6 QUESTIONS OF VALUES AND ETHICS
Legal and Ethical Knowledge for Nurses
Understanding the legal and ethical issues involved in nursing practice is critical for all nurses, especially managers and leaders. Legal and ethical issues are intertwined in many ways, but the two entities are distinct bodies of thought and practice. Ethics and laws both derive from societal values. Ethics is a branch of philosophy that involves clariﬁcation of the “shoulds” and “oughts” of individuals and society. Ethical decision making entails a distinctive choice between undesirable options. Ethical algorithms help to guide decisions by looking at multiple dimensions of the situation under review. Laws, on the other hand, are set down by the state or federal governments, administrative agencies, or courts, to establish boundaries of behaviors for society. The legal process constantly questions and debates the law on both legal and ethical planes. To clear some of the confusion that often sur-rounds ethics and law, it is important to point out that ethics deals with the “should and should nots” that are related to behavior or actions taken by an individual. Ethics also deals with the questions of why an action is reprehensible or not reprehensible (Fry & Veatch, 1992). The legality of these choices is always a strong consideration when attempting to resolve ethical dilemmas. Ethical dilemmas in health care come up frequently, and they often address life and death issues. Nurse leaders must be prepared to address these issues in order to guide the members of their nursing staff. This chapter considers the aspects of the legal system with which the nurse leader must become familiar and then explores the foundations of ethics and ethical decision making.
The Legal System
The American legal system is based on the early English system of common law. Common law refers to case law that is directed and made by a judge rather than by a governmental legislative body. This type of law is set by precedent or the principles of stare decisis, along with the factual scenario of a given case. These laws build from one case to the next, as each judge’s decision sets the precedent for future cases. In addition to federal law, Pohlman points out that each state court system has it own “case law [emphasis added] based on the interpretation of its respective statutes” (Pohlman, 1990, p. 296). State and federal legislative bodies create statutes according to societal need. Administrative agencies detail the implementation of these statutes, and the courts interpret confusion over the meaning of the statutes.
Federal laws affect nursing practice by setting minimum standards of care for all agencies receiving federal funding. Nurses must become familiar with federal legislation, such as the Health Insurance Portability and Accountability Act, which guarantees the privacy of a patient’s personal health information; the Emergency Medical Treatment and Active Labor Law (EMTALA), and the Americans With Disabilities Act (ADA). According to Moy (2003), EMTALA prohibits refusal of care for indigent and uninsured patients seeking emergency care in the emergency department. It prevents hospitals from “dumping” indigent individuals on other hospitals. The ADA also affects nursing intimately. This law proscribes any discrimination against individuals with disabilities by offering them the same opportunities as individuals without disabilities. For instance, if an individual with disabilities is the most qualiﬁed individual for a job but requires reasonable accommodations by the employer in order to take the job, the employer must make these accommodations. See Box 5-1 for others federal laws affecting nurses.
State laws also regulate nurses. Nurse practice acts (NPAs) are created by state legislatures to deﬁne, limit, and oversee nursing practice. Nurses must be familiar with the NPA in the state in which they are practicing. NPAs set the requirements for becoming licensed as a nurse in a given state, for renewing one’s license, and for continuing education. They deﬁne the duties and responsibilities of nurses in the state and limit the scope of practice. Many NPAs include safe harbor laws, which limit nurses to practicing only in their area of expertise. For example, they prevent a rehabilitation nurse from being pulled into intensive care because of a staff shortage. Other NPAs include good samaritan provisions, which protect nurses from liability for
volunteering to help in an emergency situation. These provisions apply, for example, if a nurse stops at the scene of a car accident to assist victims. If something goes wrong, the victims of the car accident could not sue the nurse for malpractice. NPAs also address charting and physician orders. They specify that nurses must be skillful, correct, timely, and thorough in their charting. With respect to physician orders, most NPAs make nurses responsible for ensuring that orders are clear and accurate. If the nurse needs clariﬁcation, she must seek it from the physician giving the orders. The nurse is obligated to follow the physician order, but if she believes that doing so would be dangerous to the health of the patient, she is responsible for contacting her supervisor and following through with the institution’s policy regarding physician orders.
Along with federal and state statutes, common law guides nursing practice. In order to understand how common law works in practice, consider the precedent-setting case of Utter v. United Hospital Center, Inc. (Giordano, 2003). This case involved a patient developing compartment syndrome after his arm was put in a cast. The nurse caring for this patient failed to acknowledge and recognize the signs and symptoms of compartment syndrome and did not request medical intervention. This case set a legal precedent that is still followed by other courts: nurses are required to exercise independent judgment to ensure patient safety and to prevent harm. Case law touches on a range of issues that involve nursing practice, including nursing malpractice, practicing medicine without a license, wrongful termination, legal challenges to a nurse’s license, and questions regarding collective bargaining and labor laws. Nurse managers must work in collaboration with risk managers to make staff nurses aware of and educated about relevant case law.
There are two major categories of common law that nurses must understand: civil and criminal law. Civil law involves violations between people regarding everyday matters. Criminal law regulates offenses against individuals and society, violations made with criminal intent. Tort law is one of the major branches of civil law. Contracts is the other major branch. According to Hall (1990), a tort is a wrongdoing or injury that is committed against a person’s property or person. The basis of this type of action is the liability by one individual against another. Contracts law revolves around an offer and acceptance of terms between two or more individuals or organizations. The law speciﬁes when these agreements should be upheld and when they should not be upheld.
There are two types of torts: unintentional and intentional.
Unintentional torts include the two types of tort that most frequently affect nurses, negligence and malpractice. Negligence is the failure to act as a reasonable or prudent person would act in the same or similar circumstances. Malpractice is a form of negligence committed by a professional, such as a nurse, by which professional misconduct, unreasonable lack of professional skills, and/or noncompliance with accepted standards of care causes injury to the client (Creighton, 1986).
There are a number of elements involved in both negligence and malpractice (Box 5-2). In order to establish liability for negligence, the existence of a duty must ﬁrst be established. This duty and/or
obligation from the nurse to the patient is created by law, standards of practice, or contract (Creighton, 1986). For instance, if a nurse is late to shift change, the nurse waiting for the nurse running late may not leave or abandon the clients in their care until the other nurse arrives because that nurse hasa legal duty to the clients. If there is an urgent reason that the nurse on duty must leave, then the manager or supervisor must be notiﬁed so that another nurse may ﬁll the position until the late nurse arrives. This leads to the second element needed to establish negligence, a breach of duty by the nurse. If the nurse breaches a duty (i.e., left the clients without waiting for the late nurse to arrive and without ﬁnding a replacement), there is evidence of the second element of negligence (Fry & Johnstone, 2002).
The third element needed to establish liability for malpractice is causation, or proximate cause. Causation means that the nurse’s breach of duty is reasonably close to or causally connected to the injury or damage to the client. Damage or actual harm is the fourth element needed to prove malpractice. Without harm or injury, no cause of action exists. This harm may be physical, emotional, and/or ﬁnancial (Furrow, et al., 1991). There must be proof of a direct relationship between not meeting a standard and the injury sustained by the client. The ﬁfth and ﬁnal element of malpractice is the forseeability of an event. Foreseeability in this context means that the damages must be a reasonably expected result from the breach of duty. Nurse executives/managers need to be aware of the current trend toward the criminalization of professional nurses’ negligence. A nurse-attorney shares a personal communication of May 14, 1997, reported by Burkhardt and Nathaniel (1998). The communication is as follows: “Until recently, the risk of criminal prosecution for nursing practice was non-existent unless nursing action arose to the level of criminal intent, such as the case of euthanasia leading to murder charges. However, in April, 1997, three nurses were indicted by a Colorado grand jury for criminally negligent homicide in the death of a newborn. Public records show that one nurse was assigned to care for the baby. A second nurse offered to assist her colleague in caring for the baby. A third nurse was a nurse practitioner working in the hospital nursery. Because the baby was at risk for congenital syphilis, the physician ordered that the nurse give 150,000 units of intramuscular penicillin, which would have required ﬁve separate injections. In relation to other problems the same day, the baby was subjected to a lumbar puncture, which required six painful attempts. To avoid inﬂicting further pain, Nurse Two asked the nurse practitioner if there was another route available for administration of the penicillin. Nurse Two and the nurse practitioner searched recognized pharmacology references and determined that IV administration would be acceptable. The nurse practitioner had the authority to change the route and directed Nurse Two to administer the medication intravenously rather than intramuscularly. Unrecognized by the nurses, the pharmacy erroneously delivered the medication prepared and ready to administer in a dose ten times greater than was ordered—1.5 million units.
As Nurse Two was administering the medication IV, the baby died. The Colorado Board of Nursing initiated disciplinary proceedings against Nurse Two and the Nurse Practitioner, but not against Nurse One. The grand jury indicted all three nurses on charges of criminally negligent homicide, but did not indict the pharmacist” (Burkhardt & Nathaniel, 1998, p. 124). This is a very disturbing example of the criminalization of negligence. The case should be made that the nurses should have double-checked the medication, but there really does not seem to be criminal intent involved. However, recklessness can rise to the level of crimi nal negligence, and in this case recklessness, not intent, became the issue. Extreme cases of negligence that rise to the level of recklessness, however, can sometimes replace the need for criminal intent. Vicarious liability arises when other parties are held responsible for causes of negligence. In these cases, employers become responsible for employees’ actions. Most employees are supervised, so employers, by virtue of their oversight responsibilities, are held accountable for negligent acts employees commit in the course of employment. Employers also tend to have “deeper pockets” than individual employees, so the doctrine of vicarious liability affords injured clients a greater pool of resources from which to draw. There is often the temptation by nurses to believe they are protected by their employer, but they need to keep in mind the principle of indemniﬁcation when practicing.Under this doctrine, the institution may in turn sue the nurses for damages paid out for substandard care. Nurse managers play an important role in avoiding corporate liability problems by ensuring that employees are delivering high-quality care to their consumers. They must recognize the signiﬁcance of information gathered, reports, implementation of plans, and evaluation of care on an ongoing basis. This includes client satisfaction surveys and/or other tools, which give information on the consumers’ perception of the care they have received in the institution.
Intentional torts are “willful or intentional acts that violate another person’s rights or property” (Berzweig, 1996). There are basically three components to intentional torts:
■ The acts are intended to interfere with the plaintiff and/or the plaintiff’s property.
■ The acts are intentional by the defendant.
■ The acts cause the consequences.
There is no legal requirement for the act causing injury or damage, only proof of intention is sufficient for the courts (Fiesta, 1988). Intentional torts include fraud, assault, battery, informed consent, false imprisonment, invasion of privacy, and defamation, which includes slander and libel. This section brieﬂy describes each in turn. Fraud is deliberate deception to gain unfair or unlawful advantage of a situation. Fraud may occur if a nurse falsiﬁes her employment record or any records at her disposal. According to Guido (2001), civil assault is a threat to touch an individual without consent and causing an immediate fear of harm. The touch does not have to take place; the individual just has to be fearful that it will take place. Battery, on the other hand, is the actual and unlawful touching of the individual’s body or clothes or anything attached to the individual without the individual’s consent. The nurse manager must make sure that their employees understand these two intentional torts and the differences. Fiesta (1988) presents an interesting case in which a Christian Scientist client refused medication and treatment. This client was nonetheless forced to take medication, which the courts ultimately ruled was a battery and awarded remuneration.
Interestingly, one of the most common examples of battery in a hospital setting is surgery being performed without informed consent. Informed consent is the process whereby a client is informed of all possible outcomes, risks of treatments, and alternatives in order to be able to consent freely to the recommended procedure. This means the client has the opportunity and the freedom to make choices in health-care treatment. Confusion arises when the patient is not mentally competent to make decisions about treatment, when there is a language or cultural barrier to understanding the explanation of the treatment and risks, when the patient has not reached legal age to consent but is an emancipated minor, in emergency situations, and when patients refuse to consent despite expected dire consequences for refusal. State laws vary on these subjects. Informed consent is an active and complex area of litigation. Nurses should ensure that valid informed consent exists before performing or assisting with any procedure or treatment. Otherwise, nurses risk possible cause of action for battery. According to Creighton (1986, p. 197), false imprisonment is the unjustiﬁable and unlawful detention of a client within ﬁxed boundaries or an act with the intention to keep the individual in such a conﬁnement. There are many cases involving false imprisonment. In Big Town Nursing Home, Inc. v. Newman (1970), a 67-year-old man was brought to the nursing home by a nephew, and when he tried to leave, the staff restrained him and denied him use of the telephone or his clothes. The court found the reckless actions of the nursing home willful and malicious in detaining him.
Invasion of privacy is the right to be left alone or free from unwanted publicity. Fiesta (1988) describes four types of privacy invasion: the intrusion of the client’s physical and mental solitude, public disclosure of private facts, any type of publicity that puts the client in the public eye under false pretenses, and any type of appropriation that is a beneﬁt due to the client’s name or likeness (p.160). The case of Bethiaume v. Pratt involved a dying client who had cancer of the larynx and was repeatedly photographed for use by the physician.
The client asked not to be photographed, but these wishes were ignored, and the court found the physician liable for invasion of privacy (Fiesta, 1988, p.160). Nurse leaders and managers must make sure that a client’s privacy is not invaded during their care. This includes ethical as well as legal overtones in client care delivery. Conﬁdentiality is one of the ethical principles that nursing practice upholds via the American Nurses Association Code of Ethics with Interpretative Statements (2001). Nurse managers must make certain that the privileged information regarding clients in their care is kept conﬁdential. Nurses are privy to highly conﬁdential information regarding client care. Information should be disseminated exclusively on a need-to know basis. Nurse managers should also caution their staff not to discuss interesting client cases in open areas. Nurse managers are charged with the maintenance of nursing standards within the ranks of their nursing staff.
The area of contract law most relevant to nurse managers is employment. Most employment relationships between nurses and employers are “at will,” which allows the employees to quit “at will” and the employer to terminate “at will,” for no reason. An actual employment contract between employee and employer is more binding, however. The nurse promises to provide speciﬁc nursing services in exchange for ﬁnancial reimbursement. If either side violates its promises under the contract, the contract has been breached, and the other part may seek damages.
Contracts also come into play in the labor law arena. Many nurses work under the auspices of a union. The Massachusetts Nurses Association (2003) points out that 35% of nurses with union affiliation make a higher wage and work less mandatory overtime than nonunion nurses. This brings into play collective bargaining agreements, which protect the nurse and will not allow the discharge of a nurse without “good cause.” Nurse
Practice to Strive
supervisors are not allowed to participate in collective bargaining.
Ethics is a philosophy based on moral values and reasoning. It contains distinct conduct rules that
regulate particular choices of actions or decisions (Mappes & DeGrazia, 2001). These rules are based on philosophical theories. Ethics and ethical decision making stem from works of major philosophers, such as Immanuel Kant, Rawls, and Mill (Brannigan & DeGrazia, 2001). Deontology, or formalism, is a theory that focuses on an individual’s motives rather than on the consequences of actions.
Deontology encompasses natural law and incorporates dutiful actions of the individual (Hill & Zweig, 2003). Kant further recognized that reasoning is sufficient in leading an individual to moral actions and that these actions should be commenced as ends in themselves rather than as means to an end (Raphael, 1994). For example, a physician asks a nurse to monitor a depressed 40-year-old patient who has been placed on a new, experimental antidepressant medication. The nurse monitors the patient and tells the physician that the patient said,“The medication makes me feel nauseated all of the time,” but the depression has lifted. The physician makes the decision to maintain the patient on the medication because of the need to continue testing on this new medication. The physician is using the patient as a means to an end rather than demonstrating concerns for the patient’s needs and feelings. Kant insisted that moral actions be placed within the boundaries of reason. He further pointed out that an action is not right unless it has the capability of becoming a binding law for everyone. For instance, in truth telling, if the caveat of telling a lie to please a patient exists, then to tell the truth is not a categorical imperative for everyone.
The other major ethical theory is teleology, or consequentialism. Utilitarianism, which is part of teleology and supports the “the greatest good for the greatest number of people,” considers consequences of actions (Beauchamp & Childress, 2001). For instance, if there were to be a ﬂu epidemic and ﬂu vaccine was limited, the decision would be to allow the greatest number of individuals who would be affected to receive the vaccine ﬁrst. If after their vaccinations, more vaccine became available, then the remainder of the population could be vaccinated. Utilitarianism truly considers real-life and commonsense approaches. John Stuart Mill expressed the view that pleasure and happiness have different qualities. This followed with the distinction that applying the golden rule in one’s conduct takes precedence over immediate gratiﬁcations. Mill thought that the greatest happiness must involve everyone concerned, not just an individual. Therefore, the emphasis of this principle is based on groups aimed at producing the most happiness, focusing on utility, consequences, and means to an end (Raphael, 1994).
Another ethical theory is the more contemporary ethics of care. Mappes and DeGrazia (2001) point toaccepting complex circumstances, the people involved must utilize critical thinking within the context of solving or coming to a resolution of the ethical situation.
Mappes and DeGrazia (2001) also considered virtue ethics as part of the ethical picture. Virtue ethics, according to these authors, originated with Aristotle and is based on the character of the individual. Virtue ethics deals with the good or virtuous character traits that may be engendered within the individual. Aristotle named courage as a virtue, striking a balance between excess courage (rashness) and appropriate courage within a situation. The Greek philosophers always strove for balance between two ends of excesses. Balance was always considered the best approach in dealing with virtues. Aristotle also believed that virtues were attained and developed through training and routine practice. In understanding virtue ethics, it would be reasonable to believe that virtuous individuals facing complex ethical dilemmas would make the right decisions due to their virtuous character.
Beauchamp and Childress (2001) laid the foundation for ethical dilemma resolution in their ﬁrst edition of Principles of Biomedical Ethics. This book is now into its ﬁfth edition and continues to act as a guide for ethical decision making. Nurse leaders/managers need to consider the following ethical principles in their decision-making process or if they are participating on an ethical committee.
The principles listed in Box 5-3 act as a basic foundation for ethical decision making. The ﬁrst principle is autonomy, which involves the right to self-determination and to make independent personal decisions regarding care. Beauchamp and Childress (2001) imply that the principle of autonomy is sometimes described as respect for autonomy. An example in health care is the patient’s right to refuse treatment. The only restriction on autonomy that may preclude this right would be a com
municable disease, in which case the patient’s autonomy would be restricted. Devettere (2000) points to the Patient Self-Determination Act of 1990 as the ﬁrst federal initiative that was introduced and designed to educate patients on the use of advance directives. Currently, hospitals and other institutions provide education and paperwork for patients being admitted who have not implemented an advance directive.
Beneﬁcence is a principle that speaks to deeds of charity, mercy, and kindness toward the individual. It also means promoting the welfare of others (Beauchamp & Childress, 2001) or doing good. Nurses, by the nature of nursing practice, perform beneﬁcent acts.
Nonmaleﬁcence literally means to not harm the patient. Munson (2004) believes this is the overriding principle in the care of patients. Aiken and Catalano (1994) declares that nonmaleﬁcence is the other side of beneﬁcence but that the two cannot be considered independent of each other. Nurses may sometimes violate this principle in the short term in order to give a positive long-term result. An example is chest compressions in the event of heart stoppage in an elderly patient; ribs may be broken, and/or sternal fractures may occur that are harmful, but recovering the patient’s life takes precedence over the harm.
The principle of justice is actually the deontological ethical theory. According to Beauchamp and Childress (2001), it encompasses the entire ﬁeld of ethics and refers to the right to be treated justly, fairly, and equally. Munson (2004) points out that justice in health care often refers to distributive justice and/or the distribution of scarce health-care resources. Social justice becomes a part of this;
Munson continues that it implies fairness in the treatment of individuals. Nurses should be aware that when indigent patients arrive in the emergency department, they must be treated in an equitable way and that if persons require emergency service due to trauma, nurses must proceed to deliver the service as deemed appropriate. This goes along with Rawls’ concept of a Theory of Justice (1971). Brannigan and DeGrazia (2001) cited Rawls’ two principles of equality and justice: (1) that everyone should be given equal liberty no matter what adversities exist; and (2) that differences among people ought to be recognized by being inclusive of the least advantaged and given their share of improvements. Others have explored this concept in health care, according to Brannigan and Boss, by proposingequitable health-care systems, benchmarks, and accessible points of entry. Fidelity focuses more on the delivery of health care and literally means keeping one’s promises or obligations to an individual. Munson (2004) suggests that keeping these commitments becomes of paramount importance when considering patient care standards that are to be met by the nurse.
Likewise, nurse managers are bound by their commitments to their employees. In particular, a verbal commitment involving a shift change is a contract with the employee and should be considered as such by the manager.
Veracity involves truth telling by all concerned in patient care. The nurse certainly has an obligation to tell the truth, for instance, when a patient asks about his or her condition. This, however, can take on tones of nonmaleﬁcence when, for example, a cancer patient asks the nurse how long he might live. In this instance, it may be the duty of the nurse not to take hope away from the patient and to provide a positive answer to this question. The answer might include the idea that no one is able to predict death and that there is always hope in life. Here again the balancing of beneﬁcence and nonmalfeasance within the boundaries of veracity is important in the nurse’s actions (Munson, 2004).
The sanctity of life principle is a part of ethical decisions when it comes to withholding or with drawing life-sustaining treatments or assisting sui cide. Sanctity of human life is deﬁned as the obligation not to take human life (Fry & Veatch, 2000). The American Nurses Association (ANA) implies that nurses caring for patients should direct their care toward the relief and prevention of the suffering that is often associated with the process of dying (ANA, 1985, p. 4). This brings into focus the ANA’s position statement (1994) on active euthanasia and its position statement on withholding nutrition and hydration for the patient (ANA, 2001). The latter position should be made by the client or surrogate with the health-care team. Theeducate client family members about the dying process and provision of comfort measures (ANA Ethics and Human Rights Position Statements, April 2, 1992).
ETHICAL DECISION MAKING
Nurses must learn how to make ethical decisions, and nurse managers/leaders must direct and guide nurses in making such decisions. Nurses, in increasing numbers, are being invited to participate on ethical committees. These committees are structured with members of the health-care team, administrators, risk managers, attorneys for the institution, and others. A popular ethical decision model called MORAL was put forward by Thiroux (1977) and Halloran (1982). This model offers a very concise and systematic way of making ethical decisions (Box 5-4). It is most important that ANA carefully considered the beneﬁt-and-harm relationship of withholding nutrition, recognizing that, sometimes, living causes more harm to the individual than dying. The ANA differentiates between artiﬁcial nutrition and the individual being able to consume food and water by mouth. The ANA states that only artiﬁcial nutrition may or may not be justiﬁed. If the individual is unable to make decisions, then the surrogate must be relied upon. Nurses must continue to give good care and
ethical decisions be reached in a timely manner. and the use of this model certainly facilitates the process.
Ethics and ethical decision making have become a thread that is followed throughout the nursing curriculum. The American Association of Colleges of Nursing (AACN) has presented a set of nursing values for nursing students to internalize into their nursing education (Box 5-5). These essential values follow closely the aforementioned ethical principles as a guide for the profession and provide a foundation for future nursing leaders and managers to build upon.
All Good Things…
Legal and ethical issues are moving to the forefront of professional nursing practice. The current societal values are changing, and there is an increasing abundance of litigation in the health-care arena. Along with this, the rapid changes in technological advancement keep health professionals in a constant state of training. Nurse executives and managers must know the law and ethics as well as understand the ramiﬁcations of making sure their employees are also knowledgeable of the law and ethical dilemmas. The laws that affect nurses are critical for nurse executives to understand and follow by making their employees knowledgeable about the pitfalls that may arise due to not meeting standards of care in their units and what may happen to them legally due to this failure to meet standards of care. Along with the legalities of practice and care go the ethical issues involved in practice. Understanding ethical foundations, ethical decision making, and ethical committees is an important part of the nurse executive/managerial role.
1. Legal and ethical issues are intertwined but:
A. They are not distinct bodies of thought or practice.
B. They are individual and distinct bodies of thought and practice.
C. Have no effect on each other.
D. Are not of great inﬂuence on each other.
2. Ethics is a body of knowledge that deals with:
A. Primarily legal aspects of health care.
B. Trying to get individuals to behave correctly.
C. The “shoulds” and “should nots” of individual behavior or actions.
D. Religion only
3. Common law refers to:
A. Laws that societies have in common.
B. Ethical ideas only.
D. Case law.
4. Some of the federal laws affecting nurses are:
A. Not important because only state laws impact nursing.
B. Age discrimination act and equal pay act.
C. Very important but not relevant to practice.
D. The nurse practice acts.
5. It is important for nurses to know the Nurse
Practice Act in their state because:
A. It affects their practice.
B. It authorizes their licensure.
C. Neither a nor b.
D. Both a and b.
6. Nonmaleﬁcence actually means:
A. For the nurse to take care of the client.
B. There is negligence.
C. To not harm the patient.
7. Deontology encompasses:
B. Natural law.
D. All of the above.
8. Ethic of care is:
A. Part of all health-care philosophy.
C. Formulated by John Mill.
D. Based on the moral experiences of women.
9. Ethics is:
A. Based on moral values and reasoning.
B. Only part of the legal system.
C. Not as important as the legal system.
D. Important to philosophical studies.
10. Ethical principles are:
A. Autonomy, ﬁdelity, veracity.
B. Only abstract ideas.
C. Not used in practice.
D. Not applicable to legal situations.
Workplace Communication Relationships
Effective communication demands that the parties involved in communication have a shared and clear appreciation of the various definitions and parameters about which information is being exchanged. According to Stefano Baldi and Ed Gelbstein (“Jargon, Protocols and Uniforms as barriers to effective communication”): Workplaces are witness to generally five types of communication relationships: Collaborative, Negotiative, Competitive, Conflictive and Non-recognition.
The diagram below illustrates how these are connected to each other and how these relationships are potentially unstable and as a result of which a relationship can develop from one type to another either to improve the effectiveness of communication (the positive development path) or slide into a complete collapse of communication (the negative development path).
Non-recognition relationship blocks any meaningful exchange by refusing to acknowledge that one or more of the players in the desired exchange has no rights whatsoever.
Conflictual relationship is a situation in which the parties recognize each other but are no longer able to work towards a win-win result and resort to verbal abuse and physical violence instead. These types of relationships present a fundamental obstacle to effective communication. The other three relationships are often of an unstable nature, in the sense that a change in the relationship can be triggered by a relatively minor event – even just one word that is inappropriate at the time - and this can happen very quickly. In the collaborative relationship the needs and positions of all the parties are clearly defined and understood and everyone involved shares the will to succeed, as well as information, equipment, accommodation and logistic arrangements, for example. The negotiative relationship has much in common with the collaborative scenario except that some needs and positions may not have been defined clearly enough and require discussion and trading to reach a mutually acceptable outcome. Collaborative and negotiative relationships can quickly become competitive relationships when one of the players needs to (or decides to) play a role different from that which was originally agreed upon. This new role could also result in some form of overlap with the responsibilities of others. Another kind of competitive relationship occurs when a “new player” joins an established effort and expects to obtain rights, privileges and concessions from other players. Competitive relationships can, if not properly managed, quickly deteriorate into non-recognition, conflict and exclusion.
At this point, the concepts of credibility and trust become important. Without either of these, effective communication is simply not possible. Neither credibility nor trust is automatically and instantly given – they need to be earned.
The diagram below attempts to show how credibility and trust develop over time. At the early stages of a relationship one’s own character will determine that whether she assigns the person s/he is dealing with an optimistic profile of credibility and trustworthiness or a cautious profile. As the relationship develops over time it can follow many different paths – the diagram pictures a happy situation where the credibility and trustworthiness of the person in question actually increases after the early relationship (if only this were the case all the time!) until it reaches a high level denoting a mature and stable relationship.
The one curve that matters in this diagram is the one showing the catastrophic loss of credibility or trust, which is usually irrecoverable, as this implies the end of any meaningful and effective communication.
Four responses or roles that often cause difficulty in communications, as well as in relationships and task activities, are the:
1. Placater: The Placater always talks in an ingratiating way, trying to please, apologizing and never disagreeing, no matter what.
• WITH WORDS the placater always agrees. For example: “Whatever you want is okay. I am just here to make you happy.”
• WITH BODY the placater indicates a sense of helplessness.
• WHILE ON THE INSIDE the placater feels: “I feel like nothing: without him or her, I am dead. I am worthless.”
2. Blamer: The Blamer is a fault-finder, a dictator, a boss and always acts superior.
• WITH WORDS the blamer always disagrees, and says (or seems to say): “You never do anything right. What is the matter with you?” Or, “If it weren’t for you, everything would be all right.”
• WITH BODY the blamer indicates: “I am the boss around here.”
• WHILE INSIDE the feeling is: “I am lonely and unsuccessful.”
3. Computer: The Computer is very correct, very reasonable with no semblance of any feeling showing. He or she is calm, cool and collected, and is almost totally disinterested and tries to sound intellectual. The computer uses big words.
• WITH WORDS the computer is ultra-reasonable. For example: “If one were to observe carefully, one might notice the work-worn hands of someone present here.”
• WITH BODY the computer is stoic like a machine and seems to be saying: “I’m calm, cool and collected.”
• WHILE ON THE INSIDE the computer may really be saying:“I feel vulnerable.”
4. Distracter: The Distracter never makes a direct response to anything. Anything he or she says is totally irrelevant to what anyone else is saying or doing.
• WITH WORDS the distracter makes no sense and is totally irrelevant.
• WITH BODY the distracter is angular and off somewhere else.
• WHILE ON THE INSIDE the distracter may be saying:“Nobody cares. There is no place for me.”
Mutual trust and respect are the foundation for effective communications. When both of these exist, goals can be developed to which all individuals and groups are committed.
Communication systems and procedures based on shared goals and developed cooperatively are those most supported, most adhered to, and consequently most efficient.
Interpersonal Relations and Group Processes
Intuitively, most of us probably think the term ‘social’ means doing things with (or being in the presence of ) other people, and that social psychology is therefore about the causes and effects of this ‘social presence’. Although social psychologists use the term ‘social’ in a much broader way than this, the effect of the physical presence of other people on our behaviour remains an important research question.
In fact, in 1898 Triplett designed one of the earliest social psychology experiments to address this very question. He discovered from analysis of published records that cyclists go faster when paced by another cyclist, and he decided to investigate this phenomenon under more controlled conditions. Triplett had 40 children reel in ﬁshing lines, either alone or in pairs, and he discovered that the children tended to perform the task more quickly when in the presence of someone else doing the same task. Triplett attributed this ‘quickening effect’ to the arousal of a competitive instinct. Some years later, F. Allport coined the term social facilitation to refer to a more clearly deﬁned effect in which the mere presence of conspeciﬁcs (i.e. members of the same species) would improve individual task performance.
These conspeciﬁcs might be co-actors (i.e. doing the same task but not interacting) or simply a passive audience (i.e. observing the task performance). Research (much of it with an exotic array of different species) seemed to conﬁrm this. We now know that cockroaches run faster, chickens, ﬁsh and rats eat more, and pairs of rats copulate more when being ‘watched’ by members of their own species. However, later research found that the presence of conspeciﬁcs sometimes impairs performance, although it was often unclear what degree of social presence produced impairment (i.e. coaction or a passive audience). Zajonc put forward a drive theory to explain social facilitation effects. He argued that, because people are unpredictable, the mere presence of a passive audience instinctively and automatically produces increased arousal and motivation. This was proposed to act as a drive that produces dominant responses for that situation (i.e. well learned, instinctive or habitual behaviours that take precedence over alternative responses under conditions of heightened arousal or motivation). But do dominant responses improve task performance? Zajonc argued that if the dominant response is the correct behaviour for that situation (e.g. pedaling when we get on a bicycle), then social presence improves performance (social facilitation).
Zajonc’s explanation of social facilitation/inhibition
But if the dominant response is an incorrect behaviour (e.g. trying to write notes in a lecture before we have understood properly what is being said), then social presence can impair performance (social inhibition). Zajonc believed that drive was an innate reaction to the mere presence of others. Other views are that drive results from an acquired apprehension about being evaluated by others or from conﬂict between paying attention to a task and to an audience . Still other researchers discard the notion of drive entirely. They suggest that social facilitation may occur because of distraction and subsequent narrowing of attention, which hinders performance of poorly learned or difﬁcult tasks but leaves unaffected or improves performance of well learned or easy tasks.
Alternatively, social presence might motivate concern with self-presentation – i.e. how we appear to others (rather than concern speciﬁcally about being evaluated by them) or make us more self-aware. This might then increase cognitive effort, which is considered to improve performance on easy tasks but not on difﬁcult tasks (where failure and social embarrassment might be anticipated). Overall, then, the empirical ﬁnding from this body of research is that the presence of others improves performance on easy tasks, but impairs performance on difﬁcult tasks. But no single explanation seems to account for social facilitation and social inhibition effects. Instead, several concepts – including arousal, evaluation apprehension, and distraction conﬂict – are involved. Bystander apathy and intervention One type of behaviour that might be affected by the presence of other people is our inclination to offer help to someone who needs it. This question can be studied from many perspectives. One of these is evolutionary psychology – do people help others simply as members of their own species, or only those with whom they shares genes? (see Batson, 1983; and Dawkins’, 1976, notion of the ‘selﬁsh gene’). Another perspective is that of socialization – do we learn to help others as a result of direct instructions, reinforcement, social learning and modelling?
Two of the most important lines of research on helping by social psychologists have focused on situational factors that encourage or discourage helping, and on what motives may underlie helping others.
A critical feature of the immediate situation that determines whether by standers help someone who is in need of help (bystander intervention) is the number of potential helpers who are present. This approach was stimulated by the widely reported murder of Kitty Genovese in New York in 1964: although 38 people admitted witnessing the murder, not a single person ran to her aid. To explain bystander intervention (or its opposite – apathy), Darley, Latané and others carried out a series of classic experiments.
Numerous studies indicate that the willingness to intervene in emergencies is higher when a bystander is alone. In one of the ﬁrst experiments showing this effect, students overheard that a woman working in the ofﬁce next door had climbed onto a chair, fallen on the ﬂoor and lay moaning in pain. This incident lasted 130 seconds. In one condition, the student who overheard the information was alone. In a second condition, another student (a confederate of the experimenter, who had been instructed to be passive) was also present. In a third condition, the student participant was with a stranger at the time of the accident, and in a fourth condition the student participant was with a friend.
Although two people could have intervened in the third and fourth conditions, in only 40 per cent of stranger dyads and 70 per cent of friend dyads did at least one student intervene. The individual likelihood of intervention has to be calculated according to a special formula that corrects for the fact that two people are free to act in two conditions (with stranger; with friend), but only one person is free to act in the remaining two conditions (with passive confederate; alone). The individual likelihood of intervention was in fact twice as high when students were with a friend (i.e. fourth condition) compared with a stranger (i.e. third condition). Both of these corrected intervention rates for the third and fourth conditions were lower than in the condition where the participant was alone (ﬁrst condition), but higher than in the second condition, where there was a passive confederate present at the time of the accident (see ﬁgure 18.3).
The effect of the presence and identity of others on bystander intervention
in an emergency
Subsequent research indicated that three types of social process seem to cause the social inhibition of helping in such situations:
1. diffusion of responsibility (when others are present, our own perceived responsibility is lowered);
2. ignorance about how others interpret the event; and
3. feelings of unease about how our own behaviour will be evaluated by others present.
So, witnesses to the Kitty Genovese murder may have failed to intervene because:
1. they saw other people present, and so did not feel responsible;
2. they were unsure about how the others present interpreted the situation; and
3. they were embarrassed about how they might look if they rushed in to help when, for some reason, this might be inappropriate.
On the basis of studies such as this, Latané and Darley proposed a cognitive model of bystander intervention. Helping (or not) was considered to depend on a series of decisions:
1. noticing that something is wrong;
2. deﬁning it as an emergency;
3. deciding whether to take personal responsibility;
4. deciding what type of help to give; and
5. implementing the decision.
Bystanders also seem to weigh up costs and beneﬁts of intervention vs. apathy before deciding what to do. Piliavin, Dovidio, Gaertner and Clark proposed a bystander calculus model that assigns a key role to arousal. They proposed that emergencies make us aroused, situational factors determine how that arousal is labelled and what emotion is felt (see chapter 6), and then we assess the costs and beneﬁts of helping or not helping before deciding what to do.
To summarize ﬁndings from this area of research, the presence of multiple bystanders seems the strongest inhibitor of bystander intervention due to diffusion of personal responsibility, fear of social blunders and social reinforcement for inaction. In addition, the costs of not helping are apparently reduced by the presence of other potential helpers. People tend to help more if they are alone or among friends, if situational norms or others’ behaviour prescribe helping, if they feel they have the skills to offer effective help, or if the personal costs of not helping are high.
Motives for helping
A rather different line of research has concentrated on the motives underlying helping (or, more generally, prosocial behaviour) – in particular, whether people help for altruistic or egoistic motives. A discussion of the genetic argument is beyond this chapter.
Batson and colleagues had female students observe ‘Elaine’, an experimental confederate, who was apparently receiving electric shocks. In the second trial of the experiment, Elaine appeared to be suffering greatly from the shocks, at which point the experimenter asked the female observer whether she would be willing to continue with the experiment by taking Elaine’s place.
In one condition, participants believed that Elaine shared many attitudes with them. In another condition, they were led to think that she held dissimilar attitudes. The experiment also manipulated difﬁculty of escape. In the ‘easy escape’ condition, participants knew that they could leave the observation room after the second trial, which meant that they would not be forced to continue observing Elaine’s plight if the experiment continued with her. In the ‘difﬁcult escape’ condition, they were instructed to observe the victim through to the end of the study.
Percentage of participants who helped Elaine, depending on similarity/empathy and difﬁculty of escape
As ﬁgure shows, participants only took up the option offered by the ‘easy escape’ condition and failed to help when the victim had dissimilar attitudes. These results were interpreted as being consistent with the hypothesis that high attitude similarity increases altruistic motivation, whereas low attitude similarity encourages egoistic motivation.
Batson’s altruism theory was opposed by the view that people were, in fact, helping for selﬁsh, rather than altruistic, motives. So helping could sometimes be motivated by an egoistic desire to gain relief from a negative state (such as distress, guilt or unhappiness) when faced with another person in need of help. Although a meta-analysis by Carlson and Miller did not support this idea, there is continued controversy between the ‘altruists’ and ‘egoists’ as to why we help. Batson continues to maintain that helping under the conditions investigated by him is motivated positively by the feeling of ‘situational empathy’, rather than by an egoistic desire to relieve the ‘situational distress’ of watching another person suffer.
Helping is also increased by prosocial societal or group norms.These can be general norms of reciprocity or social responsibility, or more speciﬁc helping norms tied to the nature of a social group (e.g. ‘we should help older people’).
Other factors that increase helping include being in a good mood and assuming a leadership role in the situation. Research has also shown that, relative to situational variables, personality and gender are poor predictors of helping.
Note that many of these studies on helping are ‘high impact’ experiments – fascinating to read about but potentially distressing to participate in. Because of the greater sensitivity to ethical issues in research today (see chapter 2), it would be difﬁcult now to conduct some of these studies, as well as other studies described in this chapter.
The influence of authority
The research on both social facilitation and helping shows that the mere presence of other people can have a clear effect on behaviour. But this effect can be tremendously ampliﬁed if those others actively try to inﬂuence us – for example, from a position of authority.
Legitimate authority ﬁgures can be particularly inﬂuential; they can give orders that people blindly obey without really thinking about the consequences. This has been the focus of one of social psychology’s most signiﬁcant and socially meaningful pieces of research.
Milgram discovered that quite ordinary people taking part in a laboratory experiment were prepared to administer electric shocks (450V), which they believed would harm another participant, simply because an authoritative experimenter told them to do so. This study showed that apparently ‘pathological’ behaviour may not be due to individual pathology (the participants were ‘normal’) but to particular social circumstances. The situation encouraged extreme obedience.
Milgram subsequently conducted a whole series of studies using this paradigm. One of his most signiﬁcant ﬁndings was that social support is the single strongest moderator of the effect. So, obedience is strengthened if others are obedient, and massively reduced if others are disobedient.
Milgram investigated the role of peer pressure by creating a situation with three ‘co-teachers’, the participant and two confederates. The ﬁrst confederate presented the task, the second registered the learner’s responses, and the participant actually administered the shocks. At 150V, the ﬁrst confederate refused to continue and took a seat away from the shock generator. At 210V, the second confederate refused to continue. The effect of their behaviour on the participants was dramatic: only 10 per cent of the participants were now maximally obedient (see ﬁgure 18.5). In contrast, if the teacher administering the learning task was accompanied by a co-teacher, who gave the shocks, 92 per cent of the participants continued to be obedient to the end of the study. The powerful role of interpersonal factors (i.e. peers who had the temerity to disobey) was evident from this investigation.
One unanticipated consequence of Milgram’s research was a ﬁerce debate about the ethics of social psychological research. Although no electric shocks were actually given in Milgram’s study, participants genuinely believed that they were administering shocks and showed great distress.
Was it right to conduct this study?
This debate led to strict guidelines for psychological research. Three of the main components of this code are (i) that participants must give their fully informed consent to take part, (ii) that they can withdraw at any point without penalty, and (iii) that after participation they must be fully debriefed
Obedience as a function of peer behaviour.
AFFILIATION, ATTRACTION AND CLOSE RELATIONSHIPS
Seeking the company of others
Human beings have a strong need to afﬁliate with other people, through belonging to groups and developing close interpersonal relationships. The consequences of social deprivation are severely maladaptive (ranging from loneliness to psychosis), and social isolation is a potent punishment that can take many forms (solitary conﬁnement, shunning, ostracism, the ‘silent treatment’).
Most of us choose to spend a great deal of time with others, especially when we
experience threat or feel anxious. Our motives for afﬁliation include social comparison, anxiety reduction and information seeking. Hospitals now routinely encourage surgical patients who have undergone the same medical procedure to talk to others to help reduce anxiety.
People usually seek out and maintain the company of people they like. We tend to like others whom we consider physically attractive, and who are nearby, familiar and available, and with whom we expect continued interaction. How many of your friends at college live close to you on campus? The likely answer is ‘many of them’. We also tend to like people who have similar attitudes and values to our own, especially when these attitudes and values are personally important to us.
The importance of social support Generally, having appropriate social support is a very powerful ‘buffer’ against stressful events. Cohen and Hoberman found that, among individuals who felt that their life was very stressful, those who perceived themselves to have low social support reported many more physical symptoms (e.g. headaches, insomnia) than those who felt they had high social support (see ﬁgure 18.6).
The relationship between perceived stress and physical symptomatology for individuals low and high in social support.
Overall, the evidence is clear – social integration is good for our physical and psychological health. Social exchange theory A general theoretical framework for the study of interpersonal relationships is social exchange theory. This approach regards relationships as effectively trading interactions, including goods (e.g. birthday presents), information (e.g. advice), love (affection, warmth), money (things of value), services (e.g. shopping, childcare) and status (e.g. evaluative judgements). A relationship continues when both partners feel that the beneﬁts of remaining in the relationship outweigh the costs and the beneﬁts of other relationships.
According to this framework, these considerations apply to even our most intimate friendships. We now turn to a consideration of these closest relationships in our lives. It is argued that these relationships are also based on complex cost–beneﬁt analyses (‘she brings the money in and is practical, but I have a secure pension and do more for the children’). According to the more speciﬁc equity theory, partners in such relationships are happier if they feel that both partners’ outcomes are proportional to their inputs, rather than one partner receiving more than they give.
Happy vs. distressed relationships A major characteristic of happy, close relationships is a high degree of intimacy. According to Reis and Patrick (1996), we view our closest relationships as intimate if we see them as: caring (we feel that the other person loves and cares about us); understanding (we feel that the other person has an accurate understanding of us); and validating (our partner communicates his or her acceptance, acknowledgement and support for our point of view).
Unhappy or ‘distressed’ relationships, on the other hand, are characterized by higher rates of negative behaviour, reciprocating with such negative behaviour when the partner behaves negatively towards us. Reciprocation, or retaliation, is the most reliable sign of relationship distress. Those in unhappy relationships also tend to ignore or cover up differences, compare themselves negatively with other couples and perceive their relationship as less equitable than others. They also make negative causal attributions of their partner’s behaviours and characteristics. For example, being given ﬂowers might be explained away with ‘He’s just trying to deal with his guilt; he’ll be the same as usual tomorrow.’ In a happy relationship, the explanation is more likely to be something like ‘It was nice of him to ﬁnd time for that; I know how stressed he is at the moment.’
The investment model
Ultimately, what holds a relationship together is commitment – the inclination to maintain a relationship and to feel psychologically attached to it. According to the investment model, commitment is based on one or more of the following factors: high satisfaction, low quality of alternatives, and a high level of investments. Highly committed individuals are more willing to make sacriﬁces for their relationship, and to continue it even when forced to give up important aspects of their life.
Close relationships do, regrettably, often dissolve, sometimes as a result of extreme levels of violence committed within intimate relationships. The ending of a relationship is often a lengthy, complex process, with repeated episodes of conﬂict and reconciliation. Women tend to terminate intimate relationships more often than do men and are more distressed by relationship conﬂict.
But for both partners the consequences can be devastating. The physical and mental health of divorced people is generally worse than that of married people, or even people who have been widowed or never married. Factors that predict better adjustment to divorce include having taken the initiative to divorce, being embedded in social networks, and having another satisfying and intimate relationship.
Group structure and process
One morning before class the psychology instructor wrote something at the end of the chalkboard, intending it for discussion later in the hour. After class had begun, a student waved his hand and stood up, asking about the irrelevant material. Chiefly to avoid embarrassment to the student, the instructor gave a brief explanation. The young man then took his seat amid glances from others.
Later, the same student rose again. This time he declared in a loud voice: "I don't like this class. This is the worst lecture I've ever heard." The glances of the other students changed to snickers and whispers, undoubtedly concerning the instructor as well as the student. After a brief response by the instructor, the young man took his seat once again.
Roles and Hierarchies
The student's reaction distinctly disrupted the class, for he did not confine his comments to academic issues. This out-of-role behavior, as attested by the whispers and giggles, was given considerable weight in forming an impression of the student.
Formal and Informal Roles In class, each student has a formal role, which is a pattern of behavior expected of a group member. A role typically is associated with a certain status or standing in the group. The student, who occupies a position of less overall responsibility than the instructor, has a narrower role in the classroom. The student is expected to learn from the instructor, not to make criticisms. The instructor has overall responsibility for the class and its members, a role that entails leadership responsibilities.
Roles are often complementary. The role of instructor cannot be described without reference to the role of student. Politicians have no role without a constituency. Short-order cooks respond to hungry patrons and vice versa. Appropriate behavior for a given role depends upon the roles played by others.
An individual also may have an informal role, apart from any official position in a group. When among friends, a light-hearted student may assume the role of jokester, although never elected or appointed to this position. A humorous remark about the lecture would not be surprising outside of class; it might be all too common in some instances.
In daily life most of us assume several roles and become adept at changing from one to the other. A man assumes the role of instructor in class, the role of husband with his wife, the role of spectator at a sporting event, and that of father with his children. Social scientists say that he exhibits different "selves" in these various roles.
Human Hierarchies Among human beings playful aggressiveness in children, if unchecked or unsupervised, should theoretically result in a dominance based on fighting, and such a hierarchy develops in street gangs and certain primitive societies. A member of one city gang said, "Nutsy was the head of our gang once. I was his lieutenant. He was bigger than me, and he walloped me different times before I walloped him….After I walloped him, I told the boys what to do".
Usually a person's status is based on something other than physical domination. Bowling performance was closely associated with status in this city gang because it became the chief social activity of the group. It was the means by which an individual could gain, lose, or maintain prestige.
Important determinants of status in human society include money, education, intelligence, and also physical competence, as demonstrated in entertainment and athletics. Social hierarchies are based on the interaction of many such characteristics.
Taking our place in the group
Almost all groups are structured into speciﬁc roles. People move in and out of roles, and in and out of groups. Groups are dynamic in terms of their structure and their membership. But ﬁrst of all, of course, people need to join groups.
We join groups for all sorts of reasons, but in many cases we are looking for company (e.g. friendships and hobby groups) or to get things done that we cannot do on our own (e.g. therapy groups, work groups and professional organizations). We also tend to identify with large groups (social categories) that we belong to – national or ethnic groups, political parties, religions, and so forth.
Research on group formation generally examines the process, not the reasons. One view is that joining a group is a matter of establishing bonds of attraction to the group, its goals and its members. So a group is a collection of people who are attracted to one another in such a way as to form a cohesive entity. This approach has been used extensively to study the cohesiveness of military groups, organizational units and sports teams. Another perspective, based on social comparison theory, is that we afﬁliate with similar others in order to obtain support and consensus for our own perceptions, opinions and attitudes.
A third approach rests on social identity theory. According to this frame-work, group formation involves a process of deﬁning ourselves as group members, and conforming to what we see as the stereotype of our group, as distinct from other groups. We categorize ourselves in terms of our group’s deﬁning features – e.g. ‘we are psychology students, we are studying a useful subject’. This process describes and evaluates who we are and is responsible for group phenomena such as group cohesion, conformity to norms, discrimination between different groups, and so forth.
The process of joining and being inﬂuenced by a group doesn’t generally happen all at once. It is an ongoing process. The relevant mechanisms have been investigated by many social psychologists interested in group development, or how groups change over time. One very well established general model of group development is Tuckman’s ﬁve-stage model:
forming – initially people orient themselves to one another;
storming – they then struggle with one another over leadership and group deﬁnition;
norming – this leads into agreement on norms and roles;
performing – the group is now well regulated internally and can perform smoothly and efﬁciently;
adjourning – this ﬁnal stage involves issues of independence within the group, and possible group dissolution.
More recently, Levine and Moreland have provided a detailed account of group socialization – how groups and their members adapt to one another, and how people join groups, maintain their membership and leave groups. According to this account, groups and their members engage in an ongoing cost–beneﬁt analysis of membership (similar to the kinds of analyses that we have already discussed as being relevant in regulating dyadic interpersonal relationships). If the beneﬁts of the group membership outweigh the costs, the group and its members become committed to one another.
This approach highlights ﬁve generic roles that people occupy in groups:
prospective member – potential members reconnoitre the group to decide whether to commit;
new member – members learn the norms and practices of the group;
full member – members are fully socialized, and can now negotiate more speciﬁc roles within the group;
marginal member – members can drift out of step with group life, but may be re-socialized if they drift back again; and ex-member – members have left the group, but previous commitment has an enduring effect on the group and on the ex-member. Levine and Moreland believe that people move through these different roles during the lifetime of the group.
Almost all groups are internally structured into roles. These prescribe different activities that exist in relation to one another to facilitate overall group functioning. In addition to task-speciﬁc roles, there are also general roles that describe each member’s place in the life of the group (e.g. newcomer, old-timer).
Rites of passage, such as initiation rites, often mark movement between generic roles, which are characterized by varying degrees of mutual commitment between member and group.
Roles can be very real in their consequences. In the famous Stanford Prison Study , researchers randomly assigned students to play the roles of prisoners or guards in a simulated prison set-up. The ‘prison’ was located in the basement of the psychology department at Stanford University.
Before the study began, all participants were carefully screened to ensure they were psychologically stable. Zimbardo and his team planned to run the study for two weeks, while observing the participants. In fact, they had to terminate it after six days because the participants were conforming so extremely to their roles. The guards harassed, humiliated and intimidated the prisoners, often quite brutally, and the prisoners increasingly showed signs of individual and group disintegration, including severe emotional disturbance and some psychosomatic problems. The importance of this classic study was shown recently by the appalling treatment of Iraqi prisoners recorded inside Abu Ghraib jail in 2003. Roles also deﬁne functions within a group, and the different parts of the group normally need to communicate with one another. Research on communication networks focuses on centralization as the critical factor.
Some communication networks that have been studied experimentally
More centralized networks have a hub person or group that regulates communication ﬂow, whereas less centralized networks allow free communication among all roles. Centralized networks work well for simple tasks (they liberate peripheral members to perform their role) but not for more complex tasks – the hub becomes overwhelmed, delays and mis-communications occur, frustration and stress increase, and peripheral members feel loss of autonomy.
In a psychology class, knowledge of the subject matter is the chief means by which an individual gains status, though other factors are also important. The anticipated class leader therefore would be the instructor, whose authority clearly was challenged by the student's derogatory comments. On that occasion the instructor merely paused for a moment, and then he returned to the lecture.
After a few moments the student stood up once again, and this time he walked slowly to the lecture platform, mounted the steps, and confronted the instructor directly. As he stood there in shorts, sandals, and tee shirt, the room became completely silent. Then the student announced unsteadily, "I hate your necktie." In a truly quavering voice, he added, "It reminds me of my father." Some students, thinking it was a joke, which it was not, made derisive catcalls. Others gasped or sat dumbfounded.
Those near the front rose from their seats to leave the area, for there was a look of terror in the man's face. The student's remarks and the agitation in his whole person left little doubt that he was experiencing a severe emotional disturbance.
The instructor looked at the young man for several moments, and then the class episode ended as abruptly as it had begun. The young man inexplicably returned to his seat, picked up his books, and left the room. In the interim another student had departed to telephone the campus police, instructing his classmates not to interfere with the distraught young man. Soon the entire affair was under proper jurisdiction, and several weeks later the young man was released from the treatment facility to which he had been sent.
Great-Person Theory In some situations the role of helper or leader is assigned, as it was for the police officer on duty. In others it is adopted, which happened when the student telephoned for assistance. But just how and when an individual is suited for this role, assigned or adopted, has been difficult to determine. Studies of leadership for many years occupied an important niche in psychology, as investigators attempted to discover the essential traits of an effective leader.
Intelligence, flexibility, and strength of character were prominently mentioned, and it was assumed that the leader was the best-liked, most active, and most able member of the group. This expectation is known as the great-person theory of leadership. The idea here is that each person has a single status, and there is an all around "great person" at the top. It is assumed that there are differences in roles among the group members but only along a single dimension, general leadership status. The leader, furthermore, would be a leader in almost any group in which he or she was a member.
But as the research continued, the hopes for a prescriptive set of characteristics faded for two reasons. First, it was discovered that different situations usually require somewhat different traits in a leader. Even if a hierarchy could be established for one situation, it would have to be reestablished in another, depending upon the traits of the group members. Second, even within one situation, there seem to be at least two distinctly different leadership roles, each making its own contribution to the group process.
Complementary Leaders These findings on modes of leadership have been obtained in studies of group discussions by using a method called interaction process analysis, in which the interactions of group members are analyzed with respect to several response categories. The aim is to discover the ways in which each member contributes to or detracts from progress toward group goals. When data from many sessions have been examined, they usually indicate two general leadership styles.
There is a task specialist, who is concerned with analyzing the problem, discovering methods of dealing with it, and implementing the best solution. This person is oriented to a specific obstacle or threat in the group, and usually he or she ranks highest on activity and best ideas. There is also a social specialist, who emerges as the central figure in group cohesion and maintenance of group morale. Also called the maintenance specialist, this person often has a good sense of humor and usually ranks highest on likeability.
On rare occasions the two roles are held by the same person, lending some small support for the great-person theory. But especially as the group continues to function, different individuals emerge in these capacities.
Some cautions are in order, however. First, the method of interaction process analysis is intended to have broad usefulness, but the findings have been derived largely from a laboratory context. We cannot be confident that two separate leadership styles would emerge in spontaneous situations. The student who gave instructions to his classmates and then telephoned for assistance might also have been the social specialist in that instance. Or there may be no significant social-emotional specialist during an emergency.
Leaders and Situations There are, however, a few general characteristics of leadership. The individual who assumes control is usually above average in intelligence, though not necessarily the most brilliant individual in the group. The leader must be bright but not deviant, perhaps demonstrating some truth in an old political maxim:
The best-qualified person, in terms of ability, is not popular enough to be elected. Second, any enduring leader must be close to the group members in attitudes and interests. If the members tend to be authoritarian, the leader must be at least moderately authoritarian as well.
If just one person is to be chosen leader, certain factors will be influential. A task leader is likely to be most suitable if the morale of the group is unusually good or if the group has deteriorated almost to the point of disintegration. In both cases a task-oriented, almost dictatorial leader may be acceptable. When conditions are neither extremely favorable nor extremely unfavorable, a social leader is likely to be effective for group performance. The primary need here is to maintain solidarity and cohesion in the group.
As the group goals change, a leader may become a follower, especially in a very large group, such as a whole nation. Different situations require different leadership abilities, as we saw earlier. Here again, we encounter an interaction effect. The type of leadership that proves most effective depends upon the situation, the level of development of the group, and its goals (Figure 18.20).
As we conclude this chapter, you are perhaps wondering how your authors knew this psychology class so well. The leadership role in this particular instance fell to one of us, the course instructor. But which of us wears traditional neckties, gives rousing lectures, and participated in this unexpected episode? The reader is left to decide.
The most basic role differentiation within groups is into leaders and followers. Are some people ‘born to lead’ (think of Lady Margaret Thatcher, Sir Ernest Shackleton or Sir Alex Ferguson), or do they acquire leadership personalities that predispose them to leadership in many situations?
Extensive research has revealed that there are almost no personality traits that are reliably associated with effective leadership in all situations. This ﬁnding suggests that many of us can be effective leaders, given the right match between our leadership style and the situation. For example, leader categorization theory states that we have leadership schemas (concerning what the leader should do and how) for different group tasks, and that we categorize people as effective leaders on the basis of their ‘ﬁt’ to the task-activated schema. A variant of this idea, based on social identity theory (see below), is that in some groups what really matters is that you ﬁt the group’s deﬁning attributes and norms and that, if you are categorized as a good ﬁt, you will be endorsed as an effective leader.
Perhaps the most enduring leadership theory in social psychology is Fiedler’s contingency theory. Fiedler believed that the effectiveness of a particular leadership style was contingent (or dependent) on situational and task demands. He distinguished between two general types of leadership style (people differ in terms of which style they naturally adopt): a relationship-oriented style that focuses on the quality of people’s relationships and their satisfaction with group life; and a task-oriented style that focuses on getting the task done efﬁciently and well.
Are some people ‘born to lead’, or do they acquire leadership personalities that predispose them to leadership?
Relationship-oriented leaders are relaxed, friendly and sociable, and derive satisfaction from harmonious group relations. Task oriented leaders are more aloof and directive, are not concerned with whether the group likes them, and derive satisfaction from task accomplishment.
Fiedler measured leadership style using his ‘least preferred coworker’ (LPC) scale. The idea is to measure how positively a leader views the co-worker that they hold in lowest esteem. He predicted that relationship-oriented leaders would be much more positive about their least preferred co-worker than task-oriented leaders. So, for relationship-oriented leaders, even the least-liked group member is still quite liked.
Fiedler was also able to classify situations in terms of how much control was required for the group task to be effectively executed. A substantial amount of research has shown that task oriented leaders are superior to relationship-oriented leaders when situational control is very low (i.e. poorly structured task, disorganized group) or very high (i.e. clearly structured task, highly organized group). But relationship-oriented leaders do better in situations with intermediate levels of control.
Fiedler’s model of leadership is, however, a little static. Other approaches have focused instead on the dynamic transactional relationship between leaders and followers.
According to these approaches, people who are disproportionately responsible for helping a group achieve its goals are subsequently rewarded by the group with the trappings of leadership, in order to restore equity. Hollander suggested that part of the reward for such individuals is their being able to be relatively idiosyncratic and innovative. So, people who are highly conformist and attain leadership in a democratic manner tend to accumulate signiﬁcant idiosyncrasy credits that they can then expend on innovation once they achieve leadership. In other words, you ﬁrst have to conform before you can innovate. (For a different view to this one, see the section below on ‘minority inﬂuence’.)
Leaders who have a high idiosyncrasy credit rating are imbued with charisma by the group, and may be able to function as transformational leaders (see chapter 20).
Charismatic transformational leaders are able to motivate followers to work for collective goals that transcend self-interest and transform organizations. They are proactive, change-orientated, innovative, motivating and inspiring and have a vision or mission with which they infuse the group. Transformational leaders are also interested in others, able to create commitment to the group and can extract extra effort from (and generally empower) members of the group.
How groups influence their members
We have seen how the presence of other people can make us less inclined to help someone, and how other people can persuade us to obey their orders. Groups can also exert enormous inﬂuence on individuals through the medium of norms.
Although group norms are relatively enduring, they do change in line with changing circumstances to prescribe attitudes, feelings and behaviours that are appropriate for group members in a particular context. Norms relating to group loyalty and central aspects of group life are usually more speciﬁc, and have a more restricted range of acceptable behaviour than norms relating to more peripheral features of the group. High-status group members also tend to be allowed more deviation from group norms than lower-status members.
Sherif carried out one of the earliest, and still most convincing, demonstrations of the impact of social norms, deliberately using an ambiguous stimulus. He placed participants alone or in groups of two or three in a completely darkened room. At a distance of about 5 m, a single and small stationary light was presented to them. In the absence of reference points, the light appeared to move rather erratically in all directions – a perceptual illusion known as the autokinetic effect.
Sherif asked his participants to call out an estimate of the extent of movement of the light, obviously without informing them of the autokinetic effect. Half of the participants made their ﬁrst 100 judgements alone. On three subsequent days they went through three more sets of trials, but this time in groups of two or three. For the other half of the participants, the procedure was reversed. They underwent the three group sessions ﬁrst and ended with a session alone.
Participants who ﬁrst made their judgements alone developed rather quickly a standard estimate (a personal norm) around which their judgements ﬂuctuated. This personal norm was stable within individuals, but it varied highly between individuals. In the group phases of the experiment, which brought together people with different personal norms, participants’ judgements converged towards a more or less common position – a ‘group norm’. With the reverse procedure employed with the other half of the participants, this group norm developed in the ﬁrst session and persisted into the later session, when participants were evaluated alone. Figure 18.9 illustrates both sets of ﬁndings. The funnel effect in the left panel reveals the convergence in the (median) judge ments of three participants who ﬁrst judged alone (session I) then later on in each other’s presence (sessions II, III and IV). The right panel shows the judgements of a group of three participants who went through the procedure in the reverse order (i.e. ﬁrst judged together, then alone). Here the group convergence is already present in the ﬁrst session, and there is no sign of funnelling out in the ﬁnal ‘alone’ session.
In subsequent studies, Sherif found that, once established, this group norm persisted, and that it strongly inﬂuenced the estimations of new members of the group.
In another study, Jacobs and Campbell used a group of confederates who unanimously agreed upon a particular judgement. After every 30 judgements, they replaced a confederate by a naive participant until the whole group was made up of naive participants. Their results indicated that the norm had a signiﬁcant effect on the naive participants’ judgements, even after all the confederates had been removed from the judgement situation.
Sherif ’s autokinetic experiments show how norms develop and inﬂuence people – but the actual process through which people conform is less obvious. The participants in Sherif’s study were publicly calling out their estimates of a highly ambiguous stimulus. Perhaps they were worried about looking foolish, or were simply uncertain. People may have conformed for one of two reasons, each linked to a distinct form of social inﬂuence:
1. They may have been concerned about social evaluation (e.g. being liked or being thought badly of ) by the others in the group (normative inﬂuence).
2. They may have used the other group members’ judgements as useful information to guide them in an ambiguous task on which they had no previous experience (informational inﬂuence).
A series of experiments by Asch tried to rule out informational inﬂuence by using clearly unambiguous stimuli. In his ﬁrst study, Asch invited students to participate in an experiment on visual discrimination. Their task was simple enough: they would have to decide which of three comparison lines was equal in length to a standard line. On each trial, one comparison line was equal in length to the standard line, but the other two were different (see ﬁgure 18.10).
The task was apparently very easy: a control group (who made their judgements in isolation) made almost no errors, ruling out the informational inﬂuence component of this study. In the experimental condition, participants were seated in a semicircle and requested to give their judgements aloud, in the order in which they were seated, from position 1 to position 7. In fact, there was only one real participant, seated in position 6. All the other ‘participants’ were in fact confederates of the experimenter who, on each trial, unanimously gave a predetermined answer. On six ‘neutral’ trials (the ﬁrst two trials and four other trials distributed over the remaining set), the confederates gave correct answers. On the other 12 ‘critical’ trials, the confederates unanimously agreed on a predetermined, incorrect line. The neutral trials, particularly the ﬁrst two trials, were added to avoid suspicion on the part of the real participant, and to ensure that the confederates’ responses were not attributed to poor eyesight by the participant.
Like Milgram’s obedience study, this paradigm had a tangibleimpact on the real participants. They showed signs of being uncomfortable and upset, gave the experimenter and the other participants nervous looks, sweated nervously and gesticulated in vain. The results reveal the powerful inﬂuence of an obviously incorrect but unanimous majority on the judgements of a lone participant. In comparison with the control condition (which yielded only 0.7 per cent errors), the experimental particpants made almost 37 per cent errors. Not every participant made that many errors, but only about 25 per cent of Asch’s 123 participants did not make a single error. Presumably, conformity was produced through normative social inﬂuence operating in the line judgement task.
Subsequent Asch-type experiments have investigated how majority inﬂuence varies over a range of social situations. These studies found that conformity reaches full strength with three to ﬁve apparently independent sources of inﬂuence. Larger groups of independent sources are not stronger, which perhaps runs counter to our intuitions, and non-independent sources (e.g. several members of the same coalition or subgroup) are seemingly treated as a single source.
Conformity is signiﬁcantly reduced if the majority is not unanimous. Dissenters and deviates of almost any type can produce this effect. For example, Allen and Levine showed that conformity is even reduced by a deviate who has visibly thick lenses in his glasses, although this ‘invalid’ supporter had much less impact than a ‘valid’ supporter with no glasses (see ﬁgure 18.11).
For most of us, conformity means coming into line with majority attitudes and behaviours. But what about minority inﬂuence? Minorities face a social inﬂuence challenge. By deﬁnition, they have relatively few members; they also tend to enjoy little power, can be viliﬁed as outsiders, hold ‘unorthodox’ opinions, and have limited access to mainstream mass communication channels. And yet minorities often prevail, bringing about social change. Research suggests that minorities must actively create and accentuate conﬂict to draw attention to themselves and achieve inﬂuence . Members of the majority may be persuaded to move in the direction of the minority, in order to reduce the conﬂict they provoke. To have an impact, minorities need to present a message that is consistent across group members and through time, but not rigidly presented. Minorities are also more effective if they appear to be acting on principle and making personal sacriﬁces for their beliefs.
These strategies disrupt majority consensus and raise uncertainty, draw attention to the minority as a group that is committed to its perspective, and convey a coherent alternative viewpoint that challenges the dominant majority views. It also helps if the minority can present itself as an ingroup for the majority. For example, you might be opposed to increased tuition fees at university. But a minority of students from your own university (an ingroup minority) could conceivably win you round by arguing that such fees would provide bursaries for less well-off students.
The ﬁlm Twelve Angry Men provides a dramatic ﬁctitious example of how minority inﬂuence occurs. Twelve jurors have to decide over the guilt or innocence of a young man charged with the murder of his father. At the outset, all but one of the jurors are convinced of the youth’s guilt. The lone juror (played by Henry Fonda) actively attempts to change their minds, standing ﬁrm, committed, self-conﬁdent and unwavering. One by one the other jurors change sides, until in the end they all agree that the accused is not guilty.
Other examples of minority inﬂuence include Bob Geldof ’s Band Aid movement to raise money for famine relief, and new forms of music and fashion. Moscovici proposed a dual-process theory of majority/minority inﬂuence. He suggested that people conform to majority views fairly automatically, superﬁcially and without much thought because they are informationally or normatively dependent on the majority.
In contrast, effective minorities inﬂuence by conversion. The deviant message achieves little inﬂuence in public, but it is processed systematically to produce inﬂuence (e.g. attitude change) that emerges later, in private and indirectly. Subsequent research has demonstrated minority inﬂuence occurring after the main part of the experiment has ﬁnished, i.e. later, revealed by written answers rather than spoken responses, i.e. in private, and on indirectly related issues as opposed to the target issue, e.g. attitude change regarding euthanasia, following direct inﬂuence on the topic of abortion. Support for Moscovici’s dual-process theory is mixed. Using the framework of cognitive theories of persuasion (see discussion of the ‘elaboration likelihood model’ in chapter 17), it appears that both minorities and majorities can instigate either superﬁcial or systematic processing of their message, depending on situational factors and constraints. But overall, the weight of evidence is tipped slightly towards Moscovici’s claim that minorities instigate deeper processing of their message. Nemeth proposed that minorities induce more divergent thinking (thinking beyond a focal issue), whereas majorities induce more convergent thinking (concentrating narrowly on the focal issue). Evidence supporting this contention reveals that exposure to a consistent, dissenting minority leads to generation of more creative and novel judgements or solutions to problems, use of multiple strategies in problem solving, and better performance on tasks that beneﬁt from divergent thinking. In contrast, convergent thinking induced by majorities tends to lead to mere imitation of the belief or course of action that is proposed by the majority source.
How groups get things done
Most groups exist to get things done, including making decisions and collaborating on group projects. Working in groups has some obvious attractions – more hands are involved, the human resource pool is enlarged, and there are social beneﬁts. Yet group performance is often worse than you might expect. Potential group gains in effectiveness and creativity seem to be offset by negative characteristics of group performance, including the tendency to let others do the work, sub-optimal decision making, and becoming more extreme as a group than as individual members. As we shall see, some of these drawbacks are due to problems of coordination, and others are due to reduced individual motivation.
Individual motivation can suffer in groups, particularly where the task is relatively meaningless and uninvolving, the group is large and unimportant, and each individual’s contribution to the group is not personally identiﬁable. This phenomenon has been termed social loaﬁng (see chapter 20).
Latané and colleagues asked experimental participants (who were blindfolded and wearing headsets that played loud noise) to shout as loudly as they could under three conditions: as a single individual, as a member of a dyad or as a member of a six-person group. In a further twist, this experiment also manipulated whether participants actually did shout either alone or in the presence of one or ﬁve other group members (‘real groups’), or were merely led to believe that they were cheering with one or ﬁve others (while, in fact, they were shouting alone; so-called ‘pseudo-groups’). The blindfolds and the headphones made this deception possible.
Although groups obviously produced more noise in total than single individuals, group productivity failed to reach its full potential, since it was found that individual productivity decreased as group size increased. In ﬁgure 18.12, the dashed line along the top represents the potential performance we would expect if there were no losses or gains as individuals were combined into groups.
The line marked ‘real groups’ shows actual group performance. By creating both real and pseudo groups, Latané et al. were able to estimate how much performance loss was due to coordination and motivation losses (about 50 per cent was in fact due to each). Any productivity loss observed in the pseudo groups could only be attributed to reduced motivation, not faulty coordination, since there were no ‘co-workers’ engaged in the shouting. In the real groups, however, coordination loss could occur due to the physical phenomenon of ‘sound cancellation’ – when multiple sources produce sound, some of it is cancelled out by other sound.
Subsequent research using this and similar paradigms has shown that social loaﬁng is minimized when groups work on challenging and involving tasks, and when group members believe that their own inputs can be fully identiﬁed and evaluated through comparison with fellow members or with another group. In fact, when people work either on important tasks or in groups which are important to them, they may even work harder collectively than alone – so, in these circumstances, ‘social loaﬁng’ turns into ‘social striving’.
Group decision making
An important group function is to reach a collective decision, through discussion, from an initial diversity of views. Research on social decision schemes identiﬁes a number of implicit or explicit decision-making rules that groups can adopt to transform diversity into a group decision. These include:
· unanimity – discussion puts pressure on deviants to conform;
· majority wins – discussion conﬁrms the majority position, which becomes the group decision;
· truth wins – discussion reveals the position that is demonstrably correct; and
· two-thirds majority – discussion establishes a two-thirds majority, which becomes the group decision.
The type of rule that is adopted can affect both the group atmosphere and the decision-making process.
We often work harder on group activities, especially when the task is challenging and involving
For example, unanimity often creates a pleasant atmosphere but can make decision making painfully slow, whereas ‘majority wins’can make many group members feel dissatisﬁed but speeds up decision making.
Juries provide an ideal context for research on decision schemes. Not only are they socially relevant in their own right, but they can be simulated under controlled laboratory conditions. For example, Stasser, Kerr and Bray found that a two-thirds majority rule prevails in many juries. Furthermore, they discovered that it was possible to predict accurately the outcome of jury deliberations from knowledge of the initial distribution of verdict preferences (‘initial’ here means before any discussion has taken place). If two thirds or more initially favoured guilt, then that was the ﬁnal verdict, but if there was initially no two-thirds majority, then the outcome was a hung jury.
Group polarization and ‘groupthink’
Popular opinion and research on conformity both suggest that groups are conservative and cautious entities, and that they exclude extremes by a process of averaging. But two phenomena that challenge this view are group polarization and groupthink.
Group polarization is the tendency for groups to make decisions that are more extreme than the average of pre-discussion opinions in the group, in the direction towards the position originally favoured by the average. For example, four students whose averaged individual attitudes are mildly against abortion are likely to form an attitude as a group that is more extremely against abortion. Group polarization therefore makes group decisions more extreme. Furthermore, it can sometimes shift individual members’enduring attitudes towards the more polarized group position.
The explanation for this lies partly in the same processes of informational and normative social inﬂuence we discussed earlier. Group members learn from other group members’ arguments, and engage in mutual persuasion, but they are also inﬂuenced by where others stand on the issue, even if they do not hear each other’s arguments.
This polarization is particularly likely to occur when an important group to which an individual belongs (i.e. an ingroup) confronts a salient group to which she does not belong (i.e. an outgroup) that holds an opposing view. Here, group members seem to conform to what they see as the prototypical view held by other ingroup members (i.e. the view or position that is most similar to that of all the other ingroup members, but most different from that of the outgroup members). It is thought that conformity to the prototypical view helps to differentiate the ingroup from the outgroup.
Finally, mere repetition of arguments, which also tends to occur within groups (especially when the discussion lasts a long time, and all group members wish to express their views) can also produce polarization.
Groupthink is a more extreme phenomenon. Janis argued that highly cohesive groups that are under stress, insulated from external inﬂuence, and which lack impartial leadership and norms for proper decision making procedures, adopt a mode of thinking (groupthink) in which the desire for unanimity overrides all else. The members of such groups apparently feel invulnerable, unanimous and absolutely correct. They also discredit contradictory information, pressurize deviants and stereotype outgroups.
The consequences can be disastrous – particularly if the decision making group is a government body. A dramatic example attributed to groupthink is the decision of NASA ofﬁcials to press ahead with the launch of the space shuttle Challenger in 1986, despite warnings from engineers.The shuttle crashed seconds into its ﬂight (see next Everyday Psychology box).
A popular method of harnessing group potential is brainstorming – the uninhibited generation of as many ideas as possible, regardless of quality, in an interactive group. Although it is commonly thought that brainstorming enhances individual creativity, research shows convincingly that this is not the case. Stroebe and Diehl considered various possible explanations for this ﬁnding. They hypothesized that ‘process loss’ in brainstorming groups is due to an informal coordination rule of such groups which speciﬁes that only one group member may speak at a time. During this time, other group members have to keep silent, and they may be distracted by the content of the group discussion, or forget their own ideas. Stroebe and Diehl termed this phenomenon ‘production blocking’, because the waiting time before speaking and the distracting inﬂuence of others’ ideas could potentially block individuals from coming up with their own ideas. Stroebe and Diehl tested their hypothesis by creating ﬁve different conditions. In one condition, participants brainstormed in real interacting four-person groups (‘interactive group’ condition).
Participants in four other conditions were physically separated from one another in different cubicles. Even though participants in these conditions were seated alone, they expressed their ideas via a clip-on microphone so that they could be tape-recorded. In an ‘alone, individual, no communication’ condition participants brainstormed individually. In the three remaining ‘alone’ conditions, each cubicle contained an intercom and a display with lights, each light representing one speciﬁc group member. These lights functioned like a set of trafﬁc lights. As soon as one member of the four-person group started to speak, a voice-activated sensor switched her light to green in all of the other three cubicles. Meanwhile the other three lights on the display were red. Each individual could only speak when his or her light was green, and all the other lights were red. This technology allowed the researchers to create three different ‘alone’ conditions. In the ‘alone, blocking, communication’ condition participants took their turns following the lights, and were able to hear via the earphones what was being said by the other participants. In the ‘alone, blocking, no communication’ condition participants also had to wait for their turn before expressing their ideas, but could not hear each other’s ideas via the intercom. In the ‘alone, no blocking, no communication’ condition participants were instructed to disregard the lights and the intercom and to express their ideas whenever they wanted to.
To compare the productivity of participants working under these different conditions afterwards, Diehl and Stroebe pooled the ideas expressed by the four individuals who brainstormed alone and without communication, to make a ‘nominal group’product. Since the same idea might be suggested several times by four people working alone, without communication, whereas such repetition would not be allowed in case of free communication, redundant ideas were eliminated from the pooled set of ideas that constituted the ‘nominal group’ product.
The results of this clever study were clear-cut. Participants generated approximately twice as many ideas when they were allowed to express their ideas as they occurred (i.e. in the two non-blocking conditions) than when they had to wait their turn (i.e. in the three blocking conditions). These results suggest that ‘production blocking’ is indeed an important factor explaining the inferiority of interactive brainstorming groups. This suggests that it may be more effective to ask group members to develop their ideas separately, and only then have these ideas expressed, discussed and evaluated in a subsequent joint meeting.
Of interest, electronic brainstorming (via computers linked on a network) can be very effective, because the lack of face-to-face interaction minimizes production blocking.
Through the study of intergroup relations – how people in one group (the ‘ingroup’) think about and act towards members of another group (the ‘outgroup’) – social psychologists seek to understand a range of critical issues, including:
· crowd behaviour;
· cooperation and competition between groups;
· social identity;
· prejudice and discrimination; and
· how to replace social conﬂict with social harmony.
Deindividuation, collective behaviour and the crowd
Many researchers have emphasized the tendency of group members to act in unison, like a single entity. Early writers on crowd behaviour (who were not trained social psychologists) tended to view collective behaviour as irrational, aggressive, antisocial and primitive – reﬂecting the emergence of a ‘group mind’ in collective/ crowd situations.
In a crowd, individuals will often identify very strongly with the group and adhere very closely to group norms
The general model is that people in interactive groups such as crowds are anonymous and distracted, which causes them to lose their sense of individuality and become deindividuated. Deindividuation is thought to prevent people from following the prosocial norms of society that usually govern behaviour, because they are no longer identiﬁable (and hence no longer feel compelled to conform to social norms). It is argued that people regress to a primitive, selﬁsh and uncivilized behavioural level. Research that has manipulated anonymity by placing people in dark rooms, or having them wear hoods and robes reminiscent of the Ku Klux Klan, has generally found that deindividuation does increase aggression and antisocial behavior. On the other hand, when participants were deindividuated by wearing nursing uniforms, anonymity produced more prosocial behaviour.
More recent research has discarded the idea that crowds are irrational, and has concentrated instead on understanding how people in crowds develop a shared identity, a shared purpose and shared norms. In crowd situations, people often identify very strongly with the group deﬁned by the crowd, and therefore adhere very closely to the norms of the crowd. Crowds may only appear irrational and ﬁckle from the outside – more often than not, their behavior seems rational to members of the crowd, who may also identify speciﬁc other groups (e.g. the police, ethnic/racial groups) as a legitimate target for aggression.
Cooperation and competition between groups
Sherif provided a far-reaching and inﬂuential perspective on intergroupbehaviour. In a series of naturalistic ﬁeld experiments on conﬂict and cooperation at boys’ camps in the United States in the early 1950s, Sherif and colleagues studied group formation, intergroup competition and conﬂict reduction.
In the group-formation phase, Sherif divided new arrivals at the camps into two groups and isolated them in separate living quarters to allow them to develop their own internal structures and norms.
In the intergroup competition phase, Sherif then brought the two groups together for a series of zero-sum competitions (what one group won, the other group lost), such as tug-of-war. The typical ﬁnding at this stage was ‘ingroup favouritism’ – each group judged fellow ingroup members’ performance to be superior to that of outgroup members (see ﬁgure 18.16).
In group favouritism in estimates of performance by other ingroup and outgroup members during intergroup competition
Of especial note, the competitiveness of the between-group interactions subsequently pervaded all aspects of intergroup behaviour, becoming so extreme and conﬂictual (e.g. involving negative stereotyping of, and aggression towards, the outgroup) that most of Sherif ’s studies had to be concluded at this stage. In a replication conducted in the Lebanon, the study had to be stopped because members of one group came out with knives to attack the other group.
Having found it so easy to trigger intergroup hostility, in the conﬂict reduction phase Sherif discovered how hard it was to reduce conﬂict. The most effective strategy was to introduce a series of superordinate goals, i.e. goals that both groups desired but could only attain if they acted together. For example, when the camp truck broke down delivering supplies, neither group could push-start it on their own; but both groups working together managed to move the truck by pulling on a rope attached to the front bumper.
Impact of competition vs. superordinate goals on negative stereotypes
of the outgroup
As ﬁgure 18.17 shows, negative stereotypes of the outgroup which resulted after a period of intergroup competition were considerably less negative after the manipulation of superordinate goals. To explain his ﬁndings, Sherif focused on the importance of goals. Mutually exclusive goals cause competitive intergroup behaviour, and superordinate goals improve intergroup relations. As he pointed to the real nature of goal relations determinining intergroup behaviour, Sherif ’s theory is often called realistic conﬂict theory.
But Sherif ’s studies also found that ﬁrst expressions of ingroup favouritism occurred in the group formation phase, when the groups were isolated fromone another and knew only of each other’s existence. So the mere existence of two groups seemed to trigger intergroup behaviour, before any mutually exclusive goals had been introduced.
Social categories and social identity
Experiments by Tajfel and colleagues provided the most convincing evidence that competitive goals are not a necessary condition for intergroup conﬂict. In fact, merely being categorized as a group member can cause negative intergroup behaviour. In Tajfel’s studies, participants were randomly divided into two groups and asked to distribute points or money between anonymous members of their own group and anonymous members of the other group. There was no personal interaction, group members were anonymous, and the groups had no ‘past’ and no ‘future’ – for these reasons these groups are called ‘minimal groups’, and this experimental procedure is called the minimal group paradigm.
The consistent ﬁnding of this research is that the mere fact of being categorized is enough to cause people to discriminate in favour of the ingroup and against the outgroup. This research spawned the ‘social identity perspective’ on group processes and intergroup relations. According to this perspective, the groups that we belong to deﬁne who we are. Part of our identity and how we feel about ourselves is derived from the groups we belong to, and how we evaluate them. When we categorize ourselves and others in groups, we stereotype ourselves and outgroup members in terms of our respective group memberships, and our own group identity helps to determine our attitudes, feelings and behaviours. This process produces a sense of group identiﬁcation and belonging, as well as ingroup solidarity, conformity and bias.
According to this social identity perspective, because groups deﬁne and evaluate who we are, intergroup relations are a continual struggle to gain superiority for the in group over the outgroup. How the struggle is conducted – and the speciﬁc nature of intergroup behaviour (e.g. competitive, conﬂictual, destructively aggressive) – is thought to depend on people’s beliefs about the status relations between groups. Are status relations between groups stable or unstable, legitimate or illegitimate? And is it possible to pass from one group to another (see Tajfel, 1978)?
Effective interpersonal communication (IPC) between health care provider and client one of the most important elements for improving client satisfaction, compliance and health outcomes. Patients who understand the nature of their illness and its treatment, and who believe the provider is concerned about their well-being, show greater satisfaction with the care received and are more likely to comply with treatment regimes. Despite widespread acknowledgement of the importance of interpersonal communication, the subject is not always emphasized in medical training.
Over the past 30 years substantial investments have been made to enhance access to basic health services in developing countries. However, there have been relatively few studies that investigate the quality of the services delivered, and fewer still that study the quality of interpersonal communication.
The quality of care research that has been done shows that health counseling and provider-client communication are consistently weak across countries, regions and health services.
Even when providers know what messages to communicate, they do not have the interpersonal skills to communicate them most effectively. They often do not know how to communicate with their patients. Despite widespread acknowledgement of the critical importance of face-to-face communication between client and provider, there are few rigorous studies of health communication in developing countries.
Evidence of positive health outcomes associated with effective communication from developed countries is strong. Patient satisfaction, recall of information, compliance with therapeutic regimens and appointment keeping, as well as improvements in physiological markers such as blood pressure and blood glucose levels and functional status measures have all been linked to provider-client communication.
Thus, experience in the developed world has shown that providers can improve their interpersonal skills, leading to better health outcomes. The research described here explores whether these findings are valid and replicable in the developing countries.
Unfortunately, effective communication does not always occur naturally, nor it is easily acquired. Even when client and provider come from the same geographic area and speak the same language, they often have different educational, socio-economic and cultural backgrounds. Moreover, their expectations about the health encounter may be different, or they may be faced with other problems, such as lack of privacy during the encounter, or time constraints due to heavy patient loads.
Better communication leads to extended dialogue which enables patients to disclose critical information about their health problems and providers to make more accurate diagnoses. Good communication enhances health care education and counseling, resulting in more appropriate treatment regimes and better patient compliance. Effective interpersonal communication also benefits the health system as a whole by making it more efficient and cost effective. Thus, clients, providers, administrators and policy makers all have a stake in improved provider-client interactions.
This monograph discusses the importance of IPC as a tool for improving health care outcomes in developing countries and describes techniques for enhancing provider communication skills. It also provides a job aid and several data collection instruments that can be used in various settings. Our field experiences in Honduras, Egypt and Trinidad, described later in the text, suggest that test results in developed countries are valid and replicable in developing countries. Therefore, we hope that our findings will serve as useful models for implementing future interpersonal communication programs, and that the monograph will help interested health care policy makers and practitioners improve the quality of health care in their facilities through improved interpersonal communication. The monograph can serve as:
· an introductory overview on provider-client communication skills
· a framework for assessing IPC skills
· a guide for developing IPC training activities
· a resource describing important IPC experiences in selected developing countries.
Because each health care setting requires locally-appropriate strategies, the guide prov ides only a general framework for action, leaving health care policy makers, managers and providers to develop their own analyses and interventions. Therefore, we encourage readers to modify the content of the monograph as needed and to develop locally-appropriate examples for training and other IPC interventions.
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IPC is important because it leads directly to better health outcomes. A pathway is clearly established which links processes, such as the way health care providers communicate, to proximate outcomes, such as patient satisfaction and recall, to final outcomes, such as client compliance with treatment regimes and improved health results. Hence, our emphasis on the importance of improving provider communication skills. Figure 1 illustrates a system linking communication processes with short-term, intermediate and long-term outcomes.
As can be seen in Figure 1, the communication context is shaped by the socio-demographic characteristics of the patient and provider, as well as by the environment in which the communication takes place. The age, sex, ethnicity, and educational background of providers and clients affect how they communicate with each other. Other factors such as degree of privacy, time allotted for encounters, comfort and cleanliness of the clinic, and treatment of clients from the time they enter the clinic until they are seen by a provider, can also inhibit or enhance client-provider interaction.
While many of these socio-demographic and environmental factors are beyond their control, providers can improve IPC practices in their own clinics by adopting specific behaviors and techniques which lead to distinct positive outcomes. In the short-term, improved communication leads to more effective diagnosis and treatment of health problems; in the mediumterm, to greater compliance with treatment programs, better utilization of services, and enhanced feelings of awareness and confidence for both client and provider; in the longterm, to greater relief of symptoms, enhanced prevention and reductions in morbidity and mortality. In some cases, overall health care costs are also reduced.
What Are the Characteristics of Effective IPC? IV. What Are the Characteristics of Effective IPC? IV. What Are the Characteristics of Effective IPC? IV. What Are the Characteristics of Effective IPC? IV. What Are the Characteristics of Effective IPC?
IPC is effective when it leads to the following five outcomes:
1) the patient discloses enough information about the illness to lead to an accurate diagnosis;
2) the provider, in consultation with the client, selects a medically appropriate treatment acceptable to the client;
3) the client understands his or her condition and the prescribed treatment regimen;
4) the provider and the client establish a positive rapport;
5) the client and the provider are both committed to fulfilling their responsibilities during treatment and follow-up care.
The above outcomes, however, do not describe the steps in the process of effective communication. These steps generally include encouraging a two-way dialogue, establishing a partnership between patient and provider, creating an atmosphere of caring, bridging any social gaps between provider and client, accounting for social influences, effectively using verbal and non-verbal communication, and allowing patients ample time to tell their story.
Good interpersonal interaction between client and provider is, by definition, a two-way street where both speak and are listened to without interruption, both ask questions, express opinions and exchange information and both are able to fully understand what the other is trying to say.
Partnership Between Provider and Client
Providers and clients should view health care as a partnership in which each party contributes to maximize end results. Mutual respect and trust and joint decision-making will result in a greater likelihood of a positive outcome. Both provider and client must realize that, even though the provider is the medical expert, both are responsible for the outcome of their interaction. The patient must disclose all relevant information in order for the provider to determine a proper diagnosis and treatment; the provider must interpret and analyze the information received and effectively explain the condition and treatment options to the patient. Both should make decisions about treatment regimes, with the client making every effort to comply with the prescribed treatment and any necessary lifestyle changes the treatment implies. Providers should foster an active role for patients in their care and treatment.
Providers should encourage active questioning and interaction during office visits and should involve patients in their own health care regimes.
Atmosphere of Caring
Patients need to believe that their provider cares about them and is committed to their welfare. Both verbal and non-verbal communication help the provider convey interest and concern to patients. Being attentive, making eye contact, listening and questioning thoughtfully, and demonstrating understanding and empathy make patients feel important and worthy. On the other hand, being brusk or appearing busy or distracted makes patients feel insecure, anxious or fearful of their relationship with the provider.
Effective Bridging of Social Distance
Social distance refers to the socio-cultural-economic factors that make people feel they belong to different class tiers. Education, economic status, class, race or ethnicity, gender and age may all contribute to how close or distant two individuals feel about each other. For example, an illiterate peasant woman and a young, highly trained, city-dwelling male physician who share the same language and were raised within miles of each other are still worlds apart socially. Clients bring to medical visits a whole range of emotional, socio-cultural, economic, educational and psychological traits that affect communication. Social distance should not impede good communication, and providers must realize that many people, even those in their own circles, may not be conversant with their “language.” Therefore, they should strive to bridge any social gap that might exist between them and their clients and establish an open dialogue, a partnership and an atmosphere of caring. Clients must also do their part to bridge the social distance by being candid and communicative.
Social networks refer to those interpersonal relationships that bind people together. Typically consisting of family, friends, acquaintances, neighbors and colleagues, social networks influence differently—depending on the individual and his or her environment—a person’s desire and ability to understand and comply with professional advice. For example, in some societies the mother or mother-in-law is key decision-maker in the extended family. Therefore, teaching the young woman about the benefits and methods of birth spacing may be ineffective if her mother or mother-in-law is uninformed or opposed to this practice. Similarly, in a home where a woman cooks for the whole family, dietary recommendations that could enhance her health may not be put into effect if they interfere with the family’s culinary customs and tastes.
Effective Use of Verbal Communication
Verbal communication consists of spoken and written words people use to convey ideas. In a health care encounter, the choice of words clients and providers use greatly influences how well they understand each other. The medical jargon physicians use to describe symptoms and treatments allows them to communicate clearly and precisely with other clinicians. However, because the scientific and clinical terms may be confusing to patients, the use of such terms with patients is inappropriate.
Patients communicate during medical visits in their particular dialects, accents, cadences and slang, often making comprehension difficult for providers from other parts or regions of the country. Patients also describe health problems in peculiar ways, often reflecting their unique perspective on the illness’ origin or severity. Sometimes local perceptions can influence the way a patient describes the illness’ onset and symptoms. For example, if diarrheal diseases are common in their area, patients may not report symptoms of the disease unless they are quite severe. Because they view the symptoms as routine, patients simply neglect to mention them. For the provider, however, detection of early symptoms, even mild ones, is important in making proper diagnoses and developing appropriate treatment regimes.
Use Simple Language Medical jargon
The clinical spectrum of cholera is broad, ranging from inapparent infection to severe cholera gravis, which may be fatal in a short time period. After an incubation period of 6 to 48 hours, there is an abrupt onset of watery diarrhea. Vomiting often follows in the early stages of the illness. Signs of severity include cyanosis, tachycardia, hypotension, and tachypnea. The symptoms and signs of cholera are entirely due to the loss of large volumes of isotonic fluid and resultant depletion of intravascular and extracellular fluid, metabolic acidosis, and hypokalemia.
Not all persons that get cholera look equally sick. Some cholera patients seem to have a minor illness, while others look very sick. Some others can even die after hours of getting cholera. Because cholera germs spread within 6 to 48 hours of entering the body, the person may suddenly have a lot of watery diarrhea. Many patients also begin to vomit.
When the sick person is getting worse, his skin can become blue (especially at the lips, nose, and fingertips), he may begin to breathe quickly, his heart works very rapidly, and blood pressure drops. All this happens because the body has lost a lot of liquids and minerals through diarrhea and vomiting. The body cannot survive when it loses too much liquid and minerals.
Effective Use of Non-verbal Communication
Words express only part of a message being conveyed; tone, attitude and gestures convey the rest. Avoiding distractions, such as answering the telephone during a patient’s visit or scribbling notes on other cases, and appearing fully attentive communicate positive messages to clients. Smiling, listening thoughtfully, sitting on the same level as the patient also enhance interaction. Much non-verbal communication is specific to cultural customs. For example, while in some cultures direct eye contact is a sign of positive regard and respect, in others it is deemed improper or aggressive, particularly with members of the opposite sex. Also, while in some cultures physical contact during a conversation is considered a sign of affection, in others it might be construed as highly improper. What is important to remember is that all forms of non-verbal communication convey a message.
Often, simple gestures by the provider, such as a warm greeting or a thoughtful question, can help put the client at ease and enhance communication. Such actions do not require great effort but can have significant results. Following is an example of non-verbal communication conveying a positive message.
Non-verbal communication can have as great an impact as verbal communication but can be more easily misinterpreted. Thus, it is important for health care providers to be aware of the non-verbal messages they convey to their patients and of those their patients convey to them.
Opportunity for Patients to Speak About Their Illness
The medical visit should provide ample opportunity for a patient to describe his or her illness. Storytelling has its own healing value in that it provides patients with a release and opportunity for insight and perspective. It may also afford the health provider the insights needed to understand, interpret and explore the significance of the symptoms and clues the patient provides. A patient’s comprehension and feelings about a medical problem may be extremely important in prescribing appropriate treatment. A great deal of distress, for example, may stem from a patient’s perception about the seriousness of his or her illness, not from its actual seriousness. Providers should not minimize a patient’s anxieties, but strive to alleviate them.
All of the factors described above have been shown to enhance communication between patient and provider. However, the fact that providers follow individual approaches increases the complexity of formulating a communication skill program. To change provider behavior in concrete ways, the above factors must first be broken down into concrete skills and behaviors as illustrated in the following guidelines.
Guidelines and Norms for Effective IPC V. Guidelines and Norms for Effective IPC V. Guidelines and Norms for Effective IPC V. Guidelines and Norms for Effective IPC V. Guidelines and Norms for Effective IPC
Our research and analysis of effective IPC has led us to develop a set of guidelines and norms for health care providers. While these norms should be further tested, refined, and validated, we are confident that the issues and skills presented here are both useful and valid in improving IPC. We define three types of IPC.
· Caring/socio-emotional communication: The objective of caring or socioemotional communication is to establish and maintain a positive rapport with the patient throughout the encounter. This is an integral part of all IPC and enhances patient disclosure and compliance.
· Diagnostic communication/problem solving: The objective of diagnostic communication is for the patient and provider to share all the information needed for accurate diagnoses and appropriate treatment prescriptions.
· Counseling: The objective of counseling is to ensure that clients understand their condition and treatment options. Counseling helps them to follow treatment regimes and behavioral change recommendations, by ensuring that these are comprehensible, acceptable, and feasible. Counseling emphasizes making decisions together with the client and helping solve actual or anticipated problems.
A provider should convey expressions of caring at the outset of the encounter when rapport with the client is being established; rely on diagnostic or problem solving techniques during the history taking portion of the encounter; and use counseling skills at the end of the encounter to explain treatment and provide health education. However, all three approaches may be applicable throughout the encounter.
Within the broad category of each approach, specific communication techniques or behaviors can be identified which can improve IPC. These and related examples are presented in the following section.
A caring behavior emphasizes respect for patients and recognition that their concerns are important. Health care providers should display caring throughout the medical encounter in order to establish a trusting relationship and good rapport with the patient.
Frame the encounter — Set the tone for the interaction by greeting clients in culturally appropriate ways that communicate openness and concern. For example, the provider might frame an encounter by saying “Good morning Mrs. N., my name is Dr. N.. I’d like you to feel free to tell me about any health concerns you have.”
Use appropriate non-verbal communication — Be sure your posture, eye contact, gestures, tone of voice, manner and attitude are appropriate and conducive to dialogue with the client. For example, a provider who is scribbling notes on a chart when a patient enters, might put down the pen, close the chart, and stand up or lean forward as he greets the patient. This shows the patient that he or she has the provider’s full attention.
Solicit feelings — Invite patients to talk about how they feel, both physically and emotionally. A provider might ask a patient who is describing symptoms of her headaches, “How do the headaches make you feel? How do they affect your other activities?”
Show positive regard — Show clients, explicitly and implicitly, that they are respected and valued. For example, a provider might show positive regard for a patient by being courteous, smiling, asking the patient whether he or she is satisfied with the care received so far, or complimenting the patient’s efforts in seeking medical assistance or following treatment recommendations. Positive regard is especially important when dealing with conditions that may have a social stigma attached to them, such as tuberculosis and AIDS. It is also helpful to bridge any social distance between provider and client that might be based on age, sex, social and educational status, race, religion, or ethnicity.
Validate the patient’s experience and efforts — Recognize the patient’s experience and efforts in an honest and straightforward manner. This may be done through statements of concern, empathy or legitimizing that show the provider cares about the patient and his or her problem. For example, when dealing with a hypertensive patient who does not take his or her medicine regularly, a provider might say, “ I’m concerned that you’re not taking care of yourself.” This is likely to be more effective than scolding. Statements of empathy show that the provider understands and shares the patient’s feelings. Legitimizing statements validate the patient’s feelings. For example, a provider might tell a patient who is nervous about surgery, “I understand that you are worried about this operation,” or when counseling a cancer patient, a provider might say, “It’s easy to understand why you feel afraid and angry. Most people in your situation feel the same way at first.”
Echo patients’ emotions — Help patients express their feelings by echoing them. For example, when a patient says “I’ve been feeling very depressed lately,” the provider might respond with “It sounds like something is really getting you down.” This technique provides the patient with an invitation to elaborate further on the topic.
Express support and partnership — Let clients know you will work with them to help them get better. A provider might say, “I’m going to use all my skills and expertise to help you get better, and I’m counting on you to do your part to take care of yourself.”
Give reassurance — Encourage and reassure clients about the outcome of their condition. For example, a midwife might say to a patient, “I know you’re feeling a lot of pain and anxiety right now, but tomorrow you’ll feel much better, and you’ll have a new baby to take home with you.” In reassuring patients, it is important to be honest and realistic about the medical prognosis and to avoid premature or unjustified reassurance.
Diagnosis and Problem Solving
These skills help health care providers gather critical information for diagnoses. Use of data-gathering skills enables them to improve their accuracy and effectiveness in performing this function. The skills involve a variety of questioning techniques designed to encourage the patient to talk about all aspects relevant to the problem.
· Listen attentively and actively — Use gestures to show patients they have your full attention and ask relevant questions to indicate your understanding of what they say. You may want to face patients and nod or comment occasionally as they describe their medical condition.
· Encourage dialogue — In addition to yes/no questions, ask patients open-ended questions that encourage them to provide details about their problem. Often, one open-ended question will elicit a response that covers several yes/no questions.
· For example, instead of asking a patient “Do you have a fever? Do you get headaches? Are you nauseated?” You may simply say “Tell me about any pain and discomfort you’ve been feeling.” Once the patient describes the condition, you might need to ask one or two yes/no questions to supplement the information.
· Avoid interruptions — Do not interrupt patients when they are speaking. Wait until they have finished their thought before asking a new question. Also, avoid being interrupted by the telephone or other distractions during a patient’s visit.
· Avoid premature diagnosis and resist immediate follow-up — Wait until you have listened to the patient’s full story and have asked all the relevant questions before determining a diagnosis and treatment. The patient’s first complaints are not always the most important ones. Hasty conclusions can lead to diagnostic error. For example, when a patient reports headache pain, resist the urge to immediately assume the ailment is minor and to prescribe pain relief drugs. Instead you might say “Tell me more about how you’re feeling.” Often, a simple cure for headaches is all that is needed, but at other times the client might respond, “I’m so worried and upset, there are times when I don’t feel like getting out of bed and feel like I could die.” Such a case warrants further inquiry into the psychological and physical causes of the condition.
· Probe — Encourage patients to provide more information by asking questions or inviting them to continue speaking. For example, the provider might use phrases like “Tell me more” or “Please go on” to help patients delve deeper into the nature of their problem and their reaction to it.
· Ask about causes — Help patients share more information about their condition by asking their opinion on the causes of the ailment and what they think might help them. This technique will provide information needed to make a diagnosis and help providers evaluate the patient’s understanding of the illness.
Counseling and Education
These skills enhance providers’ ability to explain to patients their conditions, the circumstances of their illness, diagnoses and treatment options. Providers should remember that patients’ compliance with treatment regimes depends on how well they understand the nature of their illness and how they feel about the prescribed treatment.
· Explore patient understanding — Find out patients’ opinions of their illness by asking how they contracted it, whether they had the problem before and what they did about it at that time. For example, if a mother is seeking care for a child with diarrhea, the provider might ask, “How do you think children usually get diarrhea?” “How do you think your child got it?” “How did you take care of it in the past?”
· Correct misunderstandings or misinformation — Sometimes clients hold inaccurate notions about the etiology or effects of a disease, which can affect their behavior toward treatment and adversely impact on their recovery. Providers should determine a patient’s understanding of his or her problem, and politely correct any misconceptions the client may have. For example, a provider might say, “While many people believe that taking the birth control pill right before intercourse will be effective, that’s incorrect. You need to take the pill every day, whether you are going to have sex or not.” Providers should be careful not to make the client feel uneasy or inadequate for having inaccurate ideas or information, and should strive to educate by providing appropriate information.
· Use appropriate vocabulary — Providers should avoid using jargon or technical language when speaking with patients, making instead every effort to use terms that are meaningful to patients. For example, instead of asking “Have you had any respiratory difficulties lately?” the provider might say, “Have you had any difficulty breathing lately?” or “Tell me about your breathing?”
· Present information in blocks — It is important to present information in a way that the patient can easily absorb and remember. Providers should explain the diagnosis in a clear and comprehensible fashion, never in a condescending or patronizing manner. Subdividing the information into separate categories may help this process. Presenting separate blocks of information sequentially, enables the provider to monitor for understanding and absorption before moving on to the next block. This kind of presentation helps patients internalize the information presented and enhances the likelihood of effective compliance with the treatment prescribed. For example, the provider may address and sequentially convey brief information on the following topics:
• name of the disease and its etiology
• recommended treatment for the patient
• ways to prevent recurrence of the disease
• other relevant information.
· Use visual aids and/or printed materials when possible — When conveying information to patients on diseases, preventive or treatment programs, or medical devices, it is often helpful to refer to a visual display. Visual aids help patients better understand and remember the information provided. It is also helpful to make use of pamphlets with simple text and pictures about important health problems, their prevention, and their treatment.
· Recommend concrete behavioral changes — After making a diagnosis and prescribing a treatment regime, providers may recommend certain behavioral changes to their patients that would prevent the illness from recurring. These recommendations should take into consideration the patient’s ability to implement them. Rather than simply emphasizing the end results of the behavioral change, providers should identify and suggest specific steps in the behavioral change. For example, instead of telling a hypertensive patient that he needs to lose 30 pounds, the provider might say, “I’d like you to try to lose some weight by taking a 20 minute walk every day and cutting down on the amount of sugar and oil you eat.”
· Select an acceptable and feasible treatment — To the extent possible, provide the patient with a range of treatment options from which to select the one he or she prefers. For example, in providing family planning services to a mother, discuss available options and help her select the one that is best suited to her lifestyle. Conditions such as pain management, weight loss, etc., may have a number of treatment options from which the patient may choose.
· Motivate patients to comply with treatment — Once a treatment has been mapped out, the provider should try to motivate compliance with the treatment prescribed by pointing out to the patient the importance and benefits of such action. For example, in prescribing antibiotic treatment, a provider might say, “It is important for you to take your medicine three times a day until all the pills are gone. You may feel better after a few days, but if you don’t take all the pills the illness will come back, and it may be harder to cure the next time.”
· Summarize — Restate the diagnosis, treatment and its recommended steps in simple terms. In summarizing, repeat only key points. For example, a provider might conclude a counseling session by saying “I think you have a respiratory infection. Take these antibiotics with every meal until they are all gone. I’d like to see you again in two weeks to make sure you’ve completely recovered.”
· Check for understanding and absorption — Ask the client to repeat or describe the treatment instructions. Then clarify any misunderstandings the patient might have and find out whether there are any reasons that would impede the patient’s compliance with the prescribed treatment. For example, a provider might say “Just to be sure you understand how to take your medicine, would you tell me how much and how often you’ll take it?”
· Additional questions — Urge patients to ask any additional questions they may have on their current or any other medical problem. Allow ample time for a response. Avoid missing the opportunity to consult. For example, if prompted to share any additional health concerns, a mother seeking care for a baby with diarrhea may mention that she is interested in exploring birth spacing techniques, or that she is not sure of the vaccination schedule for another of her children.
· Confirm follow-up actions — Remind the patient of the next appointment date or of the next treatment action he or she will need to take. Remind the patient what to do if symptoms persist or worsen, and about danger signs that indicate he or she should seek prompt medical assistance.
In this section, we have presented a set of specific guidelines for improving the IPC skills of health care providers. The next section will outline steps in planning and implementing a training program designed to further develop these skills.
Planning and Implementing Training Activities VI. Planning and Implementing Training Activities VI. Planning and Implementing Training Activities VI. Planning and Implementing Training Activities VI. Planning and Implementing Training Activities This section deals with planning and implementation of training activities. The information provided should enable health care providers to conduct small training workshops in their own clinics or enable outside experts to train health care providers in their areas or communities. The training format and methods presented here have been tested in a variety of settings and have proven effective in the IPC training of health care providers. We have found that revisions in our training methods are always necessary to adapt the techniques to local circumstances and insights. We, therefore, encourage providers and trainers to use their own ingenuity and expertise to modify the techniques to suit local realities.
Improving IPC skills generally implies some behavior change on the part of health care providers. Programs inducing effective behavior change require both an understanding of the issues and skills involved and practice sessions in the new skills. Practice may entail first conducting exercises among peers in a controlled environment (involving self-evaluations or evaluations and feedback from colleagues or supervisors), then holding supervised or selfmonitored practice runs with actual patients and leading eventually to internalization of the new skills when they become second nature to providers who apply them instinctively.
Overall Training Approach
The IPC training program is highly flexible, allowing participants to adapt the program to local socio-cultural realities or to pinpoint specific techniques that can improve daily operations. The training activities employ a variety of methods to ensure that participants develop and learn to effectively apply new IPC skills. The methods used include:
· participatory plenary sessions that employ brainstorming and question and answer sessions, allowing participants to discover and tailor new IPC skills;
· dynamic role playing which illustrates various communication strategies and allows participants to practice them;
· mental rehearsal techniques which allow participants to test the degree of difficulty of individual IPC skills and to develop methods to master them;
· videotapes on non-verbal communication skills which are used as instructional tools.
Prior to the course, we developed:
· a guide to help participants practice the skills, which is referred in the text as “the pocket guide”, or “job aid”;8
· a training manual which allows the trainer to adapt the manual to the participants’ needs and to local realities.
Training Agenda and Format
Our IPC training program consists of approximately 20 course hours covering a 3 to 4 day span. The initial session focuses on the relevance of the skills. The following session deals with the guidelines and gives participants an opportunity to practice the new skills. The training course has a prepared list of skills or behaviors the trainer introduces to the group (Table 1).9
Each type of behavior is discussed and practiced in the participants’ native language aiming for potential improvements and adaptation to the local environment. In many of the courses given, we encouraged providers to complement training activities by trying out the skills they learned in their own practice between course sessions. These “transitional” encounters were often taped, allowing providers to work in groups to review their shared experiences, apply the skills in their local setting, and critique their newly acquired skills in a supportive environment. Different agendas for the course are included at the beginning of the training manuals presented in Appendices B, C and D.
Interpersonal Communication Behaviors
Overall socio-emotional communication
The following nine behaviors reinforce ways to make people feel comfortable during medical visits:
• Welcome patient in a warm and culturally acceptable manner.
• Use appropriate verbal and non-verbal communication (gestures, attitude, words).
• Inquire about the patient’s feelings.
• Acknowledge the patient’s initiative (to have come, to have brought the child).
• Enhance legitimizing. (Reinforce feelings that are normal.)
• Show empathy.
• Echo the patient’s emotions by encouraging him or her to express feelings freely. (Paraphrase what patient says.)
• Convey support and partnership.
• Reassure the patient. (Ease the patient’s concern by suggesting specific things he or she can do.) The health provider’s tone of voice and attitude are primarily responsible for setting the socio-emotional tone of the encounter.
Problem solving skills
Systematic use of data gathering skills enables providers to become more efficient. The following seven behaviors help providers gather necessary information for determining diagnoses:
• Listen attentively (actively).
• Encourage dialogue by asking open-ended questions.
• Avoid interruptions.
• Avoid premature diagnosis (Determine the problem only after all facts have been gathered.)
• Resist immediate follow up by listening carefully before making clinical decisions.
• Probe (explore) for more information.
• Inquire into causes, difficulties and worries related to the problem.
Counseling and Information-Education-Communication (IEC)
The following ten behaviors are effective ways to explain health issues, treatment and decisions taken.
• Check the patient’s understanding of the illness.
• Correct misunderstandings about facts.
• Use appropriate vocabulary.
• Present (explain) what the patient needs to know or do in a logical way (in blocks).
• Correct misconceptions.
• Discuss and prescribe concrete behavioral changes that are appropriate for the patient.
• Repeat, summarize key information.
• Motivate the patient to follow the recommended treatment.
• Check on acceptability/mutuality of decision making (if patient will follow the treatment).
• Make sure patient knows when to return for a follow-up visit.
• Ask patient if there is anything else he or she would like to know.
Training Materials and Methods Used
The use of training materials that document the concepts and guidelines presented is essential. Without this written documentation, participants do not have an opportunity for self-evaluation and will not be able to follow through in gaining an in-depth understanding of the new skills. The training manuals presented in the Appendices include materials that have occasionally been adapted and completed prior to the start of training sessions with the local team. For example, training methods include:
Role playing. One of the most effective methods for learning skills in a controlled setting is through role playing. Role playing enables providers to “try on” a variety of different styles and identify the ones that best suit them. Role playing also requires providers to play the part of a patient and, therefore, to experience the other side of the health care diad, and learn how providers’ different IPC styles can affect patients’ attitudes. One of the great benefits of role playing is that it can be both educational and fun. A variation on standard role playing is pantomime role playing in which the players act out a particular scene without speaking. Pantomime is particularly useful for analyzing the impact of non-verbal communication such as eye contact, physical contact, postures, gestures, smiles, attitude, etc. Because no words are spoken, players and observers can focus all their attention on the slightly exaggerated non-verbal communication.
Video and audio-taping. Another highly effective training device includes video or audio taping. Seeing or hearing oneself on tape makes one much more aware of one’s own communication style. Video or audiotape can be used in a variety of ways. Role playing can be recorded and played back instantly so that players can see how they acted and how their behavior impacted on others. Real clinical encounters can also be video or audio-taped and played back for group analysis. This technique was used effectively in training workshops in Egypt. The advantage of recording role plays or actual encounters is that the tapes can be played over and over and used to analyze various points. Moreover, tapes can be made following the training program to monitor the program participants’ IPC improvements. (Improvements can be measured more accurately and easily when a recorded baseline for comparison exists.)
Video playing. In Honduras the participants saw a video on IPC provided by the Ministry of Health in addition to a Spanish language video provided by AED.10 Unfortunately, we did not have a similar video in Arabic. In Egypt, participants expressed, in their course evaluation, a desire to view such a video, which they believed would help them more accurately master the skills required.
Mini case study or simulation guide. Throughout the course, mini case studies or simulation guides were used to develop understanding and reinforcement of IPC skills. Often these mini case studies were developed or adapted in-country, based on actual encounters. For example, to “Practice problem solving skills: Gathering data to understand client situations and problems,” participants received simulation guides for role playing of the health provider and patient. Practice sessions with open-ended questions and increased interaction between participants led to improved skills. Examples of these mini case studies are presented in the training manuals. Mini cases for Honduras can be found in Annex 8 and 8bis (Appendix D). In Egypt, the last day of training focused on improving the quality of IPC skills among colleagues and on teamwork. Following a brainstorming exercise in which participants complained about poor leadership, poor group dynamics and poor supervision in their work environment, trainers developed three mini case studies to be used as group exercises at a later date. These exercises are presented in Annexes 8, 9, and 12 of the Egyptian training manual in Appendix B.
Evaluation form. At the end of the course, participants were asked to complete evaluation forms assessing trainer effectiveness. The forms provided participants with the opportunity to comment on their learning experience and course methodology. At the same time, it provided trainers with the necessary feedback for improving their workshops. Moreover, each training day began with a plenary discussion among participants, which allowed them to focus on essential elements discussed the previous day.
Training Supervision, Monitoring, Evaluation and Follow-up
An effective training program does not end at the conclusion of the workshop but represents an element in a protracted learning cycle. After the workshop or intensive training program, providers are expected to return to their clinical settings and apply what they have learned to their daily work environment. Effective supervision and support is critical at this time to ensure that providers adopt the new skills within their old settings. In order to establish a true learning environment, supervision should be supportive rather than constraining, providing feedback and encouragement rather than threats or punishments. An important aspect of supervision and feedback is monitoring—a process in which information is collected in an ongoing manner to measure progress toward established goals or objectives. Monitoring can take a variety of forms, including (but not limited to):
· providing self-evaluation on a variety of behaviors, using a check list or other
· standard form such as a questionnaire
· having a supervisor or colleague observe an encounter with a patient
· recording audio or video tape encounters, followed by self and/or team evaluations
· conducting exit interviews with clients.
Sustained routine monitoring of clinical practices is an effective tool for improving the quality of health care services and follow-up of training programs. Monitoring procedures and protocols should be simple, user-friendly, and limited to a few key questions or observations that will yield information by which progress and the design of follow-up training activities can be gauged.
Follow-up is the process by which trainers, supervisors or colleagues determine which skills need reinforcing, additional training, or further development. Follow-up is based on the understanding that learning occurs through repetitive drill, practice, and constructive feedback. Follow-up is, therefore, an integral part of the learning cycle, as it allows for focusing on problem areas or delving deeper into areas of particular interest to participants.
Six months after the IPC training in Egypt, a follow-up effort was carried out in response to a wish by physicians to improve the quality of health services delivery and enhance patient satisfaction. These activities consisted of field visits to work sites, discussions with health providers on the relevancy of the IPC skills acquired during the training session, observation of provider-patient encounters, the compilation of physician questionnaires, and the recording of patient exit interviews. Details of the results of these follow-up activities are explained in the next chapter which presents the country’s case study.
VII. Case Studies VII. Case Studies VII. Case Studies VII. Case Studies VII. Case Studies Sections I through VI have presented a conceptual framework, outlined training strategies and described tools that can help improve the quality of IPC between providers and patients.
This section presents our research experiences to date in three countries—Honduras, Trinidad and Tobago, and Egypt. We hope that our field experiences will complement the theory presented, so that readers may feel confident in experimenting with IPC improvement efforts. In all three countries we focused on training doctors. In Honduras and Egypt a number of nurses were included in the IPC training effort. We expect that the materials derived are appropriate for training all professional health personnel, but may need some adaptation and simplification for use with peripheral health workers or community health volunteers.
In each of the three countries the training sessions covered approximately 10-15 hours of classroom work, which included presentation, discussion and practice of the new skills. The training manuals are included in their entirety in the appendices, because we felt they could provide, with minor adaptations, the basis of IPC interventions in new settings. The training manual used in Trinidad most closely follows IPC improvement models that are used in developed countries. The training manual for Honduras relates more to a developing country setting. The training manual for Egypt is based on the manual from Honduras, but benefits from revisions and improvements that were made as a result of the Honduras experience.
All three countries also used a job aid, the IPC Pocket Guide, to reinforce the training content. The job aid is presented in Appendix A in English and Spanish. In our experience, we found that it was important to allow each training group to modify the job aid as they saw fit, adapting and personalizing the IPC norms to the local environment and to individual needs.
All three case studies had a research component. The research component in Honduras was the most rigorous in terms of sampling, methods, and research design. It was based on analysis of audio-tapes and of patient exit surveys. As a result of the IPC interventions, the research resulted in improvements in practices and in documented satisfaction of providers and patients. In Trinidad, the research also relied on audio-tapes and exit interviews. Even though sampling methods were simpler, we found that the method was able to detect improvements in practices and satisfactions. In Egypt we attempted to replace the audio-tapes with an observation check list and had an even smaller sample. Unfortunately, the observation method used was not reliable, and we were unable to detect improvement in prov ider practices. We feel that this situation resulted from a lack of adequate training for all observers. We hope to continue to experiment at a later date using a different research procedure.
While our field experiences yielded much information on how IPC improvement strategies can be adapted to different cultures and health settings, we feel that our findings are still incomplete and that many additional insights on cross-cultural and organizational issues will emerge as these survey tools and approaches are applied to other geographic regions (such as Africa and Asia), and in other settings (especially peripheral health services in rural areas). We would like to encourage those who experiment with IPC interventions to share their experiences with the QAP staff, so that these experiences can be used to further develop the IPC framework and its strategies.
Prejudice and discrimination
Some of the most negative forms of intergroup behaviour are demonstrations of prejudice and discrimination. Prejudice refers to a derogatory attitude towards a group and its members, whereas discrimination refers to negative behaviour. The two are often closely interconnected.
Some theories of prejudice focus on personality, arguing that there are certain personality types that predispose people to intolerance and prejudice. The best known of these theories concerns the authoritarian personality. According to this view, harsh family rearing strategies produce a love–hate conﬂict in children’s feelings towards their parents. The conﬂict is resolved by idolizing all power ﬁgures, despising weaker others and striving for a rigidly unchanging and hierarchical world order. People with this personality syndrome are predisposed to be prejudiced.
This ‘personality’ approach has now been largely discredited, partly because it underestimates the importance of current situations in shaping people’s attitudes, and partly because it cannot explain sudden rises or falls in prejudice against speciﬁc racial groups. On the other hand, a fairly small number of people do hold generalized negative attitudes towards all outgroups (e.g. the stereotypical bigot who dislikes blacks, Asians, gays and communists), and authoritarianism is indeed associated with various forms of prejudice.
Society and identity
Contrary to personality explanations, by far the best predictor of prejudice is the existence of a culture of prejudice legitimized by societal norms. For example, Pettigrew measured authoritarianism and racist attitudes among whites in South Africa, the northern United States and the southern United States. He found more racist attitudes in South Africa and the southern United States than in the northern United States, but he found no differences in authoritarianism between these two groups.
How do such prejudiced ‘cultures’ arise? Both social identity theory and social dominance theory may provide part of the answer.
According to social identity theory, group members strive to promote a favourable identity for their group. They do this by maximizing their group’s real status advantage over other groups, and by developing belief systems that justify and legitimize their superiority. Group members achieve or maintain a positive social identity by differentiating their group from outgroups.
From the perspective of social dominance theory, people also differ in their social dominance orientation (SDO) – the extent to which they desire their own group to be dominant and superior to outgroups. According to this framework, people who have a high SDO are likely to be more prejudiced.
Modern forms of prejudice
Prejudiced attitudes are often deeply entrenched, may be passed from parents to children and are supported by the views of signiﬁcant others. Yet societal norms for acceptable behavior can and do change, sometimes creating a conﬂict between personal feelings and how they can be expressed.
For example, modern liberal norms and legislation in the United States stand against prejudice, and yet centuries of history have entrenched racist attitudes in US society. Researchers suggest that, rather than abolishing prejudice, this dynamic transforms overt ‘redneck’ prejudice into more ‘modern’ forms. Modern prejudice often presents itself as denial of the claim that minorities are disadvantaged, opposition to special measures to rectify disadvantage, and systematic avoidance of minorities and the entire question of prejudice against these minorities. New, more subtle measures are required to detect these modern forms of prejudice. For example, increasing use is being made of implicit measures (see chapter 17), which are beyond the intentional control of the individual, and so can detect prejudice even when people are aware of societal norms regarding tolerance or political correctness. Research using the ‘Implicit Association Test’ has shown that white Americans have relatively strong automatic negative associations with African Americans, but positive associations with whites (they respond faster to pairings of white faces with ‘good’ words and black faces with ‘bad’ words, than to pairings of white faces with ‘bad’ words and black faces with ‘good’ words).
Building social harmony
Prejudice and conﬂict are signiﬁcant social ills that produce enormous human suffering, ranging from damaged self-esteem, reduced opportunities, stigma and socio-economic disadvantage, all the way to intergroup violence, war and genocide.
Prejudice can be attacked by public service propaganda and educational campaigns, which convey societal disapproval of prejudice and may overcome some of the anxiety and fear that fuel it. But the problem with these strategies is that the very people being targeted may choose not to attend to the new information. Two prominent social-psychological approaches to building social harmony avoid this problem by promoting increased positive intergroup contact and changing the nature of social categorization.
There is now extensive evidence for the contact hypothesis, which states that contact between members of different groups, under appropriate conditions, can improve intergroup relations.
Favourable conditions include cooperative contact between equal-status members of the two groups in a situation that allows them to get to know each other on more than a superﬁcial basis, and with the support of relevant social groups and authorities.
Contact appears to work best by reducing ‘intergroup anxiety’about meeting members of the other group and by promoting positive intergroup orientations, such as empathy and perspective taking.
One difﬁculty is that, even if they do come to view some individuals from the other group more positively, participants in such studies do not necessarily generalize their positive perceptions beyond the speciﬁc contact situation or contact partners with whom they have engaged, to the group as a whole.
Recent work supports the idea that clear group afﬁliations should be maintained in contact situations, and that participating members should be seen as being (at least to some extent) typical of their groups. Only under these circumstances does it appear that cooperative contact is likely to lead to more positive ratings of the out group as a whole. A further limitation is that optimal intergroup contact may be hard to bring about on a large scale. Wright and colleagues therefore proposed an ‘extended contact effect’, in which knowledge that a fellow in group member has a close relationship with an out group member is used as a catalyst to promote more positive intergroup attitudes. This extended contact is therefore second-hand, rather than involving the participants in direct intergroup contact themselves, and so could potentially bring about widespread reductions in prejudice without everyone having to develop out group friendships (which anyway may be impracticable, depending on the nature of the groups).
Paolini, Hewstone, Cairns and Voci (2004) have recently shown that, by reducing intergroup anxiety, both direct and extended forms of contact contribute towards more positive views of the outgroup among Catholics and Protestants in Northern Ireland.
Decategorization and recategorization
Prejudice depends on ingroup–outgroup categorizations. So if the categorization disappears, then so should the prejudice. Is this the case, and are these kinds of interventions practical?
There are various ways in which dissolution of categories might occur, two of the most prominent being:
1. decategorization, where people from different groups come to view each other as individuals; and
2. recategorization, where people from different subgroups, such as Scots and English, come to view each other as members of a single superordinate group, such as British.
Decategorization can be difﬁcult to achieve when groups are very obviously different (e.g. Muslim girls and women who wear headscarves, compared with non-Muslims who typically do not), and where feelings run high it can be almost impossible to prevent intergroup categorizations from coming to the fore.
Recategorization may be more attainable, but it can still be difﬁcult to get people from opposing groups with a history of antipathy and conﬂict to regard themselves as members of one superordinate group. (This is part of the problem in Northern Ireland, for example.) Recategorization can also pose a threat to social identity at the subgroup level, because people do not want to abandon their cherished subgroup identities for more general (and less distinctive) superordinate identities.
A more successful strategy may be a combination of a superordinate identity and distinctive subgroup identities, so that each group preserves its distinctive subgroup identity within a common, superordinate identity. A nice example is the Barbarians invitation rugby team, which regularly plays matches against visiting international teams to the UK. They all wear the same famous blue-and-white hooped shirts, but they each wear the socks of their club team. So subgroup (club) identities are effectively viewed as complementary and valued roles within a larger, superordinate identity – the Barbarians.
At the societal level this notion relates to the social policy of multiculturalism or cultural pluralism, in which group differences are recognized and nurtured within a common superordinate identity that stresses cooperative interdependence and diversity.
This notion has been especially cultivated in some societies and countries, especially ‘immigrant countries’ such as Australia, New Zealand and Canada.
Clearly, our behaviour is inﬂuenced in complex ways by other people and the groups to which they belong. Sometimes the presence of other people can improve our performance and judgement, but sometimes their presence worsens it. Sometimes other people can encourage us to intervene and help others; sometimes they inhibit us. The outcome depends on a complex weighing up of ‘costs’ and ‘beneﬁts’ of intervening vs. not intervening. And sometimes they can make us behave in ways of which we would never have thought ourselves capable.
The social support of others can, then, be a source of physical and psychological strength. It can help us to resist pressures to conform to group norms, or give us the moral courage to disobey orders from an authority ﬁgure. But the social categorization that is a common consequence of group membership can also be a source of prejudice and conﬂict. The role of psychological research can here serve a very important professional and public role: by understanding the underlying processes, social psychology can contribute towards greater societal harmony by reducing prejudice and conﬂict.
There is a wide range of evidence regarding the effects of other people on social behaviour.
· We have highlighted some of the key theories in interpersonal relations, group processes and intergroup relations, and we have summarized the methods and ﬁndings of some of the most important studies.
· Generally, performing a task in the presence of other people improves performance on easy tasks, but impairs performance on difﬁcult tasks.
· People are more likely to help if they are on their own, or with friends. The presence of multiple bystanders inhibits intervention because responsibility is diffused and the costs of not helping are reduced.
· People are especially likely to obey orders from a legitimate authority ﬁgure, and when others are obedient.
· We are motivated to seek the company of others to compare ourselves with them, reduce anxiety and acquire new information from them. Social support from others provides a ‘buffer’ against stress.
· Close interpersonal relationships can be analysed in terms of social exchange of goods, love, information and so on. Happy close relationships are characterized by high intimacy, whereas distressed relationships tend to involve reciprocation of negative behaviour.
· We join social groups for multiple reasons, and frequently deﬁne ourselves, in part, as group members. This social identity develops over a series of stages, in which we are socialized into groups.
· Groups are typically structured into roles, of which the distinction between leader and followers is central. Group inﬂuence is affected by norms, and both majorities and minorities within groups can exert inﬂuence, albeit in different ways.
· Performance of groups is often worse than performance of individuals, because potential gains in effectiveness are offset by social loaﬁng and poor decision making. Decisions made in groups tend to be more extreme than individual decisions, sometimes with disastrous consequences. Individuals are also less creative in groups, because their ideas are blocked by those of other group members.
Our View of Self and Others
The way we look at ourselves plays an important role in how we see the world. The way we see the world plays an important role in how we see ourselves. In this sense, our view of self and others is an ever-changing circle of influence. We know that those who are happy see more positive aspects of the world than those who are depressed. We also know that living in an abusive household or an overly restrictive environment can both lead to depression. This section will explore the social areas of attribution (how we interpret those around us) and attraction (what we seek in a friend or partner).
We tend to explain our own behavior and the behavior of others by assigning attributes to these behavior. An attribute is an inference about the cause of a behavior. According to the Attribution Theory, we tend to explain our own behavior and the behavior of others by assigning attributes to these behavior.
There are basically two sources for our behavior; those influenced by Situational (external) factors and those influenced by Dispositional (internal) factors. Imagine walking into your boss's office and he immediately tells you, in an angry tone, not to bother him. An external explanation of this behavior might be, "He's really a nice guy but the stress is overwhelming. He needs a vacation." On the other hand, you might see the same behavior and say, "What a jerk, I don't know why is is so angry all the time." The same behavior is given two very opposite explanations.
Many factors play a role in how we assign attributes to behaviors. Obviously our view of the world, our previous experience with a particular person or situation, and our knowledge of the behavior play an important role. Other factors can influence our interpretation as well, and there are two important errors or mistakes we tend make when assigning these attributes.
1. Fundamental Attribution Error.
This refers to the tendency to over estimate the internal and underestimate the external factors when explaining the behaviors of others. This may be a result of our tendency to pay more attention to the situation rather than to the individual (Heider, 1958) and is especially true when we know little about the other person. For example, the last time you were driving and got cut off did you say to yourself "What an idiot" (or something similar), or did you say "She must be having a rough day." Chances are that this behavior was assigned mostly internal attributes and you didn't give a second thought to what external factors are playing a role in her driving behavior.
2. Self-Serving Bias.
We tend to equate successes to internal and failures to external attributes (Miller & Ross, 1975). Imagine getting a promotion. Most of us will feel that this success is due to hard work, intelligence, dedication, and similar internal factors. But if you are fired, well obviously your boss wouldn't know a good thing if it were staring her in the face.
This bias is true for most people, but for those who are depressed, have low self-esteem, or view themselves negatively, the bias is typically opposite. For these people, a success may mean that a multitude of negatives have been overlooked or that luck was the primary reason. For failures, the depressed individual will likely see their own negative qualities, such as stupidity, as being the primary factor.
Why are we attracted to certain people and not others? Why do our friends tend to be very similar to each other? And what causes us to decide on a mate? Many of these questions relate to social psychology in that society's influence and our own beliefs and traits play an important role. Research has found five reasons why we choose our friends.:
1. Proximity - The vast majority of our friends live close to where we live, or at least where we lived during the time period the friendship developed (Nahemow & Lawton, 1975). Obviously friendships develop after getting to know someone, and this closeness provides the easiest way to accomplish this goal. Having assigned seats in a class or group setting would result in more friends who's last name started with the same letter as yours (Segal, 1974).
2. Association - We tend to associate our opinions about other people with our current state. In other words, if you meet someone during a class you really enjoy, they may get more 'likeability points' then if you met them during that class you can't stand.
3. Similarity - On the other hand, imagine that person above agrees with you this particular class is the worse they have taken. The agreement or similarity between the two of you would likely result in more attractiveness (Neimeyer & Mitchell, 1988)
4. Reciprocal Liking - Simply put, we tend to like those better who also like us back. This may be a result of the feeling we get about ourselves knowing that we are likable. When we feel good when we are around somebody, we tend to report a higher level of attraction toward that person (Forgas, 1992; Zajonc & McIntosh, 1992)
5. Physical Attractiveness - Physical attraction plays a role in who we choose as friends, although not as much so as in who we choose as a mate. Nonetheless, we tend to choose people who we believe to be attractive and who are close to how we see our own physical attractiveness.
This last statement brings up an important factor in how we determine our friends and partner. Ever wonder why very attractive people tend to 'hang around' other very attractive people? Or why wealthy men seem to end up with physically attractive, perhaps even much younger, women? There is some truth to these stereotypical scenarios because we tend to assign "social assets" or "attraction points" to everyone we meet.
These points are divided into categories such as physical attractiveness, sense of humor, education, and wealth. If we view education as very important, we may assign more points to this category making it more likely that our friends or our mate will have more education. If we view wealth as more important then we will be more likely to find a mate who has more money.
We rate ourselves on these same categories and, at least at some level, know our score. We tend to then pick friends and partners who have a similar score that we do. Hence an attractive person hangs with other attractive people; or a wealthy older man gets the beautiful younger woman. Think about your friends and how you would rate them in these categories to find out what is important to you.
Obedience and Power
Why do we obey some people and not others? Why are you able to influence your friends? What attributes cause a person to be more influential? These questions are paramount in understanding social order. The answers to these questions also play an important role in many professions, such as sales and marketing and of course politics.
Lets start with a closer look at what 'power' is. Power is typically thought of has having a certain attribute which gives one person more influence over another. This attribute could be intelligence or experience, it could be job title, or perhaps money. According to most social psychologists, there are five types of power: coercive, reward, legitimate, expert, and referent.
Coercive power means the power punish.
Parents are said to have coercive power because they can place their child in time-out, for example; bosses have coercive power because they can fire an employee or assign an employee a less pleasing job. Reward power is almost the opposite; it is the power to reward. In that sense parents and bosses have this type of power as well, as do many others in our lives. Legitimate power refers to the power granted by some authority, such as the power a police officer has due to the local or state government or the power a professor has due to the rules of a college or university.
Expert power results from experience or education. Those individuals with more knowledge tend to have more power in situations where that knowledge is important.
For instance, the physician will have more power in a medical emergency than the plumber. But, when the pipes explode and the house is being flooded, the physician is not the person to call. Finally, referent power refers to admiration or respect. When we look up to people because of their accomplishments, their attitude, or any other personal attribute, we tend to give them more power over us. Imagine being asked to do something by your "hero" or your favorite movie star; we are very likely to comply out of admiration or respect.
Using Power to Influence Others
Now that we know what power is and how people get it, lets talk about how this power is used to influence others. Most of us know that liking and agreeing tend to go together. We agree with our friends about many issues, especially the bigger ones, and often disagree with our opponents. Also, beliefs and behaviors tend to go together. For instance, most people who believe stealing is very immoral would not steal, most who believe littering is wrong, do not litter.
What's interesting about this latter concept is what happens when our belief and our behavior do not correspond. You might think that we would change the way we act, but in the real world, we tend to change our belief about a topic before we would change our behavior. The person who believes littering is wrong, after throwing a soda can from their car window, might say to himself, "It was only one time," or "look at all the other trash on the freeway." in this sense, his belief has changed; littering is now okay if it is only done once or if others have littered first.
To equate this with influencing others, we see that if we can change the way a person behaves, we can change the way they think or feel. Imagine the car salesman who is able to convince the potential buyer that this new car is the one he wants to buy. The sales man might try to use many different techniques, but one is the 'test drive.' The theory behind this is that if the person's actions include driving the car, they are more likely to change their belief about the car.
There are other variables associated with influencing others or attitude change. Lets take a look first at what attributes the source or the talker help her influence others. First of all is power, as discussed above. The more types of power and the stronger each of these is, the more influential she will be. Second, a person must be believable in order to influence us. The source must therefore be trustworthy, after all, if we don't believe someone, they're going to have a much more difficult time changing our minds. Finally, attractiveness plays a role in how influence us. We tend to be influenced more by attractive people, including physical and social attractiveness, likeability, demeanor, and dress.
The target or listener plays a role in how he will be influenced as well. Those with low self-esteem and/or high self-doubt tend to be more influenced that others. The more we doubt our own ability, the more we look to others for guidance or input. Other factors such as age, IQ, gender, or social status do not appear to play a significant role in how we are influenced by others.
Finally, lets look at the relationship between the source and the target. First of all, there needs to be some similarity between the two people. If the target or listener does not feel any similarity with the talker, he is much less likely to accept what she is saying. After all, we have nothing in common so what could she possible know about my life. The more similar the two, the greater the influential ability. Second, there needs to be a moderate discrepancy in attitude. If the difference between the two is too large, changing the listener's attitude or belief will be too difficult. If the difference is too small, then no significant change will take place at all. The difference must be great enough that a change is possible but small enough that the listener is open to the change.
The Role of Groups
Do you think you act differently when alone than when other people are around? The answer to this question is typically a resounding 'yes.' We are concerned with our social image or how other people see us; some more than others, but very few people see no difference in their behavior. This section will discuss various theories relating to our behavior in group settings or when others are present.
Lets start with one of the most simple theory related to social psychology. When alone, we tend to be more relaxed, less concerned with the outward expression of our behavior, and are basically 'ourselves.' Add just one other person, even if we don't know that person, our behavior tends to change, and not always for the better. Research has found that when others are present, our level of arousal is increased (Zajonc, 1965). In other words, we are suddenly more aware of what's going on around us. Because of this, we tend to perform better at tasks that are well learned or simple (Guerin, 1993). When completing a difficult or new task, however, our performance level decreases and we tend to do more poorly.
This phenomenon is called Social Facilitation (Guerin, 1993), and as we try harder due to the presence of others, our performance actually decreases for difficult or unlearned tasks. Think about learning to play basketball for the first time. If you are alone, you will likely be more relaxed, and better able to concentrate. When others are watching you, however, you are more likely to be self-conscious, and therefore make more mistakes. Professional basketball players, however, because the task is so well learned, perform better when others are watching and they are able demonstrate their confidence and ability.
Group Think and Group Polarization
If you've ever been involved in a group decision making process, you've probably seen one of two things happen: either the group agrees on all of the major issues, or there is significant dissent that splits the group. If the group is cohesive; if they agree on most issues, they tend to stifle dissent because group harmony is the anticipated outcome (Janis, 1972). When we all agree, and are happy with that agreement, we typically do not want to hearopposing arguments. This phenomenon is referred to as Group Think. It can lead to impulsive decisions and a failure to identify and/or consider all sides of an argument. Some classic examples of group decisions going bad include lynch mobs, actions of the Ku Klux Klan, discrimination among hate groups, and mass riots.
Similar to this, Group Polarization refers to a groups tendency to talk itself into extreme positions. In this case, a group gets so focused and energized about a decision that it creates an internal fuel, so to speak, which pushes itself forward faster than originally intended. Imagine a group of protesters, all agreeing and deciding to picket. You can see how this could get out of hand because opposing views (Group Think) are not considered and the push to move forward for the cause is fueled internally (Group Polarization).
Another phenomenon that occurs in groups is referred to as Social Loafing. This theory states that as a group gets larger, the individual contribution decreases disproportionate to the group size (Everett, Smith, & Williams, 1992; Hardy & Latane, 1986; Ingham et al., 1974). This is due to the diffusion of responsibility created as the size of the group increases. Imagine being assigned a project to complete by yourself. Most likely you would complete 100% of it. Now if two people are involved, the percentage will typically not be 50/50. As more people are added to the group, you will end up with a small percentage doing a large portion of the work and a large percentage doing a much smaller proportion.
This last phenomenon is an unfortunate reality which has been observed far to many times in groups and in larger cities. We've all heard stories of people getting mugged, or beaten, or raped in broad daylight while people around offered no assistance. We have found that the internal push to help a person in need decreases as the group gets larger, very similar to Social Loafing. In this instance, however, people tend to be followers and will only get involved if they witness another person getting involved. What results is a group of people witnessing a crime and wondering why nobody is helping. This does not occur if you are the only person witnessing the crime. If nobody else is around, a person will tend to help the victim. The more people, however, the less likely someone will offer assistance.
The effect of illness and hospitalization
Surrounded by strangers
Procedures that are intimate
At first very dependent – then learn to move back to balance of independence/dependence
What can studying communication skills offer us as medical practitioners?
Increased nurse Job Satisfaction
Decreased Conflict Within The Consultation
More Accurate And Efficient Interviews
Better Clinical Hypothesis Generation
Increased Patient Satisfaction
Increased Patient Understanding And Recall
Improved Compliance And Disease Outcome
Decreased Medico Legal Complaints
Actual Savings In Time
More Structure And Control Of The Difficult Consultation
Many researches have also shown a significant relationship between the clinician’s interpersonal skills and patient’s motivation and satisfaction. When the nurse dominates the interview, verbally and emotionally, the result is always leads to dissatisfaction of the patients and their relatives. This may also be related to the patient’s expectation about the role of the nurse.
Patient’s satisfaction plays a major role in
assessing quality medical care in the newly adopted health system (manages
care) in the
Cognitive Satisfaction: How satisfied is the patient with their understanding of the diagnoses, treatment, and prognoses. This is related to the nurse’s Verbal Behavior.
Emotional Satisfaction: This is related to the nurse’s non-verbal behavior. The ability to show care and concern by tone of voice, eye gaze, facial expression, body movement and posture.
Effective diagnoses and treatment depends not only on identifying physical symptoms of illness, but also on the nurse’s ability to detect and respond to verbal and non-verbal cues, to elicit all relevant information (physical and psychosocial), relevant to diagnoses and treatment.
A poor communication skill is related to poor compliance. Communication skill training has a positive influence on patient compliance with prescribed medication. Effective communication enables nurses/Nurse and other health professions to pass on relevant health information, and to motivate patient to pursue healthier lifestyle. This is a very important part on health promotion.
Nurse’s Competence & Self-Assertion:
Research has also shown that better nurse’s patient’s communication can also contribute to the clinical professional and personality (self-confidence) aspects.
CORE COMMUNICATION SKILLS
Core communication skills covers three dimensions:
• nurse -patient interpersonal skills
• Information gathering skills
• Information giving skills and patient education
Advanced Communication Skills
• Skills for motivating patient adherence to treatment plans
• Other applications of core communication skills in specific situations.
Nurse-patient interpersonal skills
Appropriate physical environment
The need to establish an appropriate physical environment to enhance privacy and attentiveness. Small things like arranging seating in a manner which neither threatening nor distant, or having a curtain to create a sense of privacy will in outcome of the interview.
Greeting patients in a manner acceptable within the cultural norms in relation to age, sex. etc. will help maintain their dignity and encourage their participation.
Active listening involves using both verbal and non-verbal communication techniques. The nurse should clearly signal that the patient has his/her full attention by look, by offering acceptance and continuation signals such as nods, phrases such as “right”/”I see” etc. A willingness to listen actively is however best signaled by use of open questions to promote fuller answer.
Empathy, respect, interest, warmth and support
These issues are at the heart of interpersonal skills. They cannot easily be faked, and if nurse do not have them, they cannot easily be taught things to do by way of them. Success in this area is not a matter of skills but of attitude. However, health practitioners should clearly signal their interest in how the patient’s problem is perceived, whether it concerns them, what their hopes and expectations are.
Nurse should ask questions to discover patient perception “Does the thought of the operation worry you?”. The nurse should also learn to show respect, interest, warmth and support. This will also involve being non-judgmental in attitude. THESE ARE THE CORE FACTORS IN RAPPORT BUILDING.
Avoid medical jargon. You should consider the educational cultural and developmental level of the patient e.g., “ You have got appendicitis” is appropriate for most adults but not young children etc),. It is also important for nurses to monitor their use of potentially frightening words “Cancer”/”lump” etc.
Skills in non-verbal communication like eye contact, physical proximity, and facial expression need to be improved to enhance patient’s satisfaction and adherence to treatment. This should convey to the patient that the Health practitioner is attentive and interested.
Some patients may appear demanding, dependent or even at times, adversarial. It is the physician's responsibility to not overreact to these situations. This can be achieved by establishing limitations (boundaries) on what can be provided and suggesting appropriate ways for the patients to contact them.
Frequent phone calls, unscheduled visits, and unrealistic expectations, are ways in which some patients lose perspective of the shared responsibility of their care. Nurses need to establish boundaries for patients in a way that doesn't belittle them.
Closing the interview
In addition to the skills of setting up, beginning and continuing an interview, the way of closing the interview is also important. The nurse should clearly signal that the interview is drawing to a close, usually by summarizing what has been said and what has been negotiated.
Basic to interpersonal skills is to consider the importance of such factors as gender, cultural and socioeconomic factors, which could greatly affect perceptions of norms and standards of appropriate communication.
It is also essential for all practitioners to realize that what is needed is not only to know how to recognize a disease, but also how to recognize and to respond to a patient’s emotional response to their disease. In their interactions with patients, it is important for the clinicians to be aware of patients’ emotional responses to their situation and at the same -aware of their own emotional reactions toward the patients.
Information gathering skills
A critical part of all nurse-patient interactions involves eliciting information from patient. The core skills which are needed to facilitate the process of information gathering are skills which help to facilitate the patients’ involvement in the medical interview in away that enables the nurse to arrive at an accurate diagnosis of a patient’s problem or symptoms.
Using an appropriate balance of open to closed questions
Open questions invite an extended answer, not a “Yes/No” response. Generally questions such as “Please tell me about your pain” are better at eliciting information than closed questions such as “Is it a stabbing pain?”. Open questions are particularly useful patients are being asked to describe their problem; which they should be allowed to do minimal interruption early on in the consultation.
You need to learn to use silence appropriately as a way to encourage express themselves more fully, raise difficult topics and remember important
Clarifying patient expectations about the consultation
You need to clarify with the patient what their expectations are consultation, and should avoid making premature conclusions about the reason person’s visit to the nurse. This may helps to reveal cases where the symptom the patient is not in fact the patient’s main concern, and will also help to avoid inaccurate diagnosis of the patient’s complaints.
Clarifying the information given by the patient
You need to clarify the meaning of what the patient is saying and the nurse perceives from the patient’s non-verbal communication in order to he/she understands the patient fully.
Sequencing of events
After eliciting a broad description of the patient’s situation, students need to help the patient to sequence events and experiences in order to develop a logical of the patient’s situation.
Directing the flow of information
While it is important that patients be allowed the opportunity to communicate at the same time the student needs to learn to maintain control of the interview, by guiding the interview content towards a diagnosis of the problem.
Since a lot of information can be exchanged in consultations, you should be able to summarize the main issues raised during the consultation and should ensure that a shared understanding of these.
Information giving skills and patient education
The medical interview usually involves the nurse in providing information to the patient about their illness or problem, and when appropriate the nurse will give inform and advise about the proposed treatment plan or treatment options.
Providing clear and simple information by monitoring jargon, and by checking the patient’s understanding before (“What do you know about asthma?”) and during (“Have I made myself clear?”) the explanation process.
Using specific advice with concrete examples. Abstract or general advice/inform should be exemplified in terms that make sense to the patient “Don’t use acidic foods for example steer clear of fried things”.
Putting important things first. Research suggests that what is said first is remembered. A nurse should say first what it is most important for the patient to recall
Using repetition. Repetition should be used carefully to a level appropriate to patient. Often it is best to recycle information using slightly different words, in case the formulation has been only partly understood.
Summarizing. This is an important interview-closing skill (see above). Sum should be brief, and repeat the main points agreed in language, which is unambiguous clear. Patients may also be invited to repeat the nurse’s instruction to ensure that they shared understanding.
Categorizing information to reduce complexity and aid recall. Where the information to be conveyed is complex, or where there is a lot to be said, it should be clearly b down into manageable units which are clearly signaled to the patient, using markers s “there are three things we need to think about ... firstly/secondly/thirdly etc”.
Using tools: Complex information could well be accompanied by a series of heading and diagrams. Some nurses offer tape recorders of their consultations to patients where the information has been intellectually demanding and psychologically distressing.
Checking patient understanding of what has been said. Repeating instructions, using diagrams, written instructions, and sometimes-technical aids to explain difficult concepts are useful. The student must be competent in summarizing the information given and in checking patient understanding by asking the patient to repeat what heard and understood.
Skills for motivating patient adherence to treatment plans
The list below includes skills for the promotion of behaviour. Realistic compliance with treatment plans may require patients to make significant changes in their diet, lifestyle or daily routine on a short term or long term basis.
Providing a rationale for behavior change
Providing examples of role models
Allowing opportunities for verbal rehearsal of the details of the treatment
Feedback (positive reinforcement of constructive behaviour changes already achieved since earlier consultations)
Finally, nurses should be aware about the clincial, communication and interpersonal skills that are required when dealing with difficult patients,(e.g., overdependent, dramatizing and exaggerating, aggressive, and antisocoial personalit.
Collaboration with patients and families
To win the collaboration of patients and their families, those providing care need to elicit, negotiate and agree on a definition of the problem they are working on with each patient.
They must then agree on the targets and goals for management and develop an individualised collaborative self management plan. This plan should be based on established cognitive behavioural principles and on the evidence relating to the management of the chronic condition.
Principles of collaboration
Understanding of patients’ beliefs, wishes, and circumstances
Understanding of family beliefs and needs
Identification of a single person to be main link with each patient
Collaborative definition of problems and goals
Negotiated agreed plans regularly reviewed
Active follow up with patients
Regular team review
List of educational literature:
1. Kelly, P. (2008). Nursing Leadership and Management. (2nd ed.). Clifton Park, NY: Delmar Learning
2. Huber, D. (2000), Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.
3. Nagelkerk, J. (2000), Study Guide for Huber Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.
4. Sullivan, E. J. (2004). Becoming influential: A guide for nurses. Upper Saddle River, NJ: Pearson.
1. See required Websites:
2. Course Website – Log in @ http://www.tdmu.edu.te.ua/ukr/general/index.php
Prepared by Volkova N.M.
Adopted by Department of Medical Bioethics and Deontology sitting
11 June 2012, Minute ¹ 2