section three

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Having examined the subjective and institutional frameworks shaping the delivery of nursing care, we are now in a position to address the nature of interpersonal communication from a suitably informed perspective. Hartley (1993) provides a useful general view of interpersonal communication that builds on aspects of our previous discussion. It helps to continue our analysis of the negotiation of the active individual trying to function in a specific social setting. We examine the elements of this model further in the discussion below.

Figure I: Hartley's (1993) Model of Communication (Hartley 1993:22)

Hartley's (1993) Model of Communication (Hartley 1993:22)

Social context

All communication is situated in a specific context. Reference to interpersonal communication can seem to imply that communication can be understood through attention to the behaviour and intentions of the persons involved. And at one level it can; provided we are careful to take note of the many ways in which people are sensitive to the context in which they find themselves.

However, as we have already noted, we all have multiple identities and fulfil many social roles. Typically, our roles are situationally cued and particular identities are situationally salient, that is, made relevant by a specific context. A group of nurses sitting round a canteen table may all talk as nurses about doctors and their ways. And yet, the same nurses back on the ward may be very aware of their individual status as staff nurse, sister or practice liaison lecturer. Enjoying a sociable conversation about the foibles of doctors allows everyone to safely claim a shared identity as 'a nurse', but in the hierarchical context of the clinical setting differences in status, power and function makes the intra-group identities relevant. And, consciousness of these distinctive statuses facilitates the fluent merging of roles in delivering care.

In addition, professional socialisation involves, in part, the induction of the new staff member into a clear understanding of the norms operating in specific social contexts. For example, there is the wonderful moment in the film Cat Balou when the drunk Lee Marvin enters a room, sees lighted candles and people standing round them and starts to sing 'Happy Birthday to You': only to realise too late that these candles are at the foot of the deceased father's bed.

Therefore, the concept of community of practice applied to nursing specifically points to the way in which individuals working in a specific context, with its unique pressures and routines for managing them, are attuned to have shared expectations about what they are there to do and about the appropriate ways of behaving in order to achieve their objectives. The rapid, relatively impersonal and detached communication style between a nurse and patient in a fraught A & E department may be necessary to efficient team work in an acute setting; it would hardly be appropriate in a hospice. What we are expected to do, how we do it and how we interact with colleagues and patients whilst doing it is highly context specific. One of the dangers of professional practice is that it is possible for the norms of specific communities of practice to become overly routinised and practice becomes ossified. Contexts may become familiar but individuals are always unique.

Social identities

Hartley's (1993) model sketches an interaction between two persons in a particular context and it underlines the importance of the social identities of these interactants. Clearly, who we think we are has an impact upon how we view our relation to others. For example, the current funding of student nurses has underlined their student status and, for example, made it quite difficult for them to work the normal rotas of qualified nurses. Thus, to see yourself as a student nurse not only defines you as a 'learner' but also carries with it implicit expectations about your hours of work. The social identities we claim provide a framework of expectations which shape our expectations of ourselves and others; as well as our sense of legitimacy about having such expectations. Therefore, our social identities are not simply mechanisms for knowing how to act, but also moral claims for how we should be treated.

In addition, our social identities are not simply a set of linked rules and patterns of behaviour, they are also vehicles for the expression of our personal identity. As we have seen our egos are involved in the ways we fulfil the roles attached to our social identities. Feeling and emotion is woven into our identity claims and into our experience of living them.

Thus, when the two persons in Hartley's model come into interaction, they are not pre-programmed robots with a capacity to engage in interaction through the synchronisation of over-learned routines. They are unique individuals with needs for positive self affirmation who are about to seek to negotiate and make meaningful their interaction. We make meaning through interaction, it is not already there in the context.

Because we all engage in this social process of making communication work, we all share the same possibility that the communication can fail. As we proceed we shall examine the complexity of human communication in order that we can understand how communication may fail; and thus learn to avoid it. And, whilst the multi-channel complexity of communication provides ample possibilities for ambiguity and miscommunication, we should not allow ourselves to become fixated on the technical skills of communication. We must remain open to the humanity of human interaction. We talk of interpersonal communications; and consequently we should not forget the person within the communication process.

Nurses are used to speaking of delivering 'individualised holistic care' and are trained to see the patient as an holistic being. However, nurse education and socialisation seems less adept at enabling nurses to see themselves in the same holistic manner. In other words, communication can fail because we do not enter into communication with a rounded and open conception of the other person. At the heart of interpersonal communication then, is a process of mutual recognition. As Charles Taylor (1992) has argued, there lies at the core of Western liberalism a politics of recognition which follows a logic of - you recognise me and I recognise you; and we treat each other equally. We need the affirmation of our worth and existence by others recognition of our identity claims. But, with the complexity and fragmentation of contemporary life this is not always easily obtained. As Taylor comments:

What has come about with the modern age is not the need for recognition but the conditions in which the attempt to be recognised can fail.

(Taylor 1992:35)

Thus, in interpersonal interaction we may be hurt and offended if we feel that we are being treated solely in terms of our superficial role; that the real me is being ignored and that we are being treated like a number. So, in recognising only someone else's role in the social context, we may stereotype them and fail to engage with them as a person. In interpersonal interaction there is a need to be sensitive to the role expectations present in a specific context. But, there is also a fundamental need to recognise the distinct person with whom we are interacting.

Perception

Central to this process is the issue of 'perception'; since perception is a key element in the making of meaning. Our sensory capacities are remarkably sensitive and are well adapted to meet our needs as information receptors. The information they receive is raw physical sensory input to which we bring a learnt capacity to give it meaning. For example, the colour red may have distinctive physical properties; but its meaning and symbolic significance is a purely human product.

Like so much else that we have considered in this text, the processes of perception remind us, yet again, of how active we are in making sense of our world. Ethologists, in studying animal behaviour, distinguished between natural signs and learned symbols. Natural signs were seen as naturally pre-coded signalling systems which elicited a guaranteed response. The colour coding of a chick's gaping mouth might, for example, elicit a feeding response from a parent bird. Such natural signs play very little part in human interaction.

On the other hand, language is itself a classic example of a learned symbol system. The words window and fenêtre both have the capacity to make someone think of a window. In different languages they both stand for a window. There is no necessary relationship between the word and the object, it is merely a symbolic representation of it. Thus, the process of communication starts with shared learned signalling systems. This is an inherently cultural process. Consequently, the variety of cultures raises the inevitable prospect of different meaning systems. Even within the same language different regions and communities may have quite local words and phrases that are part of defining their identity as communities.

As a result, the sophistication of our sensory capacities is, of itself, no guarantee of our ability to effectively interpret our surroundings. We can all sit in a noisy café and hear only the voice of the person we are talking to. Or, we can sit and watch television and not hear the conversation of our relatives sitting only a yard away. The capacity for selective attention allows us all to defend ourselves from information overload. Our perceptual apparatus can be focused. We can filter out irrelevant stimuli. That, of course, implies that we already have the capacity to know what are the relevant stimuli. It comes as no surprise therefore, that much of any professional socialisation is addressed to ensuring a capacity to share an understanding of what stimuli have priority over others. For example, the lecturer is more important than the fellow student (in the lecture theatre); and the smell of a patient's breath, although unpleasant, may be (diagnostically) relevant in a way that would be repellent in an acquaintance. Triage nurses may be seen as professional specialists in selective attention. They scan a range of variables in order to make an inference about a patient's condition. Intuition, which is highly valued in nursing, is an experientially developed capacity to draw upon and interpret a very wide range of data; not all of which might be capable of being retrieved for description to a third party: it is part of the practical consciousness of the experienced nurse.

Thus, perception is partially a function of our active engagement with our environment. In one sense perception is data dependent in that we can only proceed to make sense of information that we have already accessed. Stereotypes represent one form of lazy perception in the sense that on the basis of a few elements of information we proceed to assume that a whole collection of other features must be present or true: even though we may have no relevant data.

However, even open and alert scanning of our environment cannot guarantee adequate data inputs when we operate in different cultures. What information is explicitly available may differ significantly from one culture to another and our routines of scanning may be inappropriate in different cultural settings. Not only may the data we receive have different meanings in different cultures, but additionally we may have to observe differently in order to tap the appropriate information.

Social identities/perception

In Hartley's model the arrow pointing actively in both directions between social identity and social perception indicates their intimate interrelationship. The interpretation of physical stimuli is itself a highly sophisticated learned cultural competence, but this process is further complicated when we factor in the unique subjective dynamics of the individual. It has been said that human beings are not so much rational animals as rationalising animals. This pithy statement underscores the earlier statement that human beings are not animate computers that dispassionately process data according to the principles of pure reason. At its simplest we cook the books.

As we have seen, a significant body of contemporary social psychology revolves around the assertion that human beings seek to sustain positive self-esteem. That is, we seek out positive feedback that confirms our identity and enables us to feel good about who we are. In pursuing this goal we engage in complex processes of social comparison. We compare ourselves with members of our identity groups to confirm that we are like them. And we compare ourselves with members of out-groups to reassure ourselves that we are not like them. Thus, midwives strongly resist being called nurses, but both nurses and midwives may find doctors a useful out-group. In essence, we are partisan in our social comparison and our sense of our own distinctive identity is likely to permeate our perceptual processes. Selective perception is a usual human foible.

A man and a woman may watch the same film and be excited or irritated by quite different moments in it. A member of the majority white population and a member of a minority ethnic community may watch the same comedy programme and one may see it as good fun and the other as insensitive and racist. It is questionable as to whether nurses and non-nurses experience the television programme 'Casualty' in the same way. In essence our social identities inform both what we pay attention to and how we interpret the subsequent data. Many majority white nurses may be surprised at the claims of the extent of discrimination in the NHS, while few minority ethnic nurses are likely to be surprised (Gerrish et al 1996, Beishon et al 1996).

Selective perception can therefore be understood as a dynamic cognitive process. By the interaction of a partial focusing upon the available sources of information, and an egocentric interpretation of that input, we help to shape reality in ways which are consistent with our pre-existing values and expectations. This can, of course, have a capacity to generate self-fulfilling prophecies. We expect our friends to be nice to us, and our enemies to be hostile. The same joke told against us by a friend is 'a bit of fun', but by an enemy is 'aggressive or belligerent'. Where our expectation of others is based upon group stereotypes then the additional dynamics of inter-group psychology may exacerbate this distortion.

This sort of inter-group posture in interpersonal communication can lead us to treating people as only representatives of their group or category; not as unique complex individuals. When this sort of perceptual distortion becomes part of the shared routine of a community of practice it can be very hard to challenge. You only have to think of the resilience of professional rivalries within the health and social care sector to remind yourself of the reality of this.

Thus, in any clinical context the identities that individuals bring to that site are likely to inform their perception of the environment they share. A student nurse and a mentor may be having a cup of tea during the break. It is possible that the student thinks that 'they are having a chat' and the mentor thinks this is a subtle way of giving guidance. Subsequently, the student may be angered when the content of the 'chat' is referred to in 'formal supervision'. There had not been a mutual understanding of which identities were in play in the canteen. Similarly, sexual harassment starts with the inappropriate introduction of gendered identities into a professional relationship. Yet, gender may be part of an 'appropriate use of self' in a clinical setting.

The main point is that our multiple social identities make possible a complex switching of agendas within a single social context. A misreading of the relevance of an available identity may be very damaging; and equally, any inflexibility or unwillingness to draw upon other identities may make an interaction more shallow and ineffective than it might have been.

Codes

It ain't what you do, it's the way that you do it.
It ain't what you say, it 's the way that you say it.

In these familiar phrases lies the basis of the operation of codes in interpersonal communication. When we learn languages, for example, we learn a lexicon and a grammar: a massive arsenal of words and a system for linking them in order to generate a coherent utterance. But language alone is only one vehicle of communication. As workers we may all be asked to contribute our views and yet so often the way we express ourselves gives away so much about the hierarchy of status operating amongst the participants - as well as our own feelings about that hierarchy.

In all cultures there are expectations about the manner of our performance. As we shall see below the multiple channels of communication operating in any interaction allow us to send complex, multi-layered messages. We may say the same sentence in a way that indicates warmth or hostility. We may show helpfulness, exasperation or anger when we say to a colleague in a work situation 'OK, I'll take over now'. Thus, in our interaction with others we have available a range of codes which enable us to introduce a rich variety of meaning into our communication. There is, for example, a great deal of literature in socio-linguistics that examines the operation of regional accents. And we can all, to some extent, talk 'normal' or 'posh'.

However, it is apparent that code switching between these options can give a powerful edge to our communicative impact. For example, sometimes in a formal context a deliberate switching to a more vernacular way of expressing yourself can be a means of underlining the strength of your feeling. Our awareness of the range of codes available to us helps us to negotiate our social world in ways that go well beyond the words themselves.

The relevance of codes is made particularly important when we consider the significance of Hartley's positioning of the two terms representation and presentation between the two people communicating with each other. As we will explore in more detail below, representation and presentation are two complementary processes that exist simultaneously within any interaction.

At its simplest, representation refers to the information we wish to transmit. We wish to express an opinion, ask for something or request that the other person will do something. However, running alongside this substantive message is a parallel block of messages that are seeking to define and signal the nature of the relationship between the interactants. For example, in an era when each patient has above their bed the name of their designated nurse they can ask for help in a variety of ways. For example:

"Nurse, I need to go to the toilet."
"Jo, I need to go to the toilet."
"Hey, I need to go to the toilet."

All of these statements represent the patient's immediate need to the nurse. But, in their different forms they quite powerfully signal a different assumed relationship between the patient and nurse. As we shall see below, our choice of words, body posture and tone of voice all help to signal our expectations of the nature of our interaction; and our relationship within it. This presentational element in communication is critical to our being able to smoothly choreograph our interaction.

Interpersonal interaction

Hartley's (1993) model offers a very simplified route into understanding the basic processes of interpersonal communication. It refuses to allow us to deal with two separate individuals in isolation. Clearly, an appreciation of the social context of all interactions is essential to allow us to begin to comprehend how the actors understand the rules governing their behaviour. Knowledge of the rules does not, however, allow the observer to anticipate the flow of the interaction. Each actor has his/her own unique identity and interprets the rules in a distinctly personal way. For them, an understanding of the context allows for a selection of codes which provide nuances to their behaviour and which contribute to their presentational orchestration of the interaction.

However, interpersonal communication is a dynamic and less than perfect activity. Its diversity and unpredictability is the basis of our joy in our friends' company, and pleasure - perhaps in music, theatre, cinema or literature. It is also the basis of unintentional offence, ambiguity and fear of interacting with strangers.

Representation and presentation

Before we go on to break 'Interpersonal Communication' down into its building blocks it is important that we are clear about the dual functions of communication; namely representation and presentation.

Especially in cross-cultural interactions it is not only possible to fail to transmit information adequately; more fundamentally we may fail to establish the ground rules for the basis of our interaction. The complementary concepts of representation and presentation are therefore crucial.

The distinction between representation and presentation can be technically complex to understand in terms of its academic analysis but its practical relevance is enormous. Let us start with a statement from Danziger (1976):

A verbal message is never merely a neutral transmission of information about the world outside, it is always also a communication about the relationship between the speaker and his audience.

(Danziger 1976:27)

When a lecturer stands at a podium and delivers a lecture they are transmitting information about the topic of the lecture. There is a semantic (representational) and a pragmatic (presentational) content to their behaviour. The semantic content is concerned with the ostensible topic of the dialogue, the issue that is being talked about and the pragmatic content is the 'hidden agenda'; it is about defining the relationship between the lecturer and the audience. If the lecturer sat on a desk in the front row of the lecture hall and delivered exactly the same semantic content the pragmatic content would not remain the same. The former performance might be read by the audience as saying - 'I am the lecturer - I hope you know your place.' And the second performance might be read as - 'O.K. I am the lecturer - let's enjoy sharing this session.' Note the 'might' in both of these suggested readings of the performances. For, as Danziger points out, in order to understand the semantic content we merely need a knowledge of the language. However, for an understanding of the pragmatic content that is not sufficient; we also need to know a great deal about the social norms and conventions under which the participants are operating. The context and the possible understandings of the interaction are heavily culturally defined and the codes that may be employed need to be understood.

Thus, in every interaction there is a dual dynamic as the participants seek to exchange information whilst simultaneously orchestrating their interaction through the pragmatic content of the dialogue. A great deal of courtship involves the deliberate discussion of bland inconsequential issues (semantic) whilst in many ways signalling very different agendas. Comedy sketches are full of instances of the star struck lover who cannot efficiently and subtly co-ordinate the pragmatic coding of their feelings and are too distressed to maintain the supposedly substantive topic of the conversation semantically.

Exercise 3.1 Group activity

In groups of two or three, practice exchanging the same information but with switches in the presentational dynamics.

NB: Attempting this will sensitise you to the discussion of channels of communication which follow in Section Four.

Of course, the dynamic manipulation of semantic and pragmatic content need not be so innocent or benign. Power in organisations is routinely negotiated through rules of formal politeness. Only exceptionally or when working relationships break down would a health care manager say explicitly - 'I am your superior and you will do as I say.' Or, despite justification, it is unlikely that a staff nurse in the A & E would say to a young houseman - 'Look laddie, you haven't a damn idea what to do, have you?' Hierarchies and order are maintained by such views being coded pragmatically. Shared understanding of such pragmatic codes enable members of an in-group to share their feelings about a member of an out-group, in their presence, without it being easily challenged.

Regrettably, not all of the pragmatic communication that people transmit is intentional. It is doubtful that many people wish to be called arrogant or bossy. But, leakage of their feelings for others may all too easily occur through the pragmatic content of their performance. As Danziger reminds us:

Much of the time people talk in order to confirm or to challenge the nature of their relationship to one another, and the world to which their messages refer, albeit obliquely, is the world of status and power, love and protection, hostility and politeness.

(Danziger 1997:28)

Exercise 3.2 Self reflection activity
In relation to a work or study context, reflect on the presentational (pragmatic) effect of routine encounters that you experience.

What techniques do you use for indicating the presentational (pragmatic) element of an interaction?
Think of particular instances and make a list of the techniques you most often use.

NOTE:

Where there is an absence of mutual understanding of the pragmatic codes because the actors are from different cultural backgrounds, the possibilities for misunderstanding may be enormous and potentially destructive. What in one culture signifies politeness may in another signify the reverse. What in one culture may be a signal of friendship may be in another a strong claim to intimacy. Working in a second or third language is itself semantically challenging, but working in a second culture in the 'hidden agenda' of pragmatics may be like sleep walking in a minefield.