Teaching communication via Berne's ego states

YNEDT-02473; No of Pages 3 Nurse Education Today xxx (2013) xxx–xxx Contents lists available at SciVerse ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt Big Ideas Teaching communication via awareness of Berne's personal ego states Nursing is undergoing a not so quiet revolution. With the recent Francis report the profession is under scrutiny more than ever before. The professional behaviour and empathetic skills of nurses are frequently questioned and nurses are required to develop higher level relational skills, to articulate levels of connection with patients, service users and other professionals, and to develop self-awareness and confidence in how they communicate. This article suggests that the implementation of basic Transactional Analysis (TA) training in communication would prove an asset to undergraduate nursing education. Students already received education around good communication, but it is frequently around other oriented strategies that take account of the needs and settings of those that are communicated with. Furthermore, there is little recognition of self-oriented awareness of how and why communication takes place as it does. TA training would enable nurses to reflect on why communication with particular people does or does not go well or always seems to leave them with particular feelings. With the current focus on the profession it seems that a new way is needed in our communication with ourselves, other professionals and more importantly with our patients. Perhaps implementing TA theory might be a first step towards improving communication and therefore further developing the empathy and relational skills that nurses need. Transactional Analysis (TA) is a theory developed by Eric Berne in the 1950s. Berne, a Psychoanalyst, sought an easily understandable and accessible theory of why individuals interact and communicate in that way that they do (Berne, 1961). His TA theory allows consideration of how individuals developed, the perspectives that they take and how these perspectives impact on interactions with others (the transaction). Additionally, Berne's theory offers the opportunity to consider alternative perspectives that aid communication in enabling changes to be made (the analysis of the transaction) (Berne, 1961). The two key propositions of TA are that people can change and that they have a right to be in the world. Berne suggested that every person operates out of three basic ego states that change as different interactions or transactions occur (Lapworth and Sills, 2011). These are developed before the age of seven years and are linked to particular feelings that were produced as part of early significant relationships that form blue-prints for subsequent relationships throughout life. These feelings may be recognised when a similar stimulus happens throughout our life and we may act as we did at the initial interaction, thus reinforcing the feeling. Berne's original three ego states are Parent, Adult and Child as below (Stewart, 2007) (Fig. 1). The Parent is the voice of authority, quite often our own parents or primary carer, that reinforces our earliest taught ideas, concepts and attitudes, with these rarely being actively challenged as to utility and validity. Being in the Parent ego state is recognisable by attitudes such as ‘how to’ and phrases such as ‘never’ and ‘don't’ Our Parent is formulated by events and influences that occur in early childhood (Prochasta and Norcross, 2003). The Child is our internal reaction and feelings to external events and can be characterised by acting out, sulking or feeling anxious. These feelings may not necessarily be articulated to others as behaviour but will govern our reactions and how we feel about others. When our emotions overrule our reasoning it is when the Child is in control. The Child is recognised by attitudes such as ‘tantrum’ behaviour, daydreaming, shame and being irresponsible. However, the child is also the source of fun, enthusiasm, creativity, innovation and curiosity (Prochasta and Norcross, 2003). The Adult is our ability to think rationally and to decide how we should react, what we are going to react to and whether we will act on the basis of Parent/Child data or information that has been validated ‘in the now’ by the Adult. The Adult ego state mediates between the Child and Parent and, if changes are made to our communication and interaction, they are made through the Adult. Indeed the goal of TA therapy is to strengthen the Adult and develop autonomy (Lister-Ford, 2012). Berne and those who advocate transactional analysis as a means of improving communication point to the use of this approach in promoting self-awareness and choice in how we react to and communication with others. TA is used in a wide variety of professions where communication is the key and perspective taking is seen as a vital aspect of practice. Some within nursing have suggested that it may be useful in discrete areas of practice (Hollins, 2011) but it seems that the time may be right in suggesting that TA is taught at undergraduate level to enhance communication, help develop self-awareness and perspective taking and thus develop and enhance empathy skills. Transactions are what Berne believed to be the unit of interaction. These transactions can be complimentary, when Adult to Adult communication is happening and can continue indefinitely, or crossed when a Parent to Child or Parent to Adult transaction occurs where the initiator or receiver of the transaction does not get what is expected. Crossed transactions either stop communication or realign the communication to an Adult/Adult transaction in order to continue. TA was initially thought to be an overly simplistic model (Prochasta and Norcross, 2003), however modern TA has developed with a greater understanding of psychology and a more robust emphasis on both process and outcome research. The popular application of TA in the Parent/Adult/Child (PAC) module belies the complexity of the theory, which the majority of users do not grasp unless undertaking the 5– 6 years of psychotherapy training required to become a UKPC registered psychotherapist. However, those who do use the basic PAC model as a means for mindful communication find that, with the minimum of training, it can make a significant difference to their self-awareness and as a result can impact upon the way that they do interact (Hollins, 2011). Berne's ideas have rarely been subjected to empirical research, indeed he admitted himself that he believed the TA ego states to be unobservable and therefore untestable. Further recent deepening and exploration of TA have enriched the development of theory and have allowed TA to gain recognition within the range of modalities employed in counselling and psychotherapy. The complexity of analysis, the games in which people engage and the ways that individuals 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.03.008 Please cite this article as: Kenward, L., Teaching communication via awareness of Berne's personal ego states, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.03.008 2 Big Ideas Parent (Taught) Adult (Thought) Child (Felt) Fig. 1. Berne's original ego states. find to pass the time are all things that Berne saw as significant in relation to the interactions that people have with one another. These further aspects of TA cannot be addressed in this article, but a wider variety of accessible books on the subject exist for those who would want to further explore the TA theory. Nursing is undergoing a not so quiet revolution. With the recent Francis report the profession is under scrutiny more than ever before (Francis, 2013). The professional behaviour and empathetic skills of nurses are frequently questioned and nurses are required to develop higher level relational skills to articulate levels of connection with patients and service users, other professionals, and to develop self-awareness and confidence in how they communicate. The implementation of basic TA training in communication would prove an asset to undergraduate nursing education. Students already receive education around good communication, but it is frequently around other oriented strategies that take account of the needs and settings of those that are communicated with. This is, of course vital but there is little recognition of self-oriented awareness of how and why communication takes place as it does. TA training would enable nurses to reflect on why communication with particular people does or does not go well or always seems to leave them with particular feelings. Two examples of where the TA training would be especially useful are in the mentoring relationship and in the nurse/patient relationship. To illustrate how TA may be utilised in practice an example of an interaction between a student and a mentor is used. Example Ahmed a second year student arrives in theatres on day one of his new practice placement and makes himself known to his mentor Sally. Ahmed is quite anxious about his placement. Sally is extremely busy on that particular day and had forgotten that Ahmed was arriving. She is in the process of preparing the anaesthetic room prior to the theatre list and begrudgingly she takes Ahmed with her. All goes well and Ahmed watches Sally assist the anaesthetist. During a quieter period Sally later explains how patients are intubated prior to surgery. Eliciting the knowledge that Ahmed already has, Sally asks: ‘Where would the endo-tracheal tube be inserted to enable the patient to breathe’? Ahmed hesitates; he wants to get it right, he feels nervous. Before he has had a chance to reply Sally, who is clearly irritated, replies ‘Oh come on you must know this, don't they teach you any anatomy and physiology at university these days’. Ahmed feels crushed; he knew the answer but was not entirely confident in it. Sally further mentions how she believes nurse education is ‘pointless being in universities’ and how students ‘are too clever to care’. The relationship between them is frosty with Sally becoming critical of Ahmed, and indeed students and nurse education generally, and Ahmed feeling inadequate and out of his depth. During the placement Sally frequently mentions how students do, in her opinion ‘not get involved enough’ and ‘just tend to stand there looking bored’. In this transaction Sally begins by asking a simple anatomy question in Adult mode but finds herself irritated when Ahmed does not answer quickly and with confidence. Ahmed may already sense Sally's irritation and along with his natural anxiety about his new placement he begins to feel inadequate. Sally resorts to a critical parent mode that demonstrates her own deep insecurities in the nurse education system. Speculating on the root of that is not appropriate without sitting Sally down and asking her about it; nonetheless her reaction is likely to reinforce the Child mode that Ahmed is already in, making him feel foolish, inadequate and unsure of his ability. This may, if not addressed, result in a whole placement where he takes this role to Sally's Parent role and complains of being treated like a child while Sally complains of an inept and uninterested student. What might an alternative transaction be if Sally was made aware of her ego states? In response to Ahmed's hesitation, Sally might become aware of her irritation, acknowledge it as being a Parent ego state, but choose to stay in the Adult ego state by allowing Ahmed more time to consider his answer or by encouraging him to give a tentative answer even if it might not be correct. An Adult transaction would acknowledge that Ahmed may not know the answer or may be nervous. Furthermore, Sally would, in the Adult ego state, acknowledge that the system of education, the curriculum and the development of nursing students are different as to how it was when she trained but it is quality assured, and that nurses are fit for the purpose and practice at the end. Her ideas about nurse education may not be correct, and even if they are, it is not the fault of individual students. She may also acknowledge that her practice setting can be nerve-wracking for students who frequently do not know what they can and cannot touch, who people are or what they should be doing. Ahmed in turn could have acknowledged his Child ego state when he arrived in the department but responded as an Adult to Sally in acknowledging that he was not sure about the correct response to the question, asking for some designated time with Sally to discuss his fears around the environment of theatres and how best he might be supported. He would also need to recognise within his Adult state that the comments that Sally made in relation to education were around her own inadequacy and not his. It is likely that the practice placement experience would be different if both recognised their ego states, acknowledged the issues that these brought up for them as being ego state specific, looked at their reactions in the light of rational thought as an Adult and chose to actively interact as Adults. The possibility of using this approach with difficult patients or with other professionals is endless. Transactions that are undertaken from an Adult ego state help to regulate difficult feelings produced in conversations, raise awareness of and disarm power relationships and empower nurses to take account of perspectives. This in turn has been shown to develop empathy (Howe, 2013). Brown's (1989) twenty years of research into the relationship between shame and empathy have shown that shaming a person or indeed a whole profession does not move people to change or to empathy, but moves then further away from being able to provide empathy. With the public shaming of the profession it seems that a new way is needed in our communication with ourselves, with other professional and more importantly with our patients. Perhaps implementing the TA theory might be a first step towards improving communication and therefore further developing the empathy and relational skills that nurses need. Please cite this article as: Kenward, L., Teaching communication via awareness of Berne's personal ego states, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.03.008 3 Big Ideas References Berne, E., 1961. Transactional Analysis in Psychotherapy. Grove Press, New York. Brown, B., 1989. Women and Shame: reaching out, speaking truths and building connection. 3C Press, AX Texas. Francis, R., 2013. Report of the NHS Staffordshire Foundation Trust Public Enquiry. The Stationary Office, London. Hollins, C., 2011. Transactional Analysis: a method for analysing communication. British Journal of Midwifery 19 (9), 587–593. Howe, D., 2013. Empathy: what it is and why it matters. Palgrave Macmillan, Hampshire UK. Lapworth, P., Sills, C., 2011. Introduction to Transactional Analysis. Sage Publications Ltd., London. Lister-Ford, C., 2012. Skills in Transactional Analysis Counselling and Psychotherapy. Sage Publications Ltd., London. Prochasta, J., Norcross, J., 2003. Transactional Analysis, Systems of psychotherapy: a trans theoretical analysis5th ed. Pacific Grove, CA: Brooks/Cole. Stewart, I., 2007. Transactional Analysis Counselling in Action, 3rd edn. Sage Publications Ltd., London. Linda Kenward The Open University, United Kingdom Tel.: + 44 1296 581754. E-mail address: [email protected]. Available online xxxx Please cite this article as: Kenward, L., Teaching communication via awareness of Berne's personal ego states, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.03.008