NURSES AS COUNSELOR

RAFIAH MOHD SALLEH

Introduction
Very often we hear counselling is
needed in these situation:
People with drug addicts
/smokers/bulemia
Teenage pregnant girls /Child
delinquent
Wife /husband domestic violence

Counseling in health
setting

In health setting nurses do a lot of

counselling for:
Patients needing diet modification
Patients going through
depression/griefing /sadness
Patient refusing treatment
Patient needing behaviour
modification

Content
What is counselling
An interactive process characterized by
unique relationship between counselor and
client that leads to change in one or more of
the following areas
Behaviour
Beliefs or emotional concerns relating to
perception

What is counselling
In interpersonal health counseling, the
primary goal is not to change clients' behavior
and seek their compliance with the presented
message but rather to raise critical awareness
through learning and support, to give clients
tools for making changes on their own.

(Labonte, 1994; Tones 1994; Anderson et al., 1995; Feste and Anderson, 1995; van
Ryn and Heaney, 1997; Kar et al., 1999.

Aim of counselling
The aim is personal empowerment, control
and choice, which means that patients
become aware of changes in their knowledge
and understanding, decision-making skills,
enhanced self-esteem/sense of personal
control, and development of various social,
health and life skills.

(Labonte, 1994; Tones 1994; Anderson et al., 1995; Feste and Anderson, 1995; van

Ryn and Heaney, 1997; Kar et al., 1999

Food for thoughts

Do nurses practice counselling?
Why nurses do not counsel?
What hinders nurses from doing counselling?
Are they skillful in counselling?

Nurses as Counsellors
Using counselling skills in clinical practice will improve patient
care but not all health professionals will be inclined to engage
in such interactions (Nice, 2004).
They may not feel equipped to encourage patients to disclose
problems and thus have to deal with a response of anger, guilt
or hostility (Faulkner, 1998).
Some may believe professionals should not encourage
patients to share problems if nothing can be done about
them, but while talking in itself may not solve problems it can
often help to put them into perspective and may make them
more manageable.

Nurses as Counsellors
Counselling skills such as listening and responding can be used
at any time by all levels of staff (Faulkner and Maguire, 2001).
They can enhance communication, caring and mutual respect
between nurses and both their patients and their colleagues
(Burnard, 1999).
However, nurses have traditionally seen themselves as
providers of information and advice rather than as
counsellors, focusing on their patients' feelings (Burnard and
Morrison, 1989).

Nurses as Counsellors
Although their practice should follow the relevant
guidelines and frameworks it is important to point
out that when health professionals use counselling
skills they do not have to be perfect.
These skills will be effective as long as the
professional is non-judgemental and can
demonstrate empathy and genuineness (Rowland,
1993

Nurses as Counsellors
However, from an ethical perspective health
professionals must know their limitations and the
power of their interactions with patients. These may
not always have a positive effect if the skills are poor
or used inappropriately (Ellis et al, 2003).

Nurses as Counsellors
It is vital that members of the nurses recognise both
their abilities and limitations in relation to
counselling.
They should understand when it is appropriate, with
the patient's consent, to refer them to a more
qualified counsellor, psychologist or psychiatrist for
more advanced support (NICE, 2004).

Barriers to Counselling
at nurses level
Knowledge
Some nurses reported lacking sufficient
knowledge on the subject matter being
discussed in order to provide adequate
counseling.

Jansink et al. BMC Family Practice 2010, 11:41

http://www.biomedcentral.com/1471-2296/11/41

Barriers to Counselling
at nurses level
Attitudes
Some nurses mentioned they sometimes lack motivation
themselves because they have to repeat the lifestyle message
again and again, and they have little hope that the patient will
change. That makes them feel very powerless.
Other nurses did not like to be judgmental and were hesitant
to discuss lifestyle behavior change

Barriers to Counselling
at nurses level
"It is very difficult for patients to change their lifestyles. I
have to tell them the same thing all the time, mostly
without any result. This makes me feel powerless."
"I like to see the patients pleased to come back, so I want to
have a good relationship with them. Sometimes I am too
soft. This is wrong because I have to help patients
change their lifestyles."

Barriers to Counselling
at nurses level
"It is difficult to motivate older patients with diabetes to eat
healthful food - they say: 'I am 75 years old and I do not
intend to go on a diet,' 'I have reached a good old age with my
own eating habits,' or 'If I live 10 years less - so what? I'm
alone anyway.'"
"Patients with diabetes are often not used to physical activity, so
it is very difficult for them to start exercising at an older age.
They search for excuses: 'I have a backache', 'The weather is
bad,' or 'I'm tired after a busy workday.' Any excuse not to
move."

Barriers to Counselling
at nurses level

Attitudes
Another barrier nurses mentioned is lack of empathy.
This can occur when nurses do not understand why it
is so difficult to change a specific lifestyle which is
not a barrier for themselves.
Furthermore, they found it difficult to be patient and
listen carefully when they were stressed for time.

Barriers to Counselling
at nurses level
Skills
Nurses Working faster than patients
It seems that the nurses are jumping ahead of the
patient.
Nurses had false or too high expectations for lifestyle
change by patients. This results in a righting reflex
where they push too hard for change, resulting in
resistance of the patient.
Nurses explicitly told us that they would like to have
some skills to overcome this barrier.

Barriers to Counselling
at nurses level
Skills
Deficient skills in making structured plans
They do not know how to develop a concrete and
structured action plan in cooperation with the
patient. They also reported having difficulties in
adapting their counseling to the stage in which the
patient is.

Barriers to Counselling
at nurses level
"I do not know what is the best way to counsel patients.
At the end of the consultation, I must have a concrete
action plan, such as: eat less high-fat cheese. It is difficult
to make things concrete and do this in a structured
manner."
"Sometimes I supply information too fast. The patients are in
an earlier stage of change."

Barriers to Counselling
at patients level
Knowledge
Nurses thought that while patients have a general feeling of the urgency
to change, they lack insight into their lifestyle behavior, health, and, in
particular, the effects of their diet.
Since patients think they know how to live healthy, they often refuse to
see a dietician.

Furthermore, the nurses thought that language could be a barrier for

patients from other cultures and for patients who have a low level of
understanding.
Misinformation from peers could also interfere with lifestyle counseling.

Barriers to Counselling
at patients level
According to the nurses, the unwillingness of patients to
change their lifestyle is based on a general aversion to change
and previous experience. This was seen more often among
the elderly.
Furthermore, nurses thought that patients search for excuses
not to give up their habits.

Barriers to Counselling
at patients level
1. Physical restrictions
2. Financial restrictions
3. Location of exercise programs
4. Addiction to smoking
5. Noncompliance with advice
6. Psychosocial troubles

Process
1. Opening of the encounter: developing a
reciprocal relationship.
2. Active listening: power sharing.
3. Vision of the future: emphasizing the
positive.

1. Opening of the encounter: developing a

reciprocal relationship
Nurses initiate a discussion.
At the beginning of a conversation the participants
evaluate each others aims and concerns.
Communicate with an appropriate degree of
informality- it implies intimacy and mutual respect
when a relationship is established

2. Active listening: power sharing

The nurse's way of posing questions builds up interaction.
With her questions she steers the discussion.
When the patient speaks, the nurse supports her with various
feedback -`mmm, right, of course, yes, exactly' and
sometimes by paraphrasing.

She nods a lot, bends toward the patient and looks at her.
The feedback also occasionally includes completing the
patient's sentences.

With her feedback the nurse shows that she is there to listen
to the patient, that she does not want to interrupt. Her
feedback encourages the patient to speak in a similar way .

3. Vision of the future: emphasizing the

positive
When the patient discusses the reason for her admission to
the hospital, the nurse builds up a positive, healthier vision
of the future through other patients' experiences.
She makes her professional knowledge and expertise
available to the patient situation.
Her tone is convincing, and her non-verbal messages also
inspire confidence.
She looks at the patient, reinforces her message by nodding
her head and gestures with her hands.

Nursing Implications
1. Training.
2. Provision of time for counselling
3. Develop competencies needed for counselling

self-awareness/reflexivity
emotional sensitivity
sensitivity to relationships
a facilitative / enabling way of working with clients a
framework for practice
organisational change skills
Jennifer Flueckiger, Centre for Research on Families
and Relationships, University of Edinburgh (2009)

CONCLUSION