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Patient Education and Counseling 45 (2001) 69±79
From nurse-centered health counseling to empowermental
health counseling
Marita Poskiparta*, Leena Liimatainen, Tarja Kettunen, PaÈivi Karhila
Department of Health Sciences, Faculty of Sport and Health Sciences, University of JyvaÈskylaÈ,
P.O. Box 35, 40351 JyvaÈskylaÈ, Finland
Abstract
The main goals of this study were to examine aspects of the delivery and reception of advice and questions in interaction between nurses
and patients and to describe linguistic features that constructed nurse-centered and empowermental health counseling. The research data, 38
health counseling sessions, were videotaped, transcribed verbatim, and analyzed by using an adaptation of conversational analysis. During
nurse-centered discussions, the nurses' advice did not correspond to the patients' need for information. These counseling sessions began
with check-up questions about the patients' condition and continued with factual questions about their illnesses and health care measures.
During empowering health counseling, the nurses made use of the patients' knowledge of their circumstances and supported the patients'
ability to re¯ect on their health behavior. Questioning and advising strategies were found to be crucial for building up empowermental
conversation and enhancing the impact of health counseling. # 2001 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Advice; Empowermental counseling; Nurse; Questions; Re¯ection
1. Introduction
Health counseling models have been determined in many
ways (cf. [1±3]). In this article, we concentrated on the
nurse-centered and the empowermental health counseling
models. The health professional-centered [1,4,5] model
focuses on the problem of patient control or non-compliance
while overlooking the patient's perspective [6]. In light of
such problems, patient counseling is seen as a means to
instigate controlled behavior in patients and to encourage
bene®cial health gains [7,8]. In this model, both the information itself and its delivery are designed to in¯uence the
patient's behavior [9]. From health professionals' point of
view, a health problem is presented and its appropriate
management is suggested. Recent studies have shown that
most problems between patients and health practitioners are
associated with dif®culties in communication [10±13]. The
problem for this model appears to be the patient who is
unable to understand and/or to retain the information and
lacks motivation [14]. The counseling methods that are
employed emphasize the outcome and assume a unidirectional ¯ow of information from a health professional to the
patient (cf. [11]).
*
Corresponding author. Tel.: ‡358-14-2602148 fax: ‡358-14-2602141.
E-mail address: [email protected] (M. Poskiparta).
In professional circles, increasing attention has been
given to the empowerment model of personal health counseling [2,15,16]. In the empowerment model, the patient is
the focus of the counseling process, which emphasizes
mutual participation and dialogue [2,16±18]. Patients
become conscious of changes in their knowledge and understanding, of their improved decision-making skills, their
enhanced self-esteem/sense of personal control, and the
development of various social, health, and life skills
[2,16,19,20], and health professionals facilitate this process
of re¯ection [19]. This implies that patients not only analyze
their circumstances but are also able to plan what to do next
and how to go on. The learning process begins with concrete
health experiences of individuals who re¯ect on these
experiences. In the next phase of the learning process,
abstract conceptualization, individuals make sense of new
ideas and relate them to their circumstances. In an active
experimentation process, the new knowledge is applicable in
real life [21]. These health habits are experimental and
creative; learning from them is a result of both monitoring
and re¯ection. In this learning process, re¯ection is focused
on communication, on the latent knowledge basis of action,
on the content of action, and on the views of the subjects or
their patterns of thought and action [22,23]. The assumption
is that new knowledge is gained during the guidance process
as a result of empirical realization and deliberation
[21,23,24], which means that both patients and nurses
0738-3991/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 4 0 - 9
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M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
connect new knowledge to existing knowledge. Educators
and patients participate equally to solve the problematic
situations that arise during counseling; nurses learn during
this guidance process as well [23].
In this study, re¯ection was de®ned as an essential phase
of an experimental learning process [21], where people
consciously explore their experiences on several levels
[22] in order to arrive at new understandings and behaviors
[23]. Mezirow [25] divides re¯ectivity into seven levels.
He refers to the ®rst four of these levels as consciousness and
to the last three as critical consciousness; these are considered to be higher levels. The ®rst level of consciousness
involves an act of re¯ectivity. We become conscious of a
speci®c perception, meaning, or behavior of ours or of
our habits of seeing, thinking, or acting. Affective re¯ectivity refers to becoming conscious of how we feel about
the way we perceive, think, or act or of our habits of doing
so. On the third level of re¯ectivity, that of discriminative
re¯ectivity, we assess the ef®cacy of our perceptions,
thoughts, actions, and habits of doing things, identify
immediate causes, recognize the reality contexts in which
we function, and identify our relationships in the counseling
situation. Judgmental re¯ectivity involves making and
becoming conscious of value judgments about our perceptions, thoughts, actions, and habits, in terms of whether they
are liked or disliked, beautiful or ugly, positive or negative in
communication situations.
Critical awareness, or critical consciousness, entails
becoming conscious of our awareness and critiquing it. In
the present study, the patients' assessment of the adequacy of
the concepts that they used during counseling sessions, with
regard to their understanding or judgment of the phenomenon, represented the level of conceptual re¯ectivity. Psychic re¯ectivity leads to self-realization of the habit of
making precipitant judgments about people on the basis
of limited information about them. From theoretical re¯ectivity, through which we become aware that a routine, or
taken-for-granted, practice may not be the most suitable one,
follows learning from experience or a change in perspective
[25], for example, in our dietary habits.
In health counseling, the aim of re¯ection is to build
bridges between past and present experiences in order to
determine future life actions. While re¯ection is important,
not all re¯ective processes promote learning. Without direction, re¯ection can become diffuse and disparate so that
conclusions or results fail to emerge [26]. During counseling
sessions, health educators should use guided re¯ection to
help patients to focus on conceptual frameworks. There are
several communication strategies that may result in
enhanced empowerment within a partnership that unconditionally values those who are involved [27]. Questioning
is a method of building up mutual conversation [28,29]. By
posing re¯ective questions, patients can be encouraged to
generate new patterns of cognition and behavior on their
own. Questioning can also hinder mutual communication; sometimes patients re¯ect guilt if nurses ask several
check-up questions in succession [30]. There are many types
of re¯ective questions, and the boundaries between the
different categories are ¯exible.
Tomm [31] has divided re¯ective questions into eight
groups: future-oriented questions, observer perspective
questions, unexpected context change questions, embedded
suggestion questions, normative comparison questions, distinction-clarifying questions, hypothesis-introducing questions, and process-interrupting questions. Each of the
categories contains subgroups that activate self-evaluation
with regard to one's future intentions and meanings and
one's feelings [30,31]. Re¯ective questions can support the
learning to learn process. These questions are not de®ned on
the basis of their semantic content or syntactic structure but
by the nature of the intentions in asking them. In addition,
the context plays an important role in assessing the degree of
re¯ection provoked by a particular question [30]. Re¯ective
questions enable nurses to provide new opportunities for
patient-centered discussion. In order to promote re¯ection, it
is essential that patients receive emotional and non-verbal
support. Nevertheless, recognizing patients' re¯ection may
prove dif®cult because people do not often express their
re¯ection verbally. Re¯ection can start only after patients
have successfully organized their stores of emotions and
knowledge [29,30,32].
Another common form of counseling is delivering medical advice under control of health personnel [33]. Appropriately given information can empower patients to make
decisions for themselves [5,34]. On the other hand, inappropriately conveyed advice might discourage personal
re¯ection [15]. A problem with giving advice on behavior
is that many patients are not ready for behavioral change
when they begin counseling. Advising them about the
mechanics of behavioral change can thus be misdirected
and premature because the issue of ambivalence has been
ignored. There is a growing awareness that patient participation enhances patient satisfaction and improves the outcome, at least as measured by compliance with decisions and
commitment to action plans [35,36].
According to previous studies, nurses recognize that their
nursing education prepares them to transmit factual information to their patients, but they are ill-prepared for communication that aims at a more holistic approach to health
counseling, which requires individualized patient education
and guidance [37±41]. The present article demonstrates the
principal strategies for asking questions and giving advice
and how this advice and these questions were accepted or
refused during nurse-centered health counseling sessions, on
one hand, and during empowermental health counseling
sessions, on the other hand.
2. Research data and method
This article was based on qualitative data collected from
38 nurse±patient counseling sessions in a Finnish hospital.
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
The research data were videotaped on seven wards (anesthesia, surgery, gynecology, out-patient, physiotherapy and two
internal disease wards). The participants were volunteers,
signed a research license and permitted the transcribed data
to be published. Nineteen nurses participated in this study,
and each nurse conducted two videotaped health counseling
sessions with different patients. All nurses were women and
they were between 24 and 50 years of age (mean age 36.9
years), while the group of patients consisted of 24 female
and 14 male patients whose ages ranged from 18 to 70 years
(mean age 47.9 years). The length of the nurses' careers
varied from 1 to 25 years. The lengths of the counseling
sessions were between 5 and 45 min. The researchers did not
attend the counseling sessions. The participating patients
were experiencing diverse health problems, for example
knee surgery, varicotomy, hernia operation, back operation,
were the most representative. In addition, many of patients
suffered from chronic diseases, such as hypertension,
asthma, rheumatic illnesses, and diabetes.
An adaptation of conversational analysis [42±44] was
used for this study. Studying social interaction with conversational analysis (CA) involves an effort to reveal the
methods that people use in everyday life to accomplish
whatever they are doing [45]. In the other words, CA
addresses how we do the ordinary things that we perform
routinely, such as agreeing, disagreeing, opening a conversation, etc. CA examines the organization and structure of
conversation, includes all that is said, and views speakers as
competent. In this study, CA was used to describe how the
nurses used questioning and advising during counseling in
order to facilitate re¯ection in the learning to learn processes. Videotaped counseling sessions were transcribed
verbatim. In the transcriptions, the duration of pauses in
speech was not marked exactly. In addition, non-verbal
communication, which supported speech, was interpreted,
in contrast to many recent studies [42,46] where only verbal
communication has been analyzed. A single video camera
was used, which meant that the observation of non-verbal
communication consisted of examining the session as a
whole, including eye contact, smiles, laughter, some gestures,
tone of voice, and some facial expressions. Consequently, the
emphasis of this study was examining verbal communication.
The excerpts that are presented were translated as literally
as possible from the original Finnish transcripts. The transcription symbols of communication included
()
overlapping speech
oo
low volume of speech
?
raise in pitch
@
change in voice quality
eye‡
eye contact
ha‡
hands supporting speech
nod‡
nod
bo
body leant backward
bo‡
body leant forward
underlining
emphasis
‰. . .Š
pause
ˆ
...
71
no pause
omission of text
The nurses' and the patients' questions, advice, and
answers were recorded in computer text ®les and were
selected from the total data. The analysis was carried out
on a turn-by-turn basis. Careful viewing of the videotapes
and a close reading of the transcripts revealed constructs of
speech that encouraged patients to participate in conversations and to re¯ect on their health habits. Every attempt has
been made to approach this material openly and, therefore,
no preconceived classi®cations have been used when identifying the dynamics of questioning and advising [44]. The
credibility of the ®ndings was further enhanced by triangulation of the research data [47], through acquiring data on both
verbal and non-verbal communication from the videotaped
counseling sessions. By comparing the occurrences of questioning and advising in different situations during the counseling sessions, we were able to arrive at a clear picture of the
learning to learn process in health counseling.
3. Results
3.1. Nurse-centered health counseling
Nurse-centered counseling sessions usually began with
check-up questions or with the nurses' long explanations of
the purpose of the counseling sessions. After the initial
questions, the nurses then proceeded to give advice from
guidebooks or lea¯ets even though the patients might
already have mentioned that they were informed of the
facts. In the following excerpt, the nurse did not introduce
herself because she and the patient had met on a ward. The
nurse mentioned that the reason for the counseling was to
follow a doctor's suggestion (line 3). She remembered a
conversation during the round of the doctor and mentioned a
positive change in the patient's health habits, using a low fat
product (lines 5±6), but in this case the patient answered
brie¯y (line 8). The nurse repeated the same information
twice, but this is not shown in excerpt 1 (line 7).
Excerpt 1.
1N:
So, the intention is now to discuss these
serum lipid levels,
2
because it was noticed after you were
admitted that your cholesterol
3
level was 7.1. And that's exactly what the
doctor wanted, it was his intention
4
that we should have a little talk about the
issues that concern the lipids.
5
And, well Ð it's a good thing, as was
discussed during the
6
round, that you've switched to a margarine
with less fat ±
7
the ``Keiju'' margarine . . . [eye‡]
8P
Yes
72
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
The beginning of the conversation appeared to be formal.
During this counseling session, the conversation was occasionally supported by non-verbal communication, for example, brief eye contact, but mostly the nurse and the patient
were trying to make eye contact. Mezirow [22] emphasizes
the affective features of re¯ection and the beginning of
re¯ection in analyzing different ways to perceive and communicate. In this conversation, the atmosphere was composed but did not support the patient's re¯ection. Also, the
nurse repeated the same perspective on issues when it was
her turn to speak.
In excerpt 1, it became evident in the beginning of the
session that the patient had already made dietary changes
and had been able to lower her cholesterol level a little.
Nevertheless, the nurse carefully proceeded to give a lot of
advice on eating habits that could help lower the patient's
cholesterol level. She spoke for long periods, and the patient
was forced to play the role of a listener, as in the beginning of
excerpt 2. However, on lines 8 and 9 the patient did not agree
to being a listener and did not accept the advice she was
given either.
Excerpt 2.
1N:
And then, these instructions include dietary
restrictions,
2
products that contain a lot of cholesterol; egg
yolk, that's one
3
everyone knows, liver, kidneys. And there's
going to be less
4
cholesterol when we cut down on milk fat,
meat and
5
meat products; your diet is going to change
(somewhat [eye‡]
6P:
Yeah
7N.
just that
8P:
I haven't had milk for many years,) except
what you have in
9
some, like in some foods, then it bloats me up
like something awful. It's
10
just that my belly stretches out if I have any
milk. That's it, milk's
11
not good for me. Why that is, I've no
idea[eye‡/ha‡]
12N:
Right, it was never tested?
13P:
The milk sugar, they tested that once, it was
so, I drink it up [ha‡]
14N:
Lactose test, hmm.
15P:
Right, that's it but there was nothing there,
then [eye‡]
16N:
Aha
On line 8 the patient interrupted the nurse by pointing out
an issue that worried her (line 9), i.e. that milk was a problem
for her. In her comment on line 8, the patient seemed to feel
that the nurse was somehow blaming her with her advice and
answered by stating that she had avoided drinking milk for
many years. Perhaps she would have liked to discuss fats and
nutrition in more detail although on line 11 she asked an
embedded question about the cause of her problem. After a
check-up question (line 12) and an embedded question by
the nurse (line 14), the patient answered tensely ``there was
nothing there''. We interpreted the answer as an initiative to
change the topic of the discussion. The nurse's paralingual
comment ``hmm'' also expressed disinterest in the topic
(line 14).
In excerpt 2, the patient expressed her feelings and did not
accept the role of a passive recipient. In this part of the
conversation, despite having negative feelings, she began to
re¯ect on her dietary habits on the ®rst level of re¯ection but,
instead, described physical sensations that were caused by
milk. The patient may also have had an ability to re¯ect on
the affective level but the nurse did not make use of the
patient's skills. This is in contrast to Mezirow [25] who
recommends positive affective support in re¯ection.
In the next excerpt, the nurse supplied information about
breast-feeding to a mother who had recently given birth to
her third child. The nurse's advice was not related to the
patient's needs. In the beginning, the mother implied that she
knew when her baby had had enough milk and described the
physical characteristics of the baby's behavior. Before this
excerpt she had frequently mentioned her experience at
breast-feeding, yet the nurse continued to offer advice
(excerpt 3, lines 3, 6).
Excerpt 3.
1P:
And she sucks what she needs and then she
stops and lets go and actually
2
falls asleep, I think that is when she has had
enough milk [eye‡]
3 N:
That's right. Now, just go ahead and start
feeding the baby, one breast at a
4
time. Are your nipples okay? [eye‡/ha‡]
5 P:
Yes, they are. It's all right. [eye‡]
6 N:
Always squeeze out a drop of milk to protect
your breast and your
7
nipple and it'll be all right. . . . [eye‡/ha‡]
The atmosphere seemed to be emotionally warm, there
was eye contact between the nurse and the patient, and it
appeared that all elements of a holistic and patient-centered
conversation were present. However, the nurse did not pay
attention to what the patient said (lines 1, 2, 5). She proceeded with her counseling and gave reasons for breastfeeding and commonplace advice about breast care. She kept
the conversation on this topic by carefully going through all
sections in guidebooks about breast-feeding, as was the
hospital policy (cf. [37]). The patient used her experimental
knowledge and described her baby's actions by meditating,
as Jarvis [23] has stated. We supposed that the mother had an
ability to re¯ect on her actions, at least on the ®rst level of
re¯ection, according to Mezirow [25], perhaps on a higher
level, but the nurse interrupted her re¯ection by advising.
In the following excerpt, the nurse tried to ®nd out what
the patient knew by checking her knowledge about the
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
factors that contribute to coronary disease since the patient
had recently had heart bypass surgery. She gave the patient
time to think about the question (excerpt 4, line 3). The
patient seemed to be a little uncomfortable. The nurse
continued with an alternative question and gave some cues
for the patient's answer (lines 5±7).
Excerpt 4.
1N:
The diet is, of course [. . .] you could say that
it's the first phase and it's
2
possible to make changes in it immediately,
you'll just need to watch what
3
you put into your mouth. But [. . .] There
could be something else . . ./eye‡/smile]
4P:
That's surely something [. . ./bo-/smile] [o]
It's not coming to my mind [o]
5N:
One thing, one thing crossed my mind, it's
that you sit and stand all day and
6
teach these students and [. . ./nod‡/eye‡/
smile]
7P:
and go on almost all evening [eye‡/nod‡]
8N:
I guess you sometimes have a day when you
feel that nothing hit
9
home [eye‡]
10P:
hmm [eye‡]
11N:
and it's not all that easy. But the benefit, if
you took a short walk [@] after
12
your day at work, for instance, even if you
felt tired. [eye‡]
13P:
hmm [eye‡]
14N:
I'd imagine that it would be beneficial for
you to get those books, [eye‡]
15P:
hmm [eye‡]
16N:
things out of your mind and [. . ./eye‡/ha‡]
17P:
That's true, I'm sure. [eye‡/nod‡]
The fact that the nurse suggested so many reasons for
the patient to take up physical exercise might have had the
opposite effect and may even have strengthened her guilt
feelings, which she had already expressed in many ways,
such as ``I haven't paid attention to health'' and ``I've been
a lousy walker''. The patient appeared uncertain and may
even have regarded the nurse's suggestion as derogatory.
The situation emphasized the institutional frame of counseling. During the session, the patient became quiet and
only answered brie¯y. The nurse did not seem to think
that the patient's brief answers, ``hmm'', were signs of
one-sided counseling. This was very typical during most
sessions. In nurse-centered counseling, the nurses did
not pay careful attention to their patients' feedback and
did not support an atmosphere that would have been
conducive to re¯ection.
3.2. Empowermental health counseling
In this study, both the patients and the nurses had an
important role to play in the conversations, which led to a
73
sharing of perspectives. It is recognized that the opening of a
conversation is always very important since the participants
base their actions for the entire conversation on their evaluation of the ®rst few minutes. The empowermental health
counseling sessions began with the nurses building up a
communicative relationship by examining the patient's circumstances indirectly, for example, by asking ``So, now you
can go home tomorrow. [?/eye‡/nod‡/ha‡]''. After the
patients had told about their feelings, the nurses began to
give advice. The non-verbal communication of the two
parties who were sitting side by side, their eye contact,
head movements, and nodding, supported the conversation
(see excerpt 5, lines 1, 5, 7, 10, 11). The onset of counseling
resembled the small talk that people make with friends and
created a warm atmosphere that made it easier to activate the
patient's re¯ection [20].
In excerpt 5, the patient controlled the discussion by
assessing her own actions critically. In the beginning, the
patient was eager to talk about her experiences, and the
nurse was a listener rather than an advisor, but this did not
disturb the nurse. The nurse's ®rst, embedded question
(line 1) contained meanings that activated the evaluation of
the patient's health behavior (cf. [32]). The patient evaluated her training session and was somewhat uncertain
because the relaxation exercise had not made her feel what
she had expected to feel. She assessed her existing store of
knowledge, her experiences, and how to apply them in a
new situation. She knew about healthy behavior (lines 3, 4,
6) but was realistic and conscious of her ability to carry out
the exercise (lines 17±23). The patient had committed
herself to the exercise program (lines 2±13). The nurse
encouraged her self-re¯ection by nodding, by using minimal words (``hmm'') and overlapping speech, and by
frequently looking at the patient when she was speaking
(lines 5, 7, 10, 12).
Excerpt 5.
1N:
Well, then, you've had that relaxation
cassette there. [?/eye‡/nod‡]
2P:
Yeah, I went through it this morning already,
I was trying to learn how to
3
do it [oo] without the cassette because they
said it should become quite
4
automatic, so that you wouldn't need any
instructions [ˆ]
5N:
Yeah [eye‡/nod‡]
6P:
and you'd know how to do it [laugh/ˆ]
7N:
yeah [eye‡/nod‡]
8P:
but I noticed that, you know, maybe it isn't
that easy to really concentrate
9
on it, you know, what they say on it, that if
you do it right [ˆ]
10N:
hmm [eye‡/nod‡]
11 P:
Then you'd feel like warm water was filling
[ˆ/laugh/strokes her leg and arms]
12N:
yeah [eye‡/nod‡]. . .
13P:
so well [eye‡/nod‡/ha‡/ˆ]
74
14N:
15
16
17P:
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
Would you like to borrow it for a while, so
that you could do it at home with the
cassette, for example, [. . .] every other day,
and then every other day you
could practice relaxation without it [oo]
(It's possible)
(Why not), if only it's possible? [@/eye‡/
nod‡got excited]
On line 14 the nurse's question could be interpreted as an
alternative question. The nurse continued her advice in the
same sentence and focused on the future. This excerpt was
an example of the nurse planning an exercise program for the
patient in her mind when the patient spoke. Next, the nurse
linked her advice to the patient's experience (lines 14±16).
She offered the patient a chance to continue controlled
training with the aid of the relaxation cassette, and her
advice was based on the patient's implication of unsuccessful relaxation. The patient expressed a willingness to follow
the nurse's advice (line 17). Quite often, re¯ective advice for
the learning to learn process assumes the form of a question.
In this excerpt, the nurse's ®nal question was hypothetical.
She signaled caution by pausing during the sentence (line
15) and probed gently (lines 14±17), which allowed the
patient enough time to handle an emotionally and cognitively signi®cant topic [48]. This is how the nurse and the
patient could prepare themselves for an open discussion
about it (cf. [31]).
The patient assessed her knowledge, abilities, attitudes,
and behaviors that were related to her health problem during
the counseling. The patient's answers implied the discriminative level of re¯ection (lines 2±4), and she also connected
the feelings in her actions and perceptions (cf. [25]). Women
can use their re¯ection skills in the learning to learn process,
which could be seen here on lines 8 and 9. The patient's
answers could be interpreted on the psychic level of re¯ection. She had recognized her capacity to make precipitant
judgments (cf. [25]).
During empowermental health counseling, nurses commonly made use of the patients' knowledge when they gave
advice. They were not in a hurry to advise the patients.
Instead, they ®rst asked a series of check-up questions about
the patients' opinions or activities and also gave them
personal advice by asking questions. The nurses questioned
the patients in order to assess their feelings or knowledge
(excerpt 6). The patients' answers then guided the conversation, which might continue with the nurses' questions and
advice or with the patients' questions.
Excerpt 6.
1N:
About walking, then; what do you think, do
you think you can find some
2
nice footpath at home, one that doesn't have
3
terribly steep grades and isn't too hard?
[eye‡]
4P:
I guess so, it would be great if there was
a trail of some kind in the
5
5N:
6
7
8P:
forest. [eye‡]
But it's all right when you can walk and talk,
and, of course,
you'll get out of breath, but you should be
able to talk
without difficulty. [eye‡]
Yeah. [eye‡/whispering]
Marilynn et al. [15], for example, have assumed that
giving advice does not belong to empowermental health
counseling. Our results (for example, excerpts 5, 6) do not
support their opinion. The nurses listened to what the
patients had to say and showed that they respected their
knowledge, after which they asked questions and gave
advice. In excerpt 6 (lines 5±7), the nurse's advice was
quite practical and relevant to the patient's everyday life.
It was realistically possible for the patient to follow the
concrete advice. The patient was able to analyze her
circumstances at home concerning physical exercise
(cf. [25]). Excerpt 6 was, in addition, an example of a
counseling session where the health counseling model
changed during the discussion. This counseling session
was begun in accordance with the nurse-centered model;
after the nurse had directed the discussion to the
patient's everyday life, the counseling proceeded in harmony with the empowerment model and the learning
to learn process.
In excerpt 7 there was a good example of how patients
expressed their knowledge and raised new issues during
counseling sessions. The nurse wanted to know about the
patient's views on dietary issues and clari®ed them with a
check-up question (line 1). This generated a re¯ective
answer by the patient (excerpt 7, lines 2±4).
Excerpt 7.
1N:
Then what about, you drink water, don't you?
2 P:
I usually drink water or if, if I brew beer at
home, then I'll have that.
3
But I don't want to brew it, it makes you fat if
you drink (it all the time.
4N:
Yes, there's sugar) in it and there's also (malt
in it [eye‡]
The patient was eager and very talkative and explained
her thinking to the nurse, which was indicated by overlapping speech. The nurse encouraged the patient to continue by con®rming her knowledge and gave her feedback
via brief eye contact (line 4). The patient's answer implied
knowledge about nutritional values (line 3).
In addition to questions by the nurses, empowermental
counseling also included requests for advice by the patients.
In the following excerpt, the patient sought advice on
medication for reducing her elevated blood cholesterol level
(excerpt 8, line 1). The patient revealed her knowledge in her
answer and suggested an alternative solution for reducing
the high cholesterol level (lines 8±9). Further on during the
conversation, the nurse gave positive feedback about the
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
patient's lowered cholesterol level. The atmosphere of this
counseling session was relaxed and encouraging.
Excerpt 8.
1P:
Will they give medication for this then,
if it gets worse? [eye‡]
2N:
They can give medication if there are
other risk factors. And if there
3
is any reason to believe (that there will
be. [eye‡]. . .
8 P:
So it's) the best way. There's no need
for medication,
9
(if you can do it in some other way.
[eye‡]
10N:
That is), if there's been a change in
your levels already, (then that's
11
a good thing. [eye‡]
4. Conclusions
This study revealed that the nurses used speci®c strategies
for asking questions and giving advice during empowermental health counseling. All of the analyzed counseling
sessions contained both empowermental and nurse-centered
features, which alternated during the conversations. Nevertheless, nurse-centered features were predominant. We
demonstrated how mutual participation could be achieved
through questioning and advising by the nurses and the
patients. During nurse-centered counseling, the nurses controlled the discussions by asking questions and giving
advice. Fig. 1 illustrates the structure of nurse-centered
discussions. In order to get information about the patients'
illnesses and health care measures, the nurses asked
75
check-up questions and alternative questions. The nurses'
minimal non-verbal communication supported the conversations. In this study, the patients' need for information and
their craving for emotional support were manifested when
they sought eye contact while speaking about issues that
worried them (cf. [49,50]).
During nurse-centered counseling, the nurses gave advice
from guidebooks or lea¯ets. The patients' feedback was
manifested in many different ways. They communicated
guilt or uncertainty, they explained that they were aware of
the facts, they replied brie¯y (for example, ``hmm'') or with
silence, and they interrupted the nurses or recounted concerns or experiences. Sometimes the patients asked for
advice or con®rmation of their knowledge, but often the
nurses either did not listen to or take into consideration what
the patients said (Fig. 1). These results are similar to the
results of Heritage and Se® [37]. Although, the patients
frequently indicated that they wanted to participate in the
conversations, the nurses continued to follow their own
agenda during the counseling sessions. The nurses gave
advice irrespective of their patients' answers or feedback.
The counseling became a disempowering process (cf. [51]).
During most of these health counseling sessions, the
patients did not ask any questions, and when they did the
questions were few. Tuckett et al. [49] have stated that not
asking questions is a common feature of doctor±patient
conversations. This lack of questioning by the patients might
have re¯ected a lack of con®dence and skill in many cases,
but in the case of some patients it may simply have implied
that they avoided or resisted new information [34].
The nurses' conversational strategies had the potential to
lead to empowermental counseling (Fig. 2). In the beginning
of the conversations, the nurses asked check-up questions
Fig. 1. The structure of nurse-centered health counseling.
76
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
Fig. 2. The structure of empowermental health counseling.
about the patients' condition and continued with questions
about their feelings in the past, present, or future. During the
questioning, there could be a variety of embedded, check-up,
alternative, or affective questions. According to this study,
the nurses' roles in the conversations were emphasized by
listening, by hearing, and by understanding the context of
the patients' verbal expressions, in contrast to the research of
Heritage and Se® [37]. The nurses created a positive atmosphere in which the patients were able to express their
opinions and feelings [29,30]. While the patients thought
aloud, the nurses supported their reasoning with overlapping
speech, by making sounds, seeking eye contact, and nodding. Thus, the nurses supported the patients' authority to
speak. This has not been a typical feature of health counseling, but it is desirable for building up empowermental
conversations.
This study showed that empowermental health counseling
was related to re¯ective questioning and the patient-centered
approach, which implied giving advice by activating the
patients' self-evaluation and self-determination and giving
them an opportunity to speak up and express themselves.
Conversational analysis of the nurses' and their patients'
counseling interactions indicated, as previous research has
done [5,37], that the patients did have knowledge about the
topics that the health counseling included, such as dietary
habits and physical exercise, and that they were prepared to
discuss the starting points, causes, and effects of their
actions. Health professionals should listen carefully to their
patients and help them discover the extent of their understanding [52] by asking them the proper questions. In this
study, the nurses bene®ted from the patients' feedback
during the counseling sessions and modi®ed their advising
and questioning accordingly (Fig. 2). Answering these
questions made it easier for the patients to become more
aware of their circumstances, which helped them to see them
from another person's point of view or, indeed, to monitor
them on their own. However, as we demonstrated, isolated
questions could cause anxiety in the patients if the nurses
ignored their personalities and did not pay careful attention
to their answers. Examining patients' minimal communication cues has the potential to create new approaches to health
counseling.
Besides providing information, health educators are also
in a position to offer emotional support and to develop their
patients' re¯ection skills. Positive non-verbal communication builds up an emotionally favorable atmosphere during
health counseling. Questioning and advising extend beyond
verbal expression since they also involve non-verbal cues
and paralanguage, i.e. prosodic factors as well as body
movements that are ancillary to language proper in communication. A number of studies [49,53] have indicated that
patients evaluate their health care contacts largely in terms
of personality characteristics and interpersonal style.
In this study, the nurses' communication strategies gave
the patients an opportunity to participate in the discussions,
and they supported the patients' re¯ection. Our results
indicated that, in nurse-centered counseling, the patients'
level of re¯ection was restricted to the ®rst and second levels
of re¯ection (excerpts 2±4), according to Mezirow's scale
[25]. Patients re¯ected physical sensations but also affective
feelings. However, there were cues that the patients also had
the ability to re¯ect on their own health habits; they suggested the directions in which they wanted the discussions to
continue and expressed their knowledge about the issues.
Yet the nurses did not make use of the patients' skills.
In nurse-centered counseling, the patients may have been
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
prevented from talking and re¯ecting for two principal
reasons. First, the nurses did not react to their patients'
concerns and, second, they continued on their topics despite
the fact that the patients felt uncomfortable about them,
disregarding any signals to that effect.
Re¯ection is an important element of empowermental
health counseling. Our research con®rmed, as Jarvis [23] has
suggested, that re¯ection was important for the learning to
learn process in health counseling as well (see excerpt 5). In
the data, the patients' level of re¯ection could vary from the
®rst level to the sixth level of re¯ection, according to
Mezirow's scale [25], during empowermental health counseling. The patients' re¯ection was focused on their knowledge,
skills, attitudes, and behaviors that were related to their
personal health problems or everyday life (excerpt 6). They
were also conscious of their actions, of their affective feelings,
of becoming aware of the ef®ciency of their actions, or of
making their values conscious. In other words, they manifested the ability to re¯ect on the conscious level. A few
patients showed signs during the conversations that they were
conscious of their awareness and could criticize it, but no
participant's communication exhibited features that could be
attributed to the level of critical consciousness (cf. [25]).
When interpreting the results and concerning the reliability of the method, we need to consider if any arrangements for this study were speci®cally made for the purpose
of conducting the sessions. The videotaped sessions were
ordinary health counseling conversations on hospital wards
with voluntary participants who were quite healthy, which
could possibly lead to a selection bias. The educational
levels of the patients varied from the secondary school to
university studies. The patients also readily assented to be
videotaped, and collecting the material presented no dif®culty in this respect. There was some concern as to whether
the nurses and the patients may have been subject to a
performance bias because they were aware of being videotaped and could conceivably have behaved atypically. However, we considered this negligible since no evidence of this
type of bias was found during the discussions with the
participants after the sessions [54].
Techniques to enhance the credibility of the ®nding
included data- and methodological triangulation of the
research data [47] and acquiring data that consisted of both
verbal and non-verbal communication from the videotaped
counseling sessions. By comparing the occurrences of questioning and advising in different situations during the counseling sessions, we were able to obtain a clear picture of
empowermental and nurse-centered counseling. On the
other hand, the research data did not contain information
about the patients' personal empowerment, development of
their decision-making skills, or their improved self-esteem.
The accuracy of the data interpretation was ensured by team
analysis sessions. Cultural differences have to be borne in
mind when these results are interpreted. Still, previous
studies on AIDS counseling [55], therapeutic conversations
[28,31,32], and health education [40] give cross-cultural
77
support to our ®ndings concerning the signi®cance of
re¯ective questioning for the development of collaborative
practice in health counseling. In empowermental counseling, the conversational space belongs primarily to the
patient. Its structure encourages a form of conversation in
which both nurses and patients can be involved. Such active
participation by both parties may be helpful for achieving
positive health effects. This type of counseling can be
empowermental by nature.
5. Practice implications
Our research indicated that a detailed analysis of communication could provide means for improved understanding of the nurse±patient communication process and for
adapting the communication to the patients' needs. The most
successful patient interventions foster and encourage a
partnership between patients and nurses. The key focus is
patient involvement in health-related decision-making,
which is an important factor in itself, promotes understanding, and encourages greater self-reliance. In order to achieve
these results, the patients' lay health conceptions and knowledge should be considered to be of equal or greater value
than professional medical expertise. Health counseling may
include facilitating individual patients' re¯ection and the
clari®cation and interpretation of knowledge, attitudes, and
beliefs via a process of non-hierarchical, non-coercive, and
power sharing interaction [56±58]. Re¯ective empowermental health counseling promotes the development of patients'
personal and social skills, gives them access to new information, and provides opportunities for value clari®cation,
problem solving, and decision making.
Charles et al. [17] have proposed new methods for studying doctor±patient communication and decision-making.
They suggest that it would be more important to examine
how the decision making proceeds than to describe speci®c
behaviors. Based on our results, we suggest a training
program where the development of health care professionals' communication skills could occur in practical,
dynamic communication situations, which would be videotaped and transcribed for subsequent theoretical, conscious,
and instructive analysis. Analyzing transcripts of videotaped
or audiotaped counseling sessions would make it possible to
evaluate communication skills in detail. These ®ndings also
suggest future research that would identify additional conversational features that promote critical re¯ection by
patients or would describe how professionals and those
who receive their advice create relationships. More information is also needed on how to support patients' learning to
learn processes. Study groups should include patients who
could also participate in interpreting the results.
A number of studies [49,53] have indicated that patients
evaluate their health care contacts largely in terms of
personality characteristics and interpersonal style. Most of
the characteristics and affective features of communication
78
M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79
are non-verbal. This is why also Mezirow [25] emphasizes
positive affective support in re¯ection. Our results suggest
that new and detailed research on non-verbal communication is required as a means to promote empowermental
health counseling.
In summary, effective empowermental health encounters
invite professionals, theorists and researchers alike to pay
closer attention to the patients themselves and to counseling
strategies that address patients in the broader context of their
lives. Patients' and nurses' full participation in counseling
sessions is required. They should have the opportunity to
express their knowledge of health and illness and their
feelings in particular. Building relationships by creating
learning to learn, empowermental meaning may prove to
be an important direction in health counseling.
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