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 . 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 . 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 . The counseling methods that are employed emphasize the outcome and assume a unidirectional ¯ow of information from a health professional to the patient (cf. ). * 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 . 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 . 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 70 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 . In this study, re¯ection was de®ned as an essential phase of an experimental learning process , where people consciously explore their experiences on several levels  in order to arrive at new understandings and behaviors . Mezirow  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 , 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 . 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 . 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 . There are many types of re¯ective questions, and the boundaries between the different categories are ¯exible. Tomm  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 . 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 . 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 . 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 . 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 . . . pause ... 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 . The credibility of the ®ndings was further enhanced by triangulation of the research data , 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  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  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. ). The patient used her experimental knowledge and described her baby's actions by meditating, as Jarvis  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 , 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 . 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. ). 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  5N: Yeah [eye/nod] 6P: and you'd know how to do it [laugh/] 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  10N: hmm [eye/nod] 11 P: Then you'd feel like warm water was filling [/laugh/strokes her leg and arms] 12N: yeah [eye/nod]. . . 13P: so well [eye/nod/ha/] 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/ nodgot 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 . This is how the nurse and the patient could prepare themselves for an open discussion about it (cf. ). 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. ). 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. ). 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. , 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. ). 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® . 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. ). 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.  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 . 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® . 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  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 . 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  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 , 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. ). 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 . Techniques to enhance the credibility of the ®nding included data- and methodological triangulation of the research data  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 , therapeutic conversations [28,31,32], and health education  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.  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  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. References  Fahrenfort M. Patient emancipation by health education: an impossible goal? Patient Educ Couns 1987;10:25±37.  Beattie A. Knowledge and control in health promotion: a test case for social policy and social theory. In: Gabe J, Calnaw M, Bury M, editors. The Sociology of the Health Service, London: Routledge, 1991. p. 162±202.  Tones K, Tilford S. Health Education: Effectiveness and Efficiency. London: Chapman and Hall, 1994.  Ballou M, Fetter M, Saleh K, Litwack L. Health Counseling. Ohio: American School Health Association, 1992.  Roter DL, Hall JA. Doctors talking with patients/patients talking with doctors: improving communication in medical visits. New York: Auburn House, 1992.  Rowland-Morin P, Carroll J. Verbal communication skills and patient satisfaction. Eval Health Prof 1990;2:168±85.  Drew P, Heritage J. Introduction: analyzing talk at work. In: Drew P, Heritage J, editors. Talk at Work. Cambridge: Cambridge University Press, 1992. p. 3±65.  Breemhaar B, Van den Borne HW, Mullen PD. Inadequacies of surgical patient education. Patient Educ Couns 1996;28:31±44.  Salomon P. The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry? Int J Nurs S 1993;30:323±30.  Wyatt N. Physician±patient relationships: what did doctors say? Health Commun 1991;3:157±74.  Ong LML, De Haes JCJM, Hoos AM, Lammes FB. Doctor±patient communication: a review of the literature. Soc Sci Med 1995;40:903±18.  Bottorff J, Varcoe C. Transitions in nurse±patient interactions: a qualitative ethnology. Q Health Res 1995;5:315±31.  Young M, Klingle R. Silent patient in medical care: a cross-cultural study of patient participation. Health Commun 1996;8:29±53.  Chapelle A, Campion P, May C. Clinical terminology: anxiety and confusion amongst families undergoing genetic counseling. Patient Educ Couns 1997;32:81±91.  Marilynn SA, Butler PM, Anderson RM, Funnell MM, Feste C. Guidelines for facilitating a client empowerment program. The Diabetes Educ 1995;21:308±12.  Tones K. Health education and the promotion of health: seeking wisely to empower. In: Kendall S, editor. Health and Empowerment: Research and Practice. London: Arnold, 1998. p. 57±88.  Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681±92.  Gwyn R, Elwyn G. When is a shared decision not (quite) a shared decision? Negotiating preferences in a general practice encounter. Soc Sci Med 1999;49:437±47.  Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns 1995;6:139±44.  McWilliam CL, Stewart J, Brown S, McNair K, Desai ML, Patterson N, Maestro Del, Pittman BJ. Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians. Health Promot Int 1997;12:111±23.  Kolb D. Experimental Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall, 1984.  Mezirow J. Transformative dimensions of adult learning. Oxford: Jossey Bass Publisher, 1991.  Jarvis P. Reflective practice and nursing. Nurs Educ T 1992;2: 174±81.  Tones K. Changing theory and practice: trends in methods strategies and settings in health education. Health Educ J 1993;3:125±39.  Mezirow J. A critical theory of adult learning and education. Adult Educ 1981;32:3±24.  Boud D, Walker D. Promoting reflection in professional courses: the challenge of context. S High Educ 1998;23:191±206.  Le May A. Empowering older people through communication. In: Kendall S, editor. Health and Empowerment. London: Research and Practise. Arnold, 1998. p. 91±111.  Adams J. Questions as interventions in therapeutic conversation. J Fam Psychol 1997;8:17±35.  Poskiparta M, Kettunen T, Liimatainen L. Questioning and advising in health counselling: results from a study of Finnish nurse counsellors. Health Educ J 2000;59:69±89.  Poskiparta M, Kettunen T, Liimatainen L. Reflective questions in health counseling. Q Health Res 1998;8:682±93.  Tomm K. Interventive interviewing: Part II. Reflexive questioning as a means to enable self-healing. Fam Process 1987;26:167±83.  Tomm K. Interventive interviewing: Part III. Intending to ask lineal, circular, strategic, or reflexive questions? Fam Process 1988;27:1±15.  Roter DL. Which facets of communication have strong effects on outcome: a meta-analysis. In: Stewart M, Roter DL, editors. Communicating with Medical Patients. Newbury Park: Sage Publications, 1989. P. 183±98.  Prochaska J, DiClemente C. The transtheoretical approach: crossing traditional boundaries of change. Illinois: Dow Jone-Irvin, 1984.  Ockene J, Kristeller J, Goldberg R, Amick T, Pekow P, Homer D, Quirk M, Kalan K. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Int Med 1991;6:1±8.  Gibson CH. The process of empowerment in mothers of chronically ill children. J Adv Nurs 1995;21:1201±10.  Heritage J, Sefi S. 'Just a chat': dilemmas of advice giving in interactions between health visitors and first time mothers. In: Drew P, Heritage J, editors. Talk at Work. Cambridge: Cambridge University Press, 1992. 359±417.  Johnson J. The communication training needs of registered nurses. J Cont Educ Nurs 1994;5:213±8.  Faulkner A, Webb P, Maquire P. Communication and counseling skills: health professional working in cancer and palliative care. Patient Educ Couns 1997;18:3±7.  van Ryn M, Heaney C. Developing effective helping relationships in health education practice. Health Educ Behav 1997;2:683±702.  Poskiparta M, Liimatainen L, Kettunen T. Nurses' perceptions of communication skills: self-reflection of videotaped counseling sessions. Patient Educ Couns 1999;36:3±11.  Sacks H, Schegloff E, Jefferson G. A simplest systematic of turntaking for conversation. Language 1974;50:696±735.  Sacks H, Lectures on Conversation, vol. 1. Oxford: Blackwell, 1992.  Drew P, Heritage J. Dilemmas of advice: aspects of the delivery and reception of advice in interaction between health visitors and first M. Poskiparta et al. / Patient Education and Counseling 45 (2001) 69±79        time mothers. In: Drew P, Heritage J, editors. Talk at Work. Cambridge: Cambridge University Press, 1998. P. 359±417. PeraÈkylaÈ A. AIDS Counselling. Cambridge: Cambridge University Press, 1995. Atkinson J, Heritage J, editors. Structure of Social Action: Studies in Conversation Analysis. Cambridge: Cambridge University Press, 1984. Patton M. Qualitative Evaluation and Research Methods. 2nd ed. Beverly Hills, CA: Sage, 1990. Beck CS, Ragan SL. Negotiating interpersonal and medical talk: frame shifts in the gynaecologic exam. J Lang Soc Psychol 1992;11:47±61. Tuckett D, Boulton M, Olson C, Williams A. Meetings Between Experts. New York: Tavistock, 1985. Anderson L, Sharpe P. Improving patient and provider communication: a synthesis and review of communication interventions. Patient Educ Couns 1991;17:99±124. McWilliam CL, Brown JB, Carmichael JL, Lehman JM. A new perspective on threatened autonomy in elderly persons: the disempowering process. Soc Sci Med 1994;38:327±38. 79  Ripke T. Coexistence Ð an important condition for successful negotiation between patient and doctor. In: Bensing J, SaÈtterlund Larsson U, Szecsenyi J, editors. Doctor±Patient Communication and the Quality of Care in General Practice. Utrecht: Nivel, 1998. p. 81±90.  Ruben B. What patients remember: a content analysis of critical incidents in health care. Health Commun 1993;5:99±112.  Caris-Verhallen WMCM, Kerkstra A, van der Heijden PGM, Bensing JM. Nurse-elderly patient communication in home care and institutional care: an explorative study. Int J Nurs S 1998;35:95±108.  PeraÈkylaÈ A, Bor R. Interactional problems of addressing dread issues in HIV-counselling. Aids Care 1990;4:325±38.  Labonte R. Health promotion and empowerment: reflections on professional practice. Health Educ Q 1994;21:253±68.  Piper SM, Brown PA. The theory and practice of health education applied to nursing: a bi-polar approach. J Adv Nurs 1998;27:383±9.  Williams J. Education for empowerment: implications for professional development and training in health promotion. Health Educ J 1995;54:37±47.