
6. Describe your general expectations when working with patients who are
given bad news. What are the implications for their reactions on the way you
communicate with them?
7. When expectations are violated, what are the three characteristics we rely on to
evaluate a positive or negative reaction?
8. How can self-awareness be beneficial when using nonverbal behavior to convey
empathy and support?
9. How does witnessing work? In what ways does witnessing appeal to you?
10. What are the four domains of quality of life? Do you see evidence of these in the
patients and families you care for?
11. From the list of barriers to breaking bad news, which is the most problematic
for you? Why? What nonverbal behavior will you employ to help handle the
situation?
12. What are the effects of how you feel about others? How does this impact your
emotional involvement with patients and family members?
13. How can person-centered messages be used to educate patients and families?
teaching resources and materials
EXERCISE #1
Adult Family Member, sitting at bedside:
My father has been living with us for about 3 years. A week ago he fell and broke
his hip. They found bleeding in his stomach; he’s had a hernia for over 40 years.
They went in and put the g-tube in, pulled his stomach down, and anchored it
(g-tube) to the stomach. During this time he crashed and was intubated. He came
out and for 5 days he sat here; his hip was still not fixed and he was in so much
pain. After they did hip surgery, they were never able to extubate. We removed the
tube because we knew that’s what he wanted. Everything is now failing—and I said
“stop”—his arms are so swollen from blood clots and they wanted to do tests. I said
“no”—he didn’t want that.
Discussion Questions
1. What was the turning point that shifted this patient’s general story to a palliative
story?
2. Identify the gap in this story as identified by this family member. What does this
tell you about her acceptance of the situation?
3. Practice externalization and provide an example of how you would respond to this
family member.
EXERCISE #2
Kath’s narrative—Adult daughter, primary family caregiver:
Let me introduce myself. I am Kath and by day I work as a customer service

supervisor for one of the major high street banks. I have a partner, Simon,
and a brother, and in my spare time I am a competitive archer. I am a good
organizer, caring and born on my father’s birthday more years ago than I care
to reveal!
Four years ago my mother began to disturb her neighbors by saying there was
a “strange man” in her home, a man who was my father and her husband of over
40 years. This fear and problem with recognition was so out of character for my
Mom that I took her to the doctors who arranged for “tests” to be carried out,
mainly memory and blood tests, and a brain scan. When the results came back,
49
they said that Mom had Alzheimer’s disease, Vascular dementia and Lewy Body
dementia. Each of us, my mother, father, brother and me, absorbed the multiple
diagnoses the best we could and vowed to carry on, although it was my father who
shouldered most of the responsibility for my Mom’s daily support. Dad would tell
us: “you’ve got your own lives to lead” and would only accept help, reluctantly,
when things became too difficult for him to manage. He had such strength of char-
acter and he was my anchor. We all respected his pride and independence.
On a cold, crisp December’s day, Dad was on his way to collect Mom from the
local Day Center when he had a car accident. At first all seemed ok, but he was
admitted as a precautionary measure to the hospital where he was found to have
a severe chest infection. Initially, Dad responded well to treatment, but then he
lost his sight. Funnily enough, he did not make a fuss about that, it was only when
he kept looking at a non-existent wristwatch that I became suspicious and chal-
lenged him; it was then that he admitted he could no longer see. I visited Dad each
day before breakfast so I could feed him and only left after supper time, but after
a short period of time his kidneys started to fail. Dad needed an operation to survive
but, as we were told, would not survive the operation. The most cruel paradox, with
the only tangible outcome being one we did not want to face. But we had to confront
it and honor Dad’s dignity and quality of life. Eventually, the monitors giving him life
support were unplugged and the morphine increased and I watched until Dad closed
his eyes and died. I had to let him go, the father who had given me so much uncondi-
tional love during his lifetime. It was then that Susan (nurse) entered my world.
With help I tried looking after Mom, staying with her in her home, but it was
too difficult and confusing for her. So, after a lot of thought, discussion and soul
searching, Mom agreed to go into residential care. Although I knew, on balance, it
was the right thing to happen, when the day came for her to “go there” I was heart-
broken, a feeling of loss as great as when my Dad died. Well-meaning friends say
how relieved I must feel now that Mom was in residential care: how wrong they
were! Such feelings of guilt, in letting Dad down, and of sadness, in seeing someone
you love struggle to make sense of their life and new surroundings.
Mom has insight for short periods—windows on the world as I call it—and
at these times she has such clarity. During one of her “windows” Mom may ask
me a number of questions, such as: “Has my mental state got worse?” and: “Will
I get better?” You learn to think on your feet, asking her for her telephone number,
knowing that she will remember it, and then you can say: “Can’t be so bad can it
Mom? . . . of course you will get better”—all the time knowing that is not going to
happen, but at least it gives her hope. Mom also asks about Dad. Invariably, when
I go and see her, Mom will jump up, glad to see me, take my hand, and ask: “Where’s
Dad?” I try and fight back the tears explaining that Dad, her husband, has died.
Mom has no recollection of the day of his funeral when she said she felt like crying,
but couldn’t. I smile, glad that my mother does not feel the pain as I do.
Each visit to the residential home is challenging, as you do not know what you will
find or what questions you will be asked. Sometimes friends and colleagues at work
ask me how I am doing: “Fine” I will reply, but I am not fine, feeling that every waking
moment is consumed by the sheer effort of coping and locking my emotions away.
51 Communicate
Exercise Discussion
1. Recognize individuality—What unique vulnerabilities exist for this family member?
2. Understand life prior to illness—What was Kath’s like life prior to her mother’s
illness and father’s death? What is it like now?
3. How would you describe/educate Kath about her mother’s condition (mental
health)?
4. How does Kath define quality of life? Which domain is important when providing
a plan of care for her mother?
Used with permission from: Keady, J., Ashcroft-Simpson, S., Halligan, K., & Williams,
S. (2007). Admiral nursing and the family care of a parent with dementia: Using auto-
biographical narrative as grounding for negotiated clinical practice and decision-
making. Scandinavian Journal of Caring Sciences, 21, 345–353.
exercises for verbal clarity
EXERCISE #1
Review the opening case study scenario for this chapter.
1. What communication barriers are present for Eileen?

2. Imagine you are in Eileen’s shoes and write down exactly what you would say
to Mrs. Williams after she tells you that she is worried about “abandoning her
mother-in-law.”
3. Refer to Table 2.5 of person-centered messages and evaluate your own message. Is
it at the top of the hierarchy? If not, rewrite your message so that is supportive.
EXERCISE #2
Divide students into four groups. Assign each group one of the four domains of qual-
ity of life (physical, psychological, social, and spiritual). Working in groups, have stu-
dents write an example statement for each aspect listed in their assigned domain (e.g.,
for physical well-being, students would write example statements for fatigue, sleep
disruption, etc.). Statements can be made up or can be examples that they have heard
from their practice. Once statements have been written, have groups identify specific
resources available or care plan actions that would be supportive for the patient/fam-
ily member.
EXERCISE #3
Have students write a verbal analogy and detail verbal directness statements to describe
a disease or illness (e.g., cancer, dementia, COPD). Below is an example:
Table 2.7 Communicating the Diagnosis of Congestive Heart Failure

Verbal analogy For example, congestive heart failure
could be described as a traffic jam. Just
like when the electricity goes out and
traffic lights don’t work, drivers don’t
know what to do, so they slow down or
hesitate. The same is true for the body
when the heart can longer pump blood:
blood supply and blood flow slow down.
Verbal directness You have what we call congestive heart
failure. This is a long illness. Your heart is
not like it once was. It has a harder time
squeezing the blood through your body—
and all of the veins and arteries that run
throughout your body.
Once students have drafted an analogy and verbal directness statement, pair them
up with a classmate and have students share their work, choose and refine the best one
for each, and then have pairs share with the larger group as a whole. Instructors may
want to assign specific diseases to certain parts of the classroom or as appropriate given
coursework curriculum.
exercises for nonverbal immediacy
EXERCISE #1
Patient: Let me take you back to the start. I was completely well. I was toodling along
with two little kids and a husband. He is a physician. I was teaching school, and one
day I found a football-sized mass in my abdomen. It frightened me, but because it
was so huge, I felt it had to be benign. After all, something that big could not possibly
be a cancer, and the word cancer just never even entered my mind. I was too young,
I thought. Anyway, I went into surgery not having a clue. The doctors really did not
prepare me for it except to say I had a mass. I remember exactly what he said. I woke
up from surgery to hear my surgeon say, “I have good news and bad news. I didn’t
have to remove any of your organs, but (pause) you do have cancer.” It just blew me
away . . .
1. Identify the barriers present in the delivery of bad news.

2. How would you change the delivery of bad news to this patient? What would you
say? What would you do?
53 Communicate
3. What quality-of-life domains should have been prioritized?

4. What are your general expectations of this scenario? What would you expect to
happen?
5. List three adjectives that you would use to describe this patient/family member.
6. List your perception of their living arrangements (e.g., type of housing, area in
your community, school district, extracurricular activities).
7. What is the relational history (positive or negative) between the patient and
doctor?
8. Are task and relational communication goals accomplished in this scenario?
Used with permission from: Dias, L., Chabner, B. A., Lynch, T. J., Jr., & Penson, R. T.
(2003). Breaking bad news: A patient’s perspective. Oncologist, 8, 587–596.
EXERCISE #2
Put students in pairs. Have them each share a funny story or their most embarrass-
ing moment. During the story, students who are listening should provide no feedback
(e.g., they should not laugh or smile, which is a violation of expectations). Then ask
students:
1. Was it hard for you to continue communicating/sharing when you received no

feedback? Did you alter your story because of it? If so, how?
2. Alternatively, how did it feel to mask your emotions?
comprehensive exercises for

chapter material
RESPONDING TO DENIAL
Show students a clip from a film (see the table below) and ask them to write how they
would respond to the patient (verbally and nonverbally).
Optional: Scene/dialogue can be role-played between two students.
FOLLOWING BAD NEWS

The following is an excerpt from the 1983 film Terms of Endearment, where Debra
Winger’s character is given the following prognosis by her doctor:
“The response to the drugs we tried isn’t what we hoped. But there are investiga-
tory drugs which we are willing to utilize. However if you become incapacitated
Table 2.8 Recommended Movie Examples

Examples
Movie Scene/Dialogue
Stepmom (1998) Susan Sarandon’s character reacts to the news of more cancer:
“But you said the last time that you got it all. So if you were wrong
the last time then there’s a good chance you’re wrong this time
because the last time you . . . but people . . . you . . . we . . . we can
beat it. I mean people beat it all the time right?”
My Life (1993) Michael Keaton’s character reacts to news that he has 3–4 months
to live: “Come on. I’m still in the game here man. There are a lot
of other therapies . . . treatments.” The next scene shows him and
his wife walking to their car when suddenly he stops and runs
back to confront the doctor: “Who the hell do you think you are?
To take away my hope like that. That’s all I have.”
Brian’s Song (1971, After more surgery Brian awaits news from the doctor.
2001) Agitated, he turns to his friend: “I want them to check me
out and get me out. There’s too many sick people around
here. . . . Everyone’s talking to me like I’m a child.” When the
doctor comes in and tells him that the cancer has spread to his
lungs, Brian responds by yelling and throwing things across
his hospital room.
Beaches (1988) Toward the end of the film, Barbara Hershey’s character stops
taking phone calls. When confronted with this, she responds: “I
don’t care what they (her friends) think.” An argument ensues,
and Bette Midler’s character comments that she hasn’t changed
clothes in a week.
Hillary: “Just leave me alone. Okay. That’s all I want is to be left
fucking alone . . . You don’t know what this feels like at all. I’m
the one who won’t live to see my daughter grow into a woman.
I hate it. I don’t want it to be over with yet. . . . So you don’t
understand what this feels like. Alright. You’re still in the land of
the living.”
or it becomes unreasonable for you to handle your affairs for a block of time, it
might be wise to make some decisions now. Any questions?” Emma responds: “No.
I know what you are saying. I have to figure out what to do with my kids.”
1. What barriers are present in this delivery of bad news?

2. Rewrite this dialogue so that it is more person centered and conveys comfort.
3. If left alone with this patient following this scene, what would you say to her?
What could you do for this patient?
55 Communicate
USING GROUP WORK TO INTRODUCE STUDENTS TO

AFFECTIONATE COMMUNICATION
The Activity
Before beginning this activity, instructors should read Morman and Floyd (1998). In
it, the authors define affectionate communication as “an individual’s intentional and
overt enactment or expression of feelings of closeness, care, and fondness for another”
(p. 145). Additionally, the three dimensions of affectionate communication (i.e., ver-
bal, nonverbal, and supportive communication) are identified.
This activity allows students to create their own examples of affectionate expression
by placing them in one of two roles: that of the healthcare provider who works with
patients or that of a family member. As healthcare providers, students are to create a
list of behaviors they should use to demonstrate their fondness and positive regard for
their patient. Meanwhile, the other students, working as family members, should also
create a list of behaviors they should use to demonstrate their fondness and positive
regard for their loved one. This activity lasts approximately 15 minutes, with an addi-
tional 45 minutes needed for discussion and debriefing.
First, divide students into two groups, with each group congregating on opposite
sides of the classroom. Once divided into two groups, each group should then be sub-
divided into smaller groups of three members each. Once in these groups, begin this
activity by telling one half of the students that they are to imagine they are colleagues
working at a local hospital. The other half should then be told they are family members
with a loved one at a local hospital. An example script is listed below.
Health Care Provider Script Sample:
You are a healthcare provider who works with patients at a local hospital. Over
time, you and your colleagues notice your patients, while successful at their exer-
cises, are suffering from low morale. After conversing with each other, you and
your fellow healthcare providers decide to take a more active role in communicat-
ing feelings of liking and fondness to your patients. Collectively, you decide that
by sharing your liking and fondness, your patients will experience an increase in
morale and feel more positive. A meeting is arranged for all the healthcare provid-
ers at the local hospital. At the meeting you and your colleagues brainstorm a list
of behaviors that should be used with your patients.
Those working in the healthcare provider condition should then generate as many
examples as possible of nonverbal, verbal, and supportive affectionate communication
behaviors to use with their patients. The other students, working as family members,
should receive the following prompt.
Family Member Script Sample:
A member of your family is staying in a local hospital for cancer care. Over time,
you and the other members of your family notice that your loved one is suffering
from low morale. After conversing with each other, you and your family decide to
take a more active role in communicating feelings of liking and fondness to your
loved one. Collectively, you decide that by sharing your liking and fondness, your
loved one will experience an increase in morale and feel more positive. The entire
family decides to meet and discuss what types of behaviors they could use with
their loved one to express liking and fondness.
Those acting as family members should create examples of verbal, nonverbal, and
supportive affectionate expressions. All students should receive 15 minutes to identify
as many behaviors as possible. Instructors might consider providing groups with a
definition of verbal, nonverbal, and supportive affectionate expressions. Floyd (2006b)
identifies verbal affectionate communication as phrases such as “I like you,” nonver-
bal affectionate communication includes behaviors such as hugging, kissing, or hold-
ing hands, and supportive affectionate communication includes actions of social and
instrumental support such as helping with a favor or loaning materials. Once the 15
minutes has expired, the groups should share their lists orally.
Used with permission from: Byrnes, K., & Myers, S. A. (2010). Using group work
to introduce students to affectionate communication. Communication Teacher, 24(3),
142–145.
DEBRIEFING
The debriefing consists of two steps. The first step is to address the groups’ examples.
The following questions can be used to facilitate the discussion:
1. What examples did your group create for expressions of verbal, nonverbal, and
supportive affectionate communication?
2. As a health care provider, what type of affectionate expression was the easiest to
create examples of?
3. As a family member, what type of affectionate expression was the easiest to create
examples of?
4. What are the similarities/differences between the health care provider examples
and the family examples?
The second step is to explain the implications of affectionate communication and

changes in the family and healthcare provider–patient interaction:
5. How would you expect the relationship between the patient and the health care
provider to change if patients received more affectionate communication?
6. How would you expect the relationship between the patient and family member to
change if patients received more affectionate communication?
57 Communicate
7. What benefits could the patient experience from receiving more affectionate
communication?
8. What benefits would the health care providers or family members receive from
giving affectionate communication?
Once this in-class debriefing is completed, students should be given the opportu-
nity to raise any additional issues or questions. After all issues and questions have been
addressed, the instructor should conclude class by reminding the students the purpose
of the activity, which was to identify and create examples of affectionate communi-
cation, and examine the effect affectionate communication can have on individual’s
well-being.
REFERENCES AND SUGGESTED READINGS

Floyd, K. (2006a). Human affection exchange: XIII. Affectionate communication is associ-
ated with diurnal variation in salivary free cortisol. Western Journal of Communication,
70, 47–63.
Floyd, K. (2006b). Communicating affection: Interpersonal Behavior and Social Context. New
York: Cambridge University Press.
Floyd, K., Hess, J. A., Miczo, L. A., Halone, K. K., Mikkelson, A. C., & Tusing, K. J. (2005).
Human affection exchange: VIII. Further evidence of the benefits of expressed affection.
Communication Quarterly, 53, 285–303.
Floyd, K., Mikkelson, A. C., Tafoya, M. A., Farinelli, L., La Valley, A. G., Judd, J., et al. (2007).
Human affection exchange: XIII. Affectionate communication accelerates neuroendocrine
stress recovery. Health Communication, 22, 123–132.
Morman, M. T., & Floyd, K. (1998). The measurement of affectionate communication.
Communication Quarterly, 46, 144–162.
3
orientation and opportunity
George is a nurse practitioner in a large outpatient renal dialysis center where he

has practiced over the past 10 years. He and his colleagues are proud of the excel-
lent care provided to their dialysis patients, although George has begun to rec-
ognize deficiencies in care provided to patients at the end of life. His colleagues
have dismissed his concerns, but a new nurse, Sheila, who has joined the clinic,
has made similar observations. George and Sheila have discussed the problem of
patients who continue on dialysis despite the enormous burdens—even as it is
evident they will die soon. Recently, one of George’s favorite patients, an elderly
World War II Veteran and first-generation Italian-American, Lanz (who has
always reminded George of this own grandfather), developed serious complica-
tions, and George felt that perhaps a team conference should be convened to
reevaluate the goals of care. Though Lanz was always a man of few words and
difficult to talk to, George felt a great respect for him as well as a deep concern
for his declining quality of life. At his last visit, Lanz was accompanied by his
sister and a niece. All of them seemed weary, and Lanz embraced George when
leaving, thanking him for his years of care. The clinic was very busy, and George
had little time to spare, but he asked Lanz how he was “holding up.” Lanz simply
replied that he was “tired” and not so sure how much longer he could “fight.”
Unfortunately, no such team communication occurred about his declining
status, and a few days later Lanz developed acute cardiac failure, was resusci-
tated at home by emergency technicians and admitted to a hospital CCU where
he underwent 4 days of aggressive care and mechanical ventilation and two
additional resuscitations, and died amid a third cardiac arrest. George learned
of Lanz’s death only when he failed to appear for his dialysis treatment. The
following day George phoned his home and was told by Lanz’s niece that his
funeral was being held that very day.
Sheila, sensing George’s grief, offered to relieve him at the center and give
George some time alone. He thanked Sheila, saying, “There must be a better way
to care for these patients at the end of life.”
George is now left to wonder about Lanz and his family as they endured high levels of
invasive intervention too near the end of life—potentially because of low health liter-
acy and little communication about care options and disease trajectory. As a nurse pre-
sent for so many dialysis treatments with Lanz, George had seen his dwindling health
59
and increasing tiredness. Many nurses have observed and been distressed over similar
ethical dilemmas of patient treatment and its futility. George shared a connection with
Lanz and is haunted by the care decisions that were never intentionally planned for this
patient. George feared what was ahead for Lanz but was unsure about how to engage
him in challenging subjects about withdrawing dialysis, advance directives, his family
concerns. These issues followed George in his care for Lanz and turned into anxieties
and regrets in light of the intensive period of resuscitations that punctuated the final
days of Lanz’s life.
Palliative care is a philosophy of care that penetrates every area and specialty of
nursing. Palliative care is a fundamental element of nursing that transcends practice
areas and roles (Dahlin, 2010). For advanced-practice nurses specializing in palliative
care, coordinating communication with the patient and family about the illness and
treatment options is central to care. However, the communication traps and frustra-
tions in providing this care are many. Identifying influencing factors such as low health
literacy and cultural differences will facilitate the work of educating the patient and
family about the illness and their options for care.
The “O” in COMFORT, the matter of interest for this chapter, deals with orientation
and opportunity for a patient and family facing serious, chronic, or terminal illness. An
overarching concept in this chapter is that of accommodation, and ideas from commu-
nication accommodation theory will help explain accommodation in clinical practice.
The first idea introduced in this chapter is health literacy and how this determines the
kind of care, cost of care, experience of care, quality of care, choice of care, and the
nurse’s experience of providing that care. Second, the chapter presents cultural theory
and how this colludes intractably with health literacy—for any patient and family.
The ideas of communication accommodation, health literacy, and culture come
together to help identify nursing skills to better understand patients and families and
facilitate shared understanding with them about care choices and treatment in light of
their values.
CONVERGENCE AND THE PALLIATIVE CARE NURSE

Communicating the entire story of the patient’s status and options for care—and
ensuring this happens in an understandable way—is the essence of orientation to
life-limiting illness. The palliative care nurse is central to making true orientation pos-
sible, as well as appreciating and articulating what opportunities for treatment and
care exist for a patient/family. Without this information, far fewer desirable decisions,
choices, and ultimately outcomes will happen for a patient and family in the face of
treatment and dying.
Communication Accommodation Theory

Communication accommodation theory (CAT) grounds the themes in this chapter,
and therefore is a very useful foundation to use as we think of the culture of patients
and families and dealing with health literacy challenges. CAT establishes that all people
61 Orientation and Opportunity
communicate in similar and dissimilar ways and that the way in which we understand
the speech and behavior of another will determine what we think of the interaction.
Using this communication idea (Figure 3.1), we can see that nurses communicating
with patients and families will practice convergence (i.e., adapting and aligning with
their communication), divergence (i.e., increasing the differences between them), or
overaccomodation (i.e., overdoing efforts to regulate, modify, or respond to others)
(Giles, 2008).
As we address the concept of low health literacy and cultural difference throughout
this chapter, we will offer practice suggestions that will help palliative care nurses con-
verge with their patients and families rather than diverge or overaccommodate.
figure 3.1. Convergence, Divergence, and Overaccomodation

Images adapted from West, R., & Turner, L. (2010). Introduction to Communication Theory: Analysis and
Application. New York: McGraw-Hill.
Health literacy is about receiving or acquiring information, understanding that

information, and then using that information in decision making about health-related
issues. Limited health literacy affects people of all ages, races, incomes, and education lev-
els, but the impact of limited health literacy disproportionately affects low-socioeconomic
and minority groups. It affects peoples’ ability to search for and use health information,
practice healthy behaviors, and use important public health warnings.
The National Action Plan to Improve Health Literacy was released in 2010 from the
Department of Health and Human Services Office of Disease Prevention and Health
Promotion. This study prioritizes needed change in our society that will provide: (1)
health information that people can use to make decisions, (2) person-centered informa-
tion and services, and (3) a support of lifelong learning to promote good health (U.S.
Department of Health and Human Services, 2010). The nurse is at the nucleus of each
tenet. Also at the center of these goals is the idea of increasing the health literacy of
patients and families who face the complex issues of the medical world.
Limited health literacy is associated with worse health outcomes and higher costs
(U.S. Department of Health and Human Services, 2010). Researchers estimate the cost
of limited health literacy to the nation’s economy to be from $106 to $236 billion each
year, while the future costs of low health literacy might be as high as 1.6–3.6 trillion
dollars. Substantial indirect costs related to low health literacy have not even been cal-
culated in this figure, and this would include additional chronic illness, disability, lost
wages, and poorer quality of life (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007).
An earlier study identified an increased cost of $7798 per hospitalization for those
navigating illness with low health literacy (Weiss & Palmer, 2004). These figures are
staggering and distressing, but further research is needed to discover exactly where and
why these costs are incurred.
Nurses have the chance to improve orientation and opportunity for patients and
families in profound ways. But currently, there is no standard for a particular depth of
health literacy content to be included in undergraduate nursing education, and nurs-
ing education programs in general do not address the complexities of health literacy
when covering patient education. Nurses need support and direction in finding ways
to improve health literacy for patients and families in light of all that is at stake—not
just the patient and family experience, but also dimensions of ethical dilemmas and
the emotional impact of these clinical issues on burnout and professional error.
A close partner to health literacy in improving patient and family communication
in palliative nursing is an awareness of cultural theory. Though at first the two might
seems like two separate concepts, their links and mutual effects become inextricably
linked upon further examination. Cultural theory is rooted in two basic claims about
culture and power. First, culture pervades and invades all parts of human behavior.
And secondly, people are part of a hierarchical structure. To a large extent, cultural
practices and institutions permeate the way people think about and behave in life—
impacting communication, family structure and involvement, and health care decision
making. Additionally, cultural studies explain that there is power in every part of soci-
ety, and this power combines with meaning to guide people in their communications
and decisions (West & Turner, 2010).
Nursing is not a stranger to the realization of the profound cultural impact in prac-
tice. Cultural competencies and transcultural nursing are not only concepts that have
been valued in the nursing profession, but they also have been increasingly empha-
sized in nursing education given the growing diversity of our population. Using the
framework of convergence in the communication accommodation theory, the already
existing cultural competency discussion is extended here to include health literacy
improvement. Attention to these concepts is essential to improving patient and family
understanding of disease and treatment choices.
Health Literacy and Palliative Care Nursing

All populations and geographic locations seem to be affected by disparities in health
knowledge. Many studies demonstrate extreme disparities for those people with lower
incomes, lower levels of education, and older age—most specifically adults over 65,
nonwhites, those with less than a high school degree, those at or below the poverty
level, and nonnative or non-English speakers (U.S. Department of Health and Human
Services, 2010). The Department of Education offers a taxonomy of health literacy
levels that many scholars and clinicians use in designing tools and interventions to
evaluate patients and families. We simplify those categories here (Table 3.1).
It is not surprising that 30 million Americans are unable to perform even the sim-
plest everyday literacy tasks, many of whom are not literate in English. “Most of the
Table 3.1 Health Literacy and Task Competency

Health Literacy Level Task Competency
Below basic - Can identify health care activity to perform a simple set of
instructions
- Can read text with simple words
- Graphics are useful
Basic - Can read text using simple words and declarative statements
- Can extract major points
- Middle school reading level
- Graphics are useful.
Intermediate - Can accurately read prescription label and follow directions
- Can apply information on a scale to locate answers
- Can interpret information presented in narrative or graphics
Proficient - Can compare and contrast from different sources
- Can understand difficult abstract concepts pertaining to medical
information
- Able to figure costs pertaining to health insurance plan
Kutner et al. (2007). Literacy in Everyday Life: From the 2003 National Assessment of Adult Literacy
(NCES 2007–480). Washington, DC: US Department of Education, National Center for Education
Statistics.
adults with Below Basic health literacy skills would have difficulty reading a chart or
simple instructions. These same adults are more likely to report their health as poor
(42%) and are more likely to lack health insurance (28%) than adults with Proficient
health literacy” (U.S. Department of Health and Human Services, 2010, p. 9). These
numbers are at once troubling, but not a complete shock. The majority of the litera-
ture intended to guide nurses through the low–health literacy maze focuses heavily on
written materials and how to determine if a patient/family can really understand those
materials. But as we have already noted, health literacy is not entirely straightforward
in terms of reading and comprehension. Health literacy includes more than word reor-
ganization, reading comprehension, and numeracy skills. Understanding health liter-
acy in its fullness includes language, context, culture, communication skills levels, and
technology (Mancuso, 2009). Only by understanding these additional elements can we
help people acquire and apply information in the best way.
The general assumption in the literature is that patients and families with language
barriers and social determinants are likely candidates for low health literacy. What is
unique to palliative care is the reality that all patients and families experience compro-
mise in health literacy. Impeded communication, emotional stability, thought processing,
listening, and information processing all serve to lower health literacy. Though we recog-
nize studied and proven populations operating in below-basic and basic health literacy
levels, we also propose that any patient and family receiving palliative care—despite their
ethnicity, background, and appearance—be cared for as though they are operating with
lower levels of health literacy until the contrary is demonstrated.
Imagine a physician who herself was suffering from stage IV non–small cell lung
cancer. She is emotionally compromised. Her family is emotionally compromised.
Their health literacy is then compromised and lowered. So we suggest that the nurse
clinician move beyond essentialized ideas about those with low health literacy and
always work to gain an understanding of how a patient/family is processing health
information and the ways they are using information to make decisions.
Cultural Humility
Concerns about cultural insensitivity and inadequate training for patient/family com-
munication with people of diverse backgrounds draw attention to inconsistencies
between the idea of cultural competency and the reality of the practice of intercul-
tural nursing in palliative care (Gunaratnam, 2007). Gunaratnam notes that cultural
awareness in the palliative care setting is unique in that it depends on the “non-rational
and visceral components” of care (Gunaratnam, 2007, p. 470). Because cultural com-
petency exists as a movement, it has been reflected in palliative care education and
training. For palliative care, this often takes the form of lists that identify different cul-
tural and religious groups, death-related beliefs, practices, and rituals (Jones, Cason, &
Bond, 2004). Palliative care recognizes that death and dying can intensify the profun-
dity of culture and ritual. Rethinking the suggested characteristics of cultural compe-
tency, nurses could instead question the basic assumption that cultural knowledge is
something that can be “mastered.”
Cultural knowledge can be presented in a way that brings nurses and patients/fami-
lies together, rather than something that separates and differentiates. As with many
protocols and required skill sets for nurses, the “retreat behind a technique” can protect
the nursing clinician from demonstrating humility in the face of difference (Saunders
& Bains, 1983).
From a communication standpoint, which is what we offer in this volume, the basic
goal of communicating with patients and families—as well as a team and staff—is to
create shared understanding. We advocate that this is best accomplished by privileging
the narrative and the relationship with the patient/family first. In other words, valu-
ing the patient and family experience with time and communication in the clinical set-
ting heralds their journey as important and credible and necessary to moving forward
in achieving good care.
In nursing literature, cultural awareness addresses the clinician’s consciousness
about a nurse’s own reactions to individuals who are different from the clinician.
Cultural attitude is based on a clinician’s own thinking about cultural differences.
And cultural skills include the practice of culturally competent communication
(Nyatanga, 2008). Communication skills and an open dialogue are developed and
supported by a willingness to attain cultural knowledge and sensitivity (Flaskerud,
2007). Joining these cultural competency categories with patient/family interaction,
nurse communication might fall into the successful category, in which the message
intentionally sent was interpreted accurately. Then again, the message might not be
interpreted with accuracy. A message might result in miscommunication—in which a
message was intentionally sent but was not interpreted accurately (i.e., a patient/family
member does not understand dosage of pain medication due to their low health lit-
eracy surrounding numeracy). Accidental communication is sent without intent but
interpreted accurately (i.e., a nurse checking her phone, her watch, and the clock on
the wall during a short bedside encounter is presumed by the visiting family member
to be prioritizing time and task over relationship with patient). Attempted communi-
cation includes messages that were sent but not received (For example, a notation to
provide a social work consult is added to a chart and inadvertently deleted. The fam-
ily, expecting the consult to occur the following day is distressed and confused when
this visit does not materialize.). Accidental and miscommunicated messages can be
the most destructive to clinician/patient/family relationships. In this fifth category of
communication, a message is sent unintentionally and interpreted inaccurately (for
example, a NP frowns and grimaces as she enters a room with a patient/family; this is
interpreted as her dislike toward the patient/family, when in fact she is frustrated by
a previous staff interaction about a different matter altogether) (Guerrero & Floyd,
2006). This simple framework is helpful in considering the complex impact of culture
on intended and unintended messages while a nurse is attempting to make patients
and families aware of their health situation and possible care options.
The idea of potential low health literacy for every patient and family is in con-
cert with a need to practice cultural humility with all patients and families. Consider
first the culture of health care, nursing, and medicine. Those working/training/oper-
ating in this culture have been medically socialized to this culture (DuPre, 2010). This
socialization has taken thousands of hours, exposures, and personal sacrifices. Those
outside of the health care culture simply do not share in this socialization experience.
A base assumption, with the exception of patients who also live in the health care cul-
ture, can be that a cultural divide exists between nurses and all of their care receivers.
Cultural competency requirements can systematically support a static and “brass
tacks” conception of culture. As various programs in cultural competency have
matured, voices in health care have issued warnings about a too essentialized concep-
tion of culture. Scholars and health care professionals note that “culture” is always
moving and morphing as people make use of their cultural resources in creative ways,
and increase the possible blend of cultural factors as populations grow and cross paths
(Santiago-Irizarry, 1996). If we accept the definition of culture to essentially get at the
idea of competing discourses within situations characterized by an unequal distribu-
tion of power, then we must also accept health care as its own cultural context.
We are in agreement with other writers who propose that the term cultural humil-
ity can supersede the idea of cultural competence (Tervalon & Murray-Garcia, 1998).
Traditional family configurations are blurred, multiple generations of intercultural
marriages have created too many cross-fertilized cultural patterns to contain, and so
the dominant pattern in nursing to adopt standardized cultural competencies may now
be much less beneficial to the patient. Cultural humility asks nurses to adopt a “clean
slate and assess the patient regardless of their cultural orientation” (Nyatanga, 2008, p.
315). This approach to cultural sensitivity and communication asks the nurse to mind-
fully respect each patient/family member, their dignity, and their need—regardless of
an ethnic origin, religious belief, or personal attribute that might label them. Consider
this example of cultural humility. A 75-year-old woman from a large Korean family was
admitted with end-stage heart disease to the cardiology unit. The woman had a large fam-
ily including her spouse, five children, many grandchildren, siblings, and a 95-year-old
mother. The family and patient were highly anxious, speaking only in Korean to each other.
The patient’s elderly mother created an altar in the room, bringing daily offerings of fruit
and incense. A major conflict ensued when a nurse informed the patient’s mother that
incense could not be lit due to fire codes. The patient unfortunately declined and her heart
failure worsened. The family became very agitated, and the hospital patient advocate rep-
resentative was called in as the family became very distraught and dissatisfied. One of the
specific complaints was that while their mother had been hospitalized for 2 weeks and was
now dying, they had never seen a chaplain. When the patient advocate met with the nurses,
they admitted that they assumed the patient and family were Buddhist and would not
want a chaplain. The family explained that they were a family very strong in their Korean
heritage and Buddhism as a life philosophy; they also were “born-again” Christians and
were offended by the lack of spiritual care, especially since they had seen chaplains visiting
other patients, and thus they felt excluded.
The current curriculum in cultural competency does not and cannot accurately
and completely reflect the cultural world in which nurses practice. True cultural com-
petence is not a discrete end point, but rather an ongoing and active engagement in a
lifelong process. This process requires humility as nurses will continually reflect and
consider their practice, and their interaction with patients/families/staff, and ultimately
this reflection will result in better ways to communicate (Tervalon & Murray-Garcia,
1998). Cultural humility does not suggest disposing of valuable knowledge about the
health care practices of particular communities; rather, it adds flexibility to the mix
that will allow for humbleness: an opportunity for nurses to seek out and locate the
best resources for their patients and families.
LIFEWORLD IN PALLIATIVE CARE NURSING

The idea of Lifeworld is used in many areas of study and thinking, including health care.
Jurgen Habermas extended the idea of Lifeworld, making our application to the world
of the palliative care nurse useful. In short, the Lifeworld includes the entire backdrop of
a patient/family life including their communication, their culturally based understand-
ing, and their language patterns (Habermas, 1987). These are the elements of everyday
life that define their reality and create their horizon. This is what they know. This is a
patient’s or family’s specific spin on what is likely a blend of cultural competencies.
It makes sense that patients understand their health according to the context of life
most familiar to them—their everyday life. By extreme contrast, and another way of
thinking of the culture of health care, is what Mishler identifies as the Voice of Medicine
(Mishler, 1981,1984). Patients and families speak the Voice of the Lifeworld and relate
end of life to ways in which this will affect their day-to-day life. In terms of practical
differences, patients cite feelings more often than precise empirical data and experience
the global impact of illness on their life instead of identifying specific and measured
segments of poor health impact. The fallout from illness on day-to-day living is how
patients experience loss and stress. For example, a patient who learns that he can no
longer drive as a result of amyotrophic lateral sclerosis (ALS) is concerned with the loss
in no longer driving his teenage children to soccer meets and fishing tournaments.
Processing loss of a healthy body must include the contagion of life experiences and
people who are affected, not just the patient’s own practical loss of function. Diffusion
becomes a way of processing changes in the Lifeworld for a patient. While it can be
frustrating for a clinician who has a great need to impart specific information in order
to maintain a particular treatment plan, a patient’s losses are many times indirect and
less obvious to someone approaching the illness from the Medicalworld lens.
Valuing the Lifeworld of the patient/family better positions the nurse to support
integrated patient participation, as well as the humanizing focus central to palliative
care. The nurse is positioned uniquely to straddle the two Voices of the Lifeworld and
Medicine. One voice interprets the disease in its broadest context, while the other is a
voice of reduction. The nurse can weave these two voices together to accomplish what we
describe in Chapters 2 and 3 as the coexistence of task and relational communication.

In this chapter we describe the role the nurse plays in helping patients/families
gain access to information and making care decisions. We offer a variety of tools in
the clinical context while employing the ideas of assumed low health literacy and
cultural humility in the practice of palliative nursing care. The following section
will be organized using the primary categories for nursing intervention: assessing,
planning, intervening, and evaluating. The materials included here should useful as
nurses expand their skill set to include the convergent components of orientation
and opportunity.
ASSESS
George, from our opening case study, has troubling concerns that patients in his cen-
ter might be engaging in a cycle of treatment that will ultimately lower their quality
of life at the end of life. At the heart of his angst is the realization that communicating
about treatment options and care plans are not a regular part of care for the major-
ity of patients on dialysis. In the case we share, he worries for Lanz. George has not
identified the time or the manner in which to talk with Lanz about his care options,
or how he and his family might feel about those options in light of their cultural ori-
entation and family structure. Even more difficult, George does not know what Lanz
understands about his current dialysis care and his overall disease trajectory. He is
sensitive to Lanz’s age, his rich Italian-American culture, and their shared patient–
nurse relationship.
Multiple assessment tools for patients currently exist. It is important to keep in
mind that the palliative care setting is unique in terms of the potential for patient
weakness and even unconsciousness. For this reason, the family must be consid-
ered central not only in health literacy matters but also cultural humility practice.
Interactions to secure health literacy will more often than not include family and
might well include patients who cannot respond. Though several tools now exists to
assess health literacy, few are available in multiple languages, are simple to employ,
facilitate the workload of nurses, or increase satisfaction for the nurse and the
client(s) (Wallace, 2004).
Remember, health literacy is not limited to reading alone, but also writing, listen-
ing, speaking, numeracy skills, critical thinking, decision making, and cultural sen-
sitivity abilities (i.e., crossing over to the world of medicine/health care) (Singleton
& Krause, 2009). The connection between literacy and culture is inextricable. What
patients/families face in the Voice of Medicine explains a great deal of the health lit-
eracy load in addition to cultural barriers that can reduce success in care. Often there
is a simple overestimation of patient/family ability to absorb terminology (i.e., aural
literacy demand), make sense of rare words, or stay focused in the midst of words
and ideas that invite worry and anxiety (i.e., “The doctor noted a new mass on your
skull. Had you felt any headaches or other new symptoms?”) (Koch-Weser, Rudd, &
DeJong, 2010).
Many assessment tests are geared for English speakers and readers, which already
assumes too much about a patient/family. In a recent study of English-speaking
Americans who predominantly possessed their high school diplomas, nearly half of
them indicated discomfort in taking either the REALM (Rapid Estimate of Adult
Literacy in Medicine) or the s-TOHFLA (short Test of Functional Health Literacy in
Table 3.2 Checklist of Observable Cues Indicating a Need for Health Literacy and/or
Cultural Accommodation
Does patient/family display a disinterest in reading a form/instructions? y/n
“I’m too tired for this.” “I need my glasses for this.”
Is it hard for the patient/family to locate a central focus on the text? y/n
Have answers such as “no” been provided to questions asking for more y/n
information or a description?
Is there a general state of withdraw from the interaction? High nervousness? y/n
Confusion?
Have there been errors in medication, appointment times, treatment y/n
understanding?
In a shame-free environment that encourages the patient/family to share y/n
information, is the patient/family difficult to engage? Offended? Irritable?
Behavior from patient/family demonstrates that information is being withheld. y/n
Adults) (Ferguson, Lowman, & DeWalt, 2011). Many scholars warn of the stigmatiz-
ing effect of a literacy test for patients when they are already facing frightening news,
changing circumstances, and a culture of medicine that is foreign to their Lifeworld.
There is fair evidence that suggests the possible harm of literacy testing outweighs the
benefits of such testing (Paasche-Orlow & Wolf, 2007). Shame and alienation can take
the place of the best intentions to converge, or find common ground with a patient.
An additional challenge lies in the sometimes expert ability of patients and families to
conceal their confusion or lack of understanding so that it can be impossible to know
there is a lack of health literacy, or perhaps this occurs quite unintentionally as this
has been a survival technique (Cornett, 2009). And so for these complex reasons, the
clinical skills practice recommendations we make to support orientation and oppor-
tunity showcase accommodation in communication through cultural humility and
low–health literacy assumptions.
Simple observations can tell the practitioner something about patient/fam-
ily health literacy. Even if observations do not specify the communication chal-
lenge to be one of culture or health literacy, it suggests that further investigation
is needed. Table 3.2 is a basic list of clues that might indicate an existing barrier in
communication.
Targeted questions about communication are a good way to assess how the patient/
family are processing information, the environment, and their treatment choices.
Table 3.3 presents researched questions, or prompts, that can quickly identify compre-
hension and engagement (to a degree) between patient and nurse, but could also be
used between family and nurse.
COMFORT advocates for narrative care, in which the nurse is mindful of the
patient/family, and privileges their experience and concern. While the previous two
assessment items are proven to identify language deficits in health literacy, the fol-
lowing tools also attend to the special challenges of cultural humility and Lifeworld
discernment in palliative care.
Table 3.3 Suggested Communication Strategies

Clinical Communication Study Benefits Drawbacks
- How often do you have Chew, L., Bradley, K., & - Rapid collection - Questions
someone help you read Boyko, E. (2004). Brief of feedback are worded
hospital materials? questions to identify - Practitioner at a high
- How confident are you patients with inadequate administered— level of
filling out our forms health literacy. Family can lead to more literacy.
alone? Medicine, 36, 588–594. communication
- How often do you have about
problems learning about accommodation
your illness because of
difficulty understanding
information about it?
- How often do you Morris, N., MacLean, C., - Rapid collection - Questions
need to have someone Chew, L., and Littenberg, of feedback are worded
help you when you B. (2006). The Single Item - Practitioner at a high
read instructions, Literacy Screener: Evaluation administered— level of
pamphlets, or other of a brief instrument to can lead to more literacy.
written material from identify limited reading communication
us? ability. BMC Family Practice, about
7(21). doi:10.1186/1471– accommodation
2296–7-21 http://www.
biomedcentral.com/content/
pdf/1471–2296–7-21.pdf
Table 3.4 Questions Specific to Palliative Care Topic for Patient and/or Family
x How can we help you live in the best way possible for you?
x How would you like to spend your time together?
x What experiences are most important or meaningful for you?
x What fears or worries do you have about this illness?
x Do you have other worries or fears?
x What do you hope for your family?
x What kinds of needs does your family have?
x What is the hardest thing in your life right now?
x What religious or spiritual beliefs are important to you?
x What would make this time in your life (lives) meaningful?
x What makes life worthwhile?
x What kinds of medical care are unacceptable to you?
Excerpted and adapted from Dahlin, C. (2010). Communication in palliative care: An essential
competency for nurses. In B. Ferrell, & N. Coyle (Eds.), The Oxford Textbook of Palliative Nursing
(3rd ed., pp. 107–133). New York: Oxford University Press.
Table 3.5 Questions Specific to Cultural Difference

x Tell me more about you/your family.
x Where were you born and raised?
x What language would you prefer to speak?
x Where do you go for support (family, friends, church, etc.)?
x Would you like to have anyone else here with you/your family?
x Who do you want to know about your illness? Who is okay to talk with?
x How does your family make health decisions? Should I talk to you about decisions? Or
someone else?
x We want to take the best care of you that we can. What do we need to know about any
customs, practices, family rituals, etc., that are important to include in your care?
x Is spirituality or religion, or both, important to include in your care? What would that
look like?
x We want to make sure we respect how you want to be addressed/named, including how
we act when addressing you.
x Do you have a preference for a male or female caregiver?
x Do you have any foods you would especially enjoy, or that you especially like to avoid?
x Do you have any worries about how to pay for care or your medicine or care once you go
home?
Culturally Sensitive Questions Specific to Dying
x Are there any ceremonies or rituals after death you would like us to know about and
facilitate?
x What is your sense of what happens after death?
x Can we help in planning for anything you might need at death or after?
x In your family/background, do family members participate in the care of the body after
death?
x Do we need to specify a man or a woman caring for you/yours after death?
Excerpted and adapted from Mazanec, P., & Panke, J., (2010). Cultural considerations in palliative
care. In B. Ferrell, & N. Coyle (Eds.), The Oxford Textbook of Palliative Nursing (pp. 701–711). New
York: Oxford University Press.
A culture-specific set of prompts that attends to ways in which a clinical team can
accommodate difference is useful in achieving convergence with a patient/family and
also builds shared meaning with them (Tables 3.4 & 3.5). These prompts also clarify if
there will be a need for an interpreter to share the spoken word.
PLAN
Even one of the above assessment prompts could have been the opening to a con-
versation between George and Lanz. Based on information gathered, George could
have identified a useful plan of action that would lead to the best care plan for
Lanz at the end of his life. Once a nurse gains an understanding of the patient and
family through observing cues and exploring their Lifeworld through specific ques-
tions, a fairly grounded sense of health literacy as well as cultural specificity can be
discovered. Based on the nurse’s interaction, which is most productive if it avoids
a checklist of traits and invokes instead curious inquiry that facilitates storytelling
and learning about the values important to a patient, she or he will be prepared to
identify a basic plan to move forward in securing orientation and opportunity for
this patient/family. Communication accommodation through convergence will be
possible.
Identifying what to plan for a patient and family is the next step. Selecting areas of
need on the checklist below (Table 3.6) will assist in determining what kinds of inter-
ventions might best suit a nurse and patient/family.
The nurse should anticipate multicultural identities, not simply a cultural code that
aligns with a list of cultural group descriptors. A patient/family might appear to be
the same ethnicity as the nurse—even from the same place. But expect the unknown,
and the nurse should avail her or himself to this opportunity to be taught about these
unique individuals. Because of this, inviting the patient/family into the planning pro-
cess will be beneficial to the practice of palliative care. We suggest the following ques-
tion as part of any planning process:
As I participate in your care, can you think of some specific things that would
make you more comfortable with the information we are talking about? Or make
the information more clear?
Identifying concerns that need to be addressed and how to plan for the best care as the
nurse moves forward beyond assessment will help create the most useful intervention.
These points of awareness will also advance the application of communication accom-
modation directly to and for the patient in palliative care by providing tailored and
patient-specific convergence to increase nurse–patient message success.
Table 3.6 Planning for Low Health Literacy and Cultural Humility Intervention
✓ Reading or vision deficit ✓ Memory or cognitive deficit
- Clear speech - Repeat and question
- Well-described examples - Multiple message channels
- “Living room” language
✓ Medical culture divide ✓ Hearing deficit
- Examples from Lifeworld - Create visual message channels
- Elicit stories from Lifeworld - Employ interpreter and family support
- Open-ended opportunities for talk to clarify messages
✓ Language difference ✓ Pain (emotional/physician/social/spiritual)
- Translator Compromise
- Language-appropriate materials - Team members
- Open-ended opportunities for talk
INTERVENE
A potential intervention for Lanz might have involved George arranging a time to
talk with Lanz and his sister and niece during the last visit to the Dialysis Center.
This conversation might have led to George’s coordination efforts of care for Lanz,
including a visit from a social worker, subsequent advance directive, and a more
peaceful death with fewer extreme medical interventions in his last days of life. Lanz
was clearly tired of his dialysis treatment the day of his last visit. George, in reflec-
tion, regrets their lack of discussion about quality of life. They shared trust and care
over time, but never the planning conversations that could also have accompanied
that close patient–nurse dynamic.
Table 3.7 Communication Interventions

Aspect of This Intervention Goal of This Kind of Example
Communication
Partnership communication style Build trust and openness. Let patient/family decide
when teaching session should
be—best time of day.
Nurse values patient/family Facilitate disclosure. “I want to hear about the
agenda. concerns that are important
to each one of you.”
Nurse values biopychosocial Learn about Lifeworld of Take a few minutes to ask
perspective. patient and family. about family outside of the
hospital/clinic.
Not a static notion of culture Commit to learning about Listen to/ask about a typical
competence the specifics of this patient/ day in wellness. Ask more
family. questions. And then more.
Clear pathway created for patient Create opportunities for Listen. Take time. Be aware
telling/family telling of illness or narrative sharing. of the message you might
wellness story send that indicates you don’t
have the time.
Nurse relinquishes the role of Establish Learn from patient/family
expert, becoming student of the person-centeredness and about what they think is
patient/family. build a relationship. important. This will guide
your care.
Expression that patient and Empower patient and - “We are in this together.”
family are full partners in care family. - “Thank you for teaching
alliance me.”
- “You help me understand.”
Aspects of intervention adapted from Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility
versus cultural competence: A critical distinction in defi ning physician-training outcomes in mul-
ticultural education. Journal of Health Care for the Poor and Underserved, 9, 117–125.
The clinical skill intervention we want to detail first in this section is one that might
accompany or supersede other interventions simply because it is also a way of practic-
ing that coincides with the primary concern of this chapter. Person-centered inter-
viewing and care are an extension of the ideas we describe in Chapter 2. But here we
also apply the idea of cultural humility to person-centeredness. Listed above are basic
components of this kind of interviewing (Table 3.7). Communication is the kind of
care that provides the comfort here.
Communicating comfort can be the intervention. As we describe in Chapter 2,
person-centered messages are built verbally and nonverbally. Table 3.7 reflects this
idea.
Table 3.8 presents a wide variety of interventions that the nurse might pursue
depending on the needs noted during assessment and planning.
Failing to communicate with a patient/family because of low health literacy and/or
cultural differences is costly and contributes to burnout and high time costs later in the
course of care (Geller, Bernhardt, Carrese, Rushton, & Kolodner, 2008). By combining
basic interventions with person-centered communication, palliative care nurses can
break through barriers of low health literacy and cultural unfamiliarity and perform
meaningful care on behalf of their patients.
Consider the following example:
Mr. Gomez was a 60-year-old, very stoic man who was diagnosed with late-stage pan-
creatic cancer. Unfortunately, Mr. Gomez had extensive disease including liver and renal
involvement at diagnosis. He and his family were presented options for chemotherapy,
but they have declined treatment. His wife and children are also very stoic and private. A
social worker has now discussed discharge and has suggested referral to hospice. Mr. Gomez
and his family adamantly decline hospice. His wife is silent but shakes her head “no,” a
daughter utters “no way,” Mr. Gomez becomes tearful, and his eldest son speaks up to say,
“No thank you. No hospice. We can take care of our father.” The social worker shares this
information with the primary nurse, who is very concerned about this patient and family
going home alone as Mr. Gomez has extensive pain and other symptoms and she expects
he will decline rapidly. The nurse goes to the patient’s room and asks if she can talk with
the family.
She begins the conversation by saying; “I wanted to talk with you all as we plan to
get you home tomorrow, Mr. Gomez. The social worker shared with me that you were
not interested in having Hospice come out to see you. I have noticed what a wonderful
caring family you are and that you all want to provide the best care for your father.
We have found that hospice can be so helpful to patients and families like yours. I am
wondering if you can tell me more about why you are reluctant to have hospice come to
visit you at home?”
Note that in this nurse intervention, the nurse shows convergence by commu-
nicating her observations of their family. Additionally, this nurse provides under-
standing of who can be helped by hospice. In order to show humility toward this
family and understand their concerns and needs, the nurse asks them about their
reluctance.
Table 3.8 Communication Strategies

Need Intervention Example
Message Living room language “If your legs swell, we need to check
accommo- - Speak simply. for a blockage in the deep veins of your
dation - Remove medicalization of legs.”
description. As opposed to:
- Keep content practical but not “There is a possibility of deep vein
so oversimplified that patient is thrombosis. If we suspect this, we will
bored or offended. perform a doplar.”
Repetition “It would be important for the three of

- Describe idea a second and third you to talk about where you want Jill to
time. spend the last part of her life.”
- Use a different example if first “Today is the right time to make some
one seems to fail. decisions about where you would like
Jill to be.”
“Would it help to have the social worker
come around this afternoon to talk with
the three of you about deciding where Jill
will go for the rest of her care”?
Appropriately gauged examples For a person that loves to cook:

- Consider what you know about “The amount that Dr. X has prescribed
the patient as you provide is about as much as 2 tablespoons a
information. day.”
- Make examples patient specific,
patient relevant, and gauged to
their social structure.
- Use ideas and words that are
familiar.
Improving Question “What do you think about this?

patient/ - Allow time for follow-up questions. I’d like to hear your questions. I know
family - Facilitate patient/family question this can be a foreign idea.”
education asking.
Codemonstrations “I will sterilize the catheter first.

- Go through a care process together Now you take over and try the next
with the patient or family member. part. If you get stuck I am right here.”
- Do it together, with nurse playing
a part in the process.
Return demonstrations “Do you feel like you can show me the
- A volley first step now that I have shown you?”
- Nurse shows, then patient or “Once we are all feeling confident, we
family shows how to accomplish can go on to the next part.”
something.
(continued)

Patient/family teaches nurse. Now, can you teach me to organize

- Once the process is shown and these three medications for the
explained, the nurse plays the day? Pretend you are the nurse and
role of the student. I am trying to learn about these
- Let the family or patient teach medications.”
nurse the process and
execution.
Images Create simple images on site, or find

- Visuals should represent this some already created art to help the
population in a positive way. patient/family that is struggling for
- Avoid stereotypic drawings or clarity with complicated instructions or
situations that are not relevant. a substantial language barrier.
- Images are always best For example, an African American
accompanied with the family who is very hesitant to accept
spoken word for hospice may be best supported by a
reinforcement. video or brochure illustrating examples
of other African American families who
have received hospice care.
Watch video recording together. A film on advance directive or the story

- A tape can be intermittently of ALS outcomes can help a patient/
stopped to clarify or elaborate. family understand what is ahead for
- A video recording can be them.
intermittently stopped by patient/ Watching it together will help them
family to ask questions or talk to process it with the nurse, as well as
about concerns. create an additional connection with
the nurse.
Send video recording home. Patient and family might find it useful
- Patient/family will process to share this with others to help them
information differently. communicate about their illness, or to
- Access to this visual/audio is simply revisit some ideas that are hard
immensely helpful to patient/ to face or understand.
family in navigating new ideas.
Audio record your meeting. Family members hear and retain

- This can serve as a record for information differently. This record of
the patient/family to consult for a visit with a nurse can be of support in
reminders/clarity. making home care decisions.
- Varying levels of information
processing make this a helpful
tool in patient education.
(continued)

Support Interpreter Use for patient communication or

needed - Request a team member who family communication.
can facilitate communication Shared fluency can create immediate
between languages. allegiance.
- Look at the patient or family
member when talking, not the
interpreter.
Chaplain “I can talk to you about my own

- Rely on chaplaincy support to religious experiences, but I think that
help with religious and spiritual our chaplain might be of great help as
questions and concerns. you work through these questions.”
“It is perfectly normal to have these
questions, by the way.”
Social Worker “We have a palliative care team here

- Rely on social work support to to address your concerns. The team is
help with navigating place of wonderful in addressing symptoms and
care, family conflict, and difficult emotions common for patients and
transitions. families facing similar problems. I work
with them every day.”
Psychologist “I can see you are so anxious about

- Rely on psychology support to help your Dad. Would you be willing
patient/family with depression, to talk with Steve? He works with
anxiety, and general emotional the palliative care team. He is a
distress in palliative care. psychologist.”
Organ donor coordinator (ODC) “This is a really wonderful thing you

- Rely on ODC, and talk to patient are thinking about. Bill is our organ
and family with ODC about donor coordinator. He can answer some
donor concerns and questions. questions—much better than I can.
- Nurse can facilitate this And then you will better positioned to
conversation concerning cultural make a decision.”
knowledge. “I can talk with Bill to help him get a
sense of your family.”
Billing specialist “These worries about money are large

- Rely on a clinic or hospital and looming for you. I know. Can I
financial specialist to help patient/ invite Jane to come talk with you two
family navigate cost and coverage. and myself this afternoon about your
- Nurse can facilitate this Medicare coverage? She will know
conversation concerning cultural things I don’t know, and I can help her
and literacy knowledge. get a sense of your family.”
(continued)

Message Teach back “I wonder if you could relay the basic

processing - Intermittently have patient schedule of dosage for your Mom?”
participate in paraphrasing ideas “What are the main things you will
that were discussed want to do in talking with your sister
- Request that patient recall the about the advance directive?”
highpoints of conversation.
- Ask patient to summarize the
goals of the talk
Printed material clarity Specific directions, concrete terms,

- Reinforcement in text direct examples, visually clear (see
- Large print plain language resources for printed
- High contrast between text material at end of chapter)
color and paper color
- List format/bullets
Principally, whatever intervention a nurse selects, the patient and then family
should be considered. Patient/family anxiety, stressors, embarrassment, shame, lan-
guage, eyesight, hearing, mental health, and confusion should be your guide. Timing
for these interventions is also important. If the morning is harder for this family,
work with them at a different time. Or if a patient is too sick, unresponsive, or has
just been given very bad news, gauge what information must be passed on to his or
her family.
EVALUATE
Without any intervention, George is left with the heavy emotional toll of regret and
worry. What about his other patients? What can he do for them? What should he do
for them? Palliative care nursing is communication heavy in its task/relational load.
Patients and families as well as professional teammates are the best barometer for eval-
uation of intervention and care. Without reflecting on care and communication, cli-
nicians will learn little and grow less in their ability to deal with difficult cases and
cultural specificities that have not been experienced before. Reflection is the most val-
uable part of evaluation in palliative care. Cultural humility, mindfulness (Chapter 4),
teamwork (Chapter 8), and self-care (Chapter 9) are accomplished, in part, through
reflection.
Each nurse will have his or her own experience with the care of a patient and family
and will learn from that unique relationship. It is important to find out from patients
and families about their experiences accessing information and treatment options. To
Table 3.9 Prompts to Elicit Feedback

In What
Tool Given to . . . Form?
“Let me know in your own words if I am doing an okay job.” - Patient - Spoken
- Family
- Team
“How would you explain your treatment (or care) to your - Patient - Spoken
friends?” - Family - Written
“How would you explain your (this) illness to your friends?” - Patient - Spoken
- Family - Written
gain this information, ask questions at any point in their care, or even once patient/
family care is complete. Table 3.9 provides some specific prompts that can provide pal-
liative care nursing feedback.
CHAPTER SUMMARY
Orientation and opportunity are provisions of care that a nurse can provide and impact,
primarily through successfully created and sent messages. It is difficult to be successful
in sending messages to a patient and family if they remain unstudied to the nurse. Our
position in this chapter is that all patient/family health literacy levels and cultural differ-
ences must not be essentialized or assumed based on appearance or ethnicity.
Communication accommodation theory (CAT) grounds the themes in this chapter
and therefore is a very useful foundation as nurses consider all patients and families
unique in their (1) cultural specificity, and (2) health literacy challenges. CAT includes
three categories of accommodation that occur in all interactions. Convergence is
accommodation characterized by aligning and adapting communication acts that are
beneficial to the interaction and relationship.
The unique world of health care establishes a culture of medicalization that any
patient must navigate. We present the Voice of the patient’s everyday Lifeworld in jux-
taposition to the Voice of the Medicalworld. Both Voices represent radically different
perspectives on a topic, or description of a problem. This difference in Voices is a cul-
tural challenge in and of itself.
So how can nurses communicate using convergence in the face of these unique
patient/family needs? This chapter advocates that person-centered interaction that
privileges the narrative of the patient/family is the primary tool to accomplish con-
vergence. We include several assessment, planning, intervention, and evaluation tools
that will facilitate nurses to reach that narrative and employ its contents in reaching the
patient/family where they are in the health literacy levels and cultural understanding.
Reflection plays a helpful role for the nurse in building patient/family-centered com-
munication. This idea will be further explored in Chapter 4—“Mindful Presence.”
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1. Name a negative communication outcome in the clinic/hospital that could have
been prevented if culture had been approached with humility.
2. Share an example of the dueling discourses of the Lifeworld and Medicalworld
from a patient/family interaction.
3. If a patient met with a nurse alone (no family) about what symptoms to expect
in a very aggressive round of chemotherapy for Stage IV liver cancer and
appeared not to be engaging any patient education material about preparation
and side effects, what could a nurse do to ensure the messages being sent are
actually successful?
4. What is the difference between cultural competency and cultural humility?
5. Share an example of overaccommodation from the clinical setting.
6. How can divergent messages alienate a patient and family receiving care?
7. How could the ideas of orientation and opportunity be central to quality of life
in a patient/family receiving palliative care?
8. What is the role of reflection in gathering a patient/family narrative?
9. What are some ways in which nurses could teach nurses about cultural humility?
10. How is it possible that an individual who does not fit the low–health literacy
profile (socioeconomic/minority/age) could experience low health literacy in the
palliative care context?
Each day nurses practice in an increasingly diverse patient population in which they
will encounter language, culture, and health literacy challenges. The literature in nurs-
ing care indicates that cultural and low-literacy challenges are joined inextricably, yet
nursing education and training provide minimal assistance for nurses to navigate these
challenges (Singleton & Krause, 2009). There is no other practitioner as well posi-
tioned as the nurse to understand the interconnections between culture differences
and low health literacy to improve health outcomes.
What we also observe in the literature is a gap in any resource or research that
explores the family role in culture difference and low health literacy as it affects
palliative care communication. In this section we provide some materials to use
with nurses in training that will address these issues and others identified in the
chapter.
EXERCISE 1: COMMUNICATION ACCOMMODATION

THEORY ROLE PLAY
The goal of the role play is to practice convergence with this patient and family and
avoid divergence or overaccomodation.
Setting: A Mexican-American family. Three daughters in their 60s. The father is
deceased. The mother is dwindling and failing to thrive. She is 82 with increased
frailty and weighs 78 pounds. There is no advance directive. The patient’s physi-
cian has said that she is declining rapidly, and he anticipates she likely has a few
months to live. She has been at the eldest daughter’s home until the night pre-
vious to this meeting and is now hospitalized due to dehydration. The other two
daughters are also local. All three daughters are bilingual. The two younger daugh-
ters have large families. The oldest daughter cannot care for her mother any longer
due to financial strain and exhaustion. The two younger daughters have not been
active in her care and have not seen her very often during the last 3 months. The
youngest daughter, in particular, believes the oldest daughter has not been feed-
ing their mother well and that this illness is short-term and can be rectified with
proper nutrition. The mother, Rosa, is not an active participant in making decisions
about her own care and is now becoming increasingly withdrawn with little verbal
interaction.
Pat, an NP, comes by in the morning to see Rosa. She finds all three daughters in
the room and is the first practitioner to encounter the full family on site. Pat speaks
very little Spanish. The NP and social worker are hoping to help the family make dis-
charge plans.
Roles: Pat—NP
Lou—Oldest Daughter
83
Ella—Middle Daughter
CiCi—Youngest Daughter
1. What are some cultural assumptions about the Mexican-American family that this
family did not possess or demonstrate?
2. How did our NP go about gaining information about their specific story and
potential health literacy levels?
3. How did our NP demonstrate convergence? Divergence? Overaccomodation?
EXERCISE 2: LOW–HEALTH LITERACY SOLUTIONS

In the following case, nurses can connect the dots from the preceding pages/topics as
they understand specific patient experience within the domain of navigating clinical
health literacy in palliative care.
Boka, a 30-year-old Cambodian woman who had just come to the United States,
and her husband Leng, a 40-year-old Cambodian refugee who had been living in the
United States for 15 years, were expecting their first child. The obstetrician informed
them that their baby’s heart rate was very irregular, and he suspected possible prob-
lems. Boka went into early labor and delivered at 25 weeks.
Boka and Leng’s baby was placed in the NICU (neonatal intensive care unit) and
they were told that the infant would not survive. A NICU nurse drew a picture of the
heart with its chambers and valves to try to explain the cardiac defect to the couple.
Leng was shocked, stating that he could not believe the heart could not be repaired in
such a major hospital in America.
Boka and Leng did not request an interpreter and were reluctant to ask ques-
tions of their care providers. Boka and Leng were semiliterate in their country
and had been raised in a family-oriented culture and were not familiar with a
health care system in which families participated in care decisions. They strug-
gled to understand their child’s serious heart problem and early arrival. Their
exposure to physicians and nurses in Cambodia had been limited. The felt truly
lost without their family around to help them make these impossible health
decisions.
1. Do Boka and Leng understand what is happening to their child?
2. What sorts of assessments should have been gathered early on in the care of Boka?
3. What kinds of planning and intervention might have been effective with this
family?
4. At what point might a nurse request a palliative care team consult or other
support for this family?
EXERCISE 3: MORE THAN A CASE: PATHOGRAPHY IN

THE NURSING CLASSROOM
This project uses literature and the story of illness to teach the practice of palliative
nursing as well as navigate the challenges of low health literacy and/or cultural chal-
lenges. The use of fictional and autobiographical literature is proven to be meaningful
in nursing training in helping nurses identify and develop self-esteem, critical think-
ing, reflective skills, and competence in dealing with situations of low health literacy
and cultural difference (Slade, Thomas-Connor, & Tsao, 2008).
This pathography is best used if it follows combination learning on health literacy/
low health literacy that employs role play, lecture, and a group research paper.
We suggest the following works to locate pathographies for this class project:
Davis, C., & Shaefer, J (1995). Between the Heartbeats: Poetry and Prose by Nurses. Iowa City:
University of Iowa Press.
Sergi, P., & Gorman, G. (2009). A Call to Nursing: Nurses’ Stories About Challenge and
Commitment. New York: Kaplan Publishing.
Shalof, T. (2004). A Nurse’s Story. Toronto: The Canadian Publishers.
Romm, R. (2010). The Mercy Papers: A Memoir of Three Weeks. New York: Scribner.
The stages of this assignment are as follows. First, students will read the story assigned
and individually identify literacy and/or cultural issues at work in the text. Second, stu-
dents will gather in small groups and engage the study questions that the educator should
tailor for the piece read. These small groups then should join into one body for a group
discussion of themes identified in the smaller groups. Third and finally, students will select
one of the study questions and develop a short patient/family assessment essay.
Sample study questions for More Than a Case:
1. Who tells the story? Who tells the story of the protagonist? To whom is the story
told? What insights, biases, and limits does the narrator have?
2. How do you as a nurse assess the main character?
3. Your assessment should address the following:
a. Language
b. The characters’ self-esteem during care
c. Strengths and weaknesses in advocating for care
d. If you were the nurse in the story, would you do anything differently to address
the needs of ___________? To better intervene between the family and the doctor?
What would be your difficulties?
More than a Case concept adapted from Slade, D., Thomas-Connor, I., & Tsao, T. (2008). Using
pathography to develop nursing students’ culturally competent selves. Nursing Education Perspective,
19, 151–155.
EXERCISE 4: UNFOLDING CASE REFLECTION

This classroom project is a rich reflective practice opportunity for nurses to consider
how the impact of low health literacy shapes patient/family realization of treatment
options. In brief, this family engages in overtreatment of end-stage cancer days from
death as a result of low health literacy, though their profile might not readily indicate
low health literacy. This is a white family from West Oklahoma. Both husband and wife
are college educated and very wealthy owners of power companies in this part of rural
America. If tested on basic reading and language literacy, both spouses would likely rate
as highly literate. But their health literacy requires information processing and decision
making far beyond language use and comprehension. This family exemplifies the low
health literacy that many families exhibit when navigating a terminal diagnosis.
This unfolding case can be used in many pedagogical ways. The more that participants
are with one another and with their own thoughts, the more useful. Arranging students in
dyads or triads per segment of the case and then regrouping to share their discoveries in
the sequence of the story might be the most powerful use of this classroom tool.
July 10, 2009—Steve, a resident of rural West Oklahoma, thinks he has pneumonia
and sees a local family doctor with his wife. His symptoms include labored breath-
ing and exhaustion. Steve’s physician diagnoses him with gall bladder inflamma-
tion and sends him on to a local surgeon, Dr. A. At the end of this appointment,
Steve and his wife Amy talk casually with the nurse about the nuisance of surgery
in a busy life.
July 11, 2009—Dr. A. indicates that he is not sure the difficulty is gall bladder. After
the meeting with Dr. A., the nurse meets with Steve and Amy and tells them that
Dr. A. is sending Steve to the local hospital to arrange for tests. They press her on
the change of plans and why a CT scan and blood tests were ordered. They won-
der if they should be worried. The nurse assures them that this is likely routine, a
“bump in the road.”
The wife, present in the technician’s booth during the CT exam, notes white spots
throughout the scan and converses with the technician about the test. The techni-
cian inquired, “Is he really supposed to have gall bladder surgery tomorrow?” That
evening Dr. A. called Steve’s home and notifies his wife that there are spots on
Steve’s liver and summons them both to the hospital ER immediately.
Assume that you are Dr. A.’s nurse and you must disclose that gall bladder surgery
will not be performed in lieu of further testing. How you would communicate this
information? How would you respond to Steve and Amy’s concern? What you say to
Dr. A. in preparation for your task and following this disclosure to patient/spouse?
July 12, 2002—A scope of Steve’s lower colon is positive for tumor activity. Dr. A.
diagnoses Steve with colon cancer. A liver biopsy is positive for cancerous tissue as
well. Dr. A. suggests to Amy that they do not pursue surgery, chemotherapy, or any
further treatment. Dr. A. does not tell Steve this. He has this conversation with the
wife in front of several people in a hospital hallway. Steve is left alone in a hospital
room unaware of his condition, Amy stops a nurse who has only been on the floor
for an hour that day. Amy is sobbing and hysterical. She begs the nurse to explain
the diagnosis and what they can do. Knowing that Amy is in crisis and having little
information about Steve’s case, what would you include in your conversation with
Amy? How could you move forward from this moment?
July 14–20, 2009—The family goes on to a cancer center in Oklahoma for care.
Oncologists perform additional testing and alter the diagnosis from colon can-
cer to adenocarcinoma of unknown primary site and suggest the family travel to
MD Anderson Cancer Center. An advanced practice nurse meets with Steve and
Amy to arrange referral plans, and Steve and Amy ask her if this is “good news?”
They believe the doctors’ referral to MD Anderson to be an indication of a pos-
sible cure.
Knowing that Steve is suffering from metastatic adenocarcinoma of unknown pri-
mary, how would you talk to him about his care, how to proceed, and issues to
consider in his decision making?
July 20–August 10, 2009—Steve and Amy wait for an appointment at MD
Anderson. In this interim Steve becomes jaundiced; his urine is brown and reduced
in quantity. Steve receives IV fluids from the local Cancer Center and is then trans-
ported to Houston.
August 11–12, 2009—MD Anderson repeats CT and MRI scans; tumor activ-
ity in Steve’s body is accelerating. These tests are compared with the tests from
Oklahoma taken a few weeks before. The liver has become mostly cancerous in a
matter of 3 weeks.
Assume you are the intake nurse meeting with Steve and Amy. What would you
do next in assessing their understanding of his diagnosis and his care options?
The fellow for the GI (gastrointestinal) clinic meets with Steve’s wife. Steve is too
ill to participate in the conversation and is being admitted to the hospital. A Fellow
tells Amy that Steve will die and that there is no hope. Amy demands to see the
lead doctor and insists they receive chemotherapy. A nurse asks Amy to wait and
locates Dr. C., who explains the prognosis to the wife and why treatments do not
work but says he will try chemotherapy. He explains this therapy will probably not
help Steve and will make him sicker. The nurse returns to arrange chemotherapy
at the clinic later that day.
Steve receives chemotherapy that evening and becomes more ill with severe nausea
and vomiting and worsening pain.
Put yourself in the position of the GI clinic nurse. What opportunities could you
take to engage Amy and Steve in orientation and opportunity talk? What strate-
gies could be employed in talking with Dr. C. or the Fellow about Steve and Amy’s
acceptability and plan of care?
August 13, 2009—Steve becomes very ill in their hotel room. Dr. C. recommends Steve
go to MD Anderson ER. Steve waits for several hours until he can receive fluids.
August 14, 2009—Steve needs fluids again but is too ill to go and wait for them.
Dr. C. sends a nurse to their hotel with fluids. Steve stays in bed vomiting. He has
not urinated in 24 hours.
Put yourself in the visiting nurse position; what are some ways the nurse could
engage Amy in considering options for care at this point in Steve’s illness?
August 15, 2009—Amy sends for private plane to fly Steve home from Texas to
Oklahoma as Steve is too ill to travel by car or commercial air. Steve and Amy
return home.
August 16–30, 2009—Steve never leaves his bedroom again. He stops eating and
eventually stops talking. He becomes confined to bed and his pain increases expo-
nentially. Steve’s original GP, diagnosing him with gall bladder problems, visits and
prescribes pain medication in the last week of Steve’s life, but soon Steve is unable
to swallow the pill form of the medication that has been prescribed.
What do you see as the most crucial opportunity for a nurse to have made a more
positive impact on the outcome of this case in terms of orientation and communi-
cation with the patient/family about care options?
EXERCISE 5: JIGSAW SOLUTIONS FOR LOW LITERACY

AND CULTURAL CHALLENGES
Jigsaw learning is a strategy of small group self-teaching that has been practiced and
researched for over three decades. If each student’s part is essential, then each student
is essential; that is precisely what makes this strategy so effective.
Here is how it works: nursing students are divided into small learning groups
of five or six students each. Their task is to learn about ways to improve commu-
nication problems revolving around low health literacy and cultural differences in
a variety of palliative care contexts. Each jigsaw group is assigned an expert on a
particular topic of palliative care communication as it relates to orientation and
opportunity.
The situation is specifically structured so that the only access any member has to the
other five assignments is by listening closely to the report of the person reporting.
To increase the chances that each report will be critically thoughtful and useful, the
students first meet with students who have the identical assignment in their expert
groups (one from each jigsaw group). For example, students assigned to reducing
medical language meet as a team of experts, gathering information, becoming experts
on their topic, and rehearsing their presentations. It is particularly useful for students
who might have initial difficulty learning or organizing their part of the assignment; it
allows them to hear and rehearse with other “experts.”
Once each presenter is up to speed, the jigsaw groups reconvene in their initial het-
erogeneous learning group configuration. Each student in a group educates the whole
group about her or his specialty.
What is the benefit of the jigsaw classroom? First and foremost, it is a remarka-
bly efficient way to learn the material. But even more important, the jigsaw process
encourages listening, engagement, and empathy by giving each member of the group
an essential part to play in the academic activity.
We include a sampling of communication challenges that bedside nurses from the
Georgia Nurse Leaders Organization reported in the summer of 2010. These descrip-
tions can be used as contexts and situations for learning group problems. Expert group
topics will follow these nurse descriptions.
- Patients/families do not understand what I am saying or what the doctor is say-

ing. Generally, they act like they understand, and when the MD leaves the room
they ask me what he/she meant. The MD is usually in a hurry. The units are so
busy that the staff does not have enough time to sit down and really talk/listen
to the patient/family.
- I don’t have the ability to predict the best method of information delivery with
patients of all different educational and socioeconomic backgrounds.
- It is challenging to communicate how a patient/family can perform self-care, or
manage himself or herself at home with a new permanent ostomy or new diag-
nosis that needs lifelong intervention.
- A brain-dead patient’s family did not understand that body circulation does not
equate to the possibility of survival/recovery after explanations from the physi-
cian that the brain was not working. After prolonged lack of oxygen, there was
no chance of brain function getting better.
Expert group topics:
- Voice of Lifeworld versus Voice of MedicalWorld

- Practicing Cultural Humility
- Assuming Low Health Literacy
- Communication Accommodation Theory’s Convergence
- Plain Language
This concept is adapted from Aronson, E., Blaney, N., Stephin, C., Sikes, J., & Snapp, M. (1978). The
Jigsaw Classroom. Beverly Hills, CA: Sage Publishing Company.
EXERCISE 6: PLAIN LANGUAGE GAME

The plain language game can be administered in many different ways. The goal of this
classroom project is to remind nurses of their role and ability to communicate difficult
information to patients and families, especially in end-of-life situations.
In groups of six or seven, students are charged with making a difficult piece of
information understandable and comprehensible for a variety of health literacy levels
and cultural backgrounds. For instance, one group could be given the issue of explain-
ing feeding tubes versus withholding nutrition. The group then determines four or
five ways in which this message can be communicated and goes to work building
those messages. Communication channels include using language that is not steeped
in medicalese. For others, a set of pictures might accomplish an alternative message.
Especially for this sort of medical decision, the anxiety and concern surrounding the
absence of the nutrition is of most concern to families, as Western culture is bound to
the idea of food as a signifier of care/love. So, each group is charged with identifying
what the message will consist of, or how the message will be delivered. The goal is to
introduce variety and creativity to increase the tools in the nursing toolbox.
Groups should be given a week to build/design their series of messages, and
then a class session should be devoted to the delivery and discussion of these
presentations.
additional supplemental materials
Table 3.10 Communication Adaptations for the Deaf or Hearing Impaired Patient/
Family
x Find out how your patient/family would prefer to communicate.
x Communicate with intended party, even if you are using a translator or signer.
x Inquire about patient/family interest in an American Sign Language translator.
x Let the entire staff know about hearing compromise.
x Keep writing material accessible for anyone to use.
x Use instructional videos with captions.
x Use relay service telephone calls or videophone.
Adapted from Ruccione, K. (2004). Coming to terms with language. Oncology Nursing Forum, 31,
913–925.
Table 3.11 Strategies to Facilitate Health Literacy in Older Adults

x Meet when patient/family is rested.
x Build in additional time to meeting.
x Provide the best lighting possible.
x Reduce background noise as possible.
x Minimize nurse distractions.
x Adjust room temperature to suit patient/family.
x Accommodate for physical needs/limitations with wall railings, straight-backed chairs,
cushions.
Adapted from Speros, C. (2009). More than words: Promoting health literacy in older adults. Online
Journal of Issues in Nursing, 14, Manuscript 5.
websites for cultural humility

materials
CROSS CULTURAL HEALTH CARE PROGRAM

www.xculture.org
- CCHCP addresses broad cultural issues that impact the health of individuals and
families in ethnic minority communities.
EthnoMed
http://ethnomed.org
- The EthnoMed site contains information about cultural beliefs, medical issues, and
other matters pertinent to health care of recent immigrants to the United States.
Harvard School of Public Health: Health Literacy Studies

www.hsph.harvard.edu/healthliteracy
- A research group providing current data and studies on the correlation of culture
and low health literacy
ADDITIONAL WEBSITES FOR HEALTH

LITERACY MATERIALS
Below is a government health literacy LISTSERV including posts on many differ-
ent aspects of health literacy and communication. To subscribe and find the
archives, go to
http://lincs.ed.gov/mailman/listinfo/Healthliteracy/.
American Medical Association Foundation Health Literacy

http://www.ama-assn.org/ama/pub/category/8115.html
- Toolkits including online videos, manuals, and tips in clinical practice
Ask Me 3
http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/
ask-me-3-resources
- A site dedicated to improve communication between providers and patients.
Includes toolkits, fact sheets, reproducible brochures, guidelines, and more
Doak, C., Doak, L., & Root, J. (1996). Teaching Patients With Low Literacy Skills.
http://www.hsph.harvard.edu/healthliteracy/resources/doak-book/
- Book included in supplemental section is available on the Harvard site in pdf
Health Literacy: A Prescription to End Confusion

http://www.nap.edu/openbook.php?isbn=0309091179
- A comprehensive article vital to every health care practitioner is the Institute of
Medicine’s report.
Health Literacy Month

http://healthliteracymonth.org
- Articles, links, logos, and promotion suggestions to advertise October as Health
Literacy Month
Health Literacy Universal Precautions Toolkit

http://www.ahrq.gov/qual/literacy/ (also available at http://nchealthliteracy.org/
index.html)
- Sponsored by AHRQ and created by Dr. Darren DeWalt’s team at University of
North Carolina Chapel Hill School of Medicine
LINCS Health Care Provider/Health Educator Resources

http://lincs.ed.gov/lincs/resourcecollections/healthliteracy
- Easy-to-read materials, information in languages other than English, cultural
issues solutions, and activities
Literacy and Health Outcomes

http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf
- This report analyzes the effects of low health literacy on health outcomes.
North Carolina Program on Health Literacy

http://nchealthliteracy.org/index.html
Understanding Health Literacy and Its Barriers

http://www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html
- Current bibliography on the topic of health literacy
The Virginia Adult Education Health Literacy Toolkit

http://www.valrc.org/publications/healthlit/
- A one-stop resource for health literacy education needs
RESOURCES FOR DEVELOPING EASY-TO-READ MATERIAL

Clear Language Group
http://www.clearlanguagegroup.com
- Professionals doing work in health communication and particularly focusing on
the needs of the people that have low health literacy
Clear and Simple: Developing Effective Print Materials for Low Literate Readers
http://cancer.gov/cancerinformation/clearandsimple
- An outline for procedures to develop publications for people with limited
literacy skills
How to Write Easy to Read Materials

http://www.nlm.nih.gov/medlineplus/etr.html
- Four steps of development for the creation of easy-to-read material
Patient Education: An Author’s Guide

http://www.med.utah.edu/pated/authors
- A useful guide on all aspects of writing for patients/families
The Plain Language Institute

http://www.plainlanguage.gov/
- The Plain Language initiative including examples, guidelines for content and
layout, and numerous resources to support the creation of materials
4
mindful presence
Elizabeth is a night shift nurse in the surgical ICU in a large teaching hospital.
She has been a nurse for 5 years and chose the ICU as the setting for her work as
she was intrigued by the fast pace, patient acuity, and complexity of the patients
and their families. She loves the opportunity to care for the sickest patients and
feels fortunate to work in an academic center where she is a part of a team and
there are always opportunities to learn.
Over the past year, the ICU has been receiving more cancer cases as the hos-
pital has expanded its surgical oncology program. Patients travel long distances
to seek care even when they have often been told surgery is not possible for their
advanced tumors. Elizabeth has felt increasingly frustrated in the care of these
patients, often distressed in cases where very aggressive care is provided with
very invasive surgeries. Sometimes the surgeries are successful but there is tre-
mendous suffering involved; other times, these desperate patients and families
become very difficult to care for when the surgery fails. Elizabeth had begun to
feel like a “senior” ICU nurse, but now she has become uncertain about her work
and ability to provide care.
For the past 2 weeks, Elizabeth has been caring for Mr. Chun, a 70-year-old
Chinese man who underwent surgery for an advanced gastric malignancy. Mr.
Chun was a successful businessman and a very stoic, serious man. Unfortunately,
Mr. Chun developed several postoperative complications including a GI bleed,
liver failure, and respiratory failure. He is no longer verbally responsive and his
prognosis is poor. His wife, brother, 90-year-old father, and three children have
refused a family meeting, and each has insisted that the hospital keep focused on
Mr. Chun’s survival. Mr. Chun’s oldest son is serving as the family spokesperson
and proxy decision maker. He has become hostile and very angry, especially if
there is any mention of his father’s poor prognosis.
Elizabeth is caring for Mr. Chun on the night shift, and his oldest daugh-
ter, Chin Lee, returns late at night and asks if she can sit with her father. She
has always been very quiet, deferring all decisions to her brother. Elizabeth
begins her routine care for Mr. Chun, checking his ventilator and drains and
administering his many IV medications. She notices that Chin Lee is quietly
weeping, and she senses her extreme anguish and grief as she watches her
93
father, a vulnerable and weak man now with a ravaged and debilitated body
burdened by the many high-tech treatments. Elizabeth continues her patient
care as she considers how best to respond to Chin Lee and what she can pos-
sibly offer to this daughter.
In the case study above, Elizabeth finds herself in a position that palliative care nurses
face continually in their work: uncertainty in dealing with patients and families in the
face of failed surgeries or other treatments and poor prognoses, particularly when the
patient is no longer verbally responsive, and his family members refuse to meet to dis-
cuss care plans. This case is complicated in particular by the patient’s Chinese culture,
whose traditions mandate that oldest sons speak for their families—Mr. Chun’s son,
angry and hostile because of his father’s condition after surgery, only wants to focus on
his father’s survival. And yet Elizabeth discovers Mr. Chun’s oldest daughter, Chin Lee,
weeping in anguish in her father’s hospital room. In the absence of a family meeting at
which the palliative care team might help the family to discuss their possibly conflict-
ing views concerning the care plan for Mr. Chun, Elizabeth must discover other means
of ministering to this mute patient and his family, particularly at this time focusing on
his distressed daughter.
This chapter introduces the “M” concept in the COMFORT model, mindful pres-
ence. It details the concepts of mindfulness and presence, two nonverbal behaviors
that nurses can bring to patients/families when verbal behavior is necessarily limited
(as with Mr. Chun), but that also can be practiced in any patient/family interaction.
Drawing on the research in both mindfulness and presence (often called compassion-
ate or healing presence in the nursing literature), we have combined these concepts
into an essential nonverbal communication skill, mindful presence. The discussion will
also deal with empathy and active listening and will point out how essential these
competencies are for palliative care nurses and for the practice of narrative nursing.
The chapter then will discuss the importance of a nurse’s intercultural sensitivity in
the care setting. It will conclude with a brief look at the philosophical underpinning of
our notion of mindful presence—Martin Buber’s I-It/I-Thou dialectic.
MINDFULNESS
The term “mindfulness,” which originated in Buddhist philosophy, has been appro-
priated by a multitude of disciplines, including clinical psychology, social work, psy-
chotherapy, medicine, and other helping professions. This section will look briefly
at the tenets of mindfulness and will provide a rationale for what we believe is a
more accurate descriptor of the communication behavior required for palliative care
nurses—mindful presence.
In its classic sense, mindfulness describes an aspect of Buddhism that has been in
existence more than 2,500 years, only gaining acceptance in the Western world for
about the past 25 years (Day & Horton-Deutsch, 2004) as we began to recognize the
relationships between our emotions and our physical and mental health. Essentially,
mindfulness “is a state of being purposefully attentive to one’s moment-by-moment
95 Mindful Presence
experience,” (Day & Horton-Deutsch, 2004, p. 165), but this attentiveness also
includes an awareness of one’s own maladaptive cognitive habits that impede per-
sonal growth and understanding (Goleman, 1997; Kabat-Zinn, 1990). Hirst (2003)
describes mindfulness as “an awareness of being aware” (p. 360) that requires con-
centration and attention to being present in the current moment. Discussing mind-
fulness as it pertains to learning, Langer (1992, 2000) states that mindfulness entails
a flexible state of mind and an active engagement in the present, a noticing of new
things and a sensitivity to context. He contrasts it with mindlessness, which is linked
to habitual behaviors performed without attention: for example, predictable emo-
tional responses, fantasizing, worrying about the future, living with anger and hate,
and indulging in addictive behavior.
Importantly for our discussion, however, mindfulness in its truest sense is a skill
that is highly disciplined and whose cultivation and therapeutic usefulness man-
date training and daily meditation (Day & Horton-Deutsch, 2004; Kabat-Zinn, 1990;
Kabat-Zinn, Lipworth, & Burney, 1985). In fact, the skill of mindfulness is developed
through meditation (Hirst, 2003), and its therapeutic usefulness frequently involves
the teaching of Buddhist meditative practices. Mindfulness as meditation has been
empirically investigated in a number of therapeutic settings, most frequently as a
stress reduction technique in cognitive therapy and as a supportive therapy in the
treatment of cancer patients. For example, mindfulness-based therapeutic interven-
tions have been successfully utilized in psychiatric nursing (Day & Horton-Deutsch,
2004) and in cognitive therapy (Davis, 2007); mindfulness meditation has been taught
to dementia caregivers (Oken et al., 2010); mindfulness-based stress reduction tech-
niques have been utilized for both patients and health professionals (Cohen-Katz,
2004; Praissman, 2008), and mindfulness skills training has been utilized in clinical
social work (Turner, 2009). In oncology nursing, mindfulness meditation has also
been a potentially beneficial intervention for cancer patients (Matchim & Armer, 2007;
Ott, Norris, & Bauer-Wu, 2006). Smith, Richardson, Hoffman, & Pilkington (2005)
found that mindfulness-based stress reduction is a potentially valuable intervention
for improving mood and sleep quality and for reducing stress in cancer patients. Ott
(2002) utilized mindfulness meditation successfully in pediatric clinical practice. Keep
in mind that all of these studies have involved the teaching of Buddhist meditation, a
requisite skill for the practice of mindfulness.
Thus, while our communication tenet for palliative care nursing, mindful presence,
adopts many of the concepts entailing Buddhist mindfulness, it does not advocate
meditation as a requisite skill in the practice of being mindful. Rather, mindful pres-
ence involves a nurse’s being nonverbally present for a patient/family while also being
attentive, in the moment, nonjudgmental, and empathic. These ideas will be unpacked
in the following section.
MINDFUL PRESENCE
Rapgay and Bystrisky (2009), in an article that differentiates classical mindfulness from
the popular use of the word, state that popularized versions of mindfulness consider
the formal practice of daily training and meditation too demanding; the Buddhist
model of mindfulness has been altered to a “more general concept of being mind-
ful, i.e. attentive to present moment experience” (p. 149). In particular, being mindful
requires a nonjudgmental awareness of the present moment, being experientially open
and accepting (Rapgay & Bystrisky, 2009).
Anthony and Vidal (2010) discuss mindful communication as a way of improving
delegation and increasing patient safety; they define mindfulness as “a state in which
there is keen awareness of the situation; it is being ‘in the moment,’ and a way of direct-
ing or focusing attention of everyday tasks to the present moment” (p. 8) It is this
adaptation of mindfulness as mindful communication that we find most engaging as a
skill in the practice of palliative care.
PRESENCE
Mindfulness and presence are frequently discussed in tandem in the clinical psy-
chology literature. Childs (2007), for example, cites Kabat-Zinn’s (1991) seven
attitudinal foundations of mindfulness as conveying “an attentive, unprejudiced
present” (p. 369): acceptance, patience, trust (in one’s own intuition), nonjudg-
ing, nonstriving, letting go, and beginner’s mind (seeing everything as if for the
first time). Personal preference and critical thought are suspended when one is
mindful. “The word ‘presence’ is a useful summary of this account as it conveys
both present time and person present, a ‘now’ and an awareness attentive in it.
Presence requires practice and emphasizes personal experience. You have to be
there” (Childs, 2007, p. 369).
In the nursing literature, the word “presence” is more typically used to convey
many of the attitudes of mindfulness that Kabat-Zinn espoused. Often this presence is
referred to as “compassionate presence” or “healing presence,” both terms referring to
the nonverbal attentiveness and the attitudes that a mindful communicator employs.
Simon, Ramsenthaler, Bausewein, Krischke, and Geiss (2009) interviewed palliative
care professionals who described the core attitudes of professionals in palliative care.
Interviewees listed the personal characteristics of authenticity, personal presence, hon-
esty and truthfulness, openness, unconditional positive regard, and mindfulness as part
of these core attitudes. Authenticity is seen as being present and accessible rather than
behaving in a specific role; personal presence is described as a feeling of “completely
being in the here and now” (p. 408), of focusing on the other person. Mindfulness is
seen by the interviewees as cautiousness, attentiveness, humility, and acceptance. It
also means nonacting, appreciating the other in his being. As one interviewee put it,
“You know deep inside what is right and I am allowed to be the person that reminds
and supports you . . . again this inner awareness and concentration on the uniqueness
of this person, looking at what is happening” (p. 409). All of the attitudes described
in the Simon et al. (2009) study are relational competencies that palliative care profes-
sionals exhibit with their patients—these competencies in care can be seen in Table 4.1
(Simon et al., 2009, Table 3, p. 408).
97 Mindful Presence
Table 4.1 Concept of Core Attitude in Palliative Care

Personal Characteristics Experience of Core Attitude Competence in Care
Authenticity In relationship Perception

Honesty Dialogue Active listening
Mindfulness Companionship Getting involved
Esteem/appreciation Systemic approach Creating space
Openness Letting go
Personal presence Closeness/distance
Responsibility
Used with permission from: Simon, T., Ramsenthaler, C., Bausewein, C., Krischke, N., & Geiss, G.
(2009). Core attitudes of professionals in palliative care: A qualitative study. International Journal of
Palliative Nursing, 15 (8), 408, Table 3: Concept of Core Attitude in Palliative Care.
HEALING PRESENCE
The core attitudes above help to describe the concept of “healing presence” discussed
by McDonough-Means, Kreitzer, and Bell (2004), who state that, while the nursing
literature since the early 1960s has attempted to define presence and its therapeutic
importance, the emerging literature has been more conceptual than empirical. Citing
Gilje (1992) and Gardner (1985), McDonough-Means et al. discuss two dimensions
of presence: physical or “being there” and psychological or “being with.” Physical
presence involves actual proximity to the other—“seeing, examining, touching,
doing, hearing, and hugging or holding” (McDonough-Means et al., p. S-25) whereas
psychological presence entails the skills of “listening, attending to, caring, empathy,
being nonjudgmental, and accepting” (p. S-25). Ferrell and Coyle (2008) cite Benner’s
(1984) work on the significance of presence: expert nurses come to realize that their
“being” is as valuable as their “doing.” Ferrell and Coyle (2008) further state that
“presence is far more than being physically available or offering expert listening skills.
True presence is a sacred act. It is transformative for the nurse as well as for the patient
or family member” (Ferrell & Coyle, 2008, p. 85). We consider “being” and both types
of nonverbal presence—physical and psychological—to be essential competencies for
palliative care nurses.
COMPASSIONATE PRESENCE AND EMPATHY

McDonough-Means et al. (2004) further describe the characteristics of a healer that
contribute to her ability to be fully present: empathy, compassion, charisma, and spir-
ituality. One of the core attributes of a healing presence is empathy. Numerous studies
show that the ability to exhibit empathy and focused attention are a part of effective
communication in any therapeutic relationship (McDonough-Means et al., 2004).
Williams & Stickley (2010) concur that patients desire empathic nurses and discuss the
implications for teaching empathy for nurse educators.
Eide et al. (2004) explain that patients are hesitant to articulate their emotions
directly and spontaneously, presenting indirect cues to indicate emotion. In a study in
which they coded verbal transcripts of doctor–patient interaction for both explicit and
implicit expressions of emotion, they defined implicit expressions of patient emotion
as “a patient statement from which a clinician might infer underlying emotion that
has not been explicitly expressed” (p. 292). This is shown in the following example in
which a physician is talking with a patient about her hearing loss:
patient: Yes, of course you hear well, but I don’t hear it at all, so that is my
biggest handicap [The researchers coded this utterance as a “potential
empathic opportunity”—PEO—that expressed concern.]
doctor: Yes, it may be that it will get a bit better. I don’t know if it will return
to normal, but I think it’s a bit early to say, so soon after the operation that
I . . . (pp. 292–293).
In this study, the authors concluded that there were four times more implicit than
explicit expressions of patient emotion and that many opportunities to express empa-
thy are missed. They also note that despite the traditional approach to treat patients’
emotions as secondary to their diagnosis and treatment, recent studies show patients’
emotions as integral to their care.
They cite evidence for this in a study by Stewart et al. (1999) that showed that
physician acknowledgment and response to patient emotion results in improved
patient satisfaction, greater probability of adherence to physician recommen-
dations, and measurable outcomes such as improved blood pressure and blood
sugar.
Thus, listening for feelings becomes all important for the palliative care nurse.
In the case study at the beginning of the chapter, Elizabeth relies on the nonverbal
cues of her patient’s daughter—Chin Lee’s quiet weeping—to give her information
about Chin Lee’s emotional state and her possible disagreement with her brother
concerning their father’s care. Being present and empathic in the moment are par-
amount for Elizabeth.
A healing and compassionate presence is discussed by Ferrell and Coyle (2008,
2010) as a requisite for palliative care nurses. In studies dealing with the suffering
of children and their parents, nurses realized that “the greatest relief they could offer
was presence” (Ferrell & Coyle, 2008, p. 73). One nurse in describing her witnessing
of suffering wrote:
Sometimes we can only witness. We cannot fix or do the work of creating mean-

ing. This family responds to support, to ideas, to reframing, but ultimately they
have to wrestle with the guilt themselves. We can provide a container, a holding
environment of safety so they don’t have to do this in isolation. We can keep
showing up, even when it’s messy and ragged and uncomfortable. (Ferrell &
Coyle, 2008, p. 74)
99 Mindful Presence
Referring again to the opening case study, Elizabeth may not be able to offer the
Chun family any comfort other than “showing up,” witnessing with empathy and a
mindful presence of the suffering of another: “Nurses respond to suffering first and
foremost through presence. As witnesses to suffering, they serve as a compassionate
voice that recognizes the human response to illness amidst the chaos and depersonal-
ization of the health-care environment” (Ferrell & Coyle, 2008, p. 109).
ACTIVE OR DEEP LISTENING

Across all contexts of patient/family suffering—critical care, pediatrics, oncology, ger-
iatrics and other settings—Ferrell & Coyle (2008) point out the critical importance of
nursing presence and attentive listening. “Through listening to their patients, nurses
can help the person move beyond mute suffering to expressing their emotional dis-
tress . . . Nurses can ameliorate distress and help restore wholeness through this human
connection” (Ferrell & Coyle, 2008, 110).
Relational communication scholar Julia Wood (2000) discusses the skill of listen-
ing as being at least as important as talking. She distinguishes listening from hearing:
hearing is a purely physiological activity requiring no effort; listening, on the other
hand, is far more complex and effortful. Listening is defined as: “a complex process of
attending to, receiving, perceiving, organizing, interpreting, responding, and remem-
bering messages” (Wood, 2000, p. 68). Seven activities comprise the listening process,
as illustrated in Table 4.2.
Wood (2000) further notes that the basic foundation of listening is being mindful:
this entails being fully attentive to the here and now, refusing to think about what you
were doing a moment before you encountered this person and disciplining your mind
not to wander to what you will be doing later. While our normal state of mind is not
being mindful, according to Wood, the act of being mindful requires a conscious deci-
sion to attend fully to another person, refusing to focus on our own experiences and
feelings, and giving ourselves completely to the moment. Ting-Toomey (2010) dis-
cusses mindful listening as “listening deeply with all our senses open and all our per-
ceptual filters unclogged” (p. 160). She cites the Chinese character for “listening,” ting,
which means “listening with one-pointed attention with our ears, eyes, and a focused
heart” (p. 160).
LISTENING, PRESENCE, AND BEARING WITNESS

Baird (2010), in discussing spiritual care interventions in palliative care, believes that
nurses provide presence, deep listening, bearing witness, compassion, compassionate
presence, and what she terms “deep listening” as critical skills. To be compassionately
present involves more than being physically present in the patient’s room; rather,
the psychological message is given: “There is no where else I would rather be at this
moment than here with you” (Baird, p. 665). This type of presence definitely takes
more effort, energy, and intention than the mere act of being in physical proximity to
Table 4.2 The Listening Process

1. Becoming mindful Focusing on another person and the present moment, giving
full attention
2. Physically receiving Receiving a message, either through audio signals and sound
messages waves or through another means such as seeing nonverbal
communication or American Sign Language
3. Selectively perceiving Selecting aspects of noise or messages for focus, distinguishing
what’s important from what is not
4. Organizing what has Grouping information together, noting connections among
been received ideas, linking this message to previous knowledge
5. Interpreting Assigning meaning to the selected and organized material;
drawing conclusions about what the communication means
6. Responding Demonstrating interest and attention through verbal and
nonverbal feedback, asking questions, giving responses,
encouraging elaboration
7. Remembering Retaining what we consider the most important parts of
messages and the meanings we’ve assigned to them
Used with permission from: Wood, J. T. (2000). Relational Communication: Continuity and Change
in Personal Relationships (2nd ed., p. 69). Belmont, CA: Wadsworth Publishing.
the patient. Likewise, Baird believes that deep listening means “hearing what is being
said and what is not being said and trying to understand the emotions and feelings
behind the words” (p. 665). It is allowing the person to be vulnerable in our presence
so that we share in their pain and suffering.
Dahlin (2010) posits four basic elements to communication in nurse–patient rela-
tionships: imparting information, listening, information gathering, and presence and
sensitivity. All of these elements work concurrently for effective palliative care nurs-
ing. Listening requires both presence and attention so that both words and nonverbal
gestures are “heard.” Dahlin notes that it is frequently useful to ask for the patient’s
story with an open-ended question, such as “What brought you to the hospital?” or
“Tell me what has been going on” (p. 114). This permits the nurse to listen actively to
the story while also keenly observing and interpreting nonverbal behavior, particularly
expressions of emotion that might be communicating psychological or spiritual dis-
tress. Dahlin further stresses that silence is a valuable tool for the nurse to utilize—it
permits her to listen without interrupting the patient, to be present in the moment
without mentally preparing answers or replies. Such silence also conveys empathy to
the patient. Just sitting quietly may permit the patient to express a deeper level of con-
cern, and in that silence comes an opportunity and permission to self-disclose.
Case Study
An example is the case of Mildred, a 44-year-old woman being treated in the
oncology clinic for stage IV ovarian cancer. Mildred has opted for aggressive
101 Mindful Presence
chemotherapy, hoping to extend her life to be able to see the birth of her first grand-
child due in 3 months. Mildred’s nurse Karen has watched her patient decline,
becoming more cachectic with many signs that the tumor is progressing and not
responding to treatment. Today as Karen is beginning the fourth chemotherapy
infusion in the outpatient clinic, the physician enters the room and reports that
the ultrasound and lab work have confirmed their worst fear and that the tumor
has now extended to the liver. The physician, a very kind, older oncologist who
is very fond of Mildred, quickly exits, telling Mildred he will be in touch once he
has time to consider other options. Karen finishes connecting the chemotherapy
but remains seated next to Mildred, gently touching her arm in silence, acknowl-
edging the weight of the information she has received. Mildred begins to cry, and
Karen avoids the urge to jump up and get a tissue or to provide false assurances,
and instead, she sits in silence. Moments pass, then Mildred begins to speak, tell-
ing Karen that she knew she was getting worse and how difficult it has been to try
to keep positive and protect her family. Karen remains silent, offering Mildred the
space and security to absorb the latest news and its meaning.
Particularly with a dying patient, Dahlin (2010) notes that “simple presence, listen-
ing, and attending to the basic humanity of the dying patient may be one of the nurse’s
most powerful contributions” (p. 126). Being present for and witnessing the dying pro-
cess is a healing affirmation, even a sacramental gesture. “The communication skills
required include: being present with the patient in his or her state of vulnerability and
decline; consciously and non-judgmentally listening and bearing witness to the patient;
and encouraging the patient to express all feelings while resisting defensiveness if the
patient voices anger or disappointment about dying” (Dahlin, 2010, p. 126).
PATIENTS’ STORIES AND NARRATIVE NURSING

The communication skills of active, deep listening, presence, and bearing witness
invite patients’ stories as Dahlin (2010) describes above. Baird (2010) writes of “bear-
ing witness” as being present and responsive to the stories patients and their families
tell about their illness journeys: “We feel the need to share our experiences, and we feel
compelled to hear other people’s stories. To bear witness is to be present to the events
and the emotions of another’s life and experience. We find strength and comfort in
knowing that other human beings bear witness to the significant events of our lives—
the good and the bad” (Baird, 2010, p. 666). The telling of and the deep listening to
stories is perhaps the hallmark of mindful presence. Being present in the moment is
often rewarded by the trust of patients and their families as they disclose intense, often
painful illness narratives. Baird (2010) warns that interrupting the process of sharing
such stories can stop them and the emotions they release abruptly. Baird writes:
Something as simple as reaching over and touching a person while he/she is telling
the emotion-filled story can stop the flow and interrupt the process. When these
interruptions occur, there is a good chance that the story, which was so important
to tell, might never again find the opportunity to be told. It takes time, experience,
and thoughtful awareness to learn when to speak, or move, or get tissues. (Baird,
2010, p. 666)
Narrative nursing, the theoretical framework that undergirds the comfort model,
means that nurses can learn to bear witness, to sit quietly, and not to run from another
human who is suffering, even as we experience our own pain and suffering in the
process. It bespeaks a compassionate presence that permits the time and emotional
space for storytelling—that enterprise that is deeply rooted in our humanity and that
connects us to each other as no other form of communication can.
INTERCULTURAL SENSITIVITY
Elizabeth’s awareness of Chin Lee’s suffering tells us that the attribute of mindful
presence is brought to bear when a nurse attends specifically to the moment at hand,
suspends all judgment about what she sees and hears, listens deeply for emotional
expressions, and realizes that her nonverbal presence—both physically and psycho-
logically—may be the most compassionate response she can give to her patients and
their families. In our case study, Elizabeth may choose to sit in silence with Chin Lee,
perhaps touching her shoulder. But she may also decide to verbally communicate with
the grieving daughter by asking her to talk about her fears and concerns. “Please tell
me what you are most concerned about with your father’s care.” “Have you and your
brother discussed this?” These and other questions might elicit Chin Lee’s story about
how she is experiencing her father’s poor prognosis and, possibly, about her culturally
prescribed deference to her brother, which may be contributing to her anguish and
grief. It is important to note, however, that Chin Lee might not be troubled by the cul-
tural value of male dominance; nurses must be cautious to avoid imposing their own
cultural values on those who are culturally different.
Whereas we cannot expect Elizabeth to be knowledgeable about all values and norms
across a wide variety of cultures, a part of displaying mindful presence is being inter-
culturally sensitive (this is also discussed as cultural humility in Chapter 3). Sherman
(2010) discusses this sensitivity as cultural competence, which has four components in
health care contexts:
cultural diversity—recognition of diverse populations with unique values, tradi-

tions, and beliefs
cultural awareness—knowledge of cultural variations with regard to health beliefs
and practices
cultural sensitivity—recognition of individual attitudes and beliefs “and a refine-
ment of communication skills related to active listening, use of silence and
touch, conversational distance, language patterns, and the effective use of trans-
lators” (p. 10)
cultural competence—the ultimate goal, incorporating diversity, awareness, and

sensitivity into everyday practice
MARTIN BUBER’S I-IT/I-THOU DIALECTIC

From a values perspective, the entire comfort model and mindful presence specifically
can be said to derive from the philosophical roots of Jewish theologian Martin Buber’s
I-It/I-Thou dialectic on human relationships. The I-Thou is Buber’s shorthand for his
advocacy that others should be treated as sacred entities (Thou) rather than as objects
(It). Buber believed that human life finds its meaningfulness in relationships, all of
which ultimately bring us into relationship with God, the eternal Thou. Our experi-
ence of the world consists of two aspects: the aspect of experience, perceived by I-It,
and the aspect of relation, perceived by I-Thou. I-Thou relationships stress the mutual,
holistic existence of two beings who meet one another authentically—it is character-
ized by dialogue, mutuality, and exchange.
In an I-Thou relationship, you and others are seen as persons who cannot be reduced
to a simple characterization: “Each person has important life experiences that warrant
positive regard, even when the experience of others is different from your own” (Littlejohn
& Foss, 2008, p. 216). The I-It relationship, on the other hand, means that the “It” is seen
as an object to be manipulated and changed; the self is privileged over the other. There is
no dialogue, only monologue, as other people are treated as objects to be used and experi-
enced. In any therapeutic setting and certainly in the context of palliative care nursing, we
believe that mindful presence entails dialogue—the treatment of other as Thou.

This chapter discusses the M component of COMFORT, mindful presence. It details
the usefulness of the Buddhist concept of mindfulness as it combines with the idea
of compassionate or healing presence in the nursing literature. Empathy and active
listening are discussed as essential components of mindful presence, which lead also
to narrative nursing, the theoretical underpinning of the COMFORT model. Finally,
Buber’s I-It/I-Thou dialectic is offered as the philosophical root for the practice of
mindful presence. This next section provides communication tools that are helpful in
the development and utilization of mindful presence.
In the case study at the beginning of the chapter, Elizabeth must draw on her knowl-
edge of the Chun family and her intercultural sensitivity in general in order to bring
the attitude and behavior of mindful presence to the grieving daughter, Chin Lee. Most
importantly, Elizabeth must complete her routine tasks of completing her physical
exams, providing medications, and monitoring his IVs and ventilator for Mr. Chun,
and turn her full attention to being there for Chin Lee. In this case, it is likely that her
presence will be both physical and psychological. Elizabeth might choose to sit beside
Chin Lee, to touch her shoulder lightly, and to gently inquire whether she might be of
any help. But initially she also might choose to be only psychologically and nonverbally
present—permitting Chin Lee to weep without interruption and without judgment,

not attempting to console her but, rather, silently being with Chin Lee in her anguish.
Elizabeth might wait until Chin Lee speaks before speaking herself—she will realize
that her deep listening, empathy, and compassionate presence might be more comfort-
ing to the girl than anything a nurse could say.
In a study of the experience of mindfulness among hospice caregivers who reg-
ularly practice mindfulness meditation at a Zen Hospice (Bruce & Davies, 2005),
the themes emerged shown in Table 4.3 as the caregivers practiced meditation-
in-action.
Meditation-in-action: Hospice care providers practiced being in the moment by
paying attention to ordinary activities, such as the sensations of giving a massage
or bathing a resident. They experienced mindfulness not by holding onto the past
or future “but relaxing into the immediacy of whatever was happening” (Bruce &
Davies, 2005, p. 1335)—paying attention to the everyday routine of service, including
Table 4.3 Themes

Meditation-in-action
Anchoring awareness in ordinary activities
An approach to being present
Relaxing into the immediacy of what is happening
Setting an intention and being aware of intention
Abiding in liminal spaces
Sense of separation dissolves
An in-between space
Appreciating opposing tensions
Sense of in/separability between caregivers and residents
Integral to empathy and compassion
Seeing differently
Perceptions shifting
Vivid sense of appreciation and beauty
Seeing what needs to be done
Leaning into stillness of activities
Cultivating openness without agendas
Resting with groundlessness
Recognizing we are change
Letting go of wishing things were otherwise and fearing what might be
Becoming intimate with fear
Practicing abiding in the midst of emotions
Practicing continuously opening to experience
Used with permission from: Bruce, A., & Davies, B. (2005). Mindfulness in hospice care: Practicing
meditation-in-action. Qualitative Health Research, 15, 1336.
feeding, sitting with, and listening to residents. They also focused intentionally on
being open and present and on being aware of this intention.
Abiding in liminal spaces: Liminal spaces are those in which such dualities as self–
other, work life–spiritual life, and living–dying dissolve. It is an in-between space—“a
space in the hyphen within living-dying or presence-absence. In this space, oppo-
sites meet in-between, where one is both living yet dying, or present yet absent . . . An
appreciation that opposing tensions of living while dying or being joyful while sad-
dened can be held simultaneously without contradiction” (Bruce & Davies, p. 1336).
Appreciation of liminal spaces also means that caregivers and residents, self and other,
are seen as inseparable: this is integral to empathy and compassion, including self-
compassion. Working for others’ benefit also benefits the self, as described by one
hospice caregiver:
We go to the bedside . . . in an interesting way . . . to be supported. I go with gener-

osity and kindness—but there is mutuality. Our lives are interconnected . . . your
suffering is my suffering . . . you’re dying and I’m going to die. I don’t assume that I
am independent from the person in the bed. Or in a peculiar way, I don’t assume
that I am better off.
Seeing differently: This is a shift in perception that allows one to notice what has not
been seen before or to appreciate the beauty of the familiar. For example, one hospice
caregiver noted: “Preparing elegant, simple meals; having bright, clean rooms, fresh
flowers, and incense; paying attention to the vital, immaterial space; and catering to the
wishes and whims of residents as much as it was possible contributed to an expansive
environment that could accommodate suffering and peace” (Bruce & Davies, p. 1337).
Mindfulness made hospice workers see what needed to get done in supporting resi-
dents. One hospice worker asserted:
Mindfulness makes me alert to what is happening . . . I see things that I didn’t see
before; I begin to notice. For example, when there is a lot of chaos in the room . . . or,
if the commode is sitting in the middle of the room in the eye-line of the person
lying in bed—is that what she is seeing all day? Maybe it’s a convenient location for
the caregiver but maybe it’s a terrible location for the person in the bed. (p. 1337)
As residents deteriorate and withdraw, requiring less doing from the caregivers, the
lines blur between doing-nondoing: “Leaning into the stillness of whatever activity
they were doing became a meditative aspect of doing” (p. 1337). Seeing differently
also involved cultivating an open attitude, without fixed judgments and expectations,
without a script.
Resting with groundlessness: This involves a realization that change is inevitable:
By turning the lens of mindfulness on ourselves we start to see the truth of

change . . . we all understand that everything is changing, you know, we can
intellectually grasp this . . . however when we turn the lens of mindfulness on our-
selves we begin to understand that we are change . . . then I can’t hold so tightly to
this notion of solidity . . . then my whole relationship to death changes . . . it dra-
matically shifts . . . and death becomes less of a tragedy.” (Bruce & Davies, 2005,
p. 1338)
Of course, this realization also brings fear and sometimes holding onto hopes that
residents will get better. Hospice workers practicing mindful meditation explored the
question: Can caregivers be open to and witness another’s suffering in the midst of
fear, struggle, and resistance within? One hospice worker noted:
I was thinking of Aretha this morning; she was kind of scared. And I really think
creating an atmosphere where we are not scared when she is scared [is important]
where we are just there with her. And we don’t necessarily do anything with the
fear. We don’t say, ‘no, no, no’ but we don’t say, ‘YES, you’re dying, oh how horrible’
but we just kind of embrace that—then, it’s much easier for people, you know?
And I think that in itself, to be mindful that somebody is afraid and not to reject it,
not to sugar it over with something but also not to be freaked out. But to really be
with that feeling and to embrace it and to feel from our heart . . . Then, it seems the
person can usually . . . can relax.” (Bruce & Davies, 2005, p. 1339)
Caregivers learned to be with fearful residents and not to turn away from their
fear.
The emphasis was not on perfecting fearlessness but, rather, on practicing to open
to one’s experience continuously and be willing to shift, and be changed in the
process. (Bruce & Davies, 2005, p. 1330)
CHAPTER SUMMARY
The “M” in the COMFORT model—mindful presence—is both an attitude and a non-
verbal behavior that the palliative care nurse brings to patients and their families in
hospice and palliative care. Based on the Buddhist notion of mindfulness, a mindful
attitude is focused on the here and now, is “in the moment,” and is undistracted by
any stimuli other than the immediate. Presence is that quality of being there for the
patient or family member, either physically or psychologically or both, and being non-
judgmental, unscripted, and spontaneous. Thus, a mindful presence means that the
nurse is totally dedicated to the circumstances she finds in the here and now, regardless
of what has gone before or what is predicted to follow. It is a valuing of “being” over
“doing,” in the belief that compassionately bearing witness to a patient’s/family’s suf-
fering may be the greatest gift a caregiver can offer.
This type of healing or compassionate presence involves actively listening to the
patient’s/family member’s emotional state and responding to their situation with
empathy. It also entails listening to and eliciting the patient’s/family’s stories of the
illness journey. The following chapter deals with family as an integral component of
palliative care.
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1. What is the main difference between the Buddhist concept of mindfulness and
the attitude of being mindful?
2. How would you define the concept of mindful presence?
3. How is “being” valued more than “doing” in mindful presence?
4. How can presence be compassionate and healing?
5. What are some of the personal characteristics of the “core attitude” in palliative
care?
6. What are Kabat-Zinn’s seven attitudinal foundations of mindfulness?
7. How can mindful presence involve both a physical and/or a psychological
presence?
8. Why are empathy and compassion considered key characteristics of a healer who
is fully present?
9. How is active (or deep) listening linked to compassionate presence?
10. How does listening differ from hearing? (What are the seven activities that
comprise the listening process?)
11. How is witnessing a part of mindful presence?
12. How and when is silence a valuable tool?
13. How does deep listening and bearing witness help elicit patients’ and family
members’ stories?
14. How is intercultural sensitivity a part of mindful presence?
15. What are the four components of cultural competence in health care contexts?
16. How is Martin Buber’s I-It/I-Thou dialectic an appropriate philosophical
grounding for mindful presence?
educator resources
and materials
EXERCISES FOR LISTENING

Exercise 1—Practicing Active Listening
The objective of this activity is to provide nurses with the opportunity to practice
active listening. This activity is based on Beebe & Masterson’s (2000) six steps of active
listening:
1. Stop other activities.

2. Look at the speaker; focus on nonverbal cues.
3. Listen to the speaker, without interrupting.
4. Ask questions to determine the problem and clarify the speaker’s feelings.
5. Paraphrase the problem and ask the speaker if you are correct.
6. If correct, speaker should empathize by paraphrasing feelings of the speaker.
Place students into groups of three and have each student take turns playing the role
of the nurse, patient, and family member. In the patient role, the student will possess
information that he or she is reluctant to share. In the nurse role, the student will have
to progress through the six steps of active listening before the patient can reveal the
information. In the family member role, the student will be charged to prevent excuse
making, judgments, or forms of defensive communication on the parts of the patient
and nurse.
Role cards that provide the directions, a scenario, and the six steps of active lis-
tening are distributed to students. Students are told that the patient’s role card and
the family member’s role card contain a goal (the goal is the same on both cards—
for example, the goal could be “nurse must ask three questions and paraphrase two
times”), but the nurse’s role card does not contain the goal. The patient’s card also
contains a “truth,” which is the content that the nurse is trying to get the speaker to
reveal. As such, the nurse must continue to use the six steps of active listening until
the goal has been met. Once the goal has been met (as determined by the direc-
tions for the patient and the family member role cards), the truth can be revealed
to the nurse.
When distributing the role cards, be sure to emphasize that (a) the patient role may
require a little “acting” and (b) the patient may have to stall the nurse until the nurse meets
the goal listed on the role card. It takes approximately 15 minutes for members to com-
plete the activity. To debrief the activity, solicit comments about the scenario and inquire
whether the goal was met. For example, the instructor may ask: (1) how well each step of
active listening was accomplished and (2) if the scenario were conducted again, how active
listening could be improved. Ask students to indicate how the six steps of active listening
could be incorporated into situations they encounter in palliative nursing.
110
REFERENCES AND SUGGESTED READINGS

Beebe, S. A., & Masterson, J. T. (2000). Communicating in Small Groups: Principles and Practices
(6th ed.) New York: Longman.
Gibb, J. R. (1961). Defensive communication. Journal of Communication, 11, 141–148.
Scenario for Practicing Active Listening Exercise

Patient
Directions
1. Read the following scenario and be prepared to act it out.

2. DO NOT reveal the truth to the nurse until the nurse has met the goal. (This
means you may have to stall and give excuses for not wanting to talk. Be creative.)
Scenario
You are talking with the nurse in between his/her patient care duties. The nurse says
that you seem uncomfortable. You do not want to talk about your problem. It is still
too upsetting to talk about, so you make up excuses until the nurse reaches the goal.
Goal
NURSE MUST ASK TWO QUESTIONS AND PARAPHRASE TWO TIMES.
When the nurse has reached the goal, you may now reveal the truth: During your
cancer treatment, your significant other has been having an affair.
STOP LOOK LISTEN ASK QUESTIONS PARAPHRASE EMPATHIZE
Nurse
Directions
1. Read the following scenario and be prepared to act it out.
2. The truth of the situation will not be revealed to you until you have practiced the
six steps of active listening as required by this exercise.
Scenario
A patient seems very preoccupied and is possibly upset about something. The patient
has not been as outgoing as he/she has been on previous treatment visits, so ask what
the matter is.
YOU MUST CONTINUE TO PRACTICE ACTIVE LISTENING, USING THE
STEPS BELOW, UNTIL THE PATIENT REVEALS THE TRUTH TO YOU.
STOP LOOK LISTEN ASK QUESTIONS PARAPHRASE EMPATHIZE
FAMILY MEMBER
Directions
Read the scenario below. The NURSE will start by asking the PATIENT whether there
is something wrong or if there is something the patient would like to talk about. The
NURSE should practice active listening until the PATIENT reveals the truth.
Scenario
A nurse and patient are talking. The NURSE asks the PATIENT if there is something
making him/her uncomfortable. The PATIENT is not prepared to talk at first, so the
nurse must practice active listening.
Goal
NURSE MUST ASK TWO QUESTIONS AND PARAPHRASE TWO TIMES. You keep
the pair communicating until the NURSE has met the goal and the PATIENT has
revealed the truth.
DO NOT allow the NURSE to draw conclusions, express judgment, or give advice
unless requested until after the required paraphrasing has been done.
STOP LOOK LISTEN ASK QUESTIONS PARAPHRASE AND EMPATHIZE
Adapted from Elaine J. Cichon, Florida International University, Communication Teacher, Fall,
2001, 11–14.
Exercise 2—Effective Listening Role Play

First review these principles for effective listening:
Effective Listening Guidelines

1. Focus on feeling words.
2. Note the general content of the message.
3. Observe the speaker’s body language.
4. Do not fake understanding.
5. Do not tell the speaker how he/she feels.
Adapted from R. Bolton (1979). People Skills. Englewood, NJ: Prentice-Hall. In MacPhee, M. (1995).
The family systems approach and pediatric nursing care. Pediatric Nursing, 21, 5, 417–437.
Working in nurse–patient dyads, the patient expresses a current problem (e.g., the
patient is very concerned with how her oldest daughter is reacting to her poor progno-
sis). The nurse, with body posture that is relaxed but also alert and with good eye con-
tact, encourages conversation about the problem by giving simple responses that let the
patient know she is heard (e.g, “That sounds very difficult for you.” “I’m so sorry you’re
having this problem.”) The nurse should also use open-ended questions/responses that
can serve as prompts (e.g., “What can I do to help you resolve this?” “Tell me how you
see the problem being resolved.”). The nurse might also use silence to allow time for the
patient to express herself. Paraphrasing should be used to clarify the patient’s concern
and check it for accuracy: for example, “I’m hearing that you’re very concerned about
how your daughter is dealing with your prognosis.” Mirroring back the patient’s feelings
can also be useful: “It seems that you’re feeling sad and anxious about this.”
After the role play, the patient should give the nurse feedback about whether she
felt that the nurse heard her accurately and whether her nonverbal communication
expressed concern and empathy. Then the two should exchange roles and repeat the
exercise.
Adapted from MacPhee, M. (1995). The family systems approach and pediatric nursing care.
Pediatric Nursing, 21(5), 418.
Exercise 3—Exercises for Empathy

Empathic Listening
The goal of this exercise is to enhance nurses’ empathic listening skills and sensitize
their perceptual differences. Pair students and have each student take a turn sharing a
professional or personal joy or concern in his or her life. Provide students with a check-
list for “attending behaviors” (Wolvin & Coakely, 1996):
1. maintaining an appropriate and comfortable gaze

2. open body posture
3. encouraging head nods
4. responsive facial expressions
5. vocalics expressed with a tone of care and involvement
6. beneficial silence
Dyads are given 10 minutes (5 minutes per person) to share their joys and concerns.
Immediately after sharing, the speaker should write down responses to the following
questions:
1. Did the person focus her or his attention?

2. What attending behaviors were present to show the person was listening
empathically?
3. Did the listener offer any nonaccepting responses?
Using class time, or alternatively as a take-home assignment, have each student

design a greeting card that expresses an understanding of what the other person is
encountering. The essence of the card should paraphrase what the partner shared, in
other words, the empathic listener’s perception of the joy or concern. The card should
be a combination of text and illustration. They should remember to feel and think
with the other person in mind.
In addition to turning in cards as an assignment, instructors will have students give
their card to their partner. As students read the original cards created just for them,
they consider how well their partners paraphrased and perceived their feelings.
Note: An additional assignment can include grading their partner’s card or allowing
class time for partners to discuss and share the decision making behind card construc-
tion. This allows for further assessment and understanding of empathic listening skills
and identification of what skills were exhibited or lacking.
Adapted from Burns, M. M. (2001). Exercises for empathy. Communication Teacher, Summer, 13.
REFERENCES
Wolvin, A., & Coakley, C. G. (1996). Listening (5th ed.). Dubuque, IA: Brown & Benchmark.
(Provides summary of exercise created by Mari Miller Burns, Iowa Lakes Community
College, Estherville, IA.)
Exercise 4—Meditation Practice to Foster Clinician Empathy

1. Take a moment and feel the rise and fall of your breath before meeting your next
patient.
2. As you walk to the door, imagine that on the other side of the door another
human being is waiting.
3. The human being is someone who is suffering, who has hopes and dreams, and
who believes that you can help relieve his or her suffering.
4. Now open the door and say “hello.”
Adapted from Morgan & Morgan (2005), as cited in Turner, K. (2009). Mindfulness: The present
moment in clinical social work. Clinical Social Work Journal, 37, 95–108.
Exercise 5—Exercises for Mindful Presence

Preparation for and evaluation of an encounter to which you bring mindful presence
requires reflection or what Johns (2008) refers to as the “beginner’s mind” (p. 41). It is
an openness to new ideas and new possibilities. Johns (2008) recommends this struc-
tured reflection exercise both to prepare for an encounter and to evaluate it.
Model for Structured Reflection

Bring the mind home.
Focus on an experience that seems significant in some way.
What particular issues seem significant to pay attention to?
How were others feeling and why did they feel that way?
How was I feeling and why did I feel that way?
What was I trying to achieve and did I respond effectively?

What were the consequences of my actions on the patient, family, and myself?
What factors influence the way I was/am feeling, thinking, and responding to this
situation (personal, organizational, professional, cultural)?
What knowledge did or might have informed me?
To what extent did I act for the best and in tune with my values?
How does this situation connect with previous experiences?
Given the situation again, how might I respond differently?
What would be the consequences of responding in new ways for the patient, family,
and myself?
What factors might constrain me from responding in new ways?
How do I now feel about this experience?
Am I able to support myself and others better as a consequence?
What insights have I gained?
Am I more able to realize my vision as a lived reality?
Figure 1, “Model for Structured Reflection”
Adapted from Johns (2008). Passing people by (why being a mindful practitioner matters). Journal
of Holistic Healthcare, 5 (2), 37–42.
Exercise 6—Mindfulness Meditation Exercises

Mindful Eating
Take one raisin from a box of raisins, just one. Look at it carefully, touch it, smell it, and
then gingerly put it in your mouth. Bite into it and chew, then swallow.
Experience the burst of taste that you overlook when you eat raisins by the handful.
Adapted from O’Neal, J. S. (1997). Mindfulness: Treasuring the moments. Creative Nursing, 3 (3), 8–9.
A variation on this exercise is to pretend you are aliens, just arriving on Earth
and discovering this object (the raisin) for the first time. Pay attention to every-
thing you can discover about the object so that you can report on it back home
(Ott, 2002, p. 490).
Mindful Walking
One way to integrate awareness into your daily routine is through mindful walking.
Choose a short walk, such as the hallway outside your office, and begin walking,
paying attention to the entire experience of walking. (You will not be walking in order
to get anywhere but merely to attend to the act of walking itself.) Pay attention to all
the physical details and sensations of walking. Be aware of both the self and the envi-
ronment as you walk.
Adapted from Ott, M. J. (2002). Mindfulness meditation in pediatric clinical practice. Pediatric
Nursing, 28 (5), 490.
Body Scan Exercise

The body scan (described below) allows one to develop a focused awareness of the
body. The body scan permits one to develop the ability “to be a compassionate witness
to whatever is happening in the body at any particular moment in time, to be present
without judgment, expectations, or demands and without a need to change anything”
(Ott, 2002, p. 490).
Body Scan Instructions

When doing the body scan, it is important to be in a safe, comfortable place free from
distractions and interruptions. It is also important to wear loose, comfortable cloth-
ing that will not restrict the body’s breathing in any way. The body tends to cool when
doing a body scan, so a light cover may be needed to keep the body comfortably warm.
The body scan can be learned either lying down or in a seated position, although it is
more easily learned lying down.
Begin by assuming a comfortable position lying on the floor or on a bed. (A pillow
or rolled towel under the knees may be used to relieve pressure on the lower back.)
Take a few slow, deep breaths focusing on the breath itself. Then gently allow your
attention to move to the entire body as it is breathing.
Now, focus on the toes of the left foot so that the full attention is on the toes of
the left foot. Then move the awareness to the left foot, ankle, on up the calf to the
knee, the thigh, and on to the left hip. Breath is allowed to move in and out of each
part of the body as it is scanned. Next, allow awareness to move across the pelvis
and down to the toes of the right foot, then to the whole foot and up the calf to the
knee, the thigh, and to the hip and pelvis. From here move awareness up through
the lower abdomen and lower back, up to the chest, upper back, and shoulders.
Next focus awareness on the fingers of both hands, moving up the hands to the
wrists and both arms and returning to the shoulders. From here move through the
neck, throat, all parts of the face, the ears, and the top of the head.
When this is completed, breath is invited in through the toes, up through the
entire body, and out an imaginary opening at the crown of the head, so that the
breath is moving freely from one end of the body to the other. Finally, the breath is
allowed to flow in through the top of the head, down through the whole body, and
out the toes. End by feeling the entire body lying down breathing. When ready, gen-
tly deepen the breath bringing small movements to the fingers and toes, the arms,
and legs. Roll over to one side, pause briefly, and then using the arms, slowly push
up to a seated position, bringing the head up last. Pause in a seated position for a
few breaths, noticing how the body feels before proceeding to the next activity.
Used with permission from: Ott, M. J. (2002). Mindfulness meditation in pediatric clinical prac-
tice. Pediatric Nursing, 28 (5), 489.
Exercise 7
Table 4.4 Operational Steps in the STEDFAST Self-Aware Mindfulness Development
Model
To develop self-aware mindfulness in the nurse–client relationship, progress through each
step seeking help as needed. An answer of “no” at any step signals the need to mindfully
focus on one’s breath then non-judgmentally accept whatever thoughts and feelings arise
on the way to returning to one’s breath, finally emerging ready to practice self-aware
mindfulness in the nurse–client relationship.
Self-Assess
• In this present moment, what is happening with me, can I first truly and non-
judgmentally accept where I am right now and take on the therapeutic role? If no,
mindfully breathe . . . accept . . . breathe . . . When ready (continue)
Therapeutic Role
• Am I springing fully alive into the nursing role, bringing competence and caring in the
relationship? If no, mindfully breathe . . . When ready
Empathy
• As I interact, can I sense or imagine what it must feel like to live through what the
client has experienced? If no, mindfully breathe . . . When ready
• Am I able to non-judgmentally accept where the client is at this present moment? If no,
mindfully breathe . . . When ready
Detached Reflection
• Can I practice self-control to move part of myself away from the immediate client
stimuli to think about my actions/reactions? If no, mindfully breathe . . . When ready
• Can I accept and deal with overly intense or disproportionate feelings enough to not
spill beyond the boundaries of the nursing role? If no, mindfully breathe . . . When ready
• Am I using critical thinking and theory to help me monitor, analyze, and reevaluate the
original experience? If no, mindfully breathe . . . When ready
Facilitated Debriefing
• Can I/have I access/accessed person(s) who can help me process feelings, thoughts, or
actions? If no, mindfully breathe . . . When ready
• Can I accept my vulnerabilities signaled by changes in my behavior (ignoring or
overreacting) and/or my disproportionate feelings (e.g., overly liking or even disliking
the client)? If no, mindfully breathe . . . When ready
• Can I appropriately self-disclose at a level at which I feel safe? If no, mindfully
breathe . . . When ready
• Can I use theory and feedback to help me identify blind spots, receive support,
clinically problem solve, and reengage? If no, mindfully breathe . . . When ready
Alert Empathy
• Can I be alertly attentive and caringly connect with empathy yet also stay mindful
about countertransference, my self-boundary, and needs as separate from the client’s
boundary and needs? If no, mindfully breathe . . . When ready

Self-Aware Mindfulness
• Have I learned anything new about me—about life? If no, mindfully breathe . . . When
ready
• Do I more quickly enact self-control to accept and deal with intense feelings of changes
in my behavior as signals of countertransference? If no, mindfully breathe . . . When
ready
Therapeutic Use of Self
• Can I identify how, in the present moment, I distinctively use my unique fully alive self
to facilitate the client? If no, mindfully breathe . . . When ready
• Can I, with boundaries intact, invest my nonjudgmental, aware, mindful self as the
helping instrument? If no, mindfully breathe . . . When ready
• Am I ready to further develop self-aware mindfulness by reengaging the STEDFAST
self-aware mindfulness model? If no, mindfully breathe . . . When ready return to
Self-Assess
Used with permission from: Scheick, D. (2011). Developing self-aware mindfulness to manage coun-
tertransference in the nurse-client relationship: An evaluation and developmental study. Journal of
Professional Nursing, 27(2), 114–123.
5
family
Harriet Grove was an 80-year-old woman living in a residential care facility.

She was a retired nurse, and her 90-year-old husband was a resident of the
adjoining dementia care unit. Harriet had three children, all in their late 50s,
with one son residing 20 miles away and two daughters living out of state.
Six months ago Harriet was diagnosed with Stage IV ovarian cancer
(OVCA). Harriet has moderate cognitive impairment with limited decision-
making capacity and has relied on her son Bob for decision making for several
years. At the time of the OVCA diagnosis, her three children (Bob, Jane, and
Alice) met with the facility medical director and all agreed that chemotherapy or
surgery would be too burdensome and that she should receive comfort care only.
Harriet’s three children are not close in relationships and communicate infre-
quently. The three children were in agreement about the treatment decision,
although one of the daughters has since criticized her brother for not insuring
that their mother “got better care” so her OVCA would have been diagnosed
earlier. There have also been some financial conflicts, as Jane’s husband has been
very verbal in expressing his belief that Bob has wasted their inheritance by
arranging for such an expensive facility for Harriet and her husband. Alice, who
lives a thousand miles away, has been visiting monthly since the diagnosis and
seems the closest to her mother.
Harriet has been seen by hospice in the residential care facility. They have
been able to effectively treat her pain, constipation, and nausea. Harriet’s three
children have been very supportive of hospice and the goals of comfort care
only. However, a few days ago Harriet developed severe intractable vomiting
and increased abdominal pain. After 24 hours of uncontrolled symptoms, Bob
requested that they move his mother to the hospital to see if more could be done
for palliation of her symptoms.
On admission to the hospital, it is determined that Harriet’s OVCA had fur-
ther metastasized and she now has a bowel obstruction. The hospital intensivist
recommends that they ask the palliative care team to consult and convene a
family conference. Bob has not been on good terms with Jane but agrees to call
her for the family conference. Alice arrives and becomes very emotional, pan-
icked at the possibility that her mother will die. Alice asks the hospital staff to
start tube feeding and to consider surgery as she just is not ready to let go. Bob
119
becomes very upset at Alice’s request and suggests that if she had visited more
often, perhaps she wouldn’t feel the need to prolong their mother’s life.
The scene unfolding in the family conference concerning Harriet’s care is all too com-
mon and represents a typical experience for a palliative nurse. Sometimes it’s not the
patient who requires the nurse’s attention—it’s the family! Families need help under-
standing a poor prognosis, interpreting physical and cognitive changes in the patient,
and making decisions about treatment and care choices when there are no desirable
options. Anger and frustration often result from family tensions, feelings about the
disease, or fear and can be directed toward the nurse. Conflicts arise among family
members, with family and staff, and between family and patient.
Unlike other clinicians who have structured interactions with families, the palliative
care nurse has an intimate role with family members. Bedside care avails opportunities
for the nurse to be “like family” for the patient and their loved ones. Attention to family
advocacy (task communication) as well as the family’s story (relational communica-
tion) facilitates the nurse’s acceptability into the family unit. This chapter depicts the
family as a system with predictable family communication patterns that can inform
appropriate communication strategies to prevent as well as resolve conflicts concern-
ing family. Although medical decision making is often left in the hands of individu-
als biologically or legally related to the patient, we also consider family members to
include those with close, intimate relationships described as familial.
This chapter presents three tenets of family communication in palliative nursing.
Family systems perspective will illustrate the importance of family members in the
patient’s clinical story, thus revealing their status as second-order patients. The next
section will describe family communication patterns and present identifiable family
caregiver types. By adjusting communication to a family’s established communication
pattern, nurses can collaborate with the family, which serves as a conduit to the patient.
The final section of this chapter will focus on family meetings and how they can be
tailored to meet the family members’ needs. As the intricate layers of family commu-
nication are described in this chapter, we hope it will reveal the sensitive needs of the
family and warrant the attention of palliative nurses.
TAKING CARE OF THE FAMILY

Communication with families is integral to hospice and palliative care as families
and patients face decisions about aggressive care and the turn toward comfort only.
Although families (and patients) assume that information will be given to them when
asked, clinical staff typically provides updates and information to the family only when
there is a clinical change (Gold, Philip, McIver, & Komesaroff, 2009). However, families
report needing and wanting regular information updates (Gold et al., 2009; Rhodes,
Mitchell, Miller, Connor, & Teno, 2008). In the absence of routine information, family
communication efforts become focused on the nurse, who is left with the responsibil-
ity of filling in the communication gaps between clinical staff and family. The nurse
provides a bridge between the front stage of bedside care with the patient and access to
121 Family
the backstage happenings of the medical system and other clinicians. Boxes 5.1 and 5.2
provide the perspective of family caregivers.
Box 5.1
“We would like to be asked if we want to be involved and how much we want to partic-
ipate in her care. I know my Mom. It is very clear that the nurse and health care team
believe they are responsible for the medical care, but as far as the emotional part, that is
us. I had been her caregiver for three years, I felt like I needed to get in there and help and
I couldn’t. It is feeling that you are connected directly to what is happening and when
they don’t include you, you feel even more vulnerable.” (Eggenberger & Nelms, 2007)
Box 5.2
“We had a great nurse . . . He was willing to answer all our questions. If you asked him
anything he was there . . . just being personable. Telling us straight up what’s going on is
definitely helpful, but it is nice when they can bring it down to a level where we feel like
they are explaining it to us. Having nurses and doctors be honest with us and keeping us
informed helped us cope. No matter how bad it is, you would much rather hear the hon-
est truth . . . But somehow still maintaining some hope. They show us they care about
us.” (Eggenberger & Nelms, 2007)
Taking care of the family and providing family-centered care involves addressing
family burden, advocating for the family, educating about disease and illness, provid-
ing emotional support, valuing family input, and enabling flexibility and easy access
to the patient (Nelson et al., 2010). These efforts also involve helping the family work
through their feelings and say good-bye (Kaasalainen, Brazil, Ploeg, & Martin, 2007).
Not surprisingly, nurses are a central figure in the family’s memories of the death—
adequacy on the job, attitude, and empathy are remembered most, more than direct
care, hospice, or patient preferences (Munn & Zimmerman, 2006). Good death expe-
riences are derived from a singular nurse who is perceived to be in charge of care,
actively providing accurate information and emotional support as needed (Rhodes
et al., 2008).
Variations in family background and beliefs shape the nature and magnitude of
family issues that can develop during hospice and palliative care. Family functioning
and family beliefs and acceptability about prognosis vary. Families range from well
functioning, characterized by a supportive environment and good conflict resolu-
tion skills, to dysfunctional families wherein family members have suppressed anger
and hostility toward each other (Bartell & Kissane, 2005). Additionally, families have
Table 5.1 Common Problems with Family Communication

x Family doesn’t understand what is being told to them.
o “Generally, they act like they understand, and when the MD leaves the room they ask the
nurse what he/she meant. The MD is usually in a hurry. The units are so busy that the
staff doesn’t have enough time to sit down and really talk and listen to the patient/family.”
x The concept of family is different for every patient and family.
o “I suppose you could also look at the concept of family in that not everyone is directly
affected by the change but may have a ‘family’ tie that is indirect to the central concept.”
x The family doesn’t know the patient’s wishes.
o “It’s hard to communicate to a family that their family member’s health is progressively
declining and then having to ask them about the patient’s desires.”
o “It’s so hard when you don’t know what the patient wants . . . when you see the family
members struggling, saying ‘I don’t know, I don’t know. I know what I would want, but I
don’t know what he would want.’”
x The family refuses help.
o “On one occasion, I had a patient who was undergoing chemotherapy for breast cancer
who needed extra support in her home. For example, she needed home health for physical
therapy, etc. Her daughter felt that we were offering this type of service because we felt
she was unable to care for her mother—and she became angry. I had great difficulty
expressing to the daughter that I was trying to help her mother as well as her.”
a general belief about how end-of-life decision making is done within their family
(Leichtentritt & Rettig, 2002) (Table 5.1).
These beliefs are grounded in family norms and the history of decision-making
style within the family, how the family has previously negotiated disagreements, and
their perceived obligation to the family as it pertains to care. Collectively, the patient
and family have a shared past that sustains a communication dynamic best described
as a family system—a system that warrants family as “second-order” patients.
FAMILY AS SECOND-ORDER PATIENTS

As nurses witness the patient’s illness story, it becomes evident that it is embedded
within a family system (see Chapter 2 for more on witnessing). A family system is
comprised of bounded, interrelated individuals with identifiable communication
behaviors. Family members are interdependent, as they have the ability to influ-
ence one another. The interdependent relationships among family members expose
potential sources of conflict, reveal variations in health literacy within the family,
and demonstrate positive or negative family coping. Family members are considered
“second-order patients” in hospice and palliative care because they are part of a sys-
tem of communication that influences the patient’s adherence to care plans, treatment
decisions, and hospice enrollment, and they share in the end-of-life care experience
(Sherman, 1998).
123 Family
With no beginning or end, family systems are constantly interacting with their envi-
ronments, the people and information accessible to them, and respond by adapting
to stress and change or through resistance. The family system has boundaries, which
serve to protect family members. Boundaries define the system and communication
between the system and other systems (Mehta, Cohen, & Chan, 2009). Boundaries can
be permeated to allow information to come in and go out (Mehta et al., 2009). Nurses
can gain insight on the permeability of family boundaries by paying attention to family
member reactions to illness and communication between family members (including
the patient).
Clinicians trigger boundaries within the family system by introducing new “plots”
in the stories of patients and families (Sharf, Harter, Yamasaki, & Haidet, 2011). For
example, families facing a crisis such as serious, chronic, or terminal illness make every
effort to return the family to “normal” or pre-illness/diagnosis. Hospice and pallia-
tive care brings an imbalance to the family system and suggests an outcome that will
ultimately result in a shift in the family system. Family roles and responsibilities are
misplaced when a loved one is ill, and patients are often more concerned about the suf-
fering of their family members than their own suffering (Sherman, 1998). By learning
about family roles, nurses can shape their communication to protect or validate family
member identity (Leon & Knapp, 2008).
Consistent exposure and interaction with the family also allows the nurse to
recognize predictable interactions. Predictable interactions are repetitive interac-
tions among family members within the system that depict informal guidelines
which shape hierarchical roles and appropriate family communication. Patient
care permits the nurse to enter the family system and learn the rules of the family
(Elliott & Herndon, 1981) (Table 5.2).
Armed with this knowledge, the nurse can adapt his or her own communication
and use family background to simultaneously provide task and relational communica-
tion in order to meet care goals. This involves understanding how illness has impacted
family functioning and relationships, each member’s emotional reaction and intensity,
and variations in family-level involvement in care (Leon & Knapp, 2008).
Recognition of the family’s predictable interactions tells us if the family is an open
or closed system. In an open system, information is allowed in and out of the system.
Family members disclose private information about the family and permit nurses to
Table 5.2 Family-Centered Approach

Family-Centered Approach
¾ Recognize that families have patient expertise and knowledge
¾ Recognize that relationships with families are reciprocal
¾ Recognize that no hierarchy can exist between nurse and family
Used with permission from: Leon, A. M., & Knapp, S. (2008). Involving family systems in critical
care nursing: Challenges and opportunities. Dimensions of Critical Care Nursing, 27(6), 255–262.
Doi: 10.1097/01.DCC.0000338866.47164.6d
learn about vertical stressors that emerge from long-established family patterns and
relationship history between family members (Leon & Knapp, 2008). On the other
hand, in a closed system family members do not share background information or
insight into family relationships. In these instances, nurses often face the challenge of
working with families that haven’t accepted or don’t believe the terminal prognosis
(Back & Arnold, 2005). Conflict is likely to occur as family members insist on aggres-
sive care, even when nurses, physicians, and other clinical staff feel it is inappropriate
(Fine, 2010; Luce, 2010). The nurse is left to provide patient care that may seem contra-
dictory to the family or that the family may not approve of (Fine, 2010).
Working with patients requires attending to the communicative needs of the family.
The goal is to match family needs with resources and empower them through educa-
tion and support (MacPhee, 1995). Collaborating with the family requires ongoing,
structured communication that is aligned with preexisting family communication pat-
terns and is sensitive to the family structure (Leon & Knapp, 2008). The family is a con-
duit to the patient, and family competency is important to the overall care experience
(MacPhee, 1995).
FAMILY AS A CONDUIT TO THE PATIENT

When faced with a difficult patient, a patient who refuses to take medication or coop-
erate with care instructions, the nurse can turn to the family for help and mediation.
When patients are no longer able to communicate their wishes, the nurse focuses
on family members who are responsible for serving as surrogate decision makers.
Family members are important allies for the nurse. Establishing effective communi-
cation with family members enables the nurse to capture an accurate history, clarify
goals of care for patient and family (which may be different), build relationships to
develop trust, and reduce their stress (Bluestein & Latham Bach, 2007). Familiarity
with the family teaches the nurse about established communication patterns that
shape family coping and decision making. Learning to recognize these patterns
will enable the nurse to understand and predict family communication behavior
(Bluestein & Latham Bach, 2007).
Family communication patterns are the interpersonal scripts or rules for com-
munication within a family (Fitzpatrick & Ritchie, 1994; McLeod & Chaffee, 1973;
Ritchie & Fitzpatrick, 1990). Communication patterns represent learned behavior
that has been shaped by a collective family history. These family rules are governed
by two family beliefs about conversation and conformity. Conversation beliefs dic-
tate appropriate topics for family discussion, the degree to which families spend
time communicating, and whether or not the family engages in communal or
individual decision making. Conformity beliefs inform the appropriate amount
of time family members spend together, expected sharing of family resources, and
obedience to parents.
Variations in family conversation and conformity beliefs are best summarized into
four identifiable family communication patterns. Each distinguishing pattern gives
125 Family
the nurse direction on how to communicate with the family. Consensual families
value parental decision making and explaining decisions to the children, and allow
for the children to provide input. Pluralistic families have open discussions that
involve all family members and value participatory decision making. Both of these
family communication patterns illustrate open family systems that allow information
to come into the family and be discussed. On the other hand, protective families and
laissez-faire families represent closed family systems and rely on nursing interven-
tion to facilitate family communication. Protective families rely heavily on obedience
to parental authority, and family members engage in very little communication with
each other. Similarly, laissez-faire families have little family interaction, and members
are emotionally detached from each other. By distinguishing the patient and family’s
communication pattern, there is potential for family conflict to be identified. Nurses
can then adapt their communication accordingly so that problem solving and solu-
tions meet the family structure. One approach to working with families is to conduct
a family meeting (also known as a family conference) to ensure that family members
are involved in the patient’s plan of care.
FAMILY MEETINGS
Family meetings facilitate decision making about the patient’s care and include dis-
cussions about disease status, withdrawing or withholding artificial feeding, dis-
charge options, and symptom distress (Hudson, Thomas, Quinn, & Aranda, 2009;
Yennurajalingam et al., 2008). Pain and spiritual issues are more likely to be discussed
and documented when a palliative care nurse or physician is present for the family
meeting (Machare Delgado et al., 2009). Often a family meeting is prompted by the
family’s lack of understanding or information about the medical condition of the
patient or following a critical incident (Radwany et al., 2009). Commonly, family
meetings occur due to conflict between the patient and family and health care team
(Yennurajalingam et al., 2008).
While the goal of these meetings is to enable collaboration between care staff
and family members, they also benefit family decision making (Wittenberg-Lyles,
Goldsmith, Ragan, & Sanchez-Reilly, 2010). First, communication in family meet-
ings is meant to relieve the uncertainty that family members have about chronic care,
dying, and death. Nurses educate families by translating medical knowledge (Dawson,
2008) (see Chapter 3 on health literacy). Second, nurses are there to support families
and reassure them that they are making good decisions. Finally, family meetings are a
place for nurses to help mediate family conflict.
Just as each family has its own unique communication pattern and style, each fam-
ily member in a family meeting has varying needs in terms of literacy level, support,
and family arbitration. The four family communication patterns mentioned previ-
ously inform a typology of family members that can be used to predict dominant areas
of focus within the family meeting (Wittenberg-Lyles, Goldsmith, Demiris, Parker
Oliver, & Stone, 2012). The Manager Family Member enjoys a privileged position in
the family and is understood to be the head of the household. He or she is at the top
of the family hierarchy. This family member is the self-appointed family spokesperson,
limiting other family members in the decision-making process. Ultimately, this indi-
vidual is positioned to make the majority of care-planning choices in accord with the
patient. Palliative nurses must work to include other family members and make them
feel part of the care process.
Providing support and reassurance becomes the nursing focus for family meet-
ings with the Carrier Family Member. This individual surrenders to family authority,
absorbing the greatest burden and sacrifices for patient care. Communication with
other family members is limited and often the result of a long-established trend of hos-
tility within the family. Acceptance of the patient’s illness and treatment choices can
be confounding because of limited talk, but the pressure to conform to the patient’s
wishes is given priority over his or her own needs. Caregivers welcome the opportunity
to self-disclose to staff, as the family environment prohibits it. Information seeking
and suppression are a common coping mechanism. Nursing intervention is immedi-
ately needed for the Carrier Family Member as this family member is dependent upon
staff to facilitate patient requests.
Family meetings with the Partner Family Member emphasize education about the
disease, placement options, and additional information that contributes to making an
educated decision that meets the patient’s need congrugent with family expectations
for care. Typically this family member benefits from the patient’s advance care pla-
nning and family-initiated internal meetings to facilitate decision making and support.
As a result, nursing staff are there to provide further education and to support open
family discussions and the sharing of care stress. Finally, the Loner Family Member
is in greatest need of nursing intervention. This family member has little support for
decision making and care provision. Limited communication and weak relationships
with other family members results in high stress, burden, limited social support net-
works, and anger and resentment.

This chapter summarizes family communication during hospice and palliative care.
The diversity among families (and individual family members within the same fam-
ily!) was highlighted through a discussion about family systems, family communica-
tion patterns, and family meetings. Specific communication tools are now provided to
help accomplish family-centered clinical nursing practice.
Assessment
Understanding the family’s system and the family role of the primary caregiver deter-
mines the overall communication approach of the nurse. Harriet’s family from the
opening case study reveals a closed family system as family members have low inter-
dependence. The three children (Bob, Jane, and Alice) are not close, and while Alice
127 Family
Table 5.3 The Survey of Family Fields

I. Current Situation
A. Ask the patient and family about the onset of symptoms, include date
B. Ask the patient and family about the early history of the problems, include date of
prior symptoms
II. Nuclear Family Emotional System
A. Courtship: where, when, how did couple meet; characteristics; major events during
this period
B. Marriage: when, where, who attended, attitude of families origin
C. Major Events: year by year since marriage; make family diagram of nuclear family;
include moves, illnesses, births, deaths, divorce, jobs, etc.
III. Extended Family Emotional Systems
A. Major Events Between Leaving Home and the Marriage: include relationship with
the extended family for both husband and wife; dating patterns; goal and career
development; education
B. Major Events in Both Families of Origin Prior to Home and Since Leaving Home:
make a family diagram for the husband and the wife with dates and major changes;
include sibling history and description of important triangles
C. Parents’ Relationship: meeting, marriage, history of major events in their lives;
include family diagram for each parent
Used with permission from: Titelman, P. (Ed.). (1998). Clinical Application of Bowen Family Systems
Theory. Binghamton, NY: Haworth Press, p. 55.
visits her mother monthly, she doesn’t appear to be communicating with Bob. Thus,
the three children have little influence on one another. As a result, the nurse cannot
expect that any information given to one family member will be shared with another.
However, families who enjoy an open family system are different, and information
shared with one family member is likely relayed within the family.
To gain an understanding of the family system, use the outline of the “Survey
of Family Fields” (Table 5.3). Begin by first identifying individuals who are in the
nuclear family, and their gender, age, name, occupation, and educational back-
ground. Once this background information is obtained, invite the patient and
individual family members to discuss the onset of the symptoms. This should be
done with all members of the family collectively, as questions target major events
within the family.
Delving deeper into the family history and individual relationships between family
members (especially relationships with the patient) can provide direction on commu-
nication gaps within the family. Family communication gaps reveal points of tension
for the family and indicate where conflict may occur. These gaps can include strained
relationships that prohibit family members from speaking or show how families han-
dle conflict, crisis, and stressful events. The following can be used to assess for family
background (Box 5.3):
Box 5.3 Questions to be Posed by the Hospice Team to Derive a Care Plan
Horizontal Stressors
The family life cycle (to be considered by the hospice team member)
1. In what stage of life is the family, and what are the related tasks?
2. How might the terminal illness and death interfere with the accomplishment of
these tasks?
3. Will the death be out of the usual order of the life cycle events?
All of the following questions are to be posed to key family members:

Other family and environmental stressors
1. What else is going on in your family’s life?

2. What has helped you in dealing with these stressors?
3. What has not been helpful?
Vertical Stressors
Transgenerational coping styles
1. Could you give an example of a difficulty your family has faced when you were
growing up?
2. What helped your family get through this?
3. What was tried that did not help?
Family history of loss
1. What other losses has your family experienced?

2. What do you remember from those experiences?
Family rules, toxic issues, and secrets
1. What values did you learn growing up that are still important to you now?
2. What values did you learn growing up that don’t work as well for you now?
Unresolved relationships
1. Tell me about your family.

2. Who is close to whom?
Spirituality and ethnic background

Information gathered indirectly through observation and the family’s initiation of
discussion.
Used with permission from: Knapp, E. R., & DelCampo, R. L. (1995). Developing family care
plans: A systems perspective for helping hospice families. American Journal of Hospice and
Palliative Medicine, 12, 39–47.
129 Family
Table 5.4 Checklist to Assess Family Stressors
9 Coupling—Are there any family members who are newly single or new couples?
9 Expansion—Has the family recently increased in size due to addition of children or
in-laws?
9 Contraction—Has the family recently decreased in size due to adult children leaving,
family members moving away, or death?
In addition to asking specific questions about prior family experiences, nurses

should listen carefully (or witness patient/family stories; see Chapter 2) to capture
information on family life cycles and communication patterns. There are three phases
in family systems that represent varying family life cycles (Leon & Knapp, 2008). Use
the following checklist to assess additional family stressors rooted in life cycle changes
(Table 5.4).
Listen for indicators of the following communication as family members talk about
communication with other family members (Box 5.4):
Box 5.4 Listening for Indicators of Communication Patterns
Open Communication
Supportive statements
Blocked (direct communication)
Hang up phone
Refuse to answer
Agree not to talk about illness
Blocked (indirect communication)
Not responsive
Appear uncomfortable
Self-censored speech
Pro-active
Fear of causing anxiety
Reactive
Sensing someone does not want to talk and pulling back
Use of third parties
Intermediaries
Sounding boards
Used with permission from: Kenen, R., Ardern-Jones, A., & Eeles, R. (2004). We are talking,
but are they listening? Communication patterns in families with a history of breast/ovarian
cancer (HBOC). Psycho-Oncology, 13, 335–345.
Evidence of these types of communication characteristics among family members

can help determine whether the family system is open or closed.
Plan
Knowledge about the family system can provide background and context for learning
about the communication preferences of individual family members. For example, we
see two very different types of family members from within Harriet’s family. Bob has
served as the designated proxy and family spokesperson and has had regular and rou-
tine communication with health care staff throughout Harriet’s care. Comparatively,
Alice and Jane have not played such an active role; however, Alice has maintained rou-
tine visits with her mother on a monthly basis. Given the low interdependence of these
family members (even Bob is reluctant to call Jane when Harriet’s condition changes),
the nurse needs to treat these family members separately rather than as one unit that
can be approached in the same way. After the family system has been assessed, the
below chart can be used to determine specific family member types and identify family
communication patterns (Table 5.5).
There is often a range of perspectives within one family, and conflict can arise
between family members who think they know the patient best or because they are
uncertain about patient preferences (Back & Arnold, 2005). For the nursing staff tak-
ing care of Harriet, differences among family member knowledge, communication
with each other, and family role resulted in an intense family meeting caused by a lack
of understanding of hospice (which led to Bob’s request to transfer Harriet to the hos-
pital), and filled with family conflict (between Bob and Alice) and denial (for Alice).
Table 5.5 Caregiver Types and Communication Patterns

Caregiver Caregiver Burden
Type (Identified with Family Communication Patterns)
Manager x Caregiver’s hierarchical family role overpowers open family communication.

x Family input of differing viewpoints is limited.
Carrier x Caregiver relies on clinicians to facilitate patient requests.
x Caregiver follows directions from patient.
x Caregiver isolation
x Caregiver prioritizes family harmony/stasis over own feelings.
Partner x Emotional—open, honest interactions with dying loved one
x Potentially supportive environment
x Potential for immediate family support
x Potential for extended family support
x Choices not made alone—decisions made as a family unit
Loner x Little to no caregiver support or resources
x Caregiver has limited choices, solo-provider.
x Caregiver anger, resentment, abandonment, helplessness
131 Family
Table 5.6 Themes Often Discussed in Family Meetings in the Palliative Care Setting
___ The nature of the illness and its symptoms.
___ Prognosis and future predictions about the course of the illness.
___ Caregiving roles about symptom management, medications, nursing care.
___ Liaison with medical team.
___ The emotional demands of the role.
___ Importance of self-care and respite from caregiving.
___ What to expect as death approaches.
___ How to talk with the patient about death and dying.
___ The process of saying good-bye.
___ How to manage a death in the home.
___ The positive aspects of the caregiver’s role.
___ Teamwork and sharing the role of caregiver.
___ When to seek help and how.
___ Support from volunteers and other community resources.
Used with permission by Oxford University Press: Coyle, N., & Kissane, D. W. (2010). Conducting
a family meeting. In D. W. Kissane, B. D. Bultz, P. M. Butow, and I. G. Finaly (Eds.), Handbook of
Communication in Oncology and Palliative Care. New York: Oxford University Press, p. 168.
It is only when a change in Harriet’s condition occurred that the family was brought
together by a family meeting intervention. To plan for the family meeting, begin to pri-
oritize communication and support needs using the information in Table 5.6.
First, checkmark appropriate information needs for the family. Then rank-order the
checked topics to plan for what topics should be discussed first, second, third, and so
on. Keep in mind that nurses serve important functions in the context of family meet-
ings. The role of the nurse in the family meeting is summarized in Table 5.7.
Intervene
Hosting a family meeting involves providing information and creating a comforta-
ble environment to allow family members the opportunity to share their feelings and
Table 5.7 Roles of the Nurse in Family Meetings

• Share the most current, up-to-date information about the patient’s status
• Bridge established relationships built on trust between family members and newer, less
known team members
• Capture the variance of messages (some conflicting) provided by multiple providers/team
members
• Responsible for carrying out primary features of plan of care decisions
• Fulfill a professional role that includes carrying for the family
Adapted from: Nelson, J. E., Cortez, T. B., Curtis, J. R., Lustbader, D. R., Mosenthal, A. C., Mulkerin,
C., et al. (2011). Integrating palliative care in the ICU: The nurse in a leading role. Journal of Hospice
& Palliative Nursing, 13 (2), 89–94.
thoughts (Hudson et al., 2009). There is no set standard for family meeting commu-
nication, and nursing intervention can either come from being a discussion leader
or a contributing team member during the meeting (Hudson, Quinn, O’Hanlon, &
Aranda, 2008). Regardless of role, the nurse should work to make sure the family meet-
ing happens early in the patient’s care (Hudson et al., 2008).
A typical conference format includes a premeeting to set goals (see planning phase
above) and identify roles, followed by an initial inquiry to obtain the family’s under-
standing and discuss relevant case issues (Machare Delgado et al., 2009). Table 5.8
provides a helpful tool when communicating with family members. Another way to
engage family members is to ask questions. Table 5.9 shows how questions can be
asked in different ways to elicit the response needed. For example, the opening case
study does not indicate whether or not Harriet has advance care planning in place. To
help her family think about her wishes and recall any advance care planning conversa-
tions, use these questions in Box 5.5.
Box 5.5 Eliciting Patient Goals
• Did [patient’s name] ever tell you what he or she wanted for him/herself?
• Did [patient’s name] ever talk about care of another family member and state whether
they would have wanted the same type of treatment?
Used with permission from: Dahlin, C. (2010). Communication in palliative care: An essen-
tial competency in nurses. In B. Ferrell and N. Coyle (Eds.), Oxford Textbook of Palliative
Nursing (pp. 107–133, Table 5–5). New York: Oxford University Press.
Finally, remember to listen and practice nonverbal immediacy when interacting

with family members (see Chapter 2). Effective listening guidelines are summarized
in Table 5.10.
Evaluate
While communication in family meetings is important—and family meetings can
result in enhanced family learning and decision making—the nurse can extend care
offered to families that goes beyond one or two family gatherings with the health
care team. Nurses are easily available to families compared with other clinical team
members and thus gain more knowledge about the family’s coping process and early
bereavement stages. Addressing family coping as part of the evaluation process can
lead to increased or decreased nursing intervention and enable early bereavement care
(Wittenberg-Lyles & Sanchez-Reilly, 2008). Move beyond documenting communica-
tion within the family meeting and evaluate the family’s coping by asking key questions
as suggested in Box 5.6. Early bereavement care can also begin by evaluating spiritual
or religious needs of family members. Box 5.7 can be used as suggested prompts for a
discussion about spiritual needs. Box 5.8 provides common responses of children to
serious illness in the family.
133 Family
Table 5.8 Strategies for Engaging Family Members in Communication

Strategy Model Statement
Engaging Family Members/Companions in Interactions
Personal Introduction. “I’m [name] . . . it is good to meet you. I am [patient]’s nurse; I’m
glad you are here.”
Identify others “Are there other family members or people close to you that you
important but not want to be included, either at the next visit or by phone call?”
present.
Elicit concerns and “Do you have particular questions or concerns that you would like
expectations. us to discuss today?”
“Some things that the family members of the other patients have
expressed as concerns include . . . Are these on your mind too?”
Check for accuracy. “Am I correct that your question/concern about your wife’s
condition is . . . ?”
Check for agreement. “It seems that we agree that treatment X [or hospice] looks like it
might be a good choice for us to consider . . . Do you think so too?”
Validate convergence. “It is helpful that together we understand and agree about the best
treatment [care or placement] choices . . . let’s talk now about what
to do and how to get started.”
Reassure. “It is good that you are here so we can talk openly about these
things.”
“You have every reason to feel reassured that you are doing
everything possible to help your husband.”
“It is okay if you and (the patient) want more time to think about
your options. I’ll continue to care for him/her and be here for you
no matter what you decide.”
Addressing Challenges to Convergence, Relationships and Alliances
Control conversational “I understand how you feel about this; now I’d like to hear it in his/
dominance. her words.”
Acknowledge family “It may be hard to understand the test results given that he doesn’t
member/companion’s seem to feel sick or have any symptoms.”
response.
Addressing “These treatments don’t always work the way we hope and expect
anger at medical they will. We are all understandably upset when this happens.”
recommendation.
Used with permission by Oxford University Press: Albrecht, T. L., Eggly, S. S., & Ruckdeschel,
J. C. (2010). Communicating with relatives/companions about cancer care. In D. W. Kissane, B. D.
Bultz, P. M. Butow, and I. G. Finaly (Eds.), Handbook of Communication in Oncology and Palliative
Care (pp. 157–164). New York: Oxford University Press. [Table 14.1]
Table 5.9 Communication Skills Used in Family Meetings

x Circular question. Ask each family member to comment in turn on aspects of others to
promote curiosity and reflection by the group as a whole.
For example, “How are your parents and sisters coping with Dad’s illness? Who is most
upset in your view?”
x Reflexive questions. Invite the family to reflect on possibilities, hypotheses and a range of
outcomes to stimulate their internal efforts to improve family life.
For example, “What benefits might come from caring for Dad at home? In what ways
might this be hard for you or as a family group?”
x Strategic questions. Here a solution might be incorporated into the wording of the
question to more directly guide the family toward an outcome that is considered
preferable.
For example, “What change in Dad’s symptoms would need to occur for you to realize
that admission to an inpatient hospice bed is necessary?”
x Summary of family focused concerns. The family’s views are reflected back to highlight
levels of tension or discordance in different member’s opinions, while maintaining
professional neutrality, yet inviting further problem solving by the family.
For example, “As a family, you recognize your father’s desire to die at home, your
mother’s commitment to meet his wishes, and yet your concern that his confusion
is becoming unmanageable and a burden to your mother. There is no easy answer
here, as whichever solution you adopt will appear to demand more of each of you
for a time.”
Used with permission by Oxford University Press: Coyle, N., & Kissane, D. W. (2010). Conducting
a family meeting. In D. W. Kissane, B. D. Bultz, P. M. Butow, and I. G. Finaly (Eds.), Handbook of
Communication in Oncology and Palliative Care (pp. 165–175). New York: Oxford University Press.
[Box 15.2]
Table 5.10 Listening Guidelines

1. Focus on feeling words.
2. Note the general content of the message.
3. Observe the speaker’s body language.
4. Do not fake understanding.
5. Do not tell the speaker how he/she feels.
Used with permission from: MacPhee, M. (1995). The family systems approach and pediatric nurs-
ing care. Pediatric Nursing, 21(5), 417–423, 437. Table 2. Reprinted from Pediatric Nursing, 1995,
Volume 21, Number 5, pp. 417–423, 437. Reprinted with permission of the publisher.
135 Family
Box 5.6 Questions to Address Patients’ and Families’ Coping
• Have you/your family been through something like this before? How did you/your
family react/cope?
• Do you have a belief in a higher power that supports you?
• Is there anyone you’d like us to call?
• Can you anticipate any potential areas of concern for you and your family?
• Who could you call if you started to feel really sad?
• Did the patient ever tell you what they wanted for themselves?
• Is there anyone you think the patient would like to see?
• Who is supporting you now?
• Who can you call when things get more difficult?
Used with permission from: Dahlin, C. (2010). Communication in palliative care: An essen-
tial competency in nurses. In B. Ferrell and N. Coyle (Eds.), Oxford Textbook of Palliative
Nursing. New York: Oxford University Press, p. 118.
Box 5.7 Assessing Spiritual Needs
• Does your particular tradition offer you helpful religious or spiritual counsel in this
situation?
• Is there a particular person you turn to for spiritual help?
• Do you draw strength from any particular object or symbol, e.g., art, music, poetry,
religious icons?
• Do you have a particular place where you find solace?
• Are there particular people or activities that lift your spirits?
• Do you feel your own spiritual or religious practices are being neglected and, if so, how
may we assist you?
Used with permission by Oxford University Press: Hudson, R. (2009). Responding to family
caregivers’ spiritual needs. In P. Hudson and S. Payne (Eds.), Family Caregivers in Palliative
Care: A Guide for Health and Social Care Professionals (p. 45). New York: Oxford University
Press.
Box 5.8 Common Responses of Children to Illness
• Magical Thinking that results in feelings of guilt (e.g., “I once told Mommy I wished
she were dead”)
• Fears of abandonment, especially in younger children
• Fears of contracting the disease
(continued)
Box 5.8 (continued)
• Anger, withdrawal, being uncooperative, especially in adolescents

• Acting-out behavior with lack of usual attention
• Frustrations with an altered lifestyle because of decreased financial resources, less
family fun activities because of the ill person’s inability to participate, etc.
• Inability to concentrate and focus, especially regarding schoolwork
Used with permission from: Glass, E., Cluxton, D., & Rancour, P. (2010). Principles of patient
and family assessment. In B. Ferrell and N. Coyle (Eds.), Oxford Textbook of Palliative Nursing.
New York: Oxford University Press, pp. 87–106: Table 4–6.
CHAPTER SUMMARY
Families of hospice and palliative care patients need nursing care. They need some-
one to help them navigate the medical system, gain access to clinical staff and test
results, and interpret unfamiliar medical terms. They turn to the nurse to meet these
communication needs. Recognizing that the patient and family are impacted when a
family member is seriously, chronically, or terminally ill can foster partnerships and
bring supportive communication to the family’s care experience. Inquiring about the
family’s history and background and the primary caregiver’s family role, and actively
seeking the coping needs of families are qualities of family-centered nursing care.
Seeing patient and family as one can be a challenge in some settings; the next chapter
provides instruction on how to manage various work settings and strive for quality
improvement.
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McLeod, J., & Chaffee, S. (1973). Interpersonal approaches to communication research.
American Behavioral Scientist, 16, 469–499.
Ritchie, L., & Fitzpatrick, M. (1990). Family communication patterns: Measuring interper-
sonal perceptions of interpersonal relationships. Communication Research, 17, 523–544.
Schrodt, P., Ledbetter, A. M., Jernberg, K. A., Larson, L., Brown, N., & Glonek, K. (2009). Family
communication patterns as mediators of communication competence in the parent-child
relationship. Journal of Social and Personal Relationships, 26(6–7), 853–874.
Schrodt, P., Witt, P. L., & Messersmith, A. S. (2008). A meta-analytical review of family com-
munication patterns and their associations with information processing, behavioral, and
psychosocial outcomes. Communication Monographs, 75(3), 248–269.
References and Additional Readings for Family Meetings
Albrecht, T. L., Eggly, S. S., & Ruckdeschel, J. C. (2010). Communicating with relatives/com-
panions about cancer care. In D. W. Kissane, B. D. Bultz, P. M. Butow, and I. G. Finaly
(Eds.), Handbook of Communication in Oncology and Palliative Care (p. 157–164). New
Coyle, N. & Kissane, D. W. (2010). Conducting a family meeting. In D. W. Kissane, B. D. Bultz,
P. M. Butow, and I. G. Finaly (Eds.), Handbook of Communication in Oncology and Palliative
Care (p. 165–175). New York: Oxford University Press.
Dahlin, C. (2010). Communication in palliative care: An essential competency in nurses. In B.
Ferrell and N. Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp. 107–133). New York:
Dawson, K. A. (2008). Palliative care for critically ill older adults: Dimensions of nurs-
ing advocacy. Critical Care Nursing Quarterly, 31(1), 19–23. Doi: 10.1097/01.
CNQ.0000306392.02154.0700002727-200801000-00005 [pii]
Glass, E., Cluxton, D., & Rancour, P. (2010). Principles of patient and family assessment. In B.
Ferrell and N. Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp. 87–106). New York:
Gueguen, J. A., Bylund, C. L., Brown, R. F., Levin, T. T., & Kissane, D. W. (2009). Conducting
family meetings in palliative care: Themes, techniques, and preliminary evaluation
of a communication skills module. Palliative & Supportive Care, 7(2), 171–179. Doi:
S1478951509000224 [pii]10.1017/S1478951509000224
Hudson, P., & Payne, S. (Eds). (2009). Family Caregivers in Palliative Care: A Guide for Health
and Social Care Professionals. New York: Oxford University Press.
Hudson, P., Quinn, K., O’Hanlon, B., & Aranda, S. (2008). Family meetings in palliative care:
Multidisciplinary clinical practice guidelines. BMC Palliative Care, 7, 12. Doi: 1472-684X-
7-12 [pii]10.1186/1472-684X-7-12
Hudson, P., Thomas, T., Quinn, K., & Aranda, S. (2009). Family meetings in palliative care:
Are they effective? Palliative Medicine, 23(2), 150–157. Doi: 0269216308099960[pii]10.11
77/0269216308099960
Knapp, E. R., & DelCampo, R. L. (1995). Developing family care plans: A systems perspec-
tive for helping hospice families. American Journal of Hospice and Palliative Medicine, 12,
39–47.doi: 10.1177/104990919501200608
Nursing, 21(5), 417–423, 437.
Machare Delgado, E., Callahan, A., Paganelli, G., Reville, B., Parks, S. M., & Marik, P. E. (2009).
Multidisciplinary family meetings in the ICU facilitate end-of-life decision making.
American Journal of Hospice and Palliative Care, 26(4), 295–302. Doi: 1049909109333934
[pii]10.1177/1049909109333934
Wittenberg-Lyles, E., Goldsmith, J., Demiris, G., Parker Oliver, D., & Stone, J. (2012). The
impact of family communication patterns on hospice family caregivers: A new typology.
Journal of Hospice and Palliative Nursing, 14, 25–33.
141 Family
1. What are the characteristics of a family system?
2. Why are family members considered “second-order” patients?
3. How do nurses come to understand family system boundaries?
4. What is a family-centered approach?
5. What challenges arise from closed family systems?
6. How is the nurse’s role different between open and closed family systems?
7. In what ways are family communication patterns shaped?
8. How would you prepare for a family meeting with a Carrier Family Member?
9. From your (and your significant other’s, if applicable) family background, what
major events stand out as most influential in developing the family system? What
family life cycles are currently present in your own family? What vertical stressors
are present?
10. What family member type do you identify with? Explain.
11. What communication strategies would you use to engage Harriet’s daughter
Alice (from the chapter’s opening case study)? Write out what you would say to
her. What questions, if any, would you ask her?
12. What topics would you prioritize for a family meeting with Harriet’s children?
How would you rank-order the topics?
EXERCISE #1 - EXERCISES FOR FAMILY SYSTEMS THEORY

Patient: Let me take you back to the start. I was completely well. I was toodling along
with two little kids and a husband. He is a physician. I was teaching school and one
day I found a football-sized mass in my abdomen. It frightened me, but because it was
so huge I felt it had to be benign. After all, something that big could not possibly be
cancer and the word cancer never even entered my mind. I was too young, I thought.
Anyway, I went into surgery not having a clue. The doctors really did not prepare me
for it except to say I had a mass. I remember exactly what he said. I woke up from sur-
gery to hear my surgeon say, “I have good news and bad news. I didn’t have to remove
any of your organs, but (pause) you do have cancer.” It just blew me away.
During that year I had four surgeries and was in and out of the hospital. I had a
lot of time to think about what I was going to do with the rest of my life, which was
something you say when you have cancer. “Now what am I going to do? I don’t know
how long I am going to live.” No one was sure of that prognosis, and I said to myself,
“What I do know is that I don’t like what I’m doing now. I do not want to teach school
anymore. I want to do something health care related because I don’t even know where
any of my organs are and I need to know more about my body if I am going to work
with my doctors intelligently.”
While some people who interacted with me were really truly wonderful, others were
horrendous, just horrendous. I thought I could make a difference. I stopped teaching
and went into the medical field, which is actually one of the best things that could have
happened to me.
Subsequently, I have had 13 abdominal surgeries, 4 months of chemotherapy, and
6 weeks of radiation therapy. I have a tumor right now. I have not been tumor-free in
years. I have always had some tumor that is being watched. The tumor in my abdo-
men that they’re watching now will have to be operated on, or I will get experimental
therapy. I am having a computerized tomography (CT) scan next Tuesday, and so I am
sort of on edge. I am very well aware of the size of the tumor because I feel it. So, I am
very realistic about where I am at and about how things might go for me, and that’s
why I need to act.
Through my care, I have been in three different hospitals. I think my medical care
has always been excellent. I left the two previous ones, not because I was unhappy
with the medical care, but because I was unhappy with the communication with the
doctors. After one complication, the surgeon did not speak to me for the whole admis-
sion. He would come into my room everyday to check the chart and examine me, but
he never sat down to say, “This is what I found. This is what happened. This is what’s
going to happen. This is what we’re going to do.” I don’t think he could deal with a bad
result and I really was a bad result. So I left the hospital. Another doctor made me feel
like things were just hopeless. Now I have found somebody who lifts my spirits and
143 Family
who is always going to tell me he’s got something to pull out of his hat for me. I am
realistic and I know that the hat is getting a little bit shallow, but the communication
is there and I am part of a team, and that’s very important. Patients really want to feel
that they’re part of a team.
I didn’t have my cancer in isolation. I was married, was raising children, and I had
two parents who were very distressed about my cancer. They were from an older gen-
eration where they couldn’t talk about cancer. I took it upon myself to educate them.
I remember one time we sat down in my living room and I said, “Okay now, on the
count of five we are all going to say the word ‘cancer’.” They literally could not say it.
They lived far away and tended to only see me during times when I was ill. Never when
I was well. There were a lot of times when I was ill. And when I was ill, I was really ill.
What they apparently were learning from my experience was not that you can survive
cancer, but that it could be really horrible.
My father was 86 years old, a very healthy man, very robust, very active, didn’t look
a day over 70, never had a health problem, and was uncomfortable in a hospital setting.
He was just scared for me, and would say, “I will never suffer like that. I think what
you’re going through is just torture,” and at times, it really was. Some of those times
were really horrible and there was no hiding it from him. He would say, “This isn’t fair,
people shouldn’t suffer. Somehow you have the strength to do it, but I could never do
that. If I had to suffer at the end of my life, I would be active.”
My parents were becoming more frail and my mother suffered from depression. My
father then had some rectal bleeding. He dismissed it for ages but finally he went to
the doctor. The doctor sent him for a barium enema that showed an irregularity in his
colon and suggested that he probably should have a colonoscopy. I said, “Irregularity
is not a word that a radiologist uses. What does that mean? Call him back and ask
for a copy of the report.” He said, “Oh, the doctor doesn’t sound alarmed. It doesn’t
sound like anything major. I am feeling fine. Just let me be. The colonoscopy is just a
precaution.” Meanwhile he had no contact with his doctor. All the contact he has with
his internist was one telephone call to be told he had an irregularity. So I was thinking,
maybe it’s a polyp.
He finally went for the colonoscopy, and the gastroenterologist took one look at the
barium enema and said to him, “I don’t know why you are here. You clearly have a
blockage. You should have gone to a surgeon 3 weeks ago.” My father was understand-
ably startled by that. That was the first time he had heard “blockage.” He said, “You go
home.” It was Friday afternoon. “I will call your internist, and tell him you really need to
be admitted because you need surgery.” My father went home, called me immediately,
related the story, and said, “Are they trying to tell me I have cancer?” This was the first
time he had brought it up. I said, “Dad, let me get off the phone,” and I had my husband
call the gastroenterologist. So my husband called the gastroenterologist who said, “Your
father-in-law certainly has colon cancer. He should have seen a surgeon weeks ago. He
is almost completely obstructed. He really needs to have surgery tomorrow.” I called
my father back. He said, “Well, what did the doctor say?” I said, “Well, the doctor said
you really need to go to the hospital and talk to a surgeon.” He asked, “Is it cancer? Am
I going to need a colostomy?” I said, “Dad, first of all, it’s not that low down. Number
two, we don’t know if it’s cancer, but it’s an obstruction, and an obstruction has to
be removed. You can’t just live like that.” He said, “I can’t do it. I don’t want to do it.”
I could hear the distress in his voice. Evidently he got off the phone, didn’t say a word to
my mother, walked right by her, walked into another room where he had a gun, which
nobody knew about, walked out of the house, and shot himself in the head.
His suicide has changed everybody’s life. It’s the most extraordinary experience.
I had 16 years of cancer and my father couldn’t deal with the possibility of it for an
hour. I was upset that he couldn’t turn to me and have me or his doctor say, “Let’s talk
about this. Ask me questions.” My mother was also completely in the dark. My father
hadn’t verbalized any of his concern to her. But, 2 days before he committed suicide, he
said to my mother, “Well, I am having the colonoscopy on Friday and then I will know
if I have cancer or not.” What he was saying to her was, “I will know if I am going to kill
myself or not,” because that same day he went to the bank, took out $5,000 and sent me
a check for $5,000 that arrived in my mailbox the day after he killed himself with a little
note that said, “Darling, here’s a gift and mum’s the word. Love, Dad.”
After we buried my father, I made an appointment to see the internist, and I said,
“Why didn’t you pick up the phone and call me? You knew how concerned I was.” And
he said, “Because your father never told me to call you.” I said, “But my father didn’t
know what he had. You didn’t even give him the opportunity.” I asked the internist,
“How many times a month do you have a patient who has just been diagnosed with
cancer?” He said, “Maybe once or twice a month.” I was furious. “Did you ever think of
how serious it is telling somebody that they have cancer? How much thought have you
given it?” He said, “Maybe I never gave it a thought.”
I am here today, because if only one person hears this story and understands just
how traumatic giving a cancer diagnosis is, it will be worth it.
1. Does the author describe an open or closed family system? Did she and her
parents have high or low interdependence?
2. What evidence is there of system boundaries for this family?
3. What family communication pattern is characterized?
4. What family member type does this author represent?
Used with permission from: Dias, L., Chabner, B. A., Lynch, Jr., T. J., & Penson, R. T.
(2003). Breaking bad news: A patient’s perspective. The Oncologist, 8, 587–596.
REFERENCES AND SUGGESTED READINGS FOR THIS EXERCISE

Dixson, M. D. (1995.) Models and perspectives on parent-child communication. In T. Socha
& G. H. Stamp (Eds.), Parents, Children and Communication (pp. 433–462). Mahwah, NJ:
Erlbaum.
145 Family
Framer, J. R. (1985). Family Interfaces: Transgenerational Patterns. New York: Brunner Mazel.
Galvin, K. M., & Brommel, B. J. (2000). Family Communication: Cohesion and Change (5th
ed.). Boston: Allyn & Bacon.
Hoopes, M. (1987). Multigenerational systems: Basic assumptions. American Journal of Family
Therapy, 15, 195–205.
McGoldrick, M., Gerson, R., & Shellenberger, S. (1999). Genograms: Assessment and Intervention
(2nd ed.). New York: Norton.
exercises for family communication

patterns theory
EXERCISE #1
See what kind of caregiver you are most likely to be!
Make copies of the following scale and administer to your students.
Use the scale below to answer the following questions about your family:
Strongly disagree Strongly agree

1 2 3 4 5
___1. In our family we often talk about topics like politics and religion where some person
disagrees with another.
___2. My parents often say something like “Every member of the family should have some
say in family decisions.”
___3. My parents often ask my opinion when the family is talking about something.
___4. My parents encourage me to challenge their ideas and beliefs.
___5. My parents often say something like “You should always look at both sides of an
issue.”
___6. I usually tell my parents when I am thinking about things.
___7. I can tell my parents almost anything.
___8. In our family we often talk about our feelings and emotions.
___9. My parents and I often have long, relaxed conversations about nothing in particular.
___10. I really enjoy talking with my parents, even when we disagree.
___11. My parents like to hear my opinions, even when they don’t agree with me.
___12. My parents encourage me to express my feelings.
___13. My parents tend to be very open about their emotions.
___14. We often talk as a family about things we have done during the day.
___15. In our family we often talk about our plans and hopes for the future.
___TOTAL SCORE
___16. My parents often say something like “You’ll know better when you grow up.”
___17. My parents often say something like “My ideas are right and you should not ques-
tion them.”
___18. My parents often say something like “A child should not argue with adults.”
___19. My parents often said something like “There are some things that just shouldn’t be
talked about.”
___20. My parents often said something like “You should give in on arguments rather than
risk making people mad.”
___21. When anything really important is involved, my parents expect me to obey without
question.
___22. In our home, my parents usually had the last word.
___23. My parents feel that it is important to be the boss.
___24. My parents sometimes become irritated with my views if they are different from
theirs.
___25. If my parents don’t approve of it, they don’t want to know about it.
___26. When I am at home, I am expected to obey my parents’ rules.
___TOTAL SCORE
Revised Family Communication Patterns Scale

Ritchie, L. D. (1991). Family communication patterns: An epistemic analysis and conceptual
reinterpretation. Communication Research, 18, 548–565.
Ritchie, L. D., & Fitzpatrick, M. A. (1990). Family communication patterns: Measuring
intrapersonal perceptions of interpersonal relationships. Communication Research, 17,
523–544.
Scoring Instructions
Have students add up their score for items #1–15 (conversation) and #16–26 (con-
formity). The range of scores for conversation is 15–75, with a score in between 15
and 45 as low conversation and 46–75 as high conversation. Similarly, the range of
scores for conformity is 10–50, with a score in between 10 and 30 as low conformity
and 31–50 as high conformity. After students have identified their high and low qual-
ity, they should use the family caregiver typology to determine their likelihood for a
caregiver type.
EXERCISE #2
Use the following quotes from family members about their hospice and palliative care
experiences to identify the family member type and/or family communication pattern.
Additionally, describe what you would prioritize for a family meeting with this family/
family member.
1. “I think it’s hard for my sister. She is visiting from Florida and it’s harder for her
because she is the oldest in the family and there is a lot of pressure on her. I think
she feels like she has to take care of everything and keep an eye on everyone and
everything.” (Eggenberger & Nelms, 2007)
147 Family
2. A family of seven members, including a father, five children, and one grandchild,
who had gathered from several states to be together at the bedside of their mother,
said: “We are all here together and we are all doing this together. Our family has
managed by everybody pitching in and being here . . . being together is helping our
family. It’s just more comforting to know that you’ve got somebody . . . It’s been
nice to know that I won’t be the only one here, doing everything.” (Eggenberger &
Nelms, 2007)
3. Martin, primary caregiver for his mother who had Alzheimer’s disease:
I didn’t have a social support system. I think I had more support from friends and
strangers than I did from family. Family just like totally abandoned us and like she
(points to neighbor) would come over and baby-sit for me sometimes and then
the lady across the street would baby-sit for me sometimes, but I never once had
a sister-in-law or somebody ask “Can I come over and baby-sit your mama and
you go to the movie?” or something like that. There was never once that anybody
ever offered me any kind of relief.
I had my brother and his wife . . . I let them stay with me for almost two
years, and neither [of them] would just come into the room when I was chang-
ing her and ask “Can I help you turn her?” or something like that. Sometimes
when I was just so tired and exhausted I would call my nephew and say, “Could
you go ask your daddy if he can help me slide grandmother up a little bit.
I want to turn her,” and then he’d come in and assist. But it was never once
where somebody just came in and volunteered and said “Can I help you do
this?” or “Why don’t you let me watch her tonight and you go do this and you
go do that with your friends?” It wasn’t that. . . . I didn’t get mad about it. . . .
I just said [to myself] you know you just do what God would have you to do and
that’s honor your mother and that’s what I did. And I just honored her to the
fullest by taking care of her.
exercises for family meetings
EXERCISE #1
A 94-year-old woman has three adult children, a son and two daughters. Her son
and youngest daughter are present for the meeting. Up until 3 weeks ago, the
patient was living on her own. She went to see her primary care physician and was
diagnosed with a urinary tract infection. Shortly thereafter she fell at home and
was taken to the emergency room at the local hospital. When she left the hospital,
she went to her older daughter’s home for 1 week where she fell again. The family
decided it was better for the patient to return to her youngest daughter’s home
for care.
Within a week, the patient returned to the hospital and the family learned that she
has cancer. The patient spent 5 days in the hospital. The youngest daughter explains,
“It was a nightmare—every sound rattled her. She couldn’t sleep, she didn’t want to
eat.” The family requested a private room, and on the third day in the hospital she was
moved to a private room. From the hospital, the patient was transferred to a rehab
facility. During this time the daughter reports “she is in despair,” and the patient’s son
explains “she’s giving up.”
Both children report that their mother has talked about dying and has specifically
said what she wants, including specifications for what songs to play at her funeral, and
a request “to be buried with daddy.” Still, the youngest daughter reports numerous
incidents of incoherence throughout the past 3 weeks. “At this point, it’s not an option
for her to go home so . . . ”
Discussion
At this point, what would you say to this family? Here are some prompts to help you
get started. . . .
* Attempt to explain the medical reasons for the patient’s incoherence.

* Explain the dying process.
* Respond to the medical history of the patient (“This is all very normal.”).
* Focus on family dynamics (“Families like yourself that are close and communi-
cate well are very lucky.”).
* Try to summarize their main concerns (“So you are concerned that she’s not
eating.”).
FACULTY NOTE: This can be done as a classroom exercise or take-home assignment.

You can divide students into triads or small groups and assign each of them one of
these initial responses. Then have them share as a group or role-play.
The family meeting continues:
youngest daughter: “We haven’t asked her if she’s hungry; we just keep
trying to feed her. I’m worried about her dehydration and suffering. If it
wasn’t the diarrhea, I would see it as a natural process . . . but I feel like it’s
me not taking care of her . . . [crying] I want to feel like I’m not bailing on
her. I feel like I’m accelerating it.”
son-in-law: “It’s just so hard to believe that 3 weeks ago she was on her own.”
son: “How will she die?”
149 Family
Discussion
At this point, what would you say to this family? Here are some ideas to help you get
started . . .
* Introduce hospice and compare with hospital care/philosophy.

* Inquire if the family would be okay with the patient passing away at their home.
* Explain the dying process in patients with cancer.
The family meeting continues:

The youngest daughter cries. The patient’s son suggests that the family should call
their sister and ask her to come [she is about 8 hours away by car]. “Let’s call her and
have you talk to her,” he says to the nurse. As his sister dials the number, he asks the
nurse: “How long do you think it will be before my mother dies?” Before the nurse
can answer, the two sisters are on the phone, the youngest daughter announcing: “It’s
looking like hospice.” She can’t say any more, begins quietly sobbing, and gives the
phone to her brother. She leaves the room and her husband follows quickly behind
her. The patient’s son is able to provide a synopsis over the phone to his sister—she is
concerned about the legal issue of choosing hospice on behalf of her mother. During
this discussion, the youngest daughter returns to the meeting and announces that she
simply cannot make a decision and that her siblings must decide.
Discussion
At this point, what would you say to this family? What type of family system are you
working with (open or closed)? What family communication pattern does this family
demonstrate? Do any dominant caregiver types emerge?
6
openings
Peter is an RN case manager in a major urban cardiac care hospital unit. He

is currently caring for 56-year-old Felipe, an immigrant from Peru who has
recently suffered an MI (myocardial infarction). Felipe and his family (wife
Maria, sons Jose and Antonio, and daughter Carmen) speak little English and
are overwhelmed by the CCU (cardiac care unit). Despite diabetes and COPD,
Felipe has been the key family breadwinner for his own family, his elderly
mother, and elderly mother-in-law.
Felipe owns an auto repair shop and his two sons work for him. He is
extremely anxious about his MI and insistent that he must return to work soon.
Felipe likes Peter very much as Peter speaks Spanish fluently, and Felipe feels
Peter understands his responsibility as the head of the family. Unfortunately
Felipe’s hospital course has not gone well, and the damage from the MI was
worse than first estimated. Felipe has limited mobility and becomes fatigued
easily, and he and his wife are very emotional.
The diagnosis evaluation following the MI has also revealed that he has pro-
gressive renal disease associated with his diabetes, and while Peter is working to
coordinate rehabilitation services, there is some doubt about Felipe’s rehabilita-
tion potential. Felipe and his family become easily confused and overwhelmed
by the number of medical specialists who see him daily. They also feel that they
get confusing messages from each service about his status.
Peter is now attempting to arrange a transfer from the CCU to a step-down
cardiac unit. Felipe’s wife becomes very joyful, expressing her thanks to God that
this good news means her husband will be healed and back to normal. Peter feels
that none of the physicians have discussed Felipe’s actual status or prognosis.
Today, Felipe’s daughter Carmen asks to speak with Peter and tells him that
she really needs to know the truth about her father’s status so she can know if
Felipe will ever be able to return to work. The physical therapist has also paged
Peter to clarify the goals of care for his transfer. Peter is now feeling overwhelmed
as he faces a huge void in communication about Felipe’s needs and prognosis.
Anxiety. Fear. Tension. These are feelings and emotions that indicate a nurse should
promote effective communication and seek interdisciplinary collaboration rather
than avoid finding a potential solution. Peter has observed the seriously complicated
151
situation of Felipe and his family and has an accurate understanding of the complica-
tions that Felipe faces in the weeks ahead. But unlike the other clinicians working with
this family, Peter is uniquely positioned to engage in communication during the most
pivotal point of life for Felipe and his family. Peter can create an opening as he commu-
nicates with Felipe and his family and shares the “truth” that Carmen (the daughter)
longs to hear, while moving beyond this bad news information to a productive conver-
sation about transitions and goals of care.
The Oxford English Dictionary uses words like connection, opportunity, possibility,
launching, and start to describe opening. This chapter examines the communication
a nurse shares with patient and family at pivotal moments in illness; this communi-
cation can create openings for positive change. The junctures in illness explored in
this portion of the book encourage a reframing of moments of tension. Rather than
a nurse being repelled by fears of inadequacy in those junctures of transition, a nurse
can champion a patient/family and use communication to engage some of the most
challenging and rewarding clinical moments experienced in nursing practice. These
are the moments when nurses can advocate for the best care by sharing in painful times
of isolation and change for patients and families.
Some commonly experienced communication around junctures of care occurs at
the time of initial diagnosis, around treatment decision making, at the point of recur-
rence or complication, as well as when coaching patients about how they can share
their thoughts with family and how family can share thoughts with a patient. Nurses
play a key role at the end of life as patients and families struggle to forgive one another,
to say good-bye, and to locate spiritual support as they experience a loss of connec-
tion with the life they no longer know. These difficult moments present opportunities
and possibilities for resilience, but resilience and coping are less possible if the patient/
family as well as health care professionals participating in care do not attend to painful
transitions, fears, and inevitable changes.
Now that the concept of opening has been introduced, this chapter will detail the
complex patient/family communication that nurses can facilitate in transitions of care,
describe a few communication concepts to refine thinking and provide support for
improvements in clinical practice, and finally, provide practical applications to shape
nursing care plans in palliative care.
PIVOTAL POINTS OF COMMUNICATION BETWEEN

NURSE/PATIENT/FAMILY
The last two decades have seen a rise in scholarship about clinician communication
and breaking bad news. Most of this information emphasizes the role of medicine and
physician performance with little attention to the communication events encountered
after the bad news has been shared/learned (Kruijver, Kerkstra, Bensing, & van de Wiel,
2000; McCabe & Storm, 2008; National Consensus Project for Quality Palliative Care,
2011; Neff, Lyckholm, & Smith, 2002). Communication and its importance are a bed-
rock need and skill for palliative care nursing. Research in nursing and other related
health care specialties have established that communication is not a naturally acquired,
153 Openings
naïve, artless, and gifted process. Instead, studied communication is central to all clini-
cal practice decisions and processes and demands education, intensive practice, and
reflection (Dahlin, 2010; Goldsmith, Wittenberg-Lyles, Rodriquez, & Sanchez-Reilly,
2010). This resource heralds the vital role communication plays and the increasing rec-
ognition of communication’s importance by the field of nursing itself. Difficult con-
versations with patients and families coincide with transitions in care and truly require
intimate and disclosive exchanges between patient/family and nurses.
Nurses perform the heavy lifting when it comes to stewarding patients and fami-
lies to a sense of understanding throughout their disease process. As such, the pivotal
points of communication that extend beyond the bad news exchange often mirror the
disease process for a patient and family (Malloy, Virani, Kelly, & Munevar, 2010). But
just as a disease does not travel the path of a script, neither does the unfolding/tim-
ing of conversations between a patient, family, and nurse. Nurse conversations with
patients and family after the receipt of bad news have not been extensively studied, but
scholars do know that this nursing communication task is rated as highly challenging
and very common in occurrence (Malloy et al., 2010).
Discussing spiritual concerns with patient and family, talking about cultural needs
and concerns at the end of life, processing suffering with patient and family, consider-
ing decisions about advanced directives, DNR orders, withholding or withdrawing sup-
port, and sharing in the news of recurrence or fear of recurrence with patients and/or
family are some of the pivotal points that present themselves in intimate conversations
with the nurse. Nearer a patient’s death, a nurse might engage in conversations with a
patient about saying good-bye to the family or with the family about saying good-bye
to the patient. Talking about forgiveness can also be a profound need of patients and
families at the end of life, and the nurse who has provided the intimate physical care
and support will often be the likely interlocutor suited for these interactions.
The nurse is central to effective communication in these and other critical moments.
Instead of approaching these transitions in care as a list to complete, which has his-
torically been the medical model for communication protocols, the nurse’s skill set
provides opportunities for conversation in relationship with patient and family as they
deal with serious illness. The nurse has special access and opportunity to respond to
cues from the patient and family and accompany them through the most challenging
conversations of serious and terminal illness. Research investigating communication
about terminal illness prognosis indicates that adaptive communication is necessary
and must be based on patient and family acceptability of information. Additionally,
studies show that news of recurrence, prognostic estimations, or discussion about hos-
pice placement must be diffused depending on how a patient/family receives the topic
(Eggly et al., 2006; Wittenberg-Lyles, Goldsmith, Ragan, Sanchez-Reilly, 2008).
In other words, some may need to hear and discuss a particular feature of bad news
many times and even then still might not understand or accept it. Further, some fami-
lies may choose never to engage in a conversation about terminal prognosis but will
still need to talk about transitions in care for the end of life. This chapter presents
nuanced strategies for engaging these vitally important and intimate conversations
essential for patients and families to experience the best quality of life at the end of life.
Physical Well-Being Psychological Well-Being

• Distress
• Self-care
• Anxiety
• Treatment plan
• Fear
• Place of care
• Happiness
• Enjoyment
Nurse Communication: Intimate

Openings Beyond Bad News
Social Well-Being
• Family dynamics Spiritual Well-Being
• Caregiver Burden • Connectedness

Relationships external •
• Meaning of illness
to family
• Identity • Meaning of suffering
figure 6.1 Quality-of-life model and communication

Adapted from Ferrell, B. R., Dow, K. H., & Grant, M. (1995). Measurement of the quality of life in
cancer survivors. Quality of Life Research, 4, 523–531.
Intimate conversations that facilitate openings for patient and family can profoundly
and positively impact the quality-of-life domains as depicted in Figure 6.1.
Talking with a patient and his or her family, or demonstrating presence without
verbally communicating, can and does affect clinical outcomes and costs not only for
the patient and family, but also for all stakeholders (Matsayuma, Reddy, & Smith, 2006;
Zhang et al., 2009). As the quality-of life-domains are applied to concepts of com-
munication, two particular communication constructs, or theories, will support the
challenge of engaging patients and families in their intimate moments of illness tran-
sition: Communication privacy management theory, and social penetration theory.
Both theories wrestle with the problematic of disclosure and boundaries. Also, each
theory actively represents the relational connection human beings share—a concept
understood and valued by nurse clinicians.
COMMUNICATION PRIVACY MANAGEMENT

The intimacy of nursing creates an environment for frequent and unsolicited patient
and family self-disclosure. Ironically, some of this information is just plain “too much
information”; however, nurses must make decisions about how, when, and if this infor-
mation should be communicated to other family members as well as team members.
155 Openings
Communication privacy management (CPM) outlines how individuals become

owners of private information and how this ownership gives them control of private
disclosures (Helft & Petronio, 2007).
Nurses are often in the position of receiving and delivering private information and
thus have private information ownership. For example, a nurse in oncology may be
asked to share lab results, which will indicate a patient’s worsened status. Family mem-
bers often stand in shock as physicians inform them of the terminal status of a patient.
When the physician leaves, it is the nurse who is left to explain the information, answer
questions, and help families face the meaning of the information. As such, nurses
address the actual process of telling and revealing the content of private information
(task communication), as well as facilitating the impact on the individual to whom
the private information is connected and other people associated with that individual
(relational communication) (Petronio, 2002). In palliative care, private information
becomes one or more of the following pieces of information: (a) the terminal prog-
nosis, (b) hospice and palliative care services, and/or (c) patient/caregiver feeling of
burden (Wittenberg-Lyles, Goldsmith, Ragan, & Sanchez-Reilly, 2010).
Control of Private Information and Coordinating Boundaries

The way that people manage the flow and exchange of private information is a major
tenet of this theory. Boundaries can become linked as people form alliances with
information and include additional parties as recipients of certain pieces of news. But
boundaries can be restructured and revisioned as a result of time and information,
and especially as a result of relational change. Some boundaries are known as thick and
difficult to permeate, while others might be thin and more accessible.
Commonly, families request that patients not be told about their diagnosis and hospice
enrollment (Gentry, 2008). Some families have a relational history of avoiding difficult
topics or speaking indirectly about serious topics; still, limited disclosure about hospice
care can facilitate protection of family emotions and sustain denial (Gentry, 2008).
The decision to reveal private information, such as the nurse’s knowledge about the
disease, disease trajectory, and/or prognosis, can create a privacy dilemma (Petronio &
Lewis, 2011). When a privacy dilemma occurs, nurses are positioned to communicate
either vaguely or directly.
The emotionally charged nature of palliative care means that families are not as
transparent about private matters. Nurses are often inclined to soften the news, evoke
hope, and remain ambiguous. If a patient or family member asks a nurse if their loved
one is going to die—what does this mean according to CPM? Contrary to the physi-
cian’s role, nurses don’t feel like they have ownership of the information. But they do!
They are in a privacy triangle! When patients or family members share private infor-
mation about their health choices or family situations, they are inviting the nurse into
their family and their disclosure comes with communicative responsibilities.
In the instance that patient disclosures or actions diverge from what has been dis-
closed, there is a privacy dilemma for nurses. When the information is given to a nurse,
the nurse carries the task of maintaining confidentiality. The nurse must interpret the
message, carry the burden or responsibility of knowing the information, and face the
challenge of delivering the message to others (Petronio & Lewis, 2011). In essence,
nurses take on the role of privacy advocate.
TURBULENCE: PRIVACY DILEMMA

Turbulence is the upset of privacy boundaries and the communication fallout that fol-
lows. A dilemma in privacy may be handled by not talking about private information,
or an impromptu and informal boundary condition that can emerge from disclosure
of the terminal prognosis.
Turbulence also can emerge as family members try to protect the patient from his/
her own private information. Especially when physicians do not adequately disclose
terminal prognosis, family members attempt to create their own private information.
In some instances hospice and palliative care services can be deemed private informa-
tion owned by the family (Clayton, Butow, Arnold, & Tattersall, 2005). It is not unusual
for families to request that the use of hospice services be withheld from the patient
(Gentry, 2008). Additionally, the desire to keep the patient from knowing that they are
dying is sometimes articulated by the family. Families instruct health care providers
not to mention hospice, not to tell the patient that he or she is terminal, and not to talk
about death and dying in front of the patient (Planalp & Trost, 2008).
Feelings and emotions associated with the caregiver role can also create turbulence
in the disclosure of private information. While disclosure is typically used to make
sense of unexpected events and as a way of seeking support (Helft & Petronio, 2007),
turbulence is created for caregivers who do not want to disclose these feelings to their
terminally ill loved one.
The drive for search and cure can reconfigure or underscore previously established
relationship privacy rules or communication that regulates the flow of private infor-
mation between family members. Violation of privacy rules becomes necessary to keep
the hope for cure alive. For example, providing Joe with hope became a new privacy
rule that his wife Kay used to sustain their family in illness. Turbulence is created in
the family, especially when terminal news disclosures are not clearly articulated. The
traumatic event in this instance is the terminal prognosis triggering dialectical tension,
or pull between two alternatives: privacy and disclosure.
The negotiation of privacy, rather than open communication, creates multiple
boundaries as families struggle to protect the patient as well as others by not talk-
ing about the prognosis. The hospice perspective, which includes open sharing and
discussion about the prognosis, collides with the family’s desire for privacy around
the issue.
Boundary turbulence occurs when the coordination of a boundary is unclear, or
when privacy expectations clash. For instance, if Mary is in the late stages of cancer and
is in intractable pain concealed from her husband, Bob, this would be Mary’s private
information. Mary disclosing this information to a nurse to mediate the pain would
shift that boundary from a private one to a collective boundary. Mary’s desire to keep
Bob from knowing about her pain reveals the boundary type between spouses. The
157 Openings
nurse’s desire to let Bob know and help Mary with this pain could cause boundary
turbulence.
Once private information is self-disclosed to another individual, that individual
assumes co-ownership of the information. Boundaries are then managed through
rule management processes that are negotiated between individuals (Petronio, 2002).
Personal boundaries between dyadic partners can be expanded to become collective
boundaries between multiple persons, each with different boundary conditions. Thus,
individuals manage personal, dyadic, and group boundaries of private information
through privacy rules, which dictate boundary conditions. When a family member
is chronically or terminally ill, each family member itemizes different things that
become private in the midst of knowing that someone is changing/dying. Terminally
ill patients and their family members must ultimately manage collective boundaries in
the uncertainty of illness.
Personal boundaries between nurses, patients, and family members expand to
become collective boundaries such that each has a different set of boundary condi-
tions. Boundary coordination is based on the complexity of co-owning or sharing
private information that belongs to people collectively (Petronio, 2002).
SOCIAL PENETRATION THEORY

Another concept from communication that helps explain ways in which disclosure
impacts relationships is social penetration theory (SPT). The essence of SPT describes
all relationships as being in development, or progress, and that self-disclosure is at the
nexus of relational development. In this theory, social penetration refers to the process
of bonding that moves a superficial relationship to a more intimate one (Altman &
Taylor, 1973). The idea of penetration is endowed with two capacities: breadth and
depth. Breadth refers to the number of topics discussed in a relationship while depth
refers to the level of intimacy guiding a discussion topic.
Another idea central to SPT is reciprocity, or the return of openness from one per-
son to another. An individual’s willingness often leads to the other individual’s will-
ingness, and as such reciprocity has been shown to be a significant component that
advances relationships. Both SPT and the previously described CPM can be used to
support and further strategize what is known in nursing research literature about the
most productive interpersonal choices a nurse can make when caring for patients.
Think of the talk that people exchange with strangers on an airplane. Specifically,
reflect on any instances in which a total stranger disclosed heavily to another stranger
with whom he or she shared a row. These two people might not ever know the oth-
er’s name, but still the depth of information shared can be impressive. There are also
instances in which one traveler in a row of seats discloses heavily to a seatmate, but the
seatmate does not reciprocate this level of disclosure in breadth or depth. The dem-
onstrated behavior in these airplane scenarios gets at the heart of social penetration
theory. Translating this theory to the end-of-life context enlightens some of the com-
munication complexities that nurses and other health professionals encounter with
family, teams, and patients.
INTIMATE OPENINGS DURING ILLNESS

Until the 1960s, nursing literature and research promoted a distancing nursing prac-
tice that featured “control” communication and management of events with patients
(and rarely families). Closed questions, rapid succession of leading questions, and direct
statements were identified as techniques to focus on and facilitate task completion
(Clark, 1982; Meleis, 2012). But these established ideas about detachment crumbled as
the nursing process was introduced, as well as the later development of primary nursing
(Dowling, 2008). These changes in nursing heralded individualized care and a focus
on personal relationships necessitating a reframing of the nurse–patient relationship
to include commitment, closeness, and involvement as opposed to distance, control,
and detachment (Dowling, 2008). The ideas of private information disclosure and
self-disclosure are pertinent in this new modeling of nursing practice. As part of this
new conceptualization, the idea of intimacy takes on a central role and is characterized
by “closeness at physical, psychological, and spiritual levels” (Muetzel, 1988, p. 98).
Despite this paradigm shift in the nurse–patient relationship, there are still inaccura-
cies and false assumptions about sharing difficult conversations/communications with
a patient and/or family. Avoidance of situations and challenges that cannot be “fixed”
by the nurse are a common cause for avoiding intimate conversations (Gauthier, 2008).
Table 6.1 is a simple compilation of common myths about terminal illness communi-
cation shared between nurses, patients, and families.
Table 6.1 Common Myths Associated with Communication about Dying

Common Myths: Communication with Patients and
Families about Dying Communication Realities
Avoid silence in difficult moments. Silence only Silence allows for patient and family
creates more awkwardness. disclosure and communicates interest
and presence.
Dying patients and family members only want to Patients and family have existential
talk about positive things. concerns and fears to process.
Patients and family members don’t want to ask a Patients and family want to share a
clinician questions about dying and loss. relationship with clinicians and process
their questions about dying and loss.
When a patient is dying, there is little health care Health care professionals can provide
professionals have to offer. comfort measures and assistance to a
family transitioning their place and
goals of care when a patient is dying.
Adaptations from Gauthier, D. (2008). Challenges and opportunities: Communication near the
end of life. MESURG Nursing, 17(5), 291–196. Knauft, E., Nielson, E. L., Engelberg, R. A., Patrick,
D., & Curtis, J. (2005). Barriers and facilitators to end-of-life care communication for patients
with COPD. Chest, 127, 2188–2196. Kristjanson, L. (2001). Establishing goals: Communication
traps and treatment lane changes. In B. R. Ferrell & N. Coyle (Eds.), Textbook of Palliative Nursing
(pp. 331–338). New York: Oxford University Press.
159 Openings
Of course, one person alone cannot experience intimacy. Intimacy is engaged via
self-disclosure, confiding, and sharing—within a trusting relationship established on
the premise that the best solutions will be identified and enacted. The roles that both
the patient and nurse play (or the family and nurse) are significant. The dynamic com-
munication they share will make this intimacy possible (Reis & Shaver, 1988).
Knowing a patient allows a nurse to truly care for that patient (Zomorodi & Foley,
2009). The core of intimacy stems from disclosure of personal information with the
expectation that there will be understanding and acceptance. Although planning and
problem solving can occur without self-disclosure, problem solving is elongated and
protracted for the person who does not self-disclose (O’Connell, 2008). In nursing,
disclosure affirms and recognizes the interdependence of the patient and nurse, or
family and nurse.
Nurses often develop a level of health care intimacy with patients and families in the
course of caring for them (Dowling, 2008). This leads back to the idea of social penetra-
tion theory (SPT) and nursing. If a nurse develops a relationship of psychosocial care
and disclosure with a patient and family, what does that mean for the nurse in terms of
communication? The following elements from social penetration theory will guide a
nurse in strategizing communication behavior to maximize opening opportunities.
Complementary behaviors demonstrate interest in a speaker (patient/family) as they
disclose information. These behaviors maintain the focus on the patient or family, for
instance, and do not “one-up” the story, need, or concern of the individual with the
primary concern. So, for example, if a colleague complains of a cold and the long hours
he or she is working, complementary behavior would include receptive communica-
tions rather than communications that would pull focus toward the recipient, and
his or her health and exhaustion. Complementary behaviors are more important and
beneficial to the creation of patient/family/nurse intimacy than reciprocal behaviors
and communication (Prager, 1995).
Reciprocal communication equals and even surpasses the other’s conversational
content in terms of breadth and depth of disclosure. An example might be a patient
who is in her final stages of advanced cancer. A palliative care clinician comes by this
patient’s room and overshares about her own children and Thanksgiving plans in
response to the patient’s polite inquiry. A focus on the patient, her family, her chil-
dren, and her atypical Thanksgiving experience needs to be processed instead. In other
words, for the patient/family, it is more important that the clinician engage in com-
munication behaviors that express investment, care, and attention rather than a recip-
rocated disclosure. In fact, a reciprocal disclosure has the potential to diminish and
even dismiss the difficulty experienced and imparted by the patient or family. Another
way to describe this is to say that intimacy in the clinical setting is to position the nurse
in the meaning-making process with the patient or family, rather than separate out a
nurse’s meaningful experiences from the patient/family. Examine the two versions of
the same interaction in Box 6.1.
In the first version, an opening for the nurse’s self-disclosure occurs with a family
member in the course of interaction. The nurse makes good use of this self-disclosure
to establish commonality and trust but, most importantly, keeps the focus on the
Box 6.1 Communication Scenarios
Version #1
nurse: I can see the sadness on your face.

mrs. holbrook: Yes. The idea of not talking to my Mom makes me so sad. But
more terrified really. My entire world during the last 6 months has been tak-
ing care of her, first at home, then at the long- term care facility. A look or a
soft touch from her made every day better. I knew that I was a good daughter.
Overnight she doesn’t even know me. And I don’t know me. I can’t explain it.
nurse: It is horribly scary, terrifying. I went through something very much like
this with my Mom 3 years ago. It was awful.
mrs. holbrook: So you know. You get it.
nurse: Well, I understand what it was like for me. I want to understand what it
is like for you.
Version #2
nurse: I can see the sadness on your face.

mrs. holbrook: Yes. The idea of not talking to my Mom makes me so sad.
But more terrified really. My entire world during the last 6 months has
been taking care of her, first at home, then at the long- term care facility.
A look or a soft touch from her made every day better. I knew that I was a
good daughter. Overnight she doesn’t even know me. And I don’t know me.
I can’t explain it.
nurse: I’ve been there. My Mom died 3 years ago after 6 years with Alzheimer’s.
It was awful. Each day she forgot something else that just tore at my heart.
mrs. holbrook: Oh no. How did you deal with it?
nurse: Well, I . . .
patient/family member—continuing the interaction. Note that the impulse for dis-
closure of private information operates as concern for the family member and her
experience and seeks to find ways that Mrs. Holbrook can find meaning in her cur-
rent struggle. In the second version, the nurse also shows concern and orientation in
the direction of this family member’s angst. However, the nurse, presented with an
identical opportunity for disclosure, shifts the meaning-making intent away from Mrs.
Holbrook and onto the nurse’s personal trial of caregiving. While there is not a sense
that the nurse is removing a caring presence from this family member, there is a read-
justment of self-disclosure that moves into reciprocal rather than the complementary
behavior/communication. It is exactly at this moment of tension and privacy disclo-
sure that the nurse can facilitate the patient or family member in making meaning
and processing inevitable transition choices in his or her path. Maintaining focus on
patient or family disclosure will continue to communicate trust and an expression of
interest and concern.
161 Openings
Table 6.2 Team Meeting

TEAM MEETING AND OBSERVATIONAL NOTES:
Mr. Turner is an 81-year-old man with liver metastasis and pneumonia. He is now
unresponsive. The medical fellow reports to the team that he is dying. The DNP explains that
Mr. Turner just found out 3 weeks ago that he had liver cancer. He has a female friend that he
has been involved with for 5 years—and the two of them are very active and dance regularly.
Mr. Turner has children who are out of state, and they are making arrangements to come
to the hospital. The DNP reports that Mr. Turner’s girlfriend, KT, is at his bedside, crying.
Mr. Turner is breathing five breaths per minute. He’s comfortable, his eyes are open, but he’s
actively dying. The team physician asks if the children will get to the hospital in time—and
the DNP responds that this is unlikely.
Upon reaching Mr. Turner’s hospital room, the team finds KT very distraught. The DNP begins to
talk to her while she is standing next to his bed holding his hand. KT tells the DNP that she does not
want to talk in front of him. They step outside of the hospital room into a family meeting room. KT
begins telling the DNP about the events of the last 3 weeks and how they found out he had cancer.
dnp: The cancer has spread. He’s very, very sick. I think Tension indicated, as KT
you know this . . . because of all of the changes in reveals her hope that he is
him these last many days. in good health, and possible
girlfriend (kt): But he’s very active. We have horses, and denial of his active dying
he rode in a parade 3 weeks ago. You can’t go by his age. process. Intimate opening
He’s a young 81. He is in great shape really. opportunity.
dnp (explains that he is actively dying): This must be so Collective boundary—the

difficult to experience. As the nurse on his team, I really private information
think he is living out his final hours, maybe days. This of impending death is
is the time for his children to be with him. disclosed for ownership by
KT as well as health team.
kt (doesn’t acknowledge the actively dying language. Intimate opening to discuss

Instead, she describes his children’s travel plans) the goals of care.
dnp: Did you tell him they [his children] are coming? Collective boundary—
[pause]. disclosure describing
kt (does not speak but looks at DNP, eyes welling with withdraw of fluids.
tears)
dnp: Right now our main concern is to keep him pain
free.
kt: Yes, that’s so important. You all have done a
wonderful job.
dnp: We really want to make him comfortable and keep his
eyes moist as well as his mouth. And those are things
you can help him with, too. (KT nods, tears running.
Long pause.) I also wanted to talk to you about the
reality that he’s not hungry, and we will not be feeding
him.The IVs will actually lead to more pain
(continued)
Table 6.2. (continued)
and swelling. Discomfort him. (Long pause). So we

want to keep him comfortable, and right now that
means keeping his mouth moist. So we are going to
concentrate on that.
kt (Continues crying, talks about how much she loves Self-disclosure-depth

him and how she lost her own husband to lung (social penetration theory)
cancer. She cries heavily.) (Silence)
kt and dnp grab hands. Tension and intimate

dnp: How can we help you? opening opportunity
kt: I need an aspirin. I have my own health problems, and Self-disclosure-depth

car problems, and everything is happening at once. (social penetration theory)
dnp: We can get you the aspirin. As many as you need. I Complementary
always think these hard times come to me in groups, too. disclosure/behavior as
What is the hardest thing right now? opposed to reciprocal.
kt: He needs me. When he had surgery, I would sit in Intimate opening
the chair next to him and hold hands [with him]. I opportunity
would get in the bed and cuddle with him.
dnp: Well, he has a private room so you can do that. You
can get in bed with him.
kt: I can? Oh great.
dnp: Will you stay here tonight?
kt: (nods yes)
dnp: There are five things that I think help to know in times
like this—things that people might want to say to each
other—I love you, I forgive you, please forgive me, I’m
sorry, good-bye. Would you like me to write this down?
kt: Yes. I don’t have anything to forgive except him Family member
dying. (crying again) demonstrates a level of
dnp (writes it down and gives it to her) understanding facilitated
kt: I hate to tell him good-bye. I’ll just tell him I love him and I by nurse disclosure and
don’t want to be without him and I’ll always love him. intimate openings.
As the meeting ends, KT asks DNP about his ability to see. DNP explains that it is not
likely and to focus on his hearing. DNP reminds her to bring in music for him. KT
hugged DNP and went back to patient’s room. Two days later Mr. Turner died.
To demarcate movement through an actual interaction of intimate openings, the fol-

lowing observation from a veteran’s facility will be marked with some of the elements
described in this section about intimate openings (Table 6.2). Note the information
in the superimposed boxes next to the conversational turns shared between a Doctor
163 Openings
of Nursing Practice (DNP) on the palliative care team and Mr. Turner’s girlfriend, KT.
Some background observations to the events leading up to this interchange via the
team meeting are included.
This single conversation between the DNP and the family member (KT) of a ter-
minally ill patient provides an opportunity to look very closely at the communication
events that contribute to intimate openings, self-disclosure, and ultimately facilitating
transitions for a patient and family in this challenging time. Though this example of
Mr. Turner’s girlfriend, KT, closely examines the conflicted need to face active dying
and saying good-bye, there are other transformative communication opportunities
that can be facilitated by a nurse.
The extended case study in Figure 6.2 includes identifiers that note intimate open-
ings the nurse will communicate during the course of Mr. Romero’s illness, not only
to Mr. Romero, but also to the many stakeholders in this family’s experience of com-
plicated terminal illness. Central to the work of nursing is soliciting information from
patients and families, but also receiving information that might not have been requested
(Petronio, 2011). As nurses have noted in previous research, the more challenging dis-
closure events present predicaments that influence communication with the patient
and the family, create moral distress for the nurse, and can potentially mediate the
delivery of appropriate care (Schulter, Winch, Holzhauser, & Henderson, 2008). Some
research identifies a unique challenge in the nurse–patient or nurse–family dynamic
that can include information dumping, in which high rates of disclosure are revealed
to the reluctant nurse confidant (Helft & Petronio, 2007). Communication coping and
adaptability to manage this sticky situation will be further explored in Chapter 7.
Mr. Romero is a 70-year-old retired bus driver who had a history of hypertension, dia-
betes, and COPD. He was diagnosed with congestive heart failure six months ago and has
been seen frequently by a cardiologist in the clinic setting. He has been managed with sev-
eral cardiac medications but over the last few weeks has had several acute episodes of dysp-
nea. Today, the cardiology clinic nurse, Eva, asks Mr. Romero if there is something “going
on” in his life, as she is concerned about his increased shortness of breath and anxiety. Mr.
Romero admits that his wife was diagnosed with breast cancer and he has been devastated.
He said with a great sadness- “Just when I thought nothing could be worse than this heart
failure, my wife is struck down with breast cancer. She is my life. How can this be? Is there
no God? My wife, she never did a thing wrong. And now- Cancer.”
Time Out for Intimate Opening

• Tension (patient anxiety = opportunity)
• Self-disclosure
• Psychological well-being
figure 6.2 Case study

The nurse, Eva, offers her support and assures Mr. Romero that the clinic is “there for him”. Eva
listens quietly as Mr. Romero goes over again what it was like to hear the news of his wife’s cancer.

• Tension (shared silence = opportunity)
• Self-disclosure
• Psychological well-being
Eva assists Mr. Romero into the exam room and then she confers with Dr. Evans before he sees
Mr. Romero to share the information about Mr. Romero’s wife.
Three weeks later Mr. Romero returns to the clinic accompanied by his son. Eva is struck by the
rapid decline in Mr. Romero’s status. His cardiac evaluation reveals decreased cardiac function,
worsened dyspnea, edema and also weight loss. Accompanied by his son John, Eva takes the oppor-
tunity to ask John how things are going at their house. John shares that both of his parents are doing
very poorly and how after 51 years of marriage they seem to be both slipping away, each suffering in
the awareness of the other’s illness. John also tells Eva that his mother is now on hospice care as she
declined chemotherapy and has insisted on having her remaining months of life devoted to caring
for her husband. Eva gives John her card and suggests he have the hospice nurse contact him so that
they can talk about how to best coordinate care for his parents.

• Tension (caregiver burden = opportunity)
• Self-disclosure
• Physical well-being
One week later Mr. Romero is again seen in the clinic. His cardiac status continues to decline
and he is now dependent on oxygen and constant assistance. John tells Eva that he and his siblings
are now rotating weeks to stay with their parents as both decline. Eva asks John if his father has
completed an Advance Directive. She notes that she had given Mr. Romero an Advanced Directive
form to complete but it was never returned. John becomes almowst hostile, insisting that his father
will not complete such a form as it is “against their beliefs.” Eva asks John to describe their beliefs
and how Mr. Romero would want to live at the end of his life in regard to those beliefs.

• Tension (goals of care at end of life)
• Self-disclosure about family processing and family roles
• Trust built and knowledge exchanged between nurse/family/patient
• Spiritual well-being
figure 6.2 (conitnued)

165 Openings
John also shares that his sister Martina is “furious” with everyone who has given up on her
parents and she wants both to change doctors and get some “real” care. Eva offers to speak with
Martina and John expresses his thanks. He says “my crazy sister” always shows up to claim I can’t
do anything right for them.
Two weeks later Eva receives a call in the clinic from John to say Mr. Romero was admitted to the
hospital with acute chest pain. He is in the CCU. Eva conveys the message to Dr. Evans who will be
making rounds later in the morning. Eva also calls the hospital social work department and talks
with the Cardiology Social Worker to convey information about Mr. Romero. Later in the day Dr.
Evans returns to the clinic and is sad to report that Mr. Romero has had a MI, is on a ventilator, and
is unlikely to survive. Dr. Evans is very distressed, telling Eva that he has known this family for over
three years and is very fond of them. Eva listens to Dr. Evans distress, assures him of how much his
care has meant to the family. Eva also suggests that Dr. Evans consult the palliative care service, sug-
gesting that the family would benefit from the services of chaplaincy and the palliative care team as
they face decisions about life support.

• Self-disclosure about family
• Trust built and knowledge exchanged between nurse/physician
• Spiritual well-being
Dr. Evans expresses hesitancy that he doesn’t want to “abandon” his patient, Eva assures him
that involving palliative care would be a great sign of his concern for Mr. Romero and his family. Eva
also offers to call the palliative care service to convey the information for the referral.
Later in the week, Mr. Romero’s family participates in a family conference lead jointly by Dr.
Evans and the palliative care team. With the support of the hospice, Mrs. Romero was able to come
to the hospital although very ill herself, to say goodbye to her husband. The chaplain arranged for
the anointing of Mr. Romero and served communion to the family. The family also agreed to a DNR
order and two days later Mr. Romero died.
Three weeks following MR. Romero’s death, Eva received a call from John to say that his mother
had died peacefully at home with hospice. Eva thanked John for calling and expressed gratitude for
having had the opportunity to support this family during this time. She was able to hear about the
positive as well as challenging fi nal days John experienced with his family.

• Self-disclosure about family
• Interpersonal nurse/family trust
• Social and spiritual well-being in bereavement
• Spiritual support in the works for the Romero family
figure 6.2 (conitnued)

Table 6.3 Communication Tension or Avoidance

Communication Tension Quality-of-Life Domain(s) Heavily Impacted
or Avoidance Triggers in
Physical Psychological Social Spiritual
Illness
Time of initial ✓ ✓ ✓
diagnosis
Communication ✓ ✓
around treatment
decisions
Talking with patients ✓ ✓
about talking with
family
Communication ✓ ✓
around recurrence
Talking with family ✓ ✓
about talking with
patient
Communicating about ✓ ✓
saying good-bye
Narrative nursing invites the patient/family story and does not expect a certain end-
ing or outcome. Rather, narrative nursing, in conjunction with many of the ideas in
this “O” chapter, advocates for the individual experience of a patient/family, and find-
ing ways to help them navigate and process that experience. Facilitating access to pri-
vate health information, creating intimate openings to process transitions in life and
care, and understanding the impact of self-disclosure on patient/family relationships
all play an important role in practicing COMFORT.

This element of the COMFORT model offers unique tools to assist the nurse in tra-
versing the challenging yet profoundly rewarding moments of transition that require
the clinical practice of intimate communication with patient and family. The second
portion of this chapter will offer practical applications that are reflective of the nursing
care plan design. The case study that introduces this chapter situates Peter, an RN, in
an untenable situation not only with his patient and family, but also with many other
health professionals. All of the dynamics were there to facilitate an intimate opening
between Peter and Felipe, his patient. But this opening never occurred. The deterio-
ration of a patient can precipitate and force conversations and decisions that would
have been better experienced as an illness was unfolding. Examining the needs of a
patient and family is the first step in helping them make sense of their challenging
experience.
167 Openings
Table 6.4 Factors Indicating Poor Prognosis

Congestive Heart Failure Chronic Obstructive Pulmonary Disease
x New York Heart Association class IV x Cor pulmonale
(symptoms at rest) x Intensive care unit admission for
x Serum sodium levels <134 mmol/L or exacerbation
creatinine level >2.0 mg/dL attributable to x New dependence in 2 ADLs (activities
poor cardiac output of daily living)
x Chronic hypercapnia
Dementia Cancer
x Dependence in all ADLs, language limited x Karnofsky score <50
to several words, and inability to ambulate x Eastern Cooperative Oncology Group
x Acute hospitalization (especially for Score >2
pneumonia or hip fracture) x Liver metastatic tumors
x Multiple tumor sites
x Malignant bowel obstruction
x Malignant pericardial effusion
x Carcinomatous meningitis
Used with permission from Casarett, D. J., & Quill, T. (2007). “I’m not ready for hospice”: Strategies
for timely and effective hospice discussions. Annals of Internal Medicine, 146, 443–449.
Assessment
Nursing the whole patient includes assessing the needs of the whole patient, includ-
ing his or her life outside of the hospital or outpatient facility. The factors of social,
spiritual, and psychological well-being become crucial in terminal illness care pla-
nning for nurses as physical cure fades from the picture. Patients’ comfort and hap-
piness, but most particularly their social situations, are quintessential concerns as
transitions and goals of care are assessed. As an example, nurses identify their con-
cern about family coping as more intense than their concern for patient coping
at the end of life (Peterson et al., 2010). Despite nurse awareness of the profound
impact of family and home on patient care and location, nurses feel that a consid-
eration of these issues is still mightily underemployed in end-of-life nursing com-
munication skills (Reinke et al., 2010). Peter, the RN case manager, is surrounded
by information about Felipe’s social life but still does not identify a way to engage
either Felipe or his family in an intimate opening about the difficult reality of
Felipe’s prognosis and care needs.
The quality-of-life domains are a most useful construct to employ in assessing the
transitional needs of a patient. Examining this initial checklist will provide a starting
point for thinking about sharing in transitional communication with patient or family.
Table 6.3 is a list of potential tension or avoidance triggers and QoL domain impact areas
(Ferrell, 1996). As noted in previous sections of this chapter, the desire to disengage from
these areas of tension will produce and reproduce more tension the longer it is avoided.
Keeping in mind all of the sensitivities of cultural difference, health literacy levels, and
the individual patient, the tensions of end-of-life care remain somewhat consistent across
patient populations as decisions about place and goals of care are inevitable.
The literature on palliative and end-of-life nursing and medicine provides very spe-
cific information about the physical indications of a declining body. Identifying the
physical needs of a patient who is struggling with serious illness is one source of assess-
ment information that can indicate to a nurse that a conversation about transition is
of primary import. Table 6.4 includes some factors that are associated with a limited
prognosis and can provide basic triggers for communication addressing palliative or
hospice care.
Observing patient or family communication will provide a great deal of informa-
tion about the needs of a patient facing life-limiting or terminal illness. In the context
of life-limiting and terminal illness, patient expression to hasten death is an outstand-
ing invitation for discussion about his/her suffering. Often the need for relief is closely
related to transition in place of care, goals of care, or accepting the reality of immi-
nent dying and death. Patient communication can occur in the spoken word, through
silence, in writing, or by action. Here are some examples of communication about the
hastening of death that indicate an intimate nurse–patient opening:
x In written form on health care forms or personal material

x In verbal form shared with spouse or caregiver
x In verbal form shared with physician, nurse, or health care professional
x In a form of action by accepting transfer of care that the patient indicated would has-
ten death
x In verbal form with the physician or nurse; discussing administration of medication
x In verbal form triggering more frequent contact from staff
x In verbal form asking clinicians how to perform self-administered overdose
x In the form of action by declining any treatment or care that might prolong life and
improve quality of life
It is likely that Felipe knew he was very sick but may not have talked about this with
anyone, least of all his health care team. His clinicians, despite their expert profession-
alism, did not successfully address the triggers in Felipe’s case. Felipe’s and his family’s
need to know about his life-limiting illness was not part of their decision-making pro-
cess in his care plan.
Plan
Felipe’s wife believed that Felipe was improving. At the same time, Peter knows that
there is a heavy suspicion of doubt among the children of Felipe as the daughter,
Carmen, asked to hear the truth about Felipe’s prognosis. With this information, Peter
could have planned for conversations with Felipe and his family about the reality of his
prognosis and all of the ramifications this will have on their goals and place of care.
169 Openings
Table 6.5 Tensions, Boundaries, and Depth of Disclosure
• Tension Identified • Boundary Understanding • Depth of Disclosure
- What is being avoided - Does the patient possess - Has the nurse gathered
between clinicians and this private information patient perspective on this
patient? about his or her situation? tension?
- What is being avoided - Can the patient possess - Has nurse gathered
between patient and family? this private information family perspective on this
about his or her situation? tension?
- What is being avoided - Does the family posses - Has the nurse presented
between family and patient? this private information prompts to collect patient/
about their situation? family disclosure?
- What is being avoided - Can the family possess - Identify prompts that
between patient/family and this private information would accomplish patient/
health care team? about their situation? family disclosure.
- What is being avoided - Describe the boundaries - Recognize that nurse

between health care team around this family. self-disclosure is useful in
and patient/family? o Thick reaching intimacy with
o Thin patient/family.
o Permeable
- Describe the boundaries - Employ self-disclosure

around this patient. within the realm of
o Thick complementary disclosure
o Thin as opposed to reciprocal.
o Permeable
- What kind of boundary - Supply communication

turbulence is predictable that will facilitate meaning
based on knowledge of making and understanding
family/patient? among patient and family.
Once the point of tension and temptation to avoid communication have been iden-
tified, a plan for engaging a patient and/or family about a challenging time or transition
in illness can be designed. The two theories that support the ideas in this COMFORT
component are central to preparing for this kind of conversation. First, communica-
tion privacy management theory helps explain how private information is shared and
protected. Second, social penetration theory theory provides an understanding about
the ways in which self-disclosure (amount and detail) advances personal relationships
and decision making.
Determining the amount of private information that has or has not been shared
with a patient and family, as well as identifying the kind of boundaries that are upheld
in a family, is important as a nurse plans for an intimate conversation about illness.
Table 6.6 Tensions in Patient and Family Communication
Boundary
Understanding/ Patient and Family
Tension Communication Depth of Disclosure/ Communication
Identified—Openings Strategies Communication Strategies Indicating Tension
•Initial diagnosis Gentle questions Gentle questions “I want to die now.”

•Treatment choices - How are things - How are you feeling “I am scared. What is
•Family going for you? about this news? happening to me?”
disagreement - What have your - What can we do for “Am I dying?”
•Recurrence doctors told you? you? “I feel like I am losing
•Place of care - How do you see - What is important everything.”
•Patient/family things going? right now? “No one has told
onflict at end of - What do you see - What have you us this before. Why
life for the future? relied on during didn’t you all do
•Spiritual distress - Is your family other challenging something sooner?
in open times? We asked for that
communication - Can you tell me scan weeks ago.”
about this illness? more? “Is she dying? Is that
- Have you had this what is going on
conversation before? here?”
Rephrasing Rephrasing
- You describe your - So, it sounds like
family as working anger toward your
hard to keep your Dad is about his
parents from choice to decline
having to know dialysis.
the challenging
and hard things.
Statements Statements
- Every family is - Tell me what is
unique. My family important to you
is unique. With right now.
its own set of - I have also had very
challenges. hard times that
- Sometimes great seemed impossible.
opportunities
emerge for families
to connect in the
most challenging
times.
171 Openings
For example, perhaps the family is protecting the patient from knowing the progno-
sis. Inviting the patient/family to share their experience with difficult information or
changes in care is essential to palliative care. The patient and family must make mean-
ing out of the experience, and nurse self-disclosure should only serve this end; thus,
complementary disclosure is the most clinically sound practice in providing the best
care for patient and family. Essential elements in planning intimate opening commu-
nication are identified in Table 6.5. The chart does not demand a sequential applica-
tion to accomplish planning, but rather, an awareness of the components impacting
planning. Depending on the particular situation, some of these categories may be more
knowable to the nurse than others.
The nurse might be in possession of a wealth of information concerning patient
and family awareness but has avoided assessing and planning for these challenging
moments of communication. However, through intervention a patient and his or her
family can be propelled into a much-improved quality of life.
Intervene
Locating the language or the verbal communication to use in challenging transitional
moments with patients and families can produce anxiety in clinicians and has, in fact,
been a motivating factor behind the recent movement to provide clinicians with com-
munication protocols. Backing away from the idea that anxiety and tension must be
removed and avoided, and thinking instead that these sensations herald a very posi-
tive opportunity for nurse, patient, and family, is an approach that honors the patient
experience and unleashes his or her stories and needs to help all other stakeholders
in the illness process provide the best care for patient and family (Gunaratnam &
Oliviere, 2009). There are no sequences of talk prescribed in the COMFORT frame-
work, but instead, principles and components guide a holistic communication experi-
ence in an effort to care for the entire patient. Nonetheless, it can be extremely helpful
to gain a sense of particular language or communication behavior that could be poten-
tially employed or borrowed to assist in a particular instance. Intervention involves
Table 6.7 Language to Address Tensions

Tension Identified Potentially Useful Language
Clarify goals/values. - What do you hope for most in the next month?
Readjust goals. - In case you cannot make it to the wedding in person, could you
think of another way to be there? A letter we could help you write,
or a special videophone visit the day before the wedding?
Identify needs. - Do you think you might need support at home?
- What kinds of help might you need?
- Would it be helpful if we could arrange _____?
Connect goals with - It sounds like you want to be at home, enjoy your pets, and see
care needs. your husband as much as possible. A service called hospice would
support all of those hopes by . . .
(continued)

Tension Identified Potentially Useful Language
Introduce hospice. - The best way we know to give you the help you need and assure
that you can be at home is through a care service called hospice.
- A team of professionals will care specifically for you and enable
you to stay at your house. This team is specifically trained and
experienced in caring for very ill people at their homes.
- You seem upset. Does talking about hospice make you sad?
- Are you surprised to learn about how sick you are?
- I can imagine this must be very hard for your family, to know how
sick your sister is; you obviously are a very close and loving family.
- As long as I have been in health care, when it came to deciding on
hospice for my family member it was still very emotional.
Explore distress/ - Tell me about your sadness.
anxiety. - What is upsetting you the most?
Reassure. - Hospice helps people live as well as they can for as long as they can.
- Hospice has the goal of giving you the best quality of life
possible—and that means being at your house with your family.
- You can make the most of your time.
- Whatever you decide, I will be your nurse. I will continue to care
for you.
- How about we all think this over? You know I will be here to talk
with you about this, to process this decision.
- I would be glad to talk with you more about this, and we can even
invite a hospice nurse to join us to get more perspective on things.
- Let’s talk about this tomorrow. You are upset. Be with your wife now.
Adapted from Casarett, D., & Quill, T. (2007). “I’m not ready for hospice”: Strategies for timely and
effective hospice discussions. Annals of Internal Medicine, 146, 443–449.
communicating in these challenging transition times. So many of these opportuni-

ties were missed in the case of Felipe. For instance, once it was clear that Felipe was
experiencing major loss of mobility and extreme fatigue as a result of the MI, a trigger
opportunity presented itself. It was passed by, and Peter as well as the entire care team
moved on to address the next curative-only intervention without an intimate and open
communication with Felipe and his family.
Basic principles to observe in employing an intimate opening intervention include
being (a) honest and truthful, (b) always connecting to the patient’s goals and values,
(c) encouraging patient/family questions, (d) considering what would cause the nurse
anxiety if this issue were occurring in his or her own life, and (e) reserving time to be
present and listen during communication events (Gauthier, 2008). In Table 6.6, ele-
ments in the planning grid in Table 6.5 are related to interventions. Here, connections
173 Openings
are made between patient and family communication needs in transition and poten-
tially useful strategies.
Late-stage hospice intervention is still the trend in the United States. For clini-
cians and health care professionals, talking about the hospice intervention can be the
most difficult discussion to share with a patient and family. In many cases, this occurs
because little open communication about prognosis or disease progression has been
shared between clinicians and patient/family, or patient/family acceptability is so low
that information processing is unsuccessful (Wittenberg-Lyles, Goldsmith, Ragan, &
Sanchez-Reilly, 2010). A crisis often precipitates the conversation about hospice care
benefits, further compromising the communication abilities of all parties involved.
Language suggestions might be of some service in intervening in a patient’s course of
care with the concept of transitioning to hospice care (see Table 6.7).
Evaluate
Once navigated, an essential step to evaluate any nursing plan and practice is to evaluate
the action taken and its outcome(s). Chapter 5 describes some components of reflec-
tion and its fruitful impact not only on patient and family care, but also on increased
resilience for nurses as they face a grueling schedule of interactions and conflicts. The
evaluative suggestions for this COMFORT component are presented in three parts:
self, peer, and patient/family reflection.
Following an intimate opening interaction that was initiated in response to tension
in the care of a patient/family, consider the following points of reflection:
• What was the transitional interaction addressing?

• What was the tension, or work to avoid a crisis, keeping the patient/family from
addressing?
• What communication strategies/language were used in this interaction?
• Were they successful? How?
• What was unsuccessful?
• What would constitute a productive change in communication in this situation?
Understanding a patient’s needs or family need first begins with considering the
nurse’s needs, qualities, and uniqueness. Reflecting on challenging interactions enables
the clinicians to become more self-aware of how they engage certain situations and
also what effect they can have in complex illness, and ways in which others’ lives can be
improved (McGuigan, 2009).
A second element of reflection is moving beyond self-reflexivity and widening the
learning lens to include a collaborative experience (Atkinson & Claxton, 2000). The
support offered through a small group discussion or dyadic interaction introduces
additional perspectives for a nurse. Evaluate intimate opening experiences with a col-
league using these guidelines:
• A nurse can ask a colleague to her/his reflective evaluation of a communication

experience.
• The nurse provides a description of the challenging communication event.

• The nurse describes how that event made him/her feel.
• The nurse will ask the colleague/colleagues to share their views on how the event was
approached and any suggestions about the communication that was exchanged.
A third dimension of evaluating communication in difficult transition periods

involves reconnecting with a patient or family. The family and patient can be surprised
when asked for their opinions and advice on care. It is helpful to explain that clinicians
learn best about communication if there is an awareness about how patient/family
achieved an outcome (Price, 2004). One or two prompts can provide the most salient
evaluation of communication effectiveness. Below are suggested prompts that can be
adjusted for a particular context and engage patient/family in the learning process.
o You seem like you are feeling better about things today. I am interested to know what
helped you.
o Was my explanation too complicated during our previous meeting?
o What would have helped you in our discussion last week that you did not receive?
With a three-tiered effort (self/colleague/patient and family), reflective evaluation

can expand strategies in narrative understanding, listening, being present, and com-
municating during the most vital points of transition for a patient and family.
CHAPTER SUMMARY
This chapter offers specific tools to assist the nurse in traversing the challenging
yet profoundly rewarding moments of transition that require the clinical prac-
tice of intimate communication with patient and family. Revisioning tension and
avoidance as a sign that communication is needed rather than a sign that encour-
ages evasion is essential in helping a patient/family make meaning out of their loss.
Observations of tension might be clear indications of a needed transition in place
or goals of care. Complex interactions with patients and families coincide with
transitions in care and require intimate and disclosive exchanges between patient/
family and nurses.
Communication privacy management theory considers what is private informa-
tion and how that information is private depending on the relationship people
share. Social penetration theory assumes that all relationships are in development,
or progress, and that self-disclosure is at the nexus of relationship development.
Together, both of these theories support communication strategies that nurses
can employ to achieve positive outcomes in these intimate opening conversations.
Intimacy in the clinical setting places the nurse in the meaning-making process
with the patient or family, rather than separating out a nurse’s meaningful experi-
ences from the patient/family. Self-disclosure that is complementary rather than
reciprocal will enable the patient and family to experience a helpful closeness
with the nurse.
175 Openings
Facilitating appropriate access to private health information, creating intimate open-

ings to process transitions in life and care, and understanding the impact of self-disclosure
on patient/family relationships all play an important role in practicing COMFORT.
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Nurses’ identification of important yet under-utilized end-of-life skills for patients with
life-limiting or terminal illness. Journal of Palliative Medicine, 13(6), 753–759. doi: 10.1089/
jpm.2009.0423
Reis, H., & Shaver, P. (1988). Intimacy as interpersonal relations. In S. Duck (Ed.), Handbook of
Personal Relationships: Theory, Research, and Interventions (pp. 367–389). New York: Wiley
& Sons.
Saunders, J. (2004). Handling unexpected distress on the telephone: The development
of interdisciplinary training. International Journal of Palliative Care Nursing, 10,
454–459.
177 Openings
Schulter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses’ moral sensitivity and
hospital ethical climate: A literature review. Nursing Ethics, 15, 304–321.
Tuffrey-Wijne, I., & McEnghill, L. (2008). Communication difficulties and intellectual disabil-
ity in end-of-life care. International Journal of Palliative Nursing, 14, 189–194.
West, R., & Turner, L. (2007). Introducing Communication Theory: Analysis and Application
(4th ed.). New York: McGraw-Hill.
Wittenberg-Lyles, E., Goldsmith, J., Ragan, S., & Sanchez-Reilly, S. (2008). Communicating
a terminal prognosis in a palliative care setting: Deficiencies in current communication
training protocols. Social Science and Medicine, 66(11), 2356–2365.
Family Narrative and Early Palliative Care. Creskill, NJ: Hampton.
Zhang, B., Wright, A., Huskamp, H., Milsson, M., Maciejewski, M., Earle, C., et al. (2009).
Health care costs in the last week of life: Associations with end-of-life conversations.
Archives of Internal Medicine, 169, 480–488.
Zomorodi, M., & Foley, B. J. (2009). The nature of advocacy vs. paternalism in nursing:
Clarifying the “thin line.” Journal of Advanced Nursing, 65, 1746–1752.
ADDITIONAL RESOURCES
International Listening Association (ILA): www.listening.org
This site contains comprehensive information and convention and resource material about
the process of receiving, constructing meaning from, and responding to spoken and/or
nonverbal messages.
Play Therapy International: www.playtherapy.org
This site is intended to provide an international information resource for therapeutic play,
play therapy, filial play, and creative arts therapies. It is designed for anyone interested in
helping children with emotional literacy.
Schaefer, C. E., & Kadson, H. (Eds). (2006). Contemporary Play Therapy: Theories, Research
and Practice. New York: Gilford Press.
ADDITIONAL REFERENCES FOR PRIVACY

MANAGEMENT THEORY
Baider, L. (2010). Cancer and the family: The myth of words and silence. Journal of Pediatric
Hematology Oncology, 32(1), 54–57.
Cleary, M., Hunt, G. E., Escott, P., & Walter, G. (2010). Receiving difficult news: Views of
patients in an inpatient setting. Journal of Psychosocial Nursing and Mental Health Services,
48(6), 40–48.
Petronio, S. (2000). The ramifications of the reluctant confidant. In A. C. Richards &
T. Schumrum (Eds.), Invitations to Dialogue: The Legacy of Sidney M. Jourard (pp. 113–
150). Dubuque, IA: Kendall/Hunt Publishers.
Petronio, S. (2010). Communication privacy management theory: What do we know about
family privacy regulation? Journal of Family Theory and Review, 2, 175–196.
Petronio, S., Ellemers, N., Giles, H., & Gallois, C. (1998). (Mis)communicating across bound-
aries—Interpersonal and intergroup considerations. Communication Research, 25(6),
571–595.
Petronio, S., & Lewis, S. S. (2011). Medical disclosures in oncology among families, patients,
and providers: A communication privacy management perspective. In M. Miller-Day
(Eds.), Family Communication, Connections, and Health Transitions (pp. 269–298). New
York: Peter Lang.
ADDITIONAL REFERENCES FOR SOCIAL

PENETRATION THEORY
Altman, I., Vinsel, A., & Brown, B. (1981). Dialectic conceptions in social psychology: An
application to social penetration and privacy regulation. Advances in Experimental Social
Psychology, 14, 107–160.
Taylor, D., & Altman, I. (1975). Self-disclosure as a function of reward-cost outcomes.
Sociometry, 38, 18–31.
Werner, C., Altman, I., & Brown, B. B. (1992). A transactional approach to interpersonal rela-
tions: Physical environment, social context and temporal qualities. Journal of Social and
Personal Relationships, 9, 297–323.
1. What are some challenges that might occur in navigating the private boundary of
a patient when you have news that they do not yet know?
2. At what point does a private boundary become a collective boundary? Identify an
example from clinical practice that clearly demonstrates this change.
3. Describe how a nurse might deal with the boundary turbulence produced when
one adult child (a long-distance caregiver) arrives at her father’s bedside and
disagrees with other adult child’s care choice to withhold IV fluids. The local child
had not shared these care decisions with the sibling for fear there would be dissent.
4. How can a nurse recognize the importance of self-disclosure and its impact
on the patient–nurse relationship, but also monitor the importance of using a
complementary rather than reciprocal kind of self-disclosure?
5. Apply CPM to Peter’s case. What private information is Peter already in possession
of, and what boundary turbulence might be predicted?
6. Peter had a great deal of breadth knowledge about Felipe’s case. What specific
communication strategies could have been used to gain depth and potentially
move into an intimate opening with this patient/family?
7. Think back on an instance of patient/family tension. How was it handled? Name
some specific communication strategies that could have produced a better
outcome.
8. What are some ways to initiate an intimate opening for a delirious or unconscious
patient who has received curative-only care?
Exercise #1: Moving Theory to Practice with

Communication Privacy Management
In this teaching exercise, the instructor will introduce basic ideas from communica-
tion privacy management theory. Boundary coordination describes the ways in which
people manage information that is co-owned. In order for co-ownership to occur, pri-
vate information has to become collectively owned.
The objective of this activity is to illustrate one aspect of communication privacy
management theory, allowing nurses or students to clarify the concepts of personal
and collective boundaries. Nursing students will separate out into dyads. Each dyad
will be assigned a specific relationship (mother–son, friend–friend, romantic couple,
long-term married couple, and so forth). In dyads, they are to (1) develop a role play
illustrating a conversation between the two people in their assigned relationship, and
(2) center the context and topic on palliative care. The role play should contain both
text (what is spoken) and subtext (what is meant). The text should represent what the
partners actually say to each other. The subtext describes what the partners are think-
ing but not sharing aloud. For example, in an exchange between a nurse and patient,
the text could look like this:
palliative care consult nurse: Your brain tumor will not go away.
end-stage cancer patient: You will have to talk to my oncologist about our
plan.
palliative care consult nurse: We can make you more comfortable and
relieve the pressure, but we cannot take the tumor away.
end-stage cancer patient: She (oncologist) told me the radiation was our
next plan. I will be home soon. I just want to get my arm back moving.
The subtext of this exchange will look quite different:
palliative care consult nurse: Your brain tumor will not go away.
(subtext: You will not survive this tumor’s growth and spread.)
end-stage cancer patient: You will have to talk to my oncologist about our
plan.
(subtext: I am working with my oncologist, not you. We are working toward
my restoration.)
palliative care consult nurse: We can make you more comfortable and
relieve the pressure, but we cannot take the tumor away.
(subtext: We want to work with you, too, and give you support and comfort.
You will not survive this tumor.)
179
end-stage cancer patient: She (oncologist) told me the radiation was our
next plan. I will be home soon. I just want to get my arm back moving.
(subtext: I want a cure and am seeking one. I will be home just like before I
got sick.)
In pairs, students will perform their “scripts” with text and then again including sub-
text. Following their scripts, they should share a discussion addressing how the shared
information forms a collective boundary while the withheld information creates a per-
sonal boundary. Nursing students should be encouraged to think about how the ratio
of the collective boundary to the personal boundary affects the relationship and vice
versa.
Exercise adapted from West, R., & Turner, L. (2007). Introducing Communication Theory: Analysis
and Application (4th ed.). New York: McGraw-Hill.
Exercise #2: Caring for Dorothy and Bob

Nurses often face patients with little information about their lives or relationships
yet are required to provide care that is responsive to their needs. A particular set of
challenges occurs when the patient and the caregiver are both intellectually impaired,
and the patient’s case is so complicated that a major change in care and coping must
occur:
Bob and his slightly younger sister, Dorothy, arrive at the clinic. Both siblings
are single and in their early 70s. Bob is Dorothy’s caretaker. The two of them
live alone in their childhood home. Dorothy is wheelchair bound from her
end-stage cardiac disease and also has COPD and dementia. She is on oxy-
gen. Bob is attentive, but overwhelmed and unprepared by the increasing
demands of Dorothy’s care. In addition to her breathing challenges, Dorothy
is barefoot, feet swollen and unkempt. Bob shows kindness and calm as he
deals with his sister, but also limited ability to understand her disease or com-
municate with others. As Bob checks in at the front desk, Dorothy begins to
scoot her wheelchair across the lobby floor at a snail’s pace. She is purposeful
in her effort, her lungs fighting for air with each movement. As Bob finishes
his interaction with the office staff, he notices Dorothy has positioned herself
at the door to the lobby restroom, but cannot muster the strength to move
forward over the ½” grouted crevasses in the tile floor. “Dorothy, I can’t get
you in there. I can’t. You can’t get yourself in there,” says Bob. Dorothy stares
down the half-open door and black void that is the restroom. She cannot go
further. Bob cannot take her further. “Unlock your chair and let me push you
back over here.” Dorothy mutters in a slurred sound, “I don’t know how to
unlock the chair.” Bob releases the locks on her chair, and it is easy to imagine
his deep weariness. Moments later, Dorothy’s name is called by a young office
181 Openings
assistant. Bob sinks blankly into his chair, knowing that for these 15 minutes
he can rest. Someone else will have oversight of Dorothy. Dorothy, struggling
for air, frustrated and hurt by her brother’s response, goes down the hall to
meet the nurse practitioner: someone unaware of Dorothy’s life, relation-
ships, or circumstances.
After sharing this story with a class, encourage students to meet in groups and dis-
cuss how to proceed with this patient from a communication transition standpoint.
Here are some questions that will facilitate a discussion about moving Dorothy toward
transition.
• Would it be obvious to a nurse practitioner that this patient needs further support and
care in addition to the care provided by her brother?
• Would the nurse practitioner try to find out about the home caregiver, even if this
person were not in attendance at the appointment?
• What would the nurse do upon realizing Dorothy’s dementia?
• Without a previously existing relationship with Dorothy and her family, how does the
nurse proceed moving this family toward a better care situation?
Exercise #3: The M&M/Skittles Game—Sharing Information

In this course project, students will demonstrate the level of willingness or unwilling-
ness associated with sharing various types of information.
Necessary supplies include a large bag of M&Ms or Skittles, enough so that mem-
bers of the class can all have several, as well as a chart of “colors of candies” and
the disclosure associated with each color. Create a category for each color of candy.
The disclosures associated with each color should range from impersonal to more
personal.
Examples: Red = Favorite movie

Brown = Ideal vacation, destination
Yellow = Pet peeve
Green = Thing that would ultimately make me happiest
Blue = Thing I fear most
How to proceed:
1. Before revealing the color chart or the instructions for disclosure, pass around the
bag(s) of M&Ms or Skittles. Instruct students to take as many as they want from
the bag, but be sure to tell them that they must take at least one.
2. After all students have taken at least one piece of candy, then display the chart that
lists the type of disclosure associated with each color of candy used.
3. In groups or as a class, instruct students to answer the question for each candy
that they chose from the bag. If students chose several candies, they must answer
several questions. Students may find that they will be answering the same question
multiple times, but using different answers, if they chose several of the same color
of candy.
4. Lead a class discussion that focuses on these questions:
• How would you apply the concepts of breadth and depth of disclosure to the informa-
tion that you just shared during this exercise?
• Which types of information were easier to share with the group/class? Why? Which
were most difficult? Why?
Exercise adapted from West, R., & Turner, L. (2007). Introducing Communication Theory: Analysis
and Application (4th ed.). New York: McGraw-Hill.

chapter material
SUSIE AND THE POPSICLES: IDENTIFYING SOCIAL

PENETRATION THEORY AND COMMUNICATION
PRIVACY MANAGEMENT THEORY
The Pulitzer Prize–winning play Wit is a powerful tool for all clinicians training to deal
with terminally ill patients. Near the end of the play, Vivian Bearing, the protagonist, is
succumbing to death from OVCA. She has been engaged in aggressive research trials for
several months and is very sick. The play depicts Vivian’s own journey of stripping away
personal identifiers, such as professional status, treatment of others, family connections/
disconnection, and personal successes. As she is actively dying, Vivian finds her humanity
and embraces what she believes matters most in life. In one of the final scenes, Susie, her
nurse throughout most of the play, shares a long scene with her in which a DNR deci-
sion is finally discussed. Susie displays a great deal of skill in her clinical communication
practice with Vivian. This learning session with require access to the HBO version of the
script, and a basic understanding/summary of the movie. What follows are the steps and
questions to incorporate as part of the Susie and the Popsicles exercise.
• Show video segment. Share a brief discussion about this segment and the characters
of Vivian and Susie.
• Revisit the scene and search for moments of social penetration theory demonstrated
by Susie. Note examples of depth.
• Revisit the scene and search for moments of social penetration theory demon-
strated by Vivian. Note examples of depth. Note examples of breadth. How many
of each?
183 Openings
• Is reciprocal or complementary communication at work between Susie and Vivian in

their self-disclosure?
• Revisit the scene and search for moments of private information disclosure from Susie
to Vivian. What strategies does Susie use?
• How can the boundary between Susie and Vivian be described?
• What does their shared boundary quality say about their relationship?
Source used in this exercise: Edson, M. (1993). W;t. New York: Faber and Faber, Inc.
moving toward the tension: brief

communication role play scenarios
Four brief role play scenarios are included here and should be explored in very small
groups (three to four). Reverse/change roles after you have worked with the situation
for 5 minutes. After completing two versions of the role play, the participants should
discuss:
1. What verbal/language strategies were most helpful?

2. What verbal/language strategies were least helpful?
3. What nonverbal communication strategies were most helpful?
4. What nonverbal communication strategies were least helpful?
Role Play #1
Ms. Smith is a 42-year-old single mother with moderate COPD. She has been in and
out of the emergency room many times. However, this time, she is terrified as she is
more short of breath. She asks you, “People don’t die from this do they?”
How do you respond?
Role Play #2
Dr. Martha Rollin is a neurologist caring for Molly, a 21-year-old who has
Huntington’s chorea. Molly has had more difficulty speaking and moving. It has
become apparent to you and all other nursing and medical team members that
Molly is declining, and yet Dr. Rollin has been reluctant to inform Molly, her fiancé,
or her parents of her prognosis. One of the other nurses shared in report that Dr.
Rollin once mentioned that Molly reminded her of her own granddaughter, and the
resident mentioned that Dr. Rollin told him that Molly was one of her longest-term
patients. The nursing staff has become increasingly frustrated as they feel Molly,
her fiancée, and her parents need to be informed of her status. Late this evening,
Dr. Rollin returns to the hospital for a new admission, and you decide this is a good
time to discuss Molly’s care with her.
How do you initiate the discussion?
Role Play #3
Valnezio Quartera is a 76-year-old man with heart failure, severe coronary artery
disease, and aortic stenosis. He is currently back in the hospital for dyspnea and chest
pain. His wife died one year ago from a myocardial infarction. As you, the critical care
nurse, enter the room to hang an IV diuretic, Mr. Quartera asks you, “Susie, you don’t
think I’m going to die do you?”
How do you respond?
Role Play #4
Paulo Rodriquez is a 49-year-old with a recurrent brain tumor currently hospitalized
after experiencing seizures. Paulo was diagnosed at age 44 and has had extensive sur-
gery, chemotherapy, and radiation therapy. Three months ago, the brain tumor team
advised Paulo and his family that there were no further treatment options, at which
time his family took him to Mexico where he has had numerous herbal therapies and
traditional folk remedies. He has experienced weight loss, increasingly severe head-
aches, nausea, and now seizures. Following a severe seizure last week, his girlfriend
brought him back to the emergency room for care. As you wait with Paulo for a scan,
he tells you he is so tired of treatment and being taken far away and just wishes his girl-
friend and children would “give up and just let me be at home so I can play with my
dog and be with my friends.”
How do you respond?
Exercise Source
ELNEC Critical Care Training Program. (2010). Communication Module Six:
Supplemental Teaching Materials, Figure 5. Communication Role Play Scenarios. COH &
AACN. The End-of-Life Nursing Education Consortium (ELNEC) Project is a national
end-of-life educational program administered by City of Hope Medical Center (COH)
and the American Association of Colleges of Nursing (AACN), designed to enhance
palliative care in nursing. The ELNEC Project was originally funded by a grant from
the Robert Wood Johnson Foundation with additional support form funding organi-
zations (the National Cancer Institute, Aetna Foundation, Archstone Foundation, and
California Foundation).
185 Openings
Table 6.8 Suggestions for Communicating with Patients or Family Members with Limited
Understanding
• Double the consultation time if possible or schedule at a time in the day most likely to
provide the most time.
• Communicate directly with the challenged individual and then to a support person or
interpreter. Maintain nonverbals that are directed at the primary person in the interaction.
• Rearrange a question if the previous attempt garnered inconclusive or unproductive
results.
• Preview the contents of the consultation before it begins.
• Utilize additional aids (i.e., pictures, writing, symbols, etc.) and supports to increase the
health literacy level for the patient/family.
• Practicing a teachback approach might be helpful, in which the patient/family explains
back to the clinician what has been discussed or decided.
• Use language that is accessible to this person.
• Use events and places in conversation that the person will likely relate to and understand.
• The person in the consultation might have little understanding of a cause–effect dynamic
when it comes to his or her illness (e.g., continued smoking will make COPD worse).
Adapted from Tuffrey-Wijne, I., & McEnghill, L. (2008). Communication difficulties and intellec-
tual disability in end-of-life care. International Journal of Palliative Nursing, 14, 189–194.
Table 6.9 Potentially Helpful Things to Say During the Distressed Phone Call
Situation Communication
To understand emotion better “You sound pretty low.”

“I can hear the frustration in your voice.”
Identifying the issue “Earlier in the call you asked . . . ”
“So, what I think you are saying is that . . . ”
Periods of crying/silence “Take your time.”
“I’m here when you want to speak.”
“Remain silent.”
Rudeness/abusive behavior “I want to help you but will not continue
this call if you are shouting.”
“I really want to help you, but if you
continue I will have to hang up.”
Adapted from Saunders, J. (2004). Handling unexpected distress on the telephone: The develop-
ment of interdisciplinary training. International Journal of Palliative Care Nursing, 10, 454–459.
7
relating
Billy Green was a 4-year-old African American diagnosed with a brain tumor.
Over the next 3 years, he went through surgery, chemotherapy, and radiation,
and twice he experienced remissions of 10–12 months, during which time there
was hope for his long-term survival. Billy’s mother and maternal grandmother
were devout Baptists who believed in miracles, and despite each recurrence they
persisted in their faith for his recovery. Billy’s father voiced concern as he now
experienced yet another recurrence, this time the tumor causing seizures and
extensive neurological deficits.
Billy’s parents have been asked to meet with the pediatric oncology team to
make treatment decisions. His oncologist acknowledges that there are no further
traditional treatments available but does offer a new clinical trial. Mrs. Green
questions the physician about potential side effects, and the oncologist describes
possible side effects, which could include worsened seizures, hypertension, and
hemorrhage. Mr. Green then becomes very angry and emotional, announcing,
“I think it’s time you leave my boy alone. Enough!” Mrs. Green sobs but clutches
her Bible and begins to pray and chant. Billy’s grandmother comforts her daugh-
ter and son-in-law and assures both that Billy will pull through, saying, “God
isn’t going to take our boy.”
Billy’s grandmother cannot accept any outcome other than cure, at least at
this moment. Billy’s father wants to withdraw his son from curative medical
interventions and pain-inducing procedures, at least at this moment. Billy’s
mother is able to consider the impact of a clinical trial on his fragile quality
of life. Each of these three caregivers has a radically different way to engage
the news delivered to the family. What they all face is the decision of care for
Billy; what each needs is more conversation and communication that takes into
account who they are as people and as a family. This can happen if the relation-
ship between the clinician and the family/patient is prioritized.
This chapter presents relating as a strategy to advance patient and family understand-
ing. The surface of the spoken word is peeled back to consider what the action or force
of language might include. A complex architecture of goals is always at play, no matter
who is doing the speaking. Because the true motives and goals of a speaker are rarely
fully understood or realized, the recommendation in this chapter is to attend to the
187
relationship goal (sharing meaning) always, in order to facilitate the instrumental goals
(providing specific health care) of nursing. Throughout this portion of the book, there
is the opportunity to examine more closely the phenomenon of patient/family non/
acceptance of an illness status, as well as understanding patient/family perspectives on
adjusting to new information unfolding throughout a serious or terminal illness.
A set of theory-driven ideas from communication is brought together with nursing
research to ground this element of the COMFORT model. All of the concepts pre-
sented here create a mosaic of knowledge that demystifies misunderstandings, conflict,
and disconnection experienced between clinicians and patients/families during a time
in the illness trajectory when all of these parties feel the greatest need for support and
communication connection.
ADAPTING TO THE PATIENT/FAMILY

Clinicians might assume what information will be easily processed or understood by
patients and families and what information will be difficult to engage. In fact, this
latter assumption—what will be “bad news,” or difficult news—is often presumed by
clinicians. Such presuppositions are questioned in this chapter and fall into the sender-
based perspective on communication that discounts the unique circumstances of each
patient case and person.
Consider the case of Bob, whose wife is just coming out of an exploratory laparos-
copy. This procedure was at last pursued to finally locate the source of her troublesome
appetite and weight loss, as well as bouts of great nausea and cramping. Bob is ushered
down to a private meeting room, and upon entry he sees a chaplain, the surgeon, and
the nurse. Bob is very anxious simply by the efforts made to seclude him in this room
and by the conspicuous presence of the hospital chaplain. His pulse races with con-
cern. He sweats. He notes the tension in the room and the anxiety projected by the
chaplain and two clinicians. The surgeon tells Bob that she has the “worst possible
news” for him. In the surgical procedure, one large cancerous mass was found in his
wife’s upper bowel, and two lymph nodes excised were also positive. The discovery
made in surgery was a devastating one.
But, for Bob and his wife, this news carries with it relief. For 14 months her diagno-
sis had been elusive, and three physicians had dismissed her symptoms as being related
only to anxiety or suggested she had only a minor inflammatory bowel dysfunction. In
the past year, her quality of life had been reduced so radically that she was no longer
able to travel with her job or to see family. Weakness and abdominal pain had tor-
tured and worried both of them these many months. Learning a firm diagnosis that
explained all of her pain and loss felt more like a relief than staring down the worst
news of Bob’s life. The couple had already known this was a devastating health situa-
tion. Without taking into account some of the experiences of the patient and family,
the clinician has nothing to adapt to and communicates using his or her own experi-
ence as a measure for how to deliver information.
Talking and communicating in a way that is radically adaptive assumes that the
clinician cannot know the reaction or perspective of the patient/family without first
189 Relating
receiving it. Removing the clinician’s own response and opinion from the expected
communication outcome puts the “other” first. The idea of narrative nursing is under-
scored again here, and one of its central tenets is to accept that the end of the story is
not known, and that the outcome of the interaction is just as dependent on the patient
and family as it is on the clinician.
Observations of patient and family interaction with clinicians reveal that repetition,
redundancy, rejection, and selection are very present in the communication process
of absorbing illness status (Eggly et al., 2006; Wittenberg-Lyles, Goldsmith, Sanchez-
Reilly, Ragan, 2008). Additionally, there is a flawed conception among clinicians that
information central to decisions about care in illness will be clear to the patient and
family if it is presented as one focal piece of information. In fact, many patients/
families change the subject of a conversation topic during “bad news” discussions in
order to process concerns that they have, that are difficult for them, that are blocking
them from moving forward in their care. A singularity of topic is rarely experienced
in actual interactions, though that is commonly the preparation clinicians receive in
their curriculum.
Diversified approaches and responses to a subject can be referred to as the diffu-
sion of topic. For instance, consider Ben, a nurse from a palliative care team sent to
discuss plans of care with Maggie. The report Ben received from the attending physi-
cian was that Maggie was impossible to talk to and seemed to be on another planet in
terms of facing her care decisions. When Ben visited with Maggie about care options
as she faced the end of her life, Maggie was resistant and indicated many times that she
needed to get to a place “where her legs would work again.” After Ben realized he was
going down the same road as the attending physician, he stopped pressing Maggie to
do the care planning and listened to her. The investment in Maggie paid off quickly.
Ben learned that Maggie was responsible for the care of her adult autistic son and
his three dogs. She viewed these dogs as central to her son’s health and functioning.
Though Ben originally arrived at Maggie’s room with the intent to “make a plan” for
her, this central topic had to be diffused to address Maggie’s deep concern—which was
for her son, not herself.
A term that is infinitely useful in explaining patient or family acknowledgment of
changing health status is acceptability. To accept news or change is to acknowledge
that it is real and assent to that information in planning, behavior, and communi-
cation. Acceptability is arrived at with more ease if the patient/family is adapted to
first and foremost in terms of their experiences and needs. Patients and families
bring lifetimes of patterns and “baggage” into one of the most difficult chapters in
life—end of life.
Revisiting the opening pediatric case study, the grandmother could be a major fac-
tor in delaying acceptability, as Billy’s case becomes palliative and hospice appropriate.
Adjusting for these challenges can be so rewarding, especially when clinicians lay down
their own personal goals and checklists and invest in individual(s) with limited accept-
ability. Acceptability coincides with a shift in patient/family narrative from one that is
chaotic, or tightly grips the promise of restoration, to a narrative that looks ahead to
the possibilities presented through illness.
QUEST NARRATIVE
As palliative care is initiated, patients and families have a high degree of uncertainty
about the care-planning process. Many families report that they “have never done this
before” and are unsure about working with patients to provide care at home. This ambi-
guity leaves them searching for an alternative way of living with illness (Frank, 1995).
Since cure is no longer a viable outcome for their illness story, patients and families look
for other sources of meaning as a way of managing their uncertainty. The discovery
of something useful from the experience of illness is called a quest narrative (Frank,
1995). These are stories that illustrate patient/family acceptability and often include
acknowledgment of significant changes (both vocational and personal) following an
illness (Frank, 1995). Though Frank’s naming and observation of the quest narrative is
not empirically based, the authors suggest that this kind of narrative can be a useful goal
for nurses caring for patients and families facing serious and terminal illness.
As the illness story is told, the goal is to support patients and families as they work
toward rewriting a no-longer-useful story of cure. Three distinct phases comprise the quest
narrative and point to specific junctures in a patient/family member’s story identifying the
quest. In the first part of an illness story, symptoms are disregarded and refused, only to give
way to acknowledgment of the disease/illness. This acknowledgment signifies a threshold
that indicates a move toward acceptability (Frank, 1995). Next, there is a major turning
point in the illness story that is typically described (through metaphor) as a crisis or unsuc-
cessful treatment (e.g., surgery, chemotherapy, radiation). Following this critical turning
point (treatments have not been effective, a critical health/safety condition arises, or no
other treatment options exist), the patient/family gains awareness and realizes where they
are in the illness journey. Discovery is gained from the event or critical turning point and
brings a sense of identity related to the illness. Finally, changes as a result of the illness are
brought to the forefront of the patient/family’s character, and the lessons learned reveal
perseverance and the richness gained through suffering. Box 7.1 provides an example of a
patient’s perspective that is consonant with the quest narrative. The point of this chapter,
though, is to emphasize the role the nurse plays in making a narrative like the quest narra-
tive more likely and attainable. The quest narrative becomes more possible if the nurse uses
communication to intervene.
Box 7.1
“I have learned how much I love life and how precious it is . . . I have learned that no
matter what, the journey doesn’t have to be all about dark and dreariness and the end.”
—ALS patient
The nurse’s task is to enact communication skills that reduce uncertainty and reau-
thor the illness journey toward a quest narrative. By encouraging patients and family
members to reflect on the illness and its impact, the nurse can identify patient/family
sense making (why they believe this is happening, how they are interpreting changes),
191 Relating
allow them to assert control over their story, point out prior decisions and results,
establish a sense of community with the patient/family, and distinguish new identities
(Sharf & Vanderford, 2003). Nurses need to assess acceptability and adapt communi-
cation accordingly.
Patients and families are often inclined to share their story as a way of acclimating to
new staff. It is during this first storytelling that nurses can begin to decipher acceptabil-
ity. Take, for example, the first-time meeting between a hospice nurse and the mother
of a 29-year-old woman who has been referred to hospice. The referral sheet shows that
this young patient had a kidney transplant at age 7. The kidney failed approximately
14 years later. For the last 8 years, the patient has been on dialysis and has had three
strokes, and she has been bedbound with a feeding tube for over a year. Her mother
recalls the events leading up to this initial hospice visit as illustrated in Figure 7.1a.
“We are down to our last location for dialysis. Two weeks ago she came down with a rare form
of e-coli and had a temperature of 103 for three days. And because she’s hypotensive, they had to
put her on IVs and antibiotics and several heart medicines. Her hands and feet turned black. Now
she’s off and her hands are pink . . . She has been at home with us and has been able to walk and
move. She has limited vision and now her vision is totally gone. She has incredible joint pain. It’s
not going to get any better. We can take her some place, like long term care, but I don’t know what
good it will do. She’s very susceptible to infection. It’s time . . . ”
Critical Turning Point –

Acknowledges that no other
Nurse: This started a year ago? options exist following this
health crisis
“Yes, Karen had an infection in her catheter. She’s been on dialysis for 8 years.
She was born with this. She knows. Last year she had an ulcer
in her esophagus, it eroded and she had a stroke. She was in the Acknowledges disease and its
hospital from July through January . . . My head has already progression.
made the decision, but my heart is just breaking. You (hospice)
have been recommended from folks who have used you – they (hospital) would
like her gone today.”
Nurse begins to discuss hospice philosophy, focusing on time frame to death once dialysis
is stopped.
“I think she’s there, but she doesn’t want to die.”
Nurse: “Of course, she doesn’t want to die and no mother ever wants
to have a daughter die. In hospice we have cared for many families Nurse attempts to identify
whose circumstances are very much like yours. We fi nd that even meaningfulness in the
illness story, shifting this
in these very difficult circumstances, patients and families do best
toward a quest narrative.
when they can openly talk about what is happening now at the end
of life, say goodbye and to let each other know how much you love
each other. You said a few minutes ago that “It’s time . . . ”. It seems like you really are
aware that your daughter has only a few weeks of life remaining. Can we talk about how
we can best support you and Karen in the days ahead?”
figure 7.1‘ ! Illustration
In this case, a family meeting is held to determine plans and place of care for a 58-year old male.
The wife is under suspicion of attempted murder of the patient, her husband. He has been shot
from the rear twice within two months. As a result of this second shooting, the patient has been
wounded in the back and lung. He is unconscious, and will not recover.
If the wife goes to jail, she loses all rights to make decisions therefore decision-making would
transfer to the patient’s five children, of which only one son has kept in regular contact with the
patient.
The wife of the patient and her brother are present for the family meeting. Health professionals
present include a nurse, social worker, resident (R), and attending physician (AP).
Brother: What is his condition? It’s changing drastically.

[Team introduces themselves.]
Brother: He’s had a dope habit, very bad.*
Direct Act Indirect Act Multiple Goals

-Informing team -Deflecting blame TASK: protect sister
-Identifying factors RELATIONAL: reveal
contributing to shooting self as in control of
family knowledge
[Brother says to wife:] Tell them the truth, nothing but the truth, or they can’t help him. *

-Advising sister -Demonstrating innocence TASK: present family roles to team
-Assuring team of sister’s RELATIONAL: demonstrate care
innocuous role in the demise of sister to the team
of patient
Wife: He’s aggressive.*

-Announcing character -Denying fault TASK: explain her
of her spouse innocence
-Attributing shooting RELATIONAL: present
to his bad behavior herself as victimto the team
Brother: They have lost everything, there are lots of problems.*

-Disclosing loss -Positioning husband at TASK: convey a vast amount of
fault difficulty and complication to team
-Positioning wife as RELATIONAL: manage
victim caregiver for her sister
RN: Is there any other family?

Wife: Yes, he has five kids that live in Nebraska. His father is dead and his mother lives in an
Alzheimer’s facility.
RN: How long have you been with him?
Wife: 16 years.
RN: Do you have any kids?
Wife: Not any more.
Brother: She lost her only son to suicide. We have lost lots of family to suicide.
figure 7.1a! Family interaction (no patient present)

193 Relating
Wife: You should know my husband is an ex-felon. [she discusses past experiences of gunshots
produced by dying husband].*

-identifying husband -exonerating herself TASK: clarify her
as criminal of blame innocence
-deflecting guilt RELATIONAL: evoke
sympathy from team
-gaining protection
→ AP: [talks about the patient’s care and where the patient has been and what the healthcare
team has been doing]. He’s barely responding to any stimuli. He’s not communicating.
Wife: Why are there so many changes in his condition?
Resident: [explains gunshot wound impacts many physical systems which means the patient
is at risk for many complications—though the man is stable currently.]
Brother: Well, the other doctors have said to look into long-term care.
AP: Let’s talk about that. First, he’s not a candidate for rehabilitation because he cannot
communicate. The next choice is long term care and that’s probably what will happen.
He needs constant 24-hour supervision for care.
RN: Has he ever talked about what he would want if he was in a condition like this?
Brother: We’ll yes he said put me in my favorite car and drive me off a cliff.
RN: Well yes that comment is helpful. Did you share any other talks?
Wife: [explains that the patient has changed his mind many times about end-of-life
extension– and she gives examples]
Brother: He’s been addicted to many different drugs, pain medication, and stuff.
Wife: [talks about life troubles and being thankful for her brother]
Brother: Is he conscious?
RN: [explains that he doesn’t have consciousness]. He doesn’t have the capacity to make
decisions.*

-disclosing that husband -suggesting that decisions TASK: clarify husband’s
is unconscious and unable of care must be made status
to direct his own care by someone in family
-impressing upon family RELATIONAL: remind
that decisions are needed wife of her role as spouse
Resident: I agree.
RN: It’s about following the patient’s wishes. What do you think he wanted?
Wife: [breaks down crying] I don’t know.
Brother: [holding sister’s hand] [says to healthcare team] I’m sorry, but she can’t handle this.
She’s never been able to [talks about patient]
[RN explains code status is about resuscitating him if his heart stops.]
The wife and her brother do not make a decision about code status and meeting is concluded.
figure 7.1b (continued)
PROBLEMATIC INTEGRATION
Changing probabilities about the disease and changing values about acceptable quality
of life create uncertainty for the patient and family; nurse communication is necessary
to facilitate discussions about uncertainty and shift toward a quest narrative. With
multiple parties involved in a patient’s plan of care, including nurses, numerous physi-
cians and specialists, and a range of family members and family involvement as well as
other health care providers, there are large variances of communication ranging from
open, to limited, to none.
As a result, a collective dilemma exists when communication becomes nonex-
istent or limited, and life-prolonging treatment continues as a means to managing
uncertainty about a prognosis (Hines, Babrow, Badzek, & Moss, 2001). Finding the
courage and resources to start a conversation with patients and families about how to
manage new information, make sense of ambiguous communication about progno-
sis, and initiate information seeking depends on how uncertainty is managed (Step &
Ray, 2011). Problematic integration theory explains how patients/families attempt to
manage uncertainty (Babrow, 1992; Babrow & Mattson, 2003). It includes two compo-
nents used in producing and coping with uncertainty: probability, the likeliness of the
event/issue occurring, and evaluation, an assessment of the goodness of the outcome.
Uncertainty results from the problematic integration of the way a person feels about
something (positive or negative emotional value) and their perceived probability that
something will occur.
When probability and evaluation do not complement one another, then commu-
nication and decision making become difficult. Nurses must be careful to assess the
patient/family’s acceptability and recognize that the same information needed to make
informed decisions will also facilitate their coping (Hines et al., 2001). One of four
things can happen when there is no consistency between what we value and what we
think will occur. Table 7.1 provides an overview.
Ultimately, communication is often the source of problematic integration as well
as a resource for coping. Communication and decision making are easier when prob-
ability and evaluation judgments merge. But the uncertainty of illness leaves patients/
families asking difficult questions that clinicians, many times, cannot answer to the
satisfaction of the patient or family. Nurses are often asked:
¾ Why is this happening to me? Why is this happening now?

¾ How long do I have to live?
¾ Do you think I am dying?
The following examples illustrate uncertainty in various forms (the four types of
problematic integration) and include attention arrows (→) to signal cues or prompts
produced by nurses to help patients/families navigate uncertainty.
Example #1: Divergence

nurse: Anything I can do for you?
patient: I just want it like it was before.
→nurse: What do you mean, “like before”?
patient: Everybody was nice. Now they want me to leave.
→nurse: Are you ready to go home?
patient: I’m not ready to go home but they told me to go home. I don’t have
nobody [sic] to call to take me home.
195 Relating
Table 7.1 The Four Forms of Problematic Integration

Communication Behavior When What We Value Example
and What Might Occur Clash
Divergence “After these treatments I will be right

Discrepancy between what we want back at work and running my kids
(evaluative) and what is likely (probabilistic) around.”—Patient
Ambiguity “I don’t feel like a woman anymore and
Probability of the event is unknown or the word ‘freak’ is always there. Plus I
uncertain. was told it may spread to the other breast
which is like walking about with a bomb
waiting to go off ”—Breast cancer patient
Ambivalence “He (patient) knows he’s going to die. He
When two equal evaluations are present or an realizes that. About a week ago he was
event produces two contradictory responses having a hard time and he said, ‘I really
need to go, but I really don’t want to
go.’”—Caregiver
Impossibility “This is such a shock because we thought
When an individual feels absolutely certain we beat everything and we’ve been saying
that an event will not happen. This is ‘you’re going to die at an old age.’ Just last
problematic for seriously ill individuals who week he said to me, ‘You know it’s ironic
maintain hope that they will get better and that both my parents died in their 90s
live longer and it looks like I’m going to die the same
way.’”—Caregiver
nurse: You were too sleepy yesterday to go home. I know it is scary to go home,
but we will be sending the nurses to your home to check on you there. And
I bet you will be glad to be in your own house again. Who will be at home
to help care for you?
patient: My daughter.
nurse: Well, I know she came up here last night and your daughter wanted to
take you, but they couldn’t get you awake. Do you remember that?
patient: Oh, yeah.
nurse: They will be back today.
For this patient, there is a discrepancy between what he wants (to stay at the hospice
inpatient facility) and what is likely (he will go home with his daughter). The nurse
focuses the patient’s communication on upcoming interactions that will clarify what
the patient wants, in order to move the patient to acceptability.
Example #2: Ambiguity

sister of patient: She looks so good. She’s improved so much in the last 24 hours.
Her color is good and she even ate breakfast this morning.
nurse: I’m glad she’s perked up, too. We need to be cautious, though, in
thinking about her getting better. Sometimes people “rally”—meaning
they are very sick but then they perk up. I wanted to let you know that
we are also very pleased since she is really enjoying today and especially
your visit.
sister of patient: Yesterday we thought she was leaving, but today I don’t.
→nurse: Overall, while this is a good day for her; unfortunately, we know
that her body is getting much worse. Her kidneys are failing and her heart
is also much weaker. It’s very hard for loving families to have this “roller
coaster” of ups and downs. We want to really seize days like today to enjoy
while also preparing for what is to come.
In this instance, the sister of a patient focuses on aspects of health care that involve a
move toward recovery or cure. The nurse uses ambiguity here to remind this woman
that her sister’s rally is joyful, but she also communicates that the patient is moving
closer to death rather than farther from it. By using the dissonance in the sister’s state-
ments, the nurse is able to reiterate that her sister is still dying despite changes in her
affect and interaction. It would have been the less complicated path to simply allow
this family member to remain in a state of hope about a revival, but this nurse has the
wisdom to move the sister toward a clearer understanding of her loved one’s illness
trajectory.
Example #3: Ambivalence

husband [of patient]: He [referring to oncologist] just came in here and told
us we could either try for a clinical trial or do nothing and that either one
would get us the same amount of time with her.
→nurse: Oh. [silence] Okay. Did the doc give you some specific information
about the trial?
husband: No. Honestly, I don’t want to know about either option right now.
I can’t really imagine either outcome, and they both seem to be the same
thing. A nightmare in the end.
→nurse: Have you talked to her about it (referring to spouse)?
[silence]
nurse: Maybe you can just be with her now. How about I come by in a couple
of hours and talk about the options with you guys?
Although this husband is ambivalent about this wife’s condition in that he is pre-
sented with two equally difficult choices, the nurse quickly identifies that more
communication and family interaction would be a helpful first step in determin-
ing what really matters for this family. By providing some specific directions and a
timeline (2 hours), this nurse is able to prioritize the husband’s planning and pro-
vide direction for moving forward.
197 Relating
Example #4: Impossibility

patient [31-year-old woman with stage iv cervical cancer, brain mets,
left leg and right arm paralysis from spinal metastasis]: I just
need to get back to a place where I can get around with the walker. Then
I can get home. My daughter needs me. I just need to get home where I
can really focus on getting better. I am on a LISTSERV for people with this
cancer, and some say they have lived with it for 25 years. I will be one of
those people.
nurse: Is there anyone at home to take care of you?
patient: Taking care of my daughter is me taking care of me. That is how
I have beaten this thing.
→nurse: Your daughter is the most important thing to you, it sounds like.
[silence]
And it sounds like you are a tremendous mother. And facing all you have
faced the way you have done it, you love her so much.
patient: She is my life.
→nurse: I would like to come back in a little while with Ben, the social worker.
We would like to help you think about what kind of help you need once
you go home to take care of yourself and your daughter.
Readily seeing the difficulty this patient faces in understanding a shift toward active
dying, the nurse begins with a small step/plan that she shares with the patient to a
focus on her priority concern of her daughter. Sharing an understanding with the
patient about her concern and offering a next step in addressing the primary concern
is an effective way to move patients/families who seem stuck in their thinking or action
about care planning.
Problematic integration invites clinicians to recognize indicators of low acceptabil-
ity from patients and families as they grapple with their end-of-life challenges. Each of
the arrows noted in the above exemplars correlates with relational concerns/content
for these patients/family members. These interactions demonstrate the forces present
in conversations and recognize a patient or family member’s relationships and the role
relationships play in decision making. Relationship is core to the patient/family and
can serve to connect nurses with always-salient issues at end of life. Searching for addi-
tional cues from talk can be achieved by applying an idea called speech act theory. This
concept enlightens the work of identifying acceptability by also considering what is
actually being said (and done) when words are spoken.
SPEECH ACT THEORY

The core of Speech Act Theory claims that words act, or perform action. In other
words, even though words (utterances, phrases, talk) encode information from one
speaker to another, people are clearly doing more things with words than just convey-
ing information. And when people convey information, oftentimes they communicate
much more than their words encode. It is this series of complications that is addressed
in speech act theory, and the intention here is to connect the knowledge of these ideas
to the practice of palliative care nursing.
Speech act theory clarifies that words are often received in a way not intended by
the sender; this is true for a patient, family member, or clinician in the context of life-
limiting illness. Despite assessing, planning, and intervening with communication, the
patient and family bring elements to the experience of care that no clinician or team
can guess or control.
J. L. Austin (1962) claims that producing an utterance is also the performance of an
action. Searle (1969) further extrapolated on Austin’s foundation by arguing that con-
text shapes acts of speech. Austin establishes three very distinct classes of action that
are happening when we talk. Put simply, he identifies the act of saying something, what
a person is doing in saying it, and the effects of the saying.
Austin names these three levels with their own unique terms. The meaning of an
utterance itself is referred to as the locutionary act (the act of saying something). The
illocutionary speech act (what a person is doing in saying it) performs its deed at the
moment of utterance. This level of action in speech demonstrates a contextual func-
tion. A speech act produces a force and in action does something simply by being stated
(e.g., describing, answering, identifying). Perlocutionary acts (the effects of the saying)
cause a secondary effect on the listener following the illocutionary act that often can-
not be predicted (Austin, 1962). Rules and requirements necessary for certain acts of
speech and their illocutionary and perlocutionary properties are the essence of speech
act theory. Perlocutionary acts are infinite and unpredictable, and are fully subjective
depending on the speaker, listener, relationship, and context (Butler, 1997). Refer here
to the third category in Table 7.2 in which the news of the test result will have effects.
Table 7.2 Speech Acts

Utterance:
Your test result was positive.
Locutionary act: the Illocutionary act: contextual Perlocutionary act: effects

meaning of a statement function of the act on listener (predicable and
itself not predictable)
The act of saying something What someone does in The effects of saying
saying something something
- To tell someone that a - To deliver bad news of a - In sharing news of this

test result had a positive biopsy test now known bad news, the
outcome effects on this listener could
range from acceptance and
understanding to denial and
misunderstanding.
Adapted from Austin, J. L. (1962). How to Do Things With Words. Oxford, UK: Oxford University Press.
199 Relating
Speech act theorists showcase the sequence of interaction and have exhaustively
established rubrics and flowcharts to demonstrate the connection between one speech
act and the next (Table 7.2).
Butler (1997) thinks of speech acts as interpolations of the very same utterances that
came before and will come after. She places force and rich meaning in the historicity of
utterances and their previous uses and contexts. This is a powerful concept in nursing,
as many subjects for patients and families are reified by the nurse after having been ini-
tially but too minimally addressed by a physician or other health professional.
Following a terminal diagnosis delivered by a physician, curative treatment thera-
pies are often the primary point of discussion and decision making for patients and
families (The, 2004). If a diagnosis of Stage IV pancreatic cancer is shared, followed by
a discussion of chemotherapeutic choices while prognosis talk is evaded, the physician
and the patient/family bypass the larger matter of goals of care in the life remain-
ing. Butler (1997) calls this phenomenon constraint. “The effort of constraining a
term or phrase culminates in its very proliferation—an unintended rhetorical effect”
(p. 131). In not discussing something, or using language that is threatening; the thing
itself is discussed, remade, proliferated, and enlarged. The nurse is often the partner
with whom constrained topics can be engaged.
DIRECT AND INDIRECT SPEECH ACTS

Sometimes an utterance that does something (illocutionary, e.g., “How is your pain?”)
is actually doing something else by way of performing another act. In the example
question about pain, the nurse is also (depending on the context and previous conver-
sation) making a statement that she is concerned that the patient is not experiencing
good pain control. In essence, a direct speech act presents one action but in actuality is
acting on two or possibly more matters of action with that one utterance. In examin-
ing these, it is quite plausible to see how any one utterance can accomplish multiple
actions. The direct speech act unpacks the content of what someone does in saying
something, while the indirect speech act category presents plausible additional actions
exerted through the spoken word (Clark, 1979).
Understanding the way in which speech acts actually work means that they have to
be considered in light of several factors. In conversations, speakers will say something
with total confidence—assuming that other participants will fully comprehend their
indirect meaning. Consider the following scenario. If travel partner Jo asks travel part-
ner Bill, “Are you sure this is the right gate for us?” as they await an outbound flight,
there are indirect meanings at work. Jo might be meaning that he and Bill are waiting
at the wrong gate. Jo might mean that he is doubting the trust he placed in Bill’s navi-
gation. However, if Bill misses these indirect meanings, he might simply assure Jo with-
out addressing these indirects. Sometimes a very different indirect meaning or action
is interpreted instead of the one intended by the speaker.
In an effort to classify direct speech acts, it would be simplest to consider the idea of
illocutionary acts in which the speaker utters something and means exactly and liter-
ally what he or she said. But quite frequently, when a speaker says something, the force,
or action of his or her speech can carry more than one meaning. For example, “Have
we fed the dog today?” not only has the illocutionary force of finding out whether or
not the dog has been fed this day, but also whether or not the receiver of the question
could/would feed the dog.
The chart below (Table 7.3) describes the four major categories of illocutionary acts
(what someone does in saying something) (Back & Harish, 1979). Examine the direct
speech act assigned to each of these four categories, and the possible indirect speech
acts that could be produced. This should begin to help in identifying multiple actions
that are carried out within most human speech communications.
MULTIPLE GOALS THEORY

The action that is produced in speech and the multiple goals that are accomplished
in an interaction share common objectives. In fact, multiple goals theory is derived
in part from speech act theory. In earlier parts of this volume, the ideas of task and
relationship are addressed as processes undertaken in any communication exchange.
These ideas have particular salience in nursing communication. Within the course
of an interaction, people have more than one purpose; this is the basic premise of
goal multiplicity. This idea of goal multiplicity accepts that goals and conversation are
tightly intertwined, and that people almost always want more than one thing when
they engage in interaction together (Tracy & Coupland, 1990). Because communica-
tors pursue multiple and often competing goals, problems and dilemmas can be com-
mon in interaction. Add to this the context of end of life, and differing perspectives are
quickly compounded.
Every person accomplishes, or attempts to accomplish, multiple goals in interac-
tions. Sometimes these goals are emergent, and sometimes people enter an interaction
knowing very clearly what they need/want to achieve. The strategies that people use to
manage and accomplish these goals remain ambiguous and of special interest to com-
munication researchers, especially in the context of health. Two communicator goals
are considered present in every communication. The first is an instrumental goal, or
what is seen as the basic purpose of the interaction. This instrumental goal has received
the label of “task” in previous aspects of this volume—so these terms can be thought
of interchangeably. But in addition to the “task” at hand, most people are concerned
with how they present themselves and the impact of the interaction and goal pursuit
on their relationship with the person(s) in the interaction (Tracy & Coupland, 1990).
These identity/relationship concerns become their own cluster of goal multiplicity in
an interaction. So, what takes priority? And how do interactions go wrong or right?
Communication scholars deduce that sometimes people might cue one goal orienta-
tion more heavily than the other—leading to unpredictable outcomes in the interac-
tion. New goals will also emerge as each speaker/partner makes certain conversational
moves in the interaction. It is possible to see the very clear impact of communication
on this experience of relating. The authors suggest that in the COMFORT model, pri-
oritizing the goal conditions of the relationship will facilitate the task goals that are
undoubtedly weighty.
201 Relating
Table 7.3 Speech Act Categories

Speech Act Categories Utterance Direct Acts Indirect Acts
Constatives: You have low blood Informing a patient/ x Expressing that

Affirming, alleging, counts. family that lab the patient
announcing, answering, results are not in the is facing an
attributing, claiming, normal range. additional
classifying, concurring, medical problem
confirming, conjecturing, x Preparing the
denying, disagreeing, patient and family
disclosing, identifying, for planning care
informing, insisting, in light of results
predicting, ranking,
reporting, stating,
stipulating
Directives: You need to cut fast Instructing a x Warning that
Advising, alleging, asking, food out of your diet patient/family to a patient is in
begging, dismissing, in order to control eat foods lower danger of further
excusing, forbidding, your blood pressure in calorie and comorbidities
instructing, ordering, and weight. containing higher x Asking a patient
permitting, requesting, nutritional value. to change his or
requiring, suggesting, her life
urging, warning
Commissives: You will feel better Guaranteeing x Avoiding the
Agreeing, guaranteeing, before you know improvement and complicated
inviting, offering, it. (Given as a restoration. reality of a
promising, committing, false assurance to declining health
pledging someone who is situation
terminally ill) x Promising a state
of improved
health in order to
distract
Acknowledgments: Hey, your creatinine Congratulating x Accepting that
Apologizing, condoling, levels are in the patient on regulated recovery and
congratulating, greeting, normal range. You kidney function. improvement are
thanking, accepting did a great job with in sight
increasing your x Acknowledging
liquids like we asked the patient/family
you to do. effort in solving
organ problems
that can be affected
Speech act categories adapted from Austin, J. L. (1962). How to Do Things With Words. Oxford, UK:
NURSING AND RELATING

In order to unpack the theories briefly described so far in this chapter, each will be iden-
tified in the following two interactions. Both conversations analyzed here were observed
in a clinical setting at inpatient hospice units or in a VA (Veterans Administration) pal-
liative care consultation setting.
In the first exemplar, a collective dilemma unfolds in a family meeting. The circum-
stances of the patient case are unique. The wife (present at the family meeting) is under
heavy suspicion of shooting her husband, the patient, and permanently disabling him.
The meeting described here is an attempt to deal with the patient’s needs and circum-
stances in the midst of this acute family drama. The utterances analyzed for speech
act function and goals are noted as central in shaping the outcome of this interaction.
Following the dialogue, a further analysis of problematic integration issues will high-
light other communication pathways that could have resulted in increased productiv-
ity and support on behalf of this patient (see Figure 7.1b).
The boxed analyses inserted near selected utterances reveal that this family can-
not, at this time, address the matters prompting the meeting. The brother of the wife
consistently holds a position of defensiveness for his sister, and this is all they can
manage. The intent to arrange a DNR and a place of care is never explored in a way
that reaches an active decision. The brother, in particular, has campaigned to have
their side of the story heard. This must happen first before the husband’s care can
ever really be addressed.
The physician explicitly states, “He’s not communicating.” After this declaration,
some false starts are made at moving this wife/brother duo to engage end-of-life pla-
nning, and specifically DNR orders. These attempts (i.e., he doesn’t have the capacity
to make decisions; it is important to talk about code status) lead to an inconclusive end
for the time being.
Examining this interaction using the ideas from problematic integration theory
helps demonstrate why some families find it impossible to engage the quest narrative.
Rewriting the dying story so that it can include opportunity requires some acknowledg-
ment of symptoms and the reality of a prognosis. In this interaction, the brother and
wife are tightly tied to the narrative of refutation, focusing instead on the patient’s life
choices (i.e., he’s had a dope habit, very bad; there are a lots of problems; we’ve lost lots of
family to suicide; he’s aggressive; you should know my husband is an ex-felon; he’s been
addicted). Team members attempt multiple times to guide the narrative toward end-of-
life decisions for this family, but this family demonstrates divergence. Their expectation
was that this patient would not still be living (Why are there so many changes in his
condition?), and now they are faced with the probable outcome that he indeed will live
in an unconscious state for some time and require extensive care planning.
The next interaction (Figure 7.2) features an 84-year-old man with late-stage pros-
tate cancer. This patient is alone and terminally ill in an inpatient hospice. He is also
experiencing dementia and was observed having repeated memory loss about his wife’s
death. This is a fairly common challenge for nurses. The exchange highlights the rela-
tionship between the clinician and patient above all else.
203 Relating
This exchange took place between a registered nurse and an in-patient hospice patient.
RN: Mr. X, you okay? You sleepy today?
Pt: Yes. Have you seen [wife’s name]?
RN: No, [wife’s name] passed away in April. You were here.
She died peacefully. *

-clarifying that wife is -comforting TASK: orienting patient
deceased -supporting to reality
RELATIONAL: condoling
Pt: Yes (pause).

[RN pats the patient on the back.]
RN: Do you need anything? Are you in any pain?
Pt: No.
RN: Okay, I need to take your blood pressure.
[Pt starts crying, sobbing.]
RN: I know you miss her a lot. It’s not been a good year. Hang in there (he continues to rub
and pat the patient’s back).
Pt: 46 years we were married.
RN: Yes, I know. How many grandchildren do you have?
[Patient is now crying, stoically.]
RN puts blood pressure cuff on the patient, continuing to rub his back.
RN: Alright my friend, 174/84.
[Pt looks away.]

-asking patient status -recognizing emotional TASK: pursuing response
from patient distress
-empathizing in pain of loss RELATIONAL: caring for
and acknowledging loss
RN: Are you okay?

RN [grabs his hand]: I lost my wife too.
[The two men hold hands. Silence.]
Pt: I need a tissue.
RN brings tissue and returns to nursing other patients.
figure 7.2 Patient interaction (no family present)
The RN described how the patient’s dementia caused him to relive the realization
of his spouse’s death three to four times a day. He would call his daughters at home
and ask for his wife. A large sign was eventually placed on the wall of his room that
said “[patient wife’s name] died on [month, day].” When this RN was asked how he
handled this over and over again, he said: “You let him know that she has passed away
and then try to refocus his attention. The chaplain and I actually take turns handling
it because it drains you to do that 3–4 times a day . . . I can’t imagine what it does to
him.” This passage of talk displays the importance of the patient/clinician relation-
ship goals, while task goals such as checking for pain control and blood pressure are
also pursued.
The type of problematic integration this demented patient communicates is
ambivalence—in which two contradictory realities are constantly at odds (his wife
is alive/his wife is dead). His dementia moves him several times a day between two
realities; one in which his wife is there but out of reach, and one in which he learns
his wife is dead. These two places of awareness are the primary trauma and concern
for this patient. In the interaction above, the RN has a keen understanding of this
patient issue and readily orients to the very point of ambivalence for this man.

What is unknown in Billy’s case, our opening case study, is what nursing or interdisci-
plinary care plans, if any, were designed to address the family’s low acceptability of his
terminal illness. What is known is that this family is now in crisis and has not consid-
ered other pathways of life other than that of cure. The father is deeply fatigued and at
odds with his wife and mother-in-law. This fissure will become explosive at the stage of
illness they face as a family. A great deal of work is needed to steward them through the
likely death of their precious boy in the weeks ahead. Relating using communication
interventions is the most effective tool left for nurses to use with this family.
ASSESS
What Billy and his family were actually revealing about their ability to process updates
about disease progression could have been identified in their communication with
family and clinicians. From the case study, it is possible to ascertain that Billy’s mother
and grandmother are steadfast in thinking that dying is an impossibility if they rely on
their faith. Billy’s father, of course, wants his son to live and recover but has indicated
concern over the aggressive treatments on more than one occasion. Within this one
family, at least two types of problematic integration are observable (divergence: father,
impossibility: mother/grandmother).
The four pillars of problematic integration (divergence, ambiguity, ambivalence,
and impossibility) are identifiable in patient and family communication. Simply being
aware of types of problematic integration can move the nurse clinician in the direction
of improved communication. Patients and families attempt to manage uncertainty
when what they want (restoration/cure) is not likely to happen, and they perceive a
declining status. For some, engaging in communication strategies that suppress, sus-
tain, or even increase uncertainty indicates that very important matters at this point in
life are not being addressed (Sharf, Stelljes, & Gordon, 2005).
As described in this chapter, direct and indirect speech acts provide clinicians with
a greater understanding of what actions are being expressed in communicative behav-
iors, and as a result offer potential ways in which clinicians can connect relationally
with patients/families. Assess for red-flag rationalizations in patient/family decision
making that signify a need for more clinician connection in order to move through the
illness process and better care for those suffering. Table 7.4 identifies rationalizations
and definitions, example statements that might serve as vehicles for these rational-
izations and their definitions, and the four areas of problematic integration—one of
which will resonate most strongly with a particular rationalization.
Table 7.4 Rationalizations in Decision Making
Rationale Definition Example/Circumstance of This Rationalization Problematic-Integration Type Indicated
Self-efficacy Emphasizes patients’/families’ own internal I am really focusing on my strong cells and sending them x Impossibility: When an individual
controls, abilities to influence their own the best energy I can. This can change the whole prognosis feels absolutely certain of an event or
health outcomes for me. outcome
Minimizing Statements minimizing risk factors, We can get through this, no problem. Cancer is not a death x Ambiguity: When the probability of an
threat possibility of prognosis, severity of illnesssentence anymore; you just get it fixed. event is unknown or uncertain
Fatalism Emphasizes the importance of powers that The outcome here is already written. We just have to trust x Divergence: Discrepancy between what
and faith outweigh self-control, i.e., fate or God in all the technology and try everything. God gave us this we would like and what is likely
technology.
Distrust Suspicion of health information, medical They are after the money with these treatments. How can x Impossibility: When an individual
procedures, motives of staff I even know if I need these if everyone is motivated by how feels absolutely certain of an event or
much they can make off of me? outcome
Desire for Requests for information or complains I would feel better if we could get a third opinion on this. x Divergence: Discrepancy between what
information about not having enough Neither clinic has been very forthcoming about the side we would like and what is likely
effects I read about.
Living with The capacity, or even desire, to live without I am not interested in finding out what is going on. I have x Divergence: Discrepancy between what
uncertainty knowing one’s diagnosis lived with this for 3 years and so far so good. we would like and what is likely
Futility Denies or questions utility of treatment or They can’t do anything for me. I have tried a specialist x Impossibility: When an individual
procedure already. I know how to take care of this on my own. feels absolutely certain of an event or
outcome
Postponing Puts off having treatment without I guess I am not interested in moving forward with these x Divergence:
refusing, delays medical treatment after diagnostics. We know things are not good, and I think I Discrepancy between what we would like
self-recognition of symptoms need to think about this a while. and what is likely
(continued)
Rationale Definition Example/Circumstance of This Rationalization Problematic-Integration Type Indicated
Physical Concern for pain or discomfort caused I can’t go through the PET scan. I just can’t face that again. x Ambivalence: When two differing
discomfort by medical procedures, anticipated, I completely panicked about it the entire day before but I evaluations are present
experienced know I have to do this.
Will to live Emphasizes the power of self-determination I am not giving up. My kids need me, and I am determined x Ambivalence: When two differing
to survive this will not put me down. I know that my test results are evaluations are present
declining, but my team tells me to stay determined.
Adapted from Sharf, B., Stelljes, L., & Gordon, H. (2005). “A little bitty spot and I’m a big man”: Patients’ perspectives on refusing diagnosis or treatment for lung cancer.
Psycho-Oncology, 14, 636–646.
207 Relating
Just as rationalizations can be posited as speech acts, so can turning points in

dealing with serious and terminal illness. Shifts in thought, understanding, emo-
tion, connectedness, and more can produce patient as well as family turning points.
Turning points for a patient or family sometimes are identified in the way that they
are communicated. For example, John has been diagnosed with end-stage small-cell
lung cancer. He has withdrawn from his job and has told his friends and family that
he is ready for hospice. His plan and place of care are clear. As John is spending his
last night as an inpatient before heading home, he asks his bedside nurse, “What will
it feel like to die?” John needs this conversation. He has made all of the recognizable
and somewhat public gestures of adjusting to his status as a terminal patient. But
he makes the private turn to that reality after the formal planning is over. Nurse-
identified themes indicating turning points for serious and terminally ill patients are
included in Table 7.5. The emergence of these themes in conversation can be used to
assess what a patient/family needs.
PLAN
Does Billy have a voice in his own illness and its progression/treatment? This is
unknown without more conversation to gain an understanding of this family’s qual-
ity of life across all domains. In designing a plan of care to increase acceptability and
understanding, the quality-of-life domains provide grounding in the aspects of life
that need attention (Ferrell, Dow, & Grant, 1995). Creating a plan of care using these
domains is also facilitated by an awareness of the narrative told by patient/family.
Frank’s (1995) three illness narratives serve to create a goal trajectory when pla-
nning to intervene with patients/families. The restitution narrative includes the
story of returning to the state of previous health. This narrative type can coincide
with overuse of curative therapies. The chaos narrative includes the story that no
one involved has control and every aspect of life is held hostage by contingencies.
The quest narrative has been described previously in this chapter, and stories ill-
ness (sometimes a new diagnosis and sometimes a new realization of a previous
diagnosis) as a new opportunity to live differently/better. The quest narrative does
Table 7.5 Potential Turning Point

x A patient wants to talk about life, dying, and/
or death.
x A patient shows signs of protecting privacy.
x A patient’s anxiety shifts from treatment to
existential matters.
Adapted from Brataas, H. V., & Thorsnes, S. L. (2009). Cancer nurses narrating after conversations
with cancer outpatients: How do nurses’ roles and patients’ perspectives appear in the nurses’ nar-
ratives? Scandinavian Journal of Caring Sciences, 23, 767–774. doi:10.1111/j.1471–6712.2008.00679.x
not include physical restoration as the focus but, rather, meaningful ways to con-
nect to others and what exists as important for that patient and family. Designing
a communication intervention for increased family acceptability will inherently
include a movement from either the restoration or chaos narrative toward the quest
narrative.
Bringing together the quality-of-life domains and Frank’s illness narrative allows
a nurse to get at the very domain(s) in need of conversation/communication. Figure
7.3 portrays patient/family movement to the quest narrative. This combination of
ideas also can showcase the very dissonant understandings that patients/families can
maintain as identities shift, family roles are strained, and losses multiply. In serious
and terminal illness, nothing will be the same. The restoration narrative stories the
return to a predisease body, the same relationships, same activities, and same capabili-
ties. But patient and family resistance to engaging a reality that adjusts for the phys-
ical, psychological, spiritual, and social costs of terminal illness is an indicator that
communication intervention is needed. Similarly, inability to move forward with any
planning out of fear and confusion (chaos narrative) can be present whether it occurs
in the domain of physical health decisions, psychological care, spiritual concerns, or
social well-being.
INTERVENE
The language and conversation needed to move patients and families to increased
understanding and acceptance are explicated throughout this chapter (problematic
integration, illness narratives, multiple goals, speech act). All of these approaches to
intervention position the messages of the patient and family as central in cuing nurse
clinicians about the most effective communication practice.
Restitution
Narrative
Quest
narrative
Chaos narrative
figure 7.3 Illness narratives

209 Relating
To remain focused on the goal of intervening to improve patient/family under-

standing, the quest narrative tenets can serve as a driving force in implementing plans
of care to address these needs:
1. Is there some acknowledgment of a change in health and life?

- If there is not, it is up to the clinician to acknowledge these changes.
2. Are there discussions about a turning point in the illness trajectory and its impact
on the quality-of-life domains?
- If not, it is up to the clinician to facilitate recognition and hopefully discussion
about turning points.
3. Can the patient/family describe their place in the illness journey?
- If not, or if description does not account for or acknowledge change and loss, it
is up to the clinician to contribute her description of the illness journey as well.
Relating to patients and families by letting them lead in conversational importance

is a productive way to intervene. The connection between people and their conversa-
tion is a powerful thing. This second set of intervention recommendations reminds the
clinician to practice narrative nursing. The patient/family will determine what news is
bad, how the story will end, what a shift in perspective will bring to the situation, and
so on. Use the acceptability chart in Table 7.6 that identifies three primary areas of
understanding and practical approaches for intervention.
Table 7.6 Increasing Understanding

Increasing Practical Interventions to Apply
Understanding/
Understanding
Adaptive x If a patient or family revolt, or become highly agitated, give them

Communication time and space.
x If a patient/family cannot digest the reality of a diagnosis, recurrence,
turning point, give them some time and try again with a new tactic.
Diffusion of Topic x Do not force a piece of information to be central to the conversation
if the patient/family stray from it to other concerns.
x Follow the primary need of the patient/family—they have a better
idea of what it is than anyone.
x Suspend the need to achieve your goals and work. More time
invested in relating will save time as end of life approaches.
Team Based x Use human resources available on your team.
and Family x Employ the complicated dynamics in the family to serve needs of the
Interactions patient.
Used with permission from: Wittenberg-Lyles, Goldsmith, Sanchez-Reilly, & Ragan (2008).
Communicating a terminal prognosis in a palliative care setting: Deficiencies in current communi-
cation training protocols. Social Science & Medicine, 66, 2356–2365.
EVALUATE
The use of diaries in the clinical setting is rare and is typically assigned to clinical trial
tasking. As such, “diaries” are often highly sanitized of narrative and essentially serve
as a schedule of events and results. The first evaluation recommendation does enlist a
diary. However, in this particular evaluative effort, a daily account of a patient’s prog-
ress would be written in everyday language by nursing staff. This account might even
include simple drawings or photographs in some cases. The diary would be given to
the patient/family after discharge from the unit and would include a simple question-
naire with an area for comments about the diary as helpful and representative of the
experience they shared with their nurses.
In a previous study that analyzed this evaluative tool, the results showed that half
of the diaries in the sample had been reread more than 10 times by family members/
patients. Nearly 70% of the questionnaire topics were graded as very positive or posi-
tive (Bäckman & Walther, 2001).
The limitations to such evaluations include time, money, and resources. But even
on a small scale, this can be a rich tool for study. A more feasible evaluative method
is to follow a case with a chart review and identify the conversations that took place,
with whom and when. Observe the presence or absence of communication charting.
Describe and then determine if communicative practice is central enough to be con-
sidered chartable at the institution doing the evaluating.
CHAPTER SUMMARY
This chapter presents relating as one dominant strategy to advance patient and family
understanding. The surface of the spoken word is peeled back to consider what the
action or force of language might include. A complex architecture of goals is always
at play, no matter who is doing the speaking. Because the true motives and goals of a
speaker are rarely fully understood or realized, the recommendation in this chapter is
to attend to the relationship goal always in order to facilitate the instrumental goals
of nursing. Throughout this section of the book, authors provide an opportunity to
examine the phenomenon of patient/family acceptance of an illness status, as well as
understanding patient/family perspectives on adjusting to new information unfolding
throughout a serious or terminal illness.
Talking and communicating in a way that is radically adaptive assume that the clini-
cian cannot know the reaction or perspective of the patient/family without first receiv-
ing it. Narrative nursing creates the opportunity to learn about dissonance between
desired outcomes and realities of illness. The idea of problematic integration addresses
this dissonance directly. Recognizing these particular challenges can move a patient/
family toward the quest narrative and away from the experience of chaos or denial—
both of which exacerbate feelings of dissonance.
Also explored in this chapter is a study of speech acts and multiple goals. Both of
these tool sets help clinicians reveal the difficulties and stumbling blocks that patients
and families face as they work to acknowledge their changing health and identity.
211 Relating
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Babrow, A. S. (1992). Communication and problematic integration: Understanding diverg-
ing probability and value, ambivalence, and impossibility. Communication Theory, 2,
95–130.
Babrow, A. S., & Mattson, M. (2003). Theorizing about health communication. In T.
Thompson, A. Dorsey, K. Miller, & R. A. Parrot (Eds.), Handbook of Health Communication
(pp. 35–62). Mahwah, NJ: Lawrence Erlbaum.
Back, K, & Harnish, R. (1979). Linguistic Communication and Speech Acts. Cambridge, MA:
MIT Press.
Bäckman, C., & Walther, S. (2001). Use of a personal diary written on the ICU during critical
illness. Intensive Care Medicine, 27, 426–429. doi: 10.1007/s001340000692.
Brataas, H. V., & Thorsnes, S. L. (2009). Cancer nurses narrating after conversations
with cancer outpatients: How do nurses’ roles and patients’ perspectives appear
in the nurses’ narratives? Scandinavian Journal of Caring Sciences, 23, 767–774.
doi:10.1111/j.1471–6712.2008.00679.x
Butler, J. (1997). Excitable Speech: A Politics of the Performative. New York: Routledge.
Clark, H. (1979). Responding to indirect speech acts. Cognitive Psychology, 11, 430–477.
Costello, J. (2009). Last words, last connections: How augmentative communication can sup-
port children facing end of life. The ASHA Leader, December 15, pp. 8–11.
Eggly, S., Penner, L., Albrecht, T., Cline, R., Foster, T., Naughton, M., et al. (2006). Discussing
bad news in the outpatient oncology clinic: Rethinking current communication guide-
lines. Journal of Clinical Oncology, 24, 716–719.
Ferrell, B., Dow, K. H., & Grant, M. (1995). Measurement of the quality of life in cancer survi-
vors. Quality of Life Research, 4, 523–531.
Frank, A. (1995). The Wounded Storyteller. Chicago: University of Chicago Press.
Hines, S. C., Babrow, A. S., Badzek, L., & Moss, A. (2001). From coping with life to coping with
death: Problematic integration for the seriously ill elderly. Health Communication, 13(3),
327–342.
McGurk, M. (2006). A Lion in the House: Five Families. Six Years. True Stories From the War on
Cancer. Wilmington, OH: Orange Frazier Press.
Searle, J. (1969). Speech Acts: An Essay in the Philosophy of Language. Cambridge, UK:
Sharf, B., & Vanderford, M. L. (2003). Illness narratives and the social construction of health. In
T. Thompson, A. Dorsey, K. Miller, & R. Parrot (Eds.), Handbook of Health Communication
(pp. 9–34). Mahwah, NJ: Lawrence Erlbaum.
Sharf, B. F., Stelljes, L. A., & Gordon, H. S. (2005). “A little bitty spot and I’m a big man”:
Patients’ perspectives on refusing diagnosis or treatment for lung cancer. Psycho-Oncology,
14(8), 636–646. doi: 10.1002/pon.885
Step, M., & Ray, E. (2011). Patient perceptions of oncologist-patient communication about
prognosis: Changes from initial diagnosis to cancer recurrence. Health Communication,
26(1), 48–58. doi: 931971302 [pii] 10.1080/10410236.2011.527621
The, A. (2004). Palliative Care and Communication. Philadelphia: Open University Press.
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of Language and Social Psychology, 9, 1–13.
Wittenberg-Lyles, E., Goldsmith, J., Sanchez-Reilly, S., & Ragan S. (2008). Communicating
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communication training protocols. Social Science & Medicine, 66, 2356–2365. doi:
10.1016/j.sociscimed.2008.01.042
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quences of tellability: A case study of becoming disabled through sport. Sociology of Health
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Additional References for Quest Narrative
Andrews, M., Squire, C., & Tamboukou, M. (2008). Doing Narrative Research. Los Angeles:
Sage.
Frank, A. W. (1991). At the Will of the Body: Reflections on Illness. New York: Houghton Mifflin
Company.
Frank, A. W. (1995). The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of
Chicago Press.
Gubrium, J. F., & Holstein, J. A., (2009). Analyzing Narrative Reality. Thousand Oaks, CA:
Sage.
Harter, L. M., Japp, P. M., & Beck, C. (Eds.). (2005). Narratives, Health, and Healing: Communication
Theory, Research, and Practice. Mahway, NJ: Lawrence Erlbaum Associates.
Holloway, I., & Wheeler, S. (2002). Qualitative Research in Nursing (2nd ed.). Malden, MA:
Blackwell Publishing.
Website: http://www.arthurwfrank.com/publications
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Babrow, A. S. (1992). Communication and problematic integration: Understanding diverging

probability and value, ambiguity, ambivalence, and impossibility. Communication Theory,
2, 95–130.
Babrow, A. S. (2001). Uncertainty, value, communication, and problematic integration. Journal
of Communication, 51, 553–574.
Babrow, A.S., & Mattson, M. (2003). Theorizing about health communication. In T. Thompson,
A. Dorsey, K. Miller, & R. A. Parrot (Eds.), Handbook of Health Communication (pp. 35–62).
Mahway, NJ: Lawrence Erlbaum.
213 Relating
Hines, S. C., Babrow, A. S., Badzek, L., & Moss, A. (2001). From coping with life to coping
with death: Problematic integration for the seriously ill elderly. Health Communication,
13, 327–342.
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models of uncertainty about genes’ role in illness causation to guide communication about
human genetics. Journal of Communication, 54, 105–122.
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Ragan, S. (1990). Verbal play and multiple goals in the gynecological exam interaction. Journal
of Language and Social Psychology, 9, 67–84.
Searle, J. (1969). Speech Acts: An Essay in the Philosophy of Language. Cambridge, UK:
Tracy, K. (1984). The effect of multiple goals on conversational relevance and topic shift.
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Tracy, K. (1995). Action-implicative discourse analysis. Journal of Language and Social
Psychology, 14, 195–216.
1. How can problematic integration theory be used to conduct a communication

research project in nursing?
2. What is the nurse’s role in the cultivation of a quest narrative?
3. What are the implications of the term “acceptability” in serious and terminal
illness?
4. How does narrative nursing adapt to the conversation and topic diffusion of a
patient/family?
5. What is the impact of indirect speech acts produced by your team members?
6. How can nurses prioritize their relationship tasks with patients and families when
they are so pressed for time, energy, and resources?
7. What are some ways to navigate the pressure of time if patient and family topic
diffusion defies the health decisions needed to best care for a patient?
8. Consider a challenge faced in practice that involves acceptability. What is a strategy
that prioritizes the narrative of the patient or family?
Exercise #1: Problematic Integration in Families

Apply problematic integration to the following family statements about serious illness.
Please consider 1) which of the four forms of problematic integration is described
(divergence, ambiguity, ambivalence, and impossibility), and 2) what conversational
approach might be useful with this patient/family member to support them. The
first case is about a pediatric patient’s younger brother. In the second case, a caregiver
daughter describes her mother’s new diagnosis.
Passage One:
When there is an illness like that, the worst thing you can do is not talk about
it. Your kids are left to draw their own conclusions, and it scares the hell out of
them. We never talked about it in my family. Never. When you are young, you
want to know what’s going on, but nobody would tell us. We were just left out
a lot. You never did get that sense that “Everything is okay.” It was always pins
and needles. It’s one thing to think it, but to have an adult say, “Everything is
okay right now, this is what’s going on . . . ” that calming factor never did come
in. You’re a kid. Your mind wanders. You worry about things. Your own health is
jeopardized, if you’re focused on him (brother) and you don’t pay attention to
yourself.
Used with permission from: McGurk, M. (2006). A Lion in the House: Five Families.
Six Years. True Stories from the War on Cancer. Wilmington, OH: Orange Frazier Press.
Chapter One, Justin Ashcraft, p. 15.
Passage Two:
My mother was diagnosed in February 2009 with an unknown primary. She had a
malignant pericardial effusion and almost died. When she was diagnosed she was
told she had a few months to live and make her final arrangements. Her oncologist
gave her no hope.
My mom was devastated by the news initially. We decided she should have a
second diagnosis. The second diagnosis confirmed the original diagnosis.
Even though my mom was devastated by this she decided she would fight. My
mom is a very strong woman and has never complained about any medical prob-
lems at all.
The oncologist believed that chemotherapy would only be a palliative measure
and that she would not go into remission and that she would not be cured. I con-
tacted Dr. XXXX who verified her chemo treatments were right on track.
214
215 Relating
My mom has surprised everyone!!! In June of 2009 the oncologist told her she
was in remission and she has been in remission now for 9 months. I believe her
oncologist is even amazed at her being in remission.
I have heard many, many sad stories about ACUP diagnosis. However, I have
also heard some very good stories about people living for many years with an
ACUP diagnosis. I believe my mother will be one of those good stories.
Excerpted from a caregiver posting on the ACUPS group on www2.acor.org. March

20, 2010.
Exercise #2: Quest Narrative

The quest narrative is an illness story that acknowledges significant changes in
life, rather than a narrative that clings to the promise of reverting back to the
way things were before a devastating illness. Using the quotes below, answer the
questions about where this patient or family member might be in their quest and
then identify what a nurse clinician might be able to do in conversation to address
one or more of these reauthoring opportunities. Nurses can work on these quotes
individually and then discuss them in small groups to increase the production of
communication intervention ideas.
■ “I feel I needed to talk and maybe cry a little and needed his [husband] shoulder to do
so with. But was denied, this hurt me and again I felt isolated. Now that is all behind
me. Everyone acts as though nothing ever happened. I still feel the need to speak
about it but feel I have no one to talk to about it. I am not the same person.”—Lung
cancer patient in remission
Table 7.7 Quest Indicators

Does this patient Yes/No How is this revealed Relating to the
acknowledge significant in words? patient in the quest
changes in health? narrative
Has this patient Yes/No How is this revealed Relating to the
experienced a turning in words? patient in the quest
point in his or her illness narrative
experience?
Does this patient indicate Yes/No How is this revealed Relating to the
a shift in identity? in words? patient in the quest
narrative
■ “My mother flat out told me she would not talk about anything about the cancer. She
is too scared. . . . It is awful . . . She told me to grow up and I had to make my own deci-
sions and take responsibility for my treatment and she wouldn’t discuss my cancer
with me.”—Breast cancer patient
Table 7.8 Quest Indicators

Does this patient acknowledge Yes/No How is this revealed in Relating to the patient
significant changes in health? their words? in the quest narrative
Has this patient experienced Yes/No How is this revealed in Relating to the patient
a turning point in his or her their words? in the quest narrative
illness experience?
Does this patient indicate a shift Yes/No How is this revealed in Relating to the patient
in identity? their words? in the quest narrative
Exercise #3: Adapting to the Patient

All patients/families communicate uniquely. Often, the nursing task of communicating
changes in disease/function can be accompanied by a clear display from the patient/
family that the news is not being processed for what it is. In this exercise, there are
two scenarios presented in which a nurse is communicating information (task goals)
and this communication requires radical adaptivity based on the acceptability of the
patient. For the following interactions:
1. Cast the roles of the nurse and the patient and “perform” them.
2. Examine the dialogue in discussion form.
3. What seems to be the primary challenge for the nurse/patient in processing
information?
4. Identify what the nurse is expressing directly and indirectly.
5. Identify what action the patient/family is expressing directly and indirectly.
6. What recommendations can be made about an improvement in radical adaptivity
for nurse communication in each interaction?
Interaction One:
nurse: From now on your cancer will be with you. It is a kind of cancer that
has no cure at this point.
patient: Well, they haven’t actually said that.
nurse: It is not curable. [Silence]. But it is a slow cancer. And what we are
really most concerned about is your pain. Are you in pain?
patient: No. I’m fine.
nurse: Have you heard of hospice?
patient: Yes, it’s for your dying days.
nurse: Well, actually it’s for people with advanced disease. You have an
advanced disease.
patient: God, you are an optimist. I have been totally fine.
[silence]
217 Relating
patient: But I want to go home. A couple of days in hospice might be okay, but
then I want to go home.
Interaction Two:
nurse: What did the doctor tell you about the tumor?
patient: Similar comments from this doc. It seems I am going to come out
of this.
nurse: It is hard to realize that your tumor is not going to go away.
patient: During the last operation they put a chemo disk in my brain to reduce
the size of the tumor.
nurse: But, the tumor itself will not go away. So we need to figure out how
we can help you be the most comfortable and pain free.
[patient stirs in bed, mumbling, showing distress]
nurse: What do you think about what I am saying?
patient: If you can monitor the tumor . . .
nurse: Right. Yes. To make sure you are not in pain or distress.
patient: The treatment I am receiving now, whatever prognosis you all make
up . . . but I don’t know one way or the other the best treatment now.
nurse: We will take care of you. Treat you. We especially want to address your
headaches. We just cannot cure you and make it go away.
Used with permission from:Wittenberg-Lyles, Goldsmith, Sanchez-Reilly, & Ragan

(2008). Communicating a terminal prognosis in a palliative care setting: Deficiencies in
current communication training protocols. Social Science & Medicine, 66, 2356–2365.
Exercise #4: Mining the Goals

The multiple goals theory described in this chapter reminds clinicians and all health
professionals that in any interaction, each participant is likely pursuing more than one
thing. It is also probable that the goals of one person might be in conflict with the goals
of another. For just a moment, change the context of the multiple goals scene from
nursing to romance! This also requires that readers think now about the relational tasks
that are at work in all interactions.
Think about a dating situation between a young woman named Jill, and her col-
lege friend, and now romantic partner, Kendall. For just over 2 weeks, the two of them
have been “dating,” and their relationship has progressed quickly from classmates and
lunch buddies to two partners in a passionate romance. After a fun evening including
a picnic and long walk in the park, Kendall brings Jill to her dorm. He bids her good
night and they share a long kiss. As they conclude the evening, Kendall lingers, taking
Jill’s hands. With intentioned seriousness he says to Jill, “I love you.” Jill, not feeling this
same level of connection is stymied and embarrassed about the appropriate response.
She is shocked that Kendall could produce this claim after such a short time in this new
phase of their relationship. Conversationally, it is clearly her turn to speak. She takes a
deep breath and produces, “Thank you.”
Jill and Kendall had conflicting relational goals. This is a pretty stark example that
is made clear by the speech exchanged at the close of their date. The relational goal
differences are not always so clearly evidenced and in the clinical setting can become
lost or overshadowed by the instrumental goals/tasks that need to be completed. Now
that multiple goals as a theory is refreshed, the frame is changed back from romance
to the nursing context. The following story is told by the young mother of a 2-year-old
boy born at 24 weeks. Abe and his family have faced the threat of his death countless
times in the 2 years of his life. His health is compromised by breathing, digestive, and
developmental difficulties.
Abe had gone in for a test to check the level of his acid reflux and see if he had sus-
tained any damage to his esophagus. The procedure was a routine one. He would
be mildly sedated, a probe would be inserted down his throat, and we would stay
in the hospital for 24 hours while it recorded every incident of reflux. . . . When
I went to meet Abe in the recovery room after the probe was inserted, I found
him terrified, hyperventilating, and vomiting profusely. The nurse taking care of
him had just started him on a heavy dose of morphine and oxygen through a
nasal cannula because “he couldn’t calm down.” I took him, spoke to him softly
to explain what was going on, and rocked him until he settled. When I questioned
the nurse about what had occurred, it immediately became clear to me that in
treating Abe in recovery, she had not taken into account that he has significant
visual impairment. While she was pulling off medical tape, adjusting an IV, and
moving him around, he felt attacked on all fronts because he did not know what
was happening to him. If the nurse had taken a few extra minutes to consider the
patient as a whole person—not just as someone there for a ph probe—she would
have noted that he is legally blind. It was on his chart, and anyone spending time
with him can quickly tell that he does not see very much at all. Speaking with the
family would have helped, too; the nurse could have asked how to approach Abe
so that he wouldn’t be scared and could have given the necessary treatment in a
way that would be less frightening and ultimately less invasive for him. We could
have avoided the morphine, the supplementary oxygen, and, most importantly, an
experience that terrorized my 2-year-old.
Read the story of Abe and the nurse in a small group. Discuss the following questions
together:
⋅ Is the nurse at fault in this story?

⋅ Does the family member expect too much? Are her goal expectations unreasonable?
⋅ What goals take priority for the nurse? Are they the right goals in this situation?
⋅ Can the task and the relational goals be separated in this story?
219 Relating

chapter material
TALKING ABOUT TALK OR SILENCE

In this exercise, people can work together in dyads or larger numbers. Because the case
study is so simple, this is a good icebreaker for this chapter and quickly gets people to
share ideas. First, individuals should read this case silently; then, they can join together
to share their reactions and ideas for 5–10 minutes.
You come into a room to perform an intake interview with a patient new to this
care center. As you open the door to the room, you see a woman in her early 40s,
alone. She has been crying, and now tears begin to flow uncontrollably. She is una-
ble to speak and her body shakes from sobbing. What do you do?
REFLECTING ON MEMORABLE SPEECH ACTS

This brief journaling exercise is a good engagement for students new to the idea of
speech acts and multiple goals. It also uses their own life experience as primary mate-
rial for working through the ideas of indirect speech acts and considering the interac-
tion between task and relational goals.
Step One – The student recalls a memorable speech act delivered in the following
contexts/by the following people:
• A teacher (that the student knew in a student/teacher relationship)
• A spouse or parent (of the student)
• A clinician (when the student sought help as a patient or caregiver)
Step Two – The student divides a piece of paper into three sections and in each
section writes one of the three memorable utterances delivered by the teacher/
spouse or parent/clinician.
Table 7.9 The Meaning of a Message

Teacher Spouse Clinician
You are not honors material. Where did you learn to Let me show you a picture
cook? of normal.
Step Three – For each of the three utterances, the student should identify what the
indirect speech act(s) were that he or she understood based on the utterance. A
direct act unpacks the contents of what someone does in saying something. An
indirect act presents plausible additional actions exerted through the spoken
word—many of which are not controllable by the speaker. This is a useful
journaling project because the student will know the context of the memory and
the relationship dynamic shared or absent with the speaker described.
Step Four – For each of the three utterances, the students should identify what they
believed to be the goals of the speaker. What were their task goals? What were their
relational goals?
Step Five – For each of the three utterances, the student should identify what made
this utterance memorable for him or her.
This small speech analysis should give students some insight into the complicated
world of spoken communication and also the complicating variables that relational
goals impose on speech in a given context.
EXPLORING IDEAS FOR A RESPONSE

The practice of communicating with patients and families is a major portion of the
work performed by nurses. This exercise is most useful if performed with one or
two partners. The patient/family quotes below require some action from the nurse.
Consider together the most effective way to relate and adapt to your conversational
partner as you engage them. Partners are helpful in considering the various contextual
impacts that might contribute to different response options.
To facilitate this exercise in relationship to the speech acts discussed previously
in this chapter, a simple chart will identify the four major areas of action expressed
in our everyday talk. Consult this chart as you identify and reflect upon the patient/
family utterance, and the response ideas for the nurse in the interaction; it might be
helpful. Move through the patient/family quotes and discuss each one. Discussions
from one interaction will likely inform the others (see Table. 7.10).
Table 7.10 Speech Acts

Constatives: Affirming, alleging, announcing, answering, attributing, claiming,
classifying, concurring, confirming, conjecturing, denying,
disagreeing, disclosing, identifying, informing, insisting, predicting,
ranking, reporting, stating, stipulating
Directives: Advising, alleging, asking, begging, dismissing, excusing,
forbidding, instructing, ordering, permitting, requesting, requiring,
suggesting, urging, warning
Commissives: Agreeing, guaranteeing, inviting, offering, promising, swearing,
volunteering
Acknowledgments: Apologizing, condoling, congratulating, greeting, thanking,
accepting
221 Relating
Example One
The husband of a patient says to the nurse as he enters the room, “I touched her and her arm
was cold, and I touched her face and it was cold. Do you think she’s alright?”
Please write your response ideas.
Example Two
A family and patient have just been admitted to the oncology floor. An exploratory sur-
gery revealed metastatic cancer. The family and patient are totally disoriented and have no
oncologist. The sister of the patient appeals to the RN: “Can’t someone just tell us what this
is and how we deal with it? We don’t even have a doctor yet.”
Example Three
A dialysis patient has gone to her NP as she is spiking a fever. Early in the appointment, the
patient says to the NP, “I don’t know why I am going through all of this.”
Example Four
A palliative care nurse meets with a family in critical care. The patient is in her 30s and has
late-stage Huntington’s disease and sepsis and is experiencing general organ failure. The
patient’s husband says to the nurse, “She is going to shake this thing. We’ve just gotta stay
positive as a family.”
Example Five
A pediatric oncology nurse stops in to deliver medication to Tim, a 4-year-old who is receiv-
ing a blood transfusion so that he can continue his chemotherapy in order to begin radiation
in 2 weeks. Despite his grave situation, Tim is cheery upon seeing his nurse. Tim’s mother
says to the nurse, “I wish his erstwhile father would get here and relieve me for once.”
Potential clinician barriers that will interfere with relating (understanding what is
spoken by patient/family):
Table 7.11 Barriers to Relating

- Clinician lacking awareness of changes in a patient case
- Clinician unwilling to engage or discuss with patient/family
- Time constraints
- Lack of continuity in patient care over a period of time
- Relational tasking is not part of measurable nursing practice.
(continued)

- Personal preference not to engage in relating
- Lack of interprofessional cooperation/communication
• Last words and last connections at the end of life for children require the extraordi-
nary support of speech language therapists (SLTs). The nurse can identify patients and
families in need of this specialized support early on and contribute to an SLP in prep-
aration for their work (voice banking, vocabulary selection, communication device
development) with a patient and family. Supporting children’s autonomy, their ques-
tions and literacy, and their own narratives about the illness experience will increase
patient and family quality of life.
1. SLP inclusion in pediatric care services provided as early as possible will support a
child’s changing communication potential and his/her continuity of care.
2. Engage the family and patient in the idea of an SLP and establish this support as
normative.
3. Encourage self-expression of patient.
4. Create opportunities in the day when SLP therapy would be most effective.
Concepts adapted from Costello, J. (2009). Last words, last connections: How augmentative com-
munication can support children facing end of life. The ASHA Leader, December 15, pp. 8–11.
films highlighting patient/family

narrative
Aronson, I. (1997). Tell Them You’re Fine. Canada: Fanlight. http://www.fanlight.com/catalog/

films/235_ttyf.php
• Three young people with cancer confront the day-to-day realities of coping with
the impact of the disease, with therapy, and with the attitudes of family, friends,
and coworkers.
Bognar, S., & Reichert, J. (2006). A Lion in the House. USA: Independent Lens. http://www.
lioninthehouse.com
• Five families struggle with the ups and downs of cancer treatment over the course
of 6 years.
Curtis, D., & National Film Board of Canada. (2003). Bearing Witness: Jocelyn Morton. Canada:
Fanlight. http://onf-nfb.gc.ca/eng/collection/film/?id=51157
223 Relating
• Follows sculptor Jocelyn Morton over the course of her last 4 months, as she copes
with her impending death from cancer
New England Cable News. (1997). Look for Me Here: 299 Days in the Life of Nora Lenihan.
Canada: Fanlight. http://www.fanlight.com/catalog/films/244_lfmh.php
• When she learns that her cancer has recurred and metastasized, 40-year-old Nora
chooses to forego radical treatment and face death with hospice care at home.
Focusing on the comfort provided by her caregivers, family, and support network
of family, friends, and coworkers, this portrait chronicles the year from that deci-
sion to her death.
Rabow, M., Goodman, S., & Folkman, S. (2008). The Caregivers. Open Eye Pictures, California.
http://openeyepictures.com/thecaregivers
Rabow, M., Goodman, S., & Folkman, S. (2008). The Caregivers Project Film Discussion Guide.
UCSF Osher Center for Integrative Medicine. http://www.osher.ucsf.edu/patient-care/
self-care-resources/caregivers/
• The Caregivers Project teamed with Open Eye Pictures, an award-winning, non-
profit production company to create The Caregivers, an educational film about
caregiving for loved ones with an aggressive form of brain cancer. The film fol-
lows patients, their family caregivers, and physicians-in-training to reveal the
complexities of caregiving, patient–doctor–caregiver communications, and the
health care system.
Watson-Burgess, H., & National Film Board of Canada. (2005). At My Mother’s Breast. Canada:
Fanlight. http://www.fanlight.com/catalog/films/435_ammb.php
• The filmmaker’s mother, grandmother, and great grandmother all had breast can-
cer. So have two of her three aunts. The result of this work is a portrait of strong
women in one family system who find unity and peace while facing a terrifying and
tragic genetic legacy.
8
team
Mrs. Lindsey is a 52-year-old woman diagnosed with late-stage breast can-

cer. She has three teenage daughters, all in high school. Three months prior to
her diagnosis, Mrs. Lindsey’s husband moved out of the house after disclosing
that he had been having an affair with a coworker. Their divorce is in process.
Mrs. Lindsey’s mother and older sister both died from breast cancer over the
last 10 years.
Mrs. Lindsey had attempted to remain as functional as possible, but she has
been rapidly declining, including recent brain metastasis. Her daughters have
tried to care for her, but she has fallen several times while the daughters are at
school. Hospice has now been initiated, and the team social worker has con-
ducted an initial assessment, which she has presented to the team. She reports
that the ex-husband had offered to move back into the home and support his
ex-wife and their daughters. There are strong opinions expressed by the team
members. The chaplain, John, expresses his belief that Mr. Lindsey is genuinely
remorseful and that having him in the home would be very positive. A few of the
hospice nurses express their dislike for the ex-husband (“that jerk”) and believe
that it would be an insult to Mrs. Lindsey.
Over the next few weeks, Mrs. Lindsey continues to decline, and she does
reluctantly agree to have Mr. Lindsey move back in, only because of her con-
cern for her daughters. At the next team meeting, the chaplain reports that he
is very disappointed in his colleagues, as he has observed the nursing assistant
and primary nurse being very hostile toward Mr. Lindsey. The social worker
reports that she believes Mrs. Lindsey has forgiven Mr. Lindsey and would like
help in communicating her feelings to her daughters and ex-husband so she can
die peacefully.
Difficult cases such as the Lindsey family can make communicating with colleagues
challenging. Conflict can arise when team members are protective of their area of
expertise and specialized contribution to the team, or because team members simply
disagree about how best to assist patients and families. Commitment to collaboration,
role-modeling collaboration, and creating a sense of community are necessary skills
for nurses working in teams (Huston, 2008). The focus of this chapter is team com-
munication and being able to communicate effectively with colleagues, even when
225
disagreement is prevalent. This chapter will detail the main principles of interdisci-
plinary collaboration, feature team meetings as a place to resolve conflict, and identify
common team communication problems that can lead to an ineffective decision-
making process called groupthink.
INTERDISCIPLINARY TEAMS
In an interdisciplinary team, clinicians work from different orientations while at the
same time engaging in joint work. Team members representing varying disciplines
within the biopsychosocial model (traditionally, physicians, nurses, social workers,
volunteers, and chaplains) are represented on the hospice/palliative care team to
produce family-focused care (Connor, Egan, Kwilosz, Larson, & Reese, 2002). Team
members need to collaborate, integrate specialized knowledge into a comprehen-
sive plan of care, and translate discipline-specific jargon for each other (D’Amour,
Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005). Each team member holds
expertise, and leadership is influenced by the needs of the patient, family, and some-
times the team (Youngwerth & Twaddle, 2011). Ideally, under this holistic interdis-
ciplinary approach patients and families are provided with care plans that have been
assessed by experts in different disciplines (Dyeson, 2005). The holistic nature of
hospice and palliative care necessitates that team members achieve interdisciplinary
collaboration. Collaboration is an evolving practice that takes focused communica-
tion work (D’Amour et al., 2005).
INTERDISCIPLINARY COLLABORATION
Interdisciplinary Collaboration is a dynamic communication process that relies
on sharing resources, mutual dependence between team members, and sharing and
respecting positions of power afforded by credibility or expertise (D’Amour et al.,
2005). Despite discipline-specific expertise, team members share the same task and
relational communication responsibilities discussed in Chapter 2. Task communica-
tion on the team includes educating each other about successes and failures on the job
and/or appropriate communication strategies for specific patients and family mem-
bers. Meanwhile, relational communication consists of providing support to team
members and sharing workplace stress.
The model of interdisciplinary collaboration best represents the theoretical frame-
work for the interdisciplinary approach to care (Bronstein, 2003). This model includes
a combination of multidisciplinary theory of collaboration, services integration, role
theory, and ecological systems theory (Bronstein, 2003). Based on the model, inter-
disciplinary collaboration consists of: (1) interdependence and flexibility, (2) newly
created professional activities, (3) collective ownership of goals, and (4) reflection on
process. Table 8.1 illustrates an interdisciplinary collaboration observation form.
Interdependence and flexibility are characterized by interaction among team
members in order to accomplish goals. For each patient/family plan of care, team
members take on varying roles and responsibilities. Team members are dependent
227 Team
Table 8.1 Interdisciplinary Collaboration Observation Form

Date: ____________________
Observation Comments
Team Member Flexibility (team members

assume duties outside of their area of expertise to
accomplish team goals)
□ Discussed communicating with outside staff
(other physicians, hospices, nursing home)
□ Discussed speaking with patient
□ Discussed speaking with caregiver
□ No discussion of outside communication
Newly Created Activities (a clinical task that
wasn’t previously identified as a need but has now
been identified as a result of team communication)
□ Staff education took place (teaching one
another)
□ Identification of tasks to be done (e.g., “I will
call,” “Can you go out . . . ”)
□ No newly created activities generated
Collective ownership of goals (the team engages
in a shared problem solving around a problem)
□ Discussed problem(s) with informal
caregivers, other health care professionals
□ Shared frustration about job/plan of care
□ Discussed safety issues
□ No discussion of these issues
Reflective process
□ Procedural issues discussed
□ Death reviewed, if applicable
□ Workplace stress was shared and discussed.
Please check if the following issues were
discussed:
□ Pain management
□ Spiritual background/needs
□ Psychological suffering
□ Social impact (isolation, loneliness)
Were there any interruptions (cell phone, pagers)?
□ YES □ NO
Adapted from the following works:

Bronstein, L. R. (2003). A model for interdisciplinary collaboration. Social Work, 48 (3), 297–306.
Wittenberg-Lyles, E., & Oliver, D. P. (2007). The power of interdisciplinary collaboration in hospice.
Progress in Palliative Care, 15 (1), 6–12.
Wittenberg-Lyles, E. M., Parker Oliver, D., Demiris, G., & Regehr, K. (2010). Interdisciplinary collabora-
tion in hospice team meetings. Journal of Interprofessional Care, 24 (3), 264–273.
upon each other for information that determines their role within a patient’s plan of
care; each case requires team member flexibility in order to achieve care outcomes.
When spiritual needs are requested from a nurse, the nurse is able to manage spirit-
ual communication. Similarly, when a chaplain is asked opinions about pain medica-
tion use, she is able to reinforce pain education and dispel myths regarding addiction
or tolerance. Interdisciplinary team members are united by psychospiritual care, the
underlying care required to meet the needs of patients’/families’ personal labor with
terminal illness that often brings psychological suffering and spiritual realities (Grey,
1996). Psychospiritual care is complex and ambiguous and cannot be attended to best
by any one core team member.
Box 8.1
“A doctor came in and gave him an explanation that they couldn’t do any more chemo
[chemotherapy] on him. . . . The patient didn’t hear it, just didn’t hear it . . . because I was
the chaplain I said pretty much the same thing as the doctor said, but I think because
I was just a normal person . . . he could hear me.” —Palliative Care Chaplain
(Goldsmith, Wittenberg-Lyles, Rodriguez, & Sanchez-Reilly, 2010).
When information is shared among team members, newly created tasks and
responsibilities emerge and collaborative activities maximize each individual’s exper-
tise. Because team members are interdependent, sharing information with each other
leads to new tasks. Although each team member provides a special service, the team
must labor together to serve the patient and family (Grey, 1996). This can mean “doing
the job no one wants to do” on behalf of the team (O’Brien, Martin, Heyworth, &
Meyer, 2009). Collaboration requires team members to be accessible to other team
members—allowing ease and frequency of contact—so that team members can
develop mutual respect and trust (Petri, 2010).
Collaboration is produced through a collective ownership of goals as team mem-
bers have a shared responsibility for producing quality holistic care. Team members
are joined together by the experience of patients and families, collectively engaging
in the voice of the Lifeworld about disease and illness (see Chapter 4 for further
discussion) (Goldsmith, Wittenberg-Lyles, Rodriguez, & Sanchez-Reilly, 2010). In
hospice and palliative care, team members share the same view that the patient and
caregiver are an integral part of the team (D’Amour et al., 2005; Goldsmith et al.,
2010). While each discipline has its own goal of care, team members have a shared
common purpose (Katzenbach & Smith, 1993). Hospice/palliative care team mem-
bers consistently describe themselves as having high spiritual well-being, the ability
to self-actualize, and making a conscious effort to integrate spiritual beliefs into
their everyday work (Clark et al., 2007). Finally, team members can become aware of
the process of collaboration by engaging in a reflective process. By reviewing team
processes, such as plans of care, discharges, or a patient’s death, team members can
229 Team
evaluate their own collaborative process. Unfortunately, research has shown that
this is the lowest ranked aspect of collaboration among hospice and other health
care teams (Tubbs-Cooley et al., 2011; Wittenberg-Lyles, Parker Oliver, Demiris, &
Regehr, 2010) (see Box 8.2).
Box 8.2 Example of Collaboration
Collaboration is a dynamic, fluid process that transpires in daily palliative care work.
In addition to team collaboration, nurses must also collaborate with other clinicians
outside of hospice/palliative care. A typical patient visit to an Alzheimer’s Assisted Living
Facility by Lance, an RN at a local hospice, characterizes collaboration:
Upon arriving at the facility Lance is greeted at the door by Cindy, the Resident
Director, who immediately wants a private meeting. She pulls Lance into her private
office to discuss her dissatisfaction with hospice personnel. Even though Lance has
never met Cindy before, he is recognized as part of hospice staff and is interdepen-
dently related to the hospice team and agency. He must be flexible to answer all of
her questions related to the patient’s care as well as the agency’s policies regarding
patient care.
Cindy reports that the hospice medical director and licensed vocational nurse
(LVN) were there for a patient visit 2 days ago. During the visit, Sally, the unit charge
nurse, asked the hospice medical director if he would speak to the patient’s daughter
and tell her that the patient was declining. Sally felt that this would help the daugh-
ter develop realistic expectations for care in the assisted living facility. According to
Cindy, the hospice LVN called the patient’s daughter later that day and told her that
Sally asked the hospice medical director to give her a “reality check.” Consequently,
the daughter called the assisted living facility, asked for Sally, and “chewed her out
and chewed out all the staff.”
Upon hearing this, Lance was very apologetic about the circumstances. Cindy
reiterated that the hospice LVN and Sally are on the same team, and the LVN “went
behind our backs and got us in trouble.” Lance acknowledges that the LVN’s com-
munication was completely unprofessional and agrees that they are all united by
the collective goal of providing quality health care to this patient and comforting
his daughter. Cindy made it very clear to Lance that the hospice LVN was no longer
welcome at the facility, explaining: “If my charge nurse was inappropriate, then it
was your medical director’s responsibility to correct her.”
This impromptu meeting with Sally creates a new responsibility for Lance, who
must now contact the hospice medical director as well as the hospice LVN to report
on this meeting and then contact administration to change the LVN assignment for
this patient. Finally, Sally was asked to join this meeting; together the three of them
reflected on what had transpired and then established a shared communication plan
to convey to the patient’s daughter.
Interdisciplinary team (IDT) meetings are routinely held in hospice and pallia-
tive care to enable team members to practice interdisciplinary collaboration. The IDT
meeting facilitates communication that produces an interdisciplinary plan of care for
each patient. During the IDT meeting, teams form a single care plan wherein team
members share responsibilities and implement their part of the plan (Sabur, 2003).
Informal exchange of information between team members also happens prior to
and after meetings, in the hallways, over lunch, or in passing at the patient’s home
(Youngwerth & Twaddle, 2011). The example in Figure 8.1 demonstrates interdisci-
plinary collaboration in a team meeting format among a nurse (RN), medical director
(MD), social worker (SW), and Chaplain (C).
This team meeting discussion involves all team members—each member provides
information about the patient’s plan of care, and the patient’s family is addressed
within this discussion. Elements of interdisciplinary collaboration emerge from the
discussion among team members.
The collaborative process also includes conflict as part of interdisciplinary team
communication. Disagreements among team members include varying opinions
about difficult patients/families and misunderstandings/personality conflicts (Parker
Oliver & Peck, 2006; Wittenberg-Lyles, Oliver, Demiris, Baldwin, & Regehr, 2008). After
presenting a case report and summary to the team, nurses often provide their own
impressions about the patient and caregiver (Wittenberg-Lyles, Gee, Oliver, & Demiris,
2009). Troubled patients/families are discussed at greater length, and “atrocity stories”
are often relayed among team members to provide insight into patient/family living
circumstances or difficult cases (Li & Arber, 2006; Wittenberg-Lyles, 2005). Atrocity
stories are shared to recount the insensitive behavior of other clinical staff or patients/
family members. Team members are not always able to agree on a plan of care, and
a lack of understanding across disciplines can produce conflict as team members can
struggle with overlapping roles (Connor et al., 2002). These conflicts as well as others
can be managed during team meeting discussions if the team has a problem-solving
procedure in place (Parker Oliver & Peck, 2006; Wittenberg-Lyles, 2005).
GROUPTHINK
Although the goal for an interdisciplinary palliative care team is to achieve high-
performance group status, research shows that hospice and palliative care teams
more commonly perform as working groups that do not always achieve collabora-
tion (Baldwin, Wittenberg-Lyles, Parker Oliver, & Demiris, 2011; Bokhour, 2006;
Demiris, Washington, Doorenbos, Parker Oliver, & Wittenberg-Lyles, 2008; Demiris,
Washington, Parker Oliver, & Wittenberg-Lyles, 2008; Katzenbach & Smith, 1993;
Wittenberg Lyles, 2005; Wittenberg-Lyles, Gee, Oliver, & Demiris, 2009; Wittenberg-
Lyles, Parker Oliver, Demiris, Baldwin, & Regehr, 2009; Wittenberg-Lyles, Parker
Oliver, Demiris, & Cunningham, 2011). In a working group, members interact regu-
larly, share information, perspectives, and best practices, but there is no organizational
policy for how the team is evaluated as a whole, nor is there an assessment of the
productivity level of the team (Katzenbach & Smith, 1993). A study of hospice teams
231 Team
RN: [Patient’s name] is a 69 year old patient who resides at home. She has stage four ovarian
cancer. Her daughter Velma provides care. Louise (Nurse Case Manager) said yesterday she
saw her this week and she’s in bed more. She’s not getting up as often.
And her pain seems to be pretty well controlled. It’s hard to get ahold of Collective
them. Louise actually had to go back to their house for impromptu visits ownership
just because she can’t get ahold of them. You can try their cell phones— of goals –
they have those rechargeable cell phones. members of
MD: Could you agree to a time that the phone could be free so that you could the team share
call? common
RN: I don’t know. That’s a good idea. One of the problems that I know that problem and
[chaplain] has run into is he can’t get hold of anybody. attempt to
SW: We’ve made it known that we have questions and so I’ve called several problem solve.
times on several days for several weeks and nothing. I leave messages on
the track phones or the phones aren’t working.
RN: And then when they [other clinical staff] do leave messages, they will ask
them well did you get my message? And they’ll say they didn’t. So I don’t know if they’re not
checking their messages or if that part of their service isn’t working. I don’t know. The patient
sometimes complains of having numbness in her feet, and that kind of makes it hard for her
to walk. If she’s up, it’s usually always assisted with someone in the house. She does have a
walker, but lately she’s just been staying in bed most of the time. Her pain is well-controlled,
she even has a decrease in the dizziness she was having there for awhile, but then, she’s in bed
all the time—she probably doesn’t feel that dizzy, because she’s not
up as much.
SW: She needs a walker. Interdependence
RN: She has a walker and she does use it, but lately the daughter has had and flexibility –
to kind of get her up and kind of stand there and hands-on assist. SW suggests that
I’d say the daughter, she takes good care of her—making sure that the patient needs
she has food to eat, and she gets her up, but what happens is, . . . additional medical
[weekend nurse] says that when she was out there this week, she’s equipment
noticed that they’re not getting her up to go into the living room
where the TV is at.
MD: I think the lack of moving and not getting to what she wants is a concern.
RN: Right. And just the fact that if she wants to get up, they need to be
there for her.
C: Has anyone talked to her about a volunteer? Newly created
SW: I saw her on initial assessment and they are a real supportive task – Chaplain
family. There is just a lot of family visiting and the daughter’s doing identifies that a
well enough despite the intrusion of a lot of people. volunteer may be
C: I’ve been able to get the Catholic Church to get over there to give her appropriate/needed
sacraments and prayer. She was very thankful for that but she said we
could still come and visit.
RN: The biggest issue with her is the fear of her daughter having to
see her go through this, and I think you’ve [chaplain] probably
talked to her about these things, and nothing else—death doesn’t Reflective process –
seem to be an issue for her when she talks to me. More so, it’s that Psychosocial elements
Velma is going to have to see her go through all this stuff. And of care are discussed
Velma and I have talked about this this and she wouldn’t want to by the team
have it any other way.
C: I agree. I think Velma will be able to handle this.
SW: I’ll try to get there Monday, if I can get a hold of them.
RN: I’ll tell them you’ll try to call – you’ll try to call and talk to them Monday then.
figure 8.1 Interdisciplinary collaboration
found that hospice agencies do evaluate teams, but little is known about what they are
evaluating, whether or not the evaluation impacts or influences team processes, and
whether or not anything is done with this information to improve team collaboration
(Baldwin et al., 2011). Typically, team members are evaluated for individual perfor-
mance rather than team performance.
Collaboration doesn’t occur just because group members are placed in the same
room (D’Amour et al., 2005). Interpersonal and communication conflicts are
likely and can result in factions within the group and isolation of group members.
Poor decisions can be made when group members ignore each other’s conflicting
opinions or if the group doesn’t deal openly with disagreements. While meetings
are a safe place for members to share, collaborate, and be collegial, they are also a
venue for group communication that involves managing professional boundaries
and practicing conflict resolution (Arber, 2007). Thus, we move now from inter-
disciplinary teams to looking at palliative care nursing from a group communica-
tion perspective.
Although group commitment is high (goals are shared and identified) among
palliative care teams, research has found that group members in highly committed
groups are more likely to prioritize group cohesion rather than critical evaluation
of the group task (Youngwerth & Twaddle, 2011). In health care organizations,
there is a stronger relationship between strategic consensus (e.g., agreement on a
plan of care) and organizational commitment (how much an employee feels com-
mitted to the organization) rather than involvement and commitment (Carney,
2007). With organizational commitment more likely to predict consensus with
group members, there is greater likelihood that members aren’t as involved in
the collaborative decision-making process (Carney, 2007). Groupthink can occur
when “deeply involved” cohesive group members engage in a mode of thinking
that centers on unanimity over the motivation to rationally assess various courses
of action (Janis, 1982). In these groups, the focus of groupwork is on group cohe-
sion and group relations rather than decision making; groupthink results in poor
decision making and/or lack of collaboration.
Clinical palliative care work in the team environment requires nurses to be
aware of the communicative elements that can lead to groupthink. Group cohesion
may be the result of the group’s inability to engage in effective group discussion
and conflict resolution. Groupthink occurs when there is pressure on group mem-
bers to agree not to disagree (Napier & Gershenfeld, 1999). This pressure emerges
informally through the culture of the group. Group members embrace a decision
even though they recognize it may not be the best decision. Disagreements among
members are suppressed, giving way to the perception that conflict means more
work for the group (Heinemann, Farrell, & Schmitt, 1994). When groupthink
occurs, members are unable to consider all aspects of information and alternative
solutions, and fail to understand the risk of failure (Heinemann et al., 1994) (see
Box 8.3).
Box 8.3
“Contrary to the notion that teams waste time and energy arguing, those that avoid con-
flict actually doom themselves to revisiting issues again and again without resolution.”
(Lencioni, 2002, p. 202)
233 Team
Group cohesion can be triggered by a perceived threat (Degnin, 2009). Sometimes

difficult patients and/or family members can be perceived as a threat to the palliative
care team. Stereotyping patients/or family members can lead to groupthink when team
members categorize others outside of the group in ways that are considered unaccept-
able (Miller, 2009). Patients and family are considered “outsiders” to the palliative/hos-
pice process when complex family dynamics require extensive time, a patient’s eligibility
for hospice is questionable, the team perceives that family decision making is dependent
upon financial gain, the team perceives problems with the safety and compliance of
pain medication at home, or the patient/family demands care services inconsistent with
hospice benefits. Stereotyping patients and families results in “tunnel vision,” and group
members are unable to consider alternatives to the plan of care (Degnin, 2009).
A heavy emphasis on biomedical information sharing and reporting within the
group can also result in self-censorship and contribute to perceived group cohesion.
Self-censorship occurs when group members elect not to share their opinion to counter
a prevailing thought in the group (Miller, 2009). Prior research on hospice interdisci-
plinary team meetings has found that team members do not contribute equally, shared
information is primarily biomedical, there is limited structured team member support,
and psychosocial information sharing is limited (Wittenberg Lyles, 2005; Wittenberg-
Lyles, Gee, et al., 2009; Wittenberg-Lyles, Parker Oliver, et al., 2009; Wittenberg-Lyles
et al., 2011). A typical case-reporting format among hospice/palliative care teams
includes: the date the patient was admitted, a complete diagnosis, medical history of
the patient, current medications, whether there is a do-not-resuscitate order and/or a
health care proxy for the patient, and an assessment of pain management (Wittenberg-
Lyles, 2005). Social workers and chaplains who do not have a specific role in case report
formats typically do not share their opinions in patient care discussions. Consequently,
all team members are not treated equally and psychosocial information is considered
secondary. The desire to fit in with the team and cooperating to impress a workplace
superior contribute to self-censorship and groupthink (Halpern, 2009).
The following example demonstrates how a team meeting discussion can be
impacted by groupthink attitudes (Box 8.4):
Box 8.4 Team Meeting Discussions
rn-1: He’s declining, he’s very weak, he staggers and he’s fallen once. He is con-
fused a lot of the time. He’s had chest pain. Sunday he had chest pain that
required three nitros, some oral morphine, and then two more nitros to
relieve the pain. Daughter is very understanding. She provides excellent
care and support to him. She’s real sweet.
rn-2: Is the daughter in the home?
rn-1: Yeah, they live together. First she took care of her mother, now she’s taking
care of him. She told me yesterday she is a breast cancer survivor and now
had uterine cancer. Now her father’s dying. She had gotten obese during all
(continued)
Box 8.4 (continued)
of this. She’s lost almost seventy pounds with Weight Watchers® and said
she feels better now than she’s felt in many, many years. I guess with all her
health issues she started gaining a lot of weight. Health issues and caregiv-
ing issues, she gained lots and lots of weight, so she’s looking really good
and she’s feeling really good about herself, and providing really good care
for him and, and he seems to be accepting everything. I asked him if there’s
anything I could do and he said, “Well, if you could make me about 25 years
younger I’d be fine.”
r-2: Is he the one that has the girlfriend that comes there?
rn-1: No, that’s a different patient.
rn-1: Okay. Chaplain, the social worker, everybody?
(Nods of agreement)
rn: He’s starting MSIR, and maybe [medication]. You might check the chart. I can’t
remember if it was there prior to. I think we started [medication] also.
While the discussion of this patient’s plan of care did include information about
pain, pain medication, and the caregiver, the only member of the hospice team to con-
tribute to this discussion was the hospice nurse case manager. The remaining team
members, specifically the medical director, social worker, and chaplain, decided not
to share information. Self-censorship occurred when these team members nodded in
agreement and allowed the discussion about this patient’s plan of care to end. In hos-
pice, nurses often find themselves responsible for presenting patient cases, and it is
important to recognize when groupthink is occurring and work to create an environ-
ment where everyone can contribute knowledge and expertise.
In addition to group cohesion, the structure of hospice and hospital systems can
contribute to the propensity for groupthink to occur in hospice and palliative care
(Degnin, 2009). Structural characteristics are the direct result of the organizational
process that contributes to the development and maintenance of interdisciplinary
teams. Structural constraints that influence group cohesion and the ability to collabo-
rate include manageable caseloads, an organizational culture that supports and encour-
ages interdisciplinary collaboration, administrative support, professional autonomy,
and the time and space for collaboration to occur (Bronstein, 2003; Youngwerth &
Twaddle, 2011). Structural constraints produce direct pressure on dissenters, an
inherent force that pressures group members to behave and think in similar ways
(Miller, 2009). When caseloads become unmanageable, there are concerns about time,
and/or group members do not have solid information-sharing procedures in place,
the effectiveness of communication in IDT meetings can be decreased by challenges
to information flow, including access to and recording of information, documenta-
tion of services, obtaining information from absent team members, data redundancy,
and updating of recorded information (Demiris, Washington, Doorenbos, et al., 2008;
Demiris, Washington, Parker Oliver, et al., 2008). As such, the ability to engage in
235 Team
collaboration is influenced by organizational policies and procedures of the hospital

unit or hospice agency (Tubbs-Cooley et al., 2011).
Finally, the situational context of group members can lead to groupthink. The sit-
uational context is the temporary condition of the team resulting from recent events.
These factors include high stress coming from outside of the group (e.g., institution-
alized care facility staff, primary care/attending physicians, health care policy), low
self-esteem among group members (e.g., suffering compassion fatigue, recent high
frequency of patient deaths), and trouble making group decisions and talking openly
about moral dilemmas. To cope with situational factors, group members fail to engage
in collaborative problem solving and instead commit to decisions and do not change
them. Nurses must work to reevaluate decisions about plans of care as the patient’s
status changes often and new care options become available.
Other factors influence the conflict management process among members (Miller,
2009). Personal factors such as gender and cultural (racial, ethnic) differences, per-
sonality differences, or the way an individual approaches conflict (avoids or confronts)
can determine whether or not members engage in conflict management. Relational
factors include issues of power that arise between members when there are differ-
ences in age, educational training, years of experience, or hierarchical positioning in
the team/group structure.

This chapter reviews team communication in palliative nursing, explaining the inter-
disciplinary collaboration process, interdisciplinary team meetings, and the propen-
sity for groupthink among palliative care team members. Team-building skills are an
essential nurse leader competency, and we offer the following clinical tools to assist in
teamwork and communication with colleagues (Huston, 2008). Consistent with other
chapters, these tools are summarized according to each step of nursing practice.
Assessment
The team environment needs to be assessed for infrastructure that enables interdisci-
plinary collaboration and for any signs that groupthink behavior may be the norm.
Take into consideration the following elements that influence the team’s ability to
develop interdisciplinary care plans (Bronstein, 2003) (Box 8.5):
Box 8.5
¾ Professional Roles
o Is there a defined hierarchy within the team structure? How is this communicated?
o Do all team members sit at the table, or are some team members sitting outside
of the group?
(continued)
Box 8.5 (continued)
o Are team members knowledgeable about each other’s roles, responsibilities,

background/training?
¾ Personal Characteristics
o What similarities/differences do team members have with each other?
o What gender/cultural differences exist within the team?
o In what ways do team members approach conflict (avoid, confront)?
¾ Structural Characteristics
o Is there a place for team meetings that allows everyone to sit together equally? Is
there an agenda? Is an agenda prepared in advance, and is the patient’s medical
chart ready and accessible?
o Does an administrator sit in on these team meetings?
o How long do team meetings last? How many people are present?
o Are organizational policies/housekeeping conducted as part of the team meeting?
¾ History of Collaboration
o How long has the team been together?
o What conflicts have occurred in the past?
o How often are on-call staff or per diem staff included in team meetings?
If the right infrastructure is in place, team members have a greater likelihood of

achieving collaboration.
In the opening case study of this chapter we can assume that this team engages
in interdisciplinary collaboration and effective decision-making. The team meeting
is a safe environment that allows all team members to share equally. First, the social
worker provides an initial assessment to the team, suggesting that she has a regular
speaking role in the team meeting. Second, team members feel comfortable and do
share strong opinions with each other. The nurses, social worker, and chaplain all
contribute to the discussion of Mrs. Lindsey’s care plan. There does not appear to
be any direct pressure on dissenters within this group, as John (chaplain) feels com-
fortable speaking up in opposition to the rest of the team. Reflect on your own team
meetings using the checklist in Box 8.6.
Box 8.6 Checklist
✓ CHECKLIST
Are your team meetings boring?

Do they have an environment where back-channel politics and personal attacks
thrive?
Are controversial topics ignored?
(continued)
237 Team
Box 8.6 (continued)
Does the team fail to tap into all the opinions and perspectives of team members?
Does the team waste time and energy with interpersonal risk management?
If the answer was yes to any of these questions, the team may be prone to groupthink
behavior and interdisciplinary collaboration may be at risk. Here are some telltale signs
that groupthink behavior may exist:
BEWARE of GROUPTHINK!
¾ Directive, overpowering leader

¾ Isolation from others who are not associated with the team (non–team members)
¾ Lack of critical discussions
¾ Loyalty to the group (when loyalty prevails over critical thinking!)
¾ Lack of norms for procedures
Used with permission from: Lencioni, P. (2002). The Five Dysfunctions of a Team: A Leadership
Fable. San Francisco: Jossey-Bass. 204.
Plan
Team-based palliative care requires that all team members engage in the planning
process.
Although Mrs. Lindsey’s hospice team was able to effectively engage in collabo-
ration with one another, the collaborative process resulted in conflict. Conflict dur-
ing group discussions is important and reflects quality decision making. John, the
chaplain, did not allow the rest of the team to stereotype Mr. Lindsey as a “jerk.”
Rather, he highlighted the benefits of Mr. Lindsey’s involvement. John’s role dur-
ing this case discussion reflects the team’s ability to consider alternative courses
of action and avoid groupthink behavior. Other tips for avoiding groupthink are
included in Box 8.7.
Box 8.7 Tips for Avoiding Groupthink
¾ Discuss the problem and draw out different perspectives.

¾ Clarify the patient’s goal of care.
¾ Make a list of criteria for the decision.
¾ Use a voting technique to ensure all opinions are considered.
¾ Ask probing questions.
Adapted from: Whyman, W., & Ginnett, R. (2005). A question of leadership: What can leaders
do to avoid groupthink? Leadership in Action, 25 (2), 12.
For patient/family cases that are particularly troublesome, we recommend appoint-

ing a team member to serve as devil’s advocate to help the team consider all options
and enhance their ability to engage in creative problem solving. Rotating opening case
summary presentations during team meetings from among the core disciplines may
also serve this very purpose.
Intervene
Good patient care is predicated upon effective, unified teams led by a directive leader
assigned within the system (Degnin, 2009). Nurses often serve as team leaders during
palliative care team meetings, and this role can influence group communication pat-
terns. To help the team achieve collaboration, nurses need to use interpersonal relation-
ship skills to help team members establish mutual respect and trust as well as facilitate
conflict resolution (Petri, 2010). For members of Mrs. Lindsey’s team, conflict emerges
from the team’s inability to establish a collective goal for her case. Collaborative prob-
lem solving is impeded when team members do not have the same sense of the “prob-
lem.” During Mrs. Lindsey’s care planning, some team members prioritized the loss of
the marriage and betrayal as key factors that should influence decision making. On the
other hand, John recognized that the immediate need for the care plan was a primary
caregiver. Handling difficult conversations, before, after, or during team meetings, can
result in further conflict and segregation of team members—however, when handled
appropriately with the right message structure these discussions can transition into
moments that foster team membership (Figure 8.2, Boxes 8.8 and 8.9).
Box 8.8 Communication Skills and Overcoming Conflict
The following communication skills are critical to learn and practice on teams:
✓ Actively Listen: Rephrase the issue and repeat the statement.
✓ Define the Problem. Emphasize the areas of agreement and frame the area of
disagreement.
✓ Open Questions. Ask questions that encourage discussion and permit disagreement.
“Can you tell me more about it?” “What else do we need to consider?”
✓ Clarify Responses. Help others recognize members’ attitudes and feelings.
✓ Paraphrase and Reframe. Summarize discussion to ensure that the disagreement is
understood. Explore group problem solving and encourage solutions that have not
been considered before.
Tools to Overcome Conflict
• Attack the problem, not the person.

• Focus on what can be done, not on what can’t be done.
• Encourage different points of view and honest dialogue.
• Express your feelings in a way that does not blame.
(continued)
239 Team
Box 8.8 (continued)
• Accept ownership for your part of the problem.

• Listen to understand the other person’s point of view before giving your own.
• Show respect for the other person’s point of view.
• Solve the problem while building the relationship.
Used with permission from: Hyer, K. (C. Rader, Ed.). (1998). Module 20. Interdisciplinary
Collaboration for Elder Care. Funded by John A. Hartford Foundation – Institute for Geriatric
Nursing.
Evaluate
Agreeing on a problem-focused process and openness to share resources can lead to
effective interdisciplinary collaboration (Petri, 2010), yet team members still need to
reflect on these processes and evaluate their own communication. It’s likely that most
teams have never considered team goals outside of the organization’s requirement that
SHIFT
From To
Perspective
Delivery Learning
Debate Exploration
Simplicity Complexity
I understand Help me
understand.
I am right I am curious.
Language
I know what you I know the impact
intended on me.
I know who is to Let’s figure out who

blame contributed what.
Either/Or And… And… And
figure 8.2 Shifting difficult conversations from confl ict toward learning
a team meet regularly. Use the following list (Box 8.9) to establish a team goal, such as
improving/addressing the safety of home patients, which can be accomplished through
collaboration. When a team identifies a goal, team members create a measuring stick
for evaluating their own practices. Setting goals is important. But it is also important
to consider team communication processes that enable these goals to be met. When
evaluating your own team, consider the communication practices that enable effective
interdisciplinary collaboration. Table 8.1 is a form to use for team evaluation. This
form can be used by an outside evaluator, such as a nursing or medical student who is
observing your team during a hospice/palliative care rotation. Students are excellent
observers as they are not familiar with informal group dynamics, such as group rules.
The form becomes a learning tool for the student as well as an assessment tool for team
communication practices.
Box 8.9
✓ CHECKLIST
- Maintaining the functional status of the patient

- Decreasing loss in activities of daily living
- Reducing use of home health care services
- Decreasing rates of depression
- Decreasing prevalence and symptoms of delirium
- Improving caregiver health
- Improving medication adherence
- Preventing adverse drug reactions
- Decreasing hospital utilization
- Reducing hospital length of stay
- Delaying nursing home placement
- Decreasing nursing home admissions
Used with permission from: Youngwerth, J., & Twaddle, M. (2011). Cultures of interdisciplin-
ary teams: How to foster good dynamics. Journal of Palliative Medicine, 14 (5), 650–654.
CHAPTER SUMMARY
Alongside clinical knowledge in palliative care settings, nurses need team communi-
cation skills to establish a leadership role on the palliative care team. Team-building
skills include encouraging other team members to actively contribute during team
decision making, fostering opposing viewpoints when they arise in care planning, and
evaluating team goals and communication processes. Representing the cornerstone
of the COMFORT model, this chapter presented an overview of team communica-
tion, focusing on interdisciplinary collaboration and warning against communication
241 Team
processes that lead to groupthink. In truly collaborative teams, intellectual resources

are utilized, coordination is maximized, professions gain recognition, and individual
health care providers fulfill their potential within their professions (Pringle, Levitt,
Horsburgh, Wilson, & Whittaker, 2000). To achieve this potential, palliative nurses
need to remain approachable, be interpersonally skilled, and listen to their colleagues
(O’Brien, et al., 2009). Chapter 9 departs from the COMFORT model to address the
taxing work of palliative care communication, its impact within and outside of clinical
settings, and to focus on self-care as a way of improving (and maintaining!) nursing
communication skills.
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of Conflict Resolution, 40, 415–435.
1. What are the characteristics of an interdisciplinary team?
2. Provide an example of task and relational communication within a team.
3. What are the four elements of the model of interdisciplinary collaboration? Give
an example for each one.
4. In what ways do nurses practice psychospiritual care?
5. What are the collective goals of a palliative care team?
245 Team
6. For each aspect of the model of interdisciplinary collaboration, identify and

explain how the nurse’s role may impact or be impacted by other team members.
7. In what ways are palliative care teams like a working group?
8. What are the three main elements of groups that lead to groupthink?
9. How are group members pressured to avoid conflict within the group?
10. Describe a time when you opted to self-censor your participation in a group.
What circumstances or factors led to your decision?
11. Compare and contrast the two excerpts from interdisciplinary team meetings in
this chapter. Identify the similarities and differences between the two discussions
using key terms from this chapter.
12. Of the personal and relational factors that contribute to groupthink, which are
most applicable to you? How will you work to overcome them?
EXERCISES FOR INTERDISCIPLINARY COLLABORATION

Exercise #1
First, have students write down three terms that they associate with interdisciplinary
health care teams. Next, place students into small groups and have them share their
terms. Then have all groups report to the class as a whole. Have a representative from
each group write the group’s terms on the board. Then, the instructor should task the
class with narrowing the list of terms to three terms and should limit the task to no
more than 5 minutes. The instructor should give no further instructions and allow the
class to complete the task. Typically, one student emerges who leads the class in a quick
discussion in which few students participate.
The instructor should then debrief the class by facilitating a discussion about the
decision-making process. Specific questions can help the class reflect on decision mak-
ing as a team: (1) Did everyone participate in the discussion? (2) Who emerged as the
leader and why? (3) How were decisions made? After a class discussion, the instruc-
tor should poll the students by asking how satisfied they are with the terms that were
identified. Students begin to realize that they either felt empowered by their participa-
tion or disempowered and silenced by their nonparticipation. Class discussion should
now highlight reasons for compromise or collaboration. Instructors may choose to go
around the room and solicit each student to explain his or her role in the decision-
making process and reasons why he or she chose to either participate or remain the
silent majority. Finally, the instructor discusses specific collaboration techniques and
the benefits of them. For example:
1. Focused discussion toward a goal. This may be accomplished if one or more group
members:
• Determine the most important goals for the group
• Keep discussion moving by limiting extraneous conversation
• Are practical/realistic when making contributions to discussion
• Keep interest of group members by recruiting participation from those less
vocal
• Are willing to take charge of the collaboration process
• Are willing to let someone else take charge
• Create rules to guide collaboration (e.g., one person speaks at a time)
• Follow/enforce rules
2. Ensuring all options have been considered. This may be accomplished if one or
more group members:
• Explain/justify preferences for specific ideas rather than merely state them
• Recruit advocates for the available options
246
247 Team
• Require others to explain nonspecific justifications (e.g., “I just like that one.”)
• Play devil’s advocate before eliminating an option
• Allow silence so that those less vocal can have the opportunity to contribute
• Keep all group members involved
• Avoid relying on supposed democratic processes. For example, decisions made
by majority rule may bypass more valid but less popular options.
• Consider options that are more unusual or “outside of the box”
• Consider even obvious options
• Consider unlikely or “wishful thinking” options
As a follow up to this assignment, instructors can provide students with a patient case
study and ask them to collaborate on developing an appropriate plan of care. Following
this exercise, students should discover that they are more satisfied with the experience
when collaboration occurs instead of compromise.
Adapted from: Kurylo, A. (2010). Teaching the difference between compromise and
collaboration through trial and error. Communication Teacher, 24(1), 25–29.
Exercise #2
Box 8.10 details the case for this exercise. The goal of the meeting you are about to join
is to come up with an interdisciplinary care plan for Ms. J. Please decide your team
roles and prepare an agenda for the meeting. Decide how you will conduct your team
meeting. You should plan on 20 minutes for your team meeting.
Box 8.10
Debra J. is a 55-year-old woman, widowed, and living in a small rural town in the Central
Valley. She has worked on an assembly line at a local manufacturing plant for the past
25 years. She drives to work in an old car.
Debra married at 15 and had her three children before age 20. She did not graduate
from high school. Her husband died 5 years ago of a heart attack and left her a $70.00
monthly pension from his work on the railroad. She lives on her family’s farm with her
85-year-old mother. Her children are all away from home. Her two eldest live out of state,
and her youngest daughter lives in San Francisco
Medical History. BP = 150/80; Weight = 150 lbs.; Height = 5’5”
She has smoked one pack per day for 30 years, had her lower teeth extracted at age
40 with dentures made, and had three normal vaginal deliveries. She has two or three uri-
nary tract infections per year. In addition to her work on the assembly line, she works long
hours on the family farm. She is beginning to show signs and symptoms of degenerative
joint disease in her hands and knees. She comes to the clinic today for a simple check-up.
Questions
• What team members need to be involved in this case?
• What are Ms. J’s most important health issues, and who should be involved in man-
aging these issues?
• Develop a management plan for Ms. J.
Use the following grid to assess the patient’s situation from each need aspect (med-
ical, emotional, etc.) and identify the impact of the problem on the patient’s health
and quality of life. Identify community or family resources that could be redirected to
address the problem and outcomes or triggers to notify the team that the plan is or is
not working. The care plan should identify what activities are expected but also which
member of the team is responsible for initiation, follow-up, and reporting back to the
team with the results.
Table 8.2 Overarching Team Goals:

Patient’s:
Family’s:
Team’s:
Problem Expected Impact on Strengths/ Plan (What/

Outcome Health and Resources Who/When) . . .
Quality of Life Includes
Getting More
Information
Assess the actual functioning of the team—the team process and the efficiency of
addressing clinical aspects or needs. The learners/participants should be able to develop
the plan and set the priorities for the team plan of care, and be able to evaluate what
to look for and when to determine if the plan was effective. The last step reinforces the
team’s responsibility for ongoing care management and joint accountability.
Considering the patient’s medical, emotional, social, environmental, and economic
needs, answer each of the following questions:
• What is the overarching goal? At least three perspectives need to be considered and
reconciled: (a) the patient; (b) his/her family; and (c) the team.
249 Team
• What are the patient’s problems? Consider a wide range of possible foci: medical,
emotional, social, environmental, and economic.
• What is the impact of each problem on the patient’s health and quality of life?
• What strengths and resources does the patient have or can be mobilized to deal with
each problem?
• What additional information is needed to adequately define the problem or its
implications?
• What is the plan of care? What needs to be done? Who will do it? When will it
happen?
• What priority should be assigned to each problem in either a linear order or catego-
ries of importance?
• How important is its effect on the overarching problem? What other factors might
influence its relative priority?
• What outcomes should be expected for each problem? Express each in measurable
terms. When would be an appropriate time to measure the outcomes?
Used with permission from: Siegler, E., Hyer, K., Fulmer, T., & Mezey, M. (1998). Geriatric
Interdisciplinary Team Training. Module 20. Interdisciplinary Collaboration for Elder Care. Funded by
John A. Hartford Foundation – Institute for Geriatric Nursing.
Exercise #3
To help students learn to develop creative communication strategies when dealing
with complex or difficult team members, introduce the class to contrasting pictures
of an animal, for example, an angry animal versus a sweet, cuddly animal. Pictures
must be of the same animal type (e.g., dog, cat). Place students in small groups and
ask them to brainstorm creative ways to transform the angry animal into the nice
animal. Encourage them to be creative in their ideas and methods for taming the
angry animal. You should allow the groups about 15 minutes to complete the brain-
storming task.
Next, small groups should send a designated leader to the board to share their ideas
with the rest of the class. Using the ideas on the board, the instructor should review
the chapter material on groupthink. Analogies can be drawn from the class ideas to the
deliberate steps that can be taken to work with difficult team members. First, instruc-
tors should begin by identifying behaviors that can build a supportive communication
climate among team members (e.g., active listening, showing support, and expressing
solidarity). Second, instructors should discuss varying personality types and group
behaviors. For example, issues such as dominance and control can be contrasted with
the need for understanding, inclusion, affection, self-esteem, and hesitancy to speak in
a small-group format.
The class list of taming methods should be reviewed, and students should be
encouraged to develop analogies to the interpersonal and small group behaviors
(see example table below). For example, a common taming method is to feed the
animal. The instructor then has students list communication strategies related to
“feeding” a team member, such as spending more time with the individual and
engaging in social and relationship building outside of the team format.
Ideas for taming an animal and corresponding communication strategies were taken from Eckstein
(2005).
Table 8.3 Creative Team Communication Strategies

Taming Behaviors Interpersonal and Small-Group-Building Behaviors
Praise it. Confirming messages (recognition, endorsement)

Supportive message behaviors (“You are doing a good job.”)
(“I like the way you handled that.”)
Speak gently. Speak slowly, allowing for silence and clarity.
Understanding defensive responses
Assertive language
Nonassertive language
Using “I” language (“I have a hard time with . . . ”)
Confirming language
Perception checking (“So what I hear you saying is . . . ”)
Self-disclosure (“It hurt my feelings”/“I took it personally”)
Recognizing others’ existence, position, feelings
Feed it. Spending more time on social and relational group building
Bringing/sharing food with others
Pet it. Affirming nonverbal cues (smiling, hugging)
Eye contact while listening
Shaking hands in greeting
Understanding individual rules of touch
Approach slowly. Listening to help
Listening for feelings
Reading body language
Neuter it/Spay it. Understanding gender differences
Win–win problem solving
Conflict styles
Exercise #4
For instructors who wish to develop small group assignments in their course, this
assignment may be done to establish small-group relationships. First, instruct small
groups to spend time together engaging in at least four activities. A picture of all group
members engaging in the activity together must be provided for evidence of the activ-
ity. For example, one of the activities may be to share a meal together. Second, instruct
small groups to develop a set of communication rules for their small group. These
251 Team
rules will serve as a code of conduct for acceptable behaviors and group operating
procedures. Some things to consider are:
• What should a member do if he or she cannot attend a meeting? What are acceptable
reasons for absences, if anything?
• Who is going to organize the agenda for our meetings?
• What do we expect group members to do/have ready for meetings?
• How will we manage conflict?
Students should be given 2 weeks to complete their activities and provide the
instructor with a written report that summarizes activities, provides pictures of the
group’s experiences, and details the group’s set of communication rules. Ideally, groups
should present their experiences and highlight what they learned about other group
members by engaging in shared experiences.
Additional assignment: Instructors may wish to use the team’s communication rules
as a grading rubric for team assignments. The rules may also be used for peer evalu-
ation should the instructor decide to include team member evaluation of other team
members.
Adapted from: McBride, M. C. (2006). “—ing” Project: Encouraging cohesion in small groups.
Communication Teacher, 20 (2), 53–56.
Exercise #5
Ellingson (2003) provides extensive work on the backstage communication pro-
cesses of interdisciplinary teams. Pair students or establish several small groups in
the classroom. Provide students with a handout of the table below. Instruct students
to review each verbal behavior by sharing their own examples and then discussing
whether or not the communication enhances or decreases opportunities for inter-
disciplinary collaboration among team members.
Table 8.4 Characteristics of Team Communication

Verbal Behavior Definition
Request for clarification Questioning each other about information about the patient
being discussed
Request for opinion Questions that solicit opinions on issues such as patient/
caregiver affect, depression or to confirm their own opinion
or initiate discussion about how team members can resolve
problem
Offering of information Information shared that would provide practical assistance to
other team member’s communication with patient
(continued)

Verbal Behavior Definition
Offering of impressions Descriptive statements that share positive or negative
impressions and opinions about patients/caregivers
Request for reinforcement Asking team member to repeat information already
of a message mentioned to the patient.
Clinical progress Asking team members which patients had been seen and by
whom or stating when the patient had been seen.
Life talk—Patients Sharing outside patient information such as life history/
experiences
Life talk—Team members Sharing outside personal information such as life experiences
Troubles talk Complaining about scheduling, limited resources, behavior
of outside clinic staff
Handling interruptions Patient care related or personal and family concerns
Service interruptions—e.g., nurse listening to caregiver
concerns, taking phone calls from caregivers for lengths of
time
Formal reporting Primarily diagnostic (such as patient name, age, diagnosis,
medical history, primary care physician), “Yes” and “No”
responses
Organizational Issues Comments about health care system, such as billing, costs,
insurance issues
Adapted from: Ellingson, L. L. (2003). Interdisciplinary health care teamwork in the clinic back-
stage. Journal of Applied Communication Research, 31, 93–117.
COMMUNICATION ROLE REVERSAL

Exercise #1
http://kilmanndiagnostics.com/taketki.html
The Thomas-Kilmann Conflict Mode Instrument (referred to as the TKI) is a tool that
assesses a person’s behavior during conflict. There is a charge for this instrument.
Exercise #2
See also:
Adams, T. (2005). Vote red, vote green: A class exercise in groupthink dialectics. The
Florida Communication Journal, 333(1), 15–22.
9
communicating self-care needs
Nurses are in a uniquely vulnerable position in the practice of palliative care. Not only
do they witness the suffering of patients and their families—and also the anxiety and
grief of their fellow palliative care team members—but they also suffer their own pain
and grief. They are both participant and observer in what is arguably life’s most stress-
ful crisis: the transition from life to death. An inseparable relationship often exists
between the suffering person and the professional who provides care while witness-
ing that suffering, as each party is vulnerable to the other (Ferrell & Coyle, 2008).
Thus, nurses frequently must step back and ask the question: “Whose suffering am
I experiencing?” (p. 87). Particularly when patients face discouraging diagnoses, nurses
must strive to find that delicate balance in continuing to care for the patient while also
acknowledging the patient’s and family’s—as well as their own—fears.
In their book on the nature of suffering and the goals of nursing, Ferrell & Coyle
(2008) note that all nurses encounter suffering on a daily basis; yet, palliative care, hos-
pice, and oncology nurses are particularly vulnerable to patient suffering. The relief
of suffering is central to oncology nursing: “ . . . working with cancer patients means
‘being there’ for people in their most private moments of suffering and responding
to the heights and depths of their responses to this suffering” (Cohen & Sarter, 1992,
p. 1485).
Much of the suffering nurses must face is caused not only by their stress from wit-
nessing the suffering of others but also by the stress of witnessing (and occasionally
being forced to deliver) medically futile care (Ferrell and Coyle, 2008). Nurses across
care settings have identified “aggressive care” and “aggressive care denying palliative
care” as the most common sources of their distress in caring for critically ill and dying
patients and their families (Ferrell, 2006). Conflicts and feelings of moral distress
related to futile care occur between patients and their families, between patients/fami-
lies and their medical teams, or even within the medical team itself. This experience of
distress is linked to burnout—nurses’ emotional exhaustion related to the frequency
of incidents regarding care seen as futile or unbeneficial (Meltzer & Huckaby, 2004).
Thus, there is much need for nurses to be able to self-reflect, engage peer support, and
permit themselves to grieve in the face of the stress of witnessing these futile care inci-
dents (Stairs, 2000). We close this volume by emphasizing the importance of self-care,
encouraging nurses to be aware of their feelings and to communicate these feelings to
others.
253
Just as the patient and family need to tell their story, to have it be heard by others as
a way of making meaning out of what they experience and witness, nurses also need
opportunities to share their experiences and emotions with others. It is essential that
nurses be aware of and deal with their own grief and sense of loss when a patient receives
a terminal prognosis or when a patient succumbs to disease (Baird, 2010; Ferrell & Coyle,
2008; Levine & Levine, 1999, as cited in Baird). For many nurses, there is often an ina-
bility to separate their professional and personal lives when loss is so prevalent (Ablett &
Jones, 2007; Arnaert & Wainwright, 2009). Working conditions, inadequate preparation,
lack of time to relax or grieve, and staff relationships contribute to workplace stress and
necessitate communication and self-disclosure about the emotional labor of palliative
care work (Barnes, 2001; McCloskey & Taggart, 2010). Commonly, nurses do not attend
to self-care, and job stress emerges at home—impacting relationships and causing irrita-
bility, sleeplessness, and fatigue (McCloskey & Taggart, 2010).
When nurses are tired and overworked, they are unable to provide adequate care
and to appreciate their role and relationships with patients and families. Inadequate
self-care can lead to quicker emotional responses than normal, a tendency to overreact
with clinical team members and family, and anger. The call button becomes easier to
ignore, emotions become easier to tuck away and hide with busy clinical work, and
withdrawing from clinical team members, patients, and families becomes a routine
coping mechanism that results in burnout (Blomberg & Sahlberg-Blom, 2007). Some
nurses feel that the only remedy is to call in sick, feeling guilty that they want to avoid
work and momentarily escape daily pressures from their job (McCloskey & Taggart,
2010), or even worse, to leave the field of palliative care or nursing.
SPECIFIC STRESSORS IN PALLIATIVE NURSING

Nurses experience stress when working with family caregivers, during challeng-
ing clinical situations, and as a result of service delivery issues in their care setting
(Brazil, Kassalainen, Ploeg, & Marshall, 2010). Since the nurse is always available and
easily accessed, patients and families expect nurses to have competent communica-
tion skills and be able to provide answers to all inquiries about patient care (Arnaert
& Wainwright, 2009). Given such high demands, negative feelings can emerge from
personal inadequacy if nurses are not able to provide enough information and/or con-
trol the patient’s symptoms (Keidel, 2002). The intimacy of nursing care also creates
opportunities for nurses to become attached to patients and family members, often
because they are similar to loved ones in their own lives or because a particular situ-
ation resonates with them (Ablett & Jones, 2007). Nurses face difficult situations as
they struggle to be close to patients and families yet distance themselves from too
much emotional involvement (Blomberg & Sahlberg-Blom, 2007). As family caregiv-
ers become responsible for home hospice care, nurses witness caregiver burden and
patient neglect or abuse; they thus struggle with the competency of caregivers to pro-
vide care (Brazil et al., 2010).
Challenging clinical situations also reveal personal and situational variables that add
to the amount of stress experienced by palliative care nurses (Hulbert & Morrison, 2006).
255 Communicating Self-Care Needs
While palliative nurses have an awareness of their own mortality and spirituality (Ablett
& Jones, 2007), clinical situations can require nurses to enact decisions that do not reflect
their own choices or beliefs. Nurses encounter challenges related to patient decision
making, particularly when a nurse feels the patient is at risk, as well as disagreements
over the appropriateness of treatment between the provider and family (Brazil et al.,
2010). Some of the more uncomfortable circumstances include families who refute the
patient’s advance directives and insist that staff do “everything” to save the patient’s life.
Family complexities can involve working with ex-family members, dysfunctional fam-
ily systems, and requests to conceal the type of care being offered (hospice/palliative)
(Gentry, 2008). Nurses also struggle to impact care for patients when no family is pres-
ent and little is known about the patient’s life (Brazil et al., 2010).
Finally, nurses work in the dysfunction of hospital systems or hospice agencies
that sustain a complex communication climate that leaves little to no time or energy
for self-care. Nurses feel stress when workloads are high, as a result of shift work, or
an effect of staff shortages (Ablett & Jones, 2007). Although continuing education
training is regularly offered, stress can be high for nurses who learn a great deal from
on-the-job training (Arnaert & Wainwright, 2009). The organizational structure that
dictates service delivery routines can result in a lack of clear roles, professional bound-
aries that aren’t clearly defined, and multiprofessional work that is difficult to accom-
plish (Gupta & Woodman, 2010). Table 9.1 provides suggestions for how to build a
collaborative partnership among peers.
Burnout and compassion fatigue are typical responses to the stressors that palliative
care nurses confront daily (Vachon & Huggard, 2010). Nurses experience emotional
exhaustion, feelings of cynicism and detachment from the job (depersonalization),
and a sense of ineffectiveness and the lack of personal accomplishment (Maslach, 2003;
Maslach & Leiter, 2008; Maslach, Schaufeli, & Leiter, 2001). Symptoms of burnout can
be found at the physical, psychological, occupational, and social levels. Compassion
fatigue—the physical and spiritual exhaustion that comes from compassionate care-
giving, particularly in futile care—manifests in symptoms closely related to those of
posttraumatic stress disorder; in contrast to burnout, however, nurses with compas-
sion fatigue can still care and be involved.
Because of the occupational hazards of burnout and compassion fatigue, Vachon
and Huggard (2010) stress the importance of self-care for oncology and palliative care
Table 9.1 Ways to Build a Collabortive Partnership

x Work collaboratively by making suggestions to others
x Share information with others
x Continually teach others (nurses and informal caregivers) about hospice/palliative care
x Adopt a nonjudgmental approach (don’t be pushy!)
Used with permission from: Arnaert, A., and Wainwright, M. (2009). Providing care and sharing
expertise: Reflections of nurse-specialists in palliative home care. Palliative and Supportive Care,
7(3), 357–364.
nurses. Vachon (2008) notes that as oncology nurses educate cancer patients about
the importance of wellness strategies, they should take their own advice and integrate
wellness changes in their own lives. Puchalski (2008) suggests that the practice of com-
passionate presence (see also Chapter 4) lessens the likelihood of burnout and com-
passion fatigue—if health care professionals are trained to be compassionate, burnout
is likely to be diminished.
REALIZING THE NEED FOR SELF-CARE

Nurses can help prevent caregiver burnout and compassion fatigue by knowing their
own physical and emotional limits, realizing the need for self-care, and acknowledging
Table 9.2 Self-Care Planning

Physical Stress—Solutions
Stretching neck and shoulders
Practice deep breathing
Use audio recordings to assist with relaxation
Exercise—walkingListening to music
Emotional/cognitive
Explore “helper grief” by expressing feelings through talk, paint, music, dance, art, writing.
Time alone, to meditate, pray
Develop a daily release ritual
Seek comfort (bath tub, pets, praying, etc.)
Relational
Set and maintain relational boundaries
Identify your own needs
Ask for what you need
Set healthy limits with others
Spiritual
Get in touch with nature
Pray
Meditate
Read sacred or inspirational material
Participate in holy sacraments
Interact with children
RED FLAGS FOR NOT HAVING LIMITS:
Giving out your home phone or personal cell phone number
Extended visits
Thinking about the patient/family after work
Extending professional relationship to a personal relationship
Sharing more personal information than usual
Used with permission from: Jones, S. H. (2005). A self-care plan for hospice workers. American
Journal of Hospice & Palliative Medicine, 22 (2), 125–128.
Table 9.3 Actions Often Connected with Stress

Physical
Excessive tension
Becoming accident prone
Teeth grinding
Restlessness
Mental
Forgetfulness
Poor concentration
Confusion
“Spacing out”
Emotional
Pronounced mood swings
Frequent irritability
Crying spells
Lashing out
Spiritual
Chronic cynicism
Needing to “prove” oneself
Apathy
Loss of direction in life
Used with permission from: Davidhizar, R., & Shearer, R. (1996). Using humor to cope with stress
in home care. Home Healthcare Nurse, 14 (10), 825–830.
their own feelings about dying and death (Sherman, 2004). Puchalski and McSkimming
(2006) described interventions to promote healing environments in hospitals. Such
interventions focused on the spirituality of health care professionals and included
brown bag lunches and workshops on spiritual care as well as mindfulness meditation
and mindfulness-based stress reduction (mindfulness is discussed briefly in the next
paragraphs and more fully in Chapter 4). See Table 9.2 for self-care planning tips.
Because of the emphasis of mindfulness on self-care, compassion, and healing, it
is seen as a relevant intervention in promoting nurses’ attempts to care for themselves
in their stressful environments. Mindfulness-based stress reduction in particular is a
helpful self-care strategy for nurses (Mackenzie, Poulin, and Seidman-Carlson, 2006).
One way to achieve the deep personal and interpersonal understanding and sensitiv-
ity required of nurses is by practicing the tenets of mindfulness such as awareness of
the moment, nonjudging acceptance, patience, and kindness (Henry & Henry, 2003;
Mackenzie, Poulin, and Seidman-Carlson, 2006). As noted earlier, nurses are faced with
even greater stress and burnout due to an increasingly complex health care system and
sicker patients. Indicators of stress are summarized in Table 9.3. Several studies have
demonstrated reduced stress, increased coping, and improved empathy in health care
providers after they have completed a mindfulness-based stress reduction program
(Beddoe & Murphy, 2004; Galantino, Baime, Maguire, Szapary, & Farrar, 2005).
Bruce and Davies (2005) in particular found that staff and volunteers at a Zen hos-
pice who practiced mindfulness meditation reported more empathy and attentiveness
to their patients, such that it was easier for them to discuss death with their patients
and to better cope with patients’ imminent deaths. Mindfulness-based stress reduc-
tion for nurse stress and burnout has resulted in more relaxation and self-care and
improvement in both work and family relationships (Cohen-Katz, Wiley, Capuano,
Baker, & Shapiro, 2004, 2005a, 2005b).
Structured reflection—an insightful analysis of one’s own experiences, thoughts,
and feelings—is a component of communication said to occur at the intrapersonal
level or within the person herself. The essential need for palliative care nurses’ self-care
involves knowing oneself thoroughly, understanding one’s motivations, being aware
of one’s special talents and abilities but also of one’s liabilities, and being able to put
this self-knowledge to work in effective interactions with patients, families, and other
members of the health care team. The attributes of mindfulness, presence, empathy,
and deep listening, described in preceding chapters, are paramount to achieving this
self-knowledge and must be nurtured by effective palliative care nurses. Developing
such attributes also requires a keen awareness of one’s thoughts, feelings, attitudes,
beliefs, and values. By becoming more self-aware, nurses can help to better manage
those stressors in their work environment that contribute to burnout, compassion
fatigue, suffering, and grief.
One of the concepts most useful to self-care is self-compassion, the ability to
feel compassion for oneself (Neff, 2003a, 2003b; Neff, Kirkpatrick, & Rude, 2007).
Self-compassion as: “being open to and moved by one’s own suffering, experiencing
feelings of caring and kindness towards oneself, taking an understanding, nonjudg-
mental attitude toward one’s inadequacies and failures, and recognizing that one’s
experience is part of the common human experience” (Neff, 2003a, pp. 85–102).
Elements of self-compassion include common humanity (shared human expe-
rience), self-kindness (which is different from self-pity), and mindfulness (Neff,
2003a.) Self-compassion requires a fair, objective awareness of one’s emotions; it
includes the process of confronting rather than avoiding painful thoughts and emo-
tions. Developing an awareness of and appreciation for self-compassion is helpful
not only for palliative care nurses’ self-care; self-compassion also may permit nurses
to feel more compassionately toward their patients (Heffernan, Griffin, McNulty, &
Fitzpatrick, 2010).
Ferrell and Coyle (2008) point out that nurses’ spirituality may influence their
responses to suffering in ways that are similar to how patients and families experi-
ence their own spirituality in facing terminal illness: “ . . . nurses frequently struggle
in an attempt to balance the patient and family’s faith with their own and to balance
personal and professional values” (p. 96). Yet in a study conducted by Ferrell, Virani,
Grant, Coyne, & Uman (2000), nurses initially did not report their own spirituality as
being linked to their experiences of suffering. Ferrell et al. (2000) believe that this sug-
gests that nurses may have been trained to separate their own faith and personhood
from their role as nurse—that their education may be one that separates mind, body,
and spirit (teaching that is also damaging to patient care).
Sherman (2010) also advocates that palliative care nurses should engage in
self-reflection and self-healing and should explore their own values and attitudes
toward death. She further states that nurses have the potential to provide spiritual
care to their patients, yet the ongoing care of the dying may drain their energy and
uncover spiritual issues—thus, there is a need for spiritual growth and renewal as
part of staff support. A study by Hunnibell, Reed, Quinn-Griffin, & Fitzpatrick (2008)
found that hospice and palliative care and oncology nurses measured high on a scale
for self-transcendence, which is the awareness of one’s spiritual self, one’s relationship
to others and to a higher being, and finding meaning and purpose in life.
Self-compassion is also linked to emotional intelligence in nurses—the ability
to recognize and to manage emotions. Emotional intelligence is useful in potentially
enhancing patient care as well as maintaining nurses’ emotional health while also pre-
venting burnout (Davies, Jenkins, & Mabbett, 2010). Emotional intelligence creates
self-awareness, allows nurses to control their emotions, enhances assessment, and pro-
motes palliative care and leadership (Davies et al., 2010). The clinical setting of pal-
liative care requires a high level of emotional intelligence in order to foster different
coping strategies to prevent burnout. Informal team support can play a pivotal role in
sustaining emotional intelligence in such a demanding clinical environment (Davies
et al., 2010).
Borneman and Brown-Saltzman (2010) stress the need for self-care for dealing with
grief, particularly since nurses are at great risk for turning away from feeling—most
nurses receive little mentoring, debriefing, or counseling after their first death experi-
ence. Scant research has looked at the effect on nurses of cumulative losses and many
years of witnessing suffering. As a result, Borneman and Brown-Saltzman (2010) rec-
ommend: “healthcare needs healing rituals for all its health-care professionals” (p. 682).
They point out one example of such a healing ritual, a renewal program known as the
“Circle of Caring” which is a self-care weekend retreat integrating spirituality, the arts,
and community building.
In discussing palliative care nurses’ inevitable loss, suffering, grief, and bereavement,
Potter (2010) poses the need for nurses to self-assess: where am I (the nurse) on the
journey toward healing? In conflict with traditional nurse training in which nurses are
encouraged to maintain composure and not to express emotion, Potter advocates that
“constructive self-disclosure of feelings by the nurse may role-model to others a healthy
process of acknowledging and resolving the suffering of loss” (p. 208). Examining their
own personal experiences with death helps nurses to better understand their fears and
anxieties surrounding it. Potter (2010) believes that nurses must engage in self-care by:
getting support from colleagues; ensuring time for self; maintaining healthy boundar-
ies with patients/family; and tending to their physical emotional, and spiritual needs.
OPPORTUNITIES TO COMMUNICATE
SELF-CARE NEEDS
The team-based structure of palliative care can and should provide both informal
and formal environments for nurses to discuss their feelings, emotions, worries,
experiences, regrets, hopes, and anxieties related to workplace stress (Blomberg &
Sahlberg-Blom, 2007; Wittenberg-Lyles, Oliver, Demiris, Baldwin, & Regehr, 2008).
While clinical frontstage communication and activities include rounds and meet-
ings with patients and families, nurses also engage in backstage communication and
activities that occur in hallway conversations; before, during, and after team meet-
ings; and over lunch (Ellingson, 2003; Lewin & Reeves, 2011). These encounters, both
planned and unplanned in front and backstage, facilitate impression management
between colleagues and either legitimate healthy changes in the workplace or simply
perpetuate them (Lewin & Reeves, 2011; Wittenberg-Lyles, Parker Oliver, Demiris, &
Cunningham, 2011). The nurse’s station is a regular site for planned and unplanned
backstage communication.
Communication between colleagues, away from families and patients, is where
emotional work has the potential to occur. The team environment allows nurses
to vent workplace stress, share difficult patient/family situations, seek and receive
confirmation for care choices, and share emotions (Goldsmith, Wittenberg-Lyles,
Rodriguez, & Sanchez-Reilly, 2010; Wittenberg-Lyles, 2005; Wittenberg-Lyles, Gee,
Parker Oliver, & Demiris, 2009). Nurses naturally rely on other nurses to support
care decisions, especially with regard to pain management (Arnaert & Wainwright,
2009). Ad hoc as well as planned backstage communication can and should allow
nurses to work on overcoming problems with other staff members (Lewin &
Reeves, 2011).
Team meetings that take place prior to or after patient rounds, or as part of inter-
disciplinary team structure, can be used to create an appropriate interpersonal climate
for sharing and releasing the emotional burden of palliative care work. An interper-
sonal climate is the feeling or emotional mood that is created between people and can
include defensive or supportive communication (Wood, 2004). Supportive commu-
nication can foster working relationships that contribute to self-care. The way we relay
messages to one another can foster a supportive communication climate. To become
more effective at contributing thoughts on clinical decisions, nurses should engage in
language that describes instead of evaluates. Think about the difference between these
two messages: (1) “You shouldn’t have done that.” (2) “You seem to have more to do
today than usual.” The first statement evaluates what someone else has done, while the
second statement merely describes. The simple difference in these two messages is the
outcome that results in a defensive or supportive communication climate. To create
supportive climates, nurses need to remain open to other points of view and engage in
open, honest, unpremeditated communication (Wood, 2004). Ideas for coping strate-
gies can be found in Table 9.4.
Using “I statements” as discussed in Chapter 4 is one way nurses can convey their
point of view while remaining open to hearing other opinions. For example, “The
way I tend to see the issue is . . . ” is much better than saying “I’ve already decided the
best way to handle this patient is . . . ” Team discussions should also be problem ori-
ented and focus on solutions rather than blame. During clinical rounds and team
meetings, nurses should express empathy with other team members and confirm that
their thoughts and feelings are a concern to the entire team. Teams possess powerful
Table 9.4 Coping Strategies

• Do an honest self-assessment to objectively evaluate your work place
• Monitor the tendency to get overinvolved
• Ask yourself whose needs you’re trying to meet
• Consciously avoid viewing yourself as the “savior” of the terminally ill patient
• See things from the family’s perspective rather than feeling their emotions
• Feed your spiritual side, whatever that means to you
• Keep interested in and challenged by your patients’ spiritual, emotional, and physical
problems
• Set attainable goals for yourself, and reward yourself when you reach them
• Learn to say no and to ask for what you need
• Try to see each task as a challenge rather than a hassle
• Adapt your job rather than accepting it as handed to you
• Cultivate a supportive and enjoyable social network
• Share your distress and get support from friends, but do not discuss your work problems
with everybody
• Talk over your concerns with a supportive hospice staff member
• Strive for balance in your family and professional life
• Combat stress by eating healthy and getting adequate sleep and exercise
Used with permission from: Keidel, G. C. (2002) Burnout and compassion fatigue among hospice
caregivers. American Journal of Hospice and Palliative Care, 19 (3), 204.
potential for reflective practice in order to improve their own self-care experience and
sustainability as health care workers (Goldsmith et al., 2010).
Nurses should connect with other team members to form support groups, share stories
and experiences, keep a journal, and recognize their positive, individual contributions to
patient care (Sherman, 2010). Offstage is a third location that coworkers can experience
away from their work place (Lewin & Reeves, 2011). Spending time in a new context with
the people one experiences so much pressure and loss with can be a wonderful reframing
and provide people access to new characteristics and skills possessed by their coworkers.
Even in the pressure-filled spaces of the workplace, creative experiences of decom-
pression with teammates can be created. Carry-in meals for sharing, short yoga
stretches before lunch, and relieving the busiest nurse on the floor are small opportu-
nities to offer and experience self-care in the course of a busy day. “In caring for people
with life-threatening and progressive illness, nurses must remain in tune with their
own spiritual needs, healing themselves as well as others” (Sherman, 2010, p. 30).
FOCUSED SELF-REFLECTION
Once aware of the need for focused self-care, nurses can engage in focused reflection by
journaling about their thoughts and feelings, seeking support from friends and colleagues,
prioritizing celebrations such as birthdays and holidays, and engaging in other forms of
distraction such as reading, exercise, or vacation (Anewalt, 2009). Journaling is a form of
expressive writing that provides opportunity for reflection (Lauterbach & Hentz, 2005).
Expressive writing exercises require participants to reflect on their deepest thoughts and
feelings about an event or series of events (Sexton et al., 2009). Most nurses are exposed
to journaling and reflective activities during undergraduate nursing education. Journaling
can reveal interdisciplinary relationships and team processes and impact patient care and
professional development (Makowsky et al., 2009). Clinician stories about palliative care
reveal deep, intimate relationships with patients and families and spiritual strengthening,
both fostering the strength to control emotions at the bedside and devotion and loyalty to
special patients (Wittenberg-Lyles, Greene, & Sanchez-Reilly, 2007).
The ability to formulate a good story, in which both successes and losses are recognized
to create meaning and understanding, can also yield several health benefits (Graybeal,
Sexton, & Pennebaker, 2002). Writing has biological effects, including enhanced immune
systems, decreased medical health markers among individuals with chronic health prob-
lems, and reduction in physiological stress (Pennebaker, 2004). Additionally, research has
shown that an individual’s mood changes after writing (Pennebaker, 2004).
Importantly, self-care should be modeled and encouraged by nurse leaders and
nurse managers. Managers can mediate communication between clinical staff and
encourage a supportive communication climate. Early-career nurses need to learn to
emphasize self-care alongside clinical work obligations, and managers should provide
protected time for these nurses to incorporate self-care into their daily routine. Feeling
balanced involves having self-awareness, active coping, feeling spiritually enriched, and
setting boundaries between professional and personal life (Rose & Glass, 2009).
Ferrell & Coyle (2008) advocate that nurses’ suffering needs to be addressed in educa-
tion and research: “Schools of nursing and continuing education programs can teach
the skills of listening, responding to anguish, hearing ‘why’ questions, and in fundamen-
tally re-envisioning what it means to be a nurse—perhaps even helping us return to our
roots” (Ferrell & Coyle, 2008, p. 106). They cite physician Rachel Naomi Remen’s work
on how serving patients sustains nurses as health care providers, even in the face of suf-
fering and death: “our service serves us as well as others. That which uses us strengthens
us. Over time, fixing and helping are draining, depleting. Over time we burn out. Service
is renewing. When we serve, our work itself will sustain us” (Remen, 1996, p. 24).
CHAPTER SUMMARY
The uniquely stressful environment of nursing and of palliative care nursing in particu-
lar makes self-care imperative. In this chapter, we have identified how communication at
both the intrapersonal and interpersonal levels can facilitate such care. Intrapersonally,
nurses can learn to be aware of their feelings, behaviors, and values through such prac-
tices as self-reflection and journaling. In this way, both self-compassion and emotional
intelligence can be fostered—both of which help to prevent burnout and compas-
sion fatigue. Spiritual awareness can also enhance a nurse’s ability to cope with the
suffering and death inevitably experienced in the context of palliative care nursing.
Interpersonally, nurses and palliative care teams need to practice supportive rather
than defensive communication behaviors in an effort to ameliorate the stressors in
their work environments. Backstage, frontstage, and offstage communication can be

utilized both to make other members of the health care team aware of one’s self-care
needs and to seek help for resolving those needs.
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Cheltenham, UK: Nelson Thornes.
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Guilford Press.
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Emotional Upheaval. Oakland, CA: New Harbinger Press.
1. Identify factors in palliative care settings that make self-care of special importance
for nursing.
2. What are strategies for nurses to better communicate their self-care needs?
3. What strategies can organizations initiate to create environments that support
self-care of staff?
EDUCATOR RESOURCES AND MATERIALS
Activity 1
Identify three to five people or things that are important to you. When was the last time
you called that person? When did you last spend quality time with that person? When
was the last time you did that thing? How are you currently caring for yourself? What
needs to change?
Activity 2
Make a list of the ways that you can tell that you are carrying too much loss. Think
about how stress impacts your body (e.g., sleep/eating patterns), your attitude (e.g.,
moodiness, depression), and your behavior (e.g, irritability).
Activity 3
Devote one team meeting a month to reflective rounds. Ask team members to bring a
journal and devote a half hour to a prompted reflective writing exercise (Alternatively,
these exercises can be done individually). Options include:
1. Describe a time when you were angry. Identify the clinical team members
involved, their reactions, how that made you feel, and what you did. Reflect on the
chapter’s discussion of supportive communication—what changes could you have
made to your own communication to help foster support?
2. Identify the most supportive clinical team member on your team. Describe your
interactions with this person. How does this person support your own clinical
work? What is his or her most admirable communication quality? Write a
statement that conveys how much he or she means to you (Alternatively, you could
send them a note telling them!).
4. Describe your most memorable patient. Identify the significance of this patient
in terms of communication (hint: you may need to use communication
concepts talked about in previous chapters). Was a supportive communication
climate in place? If so, identify aspects of the climate and provide examples.
If not, how could things have been changed to improve the communication
climate?
4. Sit yourself in your favorite spot at work. How do you feel? What are
your thoughts? What are you thinking about? Slowly expand from your
surroundings. What else is happening around you? Go beyond your field of
vision to reflect on aspects of the workplace that detract from your favorite
place at work.
267
5. Describe the most important thing in your life. Describe the second and third
most important things. Then the fourth and fifth most important things. (This
was taken from: http://www.davidrm.com/thejournal/tjresources-exercises.
php#journaling.)
Activity 4
To foster a supportive communication climate, have interprofessional team members
engage in a buddy system once a quarter. The buddy system consists of two different
interdisciplinary team members engaging in clinical work alongside each other as com-
pared with different visits. Team members should make note of new knowledge gained
from the experience, particularly in learning about their colleague’s contribution to the
plan of care or assessment. After a patient/family interaction, colleagues should debrief
about the plan of care and compare their perceptions and goals of the interaction.
Activity 5: Journaling
x What are the qualities/characteristics that you are proud to possess? What do your
friends love about you? Can you identify how you developed these traits?
x Who are the three most influential people in your life? Are they positive influences?
Why?
x Why did you enter the nursing profession? Why are you still here? What needs to hap-
pen to keep you here?
x Some days we wonder if we make a difference, and some days we are certain that we
do. Write about a connection you made with a resident/patient/client when you knew
that you were making a difference.
Used with permission from: Stephanie Staples at http://www.nursetogether.com/Lifestyle/Lifestyle-

Article/itemId/1119/Stressed-Nurses-Try-Journaling-.aspx
Activity 6
For each emotion listed below, identify a situation with a patient, family, and other
health care provider that warranted expression of that emotion.
Table 9.5 Identifying Emotions

Emotion Patient Family Other Provider
Anxiety
Disappointment
Embarrassment
Passion
Happiness
Elaborate on one of the situations you identified by detailing the prominent

themes of the experience and describe what changes you could make to your own
communication.
Adapted from Coopman, S., & Wood, J. (2004). Student Companion for Wood’s Interpersonal
Communication: Everyday Encounters (p. 146, activity 7.1). Englewood Cliffs, NJ: Thomson Wadsworth.
Activity 7
Use the structured reflection model below to focus your attention on feelings about
your actions with patients and the insights you have gained from these experiences:
Model for Structured Reflection

Reflective cue:
x Bring the mind home.

x Focus on a description of an experience that seems significant in some way.
x What particular issues seem significant to pay attention to?
x How were others feeling and why did they feel that way?
x What was I trying to achieve and did I respond effectively?
x What were the consequences of my actions on the patient, others, and myself?
x What factors influence the way I was/am feeling, thinking, and responding to this
situation (personal, organizational, professional, cultural)?
x What knowledge did or might have informed me?
x To what extent did I act for the best and in tune with my values?
x How does this situation connect with previous experiences?
x Given the situation again, how might I respond differently?
x What would be the consequences of responding in new ways for the patient, others,
and myself?
x What factors might constrain me from responding in new ways?
x How do I now feel about this experience?
x Am I more able to support myself and others better as a consequence?
x What insights have I gained?
x Am I more able to realize my vision as a lived reality?
Adapted from: Johns, C. (1995). Framing learning through reflection within Carper’s fundamental
ways of knowing in nursing. Journal of Advanced Nursing, 22, 227.
Activity 8
Below are some self-reflective questions to assist nurses in self-understanding of their
loss, suffering, death, grief, and bereavement:
x What experiences have you had with death? Describe your earliest memory of death.
Was anything positive about it? Was anything negative about it? Have you experienced
what you would call a “good death?” Have you experienced what you would describe
as a “bad death?”
x Can you picture yourself helping someone who is dying? How? What do you have to
offer that is special and unique?
x Relate what you believe happens when someone dies. What do you fear about death?
What do you fear about your own death?
x Assume you have just received news that you have been diagnosed with a terminal
illness. What would be the most difficult things for you to have to give up during this
time?
x How do you feel about cultural attitudes or behaviors that may be different from your
own?
Used with permission from: Potter, M. (2009). Loss, suffering, grief & bereavement.
In M. Matzo & D. W. Sherman, Palliative Care Nursing: Quality Care to the End of Life (p. 209). New
York: Springer Publishing Company, Inc.
Box 9.1
Repeat the following phrases to encourage self-reflection and self-healing:
x May I offer my care and presence unconditionally, knowing that it may be met with grat-
itude, indifference, anger, or anguish.
x May I offer love, knowing that I cannot control the course of life’s suffering or death.
x May I remain in ease and let go of my expectations.
x May I view my own suffering with compassion just as I do the suffering of others.
x May I be aware that my suffering does not limit my good heart.
x May I forgive myself for things left undone.
x May I forgive all who have hurt me.
x May those whom I have hurt forgive me.
x May all beings and I live and die in peace.
Used with permission from: Halifax, J. (1999, October). Being with dying. Contemplations on
death and dying. Presentation at the Art of Dying III Conference: Spiritual, Scientific and
Practical Approaches to Living and Dying by the New York Open Center and Tibet House,
New York. Roshi Joan is the founder of Upaya Zen Center (www.upaya.org).
Box 9.2
Self-Care Assessment
Take a moment to consider the frequency with which you do the following acts of
self-care. Rate using the scale below:
4 = Often, 3 = Sometimes, 2 = Rarely, 1 = Are you kidding? It never even crossed my mind!
(continued)
Box 9.2 (Continued)
Physical Self-Care
__ Eat regularly (no skipping meals).

__ Eat healthfully.
__ Exercise at least 30 minutes five times a week.
__ Sleep 7–9 hours per night.
__ Schedule regular preventive health care appointments.
__ Take time off when ill.
__ Get massages or other body work.
__ Do enjoyable physical work.
Psychological Self-Care
__ Read a good novel or other non-work-related literature.

__ Write in a journal.
__ Develop or maintain a hobby.
__ Make time for self-reflection.
__ Seek the services of a counselor or therapist.
__ Spend time outdoors.
__ Say “no” to extra responsibilities when stressed.
__ Allow the gift of receiving (instead of just giving).
Emotional Self-Care
__ Stay in contact with important people.

__ Spend time with the people whose company is most comfortable.
__ Practice supportive self-talk; speak kindly in internal thoughts.
__ Allow both tears and laughter to erupt spontaneously.
__ Play with children and animals.
__ Identify comforting activities and seek them out.
__ “Brag” to a trusted friend or family member; be proud of accomplishments.
__ Express anger in a constructive way.
Spiritual Self-Care
__ Make time for regular prayer, meditation, and reflection.

__ Seek community among friends, neighbors, or other gatherings.
__ Cherish optimism and hope.
__ Contribute to or participate in meaningful activities of choice.
__ Be open to inspiration.
__ Use ritual to celebrate milestones and to memorialize loved ones.
__ Be aware of the nontangibles of life.
__ Listen to or create music.
(continued)
Box 9.2 (Continued)
Workplace Self-Care
__ Take time to eat lunch.

__ Make time to address both the physical and emotional needs of residents.
__ Take time to chat and laugh with coworkers.
__ Seek regular supervision and mentoring.
__ Set limits with residents, families, and colleagues.
__ Find a project or task that is exciting and rewarding in which to be involved.
__ Decrease time spent comparing work performance with others.
__ Seek a support group—even if it is only one other person.
Results
To compute your score, add all sections together and compare to the following ranges:
121–160 You’re a self-care guru! Share the wisdom with everyone around you.
81–120 You’re on the right track. Get creative in the areas of least scoring.
41–80 Uh-oh. There’s some work to do. Hunker down and focus on yourself.

ƒ 40 Are you still reading this? You’re about to self-destruct. Call 911!
Adapted from Saakvitne, K., Pearlman, L., & and Staff of the Traumatic Stress Institute (1996).
Transforming the Pain: A Workbook on Vicarious Traumatization for Helping Professionals Who
Work With Traumatized Clients. New York: W.W. Norton.
index
abiding in liminal spaces, 105 anxiety

acceptability, 189 effective communication for, 151–52
chart for, 209, 209t intimate openings with, 163f–165f
storytelling and, 191, 191f–193f appearance, communication through, 6
accidental communication, 65 artifacts, 6
accommodation, 60. See also communi- assessment
cation accommodation theory in bad news communication, 30–32,
cues indicating need for, 69, 69t 31t, 33t
culture, health literacy, and, 68–71, in family communication, 126–30,
69t, 70t, 71t 127t, 129t
interventions for improving, 75t in openings, 166t, 167–68, 167t
in planning, 71–72, 72t in orientation and opportunity, 68–71,
acknowledgement 69t, 70t, 71t
exploring ideas for response, 220–21, in relating, 204–7, 205t–206t, 207t
220t in self-care, 270–72
illocutionary, 201t in team communication, 235–37
in quest narrative, 190 assumptions, of nurses, 38–39, 39t
active listening, 99–101, 100t atrocity stories, 230
exercises for, 110–12 attempted communication, 65
steps of, 110 attitude, cultural, 65
adaptation authenticity, 96
for deaf communication, 90t awareness, cultural, 65, 102
to family, 17, 188–89, 216–17
to patient, 17, 188–89, 216–17 backstage communication, 260
adaptive communication, 17, 153–54, bad news communication
188–89 assessment in, 30–32, 31t, 33t
advocating role, task and relationship barriers to, 34t–38t
levels of communication used in, 9 clinical practice skills for, 30–44, 31t,
affectionate communication, 55–57 33t, 34t–38t, 39t, 40t–41t, 43f, 44t
aggressive care, stress caused by, 253 evaluation of, 43–44, 43f, 44t
ambiguity exercises for, 53–55, 54t
in problematic integration theory, intervention in, 38–42, 39t, 40t–41t
195–96, 195t nonverbal immediacy in, 28–30
rationalizations and, 204–7, 205t–206t planning in, 32–38, 33t, 34t–38t
ambivalence reactions to, 38
example of, 203–4, 203f relationship communication
in problematic integration theory, in, 25–26
195t, 196 scholarship about, 152
rationalizations and, 204–7, 205t–206t task communication in, 25
273
274 index
bad news communication (cont.) children, communicating with, 135–36

teaching resources and materials for, chronemics, 6
49–51 chronic obstructive pulmonary disease,
verbal clarity in, 27–28 poor prognosis with, 167t, 168
violations of expectations in, 28–30 Circle of Caring, 259
barriers to relating, 221t–222t circular questions, 134t
bearing witness. See witnessing City of Hope Medical Center, QOL
beliefs model of, xiiif, xiv
conformity, 124–25, 145–46 clarity. See verbal clarity
conversation, 124–25, 145–46 clinical outcomes, presence and, 154
of family, 121–22, 124–25, 145–46 clinical practice guidelines, NCP, x–xiv,
billing specialist, need for, 77t xt, xiiif
body movement, 5 clinical practice skills
body scan exercise, 116 for bad news communication, 30–44,
boundaries 31t, 33t, 34t–38t, 39t, 40t–41t,
coordination of, 155–56 43f, 44t
of family system, 123 for family communication, 126–36,
in planning intimate opening com- 127t, 129t, 130t, 131t, 133t, 134t
munication, 169t, 171 for mindful presence, 103–6, 104t
turbulence in, 156–57 for openings, 166–74, 166t, 167t, 169t,
breadth in social penetration theory, 157 170t, 171t–172t
M&M/Skittles game for, 181–82 for orientation and opportunity,
Buber, Martin, I-It/I-Thou dialectic of, 67–79, 69t, 70t, 71t, 72t, 73t,
103 75t–78t, 79t
Buddhist meditation, 95 for relating, 204–10, 205t–206t, 207t,
burnout, 253–56 208f, 209t
for team communication, 235–40,
cancer, poor prognosis with, 167t, 168 239f
caregiver. See also family closed family system, 124–25
feeling of burden by, 155 closeness, in nurse–patient relationship,
grief experienced by, ix 158
intimate openings and, 163f–165f cognitive impairment, breaking bad
stress caused by, 254–55 news and, 34t
turbulence with, 156 collaboration, 229. See also interdiscipli-
types of, 125–26, 130t, 145–46 nary collaboration
care planning, in bad news communica- collaborative partnership, ways of
tion, 32–38, 33t, 34t–38t building, 255, 255t
caring role, task and relationship levels collective dilemma, 194
of communication used in, 9 collective ownership of goals, 227t, 228,
Carrier Family Member, 126, 130t 231f
case-reporting, groupthink and, 233–34 comfort measures, 158t
CAT. See communication accommoda- transition and care and, 166t, 167–68
tion theory COMFORT model, ix
challenging deaths, breaking bad news communication in, 12t, 13, 23–44
and, 37t–38t family communication in, 12t, 15–16,
chaos narrative, 207–8, 208f 119–36
chaplain, need for, 77t introduction to, 11–12, 12t
275 Index
mindful presence in, 12t, 14–15, intervention in, 38–42, 39t, 40t–41t
93–107 around junctures of care, 152
openings in, 12t, 16, 151–85 mindful, 96
orientation and opportunity in, 12t, myths associated with terminal illness,
13–14, 59–79 158t
relating in, 12t, 16–18, 187–223 narrative clinical practice in, 26–27
team communication in, 12t, 18, nonverbal, 3–8, 10
225–52 nonverbal immediacy in, 5–6, 28–30
commissives, 201t nurse role in, 24–26
exploring ideas for response, 220–21, planning in, 32–38, 33t, 34t–38t
220t protocols, 171
commitment, in nurse–patient quality of life model and, 154, 154f
relationship, 158 radically adaptive, 17, 188–89
communication relationship, 4, 8–11, 25–26, 155,
accidental, 65 157, 169
adaptive, 17, 153–54, 188–89 role play scenarios, 183–84
affectionate, 55–57 scholarship about, 152
assessment in, 30–32, 31t, 33t of self-care needs, 259–61, 261t
attempted, 65 social penetration theory, 157
axioms of, 3–5 studied, 152–53
backstage, 260 successful, 65
charting, 210 supportive, 260
with children, 135–36 task, 4, 8–11, 25, 155
clinical practice skills for, 30–44, 31t, teaching resources and materials for,
33t, 34t–38t, 39t, 40t–41t, 43f, 44t 49–51
in COMFORT model, 12t, 13, 23–44 verbal clarity in, 27–28
comprehensive exercises for, 53–57, communication accommodation theory
54t (CAT), 6
control, 158 in orientation and opportunity,
defensive, 260 60–63, 61f
defining and understanding of, 1–19 role play exercises for, 83–84
effective, 151–52 communication privacy management
evaluation of, 43–44, 43f, 44t (CPM), 154–56
exercises for narrative clinical control of private information and
practice, 49–51 coordinating boundaries, 155–56
exercises for nonverbal immediacy, coordinating boundaries and, 155–56
52–53 intellectual impairment and, 180–81
exercises for verbal clarity, 51–52, 52t moving theory to practice with,
family-centered approach to, 122–24, 179–80
123t in planning, 169
family patterns of, 124–25, 126–30, Susie and popsicles exercise for,
127t, 129t, 130t, 145–47 182–83
frontstage, 260 communicator goals, 200
about hospice care services, compassionate presence, 97–99, 256.
171t–172t, 173 See also mindful presence
in interdisciplinary teams, 249–52, compassion fatigue, 255–56
250t, 251t–252t competency, cultural, 64–66, 102–3
276 index
complementary behaviors, for cultural humility, 64–67

developing intimacy, 159–60 assessment and, 68–71, 69t, 70t, 71t
complications, communication intervention and, 73–78, 73t,
around, 152 75t–78t
confidentiality, maintaining, 155–56 jigsaw learning exercise, 88–89
conflict plain language game exercise, 89
dealing with, 232 planning and, 71–72, 72t
groupthink and, 232–33 reflection and, 78–79, 79t
in interdisciplinary team meetings, web sites for, 90–92
230, 231f cultural sensitivity, 102
overcoming, 238–39, 239f cultural skills, 65
conformity beliefs, 124–25, 145–46 cultural theory, in orientation and
congestive heart failure, poor prognosis opportunity, 62–67
with, 167t, 168
consensual families, 125 deaf, communication adaptations
constatives, 201t for, 90t
exploring ideas for response, 220–21, death, family experience of, 121
220t decision making
constraint, 199 rationalizations in, 204–7, 205t–206t
content communication. See task self-disclosure and, 169
communication deconstruction, 26
contraction, of family, 129t deep listening, 99–101, 100t
control communication, 158 defensive communication, 260
convergence dementia, poor prognosis with,
nurse and, 60–67, 61f, 63t 167t, 168
role play exercises for, 83–84 denial, exercises for responding to,
conversation beliefs, 124–25, 145–46 53–55, 54t
coordinating role, task and relationship depth in social penetration theory, 157
levels of communication used in, 9 M&M/Skittles game for, 181–82
coping detachment in communication, 158
by family, 132, 135 diagnosis, communication around, 152
strategies for, 260, 261t diaries, for relating, 210
costs, presence and, 154 diffusion of topic, 189
coupling, of family, 129t dilemma, collective, 194
CPM. See communication privacy directives, 201t
management exploring ideas for response, 220–21,
critical turning point, 191f 220t
cross cultural health care program, web direct pressure on dissenters, 234
sites on, 90–91 direct speech acts, 199–200, 201t
cultural attitude, 65 assessment of, 204–7, 205t–206t
cultural awareness, 65, 102 memorable, 219–20, 219t
cultural competency, 64–66 disagreements
mindful presence and, 102–3 dealing with, 232
cultural differences, breaking bad news groupthink and, 232–33
and, 35t in interdisciplinary team meetings,
cultural diversity, 102 230, 231f
cultural domain of care, xiii overcoming, 238–39, 239f
277 Index
disclosure evaluation
in planning intimate opening com- of bad news communication, 43–44,
munication, 169t, 171 43f, 44t
privacy and, 156, 158 of family, 132–36
discomfort, rationalization for, 205t–206t of openings, 173–74
discovery, in quest narrative, 190 of orientation and opportunity com-
dissenters, direct pressure on, 234 munication, 78–79, 79t
distance in nurse–patient in problematic integration theory,
relationship, 158 194–97, 195t
distrust, rationalization for, 205t–206t of relating, 210
divergence, 61, 61f of team, 239–40
example of, 192f–193f, 202 existential domain of care, xii
in problematic integration theory, expansion, of family, 129t
194–95, 195t expectancy violations theory, 28–30
rationalizations and, 204–7, 205t–206t explicit expressions of emotion, 98
role play exercises for, 83–84 expressive writing, 262
diversity, cultural, 102 extended family emotional systems, 127t
externalization, 26–27, 32
easy-to-read material, web sites for eye contact, 5
developing, 92
eating, mindful, 115 family
education beliefs of, 121–22, 124–25, 145–46
compassionate, 42 breaking bad news to, 35t–37t
interventions for improving, 75t–76t functioning of, 121–22
effective communication, 151–52 life cycle of, 128–29, 129t
elderly. See older adults listening to, 134t
emotion. See also compassion fatigue member types of, 125–26, 130t,
breaking bad news and, 37t, 38 145–46
explicit expressions of, 98 problematic integration in, 214–15
of family, 127t as second-order patients, 122–24, 123t
implicit expressions of, 98 spirituality of, 132, 135
emotional intelligence, in nurse, 259 stress caused by, 254–55
emotional involvement, of nurses, 38–39 stressors of, 124, 128, 129t
emotional self-care, assessment of, 271 taking care of, 120–22, 122t
emotional stress family-centered approach, 122–24, 123t
actions connected with, 257t family communication
planning self-care for, 256t adapting to, 17, 188–89, 216–17
empathy, 97–99 assessment of, 126–30, 127t, 129t
exercises for, 113–14 clinical practice skills for, 126–36,
end of life 127t, 129, 130t, 131t, 132t,
intimate openings with, 163f–165f 133t, 134t
role played at, 152–53 in COMFORT model, 12t, 15–16,
social situations and, 166t, 167 119–36
speech language therapists and, 222 communication patterns exercises,
environment, 6 145–47
family system interactions with, 123 as conduit to patient, 124–25
ethical domain of care, xiv evaluation of, 132–36
278 index
family communication (cont.) stereotyping, 233

family system exercises, 142–44 structural characteristics in, 234–35
intervention with, 131–32, 133t, 134t
meeting exercises, 147–49 happiness, transition and care and, 166t,
in meetings, 125–26, 130–32, 131t, 167–68
133t, 134t haptics, 6
patterns of, 124–25, 126–30, 127t, healing presence, 97. See also mindful
129t, 130t presence
pivotal points of, 152–54, 154f healing rituals, 259
planning for, 130–31, 130t, 131t health literacy, 13–14
problems in, 122t assessment of, 68–71, 69t, 70t, 71t
teaching resources and materials for, costs of limits in, 62
142–44 cues indicating need for, 69, 69t
tension in, 170t, 172–73 exercises addressing, 84
family orientation, relationship level of intervention and, 73–78, 73t, 75t–78t
communication in, 9 jigsaw learning exercise, 88–89
family system, 122 in older adults, 90t
closed, 124–25 in orientation and opportunity,
exercises, 142–44 62–64, 63t
open, 123–25 plain language game exercise, 89
survey of, 127, 127t planning and, 71–72, 72t
fatalism, rationalization for, 205t–206t reflection and, 78–79, 79t
fatigue, compassion, 255–56 taxonomy of, 63, 63t
fear, 106 unfolding case reflection exercise for,
effective communication for, 151–52 85–88
feedback, prompts for eliciting, 79t web sites on, 90–92
feeling of burden, CPM and, 155 hearing, listening compared with, 99
flexibility, 226–28, 227t, 231f hearing impaired, communication
focused self-reflection, 261–62 adaptations for, 90t
forgiveness, nurse’s role in, 152–53 high–emotional support messages, 27,
frontstage communication, 260 40t–41t
futile care, stress caused by, 253 honesty
futility, rationalization for, 205t–206t breaking bad news and, 37t
relationship level of communication
general expectations, 28–29 in, 9
gestures, 5 horizontal stressors, 128
Gibbs reflective cycle, 43f hospice care services
grief communication about, 171t–172t, 173
caregiver, ix CPM and, 155
nurse experience of, 253–54, 259 turbulence and, 156
groupthink, 230–35 humility. See cultural humility
avoiding, 237–38
checklist for, 236–37 IDT meetings. See interdisciplinary team
personal factors, 235 meetings
relational factors, 235 I-It/I-Thou dialectic, 103
self-censorship, 233–34 I-It relationship, 103
situational context, 235 illness narrative, 207–8, 208f
279 Index
illocutionary act, 198–99, 198t intervention

categories of, 201t in bad news communication, 38–42,
direct and indirect, 199–200 39t, 40t–41t
immediacy, nonverbal, 5–6, 28–30, with family, 131–32, 133t, 134t
52–53 in openings, 170t, 171–73, 171t–172t
imminently dying patients, palliative in orientation and opportunity, 73–78,
care of, xiii 73t, 75t–78t
implicit expressions of emotion, 98 in relating, 208–9, 209t
impossibility in team, 238–39, 239f
in problematic integration theory, interviewing, person-centered, 73t, 74
195t, 197 intimate openings during illness, 158–66,
rationalizations and, 204–7, 205t–206t 163f–165f
increasing understanding, 209, 209t case study of, 163–66, 163f–165f
indirect speech acts, 199–200, 201t complementary behaviors for,
assessment of, 204–7, 205t–206t 159–60
memorable, 219–20, 219t core of, 159
individuality, recognition of, 31t example of, 161–63, 161t–162t
information dumping, 163 history of, 158
intellectual impairment, CPM and, myths about communication, 158, 158t
180–81 narrative nursing, 166
intercultural sensitivity, 102–3 intrapersonal-level communication, 258
interdependence, 226–28, 227t, 231f involvement, in nurse–patient
of family members, 122 relationship, 158
interdisciplinary care, ix–x I statements, 260
interdisciplinary collaboration, 226–30, I-Thou relationship, 103
227t, 231f
collective ownership of goals, 227t, journaling, 261–62
228 exercise for, 268
exercises for, 246–47
interdependence, 226–28, 227t kinesics, 5
interdisciplinary team meetings, 230, knowledge lack, breaking bad news and,
231f 35t
newly created tasks, 227t, 228
reflective process, 227t, 228–29 laissez-faire families, 125
interdisciplinary teams, 226 language, to address tension,
communication in, 249–52, 250t, 171t–172t
251t–252t legal domain of care, xiv
relationship building in, 250–51 life before illness, understanding of, 31t
setting goals for, 239–40, 248–49 life cycle, of family, 128–29, 129t
interdisciplinary team (IDT) meetings, Lifeworld, 67
230, 231f liminal spaces, abiding in, 105
checklist for, 236–37 listener, role of, 1–2
exercise for, 247–49 listening
interpersonal climate, 260 active, 99–101, 100t, 110–12
interpreters effective, 112–13
breaking bad news and, 34t empathetic, 113–14
need for, 77t exercises for, 110–13
280 index
listening (cont.) mindfulness exercises for, 115–16,

to family, 134t 117t–118t
for feelings, 98 mindfulness in, 94–95
skills, xii, 8, 99, 100t narrative nursing and, 101–2
literacy. See health literacy presence in, 96, 97t
locutionary act, 198–99, 198t teaching resources and materials for,
direct and indirect, 199–200 110–18, 117t–118t
Loner Family Member, 126, 130t mindlessness, 95
low–emotional support messages, 27, 40t mirroring, 113
miscommunication, 65
Manager Family Member, 125–26, 130t M&M/Skittles game, 181–82
medical information, going beyond, 31t mobilizing role, task and relationship
medically futile care, stress caused levels of communication used in, 9
by, 253 model of interdisciplinary collaboration,
meditation, 95, 103–6, 104t 226, 227t
exercises for, 114–16, 117t–118t collective ownership of goals, 227t,
in-action, 104–5, 104t 228
meetings interdependence, 226–28, 227t
family, 125–26, 130–32, 131t, 133t, newly created tasks, 227t, 228
134t, 147–49 reflective process, 227t, 228–29
interdisciplinary team, 230, 231f moderate–emotional support messages,
mental stress 27, 40t
actions connected with, 257t multicultural identities, 72
planning self-care for, 256t multiple goals theory, 200
message processing, interventions for memorable speech acts and, 219–20,
improving, 78t 219t
mindful communication, 96 mining for, 217–18
intercultural sensitivity and, 102–3 mutual influence model of
mindfulness, 94–95 communication, 1–3
exercises for, 115–16, 117t–118t myths associated with communication
of self, 269 about terminal illness, 158t
stress reduction through, 257–58
mindful presence narrative clinical practice, 26–27
active listening in, 99–101, 100t exercises for, 49–51
case study of, 100–101 mindful presence and, 101–2
clinical practice skills for, 103–6, 104t skills for, 30–44, 31t, 33t, 34t–38t, 39t,
in COMFORT model, 12t, 14–15, 40t–41t, 43f, 44t
93–107 narrative medicine, in COMFORT
compassionate presence and, 97–99 model, 12
description of, 95–96 narrative nursing, 166
empathy exercises for, 113–14 The National Action Plan to Improve
healing presence and, 97 Health Literacy, 62
listening exercises for, 110–13 National Consensus Project for Quality
Martin Buber’s I-It/I-Thou dialectic Palliative Care (NCP), clinical
and, 103 practice guidelines, x–xiv, xt, xiiif
meditation exercises for, 114–16, NCP. See National Consensus Project for
117t–118t Quality Palliative Care
281 Index
needs of patient, assessment of, 166t, open family system, 123–25

167–68, 167t openings
newly created tasks, 227t, 228, 231f additional supplemental materials,
nonverbal communication. See also 185
mindful presence assessment in, 166t, 167–68, 167t
attentiveness to, 7–8 clinical practice skills for, 166–74,
codes of, 5–8 166t, 167t, 169t, 170t, 171t–172t
importance of, 3–5 in COMFORT model, 12t, 16, 151–85
in patient-centered clinician commu- communication privacy management,
nication, 10 154–56, 179–80
nonverbal immediacy, 5–6 communication role play scenarios
in bad news communication, 28–30 for, 183–84
exercises for, 52–53 comprehensive exercises for, 182–83
NPs. See nurse practitioners evaluation of, 173–74
nuclear family emotional system, 127t during illness, 158–66, 158t, 161t–
nurse 162t, 163f–165f
assumptions of, 38–39, 39t intellectual impairment and, 180–81
communication role of, 24–26 intervention in, 170t, 171–73,
convergence and, 60–67, 61f, 63t 171t–172t
core attitudes of, 96, 97t pivotal points of communication in,
emotional intelligence in, 259 152–54, 154f
emotional involvement of, 38–39 planning in, 168–71, 169t
in family meetings, 131–32, 131t, 133t, sharing information, 181–82
134t social penetration theory, 157
grief experiences by, 253–54, 259 Susie and popsicles exercise for,
pivotal points of communication with, 182–83
152–54, 154f teaching resources and materials for,
roles and professional attributes of, 179–82
8–11 turbulence, 156–57
self-care of, 253–63 organ donor coordinator, need for, 77t
specific stresses experienced by, orientation and opportunity
254–56, 255t additional supplemental materials, 90
spirituality of, 258–59 assessment in, 68–71, 69t, 70t, 71t
suffering experienced by, 253, 262 clinical practice skills for, 67–79, 69t,
as witness in narrative clinical 70t, 71t, 72t, 73t, 75t–78t, 79t
practice, 26 in COMFORT model, 12t, 13–14,
nurse–patient relationship, reframing 59–79
of, 158 communication accommodation
nurse practitioners (NPs), bad news theory role play exercises for, 83–84
communication by, 25 communication accommodation
nursing, relating and, 202–4, 203f theory used in, 60–63, 61f
nursing process, detachment and, 158 convergence and, 60–67, 61f, 63t
cultural theory in, 62–67
offstage experiences, 261 evaluation of, 78–79, 79t
older adults, health literacy in, 90t health literacy in, 62–64, 63t
oncology nursing, 253 intervention in, 73–78, 73t, 75t–78t
open-ended questions, 113 jigsaw learning exercise, 88–89
282 index
orientation and opportunity (cont.) tension in communication with, 170t,

Lifeworld in, 67 172–73
low–health literacy exercises for, 84 withholding information from,
pathography exercise for, 85 155–56
plain language game exercise, 89 patient-centered clinician
planning in, 71–72, 72t communication
teaching resources and materials for, nonverbal behaviors used in, 10
83–89 six functions of, 10
unfolding case reflection exercise for, verbal behaviors used in, 10–11
85–88 patient-centered communication,
web sites for, 90–92 COMFORT model for, 11–19, 12t
overaccommodation, 61, 61f patient needs, assessment of, 166t,
role play exercises for, 83–84 167–68, 167t
patient stories. See narrative clinical
pain, understanding of, 12 practice
pain management, communication role PCMs. See person-centered messages
in, ix, xi perceptive attentiveness, relationship
palliative care level of communication in, 9
core attitudes in, 96, 97t perlocutionary act, 198–99, 198t
cultural aspects of, xiii direct and indirect, 199–200
domains of, x–xiv, xt, xiiif personal presence, 96
ethical and legal aspects of, xiv personal relationships, self-disclosure
of imminently dying patients, xiii and, 169
NCP clinical practice guidelines for, personal space, 6
x–xiv, xt, xiiif person-centered interviewing, 73t, 74
physical aspects of, xi person-centered messages (PCMs),
private information in, 155 27–28, 39–42, 40t–41t
psychological and psychiatric aspects phone, breaking bad news and, 34t
of, xii physical appearance, 6
QOL model for, xiiif, xiv physical domain of care, xi
social aspects of, xii planning addressing, 33t
spiritual, religious, and existential physical presence, 97
aspects of, xii physical self-care, assessment of, 271
structure and processes of, x–xi physical stress
palliative care services, CPM and, 155 actions connected with, 257t
paraphrasing, 113 planning self-care for, 256t
Partner Family Member, 126, 130t physical well-being, transition and care
pathography, exercise addressing, 85 and, 166t, 167–68
patient planning
adapting to, 17, 188–89, accommodation in, 71–72, 72t
216–17 in bad news communication, 32–38,
eliciting goals of, 132 33t, 34t–38t
family as, 122–24, 123t for family communication, 130–31,
family as conduit to, 124–25 130t, 131t
feeling of burden by, 155 in openings, 168–71, 169t
pivotal points of communication with, in orientation and opportunity,
152–54, 154f 71–72, 72t
283 Index
in relating, 207–8, 208f psychologist, need for, 77t

for self-care, 256–57, 256t psychospiritual care, 228
self-disclosure for, 159
in team, 237–38 quality of life (QOL)
pluralistic families, 125 changing values about, 193
poor prognosis, 167t, 168 City of Hope Medical Center model
postponing, rationalization for, of, xiiif, xiv
205t–206t communication and, 154, 154f
predictable interactions, of family mem- dimensions of, 33, 33t
bers, 123 illness narrative and, 207–8, 208f
presence, 96, 97t. See also mindful planning intimate opening communi-
presence cation and, 171
breaking bad news and, 35t–36t sorting information relative to, 32–38,
clinical outcomes, costs and, 154 33t, 34t–38t
compassionate, 97–99, 256 transitional needs of patient and, 166t,
relationship level of communication 167–68
in, 10 questions
primary nursing, detachment and, 158 circular, 134t
privacy. See also communication privacy myths about, 158t
management reflexive, 134t
breaking bad news and, 34t strategic, 134t
disclosure and, 156, 158 quest narrative, 190–93, 191f–193f
privacy dilemma, 155–57 planning of, 207–8, 208f
private information teaching materials for, 215, 215t, 216t
control of, 155–56
in palliative care, 155 radically adaptive communication, 17,
private information ownership, 155 188–89
probability, in problematic integration Rapid Estimate of Adult Literacy in
theory, 194–97, 195t Medicine (REALM), 68–69
problematic integration theory, 193–97 rationalizations, in decision making,
ambiguity, 195–96, 195t 204–7, 205t–206t
ambivalence, 195t, 196 REALM. See Rapid Estimate of Adult
divergence, 194–95, 195t Literacy in Medicine
in families, 214–15 reauthoring, 27
impossibility, 195t, 197 receiver, role of, 1–2
problem solving, self-disclosure for, 159 reciprocal behaviors, in developing
prompts, 113 intimacy, 159–60
protective families, 125 reciprocity in social penetration theory,
proxemics, 6 157
psychiatric domain of care, xii recurrence, communication around, 152
psychological domain of care, xii reflection
planning addressing, 33t on bad news communication, 43–44,
psychological presence, 97 43f, 44t
psychological self-care, assessment of, focused, 261–62
271 on orientation and opportunity com-
psychological well-being, transition and munication, 78–79, 79t
care and, 166t, 167–68 structured, 114–15, 258, 269
284 index
reflective process, 227t, 228–29, 231f resilience, opportunities for, 152

reflective rounds, 267–68 resting with groundlessness, 105–6
reflexive questions, 134t restitution narrative, 207–8, 208f
relating rule management processes, 157
adapting to patient/family, 188–89,
216–17 Saunders, Cicely, 12
additional supplemental materials, second-order patients, family as, 122–24,
221–22, 221t–222t 123t
assessment in, 204–7, 205t–206t, 207t seeing differently, 105
barriers to, 221t–222t self-awareness, 30, 39
clinical practice skills for, 204–10, mindfulness and, 117t–118t
205t–206t, 207t, 208f, 209t self-care, 253–63
in COMFORT model, 12t, 16–18, assessment of, 270–72
187–223 communication of needs for, 259–61,
comprehensive exercises for, 219–21, 261t
219t, 220t exercises for, 267–72, 268t
direct and indirect speech acts, focused self-reflection in, 261–62
199–200, 201t palliative nursing stressors and,
evaluation of, 210 254–56, 255t
exploring ideas for response, 220–21, planning for, 256–57, 256t
220t realizing need for, 256–59, 256t, 257t
films highlighting, 222–23 teacher resources and materials on,
intervention in, 208–9, 209t 267–72, 268t
mining goals, 217–18 self-censorship, groupthink and, 233–34
multiple goals theory, 200 self-compassion, 258–59
nursing and, 202–4, 203f self-disclosure, 158
planning in, 207–8, 208f case study of, 163–66, 163f–165f
problematic integration, 193–97, 195t decision making and, 169
problematic integration in families, in developing intimacy, 159–60
214–15 M&M/Skittles game for, 181–82
quest narrative, 190–93, 191f–193f, personal relationships and, 169
215, 215t, 216t problem solving and, 159
reflecting on memorable speech acts, self-efficacy, rationalization for,
219–20, 219t 205t–206t
speech act theory, 197–99, 198t self-knowledge, 258
teaching resources and materials for, self-reflection
214–18 exercises for, 269–70
relational stress, planning self-care for, focused, 261–62
256t sender, role of, 1–2
relationship communication, 4 sensitivity, cultural, 102
in bad news context, 25–26 service delivery, stress caused by, 255,
nursing roles and, 8–11, 155 255t
self-disclosure and, 169 short Test of Functional Health Literacy
social penetration theory in, 157 in Adults (s-TOHFLA), 68–69
relatives. See family silence
relief, need for, 168 communication through, 3–4, 8, 100,
religious domain of care, xii 113
285 Index
intimate openings with, 163f–165f s-TOHFLA. See short Test of Functional

myths about, 158t Health Literacy in Adults
situational context, in groupthink, 235 storytelling. See also narrative clinical
skills. See also clinical practice skills practice
cultural, 65 acceptability and, 191, 191f–193f
listening, xii, 8, 99, 100t strategic questions, 134t
SLPs. See speech language therapists stress
social domain of care, xii actions connected with, 257t
planning addressing, 33t aggressive care causing, 253
social penetration theory (SPT), 157 among family members, 124
complementary behaviors, 159–60 nurse experience of, 254–56, 255t
M&M/Skittles game for, 181–82 planning self-care for, 256t, 257–58
in planning, 169 stressors, family, 124, 128, 129t
Susie and popsicles exercise for, structured reflection, 114–15, 258, 269
182–83 studied communication, 152–53
social well-being, transition and care successful communication, 65
and, 166t, 167–68 suffering
social worker, need for, 77t nurse experience of, 253, 262
speaker, role of, 1–2 witnessing of, 98–99
speech act theory, 197–99, 198t support, interventions providing, 77t
direct and indirect speech acts, supportive communication, 260
199–200, 201t person-centered messages in, 27–28,
exploring ideas for response, 220–21, 39–42, 40t–41t
220t Susie and popsicles exercise, 182–83
multiple goals theory, 200 symptoms, communication about, xi
reflecting on memorable speech acts,
219–20, 219t taming methods, 249–50, 250t
speech language therapists (SLPs), for task communication, 4
end of life, 222 in bad news context, 25
SPIKES model, 11 nursing roles and, 8–11, 155
spiritual domain of care, xii teaching role, task and relationship levels
planning addressing, 33t of communication used in, 8
spirituality team communication, 225–52
of family, 132, 135 assessment in, 235–37
of nurse, 258–59 clinical practice skills for,
spiritual self-care, assessment of, 271–72 235–40, 239f
spiritual stress in COMFORT model, 12t, 18
actions connected with, 257t evaluation of, 239–40
planning self-care for, 256t groupthink, 230–35
spiritual support interdisciplinary, 226
intimate openings with, 163f–165f interdisciplinary collaboration,
nurse role in finding, 152–53 226–30, 227t, 231f, 246–47
transition and care and, 166t, 167–68 intervention in, 238–39, 239f
SPT. See social penetration theory planning in, 237–38
STEDFAST Self-Aware Mindfulness self-care through, 260–61, 261t
Development Model, 117t–118t teaching resources and materials for,
stereotyping, groupthink and, 233 246–52
286 index
tension treatment decision making, communica-

case study of, 163–66, 163f–165f tion around, 152
communication role play scenarios trust, intimate openings and, 163f–165f
for, 183–84 turbulence, in privacy boundaries,
effective communication for, 151–52 156–57
language to address, 171t–172t turning points, 207, 207t
in patient and family communication, critical, 191f
170t, 172–73
in planning intimate opening uncertainty
communication, 169t, 171 discussions about, 193–94
triggers of, 166t, 167–68 rationalization for, 205t–206t
terminal illness reduction of, 190–91
adaptive communication for, 153–54 understanding, increase in, 209, 209t
CPM and, 155
myths associated with communication verbal behaviors, in patient-centered
about, 158t clinician communication, 10–11
privacy dilemma and, 156 verbal clarity, 27–28
thick boundaries, 155 exercises for, 51–52, 52t
thin boundaries, 155 vertical stressors, 124, 128
Thomas-Kilmann Conflict Mode violations of expectations, 28–30
Instrument (TKI), 252 vocalics, 6
threat minimization, 205t–206t Voice of Medicine, 67
time Voice of the Lifeworld, 67
breaking bad news and, 34t
use and perception of, 6 walking, mindful, 115
TKI. See Thomas-Kilmann Conflict witnessing, 26, 30–32, 31t
Mode Instrument mindful presence and, 98–101
topic, diffusion of, 189 skills for, 31t
touch. See haptics working group, 230–31
transitions in care, communication workplace self-care, assessment of, 272
during, 152–53 writing, self-care through, 262

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Communication in

Oxford New York

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Published in the United States of America by

© Oxford University Press 2013

You must not circulate this work in any other form,

Library of Congress Cataloging-in-Publication Data

1. Deﬁning and Understanding Communication 1

3. Orientation and Opportunity 59

9. Communicating Self-Care Needs 253

Communication is a powerful therapeutic tool. When used well communication can

a holistic communication model—COMFORT—an acronym for seven principles

CLINICAL PRACTICE GUIDELINES FOR QUALITY

DOMAIN 1: STRUCTURE AND PROCESSES OF CARE

Table 1 Domains of Quality Palliative Care

DOMAIN 2: PHYSICAL ASPECTS OF CARE

DOMAIN 3: PSYCHOLOGICAL AND PSYCHIATRIC

DOMAIN 4: SOCIAL ASPECTS OF CARE

DOMAIN 5: SPIRITUAL, RELIGIOUS, AND EXISTENTIAL

DOMAIN 6: CULTURAL ASPECTS OF CARE

DOMAIN 7: CARE OF THE IMMINENTLY DYING PATIENT

Quality-of-Life Model Applied to Cancer Survivors

Physical Well-Being and Symptoms Psychological Well-Being

• Functional Ability • Anxiety

Social Well-Being Spiritual Well-Being

• Caregiver Burden • Suffering

ﬁgure 1 Quality-of-Life Model

DOMAIN 8: ETHICAL AND LEGAL ASPECTS OF CARE

rn: How is your family doing with all of this?

nurse: How are you feeling today?

pauses, hesitations, and other nonverbal communication. For example, in the

In sum, the nurse should be as attuned to and responsive to a patient’s nonverbal

TASK AND RELATIONSHIP AND THE

It is of further interest to note that four of the seven professional attributes of

x Fostering healing relationships

INTRODUCING THE COMFORT MODEL

Table 1.1 The COMFORT Model

C—Communicate x Learning to bear witness

orientation and opportunity, mindful presence, family, openings, relating, and

Orientation and Opportunity

“concurrently and reﬂectively” (p. 284) rather than sequentially or as an algorithm

In the next chapter, we discuss more speciﬁcally the principle of communication in

Wittenberg-Lyles, E., & Thompson, S. (2006). Understanding enrollment conversations: The

Eileen is an oncology nurse employed in a women’s cancer clinic. She previously

WHAT IS MY ROLE IN COMMUNICATING

Task Communication in the Bad News Context

Relational Communication in the Bad News Context

NARRATIVE CLINICAL PRACTICE

Patient/family members’ emotional reactions to bad news can trigger viola-

DEVELOPING CLINICAL PRACTICE SKILLS

Table 2.1 Checklist of Witnessing Skills

Table 2.2 Overview of Quality-of-Life Dimensions

✓ Physical Well-Being and Symptoms ✓ Psychological Well-Being

Table 2.3 (continued)

Table 2.3 (continued)

Table 2.3 (continued)

Table 2.3 (continued)

psychological well-being, as Mrs. Williams describes stress, anxiety, and helplessness.

Table 2.4 ✓ Checklist