Home > Focusing and ... > Medicine > Listening and Focusing: Holistic Health Care Tools for Nurses
- Reducing Stress Through Focusing
- Focusing as a Coping Strategy
- Making Behavioral Changes
- Developing a Collaborative Approach
This article explores the role of two methods of holistic communication, Active Listening and Focusing, in nursing. Active Listening, a technique for reflecting back the essence of what the patient says to you, can help patients to feel more deeply seen and understood. Focusing, a body-centered method for developing self-awareness, is a way of listening to feelings by becoming aware of body sensations that carry meaning about issues or concerns.
The article includes four uses of Focusing: reducing stress, creating better coping strategies (for example, in pain control and decision-making), making behavioral changes, and developing a collaborative approach with patients. Clinical examples (mini-Focusing moments) that demonstrate how Listening and Focusing may be integrated into daily nursing care are also included.
The patient rings the call button for the nurse. When the nurse arrives, the patient urgently requests more pain medication. The nurse explains that the patient's next dose of pain medication is not due for another two hours. The patient is upset, but says nothing. The nurse asks if the patient wants the TV on. The patient declines, and the nurse moves on to her next patient.
This scene happens, in some form or another, in hospitals every day. It is unsatisfactory for both caregiver and receiver, but there is an alternative.
Patient: [Rings call button. Nurse arrives.] I need more pain medication.
Nurse: [Looking at chart] Well, you're not due for another dose of medication for two hours. But tell me what's going on? How are you feeling right now?
Patient: Well, I'm not actually in pain right now. I'm just afraid I will be in pain before the next dose.
Nurse: So you're afraid that the pain will recur and you won't have medication to cover it.
Patient: Yes, I'm really scared. It was terrible last time. The pain was so intense.
Nurse: I'm glad you're telling me this. I wonder if anything besides additional medication could help with that scared feeling.
Patient: Just talking about it and having you understand helps it ease some. Would you be able to check in with me again in an hour?
When a nurse has many patients to attend to and too little time to spend on each one, communication can be reduce to answering questions, and telling a patient what to expect and what to do. From a holistic point of view, communicating in this way inhibits rather than aids in the healing process.
Holistic communication is the art of sharing emotional as well as factual information. It involves letting go of judgements and appreciating the patient's point of view. It begins with attentive nonverbal communication (i.e., warm, accepting eye contact, and facing the patient with arms uncrossed and an inviting facial expression). It follows with a willingness to listen to the patient's inner experience. Simply hearing what patients think and feel has a beneficial effect on their physical healing and well being. The basics for good communication are simple to learn, do not take up a lot of time, and can significantly change the quality of the patient's experience (as well as that of the nurse!). See Box 1.
The most basic form of holistic communication is "Active listening". Active listening is a specific way of hearing what a person says and feels, and reflecting that information back to the speaker. Its goal is to listen to the whole person and provide her with empathic understanding. It is the skill of paying gentle, compassionate attention to what has been said or implied. 2, 5, 12, 14 When you listen in this way to patients, you just try to reflect the other person's feelings and deeper meanings, which helps them feel heard and understood. You don't analyze, interpret, judge, or give advice. When patients are listened to in this way, they are less anxious, complain less about their caregivers, and are more likely to comply with their treatment plan.
A cardiac patient might be angry and complaining. As the nurse, you may try to avoid his room, and, when you have to be there, move in and out as quickly as possible. Avoidance is one solution, but there might be a different approach:
Patient: Where's the doctor? She said she'd be here this morning. And it took you twelve minutes to answer my call button. I wasn't pressing it for fun, you know.
Nurse: I can hear you're feeling very impatient today, and really conscious of how slowly things seem to move here. It must be difficult. I can imagine how frustrated you must be.
Patient: Damn right it's frustrating! I feel as if I'm just a number around here.
Nurse: So it feels like the delays reflect our not caring about you.
Patient: Well, there are a few good nurses like you. (Pauses. He thinks for a while.) But I do feel frustrated. And having to lie here in bed makes me feel pretty helpless.
Nurse: Can you think what might help that frustrated, helpless feeling when you do have to wait?
Patient: Actually, as long as I have something good to read I'm not so aware of how slowly things happen around here. And it helps to have you drop by once in a while.
Nurse: Well, let's make sure you have some absorbing reading. And I'll stop in again to check on you before the end of my shift. I know it can be very frustrating to be left waiting.
Active listening is a non-intrusive way of sharing a patient's thoughts and feelings. In its most simple form, you hear what the patient is saying, repeat what you heard, and then check with the patient to make sure the reflection is correct. In a more complete listening response, you don't just listen to the words, you try to reflect the feeling or intent behind the words. 6
Patient: I'm very frightened about the procedure tomorrow.
Nurse: Oh, you'll be fine. The doctor does hundreds of these every year.
Patient: I'm very frightened about the procedure tomorrow.
Nurse: So, you're frightened about the procedure. Can you say more about what's so frightening for you?
Active listening helps patients clarify and articulate their inner process. 3 For a patient, being carefully listened to can be a moving and profound experience, one that transforms the relationship between patient and nurse. Active listening is particularly relevant in a hospital setting, where patients often report that they feel isolated and invisible. It can make a difference in rebuilding a patient's sense of self. It can also be rewarding for the nurse!
Words can be used to hide feelings and meanings; active listening helps reveal those meanings. In that sense, it engages the speaker and listener in true communication.
Since the art of being a good listener is to create the space within which the speaker can sense their own imperfect feelings and thoughts, a good listening response is often all that is needed to help a patient access inner concerns and feelings. However, when a person is under stress or feeling very vulnerable, there is a tendency to close off, keeping feelings and concerns locked within, so they are hard to find and express.
So, what happens if your patient looks upset or angry, and you ask, "How are you feeling?" and the patient responds, "Fine," or says "O.K., I guess," or "I really don't know." You see that the patient is distressed; but you also observe that he is unable to find the right words to express his discomfort.
Focusing is a useful tool that can help patients connect to their inner experience in such a way as to allow a change process to unfold.
"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
Antoine de St. Exupery
The Little Prince
Most people consider that mind and body are two separate entities. But what if mind and body are just two words describing different parts of the same phenomenon? What we have come to understand is that anything that occurs in the mind is immediately transmitted to the body; and any event that occurs to the body also occurs in the mind.
Focusing is based on this notion that mind and body are intimately connected, and that by listening to the body you come to understand yourself. 5, 9 We are all familiar with a body feeling that is directly connected to something that has happened in our lives: "butterflies" in your stomach before a performance review, a tense feeling in your throat when you need to share difficult news with a patient. Focusing involves spending time with a bodily sensation that is not yet clear, and can not yet really be put into words, but which you can distinctly feel has a connection to some issue or event in your life. It involves becoming a friend to your own inner experience. 1 The process of Focusing enables people to effectively communicate with themselves - that is, to gain a deeper and more meaningful understanding of what they are feeling in the moment. 5,1,11
When people are ill or under stress, they often become absorbed with their bodies, and may even feel betrayed by them. Symptoms - such as pain, anxiety or fatigue - claim their attention.
Focusing invites a person to pay attention to the body in a different way. It allows a person to empathically connect with her body, and to understand the psychological meaning of body sensations and body discomfort, while not becoming overwhelmed by these sensations. It is useful for preventing illness, reducing stress, 7 and working with anxiety and fear. One study demonstrated that it decreased depression and improved body image in a group of patients with cancer.8 There is also some limited evidence that Focusing is useful in controlling pain, and in getting some much-needed distance from an illness. Some findings suggest that Focusing may help to improve the body's immune response. 13 Clearly, this body-centered approach can be integrated into all aspects of health care.
Focusing, first described by Gendlin, 4 is a method of getting in touch with your body's sense of a particular situation or issue. In the 1960s Professor Eugene Gendlin at the University of Chicago joined Carl Rogers in researching the question, "why is psychotherapy helpful to some, but not to others?" Gendlin and his colleagues studied hundreds of hours of taped therapy sessions. They discovered that there was a clear difference between successful and unsuccessful therapy clients. The successful clients would at times slow down their talk, become less articulate, and grope for words to describe what they were feeling. Instead of analyzing what they were feeling, they directly sensed the vague, hard-to-describe physical awareness that embodied that feeling. Gendlin developed a way to teach this powerful and effective skill of emotional healing, and named it Focusing. Focusing is a natural skill which was the key element for success in therapy.
Accessing the felt sense is one of the two main components of Focusing. A felt sense forms by paying attention to a particular event or feeling, and then noticing what is evoked inside your body. Specific words or images then come to describe the felt sense.
Nurse: How are you doing this morning?
Patient: Not so good. I can't explain it. I just feel kind of ...blah.
Nurse: Kind of a blah feeling. Can you take a moment to sense how that is in your body?
Patient: (Closing his eyes) Yeah...it feels nagging. I have a nagging worry that this infection isn't healing.
Nurse: So that blah feeling is really about your being worried. (Patient nods). Let's talk about how infections heal. I think it might help ease your worrying.
A felt sense feels meaningful, but that meaning is at first murky and unclear. As you continue to pay attention to it with an attitude of friendly acceptance, its meaning comes into focus. Once in focus, words or images emerge that match the felt sense.
In this example, the blah feeling is the felt sense, and when the nurse invites the patient to bring her attention to it, the feeling crystallizes, and she realizes she is worried. This brief process makes clear communication possible.
The second key component is the Focusing attitude. It entails staying respectful, friendly, and welcoming towards whatever emerges. If you are judgmental and critical, that attitude stifles the inner voice and closes off communication with your deeper self.
For example, if you're feeling vaguely annoyed with a colleague, it's less helpful to wall it off and pretend you're fine, then to take a moment for yourself to acknowledge that annoyance in a welcoming way. "Oh, part of me is really ticked off at her. Let me be with that annoyance and see if it can tell me more about what's so annoying." When the annoyed place "speaks", you feel a release in your whole body, the way you might if you put down a heavy package you've been carrying.
As seen in the example above, the Focusing process is not only useful for patients, it is a method that nurses can use to reduce their own stress. One can practice Focusing alone, but it is easier in the beginning to do it with a partner. Let's suppose that you decide to focus on your work, since it has been feeling more and more stressful recently. You take a few minutes for yourself, accompanied by a partner who acts as the Listener.
Listener: So, you mentioned that work has been a problem. Would you like to take some time to sense how it feels in your body?
Focuser: (Waits to sense inside). There's a tight feeling in my abdomen and shoulders.
Listener: There's a tight feeling in your shoulders and abdomen.
Focuser: It's definitely connected to work...but I can't quite get the connection....
Listener: That tight feeling is connected to work.
Focuser: Oh. Oh yes. The certification process that we're going through at the hospital is what's making me feel so tight. I feel pressured to get those reports done, while still taking care of my patients
Listener: That tight feeling is connected to the certification process at the hospital. You feel pressured.
Focuser: Yeah, I really do.
Listener: Why don't you check to see if pressured is the best word to describe that tightness?
Focuser: (Pause while playing the feeling against the word). Well, it's not really pressured; it's more like overwhelmed. That's it, I actually feel overwhelmed.
Finding out you are overwhelmed is not good news, but you will feel some relief in naming it, and you'll find that the tight feeling begins to ease.
After finding words or images for the felt sense, and trying them out until you find the ones that fit, the next step is to hear from the overwhelmed feelings, by asking, What's the crux of this? What's the worst of this? or What do these feelings need? You'll learn, perhaps, that the worst of the feeling is being afraid to let down your supervisor, and what's needed is a talk with her to get some relief from patient care, or to get an extension on the reports. When an answer comes, you'll feel the tension release in your body, and a sense of the next right "action step" to take in relation to this problem.
Focusing and Listening are effective tools for both the patient and the nurse. Because Focusing acts as a bridge between mind and body, it allows you to gain access to a state where "mind" and "body" are not separate entities. As such, it is a useful implement for unraveling the complex tapestry of illness. It helps people who are cognitively-oriented connect with the sense of their body feelings, and people who somatize connect with the meaning of their body feelings. It addresses the human being as a whole: an intricate constellation of memories, emotions, thoughts, and body sensations.
Focusing has many uses in the nurse-patient relationship, and these are outlined in Box 2.
Dealing With A Stressful Medical Environment
Both nurses and patients find the medical environment stressful. Nurses, on the front line of medical care, have constant demands on them which sometimes cause them to engage in unhealthy life choices. As a result, they frequently need to take better care of themselves. Focusing can help nurses cope with professional and personal overload and burnout.
Patients, in addition to coping with pain, surgery and treatments, and a hospital environment, often have financial and emotional burdens.12 Frequently, they worry about the future, regret past behavior, are angry and sad about their condition, and have questions, such as "Will my health insurance cover the cost of the procedure?", "What will the impact be on my family and friends?", "How will I cope with this fear and anxiety?", and "Am I going to die?" Patients need effective methods to cope with this variety of stressors.
Clearing a Space
The first step of Focusing, called "Clearing a Space", involves taking an inventory of the stressors one is carrying, so they can be "cleared out" of the body. After each stressor is removed, one can notice the beneficial effect, a distinct sense of release. This process is more useful than trying to work with the entire complex of issues, all tangled up together. One finds that there is an actual physical release in moving each stressor out of the body. This is accomplished by imagining that one is putting each concern or problem at a distance, such as in a drawer, or in a box placed at the right distance away from you, or on a boat while one imagines sitting on a beach. Sometimes the sense of release is sufficient for the moment; sometimes an immediate action step is necessary.
While it is possible to "clear a space" by yourself, it is easier in the beginning to have a partner.
Listener: Allow yourself to become relaxed and wait and see what problems or issues come up for you. Let's take an inventory.
Focuser: (Sits and waits). O.K., I've got quite a few.
Listener: Can you identify these issues one by one, as you're sensing them right now, in this moment?
Listener: Can you sense how the first issue feels in your body?
Focuser: Yes. Yes I can. It's a kind of frantic feeling... My back aches, my jaw feels tense, and I have a kind of low-grade headache...but mainly I feel a kind of buzzing in my chest.
Listener: So there's a frantic feeling and a buzzing in your chest. See if you can imagine placing that buzzing outside of you at the right distance for the moment.
[The focuser finds two more issues which she identifies and places outside her body.]
Listener: Is there anything else that comes between you and feeling a sense of well being?
Focuser: No...I don't think so. Wait - I'm still worried about my brother. There's like a lump in my throat when I think of him.
Listener: See if you can you take that lump of worry and put it aside for now as well.
Focuser: Yes....I can. It's kind of a relief. I feel more relaxed; like there's more space for me.
Listener: If you'd like, I invite you to take a few moments and just sense what it's like in your body when you've put all of those issues aside.
Clearing a space enables the focuser to get some distance from pressing issues. For patients, it creates a buffer zone which helps them gain perspective on the fears and apprehensions that accompany illness. The focusing attitude of acceptance and acknowledgement helps patients recognize their feelings without being overwhelmed by them. Patients can clear out problems, while still keeping their privacy, as they need not describe the content of the concerns, in order to place them outside of the body.
Clearing a space can also be used as a daily technique for alleviating stress. Nurses can learn to routinely take five minutes to separate from the pressures of the day, the patients you're concerned about, your volume of paperwork, and then take a few minutes to sense inside for the bodily felt perception of your difficulties. After "placing" these perceptions "outside" of yourself, you can take a few minutes to sense your essential well being -- how you would feel without these pressures. This technique can help restore energy, and allow you to return to your responsibilities while maintaining a sense of wholeness.
Given the stresses intrinsic to a medical setting, nurses also need ways not just to keep stressors at bay, but to invoke and maintain positive feelings. It can be helpful to take a few moments each day to get a felt sense of what drew you initially to your work, or what the work feels like in its most rewarding moments. It also helps to find a phrase that describes how you would like to treat yourself during the rest of the day (e.g. "with patience," "with self-acceptance," "with humor," "with love"). When you take a few moments to feel what it would be like to actually embody that positive quality, a shift normally occurs. You, your colleagues, and your patients all benefit.
A person who is sick must adapt to the challenges that arise during diagnosis and treatment. He or she must also find ways to deal with the unpredictability and vulnerability that illness evokes. Focusing empowers a person to create new ways of adapting to difficult situations.
There is often a big gap between deciding to change behavior (i.e., diet, exercise, drinking, smoking, sleep) and actually changing it. Because there are often major obstacles to altering behavior, simply knowing what needs to be changed is usually not sufficient. Focusing invites the person to check inside and see what's in the way of making a change, allowing her to have a compassionate dialogue with the reluctant aspects of herself. The reluctant aspects may speak on their own, or it may help to ask them respectful questions, such as "What makes this behavior change so hard for me? What does this resistant part of me need? What would make changing easier?" When the whole person engages in the process of change, then the change is more likely to occur.
The process of focusing facilitates a sense of trust and collaboration between nurse and patient, and, when paired with listening, it provides an excellent way for the nurse to relate to the patient's deeper concerns. What patients most often want from their health care team is not only information, but a sense of being seen and understood. Focusing and Listening are tools which can empower patients to listen to themselves, to take an active part in decision-making, and to change lifestyle behaviors.
Even mini-Focusing moments, short exchanges embedded in interactions with patients, can help both patient and nurse befriend and work with unclear or intense feelings in a new way. These moments help to align nurse and patient as allies.
There is no need for the nurse to direct the client or patient. Just by facilitating and witnessing this inner process, the patient feels more connected to the nurse, all in the space of a few minutes.
The Focusing process can be integrated into a variety of medical interactions. Any time a health practitioner shares a diagnosis, reviews treatment, engages in a decision-making process, begins a procedure, or talks with family members, Focusing and listening can increase the effectiveness of the communication.
Table 1 shows specific ways of integrating Focusing into nursing.
The doctor gives advice for a lifestyle change, or suggests a medication, and would like the patient to comply.
Nurse: "So, Mrs. Johnson, the doctor has just suggested that you cut back on red meat, begin a half hour of walking three times a week, and take your medicine twice a day. While you might agree that these are sensible suggestions, making lifestyle changes can be quite difficult. Would you be willing to take a moment to sit quietly, and check in with yourself how it feels to be asked to make these changes?
Patient: "Uh, well, sure, I guess I can do that."
Nurse: "Perhaps you can close your eyes for a second and take some moments to get a sense inside of how it feels to be asked to make these changes. And it would be helpful if you could find your way to welcome whatever comes up for you. (Pause). Can you feel any resistance or obstacle to following this program?
Patient: "Well, it seems like a lot to ask of me. Too much to think about. And I don't like having to take those pills! My best friend took them, and she had terrible stomach aches and diarrhea... and I'm afraid I'll never be able to have the discipline to exercise.
Nurse: "So, it seems like a lot to ask of you. You're afraid you won't be able to follow through on the exercise program, and you're anxious about side effects of the Lipitor.
Patient: "That's right. I don't see how I'm going to do it." (Pauses.) "Maybe if I tried exercising once a week to start."
Nurse: "O.K., so you don't quite see how you're going to do it, and you'd like to start more slowly. Check with yourself again. Does once a week feel reasonable?"
Patient: (Considers for a while.) "Yes, it does. I think I can manage that."
Nurse: "Great. That's how we'll start, then. And, with the Lipitor, I'll see if the doctor can start you at a lower dose, and I want you to call me if you notice any side effects."
Patient: "Well, thanks for listening to me. I feel better about trying to make these changes work for me."
The patient feels distraught after being given a life-threatening diagnosis.
Nurse: "Mr. Roberts, it seems that you are feeling sad. That would be totally natural given your diagnosis. Would 'sad' be the right word for what you're feeling inside right now?"
Patient: "Sure I'm sad." Pause. "But that's not the worst of it." Long pause. "I'm really worried about my family. About my wife. I don't know how she's going to take this."
Nurse: "So there's sadness, but more, there's a lot of worry there. And the worry is about how your wife is going to take this news."
Patient: "I don't know how she can take this." (He's close to tears.)
Nurse: "I understand that you're really worried about your wife. Can you set that whole worried feeling at a little distance from you so you can breath?"
Patient: "Yeah, it's right next to me."
Nurse: "Let's spend a little time with this just keeping that feeling company. (Pause) If you listened to that worried feeling, what might it tell you?"
Patient: (Pause.) "I'm scared to tell her by myself. It would help if her sister was there. She always takes things better when Susan's with her."
Nurse: "You'd be a little less worried if your wife's sister was there in the house with you when you tell her."
Patient: "Yeah. She could take it better." Pause. "I'd feel better."
Nurse: "So, I guess we have a little plan here. You're going to call your wife's sister, and have her in the house with you when you tell her about your news, right?"
Patient: "Right. That makes it a lot easier."
Listening and Focusing are invaluable skills for communicating and for reducing stress. They provide new opportunities for nurses to take better care of patients as well as themselves. While at first these new skills may seem awkward or time-consuming, with practice, you will find they are efficient and effective tools for nursing. Active Listening allows you to hear your patients' concerns in an empathetic way, allaying their anxiety and building trust between you. Focusing allows you to go beneath words and rational explanations, and attain new levels of awareness within your body. It is on this level - new and uncharted territory for most of us - that real change occurs. As Gendlin says, "One step in the body is worth a thousand steps in the mind".
|What the nurse might offer:||How It Might Be Phrased|
|To help a patient "clear a space", in order to reduce anxiety, fear, or tension||"Would you like to take a few moments to sense inside and see what's between you and feeling fine today? As each concern arises, you might want to place it at the right distance outside your body. After all concerns are placed out, take some time to feel what that is like"|
|To find a way for the patient to develop a gentle, accepting attitude.||"Can you find a way to welcome those feelings (tears, etc.)?|
|To help patients attend to their feelings||"How does the decision you've made feel in your body?" or "Can you take a moment to notice what you're feeling inside?"|
|To facilitate patients' search for words and images||"Are there any words that capture what you're feeling?" or "Is regret (fear, sadness, etc.) the right word for what you're experiencing?"|
|To reflect what the patient is feeling||"So you're feeling disappointed about the results today." (use the patient's exact words as much as possible)|
|To invite open-ended questions that the patients can ask themselves.||"What's the crux of it? What's the worst of it?" "What does this feeling need?" "What needs to happen?" "Is there a step I can take here that would be right?"|
Lutgendorf S, Antoni MH, Kumar M, et al: Changes in Cognitive Coping Strategies Predict EBV-Antibody Titre Change following a Stressor Disclosure Induction. Journal of Psychosomatic Research, 38(1), 1994