Nurses' communication must be considered in context.

RESEARCHERS ARE always encouraged when someone takes the trouble to respond to published accounts of their research. As a sociolinguist I particularly appreciated the positive and constructive response by an experienced teacher of nurses, R.Althea Hill, in the February issue of Kai Tiaki Nursing New Zealand (letters p3). She was responding to our article "Nurses communicating on the ward: The human face of hospitals" published in the December/January 2002/2003 issue of Kai Tiaki Nursing New Zealand (p14-16). We are in complete agreement about the crucial role effective communication plays in nursing.

While she endorses our overall message, and welcomes our contribution as sociolinguists, Hill takes issue with some of the details of our analysis. It is always possible different people will interpret transcribed material differently, and this is generally a useful point for readers to be aware of. However, I would like to make a couple of points which I think might be helpful to those interested in drawing on sociolinguistics, research in understanding social interaction, and perhaps also in their teaching.

Firstly, our data is part of a larger project on language in the workplace (vuw.ac.nz/lals/lwp) and the methodology we adopted in the wards was a modified form of our wider methodology. This typically involves going back to those who produced the recordings, after we have analysed them, to check our interpretations with them. In this case, the nurses who generously recorded the material, also checked our interpretations, and agreed with them.

Secondly, the specific context in which the data was collected is always an overwhelmingly important influence on the way an utterance is understood and the meaning people glean from it. So, though some of the strategies the nurses used might sound patronising when assessed on the page, they sounded very different when used in context to a particular patient who was visibly wobbly or in need of reassurance. Hill suggests the use of a question "can you pop this under your tongue?" is inappropriate, since clearly the patient can. But we all use such forms in order to be considerate of others' feelings, to be polite and take account of their dignity. Similarly, following a directive with the softener "OK?" did not sound patronising in context, rather it sounded kind and considerate of the person addressed.

The same point holds with respect to Hill's concern about the way we described two nurses "teasing" a doctor who had kept them waiting a long time. Rather than using humour to convey the message that they were rather brassed off (as they did), she suggests they should have said something like "I realise you're very busy this morning, but we paged you an hour ago. If there's likely to be a delay, we'd really appreciate your letting us know". This is admirably clear communication, and in some contexts may be exactly what is needed to get a nurse's message across. But we all know we simply cannot legislate the appropriate way of ticking someone off in all contexts. It is important to take account of myriad other factors, which mean we are always making sophisticated judgements about how best to convey our message to ensure the outcome we want. If the doctor is an experienced, self-confident doctor, s/he may well respond well to the approach Hill advocates. But if the doctor is young and run ragged by the demands of the day, then an experienced nurse may decide the assertive approach is too "heavy" in the particular circumstances. As one nurse commented, a tired doctor who is publicly reprimanded may respond very irritably, and no-one benefits then, least of all the patients. Better to use homour than a rap over the knuckles in some cases to convey the message.

Nurses who are effective communicators are incredibly skilled at selecting the. appropriate way to get their message across. They can be direct and clear when that is what they judge is required--indeed as we pointed out, 70 percent of the directives the nurses used were imperative in structure, the most direct form of all. But they always respond to particular individuals in specific contexts, taking account of the relationship they have already established, and the specific condition of the person they are talking to. This is a real skill. We simply can't prescribe how to respond in advance.

Most people report that they like assertive, clear communication. We do too, which is why we valued Hill's response. But what we learned from observing the ward nurses was that people in hospital are not always as strong and tough as they might be outside the ward, and that when doctors are tired or grumpy, nurses are remarkably sensitive to the best way of conveying their messages in ways that will ensure good outcomes for all.

Janet Holmes, MPhil

Professor of Linguistics

Victoria University

Wellington

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