From a Nurse's Perspective |
Complex Issues of Communication in the Context of Cancer Care
An ESUN Article
“And now I lay me down to sleep I pray the Lord my soul to keep.
If I should die before I wake I pray the Lord my soul to take.”
Both simple and familiar at the same time the mantra chanted by many worldwide, to begin the evening ritual of prayer, is both rich in communication and trust. Implicit in the exchange is that the message will be received and held secretly in the archives of silence, as well as be understood, no matter the how complicated, muddled, unrealistic, diverse or repetitive the request of the both young and truant at heart. This in many ways mirrors the relationship between health care professional and patient.
In a phrase borrowed from Rupert Murdoch’s recently delivered Boyer Lecture series, ‘within in the dialectic of deconstruction that we currently inhabit’, I wish to discuss what is termed by Edmund D. Pellegrino as the Healing Relationship. Over time, this has moved to be a problematic and complex set of unspoken rules and structures that play an important role in holistic care, as it involves sets of beliefs, held by both health care workers and patients. These unspoken beliefs underpin the power exchange inherent within the interplay that occurs in any given conversation, and especially between patient and health care worker. How is this unequal power exchange to be better understood before it can be addressed to the best of our ability? Power is knowledge - a commonly held and accepted view.
If we are not ill, we are well. What constitutes the mindset of illness is a perplexing question and can be variable depending on a person’s underlying held beliefs, knowledge base and ability to adjust. It may vary according to the hinge that swings the emotional pendulum to which we all sway, as well as physical well being. To accept that one is ill is to accept the concept of unwellness and subsequent loss of freedom. Illness is a state of mind defined by the patient, as well as, and perhaps independently of the health care worker (Pellegrino, 2006). However, importantly for some patients, in order to occupy a state of wellness, they may reprioritise and reconceptualise their own internal standards as to what constitutes health, and subsequently quality of life (Ridder et al., 2008). The wellness/illness interchange is not a static state.
According to Pellegrino, the three main interpretations of patient – health care worker exchange are paternalism; Hippocrates, contractual arrangement; John Locke, and commercial exchange; Knowledge being the commodity, with which the health care worker trades. Paternalism places the patient in an unequal relationship from the outset. Contractual arrangement implies a promise to help and commercial exchange involves actions that will lead to a medically competent healing decision (Pellegrino, 2006). All three are fraught with systemic inequalities. Today, holistic medicine dictates that we endeavour to make available to every patient the choice in making decisions that encompass all aspects of the persons well being. In order to do this the language of information exchange is paramount.
How then do we begin to address the inequality that exists within the communication interchange that by definition, must underpin any human relationship. At one end tied to the purse strings of deeply emotional personal attachment, transversing the rainbow, to end with the impersonal information exchange that is the hallmark of the detached. In any untoward moment, the constraints placed upon all by the current environment is time poor, coupled with the acknowledgment that human beings are both rich in diversity and complexity as well as unequal in intellect.
One two buckle my shoe, three four knock on the door, five six pickup sticks, seven eight shut the gate, nine ten start again.
Familiarity, structure, repetition and routine create the framework of our lives within which we operate, including the word patterning with which we are familiar. Meaning is derived from known associations with which we use every day and unconsciously accept. The layering effect is a daily occurrence, complex in nature and unequal in form. Decker et al purport that the unpredictable and unfamiliar nature of the cancer experience can produce high levels of uncertainty, encompassing the notions of probability, temporality and perception (Decker et al., 2007).
Perception is formed in language that we listen to and speak. In order to select a coping strategy to lessen what can only be described at best, as a stressful interlude. According to Decker et al., a framework of reference to past experiences must be constructed; an essential element in the selection of appropriate response. Automatically, this limits the young and adolescent for whom, according to Decker et al., uncertainty produces the inability to structure meaning. The experience of uncertainty may be due to ambiguity in relation to illness and symptoms, the complexity of care and treatment, lack of communication delivered in a meaningful way, as well as unpredictability of the disease process and expected outcome (Decker et al. 2007).
Today, multidisciplinary care is the hall mark of cancer care. Unequal knowledge and depth of vocabulary compound issues of trust and compliance. Multidisciplinary planning endeavours to minimise mixed messages by agreement to treatment options that may then be conveyed by any one of the team. Sensitive communication and support must be tailored to each individuals needs (Decker et al., 2007).
By understanding the three main elements of patient-health care worker exchange and the complex nature of communication, employing Jacques Derrida’s post modernist theory of deconstruction, even at a superficial level, enables us to begin to comprehend the multi factorial dilemma of the patient. With complex and unfamiliar vocabulary contained, the uncertainty or variations in the message sent can be minimised, in an effort to give clear definition to those having to make difficult treatment decisions. Management of information is paramount, based upon informed understanding of the structure within which we operate. This is the mantra of the health care worker.
Life is short, art long, opportunity fleeting, experience treacherous, judgment difficult.
-- Hippocrates --
References
Toward a Reconstruction of Medical Morality. Edmund D. Pellegrino. The American Journal of Bioethics, 6(2): 65-71, 2006.
Uncertainty in Adolescents and Young Adults with Cancer Care. Carol L Decker, PhD, MSW, Loan E. Haase, PhD, RN and Cynthia J, Bell, BSN, MS, RN. Oncology Nursing Forum – Vol 34, No 3, 2007.
Psychological adjustment to chronic disease. Denise de Ridder, Rinnie Geenan, Roeline Kuijer and Henriet van Middendorp. Vol 372. The Lancet. July 2008.
V5N6 ESUN Copyright © 2008 Liddy Shriver Sarcoma Initiative.